Datasets:

dmacres

/

mimiciii-hospitalcourse-meta

like 3

[ { "category": "Radiology", "chartdate": "2135-03-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1008769, "text": " 7:55 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich, sdh\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with trauma, fall\n REASON FOR THIS EXAMINATION:\n ich, sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRGe FRI 8:57 PM\n NO ICH or fracture. Right frontal soft tissue laceration.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma. Rule out intracranial hemorrhage, SDH.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial mass lesion,\n hydrocephalus, shift of normally midline structures, major vascular\n territorial infarct, or intracranial hemorrhage. The osseous structures are\n unremarkable. Laceration of the soft tissues overlying the right frontal bone\n with skin staples is seen. The visualized paranasal sinuses demonstrate\n minimal mucosal thickening of the maxillary sinuses and ethmoid sinus\n opacification. There is an endotracheal tube and OG tube. Fluid in the\n nasopharynx likely related to intubation.\n\n IMPRESSION:\n\n 1. No acute intracranial process.\n\n 2. Right frontal scalp injury.\n\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2135-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1008766, "text": " 7:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with intubation trauma\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n COMPARISON: None.\n\n FINDINGS: Portable view of the chest in supine position is limited due to\n overlying trauma board. Low lung volumes. Cardiomediastinal silhouette\n appears normal. Bibasilar airspace opacities consistent with atelectasis and\n possibly aspiration as seen on subsequent CT. There is no pneumothorax or\n pleural effusion. The osseous structures are unremarkable. Endotracheal tube\n is seen with the tip at the level of the carina. Repositioning is recommended.\n NG tube terminates in the stomach.\n\n IMPRESSION:\n 1. Endotracheal tube at the level of the carina. Repositioning is\n recommended.\n 2. Bibasilar airspace consolidation may represent atelectasis and possible\n aspiration.\n The findings were discussed with Dr. at the time of dictation.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2135-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1008801, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with asp pneumonia\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspiration pneumonia, evaluate interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable semi-upright chest.\n\n FINDINGS:\n\n An endotracheal tube is in place with tip terminating 4 cm from the carina, in\n unchanged position. Nasogastric tube terminates in the stomach (tip below the\n borders of the radiograph). Low lung volumes are present bilaterally and not\n significantly changed. Bilateral infrahilar opacities, more prominent on the\n left, are unchanged and could represent aspiration. Slight blunting of the\n left costophrenic sulcus could represent a small pleural effusion. No\n pneumothorax.\n\n IMPRESSION: No significant interval change in the radiographic appearance of\n the chest including bibasilar opacities consistent with atelectasis and\n aspiration/pneumonia. Probable tiny left pleural effusion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2135-03-11 00:00:00.000", "description": "R TIB/FIB (AP & LAT) RIGHT", "row_id": 1008780, "text": " 9:04 PM\n TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with deform and abrasion of right LE\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Deformity and abrasion of the right lower extremity. Rule out\n fracture.\n\n COMPARISON: None.\n\n FINDINGS: Four views of the right tibia, fibula and ankle demonstrate no\n evidence of acute fracture or dislocation. Irregularity of the distal fibula\n and lateral aspect of the distal tibia is seen and likely represent the\n sequela of prior trauma. The ankle mortise is congruent and the talar dome is\n intact. Prominence of the soft tissue overlying the right ankle joint is\n noted.\n\n IMPRESSION: No evidence of acute fracture or dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2135-03-11 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1008770, "text": " 7:55 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: frac\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with trauma, fall\n REASON FOR THIS EXAMINATION:\n frac\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRGe FRI 9:06 PM\n Multilevel degenerative changes. No acute fractures.\n ______________________________________________________________________________\n FINAL REPORT\n History: Neck injury.\n\n Technique: Multiple contiguous 3 mm axial images were obtained from the skull\n base through the thoracic inlet without intravenous contrast. Reformats in the\n coronal and sagittal planes were also obtained.\n\n Please note: this study was acquired on and made available for\n my review for the first time on .\n\n Comparison: None. No subsequent neck imaging is available at this institution\n as well.\n\n Findings: No prevertebral soft tissue swelling is seen. The cervical alignment\n is maintained without spondylolisthesis. No acute fracture is identified. The\n odontoid process is intact. Multilevel degenerative changes are seen, worse at\n the level of C4-5 with bilateral mild to moderate neural foramina stenosis,\n and C5-6 with anterior and posterior osteophytes causing mild to moderate\n narrowing of the spinal canal, and bilateral moderate neural formina stenosis.\n Most notably is a prominent posterior disk-osteophyte complex which\n encroaches upon the ventral spinal canal left of midline at C5-6.\n ETT and NGT are present. The visualized lung apices demonstrate dependent\n opacities, left greater than right best seen on CT of the chest performed the\n same day. Sinus disease as seen on CT head.\n\n Impression:\n\n 1. No acute fracture or spondylolisthesis.\n 2. Multilevel degenerative changes as described above including narrowing of\n the spinal canal at the level of C5-6. Please note, spinal stenosis\n increases risk of cord injury even from minor trauma. If clinically\n indicated (e.g. focal referrable neurologic deficit), MRI could be performed\n for more sensitive evaluation.\n\n\n (Over)\n\n 7:55 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: frac\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2135-03-11 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1008772, "text": " 8:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval\n Field of view: 48\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p fall\n REASON FOR THIS EXAMINATION:\n eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRGe FRI 9:12 PM\n ETT at the carina, repossitioning is recommended. Bibasilar consolidations may\n represent atelectasis and aspiration pneumonia. Enhancing renal mass in the\n lower pole of the right kidney concerning for RCC.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 58-year-old man status post fall downstairs. Evaluate for\n traumatic injury to the torso.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images through the chest,\n abdomen, and pelvis following the uneventful administration of 150 mL Optiray\n IV contrast. Coronal and sagittal reformations are provided.\n\n FINDINGS:\n\n CHEST: Endotracheal tube is seen with its tip at the carina. The NG tube is\n also seen with its tip in the proximal stomach. The mediastinal great vessels\n appear intact. There is no evidence of mediastinal hematoma. The heart is\n normal in size and shape. There is no pericardial effusion. There is no\n lymphadenopathy in the axilla, mediastinal or hilar distribution.\n\n Lung windows demonstrate bilateral posterior airspace consolidation, which\n likely represents a combination of atelectasis and aspiration. No worrisome\n nodules or mass lesion appreciated. No pleural effusions are present. There\n is no pneumothorax. The central airway is patent.\n\n ABDOMEN: The liver appears heterogeneous in attenuation likely due to fatty\n replacement. On image 51 of series 2, a small hyperdense area is seen in\n segment VIII, which is too small to adequately characterize, though may\n represent a small hemangioma or FNH. The spleen and pancreas appear\n unremarkable. The gallbladder contains hyperdense material near the neck,\n which likely represents small stones. The adrenal glands appear normal. The\n left kidney contains several hypodense lesions, which may represent small\n cysts. A hypervascular lesion is seen arising exophytically from the lower\n pole of the right kidney, which measures approximately 2.1 x 2.2 cm. This\n finding is worrisome for neoplasm. Additionally, there are small\n hypodensities in the right kidney, which may represent cysts. There is no\n (Over)\n\n 8:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n retroperitoneal lymphadenopathy. There is no hydronephrosis. The abdominal\n aorta and branch vessels appear unremarkable and demonstrate patency.\n\n The stomach and duodenum appear unremarkable.\n\n PELVIS: Small bowel demonstrates no evidence of ileus or obstruction. The\n large bowel appears unremarkable. Numerous diverticula are noted without\n evidence of acute diverticulitis. There is no free fluid in the pelvis. A\n Foley catheter is positioned within the collapsed bladder. Bilateral fat-\n containing inguinal hernias are noted, slightly larger on the right side.\n\n OSSEOUS STRUCTURES: No suspicious lytic or blastic osseous lesion is seen.\n Degenerative changes are noted throughout the spine. No fractures are seen.\n Note is made of a linear tract of tiny air locules in the right chest wall, of\n uncertain clinical significance.\n\n IMPRESSION:\n\n 1. Bilateral airspace consolidation in the posterior lungs, likely a\n combination of atelectasis and aspiration.\n\n 2. Hypervascular renal lesion arising from the lower pole of the right\n kidney. This lesion appears very suspicious for renal cell cancer and further\n evaluation is recommended with multiphase CT or MRI. This finding was\n discussed with Dr. at the time of this dictation. Additional\n hypodense renal lesions are most compatible with cysts.\n\n 3. Cholelithiasis.\n\n 4. Diverticulosis without evidence of diverticulitis.\n\n 5. Fat-containing inguinal hernias.\n\n 6. ET tube tip positioned at the carina. Recommendation for retraction has\n already been discussed with Dr. of surgery.\n\n 7. Small hypervascular liver lesions, incompletely assessed though likely FNH\n or hemangioma. This lesion can also be fully characterized on multiphasic CT\n or MRI.\n\n\n SESHa\n (Over)\n\n 8:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2135-03-12 00:00:00.000", "description": "Report", "row_id": 1618061, "text": "RESPIRATORY CARE NOTE\n\nPatient received from ED intubated and fully ventilated on AC ventilation s/p fall down stairs. 0400 placed on CPAP/PS 10/5 with Vt=500-600, RR=, Ve=6.5-12L. RSBI completed on PS 5=27. Plan for extubation this AM.\n\n\n , RRT\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-03-12 00:00:00.000", "description": "Report", "row_id": 1618062, "text": "NPN 0000-0700\n? 58 Y/O MALE TX FROM S/P FALL DOWN STAIRS, +ETOH. INTUBATED AT OSH DUE TO COMBATIVENESS AND ? ICH AND TX . EN ROUTE TO PT GIVEN LG AMT OF FENTANYL AND VERSED TO SEDATE WHICH CAUSED MOD HYPOTENSION AND WAS TX TSICU. ALL XRAYS/CTS OF HEAD, NECK, TORSO NEG. LG HEAD LAC-STAPLED AT OSH. OPTHO CONSULTED.\n\nPT IDENTIFIED AT AS \" \" although adm as EU Critical -no family contact thus far. Per OSH records pt is married and nods yes to this question/name when asked. SW note stating at pt's emergency contact and had been notified by . NKDA or PMH available at this time.\n\n Lightly sedated on Propofol, no apparent neuro deficits. MAEs.Pt attempting to shake head \"no\" when asked if in any pain. R>L orbital edema/ecchymosis. PERRLA 3mm/brisk. Strong cough/gag. Per x-ray and CT c-spine/TLS clear though c-collar remains on per Trauma team until physical exam is possible.\n\nHR 90's NSR, NIBP 120's-160's systolic, when Propofol briefly increased to 40mcg/kg/min, BP down to 80's. Hct stable. Skin warm, pedal pulses palpable and ? stasis ulcers to LE's, one on RLE with adaptic DSD. LG lac to R forehead stapled at OSH-sm amt sanganous drainage, DSD changed. Afebrile-no abx ordered.\n\n Weaned to CPAP . Lungs coarse bilat/dim at bases. Scant thick white secretions sxnd from ETT. Mod amt dark bloody oral secretions sxnd.\n\nAbd soft and obese, +BS. No BM. NGT to LCWS sumping sm amt dk bloody drainage. Foley with adequate clear yellow u/o Q hr. Calcium and MAgnesium repleted. D5.45NS with 20meqK+ as maint. fluids.\n\nPOC: Wean to extubate\n d/c c-collar when cleared by Trauma\n formally identify pt and family\n ? tx floor\n\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2135-03-11 00:00:00.000", "description": "Report", "row_id": 215524, "text": "Normal sinus rhythm. Probable voltage criteria for left ventricular\nhypertrophy in leads I and aVL. Q waves in leads III and aVF suggest\npossible prior inferior myocardial infarction. No previous tracing available\nfor comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2152-12-06 00:00:00.000", "description": "RENAL U.S.", "row_id": 989619, "text": " 4:08 PM\n RENAL U.S. Clip # \n Reason: Please evaluate for renal flow, hydronephrosis, hydroureter\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with acute changes in renal function, elevating creatinine\n REASON FOR THIS EXAMINATION:\n Please evaluate for renal flow, hydronephrosis, hydroureter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute changes in renal function.\n\n COMPARISON: None.\n\n FINDINGS: The right kidney measures 13.0 cm and the left 11.9 cm. The renal\n parenchymal thickness and echogenicity are normal without evidence of calculi\n or hydronephrosis. There is a 1.3 x 1.3 x 1.4 cm cyst in the upper pole of\n the right kidney.\n\n Doppler evaluation of the kidneys is limited due to motion artifact. However,\n color flow is preserved in both kidneys. The pulsed wave Doppler images\n demonstrate anterior diastolic flow and good systolic upstroke.\n The urinary bladder is not distended due to Foley catheter.\n\n IMPRESSION:\n 1. Normal renal size without evidence of hydronephrosis.\n 2. Small right renal cyst.\n 3. Limited Doppler evaluation of the kidneys demonstrates no overt evidence\n of renal vascular pathology.\n\n" }, { "category": "Radiology", "chartdate": "2152-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986892, "text": " 3:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess ETT position and position of NGT.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M s/p aneurysm coiling in angio where ETT was placed. NGT placed postop.\n REASON FOR THIS EXAMINATION:\n Please assess ETT position and position of NGT.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post aneurysm coiling in angio laboratory where ETT was\n placed. NG tube placed postoperatively; assess position of instruments.\n\n FINDINGS: AP single view of the chest with patient in sitting semi-upright\n position demonstrates the presence of an ETT seen to terminate in the trachea\n some 5 cm above the level of the carina. An NG tube is identified and seen to\n terminate in the fundus of the stomach. There is no pneumothorax or any other\n placement-related complication. There exists a left-sided perihilar density\n which was not noticed on the next preceding examination and which may\n represent a local infiltrate possible aspiration. No other pulmonary\n abnormalities are seen on this portable single view examination.\n\n IMPRESSION: Unremarkable position of ETT and NG tube. Suspicious new\n parenchymal infiltrate in left perihilar position. Follow up is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987649, "text": " 12:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man w/ SAH, s/p ACA coiling\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male status post subarachnoid hemorrhage after ACA\n coiling.\n\n COMPARISON: Chest radiographs of , dating back to .\n\n SEMI-UPRIGHT PORTABLE CHEST X-RAY: Cardiac enlargement and mediastinal\n silhouette is unchanged. Allowing for slight patient motion and slight\n under-penetration, there is no evidence of pulmonary edema or volume overload.\n No pulmonary consolidations are identified. No pneumothorax or large pleural\n effusions are identified, although the left lateral costophrenic angle is\n excluded on the current study. A right PICC is again seen in the mid SVC. An\n NG tube is seen overlying the mediastinum, however, cannot be completely\n localized; if localization is required, a repeat study with improved\n penetration would be required.\n\n IMPRESSION: Overall unchanged from and . No evidence of CHF\n or new consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 988513, "text": " 9:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for hydrocephalus/ventricle size. Please perf\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ventriculostomy\n REASON FOR THIS EXAMINATION:\n Please assess for hydrocephalus/ventricle size. Please perform study at 0500\n \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT\n\n HISTORY: 53-year-old man with ventriculostomy, assess for hydrocephalus.\n\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the skull base to\n the vertex.\n\n Again seen are bilateral ACA distribution infarcts as well as subarachnoid\n hemorrhages bilaterally. Small amount of layering blood within the left\n occipital is also again seen. A ventricular shunt is seen from a right\n frontal approach with the tip terminating in the right lateral ventricle\n posteriorly as before. There are extensive white matter hypodensities\n consistent with chronic microangiopathic changes. The ventricles are\n unchanged in size. Note is again made of a cavum septum pellucidum.\n\n Coil pack is seen in the anterior communicating artery region.\n\n Minimal mucosal thickening of the left maxillary sinus is seen with moderate\n mucosal thickening of the sphenoid sinus and the ethmoid air cells as well as\n the frontal sinus. No suspicious bony abnormalities are noted.\n\n IMPRESSION: No significant change compared to with bilateral\n subarachnoid hemorrhages, left intraventricular hemorrhage, and bilateral ACA\n distribution infarcts.\n\n No significant change in ventricular size.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-28 00:00:00.000", "description": "PERCU PLCT IVC FILTER S&I", "row_id": 988451, "text": " 5:02 PM\n PERCU PLCT IVC FILTER S&I Clip # \n Reason: IVC FILTER, IMMOBILITY, BLEED FROM ACA ANEURYSM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n Please see CareWeb Notes for the complete operative report.\n\n" }, { "category": "Radiology", "chartdate": "2152-11-16 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 986807, "text": " 8:10 AM\n CAROT/CEREB Clip # \n Reason: please assess for intervenable aneurysm.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 205\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY F/U TRANS CATH THERAPY *\n * CAROTID/CERVICAL BILAT -59 DISTINCT PROCEDURAL SERVICE *\n * CAROTID/CEREBRAL BILAT -59 DISTINCT PROCEDURAL SERVICE *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with aca aneurysm rupture\n REASON FOR THIS EXAMINATION:\n please assess for intervenable aneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF PROCEDURE: .\n\n PROCEDURE PERFORMED: Left common carotid artery arteriogram, right common\n carotid artery arteriogram, right internal carotid artery arteriogram, left\n vertebral artery arteriogram.\n\n INTERVENTIONAL PROCEDURE PERFORMED: Coil embolization of anterior\n communicating artery aneurysm with GDC coils.\n\n STAFF: . I was assisted by MD during this procedure\n\n INDICATION: Mr. is a 53 year old male who presented with an anterior\n cerebral artery aneurysm that had ruptured with massive subarachnoid\n hemorrhage, therefore we were requested to do this coil embolization. The\n risks and benefits of the procedure were discussed with the family, they\n agreed, and we went ahead with the procedure.\n\n The patient was brought to the Angiography Suite where anesthesia was induced\n in the supine position. Anesthesia was available during the procedure for\n monitoring. Both groins were prepped and draped in a sterile fashion.\n Following this the right common femoral artery was accessed using a Seldinger\n technique and a 6 French vascular sheath was placed in the right groin.\n Following this we passed 2 catheter through the sheath coaxially\n over an 038 glidewire. The left vertebral artery, the left common carotid\n artery, the right common carotid artery and the right internal carotid artery\n were catheterized and AP, lateral, oblique and three dimensional rotational\n imaging was done. This demonstrated an anterior communicating artery aneurysm\n measuring 4 into 5 mm predominantly fed from the right side. Based on the\n diagnostic findings, we decided to proceed with embolization. We now\n proceeded to place an exchange length glidewire into the right internal\n carotid artery and the catheter was exchanged out for an Envoy 6\n (Over)\n\n 8:10 AM\n CAROT/CEREB Clip # \n Reason: please assess for intervenable aneurysm.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 205\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n French catheter. This was connected to continuous infusion. 5000 units of\n heparin was given and ACT was taken and additional heparin was given to\n maintain an ACT closer to 250. Following this under roadmapping guidance, the\n right anterior cerebral artery was catheterized with a microcatheter microwire\n assembly consisting of an Echelon 014 microcatheter and X-Pedien 014\n microwire. Following this we tried to place a 4 mm Micrus coil into\n this aneurysm, however the coil kept prolapsing back into the left ACA and\n therefore we now opted to use a GDC 3D coil 4 mm. This provided a good\n framework for the aneurysm. We now continued to coil this with 4 mm into 4 cm\n coil. Two such 2D coils were used. Following this the aneurysm was completely\n obliterated. There was a small area in the anterior communicating artery into\n which one coil loop had prolapsed. Therefore we now went back and did an\n injection through the left common carotid artery to ensure that the left ACA\n was widely patent. This was found to be so. At this point the catheters were\n withdrawn and after a right common femoral artery run, the right common\n femoral artery was closed with a 6 French Angio-Seal Device.\n\n FINDINGS: Right common carotid artery arteriogram shows normal filling of the\n right external carotid artery and the right internal carotid artery. The\n right internal carotid artery arteriogram demonstrates normal filling of the\n right cervical, petrous, cavernous and supraclinoid portion. The middle\n cerebral artery and its branches are seen filling well. The anterior cerebral\n artery and its branches are seen filling well. The anterior communicating\n artery is patent and the left A1 fills from the right side. There is an\n aneurysm in the anterior communicating segment which points inferiorly\n measuring 4 into 5 mm. Left common carotid artery arteriogram shows normal\n filling of the left external carotid artery and left internal carotid artery.\n The internal carotid artery fills well along its cervical, petrous, cavernous\n and supraclinoid portion. The left A1 fills well on the left common carotid\n artery injection. Left vertebral artery arteriogram shows normal filling of\n the left vertebral artery with reflux into the right vertebral artery. The\n basilar artery and its branches along with the posterior cerebral arteries\n fill well.\n\n Right internal carotid artery arteriogram post embolization shows that the\n aneurysm is now completely obliterated with a small amount of coil in the\n anterior communicating segment. There is decreased flow into the left\n anterior cerebral arteryon the right internal carotid artery angiogram\n .However left internal carotid artery arteriogram post embolization shows good\n filling of the left anterior cerebral artery and its branches.\n\n IMPRESSION: underwent cerebral arteriography which showed anterior\n communicating artery aneurysm measuring 4 into 5 mm. This was completely\n embolized with GDC coils. There was a small amount of coil in the anterior\n communicating segment, however both anterior cerebral arteries fill well. The\n (Over)\n\n 8:10 AM\n CAROT/CEREB Clip # \n Reason: please assess for intervenable aneurysm.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 205\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left anterior cerebral artery had sluggish flow on the right internal carotid\n injection, however it fills well from the left internal carotid artery\n injection.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 988537, "text": " 11:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p BAL/bronch\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH. S/P trach/peg w/ collapse of RUL.\n REASON FOR THIS EXAMINATION:\n s/p BAL/bronch\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, :35 A.M.\n\n HISTORY: History subarachnoid hemorrhage. Right upper lobe collapse.\n\n IMPRESSION: AP chest compared to through 27:\n\n Right upper lobe has re-expanded. Atelectasis in the infrahilar left lower\n lobe is also improved. Tracheostomy tube and left subclavian line are in\n standard placements. No pneumothorax. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987269, "text": " 8:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary effusion\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n pulmonary effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:08 P.M. ON \n\n HISTORY: Shortness of breath.\n\n IMPRESSION: AP chest compared to through 17:\n\n Left perihilar consolidation has not cleared, right infrahilar consolidation\n is new. Findings suggest bilateral pneumonia particularly aspiration. Heart\n is mildly enlarged but unchanged, and azygous distention has recurred\n consistent with increased central venous pressure or volume. Nasogastric tube\n ends in the upper stomach but needs to be advanced at least 8 cm to move all\n the side ports beyond the GE junction. No pneumothorax or appreciable pleural\n effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987699, "text": " 8:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pneumothorax\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p bronch\n REASON FOR THIS EXAMINATION:\n pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination dated the same day at 12:17.\n\n FINDINGS: Right costophrenic angle was not included on the image. There is a\n new right basilar ill-defined opacity likely with associated elevation of the\n right hemidiaphragm likely reflects underlying atelectasis and/or\n consolidation. No pneumothorax is seen. The left hemithorax is relatively\n clear. The supporting lines are stable and in satisfactory positions.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 988655, "text": " 8:42 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for hydrocephalus please do at 0600 \n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with sah s/p drain removal\n REASON FOR THIS EXAMINATION:\n Assess for hydrocephalus please do at 0600 \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with subarachnoid hemorrhage status post drain\n removal. Assess for hydrocephalus.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: Again demonstrated are bilateral ACA distribution infarctions as\n well as subarachnoid hemorrhages bilaterally. A small amount of blood is\n layering within the left occipital and is unchanged. The ventricular\n shunt that had entered from the right frontal approach has been removed.\n Hemorrhage is present along the course of the catheter tract. Extensive white\n matter hypodensities are again noted consistent with chronic microvascular\n infarction. The ventricles are unchanged in size and normal. Note is again\n made of a cavum septum pellucidum.\n\n Coil pack is again noted within the anterior communicating artery region. The\n partially visualized paranasal sinuses are opacified in similar fashion to\n prior study. There are no suspicious osseous abnormalities.\n\n IMPRESSION: Status post removal of right ventriculostomy catheter with no\n evidence of hydrocephalus. Stable, evolving bilateral right ACA territory\n infarctions, bilateral subarachnoid hemorrhage, left intraventricular\n hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 988095, "text": " 11:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Infiltrates?\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fevers of unknown origin.\n REASON FOR THIS EXAMINATION:\n Infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 53-year-old man with fevers of unknown origin.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The endotracheal tube and right-sided central venous catheter are unchanged in\n position. The cardiac silhouette is within normal limits. There remains some\n streaky density seen at the left retrocardiac region, which may be due to\n atelectasis or early infiltrate which is stable. There are no signs for overt\n pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 986742, "text": " 6:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ?syncope, SAH (?traumatic) with WNC of 20 at OSh\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n History: syncope, fall\n Comparison: None\n\n Findings: Two images are obtained portably in the supine position, one with\n the trauma board and one without. Underpenetrated technique limits\n evaluation. There is increased pulmonary hazy opacity in both lungs which is\n likely technique related as the findings are not congruent on both images.\n Cardiomediastinal silhouette is grossly unremarkable. There is no\n pneumothorax. No displaced rib fractures or other osseous abnormality is\n detected.\n\n IMPRESSION:\n\n 1. No definite intrathoracic process.\n\n 2. Limited study due to underpenetrated technique and repeat radiograph is\n suggested if there is concern for acute intrathoracic process.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2152-11-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 987501, "text": " 12:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: patient continues to be somnolent. interval change.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p ACA coiling.\n REASON FOR THIS EXAMINATION:\n patient continues to be somnolent. interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 53-year-old man status post coiling of an anterior cerebral\n artery aneurysm.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: A ventriculostomy catheter again terminates in the posterior right\n lateral ventricle in an unchanged position. With the exception of interval\n clearing of some of the hemorrhagic products from the basal cisterns, the\n appearance of diffuse subarachnoid and intraventricular hemorrhages is not\n significantly changed. A left frontal intraparenchymal hemorrhage also\n appears unchanged.\n\n Diffuse effacement of cerebral sulci implying cerebral edema is unchanged.\n Hypodense areas in the left frontal lobe, as well as in a portion of the\n medial right frontal lobe, are not significantly changed. However, these\n images do suggest somewhat increased hypodensity in the right frontal area,\n partly obscured by streak artifact, but perhaps within the subcortical white\n matter. There is no shift of midline structures, and the ventricles are not\n dilated.\n\n There is similar polypoid thickening in the left maxillary sinus, but the\n mastoid air cells are clear. Aerosolized secretions are present in the\n sphenoid with moderate mucosal thickening. A nasogastric tube is present. The\n patient is edentulous.\n\n IMPRESSION: Suspected increased hypodensity in the right frontal lobe, perhaps\n in the white matter, which may represent focal edema, although ischemia cannot\n be excluded. If clinically indicated, MR could be applied to evaluate further\n if MR safety of the aneurysm coils can be established. Otherwise little\n changed from before.\n\n The findings were discussed with Dr. by DR. at 4 p.m. on\n the same day.\n\n (Over)\n\n 12:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: patient continues to be somnolent. interval change.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2152-11-24 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 987930, "text": " 4:15 PM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n Reason: Please perform perfusion study per neurosurgery protocols.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p SAH, s/p ACA coiling. Diminished movement on R\n REASON FOR THIS EXAMINATION:\n Please perform perfusion study per neurosurgery protocols. Thank you\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj FRI 11:58 PM\n Relatively unchanged distribution of intraparenchymal and subarachoid\n hemorrhage compared to . Unchanged Circle of appearance. s/p A\n com aneurysm coiling w/ associated artifact. Abnormal area of perfusion in\n the brain parenchyma (blood volume, flow, mean transit time) corresponding to\n an area of low attenuation in the left medial frontal lobe c/w infarction.\n Final read pending reconstructions.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head.\n\n CLINICAL INFORMATION: Patient with status post clipping of the aneurysm with\n possible vasospasm.\n\n TECHNIQUE: CT of the head was acquired without contrast. Following this,\n using departmental protocol CT perfusion study of the head and CT angiography\n of the head were acquired. Comparison was made with the previous CTA\n examination of .\n\n FINDINGS:\n\n BRAIN HEAD CT:\n\n Comparison was made with the previous CT examination of .\n Postoperative changes are again identified with coil in the region of anterior\n communicating artery. Subarachnoid hemorrhage is identified diffusely along\n both cerebral hemispheric sulci and sylvian fissures with some evolution of\n blood products. There is hypodensity seen in the left frontal lobe along the\n midline which extends superiorly in most of the frontal lobe along the midline\n superiorly. This hypodensity is much more pronounced from the previous study\n and indicates evolving infarct. A right frontal shunt ventricular drain\n extends to the occipital of the right lateral ventricle.\n\n CT PERFUSION STUDY:\n\n The CT perfusion study demonstrates delayed mean transit time in the left\n frontal lobe along the midline. There is also decreased blood volume seen in\n this region. Findings are indicative of left anterior cerebral artery\n territorial infarct.\n\n CT ANGIOGRAPHY:\n\n (Over)\n\n 4:15 PM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n Reason: Please perform perfusion study per neurosurgery protocols.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The CT angiography demonstrates diffuse spasm in both anterior and posterior\n circulation which is new since the previous CTA examination. The spasm\n involves both middle and anterior cerebral artery territories with more\n pronounced changes in the anterior cerebral artery region. The left anterior\n cerebral artery caliber is markedly decreased compared to the prior study. The\n region of aneurysm and coiling is obscured by the artifacts from the coil\n pack.\n\n IMPRESSION:\n\n 1. Evolving left anterior cerebral artery infarct better visualized on the\n current study. There has been some evolution of previously noted subarachnoid\n hemorrhage. No evidence of interval change in ventricular size.\n\n 2. CT perfusion study demonstrates changes indicative of infarct in the left\n anterior cerebral artery region.\n\n 3. CT angiography demonstrates diffuse vasospasm involving the arteries of\n anterior and posterior circulation predominantly the anterior circulation\n involving the anterior cerebral arteries.\n\n" }, { "category": "Radiology", "chartdate": "2152-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 989026, "text": " 3:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates?\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with subarachnoid hemorrhage - ventillator\n REASON FOR THIS EXAMINATION:\n infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 15:59 HOURS\n\n COMPARISON STUDY: .\n\n CLINICAL INFORMATION: Infiltrate, patient ventilated.\n\n FINDINGS:\n\n Tracheostomy tube is in the midline and terminates at the thoracic inlet.\n\n Left subclavian catheter terminates in the superior vena cava.\n\n There is mild bibasilar atelectasis. The upper lung zones are clear.\n Cardiomediastinal contour is within normal limits.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-27 00:00:00.000", "description": "IVC AND TRIBUTARIES US", "row_id": 988280, "text": " 4:45 PM\n IVC AND TRIBUTARIES US; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: IVC placement in AM of \n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p R ACA coiling, respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n IVC placement in AM of \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old admitted for subarachnoid hemorrhage, with cirrhosis.\n\n Additional views of the IVC were obtained. Please refer to clip for\n images and description of this portion of the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 986917, "text": " 8:31 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess drain placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH, newly placed ventriculostomy\n REASON FOR THIS EXAMINATION:\n Please assess drain placement\n CONTRAINDICATIONS for IV CONTRAST:\n subarachnoid hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with subarachnoid hemorrhage, newly placed\n ventriculostomy.\n\n HEAD CT WITHOUT CONTRAST: Comparison was made to the prior head CT dated\n . The patient is status post aneurysmal clipping. The\n patient is status post ventriculostomy, with ventricular tube coursing the\n right frontal lobe, and terminating likely in the posterior hold of the right\n lateral ventricle. The ventricular size has slightly decreased since prior\n study. Again note is made of diffuse subarachnoid hemorrhage bilaterally,\n involving bilateral cerebral fissures, cerebral sulci in bilateral cerebral\n hemispheres as well as well as middle cranial fossa, and intraventricular\n hemorrhage. The component of intraparenchymal bleed can be present in the\n left frontal lobe. Adjacent to the aneurysmal clip, note is made of slight\n increase in hypoattenuating area in the left frontal lobe, with slight\n compression of the left frontal , which could be due to increased mass\n effect; however, precise evaluation is somewhat difficult due to decompression\n of the ventricles with ventriculostomy catheter. There is very mild shift of\n normally midline structure to the right, measuring 5 mm, slightly increased\n since prior study. Again note is made of opacified ethmoid and maxillary\n sinuses. Nasogastric tube is noted. The surrounding osseous structures are\n unchanged since prior study except for ventriculostomy.\n\n IMPRESSION: Post-ventricular catheter placement, with the tip terminating\n likely in the occipital of the right lateral ventricle. Post ACA\n aneurysmal coiling, with slightly increased hypoattenuating area in the left\n frontal lobe with questionable increase in mass effect, with decrease in\n ventricular size. Slightly increased shift of normally midline structure to\n the right measuring 5 mm. Diffuse massive subarachnoid hemorrhage, with\n possible component of intraparenchymal bleed in the left frontal lobe, overall\n unchanged. Opacified mastoid maxillary and ethmoid sinuses.\n\n Follow up recommended.\n\n Dr. was paged at the completion of the study.\n\n (Over)\n\n 8:31 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess drain placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2152-11-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 988085, "text": " 9:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate ventricle size - please do study at 0500 tomorrow\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with clamped ventriculostomy drain\n REASON FOR THIS EXAMINATION:\n evaluate ventricle size - please do study at 0500 tomorrow\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with clamped ventriculostomy drain. Evaluate\n ventricle size.\n\n COMPARISON: CTA head.\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: A right frontal ventriculostomy catheter again terminates in the\n occipital of the right lateral ventricle, unchanged in position. There\n is no evidence of hydrocephalus and the ventricles are unchanged in size. The\n hypodensity within the left frontal lobe along the ACA territory consistent\n with evolving left ACA infarction has enlarged. Also demonstrated on today's\n study is hypodensity along the right ACA territory concerning for evolving\n right ACA territorial infarction. Hypodensities of the inferior frontal lobes\n and the anterior temporal lobes are unchanged, likely representing edema\n and/or infarcts. The diffuse hemispheric bilateral subarachnoid hemorrhages\n and the intraventricular hemorrhages are slightly decreased in size. There is\n no evidence of new intracranial hemorrhage. The patient is intubated and a\n nasogastric tube is present. A coil pack is again seen in the right\n supraclinoid region.\n\n IMPRESSION:\n 1. Evolving left ACA territory infarction.\n\n 2. Developing right ACA territory hypodensity likely representing\n infarction.\n 3. No evidence of hydrocephalus. The ventricles are stable. Right frontal\n placed ventricular catheter, unchanged.\n\n 4. Decreased extent of bihemispheric subarachnoid hemorrhage and\n intraventricular hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-21 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 987540, "text": " 3:37 PM\n CAROT/CEREB Clip # \n Reason: cerebral angiogram\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 120\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with possible vasospasm\n REASON FOR THIS EXAMINATION:\n cerebral angiogram\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE PERFORMED: Right common carotid artery arteriogram, left common\n carotid artery arteriogram, left internal carotid artery arteriogram, left\n vertebral artery arteriogram.\n\n STAFF: , M.D.\n\n INDICATION: The patient had undergone cerebral angiography and embolization\n of a ruptured anterior communicating artery aneurysm. He had significant\n change in his exam and was not following commands and therefore, we decided to\n do the above-mentioned angiogram to rule out vasospasm. He was unable to lie\n still for a CT perfusion.\n\n PROCEDURE: The patient was brought to the angiography suite. IV sedation was\n given under my supervision. Following this, both groins were prepped and\n draped in a sterile fashion. We now accessed the right common femoral artery\n with a #6 French vascular sheath using a Seldinger technique. The sheath was\n connected to continuous saline infusion. Following this, 2 catheter\n was advanced over an 038 hydrophilic glidewire into the aortic arch and from\n here the right common carotid artery, the left vertebral artery, left common\n carotid artery and the left internal carotid artery were selectively\n catheterized and AP, lateral views were done. The left internal catheter\n carotid artery was catheterized selectively because the left common carotid\n artery injections failed to demonstrate the anatomy of the left anterior\n cerebral artery well. These studies did not show any evidence of significant\n vasospasm which would require intervention. Therefore, the vascular sheath\n was removed, and a groin closure performed with a 6 French Angio-Seal device.\n The patient tolerated the procedure well and was taken back to the Intensive\n Care Unit, neurologically, unchanged.\n\n Findings are as follows.\n\n Right common carotid artery arteriogram shows normal filling of the external\n carotid artery and its branches. The right internal carotid artery fills well\n along its cervical petrous and supraclinoid portion. There is no spasms seen.\n The right middle cerebral artery and its branches fill well. The anterior\n (Over)\n\n 3:37 PM\n CAROT/CEREB Clip # \n Reason: cerebral angiogram\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n communicating segment is well seen with both anterior cerebral arteries\n visualized. There is some distal spasm of the right A1 anterior cerebral\n artery and the aneurysm is well coiled with no residual aneurysm.\n\n Left vertebral artery arteriogram shows normal filling of the left vertebral\n artery with the basilar artery visualized well along with its branches. There\n is specifically no vasospasm involving the basilar artery and its branches.\n\n Left common carotid artery arteriogram shows normal filling of the left\n external carotid artery, left internal carotid artery fills well, however,\n because of patient motion and other factors, the intracranial runs did not\n visualize the left anterior cerebral artery well. Under roadmapping guidance,\n a selective left internal carotid artery angiogram was done.\n\n Left internal carotid artery arteriogram demonstrates normal filling of the\n cervical, petrous, cavernous and supraclinoid internal cerebral artery. The\n middle cerebral artery and its branches fill well. The right A1 has moderate\n spasm, however, the distal branches fill.\n\n IMPRESSION: Mr. underwent cerebral angiography which demonstrates\n spasm in the distal anterior cerebral arteries bilaterally. However, all the\n large vessels are open except the left A1 segment with no evidence of spasm.\n Therefore, no intervention was attempted. The patient will be managed with\n hypertensive therapy.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-12-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 989270, "text": " 2:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: development of hydroceph?\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ACA aneursym coiling\n REASON FOR THIS EXAMINATION:\n development of hydroceph?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ACA aneurysm coiling. ? development of hydrocephalus.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Bilateral infarction in the distribution of the anterior cerebral\n arteries is again demonstrated that is slightly more hypodense compared to the\n previous exam. The right ACA infarct appears to be more extensive in extent\n with greater involvement of the posterior pericallosal region. Ventricles are\n stable in size and configuration. There is no midline shift. Extensive\n subcortical white matter hypodensity is again demonstrated. No evidence of\n new intracranial hemorrhage. Coils in the region of the anterior\n communicating artery are again demonstrated.\n\n IMPRESSION:\n 1. No evidence of hydrocephalus.\n 2. Evolving bilateral ACA territory infarction with slight expansion on the\n right.\n\n" }, { "category": "Radiology", "chartdate": "2152-11-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 986815, "text": " 8:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for hydrocephalus.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with aneurysm rupture.\n REASON FOR THIS EXAMINATION:\n Please assess for hydrocephalus.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE UNENHANCED HEAD CT\n\n HISTORY: Subarachnoid hemorrhage.\n\n Comparison is made with study from .\n\n Again noted is diffuse moderate subarachnoid hemorrhage including a large clot\n in the anterior interhemispheric fissure. There is also left frontal\n intraparenchymal hematoma. There is a small amount of intraventricular\n hemorrhage. No evidence for acute ischemia is seen. The ventricles are\n unchanged in size. There is mild dilatation of the temporal horns.\n Visualized paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n\n Stable subarachnoid hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 987534, "text": " 3:00 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: central line placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p ACA coiling.\n REASON FOR THIS EXAMINATION:\n central line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: In comparison with the study of , appears to extend to the\n mid portion of the SVC, though it is not well visualized within the\n mediastinum.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 988206, "text": " 11:16 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new left SC line\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with aneurysm clipping\n REASON FOR THIS EXAMINATION:\n new left SC line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New left subclavian line.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a left subclavian catheter that extends to the lower portion of\n the SVC. Otherwise, no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-28 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 988430, "text": " 2:34 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for anatomy of IVC for filter placement, abd\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man pre-op for trach/PEG, IVC filter\n REASON FOR THIS EXAMINATION:\n Please evaluate for anatomy of IVC for filter placement, abdominal anatomy for\n PEG\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS ON \n\n CLINICAL HISTORY: Stroke, subarachnoid hemorrhage. Assess anatomy for\n operative procedure.\n\n TECHNIQUE: Non-contrast acquisition of CT images performed from the lung\n bases through the ischial tuberosities. No prior studies available for\n comparison. Coronal and sagittal reformats also provided.\n\n FINDINGS: There is dense consolidation at the left lower lobe with air-\n bronchogram. Bilateral lower lobe subsegmental atelectasis also noted. The\n heart is mildly enlarged. There is a small hiatal hernia, and the NG tube is\n located proximally with side port at the diaphragmatic hiatus.\n\n Non- contrast evaluation of the liver, spleen, pancreas, and adrenal glands\n reveal no abnormalities. The kidneys are symmetric in size and attenuation\n with a small exophytic right renal cyst. No obstructive uropathy. No renal\n calculi. Gallbladder is present. There is no biliary dilatation. The bowel\n loops are unremarkable.\n\n PELVIS: No free air or free fluid. There are scattered atherosclerotic\n calcifications throughout a non-dilated aortoiliac system. IVC is\n anatomically normal without variant anatomy; presence or absence of thrombus\n would be difficult to evaluate on noncontrast evaluation. There is haziness to\n the subcutaneous fat anterior to the right common femoral artery, likely from\n recent central line attempt. No dilated loops of bowel.\n\n Review of bone windows reveals no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. Left lower lobe consolidation, may represent aspiration, with bibasilar\n atelectasis.\n\n 2. NGT positioned with sideport at the GE junction. Advancement is\n recommended.\n\n 3. Otherwise unremarkable non-contrast CT of the abdomen and pelvis.\n\n\n (Over)\n\n 2:34 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for anatomy of IVC for filter placement, abd\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987335, "text": " 11:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ACA coiling\n REASON FOR THIS EXAMINATION:\n infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ACA coiling with possible pneumonia.\n\n FINDINGS: In comparison with the study of , there is progressive\n clearing of the left hilar opacification, which may well have reflected\n elevated pulmonary venous pressure rather than aspiration pneumonia,\n especially in view of the enlargement of the cardiac silhouette. The\n nasogastric tube tip cannot be seen due to underpenetration of the mediastinum\n and upper abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-15 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 986745, "text": " 7:18 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: eval for cva, bleed, aneursym\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man tx from hosp w/diffuse SAH, ? traumatic. Given dilantin\n load. Crea 1.1 at OSH\n REASON FOR THIS EXAMINATION:\n eval for cva, bleed, aneursym\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 1:19 AM\n DIFFUSE SUBARACHNOID HEMORRHAGE IN BIHEMISPHERIC SULCI, SYLVIAN FISSURES, FALX\n CERBRI, CISTERNA AMBIENS, INTERPEDUNCULAR FOSSA, AND CEREBELLO PONTINE\n CISTERN. SMALL AMOUNT OF BLOOD IS SEEN IN THE FOURTH VENTRICLE AND LAYERING\n IN THE POSTERIOR HORNS OF THE LATERAL VENTRICLES. NO HYDROCEPHALUS OR SHIFT\n OF NORMALLY MIDLINE STRUCTURES. MUCOSAL THICKENING WITHIN THE BILATERAL\n MAXILLARY SINUS.\n\n CTA:\n POSTERIOR CIRCULATION: BILATERAL VERTEBRAL ARTERIES AND BASILAR ARE PATENT.\n ANTERIOR CIRCULATION: 3X 4MM ANEURYSM OF THE RIGHT PROXIMAL ANTERIOR CEREBRAL\n ARTERY. MIDDLE CEREBRAL ARTERIES ARE PATENT BILATERALLY.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with diffuse subarachnoid hemorrhage, evaluate\n for progression and vascular anatomy.\n\n TECHNIQUE: MDCT-acquired contiguous axial slices obtained through the brain\n without intravenous contrast. Subsequently, axial imaging was performed after\n administration of intravenous contrast. Curved reformats and maximal\n intensity projection images were generated.\n\n COMPARISON: Prior study from outside hospital is not available for\n comparison.\n\n FINDINGS:\n\n NON-CONTRAST CT: Diffuse areas of subarachnoid hemorrhage in bihemispheric\n sulci extending into the interhemispheric fissure, the sylvian fissure, the\n perimesencephalic cistern, interpeduncular fossa and the cerebellopontine\n angle. Small amount of blood is also seen within the lateral ventricle\n posterior horns. No evidence of mass effect or midline shift is noted. 1.7\n mm x 1.3 mm area of mixed attenuation likely representing a clot is noted in\n the anterior interhemispheric fissure. Another area representing likely\n clotted blood is noted in the medial aspect of the anterior portion of the\n frontal lobe measuring 0.9 cm x 1.6 cm. The ventricles and the sulci appear\n normal in caliber. There is no evidence of hydrocephalus. Mild mucosal\n thickening is noted in the right maxillary sinus. No other osseous or soft\n tissue abnormalities are noted. No fractures are seen.\n\n CTA HEAD AND NECK: The right anterior communicating artery demonstrates a 5\n (Over)\n\n 7:18 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: eval for cva, bleed, aneursym\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mm x 4 mm aneurysm at the junction of the A1, A2 segments with the\n anterior communicating artery. The aneurysm appears to be bilobed in shape\n with a superior and inferior projection of the lobes. No other aneurysm or\n vascular malformation is noted. Carotid and the vertebral arteries are patent\n with no evidence of stenosis, occlusion, or aneurysm.\n\n IMPRESSION:\n 1. Diffuse subarachnoid hemorrhage involving bilateral hemispheric sulci, and\n extending into the lateral ventricles, as described above.\n\n 2. Approximately 5 mm aneurysm is noted at junction of right A1/A2 and ACOM.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-15 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 986746, "text": " 7:18 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p ?syncope vs. ? fall, diffuse SAH on OSH CT\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 8:53 PM\n no fracture.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 53-year-old male status post syncope versus fall. Diffuse\n subarachnoid hemorrhage on outside CT. Evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the cervical spine from\n the skull base to the level of C4. Multiplanar reformatted images were\n obtained.\n\n FINDINGS: No fracture or subluxation. Prevertebral soft tissues are within\n normal limits. Left maxillary sinus mucosal thickening. The remainder of the\n visualized paranasal sinuses and mastoid air cells remain normally aerated.\n Note is made of ground-glass opacity within bilateral lung apices with septal\n thickening which may be relate to expiration however correlation with chest\n radiograph is recommended as small right pleural effusions are also\n demonstrated. Note is made of multiple prominent right neck lymph nodes\n measuring up to 1.3 cm along the jugular chain.\n\n IMPRESSION:\n\n 1. No fracture or subluxation.\n 2. Prominent lymph nodes along the right jugular chain, which should be\n correlated with clinical history.\n 3. Partially visualized ground glass opacity at the lung apices. Correlate\n with chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2152-11-27 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 988268, "text": " 3:40 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Please evaluate for cholecystitis/cholangitis\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Additional views of the IVC were obtained to assess for patency.\n The IVC was evaluated in its intrahepatic and proximal infrahepatic portions\n and demonstrate normal cardiac variation in flow.\n\n\n\n 3:40 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Please evaluate for cholecystitis/cholangitis\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with persistent fevers.\n REASON FOR THIS EXAMINATION:\n Please evaluate for cholecystitis/cholangitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old with persistent fevers. Evaluate for cholecystitis\n or cholangitis.\n\n No prior examinations.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture with no\n focal lesions. There is no intra- or extra-hepatic biliary ductal dilatation.\n The common bile duct measures 5 mm. The portal vein is patent with antegrade\n flow. The gallbladder is normal, without gallstones or wall thickening. There\n is no ascites. Limited view of the right kidney demonstrates no\n hydronephrosis.\n\n IMPRESSION: No evidence of cholecystitis or biliary ductal dilatation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 988156, "text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH and fevers of unknown origin\n REASON FOR THIS EXAMINATION:\n infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subarachnoid hemorrhage with fever of unknown origin.\n\n FINDINGS: In comparison with the study of , the areas of increased\n opacification at the left base, consistent with atelectasis, are less\n prominent. Tubes remain in place. No evidence of acute pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987886, "text": " 10:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening infiltrate\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH s/p evacuation, now s/p bronch\n REASON FOR THIS EXAMINATION:\n ? worsening infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post bronchoscopy.\n\n FINDINGS: In comparison with the study of , the opacification at the\n right base has cleared, presumably reflecting expectoration of a mucous plug.\n Minimal atelectatic changes are seen at the bases. Endotracheal tube tip\n still lies about 6 cm above the carina. Right central catheter extends to the\n mid portion of the SVC. The nasogastric tube has been removed.\n\n IMPRESSION: Interval clearing of the right basilar opacification.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 988467, "text": " 8:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach placement/ gtube placement/IVC filter.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ACA coiling.\n REASON FOR THIS EXAMINATION:\n s/p trach placement/ gtube placement/IVC filter.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: New tracheostomy tube, J tube placement\n\n Comparison is made to prior study performed a day earlier.\n\n New tracheostomy tube tip is 5.9 cm above the carina. Left subclavian\n catheter tip is in the lower SVC unchanged. There is no pneumothorax. Right\n upper lobe collapse is new as is left lower lobe retrocardiac opacity\n consistent with atelectasis. Cardiac size is top normal. The right lateral\n CP angle was not included on the exam.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2152-11-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 987096, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA, follow up from \n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH, decreased PaO2, increased WBC.\n REASON FOR THIS EXAMINATION:\n ? PNA, follow up from \n ______________________________________________________________________________\n FINAL REPORT\n\n , SINGLE VIEW, CHEST: 52-year-old male. Follow up pneumonia.\n\n SINGLE VIEW OF THE CHEST IS PERFORMED AND COMPARED TO .\n\n The endotracheal tube is not visualized and has been removed. The nasogastric\n tube courses below the diaphragm. The study is somewhat limited in technique.\n The heart size appears enlarged. There is unchanged mild pulmonary vascular\n congestion. No focal consolidation is seen. There is no pneumothorax.\n\n IMPRESSION: Removal of endotracheal tube. Stable mild pulmonary vascular\n congestion.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-11-20 00:00:00.000", "description": "Report", "row_id": 1676746, "text": "NURSING\n EVENTS; TEMPERATURE 102.4 AT 8 PM. MD NOTIFIED, URINE, BLOOD, CSF SENT FOR CULTURE. CXR DONE. SPUTUM NEEDED FOR CULTURE BUT UNABLE TO OBTAIN.\n OTHER VSS OVERNIGHT. REMAINS OFF NICARDIPINE GTT. HYDRALAZINE GIVEN X1 FOR SBP IN THE 170'S. NSR, OCCASIONAL PAC'S NOTED EARLY IN THE SHIFT. TEMPERATURE EVENTUALLY DROPPED, AFTER TYLENOL, TO 99.2.\n NEURO STATUS REMAINS BASICALLY UNCHANGED, IF ANYTHING, SLIGHTLY IMPROVED. MORE ALERT, SPEAKING UNDERSTANDABLY A LITTLE MORE. CONTINUES TO FOLLOW COMMANDS. SEE CARE VUE FOR FULL NEURO ASSESSMENT. VENT DRAIN CONTINUES TO DRAIN 10-25/HOUR, SEROSANGUINES DRAINAGE.\n MEDICATED X 1 FOR APPARENT DISCOMFORT WITH MORPHINE 2 MG WITH GOOD EFFECT.\n FOLEY CONTINUES TO PUT OUT GOOD URINE OUTPUT. ON LASIX . TUBE FEEDS CONTINUE AT 60/HOUR, NO RESIDUALS. NO STOOL OUT OVER THE LAST 48 HOURS. ABDOMEN SOFTLY DISTENDED WITH POSITIVE BOWEL SOUNDS.\n CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. KEEP SBP BETWEEN 120-160. MONITER FOR PAIN.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-11-20 00:00:00.000", "description": "Report", "row_id": 1676747, "text": "Nursing Progress Note: 0700-1900\n\nNeuro: Pt. is lethargic but is and follows commands consistently (he sticks out his tongue without much prodding but it is more difficult to get him to use his extremities). He MAE and has had no c/o pain. It is difficult to make him speak but he will occasionally say one word, although his speech is garbled. He oriented to name only. Ventricular drain is draining 10-20cc/hour of blood tinged fluid, ICP is . Site looks clean.\n\nCV: HR 60s-70s, NBP is consistenly lower than ABP and is also more consistent in range of 150s-180s/40s-60s (mostly between 150s-160s), ABP 140s-190s/50s-70s. He was given 10mg IV Hydralazine once for both NBP and ABP in 180s simultaneously with good effect. PIV and a-line are patent and WNL. Pt. had 1 unit platelets\n\nResp: RR teens-20s, 02 sats >97% on 6L NC. Lungs are clear to all lobes. Pt. has a good cough and brings up secretions which he then swallows. Pt. to be NT suctioned for sputum culture and then started on abx for presumed PNA.\n\nGI: BSX4,no BM on shift, TF at goal of 60cc/hour.\n\nGU:UO adequate via foley.\n\nEndo: RISS in place..\n\nSkin: Intact.\n\nSocial: Wife called, very concerned and may get a ride in this evening.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-11-25 00:00:00.000", "description": "Report", "row_id": 1676764, "text": "NURSING\n VSS OVERNIGHT. NSR, NO ECTOPY.TEMPERATURE MAX 102.8. BLOOD, URINE, SPUTUM, ALL SENT FOR CULTURE. REMAINED OFF NICARDIPINE GTT, OFF VERSED GTT. SBP KEPT BETWEEN 160-180 AS ORDERED.\n FOLEY WITH QS URINE OUTPUT. FEEDINGS VIA NGT CONTINUE AT 60/HOUR. BEGAN STOOLING THIS MORNING, MODERATE AMOUNT, INCONTINENT, G-. SKIN INTACT. VENT DRAIN REMAINS CLAPMED, LEVELED AT 20 AT THE TRAGUS, ICP'S .\n NEURO STATUS REMAINED UNCHANGED. FOLLOWING COMMANDS, MOVING EXTREMITIES ON BED. PUPILS EQUAL AND REACTIVE.OPENS EYES TO VOICE.\n CONTINUE TO MONITER NEURO STATUS. MONITER LABS, RESPIRATORY STATUS.WEAN VENT AS TOLERATED.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-11-25 00:00:00.000", "description": "Report", "row_id": 1676765, "text": "Respiratory Care\nPatient remains on full ventilatory support, switching between CPAP/PSV and AC mode. Changes dependent of patients spontaneous efforts. All changes documented in Carevue. Suction for small amounts of thick white secreations. Breath sounds diminished, somewhat coarse.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-25 00:00:00.000", "description": "Report", "row_id": 1676766, "text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--REMAINS PRETTY LETHARGIC, ONLY SPONTANEOUS MOVEMENTS NOTED TODAY IS TO PAINFUL STIMULATION. WILL OPEN EYES WHEN SUCTIONED OR MOUTH CARE GIVEN. PUPILS , EQUAL AND REACTIVE. VENT DRAIN CLAMPED TODAY, WAS OPENED 2 TIMES FOR ICP >20--MINIMAL AMOUNTS OF DRAINIAGE WITH DECREASE IN ICP.\nREMAINS FEBRILE DESPITE TYLENOL AND COOLING BLANKET.TEAM AWWARE, ON VANCO(TROUGH LEVEL DONE AROUND 1600 DOES), ZOSYN, TOBRAMYCIN.\nENDO--BLOOD SUGARS ELEVATED, TREATED WITH SLIDING SCALE, TEAM AWARE OF HIGH BLOOD SUGARS.\nGU--FOLEY, CLEAR URINE.\nRESP--TOLERATED CPAP POORLY WITH HIGH RATE AND LOW TIDAL VOLUMES. MORE COMFORTABLE ON CMV, WHICH HAS BEEN ON ALL AFTERNOON. SUCTIONED FOR LARGE AMOUNTS OF THICK CLEAR SPUTUM.\nPLAN: CONTINUE TO MONITOR NEURO STATUS, TREAT TEMP WITH TYLENOL/COOLING BLANKET. PLAN FOR HEAD CT IN AM.\nFAMILY HERE--UPDATE GIVEN, APPROPRIATELY CONCERNED.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-16 00:00:00.000", "description": "Report", "row_id": 1676736, "text": "SICU Admission NPN:\nCC:53 year-old male transfered from OSH to ED for SAH. In ED CTA performed with worsening bleed and noted aneurysm. At OSH, pt also noted elevated Troponin and CKMB. CK to MB ration low. In ED loaded with Dilantin\n\nS-\"I'm home.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Neuro exams waxes and wanes. Disoriented to location and time. Physical neuro exam without deficit and unchanged. On Nipride infusion, keeping SBP < 130. Sensitive to Nipride, doses ranging from 4-10mcg/kg/min. Otherwise HR stable. 2nd set of CKMB drawn at 0400 and pending. Desating on 2LNP to 90-92% WA, increased to 6LNP and sating > 95%. Breath sound clear and dim at bases. NPO. HUO marginal on maintenance IVF. Fluid bolused with 500ccs of LR and awaiting results. Low grade temps. WBC elevated on admission. No cultures performed.\nWife calling this mornning and updated by RN. Number in record for consents.\n\nA/P:\nTo Angio today for intervention\nKeep SBP < 130\nContinue Q1hr neuros\n" }, { "category": "Nursing/other", "chartdate": "2152-11-16 00:00:00.000", "description": "Report", "row_id": 1676737, "text": "FOCUS: CONDITION UPDATE\nDATA: PATIENT HAD HEAD CT THIS AM BEFORE ANGIO. TO ANGIO FOR AROUND 3 HRS, ANGIO AND COILING DONE. ANESTHESIA PRESENT DURING CASE. BACK TO SICU, INTUBATED AND ON PROPOFOL. PROP. OFF, UNABLE TO GET GOOD ASSESSMENT DUE TO RESP. DETERIORATION--POOR SATS AND GASES/VERY TACHYPNIC. NEURO ASSESSMENT \"OFF\" PROPOFOL--MOVED UPPERS, NOT LOWER EXTREMITIES, +CORNEAL/COUGH, IMPAIRED GAG. PUPILS 2+REACTIVE. BACK ON PROPOFOL FOR EVD PLACEMENT AT BEDSIDE. DR. BY, AWARE OF OFF PROPOFOL ASSESSMENT. DR. COMFORTABLE WITH BP 180S/ WHICH IT WAS OFF PROPOFOL. ON PROP. BLOOD PRESSURE LOWER. ADEQUATE IV ACCESS OBTAINED THIS PM, WILL PROBABLY NEED CVL TOMORROW. NGT PLACED FOR MEDS, DID DROP PRESSURE WHEN NIMODIPINE GIVEN. DILANTIN LEVEL LOW, BOLUSED WITH 500MG, WILL RECHECK LEVEL IN AM.\nPLAN: EVD WITH DRAINAGE AND MONITORING.\n SEDATION AND WAKE UP PER NERUOSURG.\n MONITOR FLUID STATUS/LYTES\n CALL HO WITH ANY CHANGES.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-16 00:00:00.000", "description": "Report", "row_id": 1676738, "text": "Respiratory Care Note\nPt received from Angio intubated and placed on AC as noted. BS are diminished, but equal upon arrival. Pt's sats dropped to 88%. BS are now coarse. Pt suctioned for large amts thick, white secretions with brown flecks and plugs. ABG at this time had a PaO2 of 56, but all other values within normal limits. FiO2 increased back to 100% and PEEP increased to 10cm. Sats slowly improved. ABG's are within normal limits with a PaO2 167. Plan to remain intubated and mechanically ventilated at this time. Plan to wean settings as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-21 00:00:00.000", "description": "Report", "row_id": 1676748, "text": "focus hemodynmics\ndata: neuro: lethargic tonite. opens eyes when name being called but does verbally answer. moves extremities on the bed but moves intermittently. occassionally will squeeze hand to command. pupils # 2=3 and reacts sluggishly. gag intact. vent drain intact at 10 above the tragus. draining sersang drainage.\n\nresp: on liters via nasal prongs. o2sat 93-97%. sputum culture sent to the lab. pipercillin and vancomycin iv ordered. temp 102.6. tylenol 650mg via tube given x2. open humified face mask added. breath sounds clear in upper lobes and diminsihed in the lower lobes. encouraged to cough but only coughs intermittently. wbc 15.1.\n\n\ncardiac: hct 33.2. k 3.7 magnesium 2.4. in nsr. bp via cuff 140-170's. aline bp 150-200's. hydralazine 10mg iv given x2 for bp > 160. bp continued to be elevated and nicardipine gtt added at 2mcg/kg/min.\n\ngu: foley intact with amber colored urine.\n\ngi: abd soft. large stool tonite. tube fdg infusing at goal rate at 60cc/hr. head elevated.\n\naction: labs as ordred. vent drain at 10 above the tragus. head dsg intact. tube fdgs at goal rate 60cc/hr. tylenol 650mg via tube for elevated temp. sputum culture obttained. pipercillin and vancomycin started. nicardipine gtt addded for bp control.\n\nrespnse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-21 00:00:00.000", "description": "Report", "row_id": 1676749, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Neuro exam q2hr. Pt more lethargic today than on Sunday (SICU and neurosurgery team aware). Pt opens eyes spontaneously and to verbal command. PERRLA (pupils were sluggish this morning, but now briskly reactive). No verbal response from pt; pt does not communicate. Pt follows simple commands inconsistently. Squeezed RN's hands, moved toes, and stuck out tongue to command. Spontaneous movement noted on all extremities. Pt can lift/hold RUE from bed spontaneously, but not to command. Moves other extremities in bed. +gag/cough/corneal reflex. Ventriculostomy drain raised to 15cm above the tragus per Dr. and neurosurgery. Vent drain with serosang output. ICP 6-14. CSF sent by neurosurgery for Gram stain and culture. Ventriculostomy dsg clean, dry, intact. Head CT done; follow up results. Febrile; Tylenol given via NGT. HR 70s-90s (NSR; rare PACs noted). Goal SBP 120-160. Nicardipine gtt infusing. Hydralazine and metoprolol IV given. See CareVue for ABP/NBP. Pt with generalized edema. DP/PT pulses easily palpable. Venodyne boots on BLE. Lungs clear, diminished at bases. O2 sat >/= 94% on face tent with FiO2 50%. Pt with strong cough; productive at times for small amount thin secretions. Abdomen softly distended with +bowel sound. Replete with fiber at 60cc/hr via NGT; no residual noted. TF stopped at 1400 per neurosurgery; SICU team aware. No bowel movement this shift. FS q6hr; treated with regular insulin sliding scale. NPH 10units given at 1000 as ordered. Foley intact with clear, amber urine. UO >/= 80cc/hr. No pressure sores noted. Pt turned and repositioned frequently to maintain skin integrity. Old left lower arm IV site pink and has small amount of serous drainage; dsg intact. No calls from family today.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro status closely; notify neurosurgery team and SICU team with any changes. Follow up result of head CT. ?angio today. Ventriculostomy drain 15cm above the tragus; monitor output and ICP. Wean O2 as tolerated. Pt needs CVL; will be placed today by SICU team. Continue antibiotics. Keep SBP 120-160. Nicardipine gtt; hydralazine prn. Update pt and wife on plan of care; provide emotional support. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-17 00:00:00.000", "description": "Report", "row_id": 1676741, "text": "ADDENDUM:\nCURRENTLY AT MAX FOR NICARDIPINE, ADDED PO HYDRALAZINE WITH EFFECT. NEED ADDITIONAL TO KEEP BP BETWEEN GOAL OF 120-160.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-26 00:00:00.000", "description": "Report", "row_id": 1676767, "text": "condition update\nD: pt lethargic with withdrawel of extremities to painful stimuli only. opens eyes to painful stimuli only. withdraw left arm more than right. Dr. neuro in to exam pt and aware. pupils are equal and reactive to light. vent drain clamped and icp > 20 X 2 AND OPENED for a short time with minimal fluid drainage and icp down to 15. when temp 103 pt more lethargic and as temp came down pt more responsive and opens eyes to stimuli. pt does not follow commands and no spontaneous movement noted.\ncardiac: nsr to sb rate 58-70. sbp 150-200/60. pt treated with hydralazine with no response. pt medicated with morphine 2mg and versed 1mg x1 with no response, sabp still greater than 180. Dr. aware and spoke with Dr. . pt started on nicardipine and titrated up to 4.0 mcg/kg/min. sbp now 150's and nicardipine titrated back to 1.5mcg/kg/min. temp 100.3-103.1. pt treated with tylenol, cooling blanket and ice packs, csf drainage sent for culture by neurosurg.\nresp: pt remains on cmv rate of 10, pt is overbreathing the vent with rate in the 20's. pt suctioned for thick white sputum and breath sounds remain coarse.\ngi: pt tolerating tube feeds at goal. abd softly distended with active bowels sounds.\ngu: foley patent and pt draining good amts of clear yellow urine.\na: continue with neuro checks. treat temp as needed. ? reculture today. titrate antihypertensives as needed.\nr: temp back up to 102.9. currently weaning nicardipine.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-26 00:00:00.000", "description": "Report", "row_id": 1676768, "text": "RESP CARE: Pt remains intubated/on vent on AC 720/10/.40/5 PEEP/overbreathing vent 10-15 bpm. Lungs slightly diminished bilat with rhonchi/sxd mod to copious amts thick white secretions. Continue to wean vent as neuro/resp status improve.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-26 00:00:00.000", "description": "Report", "row_id": 1676769, "text": "RESP CARE: AM RSBI-43\n" }, { "category": "Nursing/other", "chartdate": "2152-11-26 00:00:00.000", "description": "Report", "row_id": 1676770, "text": "please see vs sheet,assessment sheet flowsheet med sheet for specifics\n\nNeuro: pt open his eyes to painful stimuli, pupils equal and reactive to light. no spontanous movement noted. pt does withdraw all four extremties to painful stimuli. this morning no movement noted from right arm to painful stimuli, nuerosurgical resident aware. ventricular drain clamped thru-out day. ventricular drain open this morning for 5 min because icp greater than 20. pt had head ct this morning.\n\npain: pt denies any c/o pain\n\npulm: pt remains on ac, sucitoning pt for small to scant amt of whitish secretions.\n\ncards: pt in sr, to with 2 short episodes of hr up to 100's resolved on own, dr. aware, pt started on lopressor 12.5mg via ng tube . iv nicardipine restarted secondary to bp greater than 180.\n\ngi: tube feedings at goal. pt wiht with minimal residuals noted. pt abd soft. nontender. no bm noted.\n\ngu: foley catheter patent draining straw-colored urine\n\nf/e blood sugar 261 pt treated with scheduled dose of 15 units of nph 6 units of regular insulin per sliding scale.\n\nsocial: pt wife into visit. pt wife updated by nuerosurgical resident.\n\nplan: continue to monitor, check nuero signs every 2hours. keep sbp 120-180, titrate nicardipine gtt to keep sbp less than 180.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-26 00:00:00.000", "description": "Report", "row_id": 1676771, "text": "Respiratory Care\nPatient remains on current ventilator settings as documented in Carevue. Breath sounds diminished and equal.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-21 00:00:00.000", "description": "Report", "row_id": 1676750, "text": "Addendum to NPN:\nRight subclavian triple lumen central line placed. Pt went to angio this afternoon. Pt received 2mg morphine IV x2 during angiogram. Hydralazine 10mg IV given for hypertension (SBP 160-180s). Angio seal applied; DSD clean, dry, intact. Bilateral femoral pulses strongly palpable. Bilateral DP/PT pulses palpable. Pt to remain flat until approximately 1900. Pt on reverse T-. Upon returning to SICU from angio, pt's SBP continued to be 160-170s; Dr. notified. Dr. aware that pt is on 5mcg/kg/min of nicardipine gtt; HO spoke with Dr. . Per Dr. , keep SBP 120-180. Continue to monitor neuro status closely. Pt remains on non-rebreather. ABG sent in afternoon; Dr. and Dr. aware of ABG results. O2 sat on non-rebreather >/= 98%. Wean O2 as tolerated when pt able to sit up in bed.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-22 00:00:00.000", "description": "Report", "row_id": 1676751, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Arouses to voice. Inconsistently follows commands. Pupils 3mm and brisk. MAE. Vent drain 15/tragus drng bld tinged CSF. Cont w/ Q2hr neuro checks.\nCV: Febrile. Blood cx sent X2. T-max 102.2. MD aware tylenol given. SBP parameters libralized to 120-180. Slowly titrating down nicardipine gtt. Cont with nimodipine Q4hrs and prn hydralazine.\nREsp: .70% face tent. Lungs clear to diminished at the bases. + congestion + non productive cough. NTS X 1 with little results. CPT as tolerated. Sats 95-100%.\nGI/GU: TF restarted. No BM's overnoc. Pt obese belly soft NT. + BS. Foley patent drng amber urine\nEndo: RISS\nID: Vanco/zosyn\nPlan: cont with Q2hr neuro checks. Monitor resp status closely. Cont with current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2152-12-01 00:00:00.000", "description": "Report", "row_id": 1676789, "text": "NURSING\n VSS OVERNIGHT. SBP KEPT IN RANGE 120-180, REMAINS OFF NICARDIPINE GTT. NSR, NO ECTOPY. TEMP MAX 100.5 AT , DOWN TO 99.2 THIS AM.\n ON TRACH MASK 50% FIO2 AT 2100, RESPIRATIONS WERE IN THE 30'S, DIAPHORETIC, BP SLIGHTLY ELEVATED. PLACED BACK ON PSV WITH FOI2 OF 50% 5/15. RESPIRATIONS CAME DOWN TO THE 18-22 RANGE, BP NORMALIZED, APPEARED MORE COMFORTABLE. HAS REMAINED ON THOSE SETTINGS OVERNIGHT WITH ABG WNL. SEE CARE VUE FOR FULL ASSESSMENT.\n NEURO STATUS REMAINS UNCHANGED. NOT FOLLOWING COMMANDS. MOVING EXTREMITIES VERY MINIMALLY ON THE BED. PUPILS EQUAL AND REACTIVE. EYE OPENING INDEPENDANTLY AND TO PAINFUL STIMULI. SEE CARE VUE FOR FULL ASSESSMENT.\n CONTINUE WITH TUBE FEEDS AT GOAL OF 60 VIA PEG TUBE. ABDOMEN SOFTLY DISTENDED, POSITIVE BOWEL SOUNDS. NO STOOL OUT OVERNIGHT. FOLEY WITH QS URINE OUTPUT, CLEAR YELLOW.\n MEDICATED FOR DISCOMFORT WITH PERCOCET ELIXER WITH GOOD EFFECT.\n CONTINUE TO MONITER HEMODYNAMICS, NEURO STATUS. ATTEMPT TRACH MASK TODAY AGAIN. MONITER FOR DISCOMFORT PRN.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-18 00:00:00.000", "description": "Report", "row_id": 1676742, "text": "nursing progress note:\nNeuro: Pt alert most of night. occasionally requiring verbal stimuli to arouse. Pupils 2mm = & brisk. ICP initially presently 14-15. Vent drain remains 10cm above tragus and draining moderate amount of sero-sang drg. Pt follows directions consistantly, able to lift and hold. Occasionally not responding verbally but when pt does respond it is appropriate.\n\nCV: Tmax 99.9ax. HR 70-80's NSR with no ectopy. SBP 130-160's. Med with hydralazine X1 with good effect. Extremities warm with +PP. Lytes pending. Continues on nicardipine at 3.0mcg/kg/min to keep SBP <160\n\nRESP: lungs diminished, CPT with little effect. Pt C&DB on own. ABG acceptable. requiring N/C 6l, and face tent at 100%. O2 sats >95%.\n\nGI: NGT clamped. recieving meds only. ABD large round with +BS. No stool tonight.\n\nGU: foley draining adequate concentrated urine.\n\nENDO: blood sugars elevated. requiring coverage per RISS.\n\nPLAN: Cont to monitor Neuro status. SBP goal 120-160.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-18 00:00:00.000", "description": "Report", "row_id": 1676743, "text": "Nursing note (0700-1900) 16:45\n\n\nNeuro.\nPt has been mostly lethargic this shift, non verbal for most of shift despite prompting, occassionaly responds with questions of his own in relation to our questions. Moving right side more than left, follows commands. Vent drain continues to drain large amounts of blood tinged CSF, remains at 10cm above tragus.\n\nResp.\nLS clear to UL's dim to bases, large O2 requirement to maintain SpO2 >95%. Good cough, non-productive.\n\nCVS.\nNicardipine gtt to keep SBP <160mmhg. HR 70-80 NSR with no ectopy seen.\n\nGI/GU.\nTF's started this am, advancing 10cc/hr to goal of 60cc/hr, no residuals at this time. +BS with non BM his shift.\nFoley patent for adequate amounts of clear amber urine, started on PO lasix.\n\nSkin.\nAll areas intact at this time.\n\nPlan.\nContinue to monitor neuro status.\nKeep SBP <160mmHg.\nAdvance TF's to goal.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-19 00:00:00.000", "description": "Report", "row_id": 1676744, "text": "NURSING\n VSS OVERNIGHT. CONTINUES ON NICARDIPINE GTT AT 3, DOSE UNCHANGED OVERNIGHT.NSR, NO ECTOPY. TEMP MAX 99.9. O2 SATS 98-100%. LUNGS CTA, DECREASED BASES.\n NEURO STATUS UNCHANGED OVERNIGHT. FOLLOWS COMMANDS. OPENS EYES TO VOICE AND INDEPENDANTLY. MOVING ALL EXTREMITIES. PUPILS EQUAL AND REACTIVE. SPEECH GARBLED, SPEAKS IN INCOMPLETE WORDS YET EVERY 3RD NEURO CHECK WILL SPEAK CLEARLY IN FULL SENTENCES. VENT DRAIN LEVLED AT 10 AT THE TRAGUS. DRAINING 15-20/HR SEROSANGUINES DRAINAGE. CVP'S . DSG INTACT ON DRAIN SITE.\n FOLEY WITH GOOD URINE OUTPUT. RESPONDS EXTREMELY WELL TO LASIX PO 20 MG DOSE. TUBE FEEDS AT MAX, 60/HOUR. POSITIVE BOWEL SOUNDS, NO STOOL OUT OVERNIGHT. ABDOMEN DISTENDED BUT SOFT.\n MEDICATED X 2 WITH MORPHINE 2 MG FOR APPARENT DISCOMFORT. RESTLESS, MOVING ABOUT IN BED. MORPHINE EFFECTIVE.\n CONITNUE TO MONITER HEMODYNAMICS, NEURO STATUS, PAIN CONTROL. KEEP BP 120-160.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-11-19 00:00:00.000", "description": "Report", "row_id": 1676745, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Neuro exam q2hr. Pt opens eyes spontaneously and to verbal stimulus. Opens eyes when name is called. Garbled words at times; difficult to understand. No verbal response this afternoon (Dr. aware); no new interventions per HO, d/t pt still follows commands and moves extremities. Pt squeezed RN's hands and moved toes to command. Also sticks out thumbs to command at times. PERRLA. +gag/cough/corneal reflex. No seizures noted. Pt on nimodipine and phenytoin. Phenytoin 500mg IV x1 given as ordered. Ventriculostomy drain 10cm above the tragus; draining serosang output. ICP 6-15. Vent drain dsg clean, dry, intact. Tmax 101; Dr. aware. Tylenol 650mg given via NGT; continue to monitor temp. HR 60s-80s (NSR; no ectopy noted). Nicardipine gtt off. Goal SBP 120-160. Dr. notified of 20-30 point difference in systolic between NBP and ABP; per HO, follow arterial line (waveform sharp). Pt with generalized edema. DP/PT pulses palpable. Venodyne boots on BLE. Lungs clear. O2 sat >/= 93% on 6L nasal cannula. Pt with strong cough; non-productive. Abodmen softly distended with +bowel sound. Replete with fiber @ 60cc/hr infusing via NGT; goal rate. Minimal residual noted. No bowel movement. FS q6hr; treated with regular insulin sliding scale. Foley intact with clear, yellow/amber urine. UO >/= 60cc/hr. Furosemide increased to 40mg PNGT . No pressure sores noted. Pt turned and repositioned frequently to maintain skin integrity. Pt does not fit in the lift, so unable to get pt up to the chair today. Needs PT consult. wife called and stated that she will visit tomorrow; updated by RN on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Labs will be sent at 1600. Monitor neuro exam q2hr; notify HO with any changes. Ventriculostomy drain 10cm above the tragus; monitor output. Monitor ICP. Wean O2 as tolerated. Goal SBP 120-160. Continue TF at goal rate; check residuals q4hr. Update pt's family on plan of care; provide emotional support. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-27 00:00:00.000", "description": "Report", "row_id": 1676772, "text": "condition update\nD: pt opens eyes to pain. withdraws to painful stimuli right moves less than left. once moved left leg spontaneously. does not follow commands. pupils are equal and reactive to light. vent drain remains clamped at 20. icp 14-23. vent drain opened x 2 for icp > 20. cpp 50's with sbp in the 140's Dr. aware.\ncardiac: nsr- sb rates 51-60's. Dr. aware. lopressor held due to bradycardia. nicardipine weaned off and sbp 140-160. temp max 102.6 culture sent and tylenol given.\nresp: pt remains on cpap with 5 of pressure support. resp rate in the 30's. pressure suppport up to 15 and rate down to 20. suctioned frequently for thick white sputum. breath sounds are coarse and diminshed in the bases.\ngi: tube feeds are at goal with no residual. pt with large bowel movement. guaiac positive.\ngu: foley patent and draining clear yellow urine.\nskin: no areas of breakdown noted.\na: continue with neuro checks. await culture results.\nr: neuro is unchanged. continues to spike temps. pt more comfortable on 15 of pressure support. pt continues to have large amto of resp secretions.+\n" }, { "category": "Nursing/other", "chartdate": "2152-11-27 00:00:00.000", "description": "Report", "row_id": 1676773, "text": "RESP CARE: Pt remains intubated/8.0ETT/21 lip. PS increased to 15 from 5 for tachypnea with RR 30s, low vts. Present Vts 600-700/RR 16-24. Lungs rhonchi bilat. Sxd copious amts thick white/clear secretions in the early part of the shift, decreased in am. RSBI-67. Plan is for pt to have ?trach done today.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-27 00:00:00.000", "description": "Report", "row_id": 1676774, "text": "NPN (SEE CAREVUE FOE SPECIFICS)\n PT TO PAIN, NOT FOLLOWING COMMANDS, NOT TRACKING WITH EYES. PERRL. MOVING LEFT LEG SPONTANEOUSLY, HOWEVER ALL OTHER EXT MOVE IN RESPONSE TO PAIN ONLY. LEFT SIDE STRONGER THAN RIGHT. VENT DRAIN REMAINING CLAMPED ALL SHIFT, ICP 14-19. ICP RISING TO 20 DURING LINE PLACEMENT AND DRAIN OPENING TO DRAIN 20CC, ICP DECREASED BELOW 20 AND VENT DRAIN RECLAMPED. PAIN MED GIVEN ONCE WITH EFFECT.\nCV- BP 160-180, NO NICARDIPINE NECESSARY TO KEEP WITHIN GOAL. HR HIGH 40'S AND 50'S AT TIMES, SINUS WITHOUT ECTOPY, SHOWN TO TEAM THIS AM. CVL PLACED IN LEFT SC, RIGHT CVL REMOVED AND TIP SENT FOR CULTURE.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED INFREQUENTLY FOR THICK WHITISH SPUTUM. NO VENT CHANGES MADE TODAY. AWAITING PEG AND TRACH IN OR, UNSURE WHEN IT WILL HAPPEN, CALLED SEVERAL TIMES.\nGI/GU- ABD SOFT, + BS. NPO FOR NOW WITH D5 NS RUNNING AT 75CC/HR. UOP ADEQUATE, FOLEY CHANGED.\nID- TMAX 101.6. CEFAPIME STARTED TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-01 00:00:00.000", "description": "Report", "row_id": 1676790, "text": "Nursing progress note\nSee Carevue for specifics\n\nTmax: 100.3\n\nNeuro: Exam unchanged. Opens eyes inconsistently to voice. Does not follow any commands or make any spontaneous movements but MAE when stimulated. All four extremeties withdraw to deep pain. PERRL. Strong cough and gag intact.\n\nCV: SB in 50s. HTN to 200 when stimulated/suctioned, 140s-150s otherwise. SBP parameters 120-140, controlled with hydralazine, hydrochlorthiazide and pain meds with marginal result. MD aware. Hydrochlorathiazide dose added on for P.M. PICC ordered.\n\nResp: Currently on trache mask and tolerating well. Sats 100%. Strong productive cough. Expectorates copious amounts of very thick yellow/blood-tinged sputum. LS clear/diminished.\n\nGI/GU: TF to goal via PEG, no residuals, no stool this shift, abd soft/distended, +BS. Foley draining adequate yellow urine with red sediment. MD aware. Urine to be sent for reflex/cx.\n\nSocial: Wife called, updated by RN, plans to visit tomorrow.\n\nPlan: Cont to monitor resp status and SBP. Put back on vent overnoc. PICC line placement and d/c CVL. Start screening for rehab.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-12-01 00:00:00.000", "description": "Report", "row_id": 1676791, "text": "resp care\nplaced on trach mask early in shift, rr has been stable in teens to 20's. pt expectorating on own for thick yellow/bld tinged sputum. inner cannula changed as needed. 50% trach mask with sats 98-100%. nonlabored, occas.rhonchorous bs. mdi's per . last poe order for vent at noc, confirm with resident. hypertensive but resp status seems stable.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-02 00:00:00.000", "description": "Report", "row_id": 1676792, "text": "Respiratory Care:\nPatient with #8.0 Portex trach, secured via sutures and twill tape and on a 50% trach collar with SPO2>97% t/o shift and RR<28. He appears comfortable. BS with occassional rhonchi. Cough productive for med amounts of blood tinged secretions. He has been suctioned several times for the same and has received albuterol and atrovent MDIs app Q4. Ventilator discontinued from bedside at 5am.\n\nPlan: Continue with monitoring and pulmonary hygiene.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-04 00:00:00.000", "description": "Report", "row_id": 1676797, "text": "Update\nO: See carevue flowsheet for specifics.\nNeuro exam unchanged. Pserl, eyes open spontaneously, not tracking. No spont mvment of extremeties, withdraws to nailbed pressure.Goal bp 120-180 maintained w current scheduled meds. No additional prn antihtn required. O2 sats stable > 96% on trach collar 40% w bbs coarse to clear w c&r thick tan to pale yellow secretions. Tol tf via peg at goal 60cc/hr replete w fiber. Incont of mod loose brwn guiac neg stool x1. Huo qs yellow urine w sediment.Tmax 100.1. Cont on tobra and cefepime.\n\nA/P: Stable on trach collar. ? transfer to floor. ? picc line placemnt. Rehab/ placement. Cont w supportive icu care, provide emot support to family.Goal sbp 120-180 , utilize prn antihtn as needed for bp control.Check am labs results and rx as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-04 00:00:00.000", "description": "Report", "row_id": 1676798, "text": "RESP CARE: Pt remains on 50% trach collar all noc. Lungs coarse rhonchi. Sputum consistency noted to have changed from copious amts clear white and now is thick pale yellow. Atrovent MDIs still GID, given per . Will continue to follow per airway protocol.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-24 00:00:00.000", "description": "Report", "row_id": 1676758, "text": "condition update\nPlease see carevue for specifics.\nNeuro: Arouses to noxious stimuli or turning, does not follow commands -will sometimes squeeze hand though not consistently with command. Pt withdraws all extremities on the bed to nailbed pressure. Pupils are equal and reactive. Versed continues at 2mg/hr. Ms04 x's 3 for ? presumed pain/discomfort manifested by hypertension. Vent. drain 20 at tragus, draining blood tinged csf, icp 15-18.\nCV: Sinus with rare pac's. BP labile, though mainly hypertensive. Sicu h.o. and neuro- on call h.o. notified of bp, and goal of 120-180 was verified. Hydral. given x's 2, nicardipine titrated to max 3mcg/kg/min, and ms04 for presumed pain with transient response. Calcium repleted x's 1. ck's cycled.\nGI: TF at goal, minimal residual, abd. soft, +bs, no bm.\nGU: foley draining adequate amts clear yellow urine\nEndo: NPH and sliding scale\nID: t-max 102.6, tylenol given atc and cooling blanket used.\nPlan: continue neuro checks, wean midaz. as tolerated, pulmonary toileting, pain management, manage hypertension, monitor temp, continue tylenol/cooling blanket.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-24 00:00:00.000", "description": "Report", "row_id": 1676759, "text": "Resp: pt on psv 8/5/40%. Et 8.0 taped @ 24 lip. BS are coarse bilaterally with improve following suctioning. Suctioned for small to moderate amounts of thick yellow secretions. Changed to heated wire circuit.No changes noc. AM ABG 7.46/34/97/25. RSBI=38. Plan: continue to wean as tolerated to extubate?\n" }, { "category": "Nursing/other", "chartdate": "2152-11-24 00:00:00.000", "description": "Report", "row_id": 1676760, "text": "addendum\nPersistent hypertension discussed with Dr. (sicu ho) who discussed bp goal with neuro- resident - sbp in 180's can be tolerated if map <130 per neuro-. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-24 00:00:00.000", "description": "Report", "row_id": 1676761, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED THIS AM ON VERSED GTT, GTT STOPPED AND PT SLOW TO AROUSE, GTT REMAINS OFF. OPENING EYES TO PAINFUL STIMULI, NOT FOLLOWING COMMANDS, NO COMMUNICATION. ALL EXT. WITHDRAWING TO PAINFUL STIMULI, RIGHT SIDE WEAKER, SPONTANEOUS MOVEMENT NOTED FROM UPPER LEFT EXT. ONLY. DR. IN THIS AFTERNOON, FEELING AS THOUGH PT'S RIGHT SIDE APPEARING WEAKER TO PAINFUL STIMULI, CT ORDERED AND POSSIBLE ANGIO IF DECREASED PERFUSION. PUPILS SLIGHLTY UNEQUAL BUT REACTIVE.\nCV- REMAINS HYPERTENSIVE, 160-170, BUT KEPT BELOW 180 PER NSURG PARAMETERS WITH NICARDIPINE GTT AND ADDITION OF PO HYDRALAZINE. HR 70'S, NSR WITHOUT ECTOPY, NO FURTHER EPISODES OF A-FIB.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED EVERY FEW HOURS FOR COPIOUS AMOUNTS OF THICK YELLOW SPUTUM. NO VENT CHANGES MADE.\nGI/GU- ABD SOFT, TOLERATING TF AT GOAL. UOP ADEQUATE, CLEAR YELLOW.\nID- TMAX 100.9 THIS AM. TOBRAMYCIN STARTED TODAY.\n WIFE CALLED AND UPDATED ON PROGRESS\n" }, { "category": "Nursing/other", "chartdate": "2152-11-24 00:00:00.000", "description": "Report", "row_id": 1676762, "text": "respiratory care\npt on the vent no changes made tol well. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-25 00:00:00.000", "description": "Report", "row_id": 1676763, "text": "Resp: Pt rec'd on psv 8/5/40%. Ett 38.0, taped @ 21 lip. BS are coarse to clear and suctioning for small amounts of yellow/white thick secretions. No changes this shift. AM ABG 7.46/31/13/23. RSBI=48. Plan: continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-28 00:00:00.000", "description": "Report", "row_id": 1676775, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt to stimuli, opens eyes to gentle stimuli, does not track, PERLA, withdraws all extremities to nailbed pressure with noted increased weakness in R extremities in comparison to L extremities. Rare spontateous movement noted in LLE. Does not follow commands. Namodipine held x1 dose due to HR 40, MD aware. Vent drain clamped, ICP 12-19, remains 20 at tragus. Morphine prn pain with pos effect.\n\n Resp: LS coarse bilat, diminished at bases. No vent changes made over night, abg pnd. Suctioned prn for small to mod amounts of thick white sputum.\n\n CV: Remains SB with HR 40-50's, SBP 140-170's through begining of shift, SBP up to 190's around 0100, hydralazine 10mg x2 given with little efffect. Nicardapine gtt started with pos effect. Goal SBP 120-180. Noted descrepancies between cuff and aline, good waveform noted on aline, MD notified, following aline pressures. D5 1/2 NS @ 75cc/hr infusing through CVL. AM labs pnd.\n\n GI: Abd obeses, pos bs, TF off at MN. NPO for OR in am. Lg BM x1, guiac neg.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\n ID: Tmax 101.6, tylenol with pos effect. Abx as ordered.\n\nPlan: NPO for trach and PEG, and IVC filter placement in OR this AM, Vanco trough to be drawn, abx as ordered, keep SBP 120-180, neuro exams q2hrs, monitor labs, povide pt and family with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-28 00:00:00.000", "description": "Report", "row_id": 1676776, "text": "RESP CARE: Pt remains intubated with 8.0 ETT/21 lip/ No changes in vent sttings this shift. Vts on 15 PS480-700/RR 20-25. Lungs coarse/dim bibasilar.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-28 00:00:00.000", "description": "Report", "row_id": 1676777, "text": "RESP CARE: AM RSBI-51.5. Plan is for ? trach today.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-28 00:00:00.000", "description": "Report", "row_id": 1676778, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT OPENING EYES TO VOICE, NOT FOLLOWING ANY COMMANDS. MOVING ALL EXT. IN RESPONSE TO PAIN. RIGHT SIDE STRONGER THAN PREVIOUS SHIFTS. ICP 14-18 ALL SHIFT, VENT DRAIN REMAINS CLAMPED. ICP CLIMBING DURING CT SCAN, OPENED FOR 18CC OF CSF DRAINAGE, ICP RETURNED BELOW 20. DR. UNSURE OF VP SHUNT PLACEMENT TOMORROW, PT NEEDS HEAD CT IN AM. PERRL.\nCV- BP STABLE, KEPT BETWEEN 120-180, NICARDIPINE BRIEFLY THIS AFTERNOON FOR BP IN 190'S. HR BRADY IN HIGH 40'S AT TIMES, REPORTED TO TEAM DURING ROUNDS THIS AM, CONTINUE TO MONITOR.\nRESP- LUNGS CLEAR, DIMINISHED BASES. REMAINS ON CPAP ALL SHIFT. SENT TO OR THIS AFTERNOON FOR PEG, TRACH, AND IVC FILTER PLACEMENT. ABD AND PELVIC CT DONE PRIOR TO OR. SUCTIONED FOR COPIOUS THIN WHITISH SPUTUM.\nGI/GU- ABD SOFT, + BS. REMAINING NPO ALL DAY FOR OR. UOP ADEQUATE.\nID- TMAX 101.3, TYLENOL BRINGING DOWN TEMP TO 98.8. CONTINUE CURRENT ANTIBIOTICS.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-28 00:00:00.000", "description": "Report", "row_id": 1676779, "text": "Respiratory Care\nPt remains intubated (#8.0 ETT 21@lip) and on vent support. Vent changes were PS dropped from 15 to 8, pt able to maintain good Vt and RR. Lung sounds were clear and dim in bases. Suctioned for sc to cop thk white secretions. No ABGs were drawn t/o shift. Care plan is pt currently in OR for trach and peg, wean vent as tol. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-04 00:00:00.000", "description": "Report", "row_id": 1676799, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: No change in pt's neuro exam. Head CT done this afternoon MD , ? changes in CT due to no improvement in neuro exam, results pnd.\n\n Resp: Ls clear diminished at bases bilat. Pt able to C&R secretions, clear thick. Suctioned prn for small amounts of clear to white thick secretions. Remains on trach collar 50%, maintaining o2 sat > 97%.\n\n CV: Remains NSR-NSB, no ectopy noted. SBP goal 120-180, within goal with satnding meds, no additional meds required. Palp pedal pulses.\n\n GI: Abd obese, pos bs. Tol TF @ goal via PEG. BMx1, soft brown.\n\n GU: Adequate amounts o fclear yellow urine via foley cath\n\n ID: Abx d/c'd, afebrile\n\n OOB to chair via \n\n Rehab screen started today, updated pt's wife.\n\nPlan: Continue to monitor hemodynamics, monitor labs, follow neuro exam, PT, rehab screen, c/o to step down tomorrow pnd results of Ct scan.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-05 00:00:00.000", "description": "Report", "row_id": 1676800, "text": "update\nO: See carevue for specifics.\nTrached on trach mask 40% w adeq spo2 and rr. Coughs and raises mod amts of thick pale yellow secretions. Bbs clear diminish bibas.Neuro exam unchanged. Goal sbp 120-180 maintained w current scheduled antihtn meds,no prn's necessary.Abd soft obese,bowel snds present.Tol tf replete w fiber at goal, glucoses rx'd per riss and fixed dose insulin given at hs.Incontinent of loose brwn stool mod amts.Uop qs yellow w brwn sediment.Skin intact no brkdwn noted.Rehab screening started on .\nA/P: stable awaiting rehab placemnt. Bp stable ,? transfer to floor.Provide emotional support to family.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-05 00:00:00.000", "description": "Report", "row_id": 1676801, "text": "RESP CARE: Pt remains trached on 50% TC. Cuff pressure 25cmH20/8cc air. Lungs coarse bilat. Expectorates mod to lg amts thick yellow/white sputum. MDI Atrovent given per continue to follow per airway protocol.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-29 00:00:00.000", "description": "Report", "row_id": 1676780, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\nPt s/p trach, PEG and IVC filter\n\n Neuro: Pt weaned off prop gtt post-op. Pt to stimuli, opens eyes to pain, PERLA, rare spontaneous movement noted in LLE, withdraws all extremities to painful stimuli. R side weaker than L. Does not follow commands. Vent drain clamped, ICP 14-18, goal <20. Tissue noted in vent drain, MD notified, Vent drain flushed by trained RN. Morphine prn pain with pos effect.\n\n Resp: LS coarse bilat, diminished at bases. CXR showing worsening effusion into RUL. CPT prn with mod effect. Suctioned prn for mod amounts of thick blood tinged sputum. ABG wnl. Remains on CPAP fiO2 50%. Strong cough. Thrush noted on mouth, frequent mouth care done, nystatin prn.\n\n CV: Remains NSR-NSB, HR 47-60's, no ectopy noted. SBP 160-190's. Hydralazine prn with little effect. Nicardipine gtt restarted for goal SBP 120-180, pos effect noted. Labs pnd. L groin angio site wnl, palp pedal pulses. Generalized edema noted. LR @ 50cc/hr via CVL.\n\n GI: Abd obese, hypoactive bs. PEG to gravity. No BM this shift. + flatus.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\n ID: Tmax 100.3. Abx as ordered. Vanco trough 13.9.\n\n Social: Wife updated by MD upon pt's arrival to unit\n\nPlan: Monitor hemodynamics, keep SBP 120-180, monitor labs, r/s tubefeeds via PRG in AM, CT in am, pulm toileting, mobnitor neuro exam, keep ICP <20, ? VP shunt placement, provide pt and family with emotional support\n" }, { "category": "Nursing/other", "chartdate": "2152-11-29 00:00:00.000", "description": "Report", "row_id": 1676781, "text": "RESP CARE NOTE\nRECEIVED PT FROM OR WITH 8.0 PORTEX TRACH WITH INNER CANNULA IN PLACE. CUFF PRESSURE WNL. SUCTIONING THICK BLOODY AND WHITE SECRETIONS. STARTED ON AC AND WEANED TO PSV 10/5/40%. RR ON AC AND PSV REMAINS IN MID TO HIGH 20'S. VT 550-600. RSBI 53. AMBU BAG AT BEDSIDE. ALB/ATR GIVEN X 1.\nPLAN: PSV AS TOLERATED, TRACH COLLAR WHEN READY.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-29 00:00:00.000", "description": "Report", "row_id": 1676782, "text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nContinues to spike fevers 101.5po and med with tylenol with good effect. Opens eyes to stimuli and occasionally to voice. Does not follow commands and no spontaneous movements noted. Only moving slightly to painful stimuli and sternal rub. Neurosurg and sicu teams are aware of neuro status. CT done ?results. wife called for results and neurosurg notified to please call her with an update. PERLA. Lungs are coarse and occasional wheezes relieved with inhalers. Remains on cpap. Suctioned for thick blood-tinged secretions. Bronchoscopy done and samples sent. NSR-SB 50s at times. PO Nimodipine given. Nicardipine gtt off most of the day for goal sbp 120-180. UO adequate. Abdomen obese and distended. Tube feeds still on hold until later this afternoon or tonight MD and team. ICP 8-14 mostly and drain remains clamped. Plan: Cont with icp monitoring. Tube feedings to resume tonight, Gtube to gravity for now. Neuro exams q2 hours. Goal sbp 120-180, nicardipine as needed.\nPlease refer to carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-29 00:00:00.000", "description": "Report", "row_id": 1676783, "text": "Resp CAre\nPt remains trached with 8.0 portex on psv 10/5 vts range 400-600 rr 25-35. Pt went to CT today for head scan without incident and had a bronch amd a BAL was sent to the lab for culture. BLBS slightly course, mdis given , suctioned for sm amt thick blood tinged secretions. Plan to wean PS as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-30 00:00:00.000", "description": "Report", "row_id": 1676784, "text": "RESP CARE NOTE\nRECEIVED PT ON PSV 10/5 WITH RR 28-30. PSV ^TO 15 AND RR DECREASED TO 19, VT 600'S. BREATH SOUNDS DIMINISHED BUT ESSENT CLEAR. TRACH HAD SOME BLEEDING AROUND SITE FOR JUST A SHORT TIME AND RESOLVED. VERY LITTLE SECRETIONS. RSBI 40.\nPLAN: TRACH COLLAR TRIALS WHEN READY.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-30 00:00:00.000", "description": "Report", "row_id": 1676785, "text": "NURSING\n EVENTS; HYPERTENSIVE EPISODE OVERNIGHT WITH SBP IN THE 200'S. UNRESPONSIVE TO 10 MG HYDRALAZINE. NICARDIPINE GTT RESTARTED AT .5, TITRATED UP TO MAX OF 3. GTT CURRENTLY INFUSING AT 1.5 WITH SBP IN THE 160'S.\n VS OTHERWISE STABLE OVERNIGHT. NSR, NO ECTOPY. TEMPERATURE MAX 101.5. MEDICATED WITH TYLENOL FOR FEVER, EVENTUAL DECREASE TO 99.2.\n NEURO STATUS UNCHANGED OVERNIGHT. OPENING EYES INDEPENDANTLY.DOES NOT FOLLOW COMMANDS. MOVING EXTREMITIES MINIMALLY.RIGHT WEAKER THAN LEFT. SEE CARE VUE FOR FULL ASSESSMENT.\n MEDICATED FOR PAIN WITH PERCOCET ELIXER. WITH TURNING AND REPOSITIONING APPEARS AT TIMES TO BE UNCOMFORTABLE, PAIN MEDS EFFECTIVE IN APPARENT DISCOMFORT.\n FOLEY WITH GOOD URINE OUTPUT. NO STOOL OUT OVERNIGHT. ABDOMEN SOFTLY DISTENDED, POSITIVE BOWEL SOUNDS. TUBE FEEDS AT GOAL OF 60/HOUR.\n VENT DRAIN DC'D YESTERDAY LATE BT NEURO TEAM. DSD OVER SITE, DRY AND INTACT.\n CONTINUE TO MONITER HEMODYNAMICS, TEMPERATURE, LABS. MONITER NEURO STATUS. HEAD CT TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-30 00:00:00.000", "description": "Report", "row_id": 1676786, "text": "Resp. Care note\nPt received trached and vented on PSV settings as charted on resp flowsheet. PSV weaned to current setting of with TV 500-600. ABG's WNL and goal is to try on trache collar today. Albuterol and Atrovent MDI's as ordered. sxn for blood tinged secretions, bloody oozing around trache site.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-30 00:00:00.000", "description": "Report", "row_id": 1676787, "text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nContinues with fevers to 101 and medicated with tylenol. Neuro exam unchanged. CT today with no change. Started on po enalapril and po hydrochlorothiazide and remains off nicardipine gtt most of shift. Vent weaning to cpap 5/5 with good abg and currently on trach collar trial with good sats. Strong productive cough of thick blood tinged secretions. Mod-Lg amounts of blood tinged thick secretions around trach opening as well. MD aware. Abdomen softly distended and tube feeds at remain at goal and tolerated well. wife called and updated and will try to get in this weekend, has been having difficulty getting in to see her husband d/t finances and travel time. Plan: neuro exams q 2 . monitor bp for goal 120-180. Weaning on vent with trach collar trial and rest today. Involve social work and start rehab screening ?rehabs closer to home for patient and family. Please refer to carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-01 00:00:00.000", "description": "Report", "row_id": 1676788, "text": "RESP CARE NOTE\nRECEIVED PT ON 70% TRACH COLLAR AND PLACED ON PSV AT DUE TO TACHYPNEA AND DIAPHORETIC. ON PSV 15/5/50% RR CAME DOWN TO MID TEENS WITH VT 700-800. BREATH SOUNDS DIMINISHED AT BASES AND COARSE. SUCTIONING MODERATE AMTS OF THICK WHITE SECRETIONS. ABG ON CURRENT SETTINGS 7.44/39/167/27. RSBI 48. AMBU AT BEDSIDE.\nPLAN: TRACH COLLAR TRIALS AS TOLERATED\n" }, { "category": "Nursing/other", "chartdate": "2152-12-02 00:00:00.000", "description": "Report", "row_id": 1676793, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: No change in pt's neuro exam. Opens eyes to voice, withdraws all extremities to nailbed pressure, no spontaneous movement noted, PERLA. namodipine continues as ordered. Roxicet prn pain with pos effect, pt grimacing with pain.\n\n Resp: LS clear bilat, diminished in bases and R middle lobe. Remains on trach collar over night. Maintaining O2 sat >97%. Pt mobilizing secrtions on own with min suctioning, C&R copious amounts of thick clear secretions. #8 portex trach remains wnl, sutures intact.\n\n CV: Remains NSB hr 50's. SBP 130-170's, up to 190's with turning and suctioning. Hydralazine prn with little effect, SBP improved with namodipine and roxicet, SBP goal 120-180. Generalized edema noted, wgt down 3 kg from yesterday. Labs stable\n\n GI: Abd obese, slightly distended, pos bs. TF @ goal via gtube. Soft brown BM x1.\n\n GU: Adequate amounts of yellow urine via foley cath with some sedement noted.\n\n ID: T max 99.7. Abx as ordered, WBC 13.1\n\nPlan: Monitor hemodynamics, monitor labs, abx as ordered, PICC to be placed in rehab screen, PT consult, provide pt and family with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-02 00:00:00.000", "description": "Report", "row_id": 1676794, "text": "resp care\nfollowed for atrovent qid,albuterol prn (not needed today). expectorating clear on own to thick yellow when cough initiated by sxning. nard, tolerating 50% trach mask. cuff remains inflated.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-02 00:00:00.000", "description": "Report", "row_id": 1676795, "text": "Nursing Progress Note 7a-7p\nPatient remains on trach collar 50% Fio2, tolerating well. Expectorating copious amounts of clear thick secretions. Lungs clear with diminshed sound on LLL. Neuro status unchanged. Withdraws to nailbed stimuli. Afebrile during shift without tylenol q4hr. Episodes of sinus brady around 1200. Held Nimodipine and gave half dose at 1600 due to HR in low 50s and pt response to med. BP within range and controlled by PO meds. Tolerating tube feeding, adequate UO and no BM. +bowel sounds. Rehab screening to begin Monday. Wife in to visit today. Updated on plan and given informational packets from neurosurg. PLAN: Continue to monitor for sinus brady episodes and elevated BP. Continue on trach collar. Screen for Rehab. Provide emotional support to wife and patient. PT eval.\n\nPlease see CareVue for details.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-03 00:00:00.000", "description": "Report", "row_id": 1676796, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n No change in pt's neuro exam. Remained on trach collar throughout shift and maintaining o2 sat > 97%. C&R mod amounts of thick clear secretions. Suctioned PRN. Trach wnl. LS clear bilat throughout, slightly diminished at L base. SBP remained 140-170's. Aline d/c'd. ABd obese, slightly distended, small smears of stool over night, pos flatus. Tol Tf at goal via Gtube. Adequate amounts of clear yellow urine via foley cath.\n\nPlan: PICC to be placed in rehab screen to be started on Monday, continue with current plan of care, provide pt and family with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-05 00:00:00.000", "description": "Report", "row_id": 1676802, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n No change in pt's neuro exam. Namodipine d/c'd. Remains on trach collar, maintaining secretions, sat > 98% on 50% trach collar. SBP 120-160's with standing meds, HR 60-70's. OOB to chair, hoyered, PT/OT in to eval pt for rehab screen. Case management aware, screen to begin tomorrow. c/o to floor.\n\nPlan: Rehab screen, pulm toileting, transfer to floor once bed obtained\n" }, { "category": "Nursing/other", "chartdate": "2152-12-06 00:00:00.000", "description": "Report", "row_id": 1676803, "text": "Nursing Progress Note:\nNeuro: Pt remains alert but only responding to nail bed pressure. Pupils 3mm brisk. + gag and cough reflex. Moving all extremities on bed but noted as non purposeful. Appear to have no pain.\n\nCV: Tmax 99.5, HR 70's NSR with 1 episode of SVT while drawing labs from L CVL. Extremities warm with +PP. HCt stable.\n\nRESP: Tolerating trach mask O2 sats >96%. Able to cough and clear clear thick secretions.\n\nGI: Tol tube feed at goal. Abd soft with +BS. No stool tonight.\n\nGU: Foley patent, flushed X2 due to low urine output. Cont to have low urine output. Sicu team aware.\n\nENDO: blood sugars requiring coverage per RISS.\n\nPLAN: Cont to assess for any neuro advancement. Rehab screen, to transfer to 11 with telemetry. \u0013\n\n" }, { "category": "Nursing/other", "chartdate": "2152-12-06 00:00:00.000", "description": "Report", "row_id": 1676804, "text": "RESP CARE: Pt remains trached/on 50% TC all shift. Lungs dim, coarse at times. Sxd thick white sputum. Cuff pressur emaintained at 25cmH20. will continue to follow per airway protocol.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-06 00:00:00.000", "description": "Report", "row_id": 1676805, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\nNEURO- NEUROLOGICALLY UNCHANGED, CONTINUES TO OPEN EYES TO VOICE, NOT FOLLOWING COMMANDS, NO SPONTANEOUS MOVEMENT NOTED. PERRL. OOB TO CHAIR FOR A FEW HOURS WITH \nCV- BP RANGING FROM 120-180, REQUIRED HYDRALAZINE PRN X 1 WITH EFFECT. HR 80'S-90'S NSR WITHOUT ECTOPY. CVP CHECKED DUE TO LOW UOP, AVERAGING FROM .\nRESP- LUNGS CLEAR, STRONG COUGH, ABLE TO EXPECTORATE COPIOUS AMOUNTS OF WHITE THICK SPUTUM.\nGI/GU- ABD SOFT, TOLERATING TF AT GOAL. UOP DECREASING THIS AFTERNOON, FLUID BOLUS GIVEN WITH EFFECT, FOLEY FLUSHING WELL. RENAL CONSULT ORDERED FOR RISING CREATININE, ULTRASOUND TO BE DONE.\nID-AFEBRILE.\nTRANFER TO STEP DOWN CANCELLED DUE TO POSSIBLE RENAL INSUFFICIENCY.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-07 00:00:00.000", "description": "Report", "row_id": 1676806, "text": "npn\nNeuro- see neuro flow sheet, eyes open spont but not tracking, not following commands. minimal withdraw of all 4 ext to painful stim. right weaker than left. pearl.\n\n\nResp- trach collar, . 40 fio2, lungs coarse bilat, cont cough or suction thick yellow secretions.\n\n\nRenal- cr. down to 1.3 this am- see labs- huo 30-150/hr. ivf kvo, tube feed 75/hr.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-07 00:00:00.000", "description": "Report", "row_id": 1676807, "text": "Resp Care Note, Pt seen for trach check. FIO2 50%.Suctioned for mod amts thick yellow secretions. MDI'S given.Sats in the 90's. Without problem. cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-17 00:00:00.000", "description": "Report", "row_id": 1676739, "text": "SICU NPN\nS-Non-verbal post extubation.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Self extubated post Head CT. Propfol discontinued. Lethargic/somulent. Post extubation ABG wnls. Following commands inconsistently. Opening eyes to name and spontaneously. Nonverbal mostly. MAEs on bed. BUEs lifting off of bed and BLEs moving on bed. EVD not draining 2hr post insertion. Intial ICP of , Now 0-5. (+) fluctuation in pressure line. Neurosurgery and ICU on call made aware. Maintaining SBPs 120-160. On/off Nicardipine. Tolerating Nimodipine. HR 40-50s at times with stable SBP. Breath sounds clear and dim at bases. Occassionally coarse sounding. Encouraged to CBD. Depsite remains on 100% O2 FM and sating 93-96%. HUO adequate on maintenance fluid. NGT in place and clamped. NPO. Afebrile. Kefzol started while drain in place. Wife into visit with daughter this evening, updated by neurosurgery on call.\n\nA/P: Doing fair post extubation, remains mostly somulent, neuro exam unchanged. Question to IR/OR in near future.\n\nKeep SBP 120-160\nMonitor ICP closely\nNo plans for further CT unless neuro change.\nContinue q1hr neuro exams\n" }, { "category": "Nursing/other", "chartdate": "2152-11-17 00:00:00.000", "description": "Report", "row_id": 1676740, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT'S NEURO STATUS WAXING AND THROUGHOUT THE DAY. AT TIMES PT , ANSWERING QUESTIONS APPROPRIATELY, OTHER TIMES PT BUT NOT VERBAL. FOLLOWING ALL COMMANDS, ABLE TO RAISE EXT. OFF THE BED. PERRL, LEFT APPEARS SLUGGISH, MINIMALLY REACTIVE PER NSURG TEAM. VENT DRAIN OUTPUT FLUCTUATING EACH HOUR DUE TO PT MOVING ALL OVER BED AND LEVEL VARYING. ICPS . C/O \"9\" OUT OF \"10\" HEADACHE, ICP 7, NEURO STATUS UNCHANGED, CHIP MACINTOSH NOTIFIED. DR. WRITING FOR ADDITIONAL DOSE OF MORPHINE 2MG, WILL FOLLOW UP.\n PT 'S BP DIFFICULT TO CONTROL, MOVING AROUND AND DAMPENING A-LINE DESPITE SEVERAL ARM BOARDS AND REPOSITIONING. TEAM NOTIFIED THAT A-LINE AND CUFF DIFFER BY 20-30, OK TO FOLLOW CYCLING CUFF PER DR. . HR 50'S, SINUS BRADY WITH OCCASIONAL PVCS. AFTERNOON LABS PENDING.\nRESP- LUNGS CLEAR WITH DIMISHED BASES. PT ENCOURAGED TO COUGH, PRODUCTIVE. O2 SAT 93-95% ON FACE MASK AND NC.\nGI/GU- ABD SOFT, REMAINS NPO, NG TUBE TO LCWS WHEN NOT USED FOR MEDS. UOP ADEQUATE.\nID- TMAX 101 RECTALLY, DR. NOTIFIED.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-22 00:00:00.000", "description": "Report", "row_id": 1676752, "text": "Respiratory Care:\nPt electively intubated for bronch. Pt Intubated with #8 ETT, taped at 21 lip. Pt for small thick clear secretions BAL obtained and snt to lab. Lung sounds slightly coarse. SUctioned for bloody tinged secretions. Plan is to wean to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-22 00:00:00.000", "description": "Report", "row_id": 1676753, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Neuro exam q2hrs. Pt opens eyes spontaneously and to command. PERRLA. Moves all extremities spontaneously. Purposeful movement noted. Follows simple commands inconsistently. +gag/cough/corneal reflex. Pt does not appear to be in pain; no grimacing noted. Ventriculostomy drain 15cm above the tragus; serosanguinous drainage. ICP 6-13; see CareVue for CPP. Febrile. Tmax 102.3; Dr. aware. Tylenol 650mg given x2 via NGT. HR 60s-90s (NSR; no ectopy noted). Goal SBP 120-180. Nicardipine gtt now off. Hydralazine 10mg IV given x1. Pt with generalized edema. DP/PT pulses palpable. Bilateral femoral pulses strongly palpable. Right femoral angio site with dsg intact. Pt intubated today for bronchoscopy. BAL sent for culture and Gram stain. No CXR ordered post intubation per Dr. and Dr. d/t plan is to extubate pt post bronch. Ppf gtt for comfort; now off for possible extubation tonight. Lungs clear, diminished and coarse at times. Suctioned for small/moderate amount thick, blood-tinged secretions. No ABG ordered. O2 sat >/= 96%. Pt weaned to CPAP. Abdomen softly distended with +bowel sound. TF stopped at approximately 1300 for intubation and . No residuals noted. NGT intact and patent. FS q6hr; treated per regular insulin sliding scale. NPH 10units given this morning as ordered. Foley intact with clear, amber urine. UO >/= 40cc/hr. No pressure sores noted. Pt turned and repositioned frequently to maintain skin integrity. Vent drain dsg reinforced with tegaderm; clean and dry. wife and friend visited; updated by RN and Dr. on pt's condition and on plan of care. wife cried and is very worried that pt \"will not make it home.\"\n Plan: Monitor VS, I's and O's, labs. Monitor neuro status; notify HO with any changes. Wean vent setting as tolerated. ?extubate tonight or tomorrow. Restart TF after extubation. Follow up result of cultures. Continue antibiotics. Monitor ICP and ventriculostomy drain output. Vent drain 15cm above the tragus. Keep SBP 120-180. Update pt and family on plan of care; provide emotional support. Needs social work consult. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-23 00:00:00.000", "description": "Report", "row_id": 1676754, "text": "Resp: pt on psv 5/5/50%. Ett 8.0 taped @ 21 lip. BS are coarse to clear and suctioned for small to moderate amounts of tan secretions. Pt had noted ^ in wob then ^ ps to 8. AM ABG 7.45/38/177/27. RSBI=51. Plan to wean to extubate today.\n" }, { "category": "Echo", "chartdate": "2152-11-24 00:00:00.000", "description": "Report", "row_id": 98526, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 69\nWeight (lb): 270\nBSA (m2): 2.35 m2\nBP (mm Hg): 173/52\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 12:09\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.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Hyperdynamic\nLVEF >75%. Moderate resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is elongated. There is moderate symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Left ventricular\nsystolic function is hyperdynamic (EF>75%). There is a moderate resting left\nventricular outflow tract obstruction. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. There is no aortic valve stenosis. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. The left ventricular inflow pattern suggests\nimpaired relaxation. The estimated pulmonary artery systolic pressure is\nnormal.\n\nIMPRESSION: Moderate symmetric LVH with hyperdynamic LV systolic function and\na moderate resting LVOT gradient. The Valsalva maneuver could not be performed\nas the patient was intubated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-11-23 00:00:00.000", "description": "Report", "row_id": 1676755, "text": "SICU NPN\nS-Intubated and sedated.\n\nSEE CAREUVUE ALL OBJECTIVE AND TRENDS IN FLOWSHEETS.\n\nO-Remains intubated secondary to tachypenia post bronch. Febrile, Tm 103.4 and Tc 102.7. Pan cultured. Able to wean from AC to CPAP and tolerating well. ABG wnls. TFs restarted. SBPs labile. On/off Nicardipine. Nicardipine currently on. EVD still place. Neuro exam waxes and wanes.\nWife calling updated by RN.\n\nA/P: s/p SAH with coiling doing well on CPAP. Questionable wean to extubate today.\n\nContinue neuro exam\nKeep SBP 120-180\nQuestion CVL change\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-11-23 00:00:00.000", "description": "Report", "row_id": 1676756, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\nNEURO- PROPOFOL TURNED OFF THIS AM, PT SLOW TO WAKE UP. THIS AFTERNOON, PT , ALERT AT TIMES, NOT FOLLOWING COMMANDS. MAE ON THE BED. ANXIOUS AT TIMES, BITING TUBE, GRIMACING, MORPHINE 2MG GIVEN X 2 WITH FAIR EFFECT. SPOKE WITH RESIDENT CONCERNING AGITATION AND VERSED GTT TO BE STARTED. PUPILS UNEQUAL, R 2-3MM AND BRISK, L 4-5MM AND BRISK, NEURO RESIDENT SHOWN.\nCV- HYPERTENSIVE MOST OF THE SHIFT, BP REMAINING BETWEEN 150-180 WITH NICARDIPINE GTT. TEAM NOTIFIED THIS AM THAT UNABLE TO WEAN OFF GTT, NO ORDERS FOR PO MEDS AT THIS TIME, HYDRALAZINE CONTINUES PRN WITH EFFECT. HR CONVERTED TO A-FIB THIS AM (NEW FOR PT), EKG DONE, SHOWN TO TEAM. CYCLING CKS, RATE CONTROLLED IN 80'S. KCL REPLETED AND PT BACK IN NSR.\nRESP- LUNGS CLEAR WITH DIMINISHED BASES. SUCTIONED EVERY FEW HOURS FOR THICK YELLOW SPUTUM. NO EXTUBATION TODAY, PT TOO LETHARGIC. REMAINS ON CPAP 5 PS AND 8 PEEP. WILL SEND ABG THIS AFTERNOON.\nGI/GU- ABD SOFT, + BS, NO BM. TOLERATING TF AT GOAL. UOP ADEQUATE, CLEAR YELLOW.\nID- TMAX 102.7, TEAM NOTIFIED. TYLENOL GIVEN WITH FAIR EFFECT. COOLING BLANKET ON MOST OF THE DAY, ROOM KEPT COOL.\n" }, { "category": "Nursing/other", "chartdate": "2152-11-23 00:00:00.000", "description": "Report", "row_id": 1676757, "text": "Respiratory Care:\nPt remains orally intubated and vented. No vent changes done this shift. Lung sounds coarse. Suctioned for thick yellow secretions. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-07 00:00:00.000", "description": "Report", "row_id": 1676808, "text": "focus update note\nafebrile, heart rate 70s, sbp 130-150 goal 120-180.\n\nresp: pt on 10 liters 50% O2 trach mask, lung sounds clear to coarse, diminished at bases\n\ngu/gi: tube feeding at goal at 75cc hr, minimal residual, abdomen soft distended/obese, positive bowel sounds, no bm, ? start bowel regime, urine amber with sedement, urine output >50cc hr.\n\nneuro: spontaneously opening eyes, unable to communicate secondary to CVA, stuck out tounge to command x 1, coughed to command X 2, no spontaneous movement, flexes /withdraws to painful stimuli, pupils perla 3mm bilaterally. per pt's wifes reports - pt kissed wife X 4.\n\nplan: continue to monitor neuro status, awaiting step down bed\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-12-07 00:00:00.000", "description": "Report", "row_id": 1676809, "text": "RESPIRATORY CARE: PT W/ AN 8.0 PORTEX TRACH IN PLACE.\nWEARING A 50 % TRACH COLLAR W/ RR 28 BPM AND SPO2\n98 %. SX FOR THICK TAN SPUTUM. WILL C/W TRACH COLLAR\nAS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-08 00:00:00.000", "description": "Report", "row_id": 1676810, "text": "npn\nNeuro- see neuro flow sheet for eval. pt cont with minimal movement when withdrawing to stim with right weaker than left. pearl. keppra 1500 mg tid. no siezure activity.\n\n\n\nResp- tol trach collar- cont coughing up lg amounts thick yellow secretions, o2 sat >95, lungs coarse bilat.\n\n? to 11 stepdown today if bed available.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-08 00:00:00.000", "description": "Report", "row_id": 1676811, "text": "Resp Care Note, Pt remains t-collar 50%. Suctioned and expectorating mod amts thick yellow secretions. Atrovent MDI given last 0500. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2152-12-08 00:00:00.000", "description": "Report", "row_id": 1676812, "text": "discharge note\nd: pt discharged to rehab facility via acls ambulance. trach mask at 50%. feedings stopped and peg irrigated and capped. triple lumen cath in place and all ports capped. wife notified\n" }, { "category": "ECG", "chartdate": "2152-11-23 00:00:00.000", "description": "Report", "row_id": 277655, "text": "Ectopic atrial rhythm with short P-R interval. Otherwise, within normal\nlimits. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2139-12-08 00:00:00.000", "description": "Report", "row_id": 61353, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 68\nWeight (lb): 158\nBSA (m2): 1.85 m2\nBP (mm Hg): 160/105\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 09:51\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). False LV tendon (normal variant).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Characteristic\nrheumatic deformity of the mitral valve leaflets with fused commissures and\ntethering of leaflet motion. Moderate mitral annular calcification. Mild MS.\nMild (1+) MR. [Due to acoustic shadowing, the severity of MR may be\nsignificantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened. There is\nno aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are moderately thickened. The mitral valve shows characteristic\nrheumatic deformity. There is mild mitral stenosis. Mild (1+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-12-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 845918, "text": " 9:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ESRD s/p renal transplant, with hypertensive crisis and\n headache\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End stage renal disease, status-post renal transplant with\n hypertensive crisis and headache.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: None.\n\n HEAD CT: There is no acute intra or extraaxial hemorrhage. An area of low\n attenuation and volume loss is present in the left cerebellar hemisphere,\n likely secondary to prior infarct. Bilateral basal ganglia and calcifications\n are present. There are calcifications within the left vertebral artery and\n within the carotid arteries. The patient has a prosthetic left eye. The\n ventricles, cisterns, and -white matter differentiation are unremarkable.\n There is no mass effect and no shift of normally midline structures.\n\n The osseous structures are unremarkable. The mastoid air cells are normally\n aerated. There is near complete opacification of the left sphenoid air cell.\n There is apparent thickening of the bone around this air cell suggestive of a\n chronic sinus condition. The ethmoid air cells, sphenoid air cells, and\n visualized portion of the maxillary sinuses are normally aerated.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage or mass effect.\n\n 2. Encephalomalacia change in the left cerebellar hemisphere, likely\n consistent with old infarct.\n\n 3. Soft tissue density with osseous thickening in the left sphenoid air cell,\n likely consistent with chronic sinus infection or mucocele.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-12-07 00:00:00.000", "description": "GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)", "row_id": 846021, "text": " 8:24 AM\n GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) Clip # \n Reason: r/o rejection\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with acute on chronic renal failure\n REASON FOR THIS EXAMINATION:\n r/o rejection\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Acute on chronic renal failure to assess for possible\n transplant rejection.\n\n Real-time guidance was provided for the nephrology team for purposes of renal\n transplant biopsy. Two 16-gauge biopsies were obtained from the upper pole of\n the transplant with good specimens obtained and no immediate complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-12-06 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 845938, "text": " 8:03 AM\n RENAL TRANSPLANT U.S. Clip # \n Reason: r/o obstruction. Please do DOPPLER to evaluate vasculature.\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ESRD s/p cadaveric transplant ', now w/ acute renal\n failure\n REASON FOR THIS EXAMINATION:\n r/o obstruction. Please do DOPPLER to evaluate vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End stage renal disease, status-post renal transplant with acute\n renal failiure, rule-out obstruction.\n\n Comparison is made to the prior ultrasound dated .\n\n RENAL TRANSPLANT ULTRASOUND: The renal transplant is again identified in the\n right lower quadrant, measuring 12.6 cm. There is mild fullness of central\n collecting system, decreased from the prior study. There is no masses or\n stones. The cortex is preserved. The bladder is unremarkable. Note is made\n of a stent.\n\n Color flow and Doppler examination of the renal transplant was performed to\n evaluate vasculature. Normal venous flow is identified. The resistive\n indices measured in the upper mid and lower pole of the kidney range from 0.77\n to 0.82. The main renal artery is patent.\n\n IMPRESSION:\n 1. No hydronephrosis or stones.\n 2. Patent renal transplant vasculature with unchanged resistive indices.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2139-12-07 00:00:00.000", "description": "BLADDER VOLUMETRIC US", "row_id": 846076, "text": " 3:58 PM\n BLADDER VOLUMETRIC US Clip # \n Reason: please check post void residual\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with arf and renal graft\n REASON FOR THIS EXAMINATION:\n please check post void residual\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Acute renal failure and the patient was renal transplant\n and difficulty voiding; to assess for postvoid volume.\n\n Preliminary views of the bladder reveal normal wall with no filling defects,\n although there is a diverticulum seen along the dome of the bladder. Bladder\n volume prevoid is estimated at approximately 250 cc. Following voiding,\n repeat volume determination shows a residual volume of approximately140 cc.\n The diverticulum remains filled.\n\n CONCLUSION:\n\n Incomplete bladder emptying with moderate postvoid residual of 140 cc.\n Bladder diverticulum noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-12-07 00:00:00.000", "description": "PICC W/O PORT", "row_id": 846086, "text": " 4:46 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc line\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n PRELIMINARY ADDENDUM\n\n\n DR. \n DR. \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\n 4:46 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc line\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with esrd s/p kidney transplant who presented with htn urgency\n and renal failure now with only access is groin line\n REASON FOR THIS EXAMINATION:\n picc line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male status-post orthopic renal transplantation with\n need for IV access for antibiotics. IV Therapy was not able to advance a PICC\n line.\n\n PROCEDURE: This procedure was performed by Dr. and Dr. . Dr.\n , the attending radiologist, was present during the entire procedure.\n\n The patient was brought to the angiography table and placed in supine\n position. The right arm was extended. The upper arm was prepped and draped\n in the standard sterile fashion. Since no suitable veins were visible,\n ultrasound was used for localization of a suitable vein. The basilic vein was\n patent and compressible. After local anesthesia with approximately 4 cc of 1%\n lidocaine, the basilic vein was entered under ultrasonographic guidance with a\n 21-gauge needle. A 0.018 guidewire was advanced into the left subclavian\n vein. We were not able to advance the wire over the superior vena cava. A\n venogram was then performed, and demonstrated thrombosis of the right\n brachiocephalic vein and possibly the SVC. It was decided then, to place a\n midline PICC line. Based on the markers on the wire, it was determined that\n the length of 26 cm would be suitable. The PICC line was trimmed to length\n and advanced over a 4-French introducer sheath under fluoroscopic guidance\n into the right subclavian vein. The sheath was then removed. The catheter\n was flushed. A final chest x-ray was obtained. The film demonstrated the tip\n of the PICC line in the right subclavian vein. The line is ready for use. A\n STAT-lock device was applied, and the line was HEP-blocked.\n\n IMPRESSION\n 1. We were unable to place the PICC line in the SVC due to thrombosis of the\n right brachiocephalic vein and possibly the SVC.\n 2. A midline PICC line was placed with the tip in the right subclavian vein.\n The line is ready for use.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2139-12-08 00:00:00.000", "description": "R RENAL TRANSPLANT U.S. RIGHT", "row_id": 846197, "text": " 2:34 PM\n RENAL TRANSPLANT U.S. RIGHT Clip # \n Reason: r/o hydro, bleeding, and patent blood flow\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p renal transplant p/w ARF, had renal biopsy yesterday,\n now with drop in Hct and rise in creatinine. Please r/o parencymal bleed, and\n assess for hydro as well as patent blood flow through renal vessels.\n REASON FOR THIS EXAMINATION:\n r/o hydro, bleeding, and patent blood flow\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 67-year-old man status post renal transplant with acute renal\n failure. Now status post renal biopsy and dropping hematocrit and rising\n creatinine.\n\n COMPARISON: .\n\n Transplanted kidney is identified in the right pelvic fossa and measures 11.9\n cm. There is no perirenal fluid collection and no evidence of hydronephrosis.\n The bladder is remarkable for a small diverticulum.\n\n Color flow and Doppler examination of the renal transplant demonstrates patent\n renal artery and vein. Resistive indices measured from the upper and mid pole\n of the kidney range from 0.72 to 0.78.\n\n IMPRESSION:\n\n 1. Normal appearance of transplanted kidney with no evidence of perirenal\n collection or hydronephrosis.\n 2. Patent renal transplant artery and vein with stable resistive indices.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 845917, "text": " 9:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid overload\n Admitting Diagnosis: HYPERTENSIVE CRISIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with h/o HTN, ESRD s/p renal transplant, and recent CHF\n exacerbation\n REASON FOR THIS EXAMINATION:\n eval for fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 10 P.M. ON :\n\n INDICATION: Renal transplant and failure.\n\n The heart is slightly enlarged with pulmonary venous redistribution. No focal\n infiltrates are present. Post CABG changes are evident and a number of\n sutures with pleural thickening are present in the right lung apex, and these\n latter changes are unchanged over the past 3 years.\n\n IMPRESSION: Mild CHF.\n\n" }, { "category": "ECG", "chartdate": "2139-12-09 00:00:00.000", "description": "Report", "row_id": 116324, "text": "Sinus rhythm. Since the previous tracing of probably no significant\nchange in previously described features.\n\n" }, { "category": "ECG", "chartdate": "2139-12-07 00:00:00.000", "description": "Report", "row_id": 116325, "text": "Sinus bradycardia. Left atrial abnormality. Left ventricular hypertrophy.\nJ point ST segment elevation probably related to the left ventricular\nhypertrophy. Since the previous tracing of probably no significant\nchange.\n\n" }, { "category": "Nursing/other", "chartdate": "2139-12-06 00:00:00.000", "description": "Report", "row_id": 1449254, "text": "NURSING PROGRESS NOTE 2100-0700\nREPORT RECEIVED FROM . PT TX VIA AMBULANCE- ARRIVED TO 771 MICU B WITHOUT INCIDENT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 67 Y/O M PT WITH PMH OF HTN, DIABETES, HEP C, PPD POSITIVE, HEROIN ABUSE, ESRD S/P CADAVERIC TRANSPLANT IN WHO PRESENTED TO ON C/O DYSPNEA X 2 DAYS. PT NOTED TO BE HYPERTENSIVE WITH SBP 160-170'S AND PE CONSISTENT WITH CHF- TX WITH LASIX. MONITORING FOR HEROIN WITHDRAWAL. ON , PT NOTED TO HAVE HTN CRISIS WITH SBP IN THE 200'S UNRESPONSIVE TO PO MEDS. PT TX TO FOR FURTHER MANAGEMENT.\n\nNEURO: PT ALERT AND ORIENTED X 3- ABLE TO MOVE HIMSELF IN BED, FOLLOWS COMMANDS WITHOUT DIFFICULTY. SPEECH CLEAR. EQUAL STRENGTH NOTED TO 4 EXTREMITIES. PT LOST LT EYE S/P ACCIDENT, RT PUPIL IS 3/BRISK. AFEBRILE. PT HAS BEEN C/O SEVERE () HA- EMERGENT HEAD CT DONE- NEGATIVE. TX WITH TYLENOL AND OXYCODONE. NO SEIZURE ACTIVITY NOTED.\n\nRR: RA. SP02 > OR = TO 95%. BBS= ESSENTIALLY CLEAR. BILATERAL CHEST EXPANSION NOTED. DENIES ANY DIFFICULTY BREATHING OR SOB. RR- 20-25 AND REGULAR. STRONG COUGH EFFORT- NON-PRODUCTIVE.\n\nCV: S1 AND S2 AS PER AUSCULTATION. PT DENIES ANY CHEST PAIN. NSR, HR 70-80'S. SBP 160-170'S. GOAL OF SBP < 190. PALPABLE PULSES TO BILATERAL DORSALIS AND RADIALS. RT FEM GROIN LINE TLC CVL.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. BS X 4 QUADRANTS. NO BM. PASSING FLATUS. ABLE TO TAKE PO MEDS WITHOUT DIFFICULTY. NO C/O N/V/D.\n\nGU: PT VOIDS IN URINAL WITHOUT DIFFICULTY. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nSOCIAL: NO CONTACT WITH FRIENDS OR FAMILY.\n\nPLAN: MONITOR FOR HEROIN WITHDRAWAL, RENAL US THIS AM, MANAGE FOR HTN CRISIS PRN. POSSIBLE C/O. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" } ]

[ { "category": "Nursing/other", "chartdate": "2165-02-18 00:00:00.000", "description": "Report", "row_id": 1517770, "text": "NSICU Nursing admission note\n49 y/o woman admitted from PACU s/p cholecytectomy, liver resection of segments 6 & 4B and intra op US for metastatic colon ca.\n\nPMH: diabetes, HTN, IHSS, CHF, reflux, s/p chemo for colon ca, acromegly, sinusitis\n\nPSH: sigmoid colectomy for colon ca, pacemaker ' (DDD), brain tumor resection ', c-section, pituitary tumor resection.\n\nAllergies: PCN, sulfa\n\nReview of Systems:\nCV: BP 138-158/60-80s HR 70-80s paced, PA 33/17 CVP 6, unable to wedge catheter. CI 4.7 SVR 686. Pt receiving IVF d1/2NS with 20meq KCL at 100cc/hr. Started on Lopressor IV.\nRespiratory: lung sounds clear, decreased at bases, RR 28-32 regular, O2sats 100% on 3L NC\nGI: abdomen distended, soft, no BS noted. Abdomen dsg intact with 2 areas of staining noted (1x2cm & 5x10cm areas) - no changed since arrival. JP intact - 20cc bloody drainage over past 2hrs.\nNo n/v. NGT d/c'd.\nGI: foley in place, draining clear yellow urine u/o >100cc/hr\nNeuro/Pain: Pt responding to voice, oriented to person and place, responds appropriately to questions. Pt initially c/o abdomenal pain. Pt has epidural of Bupivicain 0.1% + Hydromorphone 20mcg/cc at 8cc/hr. Pain service called. Pt given lidocaine bolus by MD. Pt states pain level gradually decreasing down to 1-2.\nAccess: Pt has R iJ PA line, R radial aline\nSocial: Family visited, updated by MD.\n" }, { "category": "Nursing/other", "chartdate": "2165-02-19 00:00:00.000", "description": "Report", "row_id": 1517771, "text": "system update\nd: CARDIOVASCULAR- HR 80-100 AV PACED. SBP 150-180- CONTINUES ON LOPRESSOR 5MG IV Q4HRS ATC. PAD 12-18. CI 3.9-4.0 UNABLE TO WEDGE CATHETER.\nRESP- SATS 96-98% ON NP AT 3 LITERS, BS DIMINISHED IN BASES.\nGI- NPO EXCEPT FOR MEDS, NO BS PRESENT\nGU- CLEAR YELLOW VIA FOLEY- >100CC/HR\nNEURO- AWAKE AND ALERT, COOPERATIVE, FOLLOWS COMMANDS\nSKIN- ABD DRESSING HAS SM AMT OLD STAINING PRESENT. JP TO BULB SX WITH SM AMT SEROSANG DRAINAGE\nPAIN- EPIDURAL INFUSING AT 8CC/HR WITH GOOD PAIN CONTROL, AT 0130, PT STATES SHE IS HAVING INCREASED PAIN - APS (DR ) NOTIFIED, PT GIVEN BOLUS OF 5CC OF EPIDURAL INFUSION AND IS PRESENTLY SLEEPING\nA: HEMODYNAMICS MONITORED, LYTES REPLETED AS ORDERED\nR: STABLE POST-OP COURSE, ENCOURAGE PT TO COUGH AND DEEP BREATHE -IS Q1-2HRS\n" }, { "category": "Nursing/other", "chartdate": "2165-02-19 00:00:00.000", "description": "Report", "row_id": 1517772, "text": "TRANSFER NOTE\n\nS/P CHOLECYSTECTOMY AND LIVER RESECTION ON . PT HAS HX OF TYPE II DIABETES, CONTROLLED WITH ORAL AGENTS, HYPERTENSION AND DDD PACEMAKER, ALSO IHSS, BRAIN TUMOR RESECTION IN , AND REFLUX, SINUSITITS AND SLEEP APNEA, SHE IS ALLERGIC TO PENICILLIN AND SULFA. POST-OP COURSE DID WELL, PT IS ALERT & ORIENTED, FOLLOWS COMMANDS, MAE, CV: SWAN LINE CHANGED TO TRIPLE LUMEN OVER WIRE RT IJ TODAY, CONFIRMED BY X-RAY, ? ACCURACY OF C.O. READINGS-9.18 (OCCAS HIGH NUMBERS?), UNABLE TO WEDGE, OVER TEENS, CORE TEMP 99.3, PRESENTLY AT 100.3 ORAL, HR 80'S AV PACED, STARTED ON VERAPAMIL PO\nRESPIR: LUNGS CLEAR, DIM AT BASES\nWOUND: ABD INCISION-STERI STRIPS INTACT, SCANT OLD BLOODY DGE ON DSG, JP DRAIN MINIMAL BLOODY DGE,\nPAIN CONTROL: EPIDURAL WITH BUPIVICAINE AT 6CC/HR, (WAS AT 8CC/HR BUT PT REQUESTED TO DECREASE IT SINCE HER PAIN THRESHOLD WAS IMPROVED),\nA LINE RT RADIAL DC/D, RAUMA LINE LEFT ANTECUB TO BE ,\nPT WILL TRANSFER OUT OF SICU THIS PM\n" }, { "category": "ECG", "chartdate": "2165-02-21 00:00:00.000", "description": "Report", "row_id": 286777, "text": "Sinus rhythm. Pacemaker rhythm atrially sensed and ventricularly paced.\nPossible left atrial abnormality. Compared to the previous tracing of \nthe pacemaker rhythm persists. Otherwise, there is no significant change.\n\n" } ]

[ { "category": "ECG", "chartdate": "2133-09-24 00:00:00.000", "description": "Report", "row_id": 156287, "text": "Normal sinus rhythm. Delayed R wave transition. Cannot exclude anterior wall\nmyocardial infarction. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-09-23 00:00:00.000", "description": "Report", "row_id": 156288, "text": "Normal sinus rhythm. RSR' pattern in leads V1-V2 is probable normal variant.\nDelayed R wave transition. Compared to the previous tracing of no\ndiagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2133-09-23 00:00:00.000", "description": "Report", "row_id": 156289, "text": "Sinus rhythm at upper limits of normal rate. Generalized low voltage.\nRSR' pattern in leads V1-V2. Since the previous tracing of \nthe Q-T interval is shorter. The rhythm is more irregular. ST-T wave\nabnormalities are less prominent. Clinical correlation is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2133-09-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1256259, "text": " 9:49 AM\n CHEST (PA & LAT) Clip # \n Reason: consolidation?\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with DKA\n REASON FOR THIS EXAMINATION:\n consolidation?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: DKA, to assess for consolidation.\n\n FINDINGS: In comparison with the study of , there is again enlargement of\n the cardiac silhouette. There is better penetration of the image, so that\n there is no evidence of pulmonary vascular congestion at this time. The\n lateral view is limited due to extensive scattered radiation related to the\n size of the patient. No acute focal pneumonia.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2170-02-16 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1177558, "text": " 10:01 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: see below\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with Ogilvies syndrome assess for interval change\n REASON FOR THIS EXAMINATION:\n see below\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of ileus for interval change.\n\n COMPARISON: Portable abdominal radiograph from .\n\n TECHNIQUE: Supine and upright abdominal radiographs were obtained.\n\n FINDINGS: There is continued air-filled dilatation of the small and large\n bowel loops, similar in appearance in comparison to prior study and consistent\n with stable ileus. Otherwise, IVC filter is again visualized in the mid\n abdomen. Degenerative changes are noted throughout the lumbar spine. NG tube\n is visualized coiled in the stomach.\n\n IMPRESSION: Stable appearance of ileus with no significant interval change in\n comparison to prior study from .\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-17 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1177727, "text": " 9:47 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with Ogilvies syndrome assess for interval change\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN ON \n\n HISTORY: 67-year-old man with history of syndrome, question interval\n change.\n\n IMPRESSION: One upright and one supine view of the abdomen are compared to a\n series of the abdominal radiographs since . Today's study shows\n generalized distention of the bowel, primarily the colon, that is not as\n severe as it was on the first study in this series on . The\n rectosigmoid, currently 163 mm wide, was 186 mm and the cecum which is 8 cm\n today, was 10 cm. Nevertheless, there is substantial volume of dilated colon.\n The transverse contains air and fluid and is greater caliber, 8 cm than it has\n been before. Nasogastric tube ends in the stomach which is not distended. I\n do not see gas in the wall of any bowel, nor free intraperitoneal gas. Caval\n umbrella filter has not migrated.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177287, "text": " 10:52 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: REPOSITION OF OGT\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Reposition of the orogastric tube.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the nasogastric tube has\n been re-positioned. The tube is coiled in the proximal parts of the stomach,\n the tube could be advanced by approximately 5-10 cm. The sidehole projects\n over the gastroesophageal junction. No evidence of complications, notably no\n pneumothorax. Unchanged aspect of the heart and the lung parenchyma.\n Unchanged massively gas-filled bilateral bowel loops.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177286, "text": " 10:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ngt that seems to be coming out\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Reposition of nasogastric tube. Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the nasogastric tube has\n been pulled back. The tip of the tube now projects over the gastroesophageal\n junction. No evidence of complications, notably no pneumothorax. The tube\n needs to be repositioned and presumably moved forward by approximately 15 cm.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1177146, "text": " 9:04 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for change in distention\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with olgivies\n REASON FOR THIS EXAMINATION:\n evaluate for change in distention\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of ileus, for interval change.\n\n COMPARISON: Portable abdominal radiograph from .\n\n TECHNIQUE: Single supine portable abdominal radiograph was obtained.\n\n FINDINGS: Air-filled distended loops of small and large bowel are visualized\n with a decrease in degree of distention in comparison to radiographs from\n yesterday. IVC filter is again visualized in the mid abdomen. Osseous\n structures are grossly unremarkable. An overlying drain is visualized over\n the left lower quadrant, possibly a foley.\n\n IMPRESSION: Interval decrease in distention of small and large bowel loops\n suggestive of improving ileus.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-12 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1176825, "text": " 12:53 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval dilated colon\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with hypotension and dilated colon on KUB\n REASON FOR THIS EXAMINATION:\n eval dilated colon\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SESHa MON 3:19 PM\n Gaseous distension/dilation of bowel. no bowel obstr, likely ogilvies\n syndrome. no free air.\n ivc filter in place.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST CT SCAN OF THE ABDOMEN AND PELVIS PERFORMED ON \n\n Comparison is made with a chest radiograph from earlier today.\n\n CLINICAL HISTORY: Hypotension, radiograph demonstrating dilated colon,\n question obstruction.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images through the\n abdomen and pelvis without oral or IV contrast material. Coronal and sagittal\n reformations were provided.\n\n FINDINGS:\n\n LUNG BASES: There are bibasilar areas of atelectasis with trace bilateral\n pleural effusions. There is a coronary artery calcification noted with a\n small pericardial effusion. The NG tube courses into the proximal stomach.\n\n ABDOMEN: There is extensive gas-filled small and large bowel without definite\n signs of free air or pneumatosis. The liver is small which may be secondary\n to left lobe resection, and no focal lesions on this non-contrast study are\n seen. The spleen is unremarkable. Both adrenal glands appear normal in size\n and configuration. The pancreas is difficult to assess and appears quite\n atrophic. The kidneys bilaterally appear normal. An IVC filter is seen\n within the IVC, infrarenal. Aorta is normal in caliber, somewhat tortuous\n course with scattered areas of atherosclerotic calcification.\n\n The stomach is mostly decompressed. The duodenum is unremarkable.\n\n PELVIS: Loops of small bowel contain air-fluid levels and are mildly dilated.\n There is no point of obstruction/transition. The large bowel is markedly\n distended and dilated along its distal extent with no transition point. A\n fluid at the level of the rectosigmoid is noted, and overall findings are most\n suggestive of /pseudo-obstruction. No free fluid in the pelvis.\n Urinary bladder is only partially distended.\n\n BONES: No suspicious bony lesions. Old left posterior rib fractures noted.\n Bones are somewhat demineralized. Degenerative changes at the lumbosacral\n (Over)\n\n 12:53 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval dilated colon\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n junction. Lumbarization of S1 noted.\n\n IMPRESSION:\n 1. Dilated large bowel and small bowel without transition point with an\n overall configuration most compatible with pseudo-obstruction.\n 2. Trace bilateral pleural effusions with areas of bibasilar atelectasis,\n left greater than right.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2170-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176818, "text": " 11:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with lethargy\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n Comparison is made with prior chest radiograph from .\n\n CLINICAL HISTORY: Lethargy, hypotension, question pneumonia.\n\n FINDINGS: AP upright view of the chest is obtained. There is extensive\n gaseous distension of bowel below the diaphragm. Low lung volumes limit\n evaluation. There is no definite sign of pneumonia or CHF. Cardiomediastinal\n silhouette appears stable. No pneumothorax. Bones appear intact.\n Evaluation for free air below the diaphragm is limited given the extensive\n gas- filled bowel filling the upper abdomen. An IVC filter is incidentally\n noted in the mid abdomen.\n\n IMPRESSION: Extensive gas-filled bowel below the diaphragm. Please correlate\n clinically and with CT as needed. No definite signs of acute intrathoracic\n process.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2170-02-12 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1176845, "text": " 2:03 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for airfluid levels\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ? obstruction\n REASON FOR THIS EXAMINATION:\n eval for airfluid levels\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH PERFORMED ON \n\n Comparison made with a CT abdomen and pelvis from earlier today as well as a\n portable abdomen CT from .\n\n CLINICAL HISTORY: Abdominal pain, question obstruction or air-fluid levels.\n\n FINDINGS: A total of four images of the abdomen were provided including\n supine and lateral decubitus views. There is diffuse bowel gaseous\n distention. Suture material in the region of the sigmoid colon noted. An IVC\n filter is seen in the right mid abdomen. No free air on decubitus views.\n\n IMPRESSION: Gaseous distention of small and large bowel, better assessed on\n CT from earlier today.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-13 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1176981, "text": " 9:39 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for change in distention\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with distention, likely olgivie's, has started having BMs\n REASON FOR THIS EXAMINATION:\n evaluate for change in distention\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with distention for interval change.\n\n COMPARISON: CT abdomen and pelvis without contrast on and\n abdominal radiographs from .\n\n TECHNIQUE: Two supine abdominal radiographs were obtained.\n\n FINDINGS: There are dilated air-filled loops of small and large bowel,\n similar in size in comparison to prior study from , and suggestive\n of ileus. A suture line is visualized along the sigmoid colon. An IVC filter\n is again visualized in the right mid abdomen.\n\n IMPRESSION: Continued gaseous distention of small and large bowel remains\n unchanged and consistent with ileus.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176891, "text": " 8:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with questionable SBO\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:50 P.M. ON \n\n HISTORY: SBO. NG tube placement.\n\n IMPRESSION: Nasogastric tube ends in the stomach. Limited abdominal imaging\n on this chest radiograph shows large and small bowel dilatation and no free\n subdiaphragmatic gas. Moderate cardiomegaly has worsened since ,\n stable since and left lower lobe consolidation which cleared was\n probably atelectasis. There is no appreciable pleural effusion. Pulmonary\n vascular engorgement is borderline, exaggerated by low lung volumes.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-15 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1177353, "text": " 9:06 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for any interval change.Please perform around\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with syndrome.\n REASON FOR THIS EXAMINATION:\n Please assess for any interval change.Please perform around 0900 \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of ileus for interval change.\n\n COMPARISON: Abdominal radiograph from .\n\n TECHNIQUE: Two portable supine abdominal radiographs were obtained.\n\n FINDINGS: Again visualized are stable-appearing dilated air-filled loops of\n small and large bowel consistent with stable ileus. A previously dilated loop\n of sigmoid colon appears less distended. IVC filter is again visualized in mid\n abdomen. Osseous structures remain grossly unremarkable. An overlying drain\n consistent with a possible Foley catheter is again visualized from the midline\n to the left lower quadrant.\n\n IMPRESSION: Distended air-filled small and large bowel loops consistent with\n stable ileus. A previously dilated loop of sigmoid colon appears less\n distended.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177078, "text": " 4:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess NGT placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new NGT placement\n REASON FOR THIS EXAMINATION:\n assess NGT placement\n ______________________________________________________________________________\n WET READ: JBRe TUE 5:24 PM\n NGT ends in the corpus of the stomach. Unchanged moderate CMG but no\n significant edema. No focal consolidation. Dilated small and large bowel\n loops.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with new NG tube placement, check position.\n\n TECHNIQUE: Portable AP chest radiograph submitted for review, compared to\n prior chest radiograph .\n\n FINDINGS:\n There is gaseous distention of the visualized small bowel loops in the upper\n abdomen. This is better appreciated on the abdominal radiograph performed on\n the same date. An NG tube has been inserted, the tip of which lies within the\n stomach. Both hemidiaphragms are elevated, causing reduced lung volumes\n bilaterally, the lungs are grossly clear.\n\n" }, { "category": "ECG", "chartdate": "2170-02-12 00:00:00.000", "description": "Report", "row_id": 254155, "text": "Sinus bradycardia. Left atrial abnormality. Non-specific inferior ST-T wave\nflattening. Compared to the previous tracing of single atrial\nmorphology is now recorded while the rate has decreased. Otherwise, no\ndiagnostic interim change.\n\n" } ]

[ { "category": "ECG", "chartdate": "2126-03-19 00:00:00.000", "description": "Report", "row_id": 196347, "text": "Atrial fibrillation. Modest non-specific lateral T wave abnormalities. Since\nthe previous tracing of lateral T wave changes are slightly more\nprominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-03-18 00:00:00.000", "description": "Report", "row_id": 196348, "text": "Baseline artifact. Atrial fibrillation. Modest non-specific low amplitude\nlateral T wave changes. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2117-05-26 00:00:00.000", "description": "SCOLIOSIS SERIES", "row_id": 1198261, "text": " 3:48 PM\n SCOLIOSIS SERIES Clip # \n Reason: post-op\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with T4-L4 PSIF. Xray standing in brace please.\n REASON FOR THIS EXAMINATION:\n post-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: X-ray standing in brace.\n\n AP and lateral views of the thoracolumbar spine were obtained and\n post-processed to generate a standing AP and lateral three-foot views.\n\n Fine bony detail is considerably limited by osteopenia and technical factors.\n There are bilateral spinal rods extending from the upper thoracic to lower\n lumbar spine. No gross hardware failure is detected. There is made of sigmoid\n scoliosis of the spine, convex right in the upper thoracic and convex left in\n the lower lumbar spine. There is exaggeration of usual lordosis on these\n films obtained in brace. I suspect loss of height of several vertebral\n bodies, though this appearance is likely exaggerated by the scoliosis.\n\n There is blunting of the right hemidiaphragm and atelectasis at the right lung\n base.\n\n IMPRESSION: S/p fusion. Scoliosis and kyphosis noted. No hardware failure\n detected.\n\n" }, { "category": "Radiology", "chartdate": "2117-05-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1197969, "text": " 4:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: tube and line placement\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman intubation\n REASON FOR THIS EXAMINATION:\n tube and line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation, evaluate tube and line placement.\n\n COMPARISON: .\n\n TECHNIQUE: AP portable upright view of the chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating approximately\n 5.7 cm from the carina. A right internal jugular venous access catheter\n terminates with tip in lower SVC. Heart size and mediastinal contours are\n within normal limits. Since the previous examination there has been placement\n of bilateral paraspinal fusion rods with multiple pedicle screws. There is\n new bibasilar consolidation or atelectasis most marked at the left base with\n left retrocardiac opacity. No evidence of pneumothorax.\n\n IMPRESSION:\n 1. Endotracheal tube and right internal jugular venous access catheter in\n satisfactory position.\n\n 2. Bibasilar atelectasis or consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2117-05-24 00:00:00.000", "description": "O THOR SP,SINGLE FILM IN O.R.", "row_id": 1197891, "text": " 9:02 AM\n SP,SINGLE FILM IN O.R. Clip # \n Reason: T4-L4 POSTERIOR FUSION\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n THORACIC SPINE, .\n\n CLINICAL INFORMATION: T4-L4 posterior fusion.\n\n FINDINGS:\n\n Five total intraoperative images demonstrate posterior fusion of the\n thoracolumbar spine. Please refer to operative note for full details.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2141-12-03 00:00:00.000", "description": "Report", "row_id": 1554923, "text": "CCU Progress Note:\n\nS-\"Can I go for a walk?\"\n\nO- see flowsheet for all objective data.\n\nneuro- much more alert today- oriented to person & place- moving all extremities- pleasant & cooperative- follows command- OOB to chair- able to weight bear, so pivots well- However, walks poorly (doesn't know what to do with his feet once in a standing position)- Also, has difficulty with fine motor skills.\n\ncv- Tele: Afib rare PVC- HR 94-113- NIBP 113-141/57-93- MAPs 70-100- tolerating lopressor & captopril- started on diltiazem today without incident- Hct 35.1- K 4.0- Mg 1.9- heparin gtt 1600u/hr- PTT 56.8- Plan is for ICD placement tomorrow- D/C heparin @ 0400.\n\nresp- lung sounds coarse, diminished @ the bases- resp even, non-labored- annoyed by NC\u0013 this am- SpO2 92-95% on room air- O2 off.- CXR- resolving CHF.\n\ngi- abd soft (+) bowel sounds- taking Po well today- attemted to use commode this afternoon- no BM.\n\ngu- foley draining amber colored urine qs- (-) 400cc since 12 am- BUN 12 Crea .7\n\nA- pre-op for ICD tomorrow.\n\nP NPO after 12am- D/C heparin gtt @ 0400- monitor vs, lung sounds & I&O- trazodone ordered for sleep if needed- offer emotional support to Pt & family- keep them updated on plan of care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-12-04 00:00:00.000", "description": "Report", "row_id": 1554924, "text": "ccu npn\n\ns: \" I had cardioversion once but it doesn't help\"\n\ncv: remains in a-fib ,better rate control on lopressor, diltiazem. Improving bp on captopril. hr 77-90 a-fib with rare pvc noted. K+ 3.6 md aware. repleted w 40 meq kcl po. mg 1.9 denies c/o cp. sbp 120-140 with map's > 60. con't on heparin @ 1600u/hr. to d/c @ 0400 for icd\n\nresp; ra sats 91%, but no c/o sob. bs course to fine crackles noted bilat at bases. non productive cough noted. o2 @ 3l applied w improving sats 95-96%. at times pt will pull off 02 and forget to re-apply. o2 nc re-applied by rn w con't re-inforcment to pt to wear.\n\ngi: npo after mn for icd. appetite on eves good. able to feed self lagre finger foods. had some difficulty w fine motor skills on days. able to manage putting small pills in mouth to swallow. abd soft, non tender. no stool overnoc\n\ngu: u/o > 100cc/hr yllow without sed. see i/o\n\nskin: intact. has eccymotic area on back l side ? etioogy appears to be resolving. denies pain.\n\nneuro; a/o x2 forget month, but can recall the year. short term memory improving. can recall nurses name. knows names of shows and football games he watched today. can lift and hold all ext. able to bring cup to mouth and manage small pills. pupils 2mm brisk. he is asking appropriate questions about pending procedures. he has asked for a cigarette, and even asked to go home and come back in am for procedure. risk and benefits reviewed w pt. explanation of smoking policies reviewed w pt which were re-inforced. he has been calm. no attempts made to get oob. he has been cooperative. all side elevated. bed alarm on. and freq checks of pt completed. he received trazadone @ hs which had poor effect. dr aware. additional ambien given and he has slept in long naps.\n\nid: afebrile con't on flagyl,levofloxcin. has vanco on call for icd. presumed pna\n\nsocial: wife and son in on eves, but home for the noc. poc reviewed. wife would like to be here when pt goes for icd.\n\nP; con't npo icd today. heparin off @ 0400. pre-procedure check list initiated. follow neuro status. review poc w family. orient pt as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-12-04 00:00:00.000", "description": "Report", "row_id": 1554925, "text": "TO CATH LAB 12 NOON FOR ICD PLACEMENT .\nPRE PROCEDURE IN AFIB 80S TO 90S .TOL LOPRESSER AND DILTIAZEM AND CAPTOPRIL..R GROIN SITE C/D,GOOD DISTAL PULSES\n\nSAT 93 ON 3LNP.BS COARSE.OM ANTIBX FOR PRESUMED PNA\n\nNPO ,ACTIVE BS .ASKING FOR FOOD .\n\nLG AMT URINE VIA FOLEY C SEDIMENT .\n\nSHORT TERM MEMEORY IMPROVING .STILL SLIGHTLY CONFUSED.WANTS TO GO HOME.FAMILY PRESENT .TRANSFER TO FLOOR DEFERRED TO PROTECT PLACEMENT NEW WIRES AS PT FORGETFUL.\n\nMONITOR POST ICD PLACEMENT .\n\n" }, { "category": "Nursing/other", "chartdate": "2141-12-05 00:00:00.000", "description": "Report", "row_id": 1554926, "text": "53 YR. OLD MAN S/P CARDIAC ARREST , NOW WITH SLOWLY RESOLVING SHORT TERM MEMORY DEFECIT. ->ICD PLACEMENT.\n\nNEURO: A&O X3 MOST OF TIME. OCC. FORGETS DATE/DAY OF WEEK. PLEASANT & COOPERATIVE.\n\nRESP: O2->3L NP. BS COURSE BUT DIMINISHED AT BASES. RR 15-21. O2 SAT 93-96%.\n\nCARDIAC: HR 84-107 AFIB, NO ECTOPY. BP 99-132/67-85. L.SHOULDER DSG D&I. SLING TO L. ARM X24HRS. PT NEEDS REMINDING SLING NEEDS TO STAY ON. BR X 24HRS. C/O CP FROM CPR/SHOCK->MED. WITH ULTRAM X2 WITH MINIMAL EFFECT ACCORDING TO PT. ASKING FOR TYLENOL WITH CODEINE. MED. X1 WITH DILAUDID 1MG PO WITH GOOD EFFECR->SLEEPING.\n\nGI: APPETITE GOOD. ABD. SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PT & DRAINING YELLOW URINE WITH SEDIMENT.\n\nID: T 99.4->98.9(PO). CONT. ON PO LEVOFLOX. PO FLAGGYL D/C'D.\n\nAM LABS PENDING.\n\nPLAN: CALL OUT TO FLOOR.\n SLING UNTIL ~12 NOON\n BEDREST UNTIL ~12 NOON, THEN INCREASE ACTIVITY AS TOL.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-28 00:00:00.000", "description": "Report", "row_id": 1554906, "text": "53 YR OLD SP POLYMORPHIC VT ARREST,SEIZURE ACTIVITY TODAY .HAD FLU SHOT EARLIER .HX AFIB,ON ASA,VIAGRA .HX SMOKING,30 DRINKS A WEEK.WITNESSED ARREST,SLUMPED FORWARD,CPR BY COWORKERS.IN COARSE VF WHEN PARAMEDICS ARRIVED .DEFIBBED X3 TO ASYTOLE,ATROPINE,EPI,SHOCK TO AFIB.INTUBATED IN FIELD.REINTUBATED IN ER,IN A FIB 160S,BP 80S ,MORE SEIZURE ACTIVITY.RX C LOPRESSER 2.5 X4,ESMOLOL GTT,ATIVAN,CT SCAN NEG FOR HEAD BLEED. TROP .018 ,EKG NO MI .ARRIVED BP 60,AFIB 120.BP STABLIZED C 1.5L NS AND DC ESMOLOL.ECHO SHOWED EF 15%.PT AGAIN SEIZED EXTENDING BOTH ARMS AND LEGS AND BITING ETT.CONTROLLED C 4MG ATIVAN AND VESED GTT . TO LAB ,CLEAN CATH .IABP,SWAN PLACED .CI 2.2,INITIAL WEDGE 30.SEIZED IN CATH LAB PLACED ON PROPOFOL. TO CCU FROM LAB AFIB 120.MAPS >75.IABP 1:1 .NO BLEEDING FROM R FEMORAL SITE .PULSES BY DOPPLER .HEPARIN TO BE STARTED P REPEAT HEAD CT SCAN IF NO BLEED .COOLING C ICE BLANKET PER PROTOCOL.ON VECURONIUM ,PROPOFOL,VERSED.TOF DONE. INR 1.1.ABG 7.23/42/275/18.PEEP 5/TV650/RR 20/0N 100%.WEANED TO 60%.SX FOR BLOODY ORALLY ,MIN FROM ETT.BEFORE SEDATION PT FLEXED TO PAINFUL.PUPILS PINPOINT. OG DRAINING PINK.POS BS.DIURESING CYU .SKIN INTACT .FAMILY UPDATED BY PHYSICIAN .\n ARREST ,UNKNOWN CAUSE ,NEURO STATUS UNCLEAR\n,REPEAT CAT SCAN\nCOOLING PER PROTOCOL\nSUPPORT FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2141-11-29 00:00:00.000", "description": "Report", "row_id": 1554907, "text": "ccu npn\n\ns: intubated/mech vent\n\ncv: remains in a-fib with hr's pt's hr 120-130 with stable bp. md's aware and assessing pt. given 5mg lopressor iv x1 sedation titrated up to comfort. improving hr's 100-110 w stable bp's noted. con't on iabp 1:1 systolic unloads , diastolic unloads . pad's 18-21. periods of poor tracing from pa line, believed to be in wedge. flushed and md aware of trace. cvp's . sbp's 80-110 map's > 70. ck 396,907 troponin 0.05 current ci 3.86 pa sats drawn x2 results 95-98. blood noted to be brighter red from pa line. cvp sats sent-75. md aware and ci based on cvp sat. cxr completed to check line placment. dr in attempting to reposition line. echo done initially on adm ef 15%,global hk. started heparin @ mn ptt pending 0600. may consider po dose lopressor. initial ekg neg for ischemia. attempting to cool pt, but w travel time and ct scan cooling was off for 3 hrs. resumed cooling but ? effectiveness as system was off for ct scan.\n\nresp: #8 ett @ 24. mech vent on ac several vent changes overnoc based on abg's currently ac 40%,650 x18,5 suctioned x2 overnoc for minimal to scant white secretions. bs cl/diminished at the bases. finger stas 99-100%\n\ngi: ogt drained pink tinged mixed w barium white drainage. 300cc/o started on protonix. abd soft nontender. hypoactive bs. no stool overnoc. received load barium prior to ct scan.\n\ngu: bun creat wnl. am labs pending. received 100cc contrast in ct scan. adeqaute amt's of urine. yellow w sediment noted. ua/c&s sent and pending. los + 1295.\n\nskin: intact. l buttocks red, but inatct and blanches well. upper ext cool-wrm but w nl color. bilat lower ext. cool + doppler pules bilat, ft cool, dusky. r groin c/d swan/iabp inatct no bleed.\n\npiv: piv's x3 flushed and adeqaute. r rad a-line inserted. iabp/swan via r groin.\n\nid: temp max 99.8 wbc down to 10.3 bld cult x2 drawn\n\nneuro: neurology following pt and into assess on eves. pt will respond to deep nail bed stimulation by withdrawing rue, lle,rle. lue does not respond to deep stimulation. became restless moving bilat le. versed gentle bolus given. rate ^ 4mg, propofol rate ^ 55mcg. tof q 2-3hrs. ma 30 w twitch noted, but pt coughing and attempting to move ext. vecuronium rate ^ 0.06mcgg with adeqaute effect.\n pupils slugglish @ 1mm bilat. does not open eyes to name. unable to follow commands. repeat ct scan over noc neg thus far.\n\nlabs: k+ 3.8 received 20 meq kcl\n mg 1.8 received 2 gm mag sulfate iv\n tox screen neg\n\nsocial: wife and daughters in. wife staying in solarium overnoc. updated on poc, support given. son to arrive today. family very appreciative of care. asking approp question. social service has seen family and will f/u. pt is full code.\n\na/p: 53 yr old w a-fib adm after polymorphic vt arrest/ seizures while at work. witnessed arrest w cpr by bystanders. on arrival to er a-fib w rates 180-200 esmolol, but d/cd d/t sbp <70. witnessed seizures in ew ativan given head ct -. ekg - for ischemi\n" }, { "category": "Nursing/other", "chartdate": "2141-11-29 00:00:00.000", "description": "Report", "row_id": 1554908, "text": "(Continued)\na, but w vt and low ef taken emergently to cath. lhc- cleaned c's , rch ci 2.2,pcwp 30. iabp placed and adm to ccu. + smoker, + etoh. off bb at home d/t e.d. con't to address neuro status, follow hemodynamics, suport family. may consider mri.\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-11-29 00:00:00.000", "description": "Report", "row_id": 1554909, "text": "Resp Care\nPt. remains intubated/sedated/paralyzed on mechanical ventilation/ IABP. Rate/fio2 weaned overnight see careview for details. Brought for CT overnight to r/o PE. Results pnd.\nBs:ess. clear, secreations minimal.\nabgs:most recent reveals mild resp. alkalosis, rate wean accordingly.\nPlaN:continue current support.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-11-28 00:00:00.000", "description": "Report", "row_id": 1554905, "text": "RESPIRATORY CARE: PT FROM OSH S/P CARDIOPULMONARY ARREST.\nINTUBATED AND MECHANICALLY VENTILATED. TAKEN TO CATH LAB\nFOR IABP. FIO2 DECREASED TO .60 AND RR INCREASED TO 24\nIN RESPONSE TO LAST ABG.\n" }, { "category": "Nursing/other", "chartdate": "2141-12-01 00:00:00.000", "description": "Report", "row_id": 1554918, "text": "CCU NPN\n\nS:\"I'm in \"\nO: Please see carevue for all objective data\nneuro: awake, oriented only to self. MAE. Very poor short term memory.\nFollows commands. cooperative w/ care. At 0800 slightly diaphoretic, c/o nausea, otherwise no s/s ETOH withdrawal.\ncv: Afib 102-119, lopressor ^ to 75 mg qid. bp 130-155/82-94.\nresp: SATs 93-97% on 4lnp, lung sounds coarse,\ngi: passed speech/swallow study. Poor appitite, no stool\ngu: foley draining dk yellow urine 30-60cc/hr.+1000cc since mn.\nid: afebrile, cont on flagyl, levo\npain/comfort: c/o chest pain (from compressions), has been taking torodol and ultram RTC, w/ good effect.\nactivity: oob to chair x2 w/ 2 assists. Unsteady on feet.\nsocial: wife and 4 children in all day, updated on POC.\nA: poor short term memory s/p cardiac arrest\n afib w/ improved rate control on ^ BB\n no s/s ETOH withdrawal\nP: Monitor mental status, response to change in cv meds, monitor i/o, ? lasix. monitor for s/s ETOH withdrawal. Emotional support to family.\n" }, { "category": "Nursing/other", "chartdate": "2141-12-02 00:00:00.000", "description": "Report", "row_id": 1554919, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P VF ARREST\n\nS- \" I NEED TO GET OUT I NEED TO GET OUT!\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS IN AFIB= 100-120'S , NO VEA. BP- 140/80'S.\nWITH AGITATION EVENT 11P- HR UP TO 160'S AFIB, WITH SEDATION- HEART RATE BACK DOWN TO LOW 100'S-90'S. REMAINS ON LOPRESSOR 75 MG QID, HEPARIN GTT 1400U. CHEST PAIN AT CPR/DEFIB SITE WITH PRESSING ON AREA- REMAINS ON ULTRAM PO AND TOPICAL LIDO. GROIN SITE/PULSES STABLE.\n\n PT CONFUSED WITH SHORT TERM MEMORY LOSS S/P CV ARREST/CPR.\nFAMILY PRESENT 24/7 TO WATCH AND BE WITH PT. PT RECOGNIZING FAMILY BUT ASKING SAME QUESTIONS WITHIN SHORT TIME. RESTLESS ON EVENINGS, PLEASANT. DIFFICULT TIME TAKING EVENING MEDS- ASKING ABOUT EACH PILL AND A BIT SUSPICIOUS OVER TAKING THE ANTIBX, REFUSING AT 1ST BUT TAKING AFTER DAUGHTER CONVINCING PT TO TAKE. WITHIN 1/2 HOUR, PT MORE PICKY/DISCONNECTING FOLEY CATH TUBING TO DRAINAGE BAG. WITHIN PT BECOMING EXTREMELY AGITATED, TRYING TO GET OUT OF BED- HR UP TO 160'S AFIB, HTN. HO PRESENT, FAMILY PRESENT. PT GIVEN STAT 6 MG TOTAL ATIVAN IVP AND PUT ON STANDING ORDER ATIVAN INSTEAD OF PER CIWA SCALE AS THOUGHT TO BE IN WITHDRAWAL STATE. OVER COURSE OF THE , PT Q 2 HOUR AND GIVEN 4MG MORE IVP. WIFE/DAUGHTER PRESENT AND CONCERNED OVER PT BEHAVIOR, SPOKE AT LENGTH WITH MD/RN OVER IMPLICATION OF ETOH WITHDRAWAL. CONVINCED FAMILY TO SLEEP IN SLOARIUMN TO GET GOOD SLEEP AND PROVIDED STAFF SITTER FOR PT . FAMILY APPEARS MORE COMFORTABLE WITH FACT THAT PT IS SEDATED AND WILL NEED SUCH FOR WITHDRAWAL OVER NEXT FEW DAYS AND IT WILL NOT SET BACK HIS RECOVERY FROM CV ARREST. PT AWAKENED WITH STIMULATION. SLURRING WORDS BUT OPENING EYES, ASKING QUESTIONS.\n\n PT on LEVOFLOX/FLAGYL- CULTURES (-)\n\nGI- TAKING PILLS/LIX WITHOUT PROBLEM.\nS/P OOB TO COMMODE FOR STOOL EARLIER TODAY, ON PROTONIX/(+) BOWEL SOUNDS, NO ISSUES CURRENTLY.\n\nGU- FOLEY CATH IN PLACE. I/O (+) CLOSE TO 1 LITER EVENING- GIVEN 10 MG LASIX IVP- DISCONNECTED FOLEY CATH /TUBING SO I/O INACCURATE AS OF 12AM. UO REST OF OVERNITE FAIR - NO GREAT DIURESIS THIS SHIFT.\n\n PT ON 4LNP, DIM AT BASES- ENCOURAGED TO DEEP BREATH- TAKING SHALLOW BREATHS D/T CHEST WALL PAIN OTHERWISE. GIVEN MEDS FOR PAIN AND ENCOURAGED TO DEEP BREATHE. CURRENTLY NOW THAT SEDATED- RESPIRATORY RATE MID 20'S. DIMINISHED SOUNDS AT BASE BUT OTHERWISE CLEAR IN SPITE OF XRAY RE: CHF. APPEARS COMFORTABLE, O2 SATS MID 90'S.\n\nLINES- 3 PERIPHERALS LEFT ARM - SITES SL BLEEDING BUT FROM RESTLESSNESS/MOVING- OTHERWISE WNL.\n\nA/ PT S/P CV ARREST/CLEAR CORONARIES/DEPRESSED EF- CURRENTLY IN PRESUMED ETOH WITHDRAWAL STATE. RESPONDING WELL TO RTC BENZO.\n\nCONTINUE TO OPTIMIZE RATE/PRESSURE- IV LOPRESSOR AS NEEDED WHILE PT SEDATE. CONTINUE TO OBSERVE CULTURES FOR ANY GROWTH- ? SUBSTITUTE PO ANTIBX FOR IV AS WELL. CONTINUE CLOSE ASSESSMENT OF NEURO STATUS\nAND GIVE ATIVAN RTC 1-2 MG AS ORDERED WITHIN PARAMETERS.\nASSIST FAMILY WITH COPIING/EDUCATION RE: CV DISEASE/ETOH WITHDRAWAL/ANXOXIA. KEEP IN ICU CARE UNTIL MENTAL STATUS IMPROVES.\nCO\n" }, { "category": "Nursing/other", "chartdate": "2141-12-02 00:00:00.000", "description": "Report", "row_id": 1554920, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P VF ARREST\n(Continued)\nNSIDER MORE LASIX TODAY. AM CXR.\n" }, { "category": "Nursing/other", "chartdate": "2141-12-02 00:00:00.000", "description": "Report", "row_id": 1554921, "text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\nneuro- lethargic- oriented to person only- moving all extremities- cooperative- follows command- PERL- librium 50mg given @ 12noon as ordered- seen by neuro this afternoon- librium D/C'd, as thought is agitation is from cardiac arrest (not ETOH withdrawal)- OOB to chair with 2 assist- weight bears well, however walks poorly.\n\ncv- Tele: Afib occ PVC- HR 106-126- NIBP 124-152/76-91 MAPs 88-106- started on captopril 12.5mg TID- tolerating well- con't on lopressor 75mg QID- heparin gtt @ 1600u/hr- PTT 49.1 on 1400u/hr- repeat PTT pending- hct 33.2- K 4.1- Mg 1.9\n\nresp- In O2 4L NC- tachypnic this am- CXR- CHF- lasix 20mg IV ordered & given- diuresed well- lung sounds coarse, diminished @ bases- SpO2 94-98%.\n\ngi- abd soft (+) bowel sounds- taking Po without incident- no BM today.\n\ngu- foley draining amber-yellow colored urine- diuresed well from lasix- (-) 1500cc since 12am- BUN 13 Crea .7\n\ncomfort- c/o chest discomfort @ CPR site @ 1715- ultram 50mg Po given with good effect.\n\nA- S/P cardiac arrest with clean coronaries & low EF c/b ? ETOH withdrawal vs anoxia.\n\nP- monitor vs, lung sounds, I&O and labs- replete lytes as needed- adjust heparin gtt as per order- assess neuro status- call HO if Pt agitated- offer emotional support to Pt & family- keep them updated on\nplan of care.\n" }, { "category": "Nursing/other", "chartdate": "2141-12-03 00:00:00.000", "description": "Report", "row_id": 1554922, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P VF ARREST/ANOXIA\n\nS- \" WHERE AM I- WHY AM I HERE? I WANT TO CALL MY WIFE..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS IN AFIB- RATE 100-120'S, NO VEA. K- 3.4 ON EVES- GIVEN 60 MEQ PO. BP- 120-140/80-90'S- INCREASED CAPTOPRIL TO 25 TID, REMAINS ON 75MG LOPRESSOR QID. NO OTHER CHANGES TO CV MED REGIMEN PM PTT- 53 ON 1600U HEPARIN IV. AM LYTES/PTT/CBC PENDING.\nCHEST WALL PAIN AT SITE OF CPR/DEFIB- TREATED WITH TYLENOL 650 AND ULTRAM 50MG X 2 DOSES. BP SLIGHTLY IMPROVED ON CAPTOPRIL. TO INCREASE DOSE THIS AM.\n\nRESP- COARSE SOUNDS, NONPRODUCTIVE COUGH OCCASIONALLY. O2 SATS ASLEEP WITHOUT O2- 87%- ON 4L NP WITH O2 SATS MID 90'S. ENCOURAGED TO DEEP BREATHE/COUGH AS ABLE- PAIN WITH CHEST WALL WITH COUGHING, SO AT TIMES, GUARDING AND NOT BREATHING DEEPLY.\nNO FURTHER DIURESIS- I/O (-)1700CC AS OF 12AM AFTER AFTERNOON 20 LASIX .\n\nGU- SEE ABOVE- FOLEY CATH IN PLACE- 60-100CC/HOUR URINE OUT = CLEAR YELLOW. NO LASIX THIS SHIFT.\n\nGI- TAKING MEDS/LIX WITHOUT ISSUE. NO FOOD THIS SHIFT INGESTED.\n(+) BOWEL SOUNDS, REMAINS ON PROTONIX\n\nLINES- 2 PERIPHERALS LEFT ARM INTACT.\n\nMS/NEURO- MAE/PERRL. HOLDING OFF ON BENZOS CURRENTLY AS AGITATION THOUGHT TO BE DUE TO S/P ANOXIC INJURY S/P ARREST. GIVEN PAIN MEDS FOR CHEST WALL AND STARTED ON AMBIEN 10 MG QHS. REQUIRED ADDITIONAL 10 MG AS PT STARTED, AS LAST , TO GET RESTLESS, WANTING TO GET OUT OF BED \" GET A BEER\" , CALL HIS WIFE, ETC. ATTEMPTED TO CALL WIFE BUT NO ANSWER;FAMILY WENT HOME FOR 1ST TIME SINCE TUESDAY FOR SLEEP - EXPLAINED TO PT FAMILY WAS ASLEEP. ONCE PAIN MEDS AND SLEEPER ABSORBED, PT LESS AGITATED. WITH ANY AGITATION, HR UP TO 140'S AFIB.\nAS WELL AS HTN.\n\nSOCIAL- FAMILY CALLED TO ASK ABOUT CONDITION/STATUS. FELT COMFORTABLE GOING HOME FOR REST/SLEEP AS PLAN WAS TO MEDICATE PT FOR AND RN TO SIT IN ROOM/BE CLOSE AT HAND FOR MONITORING PT .\nSPOKE TO WIFE/DAUGHTER TO CONFIRM PLAN FOR .\n\nA/ PT S/P CV ARREST CURRENTLY HAVING ISSUES WITH AGITATION/PAIN.\n\nCONTINUE TO MEDICATED AS ORDERED WITH PAIN MEDS FOR COMFORT AS WELL AS SLEEPER AT QHS. OBSERVE CLOSELY PER CIWA SCALE AND NOTIFY HO FOR ANY BEHAVIOR CLOSE TO CIWA>10 FOR BENZO TX. KEEP PT AWARE OF PLACE/TIME/PERSON- KEEP FAMILY AWARE DAILY OF PLAN OF CARE.\nSAFETY FOR PT, SITTER HERE AND ONCE C/O TO FLOOR AND/OR POSEY IN BED FOR SAFETY. CONTINUE HEPARIN- ? COUMADINIZE SOON. RAMP UP CV MEDS TO BETTER CONTROL RATE/PRESSURE PRODUCT. AM CXR TO ASSESS LEVEL OF CHF- ? POSSIBLE MORE DIURESIS THIS AM.\nC/O TO FLOOR ONCE ASSURED PT NOT ACUTELY WITHDRAWING FROM ETOH AND SAFETY ASSURED.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-30 00:00:00.000", "description": "Report", "row_id": 1554916, "text": "CCU Progress Note:\n\nS- \"Can I go home?\"\n\nO- see flowsheet for all objective data.\n\nresp- successfully extubated this am- In O2 5L via NC- ABG 7.47-32-92-24-97%- lung sounds coarse with scattered rhonchi- non-productive cough noted- no resp distress- SPo2 94-100%.\n\ncv- Tele: Afib rare PVC noted- HR 122-139- ABP 113-159/73-90 MAPs 83-112- con't on lopressor- Hct 34.1- K 4.1- Mg 2.3- heparin gtt @ 1400u/hr resumed @ 11am- PTT @ 1700 pending.\n\nneuro- MRI done this am- now alert- oriented to person only- confused- moving all extremities- cooperative- follows command- PERL- amb from bed to chair with 2 assist- able to weight bear.\n\ngi- abd soft (+) bowel sounds- taking liquids & soft diet without incident- glucose range 121-146- no BM.\n\ngu- foley draining clear yellow colored urine qs- (-) 300cc since 12am (+) 1L LOS- BUN 10 Crea .7\n\ncomfort- c/o chest pain- S/P CPR- reported to HO- toradol ordered & given with effect- Also, requesting beer- family reports ETOH use @ home- place on CIWA scale- ativan .5mg Po given @ 1730.\n\nID- afebrile today- WBC 11.9- con't on flagyl and levofloxacin- cultures pending.\n\nA- successfully extubated today- hemodynamically stable.\n\nP- monitor vs, lung sounds, I&O and labs- monitor neuro status- monitor for signs of DT's- increase activity as tolerated- offer emotional support to Pt & family- keep them updated on plan of care.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-12-01 00:00:00.000", "description": "Report", "row_id": 1554917, "text": "53 YR. OLD MAN S/P CARDIAC ARREST->INTUBATED/CATH LAB->NO CAD. IABP PLACED. ?ASP. PNEUMONIA->FLAGGYL,LEVOFLOX. ->IABP/SWAN D/C'D ->EXTUBATED/MRI HEAD (-).\n\nNEURO: SHORT TERM MEMORY DEFICIT. AWAKE & ALERT. ORIENTED TO PERSON.\nKNOWS WHERE HE LIVES/WORKS. DISORIENTED TO PLACE, TIME, & DATE.\n\nRESP: O2->5L NP. BS COURSE BUT DIMINISHED AT BASES. RR 18-26. O2 SAT 93-97%. WILL DESAT TO 85% ON RM. AIR.\n\nCARDIAC: HR 110-130'S AF WITH OCC. COUPLETS & SHORT RUNS VT. BP 133-155/79-93. 1 EPISODE N/V, DIAPHORESIS->WITH HR 180 AF & BP 178/107\nEKG DONE. ANZIMET 12.5 VP X1, DILT 10MG VP X1 WITH VS BACK TO BASELINE. LOPRESSOR INCREASED TO 37.5MG PO Q6HRS->TOL. WELL. DILT ORDERED 10MG VP PRN HR>140->GIVEN X1. HEPARIN GTT INFUSING AT 1400U/HR. PTT THERAPEUTIC. DENIES ANGINA/SOB. DOES C/O PAIN IN CHEST D/T CPR->TORADOL/ULTRAM GIVEN WITH GOOD EFFECT. +BPPP. R. GROIN SITE C&D.\n\nGI: TOL. CL. LIX WELL & SWALLOWING PILLS WITHOUT DIFFICULTY. ABD SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE.\n\nID: AFEBRILE. URINE C&S (-). SPUTUM & BC PENDING. CONT. ON FLAGGYL & LEVOFLOX.\n\nAM LABS PENDING.\n\nPLAN: D/C ALINE\n INCREASE ACTIVITY AS TOL.\n ASSESS FOR D.T.'S\n" }, { "category": "Nursing/other", "chartdate": "2141-11-29 00:00:00.000", "description": "Report", "row_id": 1554910, "text": "CCU Progress Note:\n\nS- intubated & sedated.\n\nO- see flowsheet for all objective data.\n\ncv- Tele: Afib with occ PVC- HR 96-127- multiple doses of lopressor IV given as ordered for RAF- lopressor 25mg Po TID started- ABP 102-144/69-90 MAPs 90-107- IABP MAPs 69-85- IABP & PA line D/C'd @ 1400- no oozing or hematoma- (+) DP & PT pulses by doppler- Pt was on cool MI study- warmed & D/C'd as per protocol- Hct 36- K 4.0- Mg 2.5\ncardiac enzymes trending down- CPK 847 (last 907)- skin remains cool to touch- feet & hands cold bilaterally.\n\nneuro- sedated on propofol gtt @ 30mcq/kg/min & versed gtt@ 2mg/hr- pupils 2mm & sluggishly react to light- arms noted to posture with positioning (decorticate)- all extremities moved on bed when repositioned once vecuronium gtt D/C'd- however, no spontaneous movement noted this afternoon- no seizure activity noted this shift- EEG done- plan is for MRI today.\n\nresp- con't on vent 650/16/40/5- ABG 7.37-34- %- lung sounds with coarse scattered rhonchi bilaterally- suctioned sm-mod light tan colored mucous- SpO2 99-100%.\n\ngi- abd soft with hypoactive bowel sounds- OGT clamped @ present- tube feeding to start once MRI done- no BM today.\n\ngu- foley draining straw colored urine with sediment- U/O > 25cc/hr- I&O essentially equal today- BUN 12 Crea .6\n\nID- T max 98.2 core- WBC 11- cultures pending- on no antibiotics.\n\nendo- glucose range 123-135 today.\n\nA- S/P polymorphic VT arrest/seizures who was successfully weaned off IABP\n\nP- MRI today & once done, begin tube feeding & wean off sedation- follow hemodynamics- support family- keep them updated on plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-29 00:00:00.000", "description": "Report", "row_id": 1554911, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on A/C ventilation w/ PIP/Pplat = 24/18. SpO2 90s. ETT secure/patent. No secretions suctioned. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain full support\n" }, { "category": "Nursing/other", "chartdate": "2141-11-29 00:00:00.000", "description": "Report", "row_id": 1554912, "text": "Addendum: T 100.1 Po @ 1800- pan cultured- to begin on antibiotics- labs drawn & pending- L buttock reddened- no broken area noted- reposition off area- R groin dsg d&i- no hematoma- (+) doppler pulses of lower extremities- hemodynamically stable off IABP.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-30 00:00:00.000", "description": "Report", "row_id": 1554913, "text": "CCU Nursing Progress Note\nS-Orally intubated and sedated.\nO-Neuro-Propofol and versed gtts d/c'd at . At 2115 pt now trying to open eyes by lifting eyebrows up, all extremities moving, including both arms raised above his head. Able to lift head and shoulders off pillow. Does not look uncomfortable at this time. By 2130 pt asleep and difficult to awaken but withdrawal to nailbed pressure. At 2200 pt opens eyes looking right at nurse, and within minutes starts to look aggitated, coughing and gagging on ETT, using tongue to move ETT around. Family present and happy he moving around but upset to see him so uncomfortable. Resedated with propofol at 30mcg/kg/min. Versed left off at this time. h/o heavy ETOH will start CIWA assessments when extubated. Plan to lighten again for SBT in am. MRI/MRA brain tonight.\nCV-RAF 120-130's responding well to Dilt 10mg IVB with decrease in HR to 90's. Received second dose with aggitation with good response. Tolerating lopressor 25mg TID OGT with transient effect.\nResp-orally intubated on vent 40% 650x16AC PEEP 5 overbreathing the vent by 4-10 breaths. LS coarse upper lobes with bronchial BS lower lobes. Copious amounts of thick tan/blood tinged secretions. Strong cough and gag present.\nID remains low grade temp 100.4po to receive tylenol. Started flagyl and levofloxacilin.\nGU-foley draining yellow urine 20-30cc/hr. Team aware.\nGI-abd soft with OGT clamped. PLan to start TF this evening. No BM\nEndo-Blood sugars WNL.\nSkin-Right groin no bleeding/hematoma, Right arm eccymotic, Rt PIV x2 infiltrated and d/c'd. Arm up on pillow. Lower inside of lip sore open, non draining. Small pressure stage 1 right corner of mouth from ETT.\nSocial-married with 4 children. Wife looks tired has been here since pt admitted, sleeping in the waiting room. Son is with her tonight.\nWill have social services follow family.\nAccess-2 PIV, right rad aline.\nCode \nHealth Care Proxy-none assigned.\nA/P-53yom with cardiac arrest in setting of no CAD, s/p cath/IABP. Now with probable anoxia but moving all extremities off sedation.\nPlan to lighten this am for RSBI/SBT. Possibly start Heparin for low LVEF/AF. Start CIWA scale after extubation. Consult addiction and social services in am. Continue to keep family aware of POC and results of all testing as discussed in multi disciplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-30 00:00:00.000", "description": "Report", "row_id": 1554914, "text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. Sx for moderate amts thick tan to blood tinged secretions. ABG @ 0100 revealed a resp alkalosis RSBI 48 several mode changes attempted pt continues to have RR 23-25 W Vt 500's to 700. MD aware as is resp supervisor. Pt remains on A/C 650X16 /5 .4 Please see carevue for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2141-11-30 00:00:00.000", "description": "Report", "row_id": 1554915, "text": "ccu npn 2300-0700\nS: orally intubated and sedated\nO: Please see carevue for VS and objective data\nNeuro: Pt. had just been resedated at change of shift, Pt. on IV Propofol at 30mcg/kg/min. IV Versed remains off from previous shift. Arousable to sternal rub, flickering and opening of eyes. PERLA, 3mm brisk. Moved left arm on bed when peripheral IV placed. Not following commands, no purposeful movement noted. Strong cough to suctioning/turning, +gag. Moving tongue in mouth with mouth care, biting down on toothbrush. Wife and son back into room after Pt. resedated from previous shift. Aware of need for sedation and soft hand restraints in place for safety of lines. Awaiting MRI of head tonight.\nCVS: Hemodynamically stable with HR 112-130's AFib, brief burst to 140. Temp up to 101.1 orally. No vea noted. BP ranges via right radial aline 108-120/60-70's. MAPs >70. Lopressor via OGT increased to 25mg QID. IV Heparin started at 0030 at 1700u/hour without bolus in setting of low EF/Afib. am PTT to be drawn. Right groin D/I, without palp. hematoma, distal pulses dopplerable.\nResp; Orally intubated and mechanically ventilated on A/C 650x16, 40%/5peep. Spont. RR 7-8 over vent. ABG with resp. alkalosis; 7.47/27/95/20-1, sats 97-100%. CCU team aware, without further sedation secondary planning to lighten in am with possible extubation if neuro status improves. Resp. in to assess, brief trials on other modes with spont. TV 500's-700, RR mid 20's, RSBI 48. Remains on A/C mode. Lungs coarse with bronchial breathe sounds, suctioned for small to moderate amount of thick, tan, blood tinged secretions.\nGI:GU: Initially NPO, OGT in good placement with auscultation. Started TF briefly at 10cc/hour then dc'd within the hour for possible extubation as above. Abdomen soft with active bowel sounds, no stool. Foley to drainage with clear, amber urine, u/o 30-35cc/hour. Team aware.\nTmax 101.1 orally, received tylenol 650mg via OGT x2, temp 100.9 orally at present. Conts on IV Flagyl and Levofloxacin.\nAccess; 3rd peripheral IV placed for Heparin. All patent and intact without s/s infection/infilt.\nA: s/p cardiac arrest without CAD, awaiting MRI for neuro workup.\nP: Cont to monitor hemodynamics, assess Pt.'s response to increase Lopressor. Cont.IV Heparin, follow up with PTT and am labs. Cont to monitor resp. status with increase in spont. RR. Light from sedation with SBT/repeat RSBI. Monitor neuro status closely. Awaiting MRI of brain. Cont antibxs and follow cultures pnd, prn tylenol. Comfort and emotional support to Pt. and family. Will need CIWA scale with strong history of ETOH use.\n" }, { "category": "Echo", "chartdate": "2141-12-01 00:00:00.000", "description": "Report", "row_id": 69460, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 190\nBSA (m2): 2.00 m2\nBP (mm Hg): 150/95\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 10:34\nTest: TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Dilated LV cavity. Severe global LV hypokinesis. Severely\ndepressed LVEF.\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.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left ventricular cavity is dilated. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n2. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened.\n4. Compared with the prior study (images reviewed) of , LV function\nhas improved.\n\n\n" }, { "category": "Echo", "chartdate": "2141-11-28 00:00:00.000", "description": "Report", "row_id": 69508, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nWeight (lb): 207\nBP (mm Hg): 105/85\nHR (bpm): 118\nStatus: Inpatient\nDate/Time: at 15:44\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 report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Severe global LV hypokinesis. Severely\ndepressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is moderately dilated. The right atrium is moderately\ndilated.\n2. The left ventricular cavity size is normal. There is severe global left\nventricular hypokinesis to akinesis. Overall left ventricular systolic\nfunction is severely depressed.\n3. The aortic valve leaflets (3) are mildly thickened.\n4. The mitral valve leaflets are mildly thickened. Mild to moderate (+)\nmitral regurgitation is seen.\n5. Compared with the report of the prior study (images unavailable for review)\nof , LV function is now severely depressed.\n\n\n" }, { "category": "ECG", "chartdate": "2141-12-05 00:00:00.000", "description": "Report", "row_id": 156114, "text": "Atrial fibrillation\nExtensive ST-T changes\nSince previous tracing, no significant change\n\n" }, { "category": "Radiology", "chartdate": "2141-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938378, "text": " 7:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, assess effusion, assess fluid status/vascula\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M s/p VT arrest with concern for resolving pneumonia.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, assess effusion, assess fluid status/vascular congestion.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY, .\n\n COMPARISON FILMS: .\n\n HISTORY: 53-year-old male status post VT arrest with concern for resolving\n pneumonia.\n\n FINDINGS: There is a new faint haziness over the right lung base with slight\n obscurity of the right hemidiaphragm which may be the result of a new or\n enlarging layering pleural effusion. The central vascular congestion is\n unchanged from the patient's prior examination. There is no pneumothorax.\n Heart size is stable.\n\n IMPRESSION:\n 1. Possible new/enlarging right pleural effusion. Unchanged pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938467, "text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for worsening heart failure or development o\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M s/p VT arrest with concern for resolving pneumonia and worsening heart\n failure.\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening heart failure or development of interval\n infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n HISTORY: VT, evaluate for heart failure.\n\n One portable view. Comparison with . There is interval improvement in\n pulmonary vascular congestion. Hazy density at the right lung base has\n improved as well. The heart and mediastinal structures are unremarkable for\n technique. The bony thorax is grossly intact.\n\n IMPRESSION: Interval improvement in pulmonary vascular congestion and\n interval decrease in right pleural fluid.\n\n" }, { "category": "Radiology", "chartdate": "2141-11-30 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 938074, "text": " 7:29 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: pls evaluate for acute bleed, mass, stroke\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with seizure activity, found down in cardiac arrest.\n REASON FOR THIS EXAMINATION:\n pls evaluate for acute bleed, mass, stroke\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with seizure activity and cardiac arrest.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted sequences were obtained through the\n brain with diffusion-weighted imaging.\n\n FINDINGS: There is no slow diffusion to indicate an acute infarct. There is\n a large amount of patient motion artifact on these images, precluding detailed\n evaluation of the brain. However, there is no midline shift, mass effect or\n hydrocephalus. The brain parenchymal signal appears normal within the limited\n scope of this exam. There is minimal mucosal thickening throughout the\n paranasal sinuses.\n\n IMPRESSION: Limited examination. No acute infarct. No mass effect or\n midline shift.\n\n MRA.\n\n TECHNIQUE: 3D time-of-flight MRA of the circle of .\n\n FINDINGS: The circle of is normal with no evidence of aneurysms or\n significant intracranial atherosclerotic disease.\n\n IMPRESSION: Normal circle of MRA.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937864, "text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, assess for effusion.\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ischemia.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, assess for effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with ischemia.\n\n COMPARISON: None.\n\n SUPINE FRONTAL CHEST RADIOGRAPH: ET tube terminates 3.4 cm above the carina.\n The nasogastric tube tip is not visualized but extends at least to the antrum\n of the stomach. The mediastinum is not widened. The heart is at the upper\n limits of normal. Lung volumes are low. There is mild pulmonary vascular\n congestion, which is likely related to both low volumes and supine position.\n The lateral aspect of the right costophrenic angle is excluded from the film.\n No large pleural effusions are seen. There are no pneumothoraces.\n\n IMPRESSION: No acute pulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2141-11-28 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 937905, "text": " 8:54 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: R/o intracranial pathology, assess for bleed.\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with vfib arrest with seizure-like activity.\n REASON FOR THIS EXAMINATION:\n R/o intracranial pathology, assess for bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with V-fib arrest and seizure activity. Evaluate\n for intracranial pathology.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift\n of normally midline structures. There is no major vascular territorial\n infarction. The density values of the brain parenchyma are within normal\n limits. The -white matter differentiation is preserved. There are\n nasopharyngeal secretions due to intubation. There are no enhancing masses.\n\n In the right orbit, there is a rounded hyperdense focus that is causing some\n mass effect on the posterior globe and possibly represents a dilated vessel.\n It enhances and follows the path of the superior opthalmic vein, consistent\n with a continuation of that vessel. The globes are intact bilaterally. There\n is a small amount of mucosal thickening in the right maxillary sinus. The\n remaining paranasal sinuses and mastoid air cells are appropriately\n pneumatized and aerated.\n\n IMPRESSION:\n 1. No intra- or extra-axial hemorrhage.\n 2. No enhancing masses.\n\n" }, { "category": "Radiology", "chartdate": "2141-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937913, "text": " 2:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval location of PA catheter\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M s/p VT arrest, now w/ swan, and IABP, PA sat 98%, MVO2 sat 75% - ? shunt\n vs. transseptal crossing of PA line.\n REASON FOR THIS EXAMINATION:\n eval location of PA catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Discrepancy in venous saturations. Evaluate location of PA\n catheter.\n\n COMPARISON: CXR .\n\n FINDINGS: Portable supine radiograph of the chest (2 views total).\n\n Endotracheal tube is approximately 2.8 cm from the carina. Nasogastric tube\n is unchanged in position. Intraaortic balloon pump is identified on the\n second image and is in appropriate position. Femoral pulmonary artery\n catheter is identified which is too far peripheral in the right pulmonary\n artery system.\n\n The cardiomediastinal silhouette appears stable. Lung volumes are again noted\n to be low. Mild pulmonary, vascular congestion is also stable, and likely\n related to low lung volumes and patient positioning. No pleural effusions or\n pneumothoraces are identified.\n\n IMPRESSION: Unsatisfactory position of pulmonary artery catheter. This\n should be withdrawn approximately 8 cm for better positioning. Satisfactory\n placement of intraaortic balloon pump. Otherwise, stable appearance of lungs.\n\n Findings discussed with the house staff who informed that the pulmonary\n catheter has been withdrawn some and a followup chest x-ray is pending for\n further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2141-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937952, "text": " 10:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o infiltrate, assess for effusion, assess catheter placeme\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M s/p VT arrest, now w/ swan, and IABP, PA sat 98%, MVO2 sat 75% - ? shunt\n vs. transseptal crossing of PA line.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, assess for effusion, assess catheter placement, assess for\n pneumomediastinum.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 10:35 a.m. on \n\n INDICATION: Evaluate for infiltrate, effusion. Assess pulmonary artery\n catheter placement.\n\n FINDINGS: Compared with 3:07 a.m. earlier this morning, the Swan-Ganz has now\n had been withdrawn and now lies with its tip in an unremarkable position at\n the level of the right main PA. The IABP tip is unchanged projecting between\n the aortic knob and left mainstem bronchus. ETT is also unchanged in\n unremarkable position.\n\n No CHF, infiltrates or effusions.\n\n No obvious pneumothorax or pneumomediastinum, allowing for technique and\n positioning.\n\n IMPRESSION: Improved, now unremarkable, positioning of femoral PA catheter.\n\n" }, { "category": "Radiology", "chartdate": "2141-11-28 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 937906, "text": " 8:56 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: VFIB ARREST, SEIZURE, ? PE VS ACUTE ABD PROCESS\n Admitting Diagnosis: VENTRICULAR ARREST\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with vfib arrest with seizure-like activity.\n REASON FOR THIS EXAMINATION:\n r/o pulmonary embolism.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: V fib arrest with seizure-like activity, rule out pulmonary\n embolism.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the chest, abdomen, and pelvis were\n obtained after the administration of IV and oral contrast. Multiplanar\n reformatted images were also obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: Numerous paraspinal and suprascapular\n collaterals are demonstrated on the right. There is an endotracheal tube that\n terminates above the carina. There is a Swan-Ganz catheter that enters via\n the inferior vena cava and terminates in a right upper lobe pulmonary arterial\n branch. The evaluation is nondiagnostic for pulmonary embolism. The aorta\n and great vessels are grossly patent. There is an apparent metallic density\n in the descending thoracic aorta that terminates approximately 5.5 cm distal\n to the takeoff of the left subclavian artery that presumably represents an\n intraaortic balloon pump. There are bilateral pleural effusions and\n associated compressive atelectasis. There is no pneumothorax.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The aorta is obscured by artifact and\n that presumably represents an intraaortic balloon pump. There is a Swan-Ganz\n catheter in the inferior vena cava that enters via the right groin. Limited\n evaluation of the liver, gallbladder, pancreas, and spleen is unremarkable.\n The adrenal glands are grossly unremarkable. There are several hypodense\n areas that project in the renal collecting systems that may represent excreted\n contrast. There is no evidence of hydronephrosis. Small and large bowel are\n grossly unremarkable. There is no intra-abdominal free fluid or free air.\n\n CT OF THE PELVIS WITH IV CONTRAST: A catheter is present within the bladder.\n Air within the bladder is presumably secondary to Foley catheterization. There\n are scattered sigmoid diverticula without evidence of diverticulitis. No\n pelvic free fluid.\n\n Bone windows reveal degenerative changes with no suspicious lytic or sclerotic\n lesions.\n\n IMPRESSION:\n 1. Non-Diagnostic evaluation for pulmonary embolism.\n (Over)\n\n 8:56 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: VFIB ARREST, SEIZURE, ? PE VS ACUTE ABD PROCESS\n Admitting Diagnosis: VENTRICULAR ARREST\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Bilateral pleural effusions with associated compressive atelectasis.\n 3. Lines and tubes as described above.\n 4. No acute intra-abdominal pathology.\n\n" }, { "category": "Radiology", "chartdate": "2141-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938252, "text": " 10:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change.\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M s/p VT arrest with concern for resolving pneumonia.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Cough.\n\n Portable AP chest radiograph compared to .\n\n The patient was extubated in the meantime interval with the NG tube and\n Swan-Ganz catheter removed. The heart size is normal. There is increased\n perihilar opacity and bilateral interstitial prominence suggesting congestive\n heart failure. No sizeable pleural effusion is identified. There is no\n pneumothorax.\n\n IMPRESSION: New pulmonary edema. Findings were communicated to Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2141-12-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 938725, "text": " 11:41 AM\n CHEST (PA & LAT) Clip # \n Reason: lead placementPost ICD lead placement\n Admitting Diagnosis: VENTRICULAR ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with VF arrest\n REASON FOR THIS EXAMINATION:\n lead placementPost ICD lead placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PA AND LATERAL\n\n INDICATION: History of VF arrest, now ICD lead placed, check placement.\n\n FINDINGS: AP and lateral chest views obtained with patient in sitting semi-\n erect position demonstrate the presence of a permanent pacer in left anterior\n axillary position. A single electrode includes two local electrode\n enforcements and is seen to terminate with its tip in the apical portion of\n the right ventricle. No pneumothorax has developed and no other placement-\n related complications are identified.\n\n Comparison is made with a previous chest examination of and\n the pulmonary congestive pattern has normalized. On the frontal view, no\n blunting of the lateral pleural sinuses can be identified; however, on the\n underexposed lateral view somewhat obscured by the non-elevated arm, a mild\n blunting of the posterior pleural sinus is identified.\n\n IMPRESSION: Successful placement of ICD device with electrode tip terminating\n in apical portion of right ventricle.\n\n\n\n\n\n\n\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2184-03-10 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1234609, "text": " 9:55 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # \n Reason: PE protocol with runoff to the abdomen\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVC, OR for ankle fx's. Then PEA arrest, has required 7\n units of PRBC\n REASON FOR THIS EXAMINATION:\n PE protocol with runoff to the abdomen\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SJBj WED 12:17 PM\n 1. No pulmonary embolism or acute aortic pathology\n 2. Left lower lobe atelectasis\n 3. No hematoma or other acute process to explain anemia and PEA arrest\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post unrestrained MVC and ORIF for lower\n extremity fractures approximately 24 hours ago. The patient had PEA arrest\n this morning with anemia requiring seven units of PRBC.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT data were acquired through the chest before intravenous\n contrast. Post-contrast MDCT data were acquired through the chest, abdomen,\n and pelvis. Three-minute delayed scans were acquired through the abdomen and\n pelvis.\n\n FINDINGS:\n\n CHEST: There is a moderate amount of atelectasis at the left base and small\n amount at the right base. Tiny right effusion is present. No focal\n consolidation or pneumothorax is seen. Contrast opacification of the\n pulmonary artery tree is adequate for evaluation to the subsegmental level.\n There are no pulmonary emboli or filling defects. The aorta is normal in\n caliber throughout its length with no aneurysm or dissection. Scattered foci\n of soft and calcified atheromatous plaque are seen in the descending aorta.\n The heart is otherwise unremarkable. There are no pericardial effusions.\n\n ABDOMEN: The liver enhances homogeneously. No focal liver lesions are\n identified. The gallbladder is thin-walled and not distended. The pancreas,\n spleen and adrenal glands are unremarkable. The kidneys are unremarkable. No\n ascites, mesenteric or retroperitoneal adenopathy is identified. Diffuse\n aortic calcifications are seen. There is no aneurysmal dilatation. No\n retroperitoneal hematoma is seen. Small and large bowel are of normal caliber\n and appearance.\n\n PELVIS: The colon shows diffuse diverticulosis without any evidence of\n diverticulitis. The remainder of the bowel is normal in caliber. The bladder\n is partially decompressed around the Foley catheter. There is no free pelvic\n (Over)\n\n 9:55 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # \n Reason: PE protocol with runoff to the abdomen\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluid. Bilateral fat-containing inguinal hernias are seen. There is no\n inguinal or pelvic adenopathy.\n\n No fractures, lytic or sclerotic lesions are appreciated.\n\n IMPRESSION:\n 1. No pulmonary embolism or acute aortic pathology\n 2. Left lower lobe atelectasis\n 3. No hematoma or other acute process to explain anemia and PEA arrest\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1234560, "text": " 3:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid overload\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVC with b/l ankle fractures, aggressively resuscitated in\n OR\n REASON FOR THIS EXAMINATION:\n eval for fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for fluid overload.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are low. There is moderate pulmonary edema and\n moderate cardiomegaly. No pleural effusions. No focal parenchymal opacity\n suggesting pneumonia. No current evidence of rib fractures. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-10 00:00:00.000", "description": "RP ANKLE (AP, MORTISE & LAT) RIGHT PORT", "row_id": 1234561, "text": " 3:40 AM\n ANKLE (AP, MORTISE & LAT) RIGHT PORT Clip # \n Reason: eval for dislocation\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M s/p MVC vs guard rail as unrestrained driver with open left ankle fracture\n s/p I&D + ex-fix, right ankle fracture s/p splinting, and scalp laceration s/p\n repair with acute kidney injury and agitation.\n REASON FOR THIS EXAMINATION:\n eval for dislocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma. Fracture-dislcations involving ankle and talonavicular\n joints.\n\n Three views of the right ankle obtained bedside. Since exam one day previous,\n there is marked improvement in the fracture-subluxation of the ankle joint and\n talonavicular joint is now normally positioned. Again noted are the displaced\n fractured medial malleolus and distal fibula as well as fractured proximal\n fifth metatarsal. Exam slightly limited by overlying cast and bedside\n positioning.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-10 00:00:00.000", "description": "L CT LOW EXT W/O C LEFT", "row_id": 1234572, "text": " 6:30 AM\n CT LOW EXT W/O C LEFT Clip # \n Reason: Please obtain CT scan of Right Ankle and foot\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fx\n REASON FOR THIS EXAMINATION:\n Please obtain CT scan of Right Ankle and foot\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT scan of the left lower leg without contrast performed on .\n\n CLINICAL HISTORY: Patient with multiple fractures of bilateral foot and\n ankles.\n\n FINDINGS: Comparison is made to the prior radiographs from and , .\n\n There are numerous fractures identified within the foot and ankle.\n\n There is a fracture involving the medial malleolus with the majority of\n malleolus displaced medially and anteriorly with the maximal displacement\n measuring 9 mm. There is surrounding soft tissue swelling and gas in the\n medial and lateral soft tissues about the ankle.\n\n The distal fibula is fractured and displaced by one shaft width anteriorly.\n There are several bony fragments in the fracture gap. This is best seen on\n the sagittal reformatted images. The ankle mortise is widened medially.\n\n There is a fracture involving the talar head at the medial aspect. There are\n small fractures involving the medial aspect of the navicular, cuboid, and of\n the medial, middle and lateral cuneiforms, most prominent at their inferior\n aspects.\n\n Fractures involving the base of the first through fourth metatarsals are seen.\n There is a fracture involving the proximal shaft of the fifth metatarsal.\n\n There is external fixation hardware with pins in the tibial cortex and in the\n calcaneus.\n\n Due to the artifact from the hardware, the soft tissues are not well assessed\n in the region of the ankle. There are surgical clips and a prominent amount\n of soft tissue swelling and gas consistent with the recent surgery.\n\n IMPRESSION:\n\n 1. Bimalleolar fractures with displacement of the lateral malleolus\n anteriorly with asymmetry of the ankle mortise.\n\n 2. Fracture involving the talar neck and head.\n (Over)\n\n 6:30 AM\n CT LOW EXT W/O C LEFT Clip # \n Reason: Please obtain CT scan of Right Ankle and foot\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Minimally displaced fractures involving the medial navicular, medial\n cuboid and the medial, middle and lateral cuneiforms.\n\n 4. Fractures involving the first through fourth metatarsal bases.\n\n 5. Fracture to the proximal shaft of the fifth metatarsal.\n\n 6. Prominent amount of soft tissue swelling and gas consistent with recent\n surgery.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1234573, "text": " 6:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MVC; PEA ARREST; E/F ACUTE BLEED\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post MVC, now with PEA arrest. Evaluate\n for acute bleed.\n\n COMPARISONS: Head NECT of .\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without administration of IV contrast.\n\n FINDINGS: There is suboptimal positioning and scan angulation. Within this\n limitation, no evidence of hemorrhage, edema, mass effect, or infarction. The\n size and configuration of the ventricles and sulci are normal for age. Mild\n confluent periventricular white matter hypodensities are likely secondary to\n small vessel ischemic disease.\n\n An endotracheal tube and an enteric tube are present. Partial\n fluid-opacification of the nasal cavity, nasopharynx, and mastoid air cells is\n new since the prior exam, and likely related to intubated state. No fracture\n is identified. Posterior scalp edema has also increased since the prior exam,\n compatible with redistribution of fluid in the subgaleal space, status post\n fluid resuscitation. The globes and orbits are intact.\n\n IMPRESSION:\n 1. No intracranial hemorrhage, edema or mass effect.\n 2. Increased posterior scalp edema, compatible with fluid redistribution.\n 3. Partial fluid-opacification of nasal cavity and nasopharynx, likely related\n to intubation and supine positioning.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-10 00:00:00.000", "description": "R CT LOW EXT W/O C RIGHT", "row_id": 1234574, "text": " 6:36 AM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: Please obtain CT of Right Ankle and Foot\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fx\n REASON FOR THIS EXAMINATION:\n Please obtain CT of Right Ankle and Foot\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE RIGHT LOWER LEG WITHOUT CONTRAST, \n\n CLINICAL HISTORY: Patient with bilateral foot and ankle fractures. Status\n fractures within the right ankle and foot.\n\n FINDINGS: Comparison is made to radiographs from and .\n\n There are multiple fractures seen in the right foot and ankle.\n\n There is a complex fracture involving the medial malleolus. There is a\n fracture involving the lateral malleolus and the distal fibula is displaced\n laterally. There is abnormal widening of the ankle mortise with the tibia\n displaced medially in relation to the talar dome by 9 mm.\n\n There are baseline osteoarthritic changes involving the tibiotalar joint with\n subchondral cystic changes, spurring and flattening of the talar dome.\n Degenerative changes of the talonavicular joint are also seen.\n\n There is fracture involving the sustentaculum tali with several bony fragments\n in the middle facet of the posterior subtalar joint.\n\n Evaluation of the foot demonstrates a complex fracture involving the base of\n the fifth metatarsal. There are small non-displaced fractures through the\n second through fourth metatarsal bases as well.\n\n There is a fracture involving the base of the first proximal phalanx medially.\n This is at the site of severe degenerative change of the first MTP joint.\n Moreover, there is an acute fracture of the fibular sesamoid with separation\n of the fracture fragments by 6 mm.\n\n There is a prominent amount of soft tissue swelling surrounding the injury.\n No entrapped tendons are seen. The medial, lateral, anterior and Achilles\n tendons are grossly normal.\n\n IMPRESSION:\n 1. Bimalleolar fracture with widening of the ankle mortise.\n 2. Fracture of the sustentaculum tali with multiple fragments extending into\n the middle facet of subtalar joint.\n 3. Fracture of the second through fifth metatarsal bases.\n 4. Fracture of the base of the first proximal phalanx.\n 5. Fracture of the fibular sesamoid at the first MTP joint with displacement\n (Over)\n\n 6:36 AM\n CT LOW EXT W/O C RIGHT Clip # \n Reason: Please obtain CT of Right Ankle and Foot\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n by 6 mm.\n 6. Baseline degenerative changes of the tibiotalar, and first MTP joint.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1234571, "text": " 6:26 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: e/f acute cardiopulmonary disease\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p CVA --> PEA arrest\n REASON FOR THIS EXAMINATION:\n e/f acute cardiopulmonary disease\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: To evaluate for acute cardiopulmonary disease. Status post CVA,\n PEA arrest.\n\n TECHNIQUE: Portable supine chest view was reviewed in comparison with most\n recent radiograph acquired 3-4 hours apart.\n\n FINDINGS:\n\n Endotracheal tube ends approximately 5.3 cm from the carina and is\n appropriately positioned. Orogastric tube is seen coursing below the\n diaphragm; however, its distal end is of radiographic view. Right internal\n jugular line extends to upper SVC.\n\n Mild-to-moderately enlarged heart, bilateral perihilar haze, prominent right\n pulmonary artery and diffuse lung haziness obscuring the bronchovascular\n marking suggest moderately severe pulmonary edema. There are presumed small\n bilateral effusions. No pneumothorax.\n\n IMPRESSION: Moderately severe pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1234736, "text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p s/p MVC with b/l ankle fractures, aggressively resuscitated\n in OR\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post motor vehicle collision with bilateral ankle\n fracture, aggressively resuscitated. To look for interval changes.\n\n TECHNIQUE: Portable semi-erect chest view was reviewed in comparison with\n prior radiograph from .\n\n FINDINGS: Monitoring and supporting devices are in standard position. Mild\n to moderately severe pulmonary edema has symmetrically improved on the right\n side, but unchanged on the left side. Bilateral small pleural effusions are\n presumed. Retrocardiac density is increased since , reflecting\n an increased left lower lung atelectasis. There is no pneumothorax.\n\n IMPRESSION: Over last 24 hours mild to moderately severe pulmonary edema has\n symmetrically improved on the right side and unchanged on the left side.\n Bilateral small pleural effusions are presumed.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1234887, "text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ICU rounds\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with ICU\n REASON FOR THIS EXAMINATION:\n ICU rounds\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n FINDINGS: In comparison with the study of , there is continued enlargement\n of the cardiac silhouette with pulmonary edema and bilateral pleural effusions\n with compressive atelectasis at the bases. Little overall change.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1235102, "text": " 11:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for stroke\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M s/p MVC vs guard rail as unrestrained driver with open left ankle fracture\n s/p I&D + ex-fix, right ankle fracture s/p splinting, and scalp laceration s/p\n repair s/p PEA arrest likely from OSA respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SUN 1:15 AM\n No acute intracranial process.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old, status post PEA arrest. Please assess for\n infarction.\n\n TECHNIQUE: Axial CT images of the head were obtained.\n\n COMPARISON: CT of the head from .\n\n FINDINGS:\n There is no evidence of hemorrhage, edema, mass effect, or infarction. The\n ventricles and sulci are normal in size and configuration. The -white\n matter differentiation is well preserved. There are moderate centrum\n semiovale and periventricular confluent hypodensities consistent with sequela\n of chronic small vessel disease.\n\n There is opacification of the sphenoid sinus and partial opacification of the\n ethmoid air cells. There is circumferential mucosal thickening of the\n maxillary sinuses. The nasopharynx is opacified. A nasogastric tube and\n endotracheal tube are partially visualized.\n\n There are no suspicious lytic or sclerotic bony lesions.\n\n IMPRESSION:\n No acute intracranial process.\n\n NOTE ADDED AT ATTENDING REVIEW: The patient has bilateral exophthalmos. The\n medial and lateral rectus muscles appear thickened. This is most\n characteristic of thyroid eye disease. In the setting of trauma, clinical\n consideration should be given to a carotid cavernous fistula, which also could\n produce these findings. However, the latter lesion would be expected to be\n associated with vascular congestion of the orbital fat, not observed in this\n case, a bruit, and chemosis on clinical examination.\n\n The CT does not demonstrate evidence of infarction. However, if there is\n ongoing concern of anoxic injury, an MR will be far more sensitive.\n (Over)\n\n 11:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for stroke\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2184-03-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1234492, "text": " 1:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for fractures or dislocation. Trauma.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 71M unrestrained driver in MVC - struck guardrail on driver side -\n entered vehicle\n REASON FOR THIS EXAMINATION:\n Assess for fractures or dislocation. Trauma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RBLd TUE 2:28 PM\n no acute intracranial hemorrhage or fracture.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male unrestrained driver in MVC, assess for fracture\n or hemorrhage.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered. Coronal and sagittal reformats were performed.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or\n acute territorial infarction. There is a small lacune in the right putamen.\n Mild periventricular white matter hypodensity is consistent with chronic small\n vessel ischemic disease. The visualized ventricles and sulci are normal in\n size and configuration for the patient's age. The visualized paranasal\n sinuses and mastoid air cells are well aerated. No fracture. There is a small\n subgaleal hematoma overlying the right vertex, best seen on series 400B, image\n 70. No foreign object is identified.\n\n IMPRESSION: No acute intracranial process. No acute fracture. Small right\n vertex subgaleal hematoma.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-09 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1234493, "text": " 1:03 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Assess for fractures or dislocation. Trauma.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 71M unrestrained driver in MVC - struck guardrail on driver side -\n entered vehicle\n REASON FOR THIS EXAMINATION:\n Assess for fractures or dislocation. Trauma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RBLd TUE 2:29 PM\n no acute fx/dislo\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old male, a restrained driver in MVC. Assess for\n fracture.\n\n COMPARISON: None available.\n\n TECHNIQUE: Helical MDCT images were obtained through the cervical spine.\n Coronal and sagittal reformations were performed.\n\n FINDINGS: There is no acute fracture or malalignment. The prevertebral and\n paravertebral soft tissues are unremarkable. There is no hematoma identified.\n There are mild emphysematous changes in the apices of the lungs bilaterally.\n The thyroid is unremarkable.\n\n IMPRESSION: No acute fracture or malalignment.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-11 00:00:00.000", "description": "B ANKLE (AP, MORTISE & LAT) BILAT", "row_id": 1234827, "text": " 3:30 PM\n ANKLE (AP, MORTISE & LAT) BILAT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. BILATClip # \n Reason: ORIF RIGHT ANKLE FX REPAIR/ EX-FIX REPAIR LEFT ANKLE\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL ANKLE RADIOGRAPH PERFORMED ON \n\n Comparison is made with prior studies from and .\n\n CLINICAL HISTORY: ORIF right ankle, ex-fix left ankle, assess hardware.\n\n FINDINGS: Multiple intraoperative images were obtained for surgical guidance.\n On the right, lag screws stabilize the medial malleolus. A side plate and\n perpendicularly oriented screws stabilize the distal fibular fracture in\n anatomic alignment. A syndesmotic screw is also noted. On the left, medial\n side plate and multiple screws stabilize the medial malleolar fracture\n fragment. Distal fibular fracture is noted with slight lateral displacement\n of the distal fracture fragment.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-09 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 1234486, "text": " 12:38 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 71M with MVC\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post MVC, evaluate for fracture or bony\n abnormality.\n\n COMPARISON: None available.\n\n FINDINGS: No pneumothorax or pleural effusion. The lungs are clear. There\n is mild cardiomegaly. The cardiac, hilar, and mediastinal contours are\n normal. No fracture is identified. One AP view of the pelvis demonstrates no\n acute fractures or dislocations, however, this is severely limited due to\n patient's body habitus.\n\n IMPRESSION:\n 1. No acute intrathoracic injury is identified.\n\n 2. No acute fracture or dislocation in the pelvis however evaluation is\n severely limited due to patient's body habitus.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-09 00:00:00.000", "description": "B ANKLE (2 VIEWS) BILAT", "row_id": 1234491, "text": " 12:58 PM\n ANKLE (2 VIEWS) BILAT Clip # \n Reason: Assess for fracture/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 71M s/p MVC - unrestrained, concern for LLE open fracture dislocation\n REASON FOR THIS EXAMINATION:\n Assess for fracture/dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post MVC concern for left lower extremity\n open fracture or dislocation.\n\n COMPARISON: None available.\n\n FINDINGS: Two views of the right ankle and one view of the left ankle.\n Overlying cast or splint slightly limits evaluation. Within this limitation,\n there is dislocation of the right ankle with lateral displacement of the talus\n in relation to the tibia. There is a distal fibular fracture with a distal\n fragment displaced posteriorly. There is a talonavicular dislocation and mild\n widening at the calcaneocuboid joint. There is also likely a medial malleolus\n fracture. There is a displaced proximal fifth metatarsal fracture.\n\n Only one view was given of the left ankle. The left ankle is dislocated with\n the talus displaced medially compared to the tibia. There is also displaced\n fracture of the medial malleolus. There is likely less-well visualized\n fracture of the lateral malleolus as well as the distal fibula. There are\n proximal and distal fifth metatarsal fractures.\n\n IMPRESSION: Multiple fractures and dislocations of bilateral ankles as\n described above.\n\n" }, { "category": "Echo", "chartdate": "2184-03-18 00:00:00.000", "description": "Report", "row_id": 105145, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 68\nWeight (lb): 240\nBSA (m2): 2.21 m2\nBP (mm Hg): 93/43\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 14:15\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient intubated and sedated with a propofol drip during the entire\nprocedure.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Good RAA ejection velocity (>20cm/s).\nLipomatous hypertrophy of the interatrial septum. No ASD by 2D or color\nDoppler. Prominent Eustachian valve (normal variant).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: No atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No aortic valve abscess. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). The patient was under general\nanesthesia throughout the procedure. No glycopyrrolate was administered. No\nTEE related complications. Echocardiographic results were reviewed with the\nhouseofficer caring for the patient.\n\nConclusions:\nRight atrial appendage ejection velocity is good (>20 cm/s). No atrial septal\ndefect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the descending thoracic aorta to 40 centimeters from the incisors.\nThe aortic valve leaflets (3) are mildly thickened. No masses or vegetations\nare seen on the aortic valve. No aortic valve abscess is seen. No aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. No mass or\nvegetation is seen on the mitral valve. No vegetation/mass is seen on the\npulmonic valve. There is no pericardial effusion.\n\nIMPRESSION: No valvular vegetation, abscess, or intracardiac mass/thrombus\nvisualized.\n\nThe housestaff team caring for the patient was notified in person of the\nresults on at 13:40.\n\n\n" }, { "category": "Echo", "chartdate": "2184-03-10 00:00:00.000", "description": "Report", "row_id": 105146, "text": "PATIENT/TEST INFORMATION:\nIndication: s/p MVC and PEA arrest. Evaluate LV/RV\nHeight: (in) 69\nWeight (lb): 261\nBSA (m2): 2.32 m2\nBP (mm Hg): 122/61\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 11:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root.\n\nAORTIC VALVE: No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus. Suboptimal image\nquality - ventilator.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nRight ventricular chamber size and free wall motion are normal. The aortic\nroot is mildly dilated at the sinus level. There is no aortic valve stenosis.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Physiologic mitral regurgitation is seen (within normal limits).\nThere is borderline pulmonary artery systolic hypertension. There is an\nanterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Normal regional and global biventricular systolic function. No\npathologic valvular abnormalities. Prominent anterior fat pad.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-09 00:00:00.000", "description": "BOP ANKLE (AP, LAT & OBLIQUE) BILAT IN O.R. PORT", "row_id": 1234529, "text": " 5:38 PM\n ANKLE (AP, LAT & OBLIQUE) BILAT IN O.R. PORT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. PORT BILATClip # \n Reason: OPEN REDUX LEFT ANKKLE, CLOSED REDUX RIGHT ANKLE IN OR\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture dislocation about the ankle.\n\n This exam consists of 14 intraoperative radiographs of both the left and right\n ankles. Fracture dislocations of the right distal tibia and fibula as well as\n the proximal fifth metatarsals have been reduced since exam earlier same day.\n On the left, an external fixation device has been placed with the percutaneous\n pins through the mid tibial shaft and apparently through the os calcis.\n Multiple fractures are again seen in relationship to this left ankle.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235017, "text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man in ICU\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY, \n\n COMPARISON: radiograph.\n\n FINDINGS: Cardiac silhouette is enlarged, but stable in size. Widespread\n airspace opacities in the left lung, particularly in the perihilar and basilar\n regions have worsened in the interval, whereas opacities in the right lung\n have improved since the recent radiograph. Findings could potentially\n represent asymmetrical pulmonary edema, but a superimposed secondary process\n in the left lung such as aspiration should be considered in the appropriate\n clinical setting. Persistent small left pleural effusion is noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-04-02 00:00:00.000", "description": "RP ANKLE (AP, MORTISE & LAT) RIGHT PORT", "row_id": 1237587, "text": " 8:55 AM\n ANKLE (AP, MORTISE & LAT) RIGHT PORT Clip # \n Reason: Please assess for interval change. Thanks.\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p MVC with right ankle fracture. Please perform as portable\n study.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF.\n\n FINDINGS: In comparison with the study of , there are again metallic\n fixation devices about fractures of the distal tibia and fibula. Overall\n alignment is unchanged. Some new bone formation is suggested, though the\n fracture lines are still evident.\n\n What appears to be somewhat extensive heterotopic opacification is seen\n adjacent to the medial aspect of the talus.\n\n There appears to be a lucency crossing the base of the fifth metatarsal that\n represents a fracture but is not well visualized on this study.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-15 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1235173, "text": " 5:00 AM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST\n Reason: eval for ischemia or underlying process\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with altered mental status and hx of hypoxic cardiac arrest\n REASON FOR THIS EXAMINATION:\n eval for ischemia or underlying process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc MON 1:45 PM\n 1. Few small white matter infarcts seen bilaterally, suggestive of embolic\n disease. No evidence of anoxic brain injury.\n 2. Patent carotid and vertebral arteries and circle of .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with altered mental status and history of hypoxic\n cardiac arrest, to assess for ischemia.\n\n COMPARISON: CT of the head without contrast, .\n\n TECHNIQUE: Multiplanar multisequence MR imaging of the head was performed\n without intravenous contrast. Axial 3D time-of-flight sequences of the head\n were performed.\n\n FINDINGS:\n\n MRI OF THE BRAIN: No hemorrhage, edema, masses or mass effect is seen. Three\n small areas of slow diffusion seen in the left frontal, left parietal, and\n right occipital white matter, represent small acute infarcts. Bilateral\n periventricular white matter FLAIR hyperintensities seen in bilateral\n parieto-occipital lobes, suggest small vessel ischemic disease. The\n ventricles and sulci are mildly prominent, consistent with mild age-related\n involutional changes. No abnormalities are seen in the diffusion-weighted\n imaging sequences.\n\n There is opacification of bilateral sphenoid sinuses.\n\n MRA: The intracranial portions of the vertebral and bilateral internal\n carotid arteries are patent. The basilar artery and its major branches\n including the COW are patent. The anterior cerebral and middle cerebral\n arteries are patent. No vascular occlusion, stenosis or large aneurysm\n formation is detected.\n\n The orbits are unremarkable.\n\n IMPRESSION:\n 1. Few small white matter infarcts seen bilaterally, suggestive of embolic\n disease. No evidence of anoxic brain injury.\n 2. Patent carotid and vertebral arteries.\n (Over)\n\n 5:00 AM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST\n Reason: eval for ischemia or underlying process\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2184-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235930, "text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with aspiration event\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 71-year-old male with aspiration.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is a right IJ central venous line with distal lead tip in the mid SVC.\n The feeding tube and tracheostomy tube are unchanged. There is again seen\n cardiomegaly and diffuse airspace opacities bilaterally consistent with\n pulmonary edema. Multifocal pneumonia would also have to be considered.\n There is a left-sided pleural effusion and a left retrocardiac opacity as\n well. Overall these findings are stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236647, "text": " 10:02 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval post bronch\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M s/p MVC vs guard rail as unrestrained driver with open left ankle fracture\n s/p I&D + ex-fix, right ankle fracture s/p ORIF, and scalp laceration s/p\n repair s/p PEA arrest likely from OSA respiratory failure\n REASON FOR THIS EXAMINATION:\n eval post bronch\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male status post MVC, PEA and cardiac arrest with\n respiratory failure, evaluate post bronch.\n\n COMPARISON: Prior radiographs from and .\n\n FINDINGS: Single AP portable chest radiograph was obtained. Since the most\n recent prior radiograph, there is slight improvement in diffuse bilateral\n pulmonary opacities, particularly on the left. There is a small left-sided\n pleural effusion which is mostly unchanged. There is no evidence of\n pneumothorax. Moderate cardiomegaly is stable. Right PICC tip is unchanged.\n\n\n IMPRESSION: Slight improvement in diffuse bilateral diffuse pulmonary\n opacities, particularly on the left.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235761, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known pneumonia. Concern for septic pulmonary emboli on recent\n CT-Chest.\n\n COMPARISON: Multiple priors from through .\n\n FINDINGS: Portable AP chest radiograph demonstrates the patient has been\n extubated and a tracheostomy tube placed. The right IJ catheter terminates in\n the standard position. The NG tube courses below the diaphragm and terminates\n outside the field of view. Bilateral parenchymal opacities are worsened from\n , particularly in the left upper lung. Small bilateral pleural\n effusions are unchanged. The cardiomediastinal silhouette is stable. There\n is no pneumothorax.\n MJMgb\n\n" }, { "category": "Radiology", "chartdate": "2184-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236482, "text": " 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever, VAP\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with fever and VAP, question interval change.\n\n COMPARISONS: Portable chest radiograph from .\n\n FINDINGS: Since the prior radiograph, the NG tube has been removed. The\n tracheostomy tube is in place. There has been no significant change in\n bilateral diffuse parenchymal opacifications. The cardiac silhouette is\n unchanged. There are no new parenchymal opacities.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235178, "text": " 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval status of pneumonia\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n eval status of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluate for pneumonia.\n\n TECHNIQUE: Single PA upright chest view was read in comparison with multiple\n prior radiographs, with the most recent from .\n\n FINDINGS: Over last 24 hours, worsened left mid and lower lung opacities is\n concerning for aspiration pneumonia, give prior aspiration changes as\n reflected by radiograph sequence between and . Mild\n opacity in the right lower lung likely from atelectasis or aspiration is\n unchanged since yesterday. Top normal heart size, mediastinal and hilar\n contours have been stable. Tip of the endotracheal tube ends approximately\n 3.5 cm above the carina and is appropriate. Right internal jugular line\n terminates at mid SVC. Effusions, if any, are small bilaterally, unchanged\n since yesterday.\n\n IMPRESSION: Worsening of the left mid and lower lung opacities may represent\n developing aspiration pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2184-03-22 00:00:00.000", "description": "Report", "row_id": 305461, "text": "Baseline artifact. Sinus rhythm. Probably normal tracing. Since the previous\ntracing probably no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2184-03-20 00:00:00.000", "description": "Report", "row_id": 305462, "text": "Sinus rhythm. Since the previous tracing there is technical improvement.\nST-T wave abnormalities may be improved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2184-03-19 00:00:00.000", "description": "Report", "row_id": 305463, "text": "Baseline artifact. Sinus rhythm. T wave abnormalities. Since the previous\ntracing of the rate is slower. ST-T wave abnormalities are less\nprominent on the present tracing.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2184-03-12 00:00:00.000", "description": "Report", "row_id": 305464, "text": "Sinus tachycardia with increase in rate compared to the previous tracing\nof . The previously mentioned ST-T wave changes persist without\ndiagnostic interim change. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2184-03-12 00:00:00.000", "description": "Report", "row_id": 305465, "text": "Sinus tachycardia. Early precordial R wave transition. T wave inversions in\nleads I and aVL with biphasic T waves and low amplitude T waves in\nleads II, III and aVF. Biphasic to inverted T waves in leads V5-V6. Consider an\ninferolateral ischemic process. Followup and clinical correlation are\nsuggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2184-03-10 00:00:00.000", "description": "Report", "row_id": 305466, "text": "Baseline artifact. Probable sinus rhythm. Otherwise, uninterpretable.\nNo previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236749, "text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with VAP\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: VAP, interval change.\n\n CHEST, SINGLE AP VIEW\n\n Compared with at 10:01 a.m. and allowing for technical differences,\n left-sided confluent opacities may be slightly improved. Otherwise, I doubt\n significant interval change.\n\n Again seen is the tracheostomy, diffuse bilateral opacities, and enlarged\n cardiomediastinal silhouette, with left lower lobe collapse and/or\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235346, "text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia, to look for interval changes.\n\n TECHNIQUE: Semi-erect portable chest were read in comparison with multiple\n prior radiographs with the most recent from , acquired over 24\n hours apart.\n\n FINDINGS: With the patient's neck in flexed position, the tip of the\n endotracheal tube ends approximately 3 cm from the carina and is appropriate\n in position, right internal jugular line tip is at upper SVC and orogastric\n tube courses below the diaphragm into the stomach, but its distal end is out\n of radiographic view. Since yesterday, the left mid and lower lung\n consolidation has improved. Increased retrocardiac density likely atelectasis\n and/or consolidation is no different. Heart size, mediastinal and hilar\n contours are stable.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235607, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia. Evaluation for interval change. Recent CTA raised\n concern for septic pulmonary emboli.\n\n COMPARISONS: .\n\n FINDINGS: AP chest radiograph. The ET tube and right IJ tube terminate in\n the standard position. NG tube courses below the diaphragm and terminates\n outside the field of view. Bilateral parenchymal opacifications and small\n pleural effusions are more evenly distributed than on . Left lower\n lobe pneumonia is unchanged. The cardiomediastinal silhouette is stable.\n There is no pneumothorax.\n MJMgb\n\n" }, { "category": "Radiology", "chartdate": "2184-03-23 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1236240, "text": " 8:38 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: r/o DVT\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with tachycardia, LE fx's\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with bilateral lower extremity fractures, who now\n presents with tachycardia.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n Grayscale and color Doppler images of bilateral common femoral, superficial\n femoral, deep femoral, greater saphenous, and popliteal veins were obtained\n with normal flow, compressibility and augmentation. Color flow in proximal\n calf veins are demonstrated. Distal calf veins were not interrogated due to\n overlying cast material.\n\n IMPRESSION:\n\n No evidence of deep venous thrombosis in bilateral lower extremities. Distal\n calf veins not visualized due to overlying cast material.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-23 00:00:00.000", "description": "BP ANKLE (AP, MORTISE & LAT) BILAT PORT", "row_id": 1236245, "text": " 9:11 AM\n ANKLE (AP, MORTISE & LAT) BILAT PORT Clip # \n Reason: f/u fx's - portable ok\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with b/l anjkle fx's\n REASON FOR THIS EXAMINATION:\n f/u fx's - portable ok\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with bilateral bimalleolar ankle fractures,\n status post ORIF.\n\n COMPARISON: Comparison is made to CT lower extremity, right and left, , .\n\n TECHNIQUE: Bilateral AP, mortise, and lateral radiographs of the ankle.\n\n FINDINGS:\n\n RIGHT ANKLE: Patient is status post ORIF of bimalleolar fractures. Seen is\n semitubular fibular plate fixating the lateral malleolus with a combination of\n cortical and locking screws. Cortical and locking screws are seen fixing the\n medial malleolar fracture. A long 3-mm K-wire is seen inserted into the\n plantar aspect of the foot towards the tibia maintaining the alignment of the\n calcaneus, talus, and tibia. No obvious hardware complications are\n identified. Previously documented fractures of sustentaculum tali, fifth\n metatarsal, first proximal phalanx, and fibular sesamoid at the first MTP are\n not well appreciated in these radiographs.\n\n LEFT ANKLE: Patient is status post ORIF of medial malleolar fracture.\n External fixation device is seen still in place including the lateral and\n medial malleolus in reduction. Metallic plate affixed with screws is seen\n along the medial aspect of the distal tibia holding the fragments of the\n medial malleolus in near anatomic alignment. Comminuted displaced distal\n fibular fracture is seen essentially unchanged with no apparent hardware\n modifications. There is no complication in the hardware of the media\n malleolar fracture or in the external fixation device. Previously documented\n fractures of the medial navicular, cuboid, and cuneiforms and fractures of the\n fourth and fifth metatarsals are not well appreciated on this radiographic\n study.\n\n IMPRESSION:\n 1) No hardware complications identified. Ankles bilaterally are in\n approximate anatomic alignment.\n 2) The left is held in position with external fixator; distal left fibular\n fracture unchanged in appearance.\n (Over)\n\n 9:11 AM\n ANKLE (AP, MORTISE & LAT) BILAT PORT Clip # \n Reason: f/u fx's - portable ok\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2184-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236613, "text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with VAP\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST:\n\n REASON FOR EXAM: Pneumonia.\n\n Comparison is made with prior study .\n\n Cardiomegaly is stable. Widening mediastinum has increased suggesting\n worsening vascular congestion. Diffuse lung consolidations larger in the left\n lung are grossly unchanged. Tracheostomy tube is in the standard position.\n Right PICC tube is at the cavoatrial junction.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236364, "text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever, VAP\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Fever, ventilator-associated pneumonia. Evaluation for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Widespread bilateral parenchymal opacities with air bronchograms show\n comparable distribution and severity. The tracheostomy tube and the\n nasogastric tube are in unchanged position. Unchanged size of the cardiac\n silhouette. No new parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237091, "text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change. Thanks.\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M with trach\n REASON FOR THIS EXAMINATION:\n Please assess for interval change. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:09 A.M., \n\n HISTORY: Tracheostomy tube. Increased hypoxia.\n\n IMPRESSION: AP chest compared to through 23:\n\n Severe diffuse infiltrative pulmonary abnormality greater in the left lung\n than the right has not changed appreciably since after worsening\n compared to . Simplest explanation is pulmonary edema. Tracheostomy\n tube in standard placement. Mild cardiomegaly stable. Pleural effusions are\n presumed, but not large.\n\n Right PIC line ends at or just below the superior cavoatrial junction.\n Withdrawal of 15 mm would assure its location in the low third of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-29 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1237011, "text": " 1:23 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: evaluate for possible DVT\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with need for possible graft. needs venous assessment\n REASON FOR THIS EXAMINATION:\n evaluate for possible DVT\n ______________________________________________________________________________\n FINAL REPORT\n VENOUS DUPLEX\n\n Patient in need of bypass.\n\n Duplex evaluation is performed of both lower extremities. Right greater\n saphenous vein is patent showing diameters of 0.3 to 0.46. Left shows\n diameters of 0.36 to 0.7.\n\n IMPRESSION: Patent bilateral greater saphenous veins with diameters as noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235145, "text": " 4:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate placement of ETtube\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with ET tube. eval location\n REASON FOR THIS EXAMINATION:\n evaluate placement of ETtube\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: radiograph.\n\n FINDINGS: Tip of endotracheal tube terminates approximately a centimeter\n above the carina. This information has been communicated by telephone to Dr.\n at 4:55 p.m. on at the time of discovery. Cardiac\n silhouette is mildly enlarged, and accompanied by pulmonary vascular\n engorgement and shifting perihilar opacities which are now more prominent in\n the right peri- and infrahilar region than on the left. This probably\n represents change in distribution of pulmonary edema, but coexisting\n aspiration is possible in the appropriate clinical setting. There remains\n dense left retrocardiac opacity and layering left pleural effusion. There is\n also an apparent new small layering right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236852, "text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate process\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with recent pneumonia\n REASON FOR THIS EXAMINATION:\n evaluate process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent pneumonia, evaluate.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n A tracheostomy tube is in place. There is dense retrocardiac density, with\n obscuration of left hemidiaphragm, consistent with left lower lobe collapse\n and/or consolidation. Probable small left effusion. There is vascular\n plethora, vascular blurring, and interstitial edema, consistent with CHF.\n Equivocal minimal blunting of the right costophrenic angle.\n\n Compared with at 5:41 a.m., the overall appearance is similar.\n Possible very slight interval improvement in the CHF findings.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236220, "text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna. Interval change.\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fever, VAP.\n REASON FOR THIS EXAMINATION:\n ? pna. Interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, pre-existing relatively\n extensive bilateral parenchymal opacities have further increased in extent.\n They likely represent a combination of pneumonia and pulmonary edema.\n\n Borderline size of the cardiac silhouette. Unchanged tracheostomy tube and\n nasogastric tube. The presence of a small-to-moderate left pleural effusion\n cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1235480, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pneumonia, to assess for interval changes.\n\n TECHNIQUE: A supine portable chest view was read in comparison with the most\n recent radiograph from .\n\n FINDINGS:\n\n Endotracheal tube tip is 3.6 cm above the carina with the patient's neck in\n flexed position and is appropriate, right internal jugular line ends at mid\n SVC, and a feeding tube is seen coursing below the diaphragm into the stomach;\n however, its distal end is off the radiographic view.\n\n Left lung opacities concerning for pneumonia have progressed over the last 24\n hours and now involve the left upper lung. Mild right lung base atelectasis\n is unchanged. Mild to moderately enlarged heart size is stable. Mediastinal\n and hilar contours are unchanged.\n\n IMPRESSION: Worsening of left lung pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1235981, "text": " 2:05 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 48 cm right brachial Picc \n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 48 cm right brachial Picc \n ______________________________________________________________________________\n WET READ: MDAg SAT 3:11 PM\n Low lung volumes. R PICC appears to end in the R atrium. if pulled back 3cm,\n it will be in the mid-distal SVC.\n -MAgarwal d/ (IV RN) by phone at 3:05pm \n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: Patient with a central line.\n\n FINDINGS: There is a right-sided central line with distal lead tip in the\n proximal right atrium. This could be pulled back 3 cm for more optimal\n placement. Endotracheal tube, nasogastric tube, and right IJ central venous\n line are in unchanged position. There is a left retrocardiac opacity.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236035, "text": " 5:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate status of pneumonia\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n evaluate status of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia, to assess for change.\n\n FINDINGS: In comparison with the study of , the right IJ catheter has\n been removed. Other monitoring and support devices remain in place.\n\n The overall appearance of the heart and lungs is essentially unchanged, though\n there is suggestion of more coalescence of opacification at the right base\n that could represent a developing consolidation.\n\n A second image showing an endotracheal tube appears to not relate to this\n patient.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237407, "text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change.\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with trach.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with trach, assess for interval change.\n\n COMPARISON: Portable chest radiograph from .\n\n FINDINGS: Since the prior radiograph, there has been no significant interval\n change. Again seen is unchanged prominence of the pulmonary vasculature\n consistent with pulmonary edema. Tracheostomy tube is unchanged in position.\n There is stable cardiomegaly. A right PICC is seen with the tip unchanged in\n position.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-17 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1235536, "text": " 1:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: febrile, ? efussion, PNA\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M s/p MVC w/ scalp lac and bilateral ankle fx, now s/p LLE washout/ external\n fixation, R ankle ORIF, and scalp laceration closure. Course c/b PEA arrest.\n REASON FOR THIS EXAMINATION:\n febrile, ? efussion, PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of trauma with bilateral ankle fractures and external\n fixation. Complications have included PEA arrest. Concern for pneumonia or\n effusion.\n\n TECHNIQUE: MDCT images were obtained through the chest before and after the\n administration of 100 cc of Omnipaque intravenous contrast material. Coronal\n and sagittal reformations as well as oblique MIPs were acquired.\n\n COMPARISONS: CT of the torso on . Multiple prior chest\n radiographs from 4th through 11th.\n\n FINDINGS: There are new small bilateral pleural effusions as well as\n worsening dependent pulmonary opacifications. Also noted are new peripheral,\n predominantly subpleural opacities most notably in the right lung,\n (3:5,8,12,17). These opacities have solid centers with surrounding\n ground-glass halos. Some of these peripheral opacities contain calcifications\n of unclear etiology (4:56).\n\n Opacification in the pulmonary arteries is suboptimal for evaluation of\n peripheral emboli. However, there is no large central pulmonary embolus. The\n ET tube and NG tube terminate in standard position. A central venous line\n terminates in the SVC. The airways are patent to the subsegmental level.\n There is no pneumothorax. There are multiple prominent mediastinal lymph\n nodes that do not meet pathologic criteria though they do appear to have\n enlarged when compared to CT on .\n\n A calcified granuloma in the spleen is unchanged. There is mild cardiomegaly,\n unchanged. Atherosclerotic calcification of the coronary arteries are noted,\n particularly in the LAD.\n\n OSSEOUS STRUCTURES: There are no lytic or blastic lesions suspicious for\n malignancy.\n\n IMPRESSION:\n 1. Multiple peripheral pulmonary opacities could represent septic emboli.\n Aggressive search for a source of infection is recommended.\n 2. Increased bibasilar consolidation of the dependent lungs, most likely\n representing atelectasis, though an infectious process is possible.\n 3. New small bilateral pleural effusions.\n\n (Over)\n\n 1:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: febrile, ? efussion, PNA\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The case was discussed by Dr. with Dr. by phone at\n approximately 5:10 p.m. on .\n MJMgb\n\n" }, { "category": "Radiology", "chartdate": "2184-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1236938, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, thanks\n Admitting Diagnosis: BILATERAL ANKLE FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with trach, left lung opacities\n REASON FOR THIS EXAMINATION:\n interval change, thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with trachea, left lung opacities, interval\n changes.\n\n TECHNIQUE: Semi-erect portable chest view was read in comparison with\n multiple prior chest radiographs, with the most recent from .\n\n FINDINGS:\n\n Moderately diffuse left lung opacities have worsened whereas diffuse and mild\n right lung opacities are unchanged. Top normal heart size is similar but over\n last 24 hours there is widening of the upper mediastinum and pulmonary hila\n suggesting increased mediastinal and pulmonary vascular congestion. Increased\n retrocardiac density reflecting left lower lung atelectasis is also worse.\n Small left pleural effusion is unchanged. Right PICC line tip is at lower\n SVC/cavoatrial junction. Tracheostomy tube is in position.\n\n IMPRESSION: Asymmetric left side more than right diffuse lung opacities,\n unchanged on the right side and worse on left, and widening of the upper\n mediastinum and prominent pulmonary vasculature which is new since yestarday\n suggest worsening of moderate asymmetric pulmonary edema . Presumed small\n left pleural effusion is unchanged and left lower lung atelectasis has\n worsened over the same duration.\n\n" } ]

[ { "category": "Echo", "chartdate": "2146-11-10 00:00:00.000", "description": "Report", "row_id": 68593, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. H/O cardiac surgery.\nHeight: (in) 65\nWeight (lb): 140\nBSA (m2): 1.70 m2\nBP (mm Hg): 178/50\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 10:07\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 markedly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferior - hypokinetic; mid inferior -\nhypokinetic; basal inferolateral - hypokinetic; mid inferolateral -\nhypokinetic; basal anterolateral - hypokinetic; inferior apex - hypokinetic;\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. Mild to moderate (+) aortic regurgitation is seen.\n\nMITRAL VALVE: There is moderate mitral annular calcification. Moderate to\nsevere (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is mildly depressed. Resting regional wall motion\nabnormalities include severe inferior and inferolateral hypokinesis along with\nbasal lateral hypokinesis. Right ventricular systolic function is normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. Mild to moderate (+) aortic regurgitation is seen. Moderate to\nsevere (+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2146-11-10 00:00:00.000", "description": "Report", "row_id": 1347545, "text": "CCU Nursing Transfer Note:\n\nPlease see admit note for history.\n\nNeuro: Pt lethargic sleeping on and off most of the day. Pt arouses to voice. Moving all extremities spontaneously with encouragement. Pt conts to c/o coccyx discomfort with movement. Pt is unable to lay on back due to discomfort therefore is turning side to side with one assist. Pt denies the need for pain medication. Noon xanax dose held secondary to lethargy. Await PT consult after pt rules out for MI. Pt remains on bedrest at this time.\n\nCV: SR HR 64-71 no ectopy. Pt denies CP. SBP 166-188 therefore NTG gtt increased to 133mcg(60mcg) with decrease in SBP 150's. Weaning NTG gtt as tolerated. Pt restarted on cardiac regimen per team we will cont to hold beta blockers. Palpable pulses. Hep gtt d/c'd. Pt transfused 1u PRBC's for HCT 26.6 recheck HCT this evening.\n\nPt underwent a echo today, awiting results. CK's flat.\nEP consulting for possible EP studies .\n\nPULM: LS diminished bibasilary. Pt denies SOB. NC 2L sats 96-97% trend to 89% on rm air while asleep.\n\nGI: Abd soft NT +BS. LBM 2 days ago per pt. Pt conts on bowel regimen a/o. NPO after mn for EP studies.\n\nGU: Foley cath patent draining clear yellow urine. BUN 96 Creat 2.9.\n-2140 912 since mn.\n\nSKIN: intact\n\nPROPH: protonix po.\n\nENDO: BS WNL. Reg insulin SS if indicated. NPH held this am secondary to low BS and NPO status.\n\nLINES: 2 PIV.\n\nSOCIAL: Husband at bedside\n\nDISPO: Full Code\n\nA/P: Wean NTG gtt to off. Check pm HCT. Encourage po's. NPO after mn.\n Provide support. Transfer to cardiac floor.\n" }, { "category": "Nursing/other", "chartdate": "2146-11-10 00:00:00.000", "description": "Report", "row_id": 1347544, "text": "CCU NURSING ADMISSION NOTE: PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n65 YO WOMAN ADMITTED WITH BRADYCARDIA AND CP.\n\nHPI: HAD SYNCOPAL EPISODE ADMITTED TO HOSPITAL,ON HALTER MONITOR THERE. WITH THE FALL INJURED COCCYX. WAS TRANSFERRED TO REHAB. ON ARRIVAL C/O CP8/10. NOTED TO HAVE HR IN 40'S.GIVEN 3 SL NTG WITH GOOD PAIN RELIEF AND BROUGHT TO EW.\n EW-NO CHEST PAIN BUT SOME BILATERAL NECK PAIN. STARTED ON NTG DRIP, BOLUSED WITH HEPARIN AND DRIP STARTED.ALSO GIVEN AMP ATROPINE WITH NO IMPROVEMENT IN HR. A&O X3. BP 170/58 HR 40'S.\n\nPMH: CAD( S/ ',MI '&'), HTN,RENAL INSUFF, S/P CEA,IDDM,S/P LEFT FEM ',PVD,CVA AFTER CEA,CHOLE ',CHF EF 45-50%,KNOWN AI,MR .\n\nALLERGIES:HYDRALAZINE\n\nROS:\n\nCARDAIC: RESUMED MOST OF ANTIHYPERTENSIVES,BETA BLOCKERS HELD. SERIAL CK'S LAST ONE DUE 6:30. FIRST TWO 66 AND 61. HR HAS BEEN MOSTLY IN THE 60'S. BP HAS REMAINED HIGH 150-180/80-120. K WAS 6.0 IN EW NOW DOWN TO 5.3 . NO CP REMAINS ON NTG AND HEPARIN.\n\nRESP: 2L NP CLEAR.SATS MID TO HIGH 90'S\n\nID: AFEBRILE\n\nENDOCRINE: FS HAVE BEEN FOLLOWED LAST ONE 98 AT 6AM. DID NOT GIVE NPH LAST EVENING\n\nGU:#14 FOLEY PLACED,GOOD UO. BUN 96 CREAT 2.9\n\nGI: CLEAR LIQUIDS ON EVES NOW NPO\n\nNEURO: ALERT AND ORIENTED X3\n\nCOMFORT: HAS BACK PAIN FROM RECENT FALL,GIVEN TYLENOL#3 WITH GOOD PAIN RELIEF.\n\nHEME: HCT 26.3 TRANSFUSED ONE UNIT PACKED CELLS. BASELINE HCT 32.\n\nA/P: DOES NOT APPEAR TO HAVE AN MI\n HR HAS STABILIZED TO 60'S WITH PAUSES\n EP TO CONSULT ON PT FOR POSSIBLE STUDY\n" }, { "category": "ECG", "chartdate": "2146-11-10 00:00:00.000", "description": "Report", "row_id": 148292, "text": "Sinus rhythm. Left atrial abnormality. Intraventricular conduction delay. Left\nventricular hypertrophy with ST-T wave abnormalities. Compared to the previous\ntracing of the rhythm is now sinus.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2146-11-09 00:00:00.000", "description": "Report", "row_id": 148293, "text": "Normal sinus rhythm with variable P-R interval and rate and no dropped beats.\nThis suggests a competing rhythm between sinus bradycardia and junctional\nrhythm. Left atrial abnormality and left ventricular hypertrophy are present.\nIntraventricular conduction delay. Compared to the previous tracing of \na sinus mechanism is now present\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2146-11-09 00:00:00.000", "description": "Report", "row_id": 148294, "text": "Junctional rhythm, rate 43. Left ventricular hypertrophy with repolarization\nabnormality. Intraventricular conduction delay. Compared to the previous\ntracing of the rate is slower and the rhythm is junctional.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2146-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 746041, "text": " 9:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 65 yo with severe CAD, PVD, DM with atypical CP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with see above; please evaluate mediastinum carefully\n REASON FOR THIS EXAMINATION:\n 65 yo with severe CAD, PVD, DM with atypical CP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 65 year old woman, please evaluate mediastinum, atypical chest\n pain.\n\n CHEST PORTABLE: Comparison is made to a prior study of . There is mild\n cardiomegaly. The mediastinal and hilar contours are unremarkable. There is\n upper zone vascular redistribution haziness of the vasculature. The lungs are\n clear. There are no pleural effusions.\n\n IMPRESSION: Status post CABG. Cardiomegaly with mild CHF.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2174-12-12 00:00:00.000", "description": "Report", "row_id": 1615368, "text": "ccu nursing progress note\ns: \"it must be that naprosyn...the pain is much better today\"\no: pls see carevue flowsheet for complete vs/data/events\ncv: cont to c/o cp tho this is mild, postional and at times completelt gone. ^'d pain w echo done at bedside. much improved w naprosyn and tolerable.\nhr 70s mostly in wenkebach. no prolonged pauses. holding lopressor d/t heart rhythm and bp on low side. bp 82-100/40-50 via nbp.\nremains on heparin at 1250units/hr. ptt 54, goal 50-80. has mod-lrg ecchymosis at r fem site extending to hip and upper thigh, soft. hct 31.\nid: t max 100.6 po. 98 at 4pm. cultures sent this am. foley removed.\nresp: bs dim at bases. rr low 20s. no cough. enc i/s use, moving to 750cc w good effort.\ngi: tol diet w fair intake. had formed bm, ob -. bs 141.\ngu: foley removed at 3pm. dtv 9pm-11pm. rec'd 2 500cc fluid boluses for low uop without much response. bun/cr stable.\nact: oob to ch several times, tol well. c/o feeling weak.\nsocial: wife visited late in eve w son. updated as to poc or on wednesday.\na: s/p mi, awaiting cabg, delayed d/t fever. pain improved w naprosyn, likely pleuritic. second degree hb.\np: follow for ischemia, chf, arrhythmia, bleeding complications. preop for wednesday. med for pain. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2174-12-13 00:00:00.000", "description": "Report", "row_id": 1615369, "text": "CCU Nursing Progress Note 1900-0700\nS: denies cp\n\nO: see CCU flow sheet for complete objective data\n\nCV: Remains in Mobitz Type I second degree AV block. V rate 75-95. BP 90-107/50-67. Given NS 500 cc fluid bolus X1. Urine dark amber in color po lopressor d/c'd. Heparin @ 1250 units/hour, PTT last evening 60.9 (goal 50-80, second PTT within goal range). Pericardial friction rub, pulsus < 10 mm. Pain free on tid naprosyn dose. By echo report EF ~ 40%, mod MR, \"trivial/physiologic\" pericardial effusion. NPO after midnight in case of surgery today--on the schedule for Wednesday. CABG has been on hold d/t temp and Plavix load in cath lab. R groin ecchymotic with hematoma size ~ quarter, no bruit. Feet warm with weakly palpable pulses.\n\nResp: remains on RA with sats >95%. Lungs with bibasilar crackles. Using inc when awake (with reminders to do so). To go to x-ray today for PA/Lat x-ray.\n\nID: t max 100 po. Cultures PND.\n\nGI: NPO after mn. Abd soft, last BM \n\nGU. voiding at bedside, urine dark amber color. po's encouraged.\n\nSkin: intact. Small amount of bleeding on chest over a mole.\n\nAccess: PIV X2.\n\nA: remains in Mobitz I, s/p IMI with ? RV involvement. Awaiting CABG. Low grade temp.\n\nP: continue to monitor HR/Rhythm/BP. Monitor R groin site with activity advancement. Follow T and cultures. Naprosyn as ordered. Continue with pre-op teaching. continue to enc use of inc . OOB to C tid as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-12-10 00:00:00.000", "description": "Report", "row_id": 1615363, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: Hr 75-88 NSR BP 95-123/42-73 CK's rising 1145-1521 Echo-free inferior wall hypokinesis,EF 40%. integrillin started at 12:30. heparin started at 8:30.one episode of jaw,ear and back pain this morning ^ 2,3 &F 2-3mm,treated with 2mg morphine with good results. Pulses easily palpable\n\nResp: lungs clear,sats 96-99 on 2l NP\n\nID: Tmax 100.1 po at 4pm\n\nHeme:PTT 55.2 on heparin within goal range. repeat HCT 33.5(32.9)\n\nGU/Volume: had received fluid boluses overnight,urine output 30-100/hr postive over 4l\n\nGI: fair appetite\n\nSocial: wife and son in to visit,wife talked by phone to Dr and Dr \n\nA/P: 66 yo s/p STEMI w/ 3VD awaiting on heparin and integrillin.\nhemodynamically stable. cont with med management\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-12-11 00:00:00.000", "description": "Report", "row_id": 1615364, "text": "CCU NPN 1900-0700\n66 y/o M c hx of HTN and AAA, presents to ED night c SSCP radiating to back & btwn shoulder blades. ST elevations 4-5mm in II, III, AVF c ST depressions v2-v6. CODE STEMI- R/I IMI. Heparin/Integrillin gtt started. Sent to Cath Lab->severe 3VD. Unsuccessful PCI of occluded RCA. C- consult and plan to medically manage for now (C- declined emergent CABG d/t anticoagulation load. Sent to CCU . Given aggressive IVF to maintain MAPs >60. Echo on shows EF 40% and severe hypokinesis of inf wall and mod hypokinesis of posterior wall. Continues to have CP, improvement in ST elevations inferiorly.\n\nS: \"Can you help me out with this pain\"\n\nO: Pls see careview for all objective data\n\nCV: HR 70-80s NSR, no ectopy. NIBP 90-100s/50-60s. Integrillin at 2mcg/k/min-> to shut off at 0630 (on for 18hrs total). Heparin gtt at 1050 units/hr. PTT at 0400 73.5-remains in therapeutic range. R femoral cath site ecchymotic, area soft, dsg CDI. 500cc NS bolus given for decreased u/o and borderline BPs. C/o R and L sternal CP, increased upon palpation and upon inspiration. Medicated with IV morphine sulfate and Percocet. Pls see careview and for addt'l data. Pulsus Paradoxus <10. No audible rub, heart sounds distant. CKs peak at 1500- 1521, now trending down. HCT stable at 31.8 (33.5), K 3.8.\n\nRESP: Continues on 2L o2 NC c sats 98-100%. No c/o SOB. LS dim, Crackles at bilat bases-> way up at times. C/DB and IS encouraged-IS at bedside. Needs encouragement as pt c/o pain upon inspiration. Pt had episodes of sleep apnea >20secs.\n\nNEURO: A&Ox3. Self positions in bed. Using call light to notify RNs when pain is increasing\n\nGI/GU: No BM. Drinking fair amts of water. Cardiac diet. U/O via foley 15-50cc/hr-output increased to 40-50cc/hr after NS bolus. Blood noted on sheets, appears to be from pt turning in bed and pulling on catheter. Urine appearing more concentrated-slowing down. Currently +600/day and +5.5L LOS.\n\nID: TMax 100.2 PO.\n\nENDO: On RISS, no coverage needed.\n\nA/P: Pt hemodynamically stable with borderline BPs experiencing pericarditic-like pain and anticoagulated, awaiting CABG. Continue to monitor BP closely-? more fld boluses as pt is preload dependent. Monitor for s/sx cardiac tamponade-monitor for pulsus paradox, widened pulse pressure, ?echo in AM to access for pericardial effusion. Monitor urine response and renal fxn, temp- ?BCX, lytes, PTT at 1000, CP-medicate as needed. Give Lopressor a/o, enc C/DB and IS. Continue to provide emotional support to pt and family and update on POC.\n" }, { "category": "Nursing/other", "chartdate": "2174-12-11 00:00:00.000", "description": "Report", "row_id": 1615365, "text": "CCU NPN: see flowsheet for objective\n\nCardiac: HR 77-98 NSR HR rate increasing all day,lopressor increased from 12.5 to 25 no change in HR at 6pm increased to 50mg. BP 105-123/64-80 CP off and on all day with increasing morphine needed to relieve pain, also ativan added for anxiety. EKG now shows q's and inverted T's.\n\nResp: on 2 l NP,crackles at bases in am,now clear\n\nGU: urine output 30-40/hr then had 2 hours with urine output to 200-300. now decreased again to 20-40/hr.\n\nID: tmax 99\n\nGI: fair appetite,+ BS no stool\n\nHeme: cont on heparin at 1050/hr PTT sent at 6pm,also repeat HCT sent\n\nNeuro/Pain: after morphine for CP awakened a little confused,then oriented though stated \" I need the window open to see\" when asked about his pain. falls deep asleep after morphine. when his wife came in to visit initially he was drowsy then started c/o writhing pain.now sleeping after morphine and ativan\n\nSocial: wife and son spoke with surgeon this morning\n\nA: 66 yo gentleman s/p Inferior medical mangement until surgery tomorrow, now with increasing pleuritic CP,requiring increasing amounts of morphine.\n\nP: follow PTT and adjust heparin\n check repeat HCT\n Morphine for pain and ativan for anxiety\n emotional support pt and family\n NPO after midnight\n" }, { "category": "Nursing/other", "chartdate": "2174-12-12 00:00:00.000", "description": "Report", "row_id": 1615366, "text": "CCU NPN 1900-0700\n66 y/o M with HX HTN AND AAA, presented to ED c SSCP radiating to back and btwn shoulder blades. R/I for IMI, heparin and integrillin/loaded with Plavix. Sent to cath lab->90% LAD @ D1 bification, 80% prox stenosis Lcx, RCA long thrombus c distal occlusion. Collaterals from LMCA. Unsuccessgul PCI of occluded RCA. Reffered to C- for CABG-declined d/t anticoag/plavix load. Sent to CCU for medical management, awaiting to have surgery. Aggressive flds given to maintain stable BPs. Echo -EF 40% and severe hypokinesis infer free wall and mod hypokinesis posterior wall. Pt has been having constant CP throughout CCU stay requiring IV Morphine Sulfate and PO Percocet for breakthrough pain.\n\nS: \"When are they going to wheel me in?\"\n\nO: Pls see careview for all objective data\n\nCV: HR 80-90s, NSR. SBPs via non-invasive cuff 90s-100s. When pt asleep, SBPs down to 80s-low 90s. Shortly after 0100, pt noted to be in 2nd degree HB-wenchebach. CCU intern notified and came in to see pt. EKG done. Pt c/o R and L sternal CP-worse upon inspiration. Medicated with 1mg Morphine Sulfate x1 with positive effect-painfree, and appearing more comfortable. +rub, neg- pulsus paradoxus(< 10). R femoral cath site c lg ecchymosis- medial and lateral aspect of R hip. PP palp bilat.\n\nHEME: Continues on Heparin gtt at 1050 units/hr. HCT to be drawn with AM labs.\n\nRESP: Continues on O2, 2L NC with O2 sats 97-100%. RR in 20s. No c/o SOB. LS diminished/clr. Crackles bilat at bases to way up. C/DB and IS encouraged- difficult for pt as pain increases upon inspiration.\n\nNEURO: Pt A&Ox3. Slightly confused when pt woke up from nap-did not know day. Bed low and alarm on, call bed within reach for safety d/t pain medication. Sleeping comfortably, dozing intermittently. No ativan needed.\n\nGI/GU: No stool. NPO after MN for scheduled CABG. Poor u/o via Foley catheter-draining amber, very concentrated urine 20-50cc/hr. 250cc NS x1 bolus given with no effect.\n\nID: Low grade temp- TMax 100.3. Sheets changed d/t sweating x1.\n\nSKIN: Intact. HIBA cleanse for surgery.\n\nACCESS: 2 PIVs\n\nA/P: 66 y/o gentleman with new Wenchebach-hemodynamically stable-Plan to hold Lopressor this AM or give lower dose this AM, to have triple bypass this AM. No urinary response to fld bolus. Continue to monitor hemodynamics, u/o, temp spike, resp status-enc C/DB and IS. Answer questions/concerns re: surgery-provide emotional support to pt and family and update on POC.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-12-12 00:00:00.000", "description": "Report", "row_id": 1615367, "text": "Addendum\nTemp spike to 101.5 PO. No chills/rigors. CCU intern Dr. C-. NO CABG today. BCx x2, and Ucx sent. WBC up 18.4 (13.6). PTT this am 46.8. Heparin gtt increased to 1250 units/hr at 0600. Next PTT due at 12 pm. BUN/Cr and Lytes WNL. Wife in at 0545, updated on Plan. Lopressor held this AM. 1mg Ativan given for anxiety-results pending. Awaiting further plan.\n" }, { "category": "Nursing/other", "chartdate": "2174-12-10 00:00:00.000", "description": "Report", "row_id": 1615362, "text": "Nursing Admit Note\n0100-0700\nThis is a 66 yr old male who presented to EW with sscp radiating to his back and between shoulder blades.EKG with 4- elevations in 2,3,F and st depressions in V2-V6. He was brought urgently to the cath lab and had a cath via the right approach. He has 3VD with 90% stenosis in the LAD at the D1 bifurcation, LCX 80% prox stenosis and the RCA witha long thrombus with distal occlusions..collaterals from the LMCA. His venous/arterial sheath were pulled at 0100. SBP very dependent on aggressive IV fluid support. 1/2 ns at 100 cc/hr with BP falling to the 70's...a total of 3l of NS infused throughout the night with goal map >60. HR trending to the high80's.. given 12.5 mgo po lopressor without signficant change in HR .SBP 110'/70's.. HR 60-90's..right groin with moderate size soft hematoma. Pulses palpable.Feet cool\nResp lungs clear ..\nGI/GU urine output per flowsheet\nNeuro alert and oriented ..wife to call with dilantin dose in am\nMedical management of STEMI ..CT to be consulted to consent pt for surgery\nam labs pndg\nC/O of lowre back pain ..percocet one tab times 2\nEcho today\n" }, { "category": "Echo", "chartdate": "2174-12-12 00:00:00.000", "description": "Report", "row_id": 102334, "text": "PATIENT/TEST INFORMATION:\nIndication: Murmur. Myocardial infarction. ? Ventricular septal defect. ?mitral regurgitation.\nHeight: (in) 68\nWeight (lb): 185\nBSA (m2): 1.98 m2\nBP (mm Hg): 99/56\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Transmitral Doppler E>A and TDI E/e' <8 suggesting\nnormal diastolic function, and normal LV filling pressure (PCWP<12mmHg). No\nresting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid inferior -\nhypo; septal apex - hypo; inferior apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with hypokinesis of the inferior wall, distal septum and\napex. Transmitral and tissue Doppler imaging suggests normal diastolic\nfunction, and a normal left ventricular filling pressure (PCWP<12mmHg). 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 leaflets are structurally normal. There\nis no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , mild mitral\nregurgitation is now identified with normal valve mophology suggestive of\npapillary muscle dysfunction. Regional left ventricular systolic function of\nthe inferolateral wall is improved.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Echo", "chartdate": "2174-12-10 00:00:00.000", "description": "Report", "row_id": 102335, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function\nHeight: (in) 69\nWeight (lb): 185\nBSA (m2): 2.00 m2\nBP (mm Hg): 117/7\nHR (bpm): 84\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: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Depressed LVEF. No\nresting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Borderline\nnormal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\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 mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. LV systolic function\nappears mildly-to-moderately depressed (ejection fraction 40 percent)\nsecondary to severe hypokinesis of the inferior free wall and moderate\nhypokinesis of the posterior wall. There is no ventricular septal defect.\nRight ventricular chamber size is normal. Right ventricular systolic function\nis borderline normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2174-12-14 00:00:00.000", "description": "Report", "row_id": 102421, "text": "PATIENT/TEST INFORMATION:\nIndication: Emergent TEE for Cardiopulmonary arrest\nHeight: (in) 68\nWeight (lb): 180\nBSA (m2): 1.96 m2\nStatus: Inpatient\nDate/Time: at 14:40\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\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. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nTEE placed in the OR to evaluate etiology of cardiopulmonary arrest.\nSuboptimal imaging is noted. There is noted hemopericardium along the\nposterior aspect of the heart measuring at greatest diameter 5.1 cm (This\nmeasurement was taken after patient expired). There is no apparent aortic\ndissection.\n\n\n" }, { "category": "ECG", "chartdate": "2174-12-12 00:00:00.000", "description": "Report", "row_id": 290122, "text": "Sinus rhythm. Mobitz type I second degree A-V block. There are Q waves\nin the inferior leads with ST segment elevations and terminial T wave\ninversions consistent with acute or evolving inferior myocardial infarction.\nCompared to the prior tracing Mobitz type I A-V block is new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2174-12-12 00:00:00.000", "description": "Report", "row_id": 290123, "text": "Sinus tachycardia. The P-R interval is prolonged. There are Q waves in the\ninferior leads with ST segment elevations and terminal T wave inversions\nconsistent with acute or evolving myocardial infarction. Compared to the prior\ntracing ST segment elevations are now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2174-12-10 00:00:00.000", "description": "Report", "row_id": 290351, "text": "Normal sinus rhythm with A-V conduction delay. Left atrial abnormality.\nST segment elevations in the inferior leads consistent with inferior myocardial\ninfarction. Compared to tracing #1 the ST segment elevations have diminished.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2174-12-09 00:00:00.000", "description": "Report", "row_id": 290352, "text": "Normal sinus rhythm with marked ST segment elevations in leads II, III and aVF\nconsistent with acute inferior myocardial infarction with reciprocal changes\nin leads V1-V2. Frequent premature ventricular contractions. No previous\ntracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2174-12-13 00:00:00.000", "description": "Report", "row_id": 290121, "text": "Sinus rhythm. Mobitz type I second degree A-V block. Inferior Q waves with\nST segment elevations and terminal T wave inversions consistent with acute or\nevolving inferior myocardial infarction. Compared to tracing of \nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2174-12-11 00:00:00.000", "description": "Report", "row_id": 290347, "text": "Artifact is present. Sinus rhythm. There are Q waves in the inferior\nleads consistent with T wave inversions consistent with prior inferior\nmyocardial infarction. Compared to the prior tracing ST segment elevation\nis no longer present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2174-12-11 00:00:00.000", "description": "Report", "row_id": 290348, "text": "Normal sinus rhythm with borderline A-V conduction delay. Q waves in the\ninferior leads with T wave inversions suggestive of evolving inferior\nmyocardial infarction. No change from tracing #4.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2174-12-10 00:00:00.000", "description": "Report", "row_id": 290349, "text": "Normal sinus rhythm with borderline A-V conduction delay with prominent\nQ waves in leads III and aVF and T wave inversions in the inferior leads\nsuggestive of evolving inferior myocardial infarction.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2174-12-10 00:00:00.000", "description": "Report", "row_id": 290350, "text": "Normal sinus rhythm. A-V conduction delay. Q waves in leads II, III and aVF\nwith persistent ST segment elevation suggestive of evolving inferior myocardial\ninfarction compared to tracing #2.\nTRACING #3\n\n" } ]

[ { "category": "ECG", "chartdate": "2140-03-08 00:00:00.000", "description": "Report", "row_id": 287922, "text": "Sinus bradycardia with 1st degree A-V block\nLate R wave progression - probable normal variant\nConsider left ventricular hypertrophy in lead aVL\nSince previous tracing of , decreased voltage in leads l, aVL\n\n" }, { "category": "Physician ", "chartdate": "2140-03-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 322798, "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 with schizoaffective disorder, CKD, OSA, presented with\n pancytopenia, hypothermia, ARF on CRF, hyperkalemia.\n 24 Hour Events:\n EKG - At 08:39 PM\n URINE CULTURE - At 01:08 AM\n Seen by renal service to address need for hemodialysis.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96.1\n HR: 81 (68 - 83) bpm\n BP: 114/67(79) {84/51(59) - 119/74(84)} mmHg\n RR: 20 (9 - 34) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 3,473 mL\n 2,387 mL\n PO:\n TF:\n IVF:\n 473 mL\n 2,327 mL\n Blood products:\n Total out:\n 1,165 mL\n 900 mL\n Urine:\n 365 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,308 mL\n 1,487 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n SpO2: 97%\n ABG: 7.23/44/74/18/-8\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, No(t)\n Anxious, appears very comfortable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: very distant BS\n not able to eval JVD due to obesity\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n anterior)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed,\n some\n Labs / Radiology\n 9.3 g/dL\n 77 K/uL\n 79 mg/dL\n 6.0 mg/dL\n 18 mEq/L\n 5.7 mEq/L\n 67 mg/dL\n 116 mEq/L\n 145 mEq/L\n 29.0 %\n 3.9 K/uL\n [image002.jpg]\n 08:16 PM\n 06:00 AM\n WBC\n 3.9\n Hct\n 29.0\n Plt\n 77\n Cr\n 6.0\n TCO2\n 19\n Glucose\n 79\n Other labs: Lactic Acid:1.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL,\n PO4:4.9 mg/dL\n Imaging: unremarkable CXR\n Assessment and Plan\n Hypothermia and leukopenic but so clinically well don't believe SIRS is\n appropriate diagnosis. Chronic hypothermia.\n ARF on CRF. Renal service involved. Hyperkalemia corrected.\n Pancytopenia of unknown etiology. Undergoing eval.\n Request HIV test.\n Determine extent of outpatient evaluation- if not started will request\n hem/onc consult.\n Schizoaffective disorder.\n Psych involved.\n Restarted outpatient antipsychotics.\n OSA.\n On BiPAP for sleep.\n SW consult for home needs- seems like he would benefit from group home.\n Other issues per Dr note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:54 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": "2140-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322801, "text": "Chief Complaint: 56 year old man with hx of schizoaffective disorder,\n CKD stage IV, OSA presenting hypothermia to 90 degrees with ARF,\n hyperkalemia and pancytopenia.\n 24 Hour Events:\n - Patient hypotensive to the 80s while sleeping. Fluid responsive after\n 500cc boluses x2\n - Patient alert and oriented this morning, normotensive\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.3\nC (95.5\n Tcurrent: 35.3\nC (95.5\n HR: 79 (68 - 80) bpm\n BP: 107/57(66) {84/51(59) - 117/74(84)} mmHg\n RR: 23 (9 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,473 mL\n 1,874 mL\n PO:\n TF:\n IVF:\n 473 mL\n 1,874 mL\n Blood products:\n Total out:\n 1,165 mL\n 480 mL\n Urine:\n 365 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,308 mL\n 1,394 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n SpO2: 94%\n ABG: 7.23/44/74/18/-8\n Physical Examination\n Gen: NAD\n HEENT: NCAT\n CV: RRR, distant heart sounds\n Pulm: CTAB anteriorly, no wheezes or rales\n Abd: Obese, NTND, NABS\n Ext: Chronic venous stasis changes, 2+ BLE edema to knees\n Labs / Radiology\n 77 K/uL\n 9.3 g/dL\n 79 mg/dL\n 6.0 mg/dL\n 18 mEq/L\n 5.7 mEq/L\n 67 mg/dL\n 116 mEq/L\n 145 mEq/L\n 29.0 %\n 3.9 K/uL\n [image002.jpg] AG 11\n 08:16 PM\n 06:00 AM\n WBC\n 3.9\n Hct\n 29.0\n Plt\n 77\n Cr\n 6.0\n TCO2\n 19\n Glucose\n 79\n Other labs: Lactic Acid:1.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL,\n PO4:4.9 mg/dL\n Assessment and Plan\n A/P 56 year old man with hx of schizoaffective disorder, CKD, HTN and\n morbid obesity who is admitted after being found by his VNA\n hypothermic, in acute on chronic renal failure and with hyperkalemia to\n 6.3, off his psychiatric meds for 2 weeks.\n # Hypothermia: Differential includes sepsis, hypothyroidism, adrenal\n insufficiency, medication-induced (clonidine, metoprolol,\n neuroleptics), hypoglycemia or malnutrition. Patient has been\n hypothermic during his prior extended admission as well with no clear\n etiology. He met SIRS criteria on admission with hypothermia and WBC,\n but has no left shift or bands on diff or tachypnea. No clear evidence\n of infection as CXR shows improvement in pulmonary vascularity and no\n evidence of pneumonia. Amylase and ALP mildly elevated, but LFTs\n otherwise wnl. UA with 3 WBC, small blood, trace leuks, neg nitrite.\n Ucx pending. No other signs or symptoms of infection. PM cortisol sent\n without evidence of adrenal insufficiency. Patient has not been\n hypothyroid in the past, and had a normal stim test in .\n Glucose has been normal (98 on presentation, 87 now). Albumin is 3.3.\n - Urine cx pending, bcx x2 NGTD\n - PM Cortisol 12.6, can consider -stim though no good reason for\n patient to be adrenally insufficient\n - TSH pending, FT4 testing in was normal\n - As no clear evidence of infection and patient clinically appears\n well, will hold off on antibiotics for now. Should he become unstable,\n will start broad coverage.\n - Continue to monitor, bear-hugger prn for T< or = 93\n # Acute on chronic kidney disease: Patient has stage V kidney disease\n thought to be secondary to hypertension. His creatinine on admission\n was 6.3 which is increased from him baseline around 5. Patient was\n hypotensive and hypothermic on presentation, likely prerenal in the\n setting of poor PO/hypovolemia. Renal consult called recommending HD\n at this time, though it appears patient and his outpatient nephrologist\n have been reluctant in the past.\n - Per renal, discussions between patient, guardian and \n nephrologist to discuss HD at this time\n - Low K, low phos diet\n - Bicarb and kayexelate for hyperK, sevelamer as per home regimen\n - IVF prn for hypovolemia\n - Sent UA, urine lytes, though patient has received 3L NS in the ED,\n protein/creatinine ratio\n - Continue to follow with renal team\n # Hyperkalemia: Patient has chronically elevated K in the setting of\n CKD. Acute elevation in the setting of acute on chronic renal\n failure. Insulin/dextrose, bicarb, kayexelate given in ED\n - Continue bicarb in IVF for now as needed\n - Recheck K this am still elevated at 5.7, will give additional dose of\n kayexlate\n - Will continue to monitor\n # Pancytopenia: Patient has had low WBC, Hct and platelets in the past,\n though these appear to be even lower now and trending down since\n admission. He had work up during last admission including negative\n HITT Ab and a normal peripheral smear. He was initially started on\n epogen at that time, but it was discontinued once his anemia resolved.\n Last iron panel in showed iron of 130, TIBC 361, ferritin 131 and\n TRF 278. SPEP/UPEP at that time were wnl. No history of liver\n disease/alcohol abuse. He does not appear to be on any offending\n medications at this time.\n - Continue to monitor for now\n - Checking peripheral smear\n - B12 and folate last checked in and were normal, pending now\n - TSH pending\n - Will consent guardian and send HIV as infection can present like\n myelodysplasia\n - Touch base with outpatient PCP to determine if patient has had work\n up for pancytopenia in the past such as bone marrow. Can consider\n involving heme/onc if he has not been evaluated for this in the past.\n # Schizoaffective disorder with psychosis: Patient is on risperidone\n and abilify as an outpatient, and it is unclear as to when he stopped\n taking these medications. At this time, the patient reports that the\n psychotropic medications make him tired, and since he does not feel\n psychotic, he does not want to take them. He has been unable to care\n for himself at home despite increased home health care arranged after\n his prior admission. Psychiatry was consulted from the ED who\n recommended he be started back on Risperdal 1mg qhs. Patient is\n currently pleasant and cooperative.\n - Patient's legal guardian, appointed on is .\n Will contact her in the morning for discussion of further management.\n - Restarted risperdal as per psych, send TSH\n - Continue to follow with psychiatry\n - SW consult as patient does not appear to be capable of caring for\n himself at home. He may require more structured living situation such\n as group home.\n # Obstructive sleep apnea: Patient was found to have sleep disordered\n breathing during his last admission. At that time, he was started on\n nightly BiPAP, though the patient has not been using this at home.\n - Started patient on his prior settings for BiPAP (10/7/2L)\n # Hypertension: The patient has a long-standing history of hypertension\n and is on a number of medications at home including toprol XL,\n amlodipine, clonidine patch and norvasc. He has been normotensive\n since admission. Unclear whether patient has been taking his\n medications as home, as by report, he had not taking medications for 2\n weeks.\n - Will hold on home blood pressure medications for now as patient is\n normotensive with HRs in the 70s.\n - Continue to monitor, will add back home medications as tolerated\n # Dyslipidemia: Continue simvastatin 10mg daily\n # Gout: Continue allopurinol, renally dosed (100mg qoday)\n # FEN: Sodium bicarb in D5W prn for K and volume repletion, renal diet\n (low K, low Phos), phos binder, replete lytes prn, nephrocaps\n # PPX: SQ heparin, no need for ppi at this time\n # Code: FULL\n ICU Care\n Nutrition: PO, renal diet\n Glycemic Control: adequate\n Lines:\n 20 Gauge - 06:54 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: NA\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: Call out to medicine floor\n" }, { "category": "Nursing", "chartdate": "2140-03-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 322803, "text": "56 y/o M w/ a PMH significant for schizoaffective disorder, CRF,\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Hypothermia\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-03-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 322806, "text": "Demographics\n Attending MD:\n ,\n Admit diagnosis:\n HYPOTHERMIA;TELEMETRY\n Code status:\n Full code\n Height:\n Admission weight:\n 169.9 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: stage V chronic kidney disease,Schizoaffective\n disorder,Morbid obesity,Gout Chronic LE edema,Dyslipidemia,Severe OSA\n (prior Bipap settings 2L O2),\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:117\n D:70\n Temperature:\n 96.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,587 mL\n 24h total out:\n 1,060 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 06:00 AM\n Potassium:\n 5.7 mEq/L\n 06:00 AM\n Chloride:\n 116 mEq/L\n 06:00 AM\n CO2:\n 18 mEq/L\n 06:00 AM\n BUN:\n 67 mg/dL\n 06:00 AM\n Creatinine:\n 6.0 mg/dL\n 06:00 AM\n Glucose:\n 79 mg/dL\n 06:00 AM\n Hematocrit:\n 29.0 %\n 06:00 AM\n Finger Stick Glucose:\n 87\n 10:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: 3 Bags clothing, 2 books\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: 0\n Credit Cards: 3 credit cards/1 debit\n Cash / Credit cards sent home with: Transferred w/ patient\n Jewelry:\n Transferred from: M/\n Transferred to: 11 R\n Date & time of Transfer: 12:00 AM\n Briefly this is 56 y/o M w/ a PMH significant for schizoaffective\n disorder/CRF/OSA, who presented to the ED (after being found @ home by\n VNA) hypothermic to 90 degrees w/ acute on chronic renal failure,\n hyperkalemic and pancytopenic\n In the ED he transiently dropped his BP to 80\ns systolic which\n responded well to 500cc NS boluses x 2. Serum K on presentation 6.3. A\n EKG was unremarkable w/ the exception of a pre exisiting 1^st degree\n AV block. He received kayexalate, thiamine, bicarb, dextrose/insulin,\n and was transferred to the M/SICU for further management.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K currently 5.7\n Action:\n Administered a 3^rd dose of Kayexelate\n Response:\n Remains hyperkalemic\n Plan:\n Renal to discuss plans for HD w/ outpatient nephrologist and legal\n guardian\n Hypothermia\n Assessment:\n Currently 96.1 oral up from baseline of 94-95 degrees\n Action:\n Bair hugger d/c\n Response:\n Remains normothermic per pts baseline\n Plan:\n Continue to follow per routine\n Hypotension (not Shock)\n Assessment:\n Received 500cc NS overnight for SBP high 80s while sleeping\n Action:\n Monitored NBP per routine\n Response:\n Remained normotensive since :00\n Plan:\n Continue to monitor\n Plan: All VSS and the pt is currently called out and awaiting a bed on\n the floor. Psych consult recommended restarting home dose of respirdal\n which was administered overnight. Renal consult feels HD is likely\n indicated however further discussion will be required as pt has a legal\n guardian as well as an outpatient nephrologist. Social Work/Case\n management to follow as pts needs clearly exceed current outpatient\n services.\n" }, { "category": "Physician ", "chartdate": "2140-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322778, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 08:39 PM\n URINE CULTURE - At 01:08 AM\n - Patient hypotensive to the 80s while sleeping. Fluid responsive after\n 2 500cc boluses\n - Patient alert and oriented this morning, normotensive\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.3\nC (95.5\n Tcurrent: 35.3\nC (95.5\n HR: 79 (68 - 80) bpm\n BP: 107/57(66) {84/51(59) - 117/74(84)} mmHg\n RR: 23 (9 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,473 mL\n 1,874 mL\n PO:\n TF:\n IVF:\n 473 mL\n 1,874 mL\n Blood products:\n Total out:\n 1,165 mL\n 480 mL\n Urine:\n 365 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,308 mL\n 1,394 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n SpO2: 94%\n ABG: 7.23/44/74/18/-8\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 77 K/uL\n 9.3 g/dL\n 79 mg/dL\n 6.0 mg/dL\n 18 mEq/L\n 5.7 mEq/L\n 67 mg/dL\n 116 mEq/L\n 145 mEq/L\n 29.0 %\n 3.9 K/uL\n [image002.jpg]\n 08:16 PM\n 06:00 AM\n WBC\n 3.9\n Hct\n 29.0\n Plt\n 77\n Cr\n 6.0\n TCO2\n 19\n Glucose\n 79\n Other labs: Lactic Acid:1.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL,\n PO4:4.9 mg/dL\n Assessment and Plan\n A/P 56 year old man with hx of schizoaffective disorder, CKD, HTN and\n morbid obesity who is admitted after being found by his VNA\n hypothermic, in acute on chronic renal failure and with hyperkalemia to\n 6.3, off his psychiatric meds for 2 weeks.\n # Hypothermia: Differential includes sepsis, hypothyroidism, adrenal\n insufficiency, medication-induced (clonidine, metoprolol,\n neuroleptics), hypoglycemia or malnutrition. Patient has been\n hypothermic during his prior extended admission as well with no clear\n etiology. He does meet SIRS criteria with hypothermia and WBC, but has\n no left shift or bands on diff or tachypnea. No clear evidence of\n infection as CXR shows improvement in pulmonary vascularity and no\n evidence of pneumonia. Amylase and ALP mildly elevated, but LFTs\n otherwise wnl. UA/ucx not sent. No other signs or symptoms of\n infection. PM cortisol sent without evidence of adrenal\n insufficiency. Patient has not been hypothyroid in the past, and had a\n normal stim test in . Glucose has been normal (98 on\n presentation, 87 now). Albumin is 3.3.\n - Send UA/urine cx\n - PM Cortisol 12.6, can consider -stim though no good reason for\n patient to be adrenally insufficient\n - TSH pending\n - As no clear evidence of infection and patient clinically appears\n well, will hold off on antibiotics for now. Should he become unstable,\n will start broad coverage.\n - Continue to monitor, bear-hugger prn\n # Acute on chronic kidney disease: Patient has stage V kidney disease\n thought to be secondary to hypertension. His creatinine on admission\n was 6.3 which is increased from him baseline around 5. Patient was\n hypotensive and hypothermic on presentation, likely prerenal in the\n setting of poor PO/hypovolemia. Renal consult called recommending HD\n at this time, though it appears patient and his outpatient nephrologist\n have been reluctant in the past.\n - Per renal, discussions between patient, guardian and \n nephrologist to discuss HD at this time\n - Low K, low phos diet\n - Bicarb and kayexelate for hyperK, sevelamer as per home regimen\n - IVF prn for hypovolemia\n - Send UA, urine lytes, though patient has received 3L NS in the ED,\n will send protein/creatinine ratio\n - Continue to follow with renal team\n # Hyperkalemia: Patient has chronically elevated K in the setting of\n CKD. Acute elevation in the setting of acute on chronic renal\n failure. Insulin/dextrose, bicarb, kayexelate given in ED\n - Continue bicarb in IVF for now\n - Recheck K on ABG was 5.6, will give additional dose of kayexlate\n - Will continue to monitor\n # Pancytopenia: Patient has had low WBC, Hct and platelets in the past,\n though these appear to be even lower at this time. He had work up\n during last admission including negative HITT Ab and a normal\n peripheral smear. He was initially started on epogen at that time, but\n it was discontinued once his anemia resolved. Last iron panel in \n showed iron of 130, TIBC 361, ferritin 131 and TRF 278. SPEP/UPEP at\n that time were wnl. No history of liver disease/alcohol abuse. He does\n not appear to be on any offending medications at this time.\n - Continue to monitor for now\n - Check peripheral smear\n - Recheck B12 and folate as last one was and was normal\n - TSH pending\n - Can consider heme/onc consult if persistently low\n # Schizoaffective disorder with psychosis: Patient is on risperidone\n and abilify as an outpatient, and it is unclear as to when he stopped\n taking these medications. At this time, the patient reports that the\n psychotropic medications make him tired, and since he does not feel\n psychotic, he does not want to take them. He has been unable to care\n for himself at home despite increased home health care arranged after\n his prior admission. Psychiatry was consulted from the ED who\n recommended he be started back on Risperdal 1mg qhs. Patient is\n currently pleasant and cooperative.\n - Patient's legal guardian, appointed on is .\n Will contact her in the morning for discussion of further management.\n - Restart risperdal as per psych, send TSH\n - Continue to follow with psychiatry\n # Obstructive sleep apnea: Patient was found to have sleep disordered\n breathing during his last admission. At that time, he was started on\n nightly BiPAP, though the patient has not been using this at home.\n - Will start patient on his prior settings for BiPAP (10/7/2L)\n # Hypertension: The patient has a long-standing history of hypertension\n and is on a number of medications at home including toprol XL,\n amlodipine, clonidine patch and norvasc. He has been normotensive\n since admission. Unclear whether patient has been taking his\n medications as home, as by report, he had not taking medications for 2\n weeks.\n - Will hold on home blood pressure medications for now as patient is\n normotensive with HRs in the 70s.\n - Continue to monitor, will add back home medications as tolerated\n # Dyslipidemia: Continue simvastatin 10mg daily\n # Gout: Continue allopurinol, renally dosed (100mg qoday)\n # FEN: Sodium bicarb in D5W for now x2 L, renal diet (low K, low Phos),\n phos binder, replete lytes prn, nephrocaps\n # PPX: SQ heparin, no need for ppi at this time\n # Code: FULL\n ICU Care\n Nutrition: PO\n Glycemic Control:\n Lines:\n 20 Gauge - 06:54 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: NA\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322781, "text": "Chief Complaint: 56 year old man with hx of schizoaffective disorder,\n CKD stage IV, OSA presenting hypothermia to 90 degrees with ARF,\n hyperkalemia and pancytopenia.\n 24 Hour Events:\n - Patient hypotensive to the 80s while sleeping. Fluid responsive after\n 2 500cc boluses\n - Patient alert and oriented this morning, normotensive\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.3\nC (95.5\n Tcurrent: 35.3\nC (95.5\n HR: 79 (68 - 80) bpm\n BP: 107/57(66) {84/51(59) - 117/74(84)} mmHg\n RR: 23 (9 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,473 mL\n 1,874 mL\n PO:\n TF:\n IVF:\n 473 mL\n 1,874 mL\n Blood products:\n Total out:\n 1,165 mL\n 480 mL\n Urine:\n 365 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,308 mL\n 1,394 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n SpO2: 94%\n ABG: 7.23/44/74/18/-8\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 77 K/uL\n 9.3 g/dL\n 79 mg/dL\n 6.0 mg/dL\n 18 mEq/L\n 5.7 mEq/L\n 67 mg/dL\n 116 mEq/L\n 145 mEq/L\n 29.0 %\n 3.9 K/uL\n [image002.jpg]\n 08:16 PM\n 06:00 AM\n WBC\n 3.9\n Hct\n 29.0\n Plt\n 77\n Cr\n 6.0\n TCO2\n 19\n Glucose\n 79\n Other labs: Lactic Acid:1.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL,\n PO4:4.9 mg/dL\n Assessment and Plan\n A/P 56 year old man with hx of schizoaffective disorder, CKD, HTN and\n morbid obesity who is admitted after being found by his VNA\n hypothermic, in acute on chronic renal failure and with hyperkalemia to\n 6.3, off his psychiatric meds for 2 weeks.\n # Hypothermia: Differential includes sepsis, hypothyroidism, adrenal\n insufficiency, medication-induced (clonidine, metoprolol,\n neuroleptics), hypoglycemia or malnutrition. Patient has been\n hypothermic during his prior extended admission as well with no clear\n etiology. He does meet SIRS criteria with hypothermia and WBC, but has\n no left shift or bands on diff or tachypnea. No clear evidence of\n infection as CXR shows improvement in pulmonary vascularity and no\n evidence of pneumonia. Amylase and ALP mildly elevated, but LFTs\n otherwise wnl. UA/ucx not sent. No other signs or symptoms of\n infection. PM cortisol sent without evidence of adrenal\n insufficiency. Patient has not been hypothyroid in the past, and had a\n normal stim test in . Glucose has been normal (98 on\n presentation, 87 now). Albumin is 3.3.\n - Send UA/urine cx\n - PM Cortisol 12.6, can consider -stim though no good reason for\n patient to be adrenally insufficient\n - TSH pending\n - As no clear evidence of infection and patient clinically appears\n well, will hold off on antibiotics for now. Should he become unstable,\n will start broad coverage.\n - Continue to monitor, bear-hugger prn\n # Acute on chronic kidney disease: Patient has stage V kidney disease\n thought to be secondary to hypertension. His creatinine on admission\n was 6.3 which is increased from him baseline around 5. Patient was\n hypotensive and hypothermic on presentation, likely prerenal in the\n setting of poor PO/hypovolemia. Renal consult called recommending HD\n at this time, though it appears patient and his outpatient nephrologist\n have been reluctant in the past.\n - Per renal, discussions between patient, guardian and \n nephrologist to discuss HD at this time\n - Low K, low phos diet\n - Bicarb and kayexelate for hyperK, sevelamer as per home regimen\n - IVF prn for hypovolemia\n - Send UA, urine lytes, though patient has received 3L NS in the ED,\n will send protein/creatinine ratio\n - Continue to follow with renal team\n # Hyperkalemia: Patient has chronically elevated K in the setting of\n CKD. Acute elevation in the setting of acute on chronic renal\n failure. Insulin/dextrose, bicarb, kayexelate given in ED\n - Continue bicarb in IVF for now\n - Recheck K on ABG was 5.6, will give additional dose of kayexlate\n - Will continue to monitor\n # Pancytopenia: Patient has had low WBC, Hct and platelets in the past,\n though these appear to be even lower at this time. He had work up\n during last admission including negative HITT Ab and a normal\n peripheral smear. He was initially started on epogen at that time, but\n it was discontinued once his anemia resolved. Last iron panel in \n showed iron of 130, TIBC 361, ferritin 131 and TRF 278. SPEP/UPEP at\n that time were wnl. No history of liver disease/alcohol abuse. He does\n not appear to be on any offending medications at this time.\n - Continue to monitor for now\n - Check peripheral smear\n - Recheck B12 and folate as last one was and was normal\n - TSH pending\n - Can consider heme/onc consult if persistently low\n # Schizoaffective disorder with psychosis: Patient is on risperidone\n and abilify as an outpatient, and it is unclear as to when he stopped\n taking these medications. At this time, the patient reports that the\n psychotropic medications make him tired, and since he does not feel\n psychotic, he does not want to take them. He has been unable to care\n for himself at home despite increased home health care arranged after\n his prior admission. Psychiatry was consulted from the ED who\n recommended he be started back on Risperdal 1mg qhs. Patient is\n currently pleasant and cooperative.\n - Patient's legal guardian, appointed on is .\n Will contact her in the morning for discussion of further management.\n - Restart risperdal as per psych, send TSH\n - Continue to follow with psychiatry\n # Obstructive sleep apnea: Patient was found to have sleep disordered\n breathing during his last admission. At that time, he was started on\n nightly BiPAP, though the patient has not been using this at home.\n - Will start patient on his prior settings for BiPAP (10/7/2L)\n # Hypertension: The patient has a long-standing history of hypertension\n and is on a number of medications at home including toprol XL,\n amlodipine, clonidine patch and norvasc. He has been normotensive\n since admission. Unclear whether patient has been taking his\n medications as home, as by report, he had not taking medications for 2\n weeks.\n - Will hold on home blood pressure medications for now as patient is\n normotensive with HRs in the 70s.\n - Continue to monitor, will add back home medications as tolerated\n # Dyslipidemia: Continue simvastatin 10mg daily\n # Gout: Continue allopurinol, renally dosed (100mg qoday)\n # FEN: Sodium bicarb in D5W for now x2 L, renal diet (low K, low Phos),\n phos binder, replete lytes prn, nephrocaps\n # PPX: SQ heparin, no need for ppi at this time\n # Code: FULL\n ICU Care\n Nutrition: PO\n Glycemic Control:\n Lines:\n 20 Gauge - 06:54 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: NA\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-03-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322791, "text": "Chief Complaint: 56 year old man with hx of schizoaffective disorder,\n CKD stage IV, OSA presenting hypothermia to 90 degrees with ARF,\n hyperkalemia and pancytopenia.\n 24 Hour Events:\n - Patient hypotensive to the 80s while sleeping. Fluid responsive after\n 500cc boluses x2\n - Patient alert and oriented this morning, normotensive\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.3\nC (95.5\n Tcurrent: 35.3\nC (95.5\n HR: 79 (68 - 80) bpm\n BP: 107/57(66) {84/51(59) - 117/74(84)} mmHg\n RR: 23 (9 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,473 mL\n 1,874 mL\n PO:\n TF:\n IVF:\n 473 mL\n 1,874 mL\n Blood products:\n Total out:\n 1,165 mL\n 480 mL\n Urine:\n 365 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,308 mL\n 1,394 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PPS\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n SpO2: 94%\n ABG: 7.23/44/74/18/-8\n Physical Examination\n Gen: NAD\n HEENT: NCAT\n CV: RRR, distant heart sounds\n Pulm: CTAB anteriorly, no wheezes or rales\n Abd: Obese, NTND, NABS\n Ext: Chronic venous stasis changes, 2+ BLE edema to knees\n Labs / Radiology\n 77 K/uL\n 9.3 g/dL\n 79 mg/dL\n 6.0 mg/dL\n 18 mEq/L\n 5.7 mEq/L\n 67 mg/dL\n 116 mEq/L\n 145 mEq/L\n 29.0 %\n 3.9 K/uL\n [image002.jpg] AG 11\n 08:16 PM\n 06:00 AM\n WBC\n 3.9\n Hct\n 29.0\n Plt\n 77\n Cr\n 6.0\n TCO2\n 19\n Glucose\n 79\n Other labs: Lactic Acid:1.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.4 mg/dL,\n PO4:4.9 mg/dL\n Assessment and Plan\n A/P 56 year old man with hx of schizoaffective disorder, CKD, HTN and\n morbid obesity who is admitted after being found by his VNA\n hypothermic, in acute on chronic renal failure and with hyperkalemia to\n 6.3, off his psychiatric meds for 2 weeks.\n # Hypothermia: Differential includes sepsis, hypothyroidism, adrenal\n insufficiency, medication-induced (clonidine, metoprolol,\n neuroleptics), hypoglycemia or malnutrition. Patient has been\n hypothermic during his prior extended admission as well with no clear\n etiology. He met SIRS criteria on admission with hypothermia and WBC,\n but has no left shift or bands on diff or tachypnea. No clear evidence\n of infection as CXR shows improvement in pulmonary vascularity and no\n evidence of pneumonia. Amylase and ALP mildly elevated, but LFTs\n otherwise wnl. UA with 3 WBC, small blood, trace leuks, neg nitrite.\n Ucx pending. No other signs or symptoms of infection. PM cortisol sent\n without evidence of adrenal insufficiency. Patient has not been\n hypothyroid in the past, and had a normal stim test in .\n Glucose has been normal (98 on presentation, 87 now). Albumin is 3.3.\n - Urine cx pending, bcx x2 NGTD\n - PM Cortisol 12.6, can consider -stim though no good reason for\n patient to be adrenally insufficient\n - TSH pending, FT4 testing in was normal\n - As no clear evidence of infection and patient clinically appears\n well, will hold off on antibiotics for now. Should he become unstable,\n will start broad coverage.\n - Continue to monitor, bear-hugger prn for T< or = 93\n # Acute on chronic kidney disease: Patient has stage V kidney disease\n thought to be secondary to hypertension. His creatinine on admission\n was 6.3 which is increased from him baseline around 5. Patient was\n hypotensive and hypothermic on presentation, likely prerenal in the\n setting of poor PO/hypovolemia. Renal consult called recommending HD\n at this time, though it appears patient and his outpatient nephrologist\n have been reluctant in the past.\n - Per renal, discussions between patient, guardian and \n nephrologist to discuss HD at this time\n - Low K, low phos diet\n - Bicarb and kayexelate for hyperK, sevelamer as per home regimen\n - IVF prn for hypovolemia\n - Send UA, urine lytes, though patient has received 3L NS in the ED,\n will send protein/creatinine ratio\n - Continue to follow with renal team\n # Hyperkalemia: Patient has chronically elevated K in the setting of\n CKD. Acute elevation in the setting of acute on chronic renal\n failure. Insulin/dextrose, bicarb, kayexelate given in ED\n - Continue bicarb in IVF for now as needed\n - Recheck K this am still elevated at 5.7, will give additional dose of\n kayexlate\n - Will continue to monitor\n # Pancytopenia: Patient has had low WBC, Hct and platelets in the past,\n though these appear to be even lower now and trending down since\n admission. He had work up during last admission including negative\n HITT Ab and a normal peripheral smear. He was initially started on\n epogen at that time, but it was discontinued once his anemia resolved.\n Last iron panel in showed iron of 130, TIBC 361, ferritin 131 and\n TRF 278. SPEP/UPEP at that time were wnl. No history of liver\n disease/alcohol abuse. He does not appear to be on any offending\n medications at this time.\n - Continue to monitor for now\n - Checking peripheral smear\n - B12 and folate last checked in and were normal, pending now\n - TSH pending\n - Can consider heme/onc consult if persistently low\n # Schizoaffective disorder with psychosis: Patient is on risperidone\n and abilify as an outpatient, and it is unclear as to when he stopped\n taking these medications. At this time, the patient reports that the\n psychotropic medications make him tired, and since he does not feel\n psychotic, he does not want to take them. He has been unable to care\n for himself at home despite increased home health care arranged after\n his prior admission. Psychiatry was consulted from the ED who\n recommended he be started back on Risperdal 1mg qhs. Patient is\n currently pleasant and cooperative.\n - Patient's legal guardian, appointed on is .\n Will contact her in the morning for discussion of further management.\n - Restarted risperdal as per psych, send TSH\n - Continue to follow with psychiatry\n # Obstructive sleep apnea: Patient was found to have sleep disordered\n breathing during his last admission. At that time, he was started on\n nightly BiPAP, though the patient has not been using this at home.\n - Started patient on his prior settings for BiPAP (10/7/2L)\n # Hypertension: The patient has a long-standing history of hypertension\n and is on a number of medications at home including toprol XL,\n amlodipine, clonidine patch and norvasc. He has been normotensive\n since admission. Unclear whether patient has been taking his\n medications as home, as by report, he had not taking medications for 2\n weeks.\n - Will hold on home blood pressure medications for now as patient is\n normotensive with HRs in the 70s.\n - Continue to monitor, will add back home medications as tolerated\n # Dyslipidemia: Continue simvastatin 10mg daily\n # Gout: Continue allopurinol, renally dosed (100mg qoday)\n # FEN: Sodium bicarb in D5W prn for K and volume depletion, renal diet\n (low K, low Phos), phos binder, replete lytes prn, nephrocaps\n # PPX: SQ heparin, no need for ppi at this time\n # Code: FULL\n ICU Care\n Nutrition: , \n Glycemic Control:\n Lines:\n 20 Gauge - 06:54 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: NA\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2140-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322774, "text": "Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt came to ED with K of 6.9.Pt had keyxelate,IV insulin,50%dextrose and\n calcium gluconate.Repeat K after arrival to ICU was 5.6.\n Action:\n EKG done to r/o any changes.Keyxelate given.\n Response:\n NO EKG changes. Awaiting am labs to be drawn.\n Plan:\n Will need to draw am labs to follow the K levels..Pt is a difficult\n stick,might need phelobotomy to come down to do it.Paged phlebotomy.\n Hypotension (not Shock)\n Assessment:\n Pt was hypotensive down to 80\ns systolic.\n Action:\n Had fluid bolus 500cc x2 with effect.Pt is also getting sodium bicarb\n drip.\n Response:\n Bp within limits now.Pt is getting the 2^nd bag of bicarb.\n Plan:\n Monitor BP and FB as needed.\n Hypothermia\n Assessment:\n Temp b/w 94.5-95.5.\n Action:\n Blankets applied and increased the room temp.\n Response:\n Temp is 95.5 now. Pt states that this is his normal temp.\n Plan:\n Follow temp curve.\n Pt has got sleep apnea,but has not been using bipap at night.Was put on\n Bipap for @4hrs overnight after which pt refused to put it on.\n" }, { "category": "Nursing", "chartdate": "2140-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322762, "text": "Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt came to ED with K of 6.9.Pt had keyxelate,IV insulin,50%dextrose and\n calcium gluconate.Repeat K after arrival to ICU was 5.6.\n Action:\n EKG done to r/o any changes.Keyxelate given.\n Response:\n NO EKG changes. Awaiting am labs to be drawn.\n Plan:\n Will need to draw am labs to follow the K levels..Pt is a difficult\n stick,might need phelobotomy to come down to do it.Paged phlebotomy.\n Hypotension (not Shock)\n Assessment:\n Pt was hypotensive down to 80\ns systolic.\n Action:\n Had fluid bolus 500cc x2 with effect.Pt is also getting sodium bicarb\n drip.\n Response:\n Bp within limits now.Pt is getting the 2^nd bag of bicarb.\n Plan:\n Monitor BP and FB as needed.\n Hypothermia\n Assessment:\n Temp b/w 94.5-95.5.\n Action:\n Blankets applied and increased the room temp.\n Response:\n Temp is 95.5 now. Pt states that this is his normal temp.\n Plan:\n Follow temp curve.\n Pt has got sleep apnea,but has not been using bipap at night.Was put on\n Bipap for @4hrs overnight after which pt refused to put it on.\n" }, { "category": "Nursing", "chartdate": "2140-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322758, "text": "Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt came to ED with K of 6.9.Pt had keyxelate,IV insulin,50%dextrose and\n calcium gluconate.Repeat K after arrival to ICU was\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Hypothermia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2140-03-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 322738, "text": "Chief Complaint: 56 year old man with hx of schizoaffective disorder,\n CKD stage IV, OSA presenting hypothermia to 90 degrees with ARF,\n hyperkalemia and pancytopenia.\n HPI:\n The patient is a 56 year old man with hx of schizoaffective disorder,\n CKD stage IV, OSA presenting hypothermia. Found by VNA to have stopped\n taking psych meds. On arrival, hypothermic to 90 degrees.\n In the ED his vitals were 32.7C 64 111/71 20 99%RA. He transiently\n dropped his sbp to 92 with responded to NS. Serum potassium was\n notable at 6.3. A EKG was unremarkable for peaked T waves. He received\n kayexalate, thiamine, bicarb 1amp, dextrose/insulin. He received\n vancomycin/ceftazadime. A CXR was improved from prior. Psychiatry was\n consulted who recommended re-introducing risperdal and would continue\n following.\n He denies pain, shortness of breath, chest pain, nausea, headache,\n visual changes, abdominal pain, diarrhea, dysuria, or other symptoms.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin 1gm IV x1 at 3:30 pm \n Ceftazidime 2gm IV x1 at 5:00 pm \n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Hypertension\n -stage V chronic kidney disease\n -Schizoaffective disorder\n -Morbid obesity\n -Gout\n -Chronic LE edema\n -Dyslipidemia\n -Severe OSA (prior Bipap settings 2L O2)\n Non-contributory\n Tobacco: Denies\n Alcohol: Denies\n Other: Pt was born and raised in . He attended college at\n and reported that he went to medical school for a brief time at\n Duke. He later worked at as a librarian in the \n Science Library. Pt currently lives alone in (which was arranged through Housing). Prior to\n this he had been living in , which he was removed from due to\n poor hygiene. Pt is estranged from his family; reported to have a\n brother who lives in and rest of family in North or South\n .\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Jaundice\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Neurologic: No(t) Headache\n Flowsheet Data as of 11:05 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 34.8\nC (94.7\n Tcurrent: 34.8\nC (94.7\n HR: 76 (76 - 79) bpm\n BP: 117/74(80) {101/55(66) - 117/74(80)} mmHg\n RR: 26 (9 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,250 mL\n PO:\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 0 mL\n 1,125 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,125 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.23/44/74//-8\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Edema Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing,\n Asterixis in bilateral upper extremities\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place and time, Movement: Purposeful\n Labs / Radiology\n 5.6 mEq/L\n [image002.jpg]\n \n 2:33 A4/15/ 08:16 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 19\n Other labs: Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: Na 144 Cl 118 BUN 74 AGap=11\n K 6.3 CO2 15 Cr 6.3\n estGFR: (click for details)\n CK: 166 MB: 13 MBI: 7.8 Trop-T: 0.02\n Ca: Pnd Mg: Pnd P: Pnd\n ALT: 22 AP: 127 Tbili: 0.1 Alb: 3.3\n AST: 19 LDH: 212 Dbili: TProt:\n : 141 Lip: 32\n TSH:Pnd\n .\n WBC 3.4 Hb 9.4 Hct 29.9 Plt 87 MCV 97\n N:56.1 Band:0 L:33.4 M:6.5 E:2.3 Bas:1.8\n Hypochr: 1+ Anisocy: 1+ Macrocy: 1+ Microcy: 1+ Polychr: OCCASIONAL\n Plt-Est: Low\n .\n 2:00pm: pH 7.19 pCO2 47 pO2 84 HCO3 19 on RA\n 8:16pm: pH 7.23 pCO2 44 pO2 74 HCO3 19 on RA\n K:5.6 Lactate:1.1\n Imaging: CXR: the pulmonary vascularity has reduced to a normal level.\n There is prominence of the transverse diameter of the heart, some of\n which may be secondary to low lung volumes. No evidence of acute\n pneumonia.\n Microbiology: BCX x2 NGTD\n ECG: Sinus, regular, rate of 74, PR prolongation, narrow QRS, LAD, poor\n R wave progression, no peaked Ts or STT wave changes unchanged from\n prior dated \n Assessment and Plan\n A/P 56 year old man with hx of schizoaffective disorder, CKD, HTN and\n morbid obesity who is admitted after being found by his VNA hypothermic\n and off his psychiatric meds for 2 weeks.\n # Hypothermia: Differential includes sepsis, hypothyroidism, adrenal\n insufficiency, medication-induced (clonidine, metoprolol,\n neuroleptics), hypoglycemia or malnutrition. Patient has been\n hypothermic during his prior extended admission as well with no clear\n etiology. He does meet SIRS criteria with hypothermia and WBC, but has\n no left shift or bands on diff or tachypnea. No clear evidence of\n infection as CXR shows improvement in pulmonary vascularity and no\n evidence of pneumonia. Amylase and ALP mildly elevated, but LFTs\n otherwise wnl. UA/ucx not sent. No other signs or symptoms of\n infection. PM cortisol sent without evidence of adrenal\n insufficiency. Patient has not been hypothyroid in the past, and had a\n normal stim test in . Glucose has been normal (98 on\n presentation, 87 now). Albumin is 3.3.\n - Send UA/urine cx\n - PM Cortisol 12.6\n - TSH pending\n - As no clear evidence of infection and patient clinically appears\n well, will hold off on antibiotics for now. Should he become unstable,\n will start broad coverage.\n - Continue to monitor, bear-hugger prn\n # Acute on chronic kidney disease: Patient has stage V kidney disease\n thought to be secondary to hypertension. His creatinine on admission\n was 6.3 which is imcreased from him baseline around 5. Patient was\n hypotensive and hypothermic on presentation, likely prerenal in the\n setting of poor PO/hypovolemia. Renal consult called recommending HD\n at this time, though it appears patient and his outpatient nephrologist\n have been reluctant in the past.\n - Per renal, discussions between patient, guardian and \n nephrologist to discuss HD at this time\n - Low K, low phos diet\n - Bicarb and kayexelate for hyperK, sevelamer as per home regimen\n - Send UA, urine lytes, though patient has received 3L NS in the ED\n - Continue to follow with renal team\n # Hyperkalemia: Patient has chronically elevated K in the setting of\n CKD. Acute elevation in the setting of acute on chronic renal\n failure. Insulin/dextrose, bicarb, kayexelate given in ED\n - Continue bicarb in IVF for now\n - Recheck K on ABG was 5.6, will give additional dose of kayexlate\n - Will continue to monitor\n # Pancytopenia: Patient has had low WBC, Hct and platelets in the past,\n though these appear to be even lower at this time. He had work up\n during last admission including negative HITT Ab and a normal\n peripheral smear. He was initially started on epogen at that time, but\n it was discontinued once his anemia resolved. Last iron panel in \n showed iron of 130, TIBC 361, ferritin 131 and TRF 278. SPEP/UPEP at\n that time were wnl. No history of liver disease/alcohol abuse. He does\n not appear to be on any offending medications at this time.\n - Continue to monitor for now\n - Can consider heme/onc consult if persistently low\n # Bipolar disorder/schizoaffective disorder with h/o psychosis: Patient\n is on risperidone and abilify as an outpatient, and it is unclear as to\n when he stopped taking these medications. At this time, the patient\n reports that the psychotropic medications make him tired, and since he\n does not feel psychotic, he does not want to take them. He has been\n unable to care for himself at home despite increased home health care\n arranged after his prior admission. Psychiatry was consulted from the\n ED who recommended he be started back on Risperdal 1mg qhs. Patient is\n currently pleasant and cooperative.\n - Patient's legal guardian, appointed on is .\n Will contact her in the morning for discussion of further management.\n - Restart risperdal as per psych, send TSH\n - Continue to follow with psychiatry\n # Obstructive sleep apnea: Patient was found to have sleep disordered\n breathing during his last admission. At that time, he was started on\n nightly BiPAP, though the patient has not been using this at home.\n - Will start patient on his prior settings for BiPAP (10/7/2L)\n # Hypertension: The patient has a long-standing history of hypertension\n and is on a number of medications at home including toprol XL,\n amlodipine, clonidine patch and norvasc. He has been normotensive\n since admission. Unclear whether patient has been taking his\n medications as home, as by report, he had not taking medications for 2\n weeks.\n - Will hold on home blood pressure medications for now as patient is\n normotensive with HRs in the 70s.\n - Continue to monitor, will add back home medications as tolerated\n # Dyslipidemia: Continue simvastatin 10mg daily\n # Gout: Continue allopurinol, renally dosed (100mg qoday)\n # FEN: Sodium bicarb in D5W for now, renal diet (low K, low Phos), phos\n binder, replete lytes prn, nephrocaps\n # PPX: SQ heparin, no need for ppi at this time\n # Code: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:54 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: NA\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2140-03-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 322741, "text": "Chief Complaint: 56 year old man with hx of schizoaffective disorder,\n CKD stage IV, OSA presenting hypothermia to 90 degrees with ARF,\n hyperkalemia and pancytopenia.\n HPI:\n The patient is a 56 year old man with hx of schizoaffective disorder,\n CKD stage IV, OSA presenting hypothermia. Found by VNA to have stopped\n taking psych meds. On arrival, hypothermic to 90 degrees.\n In the ED his vitals were 32.7C 64 111/71 20 99%RA. He transiently\n dropped his sbp to 92 with responded to NS. Serum potassium was\n notable at 6.3. A EKG was unremarkable for peaked T waves. He received\n kayexalate, thiamine, bicarb 1amp, dextrose/insulin. He received\n vancomycin/ceftazadime. A CXR was improved from prior. Psychiatry was\n consulted who recommended re-introducing risperdal and would continue\n following.\n He denies pain, shortness of breath, chest pain, nausea, headache,\n visual changes, abdominal pain, diarrhea, dysuria, or other symptoms.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin 1gm IV x1 at 3:30 pm \n Ceftazidime 2gm IV x1 at 5:00 pm \n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -Hypertension\n -stage V chronic kidney disease\n -Schizoaffective disorder\n -Morbid obesity\n -Gout\n -Chronic LE edema\n -Dyslipidemia\n -Severe OSA (prior Bipap settings 2L O2)\n Non-contributory\n Tobacco: Denies\n Alcohol: Denies\n Other: Pt was born and raised in . He attended college at\n and reported that he went to medical school for a brief time at\n Duke. He later worked at as a librarian in the \n Science Library. Pt currently lives alone in (which was arranged through Housing). Prior to\n this he had been living in , which he was removed from due to\n poor hygiene. Pt is estranged from his family; reported to have a\n brother who lives in and rest of family in North or South\n .\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Jaundice\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Neurologic: No(t) Headache\n Flowsheet Data as of 11:05 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 34.8\nC (94.7\n Tcurrent: 34.8\nC (94.7\n HR: 76 (76 - 79) bpm\n BP: 117/74(80) {101/55(66) - 117/74(80)} mmHg\n RR: 26 (9 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,250 mL\n PO:\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 0 mL\n 1,125 mL\n Urine:\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,125 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.23/44/74//-8\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Edema Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing,\n Asterixis in bilateral upper extremities\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place and time, Movement: Purposeful\n Labs / Radiology\n 5.6 mEq/L\n [image002.jpg]\n \n 2:33 A4/15/ 08:16 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 19\n Other labs: Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: Na 144 Cl 118 BUN 74 AGap=11\n K 6.3 CO2 15 Cr 6.3\n estGFR: (click for details)\n CK: 166 MB: 13 MBI: 7.8 Trop-T: 0.02\n Ca: Pnd Mg: Pnd P: Pnd\n ALT: 22 AP: 127 Tbili: 0.1 Alb: 3.3\n AST: 19 LDH: 212 Dbili: TProt:\n : 141 Lip: 32\n TSH:Pnd\n .\n WBC 3.4 Hb 9.4 Hct 29.9 Plt 87 MCV 97\n N:56.1 Band:0 L:33.4 M:6.5 E:2.3 Bas:1.8\n Hypochr: 1+ Anisocy: 1+ Macrocy: 1+ Microcy: 1+ Polychr: OCCASIONAL\n Plt-Est: Low\n .\n 2:00pm: pH 7.19 pCO2 47 pO2 84 HCO3 19 on RA\n 8:16pm: pH 7.23 pCO2 44 pO2 74 HCO3 19 on RA\n K:5.6 Lactate:1.1\n Imaging: CXR: the pulmonary vascularity has reduced to a normal level.\n There is prominence of the transverse diameter of the heart, some of\n which may be secondary to low lung volumes. No evidence of acute\n pneumonia.\n Microbiology: BCX x2 NGTD\n ECG: Sinus, regular, rate of 74, PR prolongation, narrow QRS, LAD, poor\n R wave progression, no peaked Ts or STT wave changes unchanged from\n prior dated \n Assessment and Plan\n A/P 56 year old man with hx of schizoaffective disorder, CKD, HTN and\n morbid obesity who is admitted after being found by his VNA\n hypothermic, in acute on chronic renal failure and with hyperkalemia to\n 6.3, off his psychiatric meds for 2 weeks.\n # Hypothermia: Differential includes sepsis, hypothyroidism, adrenal\n insufficiency, medication-induced (clonidine, metoprolol,\n neuroleptics), hypoglycemia or malnutrition. Patient has been\n hypothermic during his prior extended admission as well with no clear\n etiology. He does meet SIRS criteria with hypothermia and WBC, but has\n no left shift or bands on diff or tachypnea. No clear evidence of\n infection as CXR shows improvement in pulmonary vascularity and no\n evidence of pneumonia. Amylase and ALP mildly elevated, but LFTs\n otherwise wnl. UA/ucx not sent. No other signs or symptoms of\n infection. PM cortisol sent without evidence of adrenal\n insufficiency. Patient has not been hypothyroid in the past, and had a\n normal stim test in . Glucose has been normal (98 on\n presentation, 87 now). Albumin is 3.3.\n - Send UA/urine cx\n - PM Cortisol 12.6, can consider -stim though no good reason for\n patient to be adrenally insufficient\n - TSH pending\n - As no clear evidence of infection and patient clinically appears\n well, will hold off on antibiotics for now. Should he become unstable,\n will start broad coverage.\n - Continue to monitor, bear-hugger prn\n # Acute on chronic kidney disease: Patient has stage V kidney disease\n thought to be secondary to hypertension. His creatinine on admission\n was 6.3 which is increased from him baseline around 5. Patient was\n hypotensive and hypothermic on presentation, likely prerenal in the\n setting of poor PO/hypovolemia. Renal consult called recommending HD\n at this time, though it appears patient and his outpatient nephrologist\n have been reluctant in the past.\n - Per renal, discussions between patient, guardian and \n nephrologist to discuss HD at this time\n - Low K, low phos diet\n - Bicarb and kayexelate for hyperK, sevelamer as per home regimen\n - IVF prn for hypovolemia\n - Send UA, urine lytes, though patient has received 3L NS in the ED,\n will send protein/creatinine ratio\n - Continue to follow with renal team\n # Hyperkalemia: Patient has chronically elevated K in the setting of\n CKD. Acute elevation in the setting of acute on chronic renal\n failure. Insulin/dextrose, bicarb, kayexelate given in ED\n - Continue bicarb in IVF for now\n - Recheck K on ABG was 5.6, will give additional dose of kayexlate\n - Will continue to monitor\n # Pancytopenia: Patient has had low WBC, Hct and platelets in the past,\n though these appear to be even lower at this time. He had work up\n during last admission including negative HITT Ab and a normal\n peripheral smear. He was initially started on epogen at that time, but\n it was discontinued once his anemia resolved. Last iron panel in \n showed iron of 130, TIBC 361, ferritin 131 and TRF 278. SPEP/UPEP at\n that time were wnl. No history of liver disease/alcohol abuse. He does\n not appear to be on any offending medications at this time.\n - Continue to monitor for now\n - Check peripheral smear\n - Recheck B12 and folate as last one was and was normal\n - TSH pending\n - Can consider heme/onc consult if persistently low\n # Schizoaffective disorder with psychosis: Patient is on risperidone\n and abilify as an outpatient, and it is unclear as to when he stopped\n taking these medications. At this time, the patient reports that the\n psychotropic medications make him tired, and since he does not feel\n psychotic, he does not want to take them. He has been unable to care\n for himself at home despite increased home health care arranged after\n his prior admission. Psychiatry was consulted from the ED who\n recommended he be started back on Risperdal 1mg qhs. Patient is\n currently pleasant and cooperative.\n - Patient's legal guardian, appointed on is .\n Will contact her in the morning for discussion of further management.\n - Restart risperdal as per psych, send TSH\n - Continue to follow with psychiatry\n # Obstructive sleep apnea: Patient was found to have sleep disordered\n breathing during his last admission. At that time, he was started on\n nightly BiPAP, though the patient has not been using this at home.\n - Will start patient on his prior settings for BiPAP (10/7/2L)\n # Hypertension: The patient has a long-standing history of hypertension\n and is on a number of medications at home including toprol XL,\n amlodipine, clonidine patch and norvasc. He has been normotensive\n since admission. Unclear whether patient has been taking his\n medications as home, as by report, he had not taking medications for 2\n weeks.\n - Will hold on home blood pressure medications for now as patient is\n normotensive with HRs in the 70s.\n - Continue to monitor, will add back home medications as tolerated\n # Dyslipidemia: Continue simvastatin 10mg daily\n # Gout: Continue allopurinol, renally dosed (100mg qoday)\n # FEN: Sodium bicarb in D5W for now x2 L, renal diet (low K, low Phos),\n phos binder, replete lytes prn, nephrocaps\n # PPX: SQ heparin, no need for ppi at this time\n # Code: FULL\n ICU Care\n Nutrition: PO, renal diet\n Glycemic Control:\n Lines:\n 20 Gauge - 06:54 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: NA\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2140-03-09 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 322742, "text": "Chief Complaint: Hyperkalemia & hypothermia\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 56 year old man with schizo-affective who was brought in from home with\n hypothermia, hyperkalemia and ARF on CRI. Had evidentally not taken\n his meds for approximately 2 weeks.\n In the ED, received kayexolate, bicarb, dextrose, insulin, calcium and\n antibiotics. Was seen by psych who recommended restarting risperdal.\n Was hypothermic on a recent admission to , evaluation was\n unrevealing.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective disorder\n Gout\n OSA\n HTN\n Morbid obesity\n CRI\n Non contributory\n Occupation: Former Librarian\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: Went to & worked there as a librarian. Lives alone.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Myalgias\n Integumentary (skin): No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Neurologic: No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: non compliant with med\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\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: 34.8\nC (94.7\n Tcurrent: 34.8\nC (94.7\n HR: 76 (76 - 79) bpm\n BP: 117/74(80) {101/55(66) - 117/74(80)} mmHg\n RR: 26 (9 - 26) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,473 mL\n 40 mL\n PO:\n TF:\n IVF:\n 473 mL\n 40 mL\n Blood products:\n Total out:\n 1,165 mL\n 0 mL\n Urine:\n 365 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,308 mL\n 40 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PPS\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n SpO2: 94%\n ABG: 7.23/44/74//-8\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Distant), No(t) S3, No(t) S4,\n (Murmur: No(t) 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), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: No(t) Muscle wasting\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, asterixis\n Labs / Radiology\n 6.3\n 74\n 15\n 118\n 6.3\n 144\n [image002.jpg]\n 08:16 PM\n WBC\n 3.4\n Hct\n 30\n Plt\n 87\n TC02\n 19\n Other labs: CK / CKMB / Troponin-T:166, ALT / AST:22/19, Amylase /\n Lipase:/132, Band:0, Lactic Acid:1.1 mmol/L, Albumin:3.3\n Fluid analysis / Other labs: 7.19/47/84 on RA\n 7.23/44/74\n Repeat K 5.6\n Imaging: Clear lungs except perhaps a small effusion on the right.\n Splayed carina and prominent hila - ? lymphadenopathy\n ECG: NSR at 74. Either severe PR prolongation or U-waves, poor R-wave\n progression which is old. LAD. No particularly peaked T-waves\n Assessment and Plan\n 56 year old man with schizoaffective disorder who has hypothermia of\n unclear etiology and ARF and CRI.\n 1. Hypothermia - could be early infection, hypothyroidism, adrenal\n insufficiency, CNS regulated. Reasonable to culture now though does\n not seem acutely infected. Check thyroid studies, though they were\n recently checked. Hold on repeat stim for now unless his SBP is\n low. Will also hold on antibiotics for now since he was given some in\n the ED already.\n 2. ARF on CRI - will talk to renal who already knows him. Has been\n hydrated and we will do the same but use d5 with bicarb. Send UA and\n lytes. Will retreat with kayexolate. Follow his K closely. Need to\n continue discussion about HD initiation.\n 3. Pancytopenia - cause unclear. check b12/folate/TSH/HIV. Check\n peripheral smear.\n 4. Schizoaffective disorder - restarted risperdal as per psych who will\n follow.\n 5. OSA/Sleep disorder breathing - restart baseline BIPAP (which he\n doesn't use at home)\n 6. HTN - right now low-ish BP, hold meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 06:54 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments: Will need to contact HCP\n status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2140-03-09 00:00:00.000", "description": "Generic Note", "row_id": 322744, "text": "TITLE:\n Resp Care Note, Pt placed on nasal bipap 10/5 with O2 2lpm titrated for\n sats of 95%.Pt asked to be taken off at 0400.Now on 2lpm nasal\n cannula.Will cont to monitor resp status.\n" } ]

[ { "category": "Radiology", "chartdate": "2200-09-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1256913, "text": " 7:20 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Proper placement of CVL\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with GIB, sp new CVL\n REASON FOR THIS EXAMINATION:\n Proper placement of CVL\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left IJ catheter that extends to the mid portion of the SVC.\n Otherwise, little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1256906, "text": " 12:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with GIB, recently intubated for airway protection\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n FINDINGS: Endotracheal tube tip lies approximately 4.5 cm above the carina.\n Nasogastric tube extends to the stomach, though the side hole is above the\n esophagogastric junction. There is some patchy opacification at the left\n base. Although this could merely be atelectasis, in the appropriate clinical\n setting, a developing pneumonia would have to be considered.\n\n\n" }, { "category": "ECG", "chartdate": "2200-09-11 00:00:00.000", "description": "Report", "row_id": 216578, "text": "Sinus rhythm. Prolonged Q-T interval. Low voltage in the limb leads.\nInferior T wave abnormalities. Compared to the previous tracing of \nlow voltage and prolonged Q-T interval are new.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2142-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079038, "text": " 11:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute intrapulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with acute onset SOB, syncope\n REASON FOR THIS EXAMINATION:\n eval for acute intrapulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath, to evaluate for pulmonary process.\n\n FINDINGS: In comparison with the study of , the central catheter\n remains in position. Low lung volumes, but no evidence of acute focal\n pneumonia, vascular congestion, or pleural effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2142-04-16 00:00:00.000", "description": "Report", "row_id": 292028, "text": "Sinus tachycardia with diffuse low voltage. Delayed R wave transition.\nNon-specific ST-T wave abnormalities. No diagnostic change from previous\ntracing of .\n\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 574061, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. No c/o abd pain. Nauseated after dinner\n Action:\n Compazine given, Pain assessed freq\n Response:\n Gd effect w/ compazine, Pt comfortable all night, slept well\n Plan:\n Pain management, compazine PRN, ? diagnostic ultrasound and\n paracentesis for worsened ascites. Monitor temps/WBCs, ABX as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, tachycardic w/ HR 100s.\n Action:\n 1 unit PRBC given\n Response:\n HD stable, HR down to 70-90s SR. AM HCT 20.1\n Plan:\n Continue to follow VS, serial HCTs, transfuse for HCT >21\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Rec\nd IVF 100cc/hr x1 L. Urine lytes sent\n Response:\n AM Cr 1.3\n Plan:\n Continue to monitor, f/u w/ urine lytes. Continue stress dose steroids\n (s/p renal transplant), ? transition to PO\n" }, { "category": "Nursing", "chartdate": "2142-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573976, "text": "Cancer (Malignant Neoplasm),\n Assessment:\n Frail looking- pale- Hct 21- abdominal ascites noted- R subclavian\n portacath accessed & dry intact- c/o R upper quadrant/abdominal pain.\n Action:\n MS contin 30mg Po given- repositioned- 1u PRBC\ns ordered- PT is DNR/DNI\n Response:\n Plan:\n Medicate for comfort- antibiotics as ordered- follow labs.\n" }, { "category": "Nursing", "chartdate": "2142-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573977, "text": "Cancer (Malignant Neoplasm),\n Assessment:\n Pale- Hct 21- abdominal ascites noted- R subclavian port-a-cath\n accessed & dsg intact- c/o R upper quadrant/abdominal pain.\n Action:\n MS contin 30mg Po given & repositioned- PT is DNR/ Pt is DNR/DNI\n Response:\n Pain relief noted within 1/2hr of pain med.\n Plan:\n Medicate for comfort- antibiotics as ordered- monitor VS- follow labs.\n" }, { "category": "Physician ", "chartdate": "2142-04-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 573981, "text": "Chief Complaint: SOB\n HPI:\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis x 1.\n .\n This morning, the patient's wife found him in the showers, crouching\n over, rigoring, with dyspnea, complaining of generalized weakness. At\n home, T was 98.1. His symptoms are associated with worsening abdominal\n distention over the last few days. He also complains of watery diarrhea\n over the last few months. He denies headache, visual changes, weakness\n or paresthesias. No changes in smell. No CP. No sore throat, cough\n rhinorrhea. No weight loss. Had similar symptoms on thursday but did\n not make much of them. Over last few weeks had decreased appetite and\n has been taking appetite stimulant. His anginal equivalent is chest\n pain.\n .\n Patient received C2D15 of his gemcitabine and oxaliplatin on .\n His first cycle was uncomplicated.\n .\n Of note, his clopidogrel and ASA were discontinued in for liver\n biopsy.\n .\n In ED, T 95.5, BP 80-100s/50-70s (baseline SBP 100s), HR 120s, RR 24,\n 100%RA. Exam revealed distended abdomen with significant hepatomegaly.\n ECG showed no ischemic changes. Labs were notable for Hct 21, AG of 16\n with lactate 4.5. He received 3L NS, and HR decreased to 90s. With\n hypothermia, tachycardia, lactic acidosis, and ongoing chemo, he\n received empiric vancomycin and pip-tazo and was admitted to the MICU.\n .\n In the floor he complains of abdominal pain and worsened abdominal\n distention. He doesnt have any other complaints but expresses being sad\n regarding his cancer burden.\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n coughs. Denied chest pain or tightness, palpitations. No dysuria.\n Denied arthralgias or myalgias. Denies hematochezia, melena,\n arthralgias.\n .\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Horse Blood Extract\n Unknown;\n Morphine\n Nausea/Vomiting\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule, Dose Pack\n - 1 Capsule(s) by mouth once a day Take 125mg 1 hr prior to\n chemotherapy on day 1 and 80mg tablet in am first and second day after\n chemo\n AZATHIOPRINE [IMURAN] - 50 mg Tablet - 2 Tablet(s) by mouth daily\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other\n Provider) - 50,000 unit Capsule - one Capsule(s) by mouth one tablet\n per week times 4 weeks Last dose taken on \n LORAZEPAM - 0.5 mg Tablet - Tablet(s) by mouth q6-8hrs as needed\n for nausea, anxiety, insomnia avoid if ovrsedated\n MEGESTROL - 400 mg/10 mL Suspension - mL by mouth once a day\n Start at 10mL, can increase to 20mL\n METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth prior to meals\n (three times a day)\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Tablet Sustained Release 24 hr\n - one Tablet(s) by mouth once a day\n MORPHINE - 30 mg Tablet Sustained Release - One Tablet(s) by mouth\n Twice daily, every 12 hours\n MORPHINE - 15 mg Tablet - one Tablet(s) by mouth every six horus as\n needed for as needed for pain\n PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1\n Tablet(s) by mouth daily. brand name only\n PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth daily\n PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth three\n times a day as needed for nausea\n SERTRALINE [ZOLOFT] - 100 mg Tablet - 1 Tablet(s) by mouth daily\n SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily\n Past medical history:\n Family history:\n Social History:\n - Cholangiocarcinoma: dx'ed , ongoing gemcitabine and\n oxaliplatin, followed by Dr. \n - Renal transplant (LRRT) to post-strep GN, on azathioprine\n - CAD with MI in s/p stent. MI in and area of\n stent was found to be occluded but no other interventions done.\n First stent was BMS; found to have total occlusion; at\n subsequent cath had attempt at correcting with placement of \n /b dissection and resulting no flow at end of procedure.\n - TIA/stroke in left eye causing decreased vision\n - Hyperlipidemia\n - Depression\n - Hypertension\n - Avascular necrosis of his left patella\n - Recent diagnosis of adenocarcinoma at liver, s/p liver biopsy\n .\n - Mild chronic cardiomyopathy with LVEF of 50-55%\n - Small secundum ASD\n - Hiatal hernia\n Mother had cancer; maternal uncle and paternal aunt had liver\n cancer. Maternal aunt had pancreatic cancer. The patient does not know\n if they had cirrhosis or not.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married. No smoking, he drinks alcohol almost on a daily basis,\n 2 to 3 drinks daily. This has been ongoing for 15 to 20 years. He also\n smokes marijuana a few times per week due to nausea. He denies any\n cocaine or heroin. He works in school food services\n Review of systems:\n Flowsheet Data as of 06:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 102 (100 - 102) bpm\n BP: 88/50(60) {88/50(60) - 113/70(78)} mmHg\n RR: 12 (12 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: distended and tympanic but soft, non-tender, bowel sounds\n present, no rebound tenderness or guarding, unable to appreciate hsm on\n palpation, percussion consistent with hepatomegaly.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN2-12 intact, intact sensation to touch and 5/5 strength\n throughout.\n Labs / Radiology\n 122\n 1.5\n 23\n 20\n 100\n 3.5\n 136\n 21\n 9\n [image002.jpg]\n Other labs: PT / PTT / INR:PT: 18.4 PTT: 29.5 INR: 1.7 , CK / CKMB /\n Troponin-T:CK: 49 MB: Notdone Trop-T: Pnd\n Imaging: CXR : no PNA, edema\n CT C/A/P : 1. Increased abdominal and pelvic ascites which may be\n causing the patient abdominal discomfort. 2. Overall stable size to\n heterogeneously enhancing liver masses. Mass in segment IVb of the\n liver, however, might have slightly increased in size. 3. Splenomegaly.\n 4. Bilaterally absent abdominal kidneys. Transplanted right pelvic\n kidney contains multiple stable parapelvic cysts.\n 5. Diverticulosis without diverticulitis. Minimal ground glass\n opacities in the right base may be due to atelectasis, however, trace\n areas of infection or inflammation cannot be fully excluded.\n CT Head : negative for mass or hemorrhage.\n Microbiology: Bcx PND\n Assessment and Plan\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n # Hypothermia, tachycardia consistent with SIRS: Septic etiology is\n high on the differential given his chemotherapy. He is not neutropenic\n at this time. Abdominal distention is concening for SBP. The dyspnea\n suggest PNA as source of infection but no other symptoms Also negative\n CXR. Diarrhea and nausea are chronic in nature and thus low probability\n for intestinal source. Hypovolemic shock is another likely etiology.\n ACS is unlikely but will consider given his history.\n - Diagnostic w/u includes diagnostic ultrasound and if worsended\n ascities consider paracentesis, blood/urine/sputum/stool cx, CE, ECG.\n - Will continue vanc and pip/tazo as empiric rx.\n - Will continue IVF\n - Will monitor fever curve and WBCs\n - If ascites present then will consider thx para.\n # Lactic acidosis: likely related to hypovolemia. Septic shock is also\n in the differential.\n - Will monitor lactates and continue IVF.\n # Normocytic anemia with elevated RDW: chemotherapy related.\n - will check fe, b12, folate\n - transfuse for HCT>21 unless active ischemia or bleeding\n # Thrombocytopenia: Related to chemotherapy and perhaps intrahepatic\n obstruction of portal circulation leading to hypersplenism.\n - Monitor plt count and transfuse >10 unless active bleeding.\n # ARF (cre 1.5/1.0): hypovolemia vs sepsis\n - will check u lytes, although he has already been fluid recussitated\n # Hypertension: Normotensive. Holding BB.\n # Cholangiocarcinoma, dx'ed , on gemcitabine and oxaliplatin\n #C2D15 on .\n - continue nausea management\n # h/o CAD with MI s/p BMS c/b in stent thrombosis and DES without\n flow improvement. Anginal equivalent is chest pain. LVEF of 50-55%.\n - ROMI as above\n - cont asa, statin, off plavix since .\n # h/o bilateral renal resection s/p remote renal transplant\n - on azathioprine and prednisone; will hold azathioprine until cx\n negative.\n - stress dose steroids\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: PNB, PPI\n # Access: peripherals\n # Code: DNR/DNI\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2142-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573982, "text": "62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n Cancer (Malignant Neoplasm), cholangiocarcinoma\n Assessment:\n Pale- Hct 21- abdominal ascites noted- R subclavian port-a-cath\n accessed & dsg intact- c/o R upper quadrant/abdominal pain.\n Action:\n MS contin 30mg Po given & repositioned- PT is DNR/ Pt is DNR/DNI\n Response:\n Pain relief noted within 1/2hr of pain med.\n Plan:\n Medicate for comfort- antibiotics as ordered- monitor VS- transfuse\n blood when available- follow labs.\n" }, { "category": "Nursing", "chartdate": "2142-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573970, "text": "Cancer (Malignant Neoplasm),\n Assessment:\n Frail looking- pale- abdominal ascites noted- R subclavian portacath\n accessed & dry intact- c/o R upper quadrant/abdominal pain.\n Action:\n MS contin 30mg Po given- repositioned\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 574037, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. No c/o abd pain. Nauseous after dinner\n Action:\n Compazine given, Pain assessed freq\n Response:\n Gd effect w/ compazine, Pt comfortable all night, slept well\n Plan:\n Medicate for pain, ? diagnostic ultrasound and paracentesis for\n worsened ascites. Monitor temps/WBCs, ABX as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, tachycardic w/ HR 100s.\n Action:\n 1 unit PRBC given\n Response:\n HD stable, HR down to 70-90s SR. AM HCT 20.1\n Plan:\n Continue to follow VS, serial HCTs, transfuse for HCT >21\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Rec\nd IVF 100cc/hr x1 L. Urine lytes sent\n Response:\n AM Cr 1.3\n Plan:\n Continue to monitor, f/u w/ urine lytes. Continue stress dose steroids\n (s/p renal transplant), ? transition to PO\n" }, { "category": "Physician ", "chartdate": "2142-04-17 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 574133, "text": "Chief Complaint: weakness, rigors\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n URINE CULTURE - At 03:54 AM\n UA/ UCx\n transfused 1 unit \n stress dose steroids\n History obtained from Patient\n Allergies:\n History obtained from PatientHorse Blood Extract\n Unknown;\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37\nC (98.6\n HR: 89 (80 - 104) bpm\n BP: 107/67(76) {88/50(60) - 117/76(85)} mmHg\n RR: 12 (10 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,612 mL\n 476 mL\n PO:\n 180 mL\n 120 mL\n TF:\n IVF:\n 1,150 mL\n 356 mL\n Blood products:\n 282 mL\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,612 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 102 K/uL\n 6.7 g/dL\n 112 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 105 mEq/L\n 137 mEq/L\n 20.1 %\n 4.0 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 4.0\n Hct\n 20.1\n Plt\n 102\n Cr\n 1.3\n TropT\n 0.01\n Glucose\n 112\n Other labs: CK / CKMB / Troponin-T:48//0.01, Ca++:7.5 mg/dL, Mg++:1.9\n mg/dL, PO4:4.0 mg/dL\n Imaging: cxr yesterday clear\n Microbiology: ngtd\n Assessment and Plan\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n CANCER (MALIGNANT NEOPLASM), OTHER\n CANCER (MALIGNANT NEOPLASM), HEPATIC (LIVER)\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n .\n # Hypotension: Most likely secondary to hypovolemia from vomiting and\n diarrhea. Was concerning for sepsis, but no evidence of ongoing\n infection. BP improved appropriately with IVF.\n - continue Vanco/Zosyn another 24 hours and d/c if blood/urine cx\n remain negative\n - If develops abdominal pain or fever then will pursue paracentesis\n - 2 units RBCs for volume repletion today\n ..\n # Anemia: likely from chemo and hemodilution\n - transfuse 2 units today\n - guiaic stools\n - iron studies consistent with chronic disease\n - d/c aspirin, has been off of this\n .\n # Lactic acidosis: likely related to hypovolemia. Septic shock is also\n in the differential.\n - recheck lactate this AM\n .\n # Thrombocytopenia: Related to chemotherapy and perhaps intrahepatic\n obstruction of portal circulation leading to hypersplenism.\n - Monitor plt count and transfuse >10 unless active bleeding.\n - d/c aspirin\n .\n # ARF (cre 1.5/1.0): hypovolemia vs sepsis\n - urine Na<10 this am even after IVF and blood products, transfuse 2\n units today for further volume repletion\n - Cr improved today\n .\n # Hypertension: Normotensive. Holding BB.\n .\n # Cholangiocarcinoma, dx'ed , on gemcitabine and oxaliplatin\n #C2D15 on .\n - continue nausea management\n .\n # h/o CAD with MI s/p BMS c/b in stent thrombosis and DES without\n flow improvement. Anginal equivalent is chest pain. LVEF of 50-55%.\n - ruled out for ACS\n - cont statin, off plavix since . , d/c asa\n # h/o bilateral renal resection s/p remote renal transplant\n - on azathioprine and prednisone; will hold azathioprine until cx\n negative.\n - stress dose steroids, switch back to prednisone today\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: PNB, PPI\n # Access: peripherals\n # Code: DNR/DNI\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:Transfer to floor\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: 62M CAD (MI, DES), CVA, HTN, renal\n transplant, cholangiocarcinoma, ongoing chemorx via port, chills,\n rigors, progressive abdominal girth and DOE. SBP 80-100 in ED c HR\n 120s, HCT 21, lactate 4.5. Started on vanco / zosyn, 3L NS, admitted to\n MICU. Transfused overnight, stable.\n Exam notable for Tm 98.9 BP 110/60 HR 85 RR 18 with sat 97 on RA. Frail\n man, NAD. JVD flat. CTA B. RRR s1s2. Dist +BS / ascites. Tr edema. Labs\n notable for WBC 4K, HCT 20, K+ 3.5, Cr 1.3 (from 1.5). CXR with clear\n lungs.\n Agree with plan to manage likely resolving hypovolemia with gentle\n fluids, taper abx to off if cx neg at 48h, and transfuse 2 units PRBCs\n for anemia in the setting of recent chemo. Will hold off on\n paracentesis unless he is symptomatic w/r/t DOE. Given hx chronic\n steroid use, transition back to prednisone PO today. For ARF s/p\n transplant, creatinine is falling with volume, Una low, continue\n azathioprine and consult renal transplant team. For CAD - no acute\n evidence of ACS, will cycle given hx and ongoing medical stress.\n Remainder of plan as outlined above. Will transfer to OMED / \n today.\n Total time: 25 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:51 PM ------\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 574166, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. Blood and urine cultures pending. Started on zosyn and\n Vancomycin. Received IV fluids DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. Occ c/o abdominal pain. Occ c/o nausea responding to\n compazine (last dose 5/18 evening). T max 99.4 po.\n Action:\n Given 2 mg IV morphine for abdominal pain at rest. Also receiving\n standing dose of MS contin.\n Response:\n Plan:\n Pain decreased to with management as above. Compazine for\n nausea,. Monitor temp, antibiotics as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, given 1 unit PRBC overnight with repeat Hct 20 , ?\n d/t ^^^IV fluids\n Action:\n 2 Units PRBC given today, Hct 24 in between units. 2^nd unit finished\n at 1730.\n Response:\n Hct stable. No signs of transfusion reaction. HR80\ns-90\ns NSR, SBP\n 100-114\n Plan:\n Continue to follow VS, Monitor Hct\nHct due @ .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Received 1 L IVF overnight. Received 2 units PRBC today. Pt with fair\n po intake, has not voided since 0300. Pt refusing to attempt to void\n with urinal, or with sitting on commode chair. Expressed concern re:\n lack of voiding since night shift with his hx of renal transplant.\n Have suggested to pt that we attempt to scan his bladder\nhe adamantly\n refuses this. He states that he will void when he wants to. Pt\ns wife\n feels this is his attempt to maintain control over some aspect of his\n care. Dr. notified.\n Response:\n AM Cr 1.3\n Plan:\n Continue to monitor I/O. Follow Cr. Spoke further with Dr re:\n U/o\nto receive 1L NS over one hour enroute to .\n Neuro: pt is oriented X3, although is slow in recalling month. Episode\n of hallucination @ 1200\nthought he could see a band with instruments in\n the unit\ninsistent about what he had seen. MICU resident notified.\n Wife states that he has not hallucinated in the past, but she describes\nalzheimer\ns like behavior, requiring brain scan in the past.\n No\n further episodes of hallucinations.\n Skin: intact , coccyx gets pink very easily, but blanches. Have\n instructed pt to lye on side as much as possible.\n Social: wife \n Access: cath and L arm #18\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n DEHYDRATION\n Code status:\n DNR / DNI\n Height:\n 70 Inch\n Admission weight:\n 67.8 kg\n Daily weight:\n Allergies/Reactions:\n Horse Blood Extract\n Unknown;\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Precautions:\n PMH:\n CV-PMH: CAD, Hypertension\n Additional history: S/P kidney transplant post strep GN- CAD\n w/ MI - s/p stents- TIA/ stroke in L eye causing decreased\n vision- hyperlipidemia- depression- avascular necrosis L patella- mild\n chronic cardiomyopathy w/ LVEF 50-55%- small secundum ASD- hiatal\n hernia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:76\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 98 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 2,208 mL\n 24h total out:\n 350 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:53 AM\n Potassium:\n 3.6 mEq/L\n 02:53 AM\n Chloride:\n 105 mEq/L\n 02:53 AM\n CO2:\n 20 mEq/L\n 02:53 AM\n BUN:\n 20 mg/dL\n 02:53 AM\n Creatinine:\n 1.3 mg/dL\n 02:53 AM\n Glucose:\n 112 mg/dL\n 02:53 AM\n Hematocrit:\n 24.1 %\n 01:50 PM\n Finger Stick Glucose:\n 184\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: 7 South\n Date & time of Transfer: .\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573997, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. No c/o abd pain. Nauseous after dinner\n Action:\n Compazine given, Pain assessed freq\n Response:\n Gd effect w/ compazine, Pt comfortable all night, slept well\n Plan:\n Medicate for pain, ? diagnostic ultrasound and paracentesis for\n worsened ascites. Monitor temps/WBCs, PLTs\n Anemia, other\n Assessment:\n HCT 21 on admission, tachycardic w/ HR 100s.\n Action:\n 1 unit PRBC given\n Response:\n HD stable, HR down to 70-80 SR. AM HCT pnd\n Plan:\n Continue to follow VS, serial HCTs, transfuse for HCT >21\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Rec\nd IVF 100cc/hr x1 lytes to be sent\n Response:\n AM Cr pnd\n Plan:\n Continue to monitor, f/u w/ urine lytes. Continue stress dose steroids\n (s/p renal transplant), ? transition to PO\n" }, { "category": "Physician ", "chartdate": "2142-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 574082, "text": "Chief Complaint: weakness, rigors\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n URINE CULTURE - At 03:54 AM\n UA/ UCx\n transfused 1 unit \n stress dose steroids\n History obtained from Patient\n Allergies:\n History obtained from PatientHorse Blood Extract\n Unknown;\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37\nC (98.6\n HR: 89 (80 - 104) bpm\n BP: 107/67(76) {88/50(60) - 117/76(85)} mmHg\n RR: 12 (10 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,612 mL\n 476 mL\n PO:\n 180 mL\n 120 mL\n TF:\n IVF:\n 1,150 mL\n 356 mL\n Blood products:\n 282 mL\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,612 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 102 K/uL\n 6.7 g/dL\n 112 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 105 mEq/L\n 137 mEq/L\n 20.1 %\n 4.0 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 4.0\n Hct\n 20.1\n Plt\n 102\n Cr\n 1.3\n TropT\n 0.01\n Glucose\n 112\n Other labs: CK / CKMB / Troponin-T:48//0.01, Ca++:7.5 mg/dL, Mg++:1.9\n mg/dL, PO4:4.0 mg/dL\n Imaging: cxr yesterday clear\n Microbiology: ngtd\n Assessment and Plan\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n CANCER (MALIGNANT NEOPLASM), OTHER\n CANCER (MALIGNANT NEOPLASM), HEPATIC (LIVER)\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n .\n # Hypothermia, tachycardia consistent with SIRS: Septic etiology is\n high on the differential given his chemotherapy. He is not neutropenic\n at this time. Abdominal distention is concening for SBP. The dyspnea\n suggest PNA as source of infection but no other symptoms Also negative\n CXR. Diarrhea and nausea are chronic in nature and thus low probability\n for intestinal source. Hypovolemic shock is another likely etiology.\n ACS is unlikely but will consider given his history.\n - Diagnostic w/u includes diagnostic ultrasound and if worsended\n ascities consider paracentesis, blood/urine/sputum/stool cx, CE, ECG.\n - Will continue vanc and pip/tazo as empiric rx.\n - Will continue IVF and transfuse today\n - Will monitor fever curve and WBCs\n - If ascites present then will consider thx para.\n .\n # Lactic acidosis: likely related to hypovolemia. Septic shock is also\n in the differential.\n - Will monitor lactates and continue IVF.\n .\n # Normocytic anemia with elevated RDW: chemotherapy related.\n - will check fe, b12, folate\n - transfuse another 2 units today given recent chemo and hypovolemia\n .\n # Thrombocytopenia: Related to chemotherapy and perhaps intrahepatic\n obstruction of portal circulation leading to hypersplenism.\n - Monitor plt count and transfuse >10 unless active bleeding.\n .\n # ARF (cre 1.5/1.0): hypovolemia vs sepsis\n - urine Na<10 this am even after IVF and blood products\n - Cr improved today\n # Hypertension: Normotensive. Holding BB.\n # Cholangiocarcinoma, dx'ed , on gemcitabine and oxaliplatin\n #C2D15 on .\n - continue nausea management\n # h/o CAD with MI s/p BMS c/b in stent thrombosis and DES without\n flow improvement. Anginal equivalent is chest pain. LVEF of 50-55%.\n - ruled out for ACS\n - cont asa, statin, off plavix since .\n # h/o bilateral renal resection s/p remote renal transplant\n - on azathioprine and prednisone; will hold azathioprine until cx\n negative.\n - stress dose steroids, switch back to prednisone today\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: PNB, PPI\n # Access: peripherals\n # Code: DNR/DNI\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 574112, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. Blood and urine cultures pending. Started on zosyn and\n Vancomycin. Received IV fluids DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. Occ c/o abdominal pain. Occ c/o nausea responding to\n compazine (last dose 5/18 evening). T max 99.4 po.\n Action:\n Given 2 mg IV morphine for abdominal pain at rest. Also receiving\n standing dose of MS contin.\n Response:\n Plan:\n Pain management as above. Compazine for nausea,. Monitor temp,\n antibiotics as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, given 1 unit PRBC overnight with repeat Hct 20 , ?\n d/t ^^^IV fluids\n Action:\n 2 Units PRBC given today, Hct 24 in between units.\n Response:\n Hct stable. No signs of transfusion reaction.\n Plan:\n Continue to follow VS, Monitor Hct.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Received 1 L IVF overnight. Received 2 units PRBC today.\n Response:\n AM Cr 1.3\n Plan:\n" }, { "category": "Physician ", "chartdate": "2142-04-16 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 573990, "text": "Chief Complaint: SOB\n HPI:\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis x 1.\n .\n This morning, the patient's wife found him in the showers, crouching\n over, rigoring, with dyspnea, complaining of generalized weakness. At\n home, T was 98.1. His symptoms are associated with worsening abdominal\n distention over the last few days. He also complains of watery diarrhea\n over the last few months. He denies headache, visual changes, weakness\n or paresthesias. No changes in smell. No CP. No sore throat, cough\n rhinorrhea. No weight loss. Had similar symptoms on thursday but did\n not make much of them. Over last few weeks had decreased appetite and\n has been taking appetite stimulant. His anginal equivalent is chest\n pain.\n .\n Patient received C2D15 of his gemcitabine and oxaliplatin on .\n His first cycle was uncomplicated.\n .\n Of note, his clopidogrel and ASA were discontinued in for liver\n biopsy.\n .\n In ED, T 95.5, BP 80-100s/50-70s (baseline SBP 100s), HR 120s, RR 24,\n 100%RA. Exam revealed distended abdomen with significant hepatomegaly.\n ECG showed no ischemic changes. Labs were notable for Hct 21, AG of 16\n with lactate 4.5. He received 3L NS, and HR decreased to 90s. With\n hypothermia, tachycardia, lactic acidosis, and ongoing chemo, he\n received empiric vancomycin and pip-tazo and was admitted to the MICU.\n .\n In the floor he complains of abdominal pain and worsened abdominal\n distention. He doesnt have any other complaints but expresses being sad\n regarding his cancer burden.\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n coughs. Denied chest pain or tightness, palpitations. No dysuria.\n Denied arthralgias or myalgias. Denies hematochezia, melena,\n arthralgias.\n .\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Horse Blood Extract\n Unknown;\n Morphine\n Nausea/Vomiting\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule, Dose Pack\n - 1 Capsule(s) by mouth once a day Take 125mg 1 hr prior to\n chemotherapy on day 1 and 80mg tablet in am first and second day after\n chemo\n AZATHIOPRINE [IMURAN] - 50 mg Tablet - 2 Tablet(s) by mouth daily\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other\n Provider) - 50,000 unit Capsule - one Capsule(s) by mouth one tablet\n per week times 4 weeks Last dose taken on \n LORAZEPAM - 0.5 mg Tablet - Tablet(s) by mouth q6-8hrs as needed\n for nausea, anxiety, insomnia avoid if ovrsedated\n MEGESTROL - 400 mg/10 mL Suspension - mL by mouth once a day\n Start at 10mL, can increase to 20mL\n METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth prior to meals\n (three times a day)\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Tablet Sustained Release 24 hr\n - one Tablet(s) by mouth once a day\n MORPHINE - 30 mg Tablet Sustained Release - One Tablet(s) by mouth\n Twice daily, every 12 hours\n MORPHINE - 15 mg Tablet - one Tablet(s) by mouth every six horus as\n needed for as needed for pain\n PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1\n Tablet(s) by mouth daily. brand name only\n PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth daily\n PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth three\n times a day as needed for nausea\n SERTRALINE [ZOLOFT] - 100 mg Tablet - 1 Tablet(s) by mouth daily\n SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily\n Past medical history:\n Family history:\n Social History:\n - Cholangiocarcinoma: dx'ed , ongoing gemcitabine and\n oxaliplatin, followed by Dr. \n - Renal transplant (LRRT) to post-strep GN, on azathioprine\n - CAD with MI in s/p stent. MI in and area of\n stent was found to be occluded but no other interventions done.\n First stent was BMS; found to have total occlusion; at\n subsequent cath had attempt at correcting with placement of \n /b dissection and resulting no flow at end of procedure.\n - TIA/stroke in left eye causing decreased vision\n - Hyperlipidemia\n - Depression\n - Hypertension\n - Avascular necrosis of his left patella\n - Recent diagnosis of adenocarcinoma at liver, s/p liver biopsy\n .\n - Mild chronic cardiomyopathy with LVEF of 50-55%\n - Small secundum ASD\n - Hiatal hernia\n Mother had cancer; maternal uncle and paternal aunt had liver\n cancer. Maternal aunt had pancreatic cancer. The patient does not know\n if they had cirrhosis or not.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married. No smoking, he drinks alcohol almost on a daily basis,\n 2 to 3 drinks daily. This has been ongoing for 15 to 20 years. He also\n smokes marijuana a few times per week due to nausea. He denies any\n cocaine or heroin. He works in school food services\n Review of systems:\n Flowsheet Data as of 06:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 102 (100 - 102) bpm\n BP: 88/50(60) {88/50(60) - 113/70(78)} mmHg\n RR: 12 (12 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: distended and tympanic but soft, non-tender, bowel sounds\n present, no rebound tenderness or guarding, unable to appreciate hsm on\n palpation, percussion consistent with hepatomegaly.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN2-12 intact, intact sensation to touch and 5/5 strength\n throughout.\n Labs / Radiology\n 122\n 1.5\n 23\n 20\n 100\n 3.5\n 136\n 21\n 9\n [image002.jpg]\n Other labs: PT / PTT / INR:PT: 18.4 PTT: 29.5 INR: 1.7 , CK / CKMB /\n Troponin-T:CK: 49 MB: Notdone Trop-T: Pnd\n Imaging: CXR : no PNA, edema\n CT C/A/P : 1. Increased abdominal and pelvic ascites which may be\n causing the patient abdominal discomfort. 2. Overall stable size to\n heterogeneously enhancing liver masses. Mass in segment IVb of the\n liver, however, might have slightly increased in size. 3. Splenomegaly.\n 4. Bilaterally absent abdominal kidneys. Transplanted right pelvic\n kidney contains multiple stable parapelvic cysts.\n 5. Diverticulosis without diverticulitis. Minimal ground glass\n opacities in the right base may be due to atelectasis, however, trace\n areas of infection or inflammation cannot be fully excluded.\n CT Head : negative for mass or hemorrhage.\n Microbiology: Bcx PND\n Assessment and Plan\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n # Hypothermia, tachycardia consistent with SIRS: Septic etiology is\n high on the differential given his chemotherapy. He is not neutropenic\n at this time. Abdominal distention is concening for SBP. The dyspnea\n suggest PNA as source of infection but no other symptoms Also negative\n CXR. Diarrhea and nausea are chronic in nature and thus low probability\n for intestinal source. Hypovolemic shock is another likely etiology.\n ACS is unlikely but will consider given his history.\n - Diagnostic w/u includes diagnostic ultrasound and if worsended\n ascities consider paracentesis, blood/urine/sputum/stool cx, CE, ECG.\n - Will continue vanc and pip/tazo as empiric rx.\n - Will continue IVF\n - Will monitor fever curve and WBCs\n - If ascites present then will consider thx para.\n # Lactic acidosis: likely related to hypovolemia. Septic shock is also\n in the differential.\n - Will monitor lactates and continue IVF.\n # Normocytic anemia with elevated RDW: chemotherapy related.\n - will check fe, b12, folate\n - transfuse for HCT>21 unless active ischemia or bleeding\n # Thrombocytopenia: Related to chemotherapy and perhaps intrahepatic\n obstruction of portal circulation leading to hypersplenism.\n - Monitor plt count and transfuse >10 unless active bleeding.\n # ARF (cre 1.5/1.0): hypovolemia vs sepsis\n - will check u lytes, although he has already been fluid recussitated\n # Hypertension: Normotensive. Holding BB.\n # Cholangiocarcinoma, dx'ed , on gemcitabine and oxaliplatin\n #C2D15 on .\n - continue nausea management\n # h/o CAD with MI s/p BMS c/b in stent thrombosis and DES without\n flow improvement. Anginal equivalent is chest pain. LVEF of 50-55%.\n - ROMI as above\n - cont asa, statin, off plavix since .\n # h/o bilateral renal resection s/p remote renal transplant\n - on azathioprine and prednisone; will hold azathioprine until cx\n negative.\n - stress dose steroids\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: PNB, PPI\n # Access: peripherals\n # Code: DNR/DNI\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\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: 62M CAD (MI, DES), CVA, HTN, renal\n transplant, cholangiocarcinoma, ongoing chemorx via port, chills,\n rigors, progressive abdominal girth and DOE. SBP 80-100 in ED c HR\n 120s, HCT 21, lactate 4.5. Started on vanco / zosyn, 3L NS, admitted to\n MICU.\n Exam notable for Tm 99.4 BP 88/50 HR 105 RR 18 with sat 97 on RA. Frail\n man, NAD. JVD flat. CTA B. RRR s1s2. Dist +BS / ascites. Tr edema. Labs\n notable for WBC K, HCT 21, K+ 3.5, Cr 1.5. CXR with clear lungs.\n Agree with plan to manage hypotension and possible septic physiology\n with vanco / zosyn, pancx, IVF and vasopressor support via port if\n necessary. Exam is most c/w hypovolemia rather than severe sepsis, but\n he remains at significant risk for both. Will pancx and tap effusion\n for dx/rx, esp if increasingly symptomatic w/r/t DOE. Given hx chronic\n steroid use, will give HC 25 q8h for now and hope to transition back to\n prednisone PO in AM. Will transfuse for acute anemia in the setting of\n recent chemo, goal >25. For ARF s/p transplant, will hydrate and check\n urine lytes, RD meds, continue azathioprine and consult renal\n transplant team. For CAD - no acute evidence of ACS, will cycle given\n hx and ongoing medical stress. 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: 07:33 PM ------\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573996, "text": "DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. No c/o abd pain\n Action:\n Pain assessed freq\n Response:\n Pt comfortable all night, slept well\n Plan:\n Medicate for pain, ? diagnostic ultrasound and paracentesis for\n worsened ascites. Monitor temps/WBCs, PLTs\n Anemia, other\n Assessment:\n HCT 21 on admission, tachycardic w/ HR 100s.\n Action:\n 1 unit PRBC given\n Response:\n HD stable, HR down to 70-80 SR. AM HCT pnd\n Plan:\n Continue to follow VS, serial HCTs, transfuse for HCT >21\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Rec\nd IVF 100cc/hr x1 lytes to be sent\n Response:\n AM Cr pnd\n Plan:\n Continue to monitor, f/u w/ urine lytes. Continue stress dose steroids\n (s/p renal transplant), ? transition to PO\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 573998, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. No c/o abd pain. Nauseous after dinner\n Action:\n Compazine given, Pain assessed freq\n Response:\n Gd effect w/ compazine, Pt comfortable all night, slept well\n Plan:\n Medicate for pain, ? diagnostic ultrasound and paracentesis for\n worsened ascites. Monitor temps/WBCs, PLTs. ABX as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, tachycardic w/ HR 100s.\n Action:\n 1 unit PRBC given\n Response:\n HD stable, HR down to 70-80 SR. AM HCT pnd\n Plan:\n Continue to follow VS, serial HCTs, transfuse for HCT >21\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Rec\nd IVF 100cc/hr x1 lytes to be sent\n Response:\n AM Cr pnd\n Plan:\n Continue to monitor, f/u w/ urine lytes. Continue stress dose steroids\n (s/p renal transplant), ? transition to PO\n" }, { "category": "Physician ", "chartdate": "2142-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 574088, "text": "Chief Complaint: weakness, rigors\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n URINE CULTURE - At 03:54 AM\n UA/ UCx\n transfused 1 unit \n stress dose steroids\n History obtained from Patient\n Allergies:\n History obtained from PatientHorse Blood Extract\n Unknown;\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37\nC (98.6\n HR: 89 (80 - 104) bpm\n BP: 107/67(76) {88/50(60) - 117/76(85)} mmHg\n RR: 12 (10 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,612 mL\n 476 mL\n PO:\n 180 mL\n 120 mL\n TF:\n IVF:\n 1,150 mL\n 356 mL\n Blood products:\n 282 mL\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,612 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 102 K/uL\n 6.7 g/dL\n 112 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 105 mEq/L\n 137 mEq/L\n 20.1 %\n 4.0 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 4.0\n Hct\n 20.1\n Plt\n 102\n Cr\n 1.3\n TropT\n 0.01\n Glucose\n 112\n Other labs: CK / CKMB / Troponin-T:48//0.01, Ca++:7.5 mg/dL, Mg++:1.9\n mg/dL, PO4:4.0 mg/dL\n Imaging: cxr yesterday clear\n Microbiology: ngtd\n Assessment and Plan\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n CANCER (MALIGNANT NEOPLASM), OTHER\n CANCER (MALIGNANT NEOPLASM), HEPATIC (LIVER)\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n .\n # Hypotension: Septic etiology is high on the differential given his\n chemotherapy. He is not neutropenic at this time. Abdominal distention\n is concening for SBP. The dyspnea suggest PNA as source of infection\n but no other symptoms Also negative CXR. Diarrhea and nausea are\n chronic in nature and thus low probability for intestinal source.\n Hypovolemic shock is another likely etiology. ACS is unlikely but will\n consider given his history.\n - continue Vanco/Zosyn another 24 hours and d/c if\n blood/urine/sputum/stool cx remain negative\n - Will continue vanc and pip/tazo as empiric rx.\n - Will continue IVF and transfuse today\n - Will monitor fever curve and WBCs\n - If ascites present then will consider thx para.\n .\n # Lactic acidosis: likely related to hypovolemia. Septic shock is also\n in the differential.\n - Will monitor lactates and continue IVF.\n .\n # Normocytic anemia with elevated RDW: chemotherapy related.\n - will check fe, b12, folate\n - transfuse another 2 units today given recent chemo and hypovolemia\n .\n # Thrombocytopenia: Related to chemotherapy and perhaps intrahepatic\n obstruction of portal circulation leading to hypersplenism.\n - Monitor plt count and transfuse >10 unless active bleeding.\n .\n # ARF (cre 1.5/1.0): hypovolemia vs sepsis\n - urine Na<10 this am even after IVF and blood products\n - Cr improved today\n # Hypertension: Normotensive. Holding BB.\n # Cholangiocarcinoma, dx'ed , on gemcitabine and oxaliplatin\n #C2D15 on .\n - continue nausea management\n # h/o CAD with MI s/p BMS c/b in stent thrombosis and DES without\n flow improvement. Anginal equivalent is chest pain. LVEF of 50-55%.\n - ruled out for ACS\n - cont asa, statin, off plavix since .\n # h/o bilateral renal resection s/p remote renal transplant\n - on azathioprine and prednisone; will hold azathioprine until cx\n negative.\n - stress dose steroids, switch back to prednisone today\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: PNB, PPI\n # Access: peripherals\n # Code: DNR/DNI\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2142-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 574089, "text": "Chief Complaint: weakness, rigors\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n URINE CULTURE - At 03:54 AM\n UA/ UCx\n transfused 1 unit \n stress dose steroids\n History obtained from Patient\n Allergies:\n History obtained from PatientHorse Blood Extract\n Unknown;\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37\nC (98.6\n HR: 89 (80 - 104) bpm\n BP: 107/67(76) {88/50(60) - 117/76(85)} mmHg\n RR: 12 (10 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,612 mL\n 476 mL\n PO:\n 180 mL\n 120 mL\n TF:\n IVF:\n 1,150 mL\n 356 mL\n Blood products:\n 282 mL\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,612 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 102 K/uL\n 6.7 g/dL\n 112 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 105 mEq/L\n 137 mEq/L\n 20.1 %\n 4.0 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 4.0\n Hct\n 20.1\n Plt\n 102\n Cr\n 1.3\n TropT\n 0.01\n Glucose\n 112\n Other labs: CK / CKMB / Troponin-T:48//0.01, Ca++:7.5 mg/dL, Mg++:1.9\n mg/dL, PO4:4.0 mg/dL\n Imaging: cxr yesterday clear\n Microbiology: ngtd\n Assessment and Plan\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n CANCER (MALIGNANT NEOPLASM), OTHER\n CANCER (MALIGNANT NEOPLASM), HEPATIC (LIVER)\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n .\n # Hypotension: Septic etiology is high on the differential given his\n chemotherapy. He is not neutropenic at this time. Abdominal distention\n is concening for SBP. The dyspnea suggest PNA as source of infection\n but no other symptoms Also negative CXR. Diarrhea and nausea are\n chronic in nature and thus low probability for intestinal source.\n Hypovolemia is another likely etiology. ACS was ruled out overnight.\n - continue Vanco/Zosyn another 24 hours and d/c if blood/urine cx\n remain negative\n - Will continue vanc and pip/tazo as empiric rx.\n - Will continue IVF and transfuse today\n - Will monitor fever curve and WBCs\n - If develops abdominal pain or fever then will pursue paracentesis\n .\n # Lactic acidosis: likely related to hypovolemia. Septic shock is also\n in the differential.\n - recheck lactate this AM\n .\n # Normocytic anemia with elevated RDW: chemotherapy related.\n - will check fe, b12, folate\n - transfuse another 2 units today given recent chemo and hypovolemia\n .\n # Thrombocytopenia: Related to chemotherapy and perhaps intrahepatic\n obstruction of portal circulation leading to hypersplenism.\n - Monitor plt count and transfuse >10 unless active bleeding.\n .\n # ARF (cre 1.5/1.0): hypovolemia vs sepsis\n - urine Na<10 this am even after IVF and blood products\n - Cr improved today\n .\n # Hypertension: Normotensive. Holding BB.\n # Cholangiocarcinoma, dx'ed , on gemcitabine and oxaliplatin\n #C2D15 on .\n - continue nausea management\n # h/o CAD with MI s/p BMS c/b in stent thrombosis and DES without\n flow improvement. Anginal equivalent is chest pain. LVEF of 50-55%.\n - ruled out for ACS\n - cont asa, statin, off plavix since .\n # h/o bilateral renal resection s/p remote renal transplant\n - on azathioprine and prednisone; will hold azathioprine until cx\n negative.\n - stress dose steroids, switch back to prednisone today\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: PNB, PPI\n # Access: peripherals\n # Code: DNR/DNI\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2142-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 574094, "text": "Chief Complaint: weakness, rigors\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n URINE CULTURE - At 03:54 AM\n UA/ UCx\n transfused 1 unit \n stress dose steroids\n History obtained from Patient\n Allergies:\n History obtained from PatientHorse Blood Extract\n Unknown;\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Lipitor (Oral) (Atorvastatin Calcium)\n Drowsiness/Fati\n Last dose of Antibiotics:\n Vancomycin - 11:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:55 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37\nC (98.6\n HR: 89 (80 - 104) bpm\n BP: 107/67(76) {88/50(60) - 117/76(85)} mmHg\n RR: 12 (10 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,612 mL\n 476 mL\n PO:\n 180 mL\n 120 mL\n TF:\n IVF:\n 1,150 mL\n 356 mL\n Blood products:\n 282 mL\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,612 mL\n 126 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///20/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 102 K/uL\n 6.7 g/dL\n 112 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 105 mEq/L\n 137 mEq/L\n 20.1 %\n 4.0 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 4.0\n Hct\n 20.1\n Plt\n 102\n Cr\n 1.3\n TropT\n 0.01\n Glucose\n 112\n Other labs: CK / CKMB / Troponin-T:48//0.01, Ca++:7.5 mg/dL, Mg++:1.9\n mg/dL, PO4:4.0 mg/dL\n Imaging: cxr yesterday clear\n Microbiology: ngtd\n Assessment and Plan\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n CANCER (MALIGNANT NEOPLASM), OTHER\n CANCER (MALIGNANT NEOPLASM), HEPATIC (LIVER)\n 62-year-old M with history of cholangiocarcinoma (C2D15 gemcitabine and\n oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention.\n .\n # Hypotension: Most likely secondary to hypovolemia from vomiting and\n diarrhea. Was concerning for sepsis, but no evidence of ongoing\n infection. BP improved appropriately with IVF.\n - continue Vanco/Zosyn another 24 hours and d/c if blood/urine cx\n remain negative\n - If develops abdominal pain or fever then will pursue paracentesis\n - 2 units RBCs for volume repletion today\n ..\n # Anemia: likely from chemo and hemodilution\n - transfuse 2 units today\n - guiaic stools\n - iron studies consistent with chronic disease\n - d/c aspirin, has been off of this\n .\n # Lactic acidosis: likely related to hypovolemia. Septic shock is also\n in the differential.\n - recheck lactate this AM\n .\n # Thrombocytopenia: Related to chemotherapy and perhaps intrahepatic\n obstruction of portal circulation leading to hypersplenism.\n - Monitor plt count and transfuse >10 unless active bleeding.\n - d/c aspirin\n .\n # ARF (cre 1.5/1.0): hypovolemia vs sepsis\n - urine Na<10 this am even after IVF and blood products, transfuse 2\n units today for further volume repletion\n - Cr improved today\n .\n # Hypertension: Normotensive. Holding BB.\n .\n # Cholangiocarcinoma, dx'ed , on gemcitabine and oxaliplatin\n #C2D15 on .\n - continue nausea management\n .\n # h/o CAD with MI s/p BMS c/b in stent thrombosis and DES without\n flow improvement. Anginal equivalent is chest pain. LVEF of 50-55%.\n - ruled out for ACS\n - cont statin, off plavix since . , d/c asa\n # h/o bilateral renal resection s/p remote renal transplant\n - on azathioprine and prednisone; will hold azathioprine until cx\n negative.\n - stress dose steroids, switch back to prednisone today\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: PNB, PPI\n # Access: peripherals\n # Code: DNR/DNI\n # Communication: Patient\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 04:00 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP: n/a\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 574143, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. Blood and urine cultures pending. Started on zosyn and\n Vancomycin. Received IV fluids DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. Occ c/o abdominal pain. Occ c/o nausea responding to\n compazine (last dose 5/18 evening). T max 99.4 po.\n Action:\n Given 2 mg IV morphine for abdominal pain at rest. Also receiving\n standing dose of MS contin.\n Response:\n Plan:\n Pain decreased to with management as above. Compazine for\n nausea,. Monitor temp, antibiotics as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, given 1 unit PRBC overnight with repeat Hct 20 , ?\n d/t ^^^IV fluids\n Action:\n 2 Units PRBC given today, Hct 24 in between units. 2^nd unit finished\n at 1730.\n Response:\n Hct stable. No signs of transfusion reaction. HR80\ns-90\ns NSR, SBP\n 100-114\n Plan:\n Continue to follow VS, Monitor Hct\nHct due @ .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Received 1 L IVF overnight. Received 2 units PRBC today. Pt with fair\n po intake, has not voided since 0300. Pt refusing to attempt to void\n with urinal, or with sitting on commode chair. Expressed concern re:\n lack of voiding since night shift with his hx of renal transplant.\n Have suggested to pt that we attempt to scan his bladder\nhe adamantly\n refuses this. He states that he will void when he wants to. Pt\ns wife\n feels this is his attempt to maintain control over some aspect of his\n care. Dr. notified.\n Response:\n AM Cr 1.3\n Plan:\n Continue to monitor I/O. Follow Cr. Spoke further with Dr re:\n U/o\nto receive 1L NS over one hour enroute to .\n Neuro: pt is oriented X3, although is slow in recalling month. Episode\n of hallucination @ 1200\nthought he could see a band with instruments in\n the unit\ninsistent about what he had seen. MICU resident notified.\n Wife states that he has not hallucinated in the past, but she describes\nalzheimer\ns like behavior, requiring brain scan in the past.\n No\n further episodes of hallucinations.\n Skin: intact , coccyx gets pink very easily, but blanches. Have\n instructed pt to lye on side as much as possible.\n Social: wife \n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 574144, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. Blood and urine cultures pending. Started on zosyn and\n Vancomycin. Received IV fluids DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. Occ c/o abdominal pain. Occ c/o nausea responding to\n compazine (last dose 5/18 evening). T max 99.4 po.\n Action:\n Given 2 mg IV morphine for abdominal pain at rest. Also receiving\n standing dose of MS contin.\n Response:\n Plan:\n Pain decreased to with management as above. Compazine for\n nausea,. Monitor temp, antibiotics as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, given 1 unit PRBC overnight with repeat Hct 20 , ?\n d/t ^^^IV fluids\n Action:\n 2 Units PRBC given today, Hct 24 in between units. 2^nd unit finished\n at 1730.\n Response:\n Hct stable. No signs of transfusion reaction. HR80\ns-90\ns NSR, SBP\n 100-114\n Plan:\n Continue to follow VS, Monitor Hct\nHct due @ .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Received 1 L IVF overnight. Received 2 units PRBC today. Pt with fair\n po intake, has not voided since 0300. Pt refusing to attempt to void\n with urinal, or with sitting on commode chair. Expressed concern re:\n lack of voiding since night shift with his hx of renal transplant.\n Have suggested to pt that we attempt to scan his bladder\nhe adamantly\n refuses this. He states that he will void when he wants to. Pt\ns wife\n feels this is his attempt to maintain control over some aspect of his\n care. Dr. notified.\n Response:\n AM Cr 1.3\n Plan:\n Continue to monitor I/O. Follow Cr. Spoke further with Dr re:\n U/o\nto receive 1L NS over one hour enroute to .\n Neuro: pt is oriented X3, although is slow in recalling month. Episode\n of hallucination @ 1200\nthought he could see a band with instruments in\n the unit\ninsistent about what he had seen. MICU resident notified.\n Wife states that he has not hallucinated in the past, but she describes\nalzheimer\ns like behavior, requiring brain scan in the past.\n No\n further episodes of hallucinations.\n Skin: intact , coccyx gets pink very easily, but blanches. Have\n instructed pt to lye on side as much as possible.\n Social: wife \n" }, { "category": "Nursing", "chartdate": "2142-04-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 574145, "text": "62-year-old M w/ h/o cholangiocarcinoma dx\nd (C2D15 gemcitabine\n and oxaliplatin on ), CAD, remote renal transplant, who presents\n with diffuse weakness, rigors, dyspnea, emesis and abdominal\n distention. Blood and urine cultures pending. Started on zosyn and\n Vancomycin. Received IV fluids DNR/DNI\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Abdominal ascites. Occ c/o abdominal pain. Occ c/o nausea responding to\n compazine (last dose 5/18 evening). T max 99.4 po.\n Action:\n Given 2 mg IV morphine for abdominal pain at rest. Also receiving\n standing dose of MS contin.\n Response:\n Plan:\n Pain decreased to with management as above. Compazine for\n nausea,. Monitor temp, antibiotics as ordered\n Anemia, other\n Assessment:\n HCT 21 on admission, given 1 unit PRBC overnight with repeat Hct 20 , ?\n d/t ^^^IV fluids\n Action:\n 2 Units PRBC given today, Hct 24 in between units. 2^nd unit finished\n at 1730.\n Response:\n Hct stable. No signs of transfusion reaction. HR80\ns-90\ns NSR, SBP\n 100-114\n Plan:\n Continue to follow VS, Monitor Hct\nHct due @ .\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr on admission 1.5\n Action:\n Received 1 L IVF overnight. Received 2 units PRBC today. Pt with fair\n po intake, has not voided since 0300. Pt refusing to attempt to void\n with urinal, or with sitting on commode chair. Expressed concern re:\n lack of voiding since night shift with his hx of renal transplant.\n Have suggested to pt that we attempt to scan his bladder\nhe adamantly\n refuses this. He states that he will void when he wants to. Pt\ns wife\n feels this is his attempt to maintain control over some aspect of his\n care. Dr. notified.\n Response:\n AM Cr 1.3\n Plan:\n Continue to monitor I/O. Follow Cr. Spoke further with Dr re:\n U/o\nto receive 1L NS over one hour enroute to .\n Neuro: pt is oriented X3, although is slow in recalling month. Episode\n of hallucination @ 1200\nthought he could see a band with instruments in\n the unit\ninsistent about what he had seen. MICU resident notified.\n Wife states that he has not hallucinated in the past, but she describes\nalzheimer\ns like behavior, requiring brain scan in the past.\n No\n further episodes of hallucinations.\n Skin: intact , coccyx gets pink very easily, but blanches. Have\n instructed pt to lye on side as much as possible.\n Social: wife \n Access: cath and L arm #18\n" } ]

[ { "category": "Radiology", "chartdate": "2173-05-22 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 867084, "text": " 12:52 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: r/o abcess/colitis\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with new DKA & abd pain/tenderness, guiac positive stool.\n REASON FOR THIS EXAMINATION:\n r/o abcess/colitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk SAT 1:53 AM\n no abscess or colitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New DKA, abdominal tenderness, guaiac positive stool.\n\n TECHNIQUE: Axial images through the abdomen and pelvis with oral contrast\n only. IV contrast was not administered at the request of the referring\n clinician due to increased creatinine.\n\n Reformatted images were obtained in multiple planes.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is minimal bibasilar dependent\n atelectasis with some linear atelectasis in the left lower lobe. A feeding\n tube terminates within the stomach. On this unenhanced scan, the liver,\n spleen, adrenal glands, pancreas, and gallbladder are normal. The right\n kidney is normal. There is a tiny 2-3 mm left renal stone. There is\n prominence of the left renal pelvis, which could represent an extrarenal\n pelvis or a peripelvic cyst. The ureters are normal. There is calcification\n of the descending aorta, which is normal in caliber. No identified\n pathologically enlarged lymph nodes. No free air or free fluid in the abdomen.\n The large and small bowel are unremarkable.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is within the bladder.\n The rectum and sigmoid colon appear normal. The uterus and ovaries are not\n clearly identified. The appendix is normal. There are no pathologically\n enlarged inguinal lymph nodes. No free fluid in the pelvis.\n\n BONE WINDOWS: No suspicious osteolytic or sclerotic lesions.\n\n IMPRESSION:\n 1) No evidence of abscess or colitis or other significant pathology on this\n unenhanced scan.\n 2) Small nonobstructing left renal stone.\n\n" }, { "category": "Radiology", "chartdate": "2173-05-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 867060, "text": " 6:37 PM\n CHEST (PA & LAT) Clip # \n Reason: acute?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with\n REASON FOR THIS EXAMINATION:\n acute?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female with fevers.\n\n PA AND LATERAL VIEWS OF THE CHEST: Cardiac silhouette, mediastinal, and hilar\n contours are normal. The pulmonary vasculature is normal. Both lungs are\n clear without infiltrates, effusions, or consolidations. The surrounding soft\n tissue and osseous structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "ECG", "chartdate": "2173-05-24 00:00:00.000", "description": "Report", "row_id": 116341, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , atrial flutter not present\n\n" }, { "category": "ECG", "chartdate": "2173-05-22 00:00:00.000", "description": "Report", "row_id": 116342, "text": "Atrial flutter with rapid ventricular response\n- 2:1 A-V block\nRepolarization changes may be partly due to rate/rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2173-05-21 00:00:00.000", "description": "Report", "row_id": 116343, "text": "Possible atrial flutter with rapid ventricular response\nExtensive ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rate/rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2173-05-21 00:00:00.000", "description": "Report", "row_id": 116344, "text": "Sinus tachycardia\nPossible left atrial abnormality\nST junctional depression is nonspecific\nNo previous tracing\n\n" }, { "category": "ECG", "chartdate": "2173-05-21 00:00:00.000", "description": "Report", "row_id": 116345, "text": "Atrial flutter with rapid ventricular response\n - 2:1 A-V block\nrSr'(V1) - probable normal variant\n Extensive T wave changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rate/rhythm\nSince previous tracing of , atrial flutter is new\n\n" }, { "category": "Nursing/other", "chartdate": "2173-05-22 00:00:00.000", "description": "Report", "row_id": 1459007, "text": "MICU NURSING ADMISSION NOTE\nms is a 67 yo admitted overnight from the er w/new onset dka. she reports several days of weakness, lethargy, +n/v pta. she is science and has not sought medical attention for many years. blood sugars in the 600's on presentation to the er.\n\nros-\n\nneuro- alert and oriented. lethargic mostly, but arouses to stimulation and will answer q's when asked. mae. no deficits noted\n\ncv/resp- hr 140 on admission. ?new onset afib ?r/t dka vs. longer standing issues as not been to see a physician for while. hr/bp responded to 2.5 iv lopressor down to 90-1teens, bp 104-1teens. cycling enzymes. heparin/asa deferred at this time. cont to attempt better rate control w/lopressor although bp borderline. l/s cl. pt on ra. no sob/cp.\n\ngi/gu- reportedly vomiting in the er, also w/several days hx of n/v at home. ct in er negative. received 3 bottles of contast dye.. +bs, guiac neg from below per er notes. bun/cr trending down 66/1.6 w/hydration. dilute/clear.\n\nid- afebrile w/admission to micu. leukocytosis w/no bands. given levo/flagyl in ew. will send bc this am w/lab draw.\n\ncont freq chem/q2hrs.. follow fingersticks, f/u blood cultures. will send spec to blood bank for possible need for transfuse. agressive fluids, trend wbc, temp curve, response to bb regimine.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-05-24 00:00:00.000", "description": "Report", "row_id": 1459012, "text": "FIANRD 4 ICU NPN 0700-1900\nThis AM pt dozing, easily arousable. Unable to state full name. This afternoon pt OX3, awake.\nInsulin gtt titrated to BS. On & off X2 throughout the day. Given eve glargine at 1600. Gtt d/c'd at 1730.\nStarted on diet. Appitite fair.\nHad mod, lt brown, loose stool with few streaks blood. OB negative. Hemmorhoidds noted. Crit atable.\nT max 99.7 PO\nUO adequate.\nCont on IV lopressor 2.5IV Q6 hrs. HR initially 70's-80's NSR without PAC's/VEA. This afternoon HR 80's & 90's NSR with frequent PAC's. BP stable\nBS clear. Sats high 90's on RA.\n\nA/P: Stable. Transitioning to SC insulin- glargine with humalog SS. Follow BS Q6 hr. Cover with SS PRN.\nFollow temp\n? switching lopressor to PO & increasing dose.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-05-25 00:00:00.000", "description": "Report", "row_id": 1459013, "text": "NPN 7P-7A\n\nNEURO:PT A/OX1 REORIENTED TO PLACE AND TIME OF DAY. ICU TEAM AWARE.DENIES PAIN.BED ALARM ON FOR SAFETY.SHE IS ABLE TO MAE.\n\nRESP: LS CLEAR BILAT BUT DIMINSHED. O2 SAT ON RA 98%.\n\nCV:NSR PVC AND PAC NOTED. HR 57-78. B/P 93/39 WHILE SLEEPING SBP 83. TIMES ONE.\n\nGI/GU: POOR PO FLUID INTAKE. +BS TWO MUSTARD COLORED LOOSE STOOL. HEMMORHOIDS NOTED ON DAY SHIFT. FOLEY CATH CLEAR UA OUT PUT 30-50CC/HR.\n\nENDO: INSULIN GTT OFF. FS QID 2400 FS 83.NO INSULIN GIVEN.\n\nSKIN: INTACT\n\nPOC: FS QID. HUMALOG SSI AND GLARGINE IN AFTERNOON(1600).? CALL OUT.\n" }, { "category": "Nursing/other", "chartdate": "2173-05-22 00:00:00.000", "description": "Report", "row_id": 1459008, "text": "Review of systems:\n\nNeuro: Pt alert and oriented x 3 but seems to have a large knowledge deficit and a poor historian, ? baseline MS. Pt able to follow simple commands, answer questions appropriatly, and make purposeful movements. Pt very lethargic, sleeping most of the afternnon. Pt MAE, .\n\nCV: pt remains in AFIB with HR > 90 and BP borderline low, pt only tolerates small doses of lopressor for rate control. will continue to hydrate pt to help with r/r and BP.\n\nResp: Pt sao2 > 95% on RA. Pt has + BBS, clear throughout.\n\nGI/GU: pt has + hyperactive BS x 4q, no stool but passing flatus. pt with good UO per foley cath. Pt tried to take small sips today, unable to keep water down.\n\nEndo: pt remains on insulin gtt for tight BS control, plan to switch to s/s when pt can tolerate po's, see careview for current gtt rate.\n" }, { "category": "Nursing/other", "chartdate": "2173-05-23 00:00:00.000", "description": "Report", "row_id": 1459009, "text": "MICU NPN 1900-0700\nMS. TO IMPROVE SLOWLY. MUCH BETTER HYDRATED TONIGHT. SL MORE AWAKE BUT STILL LETHARGIC. ODD IN SOME RESPONSES, BUT ORIENTED X3. INSULIN GTT REMAINS ON .5U/HR. BLOOD SUGARS 130-150'S MOST OF NIGHT. NA REMAINS ELEVATED TO 156 AT MIDNIGHT. K 4.6. IVF INCREASED BACK TO 200CC/HR CHANGED TO D51/2NS. WILL ATTEMPT PO'S AGAIN THIS AM. LOPRESSOR HELD X2 OVERNIGHT AS MAPS BETWEEN 50-60 OVERNIGHT. HR 80-120'S AFIB/FLUTTER, RARE PVC NOTED. REMAINS GOOD. CR DOWN TO 1.1. AM LABS TO BE DRAWN SHORTLY. CONT TO SUPPORT, ATTEMPT PO'S THIS AM, SS INSULIN.\n" }, { "category": "Nursing/other", "chartdate": "2173-05-23 00:00:00.000", "description": "Report", "row_id": 1459010, "text": "Review of systems:\n\nNeuro: Pt remains alert and oriented x 3 but still lethargic but MS improving, Pt MAE,.\n\nResp: Pt sao2 > 95% on RA, +BS CTA\n\nCV: Pt BP stable WNL, pt remains in AFIB/AFLUTTER but rate in better control today with hydration and metropolol. Pt still reciving 200cc/hr D5 1/2NS.\n\nGI/GU: pt with good uo per foley cath, no BM today. pt still with no appetite and unable to keep down water.\n\nEndo: pt remains in insulin gtt for sugar control, plan to switch to s/s once tolerating PO's\n" }, { "category": "Nursing/other", "chartdate": "2173-05-24 00:00:00.000", "description": "Report", "row_id": 1459011, "text": "micu npn 1900-0700\nplease see carevue flowsheet for all objective data\n\nneuro- remains oriented, more alert and interactive overnight.\ncv- received pt remained in afib/flutter. tolerated dose of lopressor at 2300. ~0300 pt converted to sinus rate of 70's, occ to freq pac's. bp's 90's sys, maps 50-60 since conversion.. k/phos repleted overnight. na improving to norm.\nresp- remains on ra. sats >96%. ls clear.\ngi/gu- remains npo. pt w/no appetite. remains on insulin gtt. ivf changed over to 0.45 ns w/o dextrose, gtt has been off sev times o/n. has been out of dka since yesterday. ?attempt po's again today w/ss reg insulin if able to tolerate. good via foley catheter. no bm overnight(had mod ob neg sat night).\nid- t max to 99.6. no abx. wbc normal\ncont freq chem checks, follow na, k, bs. switch to ss insulin when able to tolerate po's.\n" } ]

[ { "category": "ECG", "chartdate": "2173-11-25 00:00:00.000", "description": "Report", "row_id": 206803, "text": "Sinus rhythm. Compared to the previous tracing of no significant\ndiagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2173-11-25 00:00:00.000", "description": "Report", "row_id": 206804, "text": "Sinus rhythm. Probable left atrial abnormality. Left bundle-branch block. No\nprevious tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2173-11-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 939486, "text": " 9:54 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess for cardiopulm process\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with MDS with c/o productive cough, fever, and sob with\n exertion\n REASON FOR THIS EXAMINATION:\n please assess for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Productive cough, fever, and shortness of breath.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: Patient is status post median sternotomy and CABG:\n Cardiac silhouette is mildly enlarged but stable in size. Bilateral perihilar\n opacities with sparing of the lung apices are slightly improved over the\n interval. Persistent bibasilar opacities, left greater than right. No\n sizable pleural effusions are identified. Mild degenerative changes noted in\n the mid thoracic spine.\n\n IMPRESSION: Interval improvement in bilateral patchy consolidations likely\n representing interstitial edema given the waxing/ appearance.\n Persistent bibasilar atelectasis/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 939156, "text": " 5:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for disease progression\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with leukemia, sob, hypoxia, pneumonia\n\n REASON FOR THIS EXAMINATION:\n eval for disease progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Known shortness of breath and pneumonia.\n\n Portable AP chest radiograph compared to .\n\n The heart size remains enlarged, unchanged. The bilateral perihilar opacities\n with some sparing of lung apices are grossly the same. No sizeable pleural\n effusion is present. The previously demonstrated rounded area of lucency in\n the right middle lobe does not exist on the current radiograph.\n\n IMPRESSION: No change in the appearance of bilateral patchy consolidations.\n The patient is demonstrating either congestive heart failure or severe\n pneumonia. Please correlate clinically.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 939048, "text": " 10:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess chest for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with leukemia, sob, hypoxia\n REASON FOR THIS EXAMINATION:\n assess chest for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Upright portable chest x-ray.\n\n INDICATION: Hypoxia. Shortness of breath.\n\n COMPARISONS: There are no prior studies available for comparison.\n\n The heart is enlarged. The aorta appears tortuous. There are multiple median\n sternotomy wires at the midline and multiple small clips overlying the left\n heart border and midline. Bilateral patchy opacities with sparing of the\n apices and prominent pulmonary vessels favor pulmonary edema. However, there\n is a rounded area of lucency seen in the right middle lobe area that could\n represent underlying cavitary pneumonia. There is a small right-sided pleural\n effusion. The patchy opacities obscure the left costophrenic angle and a left\n pleural effusion cannot be completely excluded.\n\n IMPRESSION: Given underlying cardiac history, CHF is favored. Underlying\n pneumonia cannot be excluded on this examination. Recommend serial follow-up\n examinations.\n\n Findings were discussed with Dr. at approximately 11 a.m. on by\n Dr. on the telephone.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-25 00:00:00.000", "description": "Report", "row_id": 1496099, "text": " 4 ICU nursing progress note:\n Pleasant 71 y/o gentleman admitted from ew with ??CHF/pneumonia.\nPt has had 3-4d hx of cough and sob..(is followed in clinic)..called yesterday and started on azithromycin. To clinic today..acutely sob going up stairs and developed chest tightness.\nStarted on IV NTG and antibiotics in ew. Sent to ICU for further monitoring.\n Respiratory: Hypoxic in ew. Arrived in ICU on 100% NRB..rr 18-22..mild cough..states he has coughed up blood. (none here).\nBS decreased at bases. Changed to 4l nc with sats 92-94%.\n Cardiac: NTG at 20mic/hr=3gtts. BP 140's. HR 70 nsr. No further chest discomfort. Pt also given lasix in ew..\n Neruo: Alert/orientated..\n Heme: WBC 50's..being treated for CML..diagnosed in . Has constant back pain.\n GI: Currently npo..+bs no stool\n GU: Foley cath in place..clear urine.\n ID: Afebrile..??new antibiotics..awaiting orders.\n Social: Son and friend in to visit. phone# in chart.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-26 00:00:00.000", "description": "Report", "row_id": 1496100, "text": "micu nsg progress note.\no:pulm=while sleeping flat in bed sats to mid 80's. wo co sob/dyspnea. breath sounds=clear. shovel mask 100% added w sats improving to mid 90's. ho aware.\n cv=pf. hemody stable. ntg remains @ 20mcg.\n gu=foley. adeq uo.\n id=afebrile. abx as ordered.\n labs=am sent.\n\na:desat when sleeping/lying flat-?cause.\n\np:contin present management. support as indicated.\n" } ]

[ { "category": "Radiology", "chartdate": "2151-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207875, "text": " 1:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with bilateral PE, recent cardiomyopathy, tachypnea and\n decreased BS\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with bilateral PEs and recent cardiomyopathy\n with tachypnea and decreased breath sounds. Evaluate for interval change.\n\n COMPARISON: Multiple prior studies including most recent of .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Compared to the most recent exam, there is\n improved aeration of the right base. Small left effusion has improved. There\n is slight decrease in interstitial opacity compatible with decreasing edema.\n Cardiomediastinal silhouette is stable within limits of positioning. There is\n no new consolidation or pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2151-08-14 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1207722, "text": " 7:10 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: evidence of pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n evidence of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: .\n\n CLINICAL HISTORY: Altered mental status, assess pneumonia.\n\n FINDINGS: AP semi-upright portable chest radiograph is obtained. There is\n increased consolidation at the right lung base concerning for pneumonia. In\n addition, there is retrocardiac opacity which is not significantly changed\n which could represent pneumonia or atelectasis. There may be bilateral small\n pleural effusions. There is pulmonary vascular engorgement compatible with\n pulmonary interstitial edema. Heart size appears grossly stable. Bony\n structures appear intact.\n\n IMPRESSION: Consolidations at both lung bases, new on the right concerning\n for pneumonia. Left lower lobe consolidation could represent atelectasis or\n pneumonia. Interstitial edema also noted.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2151-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208845, "text": " 12:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for consolidation or effusion\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 yo F, w/ h/o TBI, admitted with AMS/fevers, found to have PEs, now with\n worsening leukocytosis\n REASON FOR THIS EXAMINATION:\n evaluate for consolidation or effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Pulmonary embolus, now with worsening leukocytosis,\n evaluate for consolidation.\n\n CHEST:\n\n Comparison film . Hiatal hernia is again noted. The position of\n the PICC line is also unchanged.\n\n The left costophrenic angle is sharp. The right costophrenic angle is\n present. Some effusion essentially unchanged since the prior chest x-ray. No\n new infiltrates are present.\n\n\n" }, { "category": "Echo", "chartdate": "2151-08-16 00:00:00.000", "description": "Report", "row_id": 91554, "text": "PATIENT/TEST INFORMATION:\nIndication: H/O Takasubo (recent) cardiomyopathy. New Pulmonary Embolism. Left ventricular function. Right ventricular function.\nHeight: (in) 64\nWeight (lb): 220\nBSA (m2): 2.04 m2\nBP (mm Hg): 105/54\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 10:42\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Large LV thrombus. TDI E/e' >15, suggesting PCWP>18mmHg.\nNo resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Normal descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor suprasternal views. Suboptimal image quality as the\npatient was difficult to position. Suboptimal image quality - body habitus.\nSuboptimal image quality - patient unable to cooperate. Echocardiographic\nresults were reviewed by telephone with the houseofficer caring for the\npatient. Left pleural effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. A 3x2cm mobile mass is seen along\nthe distal anteroseptal wall c/w thrombus. There is mild regional left\nventricular systolic dysfunction with focal hypokinesis of the distal half of\nthe anterior septum. The remaining segments contract normally (LVEF = >55 %).\nTissue Doppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe ascending aorta is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis. Trace\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. There is\nmild pulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size with mild regional systolic\ndysfunction. Large mobile intraventricular echodensity most c/w thrombus.\nPulmonary artery systolic hypertension.\nCompared with the prior study (images reviewed) of , regional and\nglobal left ventricular systolic function is markedly improved and an apical\nmass/likely thrombus is now seen. The estimated PA systolic pressure is now\nlower.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1208187, "text": " 2:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 48cm right picc. tip?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 48cm right picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: 48-year-old woman with new PICC line placement on the right side.\n\n TECHNIQUE: AP upright radiograph of the chest.\n\n Comparison was made with prior chest radiographs through \n with the most recent from .\n\n FINDINGS: Both lung volumes are low. Moderate right and minimal left pleural\n effusion, bibasilar atelectasis, left more than right, are all unchanged since\n . There is no discrete lung opacity in the right upper\n zone, corresponding to the suspicious area for pneumonic consolidation on the\n prior radiograph dated . Differences in the haziness of\n bilateral lungs is attributed to the radiation and technique and patient\n positioning. A PICC line terminates in the right atrium. Consider retracting\n the catheter by approximately 4 cm.\n\n IMPRESSION: The tip of the right PICC line terminates in the right atrium.\n Consider retracting by 4 cm. Since , moderate right, mild\n left and bilateral lower lung atelectasis, left more than right are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-14 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1207728, "text": " 8:53 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with unilateral left lower extremity edema, bed bound\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n WET READ: IPf SAT 9:42 PM\n Complete occlusion of left CFV, SFV, and veins of the left calf.\n Right lower extremity veins are patent.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left lower extremity swelling.\n\n COMPARISON: No images for comparison at the time of dictation.\n\n FINDINGS: Grayscale and Doppler evaluation of the bilateral CFV, SFV, and\n popliteal veins.\n\n Left: There is complete occlusion of the left common femoral, superficial and\n deep femoral, popliteal vein and veins of the left calf.\n\n Right: There is normal compressibility, flow and augmentation in the right\n common femoral, superficial femoral, and popliteal veins.\n Flow is seen on color images in the veins of the right calf; somewhat\n suboptimal evaluation.\n\n IMPRESSION:\n 1. Occlusive thrombus throughout the interrogated veins of the left leg.\n 2. No right leg DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-15 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1207785, "text": " 10:12 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with concern for PE, found to have DVT\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc SUN 4:17 PM\n 1. Extensive pulmonary embolism involving the right main pulmonary artery,\n extending into the lobar and segmental branches of the right lower lobe, with\n likely a developing infarction of the right lower lobe. Pulmonary embolism\n involving the anterior segmental artery of the left upper lobe.\n 2. No evidence of right heart strain.\n 3. New thrombus within the left ventricle.\n 4. A small to moderate right pleural effusion, trace left pleural effusion.\n 5. Large hiatal hernia containing a major portion of the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with concern for pulmonary embolism, found to\n have DVT.\n\n COMPARISON: CT chest, abdomen and pelvis .\n\n TECHNIQUE: MDCT helical images were acquired through the chest before and\n after administration of 100 cc Optiray intravenous contrast. Sagittal and\n coronal reformats and oblique reformats were generated and reviewed.\n\n FINDINGS: There is extensive pulmonary embolism involving the distal right\n main pulmonary artery, extending into the interlobar pulmonary artery. Also\n seen is emboli extending into the segmental branches of the right lower lobe.\n In the left lung, emboli are seen in the anterior segmental artery of the left\n upper lobe (4:20). There is volume loss and heterogeneous consolidation\n involving the right lower lobe, consistent with a developing pulmonary\n infarction. Patchy ground-glass opacities seen in both lungs, likely relate\n to poor inspiratory effort. No concerning lung lesions or masses are\n identified. Moderate sized right pleural effusion and a trace simple left\n pleural effusion are seen. No significant mediastinal, hilar or axillary\n adenopathy is seen. There is a 2.9 x 1.8 cm measuring thrombus within the left\n ventricle aneurysm (4:55). There is no pericardial effusion.\n\n An uncomplicated large hiatal hernia containing nearly the entire stomach in\n an organoaxial position, is unchanged. Hypodense lesion in the left hepatic\n lobe (4:72) is unchanged since the prior study.\n\n BONES AND SOFT TISSUES: No bone lesions suspicious for infection or\n malignancy are detected. No acute fractures are identified.\n\n IMPRESSION:\n (Over)\n\n 10:12 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Extensive pulmonary embolism involving the right main pulmonary artery,\n extending into the lobar and segmental branches of the right lower lobe, with\n likely a developing infarction of the right lower lobe. Pulmonary embolism\n involving the anterior segmental artery of the left upper lobe.\n 2. No evidence of right heart strain.\n 3. New thrombus within the left ventricle.\n 4. A small to moderate right pleural effusion, trace left pleural effusion.\n 5. Large hiatal hernia containing a major portion of the stomach.\n\n The findings were discussed with Ms. (N.P) immediately after the\n study by Dr , via telephone.\n\n" }, { "category": "Radiology", "chartdate": "2151-08-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207723, "text": " 7:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute intracranial process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent intraparenchymal hemorrhage presenting with acute\n altered mental status\n REASON FOR THIS EXAMINATION:\n acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 9:36 PM\n 1. Interval evolution and decrease of size of intraparenchymal left temporal,\n intraventricular, and subarachnoid hemorrhage.\n 2. Left occipital mixed density subdural and small intraparenchymal hemorrhage\n still is relatively high in density and re-bleed cannot be excluded. Follow-up\n CT is recommended.\n 3. No obstructive hydrocephalus.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with recent intracranial parenchymal\n hemorrhage, now presenting with acute mental status change.\n\n TECHNIQUE: Axial noncontrast CT images of the head were obtained. Coronal\n and sagittal reformats were acquired.\n\n COMPARISON: CT of the head from .\n\n FINDINGS: The previously seen left temporal lobe parenchymal hemorrhage\n appears decreased in overall density and size, compatible with interval\n evolution. There is a small mixed density (iso and hyperdense) subdural\n hematoma along the left posterior cerebral convexity measuring up to 8-mm in\n thickness. Trace subarachnoid hemorrhage persists with small hematocrit levels\n noted in the lateral ventricles. There is no hydrocephalus. The CSF density\n collection abutting the right frontal lobe no longer contains blood.\n\n There is no herniation or significant mass effect. There is no evidence of\n acute major vascular territorial infarction. Stable nondepressed fracture of\n the occipital bone. The paranasal sinuses and mastoids are clear.\n\n IMPRESSION:\n 1. Interval evolution of left temporal lobe parenchymal hemorrhage.\n 2. Acute on subacute left posterior cerebral SDH (8-mm). Short-term followup\n CT is recommended.\n 3. Trace residual SAH with small intraventricular hemorrhage.\n\n\n (Over)\n\n 7:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2151-08-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1208096, "text": " 8:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change after 48hrs on anticoagulation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent history of intracranial hemorrhage. Now on\n argatroban for heparin induced thrombocytopenia\n REASON FOR THIS EXAMINATION:\n interval change after 48hrs on anticoagulation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRAf TUE 12:07 PM\n PFI: No change in left temporal parenchymal hemorrhage and left posterior\n subdural hematoma. No new areas of hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent intracranial hemorrhage, now on argatroban for HIT, evaluate\n change after 48 hours on anticoagulation.\n\n COMPARISONS: CT without contrast of the head from .\n\n TECHNIQUE: Axial non-contrast CT images of the head were obtained. Coronal\n and sagittal reformations were provided.\n\n FINDINGS: The previously seen left temporal lobe intraparenchymal hemorrhage\n appears unchanged in size and density. The small focus of subdural hematoma\n seen along the left posterior cerebral convexity is also unchanged (2:17). A\n small amount of blood persists in the occipital of the left lateral\n ventricle and is no longer seen in the right occipital . No new\n hemorrhage, edema, or shift of the midline structures. A stable non-displaced\n fracture of the occipital bone extending into the occipital condyle is\n unchanged. Again seen is a right frontal arachnoid cyst with no evidence of\n internal hemorrhage. The imaged paranasal sinuses and mastoid air cells are\n clear.\n\n IMPRESSION: No change in left temporal parenchymal hemorrhage and left\n posterior subdural hematoma. No new areas of hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2151-08-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1208097, "text": ", K. MED CC7A 8:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change after 48hrs on anticoagulation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent history of intracranial hemorrhage. Now on\n argatroban for heparin induced thrombocytopenia\n REASON FOR THIS EXAMINATION:\n interval change after 48hrs on anticoagulation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change in left temporal parenchymal hemorrhage and left posterior\n subdural hematoma. No new areas of hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2151-08-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1208451, "text": " 9:58 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: e/o worsening bleed, new CVA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent ICH unchanged on imaging 2 days ago. On\n anti-coagulation and now with acute MS changes.\n REASON FOR THIS EXAMINATION:\n e/o worsening bleed, new CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:58 PM\n PFI: No new areas of hemorrhage. Unchanged left temporal lobe\n intraparenchymal hematoma and resolving subdural and subarachnoid hemorrhages.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracerebellar hemorrhage, now on anticoagulation with acute mental\n status changes, evaluate for worsening bleed.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial sections through the brain without contrast.\n\n FINDINGS: The previously seen left temporal lobe intraparenchymal hemorrhage\n appears unchanged in size and density. The previously seen small foci of\n subdural and subarachnoid hemorrhages are less conspicuous on this exam.\n There has been resolution of the intraventricular hemorrhage. No new areas of\n hemorrhage, edema, or shift of normally midline structures is seen. Again\n noted is a stable nondisplaced fracture of the right occipital bone extending\n into the occipital condyle. The right frontal arachnoid cyst is unchanged\n with no internal hemorrhage. The imaged paranasal sinuses and mastoid air\n cells are well aerated.\n\n IMPRESSION: No new areas of hemorrhage. Unchanged left temporal lobe\n intraparenchymal hematoma and resolving subdural and subarachnoid hemorrhages.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1208452, "text": ", E. MED CC7A 9:58 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: e/o worsening bleed, new CVA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with recent ICH unchanged on imaging 2 days ago. On\n anti-coagulation and now with acute MS changes.\n REASON FOR THIS EXAMINATION:\n e/o worsening bleed, new CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No new areas of hemorrhage. Unchanged left temporal lobe\n intraparenchymal hematoma and resolving subdural and subarachnoid hemorrhages.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-08-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208450, "text": " 9:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate pulmonary edema and intrapulmonary process\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 y/o woman s/p unwitnessed fall down 6 stairs, +LOC, presents with L\n intraparenchymal hemorrhage and L subarachnoid hemorrhage\n REASON FOR THIS EXAMINATION:\n evaluate pulmonary edema and intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 84-year-old woman status post fall and now with left\n intraparenchymal hemorrhage. Please evaluate for pulmonary edema or other\n intrapulmonary process.\n\n COMPARISON: Multiple priors, most recently from .\n\n FINDINGS: In comparison to prior examination, the bibasilar opacities still\n exist, right greater than left. There are no new discrete focal\n consolidations or opacities. Moderate right and minimal left pleural effusion\n along with bibasilar atelectasis is once again seen and unchanged. Mild\n pulmonary edema is also unchanged from the prior study. A PICC line is seen\n terminating likely within the low SVC. There are no pneumothoraces. There is\n a hiatal hernia, unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2151-08-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207882, "text": " 4:02 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with bilateral PE, LV thrombus, increasing respiratory\n distress, new pneumothorax\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with bilateral PE, left ventricular thrombus\n and increasing respiratory distress. Evaluate for interval change.\n\n COMPARISON: at 1:28 a.m.\n\n UPRIGHT AP VIEW OF THE CHEST Compared to most recent study, there is no\n pneumothorax. Bibasilar opacities and effusions are unchanged. Increased\n conspicuity of a right upper lung opacity with air bronchograms is concerning\n for developing infection. Mild pulmonary edema is stable.\n\n" }, { "category": "ECG", "chartdate": "2151-08-16 00:00:00.000", "description": "Report", "row_id": 250960, "text": "Sinus tachycardia. Compared to the previous tracing of there has been\nsome resolution of the anterolateral T wave abnormalities. Otherwise, no\ndiagnostic interim change. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2151-08-14 00:00:00.000", "description": "Report", "row_id": 250961, "text": "Sinus tachycardia. Rightward axis. Extensive T wave ivnerfsions in\nleads I, II, aVL and V3-V6. Compared to the previous tracing of sinus\ntachycardia is new and the T wave inversions are more pronounced.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2195-05-31 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 830239, "text": " 1:57 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post trauma.\n\n AP CHEST: The hilar and mediastinal contours are within normal limits. No\n fractures are identified. No infiltrates, effusions or vascular congestion.\n No pneumothorax. Prominent cardiac contour, possible accentuated by\n technique.\n\n AP PELVIS: No fracture or dislocations are identified. No bone destruction.\n The hip and SI joints are normal.\n\n IMPRESSION: No evidence of trauma to the chest or pelvis.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-05-31 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 830243, "text": " 2:08 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: 26YO MALE S/P FALL, R/O INJURY\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n 26YO MALE S/P FALL\n R/O INJURY\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SUN 3:04 PM\n Hemoperitoneum with laceration of the right lobe of the liver and complex\n splenic laceration.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Status post fall, evaluate for injury.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous helically acquired axial images were obtained through\n the abdomen following the administration of 150 cc of intravenous Optiray in\n the arterial, portal venous, and delyed phases. The delayed images were\n extended to include the pelvis.\n\n CONTRAST: Intravenous nonionic contrast was administered due to the rapid rate\n of bolus injecion prior to this examination.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: No pleural effusions. There are\n dependent changes within the lower lobes bilaterally. The visualized portions\n of the heart and pericardium appear unremarkable. There is massive\n hemopheritoneum extending through the entire abdomen and layering within the\n pelvis. In the region of the right lobe of the liver inferiorly (series 2A,\n image 57), there is heterogeneity and density of the blood consistent with\n acute hemorrhage. No definite site of arterial extravasation of contrast is\n seen. A similar area of increased density within the hemoperitoneum is seen\n just adjacent to the splenic tip (series 2A, image 49). AT this location,\n there is a collection of contrast enhancement just adjacent to a parenchymal\n defect within the spleen, likely indicative of active extravasation. Lucent\n defects are identified within the right lobe of the liver (series 2B images\n 141 and 145), suggestive of laceration of the right lobe of the liver. Complex\n splenic laceration is seen at the tip of the spleen and extending along the\n lateral margin of the body of the spleen. Laceration does not appear to\n extend to the splenic hilum and there is opacification of the splenic artery\n and vein. The portal vein is patent. The pancreas, and right adrenal gland\n appear unremarkable. The left adrenal gland demonstrates fullness and\n heterogeneity and internal density, measuring up to 1.0 x 2.6 cm.\n There are symmetric nephrograms bilaterally without evidence of fluid\n collections directly opposed to the renal parenchyma and without evidence of\n laceration of the renal parenchyma. The ureters are not dilated, and there is\n no extravasation of contrast opacified urine on the delayed images. There is\n no free intraperitoneal air. Large and small bowel loops are normal in\n calbier, and no abdnormal bowel wall thickening is apparent. The aorta is\n (Over)\n\n 2:08 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: 26YO MALE S/P FALL, R/O INJURY\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n normal in caliber throughout. The inferior mesenteric artery, renal arteries,\n superior mesenteric artery, and celiac trunk appear patent.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: A Foley catheter is in place\n within the bladder, and there is contrast and a small amout of gas within the\n bladder. No extravasation of contrast opacified urine is identified on the\n delayed images. There is a large amount of blood layering in the pelvis,\n contiguous with the hemoperitoneum described within the abdomen. The prostate\n and seminal vessicles appear unremarkable. The rectum and sigmoid colon\n appear unremarkable. There is no pathologic appearing pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: Bone windows demonstrate no evdience of fracture.\n\n IMPRESSION:\n 1. Massive hemoperitoneum, with varying densities within the extravasated\n blood surrounding the liver and spleen, indicative of acute hemorrhage and\n probable active extravasation. Lacerations of the right lobe of the liver and\n of the spleen.\n 2. Enlargement and heterogenous density of the left adrenal gland consistent\n with adrenal adenolipoma.\n 3. No other solid organ injury identified. No free intraperitoneal air.\n 4. No fractures identified.\n\n These results were discussed immediately with the trauma team caring for the\n patient.\n\n ADDENDUM:\n\n MULTIPLANAR REFORMATTED IMAGES: Additional coronal and sagittal multiplanar\n reformatted images are provided. Coronal and sagittal reformatted images\n demonstrate a large amount of blood within the peritoneum. No fractures are\n identified on the reformatted images. The ureters and collecting systems\n appear unremarkable, and no extravasation of contrast opacified urine is\n identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-05-31 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 830244, "text": " 2:18 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: 26YO MALE S/P FALL, R/O INJURY\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SUN 3:27 PM\n No fracture identified. Marked reversal of the normal cervical lordosis\n centered at C5-6, a finding which could be consistent with ligamentous injury.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Status post fall, evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Helically acquired axial non-contrast CT scanning of the cervical\n spine was performed. Coronal and sagittal reformatted images are provided.\n\n CT OF THE CERVICAL SPINE WITHOUT IV CONTRAST: The cervical spine is imaged\n from C1-T1. No fracture or dislocation is identified within the component\n vertebrae. There is marked reversal of the normal cervical lordosis centered\n at C5-6. In addition, the C5-6 intervertebral facet joints appear possibly\n minimally widened on the sagittal reformatted images. There is right convex\n scoliosis of the cervical spine centered at this level. At the C5-6\n intervertebral disc space, there is slight narrowing of the disc space\n anteriorly with respect to the posterior dimension, while there is minimal\n narrowing of the C6-7 intervertebral disc space posteriorly relative to its\n anterior dimension. The visualized outlines of the thecal sac appear\n unremarkable. The prevertebral soft tissues appear unremarkable. A small\n amount of soft tissue density is seen within the trachea (series 2, image 87),\n possibly representing secretions within the trachea. The visualized portions\n of the mastoid air cells and paranasal sinuses are normally pneumatized.\n\n IMPRESSION:\n\n 1) No fracture or dislocation of the cervical spine.\n 2) Reversal of the normal cervical lordosis, slight asymmetry of the\n intervertebral facet joints, and minimal asymmetry of the intervertebral disc\n spaces centered at C5-6 and to a lesser extent C6-7, findings which could be\n consistent with ligamentous injury. Correlation with physical examination,\n and if clinically indicated, MRI of the cervical spine is recommended for\n further evaluation.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2195-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 830246, "text": " 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check for pneumothorax/line placement\n Admitting Diagnosis: LIVER LACERATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old man with s/p injury with splenic laceration. s/p trama line\n placement in left subclavian\n REASON FOR THIS EXAMINATION:\n check for pneumothorax/line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n PORTABLE SUPINE CHEST: There is a left subclavian introducer, with its tip in\n the left subclavian vein at the level of the left clavicular head. There is\n no evidence of pneumothorax. The cardiac and mediastinal contours are within\n normal limits, allowing for supine technique. The lungs are clear.\n\n IMPRESSION: Tip of left subclavian introducer in left subclavian vein; no\n pneumothorax.\n\n" }, { "category": "Nursing/other", "chartdate": "2195-05-31 00:00:00.000", "description": "Report", "row_id": 1451825, "text": "TSICU NSG ADMIT NOTE\nO: 24 Y/O MALE IN AREA FROM NY FOR ULTIMATE GAME AND HAD COLLISION TO L FLANK W/ CLEET. ADMITTED TO OSH W/ C/O L FLANK PAIN. EPISODE OF HYPOTENSION REQUIRING FLUID BOLUS AND TAKEN TO CT SCAN WHICH SHOWED ?LIVER LAC, SPLENIC LAC. PT MED TO . IN EW, HYPOTENSIVE, BRADYCARDIC, NAUSEA (?VAGAL) TXED W/ FLUID BOLUS AND ZOFRAN. REPEAT CT SCAN SHOWED GRADE 3 SPLENIC LAC. (NO LIVER LAC).\nTRANSFERRED TO TSICU FOR MONITORING AND SERIAL HCTS.\n\nPMH:\nWRIST SURGERY\nKNEE SURGERY\nADENOIDECTOMY\nHERNIA AS CHILD\n\nALLERGIES: PCN\n\nMEDS: NONE\n\nPT ADMITTED TO SICU W/ BASELINE HCT 37.9 AND IN STABLE CONDITION AT 4PM. A-LINE PLACED W/ BP 130/50, CVP 10. RECEIVED 2MG MS04 INITIALLY W/ GD EFFECT. 7PM PT DEVELOPED INCREASE IN PAIN AFTER RECEIVING 3MG MS04. DIFFICULTY W/ INSPIRATION AND SUDDEN DROP IN SBP TO 70'S. HR 101. REPEAT HCT 27. HO NOTIFIED AND PT TAKEN TO OR FOR SPLENECTOMY.\n" } ]

[ { "category": "Echo", "chartdate": "2163-05-13 00:00:00.000", "description": "Report", "row_id": 95259, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nWeight (lb): 233\nBP (mm Hg): 91/50\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 15:12\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Small LV cavity. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nHyperdynamic LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is moderately dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small. Due\nto suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Left ventricular systolic function is hyperdynamic (EF\n70-80%). Right ventricular chamber size and free wall motion are normal. The\nnumber of aortic valve leaflets cannot be determined. The aortic valve\nleaflets are mildly thickened. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2163-05-11 00:00:00.000", "description": "Report", "row_id": 251474, "text": "Sinus rhythm\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\ncannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2163-05-11 00:00:00.000", "description": "Report", "row_id": 251475, "text": "Sinus rhythm\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\ncannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , further ST-T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2163-05-10 00:00:00.000", "description": "Report", "row_id": 251476, "text": "Sinus rhythm\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\ncannot exclude in part ischemia - clinical correlation is suggested\nNo previous tracing available for comparison\n\n" }, { "category": "ECG", "chartdate": "2163-06-05 00:00:00.000", "description": "Report", "row_id": 254955, "text": "Sinus rhythm with first degree atrio-ventricular conduction delay.\nP-R interval 220 milliseconds. Inferior myocardial infarction. Right\nbundle-branch block. Compared to the previous tracing the cardiac rhythm is now\na sinus mechanism.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2163-06-04 00:00:00.000", "description": "Report", "row_id": 254956, "text": "Atrial fibrillation, average ventricular rate 63. Compared to the previous\ntracing the ventricular rate is now slower.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-06-03 00:00:00.000", "description": "Report", "row_id": 254957, "text": "Atrial fibrillation, average ventricular rate 105. Right bundle-branch block.\nDiffuse non-diagnostic repolarization abnormalities. Compared to the previous\ntracing of cardiac rhythm is now atrial fibrillation.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2163-06-02 00:00:00.000", "description": "Report", "row_id": 254958, "text": "Sinus tachycardia. Prior inferior myocardial infarction. Non-specific\ninferolateral ST-T wave flattening. Right bundle-branch block. Compared to the\nprevious tracing of the ECG is of poor technical quality. There is no\napparent diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2163-05-24 00:00:00.000", "description": "Report", "row_id": 254959, "text": "The rhythm is likely sinus with A-V conduction delay. P-R interval 0.22. There\nis much baseline artifact. Right bundle-branch block. Low precordial lead\nvoltage. Compared to the previous tracing of no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2163-05-17 00:00:00.000", "description": "Report", "row_id": 254960, "text": "Sinus rhythm\nProbable left atrial abnormality\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\nclinical correlation is suggested\nSince previous tracing of , atrial fibrillation absent and ST-T wave\nchanges decreased\n\n" }, { "category": "ECG", "chartdate": "2163-05-12 00:00:00.000", "description": "Report", "row_id": 254961, "text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of atrial fibrillation is a new rhythm and the rate is more\nrapid. Otherwise, there is no diagnostic change.\n\n\n" }, { "category": "ECG", "chartdate": "2163-05-12 00:00:00.000", "description": "Report", "row_id": 254962, "text": "Sinus rhythm\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\ncannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , further ST-T wave changes present\n\n" }, { "category": "Radiology", "chartdate": "2163-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 915400, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? consolidation\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now now in resp failure, s/p intubation,\n copious secretions\n REASON FOR THIS EXAMINATION:\n ? consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure.\n\n CHEST AP: Compared to the prior study from two days earlier, there has been\n no interval change in the cardiopulmonary status. The heart size, mediastinal\n and hilar contours are unremarkable. The lungs are clear. No pleural\n effusions are identified. The tip of the endotracheal tube is about 4 cm\n above the carina. A right-sided central line is seen with its tip in\n unchanged position. The tip of the NG tube is below the stomach.\n\n IMPRESSION: No change, no acute process.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-29 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 916399, "text": " 10:14 AM\n PORTABLE ABDOMEN Clip # \n Reason: NGT placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with vomiting\n\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP ABDOMEN, .\n\n HISTORY: Vomiting. Check NG tube placement.\n\n IMPRESSION: Supine view of the upper abdomen excludes the right lateral\n abdomen. Feeding tube is coiled several times in the stomach. Contrast \n is present in the left colon. The colon is mildly distended with gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 915215, "text": " 3:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval endotracheal tube placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in severe resp failure w/ PA pressures\n 67/35, no wedge available, and LLL PNA\n\n REASON FOR THIS EXAMINATION:\n eval endotracheal tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of patient after abdominal aortic aneurysm\n repair.\n\n Portable AP chest radiograph compared to .\n\n _____ at 14:25.\n\n The ET tube tip, the right internal jugular line tip, and the NG tube are in\n standard position. The heart size is normal. The cardiomediastinal\n silhouette is unchanged. The lungs are clear and there is no pleural\n effusion.\n\n IMPRESSION: No change in the meantime interval in comparison to the previous\n film.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 915433, "text": " 1:45 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new left subclavian triple lumen\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now now in resp failure, s/p intubation,\n copious secretions\n REASON FOR THIS EXAMINATION:\n new left subclavian triple lumen\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 65-year-old woman with abdominal aortic aneurysm, now with\n respiratory failure.\n\n FINDINGS: Comparison is made to previous study from earlier today.\n\n The endotracheal tube, right-sided IJ catheter, nasogastric tube, and median\n sternotomy wires are unchanged. There has been placement of a new left-sided\n subclavian catheter with the distal tip in the mid SVC. The cardiac\n silhouette is upper limits of normal. Several surgical clips are seen within\n the left hilar region. There are no signs for overt pulmonary edema or focal\n consolidation or pleural effusions. No pneumothoraces are identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 914573, "text": " 7:34 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: sp bronch\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in afib and increasing left sided pressures\n\n REASON FOR THIS EXAMINATION:\n sp bronch\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:42 .\n\n HISTORY: Aortic aneurysm now in afib.\n\n IMPRESSION: AP chest compared to 6:18 p.m.:\n\n Right lower lobe atelectasis has cleared. Left lower lobe atelectasis has\n not. Small-to-moderate left pleural effusion is stable. Heart is normal size\n and the mediastinum is midline. ET tube, nasogastric tube, and Swan-Ganz\n catheter all in standard placements. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 914692, "text": " 8:49 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: confirmation of line readjustment\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in rersp failure and LLL PNA\n\n REASON FOR THIS EXAMINATION:\n confirmation of line readjustment\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , AT 8:49 A.M.\n\n COMPARISON: , at 4:56 a.m.\n\n INDICATION: Line readjustment.\n\n A right internal jugular catheter has been advanced, and now terminates in the\n region of the junction of the right brachiocephalic vein and superior vena\n cava. There is no pneumothorax, and there is otherwise no change since the\n recent radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916068, "text": " 2:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval trach placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now with new tracheostomy\n REASON FOR THIS EXAMINATION:\n eval trach placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS PA AND LATERAL\n\n History of AAA repair and tracheostomy.\n\n Tracheostomy tube is 4 cm above carina. Status post CABG. The NG tube is in\n stomach with distal end not included on film. No pneumothorax. Mild\n atelectasis left lung base and possible mild blunting of left costophrenic\n angle.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 914609, "text": " 10:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check CVL (line change)\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in afib and increasing left sided pressures\n\n REASON FOR THIS EXAMINATION:\n check CVL (line change)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check CVL, line changed.\n\n Comparison is made to .\n\n PORTABLE SUPINE RADIOGRAPH OF THE CHEST: The Swan-Ganz catheter has been\n removed. There is a new right internal jugular vein central venous catheter\n with the tip over the mid SVC. The endotracheal tube is located with the tip\n at the level of the clavicles, approximately 5.4 cm above the carina. The tip\n of the NG tube is not clearly seen, but is likely located near the\n gastroesophageal junction. No pneumothorax is seen. There is interval\n improvement in the left pleural effusion.\n\n IMPRESSION: No pneumothorax after line placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-01 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 916901, "text": " 1:20 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place dobhoff and d/c NGT\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with need for dobhoff for rehab\n REASON FOR THIS EXAMINATION:\n please place dobhoff and d/c NGT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old woman, need for Doppler for rehabilitation.\n\n NASOINTESTINAL TUBE PLACEMENT: The patient was prepped with lubricant jelly\n and 8 French - catheter was in inserted through the nostril.\n Multiple attempt had been made to pass the tube through pylorus, however, was\n not successful. The contrast did not go through the duodenum either. After\n discussion with Dr. , the tube was placed with the tip in prepyloric\n position, and was taped.\n\n IMPRESSION: Unsuccessful nasointestinal tube placement, with the tip of the\n tube terminating in prepyloric position. The findings were discussed with the\n referring physician, . , by telephone at the completion of the\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-28 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 916318, "text": " 10:50 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess for ileus, obstruction pattern, etc\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with vomiting\n REASON FOR THIS EXAMINATION:\n please assess for ileus, obstruction pattern, etc\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Vomiting.\n\n ABDOMEN, SINGLE SUPINE VIEW: The post-pyloric tube placed on ,\n remains in satisfactory position. Oral contrast is seen within loops of large\n and small bowel. There is no evidence of free air or bowel dilatation to\n suggest an ileus or obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916175, "text": " 9:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for dobhoff placement- post-pyloric? etc\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p dobhoff feeding tube placement\n REASON FOR THIS EXAMINATION:\n Please assess for dobhoff placement- post-pyloric? etc\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:10 A.M.\n\n HISTORY: _____ feeding tube placement.\n\n IMPRESSION: AP chest compared to and 15:\n\n Feeding tube with the wire stylet in place passes at least as far as the\n pylorus and is either coiled in the distal stomach or passes into the\n duodenum. Right lung is clear. Mild atelectasis is developed at the left\n lung base. Heart is not enlarged. It could be a small left pleural effusion,\n but no pneumothorax is present. Tracheostomy tube is in standard placement.\n Tip of the left subclavian line projects over the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916529, "text": " 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for NG placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p NG\n REASON FOR THIS EXAMINATION:\n please assess for NG placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n COMPARISON: .\n\n CHEST: AP upright portable view. The small caliber nasogastric tube\n terminates in the stomach, with tip turned up towards the fundus. The large\n caliber feeding tube has been removed since the previous study. A\n tracheostomy tube and a left subclavian central venous catheter remain in\n unchanged positions. Cardiac and mediastinal contours are unchanged. There\n is a new opacity at the left lung base, likely representing a combination of\n left lower lobe atelectasis and pleural effusion. There is no pulmonary\n edema.\n\n IMPRESSION:\n 1. Nasogastric tube positioned in stomach.\n\n 2. New left lower lobe atelectasis and small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2163-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916329, "text": " 12:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess new NG placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p dobhoff feeding tube placement\n\n REASON FOR THIS EXAMINATION:\n Please assess new NG placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:50 P.M. ON \n\n HISTORY: Dobbhoff feeding tube. Assess placement.\n\n IMPRESSION: AP chest compared to 10:10 a.m. on :\n\n Feeding tube and nasogastric drain pass into the stomach and out of view.\n Tracheostomy tube and left subclavian central venous line are in standard\n placements also. Heart size normal. Lungs clear. Tiny left pleural effusion\n may be present. No mediastinal widening or pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 914064, "text": " 4:05 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Locate swan tip and r/o pneumothorax.\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with\n REASON FOR THIS EXAMINATION:\n Locate swan tip and r/o pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:44 A.M., .\n\n HISTORY: New Swan-Ganz catheter. Rule out pneumothorax.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Tip of the Swan-Ganz catheter projects over the pulmonary outflow tract. ET\n tube tip is at the upper margin of the clavicles, and a nasogastric tube\n passes into the stomach and out of view. There is no pneumothorax, pleural\n effusion, or mediastinal widening. The heart is borderline enlarged, and\n there is mild-to-moderate vascular engorgement of the hila suggesting\n borderline cardiac decompensation.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 914560, "text": " 4:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute cardiopul process?\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in afib and increasing left sided pressures\n\n REASON FOR THIS EXAMINATION:\n acute cardiopul process?\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest, 4:18 p.m., .\n\n HISTORY: Aortic aneurysm. Atrial fibrillation.\n\n IMPRESSION: AP chest compared to :\n\n Right lower lobe atelectasis is new. Consolidation in the left lower lobe\n developed between and , subsequently unchanged accompanied by\n increasing moderate left pleural effusion. Heart size normal. ET tube in\n standard placement. Nasogastric tube ends in the upper or mid stomach. Tip\n of the Swan-Ganz line projects over the right pulmonary artery. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 914219, "text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AAA with increased oxygen requirements\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with\n\n REASON FOR THIS EXAMINATION:\n s/p AAA with increased oxygen requirements\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post AAA repair, increased oxygen requirement.\n\n COMPARISON: .\n\n FINDINGS: An endotracheal tube remains in stable position. The distal\n portion of the NG tube is not well seen. A Swan-Ganz catheter terminates in\n the right pulmonary artery.\n\n There is persistent pulmonary vascular engorgement without overt pulmonary\n edema. The lung volumes remain low. There may be a small left pleural\n effusion. No pneumothorax is present.\n\n" }, { "category": "Radiology", "chartdate": "2163-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 914351, "text": " 12:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm infiltrate\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in afib and increasing left sided pressures\n\n REASON FOR THIS EXAMINATION:\n r/o pulm infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:33 A.M. ON \n\n HISTORY: AAA. Afib. Increasing left heart pressures.\n\n IMPRESSION: AP chest compared to and :\n\n Left lower lobe atelectasis is worsened appreciably accompanied by at least a\n small left pleural effusion. Mild pulmonary edema has also worsened. Mild\n cardiomegaly stable. Tip of the ET tube above the sternal notch is at least\n 5.5 cm from the carina. Tip of the Swan-Ganz line projects over the right\n pulmonary artery. Nasogastric tube passes into the stomach and out of view.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 915746, "text": " 11:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for PNA, pulmonary edema\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now now in resp failure, s/p intubation,\n copious secretions\n REASON FOR THIS EXAMINATION:\n Please assess for PNA, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post abdominal aortic aneurysm repair with respiratory\n failure, intubation and copious secretions.\n\n COMPARISON: .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Patient is status post median sternotomy,\n and CABG. Mild cardiomegaly is unchanged. The endotracheal tube, left\n subclavian central venous catheter, nasogastric tube remain in standard\n positions. Pattern of mild pulmonary edema is improved in the interval. The\n lungs are otherwise clear without focal consolidation, pleural effusions, or\n pneumothorax. Multiple abdominal skin staples are again seen within the\n midline.\n\n IMPRESSION:\n 1) Mild cardiomegaly with improvement in mild pulmonary edema.\n\n 2) No pneumonia.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2163-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 915115, "text": " 3:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ARDS, worsening hypoxemia post-op after ruptured AA\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in severe resp failure w/ PA pressures\n 67/35, no wedge available, and LLL PNA\n\n REASON FOR THIS EXAMINATION:\n eval for ARDS, worsening hypoxemia post-op after ruptured AAA repair c/b\n take-back for b/l thrombectomies of prior fem-dp bypass on both legs query ARDS\n vs pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Worsening hypoxemia in a patient after AAA repair.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is at the lower level of the clavicles. The right internal\n jugular line tip is in the distal portion of the jugular vein, its junction\n with the subclavian vein. The heart size is normal. The appearance of the\n post-CABG sternal wires is unchanged. The lungs are clear and there is no\n pleural effusion.\n\n IMPRESSION:\n\n 1. Too high position of the right internal jugular line. No evidence of\n acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 915190, "text": " 2:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: NGT placed eval placement\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in severe resp failure w/ PA pressures\n 67/35, no wedge available, and LLL PNA\n\n REASON FOR THIS EXAMINATION:\n NGT placed eval placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AAA with new nasogastric tube placement.\n\n COMPARISON: at 3:51.\n\n UPRIGHT AP VIEW OF THE CHEST: Nasogastric tube tip lies within the stomach.\n The patient is status post median sternotomy and CABG. A right internal\n jugular central venous catheter tip lies within the distal internal jugular\n vein. Pulmonary vascularity is normal and the lungs appear clear. The left\n costophrenic angle and apices of the lungs are excluded from this study.\n Midline surgical skin staples are again demonstrated overlying the abdomen.\n\n IMPRESSION: Nasogastric tube tip within the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-10 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 914045, "text": " 9:47 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval AAA size, rupture; please also evaluate for kidn\n Field of view: 42 Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with abdominal pain radiating to back, says she has a known\n AAA (?size); I suspect renal stone\n REASON FOR THIS EXAMINATION:\n please eval AAA size, rupture; please also evaluate for kidney stones\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa TUE 10:35 PM\n 5.7 cm infrarenal abdominal aortic aneurysm with mural thrombus, sorrounded by\n hyperdense (45HU) fat stranding and soft tissue, srtongly worrisome for\n rupture and hematoma. (No active extravasation is noted.)\n\n Fatty liver. Sigmoid diverticulosis.\n 5 mm nodule in left lower lobe, follow in 3 months.\n WET READ VERSION #1 MNIa TUE 10:19 PM\n 5.7 cm infrarenal abdominal aortic aneurysm with mural thrombus, sorrounded by\n hyperdense (45HU) fat stranding and soft tissue, srtongly worrisome for\n rupture and hematoma. (No active extravasation is noted.)\n WET READ VERSION #2 MNIa TUE 10:19 PM\n 5.7 cm infrarenal abdominal aortic aneurysm with mural thrombus, sorrounded by\n hyperdense (45HU) fat stranding and soft tissue, srtongly worrisome for\n rupture and hematoma. (No active extravasation is noted.)\n\n Fatty liver. Sigmoid diverticulosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old woman with abdominal pain radiating to back. No\n abdominal aortic aneurysm.\n\n TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained\n with and without the administration of IV contrast , with CTA technique.\n\n No comparison.\n\n FINDINGS: Note is made of 5.3-cm infrarenal abdominal aortic aneurysm with\n mural thrombus, surrounded by hyperdense fat stranding and soft tissue\n measuring up to 46 , most likely representing abdominal aortic aneurysm with\n impending rupture. No definite abscess is identified, however, the\n possibility of infection cannot be totally excluded. Celiac, SMA, and iliac\n vessels are patent. No evidence of active extravasation is noted. Left kidney\n is atrophic, with very small left renal artery. Right kidney is unremarkable.\n\n Note is made of fatty liver. No focal liver lesion. The bladder, spleen,\n pancreas, adrenal glands, and the visualized portions of large and small\n intestines are within normal limits. No lymphadenopathy.\n\n PELVIS: Note is made of sigmoid diverticulosis. Otherwise, the visualized\n (Over)\n\n 9:47 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: please eval AAA size, rupture; please also evaluate for kidn\n Field of view: 42 Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n portions of the small intestines are within normal limits. No ascites. No\n lymphadenopathy.\n\n In the visualized portion of the chest, note is made of coronary artery\n calcification in this patient who is status post CABG. Note is made of 5-mm\n noncalcified pulmonary nodule in the left lower lobe, which needs to be\n followed in three months. Note is made of atherosclerotic disease of the\n thoracoabdominal aorta.\n\n There is no suspicious lytic or blastic lesion in skeletal structures.\n\n IMPRESSION:\n 1. 5.3-cm infrarenal abdominal aortic aneurysm with mural thrombus,\n surrounded by hyperdense soft tissue and fat stranding suggestive of impending\n rupture with hematoma. No definite abscess is identified, however,\n superimposed infection cannot be totally excluded. No evidence of active\n extravasation.\n\n 2. Sigmoid diverticulosis.\n\n 3. Fatty liver.\n\n 4. 5-mm noncalcified pulmonary nodule in left lower lobe. Please follow in\n three months.\n\n The information was discussed with the ED physicians and surgery resident,\n including Dr. in person at the time of examination, and it was also\n flagged to ED dashboard.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 914668, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrapulmonary process\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA now in rersp failure and LLL PNA\n\n REASON FOR THIS EXAMINATION:\n r/o intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever in a patient after AAA repair.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 5 cm above the carina. The right internal jugular line is\n in distal portion of the jugular vein, too high. The NG tube tip is in the\n stomach.\n\n The heart size is stable. There is no evidence of congestive heart failure or\n local infiltrate as well as no pleural effusion.\n\n IMPRESSION:\n 1. No evidence of pneumonia.\n\n 2. Proximal position of the right internal jugular vein line.\n\n" }, { "category": "Radiology", "chartdate": "2163-05-27 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 916225, "text": " 3:33 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post-pyloric Dobhoff\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA repair\n REASON FOR THIS EXAMINATION:\n please place post-pyloric Dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unable to wean off vent, need for post-pyloric Dobbhoff tube.\n\n POST-PYLORIC FEEDING TUBE PLACEMENT UNDER FLUOROSCOPIC GUIDANCE: A 120 cm 8\n French - feeding tube was inserted into the fourth portion of\n the duodenum under fluoroscopic guidance. The position was confirmed by\n injection of approximately 10 cc of Gastrografin. No immediate complications\n were seen.\n\n IMPRESSION: Successful post-pyloric feeding tube placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-03 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 917261, "text": " 6:45 PM\n RENAL U.S. PORT Clip # \n Reason: Please perform duplex renal U/S to assess for renal artery s\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with uncontrolled hypertension, s/p AAA repair\n REASON FOR THIS EXAMINATION:\n Please perform duplex renal U/S to assess for renal artery stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old female with uncontrolled hypertension and status post\n AAA repair, evaluate for renal artery stenosis.\n\n No prior studies for comparison.\n\n DUPLEX RENAL ULTRASOUND: This study is technically limited. The left kidney\n was not able to be visualized. Right kidney measures 12.2 cm. There are no\n stones or hydronephrosis. Normal-appearing arterial waveforms with RIs\n ranging from 0.75-0.78 are seen in the mid pole and lower pole of the right\n kidney. Poor arterial visualization of arterial waveforms in the upper pole\n of the right kidney is likely secondary to the marked limitations of this\n study.\n\n IMPRESSION:\n\n Markedly limited study do to patient body habitus and intubated stated. No\n stones or hydronephrosis. Comment on renal artery stenosis cannot be made. If\n there is high clinical concern, MRA can be performed.\n\n These findings were discussed with Dr. at 12:45 a.m. on .\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 917303, "text": " 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrates\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman s/p AAA repair\n REASON FOR THIS EXAMINATION:\n eval infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal aortic aneurysm repair.\n\n Single portable chest radiograph demonstrates no change in the\n cardiomediastinal contours compared with . Tracheostomy tube is in\n good position. A nasogastric tube is seen to course along the esophagus and\n off the inferior aspect of the imaged field of view. The right costophrenic\n angle is excluded from the imaged field of view. I doubt the presence of a\n left-sided effusion. Left subclavian central venous catheter is seen with its\n tip in the SVC. No pneumothorax. No consolidation is evident. The patient\n is status post median sternotomy.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-24 00:00:00.000", "description": "Report", "row_id": 1466844, "text": "respiratory care\npt continues to be orally intubated/ventilated. BS: diminshed bilaterally with occasionaly inspir/expir wheezes. MDI's administered Q4hrs. Low-grade temp noted. Suctioned for large amounts of thick white secretions. ABG: slightly acidotic this morning--tidal volume increased from 450-500ccs. Pt currently resting on A/C 500/14/PEEP 15/.40. PIP/Plat 29/27 respectively. Autopeep measured between depending on level of sedation. Plan to continue current support at this time. Plan for trach in the future when PEEP at a safe level to maintain adequate oxygenation.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-27 00:00:00.000", "description": "Report", "row_id": 1466856, "text": "npn 23:15-07:00 addendum remarks:\n\nerror entry re change of ventilator setting TV increase from 450 to 500, was an order to document a previous change;\nABG however obtained at 04:00 showed increased in pCO2 to 54, result may affect plan for decrease in peep this a.m.;\n\n2a serum K+ 4.7, therefore no supplement required for this lab result;\n4a FS 145, to be covered w/ RISS as ordered;\n4a tube feed resid was 60 cc's--both TF resid and FS result suggest absorption of tube feeds.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-27 00:00:00.000", "description": "Report", "row_id": 1466857, "text": "Respiratory Care Note:\n patient remains on full ventilatory support this shift. Peep level lowered to 12, ABG's pending. For other changes and specifics please refer to carevue. BS are coarse throughout, MDI's administered as ordered this shift. SX for a small to often moderate amount of thick tan secretions via trach. Cuff pressure 20. SPO2 remained 96-100%. No RSBI this am due to high peep level. patient remained afebrile. Plan is to continue to diurese and wean peep levels as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-27 00:00:00.000", "description": "Report", "row_id": 1466858, "text": "Resp Care\nPt remains trached on on A/C. Dropped Peep from 12 to 10. Pt transported to fluro w/o incident. Pt PO2 continues to drop into 60's and may require another recruitment maneuver. MDI's given, no other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-27 00:00:00.000", "description": "Report", "row_id": 1466859, "text": "nuero: when propofl shut off, pt did open her eyes would move all four extremties, pt also did follow commands. pt presently sedated on propfol\n" }, { "category": "Nursing/other", "chartdate": "2163-05-27 00:00:00.000", "description": "Report", "row_id": 1466860, "text": "nuero: when propfol off for 10min. pt did move all four extremties, pt did follow commands( i.e show me your thumb on both hands). pupils remain equal and reactive to light. eye lid continue to be edemous, eyes red, applying artifcial tear, and e-mycin eye ointment as ordered. pt presently sedated on fentanyl 50mcg/hr and propofol weaned down to 20mcg/kg/min.\n\npulm: pt continue on ac, fio2 40%, peep weaned down to 10, please ee flow sheet for vent settings.last abg 7.50/48/69/39 dr. . aware, dr. also aware, no vent changes ordered. suctioning pt for thick yellow/whitish secretions.\n\ncards: pt in sr to sb. lopressor dosage changed to 25mg . pt recieved hydralazine 10mg iv x2 because sbp greater than 150(please see flow sheet. pt recieved 40mg of iv lasix with good diureisis.\n\ngi: feeding tube advanced by dr. this morning kub done, feeding tube not post pyloric, dr. . aware. pt went down to fluroscopy this afternoon to have feeding tube placed. after returning back from fluroscopy, pt vomited x2 bilous vomit, dr. aware, dr. aware. tube feedings not restarted per dr. .pt incontinent of 3 large stools. pt has diaper on.\n\ngu: foley patent.\n\nf/e: nph insulin held this morning secondary to feeding tube not post plyoric, blood sugar at 1700 188 tx'd with 9 units of regular per sliding scale. ica 1.10 pt recieved 2gm of calicum gluconate..\n\nskin: pt with reddened spot on back of head, no skin breakdown on head noted. pt with reddened area on back, no skin breakdown noted.\n\npain: fentanyl gtt increased to 50mcg/hr per dr. \n\nsocial: pt husband and on called today for an update\n\nplan: conitinue to monitor, monitor resp. status, check abgs. wean propofol to off, pt has prn ativan ordered.. keep sbp less than 150. ? restarting tube feedings this everning.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-28 00:00:00.000", "description": "Report", "row_id": 1466861, "text": "focus hemdynmics\ndata: neuro: propofol gtt off. eyes open and following covverstation. mouths words slowly. nods head apprioaiately. moves legs on the bed. and squeezes hand slowly to command.\n\nresp: suctioned for lg amt of thick white sputum. peep increased to 12. o2sats 96-100%. lg amt of oral secretitions. breath sounds course this am. trach patent and care done x3. trach foam neck wrap changed.\n\ncardiac: remains in nsr except after receiving lopressor 25mg via tube. hr down to 50's. bp > 100syst. fentanyl gtt for pain.\n\ngu: foley patent and draining yellow- amber urine. lasix 40mg ivp give\nas ordered and u.o > 30cc/hr.\n\ngI : abd soft and active bowel sounds. lg ecchymotic area on abdomen ? 2 to heparin sc injections. tube fdgs on hold tonite. lg quiac postitive stool. abd incision intact and no drainage noted. on fluconazole via tube .\n\naction: labs as ordered. suctioned prn. fentanyl gtt infusing. propofol gtt d/c'd. following conversations/ ativan prn. tube fdgs held and nph insulin held tonite. trach care done x3. update to husband.\n\nresponse: monitor closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-28 00:00:00.000", "description": "Report", "row_id": 1466862, "text": "Resp care\nPt continues to be intubated and vented. peep was increased from 10 to 12 this shift due to low PaO2, please see careveu for ABG. no other vent changes this shift. pt suctioned for mod amts of thick yellow/white sputum and plugs. will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-19 00:00:00.000", "description": "Report", "row_id": 1466827, "text": "Status D\nSee Careview for specifics\n\nNeuro: no change. Pt. sedated on fent. & propofol. Follows commands inconsistently. Moves lower extremeties on bed and to command. No movement in upper extremities.\n\nCV: HR maintained in 60s with lopressor fixed dose. SBP maintained at goal < 140s, except can incease briefly to 180s-90s when turned, suctioned.\n\nResp: LS coarse throughout. Sxn'd for thick yellow/tan secretions. Fi02 decreased from 40 to 50, rate from 21 to 19. Tolerating moderately well with sat 95-96%. PEEP decreased to 14 per balloon study. ET tube, NG tube & balloon advanced d/t migration.\n\nGU: Lasix gtt off, urine output 40-80cc/hr.\n\nGI: BS present. No stool. Bowel regimen started.\n\nSkin: diffuse pink lesions on trunk. Levofloxacin d/c'd & replaced with cefepime.\n\nSocial: daughter & son in to visit.\n\nPlan: Continue with slow wean from vent with close monitoring of lung sounds, sats, ABGs. Keep family up to date on decision regarding trache.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-20 00:00:00.000", "description": "Report", "row_id": 1466828, "text": "data: temp 100.8 down w/ tylenol to 97.1 hr 54-65 nsr w/o ectopies. lopressor 50mg held for hr<60. b/p stable with sb/p<150. cvp 12-14.\nurine low of 20cc for 1hr-lasix 40mg ivp x2 given w/ urines >100cc for six hrs. k+ and ca+ repleted. fliud balance +1500/24hr period.\npt slightly sedated on low dose ppf gtt and fentanyl gtt for comfort/\nvent complaince. moving lower extremies on bed. no mvmt seen in upper extremies.\nt. fdg @ goal 80cc/hr w/ residual 100cc. blood sugars remain high. nph and ssri increased. abd. soft obese. bm x2 small amt mucous yellow stool.\npt suctioned large amts thick white sputum q3hrs- lots of oral secretions. o2sats 96-99% on 40% fio2/14peep/cmv\n" }, { "category": "Nursing/other", "chartdate": "2163-05-20 00:00:00.000", "description": "Report", "row_id": 1466829, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT MILDLY SEDATED ON SMALL AMOUNT OF PROPOFOL AND FENTANYL GTTS. OPENS EYES SPONTANEOUSLY, FOLLOWS SOME COMMANDS AND ABLE TO NOD HEAD IN RESPONSE TO SOME SIMPLE QUESTIONS. MOVING LOWER EXT. SPONTANEOUSLY ON THE BED, SOME SPONTANEOUS MOVEMENT ALSO NOTED FROM RIGHT ARM.\nCV- BP STABLE IN 120-140'S, RISING TO 200 WHEN COUGHING OR BEING SUCTIONED. HR 50'S, NSR WITHOUT ECTOPY. LOPRESSOR HELD THIS AM DUE TO LOW HR, WILL CONTINUE TO MONITOR AND GIVE WHEN PT CAN TOLERATE. CVP 15-18, NO LASIX TODAY DUE TO ELEVATED CREATININE, WILL FOLLOW UP THIS EVENING ON FLUID STATUS.\nRESP- LUNGS COARSE, SUCTIONED FREQUENTLY FOR LARGE AMOUNTS OF FROTHY WHITE SPUTUM. O2 SAT RANGING FROM 95-98% ON AC, RATE DECREASED THROUGHOUT THE DAY, PEEP REMAINS AT 14. ABGS IMPROVING WITH CHANGES.\nGI/GU- ABD SOFT, HYPO SOUNDS. TOLERATING TF WITH RESIDUALS UNDER 100CC. BS REMAINS IN 200'S DESPITE INCREASE IN AM NPH. SPOKE TO DR. AND WILL START GTT WHEN IT ARRIVES FROM PHARMACY. UOP ADEQUATE, IV FLUIDS MINIMIZED TO AVOID FLUID OVERLOAD.\nID- TMAX 99.6\n" }, { "category": "Nursing/other", "chartdate": "2163-05-21 00:00:00.000", "description": "Report", "row_id": 1466830, "text": "Respiratory Therapy\npt remains orally intubated on full resp.support of A/C 450X14 peep of 14 (per esophageal balloon evaluation) and .35. BS coarse rhonchi throughout. Sx for copious amts clear to rusty secretions. At MN esoph. bal appeared dislodged it was extended out of her mouth about 2 inches an partially rolled inback of mouth. Balloon removed and placed in bag on vent. MDI's as ordered. Plan trach when peep is weaned.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-25 00:00:00.000", "description": "Report", "row_id": 1466845, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED ON PROPOFOL AND FENTANYL GTTS. LEVEL OF AROUSAL VARIES THROUGHOUT THE NIGHT. OCCASIONALLY NODDING HEAD \"NO\" IN RESPONSE TO \"ARE YOU HAVING PAIN?\" NOT FOLLOWING COMMANDS, MOVING LOWER EXT. IN RESPONSE TO PAIN, UPPER EXT OCCASIONALLY MOVE ONLY SLIGHTLY IN RESPONSE TO PAIN. PERRL.\nCV- BP STABLE IN 120-130'S. HR SINUS BRADY, LOPRESSOR HELD OVERNIGHT. OCCASIONAL PACS, LYTES CHECKED AND REPLETED FOLLOWING DOSE OF LASIX AND AGAIN WITH AM LABS.\nRESP- LUNGS COARSE AT TIMES. SUCTIONED FREQUENTLY FOR COPIOUS AMOUNTS OF THICK LIGHT YELLOW SPUTUM, LARGE AMOUNT OF ORAL SECRETIONS. NO VENT CHANGES THIS SHIFT, AM ABGS UNCHANGED FROM PREVIOUS, O2 SAT 95-98% THROUGHOUT THE NIGHT.\nGI/GU- ABD SOFT, PRESENT BS SOUNDS. NO BM THIS SHIFT. TUBE FEEDS STOPPED AT 2AM AND MAINTANENCE FLUID STARTED FOR TRACH PROCEDURE TODAY. ADEQUATE, DIURESED FROM LASIX 40MG IN THE EVENING, WILL FOLLOW UP THIS AM AND WILL CONTINUE INTERMITTENT DIURESIS TO KEEP PT NEG. URINE APPEARING PINK TINGED DURING THE EVENING, DR. NOTIFIED, ? TRAUMA DURING REPOSITIONING, NO FURTHER EPISODES.\nID- TMAX 100.3\n" }, { "category": "Nursing/other", "chartdate": "2163-05-25 00:00:00.000", "description": "Report", "row_id": 1466846, "text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. BS prior to suctioning scattered crackles and exp. wheezes and diminished bases which improved after sx and MDI's. Sx for copious amts thick pale yellow secretions. MDI's as ordered. ABG 7.41/56/90/37. No RSBI D/T high peep. Plan: diurese, and wean peep as tol.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-25 00:00:00.000", "description": "Report", "row_id": 1466847, "text": "Status: update\nSee Carevue for specific data\n\nNeuro: sedated on propofol & fentynal. During daily wake up opened eyes spontaneously & followed commands to move lower extremities. No movement in upper extremities. Localizes/withdraws to pain in lower extremities. Responds to painful stimuli in upper extremities with grimacing.\n\nCV: Sinus brady 55-60. ABP 120s-140s. Can increase to 180s with stimulation and increased to 200 during daily wake up.\n\nResp: remains on full ventilation with PEEP of 15. LS clear/coarse. Sats 94%-98%. Sxn'd approx q2h for large thick yellow secretions. OR trache placement scheduled.\n\nGI: Feeding tube clamped pending trache/PEG procedure. Insulin gtt off. NPH dose held. Glucose tx with sliding scale. No stool.\n\nGU: 40 mg lasix x 1 and currently negative 600cc since midnight. Goal is 1L negative for current 24 hr. period.\n\nSkin: Edematous conjunctiva tx with artificial tears/eurythromycin. Incision staples C&D, open to air. Small breakdown right lower back above hip tx with nystatin ointment.\n\nSocial: Husband called, updated on trache procedure.\n\nPlan: Cont. diuresis as needed to meet 24 hr. fluid goal. Monitor respiratory status and sxn to maintain oxygenation. Wean sedation as blood pressure allows.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-18 00:00:00.000", "description": "Report", "row_id": 1466823, "text": "sicu update\nneuro: remains on low dose propofol. does arouse to verbal stim. moves LE to command, not UE. perl. rarely nods to questions asked. fentanyl drip cont w/out change.\n\ncv: vss as per flowsheet. cvp upper teens. sinus brady 50's, no ect noted. 1400 lopressor held for HR as pt was also due for amiodarone. sbp 100-120 much of shift. lasix drip d/c for prn ivp dosing. 40mg iv given at 1500. lytes repleted.\n\nresp: lungs clear,dim bases. coarse @ times. sx for sm to mod thick white secretions. mod amt oral/nasal thick clear/white secretions cont. vent changes made w/ decreasing of ac rate w/ I/E adjustments. (refer to flow). abg wnl so far. o2 sats 96-99%.\n\ngi/gu: uop as noted. shooting for euvolemic thogh pt + ~650cc at present. lasix just given as noted. last dose diamox at 1400. abd obese. bsp. no bm, + flatus. no resids. nph added to glucose control. na+ to 146 and creat stable at 1.9 this afternoon.\n\nid: no new issues. needs random vanco level at .\n\nsocial: husband/son update by phone.\n\nassess: stable day. tol vent changes so far. + I & O.\n\nplan: prn lasix. vent changes as ordered. nph added.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-18 00:00:00.000", "description": "Report", "row_id": 1466824, "text": "Resp Care:\n Patient remains intubated and sedated now on A/C of 450 x 21, 40% and +17PEEP. BS= bilat, diminished. Suctioned for small amounts of thick whitish sputum and receiving albuterol MDIs Q4. ABG with compensated resp acidosis. See Carevue flowsheet for details. Plan to continue supportive care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-23 00:00:00.000", "description": "Report", "row_id": 1466840, "text": "Resp Care: Pt remains intubated via #7 ETT secured 23cm at lip. BS coarse bilat. Sx'd for copious amts thick white frothy sputum. Spec sent. Spec from \"yeast\". MDI's given as ordered. Multiple PEEP changes made per Teams. EP study reveals PEEP= 22cm. Teams aware. Current vent settings= A/C 450-14-.40-15PEEP. ABG WNL (chronic compensated resp acidosis). NO other vent changes made this shift. Plan: cont vent support. Please see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-19 00:00:00.000", "description": "Report", "row_id": 1466825, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: More alert this shift. Following some commands. Nodding to simple questions. Moving lower extremities to command and at times noted to have some spontaneous movement. Remains lightly sedated on low dose prop gtt. Fent gtt cont at 50mcg for pain mmgt.\nCV: HR-SB most of noc. No noted ectopy. SBP maintained within parameters w/o intervention. T-max 100.1 Lasix gtt remains off. Given 40mg of lasix over noc to maintain uop. Bun/creatinine elevating no additional lasix given. +DP/PT pulses remain palpable.\nResp: Fi02 ^^ to .50% d/t P02 in 60's and desats to 93/94% from 97/98%. Sxn for copious amts of yellow secretions. Current vent settings a/c .50% 450X21 with 17/peep. Lungs clear/coarse to diminished at the bases.\nGi/Gu: Unchanged remains with no BM. Team aware. Foley patent drng adequate urine\nID: Remains on mult abx\nEndo: RISS\nPlan: cont with slow vent wean as tolerated. ? Bronchoscopy today for increased secretions. Cont to moniter hemodynamics and monitor patient for increased s/s of sepsis. cont with current plan of care. Follow through with SS consult.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-19 00:00:00.000", "description": "Report", "row_id": 1466826, "text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. BBS-coarse t/o w/diminished bases. Sx'ed for copious amt thick secretions changing over shift from tan to yellow. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-24 00:00:00.000", "description": "Report", "row_id": 1466841, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED ON PROPOFOL AND FENTANYL GTTS, OPENING EYES TO PAINFUL STIMULI. NOT FOLLOWING COMMANDS, WITHDRAWS SLIGHTLY TO PAINFUL STIMULI IN LOWER EXT. ONLY. PERRL. PT DOES NOT APPEAR TO BE IN ANY PAIN.\nCV- BP STABLE IN 120-130 RANGE, HR 50'S, NSR, LOPRESSOR HELD. OCCASIONAL PVCS, LYTES MONITORED CLOSELY DUE TO FREQUENT DOSES OF LASIX, WILL REPLETE AS NEEDED.\nRESP- LUNGS COARSE A TIMES, SUCTIONED EVERY FEW HOURS FOR THICK WHITISH SPUTUM. PT CONTINUES TO HAVE STRONG COUGH. O2 SAT 95-97%, NO VENT CHANGES MADE OVERNIGHT.\nGI/GU- ABD SOFT, PRESENT BS. TOLERATING TF WITH MINIMAL RESIDUAL. INSULIN GTT CONTINUES AND TITRATED TO KEEP BS LESS THAN 140. ADEQUATE, PT 1L POSITIVE AT MIDNIGHT DESPITE INTERMITTENT DOSES OF LASIX. ADDITIONAL LASIX 40MG GIVEN THIS AM TO KEEP PT NEG FOR THE DAY.\nID- TMAX 99.4\n" }, { "category": "Nursing/other", "chartdate": "2163-05-24 00:00:00.000", "description": "Report", "row_id": 1466842, "text": "Respiratory Care Note:\n\n Pt remain orally intubated & sedated on full ventilatory sypport. No vent changr maded. We are sxtn routinely for small amt of thick whitish secretions from ETT. Plan: wean as tol & Continue presentICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-24 00:00:00.000", "description": "Report", "row_id": 1466843, "text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics.\n\nNEURO: PERRLA 2 and brisk. Unable to open eyes d/t ocular edema. Does not follow commands. Moves LE's spontaneously but not purposefully. Noted to move RUE x 2 when suctioning. No movement on LUE. +gag, +cough.\n\nRESP: LS coarse and diminished. Occ LS wheezy. Neb treatment with good effect. In the AM copious amts of thick white and clear secretions. pressure done at bedside by respiratory. Episodes of desatting in the late am, CXR done no changes. Much less secretions in the early afternoon.\n\nCARDIAC: Tmax 99.5. HR 54-72 SR. SBP 100-134. +PP by doppler. P-boots on.\n\nGI: Abd large soft +BS. Abd binder taken off MD. TF changed to Pulmonary @30cc/hr. Tolerating well. Small loose stool x 2. +flatus. TF residual 60cc-80cc.\n\nGU: Foley intact draining clear yellow urine. 40mg Lasix with min effect. Goal is (-1L).\n\nINTEG: Abd staples intact with no drainage. Eccymotic area on Left side of incision improving. Occular edema aqua tears, lacrilube erythromycin applied. 2x2 gauze moistened with NS folded and applied to eyes to keep moist.\n\nPSYCH/SOCIAL: Husband called to discuss possibility of trache. RN explained benefits of trache and reasons why trache is necessary. Long term use of trache, weaning from trache, secretion management, and going to rehab with a trache was also discussed.\n\nPLAN: Monitor resp and secretions, Maintain SBP<140, Attempt to diurese -1L today, Provide extra comfort and reassurance.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-25 00:00:00.000", "description": "Report", "row_id": 1466848, "text": "Resp Care\nPt remains intubated on A/C. MDI's given. Pt suctioned for large amt of thick tan secretions. Plan is for trach in OR. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-26 00:00:00.000", "description": "Report", "row_id": 1466849, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED ON PROPOFOL AND FENTANYL GTTS. AROUSABLE TO VOICE, NOT FOLLOWING COMMANDS. SLIGHT MOVEMENT FROM LOWER EXT., OCCASIONALLY SPONTANEOUS, NO MOVEMENT FROM UPPER EXT. PERRL.\nCV- BRADYCARDIC ALL SHIFT, 45-55, SINUS, WITHOUT ECTOPY. DR. NOTIFIED AND LOPRESSOR HELD. BP STABLE IN 120-140 RANGE.\nRESP- LUNGS MOSTLY CLEAR, COARSE A TIMES, RELIEVED BY SUCTIONING. SUCTIONED EVERY FEW HOURS FOR COPIOUS AMOUNTS OF THICK WHITISH YELLOW SPUTUM. O2 SAT 95-98%, NO VENT CHANGES OVERNIGHT, AWAITING TRACH.\nGI/GU- ABD SOFT, + BS. NG TUBE PLACED ON WALL SUCTION, REMAINS NPO FOR TRACH PROCEDURE. NO STOOL. DIURESED WELL FOLLOWING LASIX 40MG IN THE EVENING. AT MIDNIGHT, PT WAS ABOUT 1 1/2 LITERS NEG.\nID- AFEBRILE. FLUCONAZOLE STARTED.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-26 00:00:00.000", "description": "Report", "row_id": 1466850, "text": "Respiratory Care Note:\n patient remains on full vent support with high peep levels required. Total peep measured to be 15.7 this shift. For specifics please refer to carevue. BS are clear, coarse at times relieved by suctioning. Secretions pale yellow. No RSBI this am due to peep level of 15. patient remained afebrile. SPO2 remained 95-100%. MDI's administered as ordered. Awaiting trach.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-26 00:00:00.000", "description": "Report", "row_id": 1466851, "text": "Resp Care\nPt trached in OR. PT has # 8 portex and is tolerating well on A/C. Pt required recruitment maneuver, beacuse of lost PEEP during procedure. Pt responded well to recruitment. Pt PO2 went from 63 to 89. FIO2 dropped from 50 to 40. Pt suctioned for copious amt of thick yellow and blood tinged sputum. MDI's given. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-26 00:00:00.000", "description": "Report", "row_id": 1466852, "text": "Status: A\nSee Carevue for specific data\n\nNeuro: pt. sedated on ppf & fent. During daily wake up opened eyes spontaneously, followed all commands, moved all extremities on bed.\n\nCV: Sinus brady all shift in 50s. Hypertensive in 170s s/p trache procedure. 10 mg hydralazine x 2 given with poor effect. 10 mg labetelol x 1 given and BP down to 140s. Team target is < 140.\n\nResp: Trache placement in OR d/t high PEEP. PEEP decrease from 15 to 12 not tolerated. Pt currently back to PEEP 15, Fi02 40. Sats improved s/p trache 98-100%. LS coarse/clear. Sxn'd for thick yellow secretions.\n\nGU: 40 mg lasix x 1 given, diuresed approx 1000 cc. Goal 1-1.5 L negative by midnight. Lytes repleted.\n\nGI: BS present. TF started at 10cc/hr to increase q6 for goal of 30cc/hr. No stool.\n\nSocial: Husband called, updated on trache procedure and POC.\n\nPlan: Monitor SBP and tx as indicated to stay within parameters. Continue to diuresis to meet fluid goals. Wean from vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-26 00:00:00.000", "description": "Report", "row_id": 1466853, "text": "FULL CODE Contact Precautions- Rectal swab NKDA\n\n\nNeuro: On Propofol and fent gtts, opens eyes to stim, moves upper and lower extrems to tactile stim bilat. Pupils 2mm/brisk. +gag and cough.\n\nCV: HR=50s, NSR, no ectopy and BP=120/50s. BP had been elevated to 170s/ after trach placement today w/ no effect from hydralazine and intially moderate effect from one dose of labetalol 10mg IVP down to 150s/. Then about 2 hours later, BP down to 120-140/. Lopressor had been held last night r/t <HR in 40s - restarted on Lopressor 37.5mg instead of 25mg TID. Dose given at w/ no change in HR - remains in the 50s and BP down to 103-107/40s. +periph pulses, feet a bitcool, otherwise warm/dry skin, no lower extrem edema, but +scleral edema. CVP=12 after dose of Lasix this afternoon after it had been up to 20.\n\nResp: AC 500x14 P=15 and Fi02 down to 40% earlier this afternoon - repeat ABG good- Pa02 up to 93 from 80s. Initally suctioned bloody secretions via new trach after procedure, w/ next sx slightly blood-tinged to no blood at all - thick tan secretions. Lungs coarse thru-out all fields. RR 14-17.\n\nGI/GU: Abd soft, round, obese, +BS. Unable to place PEG in the OR today due to poor illumination/visualization. TF restarted - Novasource Pulmonary at 10cc/hr, increasing by 10cc/hr q4 for a goal of 30cc/hr. Tol ok - no resid. Foley cath w/ clear yellow urine - received a dose of Lasix 40mg this afternoon and diuresed well and will receive another dose at midnight tonight - weight still ^^ significantly.\n\nSkin: Buttocks/coccyx/heels intact. Abd incision w/ staples intact - clean/dry, no drainage, no dressing.\n\nID: afebrile - on flucanozole and cefipime.\n\nAccess: LSC TLC, L rad a-line\n\nLabs: Repeat Ca and K this evening a bit low - repleted.\n\nSocial: No phone calls or visits this evening.\n\nPlan: Wean vent as tol. Increase TF to goal as tol. Lasix later tonight, monitor u/o and wieght. Monitor cardiac status - lopressor as scheduled, labetalol and hydralazine prn. Monitor neuro status.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-26 00:00:00.000", "description": "Report", "row_id": 1466854, "text": "Son, , and daughter-in-law in to see pt - updated on pt's status by nurse and Dr .\n\nFS at 2200=143 - given 24 units NPH as scheduled and 6 units reg insulin per RISS. Increasing TF to goal at 30cc/hr by midnight.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-27 00:00:00.000", "description": "Report", "row_id": 1466855, "text": "npn 23:15-07:00 (see also carevue flownotes for objective data)\n\ndx: surgical repair ruptured AAA, c/b pna/failure to wean from ventilator\n trach (unable to do PEG d/t unable to adequately visualize)\n\nPMHx: htn, CAD, DMII, a-fib, known AAA, obesity\nPSHx: CABG , c-section, ventral hernia repair\n\n65 yo obese woman, underwent procedure as above; with significant interstitial tissue total body fluid gain; have been trying to diurese pt and wean from ventilator for several days; has been on abx, insulin gtt, diuretic gtt; recently tube feed changed to provide less water absorption.\n\nneuro:\nsedated on fentanyl at 40 mcgs/hr, and propofol at 40 mcg/k/min, which is abit of a wean compared to a few days ago; previously pt was not respoding to daily wake up, however, yesterday reportedly pt did respond abit likely with the decrease in sedation; no spontaneous movement observed, does open eyes to noxious stimuli.\n\nc-v:\nhx a-fib, hx coumadin, reversed at admission in preparation for surgery; currently is only on ASA and hep SQ;\nlopressor changed to 37.5 , was previously on lopressor s/p CABG ; hrt rate low was 49 over the night, previous baseline 50's on current meds;\nno prn anti-hypertensives needed this 8 hrs--goal is for sbp < 140, a-line has been 120's 130's thi night;;\ndid have recurrence of a-fib , resolved w/ amiodarone gtt then switched to po;\ncurrently trying to diurese pt of approx 2 L per 24 hrs, for both cardiac and respiratory issues;\nas of hct stable at 27;\n\nresp:\nas stated, continue to try diuresing pt of excess body fluid;\nadmit wt 91, this a.m.'s () wt 102.6, down from 103.2 of yesterday ();\nduring the night set TV increased from 450 to 500, will get ABG soon;\nplan is to decrease peep again from 15 to 12 approx 05:30/06:00;\nas stated, s/p trach ;\nABG to be obtained after change;\n\ng-i/endo:\nTF's of Novasource w/ additive increased to 30 mls per hr, which is goal; will check resid later in the shift;\nreceived NPH and Regular insulin last eve at 22:00 as ordered, there was a question of tube feed leaking through vent of NGT, therefore FS's checked q 2 hrs, was 105 at 12a, and 125 at 2a;\nno stool so far this night, pt receiving docusate as ordered;\n\nlytes:\nfollowing K+ closely d/t lasix, and pt's cardiac hx;\nanticipate continued supplementation;\n\naccess:\na-line and cvl patent; cvl drssg changed per sterile technique, dated;\n\nsocial:\nno calls from family this 8 hrs\n\nPLAN:\ncheck results a.m. labs, supplement lytes as ordered\ndecrease peep per RT at approx 05:30\ncheck ABG's post vent changes\nHOB > 30 degrees;\nabx as ordered;\ncontinue diuresis, goal approx 2 L per 24 hrs\nupdate family prn\nFS q 6 hrs, w/ routine scheduled NPH, and RISS\nper note on wall, abdominal binder for turning pt\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-22 00:00:00.000", "description": "Report", "row_id": 1466836, "text": "CONDITION UPDATE\nVSS. LOWGRADE TEMP. ALERT. NOT FOLLOWING COMMANDS. MOVING LEGS TO STIMULI. NO MOVEMENT NOTED UPPER EXTREMITIES. PUPILS EQUAL AND BRISKLY REACTIVE. LUNGS COARSE TO DIMINISHED AT BASES BILAT. THIS PM SAT DECREASING TO 92 TO 93% DESPITE AGGRESSIVE SUCTIONING. RESP THERAPIST NOTIFIED. FIO2 INCREASED TO 50%. PT ALSO NOTED TO BE ASYNCHRONOUS (BREATHING) ON THE VENT. PPF INCREASED TO 35MCG/KG/MIN. ESOPHAGEAL BALLOON PLACED BY RESPIRATORY THERAPISTS - MEASUREMENTS TAKEN. OCC SUCTIONING THICK WHITE -TO TAN/BLD STREAKED SPUTUM. ABD SOFTLY DISTENDED. SURGICAL INCISION C/D - STAPLES INTACT. LG AREA OF ECCHYMOSIS REMAINS LEFT OF INCISION. U/O QS VIA FOLEY. NO STOOL THIS SHIFT.\nCONT TO MONITOR FOR S/S OF INFECTION. PAIN MANAGEMENT. DIABETIC MANAGEMENT. AGGRESSIVE PULM TOILET. WEAN FROM VENT AS TOLERATES. PT FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-22 00:00:00.000", "description": "Report", "row_id": 1466837, "text": "Resp Care: pt remains intubated via #7 ETT secured 23cm at lip. BS sl decreased w/ bilat rhonchi. Sx'd for small to mod amts thick tan and bld streaked sputum. Rate decreased to 16bpm MD. re-inserted. PEEP ^'d to 24cm MD PEEP study. ABG pending. Plan: cont vent support. PLease see carevue for further vent inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-23 00:00:00.000", "description": "Report", "row_id": 1466838, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: PERRLA (2-3mm; brisk). Pt opens eyes spontaneously at times. Other times, pt opens eyes to voice/noxious stimuli. Pt does not follow any commands. Nonpurposeful, spontaneous movement. No movement noted on BUE. Pt withdraws BLE when nailbed pinched. Continue fentanyl gtt; weaned to 55mcg/hr. Ppf gtt @ 35mcg/kg/min. Pt does not appear to be in pain; no grimacing noted and VSS.\nCV: Tmax 99.5. HR 60-70s (NSR). ABP 100-120s/40s. CVP 11-16. Pt w/ + generalized edema. Bilat eyes very edematous; eyes covered w/ gauze soaked in NS. Erythromycin ointment and artificial tear ointment applied to OU. ?needs opthalmology consult today. 24hr net I&O balance was approx +1832cc. DP/PT pulses dopplerable. HCt 24.1; WBC 13.5. Pt on Cefepime 1gram IV q24hr. BUN 46, Cr 1.2.\nPulm: Lungs coarse, diminished at bases. CMV: 40%, Vt 450x14, PEEP decreased to 18 (from 24 per Dr. ). ABG showed compensated respiratory acidosis (Dr. aware). in place. RR 14-20. O2 sat>/= 96%. Pt suctioned for small amount thick, white secretions.\nGI: Abdomen obese; +BS. Promote w/ fiber @ 80cc/hr (goal rate) via NGT. Residual checked q4hr (15-100cc). Hold TF if residual >/= 200cc. No BM this shift.\nEndo: Insulin gtt currently @ 8units/hr. FS q1hr while on gtt. Goal BS 80-120. NPH 24units given as ordered.\nGU: Foley intact w/ clear, yellow urine. UO 30-80cc/hr.\nInteg: Abdominal incision w/ staples intact; clean and dry. Abdominal binder on. Large area of ecchymosis noted on left side of incision; unchanged.\nPlan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. ?wean vent setting as ordered by HO and as tolerated by pt. Titrate Ppf and fentanyl gtt for sedation. Titrate insulin gtt to keep BS 80-120; check BS q1hr. ?opthalmology consult today. Discuss plan of care w/ pt and family. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-23 00:00:00.000", "description": "Report", "row_id": 1466839, "text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 2 and brisk. Did not follow commands today. BLE withdraw minimally to noxious stimuli. BUE no movement to noxious stimuli. Does not nod or shake head to questions asked. +gag, +cough. Weak corneals (difficult to assess d/t edema).\n\nRESP: LS coarse. Deep sxn for scant to copious amts of clear and yellow frothy secretions. Attempting to wean vent throughout shift barely tolerating. testing done at bedside with MD's and respiratory. Sputum cx sent.\n\nCARDIAC: Tmax 100.4. HR 60-70's NSR. SBP 98-140 goal is <140. +PP by doppler. Diuresed 1L with 20mg Lasix. 1 unit of PRBC for HCT 24.\n\nGI: Abd obese soft +BS. Tol TF at goal. TF residual 90-120cc TF to be held for >200cc. Abdominal binder on at all times. Small amt of loose stool. +flatus.\n\nGU: Foley intact draining qs clear yellow urine.\n\nINTEG: Ecchymotic area on abdomen. Abd staples cdi no drainage. Increased occular edema. Cool moist gauze applied, erythromycin and Akiwa tears applied. Several MD's assessed occular edema throughout shift.\n\nPSYCH/SOCIAL: Daughter visited slightly teary and anxious about mother. Was less tearful after MD discussed plan of care.\n\nPLAN: Continue to wean vent as tolerated, Maintain SBP <140, Monitor I&O's, Monitor for pain and discomfort, Provide extra comfort and support to patient and family.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-21 00:00:00.000", "description": "Report", "row_id": 1466831, "text": "focus hemodymics\ndata: neuro: on iv propofol and fentanyl gtt. moves legs on bed intermittently. no movement in right arm and limiited amt of movement in left arm. eyes extremely swollen and red. eye oint applied as ordered. when name called bp elevates > 160.\n\nresp: suctioned for thick white sputum. suctioned freq q1/2hr. o2sat down to 92-93% when vent on 35%. back on 40%. pco2 53 and po2 > 100.\n\ncardiac: remains in nsr. hct 25.9 and wbc 14.9. k 3.8\n\ngu: foley patent ad draining yelllow urine. creat 1.6 and bun 54. lasix 20mg iv x1 given on the dday shift. positive I and O at 2400 and dr aware.\n\ngi abd distended. hypoactive bowel sounds. incision intact with staples patent. abd binder intact. stool x1 mod amt\n\naction: suctioned prn. insulin gtt initiated and blood sugars q1hr. nph insulin given also per dr . fentanyl and propofol gtt infusing. tube fdg infusing. venodynes intact. abd binder in place. update given to son and husband.\n\nrespnse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-21 00:00:00.000", "description": "Report", "row_id": 1466832, "text": "CONDITION UPDATE\nVSS. HYPERTENSIVE THIS AM. FENT AND PROPOFOL DRIPS INCREASED W/ EFFECT. DR. NOTIFIED. AROUSEABLE TO VOICE, AT TIMES SPONTANEOUSLY OPENING EYES. NOT FOLLOWING COMMANDS. LOCALIZING PAIN. NO MOVEMENT NOTED UPPER EXTREMITIES. LUNGS COARSE THROUGHOUT. OCC SUCTIONING FOR THICK WHITE SPUTUM. TMAX 102 - PAN CULTURED MD'S ORDERS. ABD SOFT, OBESE - HYPO BOWEL SOUNDS. ABD BINDER INTACT. ABD INCISION - STAPLES INTACT, C/D - SM AMT OF ECCHYMOSIS NOTED. U/O QS VIA FOLEY. NO STOOL THIS SHIFT. APPEARS TO BE COMFORTABLE ON FENTANYL DRIP. NO GRIMACING NOTED. CONT TFEED W/O INCIDENT.\nCONT TO MONITOR FOR S/S OF INFECTION. DIABETIC MANAGEMENT PER PROTOCOL AND ORDERS. PAIN MANAGEMENT. MAINTAIN SKIN INTEGRITY. CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-21 00:00:00.000", "description": "Report", "row_id": 1466833, "text": "Resp Care\nPt remains vented, decease from 14 -> 12, inc I time from 1.2 ->1.4. ABGs satisf, Sxn small thick white,\n" }, { "category": "Nursing/other", "chartdate": "2163-05-22 00:00:00.000", "description": "Report", "row_id": 1466834, "text": "Nursing Note--B Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and brisk. Weak corneals. Strong gag and cough. Rarely nods and shakes head to questions asked. Follows commands with LE's and tongue. No movement with BUE's. Withdraws minimally to noxious stimuli with UE's.\n\nRESP: LS coarse and diminished. Deep sxn for small to copious amts of thick white and clear secretions. See carevue for complete vent setting changes and abg results.\n\nCARDIAC: Tmax 100.8 HR 60-70's NSR. SBP 110-125. +PP. P-boots on.\n\nGI: Abd obese soft +bs. Abd binder on. Tol TF at goal. Large loose brown stool.\n\nGU: Draining qs clear yellow urine.\n\nINTEG: Eccymotic area on abdomen. See carevue for complete assessment.\n\nENDO: FS 98-157 goal is 80-120. Insulin gtt titrated to maintain goal.\n\nPLAN: Wean vent as tolerated, Q1 FS, Monitor VS and temp, Provide extra comfort and encouragement.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-22 00:00:00.000", "description": "Report", "row_id": 1466835, "text": "Resp: pt on a/c 12/450/14+/40%. Ett #7 retaped and secured @ 23 lip. BS are coarse with some crackles noted. Suctioned for moderate amounts of thick tannish/white secretions. MDI's administered as ordered with improvement noted. Vent changes (see carview for changes and abg's) Present settings a/c 18/450/12+/40% with am abg 7.37/54/90/32. No further changes noted.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1466812, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED THIS AM ON PROPOFOL, FENTANYL GTT, AND VERSED. VERSED STOPPED PER TEAM THIS AM. PROPOFOL WEANED DOWN TO 15MCG AND ATIVAN GIVEN INTERMITTENTLY. PROPOFOL OFF FOR A FEW HOURS HOWEVER PT BECAME HYPERTENSIVE TO 180'S AND BEGAN OVERBREATHING VENT. SPOKE TO PRIMARY TEAM, PROPOFOL OK TO CONTINUE AT SMALL DOSES. WHEN PT AWAKE, FOLLOWING COMMANDS AND MOVING ALL EXT. NODDING \"NO\" TO PAIN. PUPILS EQUAL, LEFT SLIGHTLY MORE SLUGGISH.\nCV- BP STABLE WHEN PT COMFORTABLE, 110-130. HR 60'S-70'S, NSR WITHOUT ECTOPY. LOPRESSOR CONTINUES Q4HRS WITH GOOD EFFECT FOR CONTINUED BETA BLOCKADE. SWAN DC'D THIS AM, TRIPLE LUMEN CONFIRMED BY X-RAY.\nRESP- LUNGS COARSE AT TIMES, CONTINUES TO HAVE THICK YELLOW, FOUL SMELLING SPUTUM. LEVOFLOX. STARTED THIS AM. NO VENT CHANGES MADE, O2 SAT VARIES FROM 93-96%.\nGI/GU- ABD DRESSING CHANGED, SCANT SEROSANG, STAPLE INTACT. ABD BINDER LEFT IN PLACE. HYPO SOUNDS, TUBE FEEDS STARTED AT ONLY 10CC/HR FOR NOW. UOP ADEQUATE, LASIX GTT CONTINUES AT 5-7MG/HR FOR A GOAL OF 2L NEG BY MIDNIGHT.\nID- TMAX 101.3 THIS AM PER SWAN, DECREASED WITHOUT INTERVENTION TO 99.7 WHEN ROOM COOLED AND BLANKETS REMOVED. BC X2 SSENT, URINE ALSO SENT.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-16 00:00:00.000", "description": "Report", "row_id": 1466813, "text": "Respiratory Care Note:\n received patient on full vent support this shift. No changes have been made. For specific settings please refer to carevue. patient continues to require high peep levels. BS are clear. SX for a small amount of white/yellow thick secretions via ett. No RSBI this am due to peep level of 17. SPO2 fluctuated between 91-95%. patient remained afebrile this shift. not overbreathing vent. Latest ABG is within normal limits. Will continue to monitor closely and wean peep as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-16 00:00:00.000", "description": "Report", "row_id": 1466814, "text": "NPN (NOC):\n\nRESP: PT REMAINS INTUBATED. CURRENT VENT SETTINGS: A/C 25/400/60% + 17 PEEP. NOT OVERBREATHING SET RATE. ABG: 151/45/7.42/30. BS'S CLEAR. SX'D Q 2 HRS FOR SM AMTS OF THICK WHITE TO YELLOW SECRETIONS. AFEBRILE.\n\nCV: REMAINS IN NSR ON AMIO DRIP. SBP'S MAINTANED UNDER 150.\n\nNEURO: REMIANS SEDATED ON PROPAFOL DRIP AT 15 MCG'S AND FENTYNL AT 100 MCG'S. NEEDED ATIVAN IVB X1 FOR HYPERTENSION W/ GOOD EFFECT.\n\nGI: TOL TROPHIC FEEDS WELL. FS'S CONSISTANTLY 150 ON SQ INSULIN SO DRIP RESTARTED W/ MUCH BETTER CONTROL, RATE CURRENTLY AT 3U/HR.\n\nGU; I&O - 2 LITERS AT MN. LASIX CONT AT 5 MG/HR. KCL 40 MEQ GIVEN X 1 FOR K OF 3.9. REPEAT 4.1. CA 2 AMPS GIVEN IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-02 00:00:00.000", "description": "Report", "row_id": 1466882, "text": "Pt awaiting Rehab bed\n\nNeuro-AA oriented, mouths words Non focal denies pain, anxious at times with trach and the need for sx medicated with ativan with effect\nCV-MP SR SBP control on multiple medications via feeding tube\nResp-trach collar, strong cough unable to expecturate, sx q2 hours for thick yellow secretions LS coares upper lobes dim at base\nGI-TF changed to incrase volume r/t low u/o\n\nPlan-cont pulm toilet, advance activity, cont rehab\n" }, { "category": "Nursing/other", "chartdate": "2163-06-02 00:00:00.000", "description": "Report", "row_id": 1466883, "text": "Respiratory Therapist\nPatient is still on TM doing fine suctioned for small thick white, plan is to have patient rest on the vent tonight and get transferred to rehab tommorrow, no ABGs done today.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-05 00:00:00.000", "description": "Report", "row_id": 1466894, "text": "Resp Care,\nPt. remains on 50% collar all noc. Sat 97-100%. C&R and suctioned for large amount white sputum. Xopenex x 1 this shift, held this am due to tachycardia. Cont. collar trial as tol.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-03 00:00:00.000", "description": "Report", "row_id": 1466884, "text": "Resp: pt on 50% T/C. Placed back on vent psv 5/5/40% to rest noc. BS are coarse bilaterally. Suctioned for moderate amounts of thick yellow secretions. Pt is scheduled to be d/c to rehab today. Will place back on 50% T/C.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-03 00:00:00.000", "description": "Report", "row_id": 1466885, "text": "foucs hemodymics\ndata: neuro: awake and following conversation. moves all extremities on the bed. at times attempts to help with turning in the bed.\n\nresp: on trach collar and suctioned for thick white sputum. back on vent for the nite and tol well. o2sats 95-100% abg's this am 7.38-55-124-34.\n\ncardiac remains in nsr. hct 29.7 inr 1.0 mag 2.6\n\ngu: foley patent and draining amber colored urine. creat 0.9 and bun 29.\n\ngI abd obese and distended. lg amt of brown foul smeling stool. tube fdg at goal of 80cc/hr.\n\naction: suctioned prn. back on the bed tonite. ativsan prn. tube fdgs tol well. no vomitting tonite. labs as ordered. update to husband. to go the rehab today.\n\nresponse: monitor closely\n" }, { "category": "Nursing/other", "chartdate": "2163-06-03 00:00:00.000", "description": "Report", "row_id": 1466886, "text": "nuero: pt open his eyes when you call her name. pt does follow commands. pupils equal and reactive to light.\n\npain: pt denies any c/o apin.\n\npulm: pt continues on trach collar. suctioning pt a lot for thick whitish secretions. abg done result pending. lungs coarse.\n\ncards: pt with runs of afib hr 120's-130's, also pt with an eposide of hr transiently dropping down to 40's and then going back up to 70-80's at times pt is in 1 avb, dr. aware. dr. aware. ekg done and given to dr. . sbp has been less than 160. pt continues on amiodarone.\n\ngi: pt has tube feedings at goal, no residuals noted. pt has no bm today.\n\ngu: pt with blood tinged urine,dr. aware, dr. aware, u/a to be sent.\n\nf/e: blood sugar 273 tx'd with 8 units of regular insulin per sliding scale.\n\nplan: continue to monitor, monitor cardiac arrithmias. send u/a, montior resp. status.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-03 00:00:00.000", "description": "Report", "row_id": 1466887, "text": "Respiratory Therapist\nBreath sounds clear diminished, suctioned for moderate thick white, spent the whole day on 50% cool mist via trach collar, ABGs at 1630 revealed a fully compensated metabolic alkalosis with normoxemia, most of the day patient was into Normal Sinus Rhythm but has had some episodes of 1st degree AV block, transfert to has been postponed due to lack of bed in the mean time patient will stay on trach collar during day, and on ventilator at night and cardiac status will continue to be monitored.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-14 00:00:00.000", "description": "Report", "row_id": 1466807, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED ON PROPOFOL AND FENTANYL GTTS, MINIMALLY RESPONSIVE THIS AM, PROPOFOL TITRATED DOWN THROUGHOUT THE DAY, CAN HAVE ATIVAN IV IF NEEDED. WHEN SEDATION DECREASED OR STOPPED, PT BECOMES HYPERTENSIVE TO 180'S. MOVING ALL EXT. IN RESPONSE TO PAIN, NO MINIMAL MOVEMENT NOTED FROM EXTREMETIES. PUPILS EQUAL, LEFT REMAINS SLIGHTLY SLUGGISH.\nCV- BP STABLE WHEN CALM AND SEDATED, 120-130'S. CLONIDINE PATCH PLACED, TO BE CHANGED Q WEEK. HR 60'S, NSR, NO ECTOPY NOTED. WILL CHECK LYTES THIS AFTERNOON. PALPABLE PERIPHERAL PULSES, EXTREMETIES WARM.\nRESP- LUNGS CLEAR, COARSE AT TIMES. SUCTIONED EVERY HOUR FOR COPIOUS AMOUNTS OF THICK YELLOW SPUTUM. TEAM NOTIFIED AND SPUTUM SENT. O2 SAT 93-94% MOST OF THE SHIFT. PEEP INCREASED TO 15 WITHOUT EFFECT. ABGS DRAWN THROUGHOUT THE DAY, PO2 LOW, INCREASE FIO2. WILL FOLLOW UP WITH ABGS.\nGI/GU- ABD SOFT, HYPO SOUNDS, ABDOMINAL BINDER ON. NO BM. NG TUBE TO LCWS, DRAINING LARGE AMOUNTS OF BILIOUS SPUTUM. UOP ADEQUATE, CURRENTLY ABOUT 800CC NEGATIVE ON LASIX GTT WITH GOAL OF LITERS NEGATIVE.\nID- TMAX 100.4\n" }, { "category": "Nursing/other", "chartdate": "2163-05-14 00:00:00.000", "description": "Report", "row_id": 1466808, "text": "resp care - Pt remains intubated on A/C 430/25/15 60% Pt was suctioned for mod thk yellow secretions. ABG showed hypoxia. PEEP was raised to 15. Continued respiratory support planned.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1466809, "text": "Respiratory Care Note:\n Patient bronched at beginning of shift for thick white secretions. Oxygenation improving with PEEP decreased to 15. She receives albuterol app Q4prn for wheezing and responds well to it. Plan to continue monitoring and weaning off PEEP as tolerated. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1466810, "text": "NPN (NOC):\n\nRESP: BRONCH PERFORMED AT 7PM. SX'D FOR COPIOUS SECRETIONS, SPEC SENT. OXYGENATION THEN IMPROVED. CXR W/ CLEARING OG R ARTELECTASIS, LLL CONSOLIDATION. LEVOFLOX BEGUN. CURRENT VENT SETTINGS: A/C 25X430X50% + 15 PEEP. AM ABG; 70/48/7.35/25. BS'S WHEEZY IN AM, GIVEN NEB W/ RELEIF.\n\nCV: AMIODARONNE CONT AND PT REMAINS IN NSR. LOPRESSOR CONT AT 20 MG Q 4HRS W/ HR'S IN THE 60'S AND 70'S. SBP'S MAINTAINED BELOW 150. SWAN NOS: CO 5-6 RANGE, SVR 900- 1200 RANGE, CVP'S LOW TEENS, UNABLE TO WEDGE. PLAN IS TO CHANGE SWAN TO CVL TODAY.\n\nNEURO; PT IS HEAVILY SEDATED. MIDAZ 2 MG IV BEGUN AT 6:30 AM, PROPAFOL TO BE WEANED TO OFF.\n\nGI: NGT TO LCS PUT OUT 100 CC'S BILE. TO BEING TROPHIC FEEDS TODAY.\n\nGU: PUTTING OUT 200/HR TO LASIX DRIP AT 7 MG. K RECHECKED = 3.7, ADDITIONAL 40 MEQ'S REPLACED.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-15 00:00:00.000", "description": "Report", "row_id": 1466811, "text": "resp care - Pt remains intubated on 60% A/C 430/25 PEEP raised to 17.\nPt suctioned for thick yellow secretions. BS wheezes in LL, diminished in RL. No ABGs today. Continued resp monitoring planned.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-01 00:00:00.000", "description": "Report", "row_id": 1466877, "text": "Events: Traveled to fluoro fo feeding tube, FT remains in stomach Tf to start\n\nNeuro: non focal, with sclera hemorrhage improving, Pain management/anxiety: Fentanly drip d/c and fentanly patch started with effect, pt c/o of anxiety with increase SBP with activity and suctioning, ativan given PRN wih effect\nCV-HTN managment with triple medications, NTG drip weaned to off, clonidine patch, hydralazine ATC, prasozin started, vasotec, and enalapril all via NGT, MP SR with occass PVC and 1x run Afib continues on amiodarone, and lytes repleted, CSM WNL, SQ heparin and SCDS for DVT prophylaxis\nResp-ML trach site with sutures, LS coarse rhonchi upper lobes dim at base 40% TV 500-800, to trach collar, sx for mod thick yellow\nGI-TF to start, +BS, glucose covered with SS to start PO agents for glucose in PM\ngu-Lasix this am, maintain even I/O, urine with trace sediment, foul odor from peri-area and cath, SICU team updated\nSKin-abd incision healing\n\nPlan-trach collar, pulmonary toilet, rest on vent overnight, continue to maintain SBP <160, ?hold NPH tonight when starting po agents, start TF, ?recheck KUB in AM to assess tube migration, cont ativan for anxiety, rehab screen in progress\n" }, { "category": "Nursing/other", "chartdate": "2163-06-01 00:00:00.000", "description": "Report", "row_id": 1466878, "text": "Resp Care\n\nPt weaned to 50% t-mask with follow up abg of 7.36/54/129/32. BS are coarse and suctioning thick yellow sputum\n" }, { "category": "Nursing/other", "chartdate": "2163-06-02 00:00:00.000", "description": "Report", "row_id": 1466879, "text": "condition update\nneuro: opens eyes spont. , mae, follow commands, denies pain, nodding and mouthing words appropriately.\nCV: nsr, no ectopy noted. sbp dipped 90's overnight, some hypertensive meds held, sbp returned to 130's without intervention. Dr. aware. +palp peripheral pulses. u/o dropped off this am, received 500cc bolus of ns with effect.\nResp: returned to cpap overnight, suctioned for mod. amts. thick yellow sputum, ls coarse and diminished.\nGI: tf continues at goal, one episode of ~50cc emesis early in evening. abd soft, +bs, no bm.\nGu: urine noted to be leaking around foley insertion site, foley was replaced. foley draining amber clear urine.\nEndo: bs at 0345 was 41, amp. d50 given, repeat bs 119. dr. notified, sliding scale adjusted.\nplan: continue to monitor bp, monitor u/o, trach. collar today, transfer to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-02 00:00:00.000", "description": "Report", "row_id": 1466880, "text": "Respiratory Care Note:\n patient rested last evening on CPAP/PS, alternating with a trach mask/cool mist. patient currently on a 50% cool mist, tolerating well. BS are coarse to diminished at the bases. SX for a moderate amount of yellow thick secretions via trach. RSBI this am is 21.6 on 0 peep and 5 psv. patient remained afebrile. MV ranged from 6-7 L. SPO2 remained 98-100%. MDI's administered as ordered. Plan is to continue on trach mask as tolerated and transfer to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-02 00:00:00.000", "description": "Report", "row_id": 1466881, "text": "addendum\nt-wave inversion noted on tele monitor this am, dr. notified, ekg obtained. EKG reviewed by Dr. and Dr. , ?? new t-wave inversion in leads v2/v3. No new orders at this time, Dr. will discuss with team.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-13 00:00:00.000", "description": "Report", "row_id": 1466801, "text": "significant event. pt reloaded with 150mg of iv amiodarone. amiodarone remains at .5mg/min. pt recieved 20mg of iv lasix. lasix gtt started presently at 2mg/hr.\n\nnuero: pt not opening eyes to verbal command,pt not withdrawing from painful stimuli. pupils equal and reactive to light. dr. , dr. aware. propofol gtt shut off. after app. 20min.pt did open her eyes when you called her name. pt not following commands. pt did move her legs on bed, no spontanous movement noted in upper extremteis, but pt did withdraw upper extremties pt painful stimuli, dr. present during nuero assessment. propfol gtt restarted as ordered. pt with orbital edema, eye ointment applied.\n\npain: pt continues on fentanyl gtt at 100mcg/hr as ordered.\n\npulm: pt continues on ac. see flowsheet for settings. suctioning pt for small amt of yellow secretions. abg 7.32/45/85/24,dr. aware.\n\ncards: pt recieved amiodarone bolus, amiodarone remains at .5mg/min, pt converted back to sr. co 4.49, ci 2.15, svr 837 dr. , dr. aware. wedge this morning 29, pt recieved 20mg of iv lasix and lasix gtt started at 2mg/hr. cardiac echo done. second set of ck' and iso sent.\n\ngi: pt remain npo.\n\ngu: u/o 30cc/hr prior to lasix\n\nabd: abd. incison with staples no drainage noted, dsd over site. abd. binder remains on.\n\nf/e: blood sugar 130 tx'd with 2 units of regular insulin per sliding scale.\n\n\nplan: continue to monitor, titrated lasix gtt goal is to have pt 2 liter negative today. check electroyles as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-13 00:00:00.000", "description": "Report", "row_id": 1466802, "text": "Resp Care\n\nPt remains on full vent support with an abg of 7.32/45/85/24. MV is being maintained at 10L. BS are generally clear and with rhonchi suctioining is required. Suctioning thick yellow sputum\n" }, { "category": "Nursing/other", "chartdate": "2163-05-13 00:00:00.000", "description": "Report", "row_id": 1466803, "text": "resp care- Pt remains intubated on A/C 400/25/10 60%. BS wheezes t/o. Sx mod amt of yellow thick secretions. Blood gas slightly acidotic. Continued respiratory monitoring planned.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-13 00:00:00.000", "description": "Report", "row_id": 1466804, "text": "continues on propofol and fentanyl, not waking up for nuero checks per dr. . remains in sr. sbp up to 150's, dr. aware. lopressor to be increased to 15mg. pt recieved an additional 20mg of iv lasix and lasix gtt increased to 4mg/hr. dr. aware.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-14 00:00:00.000", "description": "Report", "row_id": 1466805, "text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. Attempted to wean O2, but returned to 60% due to significant decrease in PaO2. BBS-exp wheeze and diminished bases, no change post BD therapy. Sx'ed for thick, yellow secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-14 00:00:00.000", "description": "Report", "row_id": 1466806, "text": "2300-0700 SICU Nursing Note\nEvents: Unsuccessful attempt to wean 02 to 50 % during evening with decrease in p02---returned 02 to 60 % with improved ABG. Remains sedated on IV Propofol and IV Fentanyl gtts, HR control with IV Amiodarone and Lopressor. Hemodynamically stable.\n\nNeuro: IV Fentanyl at 100 mcgs/hr and IV Propofol at 40 mcgs/kg/min. Withdraws to painful stimuli, opens eyes to stimulation , not moving extremities and not following commands, right pupil 3mm and brisk, and left pupil 3mm and sluggish (reported to be same yesterday). Bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\n\nCardiac: HR= 63-67 SR with rare PVC noted. No evidence of RAF. IV Amiodarone dose decreased to 0.25 mg/min at MN as ordered. IV Lopressor Q 4hr. Left radial Aline with good waveform. BP= 100-120/40-50. Right IJ PA line site C/D/I and PA with good waveform. PA= 41-49/22-29. CVP= 19 initialy with trend down to 13 this am. PCWP= 31 initially with trend down to 22 this am. Co= 5.27, CI= 2.52, SVR= 880. Continues on IV Lasix gtt at 4 mg/hr with weight unchanged from yesteday and pt neg. 300 ml since MN ( remains 5.5 L positive for LOS). Positive bilat DP/PT by doppler with feet warm to touch. Ionized calcium= 1.08---treated with 2 gms. Calcium gluconate. K= 3.7---treated with 40 mEq KCL.\n\nResp: Attempt to wean 02 to 50% with p02=69.....FI02 increased back to 60 % for night with good abg= 7.34-44-85. Remained on 400-60%- AC=25 with Peep=10 all night with Sats 93-95%. TV increased to 430 this am with ABG to be sent. Lungs remain clear in bilat upper lobes and diminished at bilat. bases. ETtube suctioned for mod. amts. thick yellow sputum and orally suctioned for same.\n\nGI: Abd distened with distant hypoactive bowel sounds noted. NGtube placement checked by ausculatation and draining small amts bilious liquid to LWS. Abd incision with staples and DSD intact with binder present.\n\nGU: Foley to CD draining clear yellow urine in good amts >50ml/hr.\n\nSkin: Abd. incision with DSD C/D/I. Otherwise skin grossly WNL and no breakdown noted.\n\nEndo: Fingersticks QID---4am= 120---no coverage required.\n\nID: Tmax= 100. WBC= 7.0......no antibx at present time.\n\nSocial: husband called this am and was updated on pt's condition during the night.\n\nPlan: Continue aggressive diuresis and wean vent and sedation as tolerated, Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-31 00:00:00.000", "description": "Report", "row_id": 1466873, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, MOUTHING WORDS APPROPRIATELY. DENIES PAIN, FENTANYL GTT WEANING DOWN AND MORPHINE ORDERED PRN. MOVING ALL EXT. AND FOLLOWING COMMANDS. OOB WITH .\nCV- REMAINS SLIGHTLY HYPERTENSIVE IN 150'S-160'S. VASOTEC DC'D PER ICU TEAM AND HYDRALAZINE WRITTEN FOR PO Q 6HRS. TEAM OK WITH BP 160 OR LESS. HR 60'S-70'S, NSR, NO FURTHER BRADYCARDIA TODAY, NO ECTOPY.\nRESP- LUNGS CLEAR, SUCTIONED FOR LARGE AMOUNTS OF THICK WHITISH SPUTUM, HOWEVER MUCH LESS THAN PREVIOUS DAYS. WEANED TO CPAP AND WILL CHECK ABG, DENIES ANY SOB. CONTINUES TO GAG WHEN SUCTIONED AND OCCASIONALLY APPEARS TO DRY HEAVE, HOWEVER NOT ACTUALLY VOMITING ANYTHING.\nGI/GU- ABD SOFT, +BS. TUBE FEED AT GOAL AND TOLERATING WELL, MINIMAL RESIDUALS. DECREASING THROUGHOUT THE DAY, BECOMING CONCENTRATED, NEED ADDITIONAL LASIX TODAY, BUT WILL FOLLOW UP WITH TEAM. PT IS CURRENTLY ABOUT 700CC NEG.\nID- AFEBRILE. ANTIBIOTICS DC'D.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-31 00:00:00.000", "description": "Report", "row_id": 1466874, "text": "Respiratory Care: Pt remains trached and vented, recieved on AC. Able to wean vent support to PS 5/5, pt tolerating well, Vt between 600-850, RR 7-14 keeping MV 6.5 and 7.5. Good follow up ABGs. breath sounds coarse that cleared with suctioning. Sx for thick white secretions. MDI's given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-01 00:00:00.000", "description": "Report", "row_id": 1466875, "text": "Respiratory Care Note:\n patient remains on CPAP/PS this shift with no changes being made. For specifics please refer to carevue. BS are coarse throughout, diminished at the bases. SX for a small amount of white to pale yellow thick secretions via trach. patient often gags when suctioned. RSBI this am is 27 on 0 peep and 5 psv. patient remained afebrile this shift. MDI's administered as ordered. SPO2 remained 99-100%. Volumes ranged between 561-716 and RR ranged between . Plan is to maintain support and wean to a trach collar when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-01 00:00:00.000", "description": "Report", "row_id": 1466876, "text": "condition update\nsee carevue for specifics;\nNeuro: , to command, fent. gtt continues, nodding and mouthing words appropriately.\ncv: hypertensive thoughout the night, especially with coughing, stimulation, etc. Dr. aware, hydralazine given prn and as an extra x's 1 dose with little effect. vasotec dose given this am also with little effect (vasotec previously held d/t n/v). Vascular team notified, po regimen will be adjusted this am per Dr. .\nResp: remains on cpap 5/5, suctioned for mod. amts. thick white to tan/yellow sputum. ls coarse and diminished. 02 sat 99-100.\nGI: pt had several episodes of vomitting this evening, dr. notified. tf held, and ngt to placed to lws. Vomitting and gagging appears to occur after in conjunction coughing/suctioning. Anzemet given x's 1, though pt denies nausea. abd is soft, no bm, colace given, +bs and +flatulance.\ngu: foley draining adequate amts. clear to amber urine, marginal amts. this am, Dr. was notified, u/o since increased without intervention.\nEndo: covered with sliding scale and nph dose d/t npo status\nplan: continue pulmonary toileting, post-pyloric ngt placement today in IR, blood pressure control, goal sbp <160.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-11 00:00:00.000", "description": "Report", "row_id": 1466793, "text": "STATUS\nD: LOW GRADE TEMP..PERL MOVES ALL EXTREM'S TO STIMULI DOESN'T FOLLOW COMMANDS..REMAINS ON PROPOFOL/FENT/NTG GTT'S\nA: SWAN OUT TO 40CM REPOSITIONED BY DR TO 50CM ABLE TO WEDGE NOW 13-17..CO ..CI >2.0..STARTED ON IV LOPRESSOR Q4H & NTG GTT WEANED OFF..MULTIPLE VENT CHANGES & ABG'S(SEE FLOW SHEET)SUCTIONED FOR MIN WHITE..INR 1.6 GIVEN 1U FFP REPEAT INR 1.5..HCT 28 1U PC ORDERED..BS'S >160 STARTED ON INSULIN GTT TO KEEP BS <120..ABD INCISION C&D ABD BINDER ON..HUO'S BORDERLINE 30-70CC/H..NG DRAINING SM AMT BROWN\nR: STABLE\nP: REPEAT LABS AFTER PC'S IN..MONITOR VENT STATUS & ABG'S CLOSELY INSULIN GTT TO KEEP BS <120..CONTINUE TO MONITOR NEURO STATUS\n" }, { "category": "Nursing/other", "chartdate": "2163-05-12 00:00:00.000", "description": "Report", "row_id": 1466798, "text": "STATUS\nD: LOW GRADE TEMP..REMAINS ON FENT & PROPOFOL GTT'S..MOVES ALL EXTREM'S TO STIMULI..P=RL..DOESN'T FOLLOW COMMANDS\nA: NO VENT CHANGES..HYPERTENSIVE WITH TURNING ON RT SIDE..NTG GTT RESTARTED..EXTRA DOSE LOPRESSOR GIVEN WITH MIN EFFECT>>>PT TURNED ON BACK WITH DECREASE IN BP..TURNING PT ON LF SIDE DOESN'T SEEM TO EFFECT PT'S BP...HO & DR AWARE..LASIX 20MGM X2 GIVEN WITH MIN EFFECT BLADDER PRESSURE 26..ABD DSG/BINDER UNCHANGED..REPEAT HCT 27 NO COLLOID ORDERED\nR: CONDITION GUARDED\nP: CONTINUE TO MONITOR PULMONARY & HEMODYNAMIC STATUS FREQ/AS ORDERED\nMONITOR FREQ LAB'S PER HO ORDERS\n" }, { "category": "Nursing/other", "chartdate": "2163-05-13 00:00:00.000", "description": "Report", "row_id": 1466799, "text": "Nursing note:\n Remains sedated on Fentanyl and Propofol gtts, opens eyes spont and to voice. PERRLA. MAE weakly on bed, purposeful in movements, does not follow commands. Lung sounds clear, dim to bases. No vent changes overnight, sats slightly lower - 92-95%, ABGs acceptable. Core temp max 101.3. SR w/PACs early in evening, RAF to 130s at 2300. Given 20mg total Lopressor IV w/o effect. Loaded w/Amio and begun on Amiodarone gtt w/some rate control but remains in afib. SBP initially 120s but decreased to SBP in 90s after mult. doses Lopressor. CVP 15-17. CO/CI per Carevue, CI remains >2. Wedge 20-26. Good diuresis w/Lasix 20mg IVP. +Hypo BS, abdomen softly distended. -stool. Binder in place. +peripheral pulses, +mild generalized edema. Gross orbital edema, eye gtts and ointment applied PRN. Skin intact. Family in visiting, took pt's belongings home w/them (daughter .)\n\nA/P: RAF on Amio gtt s/p ruptured AAA repair, fluid overloaded - diuresing well with Lasix. Continue to monitor cardiopulmonary status closely, aggressive diuresis, support.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-13 00:00:00.000", "description": "Report", "row_id": 1466800, "text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. BBS-clear w/decreased bases, no change post BD therapy. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-30 00:00:00.000", "description": "Report", "row_id": 1466869, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, MOUTHING WORDS APPROPRIATELY, MOVING ALL EXT. DENIES PAIN, REMAINS ON FENTANYL GTT. MAE, OOB TO CHAIR WITH . BECOMING AGITATED THIS AFTERNOON, FEELING ANXIOUS, ATIVAN 1MG X 1 GIVEN WITH GOOD EFFECT.\nCV- HYPERTENSIVE TO 180'S-200, NITRO GTT INCREASED THROUGHOUT THE DAY, FAIR EFFECT. ENALAPRIL AND NORVASC STARTED PO WITH FAIR EFFECT FOR BP CONTROL. HYDRALAZINE PRN INCREASED TO 20MG. ABLE TO WEAN NITRO GTT OFF THIS AFTERNOON FOLLOWING ADMINISTRATION OF ATIVAN. BRADYCARDIA IMPROVED, HR IN 60'S MOST OF THE DAY WITHOUT ECTOPY. K REPLETED THIS AFTERNOON.\nRESP- LUNGS COARSE, SUCTIONED EVERY FEW HOURS FOR MODERATE AMOUNTS OF THICK WHITE SPUTUM. PEEP WEANED TO 5 AND ABG SATISFACTORY.\nGI/GU- ABD SOFT WITH +BS. DOBHOFF DC'D AND NG TUBE PLACED AND CONFIRMED BY X-RAY. TF STARTED AND ALMOST AT GOAL WITH MINIMAL RESIDUALS. PLAN TO CONTINUE FEEDING AS LONG AS RESIDUALS REMAIN LOW. A FEW EPISODES OF GAGGING AFTER SUCTIONING, NO VOMITING. NO BM TODAY. ADEQUATE, DIURESIS CONTINUES WITH LASIX 40MG .\nID- AFEBRILE\n" }, { "category": "Nursing/other", "chartdate": "2163-05-30 00:00:00.000", "description": "Report", "row_id": 1466870, "text": "Resp Care\nPt continues to be trach on vent. PEEP weaned today from 8 down to 5 ABGs good on 5 of peep (please see carevue for specifics). Pt continues to have mod amts of secretions and course BS. MDIs given. Will continue to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-11 00:00:00.000", "description": "Report", "row_id": 1466794, "text": "resp care\npt continues to be intubated and mechanincally ventilated on A/C. Vt decreased today using lung protective strategies and RR increased to maintain Ve. PLease see carevue for current vent settings and correlating ABGs. Pt has slightly course BS bilaterally with only scant amts of secretions. will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-12 00:00:00.000", "description": "Report", "row_id": 1466795, "text": "Events:\n\n2u FFP for INR>1.7, decrease u/o to 25cc/hr, responded to blood volume\nSAo2 94, Pao2 64, increased PEEP with improved Pao2 74, remains with metabolic acidosis\n\nNeuro-PERLLA, does not follow commands, moves all extrem, grimace, biting down on ETT with activity/stimuli, propofol and fentanly increased for pts comfort with effect\nCV-MP SR with BBB and inverted T waves, betablockers ATC, NTG drip titrated for SBP 100-140, CI>2.0, CSM WNL, SCDS and heparin SQ for DVT prophylaxis\nResp-AC 25, TV 400, PEEP 10, 50%, PIP 34, LS grossly dim upper airway exp wheeze, albuterol nebs given with effect\nGI-abd large round soft abd binder on, abd incision with DSD CDI, NGT bilious secretions out, insulin drip fro glucose less than 120\nGU-urine out concentrated CR 1.4\nID-kefzol\n\nPlan- wean propofol to off assess neuro exam, cont fentanly for pain control, cont lopressor, wean NTg to off maintain tight blood pressure paramaters 100-140 SBP, may need diuresis, monitor acid base balance and renal function, continue tight glycemic control\n" }, { "category": "Nursing/other", "chartdate": "2163-05-12 00:00:00.000", "description": "Report", "row_id": 1466796, "text": "Events:\n\nDesats 89-90, sx for minimal secretions, increased sedation for ventilation and increase Fio2, CVP 18-20 and PCWP 23 with decrease u/o, noted ST depression on EKG, 12 lead EKG done noted previous EKG with invert T waves now with slight ST depression, cardaic and troponin sent, NTG continues\n\nPlan- CXR, ?diuresis, increase betablocker, serial cardiac enzymes, follow ABG\n" }, { "category": "Nursing/other", "chartdate": "2163-05-12 00:00:00.000", "description": "Report", "row_id": 1466797, "text": "Respiratory Care:\n\nPatient intubated on mechanical support. Patient requiring increased peep levels/Fio2 for low PaO2. Bs faint expiratory wheezes noted R lung, otherwise lungs clear and decreased bilaterally. Albuterol MDI given Q4hr. Wheezes resolving. Metabolic acidosis. Fluid positive. Pt. desating to 89%. Fio2 increased to 60%. RN, ventricular ectopy, ST changes this shift. No further Peep changes made at this time.\nPlan: Continue with mechanical support and increased peep as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-31 00:00:00.000", "description": "Report", "row_id": 1466871, "text": "condition update\nneuro: alert, follows commands, nodding and mouthing words appropriately. pupils equal and reactive. fentynal gtt continues with adequate pain control.\ncv: hr sinus, 50's-60's, no ectopy. Pt hypertensive with coughing or stimulation, hydralazine given prn for goal sbp <150. Palp. peripheral pulse. K+ 3.8 repleted with 40 meq. + diuresis with schedule lasix dose.\nResp: no vent changes, abg acceptable. ls coarse diminished, suctioned frequently for mod. amts. thick white sputum. Trach. care done.\nGI: abd soft, +bs, no bm overnight. tf increased to 30cc/hr (goal), residuals are minimal. At approx 0100, after strong coughing, pt appeared to gag and vomitted approx. 10cc tube feed/bilious emesis. Pt denies nausea. No further emesis. Ok to continue tube feeds per dr. .\nGU: foley draining adequate amts. clear yellow urine.\nEndo: covered with ssri and 12 units nph, as discussed with Dr. .\nPlan: oob to chair, continue pulmonary toileting and vent. weaning, continue bp control,goal sbp <150.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-31 00:00:00.000", "description": "Report", "row_id": 1466872, "text": "Respiratory Care\nPt remain trached and on vent support. Pt is trached with a #7 Portex. Cuff was inflated with no leak. Current vent settings are A/C 500/14/40%/5. No vent changes were made during shift. Lung sounds had course rhonchi that cleared after suction. Pt was suction for moderate amounts of thick white sputum. Pt had a RSBI of 21.7. No recent gas has been drawn. Pt received MDI's with increase in air movement. Care plan is to remain unchanged.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-17 00:00:00.000", "description": "Report", "row_id": 1466819, "text": "Update: D\nSee Careview for specific data\n\nNeuro: Sedated on propofol & fentynal. Responds to voice with eye opening and localizes with painful stimuli. Follows commands inconsistently during daily wake up.\n\nCV: HR at target in 60s with increase to 70s 1-2 hrs pre-lopressor & amiodarone dose. SBP stable at < 150 except with stimulation can elevate to 180s.\n\nResp: FiO2 decreased from 50 to 45. Initial O2 sats to 94% and ABGs suggested poor tolerance. Sats have since increased to 99%. Follow up ABGs needed to determine additional vent changes. LS coarse throughout. Strong cough & sxn for mod. thick yellow sputum.\n\nGI TF at 50cc, no residuals, advance q6 to goal of 80. No stool this shift.\n\nGU: u/o 100-240cc/hr on mg/hr lasix gtt for 24 hr goal of neg 1-2L.\n\nSkin: abd incision sutures clean/dry. DSD changed. Diffuse slightly raised pink lesions noted across trunk. Dr. notified, 25 mg Benadryl given.\n\nSocial: family in to visit\n\nPlan: Monitor respiratory status, wean from vent as tolerated. Monitor hemodynamic status & wean from sedation as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-17 00:00:00.000", "description": "Report", "row_id": 1466820, "text": "Resp Care\nPt remains vented on AC with +17 Peep and .45. PaO2 still only in 70s. Sat running hi 90s. BS course throughout with prod sxn. Plan is too take small steps towards weaning.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-18 00:00:00.000", "description": "Report", "row_id": 1466821, "text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. BBS-Clear and diminished, no change post BD therapy. Sx'ed for thick, white secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-18 00:00:00.000", "description": "Report", "row_id": 1466822, "text": "NURSING PROGRESS NOTE\nPlease see carvue for specifics:\nNeuro: Pt remains lightly sedated low dose prop gtt. Pt arouses to voice and does not follow commands. Withdraws to pain. Remains on Fent gtt at 50mcg/hr for pain mmgt with good effect.\nCV: HR-SB-NSR no noted ectopy. BP remains within paramenters. DP/PT pulses palpable. + Cap refill. Extremities warm. Remains with low grade temps. Cont on lasix gtt goal -liter by MN.\nResp: Current vent setting A/C .40% 450X27 w/17 peep. Lungs clear to diminished at the bases. Abg's + alkolosis Diamox given. Tolerating 40% Fi02 well. Sxn mult X's for mod-copious amts of secretions. + Strong productive cough.\nGI/Gu: Abd soft + bruising to abd area. Tolerating TF well currently at goal with minimal residuals. + BS no BM. Foley patent drng adequate urine.\nEndo: RIss\nID: Started on vanc and flagyl. WBC's rising\nPlan: Cont with slow vent wean as tolerated. ? eventual trach. Cont to monitor pt's hemodynamics. Cont with emotional support to family. SS email overnoc per family request. Cont with current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2163-06-05 00:00:00.000", "description": "Report", "row_id": 1466895, "text": "npn\nNeuro- follows commands and mae, mso4 prn.\n\nResp- cont to tol trach collar with .40 fio2, sxn prn thick yellow secretions. lungs coarse with occasional insp wheeze bilat, nebs pr resp therapy.\n\n pt cont in a fib overnoc and early this am- had episode of block/asystole rhythm lasting few seconds this am- no change in bp and remaining , converted to sinus rhythm- ekg done and md aware. Followed by cardilogy- plan at this time- to consult ep for pacemaker. Will likely schedule pacemaker for . (see flow sheet for all #'s).\n" }, { "category": "Nursing/other", "chartdate": "2163-05-29 00:00:00.000", "description": "Report", "row_id": 1466867, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT AND MOUTHING WORDS, FOLLOWING COMMANDS. PT BECOMING FRUSTRATED AT TIMES WHEN TRYING TO TALK, COUGHING, BECOMING HYPERTENSIVE. ATIVAN .5MG IV GIVEN X 1 WITH GOOD EFFECT FOR MILD ANXIETY AND NOT OVER SEDATING. MOVING ALL EXT. PERRL. DENIES PAIN.\nCV- BECOMING HYPERTENSIVE AT TIMES TO 200 WHEN COUGHING, BEING SUCTIONED. WHEN BP REMAINING IN 160'S WITHOUT STIMULATION, HYDRALAZINE GIVEN PRN WITH GOOD EFFECT. REMAINS BRADYCARDIC IN HIGH 40'S-50'S WITHOUT ECTOPY. LYTES CHECKED THIS AFTERNOON, K 2.9 AND REPLETED.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED FREQUENTLY FOR COPIOUS AMOUNTS OF THICK WHITISH SPUTUM. O2 SAT IMPROVED TODAY, 95-99% ON 40%. PEEP WEANED TO 8 SUCCESSFULLY WITH SATISFACTORY ABGS.\nGI/GU- ABD SOFT, HYPO SOUNDS. TUBE FEED OFF FOR MOST OF THE DAY. CHEST X-RAY DONE TO CHECK DOBHOFF PLACEMENT, SHOWING COILED IN THE STOMACH, NO LONGER POST-PYLORIC. PT VOMITING SMALL AMOUNTS OF GREENISH BILE, HAPPENING ONLY FOLLOWING SUCTIONING AND APPEARS TO BE CAUSED BY GAG REFLEX. TUBE FEED RESTARTED PER DR. , HOWEVER TO REMAIN TROPHIC ONLY OVERNIGHT. SCANT AMOUNT OF LOOSE STOOL, MOSTLY ABSORBED INTO PAD, UNABLE TO GUIAC, BUT NOT APPEARING TO BE POSITIVE.\nID- AFEBRILE\n HUSBAND AND TWO CHILDREN IN TODAY, UPDATED ON PROGRESS, FAMILY WEEPY.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-30 00:00:00.000", "description": "Report", "row_id": 1466868, "text": "focus hemodynmics\ndata: neuro: more awake tonite and engaging in conversation. pt mouthing words. pt becomes anxious at times especially while being suctioned. reassurance given. moves all extremities on the bed. moves hands up to her trach.\n\nresp: suctioned for copius amts of thick white sputum. o2sat 90's. hob elevated to 30-45 degrees. trach care done x3.\n\ncardiac: bp elevated to 180-190's. hyralazine 10mg iv given. bp continues to be> 170's. fentanyl gtt at 50mcg/hr. dr in and aware of elevated bp. nitroglycerine gtt started and titrated to keep bp < 150. hct 29.3 k 3.4 and repleted with 40meq kcl. magnesium level 2.1\n\ngu: foley patent and ddraining yellow urien. creat 1.3 . lasix 40mg iv given as ordered. good response from the lasix. diamox iv given as ordered.\n\ngi : abd obese and distended. stool x2 brown with some flecks of blood noted. guiac positive. tube fdgs held at 2400 due to pt going to flouro this am to pass fdg tube post pyloric.\n\naction: suction prn. labs as ordered. nitroglyclerine gtt started and titrated. tube fdgs on hold at 2400 for flouro trip this am. fentanyl gtt at 50mcg/hr. k repleted. nph insulin held due to npo. family in\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-05 00:00:00.000", "description": "Report", "row_id": 1466896, "text": "Resp Care Note:\n Patient on 50% trach collar for >24 hours and tolerating well. vent discontinued from bedside. She is receiving levalbuterol (xopenex) Q6prn for wheezing and has been suctioned and coughs productively for thick, yellow-tinged secretions. Plan to monitor and continue with pulmonary hygiene.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-06 00:00:00.000", "description": "Report", "row_id": 1466897, "text": "nsg.progress notes:\nsee flow sheet for specific:\nNeuro : A&O,MAE,PERL,obeying commands,communicating with mouthing words,prn ativan& morphin\nCV: NSR,no ectopy,BP wnl,Hydralazine Po with good effect,fluid bal.+ 200by MN\nResp: trach collar with 10L o2 tolerated,o2 sat wnl,strong productive cough,coughing out yellow thick secretion most of the time,Sxn prn,LS coarse - clear.\nGI: Tf tolerated,BS+,abd obese,no bm today\nGU: foley cath patent amber coloured urine.adq amt.\nEndo: FS Q6H,ssri& NPH\nAct: bed fast,turned & position changed Q2H.\nId: Afebrile,VSS.vancomycin 1000mg to start from \nSocial: visited by pt's son & updated with him.\nprocedure : for pace maker insertion on tuesday,hold heparin ,NPO from MN,& to start vancomycin on same day.to get consent\nplan: cont monitoring,pulm hygiene,arrange for rehab after pace maker insertion.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-06 00:00:00.000", "description": "Report", "row_id": 1466898, "text": "Resp Care,\nPt. remains on 50% collar. C&R and suctioned for thick white sputum. Xopenex given x 2 this shift. BS coarse wheezes.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-06 00:00:00.000", "description": "Report", "row_id": 1466899, "text": "NPN: Review of Systems\nNeuro: . Communicating by mouthing words. Cooperative. DEnied pain, but reported feeling anxious. 1mg IV ativan w/ good relief.\n\nResp: Pt has been on TM since and is tolerating well. BS are clear-> coarse. Requires suctioning q 1-2hrs for thick yellow secretions. Breathing unlabored. Sao2=98%. Trach care done. Tolerates CPT. Strong productive cough.\n\nCV: SR w/ HR 70s-80s. No ectopy. SBP 129-180/. PRN doses of hydralazine given w/ brief effect. Afebrile. Skin warm/dry.\n\nGI: Abdomen is obese. Midline incision healed. Promote w/ fiber infusing at goal rate of 80cc/hr. Held for transfer.\n\nEndo: Blood sugar high->10am=214 for which fixed NPH dose of 18 units, and Regular insulin sliding scale dose of 15 units given. Blood sugar=235 at 1500-> 15 units of regular insulin given and Tubefeedings on hold for transfer.\n\nGU: Foley to gravity draining clear yellow urine.\n\nSkin:No pressure wounds present.\n\nSocial: Husband called. Dtr also called and is aware that Pt will be transferred to . Spoke w/ Dr. who comfirmed Pt's transfer and that pacemaker was not going to be placed.\n\nA: Pt tolerating Trach mask. Requires suctioning q1-2hrs. Hemodynamics stable.\n\nP: Transfer to for rehabilitation.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-11 00:00:00.000", "description": "Report", "row_id": 1466791, "text": "Resp. Care:\n Pt. placed on vent. upon arrival to sicu from O.R.--S/P emergent AAA repair. Able to wean Fi02 to 60%, but pt. requiring a high Ve to help improve acid/base status. Please see flow sheet for details. Will cont. to follow closely. BS- diminished/equal bilat. with few coarse rales. Sx- sm. thick pale yel.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-11 00:00:00.000", "description": "Report", "row_id": 1466792, "text": "65 year old female admit to SICU s/p infrarenal AAA repair for ruptured AAA\nEBL 1500cc, 3u FFP, 3u PRBC, x-clamp 96minutes,\nPt remains intubated, propofol and fentanly drip, PERLLA\nCV-MP SR with invert T waves and BBB, goal SBP 100-140 NTG drip, neo weaned off fluid bolus given for acidosis and decrease CI, ?MR <2, Svo2 79 Fick CI>3, SCDS on bilat, generalized edema\nResp-LS dim coarse upper lobes, AC rate increased for resp acidosis\nGI-NGT, tight glycemic control, absent BS, abd large round incision with DSD intact, abd binder on\nGU-u/o 20-30cc/hr, IVF at 125cc/hr\nID-kefzol\n\nPlan-Maintain SBP 100-140, follow FICK CO/CI, may require fluid bolus for acid base balance, monitor lactate, cont ABX, monitor renal fucntion and u/o, tight glycemic control, pain management, FFP for INR less than 1.5\n" }, { "category": "Nursing/other", "chartdate": "2163-05-16 00:00:00.000", "description": "Report", "row_id": 1466815, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT REMAINS SLIGHTLY SEDATED ON PROPOFOL AND FENTANYL GTTS. FENTANYL DECREASED AND PROPOFOL REMAINS AT 15MCGS. OPENS EYES TO VOICE, DOES NOT FOLLOW COMMANDS. MOVES LOWER EXT. ONLY SLIGHTLY ON THE BED AND ONLY IN RESPONSE TO PAIN. PUPILS EQUAL AND REACTIVE.\nCV- LOPRESSOR STARTED 100MG PO TODAY WITH EXCELLENT EFFECT. SUCCESSFUL IN WEANING PROPOFOL WITHOUT CAUSING HYPERTENSION DUE TO INCREASE IN BP MEDS. HR 60'S, NSR WITHOUT ECTOPY. KCL CHECKED THIS AFTERNOON AND REPLETED PER SLIDING SCALE.\nRESP- LUNGS CLEAR, SUCTIONED ONLY A FEW TIMES FOR SMALL AMOUNTS OF THICK LIGHT TAN SPUTUM. O2 SAT 100% MOST OF THE DAY, FIO2 WEANED DOWN TO 40% AND SATISFACTORY ABGS DRAWN WITH EACH CHANGE. ESOPHAGEAL BALLOON PLACED BY RESP. WILL TRY TO WEAN PEEP TOMORROW.\nGI/GU- ABD SOFT WITH HYPO SOUNDS. TUBE FEED REMAINS TROPHIC, TEAM MENTIONED INCREASING, WILL FOLLOW UP. INSULIN GTT NOT TITRATED, BS STABLE THROUGHOUT THE DAY. UOP ADEQUATE AND LASIX GTT CONTINUES FOR GOAL OF 2L NEG. BY MIDNIGHT.\nID- TMAX 100.5\n" }, { "category": "Nursing/other", "chartdate": "2163-05-16 00:00:00.000", "description": "Report", "row_id": 1466816, "text": "Resp Care\nPt vented on AC, PEEP at 17, FiO2at 60%, Bld press needs to be kept low due to AAA. Esophageal balloon study done at 3pm. Result in patient chart, justified use of 17 peep that it was not over distending.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-17 00:00:00.000", "description": "Report", "row_id": 1466817, "text": "condition update\nD: pt remains sedated on fentanyl and propofol drip. fentanyl temporarily increased to 60mcgs/hr after bath due to tachypnea and pt not settling down. fentanyl decreased back to 50mcs/hr at 1am. pt appears comfortable. pupils equal and reactive to light. pt withdraws to painful stimuli. pt turns head to voice and does not follow commands at this time.\ncardiac: pt remains in nsr rate in the 60's pt continues on lopressor at 100mg q8 and amiodorone drip remains off with pt on po. dose. temp max 101.7 and pt pan cultured. tylenol given and temp down to 100. cvp is . pt remains on lasix drip and goal of 2liters negative obtained. lasix decreased to 6mg/hr.\nresp: see flowsheet for abgs. pt remains on 50%. cmv and 17 of peep. breath sounds remain clear to coarse and diminished in the bases. pt suctioned for large amts of thick yellow sputum. sputum culture sent.\ngi: pt remains on tube feeds of promote with fiber at 30cc/hr. residuals 2-10cc. aabd is obese and hypoactive bowel sounds. pt passing flatus.\ngu: good urine output on lasix drip. pt 2liters negative for 24 hrs.\nskin: abd dressing changed and remains dry and intact. staples are clean and dry and abd binder remains on.\na: continue to titrate lasix for goal. assess for pain and adjust fentanyl and propofol as needed. await culture results.\nr: temp down with tylenol. pt appears comfortable at this time on current rates with hr of 65 and sbp 116/52 and pt no over breathing the vent. pt with increase in secretions suctioned out of et tube.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-05-28 00:00:00.000", "description": "Report", "row_id": 1466863, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, REMAINS ON FENTANYL GTT AT 50MCGS. FOLLOWING COMMANDS AND MOUTHING WORDS APPROPRIATELY. MOVING ALL EXT. ON THE BED. PERRL.\nCV- BP STABLE, OCCASIONALLY RISING TO 160'S WHEN PT COUGHING, BEING SUCTIONED, AND DECREASES TO 120-130'S WHEN CALM. REMAINS BRADY IN 50'S WITHOUT ECTOPY. LYTES REPLETED AS NEEDED.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED FREQUENTLY FOR MODERATE AMOUNTS OF THICK WHITE SPUTUM. O2 SAT DROPPING AT TIMES TO 92-93%, RISING TO 96% FOLLOWING SUCTIONING. ABG THIS AFTERNOON SHOWING PAO2 IN THE 70'S, PH 7.49. DIAMOX ORDERED X 2 DOSE FOR ALKALOSIS.\nGI/GU- ABD SOFT, + BS. PT VOMITED AMOUNT OF BILE THIS AM, NG TUBE PLACED, KUB DONE. NG TUBE TO LCWS AND POST PYLORIC TUBE WITH TUBE FEEDING, ADVANCE AS TOLERATED TO GOAL PER DR. . BEGINNING TO DROP OFF THROUGHOUT THE DAY, AVERAGING 20-50CC/HR, CONCENTRATED. DR. NOTIFIED OF DECREASING URINE OUTPUT AND ORDERED DIAMOX ONLY, NO FURTHER LASIX AT THIS TIME.\nID- AFEBRILE\n" }, { "category": "Nursing/other", "chartdate": "2163-05-28 00:00:00.000", "description": "Report", "row_id": 1466864, "text": "Respiratory Care\n\n Pt continues on full ventilatory support. No changes made. MDI's as ordered. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-29 00:00:00.000", "description": "Report", "row_id": 1466865, "text": "Resp Care\nPt remains on CMV, no vent changes, stable shift. Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-05-29 00:00:00.000", "description": "Report", "row_id": 1466866, "text": "FOCUS HEMODYNMICS\nDATA: neruoz; opens eyes to name and follows you around in the room . eyes continue to be red and erythromycin eye oint applied. moves legs on the bed. attempts to squeeze hand upon command.\n\nresp: suctioned for copius amts of thick white sputum. occ plug noticed. o2sat 90's. resp rate20's. wbc 8.5\n\ncardiac: heart rate brady 50's. bp > 130- 170's fentanyl gtt for pain control. k 3.4 and repleted with 20meq kcl iv. hct 27.9.\n\ngu: foley patent and draining amber colored urine. lasix 40mg iv givena and diamox iv x1 given. creat 1.2 and bun 34.\n\ngI abd soft and distended. stool x2 brown with some blood. tube fdg infusing at 20cc hr and increased to 30cc/hr. hob at 30. vomitted approx 200cc of bilious drainage. tube fdg on hold at present dr aware. reglan 10mg iv q6hrs ordered.\n\naction: labs as ordered. suctioned prn. fentanyl gtt for pain control and effectilve. tube fdgs on hold presently due to emesis. reglan ordered q6hrs. k repleted\n\n response: monitor closlely\n" }, { "category": "Nursing/other", "chartdate": "2163-05-17 00:00:00.000", "description": "Report", "row_id": 1466818, "text": "Resp Care,\nPt. remains intubated on A/C overnoc. No vent changes this shift. Remains on 50% and 17 peep. ABG acceptable. Suctioned for large amount thick yellow sputum, spec sent. Maintain current vent settings, see carevue.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-03 00:00:00.000", "description": "Report", "row_id": 1466888, "text": "add: pt continues to be afib rate 110-117, pt did have an eposide of hr dropping down to 50's,dr. , dr. dow aware. 12 lead ekg done. pt suctioning pt for scant amt of blood tinged sputum. hct sent, k,mg, phosphorous sent results pending.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-04 00:00:00.000", "description": "Report", "row_id": 1466889, "text": "Resp Care\n\nPt returned to cpap/psv with settings on for the night after being on 50% t-mask for entire day. MV on cpap/psv being maintained in the 8-10L range with TV's in the mid 600's. BS are coarse and suctioning tan white sputum. Cuff pressure being maintain at 14 cmH2o\n" }, { "category": "Nursing/other", "chartdate": "2163-06-04 00:00:00.000", "description": "Report", "row_id": 1466890, "text": "Please See Careve for Specifics.\n\nUneventful night except for the following: 2.5mg IV lopressor MRx1 adm per Cardiology recommendations. 2.5mg adm at 2110 and Hr remained 100-110's. After 30 minutes an additional 2.5mg IV lopressor and HR decreased to 40's-50's for about 5minutes and SBP decreased to 90-100's. SICU team aware. No further intervention at this time. HR throughout night remained in afib 100-120's.\n\nPOC: Continue to monitor hemodynamics, assist transfer to rehab, trach collar durring the day as tolerates. Continue to offer pt and pt family emotional and spiritual support.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-04 00:00:00.000", "description": "Report", "row_id": 1466891, "text": "npn\n pt opens eyes spont and follows commands, mae, mso4 prn.\n\nResp- tol trach collar .50 fio2- cont to require freq sxn thick white secretions- lungs coarse bilat. sao2 >95%.\n\nHemodynmics- cont a fib with rates up to 130- sbp cont >100 with map >65 with increased hr. Cardiolgy following pt- cardioversion attempt this pm- hr decrease to 50's to 60's post cardioversion- cont a fib. (propofol during cardiversion). Hr return to 120's 2.5 hrs post cardioversion- sicu md aware. troponin from labs this am .11. - plan to cont x 3 sets.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-04 00:00:00.000", "description": "Report", "row_id": 1466892, "text": "Respiratory Care Note:\n Patient weaning on 50% trach collar with abg pending. she appears comfortable. Suctioned for small -med amounts of thick yellow. Cardioverted today for afib with return of arrhythmia. Plan to try to keep off vent tonight as tolerated. remains on standby at this time.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-05 00:00:00.000", "description": "Report", "row_id": 1466893, "text": "nsg.progress notes:\nsee flow sheet for specific:\nNeuro: A&O,obeying commands,MAE,trying to communicate with mouthing words.\nCV: remains on A fib with occ.pac's & sicu MD aware,lopressor 12.5mg po with fair effect,hr 100-135,sbp wnl, on hydralazine po.lasix 20mgX1 with good effect still hemeturic,fluid balance -ve 800ml by MN.\nlt,sc central line blocked lumen tpa'd with 1mg by IV nurse,patent now\nresp: tolerated trach mask,o2 sat 98-100% on 10L O2.LS coarse -clear.strong productive cough,sxn thick white secretion,ABG acceptable.\nGI: TF promote with fiber 80ml/hr ,tolerated abd obase,BS +,no BM\nGU: foley cath patent ,hemeturia,team aware\nEndo: FS q6h,on SSRI & NPH,bld sug @ 200's.\nACT: bed fast turned & position changed Q2H,pt helps to turn.\nID: afebrile.\nPlan: cont monitoring,pulm.hygiene,cardiac monitoring, Bld .sug check.? needs tightning of SS\n" } ]

[ { "category": "Echo", "chartdate": "2101-07-29 00:00:00.000", "description": "Report", "row_id": 62356, "text": "PATIENT/TEST INFORMATION:\nIndication: ? Endocarditis\nBP (mm Hg): 156/80\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 16:33\nTest: Portable TEE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium/left atrial appendage or\nthe body of the right atrium/right atrial appendage. Left atrial appendage\nejection velocity is good (>20 cm/s). All four pulmonary veins were identified\nand found to enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No atrial septal defect is seen by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: There are simple atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: There are three aortic valve leaflets. The aortic valve leaflets\nare moderately thickened. No masses or vegetations are seen on the aortic\nvalve. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. No mass or\nvegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened.\nPhysiologic 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\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. There are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are moderately thickened. A gradient was not\nassessed (see TTE). No discrete masses or vegetations are seen on the aortic\nvalve. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No discrete mass or vegetation is seen on the mitral valve.\nModerate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is no pericardial effusion.\n\nIMPRESSION: Moderate mitral regurgitation without focal vegetation. Moderate\naortic leaflet thickening with trace aortic regurgitation. No discrete\nvegetation or abscess identified.\n\n\n" }, { "category": "Echo", "chartdate": "2101-07-29 00:00:00.000", "description": "Report", "row_id": 62357, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 62\nWeight (lb): 140\nBSA (m2): 1.64 m2\nBP (mm Hg): 179/70\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 11:11\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Regional left ventricular wall motion is normal. There\nis no resting left ventricular outflow tract obstruction.\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 normal in\ndiameter.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are moderately thickened. There is moderate aortic valve\nstenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. No mass or\nvegetation is seen on the mitral valve. There is mild thickening of the mitral\nvalve chordae. Moderate (2+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data. The echocardiographic results were reviewed by\ntelephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (?#) are moderately thickened. A vegetation\nis not seen, but cannot be fully excluded due to the deformed valve. There is\nmoderate aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. No mass or vegetation is seen on the\nmitral valve. Moderate (2+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the\ntransaortic gradient has increased and calculated aortic valve area decreased,\nbut overall aortic valve morphlogy is similar. The severity of mitral\nregurgitation (mild on review of the prior study) and estimated pulmonary\nartery systolic pressures have increased.\nIf the clinical suspicion for endocarditis is high, a TEE may be better able\nto define the mitral valve.\n\nIMPRESSION:\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-08-04 00:00:00.000", "description": "FLUORO 1 HR W/RADIOLOGIST", "row_id": 832736, "text": " 8:42 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: for long-term abx\n Admitting Diagnosis: ACUTE RENAL FAILURE;CHANGE IN MENTAL STATUS\n ********************************* CPT Codes ********************************\n * REPOSITION CATHETER FLUORO 1 HR W/RADIOLOGIST *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with MSSA osteomyletis/sepsis\n REASON FOR THIS EXAMINATION:\n for long-term abx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post placement of right brachial PICC line on the floor. Tip\n noted to be in brachiocephalic vein. Please reposition or replace.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. \n . Dr. , the staff radiologist, was present and supervising\n throughout. With the patient on the angiographic table, the right upper\n extremity was prepped and draped in standard sterile fashion. Under\n fluoroscopy, it was determined that the tip of the catheter was indeed in the\n brachiocephalic vein. However, as it had been withdrawn on the floor, there\n was approximately 9 cm of the catheter outside the patient's skin. A .018\n guidewire was therefore advanced through the existing catheter into the\n superior vena cava under fluoroscopic guidance. The catheter was then advanced\n over the guidewire until the tip was positioned at the distal superior vena\n cava. The guidewire was the withdrawn. The catheter was capped, flushed, and\n heplocked.\n\n FINDINGS: A final AP chest x-ray demonstrated the tip of the catheter to be in\n the distal superior vena cava above the right atrium. The line was heplocked\n after a StatLock was applied. The line is ready for use.\n\n COMPLICATIONS None.\n\n IMPRESSION: Successful repositioning of a right brachial vein PICC line. The\n tip is in the superior vena cava just above the right atrium. The line is\n ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2101-07-30 00:00:00.000", "description": "MR CONTRAST GADOLIN", "row_id": 832238, "text": " 9:55 PM\n MR L SPINE WITH CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: ADD GADOLINIUM IMAGING\n Admitting Diagnosis: ACUTE RENAL FAILURE;CHANGE IN MENTAL STATUS\n Contrast: MAGNEVIST Amt: 11CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o lymphoma,osteomyelitis, with GPC bacteremia of\n unknown etioloy, TEE neg, with acute low back pain s/p MRI L-spine W/O\n Gadolinium demonstrating osteomyelitis with no evidence fluid collection\n REASON FOR THIS EXAMINATION:\n ADD GADOLINIUM IMAGING\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Gadolinium-enhanced images for further evaluation of\n epidural masses.\n\n Exam compared to prior study of at 14:00.\n\n FINDINGS: There are small anterior epidural fluid collections at L4. There is\n a large posterior epidural fluid collection at L5/S1 and a second large\n epidural fluid collection posteriorly from S2 to S3. There are anterior\n epidural fluid collections at L5/S1. There is anterolisthesis of L5 forward\n relative to S1. There is canal stenosis attributable to these large posterior\n epidural fluid collections, presumably representing abscess.\n\n IMPRESSION: Multiple epidural abscesses with canal stenosis as described.\n\n\n" }, { "category": "ECG", "chartdate": "2101-07-28 00:00:00.000", "description": "Report", "row_id": 120756, "text": "Sinus rhythm with borderline resting sinus tachycardia. Possible left atrial\nabnormality. Slightly peaked T waves which may be physiologic variant. Exclude\nhyperkalemia if clinically indicated. Compared to the previous tracing\nof the heart rate is somewhat faster and precordial voltage is not as\nprominent. T waves are slightly more peaked. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-07-31 00:00:00.000", "description": "Report", "row_id": 120754, "text": "Sinus rhythm. The apparent ST segment elevation in the second and third\ncomplexes in leads VI-V2 is most likely artifact. Compared to the previous\ntracing of the rate has slowed. Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2101-07-28 00:00:00.000", "description": "Report", "row_id": 120755, "text": "Resting sinus tachycardia. Left atrial abnormality. Non-diagnostic J point\nsagging. Slightly peaked but not absolutely tall T waves which may be related\nto increased heart rate. Exclude hyperkalemia if clinically indicated. Compared\nto the previous tracing of the heart rate is faster.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-07-29 00:00:00.000", "description": "Report", "row_id": 1491822, "text": "General: Pt admitted from the EW around 2200. Orient to name only.\n\nNeuro: Pt confused. Slept well.\n\nResp: Lungs have crackles throughout. No cough. O2 4l via NC. Sats mid to upper 90's. T Max 99.4 PO at 2200.\n\nC/V: HR 70's to 90's and sinus. No ectopy noted. Pt has a murmur. MBP 80's to low 100's. Given Lopressor 5mg IV gtt over 30 min and a 2nd dose over 60 min.\n\nGU/GI: Foley cath intact and draining dark amber urine in small amts until given 2 boluses of NSS 500ml. Now making urine WNL.\n\nEndo: Lactic acid 3.7. Please see other labs.\n\nSocial: Pt lives at home but has recently been living at a rehab facility in .\n\nPlan: Monitor labs and hemodynamics.\n" }, { "category": "Nursing/other", "chartdate": "2101-07-30 00:00:00.000", "description": "Report", "row_id": 1491825, "text": "M/SICU NPN for 7a-1000: FULL CODE Allergic to Cardura, Flomax, IV contrast dye.\n\n SEE FLOWSHEET FOR MORE DETAILS\n\nPlease see transfer note for my shifts NPN.\n" }, { "category": "Nursing/other", "chartdate": "2101-07-29 00:00:00.000", "description": "Report", "row_id": 1491823, "text": "M/SICU NPN for 7a-7p: FULL CODE Allergies:IV Contrast Cardura Flomax\n\n CONTACT Precautions for MRSA/RECENT SHINGLES.\n\n SEE FLOW FOR MORE DETAILS\n\n\nNeuro: Remains confused and only oriented to self, PERLA, MAE, Min. assistance with turning and repositioning. Noted pt. to keep head turned to left frequently, but is able to turn head to right when asked to do so. Follows simple commands. Recognizes sister and nephew.\n\nRESP: Remains on 02 via NC at 2L with adequate sats. Lung sounds have been with crackles in bases to coarse throughout. No SOB/dsypnea noted. RR equal and unlabored.\n\nCV: Remains in NSR-ST. BP stable with some elevation at times. No antihypertensive meds ordered today. Some generalized edema to extremities noted. Palp. peripherial pulses x 4. Afebrile. IV access includes PIV's x 2 #18g.'s. Cardiac ECHO done at bedside today, which could not r/o vegetation to valves. Thus, TEE done at bedside, which was Normal MD's. IVF of NS conts. at 150cc/hr.\n\nGI: + BS noted. Remains NPO due to neuro status. No BM today. Abd. is soft, non-tender, non-distended.\n\nGU: Foley in place with adequate urine output.\n\nSKIN: Noted healing varicella (shingles) to lower portion of back. Also, pt. has blood-filled blisters to scrotum that have bursted and oozed a small amount today. Bruising to arms, but no other breakdown noted.\n\nSOCIAL: Daugther has called several times today and states she will be in sometime tonight. Sister and nephew in and spoke at length with /TEAM.\n\nPlan: Cont. with current plan of care. Check for possible transfer to floor tonight or in AM. Monitor per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2101-07-30 00:00:00.000", "description": "Report", "row_id": 1491824, "text": "Neuro: Pt continues to be confused, saying things that make no sense but appears to be clearer than last evening. Reorientated often.\n\nResp: O2 2L via NC with sats upper 90's. Lungs are throughout. Pt is beginning to cough to clear throat but has not produced any sputum.\n\nC/V: MBP has been 80's to 1teens. HR is 70's to 90's and sinus. There has been no ectopy noted. Pt denies CP.\n\nGU/GI: Foley intact and draining dark yellow urine. Urine output had slowed down, pt was given a 500cc bolus of NSS at 0100 with good effect. Abd is soft with hypo BS. Given bowel meds last evening with 2 large light brown, slightly heme + BM's. Pt incontinant x1 but called for assistence the second time. Pt reports relief of stomach discomfort.\n\nEndo: FS at 2400 110 with no ins coverage required.\n\nSocial: Daughter visited last evening and grandson called for update.\n\nPlan: Monitor labs and VS's. Assess orientation and provide reorientation as needed. ? out to floor today?\n" } ]

[ { "category": "ECG", "chartdate": "2176-09-22 00:00:00.000", "description": "Report", "row_id": 207748, "text": "Sinus arrhythmia\nLateral T wave changes are nonspecific\n\n" }, { "category": "Radiology", "chartdate": "2176-09-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 932547, "text": " 6:37 AM\n PORTABLE ABDOMEN Clip # \n Reason: please do KUB to eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with bowel prolapsed through vagina\n REASON FOR THIS EXAMINATION:\n please do KUB to eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female with bowel prolapse. Evaluate for\n obstruction.\n\n SINGLE VIEW OF THE ABDOMEN SUPINE:\n\n Air-filled and stool-filled loops of colon are present with no evidence of\n pathological dilatation. Air is seen overlying the rectum. There is no\n evidence of small or large bowel obstruction. Surrounding osseous and soft\n tissue structures are unremarkable.\n\n IMPRESSION:\n\n No evidence of obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-09-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 932579, "text": " 10:42 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval CVL\n Admitting Diagnosis: EXPLORATORY LAPORATOMY/? BOWEL PROLAPSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with recent Xlap, SBR, repair of vaginal prolapse\n REASON FOR THIS EXAMINATION:\n eval CVL\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST FOR LINE PLACEMENT, AT 11:49 A.M.\n\n HISTORY: Recent surgery. Central line placement.\n\n COMPARISON: None.\n\n FINDINGS: A left internal jugular approach central line is noted with the\n distal tip overlying the superior vena cava, approximately 2 cm proximal to\n the junction with the right atrium. A nasogastric tube is present with the\n distal tip coiled within the gastric fundus. Lung volumes are diminished,\n however, there is no focal consolidation. There is a tortuous aorta. The\n cardiac silhouette is borderline enlarged even accounting for patient and\n technical factors. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Central line as above. No pneumothorax seen. Diminished lung\n volumes with no focal consolidation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-09-26 00:00:00.000", "description": "Report", "row_id": 1420475, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nPT C/O OF NAUSEA THIS AM AND REGURGITATING SMALL AMTS OF GREEN BILIOUS LIQUID, MEDICATED W/ ANZEMET 12.5MG IVP W/ GOOD RELIEF, DR. AND DR. AWARE, CONT TO MONITOR. AT APPROXIMATELY 15:00, PT C/O OF MORE NAUSEA AND VOMITTED APPROXIMATELY 100CC BILIOUS LIQUID, DR. INFORMED, NGT PLACED AND DRAINED 750CC DARK GREEN BILIOUS FLUID. PT RELIEVED FROM NAUSEA AND NGT TO LCWS (DR. ALSO AWARE). REPEAT HCT 26.9, VSS STABLE. CONT TO MONITOR VS, LABS, NGT OUTPUT, CONT CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-27 00:00:00.000", "description": "Report", "row_id": 1420476, "text": "NPN (NOC):\n\nPT HAD A GOOD NIGHT. REQUESTED AND RECIVED FENTYNL 25 MCG'S IV AT 11 PM AND SLEPT FOR THE REST OF THE NIGHT. SHE IS EASY TO AROUSE AND ORIENTED. RR TEENS, REG, UNLABORED. SATS IN HIGH 90'S ON 2 LITERS NC. LUNGS ARE CLEAR. USING IS WHEN AWAKE. ABD IS SOFTLY DISTENDED, BS'S RETURNING. NGT PT OUT 100 CC'S BILE OVERNOC. TPN AND IVF CONT AT A TOTAL OF 75 CC PER HR. URINE OUTPUT IS GREAT. AM HCT = 23%. DR. IS AWRAE. BECAUSE SHE IS HEMODYNAMICALLY STABLE, WILL NOT TRANSFUSE FOR NOW BUT WILL DISCUSS WITH TEAM ON ROUNDS.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-27 00:00:00.000", "description": "Report", "row_id": 1420477, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt pleasant and cooperative w/ care. Alert and oriented x3. Follows commands and moves all extremities. PERRLA (4mm bilat; sluggish). Pt w/ clear speech. VSS. Afebrile. HR 58-70s (NSR/sinus arrhythmia at times). NBP 100-110s/30-40s. Metoprolol 2.5mg IV q6hr ordered. Pt w/ +1 edema on BLE. DP/PT pulses palpable. Vendoyne boots on. Hct to be checked at 1600; continue to monitor. Fentanyl 25mcg given for incisional pain w/ +effect. Pt c/o dizziness this AM (while lying in bed) after fentanyl given, but dizziness subsided after approx 10 minutes. Pt then able to get out of bed to chair w/ 2 assists; steady gait. Physical therapy to see pt for ambulation. Abdomen softly distended w/ hypoactive BS. No BM; no flatus per pt. NGT to low continuous suction w/ green/brown bilious drainage. Pt c/o sore throat d/t NGT; Cepacol given. TPN and IVF to total 75cc/hr. FS q6hr. FS this AM was 166; treated per regular insulin sliding scale. Insulin added to new bag of TPN. Lungs clear, diminished at bases. Cough/deep breathing encouraged. Pt w/ weak, nonproductive cough. Cough pillow given. Pt using incentive spirometer approp; inspiratory volume: 500-750mL. No c/o shortness of breath. RR 13-22. O2 sat >/= 96% on 1L nasal cannula. O2 sat decreases to 91-92% on room air. Abdominal incision w/ staples clean, dry, and intact; abd DSD changed this AM. Pt's family to visit this afternoon.\nPlan: Monitor VS, I's and O's, labs. Check Hct at 1600. Encourage cough/deep breathing, IS use. Offer pain med and Cepacol as needed. Monitor abdominal incision and NGT output. Update pt and family on plan of care. Continue ICU care and treatment. ?transfer to floor tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-28 00:00:00.000", "description": "Report", "row_id": 1420478, "text": "Nursing Progress Note\nneuro: intact\nCV: febrile to 101.4, wbc 6.8, HO notified, no cx at this time. vss.\nPulm: np at 1 L sats 94-99. using IS when awake, coughing well. BS clear upper, crackles in bases.\nGI: ng to lcws. no bowel sounds noted. no flatus, no BM.\nGU: u/o good.\n\nIncision: clean and dry, dsd intact, pain controlled with fentanyl 25 mcg iv x 2.\n\nPlan ? tx to floor today\n" }, { "category": "Nursing/other", "chartdate": "2176-09-24 00:00:00.000", "description": "Report", "row_id": 1420470, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT A&O X3, FOLLOWING COMMANDS, MAES. C/O ABD INC PAIN, INCREASED W/MVMT & TURNING, MORPHINE 1-2MG GIVEN W/RELIEF. HR 60S-80S, NSR, SBP 90S-130S, LOPRESSOR 5MG IV GIVEN. AFEBRILE, AM HCT 25.1-DOWN FROM 27.5, HO AWARE-NO INTVN AT THIS TIME, CONT TO MONITOR PER PLATINUM . NARD, O2 SATS 98-100% ON 2L N/C. LUNG SNDS CLEAR, SLIGHTLY DIMINSIHED AT BASES. C/DB & IS USE ENC'D, ABD SOFT, RLQ/INC TENDERNESS TO PALP, +BS, CONT NPO. ADEQUATE HRLY U/O. PT TURNS WELL W/MIN ASSIST, SKIN W/D/I, ABD INC DSG CHANGED THIS PM, C/D/I.\nPLAN: CONT TO MONITOR HCT, PAIN MGMT, ENC C/DB & IS USE. TRANSFER TO FLR WHEN BED AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-24 00:00:00.000", "description": "Report", "row_id": 1420471, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nPT'S HCT TO 23.9 THIS AM, PT SYMPTOMATIC WITH SBP, TACHYCARDIA AND DIZZINESS. DR. AND DR. AWARE, RECEIVED 2 UNITS PRBC'S. PTT INC TO 70.6, RECEIVED 2UNITS , REPEAT PTT 40.8. PT WENT TO OR TO LOOK FOR ?BLEEDING SOURCE, FOUND LRG CLOTS AND NO BLEEDING SOURCE, ALSO RECEIVED 2UNITS PRBC'S INTRA-OP AND 2UNTS FFP'S, REPEAT HCT 30.0 UPON ARRIVAL TO SICU. AWAITING REPEAT COAGS. PT A&OX3, MAE, FOLLWING COMMANDS. LUNG SOUNDS CLEAR, O2 SAT 98-99% ON 2L VIA NC. ABD SOFT TENDER TO TOUCH, ABSENT BS, DRSG C/D/I. FOLEY DRAINING ADEQ CLEAR AMBER URINE. MEDICATED W/ FENTANYL 12.5MCG IVP W/ GOOD EFFECT.\nCONT TO MONITOR VS, LABS, NEURO STATUS, PAIN. CONT CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-25 00:00:00.000", "description": "Report", "row_id": 1420472, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT A&O X3, FOLLOWS COMMANDS, MAES. C/O INTERMITTENT ABD INC PAIN, FENTANYL 12.5MCG GIVEN W/RELIEF. HR 60S-70S, NSR, SBP 110S-120S, T-MAX 99.5, PALP PP. AM HCT 28.6-UP FROM 28.2, PTT 34.4, HO AWARE. O2 SATS 98-100% ON 2L N/C, LUNGS CLEAR, SLIGHTLY DIMINISHED AT BASES. USING IS FREQUENTLY, C&DB ENC. CONT NPO,+BS, NO FLATUS, ABD SOFT, SLIGHTLY TENDER TO BLQ. ABD DSG C/D/I, NO DRNG. PT TURNS WELL UNASSISTED.\n CONT SERIAL HCTS, PAIN MGMT, ENC C&DB/IS USE, FAMILY SUPPORT, ?TRANSFER TO FLR.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-25 00:00:00.000", "description": "Report", "row_id": 1420473, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nHCT TO 26.3 FROM 28.6, VSS, ASYMPTOMATIC--DR. AND DR. AWARE. PLT SLOWLY TRENDING UP CURRENTLY 85 (PREV 76). PTT PENDING. CONT TO MONITOR VS, LABS, CONT CURRENT MGMT\n" }, { "category": "Nursing/other", "chartdate": "2176-09-26 00:00:00.000", "description": "Report", "row_id": 1420474, "text": "NPN\nD:neuro intact, afeb, VSS, Hct stable.\nCV:occas ST 110, 70s at rest, Pt required 500ml LR bolus for CVP3 and\ndwindling u/o down to 18ml.\nGI:Pt regurged bile colored fluid approx 50ml x 1, h.o notified and plan to reinsert NGT only if regurg continues.\nResp:Pt using IS independently up to 750, coughed and raised mucous containing blood, h.o. notified.\nGU:As above oliguric 18ml x1.\nSkin:Overall intact, hematoma rt and lt upper arms noted, h.o notified and stated this is not new he saw them the other day. Abd incision sutures intact.\nLabs:Hct 27 and Mg 1.9 Calcium 7.8 will treat magnesium.\nPain controlled with Fent 25mg IVP.\nPlan:Continue plan of care, ? transfer today.\n" }, { "category": "Radiology", "chartdate": "2176-09-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 933462, "text": " 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: Eval line placement, eval for PNA\n Admitting Diagnosis: EXPLORATORY LAPORATOMY/? BOWEL PROLAPSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with new L IJ, with fever\n REASON FOR THIS EXAMINATION:\n Eval line placement, eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: IJ line placement.\n\n This is PA and lateral chest on , two views.\n\n Comparison with .\n\n There is interval development of moderate bilateral pleural effusions.\n Subsegmental atelectasis is present at the bases. A small area of\n consolidation at the left base cannot be excluded. The heart and mediastinal\n structures are unremarkable in appearance as before. A nasogastric tube and\n left internal jugular catheter remain in place.\n\n IMPRESSION: Interval development of bilateral pleural effusions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-09-22 00:00:00.000", "description": "Report", "row_id": 1420466, "text": "admit note\npt admitted to sicu from OR following small bowel obstruction, ileocecal reanastamosis, vaginal cuff closure secondary to bowel protruding from vaginal introitus on admission. pt initially 94.3 po and bair hugger appleied pt temp increased to 96.9- pt was complaining of feeling hot, bair hugger was removed and temp rechecked a few hours later- Temp was 95 and bair hugger was reapplied. otherwise vss.\n\nresp: lsc teaching performed with incentive spirometer, o2 sat 100 % o2 weaned to 2 liters via nasal cannula\n\nneuro: pt alert and oriented, prior cataract surgery irregular pupil on right, left reactive briskly 2-3 mm, pt mae with good strength, able to turn in bed, following commands consistently\n\nabd : original dressing intact small amount of sanguinous drainage present icu resident and platinum surgery resident assessed and aware will continue to moniotr, bowel sounds present , no flatus, no bm. pt npo with NGT draining bilious drainage.\n\npain: pt denied abd pain and refuses pain medication post op at this time.\n\nvascular: palapable pulses in distal extremities, all extremities pink and warm.\n\nplan: continue to hct, moniotr and treat for pain, moniotr for signs and symptoms of bleeding, wean o2 as tolerated, normothermic with bair hugger as needed.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-23 00:00:00.000", "description": "Report", "row_id": 1420467, "text": "cv: hr 60-65 ns no ectopy. bp stable.\n\ngi: bowel sounds present. ng to lcws drained small amount of yellow greenis bilious 50 cc overnight.abd dressing weeeeeet with sanguinous drainage . dr notified of increase drainage. This a.m. dressing saturated and blood oozing out from dressing. platinum team notified and ho to bedside. few stitiches to incision to control bleeding. dsd applied. hct had drifted down to 33 from 37 throuout the evening. stat hct checked this a.m. and it stabilized at 33.\n\ngu: foley draining clear yellow urine.\n\nresp: pt very active doing her IS independently. o2 at 3l nc\n\nneuro: alert oriented cam and cooperative.\n\nendo: q 6 hour blood sugars covered with sliding scale as needed.\nplan: monitor dressing for increse drainage. monitor hct as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-23 00:00:00.000", "description": "Report", "row_id": 1420468, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nABD INCISION SUTURED BY DR. THIS MORNING FOR INCREASED BLOODY DRAINAGE, DRSG C/D/I. REPEAT HCT THIS AFTERNOON TO 29.1, DR. AND DR. AWARE, MONIOTR VS, RECHECK HCT AT 22:00. CONT CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-24 00:00:00.000", "description": "Report", "row_id": 1420469, "text": "NURSING NOTE\nSm amt serosang drng to ABD dsg noted this am, SBP dropped to 74 x1 this am, back up to 92 upon re-checking, Dr. aware, ?transfusion w/falling HCT.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-28 00:00:00.000", "description": "Report", "row_id": 1420479, "text": "nuero: pt alert and oriented x3, pleasant. pt follows commands.\n\npain: pt c/o of incisional pain, she stated yesterday after she recieved fentanyl for pain she c/o of being dizzy for 10min. dr. , dr. aware. pt recieved only 12.5mg of iv fentanyl with good effect on pain. pt stated that the dizziness only lasted for about 3minutes this morning. this afternoon pt c/o pain recieved 12.5mg of fentanyl and denied any dizziness after recieving fentanly. pt had good relief of pain.\n\npulm: lung clear, but has crackles at bases. pt presently on room air, 02 sat 94-96%. pt using incentive spirometer, and coughing and deep breathing.\n\ncards: pt in sr, no ectopy noted. sbp has been greater than 100. iv lopressor increased to 5mg iv every six hours which pt has tolerated so far.\n\ngi: ng tube clamped for 4hours, pt with only 60cc bilous residual of ng tube, dr. aware. ng tube d/c'd. abd. remains soft distended pt with hypoactive bowel sounds.\n\ngu: pt has foley catheter draining clear yellow urine\n\nid: temp 101.2 blood cultures done, u/a sent. left ij triple lumen changed over a wire. left ij triple lumen placement confirmed by cxr per dr. .\n\nheme: repeat hct 24,dr. aware\n\nactivity: pt oob to chair with two assist which she tolerated fine. pt ambulated in room which she tolerated fine.\n\nplan: to transfer to floor when bed aviable.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-29 00:00:00.000", "description": "Report", "row_id": 1420480, "text": "condition update\nd: doing well during the night. medicated x 2 with fentanyl 12.5mcg for pain with good relief. pt with 3 loose stools trace guaiac positive. abd soft and dressing is dry and intact. pt remains on tpn at 63.5cc/hr. iv fluid dc'd.\na: medicate for pain as needed. transfer today when bed is avaailable.\nr: fentanyl effective in relieving pain. ? stool for cdiff. ? advance diet to sips of clears.\n" }, { "category": "Nursing/other", "chartdate": "2176-09-29 00:00:00.000", "description": "Report", "row_id": 1420481, "text": "Nursing Progress Note\n/See carevue for details D:Neuro changes included 1 seizure episode lasting 1-2 min where pt's arms and back were shivering. Neuromed resident notified and dilantin level added to am lab work already had been sent and dilantin 100mg IVPB given. No further seizures post dilantin. Mannitol was given as serum osmo and serum sodium were w/i parameters given. Pt taken to MRI however did notb stay still for MRI and it was stopped neuromed chief resident notified and agreed to stop study.\nPlan:Seizure precautions\nContinue plan of care\n\n" }, { "category": "Nursing/other", "chartdate": "2176-09-29 00:00:00.000", "description": "Report", "row_id": 1420482, "text": "Please disregard above note as it was written on the wrong pt\n" }, { "category": "Nursing/other", "chartdate": "2176-09-29 00:00:00.000", "description": "Report", "row_id": 1420483, "text": "NPN\nPlease see CareVue for full assessments\nNEURO: intact. MAE and follows all commands. No c/o pain throughout the day.\nCV: NSR. No ectopy. HR and BP stable. PPP. Pboots in place.\nRESP: NARD. Denies SOB. BLS CTA. Occas. crackles @the bases. Clears with strong cough. Independent w/IS use. 97% 1L NC.\nGI: Tol sips H2O. No N/V. TPN infusing via right CVL. Abd soft, distended. +BS. Large amt trace guaiac + stool. Incontinent of stool during ambulation.\nGU: Patent foley draining adequate amts dark yellow urine.\nACTIVITY: Amb x1 around unit using WC as walker. Assist x1. Pt. states BLE still feel weak but improved since yesterday.\nPLAN: transfer to floor when bed available, prepare pt/inform family, assist w/activity&ADL's.\n" } ]

[ { "category": "Radiology", "chartdate": "2174-08-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 975900, "text": " 1:27 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact # if abnormal\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVR/cabg x2/IABP\n REASON FOR THIS EXAMINATION:\n postop film-contact # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVR/CABG.\n\n SUPINE PORTABLE CHEST RADIOGRAPH\n\n Comparison is made to preoperative films dated . Patient is\n status post median sternotomy with endotracheal tube terminating approximately\n 2.5 cm from the carina in this chin down position. Swan-Ganz catheter\n terminates within the right main pulmonary artery, and intraaortic balloon\n pump terminates below the left subclavian vessel projecting over the left main\n stem bronchus. OGT sideport is above the GE junction with tip likely within\n the gastric fundus. Multiple mediastinal drains are identified. There is no\n evidence of pneumothorax with mild fluid overload and left lower lobe\n atelectasis, and equivocal overdistention of the endotracheal tube balloon\n cuff. An ill-defined right lower lobe opacity may represent atelectasis or\n alveolar edema. A MVR is noted.\n\n IMPRESSION:\n 1. Sideport of OGT above the GE junction with equivocal overdistention of\n endotracheal tube balloon cuff, otherwise appropriate positioning to multiple\n lines and tubes.\n\n 2. Expected postoperative mild fluid overload and left lower lobe atelectasis\n with right lower lobe opacity reflecting either atelectasis or alveolar edema.\n\n D/w PA at 4 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2174-08-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976060, "text": " 12:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVR/cabg x2/IABP\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Evaluate interval change, status post CABG.\n\n COMPARISON: and 28, .\n\n PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST AT 12:35 P.M: The aortic balloon\n catheter is seen in the descending aorta in a slightly low position,\n approximately 5.5 cm below the aortic arch. Other lines and tubes are in\n satisfactory and unchanged position. There is bibasilar atelectasis, improved\n on the right and worse on the left. The hazy right lower lobe opacity is\n largely unchanged from the prior exam. Pulmonary vasculature remains slightly\n congested, consistent with mild fluid overload. The cardiomediastinal\n silhouette has a normal postoperative appearance.\n\n IMPRESSION: Bibasilar atelectasis, slightly worse on the left. No other\n interval change.\n\n" }, { "category": "Radiology", "chartdate": "2174-08-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976534, "text": " 2:21 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVR/cabg x2 now s/p R chest tube removal.\n\n REASON FOR THIS EXAMINATION:\n evaluate for PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, SINGLE VIEW, \n\n CLINICAL INFORMATION: 85-year-old male status post mitral valve replacement,\n right chest tube removal, evaluate for pneumothorax.\n\n COMPARISON STUDY: at 10:30.\n\n The right-sided chest tube has been removed. There is a tiny residual right\n apical pneumothorax. The remainder of the chest is unchanged. There is\n continued cardiomegaly, mild congested failure. Bibasilar atelectasis.\n Swan-Ganz catheter unchanged. Median sternotomy.\n\n IMPRESSION:\n\n 1. Status post removal of right chest tube. Tiny right apical pneumothorax.\n\n 2. The remainder of the chest is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-08-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 977264, "text": " 2:10 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with mr\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old man with mitral valve regurgitation following recent\n repair.\n\n CHEST, PA AND LATERAL: Comparison is made to prior day. The patient is\n status post sternotomy and mitral valve replacement. The cardiac and\n mediastinal contours are unchanged. There is a better defined pleural-based\n loculation of pleural fluid along the right lower lateral hemithorax, as well\n as a possible residual subpulmonic effusion. A moderately large more free-\n flowing left-sided pleural effusion is again visualized with associated left\n lower lobe opacity. Pulmonary vascular congestion has resolved. There is no\n pneumothorax.\n\n IMPRESSION: Bilateral pleural effusions, including a prominent loculation\n within the right hemithorax. Resolution of congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2174-08-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976508, "text": " 10:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVR/cabg x2 now s/p meds tube x2 removal and L chest tube\n removal.\n REASON FOR THIS EXAMINATION:\n Eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ONE VIEW \n\n CLINICAL INFORMATION: Question pneumothorax. 85-year-old man status post\n mitral valve replacement status post left-sided chest tube removal.\n\n COMPARISON STUDY: .\n\n FINDINGS:\n\n The left-sided chest tube has been removed. No pneumothorax is identified.\n There is opacification of the left lung base presumed to represent small\n pleural effusion and atelectasis. There is cardiomegaly with mild pulmonary\n congestion consistent with mild congestive failure. Patient is status post\n median sternotomy. Chest tube at the right base remains in place.\n\n Patient has been extubated. NG tube has been removed.\n\n IMPRESSION:\n 1. Status post left chest tube removal. No pneumothorax.\n 2. Cardiomegaly. Mild congestive failure.\n\n" }, { "category": "Radiology", "chartdate": "2174-08-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976355, "text": " 8:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?LLL PNA\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVR/cabg x2/IABP\n\n REASON FOR THIS EXAMINATION:\n ?LLL PNA\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: S/P MVR and CABG, assess left lower lobe.\n\n Comparison is made with prior study dated .\n\n Post-operative cardiomediastinal silhouette is unchanged. Right Swan-Ganz\n catheter tip is in unchanged position in the main pulmonary artery facing the\n right pulmonary artery. ET tube is in standard position. NG tube tip is in\n the stomach. Mediastinal and bibasilar chest tubes remain in place. Mild\n fluid overload is stable. Small bilateral pleural effusions greater in the\n left side are unchanged. Left lower lobe retrocardiac opacity consistent with\n atelectasis is stable.\n\n IMPRESSION: No significant changes.\n\n\n\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2174-08-11 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 975293, "text": " 6:49 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with mr\n REASON FOR THIS EXAMINATION:\n pre-op MVR\n ______________________________________________________________________________\n FINAL REPORT\n PRE-OPERATIVE PA AND LATERAL CHEST X-RAY, AT 18:51 HOURS\n\n HISTORY: Mitral regurgitation, pre-operative for mitral valve repair.\n\n COMPARISON: None.\n\n FINDINGS: There is a right pleural effusion with a component extending within\n the major fissure resulting in hazy opacification of the right lung base on AP\n view. There is associated atelectasis. No definite consolidation is noted\n although evaluation of this region is limited. Elsewhere, there is no\n pneumonia. The mediastinum is unremarkable. The cardiac silhouette is within\n normal limits for size. There is no pneumothorax. The visualized osseous\n structures are unremarkable.\n\n IMPRESSION: Right pleural effusion with associated basilar atelectasis. No\n definite superimposed consolidation is seen. Preliminary report was provided\n by Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2174-08-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 977103, "text": " 3:47 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with mr\n\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mitral valve repair. Assess for interval change.\n\n PA AND LATERAL CHEST RADIOGRAPHS\n\n Comparison is made to examination. In the interval, epicardial\n leads and Swan-Ganz catheter have been removed with slightly decreased\n widening in the superior mediastinum identified. Moderate bilateral pleural\n effusions with fluid in fissures and adjacent atelectases, not significantly\n changed. There is no evidence of pneumothorax or pulmonary edema.\n\n\n" }, { "category": "Echo", "chartdate": "2174-08-16 00:00:00.000", "description": "Report", "row_id": 83823, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG/MVR\nStatus: Inpatient\nDate/Time: at 13:53\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. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Normal interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Moderately dilated LV cavity. Severely depressed LVEF.\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic\nroot. Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] 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. No TEE related\ncomplications. The patient appears to be in sinus rhythm. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\n1. No atrial septal defect is seen by 2D or color Doppler.\n2. The left ventricular cavity is moderately dilated.\n3. Overall left ventricular systolic function is severely depressed (LVEF= 20\n%). The lateral wall and the basal inferior wall regional wall function is\nrelatively preserved.\n4. There is moderate global right ventricular free wall hypokinesis.\n5. There are simple atheroma in the aortic root. There are simple atheroma in\nthe ascending aorta. There are simple atheroma in the descending thoracic\naorta.\n6. There are three aortic valve leaflets. The aortic valve leaflets are mildly\nthickened. The noncoronary cusp is calcified. Mild (1+) aortic regurgitation\nis seen.\n7. The mitral valve leaflets are mildly thickened. Moderate to severe (3+)\ncentral mitral regurgitation is seen. There is no mitral valve prolapse or\nflail segments.\n8. The tricuspid valve leaflets are mildly thickened.\n9. Post-induction patient required intra-aortic balloon pump; epinephrine,\nneosynephrine, and nitro gtt with improvement of biventricular function.\n\nPOST-BYPASS:\nPatient off cardiopulmonary bypass with intra-aortic balloon pump,\nepinephrine.\n\nThere is mild improvement of global LV and RV systolic function. LVEF 20 to\n25%. Thoracic aortic contour is preserved.\nThere is a bioprosthetic valve in the native mitral position well seated and\nfunctioning well with no residual mitral regurgitation and a transmitral mean\ngradient of less than 5mmof Hg.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-23 00:00:00.000", "description": "Report", "row_id": 1665355, "text": "S/P CABG X 2, PORCINE MVR, IABP PLACEMENT COMPLICATED BY CARDIOGENIC SHOCK ON . POST-OP EF 20%.\n\nNEURO: A&O X 3, PLEASANT AND COOPERATIVE. MAE EQUALLY. VERY TALKATIVE, REPEATING SAME STORIES AND REQUESTS. APPREHENSIVE ABOUT ABILITY TO WALK AND REHAB PLACEMENT. ROXICET 5CC X 1 AT HS AND TYLENOL 2 PO X 1 FOR C/O INCISIONAL PAIN.\n\nPULM: N/C AT 2L, SATS > 95%. LUNGS DIMINISHED-CRACKLES IN BASES MORESO RLL. EUPNEIC. USING IS TO 500CC.\n\nCV: NSR WITHOUT ECTOPY, HR 80'S. MILRINONE GTT AT 0.125MCG/KG. CCO SWAN RIJ, SVO2 60'S. MVO2 66, CI > 2.2, CVP 3-8, PAP WNL. PEDAL PULSES PALPATED. STERNAL INCISION CLEAN AND DRY. RLE INCISIONS CLEAN AND DRY. GENERALIZED EDEMA IMPROVED.\n\nENDO: NO HX DIABETES. QID SSRI COVERAGE.\n\nGI: ABDOMEN SOFTLY DISTENDED. \"I HAVEN'T HAD A BM IN OVER 4 DAYS.\" COLACE AT HS. PASSING FLATUS.\n\nGU: FOLEY TO CD DRAINING CLEAR GREEN TINGED URINE.\n\nSOCIAL: NEPHEW CALLED IN FOR UPDATE. PT NOW ASKING TO SPEAK TO SON \"IMPORTANT FINACIAL ISSUES.\"\n\nPLAN: DC MILRINONE TODAY. FOLLOW MVO2, DC SWAN IF HEMODYANMCIALLY STABLE. CONTINUE PO AMIODARONE. DC ALINE TODAY. AMBULATE ONCE SWAN IS OUT. ? TRANSFER TO 2 LATER TODAY OR TOMORROW FOR PHYSICAL THERAPY ASSESSMENTS AND RX. CASE MANAGER TO SPEAK WITH PT AND NEPHEW CONCERNING REHAB FACILITIES CLOSE TO .\n" }, { "category": "Nursing/other", "chartdate": "2174-08-23 00:00:00.000", "description": "Report", "row_id": 1665356, "text": " 7a-3p\nneuro: a+ox3, mae, follows commands, up to chair with assist x2 (much support while standing), perlaa, le edema +2/+3 pulses palpable with difficulty, tylenol po for pain control\n\ncv: sr with 1st degree avb 65-85 no ectopy, sbp 100-120, afeb, ci>2.1 by fick off cco, cco d/ced this pm 6 hours post milrinone discontinued, sv02 remained >60 all day post milrinone d/c. cvp 5-10\n\nresp: lungs cta, dim to bases (l>r), 02 sats >96 on 2L nc, moderate strength nonproductive cough, is to 750ml\n\ngi: bowel sounds present, tolerating moderate amounts regular diet, fingersticks ssri (10 units given with lunch fingerstick 211)\n\ngu: foley to gravity draining green/yellow urine with sediment\n\nlabs: stable\n\nassess: stable\n\nplan: increase activity, pulmonary toilet, deline in am and transfer to 2\n" }, { "category": "Nursing/other", "chartdate": "2174-08-24 00:00:00.000", "description": "Report", "row_id": 1665357, "text": "Patient report recieved, a+o x3, vss nsr with no ectop.breath sounds clear bil. tol. well.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-24 00:00:00.000", "description": "Report", "row_id": 1665358, "text": "neuro: awakens to name,move all ext. to command. orientated x3. states he needs to leave this unit today d/t lack of sleep. med. with oxycodone-acetaminophen for incisional discomfort and helped with sleep.\nCv: nsr with ectopy. vss.+ lower ext. edema noted.\nPulm: breath sounds clear bil. using incentive well.\nGu: u/o qs.\nGi: no c/o. +bowel sounds heard.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-20 00:00:00.000", "description": "Report", "row_id": 1665350, "text": "neuro-alert/oriented x3. pleasant/cooperative with care. voicing needs and concerns.voice hoarse. mae(weakly).\n\ncv- nsr. hemodynamics stable on amio/milrinone gtts. co/ci by fick only= 2.6. mv02 60-64%. hct 34.5 3+ generalized edema. palp. pulses.\n\nresp- 5l->3lnc=97%. moderate strength cough. not raising sputum. CT dc'd\n\ngi- abd soft. +flatus. no bm. taking clear liquids and po meds. does cough after drinking. ...BEARS WATCHING... pt requesting to incrase diet. glucose =148 tx with 4ureg ins. sc\n\ngu- adeq hourly u/o.\n\npain- 2 tylenol for c/o incisional discomfort.\n\nplan-monitor hemodynamics.u/o. resp status. evaluate swallow.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-21 00:00:00.000", "description": "Report", "row_id": 1665351, "text": "S/P CABG X 2, MR ON . IABP DC'D .\n\nNEURO: A&0 X 3. PLEASANT AND COOPERATIVE WITH CARE. MAE EQUALLY. OXYCODONE ELIXIR 5CC X 1 FOR INCISIONAL PAIN. SOMEWHAT APPREHENSIVE ABOUT REHAB PLACEMENT AT DISCHARGE.\n\nPULM: O2 AT 2L N/C. LUNGS CLEAR. STRONG COUGH, SUCTIONING FROM MOUTH WITH YANKAUR. LARGE AMOUT SEROSANGUINOIUS DRAINAGE FROM OLD CT SITE, DSG CHANGED.\n\nCV: NSR WITH RARE ECTOPY, HR 80'S-90'S. AMIODARONE GTT DC'D AT 2400, NO PO STARTED MD. MILRINONE CONTINUES AT 0.375 MCG/KG. MVO2 58-67, FICK CI 2.09-2.78. PEDAL PULSES PALPAPTED.\n\nENDO: SSRI COVERAGE FOR QID BS. BS 105-110, NO INSULIN GIVEN.\n\nGI: ABDOMEN SOFTLY DISTENDED, + BS.\n\nGU: FOLEY TO CD DRAINING QS AMTS CLEAR BROWN URINE.\n\nSOCIAL: NEPHEW CALLED IN FOR UPDATE. PT LIVES ALONE. PT STATES WAS INDEPENDENT WITH PTA, WALKED 1 MILE PER DAY, WALKED INTO \"DOCTOR OFFICE.\" SISTER DOES AND LAUNDRY. INDICAITING HE PLANS REHAB PLACEMENT CLOSE TO HIS J]HOME IN .\n\nPLAN: WEAN OFF MILRINONE THEN DC/ SWAN, CORDIS AND ALINE. TRANSFER TO 2 ONCE DELINED. CASE MANAGEMENT TO TALK WITH PT AND NEPHEW ABOUT REHAB OPTIONS CLOSE TO HIS HOME. OOB TO CHAIR. ADVANCE DIET.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-21 00:00:00.000", "description": "Report", "row_id": 1665352, "text": "NEURO~APPROPRIATE. A&OX3. FC. MAE. OOB TO CHAIR X 6 HOURS TODAY. TOL WELL. GAIT STEADY. FAMILY IN VISITING TODAY.\n\nCARDAIC~SR/SFIB BRIEFLY~>SR.CURRENTLY 98 SR. ELECTROLYTES REPLETED. MIL DECREASED TO .25 MCG/KG/MIN. CI REMAINS > 2 BY FICK.SBP~ 130'S , MAINTAINING MAPS~60-90. POS PAL PEDAL PULSES BILAT. FEET GROSSLY EDMATOUS. LASIX 20 MG IV BID STARTED TODAY.\n\nRESP~LUNGS~RALES WAY ^ BILAT. LASIX AS ABOVE. 2L NP, MAINTAINING SATS~95-97%. USING INS WELL. ^750ml TODAY. SCANT BLEEDING FROM NOSE TODAY.\n\nGI/GU~ADVANCING DIET AS TOL TODAY CL~>FL TO REG MEAL THIS EVENING. + BS. + FLATUS.\n\nENDO~TX W SSRI PER CSRU PROTOCOL.\n\nA/P~HEMODYNAMICALLY STABLE. MIL CURRENTLY @ .25 MCG/KG/MIN WITH CI>2.\nDIURESING WELL FROM LASIX. PT CONCERNED ABOUT DISCHARGE AN REHAB. SOCIAL WORKER TO BE CONSULTED. CONT W ICU INTERVENTIONS.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-19 00:00:00.000", "description": "Report", "row_id": 1665346, "text": "nursing note 7a-3p:\n\nneuro: a&ox3, mae's, fatigued & slept most of shift, remained in bed, pt came to work w/pat not optimal today on gtts will return on Sat.\n\nresp: RUL diminished, LUL clear, LL w/crackes, extubated @ 1000 this morning to Face tent now on 40% & 12L, sats>95%, rr 10-17, exporated small amounts of white thin secretions, cxr this a.m. atelectisis on left lower lobe & small one on right\n\ncardio: hr 80-100's nsr w/some pvc's, missed beats & a few runs of a-flutter, right femoral line removed, radial a-line bp >100 systolically, goal pressure map 60, vasopressin decreased to 2.4 & milrinone to 0.125 this morning, patient edemenous, cvp 5-10, pad 18-22, CI>2.0 & CO>4.0, mixed venous sats 60's, HIT screen sent today for falling platelet count, wbc 17/afebrile-no antibiotics team aware, no breakdown of skin & no drainage from dressings\n\ngu/gi: + gag/cough reflex, NPO including meds for today & may have ice chips per team, foley w/fair UO (green urine rec'd methylene blue in o.r.), very hypoactive bs & no bm, +gastric upset ?? cc - suctioned\n\nendo: weaned off insulin gtt this a.m. blood sugars in the 70's for a few hours, covered w/10units lantus @ noon for fs of 115\n\n\nplan/goal: wean off milrinone first (per team) & decrease vasopressin second, ?? start lasix & lopressor, con't monitoring plts & other labs, increase diet & activity as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2174-08-19 00:00:00.000", "description": "Report", "row_id": 1665347, "text": "See and Carevue for detailed documentation\n\nPatient off milrinone, CO/CI stable. MV SAT slowly dropping. Vasopressin off, BP goal 110-120. Patient in aflutter, in NSR briefly s/p AV pacing. Back to afib-> flutter. Amio bolus given without improvement. Amio gtt restart. CCO swan recal'd. MV SAT remians in low 50's. CO/CI stable. Patient alert, oriented, appropriate. Good urine output.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-20 00:00:00.000", "description": "Report", "row_id": 1665348, "text": "Nursing Progress Note\nPt not stooling, entered in error.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-20 00:00:00.000", "description": "Report", "row_id": 1665349, "text": "Nursing Progress Note\nNeuro: alert, oriented x 3. Forgetful. Voice soft, hoarse. Pupils 3 perla brisk, gag and cough intact. MAE very weak. Follows all commands.\n\nCVS: temp 97.5, HR nsr no ectopy rate 77, previously in new atrial flutter. Bp 119/61, cvp , pa 50/20, Fick CO 4.0, Fick CI 2.14, Mvo2 as low as 41. Attempted epinephrine drip to raise svo2, failed pa pressures too high. Returned to milrinone with bolus x 1, drip at 0.375 continues. Also amiodarone turned down to 0.5 at midnight. Right IJ cordis with CCO swan, machine recalibrated with lab values. Transfused 1 unit of prbcs no s/s reaction, no improvement of Svo2 at that time. 2 a and 2 v epicardial wires, sense and apce when pt is in sinus rythm. all lines recal and zeroed. Dressing to chest and mediastinum are cdi, left lower ext is where the other ace wraps will be.\n\nResp: ls coarse to dim at bases. Coughing non productive. Using pillow effectively. NC 4 L sats >97.\n\nGU: foley cath draining clear yellow urine.\n\nGI: tolerates ice chips. Rectal drainage golden loose into tube/gravity bag.\n\nEndo: fs bs not requiring ssri coverage at this time.\n\nPain: no apparent.\n\nSocial: no calls or family contact this shift.\n\nSee careveu flowsheet and mars for further details and values.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-18 00:00:00.000", "description": "Report", "row_id": 1665342, "text": "UPDATE\nNEURO: OPENS EYES TO VOICE AND MAE TO COMMAND. MIDAZ WEANED OFF, FENTANYL WEANING. PT REMAINS CALM. NODS HEAD NO WHEN ASKED IF HE HAS PAIN.\n\nCV: IABP 1:2 SINCE A.M. W/ STABLE SVO2 IN HIGH 60'S. IAB D/C'D @ 1525. PRESSURE HELD X 30 MIN. R GROIN SITE C&D, SOFT, W/ PRESSURE DRSG. DISTAL PULSES EASILY DOPPLERABLE. GD CSM R FOOT. SVO2 CURRENTLY 70, C.I. >3. LEVOPHED RESTARTED EARLY AFTERNOON FOR SBP 80'S, NOW OFF W/ SBP 106. HR 100 ST W/ FREQ PAC'S AND OCC DROPPED SINUS BEAT. PACER SET @ VVI 60. SCANT DRNG VIA CT'S. HCT STABLE @ 32.\n\nRESP: COARSE BS BILAT W CRACKLES R BASE. VENT WEANED TO CPAP @ 1230. RR 14, VT IN 700'S, ABG WNL. SPO2 MID 90'S ON 40% FIO2. INFREQ FOR MOD AMT THICK, WHITE SECRETIONS.\n\nG.I.: BS NOW +. OGT TO LCWS, LIGHT, THICK BILIOUS DRNG.\n\nG.U./RENAL: K+ WNL. BORDERLINE UO THIS AFTERNOON. CURRENTLY DIURESING AFTER 20MG IV LASIX.\n\nENDO: INSULIN DRIP ON/OFF FOR GLUCOSE CONTROL.\n\nA/P: TOLERATING WEANING OF DRIPS. HEMODYNAMICS WNL OFF IABP. CIRCULATION TO RLE INTACT. MONITOR FOR AFIB. REPLETE LYTES PRN AFTER LASIX. STABLE RESP STATUS ON MINIMAL VENT SUPPORT. NEURO INTACT. ?EXTUBATE THIS EVE-AWAITING DECISION ON ROUNDS. WILL D/C FENT DRIP. PAIN MED PRN.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-18 00:00:00.000", "description": "Report", "row_id": 1665343, "text": "BS coarse crackles. Suctioned for small amount white secretions. Changed to PSV 5 with NAD. RSBI - 30. Continue on PSV as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-19 00:00:00.000", "description": "Report", "row_id": 1665344, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse suct sm th pale yellow sput. ABGs stable on current settings; no changes made overnoc. Cont PSV.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-19 00:00:00.000", "description": "Report", "row_id": 1665345, "text": "CSRU A NPN:\nNEURO: Opens eyes spontaneously, follows commands and nodding head to questions appropriately. Denies any pain. Fentanyl turned off at 0645. MAE in bed.\nCV: Afeb. HR SR 80s-90s with occasional short runs of Aflutter with rates in 70s-80s. Levophed put back on overnight for low BP- currently off. Goal MAP >65. Milrinone and vasopressin at same rates. Pacer wires intact with set on V demand of 60. R groin site where balloon pulled with pressure dsg, clean, dry and intact. No hematoma noted. Dopplerable pedal pulses bilaterally. Both feet warm to touch with +CSM.\nRESP: On PSV 5/5 40% with good abg. Probable extubation this am. LS coarse with crackles at bases. Scant secretions with suctioning. O2 Sat >95%.\nGI/GU: Abd. soft with hypoactive bowel sounds. OGT to LWS with small amts bilious drainage. Foley draining clear green-tinged urine >40cc/hr. Insulin gtt continues for glucose control.\nSKIN: R radial and L groin a-lines intact. Swan/cordis to R IJ.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-17 00:00:00.000", "description": "Report", "row_id": 1665338, "text": "UPDATE\nNEURO: FACIAL GRIMACING ONLY THIS A.M. TO NOXIOUS STIMULI. PROPOFOL SEDATION TRANSITIONED TO FENTANYL/VERSED IV. CURRENTLY MOVES HEAD AND ATTEMPTED TO RAISE EYELIDS TO STIMULATION BUT NO MVMT OF EXTREMETIES NOTED.\n\nCV: PACING DISCONTINUED; CURRENTLY SR LOW 80'S, NO ECTOPY. CONT ON MULTIPLE IV INOTROPE AND VASOPRESSOR SUPPORT(SEE FLOW SHEET). IABP CONT ON 1:1 W/ GD AUGMENTATION AND UNLOADING. C.I. REMAINS >2 BY FICK METHOD. BP IMPROVED ONCE PROPOFOL OFF. MEDIASTINAL CT'S W/ MOD AMT SEROSANG DRNG. HCT STABLE @ 34.\n\nRESP: LUNG SOUNDS CLEAR, SL DIMINISHED @ R BASE. CXR REPORTEDLY \"WET\". PAO2 AND SPO2 DROPPED THIS A.M. AFTER FOR UNCLEAR . BOTH IMPROVED AFTER PEEP INCREASED FROM 10->12. FOR SM AMTS THICK, BLOOD TINGED SECRETIONS.\n\nG.I.: SM AMT BILIOUS DRNG VIA OGT.\n\nG.U./RENAL: K+ ELEVATED > 5. UO DIPPED TO 20ML OR LESS X 2 HRS.-->NOW DIURESING WELL AFTER 1 DOSE LASIX. CR 1.2(PRE-OP 1.5).\n\nENDO: CONT ON INSULIN DRIP PER PROTOCOL. GLUCOSE WNL.\n\nSKIN: INTACT. DRSGS C&D. APPROX 2X2 IN. CIRCULAR REDDENED AREA ON R BUTTOCK FROM PRESSURE.\n\nSOCIAL: BROTHER, AND NEICE IN TO VISIT AND UPDATED. THEY STATE THAT IS TO BE THE NEW CONTACT/SPOKESPERSON FOR FAMILY.\n\nA/P: HEMODYNAMICALLY STABLE W/ SIGNIFICANT MECHANICAL AND CHEMICAL SUPPORT. NEURO STATUS REMAINS NOT FULLY ASSESSED DUE TO SEDATION. CONT TO ASSESS FOR COMFORT NOW ON FENT/VERSED DRIPS. OXYGENATION IMOROVED AFTER INCREASED PEEP AND NOW DIURESIS. MONITOR LYTES CLOSELY. MINIMIZE STIMULATION. CONT GENTLE TURNING AND SKIN CARE. KEEP MAP ~70 PER N.P.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-17 00:00:00.000", "description": "Report", "row_id": 1665339, "text": "Respiratory Care\n\n Pt continues on full ventilatory support. B/S ess clear dim in bases Pt had drop in sats/ Pa02 after sxing, PEEP increased with good effect. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-18 00:00:00.000", "description": "Report", "row_id": 1665340, "text": "Resp Care\nPt remains on vent.Intubated with 7.5 ett @ 23. suctioned for scant amt of clear thin secretions. Weaning based abgs. Plan wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-18 00:00:00.000", "description": "Report", "row_id": 1665341, "text": "NEURO-SEDATED WITH FENTANYL & VERSED. PT TO VOICE AND FOLLOW COMMANDS. NODDING HEAD YES/NO TO QUESTIONS.\n\nCV- TEMP DECREASED TO 36.4C. NSR WITH RARE(BUT CONSISTANT)PVC. CA+ REPLETED X1. A-WIRES SENSE BUT DO NOT CAPTURE APPROPRIATLEY.MV02/CO-CI/ & HEMODYNAMICS STABLE DURING TITRATION OF PRESSORS.CT WITH SCANT S/S/DRG.HCT=34.2\nFEET COLD WITH DOPPLERABLE ->PALP. PULSES. 2+ GENERALIZED EDEMA.\n\nRESP- TOLERATED VENT WEAN WITH STABLE SATS/ AND ABG'S. LS CLEAR-> RHONCHOROUS -> CLEAR AFTER SXING THIN WHITE SPUTUM.\n\nGI- ABD.SOFT. + BS. OGT-> LCWSX WITHBILIUS DRG.\n\nGU-ADEQ.HOURLY U/O. URINE GREEN COLORED FROM METH BLUE GIVEN IN O.R.\n\nENDO-INSULIN GTT PER CSRU PROTOCOL. GLUCOSE LEVELS 89-136.\n\nPLAN- CONTINUE TITRATION OF GTTS AND VENT SETTINGS IT PT REMAINS STABLE. CONTINUE TO MONITOR ALL SYSTEMS.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-22 00:00:00.000", "description": "Report", "row_id": 1665353, "text": "NEURO: A&O X 3, PLEASANT AND COOPERATIVE WITH CARE. MAE EQUALLY. TALKATIVE. ROXICET ELIXIR 5CC X 1 FOR PAIN.\n\nPULM: LUNGS DIMINSHED/CRACKLES AT BASES, UPPER AIRWAYS CLEAR. STRONG PRODUCTIVE COUGH, USING IS TO 500CC. N/C AT 2L, SATS > 94%. EUPNEIC RESPIRATIONS.\n\nCV: NSR 90'S UNTIL ~ 0545 WENT INTO ATRIAL FLUTTER WITH VR 70-80. MD CALLED, 2 GMS MAG IV , LYTES RESENT. NO CHANGE IN SVO2 OR BP WHEN IN ATRIAL FLUTTER. PT UNAWARE OF CHANGE IN RHYTHM. MV02 66 WITH FICK CI > 2.4. PALPABLE PEDAL PULSES. 4+ GENERALIZED EDEMA.\n\nENDO: QID SSRI COVERAGE OF BLD SUGARS.\n\nGI: TAKING NAS DIET. ABDOMEN SOFT, + BS. PASSING FLATUS.\n\nGU: FOLEY TO CD. LARGE DIURESIS FROM LASIX 20MG IVP. URINE SLIGHTLY GREEN TINGED.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: ? AMIO BOLUS/GTT. ? NEED FOR ANTICOAGULATION. ? DC MILRINONE AND DC SWAN LINE LATER TODAY. INCREASE ACTIVITY.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-22 00:00:00.000", "description": "Report", "row_id": 1665354, "text": "See and carevue for detailed documentation\n\nNeuro: Patient alert, oriented x3, c/o of incisional/ back/ genralized discomfort tx with tylenol with good result. OOB to chair with 2 assist, weight bear well, c/o stiffness with moving. Patient remains ~anxious rehab/ not being able to walk easily. Reassured.\n\nResp: BS clear, diminished in bases. Using I/S well. On 2L NC with SAT> 97%. RA SAT 95%.\n\nCV: Rec'd patient in aflutter, rec'd amio bolus with return to NSR. PAtient with low CO/MVSAT in aflutter-> no change with increased milrinone dose -> improved with return to NSR. Remained in NSR 70-80. A wires sense/ capture. BP stable. Albumin bolus given for CVP 0-3, now 6. Milrinone weaned with stable CO/CI, CI >2, CCO correlates to FICK. Potassium and calcium repleted. Palpable pulses.\n\nGI/Endo: Taking po well. + flatus, no BM. RSSI per protocol.\n\nGU: Urine output fair to good without lasix. Draining clear yellow/ green urine via foley.\n\nSocial: Nephew called, updated. Patient requesting no one visit today.\n\nPlan: Continue cardiopulmonary monitoring. Wean milrinone as ordered. Replete lytes as needed. Encourage activity/ po's as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-17 00:00:00.000", "description": "Report", "row_id": 1665336, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick bld tinged secretions.HR-A-Paced on IABP.Sedated with propofol. Getting epinephrine,levophed,milrinnone,and pitressin. No RSBI done on peep of 10. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-17 00:00:00.000", "description": "Report", "row_id": 1665337, "text": "Nursing Progress note\nNeuro: pt remains sedated, not reversed from or paralytics. Not woke due to unstable hemodynamic status. Pupils perla pinpoint brisk. Unresposive except grimacing and coughing with turning and adls. Propofol at 40 mcg/kg/min. Bilateral soft wrist restraints to protect lines tubes and drains from interference. Gag impaired.\n\nCVS: temp 97.7, on/off bair hugger. HR 92 a paced for better CO. Underlying sinus rate 60, occasional pvc, Right BBB. BP 100/36, pa 41/24, Svo2 72, CVP 16, CO fick 6.1/ CI fick 3.26, IABP at 1:1 with good unloading. IV drips currently epinephrine at .06, Levophed at .03, Milrinone at 0.5, and vasopressin at 4.8 pulses confirmed by doppler to bles. Skin cool, dry, intact. 2 A and 2 V wires sense and pace appropriately, pacer set on ademand mode. Chest tubes, 1 wet & 1 dry with serosang scant drainage. Sternal, mediastinal and femoral dressings CDI.\n\nAccess lines: Right iJ cordis with CCO swan. Recalibrated x 2 overnight. A line femoral and radial, zeroed. PIV x 3 all in use at this time, right forearm to be dc'd when no longer needed/outdated.\n\nResp: ls diminished throughout. ETT, vented on IMV+PS .5/600/15/10/5 abg 7.44/31/120/22/-1/98% suctioned for scant thick blood tinged secretions.\n\nGI: abdomen distended, soft, bs hypoactive. OGT to LCS with scant bilious drainage.\n\nGU: Foley cath draining green tinged urine to gravity, r/t methyl blue received during surgery.\n\nEndo: regular insulin gtt at 4 units per hour per csru scale.\n\nSocial: no calls or family contact this shift.\n\nPlan: wean epi then levophed as tolerated. Remain sedated intubated untill further orders from md in am.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-08-16 00:00:00.000", "description": "Report", "row_id": 1665334, "text": "Respiratory Care\n\n Pt received S/P CABG/MVR B/S equal ventilator settings per cardiac team. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2174-08-16 00:00:00.000", "description": "Report", "row_id": 1665335, "text": "S/P CABG X 2 , MVR\nARRIVED ON VASOPRESSIN @ 4.8UNITS/HR,EPI.05MCQ,LEVO.2MCQ, SR 80'S, 160 MED CT DRAINAGE, 80 PLEURAL CT DRAINAGE. IABP 1:1 WITH GOOD UNLOADING.\n CARDIAC: SR TO APACED WITH HYPOTENSION. 2 RUNS OF ? VT/ SWICTH BUNDLE,BOTH DR. AND NP AWARE, 20 MEQ KCL AMD 2 GM MAGNESIUM GIVEN, NO FURTHER ARRYTHYMIAS NOTED. PAD'S TWENTIES, CVP LOW TWENTIES. MVO2 77-63, CI FOLLOWED BY TD UNTIL <2. FICK CI CONTINUES TO BE >2. MIRINONE STARTED AT 2200 AFTER LEVO WEANED RATHER QUICKLY DUE TO HTN, + ? PT LIGHT. VASOPRESSIN CONTINUES AT 4.8 UNITS/HR, EPI ^ TO >O6MCQ WITH DECREASE IN CI, LEVO PRESENTLY AT .01 MCQ WITH ADDITION OF MILRINONE AT .25MCQ. RECEIVED 3L LR. HCT 27 RECEIVED 2 UPC WITH HCT 29 RECEIVED 3RD UPC WITH REPEAT HCT PENDING. ADDITIONAL 20 MEQ KCL GIVEN. EXTREMITIES DRY WARMER THAN UPON ARRIVAL. DOPP PP. DSGS D+I. MIN CT DRAINAGE. ACT 150 NO TREATMENT DUE TO NOT BLEEDING. IABP SITE SOFT, NO HEMATOMA NOTED. IABP WITH GOOD UNLOADING.\n RESP: ABG + VENT SETTINGS PER FLOW, SX X 1 FOR NO SPUTUM. BS COURSE TO CLEAR UPPER, DIMINISHED BIBASILAR. NO CT LEAKS. O2 SATS> 98%.\n NEURO: NOT REVERSED TO REMAIN INTUBATED AND SEDATED OVERNIGHT. PERL. CONTINUES ON PROPOFOL AT 25 MCQ.\n GI: CARAFATE AND PROTONIX GIVEN. ABD SOFT, NONTENDER. OGT ADVANCED WITH GOOD PLACEMENT. ABSENT BOWEL SOUNDS.\n GU: MARGINAL UO 25-65 ML/HR HO AND . CRI.\n ENDO: INSULIN GTT INCREASED TO 2 UNITS AT 2215 FOR GLUCOSE 132.\n ID: VANCO Q24 TO RECEIVE IN AM.\n PAIN: RECEIVED 1 MG MORPHINE X 2 AND ADDITIONAL 2 MG MORPHINE WITH HTN.\n SOCIAL: SPOKE WITH NEPHEW OF PT OVER THE PHONE AND UPDATED HIM.\nA: CARDIOGENIC SHOCK REQUIRING IABP AND MULTI GTT SUPPORT,\nP: MONITOR COMFORT, HR AND RYTHYM, SBP- WEAN LEVO AS TOLERATED, CI- FOLLOW FICK PER DR, ,SVO2-KEEP >60,CONTINUE VASOPRESSIN, MILRINONE, EPI, CT DRAINAGE, DSGS, PP, IABP SITE, RESP STATUS-TO REMAIN INTUBATED OVERNIGHT, NEURO STATUS- PROPOFOL, I+O-UO, LABS PENDING. AS PER ORDERS.\n" }, { "category": "ECG", "chartdate": "2174-08-25 00:00:00.000", "description": "Report", "row_id": 219403, "text": "Sinus rhythm\nFirst degree A-V block\nInferior infarct - age undetermined\nInferolateral ST-T changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing of , T wave flattening noted\n\n" }, { "category": "ECG", "chartdate": "2174-08-16 00:00:00.000", "description": "Report", "row_id": 219404, "text": "Sinus rhythm\nNondiagnostic inferior Q wave\nT wave changes\nLow QRS voltages\nSince previous tracing of , the heart rate is slower, and T wave\nabnormalities more marked\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2174-08-11 00:00:00.000", "description": "Report", "row_id": 219405, "text": "Sinus tachycardia. Inferior myocardial infarction, age indeterminate. Low limb\nlead voltage. Non-specific diffuse ST-T wave changes. Cannot rule out ischemia.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2119-12-09 00:00:00.000", "description": "Report", "row_id": 97057, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 74\nWeight (lb): 250\nBSA (m2): 2.39 m2\nBP (mm Hg): 135/46\nHR (bpm): 36\nStatus: Inpatient\nDate/Time: at 15:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Mildy dilated aortic root.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric MR jet. Mild\n(1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nConclusions:\nThe left atrium is dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. There is no ventricular septal defect. The aortic root is\nmildly dilated at the sinus level. The number of aortic valve leaflets cannot\nbe determined. The aortic valve leaflets are moderately thickened. There is no\naortic valve stenosis. Mild to moderate (+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. An eccentric, posteriorly\ndirected jet of Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. The estimated pulmonary artery systolic\npressure is normal.\n\nIMPRESSION: poor technical quality due to patient's body habitus. Left\nventricular function is probably normal, a focal wall motion abnormality\ncannot be fully excluded. The right ventricle is not well seen. Midl aortic\nand mitral regurgitation.\n\nCompared with the prior study (images reviewed) of , image quality is\nbetter. Mild to moderate aortic and mild mitral regurgitation can be seen on\nthe current study.\n\n\n" }, { "category": "ECG", "chartdate": "2119-12-08 00:00:00.000", "description": "Report", "row_id": 287263, "text": "ECG interpreted by ordering physician.\n see corresponding office note for interpretation.\n\n" }, { "category": "ECG", "chartdate": "2119-12-12 00:00:00.000", "description": "Report", "row_id": 287264, "text": "A-V sequential pacing. Since the previous tracing of A-V pacing is now\nseen.\n\n" }, { "category": "ECG", "chartdate": "2119-12-10 00:00:00.000", "description": "Report", "row_id": 287265, "text": "Sinus bradycardia with second degree A-V block with 2:1 response. Right\nbundle-branch block. Left axis deviation may be due to left anterior fascicular\nblock and possible inferior myocardial infarction of indeterminate age,\nalthough the latter is non-diagnostic. Diffuse ST-T wave abnormalities are\nprimary and cannot exclude myocardial ischemia. Clinical correlation is\nsuggested. Since the previous tracing of 2:1 response is present\nthroughout with higher grade block not seen.\n\n" }, { "category": "ECG", "chartdate": "2119-12-09 00:00:00.000", "description": "Report", "row_id": 287497, "text": "Sinus bradycardia with initially probable 2:1 conduction followed by 3:1\nconduction. Right bundle-branch block. Left anterior fascicular block. Diffuse\nnon-specific ST-T wave changes. Clinical correlation is suggested. Compared to\ntracing #4 higher degrees of A-V block are seen on the current tracing.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2119-12-09 00:00:00.000", "description": "Report", "row_id": 287498, "text": "Sinus rhythm with either 2:1 block or ventricular escapte at half the sinus\nrate. There is right bundle-branch block, left anterior fascicular block.\nNon-specific lateral ST-T wave changes. Compared to tracing #3 there is no\nchange. Clinical correlation is suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2119-12-09 00:00:00.000", "description": "Report", "row_id": 287499, "text": "Sinus rhythm with 2:1 block or a ventricular escape occurring at half the sinus\nrate. Right bundle-branch block. Left anterior fascicular block. Non-specific\nlateral ST-T wave changes. Compared to the previous tracing #2 there is no\nchange.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2119-12-08 00:00:00.000", "description": "Report", "row_id": 287500, "text": "Sinus rhythm. There appears to be either 2:1 block or ventricular escape\noccurring at half the sinus rate. Right bundle-branch block. Left anterior\nfascicular block. Non-specific lateral ST-T wave changes. Compared to\ntracing #1 there is no change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2119-12-08 00:00:00.000", "description": "Report", "row_id": 287501, "text": "Sinus rhythm. There appears to be 2:1 block with the conducted P wave\nconducting with a long P-R interval. It is, however, possible that there is\nA-V dissociation and that the ventricular rhythm is an escape rhythm. Right\nbundle-branch block. Left anterior fascicular block. Non-specific inferior and\nlateral ST-T wave changes. Compared to the previous tracing of the\noverall rate is decreased and abnormal conduction is seen on the current\ntracing. On the prior tracings the P-R interval is prolonged but not to the\nsame extent as on the current. Clinical correlation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2186-09-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1156659, "text": " 6:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls eval for interval changes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with traumatic ICH\n REASON FOR THIS EXAMINATION:\n pls eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa MON 6:34 PM\n no significant change in frontparietal subarachnoid hemorrhage predomnantly\n along right central sulcus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup of intracerebral hemorrhage.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast. Axial, coronal, and sagittal reformations were\n prepared.\n\n COMPARISON: CT scan dated obtained approximately seven hours\n prior.\n\n FINDINGS: There is no significant change in foci of subarachnoid hemorrhage,\n predominantly layering along the right central sulcus and adjacent\n frontoparietal sulci. No areas of new hemorrhage are seen. No mass effect is\n present. Prominence of the ventricles and sulci likely reflects generalized\n atrophy, age related. No fracture or concerning osseous lesion is seen. A\n right occipital soft tissue hemoatoma with foci of subcutaneous emphysema and\n several staples is seen. The visualized paranasal sinuses are clear.\n\n IMPRESSION: No significant change in right frontoparietal subarachnoid\n hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2186-09-04 00:00:00.000", "description": "CT PELVIS ORTHO W/O C", "row_id": 1156665, "text": " 7:05 PM\n CT PELVIS ORTHO W/O C Clip # \n Reason: define fx / dl\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with pelvic fracture from fall\n REASON FOR THIS EXAMINATION:\n define fx / dl\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa MON 10:24 PM\n Comminuted left superior and inferior pubic rami fractures.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman with pelvic fractures after fall.\n\n COMPARISON: Not available at the .\n\n TECHNIQUE: MDCT axial images of the pelvis were obtained without\n administration of intravenous contrast. Coronal and sagittal reformatted\n images were obtained and reviewed.\n\n FINDINGS:\n\n There is a nondisplaced fracture of the left hemisacrum, extending anterior to\n posterior, the inferior aspect of the fracture does appear to violate the\n sacroiliac joint (2:34). The fracture does not involve the neural foramina.\n Additionally, there is comminuted fracture of the anterior acetabular column\n and a slightly angulated fracture involving quadrilateral plate of the\n acetabulum. There is a nondisplaced fracture of the superior pubic ramus and\n displaced comminuted fracture of the left inferior pubic ramus with overriding\n of the fracture fragments. There is a subtle non-displaced fracture of the\n right inferior pubic ramus (2:86). There is hematoma adjacent to the\n acetabular fracture, extending into the inguinal region and expanding the\n adductor muscle component.\n\n The femoral heads and necks appear intact.\n\n There is enthesopathy at the hamstring attachments bilaterally. There is\n narrowing and spurring at both femoroacetabular joints. There is a\n compression deformity of the L4 vertebral body of uncertain chronicity.\n\n Limited evaluation of the lower lumbar spine demonstrates multilevel\n degenerative changes, with spinal canal stenosis worst at imaged level L5-S1,\n where disc bulge, facet arthropathy produce spinal canal stenosis.\n\n Incidentally noted is extensive sigmoid diverticulosis with no evidence of\n acute diverticulitis on this non-contrast study. There are atherosclerotic\n calcifications of the abdominal aorta, which is normal in caliber.\n\n The urinary bladder is decompressed around the Foley catheter. There is a\n left inguinal hernia, containing fat.\n (Over)\n\n 7:05 PM\n CT PELVIS ORTHO W/O C Clip # \n Reason: define fx / dl\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Comminuted fractures of the anterior column and quadrilateral plate of the\n acetabulum with adjacent hematoma.\n\n 2. Additional fractures of superior and inferior left pubic rami, inferior\n right pubic ramus and left sacrum.\n\n 3. L4 compression fracture of uncertain chronicity.\n\n 4. Incompletely imaged lower lumbar DJD with spinal canal stenosis worst at\n imaged L4-5 and L5-S1 level.\n\n 5. Sigmoid diverticulosis.\n\n Final report was discussed with Dr. on .\n\n" }, { "category": "Radiology", "chartdate": "2186-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1156681, "text": " 9:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion or pna?\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with dizziness and fall.\n REASON FOR THIS EXAMINATION:\n pleural effusion or pna?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dizziness and fall, to assess for pleural effusion and pneumonia.\n\n FINDINGS: In comparison with the earlier study of this date, allowing for\n marked differences in technique, there is no definite change. No evidence of\n pneumothorax or increasing pulmonary venous pressure. The old healed rib\n fractures are not well seen due to differences in the degree of obliquity.\n\n No convincing evidence of acute pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-09-08 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1157184, "text": " 2:01 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, TACHYCARDIA. ? PE\n Admitting Diagnosis: BLUNT TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with shortness of breath, tachycardia, desaturation\n REASON FOR THIS EXAMINATION:\n ?pulmonary embolus\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EAGg FRI 3:28 AM\n No e/o PE to the segmental level. No e/o acute aortic abnl. B/l atelectasis.\n Nonspecific mediastinal lymph nodes measuring up to 9 mm. Incompletely\n evaluated large right thyroid nodule w/ calcification should be further\n evaluated with u/s if not previously performed. Fatty liver.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, tachycardia, desaturation. Evaluate for\n pulmonary embolism.\n\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\n performed before and after the administration of intravenous Optiray (100 cc)\n during full inspiration and held shallow inspiration respectively. Images are\n presented for display in the axial plane at 5- and 2.5-mm collimation.\n Multiplanar reformation images are also submitted for review.\n\n COMPARISON: No prior CT thorax is available for comparison.\n\n FINDINGS: There is asymmetric enlargement of the right lobe of thyroid which\n extends retrosternally and is partially calcified (2:3), with deviation to the\n left of the trachea and moderately-severe reduction in the coronal diameter\n from 18 mm to 8mm in coronal diameter and from 334 mm2 to 152mm2 in cross\n sectional area when comparing the non compressed upper trachea to the\n compressed upper tracheal segment. An aberrant right subclavian artery\n posteriorly indents the esophagus. The esophagus is patulous above and below\n this level until its lower portion where the ectatic moderately calcified\n normal caliber thoracic aorta compresses it.\n\n Allowing for the limitation of significant respiratory motion artifact, there\n is no evidence of consolidation or a pulmonary mass. There is no evidence of\n pulmonary embolism.\n\n Atherosclerotic calcification of the coronary arteries is moderately severe.\n The main pulmonary artery is mildly enlarged (35 mm transverse diameter).\n There is no pleural effusion. There is no pathologic enlargement of the\n supraclavicular, axillary, or mediastinal lymph nodes. The largest\n mediastinal lymph node in the subcarinal station measures 9 mm in short axis\n diameter. A 7 mm right breast retroglandular fat nodule, possibly a lymph\n node,\n The airways are patent to the subsegmental level. Anterior indentation of the\n posterior wall of the bronchus intermedius and left main bronchus suggests a\n (Over)\n\n 2:01 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, TACHYCARDIA. ? PE\n Admitting Diagnosis: BLUNT TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n tendency to bronchomalacia. Air trapping in both lower lobes with mosaic\n attenuation in appearance is moderately severe (3:49). Associated bronchial\n wall thickening in both lower lobes is moderately severe. Bilateral lower lobe\n atelectasis is moderately severe.\n\n The study is not tailored for subdiaphragmatic evaluation, only to confirm a\n moderately large sliding hiatus hernia and normal-appearing adrenals.\n Generalized osteopenia, degenerative disc disease and multilevel osteophytosis\n of the thoracic spine are moderately severe. Multiple right posterior rib\n fractures are healed.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Bilateral lower lobe bronchial wall thickening, air trapping and\n bilateral( bronchus intermedius and left main) bronchomalacia.\n 3. Large left thyroid goiter, causes significant upper airway narrowing.\n 4. 7 mm right breast retroglandular fat nodule, possibly a lymph node, merits\n clinical/mammographic evalution.\n\n" }, { "category": "Radiology", "chartdate": "2186-09-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1157171, "text": " 8:13 PM\n CHEST (PA & LAT) Clip # \n Reason: ?pleural effusions\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n ?pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath with possible pleural effusion.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n somewhat better inspiration. No evidence of acute pneumonia or vascular\n congestion. Streaks of atelectasis are seen at the bases. There is some\n prominence of the central pulmonary vessels on the right, raising the\n possibility of pulmonary hypertension.\n\n Displacement of the lower cervical trachea to the left suggests a right\n thyroid mass.\n\n\n" }, { "category": "Echo", "chartdate": "2186-09-11 00:00:00.000", "description": "Report", "row_id": 88825, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 68\nWeight (lb): 180\nBSA (m2): 1.96 m2\nBP (mm Hg): 128/70\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 15:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Small LV cavity. Hyperdynamic LVEF\n>75%. Mild 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.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small. Left\nventricular systolic function is hyperdynamic (EF>75%). There is a mild\nresting left ventricular outflow tract obstruction. Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Trivial mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is an anterior\nspace which most likely represents a prominent fat pad.\n\nIMPRESSION: Moderate symmetric LVH. Hyperdynamic left ventricular systolic\nfunction with a mild resting LVOT gradient. No significant valvular\nabnormality. Mild pulmonary artery systolic hypertension.\n\n\n" }, { "category": "ECG", "chartdate": "2186-09-07 00:00:00.000", "description": "Report", "row_id": 240991, "text": "Artifact is present. Probable atrial fibrillation versus sinus rhythm with\nfrequent atrial ectopy in the presence of artifact. Ventricular ectopy versus\naberrant conduction. Non-specific ST-T wave changes. Compared to the previous\ntracing the rhythm has changed.\n\n" }, { "category": "ECG", "chartdate": "2186-09-05 00:00:00.000", "description": "Report", "row_id": 240992, "text": "Sinus rhythm with frequent ventricular ectopy. Diffuse non-specific ST-T wave\nflattening. Otherwise, no diagnostic interim change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2186-09-04 00:00:00.000", "description": "Report", "row_id": 240993, "text": "Sinus rhythm with increase in rate as compared to prior tracing of .\nDiffuse non-specific ST-T wave flattening. No diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-09-04 00:00:00.000", "description": "Report", "row_id": 240994, "text": "Sinus rhythm. Baseline artifact. Diffuse non-specific ST-T wave flattening.\nRepeat tracing of diagnostic quality is suggested. No previous tracing\navailable for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2119-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1185022, "text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p x-lap for colon perforation\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post colon perforation, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated and the nasogastric tube has been removed. A right and a left\n central venous access line are in unchanged position. The lung volumes have\n slightly decreased and signs of mild to moderate pulmonary edema are still\n visible. There is an unchanged relatively extensive left pleural effusion\n that distributes in a slightly different manner than on the previous\n radiograph, but its extent appears to be unchanged. Moderate cardiomegaly.\n Mild right perihilar atelectasis at the bases of the right upper lobe. No\n right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-04-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1184630, "text": " 6:22 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line position\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man a/p total abdominal colectomy and s/p RIJ TLC\n REASON FOR THIS EXAMINATION:\n eval line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man status post total abdominal colectomy and right\n IJ TLC placement. Evaluate line position.\n\n COMPARISON: CT torso .\n\n SINGLE FRONTAL VIEW OF THE CHEST: The endotracheal tube ends 3.3 cm above the\n carina. A right-sided central venous line ends in the lower SVC. A\n left-sided central venous line ends in the mid SVC. Lung volumes are low with\n bibasilar atelectasis. There is likely a small left-sided pleural effusion.\n Retrocardiac opacity is likely a combination of atelectasis and a small\n pleural effusion. There is mild pulmonary edema. There is no pneumothorax.\n Cardiomediastinal contours are within normal limits. Free intra-abdominal air\n is consistent with recent surgery.\n\n IMPRESSION:\n 1. Right central venous line ends in the lower SVC. No pneumothorax.\n 2. Mild pulmonary edema with small left pleural effusion and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2119-04-26 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1185434, "text": " 5:15 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: swelling of left upper extremity, please rule out DVT\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with metastatic pancreatic adenocarcinoma s/p subtotal\n colectomy for perforation from metastases now with LUE swelling\n REASON FOR THIS EXAMINATION:\n swelling of left upper extremity, please rule out DVT\n ______________________________________________________________________________\n WET READ: JBRe WED 7:40 PM\n No DVT.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with left upper extremity swelling.\n\n TECHNIQUE:\n Grayscale and color Doppler ultrasound images of the left upper extremity were\n performed.\n\n COMPARISON: There are no comparison studies available.\n\n FINDINGS:\n There is normal compressibility, flow, and augmentation of the left jugular,\n subclavian, axillary, brachial, basilic and cephalic veins.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Echo", "chartdate": "2119-04-26 00:00:00.000", "description": "Report", "row_id": 87032, "text": "PATIENT/TEST INFORMATION:\nIndication: Persistent pressor requirements.\nWeight (lb): 255\nBP (mm Hg): 103/55\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 11:24\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Doppler parameters are most consistent\nwith Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\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. Left pleural\neffusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left atrium is moderately dilated. Left\nventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Doppler parameters are most consistent\nwith Grade I (mild) left ventricular diastolic dysfunction. The number of\naortic valve leaflets cannot be determined. There is no aortic valve stenosis.\nNo aortic regurgitation is seen. The mitral valve leaflets are not well seen.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: poor technical quality study. Left ventricular function is\nprobably normal, a focal wall motion abnormality cannot be fully excluded. The\nright ventricle is not well seen. No pathologic valvular abnormality seen.\nMild pulmonary artery systolic hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-04-26 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1185393, "text": " 11:39 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please eval for evidence of obstruction, cholecystitis\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with risinig bili to 6.0\n REASON FOR THIS EXAMINATION:\n please eval for evidence of obstruction, cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND ABDOMEN\n\n INDICATION: Rising bilirubin. H/O metastatic pancreatic cancer. Recent\n laparotomy for sigmoid colon perforation.\n\n COMPARISON: Outside hospital CT .\n\n FINDINGS:\n\n Technically difficult examination due to the patient being ventilated and\n portable technique. There is limited penetration likely secondary to\n intra-abdominal air from recent laparotomy which obscures imaging somewhat.\n\n Limited views of the liver demonstrate normal liver echotexture without focal\n mass. No intrahepatic biliary dilatation. Small amount of perihepatic\n ascites. There is mild gallbladder wall thickening and distension. There are\n multiple gallstones and sludge identified within the gallbladder. It is\n difficult to assess for acute cholecystitis in this setting due to the\n presence of ascites. Clinical correlation recommended. If concerned, then\n further evaluation with HIDA gallbladder scan recommended.\n Common bile duct measures 4mm. The main portal vein is patent and demonstrates\n forward flow.\n Structures in the midline not easily seen due to overlying bowel gas.\n\n IMPRESSION:\n\n 1. Mild amount of perihepatic ascites.\n\n 2. Distended gallbladder with wall edema, stones and sludge. The findings are\n nonspecific in this clinical setting though acute cholecystitis cannot be\n excluded - further evaluation with HIDA recommended if clinically indicated.\n\n CASE DISCUSSED WITH DR. AT 16:30 HRS VIA TELEPHONE\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2119-04-28 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1185688, "text": " 1:42 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: video swallow study\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ?difficulty swallowing post prolonged ICU stay\n REASON FOR THIS EXAMINATION:\n video swallow study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dysphagia.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Oropharyngeal swallowing video fluoroscopy was performed in\n conjunction with the speech and swallow division. Multiple consistencies of\n barium were administered.\n\n FINDINGS:\n\n Barium passes freely through the oropharynx and esophagus without evidence of\n obstruction. No gross aspiration was noted. Multiple episodes of penetration\n were seen with thin consistency barium and nectar.\n\n IMPRESSION:\n\n No evidence of gross aspiration; however, given multiple episodes of\n penetration with various consistencies of barium, patient is at higher risk\n for aspiration.\n\n For details and recommendations, please refer to speech and swallow division\n note in OMR.\n\n" }, { "category": "Radiology", "chartdate": "2119-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1184675, "text": " 11:19 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OG tube placement\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: NG tube placement.\n\n Portable AP chest radiograph was reviewed with comparison to \n obtained at 06:28 a.m.\n\n The NG tube tip is coiled in the proximal stomach with its tip being in the\n stomach. The ET tube tip is 4.5 cm above the carina. The right internal\n jugular line tip is at the cavoatrial junction. There is a left pleural\n effusion present. There is free air below the diaphragm, slightly decreased\n since the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2119-05-02 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1186081, "text": " 4:31 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: confirm tube placement\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with dobhoff/ngt placement\n REASON FOR THIS EXAMINATION:\n confirm tube placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SZm TUE 5:40 PM\n 1. Nasoenteric tube likely in place within the cardia of the stomach.\n 2. Large air fluid level in the RUQ believed to most likely represent a large\n extraluminal collection.\n 3. Dilated loops of small bowel in the right upper quadrant could represent\n early evolving small bowel obstruction.\n\n Findings Discussed with at 5 PM by phone with \n .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old male, question of nasogastric tube placement.\n\n COMPARISON: CT from outside hospital from .\n\n FINDINGS: A nasogastric tube tip projects over the cardia of the stomach with\n some contrast material within the gastric fundus after presumed injection of\n contrast through the NGT. There is a large air-fluid level within the right\n upper quadrant and right mid abdomen which contains an air fluid level on the\n upright view and most likely represents a large extraluminal collection.\n There are several dilated air-filled loops of small bowel in the right upper\n quadrant that could represent early or evolving small bowel obstruction.\n There is a nephrostomy tube seen in unchanged position. There are midline\n staples seen in place.\n\n IMPRESSION:\n 1. Nasoenteric tube tip likely located in the fundus of the stomach.\n 2. Large air fluid level in the RUQ believed to most likely represent a large\n gas and fluid containing extraluminal collection. Recommend CT for further\n evaluation.\n 3. Dilated loops of small bowel in the right upper quadrant could represent\n early or evolving small bowel obstruction.\n\n Findings Discussed with at 5 PM by phone with \n .\n\n" }, { "category": "Radiology", "chartdate": "2119-05-02 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1186082, "text": ", S. CC6A 4:31 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: confirm tube placement\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with dobhoff/ngt placement\n REASON FOR THIS EXAMINATION:\n confirm tube placement\n ______________________________________________________________________________\n PFI REPORT\n 1. Nasoenteric tube likely in place within the cardia of the stomach.\n 2. Large air fluid level in the RUQ believed to most likely represent a large\n extraluminal collection.\n 3. Dilated loops of small bowel in the right upper quadrant could represent\n early evolving small bowel obstruction.\n\n Findings Discussed with at 5 PM by phone with \n .\n\n" }, { "category": "Radiology", "chartdate": "2119-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1185069, "text": " 10:57 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate Dobhoff tube placement\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with septic shock\n REASON FOR THIS EXAMINATION:\n evaluate Dobhoff tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:23 A.M. on :\n\n HISTORY: Patient in septic shock. Evaluate Dobbhoff tube placement.\n\n A frontal view of the torso centered at the gastroesophageal junction includes\n the lung apices. It shows a feeding tube with the wire stylet pulled back\n from the tip, ending in the upper stomach. Left lower lobe collapse persists.\n Moderate left pleural effusion is smaller than it was at 5:25 a.m. Right lung\n is grossly clear. Moderate cardiomegaly stable. Left subclavian line ends in\n the upper SVC, right jugular line in the region of the superior cavoatrial\n junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1184802, "text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p colectomy\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after colectomy.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The ET tube tip is approximately 4 cm above the carina. The NG tube tip is in\n the stomach. The right internal jugular line tip and left subclavian line tip\n are at the level of cavoatrial junction. Cardiomediastinal silhouette is\n unchanged. There is also redemonstration of left retrocardiac atelectasis,\n left pleural effusion, and the patient continues to be in interstitial\n pulmonary edema that appears to be unchanged since the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-04-25 00:00:00.000", "description": "CHG NEPHROTOMY/PYLOSTOMY TUBE", "row_id": 1185269, "text": " 2:05 PM\n URIN CATH CHECK Clip # \n Reason: please evaluate tube and replace if needed. HCP is V\n Admitting Diagnosis: BOWEL PERFORATION\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * CHG NEPHROTOMY/PYLOSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with R nephrostomy s/p breakage\n REASON FOR THIS EXAMINATION:\n please evaluate tube and replace if needed. HCP is (wife)\n \n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Exchange of existing 8.5 French right percutaneous nephrostomy\n catheter for a new nephrostomy catheter.\n\n HISTORY: 60-year-old man with right nephrostomy tube which has become\n fractured. Request is to exchange the tube.\n\n ANESTHESIA: The patient was accompanied by the anesthesiology service who\n administered 3mg iv Versed. Please see relevant documentation. In addition,\n the patient received 25 mg of Benadryl given the history of previous urticaria\n secondary to iodinated contrast medium.\n The patient also received 6mls of 1% lidocaine along the nephrostomy tract.\n\n RADIOLOGISTS: Dr. and Dr. performed the procedure.\n\n PROCEDURE AND FINDINGS: Informed consent was obtained from the healthcare\n proxy outlining the risks and benefits of the procedure involved. Following\n this, the patient was brought to the angiography suite and placed in a left\n lateral position on the imaging table. Following administration of Versed for\n sedation, the tube and existing catheter were prepped and draped in the usual\n sterile fashion. A pre-procedure huddle and timeout were performed as per\n protocol.\n\n A scout lateral image demonstrated expected position of the nephrostomy\n catheter. Examination of the hub of the catheter demonstrated that the\n pigtail retaining suture had fractured related to the patient pulling the\n tube. The skin retention suture, however, remained intact. Injection of a\n small amount of contrast confirmed that the catheter tip remained within the\n right renal pelvis. The catheter was cut and an 0.035 wire advanced\n through the catheter and coiled within the renal collecting system. The\n catheter was removed and a new 8.5 French Cook nephrostomy catheter advanced\n over the wire with the pigtail formed in the right renal collecting\n system. Injection of dilute contrast confirmed satisfactory position with\n flow of contrast into the upper ureter.\n The pigtail was formed and the catheter secured with a 0 silk anchor suture,\n StatLock and Flexi-Trak dressing. The catheter was attached to a drainage\n bag. There were no early complications. The patient tolerated the procedure\n well.\n (Over)\n\n 2:05 PM\n URIN CATH CHECK Clip # \n Reason: please evaluate tube and replace if needed. HCP is V\n Admitting Diagnosis: BOWEL PERFORATION\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Uncomplicated over the wire exchange of fractured right\n nephrostomy catheter for a new 8.5 French Cook nephrostomy catheter via the\n existing tract. There were no early complications and the patient tolerated\n the procedure well.\n The patient would require routine change in three months if the catheter\n remains in situ.\n\n The attending radiologist has reviewed the images and report.\n\n" }, { "category": "Radiology", "chartdate": "2119-05-02 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1186220, "text": " 9:18 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Eval to follow up KUB findings.\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ?fluid collection vs gastric volvulus on CT\n REASON FOR THIS EXAMINATION:\n Eval to follow up KUB findings.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 1:56 AM\n 1. right pleural effusion.\n 2. large amount of free air.\n 3. status post colectomy with ileostomy and possible hartmann closure.\n 4. extensive free fluid.\n 5. distended 3rd portion of duodenum and proximal jejunum with transition\n point not clearly visualized although loops of bowel are collapsed thereafter.\n 6. clear source of free air is not seen as there does not seem to be\n extraluminal contrast. Patient's surgery was 10days ago.\n 7. extensive anasarca.\n\n d/w Dr. at 151am and with Dr. at 152am on via\n tel.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient, with history of colectomy with ileostomy\n and Hartmann's pouch with new air-fluid level on abdominal radiograph for\n gastric volvulus.\n\n COMPARISON: Outside hospital abdominal CT from .\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the base of the\n lungs to the pubic symphysis after the administration of oral contrast and\n without the administration of IV contrast. Multiplanar reformatted images\n were prepared.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are new bilateral pleural\n effusions in the bases of the lungs, greater on the left than the right, with\n adjacent airspace atelectasis. The visualized portions of the heart remain\n unchanged.\n\n Evaluation of the abdominal structures is limited due to lack of IV contrast.\n Extensive free fluid is visualized throughout the abdominal cavity and\n increased in comparison to prior study. Furthermore, there is extensive free\n air visualized throughout the abdominal cavity but decreased in comparison to\n prior study. There is mild distention of the stomach and the third portion of\n the duodenum; however, the bowel loops appear decompressed from thereon, and\n there is no evidence of definite ileus or obstruction. Oral contrast is\n visualized distally throughout the small bowel. The patient is status post\n colectomy with ileostomy and Hartmann's pouch. Post-surgical changes are\n (Over)\n\n 9:18 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Eval to follow up KUB findings.\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n visualized throughout the anterior abdomen.\n\n Otherwise, right nephrostomy tube is again visualized. The left kidney\n appears normal. Fullness is visualized at the tail of the pancreas with\n multiple metallic densities representing clips/seeds. The spleen appears\n within normal limits. Multiple mesenteric lymph nodes are visualized\n throughout the abdominal cavity. There is also extensive anasarca which is\n new in comparison to prior study.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Free fluid is also visualized\n throughout the pelvis. Otherwise, the patient is status post colectomy with\n Hartmann's pouch. The bladder appears within normal limits. There is no free\n air in the pelvis. Multiple inguinal lymph nodes are visualized but do not\n meet CT size criteria for pathologic lymphadenopathy.\n\n IMPRESSION:\n 1. Extensive abdominal free fluid and free air in a patient with history of\n recent colectomy and ileostomy. It is worth noting that the amount of free\n air has decreased in comparison to .\n 2. New bilateral pleural effusions, greater on the left than the right.\n 3. Status post colectomy with ileostomy and Hartmann's closure.\n 4. Extensive anasarca.\n\n These finding were discussed by Dr. with Dr. at 1:51am and\n with Dr. at 1:52am on via telephone.\n\n" }, { "category": "Radiology", "chartdate": "2119-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1185345, "text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for intrapulmonary process\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p subtotal colectomy\n REASON FOR THIS EXAMINATION:\n evaluate for intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man status post subtotal colectomy. Evaluate for\n intrapulmonary process.\n\n COMPARISON: Multiple priors, most recent .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Dobbhoff tube remains in the proximal\n stomach, unchanged. The right and left-sided central venous lines end in the\n lower SVC. Mild pulmonary edema persists, but is improved. There is a small\n left-sided pleural effusion, stable. Retrocardiac opacity is also unchanged,\n likely a combination of atelectasis and pleural effusion. There is no\n pneumothorax.\n\n IMPRESSION: Improving pulmonary edema. Small left-sided pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2119-05-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1186640, "text": " 5:59 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check new picc placement 48 cm non heparinized DL right arm\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with need for TPN /MEDS only with single port a cath left\n REASON FOR THIS EXAMINATION:\n check new picc placement 48 cm non heparinized DL right arm\n ______________________________________________________________________________\n WET READ: SAT 1:07 AM\n right picc tip traced upto mid svc. left port-a-cath tip at cavoatrial .\n ng tube noted, tip not visualized. left-sided pleural effusion, stable.\n Retrocardiac opacity is also unchanged, likely a combination of atelectasis\n and pleural effusion. opacification in the left mid lung zone is more\n prominent on todays study and may represent atelectasis vs layering pleural\n effusion, however underlying infection can't be excluded. d/w ivn \n at approx 9pm on via tel.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: TPN. Check line placement.\n\n One portable view. Comparison with the previous study of . Hazy\n density on the left consistent with pleural fluid is again demonstrated. The\n retrocardiac area is quite dense consistent with underlying atelectasis and/or\n consolidation, as before. There is additional streaky density consistent with\n subsegmental atelectasis bilaterally. Mediastinal structures are unchanged.\n A feeding tube has been withdrawn. A nasogastric tube or orogastric tube has\n been inserted and terminates well below the diaphragm in the region of the\n stomach. A left subclavian catheter terminates in the superior vena cava as\n before. A PICC line has been inserted on the right and can be followed to the\n mid superior vena cava. Its tip is not clearly identified.\n\n IMPRESSION: Line placement as described.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1185170, "text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with bowel perforation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bowel perforation, evaluate for interval change.\n\n COMPARISON: Radiographs dating back to and most recently .\n\n FINDINGS: A moderately large left pleural effusion has increased in size\n since . Hazy opacity in both lungs may be attributable in part to\n posteriorly layering left-sided pleural effusion with the right-sided opacity\n probably reflects mild edema. Moderate cardiomegaly, left lower lobe\n atelectasis and the satisfactory positions of the Dobhoff, right internal\n jugular and left subclavian central venous catheters are unchanged since\n .\n\n IMPRESSION:\n 1. Acute pulmonary edema, worsened since .\n 2. Enlarging left moderately large pleural effusion.\n 3. Satisfactory position of medical devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-04-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1185058, "text": " 10:21 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o acute IC process\n Admitting Diagnosis: BOWEL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with acute agitation\n REASON FOR THIS EXAMINATION:\n r/o acute IC process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MLHh MON 12:53 PM\n Chr atrophy. No acute process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old male with acute agitation.\n\n There are no prior examinations for comparison.\n\n TECHNIQUE: Contiguous non-contrast axial CT images were obtained through the\n brain, and reconstructed at 5-mm intervals.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or\n infarct. The ventricles and sulci are prominent, consistent with age-related\n involutional changes. Periventricular and subcortical white matter\n hypodensities reflect small vessel ischemic disease. Paranasal sinuses and\n mastoid air cells are clear. Orbits and intraconal structures are preserved.\n\n IMPRESSION: Chronic atrophy. No acute intracranial process.\n\n" }, { "category": "ECG", "chartdate": "2119-04-24 00:00:00.000", "description": "Report", "row_id": 241363, "text": "Sinus tachycardia. Modest right ventricular conduction delay pattern may be\nincomplete right bundle-branch block. Modest diffuse T wave changes are\nnon-specific. Baseline artifact makes assessment difficult. Since the\nprevious tracing of sinus tachycardia has replaced sinus bradycardia and\ndiffuse T wave changes are now present.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2194-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775171, "text": " 10:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P CHEST TUBE REMOVAL. CHECK FOR PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n S/P CHEST TUBE REMOVAL. CHECK FOR PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removal. Question pneumothorax.\n\n COMPARISON: None.\n\n FINDINGS: Sternal wires and right sided internal jugular central venous\n catheter are present. No pneumothorax. The heart is enlarged. There is\n bibasilar atelectasis and small bilateral pleural effusions. The soft tissue\n and osseous structures are unremarkable.\n\n IMPRESSION: No pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-12-04 00:00:00.000", "description": "Report", "row_id": 1562225, "text": "NEURO: LETHARGIC BUT ROUSABLE, ORIENTED X 3, MAE.\nCARDIAC: MP SR WITHOUT, SWAN DC'D. RT FFEM A LINE DC'D. LABS WITHIN NL LIMITS, CT DRAINAGE 20-60 , REMAIN IN OVERNOC. PATIENT OOB WITH HELP OF 2 AFTER STATING THAT WE MUST BE CRAZY, NO WAY WAS HE GOING TO BE ABLE TO GET OOB.\nRESP: CS COARSE WITH EXP WHEEZES EARLY AM, NEB TX GIVEN WITH EFFECT. RR ^ 32-40, PATIENT STATES UNABLE TO TAKE DEEP BREATHS DUE TO PAIN. HO ASKED RE TORIDOL AND TOLD NO DUE TO AGE, RENAL #'S NORMAL. PATIENT UNABLE TO DO SPIROCARE OR COUGH WELL. TORIDOL ORDERED BY FELLOW, RR DOWN TO 20'S.\nGI: POOR APPETITE, ENCOURAGING FOOD.\nGU: URINE OUTPUT ^ AFTER IV LASIX, K+ NL, NO NEED FOR TX.\nENDO: WITHIN RANGE, NO TX NEEDED.\nNO INTERACTION WITH FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2194-12-05 00:00:00.000", "description": "Report", "row_id": 1562226, "text": "NEURO: PTALERT ORIENTED VERY ANXIOUS AT TIMES, C/O THAT EVERYTHING HURT WHEN TOUCHED DID NOT EXPECT THIS TO HAPPEN. PT REASSURED THAT HE WAS DOING WELL BETTER SPIRITS IN AM.\nRESP: O2 SATS 96-98% ON 4L NP COUGHING AND DEEP BREATHING WITH LOTS OF ENCOURAGEMENT. PAIN WAS LESS SEVERE WHEN COUGHING AFTER CHEST TUBES D/C'D.\nC/V: VSS STABLE NO DRIPS REQUIRED. ALINE D/C'D THIS AM.\nGI: TOLERATING DIET WELL.'\nGU: URINE OUTPUT BORDERLINE ALL NIGHT GIVEN 40MG IV LASIX X 1 THIS AM.\nSKIN: INCISION CLEAN AND DRY NO DRAINAGE.\nPAIN: PT HAVE SHARP STABBING PAIN LAST EVENING WHENEVER HE WOULD COUGH OR DEEP BREATH UNABLE TO GET PT TO DO THIS CHEST TUBE DRAINAGE HAD TAPERED OFF SO HO REMOVED CHEST TUBES. PAIN MUCH IMPROVED. PT STATES THAT THE PO PAIN PILLS I GAVE TO HIM LAST NIGHT WORKED VERY WELL. CONTINUE TO MEDICATE WITH PERCOCET AS NEEDED FOR INCREASING ACTIVITY.\nPLAN: TRANSFER TO FLOOR LATER TODAY IF BED AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2194-12-04 00:00:00.000", "description": "Report", "row_id": 1562223, "text": "RESP CARE\nPT. EXTUBATED FROM PSV 5/5 ONTO 40% COOL AEROSOL. ABGS ADEQUATE PRIOR TO EXTUBATION, AUDIBLE LEAK, NO STRIDOR NOTED. SPO2 99% ON CURRENT SETTINGS,RR 20'S NARD,VENT STANDBY.\n" }, { "category": "Nursing/other", "chartdate": "2194-12-04 00:00:00.000", "description": "Report", "row_id": 1562224, "text": " CSRU 7P-7A SHIFT SUMMARY;\n\nPT S/P CABG WITH ARRIVAL TO UNIT JUST PRIOR TO SHIFT CHANGE. PT ON AND LOW DOSE NEO AND APACED FOR BP SUPPORT AT SHIFT CHANGE.\n\nNEURO; INITALLY ON AND WOKE AGGITATED AND NOT FOLLOWING COMMANDS. EVENTUALLY PT MORE AWAKE FOLLOWING COMMANDS AND MAE'S WELL EQUAL BILATERAL. POST EXTUBATION PT SLIGHTLY LETHARGIC BUT EASILY ARROUSABLE BY VOICE. WHEN AWAKE ORIENTED X3 BUT A FEW TIMES BECAME FORGETFUL AND HAD TO BE REMINDED HE WAS IN THE HOSPITAL AND HE HAD SURGERY TO HIS HEART.\n\nRESP; LUNG COARSE THRU OUT. SUCTION PRE EXTUBATION COUPLE OF TIMES FOR CLEAR TO WHITISH SECREATIONS. ABG'S WNL PRE AND POST EXTUBATION. PT PLACED ON 40% OPEN FACE MASK WITH RR AND 02 SAT'S > 95% BUT RR UP TO 30'S WITH MANIPULATION AND STIMULATION THAT CAUSES ANY DISCOMFORT. RR SETTLE BACK DOWN TO 20'S WHEN ASLEEP. ATTEMPTED TO TRY PT ON N/C AT 5LM BUT WITH MOUTH BREATHING WHEN ASLEEP HIS 02 SAT'S DROPPED TO 89% AND FM PLACED BACK ON. PT TO LETHARGIC TO GRASP POST OP TEACHING OF I.S. AND C&R POST EXTUBATION.\n\nCARDIOVAS; INITALLY ON LOW DOSE NEO AND APACED FOR BP SUPPORT. BP LABILE AND TX WITH 2 LITERS LR AND 500CC HESPAN WITH GOOD EFFECT. NEO OFF WITH MAP >60. RT FEM ALINE , RT RADIAL AND CUFF PRESSURE NOT ALWAYS CORRELATING. PACER PLACED ON ADEMAND AND EVENTALLY TURNED OFF.\nPT WITH INCREASING ISOLATED PVC'S AND ? SHORT BURSTS OF SVT.DR NOTIFIED AND DOWN TO SEE PT. REPEAT EKG DONE PT GIVEN MAG SULFATE 2 GMS WITH LESS PVC'S TIL 06OO PT HAD A 4 BEAT RUN OF VT. ALL ELECTROLYTES WNL ON AM BLD DRAW. GLUCOSE 163 DR NOTIFIED AND PT GIVEN 6U REG INSULIN PER SS SQ AT 0500. C.O. 5.00-7.00 WITH C.I.> 2.00-3.00 ALL NOC. CHEST TUBE DRAINING THIN SEROSANQ. MINIMAL AMTS.\n\n\nGI; BS NEG. DID C/O NAUSEA X1 AND MED WITH REGLAN 10MG IVP WITH GOOD EFFECT.\n\nGU; URINE OP WNL ALL SHIFT AND HAS NOT BEEN AN ISSUE.\n\nCOMFORT; C/O DISCOMFORT AROUND CT INSERTION SITE AND WITH ANY MOVEMENT. MED SEVERAL TIMES WITH MS04 2-4 MG IVP WITH GOOD EFFECT.\n\nPLAN; CONT TO MONITOR AND ASSESS WILL NEED AGGRESSIVE PULM. TOLIET POST OP TEACHING, AND MONITOR FOR INCREASING ECTOPY .\n\n\n" }, { "category": "ECG", "chartdate": "2194-12-07 00:00:00.000", "description": "Report", "row_id": 173281, "text": "Sinus rhythm\nInferoposterolateral myocardial infarct, age indeterminate - clinical\ncorrelation is suggested\nSince previous tracing of : right bundle branch block absent\n\n" }, { "category": "ECG", "chartdate": "2194-12-04 00:00:00.000", "description": "Report", "row_id": 173282, "text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\ncomplete right bundle-branch block is now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2194-12-03 00:00:00.000", "description": "Report", "row_id": 173283, "text": "Normal sinus rhythm. Inferior-posterior myocardial infarction pattern.\nCompared to the previous tracing of no major change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2194-12-02 00:00:00.000", "description": "Report", "row_id": 173284, "text": "Baseline artifact\nSinus rhythm\nProbable inferior infarct - age undetermined - clinical correlation is\nsuggested\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2164-08-27 00:00:00.000", "description": "Report", "row_id": 1522052, "text": "SOCIAL WORK\nSW met with pts , and , in ICU waiting area for supportive intervention. report that they recd a visit from NH State Police at 1 am this morning to inform them of accident. Pt is the middle of three children. Older brother is at college and younger sister is at home with neighbors. report that pt is a student at Unity College in and scheduled to go to for the semester abroad.\n\nPts mother is a physical therapist. report significant supports in their friends, family and faith community. expressed concerns about balancing being present with their son with being in their \"normal lives\" . Family home was recently put up for sale and were planning on moving to a smaller home.\n\nFamily appears to be coping with signiciant stress very well. Communication appears good between and both are open to SW intervention. SW to follow. Pls pg SW prn.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-27 00:00:00.000", "description": "Report", "row_id": 1522053, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT SEDATED ON PROPOFOL GTT. WHEN SEDATION OFF FOR EXAM, PT OPENS EYES TO VOICE, MAE, FOLLOWS COMMANDS. PERRL. PT TO MAE WHEN SEDATION ON. PT HAD REPEAT HEAD CT TODAY. ? RESULTS.\n\nCV-LOW GRADE TEMP. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. LYTES REPLETED PRN. FOLLOWING HCT.\n\nRESP-PT REMAINS INTUBATED. VENT CHANGED TO SIMV. SEE FLOWSHEET FOR ABG. LS CLEAR, SL DECREASED AT BASES BILAT. SCANT SPUTUM. RIGHT CT TO SXN WITH SEROUSSANG DRG. NO AIR LEAK NOTED.\n\nGI-ABD SOFT, NT/ND. +HYPOACTIVE BS. OGT TO LWS WITH CLEAR DRG. NO STOOL.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-SSRI, NO COVERAGE NEEDED AT THIS TIME.\n\nORTHO-C-COLLAR REMAINS ON. HAD TLSO FILMS TODAY. PT WITH LEFT L2+L4 TRANSVERSE PROCESS FX. TO REMAIN ON LOGROLL PRECAUTIONS. PT WITH LEFT CLAVICLE AND SCAPULA FX. AWAITING ORTHO TO SEE PT.\n\nSKIN-PT WITH MULTI ABRASIONS AND LACS. OF NOTE--LEFT KNEE LAC, UNABLE TO SUTURE, AREA CLEANED AND BACITRACIN AND DSD PLACED AS ORDERED. PT ALSO WITH LAC ON LEFT SHOULDER, AREA CLEANED AND BACITRACIN AND DSD APPLIED.\n\nLINES- RIGHT INTRODUCER CHANGED OVER WIRE TO TLCL, OK TO USE PER HO.\n\n , FRIEND, AND AT BEDISDE. MEET WITH SW.\n\nPLAN-CON'T WITH CURRENT PLAN.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-27 00:00:00.000", "description": "Report", "row_id": 1522054, "text": "Respiratory Care Note:\n Patient remains intubated and sedated on propofol. Transported to CT scan and also to xray this am without incident. See Carevue flowsheet. Despite pulmonary contusion, bilat upper lung zones, oxygenation is good on 40% and 5 of PEEP. BS bilat, slightly decreased RLL.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-28 00:00:00.000", "description": "Report", "row_id": 1522055, "text": "Resp: pt on simv 18/550/40%/+. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear sounds with slight coarse bases. Suctioned x3 small amount of bloody secretions. MDI's administered Q4 hrs Alb/Atr with no adverse reactions. RSBI=65, SBT initiated. 02 sats @ 99%. No further changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-28 00:00:00.000", "description": "Report", "row_id": 1522056, "text": "TSICU Nursing Progress Note\nNeuro: Pt con't to be sedated on propofol. Pt currently on 50mcg/k/min. Pt up to 70, however MD's wanted to wean vent so pts sedtation lightened. Pt written for fentanyl. given x1 with good effect. Pt able to follow commands, moves all extremeties. Pt at one point sat upright in bed. Pt restrained with bilateral soft wrist restraints. TLS still not cleared, needs logroll and c-collar still.\n\nCardiac: Pt in SR HR 68-79 no ectopy. BP, goal is to be <150 systolic; BP 118-151/65-75. BP does increase to as high as 170 systolic with sedation off. Am lytes, K, repleated.\n\nResp: Pt changed to CPAP in am .4% 0/5. RSBI 65, plan to attempt extubation. BS clear. Pt suctioned for mod amt of thick bloody clots in suptum. Pt had minimal of serosang drainage from CT. O2 sat 98-100%.\n\nGI: Pt NPO has OGT to LCS. Pt draining mod/large amt of bilious fluid. +BS, -BM.\n\nGU: Pt started on D5 1/2 NS with 20mEq K at 60cc/hr. Pt con't to have good u/o via f/c.\n\nSkin: Pt has multiple abrasions over body, covered with antibiotic ointment and covered with a DSD.\nID: low grade temp.\n\nAccess: R SC TL, L rad .\n" }, { "category": "Nursing/other", "chartdate": "2164-08-28 00:00:00.000", "description": "Report", "row_id": 1522057, "text": "TSICU Nursing Progress Note\nPts CT changed to H2O seal at 0645. Pt placed back on a rate, IMV 550*18 . Pt will go to CT later in am then extubated.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-28 00:00:00.000", "description": "Report", "row_id": 1522058, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PROPOFOL GTT OFF AFTER RADIOLOGY. PT WEANED AND EXTUBATED. PT ALERT, ORIENTED X3. SPEECH NORMAL, ORIENTED. MAE. FOLLOWS COMMANDS. PERRL. DENIES NEURO DEFICITS.\n\nCV-AFEBRILE. HEMODYNAMICALLY STABLE. SKIN W+D. +PP. PBOOTS ON.\n\nRESP-WEANED AND EXTUBATED. TOL WELL. LS CTA, DECREAED AT BASES. O2SAT 98% ON 35% FACE TENT. NARD NOTED THUS FAR. CT TO H20 SEAL WITH SM AMT SEROUSSANG DRG. NO AIR LEAK NOTED.\n\nGI-ABD SOFT, NT/ND. +BS. NPO.\n\nGU-VOIDING VIA FOLEY AEQ AMTS CL YELLOW URINE.\n\nENDO-SSRI. NO COVERAGE NEEDED.\n\nCOMFORT-FENTANYL PRN.\n\nORTHO-HAD CT OF TLSO. PT FITTED FOR BRACE. TO BE PLACED TOMORROW. LOG ROLL PRECAUTIONS REMAIN. C-COLLAR REMAINS ON.\n\nSKIN-CON'T WITH MULTI LACS AND ABRASIONS. KNEE DSG CHANGED. LEFT SHOULDER DSGS CHANGED.\n\nPLAN-CON'T WITH CURRENT PLAN. ASSESS PAIN CONTROL. NEURO CHECKS. TO HAVE TLSO BRACE. LOGROLL. NPO. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-28 00:00:00.000", "description": "Report", "row_id": 1522059, "text": "Respiratory Care Note:\n Patient weaned and extubated this afternoon. He is awake and oriented. His voice and cough are intact. Plan to follow with MDIs and med nebs as needed. R chest tube remains intact and sealed. BS bilat, decreased lower lobes and without wheezing.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-27 00:00:00.000", "description": "Report", "row_id": 1522050, "text": "TSICU NURSING ADMISSION NOTE\nS/ PT ARRIVED FROM EW, PT WAS IN HIGH SPEED ROLLOVER AUTO ACCIDENT AND WAS EJECTED FROM THE CAR. PT WAS TAKEN TO HOSPITAL ON ADM HAD GSF OF 15. PT WAS FOUND TO HAVE A RT PNEUMOTHORAX AND RT CHEST TUBE WAS PLACED. PT HAS LT SIDED PELVIC FX, LT CLAVICLE FX, LT SCAPULAR FX , ? C7 SPINOUS PROCESS FX, PULMONARY CONTUSIONS, HEAD CT NEG , ABD NEG PT INTUBATED AND C COLLARED ON ADMISSION. PT 4 L OF RL AND 2U PC BEFORE ADMSISSION TO TSICU. PT HAD INTRODUCER PLACED IN RT SUBCLAVIAN, IV'S IN RT AND LEFT ARMS. FOLEY TO GRAVITY AND CT TO 20 CM SUCTION.\n PT TACHYCARDIC AND HYPERTENSIVE UNTIL PT WAS ADEQUATELY SEDATED ON PROPOFOL , THEN BECAME HEMODYNAMICAL STABLE PT IN NSR WITH NO ECTOPY. PT HCT 40. MG 1.3 AND REPLETED.HCT REMAINS STABLE IVF AT KVO.ALINE INSERTED IN RT RADIAL ARTERY\n PT INTUBATED AND VENTILATED, NOW ON AC MODE, PT HAD RESP ACIDSOSIS, WHICH HAS IMPROVED AFTER VENT CHANGES AND ADEQUATE SEDATION. PT HAS STRONG COUGH , PRODUCTIVE OF BLOODY THIN SECRETIONS. PT NOW ON 40% FI02 WITH 10 OF PEEP 550 X22.\n PT MOVES ALL EXTREMITIES SPONTANEOUSLY BUT NOT TO COMMAND, PT IS AGITATED WHEN OFF SEDATION, PT RECEIVING PROPOFOL AT 50 MEQ /KG.MIN. DIFFICULT TO ASSESSS NEURO BECAUSE PT IS SO AGITATED, PT PERL, CORNEAL PRESENT , COUGH PRESENT. PT TO MRI OF HEAD AND NECK. PT REMAINS C COLLARED AND SPINAL PRECAUTIONS TAKEN, TLS FILMS NOT DONE.\nGI- OG TO CONSTANT SUCTION ABD IS SOFT WITH HYPOACTIVE BOWEL SOUNDS\n PT IS SPONTANEOUSLY DIURESING 300-400CC HR OF CLEAR LIGHT YELLOW URINE, URINE SENT FOR LYTES.\n PT HAS MANY ABRAISIONS AND SMALL LACS, WHICH WERE CLEANED AND DRESSED BY H.O.BUTTUCKS WERE RED ON ADMISSION.\n PT FAMILY FINALLY CONTACT AROUND 1AM BY NH POLICE AND CALLED THE TSICU AND SPOKE WITH H.O AND INFORMED MOTHER OF INJURIES FOUND,PT FATHER AND MOTHER ARRIVED HERE FROM NH AROUND 5:30AM AND WAS INFORMED BY NURSE AND H.O OF FURTHER CARE AND TESTS DONE , PT PARENTS VISITED WITH HIM AND ARE CURRENTLY IN WAITING ROOM, HE IS A COLLEGE STUDENT. HE WAS SUPPOSED TO GO TO FOR A SEMESTER IN SEVERAL WEEKS. PT HAS A BROTHER IN COLLEGE AND A SISTER WHO IS A SENIOR IN HS.SOCIAL SERVICE TO BE CONSULTED\nA/ PT HAS BEEN STABLE HEMODYNAMICALLY ONCE ADEQUATELY SEDATED, PT IS AGITATED AND DOES NOT FOLLOW COMMANDS DESPITE A NEG HEAD CT. PT WILL NEED Q1 H NEURO ASSESSMENT, PT WILL NEED TLS FILMS, MRI READ, AND FILMS OF L KNEE AND LEG, LACS AND ABRAISIONS CLEANED AND REDRESSED. CONT TO SEDATE AS NEEDED TO VENTIALTE AND KEEP HEMODYNAMICALLY STABLE. PT AND FAMILY WILL NEED SOCIAL SERVICE CONSULT\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-27 00:00:00.000", "description": "Report", "row_id": 1522051, "text": "RESP CARE\nPt currently on a/c 550x 22 40% and 10 peep. Peak/plat 26/24. BS coarse bil. Suctioned for loose bloody sput. Pt transported to and from mri without problem. cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-28 00:00:00.000", "description": "Report", "row_id": 1522060, "text": "T/SICU 7-11pm\nPt. has tolerated extubation well. Coughs productively. Gd sats. Neuro is intact, MAE. Cooperative and . C/O pain (seems to be r/t chest tube site) and has benefited briefly from fent 50mcg IV as needed. He refused percocet, \"makes me sick\". VSS. Multiple sml abrasions, bacitracin applied as possible. J collar in place, cont. on logg roll precautions. Awaits TLSO, brace. Family in most of the day, very supportive.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-29 00:00:00.000", "description": "Report", "row_id": 1522061, "text": "Respiratory Care Note:\n Patient using MDI with aerochamber with good technique. BS clear post tx, slightly diminished t/o. He used an incentive spirometer at 1,000 cc but has c/o pain. Plan to work more with IS once pain issue resolved.\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 800642, "text": " 10:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN\n\n HISTORY: Motor vehicle accident, previous study raised the question of a\n right occipital area of hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scan was obtained.\n\n FINDINGS: There is confirmation of the presence of a small area of hemorrhage\n within the dependent portion of the right occipital . There is no\n definite sign of intraparenchymal hemorrhage, hydrocephalus or shift of\n normally midline structures. Please note that the posterior fossa images are\n degraded by multiple streak artifacts. There are small air-fluid levels\n within both maxillary sinuses, with moderate mucosal thickening in both\n ethmoid sinuses. These findings presumably relate to the intubated status of\n the patient. There is also moderate diffuse soft tissue swelling over the\n subcutaneous tissues of the scalp. This latter finding is more evident on\n today's scan. Assessment of the patient's hydration status is warranted.\n\n CONCLUSION: Confirmation of the presence of a small right occipital \n intraventricular hemorrhage. Other findings as noted above.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 800612, "text": " 2:50 AM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR-ANGIO NECK WITHOUT CONTRAST\n Reason: MRI of brain, MRA with fat sats of head and neck - please ev\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with question of head injury\n REASON FOR THIS EXAMINATION:\n MRI of brain, MRA with fat sats of head and neck - please evaluate for\n verterbral disection\n ______________________________________________________________________________\n FINAL REPORT\n MRI of the brain, MRA of the head and neck. Question head injury. Evaluate\n for vertebral dissection.\n\n Sagittal and axial short TR, short TE spin echo images were performed through\n the head. Axial imaging was performed with long TR, long TE fast spin echo\n technique. FLAIR technique, gradient echo technique, and diffusion technique.\n Three dimensional time-of-flight MRA of the head and two and three dimensional\n time-of-flight MRA of the neck were performed. Comparison to a head CT of\n .\n\n FINDINGS: There is no evidence of masses, mass effect, or infarction. There\n is swelling of the scalp suggesting bilateral scalp hematomas. Although\n intraventricular hemorrhage was noted on the CT scan, this is not demonstrated\n on the current MR examination.\n\n The axial images through the neck demonstrate no evidence of dissection. The\n MRA examinations of the head and neck appear normal.\n\n Incidentally noted are endotracheal and nasogastric tubes.\n\n CONCLUSION: No evidence of vertebral dissection. No evidence of infarction or\n other brain pathology. Extensive scalp hematomas.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "L KNEE (AP, LAT & OBLIQUE) LEFT", "row_id": 800652, "text": " 10:36 AM\n KNEE (AP, LAT & OBLIQUE) LEFT; TIB/FIB (AP & LAT) LEFT Clip # \n FEMUR (AP & LAT) LEFT\n Reason: blunt trauma to left knee--eval with four views please due\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva\n REASON FOR THIS EXAMINATION:\n blunt trauma to left knee--eval with four views please due sunset view\n ______________________________________________________________________________\n FINAL REPORT\n History of trauma.\n\n No fracture. The separate corticated bone density along the left ischial bone\n is again demonstrated but does not have appearances of a\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "RP FOREARM (AP & LAT) RIGHT PORT", "row_id": 800610, "text": " 1:04 AM\n FOREARM (AP & LAT) RIGHT PORT Clip # \n Reason: please r/o fx\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p mva\n REASON FOR THIS EXAMINATION:\n please r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19 y/o male s/p MVA, pain.\n\n COMPARISONS: None.\n\n FINDINGS: Right forearm, 2 views show no evidence of fracture. The\n mineralization appears normal. The joint spaces are intact.\n\n IMPRESSION: No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-28 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 800754, "text": " 10:33 AM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: S/P MVA,EVAL LUMBAR FX\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with\n REASON FOR THIS EXAMINATION:\n transverse spine fx--eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVA. Evaluate for possible lumbar fractures.\n\n TECHNIQUE: Axial 3 mm images were obtained and reconstructed in both the\n sagittal and coronal planes.\n\n FINDINGS: There is no evidence of fracture. The vertebral bodies and\n intervertebral disc spaces are preserved in height. There is normal\n alignment. The prevertebral soft tissues appear within normal limits.\n\n IMPRESSION: Normal examination of the lumbar spine.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "C-SPINE, TRAUMA", "row_id": 800650, "text": " 10:36 AM\n C-SPINE, TRAUMA; T-SPINE Clip # \n L-SPINE (AP & LAT)\n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle trauma.\n\n COMPARISON: None.\n\n FINDINGS:\n AP, lateral, swimmer's, and odontoid views of the cervical spine allow\n visualization of C1 through C6. C7 is not visualized and cannot be assessed.\n The exam is limited by patient positioning. C1 through C7 body heights are\n preserved. Intervertebral disc space heights also appear within normal\n limits. Prevertebral soft tissues cannot be assessed due to ET tube and NG\n tube, which are in place. The odontoid view is nondiagnostic.\n\n AP and lateral views of the thoracic spine: A right subclavian central venous\n line is present with tip at the cavoatrial junction. ET tube is at the level\n of the thoracic inlet. NG tube tip is within the stomach. There appears to\n be a right apical chest tube. On the AP view, vertebral body heights appear\n preserved. The lateral view is nondiagnostic.\n\n AP and lateral views of the lumbar spine: There are probable transverse\n process fractures at L2 and L4 on the left. An old fracture through the left\n inferior pubic ramus is noted. The SI joints are within normal limits. On\n the lateral view, there is minimal retrolisthesis of L3 on L4.\n\n IMPRESSION:\n\n 1. Cervical spine series limited by patient positioning, and it does not\n include C7. Cervical spine CT is required to complete the asseessment.\n\n 2. Left L2 and 4 transverse process fractures.\n\n 3. Old left inferior pubic ramus fracture. Minimal retrolisthesis of L3 on L4.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "R HAND (AP, LAT & OBLIQUE) RIGHT", "row_id": 800651, "text": " 10:36 AM\n HAND (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: please r/o fx\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man s/p mva\n REASON FOR THIS EXAMINATION:\n please r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n 1\n RIGHT HAND, THREE VIEWS:\n\n HISTORY: Trauma.\n\n No fracture or dislocation. No bone or joint abnormalities.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2164-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 800607, "text": " 10:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumo/hemothorax, r/o fractures\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva s/p chest tube placement\n REASON FOR THIS EXAMINATION:\n r/o pneumo/hemothorax, r/o fractures\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube placement.\n\n COMPARISON: Prior chest radiograph from the same day.\n\n FINDINGS: There is an endotracheal tube in position with its distal tip 6 cm\n above the carina. There is a right sided subclavian central venous line with\n its distal tip in the upper SVC. There is a right sided chest tube in place\n with its distal tip in the region of the right lung apex. There is no evidence\n of definite residual pneumothorax on the right. There is subcutaneous air in\n the right hemithorax. The heart size and mediastinal contours are within\n normal limits. There is marked pulmonary parenchymal opacity within the upper\n lung zones consistent with pulmonary contusion. There is a displaced fracture\n of the left clavicle. There is a linear nondisplaced fracture of the left\n scapula. There is an NG tube with its distal tip seen beneath the diaphragm.\n There is no evidence of pleural effusion.\n\n IMPRESSION:\n\n 1) Lines and tubes in satisfactory position. No pneumothorax.\n 2) Marked pulmonary parenchymal opacity within both upper lung zones\n consistent with pulmonary contusion or aspiration(less likely).\n 3) Displaced fracture of the left clavicle as well as a nondisplaced fracture\n of the left scapula.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-26 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 800600, "text": " 9:45 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with mva\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EKEK MON 2:49 AM\n T1 spinous process fx of indeterminate age\n left 1st rib fx\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma\n\n TECHNIQUE: Direct axial CT imaging of the cervical spine and skull base\n without IV contrast. Additional reformatted imaging in the coronal and\n sagittal planes was also obtained.\n\n FINDINGS: The vertebral bodies are normal in height and alignment. The\n intervertebral disc spaces are preserved. The central spinal canal is widely\n patent. There is no evidence of fracture within the cervical spine. There is\n a linear nondisplaced fracture through the left posterior 1st rib. There is a\n fracture of indeterminate age traversing the spinous process at the level of\n T1. This fracture through the spinous process of T1 appears to be well\n corticated and be chronic in age.\n\n Within the visualized portions of the skull base, the mastoid air cells and\n sphenoid sinuses are clear. No definite fracture is identified within the\n visualized portions of the skull base.\n\n REFORMATTED IMAGES: Reformatted images in the coronal and sagittal planes were\n essential in evaluating the patient's cervical spine and demonstrate an acute\n fracture of the left posterior 1st rib. The sagittal images also demonstrate\n a fracture through the spinous process of T1 of indeterminate age.\n\n IMPRESSION:\n\n 1) Acute fracture through the left posterior 1st rib. Fracture through the\n spinous process at the level of T1 of indeterminate age which could represent\n a chronic fracture in its well corticated appearance.\n 2) No evidence of fracture or subluxation within the cervical spine.\n 3) Within the visualized portion of the skull base, no fractures are\n identified within the temporal bones.\n\n\n (Over)\n\n 9:45 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2164-08-26 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 800601, "text": " 9:45 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: trauma, trauma\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with mva\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EKEK MON 2:51 AM\n small r ptx. Bilateral pulmonary contusions.\n left scapula, clavicle, and 1st rib fx\n chronic left ischial tuberosity fx\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma\n\n TECHNIQUE: CT imaging of the chest, abdomen, and pelvis performed after the\n administration of 150 cc of Optiray. Nonionic contrast was used due to\n patient debility. Additional reformatting imaging of the chest was also\n obtained.\n\n CT CHEST WITH CONTRAST: There is no evidence of mediastinal hematoma. The\n thoracic aorta is of normal caliber with no evidence of traumatic aortic\n injury. There is a right sided chest tube in place with its distal tip in the\n region of the right lung apex. There is extensive subcutaneous edema along the\n right hemithorax. There is a small residual pneumothorax on the right. There\n is marked pulmonary parenchymal airspace opacity within both lungs, which is\n most prominent within the upper lung zones likely reflecting pulmonary\n contusion. There is no evidence of a large pleural or pericardial effusion.\n There is an NG tube in place with its distal tip passing into the stomach.\n There is an endotracheal tube with its distal tip lying within the lower\n trachea.\n\n CT RECONSTRUCTIONS: Images reformatted in multiple planes were essential in\n demonstrating the anatomy of the aorta and demonstrate no evidence of\n traumatic aortic injury.\n\n CT ABDOMEN WITH CONTRAST: The liver is normal in contour and attenuation with\n no evidence of hepatic mass or biliary ductal dilatation. There is no evidence\n of traumatic liver injury. The spleen, pancreas, adrenal glands, and kidneys\n are within normal limits. There is no abnormal dilatation or wall thickening\n within large or small bowel. There is a small amount of intraperitoneal air\n as well as free fluid in the perisplenic region and paracolic gutter. This\n fluid likely reflects the patient's intradiagnostic peritoneal lavage.\n\n CT PELVIS WITH CONTRAST: There is a Foley catheter in place within the urinary\n bladder. The rectum, prostate, and seminal vesicals are within normal limits.\n There is a moderate amount of free fluid within the pelvis associated with the\n patient's DPL.\n (Over)\n\n 9:45 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: trauma, trauma\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n Bone windows demonstrate a displaced fracture of the left clavicle, a\n nondisplaced fracture of the posterior 1st left rib, a nondisplaced fracture\n of the lateral aspect of the inferior scapula. There is a lucency identified\n within the spinous process of the vertebral body at the level of T1 which is\n of indeterminate age. The central spinal canal within the thoracic and lumbar\n spine is widely patent. There is a avulsion fracture of the left ischial\n tuberosity which appears chronic.\n\n IMPRESSION:\n\n 1) Bilateral pulmonary parenchymal opacity in the upper lung zones consistent\n with pulmonary contusion. Right sided chest tube in place with small residual\n pneumothorax.\n 2) Small amount of intraperitoneal air associated with free fluid within the\n abdomen that given the abscence of solid organ injury could reflect the\n patient's diagnostic peritoneal lavage.\n 3) Fractures of the left clavicle, left 1st rib, left scapula as described\n above. Fracture of the spinous process of T1 of indeterminate age. Chronic\n avulsion type fracture of the left ischial tuberosity.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 800616, "text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pulmonary contusions\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva with signs of pulmonary contusion on chest CT\n\n REASON FOR THIS EXAMINATION:\n assess pulmonary contusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: MVA. Patient with pulmonary contusion.\n\n PORTABLE AP CHEST: Comparison is made to previous films from .\n\n An endotracheal tube, nasogastric tube, and right sided chest tube remain in\n place. Cardiac and mediastinal contours are within normal limits for\n technique. Allowing for supine positioning of the patient, there is no\n evidence of pneumothorax. A bilateral pattern of alveolar opacities with an\n upper and mid lung zone predominance shows interval improvement compared to\n previous study.\n\n Note is made of a left clavicular and left scapular fracture.\n\n IMPRESSION:\n\n 1. Improving bilateral alveolar pattern, which may be due to resolving\n pulmonary contusion, aspiration, or edema.\n\n 2. Fractures involving the left clavicle and left scapula.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-26 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 800598, "text": " 9:15 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AND AP PELVIS\n\n INDICATION: Trauma.\n\n AP CHEST: An endotracheal tube is in position with its distal tip 6 cm above\n the carina. There is an NG tube passing beneath the diaphragm. The distal\n tip of the NG tube is not visualized. There is a right sided chest tube in\n place with distal tip at the right lung apex. There is a small residual right\n sided pneumothorax. There is marked pulmonary parenchymal opacity which is\n most prominent within the upper lung zones. There is a displaced fracture of\n the left clavicle. There is a tiny linear fracture through the left scapula.\n\n AP PELVIS: This examination is limited by the trauma board. There is a\n radiopaque needle overlying the lower abdomen. There is a well corticated\n fracture of the left ischial tuberosity which appears chronic in nature. There\n is no evidence of acute fracture of dislocation.\n\n IMPRESSION:\n 1) Lines and tubes in satisfactory position with bilateral upper lung zone\n pulmonary comtusions and small residual right sided pneumothorax.\n\n 2) No evidence of acute fracture or dislocation within the pelvis. Likely\n chronic avulsion type fracture of the left ischial tuberosity.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-08-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 800599, "text": " 9:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EKEK MON 2:40 AM\n small focus of high attenuation\n artifact vs traumatic hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma\n\n TECHNIQUE: Noncontrast CT of the brain.\n\n FINDINGS: There is no evidence of mass effect or shift of normally midline\n structures. The ventricles and sulci are normal in size and symmetrical. The\n differentiation of the and white matter is normal throughout. There is no\n evidence of acute major or minor vascular territorial infarct.\n\n There is a small focus of increased attenuation in the region of the right\n posterior of the lateral ventricle. There is no evidence of definite\n intra or extra-axial hemorrhage.\n\n The visualized portions of the paranasal sinuses are clear. Bone windows show\n no definite evidence of fracture. There is no significant soft tissue\n swelling identified.\n\n IMPRESSION: Small focus of high attenuation in the region of the posterior\n of the right lateral ventricle. While this finding could represent\n artifact, this focus of high attenuation could also represent hemorrhage\n associated with the patient's trauma.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 800893, "text": " 1:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube pull, please evalaute for pnueomthorax.\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva with signs of pulmonary contusion on chest CT\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube pull, please evalaute for pnueomthorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVA, status post removal of chest tube. Please\n evaluate for pneumothorax.\n\n VIEWS: A single AP portable upright view, comparison dated .\n\n The previously seen right-sided chest tube has been removed. Small right\n apical pneumothorax. Right subclavian venous access catheter in stable and\n satisfactory position. Heart size, mediastinal contours, and pulmonary\n vasculature are unchanged without cardiac failure. No areas of focal\n consolidation or pleural effusions. No mediastinal widening. Left-sided\n displaced clavicular fracture again noted.\n\n IMPRESSION: Small right apical pneumothorax status post removal of chest\n tube. No areas of focal consolidation to suggest pulmonary contusion.\n Unchanged left clavicle fracture. The clinical team was informed of these\n findings at the time of interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 800740, "text": " 8:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube to waterseal\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva with signs of pulmonary contusion on chest CT\n\n REASON FOR THIS EXAMINATION:\n chest tube to waterseal\n ______________________________________________________________________________\n FINAL REPORT\n AP SUPINE PORTABLE CHEST 9:29 A.M.:\n\n INDICATION: 19 y/o man motor vehicle accident, pulmonary contusion. Comparison\n is being made with the previous study of at 9:55 a.m.\n\n FINDINGS: The ETT remains in good position at the level of the clavicles. IV\n line is in the superior vena cava at the right hilum. NG tube is seen with the\n side hole below the diaphragm in good position. The tip is not on the film.\n The lung fields show slight improvement even allowing for technique with\n incomplete clearing of the mid upper zones bilaterally. Right chest drain\n remains positioned along the lateral chest wall in this projection with the\n tip overlying the clavicle near the apex. There is no evidence of a\n pneumothorax but some fluid layers over the left lung apex which is unchanged.\n The fractured left clavicle is noted with slight angulation.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-29 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 800926, "text": " 10:14 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: s/p CT pull today with 5% or so ptx post pull, please do a f\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva with signs of pulmonary contusion on chest CT\n after an MVC.\n REASON FOR THIS EXAMINATION:\n s/p CT pull today with 5% or so ptx post pull, please do a followup film around\n tonight. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P MVA and removal of chest tubes. Please follow up\n pneumothorax.\n\n VIEWS: Single AP portable upright view, comparison dated \n at 14 hours.\n\n FINDINGS: Tiny right apical pneumothorax persists, unchanged. No change in\n displaced fracture of left clavicle. The remainder of the lung fields appear\n clear and the heart size and mediastinal contours are within normal limits\n without cardiac failure.\n\n No pleural effusions.\n\n IMPRESSION: Unchanged tiny right apical pneumothorax. No radiographic\n evidence of pulmonary contusion. Stable left clavicle fracture.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 800641, "text": " 9:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement--s/p right SC change\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 17 year old man with mva with signs of pulmonary contusion on chest CT\n\n REASON FOR THIS EXAMINATION:\n line placement--s/p right SC change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement. 17 y/o man in a MVA with chest contusion.\n\n The current AP supine film was taken at 09:55 on and comparison\n is made with a comparable study at 05:04 early this morning. There has been\n interval placement of a right subclavian line, which lies in good position in\n the area of the SVC, near its junction with the right atrium. The bilateral\n opacities are consistent with pulmonary contusion, primarily involving the\n upper lung fields and are unchanged, as are the positions of the ET tube; the\n tip of the NG tube is not on the film. No evidence of a pneumothorax or any\n further complications.\n\n" }, { "category": "Radiology", "chartdate": "2164-08-28 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 800753, "text": " 10:33 AM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: S/P MVA,F/U T2-4 TRANS VERS FX\n Admitting Diagnosis: CHEST TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with\n REASON FOR THIS EXAMINATION:\n t2-4 trans vers fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Status post trauma; rule out fractures.\n\n TECHNIQUE: 3-mm axial images were obtained and reconstructed in both the\n sagittal and coronal planes.\n\n FINDINGS: There is a nondisplaced fracture of the posterior left first rib.\n No other rib fractures are seen. There is no evidence of pneumothorax. A\n right chest tube is in place.\n\n The thoracic spine demonstrates normal alignment. A tiny cortical stepoff is\n seen along the left anterior border of the T12 vertebral body. This finding is\n only seen on one 3-mm axial images and is therefore of dubious pathological\n significance. A tiny fracture cannot be excluded. There is no compression\n deformity of the vertebral body. There are no retropulsed fragments. There is\n no soft tissue hemorrhage surrounding the vertebral body. There is no other\n evidence of vertebral fracture.\n\n IMPRESSION:\n\n 1. Nondisplaced fracture of the posterior left first rib.\n 2. Tiny cortical stepoff seen in the T12 vertebral body, seen on only one 3-mm\n axial image, consistent with a tiny nondisplaced fracture. If patient has\n pain at this location, follow-up imaging is recommended.\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2164-08-27 00:00:00.000", "description": "Report", "row_id": 177782, "text": "Sinus rhythm\nConsider left ventricular hypertrophy by voltage\nNonspecific anterior ST elevation - ? due to chest trauma\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Radiology", "chartdate": "2138-05-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1137314, "text": " 1:19 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o interval change\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with rib fracture\n REASON FOR THIS EXAMINATION:\n r/o interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: 63-year-old man with rib fracture. Evaluate for interval change.\n\n Comparison is made to prior study from .\n\n There is again seen an area of increased density in the left lung, which\n likely represents contusion/hematoma secondary to the multiple rib fractures\n at this location. This has increased density. There is also increase in the\n left- sided effusion, which may be hemorrhagic, given the history and\n mechanism. There is also a small right-sided pleural effusion.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-12 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1136272, "text": " 5:26 PM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: splenic laceration?\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with splenic laceration?\n REASON FOR THIS EXAMINATION:\n splenic laceration?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JEKh MON 8:55 PM\n 1. no definitive evidence of a splenic lac\n 2. L chest tube x 2 w/ improvement of PTX; tiny R PTX\n 3. unchanged rib fx as previously described\n 4. L thoraco-1abd wall subcut emphysema\n 5. B pleural effusions\n 6. 6 mm enhancing area lateral to caudate lobe likely a hemangioma\n 7. hiatal hernia\n - \n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL CT\n\n INDICATION: 63-year-old man with splenic laceration.\n\n Comparison was performed to the previous CT study from .\n\n TECHNIQUE: Axial CT images were acquired through the abdomen after\n administration of the IV contrast without administration of the oral contrast.\n\n Coronal and sagittal reformations were also performed.\n\n FINDINGS: Two chest tubes are demonstrated in the left hemithorax with a\n small residual pneumothorax. Small amount of subpulmonic effusion is\n demonstrated on the left, accompanied by the secondary atelectasis. On the\n right, there is a small amount of pleural effusion with accompanying\n atelectasis. There is also minimal pneumothorax on the right, which has not\n increased compared to the prior study (series 2, image 8). Moderate\n pneumomediastinum, most prominent in the anterior part is demonstrated again.\n Moderate hiatal hernia is again seen.\n\n Liver demonstrates an accessory hepatic vein in the caudate lobe (series 2,\n image 19). Apart from that, there is no evidence of focal lesion within the\n liver. There is no evidence of intrahepatic or extrahepatic bile duct\n dilatation. The pancreas is of normal size and attenuation throughout without\n evidence of pancreatic duct dilatation. The gallbladder demonstrates\n vicarious excretion. Visualized bowel loops are within normal limits.\n Adrenals are unremarkable bilaterally. Kidneys are within normal limits.\n\n Spleen does not demonstrate any signs of laceration. There is no evidence of\n free fluid in the abdomen.\n (Over)\n\n 5:26 PM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: splenic laceration?\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: Numerous fractures of the left posterior ribs are again\n demonstrated; fractured are 8, 9, 10, and 11 on the left and 12 on the right.\n\n IMPRESSION:\n 1. Extensive trauma to the left chest, including numerous rib fractures, two\n chest tubes in the left hemithorax, small residual left pneumothorax,\n miniscule right pneumothorax, residual pneumomediastinum.\n 2. There is no evidence of spleen laceration.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136675, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62M s/p fall down stairs while intoxicated, sustained 5-11 L rib fxs c/b\n pneumothorax s/p chest tube\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Multiple rib fractures, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the two left-sided chest\n tubes are in unchanged position. There is no safe evidence of pneumothorax on\n today's image. No newly appeared focal parenchymal opacities. The right lung\n shows minimal basal atelectasis but is otherwise unremarkable. Unchanged\n position of the left-sided central venous access line. Unchanged size of the\n cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-16 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1136943, "text": " 2:13 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: DVT?\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p fall with multiple rib fractures, now with LE edema and\n pain\n REASON FOR THIS EXAMINATION:\n DVT?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Status post fall with multiple rib fractures, now with\n lower extremity edema and pain.\n\n TECHNIQUE: Grayscale, color and duplex Doppler imaging of bilateral lower\n extremities was performed from the common femoral regions through the proximal\n calf.\n\n FINDINGS: The left distal superficial femoral vein is not well visualized.\n Otherwise, there is normal spontaneous phasic flow, compressibility and\n augmentation, without evidence of intraluminal filling defect.\n\n IMPRESSION: No evidence of deep vein thrombosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1136938, "text": " 1:50 PM\n CHEST (PA & LAT) Clip # \n Reason: dc'd chest tube. evaluate for pneumothorax please.\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with multiple rib fxr, hemothorax\n REASON FOR THIS EXAMINATION:\n dc'd chest tube. evaluate for pneumothorax please.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with multiple rib fractures, pneumothorax, DC\n chest tube, please evaluate for pneumothorax.\n\n TECHNIQUE: PA and lateral radiograph of the chest was performed.\n\n COMPARISON: Portable radiographs dating from through .\n\n FINDINGS:\n Again seen is a left curvilinear line projecting over the left upper and mid\n fields consistent with a skinfold or linear calcification. There is no\n evidence of pneumothorax. Increase of left retrocardiac and right basilar\n opacity, likely secondary to atelectasis. A small right and moderate left\n pleural effusion with extension into the interlobar fissure are unchanged\n compared to earlier from the day but increased compared to .\n The cardiomediastinal silhouette and hila are normal. There are no acute bony\n soft tissue abnormalities.\n\n IMPRESSION:\n No evidence of pneumothorax. Increased moderate left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-11 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1136075, "text": " 12:43 PM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: C-Spine CT, second read r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n C-Spine CT, second read r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SUN 1:23 PM\n No acute fx or traumatic malalignment of the C spine.\n Mild posterior disc bulge at C4/5 resulting in mild canal narrowing. MRI can\n be considered if there are localizing neurological symptoms.\n Extensive L>R soft tissue emphysema, extending to the prevertebral soft\n tissues.\n Pneumomediastinum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired axial images of the C-spine were obtained without\n use of IV contrast. These images were acquired in an outside institution\n (Caritas ), and images were loaded for further review.\n\n FINDINGS: There is no acute fracture or traumatic malalignment. Extensive\n amount of subcutaneous emphysema is present in the left neck, with extension\n through the prevertebral soft tissues, and into the right subcutaneous\n tissues. In addition, there is pneumomediastinum demonstrated on the inferior\n images. There is no significant prevertebral soft tissue swelling. Moderate\n degenerative changes are present, most severe at C3/C4, and C4/C5, with mild\n posterior disc protrusion at C4/C5, resulting in minimal narrowing of the\n spinal canal at that level.\n\n Included views of the lung apices are unremarkable.\n\n IMPRESSION:\n 1. No acute fracture or traumatic malalignment of the cervical spine.\n 2. Mild posterior disc bulge at C4/5, resulting in mild canal narrowing. MRI\n can be considered for further localizing neurological symptoms.\n 3. Extensive left-greater-than-right soft tissue emphysema extending to the\n prevertebral soft tissues.\n 4. Pneumomediastinum.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1136076, "text": " 12:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SUN 1:21 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n COMPARISON. CT C- Spine from an outside institution dated .\n\n TECHNIQUE: MDCT-acquired axial images of the head were obtained without the\n use of IV contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass,\n mass effect, or large vascular territorial infarction. The ventricles and\n sulci are mildly prominent, compatible with mild diffuse cortical atrophy.\n There is no shift of normally midline structures. No acute fracture is seen.\n Moderate mucosal thickening and retention cysts are present at the bilateral\n maxillary and ethmoid sinuses. Mild mucosal thickening is present in the\n sphenoid sinus. Included views of the mastoid air cells and middle ear\n cavities are clear. Extensive left grater-than-right soft tissue emphysema,\n extending to the prevertebral space, as described on the prior CT of the\n cervical spine.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. Mild-to-moderate sinus disease.\n 3. Extensive left grater-than-right cervical soft tissue emphysema.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-15 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1136817, "text": " 10:55 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEVATED BILIRUBIN\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p fall, now with rising bilirubin\n REASON FOR THIS EXAMINATION:\n eval for hepatic pathology\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd FRI 1:05 AM\n IMPRESSION: Mildly echogenic liver can represent fatty infiltration. Please\n note that other types of hepatic disease such as hepatic fibrosis/cirrhosis\n cannot be excluded on the basis of this exam. No fluid collection or\n hematoma. No intrahepatic or extrahepatic biliary ductal dilatation.\n\n Gallbladder sludge with no secondary signs of cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Status post fall with rising bilirubin. Clinical concern\n for hepatic pathology.\n\n COMPARISON: CT of the abdomen from .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver parenchyma is echogenic. There is\n no evidence of fluid collection or hematoma. Gallbladder contains sludge.\n There is no intrahepatic or extrahepatic biliary ductal dilatation. Common\n duct measures 3 mm. Portal vein is patent. There is no free fluid in the\n perihepatic region.\n\n IMPRESSION:\n 1. Echogenic and heterogeneous liver can represent fatty infiltration. Please\n note that other types of hepatic disease such as hepatic fibrosis/cirrhosis\n cannot be excluded on the basis of this exam. No fluid collection or\n hematoma. No intrahepatic or extrahepatic biliary ductal dilatation.\n\n 2. Gallbladder sludge with no secondary signs of cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1137012, "text": " 9:53 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Interval change\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p fall down stairs while intoxicated, sustained 5-11 L rib\n fxs c/b pneumothorax\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Fall down stairs while intoxicated, left rib fractures.\n\n FINDINGS:\n Frontal view of the chest demonstrates cardiomegaly with multiple rib\n fractures on the left, subcutaneous emphysema, small left pleural effusion,\n left lower lobe atelectasis, and mild congestive failure. Little change since\n the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136228, "text": " 1:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new og tube\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate NG tube.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n An NG tube tip is difficult to evaluate, appears to be in the stomach. I\n cannot see clearly the side port. The ET tube tip is 6.4 cm above the carina.\n There are no other interval changes.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136071, "text": " 11:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute intrathoracic process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p fall down stairs\n REASON FOR THIS EXAMINATION:\n r/o acute intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old man status post fall downstairs.\n\n TECHNIQUE: Portable supine chest radiograph.\n\n COMPARISON: No prior at the time of dictation.\n\n FINDINGS: There is a moderate amount of subcutaneous soft tissue emphysema at\n the left chest wall. There is a lucent line overlying the left mediastinum\n along the aorta, compatible with pneumomediastinum. There is a lucency at the\n left lung base, tear shaped, likely be due to anterior left pneumothorax.\n There is no large pleural effusion. There are subtle patchy opacities at the\n left hemithorax which may represent atelectasis or lung contusion. Bilateral\n lung apices are excluded from the radiograph. There is an overlying trauma\n board giving suboptimal evaluation. There are multiple displaced left lateral\n lower chest wall rib fractures. A retrocardiac opacity is attributable to a\n small hiatal hernia.\n\n IMPRESSION:\n 1. Multiple left lateral displaced rib fractures.\n 2. Moderate amount of subcutaneous emphysema at the left lateral chest wall.\n 3. Pneumomediastinum.\n 4. Left anterior pneumothorax.\n 5. Patchy opacities at the left lung base may represent atelectasis or\n contusion.\n D/w Dr. at 12:20 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2138-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136072, "text": " 12:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with new chest tube placement\n REASON FOR THIS EXAMINATION:\n eval for position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with new chest tube placement.\n\n STUDY: Supine portable chest radiograph.\n\n COMPARISON: From 11:53 a.m. on , less than one hour earlier.\n\n FINDINGS: The previously described lucencies along the aortic contour and\n along the superior aspect of the left hemidiaphragm persist compatible with\n pneumomediastinum and pneumothorax. Additionally there is extensive\n subcutaneous emphysema along the soft tissues of the left thorax. There has\n been interval placement of a left-sided chest tube that projects over the left\n lower chest. Other than that there has been no other significant change.\n Multiple displaced rib fractures are noted along the left thoracic wall.\n\n IMPRESSION: Interval placement of left lower thoracic chest tube.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2138-05-15 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1136806, "text": " 7:34 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: SOB/ ileus\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p fall down stairs while intoxicated, sustained 5-11 L\n rib fxs c/b pneumothorax now with vomit\n REASON FOR THIS EXAMINATION:\n SOB/ ileus\n ______________________________________________________________________________\n WET READ: 9:03 PM\n NO EVIDENCE OF SMALL BOWEL OBSTRUCTION OR ILEUS. AIR NOTED THROUGHOUT NON\n DISTENDED LOOPS OF SMALL AND LARGE BOWEL. SEVERAL NONSPECIFIC AIR FLUID LEVELS\n IN LARGE BOWEL. NO FREE AIR. LEFT CHEST TUBE TERMINATING AT LEFT LUNG BASE.\n MULTIPLE DISPLACED LEFT SIDED RIB FX IDENTIFIED.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intoxication and fall.\n\n No comparison is available.\n\n Findings: Gas is noted throughout the colon with no distention large bowel\n loops. No free intra-abdominal air is noted. Moderate amount of subcutaneous\n emphysema of the left abdominal wall is visualized. The left chest tube is in\n place. Left lower rib fractures are noted.\n\n IMPRESSION: No evidence of small bowel obstruction, ileus or free air is\n visualized.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136847, "text": " 5:01 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval chest tube placement, ptx. please obtain 6am on \n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with chest tube s/p fall/ptx\n REASON FOR THIS EXAMINATION:\n eval chest tube placement, ptx. please obtain 6am on .\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Evaluate for pneumothorax post chest drain removal.\n\n FINDINGS: The left chest drain has been removed with no interval development\n of a pneumothorax. A linear line extending along the left upper lung is\n mostly external or possibly due to a skin fold as there are lung markings\n outside this region. The position of the left lower chest drain is unchanged.\n Pulmonary vascular congestion is slightly worse than on the previous study\n although remains mild. Atelectasis in the left lung base is unchanged. Heart\n size is top normal. A hiatal hernia is large.\n Multiple rib fractures are unchanged in position.\n\n IMPRESSION:\n No pneumothorax post chest drain removal, pulmonary vascular congestion is\n mild.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136316, "text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p vats \n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 63-year-old male status post VATS. Evaluate for\n interval change.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISONS: and .\n\n FINDINGS: The tip of an endotracheal tube is now 6.0 cm above the carina and\n is 1 cm above optimal placement, though neck extension contributes to elevated\n positioning. A left internal jugular venous catheter is with tip at the\n brachiocephalic junction. Two chest tubes are in stable positions in the left\n apex and base. Stable bibasilar atelectasis and small left effusion with no\n new focal consolidation concerning for pneumonia. No pneumothorax is seen.\n Cardiomediastinal and hilar contours are normal. Normal heart size and\n pulmonary vascularity. Left chest wall subcutaneous emphysema is unchanged in\n extent. Appearance of several left-sided rib fractures is unchanged.\n\n IMPRESSION: Endotracheal tube with tip 6.0 cm above the carina and can be\n advanced by 2 cm for optimal positioning, otherwise, no significant change.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136116, "text": " 7:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: increased heme chest tube o/p. pls eval interval.\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hemothorax\n REASON FOR THIS EXAMINATION:\n increased heme chest tube o/p. pls eval interval.\n ______________________________________________________________________________\n WET READ: JEKh SUN 9:30 PM\n increasing opacity of left chest/retrocardiac region with mediastinal widening\n and shift toward the right concerning for worsening hemothorax\n d/ @ 21:30 \n 21:21 \n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hemothorax, evaluation of interval change.\n\n FINDINGS: As compared to the previous radiograph, there is increasing density\n of the left lung combined to increasing pleural fluid with associated shift of\n the mediastinum to the right. Slightly increased mediastinal widening and\n stable amount of paraaortic and soft tissue air collection. Unchanged\n position of the left chest tube.\n\n The referring physician was notified at the time of the original wet read.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136201, "text": " 10:56 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: line\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new line placement\n REASON FOR THIS EXAMINATION:\n line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with new line placement.\n\n TECHNIQUE: Single AP radiograph of the chest was performed.\n\n COMPARISON: Single portable radiograph of the chest from and .\n\n FINDINGS:\n In the interval, a left-sided internal jugular line was placed with the tip\n terminating at the confluence of the internal jugular and left subclavian vein\n at the proximal brachiocephalic vein. The endotracheal tube terminates about\n 4.5 cm above the carina, unchanged.\n Increase of the right basilar opacity, likely atelectasis. Increase of the\n small left pleural effusion with associated atelectasis. Slight decrease of\n the extensive left chest wall subcutaneous emphysema.\n\n IMPRESSION:\n Left central line terminates in the proximal left brachiocephalic vein at the\n confluence of the internal jugular and left subclavian vein.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-15 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1136818, "text": ", J. CC6A 10:55 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEVATED BILIRUBIN\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p fall, now with rising bilirubin\n REASON FOR THIS EXAMINATION:\n eval for hepatic pathology\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION: Mildly echogenic liver can represent fatty infiltration. Please\n note that other types of hepatic disease such as hepatic fibrosis/cirrhosis\n cannot be excluded on the basis of this exam. No fluid collection or\n hematoma. No intrahepatic or extrahepatic biliary ductal dilatation.\n\n Gallbladder sludge with no secondary signs of cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2138-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136134, "text": " 12:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess tube placement\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p L vats evac of hematoma\n REASON FOR THIS EXAMINATION:\n assess tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for hematoma, assessment of tube placement.\n\n COMPARISON: , 6:59 p.m.\n\n FINDINGS: As compared to the previous radiograph, two additional chest tubes\n have been inserted on the left. The left hemithorax is now drained by three\n chest tubes. In addition, the patient has been intubated. The tip of the\n endotracheal tube projects 4 cm above the carina. Finally, the patient has\n received a left central venous introduction sheath.\n\n The pleural fluid accumulation and parts of the pre-existing left pleural air\n has been successfully drained. However, remnant pleural fluid and air are\n still seen on the image. The pre-existing slight mediastinal shift has\n resolved. There is increased transparency of the left lung, reflecting\n improved ventilation.\n\n Unchanged air collection in the left soft tissues. Unchanged size of the\n cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1137073, "text": " 10:27 AM\n CHEST (PA & LAT) Clip # \n Reason: pneuothorax after CT removed, poor CXR last night\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62M s/p fall down stairs while intoxicated, sustained 5-11 L rib fxs c/b\n pneumothorax, CT placed in ED\n REASON FOR THIS EXAMINATION:\n pneuothorax after CT removed, poor CXR last night\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, \n\n CLINICAL INFORMATION: Pneumothorax, chest tube removal, rib fractures.\n\n FINDINGS:\n\n Comparison is made to the prior study from .\n\n There are multiple rib fractures on the left. There is a focal airspace\n opacity in the left hemithorax which could represent contusion, subjacent to\n the rib fractures with fluid and a small effusion. There is a small\n right-sided pleural effusion as well. The upper lung zones are relatively\n clear. Heart is top normal in size. Mediastinum is within normal limits.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136351, "text": " 10:12 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval tube placement\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 63-year-old male patient with Dobbhoff placement, evaluate\n position of tube.\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 five hours earlier during the same day. Previously\n identified ETT not seen anymore, apparently extubated. Previously identified\n three left-sided chest tubes remain in position, two of them terminating in\n apical area, the lower one apparently in posterior medial pleural sinus. No\n pneumothorax seen; however, evidence of soft tissue emphysema in the lower\n neck area on the left side still present. There is a portion of the Dobbhoff\n line seen in the upper portion of the mediastinum making a 180 degree curve\n and apparently not advanced through the mid and lower esophagus.\n\n IMPRESSION: Malplaced Dobbhoff line requiring correction. Referring\n physician, , was paged. Referral was made to Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136155, "text": " 5:05 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Pls eval interval , PTX, lines\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hemothorax\n REASON FOR THIS EXAMINATION:\n Pls eval interval , PTX, lines\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 0:32 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant change\n except for a newly occurred minimal kinking of the most basal chest tube.\n\n Unchanged minimal left pleural air and fluid accumulation, both are unchanged\n as compared to the previous image. No relevant mediastinal shift. Unchanged\n extensive left soft tissue air collection and unchanged aspect of the\n displaced left rib fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1136639, "text": " 9:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx, CT placement\n Admitting Diagnosis: MULITPLE RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with left sided CT, patient pulling on tubes\n REASON FOR THIS EXAMINATION:\n eval for ptx, CT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 63-year-old male with left-sided chest tube.\n Evaluate for pneumothorax.\n\n EXAMINATION: Single portable chest radiograph.\n\n COMPARISONS: .\n\n FINDINGS: A malpositioned Dobbhoff tube is no longer present. A left\n internal jugular approach venous catheter is with tip in brachiocephalic vein.\n Stable appearance of a left apical and basilar chest tubes. No evidence of\n pneumothorax. The lungs remain well aerated with no new focal parenchymal\n consolidation. A large hiatal hernia is redemonstrated. Stable\n cardiomediastinal and hilar contours.\n\n IMPRESSION: Stable appearance with no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-05-11 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1136080, "text": " 1:04 PM\n CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY\n CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: Torso CT, second read r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n Torso CT, second read r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SUN 1:40 PM\n 1. Extensive left neck and chest wall subcutaneous emphysema, accompanied by\n pneumomediastinum.\n 2. Moderate-sized left pneumothorax.\n 3. Small focus of air anterior to the right lung is likely part of\n pneumoediastinum, however, close followup is recommended as this may develop\n into a pneumothorax.\n 4. left posterior rib fx, with significant displacement of 7th-11th fxs.\n 5. Hypodense linearity within the spleen may represent a laceration, however,\n further assessment is limited due to motion artifact.\n 6. No retroperitoneal or intra-abdominal hematoma.\n 7. Great vessels appear intact.\n 8. Right scapula tip fx.\n 9. Nondisplaced fx of 8th and 9th left thoracic transverse processes .\n\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and pelvis were\n obtained with use of IV contrast. 5-mm slice thickness coronal and sagittal\n reformats were performed. This examination was performed at an outside\n institution, and images are presented for further review.\n\n CT OF THE CHEST WITH IV CONTRAST: The trachea and main bronchi are intact.\n There is a moderate-sized left pneumothorax present. Small collection of free\n air anterior to the right lung may represent an early pneumothorax on the\n outside. A small left pleural effusion is concerning for a small collection\n of blood. There is mild compressive adjacent atelectasis present.\n\n Extensive subcutaneous emphysema is demonstrated along the entire left chest\n wall, with extension to the mediastinum. Mild amount of subcutaneous\n emphysema is also present within the right chest wall. The heart size is\n normal. There is no pericardial effusion. The great vessels are patent and\n normal in caliber. There is no evidence of dissection or pseudoaneurysm.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is diffuse fatty infiltration of\n (Over)\n\n 1:04 PM\n CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY\n CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: Torso CT, second read r/o trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the liver. A large hiatal hernia is present. The gallbladder, adrenal glands,\n kidneys, and intra-abdominal loops of small and large bowel are unremarkable.\n Pancreas appears normal. A faint linear hypodensity within the upper portion\n of the spleen (9:48) may represent a laceration, although this evaluation is\n somewhat limited due to motion-related artifacts at this level. Adjacent\n displaced rib fractures are seen. There is no mesenteric or retroperitoneal\n lymphadenopathy. No intraperitoneal or retroperitoneal hematoma is seen.\n There is no free air or free fluid.\n\n CT OF THE PELVIS WITH IV CONTRAST: Rectum appears normal. Sigmoid\n diverticulosis is present, with no evidence of diverticulitis. The remaining\n intrapelvic loops of small and large bowel are unremarkable. The appendix\n appears normal. There is no intrapelvic free fluid or lymphadenopathy seen.\n Included views of the bladder are unremarkable.\n\n OSSEOUS STRUCTURES: Acute fractures are present from the left fourth through\n twelfth ribs, with significant displacement of seventh through eleventh\n fractures. Nondisplaced fractures of the eighth and ninth left thoracic\n transverse processes are also present. Small displaced right scapular tip\n fracture is also seen (9:34).\n\n IMPRESSION:\n 1. Extensive left neck and chest wall subcutaneous emphysema and\n pneumomediastinum.\n 2. Moderate-sized left pneumothorax.\n 3. Small focus of air anterior to the right lung is likely part of the\n patient's extensive pneumomediastinum, however, close followup is recommended\n as this may develop into a right-sided pneumothorax.\n 4. Left fourth through twelfth posterior rib fractures, with significant\n displacement seen of the seventh through eleventh fractures.\n 5. Hypodense linear area within the spleen may represent a laceration,\n however, further assessment in this area is limited due to motion artifact.\n 6. No retroperitoneal or intra-abdominal hematoma.\n 7. The great vessels appear intact.\n 8. Right scapular tip fracture.\n 9. Nondisplaced fractures of the eighth and ninth left thoracic transverse\n processes.\n 10. Large hiatal hernia.\n\n" }, { "category": "ECG", "chartdate": "2138-05-16 00:00:00.000", "description": "Report", "row_id": 232045, "text": "Sinus rhythm. Modest precordial lead T wave changes are non-specific. Since\nthe previous tracing of the same date lateral precordial lead T wave amplitude\nis lower but there may be no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2138-05-16 00:00:00.000", "description": "Report", "row_id": 232046, "text": "Sinus rhythm. Modest right precordial lead T wave changes are non-specific.\nNo previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2154-04-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825836, "text": " 8:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 yo with h/o chf and recent asp pna s/p abx x 2 wks now w/worsening hypoxia.\n\n REASON FOR THIS EXAMINATION:\n eval chf, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening hypoxia.\n\n COMPARISON: \n\n CHEST AP: Again noted is diffuse interstitial opacities more prominent on the\n left side. This appears to be unchanged from . The heart size,\n mediastinal and hilar contours are stable. The study is unchanged.\n\n IMPRESSION: Unchanged appearance of diffuse interstitial opacities more\n prominant on the left side. This could represent an underlying process such as\n ARDS, alveolar hemorrhage or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2154-04-05 00:00:00.000", "description": "LP SHOULDER 1 VIEW LEFT PORT", "row_id": 825883, "text": " 10:16 AM\n SHOULDER 1 VIEW LEFT PORT Clip # \n Reason: eval for fracture\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man admitted for sepsis, with pain to shoulder on movement of left\n arm.\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pain left shoulder movement.\n\n LEFT SHOULDER, SINGLE VIEW: There is severely narrowed glenohumeral joint with\n sclerosis along both the glenoid and humeral head. The humeral head appears\n slightly flattened as well. No discrete fractures or dislocations. The AC\n joint and coracoclavicular distance are grossly unremarkable in this single\n image. The acromiohumeral space is slightly narrowed. Again noted are the\n diffuse opacities involving the left lung, which are grossly unchanged from\n same day chest radiograph.\n\n IMPRESSION: Severe degenerative changes of the glenohumeral joint, with\n suggestion of rotator cuff injury.\n\n" }, { "category": "Radiology", "chartdate": "2154-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825860, "text": " 6:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 yo with h/o chf and recent asp pna s/p abx x 2 wks now w/worsening hypoxia.\n\n REASON FOR THIS EXAMINATION:\n please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aspiration pneumonia with now worsening hypoxia.\n\n AP CHEST: Comparison is made with one day prior. There is no significant\n change in the diffuse interstitial opacities, greater on the left than right.\n The cardiac and mediastinal contours are stable. A small left pleural\n effusion cannot be excluded. No pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2154-04-05 00:00:00.000", "description": "Report", "row_id": 180473, "text": "Sinus rhythm. Axis to the left. Compared to the previous tracing no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2154-04-04 00:00:00.000", "description": "Report", "row_id": 180474, "text": "Sinus rhythm with tachycardia. Axis to the left. Non-specific T wave inversion\nin leads I and aVL. Left atrial abnormality. Clockwise rotation. Compared to\nthe previous tracing of ventricular ectopy is no longer present. T wave\ninversions were deeper in leads I and aVL.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2154-04-05 00:00:00.000", "description": "Report", "row_id": 1438944, "text": "nursing admission note:00-0700\nplease see fhp for full admission details and pmh.\n\npt admitted to micu-b from ed after increasing lethargy at nh with wbc bump and low grade fever, with discharge from for pneumonia\n\ncode status : dnr/dni\n\nneuro- pt spanish speaking only. per records end stage dementia. per family pt is consistently confused and disoriented. mae. perla. denies pain.\n\nresp- ls with diffuse crackles. arrived from with 100% nrb mask. respirations very labored and rate 40-50's. pt medicated with 1mg iv morphine x2 with good effect on rr. at present o2 weaned to 2-4l n/c for goal sats 90-95% and rr 14-22 at rest. npc at times.\n\ncv- hr sr-st 80-100 no ectopy noted. pt received 3 liters ns fluid resusciatation in ed, now fluids kvo.since arrival to micu pt mildly hypotensive when sleeping, bp80's-100's/30-50's. when stimulated bp 90-130.\n\ngi- abd soft +bs no stool, kept npo overnight.\n\ngu- foley patent for adequate amounts of clear yellow urine.\n\nid- wbc 20 in ed, this am 17. tmax 99.8 rectally. blood and urine cultures pending from ed. started on vanco, flagyl and cefipime.\n\naccess- 2 #18 piv's in r arm. per family no central line.\n\nsocial- pt widowed. has ten children with very large extended family. numerous family members visited last evening. spokesperson is daughter aurea .\n\ndispo- remains in micu, dnr/dni. continue to monitor resp pattern, medicate with morphine as needed. initial family discussions regarding plan of care included using pressor agents peripherally, this has been avoided overnight however to be readdressed this am with team.\n" }, { "category": "Nursing/other", "chartdate": "2154-04-05 00:00:00.000", "description": "Report", "row_id": 1438945, "text": "MICUB Nursing Progress Note\n\nPt. awaiting transfer orders to general medical unit.\n\nCVS: Via daughter translating, pt. c/o chest pain this AM. EKG done, no changes noted per Dr. . Pt. given 1mg MSO4 with relief. Pt. ruled out for an MI per enzymes on admission. Heart rate 90-110, depending on level of agitation. B/P also variable...at one point dropped down to the high 70's/syst. HO notified and pt. ordered for 250cc IVF bolus. Only 100cc were given, as B/P increased to 140/syst with agitation. Plan is for no central access, therefore, no pressors.\n\nRESP: Pt. does become tachypneic (RR of 45), tachycardic (110) and desaturates (85) when lying flat and turning side to side...requiring about 15min on 100% NRB. Lungs with crackles throughout. He is 2.3L positive, urine output of approximately 50cc/hr. Pt. is not to be intubated per PCP/family.\n\nID: T max of 99.8 axillary. Pt. will not permit a rectal temp. Continues broad spectrum coverage for pneumonia.\n\nGI: No stool. Taking \"honey thickened\" supplement without difficulty.\n\nSKIN: Small decubiti (2<dime sized) on coccyx. Area cleaned with soap and water and duoderm replaced. Pt. very resistant to turning side to side.\n\nOf note, left shoulder seems to be causing pt. a great deal of pain with any movement. Xray performed, ?results.\n" } ]

[ { "category": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462630, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Mildly febrile Tmax 100.7 this shift , became afebrile later without\n any intervention. C/O abdominal pain every 2hrs on a pain scale of\n . On dilaudid IV prn q3hrs. Abdomen distended with positive BS.\n Denies N/V . x2 small liquid stools earlier in the day. This shift\n pt had a large soft brown BM.\n Action:\n Remains NPO. Dilaudid frequency changed to q2hrs prn. Medicated with\n dilaudid q2hrs prn for pain. Also received 1x single dose of dilaudid.\n IVF LR at 150cc/hr. Receiving IV antibiotics vanc/fagyl and Cipro.\n Dilaudid frequency changed this a.m again to 0.25 q 3hrs prn. Latest\n dose given at 0645hrs\n Response:\n Good response to dilaudid. But pt states he continues to have\n constant mild pain, but tolerable.\n Plan:\n Continue abdominal exam\n NPO,IV hydration,antibiotics.\n Surgery follow up\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311. On insulin gtt\n Action: Continues on Insulin gtt , currently on 3.5 units/hr.\n Monitored qhr fingersticks\n Response: Blood sugar remains between 150-250 currently 3.5\n units/hr\n Plan: Continue insulin gtt ,titrate as per\n protocol,finger stick Q1hr\n Pt is a difficult stick. Has 2 working PIV\n Unable to obtain labs since admission to ICU. IV nurse called in .\n Obtained labs.\n" }, { "category": "Physician ", "chartdate": "2167-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 462642, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Morphine Sulfate\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 08:00 PM\n Ciprofloxacin - 12:00 AM\n Vancomycin - 07:27 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Hydromorphone (Dilaudid) - 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 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (99\n HR: 111 (93 - 111) bpm\n BP: 118/79(87) {94/19(39) - 140/79(87)} mmHg\n RR: 26 (15 - 29) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,432 mL\n 1,666 mL\n PO:\n TF:\n IVF:\n 3,432 mL\n 1,666 mL\n Blood products:\n Total out:\n 1,720 mL\n 330 mL\n Urine:\n 820 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,712 mL\n 1,336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 310 K/uL\n 11.9 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 136 mEq/L\n 35.4 %\n 10.7 K/uL\n [image002.jpg]\n 11:55 PM\n WBC\n 10.7\n Hct\n 35.4\n Plt\n 310\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:15.4/29.8/1.4, ALT / AST:, Alk Phos / T\n Bili:50/0.4, Amylase / Lipase:, Differential-Neuts:88.0 %,\n Lymph:7.9 %, Mono:3.5 %, Eos:0.3 %, Lactic Acid:1.7 mmol/L, LDH:119\n IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n APPENDICITIS\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n HYPERTENSION, BENIGN\n DIABETES MELLITUS (DM), TYPE II\n DYSLIPIDEMIA (CHOLESTEROL, TRIGLYCERIDE, LIPID DISORDER)\n .H/O ASTHMA\n .H/O BACK PAIN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:13 AM\n 20 Gauge - 10:06 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462739, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain. Elevated blood glucose controlled on insulin drip. Plan\n is to switch his drip to his normal regimen of insulin (Half dose with\n sliding scale coverage while NPO) and watch him closely and plan to\n transfer to floor tomorrow if possible after he is stabilized on his\n home regimen of insulin.\n Appendicitis\n Assessment:\n Pt with complaints of abdominal pain requiring IV dilaudid .25mg Q3hrs\n for pain. Pt afebrile with rising WBC.\n Action:\n Surgery will still hold off on abdominal surgery at this time. Pt\n continues on IV antibiotics, Vanco, flagyl, cipro. He also continues on\n IVF LR at 150cc/hr. UO is adequate.\n Response:\n Afebrile with continued abdominal pain. IVT did come up and PICC\n inserted for access and blood draws.\n Plan:\n Pt may be called out this evening if blood glucose stable off drip and\n his vital signs remain stable.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt remained on insulin drip at 5units/hr until dinner time insulin dose\n was given. 1800 pt given 20 units NPH. His fingerstick at that time was\n 80 so drip turned down to 1u/hrand we will shut off drip at 1900. Blood\n glucose should be followed Q1-2hrs.\n Action:\n Drip to be stopped at 1900, one hour after sc dose given.\n Response:\n To be followed closely with frequent fingersticks until stable off the\n drip.\n Plan:\n Follow fingerstick blood glucose closely after pt has drip d/c\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt\ns heart rate in the 105-115 range, sinus tach. BP 110-150. Denies\n complaints of chest pain or SOB. Given 500cc LR bolus to try to see if\n this will help the tachycardia.\n Action:\n Given 500cc\ns LR bolus. Surgery suggests starting pt on metoprolol 5mg\n IV Q6hr for tachycardia but team is thinking about this recommendation.\n They would like to hold off using beta blocker for now.\n Response:\n HR remains 110-116. sinus tach. BP120/50.\n Plan:\n Continue to follow pt\ns vital signs closely.\n" }, { "category": "General", "chartdate": "2167-04-27 00:00:00.000", "description": "Generic Note", "row_id": 462670, "text": "TITLE: Critical Care\n Present for the key porions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined on multidisciplinary\n rounds. Pain is being controlled with narcotics\n not substantially\n different than on adm.\n 98.9 128/77 108\n Alert\n Mod tenderness RLQ no peritoneal signs\n Chest\n few crackles at L base\n WBC 10.7\n Glu 191\n Rising WBC and vol loss on CXR are of concern. We are encouraging deep\n breathing. On broad abx but needs close monitoring of resp status.\n Plan to convert to sq insulin. Awaiting surgery decision about timing\n of surgery.\n Time spent 30 min\n" }, { "category": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462741, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain. Elevated blood glucose controlled on insulin drip. Plan\n is to switch his drip to his normal regimen of insulin (Half dose with\n sliding scale coverage while NPO) and watch him closely and plan to\n transfer to floor tomorrow if possible after he is stabilized on his\n home regimen of insulin.\n Appendicitis\n Assessment:\n Pt with complaints of abdominal pain requiring IV dilaudid .25mg Q3hrs\n for pain. Pt afebrile with rising WBC.\n Action:\n Surgery will still hold off on abdominal surgery at this time. Pt\n continues on IV antibiotics, Vanco, flagyl, cipro. He also continues on\n IVF LR at 150cc/hr. UO is adequate.\n Response:\n Afebrile with continued abdominal pain. IVT did come up and PICC\n inserted for access and blood draws.\n Plan:\n Pt may be called out this evening if blood glucose stable off drip and\n his vital signs remain stable.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt remained on insulin drip at 5units/hr until dinner time insulin dose\n was given. 1800 pt given 20 units NPH. His fingerstick at that time was\n 80 so drip turned down to 1u/hr and we will shut off drip at 1900.\n Blood glucose should be followed Q1-2hrs.\n Action:\n Drip to be stopped at 1900, one hour after sc dose given.\n Response:\n To be followed closely with frequent fingersticks until stable off the\n drip.\n Plan:\n Follow fingerstick blood glucose closely after pt has drip d/c\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt\ns heart rate in the 105-115 range, sinus tach. BP 110-150. Denies\n complaints of chest pain or SOB. Given 500cc LR bolus to try to see if\n this will help the tachycardia.\n Action:\n Given 500cc\ns LR bolus. Surgery suggests starting pt on metoprolol 5mg\n IV Q6hr for tachycardia but team is thinking about this recommendation.\n They would like to hold off using beta blocker for now.\n Response:\n HR remains 110-116. sinus tach. BP120/50.\n Plan:\n Continue to follow pt\ns vital signs closely.\n" }, { "category": "Physician ", "chartdate": "2167-04-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 462575, "text": "Chief Complaint: Abdominal Pain\n HPI:\n Mr. is a 58 y/o M with a history of CAD s/p PCI ( \n patient) who presents via the ED with one week of abdominal pain now\n progressing and with altered mental status. He reports ~6 days ago\n (Monday) he began with epigastric/chest pain that was attributed to\n heartburn that improved overnight but with transition more to right\n lower quadrant abdominal pain, severe in nature, with nausea.\n Fever/temperature curve unknown.\n In the ED at , he was febrile to 104 rectally, HR 80s to 100s and\n maintained normotension. CT scan was obtained which showed an\n appendicolith as well as inflammatory changes in the small bowel and\n cecum that were noted to be larger in magnitude than otherwise\n suggested by appendicitis. Surgery was consulted, and he was managed\n with antibiotics overnight (vancomycin, zosyn, flagyl, ceftriaxone).\n He received 4L of\n Allergies:\n Morphine Sulfate Nausea/Vomiting\n Home Medications:\n Ketoconazole 2 % Shampoo lather into eyebrow, scalp, and\n sides of nose daily while washing\n Lipitor 80 mg Tab 1 Tablet(s) by mouth daily\n Flomax 0.4 mg 24 hr Cap 1 Capsule(s) by mouth daily\n Plavix 75 mg Tab 1 Tablet(s) by mouth daily\n Nexium 40 mg Cap 1 Capsule(s) by mouth twice a day\n Advair Diskus 100 mcg-50 mcg/Dose for Inhalation 1 puff\n twice a day\n Humulin 70/30 100 unit/mL (70-30) Susp, Sub-Q Inj 42 am, 44\n pm\n Tricor 145 mg Tab 1 Tablet(s) by mouth once a day\n Aspirin 325 mg Tab, Delayed Release 1 Tablet(s) by mouth\n daily\n Niacin SR 500 mg Tab 1 Tablet(s) by mouth at hs\n Niaspan 500 mg Tab 1 Tablet Sustained Release(s) by mouth\n daily\n Atenolol 100 mg Tab 1 (One) Tablet(s) by mouth once a day\n ProAir HFA 90 mcg/Actuation Inhaler 2 puffs(s) po q 4 hrs\n prn sob, cough\n Lisinopril 5 mg Tab 1 Tablet(s) by mouth daily\n Cyclobenzaprine 10 mg Tab 1 Tablet(s) by mouth up to q 8 hrs\n pr muscle spasm.\n Imdur 30 mg 24 hr Tab 1 Tablet(s) by mouth daily\n Nitroglycerin 0.4 mg Sublingual Tab 1 (One) Tablet(s)\n sublingually prn\n Amitriptyline 75 mg Tab 1 Tablet(s) by mouth once a day\n xycodone-Acetaminophen 7.5 mg-325 mg Tab 1 Tablet(s) by\n mouth every 4-6 hours as needed for pain. Max 6 per day\n Metformin 500 mg Tab 1 Tablet(s) by mouth twice a day\n Fluticasone 50 mcg/Actuation Nasal Spray, Susp two sprays in\n each nostril twice a day\n One Touch Ultra Test Strips Use as directed and prn\n Past medical history:\n Family history:\n Social History:\n - Diabetes II\n - CAD s/p PCI ( RCA with a 4.0x18mm Penta stent)\n (add'l stents at , pt believes 3 years ago)\n - Hyperlipidemia\n - Hypertension\n - Syncopal episodes, \n - severe neck and back pain with radiculopathy s/p C7-T1 fusion\n done by Dr. . status post C3-C7 laminectomy in \n - OA of knees\n - Asthma\n - GERD\n - Psoriasis\n - : otitis media w 10 days of amoxicillin\n Past Surgical History:\n - cervical laminectomies C3-C7\n - Cervical fusion at C7-T1\n - left total knee replacement x3\n -alcoholism.\n -Siblings and parents all have HTN, heart disease.\n mom , dad died of MI, brother 51yo 3caths/stents, brother\n 58yo 5v cabg\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: abstracted from records, verified on this admit.\n married and lives with wife. Smokes 1-1.5 ppd for 40 years. Used\n to be an alcoholic but quit drinking 30 years ago. Denies other\n drug use.\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Constipation, RLQ abd pain\n Pain: Moderate\n Pain location: RLQ\n Flowsheet Data as of 11:48 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: 36.2\nC (97.1\n HR: 93 (93 - 99) bpm\n BP: 94/54(60) {94/19(39) - 117/63(75)} mmHg\n RR: 29 (20 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,337 mL\n PO:\n TF:\n IVF:\n 337 mL\n Blood products:\n Total out:\n 0 mL\n 1,000 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,337 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, dry mough\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), Cold\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, No(t) Non-tender, Distended, Tender: diffuse, mildly\n distended, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, No(t) Oriented (to): , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n [image002.gif]\n Imaging: CT A/P: Marked right lower quadrant inflammatory changes\n appear centered around a fluid distended appendix, with an\n appendicolith near its origin - while findings may represent an acute\n appendicitis, the degree of cecal wall thickening and proximal partial\n bowel obstruction are less typical and may represent a colonic\n inflammatory process. No evidence for perforation or focal fluid\n collection.\n CT Head: No intracranial hemorrhage or edema.\n Assessment:\n 1 week of abdominal pain, constipation. N/V 1 week ago, none since.\n Tolerating minimal PO. MS changes today, febrile to 104, now 100.9.\n Inflamed cecum & appendix w/ appendicolith\n ECG: on :0:40\n Sinus tachycardia at 122bpm, nl axis, intervals. Possible left atrial\n abnormality. Delayed R wave progression. No ischemic changes.\n Assessment and Plan\n 58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n APPENDICITIS / SEPSIS\n - The patient is on the surgcal service, with current plan for IV\n antibiotic management for inflammation to subside prior to\n appendectomy. We will follow exam, vitals signs, and manage\n accordingly. He will likely require additional fluid hydration. For\n now, hemodynamically stable.\n - Change abx to cipro IV 400mg q12h and metronidazole 500mg IV q8h\n - NPO\n - Pain management with morphine as needed\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - ECG stable\n - Pt believes he has a DES, will obtain exact dates and discuss with\n the surgical team to hold plavix in anticipation for possible surgical\n procedure\n HYPERTENSION, BENIGN\n Continue home BP agents except for any diuretics\n DIABETES MELLITUS (DM), TYPE II\n On an insulin gtt, will change back to sliding scales, reduce 70/30\n while NPO\n DYSLIPIDEMIA (CHOLESTEROL, TRIGLYCERIDE, LIPID DISORDER)\n - continue agents\n .H/O ASTHMA\n .H/O BACK PAIN\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:13 AM\n 20 Gauge - 10:06 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n with assessment and plan as outlined during multidisciplinary rounds.\n 58 yo with DM and CAD had epi pain that moved to RLQ one week ago. Pain\n persisted, felt gradually worse. Presented to ED with T 104, pain, HR\n 80\ns. CT\n appendicolith and ? abscess, edema\n larger than usual with\n appendiceal abscess.\n 97.1 99 117/63\n Awake, lying on R side due to pain\n Chest clear\n Abd mod abd tenderness RLQ greatest w/o peritoneal signs\n Likely ruptured appendix. Seems compensated now. Covering with\n antibiotics. Per Surgery will observe for now but if abd exam\n progresses will need exploration. No evidence of active CAD now but he\n is high risk and we are holding antiplt agents until surgical plans\n resolved. Hopefully can start back on Plavyx immed post op with\n presumed DES.\n Time spent 50 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2167-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462563, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Pt afebrile(T max was 104 in ED)extrimities are cold.\n Abdomen tender distended,positive bowel sounds, abdominal pain on\n admission,no N/V\n Bm x1-small liquidy stool\n Action:\n Frequent abdominal exam\n Iv hydration Ns 1L bolus,lactate 1.7\n On cipro/flagyl/vancomycin\n Dilaudid 0.25mg Iv X2 dose\n NPO\n Response:\n Pt more comfortable after dilaudid\n Abdominal exam remains unchanged.\n Plan:\n Continue abdominal exam\n NPO,IV hydration,antibiotics.\n Surgery follow up\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt with extensive cardiac hystory\n Action:\n Antihypertensives on hold since pt is hypotensive\n Mag repleted\n Unable to get sufficient sample for labs( PIV placed by IV nurse with\n great difficulty) ,team informed\n Response:\n Haemodinamically stable\n Plan:\n Continue to hold antihypertensives and statin\n Please call IV nurse labs.\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311\n Action:Insulin gtt started as per ICU team,finger sticks Q1hr\n Response:blood sugar remains 250-280 currently 3units/hr\n Plan:continue insulin gtt ,titrate as per protocol,finger stick Q1hr\n" }, { "category": "General", "chartdate": "2167-04-28 00:00:00.000", "description": "Generic Note", "row_id": 462912, "text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n with assessment and plan developed on multidisciplinary rounds. He\n continues to have abd pain but somewhat imrpoved. Episode of SOB and\n desat overnight but improved w/o intervention\n 97.6 114 131/66\n Obese, lying flat w/o SOB\n Obese abd with improved RLQ tenderness\n Decreased BS bilat w/o bronchial BS\n WBC 12.3\n CXR\n opacification of L lower lung field\n CXR difficult to interpret. Radiology\n consolidation vs effusion.\n Seems most likely to be effusion clinically and has decr BS. Temp\n curve trending down but WBC up sl. Glu in good control on sq insulin\n regime. Surgery following re ? of exploration.\n Time spent 30 min\n" }, { "category": "Physician ", "chartdate": "2167-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 462852, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:46 AM\n EKG - At 05:00 AM\n - was going to be called out today, but on insulin gtt, and surgery\n wanted to moniter while on sc insulin\n - overnight bs b/w 150-200 w/ NPH(on half home NPH), only req 2u HISS\n overnight\n Allergies:\n Morphine Sulfate\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Ciprofloxacin - 11:55 PM\n Metronidazole - 04:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Hydromorphone (Dilaudid) - 01:00 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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.3\n HR: 123 (107 - 123) bpm\n BP: 137/65(84) {113/53(69) - 164/96(108)} mmHg\n RR: 27 (21 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5,523 mL\n 965 mL\n PO:\n TF:\n IVF:\n 5,523 mL\n 965 mL\n Blood products:\n Total out:\n 925 mL\n 420 mL\n Urine:\n 925 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,598 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Gen: in pain, AOx3\n HEENT: MMM clear oropahryx\n CV: RRR\n Chest: CTAB\n Abd: TTP most severe at RLQ, but diffusely tender, no rebound currently\n Ext: no c/c/e\n Labs / Radiology\n 318 K/uL\n 10.8 g/dL\n 189 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 136 mEq/L\n 31.2 %\n 12.3 K/uL\n [image002.jpg]\n 11:55 PM\n 04:26 AM\n WBC\n 10.7\n 12.3\n Hct\n 35.4\n 31.2\n Plt\n 310\n 318\n Cr\n 0.9\n 0.8\n Glucose\n 191\n 189\n Other labs: PT / PTT / INR:15.4/29.8/1.4, ALT / AST:, Alk Phos / T\n Bili:50/0.4, Amylase / Lipase:, Differential-Neuts:88.0 %,\n Lymph:7.9 %, Mono:3.5 %, Eos:0.3 %, Lactic Acid:1.7 mmol/L, LDH:119\n IU/L, Ca++:8.4 mg/dL, Mg++:1.6 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n Ruptured appendix s/p acute appendicitis- being treated\n conservatively with IV abx\n Cipro/flagyl. Gen will reeval and\n possibly take to surgery once inflammation better\n - cont NPO\n - pain management w/ morphine prn\n - cont Cipro IV 400mg q12 and Flagyl 500 IV q8\n - IVF bolus as needed\n # pt currently febrile, but does not complain of cough and\n wbc/fevers likely appendicitis.\n - cxr in AM, cont to follow\n - if worsens will add vanc/zosyn\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n EKG stable,\n possible \n , BENIGN\n on home bp meds\n DIABETES MELLITUS (DM), TYPE II)\n on insulin gtt\n - will change back to sq insulin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Picc\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 462840, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS :\n Action:\n IV insulin D/C\ned @ 1900 . Changed to\n dose usual NPH (as patient\n NPO) w/sliding scale coverage.\n Response:\n FS131-211. Covered w/0-4 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to . After 0100, no longer c/o pain. WBC:\n 12.3 (10.7)\n Action:\n Received LR @ 150cc/hr. Given abx: cipro,flagyl & vanco IV.\n Medicated for pain w/0.25mg IV dilaudid q 3 hrs (each time patient\n called for pain med). Remains NPO.\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Increased HR may be due to : temp, pain, need for hydration.\n Plan:\n No surgery planned @ this time.\n .H/O asthma\n Assessment:\n Patient\ns lung sounds became more coarse as night progressed.\n Action:\n IVF: LR @ 150cc/hr decreased per surgery to 75cc/hr. Received atrovent\n neb Tx & started back on Advair. CXR @ 0530.\n Response:\n Lungs sounded more clear @ 0600. Coughing nonproductively all night.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2167-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462525, "text": "Appendicitis\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": "Nursing", "chartdate": "2167-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462526, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\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": "Nursing", "chartdate": "2167-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462527, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Pt afebrile(T max was 104 in ED)extrimities are cold,WBC\n Abdomen tender distended,positive bowel sounds, abdominal pain on\n admission,no N/V\n Action:\n Frequent abdominal exam\n Iv hydration,pain med as needed\n NPO\n Response:\n Pt more comfortable after dilaudid\n Plan:\n Continue abdominal exam\n NPO,IV hydration\n Surgery follow up\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt with extensive cardiac hystory\n Action:\n Antihypertensives on hold for upcoming surgery\n Response:\n Haemodinamically stable\n Plan:\n Continue to hold antihypertensives and statin\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311\n Action:Insulin gtt started as per ICU team,finger sticks Q1hr\n Response:\n Plan:continue insulin gtt ,titrate as per protocol,finger stick Q1hr\n" }, { "category": "Nursing", "chartdate": "2167-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462533, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Pt afebrile(T max was 104 in ED)extrimities are cold,WBC\n Abdomen tender distended,positive bowel sounds, abdominal pain on\n admission,no N/V\n Bm x1-small liquidy stool\n Action:\n Frequent abdominal exam\n Iv hydration Ns 1L bolus ,pain med as needed\n NPO\n Response:\n Pt more comfortable after dilaudid\n Abdominal exam remains unchanged.\n Plan:\n Continue abdominal exam\n NPO,IV hydration\n Surgery follow up\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt with extensive cardiac hystory\n Action:\n Antihypertensives on hold since pt is hypotensive\n Response:\n Haemodinamically stable\n Plan:\n Continue to hold antihypertensives and statin\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311\n Action:Insulin gtt started as per ICU team,finger sticks Q1hr\n Response:\n Plan:continue insulin gtt ,titrate as per protocol,finger stick Q1hr\n" }, { "category": "Physician ", "chartdate": "2167-04-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 462523, "text": "Chief Complaint: Abdominal Pain\n HPI:\n Mr. is a 58 y/o M with a history of CAD s/p PCI ( \n patient) who presents via the ED with one week of abdominal pain now\n progressing and with altered mental status. He reports ~6 days ago\n (Monday) he began with epigastric/chest pain that was attributed to\n heartburn that improved overnight but with transition more to right\n lower quadrant abdominal pain, severe in nature, with nausea.\n Fever/temperature curve unknown.\n In the ED at , he was febrile to 104 rectally, HR 80s to 100s and\n maintained normotension. CT scan was obtained which showed an\n appendicolith as well as inflammatory changes in the small bowel and\n cecum that were noted to be larger in magnitude than otherwise\n suggested by appendicitis. Surgery was consulted, and he was managed\n with antibiotics overnight (vancomycin, zosyn, flagyl, ceftriaxone).\n He received 4L of\n Allergies:\n Morphine Sulfate Nausea/Vomiting\n Home Medications:\n Ketoconazole 2 % Shampoo lather into eyebrow, scalp, and\n sides of nose daily while washing\n Lipitor 80 mg Tab 1 Tablet(s) by mouth daily\n Flomax 0.4 mg 24 hr Cap 1 Capsule(s) by mouth daily\n Plavix 75 mg Tab 1 Tablet(s) by mouth daily\n Nexium 40 mg Cap 1 Capsule(s) by mouth twice a day\n Advair Diskus 100 mcg-50 mcg/Dose for Inhalation 1 puff\n twice a day\n Humulin 70/30 100 unit/mL (70-30) Susp, Sub-Q Inj 42 am, 44\n pm\n Tricor 145 mg Tab 1 Tablet(s) by mouth once a day\n Aspirin 325 mg Tab, Delayed Release 1 Tablet(s) by mouth\n daily\n Niacin SR 500 mg Tab 1 Tablet(s) by mouth at hs\n Niaspan 500 mg Tab 1 Tablet Sustained Release(s) by mouth\n daily\n Atenolol 100 mg Tab 1 (One) Tablet(s) by mouth once a day\n ProAir HFA 90 mcg/Actuation Inhaler 2 puffs(s) po q 4 hrs\n prn sob, cough\n Lisinopril 5 mg Tab 1 Tablet(s) by mouth daily\n Cyclobenzaprine 10 mg Tab 1 Tablet(s) by mouth up to q 8 hrs\n pr muscle spasm.\n Imdur 30 mg 24 hr Tab 1 Tablet(s) by mouth daily\n Nitroglycerin 0.4 mg Sublingual Tab 1 (One) Tablet(s)\n sublingually prn\n Amitriptyline 75 mg Tab 1 Tablet(s) by mouth once a day\n xycodone-Acetaminophen 7.5 mg-325 mg Tab 1 Tablet(s) by\n mouth every 4-6 hours as needed for pain. Max 6 per day\n Metformin 500 mg Tab 1 Tablet(s) by mouth twice a day\n Fluticasone 50 mcg/Actuation Nasal Spray, Susp two sprays in\n each nostril twice a day\n One Touch Ultra Test Strips Use as directed and prn\n Past medical history:\n Family history:\n Social History:\n - Diabetes II\n - CAD s/p PCI ( RCA with a 4.0x18mm Penta stent)\n (add'l stents at , pt believes 3 years ago)\n - Hyperlipidemia\n - Hypertension\n - Syncopal episodes, \n - severe neck and back pain with radiculopathy s/p C7-T1 fusion\n done by Dr. . status post C3-C7 laminectomy in \n - OA of knees\n - Asthma\n - GERD\n - Psoriasis\n - : otitis media w 10 days of amoxicillin\n Past Surgical History:\n - cervical laminectomies C3-C7\n - Cervical fusion at C7-T1\n - left total knee replacement x3\n -alcoholism.\n -Siblings and parents all have HTN, heart disease.\n mom , dad died of MI, brother 51yo 3caths/stents, brother\n 58yo 5v cabg\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: abstracted from records, verified on this admit.\n married and lives with wife. Smokes 1-1.5 ppd for 40 years. Used\n to be an alcoholic but quit drinking 30 years ago. Denies other\n drug use.\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Constipation, RLQ abd pain\n Pain: Moderate\n Pain location: RLQ\n Flowsheet Data as of 11:48 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: 36.2\nC (97.1\n HR: 93 (93 - 99) bpm\n BP: 94/54(60) {94/19(39) - 117/63(75)} mmHg\n RR: 29 (20 - 29) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,337 mL\n PO:\n TF:\n IVF:\n 337 mL\n Blood products:\n Total out:\n 0 mL\n 1,000 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,337 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, dry mough\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), Cold\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )\n Abdominal: Soft, No(t) Non-tender, Distended, Tender: diffuse, mildly\n distended, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, No(t) Oriented (to): , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n [image002.gif]\n Imaging: CT A/P: Marked right lower quadrant inflammatory changes\n appear centered around a fluid distended appendix, with an\n appendicolith near its origin - while findings may represent an acute\n appendicitis, the degree of cecal wall thickening and proximal partial\n bowel obstruction are less typical and may represent a colonic\n inflammatory process. No evidence for perforation or focal fluid\n collection.\n CT Head: No intracranial hemorrhage or edema.\n Assessment:\n 1 week of abdominal pain, constipation. N/V 1 week ago, none since.\n Tolerating minimal PO. MS changes today, febrile to 104, now 100.9.\n Inflamed cecum & appendix w/ appendicolith\n ECG: on :0:40\n Sinus tachycardia at 122bpm, nl axis, intervals. Possible left atrial\n abnormality. Delayed R wave progression. No ischemic changes.\n Assessment and Plan\n 58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n APPENDICITIS / SEPSIS\n - The patient is on the surgcal service, with current plan for IV\n antibiotic management for inflammation to subside prior to\n appendectomy. We will follow exam, vitals signs, and manage\n accordingly. He will likely require additional fluid hydration. For\n now, hemodynamically stable.\n - Change abx to cipro IV 400mg q12h and metronidazole 500mg IV q8h\n - NPO\n - Pain management with morphine as needed\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - ECG stable\n - Pt believes he has a DES, will obtain exact dates and discuss with\n the surgical team to hold plavix in anticipation for possible surgical\n procedure\n HYPERTENSION, BENIGN\n Continue home BP agents except for any diuretics\n DIABETES MELLITUS (DM), TYPE II\n On an insulin gtt, will change back to sliding scales, reduce 70/30\n while NPO\n DYSLIPIDEMIA (CHOLESTEROL, TRIGLYCERIDE, LIPID DISORDER)\n - continue agents\n .H/O ASTHMA\n .H/O BACK PAIN\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:13 AM\n 20 Gauge - 10:06 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2167-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 462925, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:46 AM\n EKG - At 05:00 AM\n - was going to be called, but on insulin gtt, and surgery wanted to\n moniter while on sc insulin for 12 hours\n - overnight BS b/w 150-200 w/ NPH(on half home NPH), only req 2u HISS\n overnight\n - Had SOB episode this AM, given ipratropium neb, Advair, flonase (home\n meds), CXR concerning for LL infiltrate vs edema\n -EKG with sinus tach\n Subjective:\n -abd pain still present, but improved per pt\n -nausea and emesis x 1 today\n -starting to have an appetite, on clears\n -had 5 bowel movments today, some loose\n Allergies:\n Morphine Sulfate\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Ciprofloxacin - 11:55 PM\n Metronidazole - 04:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:30 PM\n Hydromorphone (Dilaudid) - 01:00 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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.3\n HR: 123 (107 - 123) bpm\n BP: 137/65(84) {113/53(69) - 164/96(108)} mmHg\n RR: 27 (21 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5,523 mL\n 965 mL\n PO:\n TF:\n IVF:\n 5,523 mL\n 965 mL\n Blood products:\n Total out:\n 925 mL\n 420 mL\n Urine:\n 925 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,598 mL\n 545 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Gen: in pain when moves, AOx3\n HEENT: MMM clear oropahryx\n CV: RRR\n Chest: CTAB\n Abd: TTP most severe at RLQ, but diffusely tender, no rebound\n currently; distention present, +BS\n Ext: no c/c/e\n Labs / Radiology\n 318 K/uL\n 10.8 g/dL\n 189 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 136 mEq/L\n 31.2 %\n 12.3 K/uL\n [image002.jpg]\n 11:55 PM\n 04:26 AM\n WBC\n 10.7\n 12.3\n Hct\n 35.4\n 31.2\n Plt\n 310\n 318\n Cr\n 0.9\n 0.8\n Glucose\n 191\n 189\n Other labs: PT / PTT / INR:15.4/29.8/1.4, ALT / AST:, Alk Phos / T\n Bili:50/0.4, Amylase / Lipase:, Differential-Neuts:88.0 %,\n Lymph:7.9 %, Mono:3.5 %, Eos:0.3 %, Lactic Acid:1.7 mmol/L, LDH:119\n IU/L, Ca++:8.4 mg/dL, Mg++:1.6 mg/dL, PO4:2.1 mg/dL\n Blood cx: pending\n Urine Cx : negative\n MRSA screen: negative\n Assessment and Plan\n 58 yo m with hx of CAD, was admitted with sever abdominal pain in RLQ\n and distension, concerning for appy with possible perforation vs\n inflammation being medically managed currently.\n Acute Appendicitis with possible rupture- being treated\n conservatively with IV abx.\n - Cipro/Flagyl/Vanco\n - Gen following, recs , take to surgery once\n inflammation improved\n - continue clears for now\n - pain management w/ morphine prn\n - cont Cipro IV 400mg q12 and Flagyl 500 IV q8\n - IVF bolus as needed\n Sinus tachycardia: Likely seconday to both pain and to inflammation.\n Sinus on EKG. Was on atenolol at home\n - changed to metoprolol 12.5 TID\n - pain medication if needed, however, do not want to mask abd pain\n SOB episode and CXR changes: possible infiltrate in left lower lung\n vs edema. WBC mildly elevated, but may be from abd infection. Pt lays\n on left side, which if it is fluid, may be why it is more visibel on\n left. However, did have some emesis and is at risk fo aspiration\n peumonitis. No current resp sx and afebrile.\n - home advair and flonase\n - PRN nebs\n - CXR in AM, cont to follow\n - Continue vanc/cipro/flagyl\n Loose Stool: 5 BMs this AM, may be secondary to abx\n - will check for C. Diff\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n EKG stable,\n possible \n - on beta bloker\n HYPERTENSION, BENIGN\n - on metoprolol, instead of home atenolol\n DIABETES MELLITUS (DM), TYPE II)\n Was transitioned from insulin gtt\n to sc NPH at\n home dose\n - titrate NPH as needed\n ICU Care\n Nutrition: Clears\n Glycemic Control: NPH and SSI\n Lines: PICC\n Prophylaxis:\n DVT: SQ hep TID\n Stress ulcer: PPI not needed for now\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition : Consider transfer to floor today after discussion with\n surgery.\n" }, { "category": "Nursing", "chartdate": "2167-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462562, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Pt afebrile(T max was 104 in ED)extrimities are cold.\n Abdomen tender distended,positive bowel sounds, abdominal pain on\n admission,no N/V\n Bm x1-small liquidy stool\n Action:\n Frequent abdominal exam\n Iv hydration Ns 1L bolus\n On cipro/flagyl/vancomycin\n Dilaudid 0.25mg Iv X2 dose\n NPO\n Response:\n Pt more comfortable after dilaudid\n Abdominal exam remains unchanged.\n Plan:\n Continue abdominal exam\n NPO,IV hydration,antibiotics.\n Surgery follow up\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt with extensive cardiac hystory\n Action:\n Antihypertensives on hold since pt is hypotensive\n Mag repleted\n Unable to get sufficient sample for labs( PIV placed by IV nurse with\n great difficulty) ,team informed\n Response:\n Haemodinamically stable\n Plan:\n Continue to hold antihypertensives and statin\n Please call IV nurse labs.\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311\n Action:Insulin gtt started as per ICU team,finger sticks Q1hr\n Response:blood sugar remains 250-280 currently 3units/hr\n Plan:continue insulin gtt ,titrate as per protocol,finger stick Q1hr\n" }, { "category": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462719, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain. Elevated blood glucose controlled on insulin drip. Plan\n is to switch his drip to his normal regimen of insulin (Half dose with\n sliding scale coverage while NPO) and watch him closely and plan to\n transfer to floor tomorrow if possible after he is stabilized on his\n home regimen of insulin.\n Appendicitis\n Assessment:\n Pt with complaints of abdominal pain requiring IV dilaudid .25mg Q3hrs\n for pain. Pt afebrile with rising WBC.\n Action:\n Surgery will still hold off on abdominal surgery at this time. Pt\n continues on IV antibiotics, Vanco, flagyl, cipro. He also continues on\n IVF LR at 150cc/hr. UO is adequate.\n Response:\n Afebrile with continued abdominal pain. IVT did come up and PICC\n inserted for access and blood draws.\n Plan:\n Pt may be called out this evening if blood glucose stable off drip and\n his vital signs remain stable.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt remained on insulin drip at 5units/hr until dinner time insulin dose\n was given. 1800 pt given 20 units NPH and we will shut off drip at\n 1900. Blood glucose has been in 150\n Action:\n Drip to be stopped at 1900, one hour after sc dose given.\n Response:\n To be followed closely with frequent fingersticks until stable off the\n drip.\n Plan:\n Follow fingerstick blood glucose closely after pt has drip d/c\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt\ns heart rate in the 105-115 range, sinus tach. BP 140-150. Denies\n complaints of chest pain or SOB. Given 500cc LR bolus to try to see if\n this will help the tachycardia.\n Action:\n Given 500cc\ns LR bolus. Surgery suggests starting pt on metoprolol 5mg\n IV Q6hr for tachycardia but team is thinking about this recommendation.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462771, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy\n Action:\n Received LR @ 150cc/hr. Given abx:\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Plan:\n Surgery may order lopressor for HR on floor. Increased HR due to:\n temp, need for hydration, pain.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462777, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to . WBC:\n Action:\n Received LR @ 150cc/hr. Given abx: cipro,flagyl & vanco IV.\n Medicated for pain w/0.25mg IV dilaudid q 3 hrs (each time patient\n called for pain med).\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Increased HR may be due to : temp, pain, need for hydration.\n Plan:\n No surgery planned @ this time.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462779, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to . WBC: (10.7)\n Action:\n Received LR @ 150cc/hr. Given abx: cipro,flagyl & vanco IV.\n Medicated for pain w/0.25mg IV dilaudid q 3 hrs (each time patient\n called for pain med).\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Increased HR may be due to : temp, pain, need for hydration.\n Plan:\n No surgery planned @ this time.\n" }, { "category": "Nursing", "chartdate": "2167-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462537, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Pt afebrile(T max was 104 in ED)extrimities are cold,WBC\n Abdomen tender distended,positive bowel sounds, abdominal pain on\n admission,no N/V\n Bm x1-small liquidy stool\n Action:\n Frequent abdominal exam\n Iv hydration Ns 1L bolus\n Dilaudid 0.25mg Iv X2 dose\n NPO\n Response:\n Pt more comfortable after dilaudid\n Abdominal exam remains unchanged.\n Plan:\n Continue abdominal exam\n NPO,IV hydration\n Surgery follow up\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt with extensive cardiac hystory\n Action:\n Antihypertensives on hold since pt is hypotensive\n Response:\n Haemodinamically stable\n Plan:\n Continue to hold antihypertensives and statin\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311\n Action:Insulin gtt started as per ICU team,finger sticks Q1hr\n Response:\n Plan:continue insulin gtt ,titrate as per protocol,finger stick Q1hr\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462766, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100.5 po BP:131-161/ HR:\n 100\ns- no ectopy\n Action:\n Received LR @ 150cc/hr. Given abx:\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stool .\n Plan:\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462767, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100.5 po BP:131-161/ HR:\n 100\ns- no ectopy\n Action:\n Received LR @ 150cc/hr. Given abx:\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Plan:\n Surgery may order lopressor for HR on floor. Increased HR due to:\n temp, need for hydration, pain.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462769, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100.5 po BP:131-161/64-96 HR:\n 100\ns- no ectopy\n Action:\n Received LR @ 150cc/hr. Given abx:\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Plan:\n Surgery may order lopressor for HR on floor. Increased HR due to:\n temp, need for hydration, pain.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462773, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to .\n Action:\n Received LR @ 150cc/hr. Given abx: Medicated\n for pain w/0.25mg IV dilaudid q 3 hrs (each time patient called for\n pain med).\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Plan:\n Surgery may order lopressor for HR on floor. Increased HR possilbly\n due to: temp, need for hydration, pain.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462775, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to . WBC\n Action:\n Received LR @ 150cc/hr. Given abx: cipro,flagyl & vanco IV.\n Medicated for pain w/0.25mg IV dilaudid q 3 hrs (each time patient\n called for pain med).\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Plan:\n Increased HR possilbly due to: temp, need for hydration, pain. Will\n hydrate. Monitor HR.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462828, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to . After 0100, no longer c/o pain. WBC:\n 12.3 (10.7)\n Action:\n Received LR @ 150cc/hr. Given abx: cipro,flagyl & vanco IV.\n Medicated for pain w/0.25mg IV dilaudid q 3 hrs (each time patient\n called for pain med). Remains NPO.\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Increased HR may be due to : temp, pain, need for hydration.\n Plan:\n No surgery planned @ this time.\n .H/O asthma\n Assessment:\n Patient\ns lung sounds became more coarse as night progressed.\n Action:\n IVF: LR @ 150cc/hr decreased per surgery to 75cc/hr. Received atrovent\n neb Tx & started back on Advair.\n Response:\n Lungs sounded more clear @ 0600. Coughing nonproductively all night.\n Plan:\n Had CXR @ 0530, check results.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462830, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH. Serum Mg 1.6,\n needs to be repleted.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to . After 0100, no longer c/o pain. WBC:\n 12.3 (10.7)\n Action:\n Received LR @ 150cc/hr. Given abx: cipro,flagyl & vanco IV.\n Medicated for pain w/0.25mg IV dilaudid q 3 hrs (each time patient\n called for pain med). Remains NPO.\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Increased HR may be due to : temp, pain, need for hydration.\n Plan:\n No surgery planned @ this time.\n .H/O asthma\n Assessment:\n Patient\ns lung sounds became more coarse as night progressed.\n Action:\n IVF: LR @ 150cc/hr decreased per surgery to 75cc/hr. Received atrovent\n neb Tx & started back on Advair.\n Response:\n Lungs sounded more clear @ 0600. Coughing nonproductively all night.\n Plan:\n Had CXR @ 0530, check results.\n" }, { "category": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462679, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain. Elevated blood glucose controlled on insulin drip. Plan\n is to switch his drip to his normal regimen of insulin (Half dose with\n sliding scale coverage while NPO) and watch him closely and plan to\n transfer to floor if possible after he is stabilized on his home\n regimen of insulin.\n Appendicitis\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\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": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462595, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Mildly febrile Tmax 100.7 this shift , became afebrile later without\n any intervention. C/O abdominal pain every 2hrs on a pain scale of\n . On dilaudid IV prn q3hrs. Abdomen distended with positive BS.\n Denies N/V . x2 small liquid stools earlier in the day. This shift\n pt had a large soft brown BM.\n Action:\n Remains NPO. Dilaudid frequency changed to q2hrs prn. Medicated with\n dilaudid q2hrs prn for pain. Also received 1x single dose of dilaudid.\n IVF LR at 150cc/hr. Receiving IV antibiotics vanc/fagyl and Cipro.\n Response:\n Good response to dilaudid. But pt states he continues to have\n constant mild pain, but tolerable.\n Plan:\n Continue abdominal exam\n NPO,IV hydration,antibiotics.\n Surgery follow up\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311. On insulin gtt\n Action: Continues on Insulin gtt , currently on 3.5 units/hr.\n Monitored qhr fingersticks\n Response: Blood sugar remains between 150-250 currently 3.5\n units/hr\n Plan: Continue insulin gtt ,titrate as per\n protocol,finger stick Q1hr\n Pt is a difficult stick. Has 2 working PIV\n Unable to obtain labs since admission to ICU. IV nurse called in .\n Obtained labs.\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462827, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS was 137 when IV insulin D/C\n Action:\n IV insulin D/C\ned @ 1900. Changed to\n dose usual NPH (as patient NPO)\n w/sliding scale coverage.\n Response:\n FS131-195 Covered w/0-2 units humalog sc q 4hrs. Also receiving NPH\n dose .\n Plan:\n Transfer to floor if FS\ns stable on sliding scale & NPH.\n Appendicitis\n Assessment:\n T 99.8-100 po BP:131-161/64-96 HR:\n 100\ns- no ectopy C/o Abdominal pain , relieved w/0.25mg\n IV dilaudid down to . After 0100, no longer c/o pain.\n WBC: (10.7)\n Action:\n Received LR @ 150cc/hr. Given abx: cipro,flagyl & vanco IV.\n Medicated for pain w/0.25mg IV dilaudid q 3 hrs (each time patient\n called for pain med). Remains NPO.\n Response:\n U/o 40-60cc/hr clear amber urine. Abdomen soft & distended w/+ bowel\n sounds. Had several medium guiac negative formed stools on .\n Increased HR may be due to : temp, pain, need for hydration.\n Plan:\n No surgery planned @ this time.\n .H/O asthma\n Assessment:\n Patient\ns lung sounds became more coarse as night progressed.\n Action:\n IVF: LR @ 150cc/hr decreased per surgery to 75cc/hr. Received atrovent\n neb Tx & started back on Advair.\n Response:\n Lungs sounded more clear @ 0600. Coughing nonproductively all night.\n Plan:\n Had CXR @ 0530, check results.\n" }, { "category": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462592, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Appendicitis\n Assessment:\n Mildly febrile Tmax 100.7 this shift. C/O abdominal pain every 2hrs\n on a pain scale of . On dilaudid IV prn q3hrs. Abdomen distended\n with positive BS. X 2 small liquid stools earlier in the day. This\n shift pt had a large soft brown BM.\n Bm x1-small liquidy stool\n Action:\n Remains NPO. Dilaudid\n Response:\n Pt more comfortable after dilaudid\n Abdominal exam remains unchanged.\n Plan:\n Continue abdominal exam\n NPO,IV hydration,antibiotics.\n Surgery follow up\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt with extensive cardiac hystory\n Action:\n Antihypertensives on hold since pt is hypotensive\n Mag repleted\n Unable to get sufficient sample for labs( PIV placed by IV nurse with\n great difficulty) ,team informed\n Response:\n Haemodinamically stable\n Plan:\n Continue to hold antihypertensives and statin\n Please call IV nurse labs.\n Diabetes Mellitus (DM), Type II\n Assessment:Blood sugar on admission 311\n Action:Insulin gtt started as per ICU team,finger sticks Q1hr\n Response:blood sugar remains 250-280 currently 3units/hr\n Plan:continue insulin gtt ,titrate as per protocol,finger stick Q1hr\n" }, { "category": "Nursing", "chartdate": "2167-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462684, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving caecum and small bowel.\n Pain controlled overnight on dilaudid .25mg IV Q3hrs. Still has c/o\n abdominal pain. Elevated blood glucose controlled on insulin drip. Plan\n is to switch his drip to his normal regimen of insulin (Half dose with\n sliding scale coverage while NPO) and watch him closely and plan to\n transfer to floor if possible after he is stabilized on his home\n regimen of insulin.\n Appendicitis\n Assessment:\n Pt with complaints of abdominal pain requiring IV dilaudid .25mg Q3hrs\n for pain. Pt afebrile with rising WBC.\n Action:\n Surgery still hold off on abdominal surgery at this time. Pt continues\n on IV antibiotics, Vanco, flagyl, cipro. He also continues on IVF LR at\n 150cc/hr. UO is adequate.\n Response:\n Afebrile with continued abdominal pain. IVT did come up and PICC\n inserted for access and blood draws.\n Plan:\n Pt may be called out this evening if blood glucose stable off drip and\n his vital signs remain stable.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt remained on insulin drip at 5units/hr. Blood glucose 150\n Action:\n Response:\n Plan:\n Follow fingerstick blood glucose closely\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt\ns heart rate in the 105-115 range, sinus tach. BP 140-150. Denies\n complaints of chest pain or SOB\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2167-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 462686, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - abd pain unchanged overnight- no change in pattern of quality of pain\n - dilaudid use to q2, and now back to q3\n S: pain currently\n Allergies:\n Morphine Sulfate\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 08:00 PM\n Ciprofloxacin - 12:00 AM\n Vancomycin - 07:27 AM\n Infusions:\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Hydromorphone (Dilaudid) - 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 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (99\n HR: 111 (93 - 111) bpm\n BP: 118/79(87) {94/19(39) - 140/79(87)} mmHg\n RR: 26 (15 - 29) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 7,432 mL\n 1,666 mL\n PO:\n TF:\n IVF:\n 3,432 mL\n 1,666 mL\n Blood products:\n Total out:\n 1,720 mL\n 330 mL\n Urine:\n 820 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,712 mL\n 1,336 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Gen: in pain, AOx3\n HEENT: MMM clear oropahryx\n CV: RRR\n Chest: CTAB\n Abd: TTP most severe at RLQ, but diffusely tender, no rebound currently\n Ext: no c/c/e\n Labs / Radiology\n 310 K/uL\n 11.9 g/dL\n 191 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 104 mEq/L\n 136 mEq/L\n 35.4 %\n 10.7 K/uL\n [image002.jpg]\n 11:55 PM\n WBC\n 10.7\n Hct\n 35.4\n Plt\n 310\n Cr\n 0.9\n Glucose\n 191\n Other labs: PT / PTT / INR:15.4/29.8/1.4, ALT / AST:, Alk Phos / T\n Bili:50/0.4, Amylase / Lipase:, Differential-Neuts:88.0 %,\n Lymph:7.9 %, Mono:3.5 %, Eos:0.3 %, Lactic Acid:1.7 mmol/L, LDH:119\n IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n Ruptured appendix s/p acute appendicitis- being treated\n conservatively with IV abx\n Cipro/flagyl. Gen will reeval and\n possibly take to surgery once inflammation better\n - cont NPO\n - pain management w/ morphine prn\n - cont Cipro IV 400mg q12 and Flagyl 500 IV q8\n - IVF bolus as needed\n # pt currently febrile, but does not complain of cough and\n wbc/fevers likely appendicitis.\n - cxr in AM, cont to follow\n - if worsens will add vanc/zosyn\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n EKG stable,\n possible \n , BENIGN\n on home bp meds\n DIABETES MELLITUS (DM), TYPE II)\n on insulin gtt\n - will change back to sq insulin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Picc\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 462933, "text": "58 y/oM with one week of RLQ pain associated with constipation found to\n have high fever to 104 rectally and significant inflammatory changes\n around the appendix involving cecum and small bowel.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSs 200s. Diet inc to cl liqs but pt having periods of N/V (bile).\n Action:\n\n dose usual NPH (as patient NPO) w/sliding scale coverage q4hr.\n Zofran 4mg x2.\n Response:\n FS 200s. Covered w/4-6 units humalog sc q 4hrs. Pt states nausea\n usually improves after he vomits.\n Plan:\n Cont q4hr FSs w/SSI and\n NPH dose while NPO.\n Appendicitis\n Assessment:\n T 98.8-99.1 po. C/O abdominal pain when he moves but refused pain\n meds at this time.\n Action:\n On cipro,flagyl & vanco IV.\n Response:\n U/o 40-60cc/hr clear amber urine. Foley dc\nd at 1600. Abdomen soft &\n distended w/+ bowel sounds. Had several medium guiac negative formed\n stools on .\n Plan:\n Followed by surgery. Possible surgery in a few days.\n .H/O asthma\n Assessment:\n Patient\ns lung sounds had become more coarse as night progressed.\n CXR-pneumonia. O2 sats 90s on 3L. Desats with exertion to high 80s but\n they improve with rest.\n Action:\n Received atrovent neb Tx & started back on Advair. OOB-chair\n independently.\n Response:\n Lungs sounded more clear. Coughing thick white sputum.all night.\n Plan:\n Needs sputum spec with next sputum. Incentive spirometry instructions\n given.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Height:\n Admission weight:\n 109.5 kg\n Daily weight:\n Allergies/Reactions:\n Morphine Sulfate\n Nausea/Vomiting\n Precautions:\n PMH: Asthma, Diabetes - Insulin, ETOH\n CV-PMH: CAD, Hypertension\n Additional history: s/p PCI, syncopal episodes , GERD, psoriasis\n Surgery / Procedure and date: cervical laminectomies C3-C7\n - Cervical fusion at C7-T1\n - left total knee replacement x3\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:146\n D:78\n Temperature:\n 99.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 113 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,329 mL\n 24h total out:\n 845 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:26 AM\n Potassium:\n 4.1 mEq/L\n 04:26 AM\n Chloride:\n 102 mEq/L\n 04:26 AM\n CO2:\n 24 mEq/L\n 04:26 AM\n BUN:\n 21 mg/dL\n 04:26 AM\n Creatinine:\n 0.8 mg/dL\n 04:26 AM\n Glucose:\n 189 mg/dL\n 04:26 AM\n Hematocrit:\n 32.0 %\n 03:00 PM\n Finger Stick Glucose:\n 185\n 12:00 PM\n Valuables / Signature\n Patient valuables: with wife\n 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 east\n Transferred to: 5S\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2167-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 462934, "text": "Diabetes Mellitus (DM), Type II\n Assessment:\n FSs 200s. Diet inc to cl liqs but pt having periods of N/V (bile).\n Action:\n\n dose usual NPH (as patient NPO) w/sliding scale coverage q4hr.\n Zofran 4mg x2.\n Response:\n FS 200s. Covered w/4-6 units humalog sc q 4hrs. Pt states nausea\n usually improves after he vomits.\n Plan:\n Cont q4hr FSs w/SSI and\n NPH dose while NPO.\n Appendicitis\n Assessment:\n T 98.8-99.1 po. C/O abdominal pain when he moves but refused pain\n meds at this time.\n Action:\n On cipro,flagyl & vanco IV.\n Response:\n U/o 40-60cc/hr clear amber urine. Foley dc\nd at 1600. Abdomen soft &\n distended w/+ bowel sounds. Had several medium guiac negative formed\n stools on .\n Plan:\n Followed by surgery. Possible surgery in a few days.\n .H/O asthma\n Assessment:\n Patient\ns lung sounds had become more coarse as night progressed.\n CXR-pneumonia. O2 sats 90s on 3L. Desats with exertion to high 80s but\n they improve with rest.\n Action:\n Received atrovent neb Tx & started back on Advair. OOB-chair\n independently.\n Response:\n Lungs sounded more clear. Coughing thick white sputum.all night.\n Plan:\n Needs sputum spec with next sputum. Incentive spirometry instructions\n given.\n" }, { "category": "ECG", "chartdate": "2167-04-28 00:00:00.000", "description": "Report", "row_id": 117171, "text": "Sinus tachycardia. Short P-R interval. Since the previous tracing of \nprobably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2167-04-26 00:00:00.000", "description": "Report", "row_id": 117172, "text": "Sinus tachycardia. Possible left atrial abnormality. Poor R wave progression.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nthe ST-T wave changes are more pronounced and the sinus tachycardia is new.\nThe QRS change in lead V3 could be positional.\n\n" }, { "category": "Radiology", "chartdate": "2167-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081502, "text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with hypoxia, tachycardia\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with hypoxia, tachycardia, evaluate for pulmonary\n edema.\n\n COMPARISON: .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: Low lung volumes limit assessment.\n Within this limitation, cardiomediastinal silhouette is probably unchanged. A\n right PICC tip is projecting over the upper SVC. There is a left pleural\n effusion. An area of consolidation in the left upper lung may represent\n fissural fluid versus consolidation.\n\n IMPRESSION: Left upper lung opacification which likely represents fissural\n fluid versus consolidation/infection. Recommend conventional PA and lateral\n for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2167-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081142, "text": " 1:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate/edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with fever and altered mental status\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate/edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 50-year-old male with fever and altered mental status.\n\n COMPARISON: .\n\n AP/UPRIGHT CHEST: Cardiomediastinal silhouette is normal. The pulmonary\n vascularity is normal. The lungs are clear without pleural effusion or\n pneumothorax. Cervical fixation hardware is again noted.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-04-26 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1081155, "text": " 3:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ABD PAIN\n Field of view: 46 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with abdominal pain, altered mental status\n REASON FOR THIS EXAMINATION:\n eval for acute abdominal process. no hx abd surgery, NO PO contrast please\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SUN 5:53 AM\n Marked right lower quadrant inflammatory changes appear centered around a\n fluid distended appendix, with an appendicolith near its origin- while\n findings may represent an acute appendicitis, the degree of cecal wall\n thickening and proximal partial bowel obstruction are less typical and may\n represent a colonic inflammatory process. No evidence for perforation or focal\n fluid collection.\n WET READ VERSION #1 ARHb SUN 5:13 AM\n Markd right lower quadrant inflammatory changes appear centered around a fluid\n distended appendix, with an appendicolith near its origin- findings consistent\n with acute appendicitis. Inflammatory wall thickening of cecum and distention\n of ileal loops are likely secondary findings. No evidence for perforation or\n focal fluid collection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old male with abdominal pain and altered mental status.\n\n TECHNIQUE: Contrast-enhanced axial imaging of the abdomen and pelvis were\n obtained with multiplanar reformatted images. 130 cc of IV Optiray contrast\n was administered uneventfully.\n\n CT ABDOMEN WITH CONTRAST: Minimal hypoventilatory changes are noted at the\n lung bases. A small amount of peribronchovascular opacity at the left lung\n base is a nonspecific finding. There is no evidence for pericardial or\n pleural effusion.\n\n The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys appear\n normal. There is no hydronephrosis or hydroureter. Atherosclerotic\n calcifications involve the abdominal aorta and its branches, although the\n abdominal aorta is of normal caliber.\n\n There are marked right lower quadrant inflammatory changes. A fluid-filled and\n distended appendix measures up to 9-mm with an appendicolith near its origin.\n There is wall thickending and edema of the adjacent cecum with distension and\n fecalization of ileal loops. There is no evidence for frank perforation and no\n focal fluid collection is identified. Some wall thickening of the adjacent\n cecum appears likely. A small amount of free fluid is adjacent to the spleen.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid colon and prostate are\n unremarkable. The bladder contains a Foley and small amounts of non-\n dependent air. There is a small amount of free pelvic fluid.\n\n (Over)\n\n 3:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ABD PAIN\n Field of view: 46 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Bone windows reveal no worrisome lytic or sclerotic lesions. Mild\n thoracolumbar spondylosis is noted.\n\n IMPRESSION:\n 1. The findings most likely represent acute appendicitis with secondary cecal\n colitis and partial small bowel obstruction, however a primary cecal\n inflammatory process causing secondary appendix changes is another diagnostic\n consideration.\n 2. Minimal peribronchovascular opacity at left lung base may be infectious or\n inflammatory.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-04-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1081153, "text": " 3:49 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: AMS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with altered MS\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SUN 5:03 AM\n No intracranial hemorrhage or edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast axial images of the head are obtained with 5-mm\n section thickness.\n\n FINDINGS: There is no intracranial hemorrhage, shift of normally midline\n structures, or evidence of acute major vascular territorial infarct. A\n small left basal ganglia chronic lacunar infarct (or prominent Virchow-\n space) is redemonstrated. The surrounding osseous structures are unremarkable\n and the imaged portions of both sinuses appear well aerated.\n\n IMPRESSION: No intracranial hemorrhage or edema.\n\n" }, { "category": "Radiology", "chartdate": "2167-04-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1081388, "text": " 12:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 55cm DL R basilic PICC placed ? tip\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with partial SBO\n REASON FOR THIS EXAMINATION:\n 55cm DL R basilic PICC placed ? tip\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line placement.\n\n Portable AP chest radiograph was compared to at 1:42 a.m.\n\n The right PICC line tip appears to be at the proximal right atrium - to\n secure its position at the low SVC should be pulled back about 2 cm. The\n cardiomediastinal silhouette is unchanged. There is interval development of\n left basal and right basal opacities most likely consistent with areas of\n atelectasis. No pneumothorax or appreciable pleural effusion is demonstrated.\n\n" }, { "category": "Radiology", "chartdate": "2167-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082082, "text": " 11:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT position confirmation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with sbo.\n REASON FOR THIS EXAMINATION:\n NGT position confirmation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:37 P.M., \n\n HISTORY: Small bowel obstruction. Check NG tube placement.\n\n IMPRESSION: AP chest compared to :\n\n A nasogastric tube can be traced at least to the mid portion of nondilated\n stomach. Left upper lobe collapse is new, mild right basal atelectasis also\n new. Findings were discussed by telephone with Dr. at the time of\n dictation. Heart size is normal. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-04-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1081970, "text": " 11:52 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?abdominal fluid collection or other process\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with appendicitis & continguous inflammation, failing to\n clinically improve\n REASON FOR THIS EXAMINATION:\n ?abdominal fluid collection or other process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:02 PM\n Persistent enlarged appendix at 12mm, with surrounding stranding with\n inflammation in the cecum, likely represents appendicitis.\n Interval worsening of the upstream dilatation of the ileum, again\n consistent with partial small bowel obstruction, also likely due to downstream\n inflammation.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITH CONTRAST\n\n INDICATION: Appendicitis and contiguous inflammation not improving\n clinically.\n\n TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained\n with oral and intravenous contrast. Coronal and sagittal reformats were\n performed. Comparison is made to prior study from .\n\n CT ABDOMEN: There is trace atelectasis at the lung bases with a new left\n pleural effusion. There is no pulmonary nodule. The liver, gallbladder,\n spleen, adrenals, and kidneys are normal. There is fatty replacement of the\n pancreas. The NG tube tip is in the stomach. There is new free fluid within\n the abdomen, which is perihepatic and perisplenic as well as in the right\n paracolic gutter. There is persistent enlargement of the appendix at 12 mm,\n with persistent cecal inflammation. There is interval worsening of the\n upstream ileal and now jejunal dilatation consistent with partial small-bowel\n obstruction. There are numerous mesenteric and retroperitoneal nodes measuring\n up to 12 mm (2, 46). There is no focal abscess or fluid collection.\n\n CT PELVIS: The sigmoid and rectum are not filled with contrast. There is\n inflammatory stranding in the pelvis. There is new free fluid in the pelvis.\n There is no inguinal or pelvic adenopathy. The prostate and seminal vesicles\n are unremarkable.\n\n BONE WINDOWS: There is mild degenerative change in the lumbar spine with disc\n space narrowing most marked at L4-5. There is no suspicious osseous lesion.\n\n IMPRESSION:\n 1. Persistent right lower quadrant inflammatory changes again likely due to\n appendicitis, with secondary colitis in the cecum. There has been interval\n worsening of the partial small-bowel obstruction. There is no focal fluid\n collection, although there is an increase in the free fluid throughout the\n (Over)\n\n 11:52 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?abdominal fluid collection or other process\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n abdomen and pelvis.\n 2. New left pleural effusion.\n\n Findings discussed with Dr from Surgery on the day of\n study.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2137-05-15 00:00:00.000", "description": "Report", "row_id": 1356873, "text": "Resp care\nPt remains on unchanged vent settings. ABGs acceptable. Bs coarse->clear. Sx mod thick blood tinged secretions. ? OR tomorrow. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-15 00:00:00.000", "description": "Report", "row_id": 1356874, "text": "TSICU NPN (0700-1900)\nREVIEW of SYSTEMS:\n\nNeuro...Remains sedated for comfort on propofol at 50mcg and fentanyl at 75mcg. Arouses quickly to voice when propofol off for 5-8min. Follows simple commands(i.e. show two fingers, show me thumb, squeeze hand.) Still no movement from RUE(thought to be brachial plexus nerve injury by physicians.) Moves all other extremites purposefully and with good strength. Pupils equal and reactive. J collar remains on. Unable to clear c-spine from flex-ex x-rays yesterday.\n\nCV...NSR with no ectopy noted. HR 70's. BP stable 110-140's/60's. CVP 7-10. Easily palpable peripheral pulses.\n\nRESP...No vent changes made today. Waiting until after OR tomorrow before start to wean from vent. On A/C 18x550 peep of 10/50%. Afternoon ABG 7.41/41/125/1/27. Episode of desaturation x1 down to 93%. CXR obtained after this. Per Dr. , x-ray stable. Lung fields initially clear--coarse this afternoon. Suctioning small to moderate amts of thick, bloody secretions. R anterior CT remains to 20cm suction. Small amt of serosang drainage. Persistant crepitus around CT site.\n\nGI....G-tube remains to gravity with moderate amt of bilious drg. OGT dc'd. Abd softly distended with hypoactive BS. Pepcid coverage.\n\nGU...IVF rate decreased to 75cc/hr. Adequate urine output. K+ 3.3 this afternoon. Repleted with 40meq KCL.\n\nID...Tmax 100.8--running persistant low grade temps. Clindamycin abx coverage.\n\nENDO...No coverage needed per RISS.\n\nHEME....Heparin subq and pboots for DVT prophylaxsis.\n\nSKIN....Laceration to forehead, lip, and chin with sutures intact. No drainage noted. Healing well. Bacitracin applied. Lac to back of head with staples. Trach incision continues to have small amt of bloody drg from superior portion of incision. Midline abd incision with staples. No redness or drg noted. Lacs to L leg cleaned with saline and bacitracin applied. All lacerations and abrasions healing well. No s/s of infection. Skin on back intact. No breakdown noted. Alternating multipodus boot.\n\nSOCIAL... mom and dad in for most of day. Consented per PLS team and anesthesia for tomorrow's OR. Family has been in contact with social work and case management.\n\nPLAN....OR TOMORROW for FIXATION of FACIAL FX's per PLS and OMS. Possible repair of R radius fx per ortho also. Keep sedated for comfort overnight. Pulmonary toilet. Replete lytes accordingly. Skin care. Support for family.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-16 00:00:00.000", "description": "Report", "row_id": 1356875, "text": "Respiratory Care:\nPt. remains on unchanged vent settings. ABG's showing oxygenation varying from good to excellent with unchanged normal range acid-base. Pt. has course B/S bilaterally with diminished aeration RLL. Rt. CT remains to SXN. SXN for copious amounts of thick, red secretions and same from oral cavity. # 8 trach patent/secure. Pt. slated for O.R. this a.m. for facial surgery. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-16 00:00:00.000", "description": "Report", "row_id": 1356876, "text": "ASSESSMENT AS NOTED\n\nSTABLE OVERNIGHT, REMAINS SEDATED ON VENT , LARGE AMNTS SECRETIONS-BLOODY/PINK.STRONG COUGH.CHEST TUBE INTACT W/O LEAK, +SMALL CREPITUS, MINIMAL DRAINAGE. LS COARSE. PO2>120\n\nNEURO: DOES NOT MOVE R. ARM(R. BRACHIAL NERVE PLEXUS DAMAGE??), FOLLOWS COMMANDS WHEN OFF SEDATION. IN CER COLLAR,\n\nCV: STABLE, NSR, NO ECTOPY, A/LINE FLING\n\nGI: G TUBE TO GRAVITY BILE 250CC, HYPO BS, NO BM\n\nGU: BRISK U/O\n\nLABS: K, MAG REPLETED\n\nPAIN: ON FENTANYL 100MCG , PROPOFOL 60MCG, FACIAL GRIMACES TO PAIN\n\nSKIN: AS PER CAREVE + BRUISED R.NECK AND L. UPPER ARM\n\nORAL: SEVERE ORAL INJURY,MISSING TEETH, LEFORT 3 FACIAL FX. ORAL SURGERY WAS IN LAST NIGHT TO ASSESS THE PATIENT\n\nSOCIAL: FAMILY WAS IN LAST NIGHT AND PLANNING TO COME IN AT 11 AM\n\nA: MVA WITH MUTIPLE FXS AND CONTUSIONS\n\nPLAN: TO OR TODAY AD-ON CASE ??? TIME. KEEP NPO, HOLD 1200 HEPARIN DOSE. PAIN CONTROL\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-16 00:00:00.000", "description": "Report", "row_id": 1356877, "text": "TSICU NPN 0700-1330:\n\nEVENTS: PT HEMODYNAMICALLY STABLE THROUGHOUT THE SHIFT. PARENTS IN ANS UPDATED FULLY. QUESTIONS ANSWERED AND SUPPORT GIVEN. PT VERY AWAKE AND RESTLESS WHEN THEY ARE IN THE ROOM. ENCOURAGED THEM TO LIMIT STIMULATION WHILE PT STILL HAS UNSTABLE FACIAL FRACTURES. PT TAKEN TO OR TO FIX RIGHT ARM AND FACIAL FRACTURES. LONG SURGERY EXPECTED.\n\nNEURO: OPENS EYES TO STIMULATION. INTERMITTENTLY FOLLOWS COMMANDS. VERY SLIGHT RIGHT LEG MOVEMENT. NO RUE MOVEMENT NOTED. MOVES LEFT ARM AND LEG PURPOSEFULLY. PERL 3MM. SEDATED ON PROPOFOL AND FENTANYL GTTS.\n\nCV: SR. ST WITH AGITATION. NO ECTOPY. COLOR PINK. SKIN WARM AND DRY. PALP DP AND PT PULSES BILAT. TRACE PERIPHERAL EDEMA. SLIGHT FLING WITH A LINE. BP STABLE.\n\nRESP: TRACH MIDLINE AND SECURE. EQUAL CHEST EXPANSION. SATS STABLE 96-99%ON CURRENT VENT SETTINGS. REMAINS ON 10 PEEP. CHEST TUBE PLACED TO WATER SEAL AGAIN TOTAL. SATS STABLE. RIGHT CHEST TUBE WITH + SCE, + TIDALING, NO LEAK, SCANT AMOUNTS SEROSANG DRAINAGE. SUCTIONING THICK BLOODY SECRETIONS FROM TRACH.\n\nGI: ABDOMEN ROUND, SOFT. HYPOACTIVE BOWEL SOUNDS. NPO. G TUBE TO GRAVITY WITH BILIOUS OUTPUT--FLUSHED TO ENSURE PATENCY. MIDLINE INCISION WITH STAPLES IN PLACE.\n\nGU: FOLEY WITH CLEAR YELLOW URINE. LR AT 75/HOUR.\n\nENDO: NO COVERAGE WITH RISS REQUIRED.\n\nID: TEMP TO 101.2. TYLENOL GIVEN. CLINDAMYCIN LAST GIVEN AT 12N.\n\nHEME: HCT STABLE. PNEUMO BOOTS. SQ HEPARIN HELD AT NOON FOR O.R.\n\nSKIN: BACK INTACT. SURGICAL MIDLINE ABDOMINAL INCISION WITH STAPLES, CLEAN AND DRY. DSD TO G TUBE SITE. TRACH SITE BENIGN. LEFT EAR WITH SMALL AMOUNTS BLOODY DRAIANGE. TEAMS AWARE. LEFT SIDE OF FACE VERY SWOLLEN. LEFT AND POSTERIOR NECK ECCHYMOTIC AND FIRM. TEAMS ALSO AWARE. R ARM SPLINT IN PLACE. ROTATING MULTI PODUS BOOTS. FACIAL LACERATIONS SUTURED BY PLASTICS--HEALING WELL.\n\nSOCIAL: PT'S PARENTS IN AND UPDATED. WAITING IN FAMILY ROOM UNTIL THE END OF SURGERY. WILL UPDATE AS NEEDED.\n\nPLAN: POST-OP CARE S/P FACIAL AND RIGHT ARM SURGERY. ONGOING PAIN CONTROL AND SEDATION AS NEEDED. OPEN COMMUNICATION WITH FAMILY. SLOW VENT WEAN. INCREASE ACTIVITY. MONITOR POOR MOVEMENT OF RIGHT EXTREMITIES. EMOTIONAL SUPPORT AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-16 00:00:00.000", "description": "Report", "row_id": 1356878, "text": "Resp care\nPt remains on unchanged vent settings. BS coarse, sx mod thick bloody secretions. Pt in OR most of shift. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-14 00:00:00.000", "description": "Report", "row_id": 1356869, "text": "Resp Care\n\nPt remained on full vent support during the shift. Did attempt to change to PSV but pt still to sedated and had a rr on 7. Suctioning thick bloody sputum. Pt transported to IR without incident\n" }, { "category": "Nursing/other", "chartdate": "2137-05-14 00:00:00.000", "description": "Report", "row_id": 1356870, "text": "TSICU Nursing Addendum Note\n***G-tube placed in angio. No complications. Placed tube to gravity upon returning to unit. Small amt of bilious drg.\n\n***Flexion extension x-rays completed under fluoroscopy. Dr. present for x-rays. Neck flexion and extension done per Dr. . Awaiting final read of x-rays per attending radiologist.\n\n***Acute desaturation down to 90-92% upon arrival back in unit after procedures. Suctioned for moderate amts of thick, bloody secretions. No improvement in sats. Dr. at BS. R CT placed back to suction. Peep increased to 10 and FiO2 to 70%. Sats rebounded back to 98%. ABG showed PO2 of 113.\n\n***Family in to visit after pt back in room. Updated on procedures. Consented per ortho for fixation of radius fx.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-15 00:00:00.000", "description": "Report", "row_id": 1356871, "text": "Resp: pt on a/c 18/550/70%/10+. Alarms on and functioning. Ambu/syringe @ hob. BS ausucultated reveal bilateral clear sounds. Notable sub Q on RS. Suctioned copious amounts of thick bloody secretions due to new trach. Decreased fio2 to 50%. ABG's 7.38/42/116/26. Surgery scheduled for today.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-15 00:00:00.000", "description": "Report", "row_id": 1356872, "text": "T-SICU NPN 1900-0700\n\nNeuro: Sedated on propofol and fentanyl gtts. When lightened, opens eyes (with difficulty d/t swelling), moves BLE's and LUE, no movement noted of RUE, unchanged, MD aware, follows commands inconsistently, able to show thumb, 2 fingers. Pupils 3mm, equal and reactive. +corneals, gag, and cough. C-collar in place at all times.\n\nCV: HR 70-80's SR, no ectopy noted. BP 120-130's/50-60's, CVP 9-12. Skin warm, dry. Pedal pulses easily palpable. sc heparin and PB's for DVT prophylaxis. Heme: hct 28.6 (28.8). Fibrinogen 946 (716).\n\nResp: LS coarse, clears with suctioning; sm->moderate amts. bloody thick secretions via ett/oral. Vent settings: ac 550x18/10PEEP/50%, adequate abg. R CT to sxn with sm. amt. serosang. drainage; +crepitus noted, not advanced beyond outline. See carevue for labs/resp. notes.\n\nGI: abd softly distended, BS hypoactive, no BM/flatus. OGT to LCWS for sm. amts. bilious drainage; G-tube to gravity drainage for sm. amt. brown/bilious output, site wnl. Pepcid for GI prophylaxis.\n\nGU: foley patent draining adequate amts. clear yellow urine. Lytes repleted.\n\nEndo: BS 94->109, no coverage per SS.\n\nID: tmax 100.8; wbc 8.6 (9.4); conts. clinda as ordered. Sputum cx pending from yesterday.\n\nSKin: back/buttocks intact. CT dsg changed, mod. amt. old serosang. drainage. Bolt site with sututres C/D/I, OTA. Splint intact to RUE. Multiple facial/BLE abrasions, see careview for specifics.\n\nPsych/social: mother, father, and brother in to visit last eve; mother called for update last noc; affect/questions appropriate.\n\nLines: R sc TLCL wnl, a-line wnl\n\nA: s/p mvc awaiting OR today for repair of radius fx, hemodynamically stable\n\nP: Monitor VS, I/O, labs. Maintain sedation/comfort. Aggressive pulmonary hygiene. OR today for radius fx, ?tomorrow for facial fx's. Needs aneshesia consent for today. Continue ongoing comfort/support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-14 00:00:00.000", "description": "Report", "row_id": 1356867, "text": "Resp: pt on 18/550/40%/+5. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear sounds. Suctioned moderate amounts of thick bloody secretions from new trach as well as oral cavity. Pt is scheduled for trip to OR this wed. Plan to remain on full support. AM ABG's 7.43/42/112/29.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-14 00:00:00.000", "description": "Report", "row_id": 1356868, "text": "TSICU Nursing Note (0700-1600)\nREVIEW of Systems:\n\nNeuro: Remains sedated with propofol and fentanyl drips. Propofol turned off x2 this shift for neuro exam. Arouses to verbal stimuli. Attempts to open eyes(limited due to swelling), moving all extremites except RUE--no movement seen here. MD's aware--feel this may be due to nerve injury--fingers warm to touch and cap refill <3sec. Following simple commands(show me thumb, two fingers.) TLS cleared today. Will attempt to clear c-spine this afternoon using flexion/extension x-rays in fluroscopy. Opthamology in to examine eyes. Pupils dilated for exam.\n\nCV....NSR with no ectopy noted. HR 70-80's. BP 110-140's/50-60's. CVP ranging . Easily palpable peripheral pulses.\n\nRESP....No vent changes made this shift due to pending procedures/x-rays. Remains on A/C 550x18 peep of 5/50%. Lung fields clear with mildly diminished bases. Suctioning moderate amts of thick, bloody secretions. R anterior CT placed to water seal this am. Crepitus around R CT site remains unchanged. Post water seal x-ray done. Small amts of serosang drg. Plan to weant to PS once pt back from procedures.\n\nGI...Pt to angio this afternoon for G-tube placement. TF's stopped this am in preparation for this. Abd soft with hypoactive BS. Pepcid coverage.\n\nGU...Adequate clear yellow urine output. IVF changed to LR at 125cc/hr. Phosphate repleted with Kphos.\n\nENDO...No coverage needed per RISS.\n\nHEME....P-boots and heparin for DVT prophylaxis. Needs spot HCT check this evening--1800-1900.\n\nSKIN....Multiple skin abrasions/lacerations--see careview for specific description. All cleaned with NS and bacitracin applied. Backside intact.\n\nSOCIAL... mom and dad in for visit. Updated on condition and plan of care per this nurse and Dr. .\n\nPLAN....Flex/ex films to clear c-spine. PLAN OR on THURSDAY for PLS to fix facial fx's. Keep sedated. Wean to PS if possible.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-17 00:00:00.000", "description": "Report", "row_id": 1356879, "text": "Respiratory Care\nPt returned from OR @ 0650, BS clr bilaterally returned to current settings. Please see carevue.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-18 00:00:00.000", "description": "Report", "row_id": 1356883, "text": "TSICU NPN 7A-7P:\n\nEVENTS: CVL CHANGED OVER WIRE. REMAINS SEDATED. LP NEGATIVE. CONTINUE MENINGITIS PROPHYLAXIS. PEEP DOWN TO 5. FAMILY IN AND UPDATED BY DR. .\n\nNEURO: OPENS RIGHT EYE TO VOICE AT TIMES--REMAINS VERY SWOLLEN. LEFT EYE SUTURED CLOSED. PUPIL 3MM AND BRISKLY REACTIVE. NO LEFT ARM MOVEMENT, SLIGHT RIGHT LEG MOVEMENT. MOVES LEFT ARM PURPOSEFULLY. REMAINS ON FENTANYL AND PROPFOL. NOT FOLLOWING COMMANDS.\n\nCV: SR WITH NO ECTOPY. COLOR PINK. SKIN WARM AND DRY. PALP DP AND PT PULSES BILAT. LARGE AMOUNT FACIAL SWELLING. BP STABLE BY CUFF AND A LINE--A LINE HAS FLING, MAPS CORRELLATE.\n\nRESP: TITRATED PEEP TO 5. TOLERATING WELL. SATS REMAINS STABLE. ABG WNL. LUNG SOUNDS CLEAR TO COARSE, DIM IN BASES. SUCTIONING THICK BLOODY SECRETIONS AND SMALL PLUGS. FEMAINS ON CPAP5/PSV 15 WITH 50% FIO2. RIGHT CHEST TUBE TO WATER SEAL. +TIDALING, NEG LEAK, SMALL AMOUNT ANTERIOR SCE. DRESSING INTACT. SCANT AMOUNTS SEROSANG FLUID NOTED.\n\nGI: ABDOMEN ROUND, SOFT. + HYPOACTIVE BOWEL SOUNDS. INCONT. SMALL AMOUNT BROWN STOOL, SOFT. STARTED TUBE FEEDS VIA G TUBE. TOLERATING. GOAL 70CC/HOUR. PEPCID.\n\nGU: FOLEY WITH CLEAR AMBER/ICTERIC URINE. REPLETED KCL AND CALCIUM.\n\nENDO: COVERAGE WITH RISS.\n\nHEME: SQ HEPARIN. PNEUMO BOOTS.\n\nID: COVERAGE WITH ROCEPHIN, VANCO, AND LEVOFLOXACIN.\n\nSKIN: SEE CAREVUE FOR SPECIFICS. LEFT ARM WITH MOTTLED AREA, COOL AT TIMES, REDNESS NOTED. TEAMS ARE AWARE. ? OLD A LINE/IV SITES. ABD INC WITH STAPLES. RIGHT ARM SPLINT. FACIAL LACS AND SUTURE LINES CLEAN AND DRY.\n\nSOCIAL: PARENTS IN AND UPDATED.\n\nPLAN: CONTINUE WITH SLOW VENT WEAN. WEAN SEDATION AS TOLERATED. IVC FILTER ON MONDAY. FOLLOW TEMPS.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-17 00:00:00.000", "description": "Report", "row_id": 1356880, "text": "NPN 0700-1900\nPt arrived from OR at 0650 s/p ORIF Leforte III fx and ORIF right radial fx.\n\nNEURO: Sedation weaned to off in AM. Pt on fentanyl gtt for pain. Arousable to stimuli, does not follow commands. Observed MAE. Pt is strong and purposeful with LUE. Left eye sutured shut, right eye may be difficult to open d/t swelling.\n\nRESP: Weaned to CPAP 10/5. CT placed to water seal. Sats WNL all shift. LS clear and diminshed bilat. Suctioned for thick bloody secretions. Large amt of oral/nasal secretions as well. Strong productive cough.\n\nCV: HR 80s BP 130s-160s/70s. A-line re-sited to right foot.\n\nHEME: Hct 28 post op. Sq heparin and pboots cont. Pt to go for IVC filter placement later this eve.\n\nGI: Abd soft with absent to hypoactive bowel sounds. TF impact with fiber started at 20/hr, then dc'd d/t pt going to OR for IVC filter. No BM this shift.\n\nGU: Adequate u/o via foley. Urine amber but clear. Lytes repleted.\n\nID: Tmax 103.8 rectally. Pan cultured. 650mg PR tylenol given and pt packed with ice packs/fan. Temp slowly decreasing (currently 102.8). TSICU and OMFS teams aware. JP fluid sent for culture. Levaquin added to abx regimen.\n\nENDO: FS covered per RISS\n\nSKIN: Multiple areas of abrasions. Oral incisions sutured and intact. Head dsg loose, however is primary dsg. Dr. notified and will evaluate need to change. Back/buttocks intact. RUE splint/ace C/D/I.\n\nSOCIAL: Family at bedside and updated over phone by Dr. .\n\nASMT: Pt s/p ORIF Leforte III and right radius. Hemodynamically stable. Alteration in body temperature. Awaiting IVC filter placement.\n\nPLAN: Cont to monitor VS, neuro checks, pain mgmt, mouth care, aggressive pulmonary hygiene, skin care, monitor culture results, monitor fever curve, iv abx, OR this eve for IVC filter.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-18 00:00:00.000", "description": "Report", "row_id": 1356881, "text": "t-sicu nsg note:\nneuro- remains sedated on propofol and fentanyl gtts, mae's, not to commands, unable to assess pupils d/t eye swelling, strong cough, when light thrashes head s->s.\n\nresp- cpap ventilation 50% fio2, 10peep and 12ps, vt's600's, rr 16-28, trach sux for sm amts of bldy plugs. bs cta in upper fields and diminished bibasilar.\n\ncvs- r pedal a-line with strong fling, nbp 130's-140's, maps 80's, hr 70's-80's nsr no ectopy, cvp 4-6 most of the night, ivf infusing @75cc/hr, tm 102.8 rx w/ pr tylenol, vanco and ceftriaxone added pnd cx results.\n\ngi- tf restarted @20cc/hr per , hold @6am pnd OR for IVC filter placement. abd soft, sl distended, hypoactive bs, neg stooling, neg flatus.\n\ngu- clear amber urine via foley.\n\nskin- facial edema w/ ice packs all shift, hob elev 30-45 degrees, abd incision w/ staples D+I.\n\nsocial- very supportive family\n\nA: stable vs, cont febrile, awaiting cx results\n\nP: monitor cvs/nvs per routine, follow labs as ordered, maintain pulm hygiene, treat fever w/ tylenol and cooling measures as tol, d/c ice packs and change to moist heat per orders, maintain hob elevated. support family.\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "SPINAL FLUORO WITH RADIOLOGIST", "row_id": 862437, "text": " 5:09 PM\n SPINAL FLUORO WITH RADIOLOGIST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ligamentous injury?\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with mvc\n REASON FOR THIS EXAMINATION:\n ligamentous injury?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 33-year-old man with motor vehicle collision and question of\n cervical spine or ligamentous injury.\n\n COMPARISONS: Recent cervical spine CT, which demonstrated no fracture.\n\n TECHNIQUE: Fluoroscopy of the cervical spine, and in lateral view.\n\n FINDINGS: The cervical spine was examined under fluoroscopy with the surgeon,\n Dr. , performing flexion and extension maneuvers to evaluate for any\n dynamic subluxations. The cervical spine is visualized from C1 through C7\n with flexion and extension. No subluxations are seen. The overall alignment\n of the cervical spine, and the atlantodens relationship, is preserved during\n the maneuvers.\n\n IMPRESSION: Somewhat limited study, as the maneuvers were not performed by\n the patient himself, who is under sedation, but no subluxation or bony\n abnormality detected by fluoroscopy. Of note, however, ligamentous injury, or\n other soft tissue injury, cannot be entirely excluded by this study.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862526, "text": " 1:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute decrease in sats.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n acute decrease in sats.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motor vehicle accident, now with acute decreased in\n saturation.\n\n COMPARISON: Radiograph dated .\n\n AP PORTABLE SUPINE VIEW OF THE CHEST: Multiple rib fractures and bilateral\n clavicular fractures are again demonstrated. There is interval removal of the\n NG tube. The right-sided chest tube, right subclavian line, and tracheostomy\n tube are unchanged. There is a small right apical pneumothorax. Right-sided\n subcutaneous emphysema is again noted. The cardiac and mediastinal contours\n are stable. Hazy diffuse opacities in both lungs are again demonstrated,\n possibly slightly improved compared to the prior study.\n\n IMPRESSION:\n 1) Small right apical pneumothorax with chest tube in place.\n 2) Interval slight improvement in diffuse bilateral hazy opacities in the\n lungs.\n 3) Left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-17 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 862756, "text": " 9:40 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: TRAUMA..EVAL FOR DVT FOR IVC FILTER PLACEMENT\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n r/o DVT for IVC filter placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Immobilization due to motor vehicle trauma. Evaluation for IVC\n filter placement.\n\n COMPARISON: No previous studies.\n\n FINDINGS: Grayscale and Doppler son of the right and left common\n femoral, superficial femoral, and popliteal veins were performed. No\n intraluminal thrombus was identified. Normal compressibility, color flow,\n waveforms, and augmentation are demonstrated bilaterally.\n\n IMPRESSION: No DVT in the right or left lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-21 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 863215, "text": " 12:23 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: please include entire mandible, 1mm cuts in all 3 planes wit\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n please include entire mandible, 1mm cuts in all 3 planes with 3D reconstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old male with surgical reconstruction of multiple facial\n fractures.\n\n TECHNIQUE: Multiplanar imaging of the facial bones with 3D reconstructions.\n\n Comparison was made to prior study dated .\n\n FINDINGS: The patient appears to be status post open reduction and internal\n fixation of mandibular, maxillary sinus, left orbital floor fractures. This\n has been accomplished through placement of malleable plates, multiple screws,\n and surgical mesh. Left mandibular ramus appears to be dislocated with\n displaced fracture of the left mandibular coronoid. There is near complete\n opacification of bilateral maxillary sinuses.\n\n IMPRESSION: ORIF of multiple facial fractures with dislocated left mandibular\n ramus and displaced fracture of the left coronoid process of the mandible.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 862843, "text": " 6:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? meningitis fevers and potential CSF leak from \n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n ? meningitis fevers and potential CSF leak from drain site\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Potential CSF leak from prior drain site.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISON: head CT.\n\n HEAD CT WITHOUT IV CONTRAST: There is a small subdural fluid collection\n anterior to the right frontal lobe. This was not seen on the prior study.\n There is no high attenuation within this collection to suggest acute\n hemorrhage. A tiny amount of extra-axial fluid is also seen anterior to the\n left frontal lobe. There is no mass effect or shift of normally midline\n structures. The ventricles, cisterns, and -white matter differentiation\n are unremarkable.\n\n Scalp sutures are present and there is soft tissue density and air within the\n left head and left facial region. The patient is status post facial bone\n fixation. Near total opacification of the paranasal sinuses is present. There\n is opacification of the left ethmoid air cells. The right ethmoid air cells\n are normally aerated.\n\n IMPRESSION:\n 1) Small right frontal subdural collection and tiny left frontal subdural\n collection. Given the low attenuation, these are likely subacute or chronic\n and there is no significant mass effect.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-16 00:00:00.000", "description": "OR FOREARM (AP & LAT) IN O.R. RIGHT", "row_id": 862659, "text": " 3:03 PM\n FOREARM (AP & LAT) IN O.R. RIGHT Clip # \n Reason: FRACTURE\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n Fracture.\n\n AP and lateral forearm taken portably in the Operating Room lacking detail\n shows post-surgical changes with clips, drains and placement of hardware with\n plate and screw stabilizing the fracture of the mid shaft of the radius.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-16 00:00:00.000", "description": "SKULL (AP, TOWNES & LAT) TRAUMA", "row_id": 862705, "text": " 8:36 PM\n SKULL (AP, & LAT) TRAUMA Clip # \n Reason: INTRA-OP FILM FOR PLACEMENT OF SREWS AND WIRES\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Placement of screws and wires.\n\n A single AP film of the skull taken portably lacking detail demonstrates\n hardware placement with screws and wires about the maxilla and mandible seen\n in the anterior projection only.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 864407, "text": " 3:45 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with acute onset of chest pain and pulm hematoma\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute onset chest pain and pulmonary hematoma. Evaluate for\n cardiopulmonary process.\n\n TECHNIQUE: PA and lateral views of the chest were obtained, compared with\n examination performed yesterday.\n\n FINDINGS: Cardiac and mediastinal silhouettes are within normal limits.\n There is a right-sided PICC terminating in the lower SVC. Tracheostomy tube\n is again seen. There is a drainage catheter present in the left upper abdomen\n and mid abdomen. Again seen is a 2.6 x 6.5 cm mass projecting over the left\n lower lungs. On the lateral view, there is also retrocardiac opacity, which\n could represent a small effusion or retrocardiac atelectasis/consolidation.\n Since the prior examination, there has been withdrawal of the PICC.\n\n IMPRESSION: No significant change in the appearance of the chest. Interval\n withdrawal of PICC, with the tip in the lower SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862876, "text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ws ct\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n ws ct\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motor vehicle accident with right pneumothorax with\n chest tube changed to waterseal.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of 1 day earlier.\n There is tracheostomy tube, which is unchanged in position with tip at the\n thoracic inlet. A right chest tube is present with tip positioned in the\n medial right lung apex. There is no pneumothorax. The appearance of the left\n lung, including the lobulated lower lobe density is unchanged in the interval.\n Again, noted are bilateral clavicular fractures and subcutaneous gas within\n the right chest wall. There is a right subclavian central venous line with\n tip in the lower superior vena cava.\n\n IMPRESSION: Appearance of the lungs unchanged from 1 day prior. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862925, "text": " 4:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: LINE CHANGE\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n LINE CHANGE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n Heart is normal in size. Increasing opacification at the left base is noted.\n A right subclavian catheter is present terminating in the lower SVC. A right-\n sided chest tube is present as before. There is a fracture of the right\n second rib and both clavicles. A tracheostomy is present.\n\n IMPRESSION: Enlarging opacity at the left base.\n Fracture, right second rib and both clavicles.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "PERC PLCMT GASTROMY TUBE", "row_id": 862414, "text": " 1:26 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: G or GJ tube for enteral feedings. Note: could it be done\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with complex facial fractures, pre-op for fixation.\n REASON FOR THIS EXAMINATION:\n G or GJ tube for enteral feedings. Note: could it be done today? Patient\n will come to fluoro this PM for flex/ex. If not, Wednesday OK.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n HISTORY: This is a 33-year-old man with complex facial fractures.\n Preoperative for fixation. Needs feeding tube for perioperative period.\n\n RADIOLOGIST: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n CONSENT: After receiving explanation of the benefits and risks of the\n procedure, written informed consent was obtained from the patient's father.\n\n TECHNIQUE: The patient was placed supine on the fluoroscopy table. The\n anterior abdominal wall was prepared in a sterile fashion. The patient's\n previous CT scan was checked for localization of the stomach and its\n relationship with other abdominal organs. The anterolateral abdominal wall\n was prepared in a sterile fashion. Insufflation of the stomach through an\n orogastric tube, an 18-gauge needle was advanced under fluoroscopy into the\n stomach in order to deploy 2 T-fasteners. Fluoroscopy showed adequate\n deployment of the T-fasteners, and the stomach wall was anchored to the\n anterior abdominal wall. Under fluoroscopic guidance, access was gained to\n the stomach with the 18-gauge needle. Contrast injection was performed to\n confirm access into the stomach. A 0.035 Amplatz guidewire was advanced\n through the needle into the stomach. The needle was removed over the wire and\n the tract was dilated with 10 and 12 French dilators. Then, a 12-French\n Wills- gastrostomy tube was advanced into the stomach under\n fluoroscopic guidance. The wire was removed and contrast injection documented\n adequate position of the tube in the body of the stomach. The tube's pigtail\n was formed and locked. A final abdominal x-ray image was obtained documenting\n adequate position of the tube in the stomach. It was secured to the skin with\n an 0 silk stitch and a dressing was applied.\n\n COMPLICATIONS: There were no immediate complications.\n\n (Over)\n\n 1:26 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: G or GJ tube for enteral feedings. Note: could it be done\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful placement of a 12-French Will- gastrostomy\n tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862367, "text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ventilated patient, assess L PTX\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n ventilated patient, assess L PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old man with recent motor vehicle accident. Evaluate\n pneumothoraces.\n\n COMPARISON: ; chest CT, .\n\n SINGLE SUPINE PORTABLE AP VIEW OF THE CHEST: The right heart border and right\n hemidiaphragm are sharply outlined. The right chest tube, right central\n venous line, tracheostomy, and NG tube remain in place. The bilateral\n multiple rib fractures and bilateral clavicular fractures, as well as the\n subcutaneous air in the right thorax remain unchanged. There are residual\n bilateral small pleural effusions, not significantly changed.\n\n IMPRESSION: Hyperlucency around right heart border and right hemidiaphragm,\n which may represent a small pneumothorax in this supine view. Upright or right\n side up decubitus views may be helpful.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 863195, "text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CT removal\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n s/p CT removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old man with MVC, right pneumothorax. Chest tube\n removed.\n\n COMPARISON: CT scan, ; chest x-ray, .\n\n SINGLE SEMI-UPRIGHT PORTABLE AP VIEW OF THE CHEST: The right chest tube has\n been removed; and the tracheostomy tube, right central venous line, left-sided\n abdominal drain, and midline abdominal staples remain in place. A tiny\n lucency outlining the right heart border indicates tiny pneumomediastinum as\n seen on CT scan of two days prior. Left pleural effusion with bilateral lower\n lobe atelectasis is again seen. Otherwise, the examination is not\n significantly changed.\n\n IMPRESSION: Tiny pneumomediastinum on the right. Continued left pleural\n effusion and bilateral lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862958, "text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient with trauma, followup pneumothorax.\n\n There is no appreciable change in the appearance of the chest since the\n previous chest x-ray at 5:00 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 863041, "text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: vent dependence\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n vent dependence\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right-sided pneumothorax. Ventilator-dependent.\n\n Examination is limited due to incomplete imaging of the periphery of the right\n lung. A right-sided chest tube remains in place. The right heart border\n appears unusually sharp, suggesting the possibility of a medial right\n pneumothorax at the base, but this has not significantly changed.\n Tracheostomy tube and subclavian vascular catheter remain in satisfactory\n position. Cardiac and mediastinal contours are stable. A moderate-sized\n layering left pleural effusion is again demonstrated. Patchy opacities in the\n perihilar regions as well as more confluent opacity in the left retrocardiac\n region are unchanged as well. Numerous skeletal fractures are again\n visualized.\n\n IMPRESSION: Stable chest radiographic appearance. Questionable anterior and\n medial basilar right pneumothorax with chest tube remaining in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-19 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 863004, "text": " 3:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: ? recent G tube placed without insufflation (spiking fevers)\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n ? recent G tube placed without insufflation (spiking fevers), also look at left\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent G-tube placement without insufflation, now with spiking\n fevers.\n\n TECHNIQUE: Multidetector CT images of the chest, abdomen, and pelvis were\n obtained with oral and intravenous contrast.\n\n COMPARISON: torso CT.\n\n CHEST CT WITH IV CONTRAST: There is a laryngeal airway with tip at the\n thoracic inlet. A right subclavian central venous line is present with tip in\n the lower superior vena cava. The heart and great vessels are unremarkable.\n Subcutaneous gas and subpectoral gas is noted within the right chest wall,\n likely related to chest tube placement. There is a right chest tube which\n layers along the posterior aspect of the lung and terminates with tip at the\n right apex. Bilateral posterior atelectasis is present with collapse and\n consolidation noted at the left lung base. Mild consolidative changes are\n also present at the right lung base. Patchy opacities within the anterior\n right lung seen on the prior study have resolved in the interval. There are\n small bilateral pleural effusions, left greater than right. A tiny right\n pneumothorax is present, which has significantly decreased in size in\n comparison to the prior study. There is no left pneumothorax.\n\n ABDOMEN CT WITH IV CONTRAST: The posterior right lobe of the liver is\n markedly improved in appearance with several residual linear low attenuation\n defects. Evaluation of the posterior abdominal organs is slightly limited due\n to the streak artifact from the patient's arm at his side. The gallbladder,\n pancreas, spleen, adrenal glands, and left kidney are unremarkable. The right\n kidney is unchanged in appearance, with laceration through the upper pole. A\n gastrostomy tube is present which is coiled within the stomach. The stomach,\n small bowel, and large bowel are unremarkable. There is a small amount of\n free fluid within the abdomen. The amount of free fluid has decreased in\n comparison to the prior study. There is also a decreased amount of\n perinephric fluid. No loculated collections are identified. The abdominal\n vasculature is normally opacified.\n\n PELVIS CT WITH IV CONTRAST: The distal ureters, bladder, rectum, and pelvic\n loops of bowel are unremarkable. There is a small amount of free fluid within\n the pelvis. There is a tiny amount of free air tracking within the\n subcutaneous tissues along the right lower quadrant. This may have been due\n (Over)\n\n 3:53 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: ? recent G tube placed without insufflation (spiking fevers)\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to prior catheter placement or chest tube placement. There is no free air\n within the abdomen.\n\n The osseous structures are unchanged in appearance, with rib fractures,\n clavicular fractures, and right acetabular fracture.\n\n IMPRESSION:\n\n 1. Tiny residual right pneumothorax.\n\n 2. Bilateral lower lobe collapse and consolidation, concerning for\n aspiration. Pneumonia can not be excluded.\n\n 3. Liver laceration, improved in appearance from .\n\n 4. Stable right kidney upper pole laceration.\n\n 5. Gastric tube properly positioned within the stomach.\n\n 6. Small amount of intraperitoneal free fluid, decreased in amount in\n comparison to the prior study. No loculated collections or free air.\n\n 7. Unchanged clavicular, rib, and right acetabular fractures.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-30 00:00:00.000", "description": "MANDIBLE SERIES INCLUD PANOREX", "row_id": 864423, "text": " 6:29 PM\n MANDIBLE SERIES INCLUD PANOREX Clip # \n Reason: Please do pan scan of face (panorex) to evaluate facial frac\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with multiple facial fractures\n REASON FOR THIS EXAMINATION:\n Please do pan scan of face (panorex) to evaluate facial fractures\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old man with multiple facial fractures. No\n radiographs are available on PACs for comparison.\n\n MANDIBLE SERIES, 6 VIEWS: Innumerable fixation plates, screws, and wires are\n seen traversing the mandible, maxilla, and wall of the maxillary sinus. Also\n seen are skin staples over the calvarium. Fracture of the mandible at the\n angle on the right is well visualized\n\n" }, { "category": "Radiology", "chartdate": "2137-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 864221, "text": " 12:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt had a right sided picc line placed and needs tip confirma\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with ? aspiration pneumonia who needs picc\n line for 10 days of IV zosyn,pt has trach. and is on MRSA precautions.\n\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: 33-year-old, motor vehicle accident with possible aspiration\n pneumonia, assess PICC position.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH. COMPARISON: . Tracheostomy\n tube is in stable position. There has been interval placement of a right-\n sided PICC, which is clearly seen into the upper portion of the SVC. Below\n this, there is continuation of a curvilinear line, which is slightly smaller\n in caliber than the PICC and continues into the right atrium to the level of\n the tricuspid valve. There is improved aeration in the right mid lung zone. A\n left lower lobe oval opacity is unchanged in appearance. No new\n consolidations are seen. The osseous structures are unremarkable. A drainage\n catheter is seen in the upper portion of the abdomen.\n\n IMPRESSION: Right-sided PICC with indeterminate position of its tip. It is\n clearly seen into the upper portion of the SVC. However, the continuation of\n a curvilinear line into the distal portion of the right atrium may or may not\n be related to the PICC line. This was discussed with the IV staff at the\n completion of the study. Improved aeration in the right lung.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-24 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 863608, "text": " 11:07 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Please do facial CT with recons to eval left facial nerve\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man s/p MVC with multiple facial fractures\n REASON FOR THIS EXAMINATION:\n Please do facial CT with recons to eval left facial nerve\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: ? Left facial nerve compromise.\n\n Multiple CT scans without contrast of the facial structures with multiplanar\n reconstructions followed by non-contrast CT of the temporal bones again with\n multiplanar reformatted images.\n\n FINDINGS: The multiple facial fractures with operative reduction and fixation\n are again identified. The appearance is similar to the previous examination\n of . Again is noted some dislocation of the left mandibular condyle.\n There is no evidence of temporal bone fracture on either side. On the right\n side, the mastoid air cells are properly aerated are generally clear as is the\n middle ear space. On the left, there is soft tissue opacification of the\n mastoid and middle ear space. There is no evidence of ossicular disruption.\n The descending facial nerve canal does not appear unusual.\n\n IMPRESSION: No definite evidence of bony abnormality to cause impingement\n upon the facial nerve. There is increased soft tissue within the left middle\n ear space and mastoid. The multiple facial mandibular fractures remain as\n before.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-12 00:00:00.000", "description": "Report", "row_id": 1356861, "text": "TSICU NPN (0700-1900)\n(Continued)\n\n\nSKIN...Large lacerations to lip and chin irrigated, debrided, and sutured per PLS team. Bacitracin applied. Laceration to posterior head stapled per Dr. . Multiple abrasions to R face and inside ears--oozing serosang drg. Gross amt of facial edema. Oozing serosang drg from L nare. Trach site with large vertical incision--oozing moderate amts of serosang drg. Xerform dsg reapplied. Dsg to midline incision intact. Lac to upper L leg cleaned with saline--W-T-D dsg applied. Backside with no breakdown noted.\n\nSOCIAL... mom and father in for visit. Updated on pt's injuries and plan of care.\n\nPLAN...Continue serial neuro exams. Monitor ICP's and CPP's. Follow ABG's/lactate. HCT Q6hrs. Replete lytes accordingly. Needs TLS, CT pelvis tomorrow. Per PLS--fixation of multiple facial fx's once swelling subsides. Per ortho---fixation of L arm and acetabular fx's once pt more stable.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-13 00:00:00.000", "description": "Report", "row_id": 1356862, "text": "NPN 7p-7a\n\n\n pt on fentanyl and propofol gtt. responds well, following commands during wake up assesment. opens eyes to voice, sqeeze and release grasp. able to show 2 fingers. localizes pain, purposful mvnt. moves left side and right lower extremity well. no movement noted in right upper ext. PERL 2 brisk GCS . ICP via bolt . cpp 60's. sclara edematous. lacralube used. -J collar in place. tls films not yet taken. cont to log roll pt.\n\nCV- Nsr rate 60's -80's b/p 120-130. CE cpk 2937 ck 26 tropi.13 Heart sounds S1S2 no murmurs or rubs noted. +peripheral pulses all 4 ext. cont facial, arms, and right upper thigh edema. p-boots on. anticoag therapy addressed with team. will discuss on rounds.\n\nResp- trach #8 portex. cont on vent. SiMV 26/50%/550/peep 12. ABG 7.47/36/11/2 lung sounds clear. bilat pneumo. left to be followed by serial CXR. right CT to 20cm wall sx. no leak noted. crepitis marked around insertion site.\n\nRenal- foley draining amber, clear urine progressivly darker. CPK 2937, u/o avg 50cc/hr. urine myoglobin sent. IVF LR 150/hr. BUN14 creat 1.1 lytes checked k, mag, and ca replaced through out night. CVP 9-10. LA 2.7\n\nGI- abd soft hypo bs. no stool. OG output from dark red to bilious. 50cc this shift. on pepcid IV.\n\nEndo- bs 110-115 no coverage needed.\n\nID- Wbc down to 14.2 pt afebrile. cont on cefazolin iv q8hrs. no results from pan cx.\n\nHeme- H/H down slightly to 36.8/12.9 plat 122, pt 14.8 INR 1.4 fibrinogen 490 md aware no replacement at this time will dicuss with team at rounds.\n\nSkin- facial lacs sutured. cleansed and bacitracin applied. face edematous. cont oozing from left nare and left ear. scant s/s drain from post head lac. lac staples OTA. bruising noted to left neck and shoulder, right lower and upper leg new md notified will dicuss with team on rounds for possible x_ray. wet-dry dsg left thigh. right arm splinted due to radial fx.\n\nsocial- mother in waiting area. brother in to visit. good understanding of event and POC\n\nPlan- serial CXR to eval left pneumo. monitor for rabdo.check urine myoglobin, cont to monitor ICP,lytes, and neuro status. TLS films to be done this am.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-13 00:00:00.000", "description": "Report", "row_id": 1356863, "text": "Resp Care: Pt continues trached and on ventilatory support with simv, no vent changes overnoc maintaining acceptable abg; bs coarse to clear, sxn thick bloody secretions, no rsbi measured d/t apnea, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-13 00:00:00.000", "description": "Report", "row_id": 1356864, "text": "Resp. Care Note\nPt remains trahced with #8 portex and vented on settings as charted on resp flowsheet. ABG's with slight resp alkalosis, so rate decreased form 26-20. Peep also decreased from with adequate oxygenation. sxn for thick bloody secretions. cont current support.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-21 00:00:00.000", "description": "Report", "row_id": 1356896, "text": "Respiratory Care Note\nPt received on CPAP + PS. Pt placed on 50% trach mask this morning as noted. Pt tolerated well. Pt sx'd for small amt of brown thin secretions. Pt placed back on CPAP + PS to rest overnight.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-22 00:00:00.000", "description": "Report", "row_id": 1356897, "text": "ROS:\n\nNeuro: Alert, follows simple commands. Fentanly gtt for pain and ativan 1 mg given x's 1 for restlessness.\n\nCV: RSR w/o ectopy. Has right subclavian MML w/cvp= 5 or <. Has right pedal ABP line. P boots and sub q heparin for dvt prophylaxis. Peripheral pulses palpable w/ease. HTN w/SBP up to 180s at times. ? relation ship to pain, fentanyl gtt ^ to see if pain related HTN. On metoprolol , dose ^ to 50 mg.\n\nResp: Trached and on vent CPAP+PS. See RT's note below.\n\nGI: PEG tube w/impact w/fiber infusin at goal at 90cc/hr w/minimal residuals. Abd soft w/active BS thoughout. Mushroom cath inplace for liq stool management. On Reglan d/t high TF residuals yesterday. H2 blocker prophylacticly.\n\nGU: Foley patent drainin clear amber urine.\n\nEndo: FSG not requiring coverage w/RSSI.\n\nChem: K 3.6, repleted w/20 kcl.\n\nSocial: No contact from family at this up to this point.\n\nPlan: Trach mask. Mobilize. PT\n" }, { "category": "Nursing/other", "chartdate": "2137-05-22 00:00:00.000", "description": "Report", "row_id": 1356898, "text": "Resp: pt on psv 12/5/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateal viscular bs. Suctioned for small amounts of thick brown secretions. AM ABG's 7.42/47/88/32. RSBI=54. Plan to place on t/c trials today as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-22 00:00:00.000", "description": "Report", "row_id": 1356899, "text": "TSICU NPN (0700-1900)\nREVIEW of SYSTEMS:\n\nNeuro...Alert, more interactive, following commands, seems appropriate. Communicates via nodding and writing. Confused about events and situation--needs reminding and reorienting to why he is in the hospital. Seems frustrated at times with situation(jaws wired shut, unable to get up to bathroom.) Brief periods of mild anxiety, restlessness noted--usually when needs to go to bathroom. Haldol given x1. Fentanyl drip dc'd. Started on fentanyl patch-100mcg. Pt c/o H/A occasionally, but no acute pain. OOB to chair for 3hours. PT worked with pt.\n\nCV....NSR with no ectopy noted. HR 80's to low 100's. BP remains mildly elevated despite lopressor 50mg . Running 140-170's/60-70's. R pedal arterial line very dampened/positional--still draws back. Running noninvasive cuff. Easily palpable peripheral pulses.\n\nRESP...Trach mask at 50% since 0800. Tolerating very well with RR in 20's and sats >98%. Lung fields clear with mildly diminished bases. Strong cough--able to expectorate most of secretions. Suctioned x3 for thick, tan secretions. Old R CT site with dsg intact.\n\nGI...Impact with fiber TF's at goal of 90cc/hr via g-tube. Minimal residuals. Abd soft with active BS. Reglan Q6hrs due to high residuals in the past. Pepcid coverage. Soft, brown BM x3 today.\n\nGU...Foley to gravity with adequate urine output. K+ repleted.\n\nENDO...No coverge needed per RISS.\n\nID...Tmax 99.0 axillary. All abx dc'd. Started on kefzol coverage only.\n\nHEME....Heparin dc'd. Started on lovenox. IVC filter in place. Pneumoboots on.\n\nSKIN....Multiple healing abrasions to face/lower ext. Incision to head with staples intact--no drg, healing well. Incision under jaw well approximated. Small area mid incision line with yellowish to serous drg. Trach site mildly reddened. Temporary sutures at g-tube site dc'd per Dr. . Jaw J/P dc'd per OMS. JP to head remains in place to gravity with scant serosang drg. Backside intact, no breakdown noted.\n\nSOCIAL.... mom and dad in throughout the day. Visited per case management. to come evalutate tomorrow.\n\nPLAN...Trach collar throughout the night if pt tolerates. Pulmonary toilet. Assess for comfort--PRN pain meds as needed. Move toward rehab screening and placement.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-22 00:00:00.000", "description": "Report", "row_id": 1356900, "text": "Respiratory Care Note\nPt received on CPAP + PS. Pt placed on trach mask at 7:30am - pt tolerating well. Plan to remain on trach mask as tolerated overnight.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-13 00:00:00.000", "description": "Report", "row_id": 1356865, "text": "\nNPN: ROS (see carevue for details)\n\nevents: bolt discontinued today by neurosurgery, site sutured, DSD placed, no drainage noted. T&L films done today, results pending. IVF changed to NS @ 200cc/hr for ?Rhabdomylosis, urine myoglobin sent yesterday, results pending.\n\nneuro: patient sedated on propofol and fentanyl, tries to open eyes, but due to swelling only able to open right eye, when lightened patient follows commands, squeezes hands, moves all extremities, right fingers move, but less than other extremities and weaker. PERLA, purposeful movements, strong cough, weak gag, +corneals\n\nCV: HR 70s-80s, SR, no ectopy noted, BP 120s-140s, CVP8-12, enzymes as in carevue, lytes repleted as ordered, p-boots on, ?start sq heparin\n\nRESP: LS coarse, diminished at bases, suctioned frequently for thick bloody secretions, strong cough, O2 sat above 97% t/o day, vent settings as noted in carevue, abg adequate\n\nGI: TF started via OGT, no residual, increased to 40cc/hr, ABD softly distended, +hypo active bowel sounds, pepcid\n\nGU: foley catheter with large amount of u/o, clear yellow.\n\nSKIN: multiple abrasion to extremities and face. facial lacs sutured by plastics yesterday, antibiotic ointment applied, right arm in splint, left ear with lac oozing s/s fluid, nose oozing bloody drainage,\n\nSOCIAL: family at bedside off and on all day, parents supportive, appropriately concerned. updated on plan/prognosis, support given.\n\nPLAN: wean vent as tolerated, OR wednesday for right arm, ?plastic/OMF plan for facial bone reconstruction, maintain comfort, monitor and support\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-14 00:00:00.000", "description": "Report", "row_id": 1356866, "text": "T-SICU NPN 1900-0700\nSee careview for details.\nROS:\n\nNeuro: sedated on propofol and fentanyl gtts. Attempts to open eyes to command, unable d/t edema. Purposeful movement of LUE, and BLE's, no movement noted of RUE. Follows commands inconsistently. Pupils 3mm, equal and reactive. +corneals, gag and cough. TLS films done yesterday, awaiting formal results. Logroll/c-spine precautions maintained at all times.\n\nCV: HR 70-80's SR, no ectopy noted. BP 120-130's/50-60's, CVP 7-10. Skin warm, dry. Pedal pulses easily palpable. sc heparin and PB's for DVT prophylaxis.\n\nHeme: hct 33.4-> 31.6->30.9; Dr. aware, cont. to follow q8hrs.\n\nResp: LS coarse, clears with suctioning, diminished at bases. Suctioned via ett and orally for sm->moderate amts. thick bloody secretions. Trach site with vertical incision with sm. amts. bloody drainage. Vent settings: AC 550x18/5 PEEP/40%, ABG 7.43/42/112/29/2. See careview for specific data/resp. notes. R CT to sxn with sm. amt. serosang. drainage, dsg intact.\n\nGI: abd soft, BS present, no flatus/BM. Impact with fiber at goal 70cc/hr with scant residuals via OGT. Pepcid for GI prophylaxis.\n\nGU: foley patent draining 100-200cc/hr yellow urine. Lytes repleted as ordered.\n\nEndo: BS 108->139, covered per SS.\n\nID: tmax 101.0; wbc 12.4. Conts. clinda as ordered, tyelnol given x1 and no cultures per Dr. at this time.\n\nSkin: back/buttocks intact; bilat. knee abrasions red/pink, no drainage OTA. Multiple facial abrasions with diminished drainage, bacitracin applied. L ear with moderate amt. bloody drainage. See carevue for details. Midline abd incision with staples intact, primary dsg intact, no staining/drainage noted. R forearm splint intact.\n\nPsych/social: pt's mother, father and uncle in to visit last eve. Mother phoned x1 and this am, affect/questions appropriate; update provided. Plans to visit later this afternoon.\n\nA: s/p mvc with multiple facial fx's, bilat. clavicle fx's, bilat. pulmonary contusions, bilat. pneumos R>L, rib fx's, R acetabular fx, sm. retroperitoneal bleed, kidney and liver lac, awaiting OR for R radial fx\n\nP: Monitor VS, I/O, labs->hct q8hrs. Aggressive pulmonary hygiene. Maintain logroll/c-spine precautions-> await final film read this am. Maintain sedation/comfort. Continue ongoing comfort/support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-23 00:00:00.000", "description": "Report", "row_id": 1356901, "text": "TSICU Nursing Progress Note\nNeuro - Pt sleeping most of shift. When awake, pt appears oriented, appropriate. Mouths words, nods appropriately to questions. Occ restless, pulling off oxygen, attempting to get OOB - calms when re-oriented.\n\nCV - SR 80s - 100s without ectopy. Arterial line dampened at times, following cuff pressure. Electrolytes WNL. Enoxeparin and pneumoboots for DVT prophylaxis.\n\nResp - Continues to tolerate trach collar. O2 sat > 97% on 50% trach collar. O2 sat 94 - 96% on room air. Strong productive cough. Suctioned x2 for minimal amt thick tan secretions.\n\nGI - Tolerating Impact with fiber at 90 cc/hour (goal) with no residual. Soft brown stool x2. Pepcid for GI prophylaxis.\n\nGU - Brisk uop via foley. Started on Ditropan for bladder spasms.\n\nEndocrine - No coverage needed per RISS.\n\nSocial - no contact with family.\n\nA - Becoming more alert. Continues to tolerate trach collar. Restless at times.\n\nP - Continue to monitor resp status. Reorient as needed. Consider transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-19 00:00:00.000", "description": "Report", "row_id": 1356886, "text": "TSICU NPN 7A-7P:\n\nWRITTEN AT 2PM--WILL ADDEND AS NEEDED.\n\nEVENTS: BRONCH DONE-LARGE AMOUNT BLOODY TISSUE/CLOTS NOTED. SENT FOR CULTURE AND CELL COUNTS. PLAN FOR CT THIS AFTERNOON OF TORSO. OFF SEDATION THIS AFTERNOON TO ASSESS NEURO STATUS. FAMILY IN AT THE TIME. INITIALLY PT AND FAMILY ALL VERY ANXIOUS. SUPPORT GIVEN AND PT . MULTIPLE AUNT/UNCLES AND IN. REMAINS FEBRILE. CULTURES PENDING. DRAIN #1 WITH COAG NEGATIVE STAPH--?CONTAMINENT.\n\nNEURO: WHEN COMPLETELY OFF SEDATION: OPENS RIGHT EYE (LEFT ONE SUTURED). FOCUSES ON SPEAKER. MAE WEAKLY BUT PURPOSEFULLY. NO FINGER MOVEMENT ON RIGHT ARM. INTERMITTENTLY FOLLOWS COMMANDS, NODS. C COLLAR REMAINS ON. HOB ELEVATED FOR SWELLING. PROPFOL AND FENTANYL GTTS AS NEEDED.\n\nCV: SR/ST WITH AGITATION. BP STABLE. MAP PF A LINE CORRELLATES WITH NBP. LARGE AMOUNT FLING FROM RIGHT PEDAL A LINE. PALP DP AND PT BILAT. LARGE AMOUNT FAIAL SWELLING PERSISTS.\n\nRESP; TRACH MIDLINE AND SECURE. PLACED BACK ON CPAP/PSV. PT MORE RESTFUL ON THIS SETTING. 50% FIO2. PEEP 5 PSV 12. RR UP TO 30S WHEN MOVING OR AGITATED. SATS 95-98%. NO EVIDENCE OF RESP DISTRESS. BLOODY SECRETIONS PERSIST.\n\nGI: ABDOMEN DISTENDED, SOFT. + HYPOACTIVE BOWEL SOUNDS. +SMEAR SOFT BROWN STOOL. IMPACT WITH FIBER GOAL INCREASED TO 85. TUBE FEEDS OFF AT 12N: PLAN FOR CT ABDOMEN WITH NEED FOR PO CONTRAST. RESIDUAL 190CC--NOT REFED. WILL RESTART AFTER CT SCAN. ASSESSING G TUBE PLACEMENT/?PERF ON CT. PEG SITE BENIGN WITH DSD IN PLACE. MIDLINE INCISION CLEAN AND DRY WITH STAPLES INTACT.\n\nGU: FOLEY WITH CLEAR YELLOW URINE.\n\nENDO: COVERAGE WITH RISS.\n\nID: TEMPS PERSIST DESPITE TYLENOL, ICE PACKS. + CULTURE FROM DRAIN #1 ON --STAPH COAG NEG. OTHER CULTURES AND CENTRAL LINE TIP FROM PENDING.\n\nSKIN: SEE CAREVUE FOR SPECIFICS. HEAD DRESSING WITH XEROFORM. SEVERAL STAPLED AREAS CLEAN AND DRY. NECK DRESSING SOILED, INTACT--WILL ADDRESS WITH OMFS WHEN HERE. 2 JP DRAINS--#1 TO GRAVITY, #2 TO BULB SUCTION. BOTH WITH CLEAR HEMOSEROUS DRAINAGE. R ARM SPLINTED. GOOD CSMS. LEFT ARM WITH 2 CLEARLY DEMARKATED ARES--PALE AND MOTTLED. ALL TEAMS AWARE. NO CHANGE IN POC AT THIS TIME. HOB ELEVATED. MOIST HEAT TO JAWS Q2 HOURS FOR APPROX 20 MIN AT A TIME.\n\nPLAN: CT SCAN. VENT WEAN. LIGHTEN SEDATION. FOLLOW NEURO EXAM. FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-19 00:00:00.000", "description": "Report", "row_id": 1356887, "text": "Resp Care\n\nPt remained on cpap/psv during the shift with 12 of pressure support. MV in the 9L range with tv's in the mid 500's. Pt had bronch today and revealing thick apparent old blood or tissure. Sent to path. Traveled to ct-scan for chest for possible source of infection\n" }, { "category": "Nursing/other", "chartdate": "2137-05-19 00:00:00.000", "description": "Report", "row_id": 1356888, "text": "NPN ADDENDUM.\n\nTOLERATED CT SCAN WELL. G TUBE TO GRAVITY BRIEFY, THEN TUBE FEEDS RESTARTED AT 70CC/HOUR. GOAL IS 85/HOUR. REMAINS OFF PROPOFOL. ATIVAN 1MG IV X2 DOSES FOR CT SCAN. TOLERATED WELL. CONTINUES ON FENTANYL GTT. OPENS EYE TO VERBAL CUES, CALM WITH CARE. WARM PACKS TO FACE.\n\nPLAN: CONTINUE WITH PLAN OF CARE. IVC FILTER SCHEDULED TOMORROW. NPO AFTER MIDNIGHT. FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-20 00:00:00.000", "description": "Report", "row_id": 1356889, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems:\nNeuro: remains on fentanyl gtt, increased as pt. nodded he was having pain with mouth care and other procedures. Receiving intermittent doses of ativan, 2 given per g tube and one iv when pt. was npo. Moves all extremtities purposefully. Does not appear to moving r fingers but has gross movement of his arm. At times gets very restless and begins to pull at tubes. L hand restrained. Cervical collar in place.\nCVS: stable. BP somewhat elevated when pt. agitated. Pulses present\nRESP: suctioned for old bloody secretions, R sided chest tube with minimal drainage. Small amount of crepitus in R side of chest. Decreased breath sounds in lower lobes. Trach with small amount foul drainage around it. Remains on psv 12, 50%, 8 peep with adequate abg.\nRENAL: lytes repleted. Urine output brisk. Weight today 82.0 kg.\nGI: belly somewhat firm. +bowel sounds. Liquid stool, currently being managed with mushroom catheter. Sent for cdiff. Tube feedings held after 2am for impending ivc placement today.\nHeme: hct stable at 25. Inr 1.1, pneumo boots and sq heparin in use. To have ivc filter placed today.\nID: continues to be febrile despite fan cooling and tylenol. WBC up to 12.8. On vancomycin, levofloxacin, ceftriaxone. One set of blood cultures sent per house officer. Sputum showing two gram neg organisms. Two blood cultures positive for gram + from . Other cultures still pending.\nSKIN: warm moist heat placed to facial area. L side of face more swollen than R. L eye suture very tight and may be causing a pressure area on eyelid. Head incision covered with xeroform. Chin incision with original dsg on. Mouth....used chlorohexadine rinse q 8 hours. Mouth is very tender. Abdominal incision approximated and no drainage.\nLINES: RSC line patent, R pedal art line in place.\nSocial: Mom called last eve for update.\nP: IVC filter today, then restart tube feeding. Continue excellent skin care and pulmonary care. support family emotionally and with information.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-20 00:00:00.000", "description": "Report", "row_id": 1356890, "text": "Respiratory Care:\nPatient remains on ventilatory support (CPAP/PSV) with no parameter changes made throughout the night. Morning abg results revealed a partially compensated metabolic alkalemia with excellent oxygenation on the current settings. No RSBI determined due to level of consciousness.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-20 00:00:00.000", "description": "Report", "row_id": 1356891, "text": "Respiratory Care Note\nPt remains on CPAP + PS. PEEP weaned tolerated well - volumes in the 600-700 range. Pt transported to cardiac cath for umbrella placement.\nPlan to remain on current suppoort as noted - wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-20 00:00:00.000", "description": "Report", "row_id": 1356892, "text": "TSICU NPN 7A-7P:\n\nEVENTS: IVC FILTER PLACED. PT TOLERATED PROCEDURE WELL. RIGHT GROIN SITE AND PULSES BENIGN. MORE APPROPRIATE WITH CARE. OOB TO CHAIR X 3 HOURS THIS AM--TOLERATED WELL. CONTINUES TO STOOL. RESTARTED TUBE FEEDS. FAMILY IN THROUGHOUT THE DAY.\n\nNEURO: ALERT AT TIMES. NODDING IN ANSWER TO SOME QUESTIONS. FOLLOWS COMMANDS INTERMITTENTLY. PERL. LEFT EYE NO LONGER SUTURED, REMAINS VERY SWOLLEN AND PT CANNOT OPEN IT HIMSELF. MAE WEAKLY, PURPOSEFULLY. NO RIGHT FINGER MOVEMENT NOTED. O.T. IN TO CREATE SPLINT FOR PT--TO WEAR CONSTANTLY, OFF FOR ONE HOUR TID TO INSPECT SKIN. VERY IMPORTANT TO KEEP PT'S FINGERS FLAT--STARTING TO DEVELOP SOME CONTRACTURE. C COLLAR ON--MEDIUM WITH GOOD FIT. FENTANYL GTT AT 150MCG/HOUR. ATIVAN 1MG IV Q2-4 HOURS WITH GOOD EFFECT.\n\nCV: SR WITH NO ECTOPY. ST WITH AGITATION. BP HYPERTENSIVE WHEN AWAKE. PALP DP AND PT BILAT. SKIN WARM AND DRY, PINK.\n\nRESP: TRACH MIDLINE AND SECURE. TRACH CARE DONE 1530. LUNG SOUNDS CLEAR. SUCTIONING SMALL AMOUNTS BROWN/OLD BLOOD TINGED SECRETIONS. ON CPAP5/PSV12. NO EVIDENCE OF DISTRESS ON CURRENT SETTINGS.\n\nGI: ABDOMEN DISTENDED, SLIGHTLY FIRM. + BOWEL SOUNDS. NAUSEA/VOMITING X1--BILIOUS FLUID NOTED. ORAL CARE DONE. PT SITTING UP AT THE TIME AND SPIT OUT THE VOMIT. ANZAMET GIVEN WITH EFFECT. TUBE FEEDS RESTARTED POST IVC FILTER PLACEMENT AT 70CC/HOUR. HIS GOAL IS 85 PER ORDER. WILL FOLLOW RESIDUALS. CONSTANT LIQUID BROWN STOOL MANAGED WITH MUSHROOM CATHETER.\n\nGU: FOLEY WITH CLEAR YELLOW URINE. BRISK AUTODIURESIS.\n\nENDO: COVERAGE WITH RISS AS INDICATED.\n\nID: LOW GRADE TEMPS PERSIST. TRENDING AXILLARY TEMPS. CONTINUES ON LEVOQUIN, VANCO AND ROCEPHIN.\n\nHEME: SQ HEPARIN. IVC FILTER. PNEUMO BOOTS.\n\nSKIN: NECK INCISION WITH SUTURES CLEAN AND DRY. BACITRACIN AND TELFA DRESSING APPLIED. HEAD INCISION WITH STAPLES. NO DRAINAGE. ATTEMPTING TO KEEP XEROFORM DRESSING IN PLACE. OLD HELAING ABRASIONS ON LEFT LEG. FACIAL EDEMA PERSISTS, ESP. LEFT SIDE. PT DOES NOT TOLERATE WARM PACKS NOW THAT HE IS MORE AWAKE. RIGHT ARM INCISION CLEAN AND DRY. OT SPLINT IN PLACE. LEFT ARM WITH 2 CLEARLY DEFINED MOTTLED/PALE AREAS. SAME TEMP AS SURROUNDING SKIN. NO CHANGE OVER THE PAST 3 DAYS. CONTINUE TO FOLLOW. BACK IS INTACT WITH NO AREAS OF PRESSURE OR BREAKDOWN. ABDOMINAL INCISION OPEN TO AIR. PEG SITE WITH DSD IN PLACE. ****SUTURES NEED TO COME OUT IN NEXT FEW DAYS****. FACIAL LACS HEALING. CHIN AREA WITH NITROPASTE PER DR. TO DECREASED DUSKINESS OF AREA. BACITRACIN TO INCISION LINES.\n\nSOCIAL: PT'S PARENTS IN ALL DAY. PT INTERMITTENTLY AWAKE AND SOMEWHAT INTERACTIVE WITH THEM. TEACHING DONE ON IMPORTANCE OF LETTING PT SLEEP, AND NOT WAKENING HIM IN ORDER TO VISIT WITH THEM. RECEPTIVE TO SUGGESTIONS. CONTINUE TO FIELD MULTIPLE APPROPRIATE QUESTIONS. PROVIDING SUPPORT.\n\nPLAN: CONTINUE WITH WEAN FROM VENT. ONGOING PAIN CONTROL/SEDATION AS NEEDED. CONTINUE AGGRESSIVE SKIN CARE. ONGOING OPEN COMMUNICATION WITH FAMILY. OOB TO CHAIR.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-21 00:00:00.000", "description": "Report", "row_id": 1356893, "text": "Resp: pt on psv 12/5/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear apecies with diminished RS. Aeration noted by am. Suctioned moderate amounts of thick brown secretions. RSBI=36 although had to terminated due to ^ bp to 190. AM ABG's 7.44/45/124/32. Will continue to wean appropriately.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-21 00:00:00.000", "description": "Report", "row_id": 1356894, "text": "t-sicu nasg note:\nneuro- pt remains on fentanyl gtt @150mcg//hr for pain controll, occ ativan for restlessness, pulling at tubes, throwing legs over siderail unable to calm pt w/ orientation, @6am pt nodding approp and following commands, mae's w/ gd strength, perrla 3-4mm.\n\nresp- bs cta, sux for min amts thick old bldy secretions, sao2 93-98%, abg wnl, settings 50% 5peep and 12ps, rr 10-16 vt600-900.\n\ncvs- tm 100.3ax, sbp 140's-150's/70's, hr 98-118 ns no ectopy,cvp 8-10, ca++ repleted, hct 24, vanco trough pnd.\n\ngi- tf held since mn d/t high residuals, residuals checked q2h and remained >100cc, reglan therapy initiated, cont to have sm amt liquid brown stool via mushroom cath, +bs. intact.\n\ngu- diuresing gd amts of clear, amber urine via foley.\n\nskin- head w/ staple line intact, attempt made to keep covered w/ xeroform, trach site w/ brownish drainage, ^ w/ coughing and neck movement. chin lac w/ ntg ointment as ordered, lip lac w/ bacitracin, l eye rx w/ lacrilube, abd incision aproximated, cd+i. l arm w/ blotches purple/red, warm to touch, r fem groin site c+d,+ pulses. jp drains intact.\n\nendo- no riss required.\n\nsocial- very supportive family\n\na: pt w/ inc restlessness, improved toward am.\n\nP: monitor cvs/nvs per routine, follow labs as ordered, monitor drain outputs, cont reglan and follow gi status, maintain pulm hygiene, cont rom to l arm as ordered.\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-21 00:00:00.000", "description": "Report", "row_id": 1356895, "text": "T-SICU NPN 0700-1900\nEvents: facial CT done this afternoon. C-collar dc'd per Dr. . Weaned to trach mask, tol. well. OOB to chair x3hrs this am.\nSee carevue for specifics.\n\nNeuro: Alert, sleeping on/off in afternoon; conts. fentanyl gtt for pain with adequate control per pt. Follows commands, MAE's. Improved movement noted of RUE, able to wiggle fingers; splint changed by OT to allow improved finger movement. Pupils 3mm, equal and reactive. Pt nods yes/no to simple questions, appropriately on/off. Restless at times, 0.5mg ativan IV with (+) effect.\n\nCV: HR 89-110's ST, no ectopy noted. NIBP 140-160's/60-80's, pedal 160-180's/60-70's. CVP 3-8. Skin warm, dry. Pedal pulses easily palpable. Started on 25mg po lopressor via G-tube today.\nHeme; hct 24\n\nResp: LS coarse, clears with suctioning; tol. trach mask most of day, placed back on vent at 1700 to rest . Expectorating mod. amts. thick blood tinged sputum. RR teens to 20, O2sats 95-100%on 50% trach mask. See carevue for labs/resp. notes.\n\nGI: abd soft, NT/D, BS present. Impact with fiber at goal 90cc/hr with scant residuals via G-tube; site wnl, cotton/sutures to be removed tomorrow. Conts. reglan as ordered. Mushroom catheter draining sm. amts. liquid brown stool, spec sent for c-diff per team request. Pepcid for GI prophylaxis.\n\nGU: foley patent draining amber/yellow urine with occ sediment 100+cc/hr. Lytes sent, awaiting results.\n\nEndo: BS 120, no coverage per SS.\n\nID: tmax 100.6ax; wbc 15.7; conts. levofloxacin/vanco/ceftriaxone as ordered.\n\nSkin: back/buttocks intact. Multiple facial/BLE lacs slowly improving. Head staples with no drainage, OTA, to be cleansed with peroxide qd. JP #2 to bulb drainage and #1 to drainage bag, both with scant serosang. output. R fem. site with transparent dsg, C/D/I, no heamtoma noted. Trach site with mod. amt. brown/yellow drainage, dsgs changed multiple times. L eye swelling slowly improving; mod. amt. serous drainage. CHlorhexidine mouth care as ordered. R arm splint changed as noted above, skin intact, no redness or breakdown noted.\n\nPsych/social: pt's mother and father in to visit, affect/questions appropriate; left in afternoon for few hours to allow pt time to rest.\n\nA: tol. vent wean, hemodynamically stable\n\nP: Monitor VS, I/O, labs/cultures. Continue aggressive pulmonary hygiene/skin care. Increase activity as tolerated. Encourage ROM/activity as per OT. Continue ongoing comfort/support to pt and family. Case management aware of need for rehab screen.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-12 00:00:00.000", "description": "Report", "row_id": 1356858, "text": "ADMIT NOTE\nMVC HIGH SPEED ROLLOVER ? HIT TREE. BLUNT CHEST, FACE AND ABD TRAUMA. UNSTABLE MANDIBLE, GCS 3 WAS MOVING UPPER EXT AT SCENE. COMBIVENT PLACED IN FIELD, UNABLE TO INTUBATE IN ED. PT TAKEN EMERGENTLY TO OR FOR TRACH, EXP LAP, AND BOLT.\n\n PT TO ALL STIMULI. GCS REMAINS 3 PUPILS 2 RIGHT UNREACTIVE LEFT SLUGGISH. ICP 26-38 MANITOL 50MG GIVEN AT 38. TEMP WAS 33.3 C BEAR HUGGER PLACED TO WARM POST SURGERY PRIOR TO CT. TEMP UP TO 96 F. PT TO CT FOR HEAD, FACIAL,C-SPINE, AND CHEST. CT PT NOTED TO MOVE LEFT ARM ONLY POSTURING TO PAIN.\n\nCV- HYPERTENSIVE AT TIMES. HR 80'S. DOWN TO 63 IN CT. UNABLE TO HEAR HEART SOUND DUE TO COARSE LOUD RONCHI LUNG SOUNDS. +PERIPHERAL PULSES. SKIN NOW WARM AND PINK\n\nRESP- TRACH #8 PORTEX, BLOODY SECREATIONS. BILAT CONTUSIONS SMALL RIGHT PNUEMO. CT PLACED UPON RETURN TO UNIT.\n\nINJURIES- R PNUEMO, LAFORT 3, R RIB FX, BILAT CLAVICAL FX, RETROPERITONEAL BLEED, SCALP,LIP,CHIN, LEFT KNEE LACS.\n\nSOCIAL- PARENTS IN WAITING ROOM. SPOKE WITH MD . HAS BEEN IN TO SEE PT AND UPDATED ON CONDITION.\n\nPLAN- CONT TO MONITOR ICP, ASSESS EXTENT OF INJURIES.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-12 00:00:00.000", "description": "Report", "row_id": 1356859, "text": "Resp. care note - Pt. remaines trached and vented, transffered to CT and back to TSICU without incident,bs clear.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-12 00:00:00.000", "description": "Report", "row_id": 1356860, "text": "TSICU NPN (0700-1900)\nEVENTS:\n\n**Head, chest, abdominal CT completed at 0745.\nINJURIES KNOWN at this time--->>\n -Leforte III fx\n -Chin, lip and forehead lacerations--sutured per PLS\n -Laceration posterior cranium--stapled per Dr. \n clavical fx\n -Rib fx's\n -Bilateral pulmonary contusions\n -Bilateral pneumothorax----R>L--Anterior CT placed on R side upon returning from CT this am. Moderate amt of serosang drg. Following L pneumo with serial CXR's.\n -Liver laceration\n -Kidney laceration\n -Posterior acetabulum fx--needs fixation per ortho at later time.\n -R radius fx--ortho to see and determine treatment\n -Multiple scattered abrasions--face, chest, belly, legs\n -EXP lap--small retroperitoneal bleed.\n\nREVIEW of SYSTEMS:\n\nNeuro...ICP's initially high this am. Once adequately sedated with fentanyl/propofol and CO2 decreased from 60 to normal range, ICP's down to 10-18. Titrating fentanyl and propfol drips to keep sedated but have adequate BP--see careview for ranges. CPP's 60's--DR. spoke with NSU team about low CPP's. Did not want any further intervention. Pupils bilaterally and reactive. Sclera very edematous. When light, opens eyes to voice and follows simple commands(show two fingers, squeeze hands.) Moves L arm and BLE well--lifts and holds. R arm minimal to no movement seen. MD's aware(thought to be d/t clavicle and arm fx.) Movements are purposeful. Field collar changed to J. Remains on logroll precautions--needs dedicated TLS films tomorrow.\n\nCV....NSR with no ectopy noted. HR 80's to low 90's. BP stable--MAP's 60-80's. Troponin initially elevated to .3---MD's feel probably due to ?cardiac contusion. EKG done--NSR. Troponin down to .2 this afternoon. New R SC TLC placed per DR. confirmed via CXR. CVP transduced--ranging . IVF's changed to LR at 150cc/hr.\n\nRESP....Multiple vent changes made in beginning of shift to lower CO2.\nCurrently on A/C 550x26 peep of 12 with FiO2 weaned to 50% now. Last ABG 7.40/45/87/1/29. Per NSU goal CO2 35-40. Notified Dr. of elevated CO2--no new vent changes ordered. Lung fields clear to auscultation. Suctioning small to moderate amts of thick, blood tinged secretions. R anterior CT to 20cm suction with approx. 400cc output since put in. Noted new crepitus around site on 1600 assessment. Dr. aware. Dsg c/d/i. Lactate elevated, but stable. Occasional fluid boluses.\n\nGI....Abd soft with absent BS. OGT to LWS with scant bloody drg. Placement confirmed via x-ray. Pepcid coverage.\n\nGU...Adequate clear yellow urine output. Ca++ and Mg repleted.\n\nID....Tmax 102.1. Pancultures sent. Tylenol given. Started on cefazolin for drain coverage.\n\nHEME...HCT 46 at beginning of shift--down to 40 mid afternoon. Following HCT's Q6hrs. Coags stable. Pneumoboots on.\n\nENDO...No coverage needed per RISS.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-19 00:00:00.000", "description": "Report", "row_id": 1356884, "text": "Respiratory Care:\nPatient required A/C ventilation rather than the CPAP/PSV he was on at the beginning of the shift. Morning abg results determined a compensated metabolic alkalemia with excellent oxygenation.\n\nNo RSBI at this time due to instability.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-19 00:00:00.000", "description": "Report", "row_id": 1356885, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems:\nNeuro: sedated with propofol and fentanyl. With stimulus, becomes quite agitated in the bed. Moves all extremtities but does not follow commands. R pupil reactive. Unable to check L pupil because eye is sutured closed. Cervical collar remains on.\nCVS: sinus rhythm. Arterial line 30 points higher than cuff pressure but maps seemingly are comparable.\nRESP: started to retain co2 so vent changed to a/c 550 X 17, 5 peep, 50% with improved abg. Decreased breath sounds in bases. Suctioned for deep red/burgundy secretions. Oozing around the trach. CXR repeated this am to look at RLL infiltrate. R chest tube to water seal. Small amount crepitus in R chest wall.\nRENAL: urine output adequate. Receiving lr @ 75/hr. Lytes repleted.\nGI: G tube in place. On tube feedings of fs impact with fiber, advanced overnight to current goal of 70cc/hr. Belly soft. Small smears of stool. On famotidine for prophylaxis.\nENDO: ssri insulin\nHeme: hct down to 25.9. INR 1.1. On sq heparin and pneumoboots. To have IVC filter .\nID: wbc 6.5. T max 103 rectally. Blood cultures X 2, urine and sputum all sent. Tylenol given q 4 hours and also used fan and ice packs in effort to normalize temp with little effect. On vanco, levoquin, ceftriaxone.\nSKIN: jaw wired, oral care given. Head elevated and warm packs applied to face. L eye suture is tight and much serosanginous oozing from L eye noted. L arm with mottled area on forearm which is unchanged. Area around trach with drainage, slightly reddened. Abdominal incision open to air, staples intact, no reddness noted. R arm splint remains in place.\nSOCIAL: mom called for update\nA: persistent fever despite triple antibiotics. ??neuro status\nP: decrease propofol and assess neuro status. Follow temp curve, use cooling methods as indicated. Follows cultures and sensitivities. Continue per omfs recommendations. Support family.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-18 00:00:00.000", "description": "Report", "row_id": 1356882, "text": "Respiratory Care\nPt remains trached on CPAP. No vent changes overnight. ABG's WNL. BS coarse pt has strong productive cough. Sx for moderate bloody plugs with lavage. Plan: wean as tolerated.\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 862193, "text": " 2:02 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n AP SUPINE CHEST X-RAY: Bilateral costophrenic angles are not seen.\n Endotracheal tube is seen approximately 6 cm superior to the carina. There is\n a right-sided pneumothorax and a fracture through the medial third of the\n right clavicle. The cardiac silhouette, mediastinal, and hilar contours are\n within normal limits. There is no emphysema within the surrounding\n subcutaneous soft tissues.\n\n AP PELVIS: The study is limited secondary to underlying trauma board. There\n is no evidence of fracture or malalignment. Bilateral sacroiliac joints and\n the pubic symphysis are within normal limits. The joint space in both hips is\n preserved. Surrounding soft tissue and osseous structures are unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862200, "text": " 5:11 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: post trach--- please call unit prior to coming pt sti\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n post trach--- please call unit prior to coming pt still in O.R.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Traffic accident with multiple traumas, tracheostomy\n placed, check position.\n\n The tracheostomy tube lies 6 cm from the carinal angle in the region of the\n thoracic inlet. A nasogastric tube is present with the sidehole at\n approximately the level of the gastroesophageal junction. The heart is not\n enlarged. Diffuse bilateral opacities are present in both lungs consistent\n with bilateral contusions. Fractures of both clavicles are present and also\n the posterior aspect of the second right rib. Small apical effusion is\n present on this side. Pneumothorax is not appreciated due to supine position.\n\n IMPRESSION: Lung contusions from rib fracture or clavicular fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 862204, "text": " 6:05 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma 3\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n trauma 3\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Axial noncontrast CT scans through the facial bones were obtained\n and coronal reformatted images are provided.\n\n FINDINGS: There are complex comminuted fractures of the mandible. There is a\n multipartite fracture of the anterior mandible, and there are additional\n fractures of the right mandibular body, with displacement of large fragments.\n The right mandibular ramus is also fractured. The left mandibular condyle is\n fractured and dislocated. This is in addition to a fracture of the left\n mandibular ramus.\n\n There are numerous fractures of the left maxillary sinus wall. The\n posterolateral aspect of the sinus is inwardly displaced and fragments extend\n into the medial aspect of the sinus cavity. There are multiple fragments of\n fractured left pterygoid plates. There may be a nondisplaced fracture of the\n right lateral pterygoid plate as well. There is a fracture through the right\n posterior maxilla, with fragments aligned, and a nondisplaced fracture of the\n right medial sinus wall. The two medial superior incisors appear to be\n dislodged. There are fractures at the base of the nasal spines. The nasal\n bones do not appear fractured or displaced.\n\n There is a fracture of the left orbital floor, which is laterally located and\n presents in combination with fractures through the lateral wall of the orbit.\n There is a small inferiorly located bone fragment, which is just below the\n inferior rectus muscle. No other bony fragments are observed within the\n orbit. There is intraorbital air, a portion of which is in the intracoronal\n space superiorly. No retrobulbar hematoma is observed. There are radiopaque\n foci along the medial and lateral surfaces of the left globe and along the\n lateral surface of the right globe. These may be within the lid or sclera,\n and this cannot be determined. Clinical correlation is recommended. The\n right orbit is intact.\n\n The superior and medial orbital bony surfaces are intact. The zygomatic\n arches are intact. There is some fluid within the paranasal sinuses, but no\n fractures appear to extend across ethmoid, frontal, or sphenoid air cells.\n There is a small locule of air posterior to the frontal sinus, which probably\n is related to placement of an intracranial pressure monitoring device.\n\n The cribriform plates are normally aligned. The anterior clinoid processes\n and optic struts appear normal.\n (Over)\n\n 6:05 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma 3\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The nasal septum is fractured.\n The visualized portions of the mastoid air cells are clear.\n\n As noted on the CT scan of the cervical spine, there is extensive cervical\n soft tissue edema, primarily around the musculature and in the deep soft\n tissue spaces of the left neck and face.\n\n IMPRESSION: Multiple facial fractures, especially on the left and involving\n the left maxilla and orbit, as well as complex numerous fractures of the\n mandible.\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 862205, "text": " 6:05 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Trauma MVC\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n Trauma MVC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motor vehicle accident, evaluate for chest and intra-\n abdominal injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Multidetector imaging was obtained from the thoracic inlet through\n the pubic symphysis following the administration of 150 cc of intravenous\n Optiray. Nonionic contrast was administered per protocol. Coronal and\n sagittal reformatted images were obtained. A 3 minute delay film through the\n abdomen was obtained.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: There is a right-sided posterior first\n rib fracture and bilateral clavicular fractures within the medial third of the\n clavicles. There is a large right-sided pneumothorax and a small left apical\n pneumothorax. The patient is intubated. There is significant artifact\n produced by the arms at the patient's side. Allowing for this, there is no\n evidence of aortic dissection. The heart, pericardium, and great vessels are\n normal in appearance. There are bilateral high-density pleural effusions and\n compressive atelectasis. A nasogastric tube is seen descending below the\n diaphragm. There is no mediastinal, axillary, or hilar lymphadenopathy.\n\n CT ABDOMEN WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: The nasogastric tube\n extends below the diaphragm and terminates within the stomach. Within the\n right upper abdomen, in the right lobe of the liver, there is AAST grade IV\n laceration involving segment 5, 6, 7, and 8 of the liver. High-density\n extravasation on delayed phase images indicates active bleeding. The left\n lobe of the liver remains intact. Low density free fluid is seen throughout\n the right side of the abdomen, which becomes denser on delayed imaging\n suggesting bleeding. Additionally, there is a laceration involving the upper\n lobe of the right kidney, with active contrast extravasation. The\n gallbladder, pancreas, spleen, and bilateral adrenals are unremarkable. The\n intra-abdominal loops of large and small bowel are within normal limits. A\n small focus of intra-abdominal free air correlates with the patient's recent\n postoperative status.\n\n CT OF THE PELVIS WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: The right distal\n ureter and bladder are unremarkable. There is no contrast within the presumed\n passage of the left ureter at the level of the iliac crest. A Foley catheter\n (Over)\n\n 6:05 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Trauma MVC\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is seen within a collapsed bladder. High-density free fluid extends into the\n pelvis. Intrapelvic loops of large and small bowel are unremarkable.\n\n BONE WINDOWS: There is a fracture through the posterior acetabular rim,\n extending into the lower iliac bone. The fracture extends to the articular\n surface. No additional fractures are seen within the lumbar, lower thoracic,\n and inferior 3 ribs.\n\n Coronal and sagittal reformatted images confirm the axial findings. MPR grade\n 2.\n\n IMPRESSION:\n\n 1) Grade 4 AAST liver laceration involving segments 5, 6, 7, and 8 of the\n liver, with evidence of active bleeding.\n\n 2) Laceration of upper pole of right kidney.\n\n 3) Large right-sided pneumothorax.\n\n 4) Left apical pneumothorax.\n\n 5) Right first posterior rib fractures.\n\n 6) Bilateral medial clavicular fractures.\n\n 7) Fracture through posterior acetabulum.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862207, "text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p right chest tube palcement\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n s/p right chest tube palcement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old man with right pneumothorax, status post right chest\n tube placement.\n\n SINGLE SUPINE PORTABLE AP VIEW CHEST: Densities over both lung fields\n indicate pulmonary edema vs. aspiration vs. contusion, or a combination of all\n of the above. A chest tube is seen in the right hemithorax; hyperlucency of\n the right diaphragmatic border indicates probable pneumothorax. Multiple\n fractures including bilateral clavicular fractures and rib fractures are again\n unchanged. Left lower lobe atelectasis is noted. An NG tube is seen with its\n tip at the diaphragm. Tracheostomy tube is unchanged in position.\n\n IMPRESSION: Successful placement of right chest tube, with persistent right\n pneumothorax. Otherwise, no significant interval change.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "B HUMERUS (AP & LAT) BILAT", "row_id": 862231, "text": " 1:26 PM\n HUMERUS (AP & LAT) BILAT; FOREARM (AP & LAT) BILAT Clip # \n Reason: right subclav placed.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n right subclav placed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC. Right pneumothorax. Trauma.\n\n Single AP views of the left and right humerus, and AP view of the left radius\n and ulna, and a single lateral radiograph of the right radius and ulna were\n obtained. Single views are inadequate to assess for fracture. No gross\n abnormalities are seen within either femur. There is a comminuted fracture\n through the mid-shaft of the right radius, with multiple dorsally displaced\n fragments. Alignment in the lateral direction cannot be assessed without an\n AP radiograph. The left radius and ulna are grossly intact.\n\n IMPRESSION: Comminuted right radial fracture, incompletely assessed. No\n other gross abnormality, but evaluation is limited with only single views.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862232, "text": " 1:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fx? Especially on right.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: AP portable chest film shows placement of a right subclavian\n catheter the tip of which is situated in the superior vena cava. The\n position has remained stable over the subsequent 4 chest x-rays.\n\n\n\n 1:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: fx? Especially on right.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n fx? Especially on right.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Severe trauma in MVA.\n\n CHEST: The right chest tube is unchanged in position. No pneumothorax is\n present. Extensive subcutaneous emphysema is seen, however.\n\n Fractures of the clavicle and second rib are again noted. Bilateral opacities\n are present less marked than on the prior film particularly on the right side,\n which is consistent with contusion. Heart remains normal in size. The\n mediastinum is not widened.\n\n The nasogastric tube has been advanced and now lies in satisfactory position.\n\n IMPRESSION: Reduction in degree of right lung contusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862382, "text": " 11:57 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: change in pulm contus.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n change in pulm contus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old man with recent MVC. Continued respiratory distress.\n\n COMPARISON: Six hours prior.\n\n Right pneumothorax seen outlining the right hemidiaphragm and right apex\n persist. Apical capping is seen on both lungs. Left lower lobe atelectasis\n is again seen. Ill-defined opacities in the right lung indicate resolving\n pulmonary contusions. Fractures in both clavicles and multiple ribs are\n stable. Staples in the mid abdomen, NG tube, right central venous line,\n tracheostomy tube, and right chest tube, as well as subcutaneous air in the\n right thorax, are not significantly changed.\n\n IMPRESSION: Continued right pneumothorax. Resolving pulmonary contusions.\n Continued left lower lobe atelectasis. Otherwise unchanged exam.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 863289, "text": " 6:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung ptX\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n lung ptX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma.\n\n COMPARISON: Radiograph dated .\n\n AP PORTABLE FRONTAL VIEW OF THE CHEST: Tracheostomy tube and right subclavian\n line are unchanged. The cardiac and mediastinal contours are stable. No\n pneumothorax is identified. There is interval improvement and interval\n clearing of the lung bases with residual left retrocardiac opacity. An\n abdominal drain is also visualized, and unchanged with skin staples overlying\n the mid abdomen. The skeletal structures are unchanged.\n\n IMPRESSION: Interval improved aeration and clearing of the lung bases with\n residual left lower lobe atelectasis. No evidence of pneumothorax. No\n definite pneumomediastinum is present.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862771, "text": " 11:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Chest tube ws\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n Chest tube ws\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n COMPARISON: .\n\n INDICATION: Pneumothorax.\n\n A tracheostomy tube, right subclavian vascular catheter, and right-sided chest\n tube remain in place. There is no evidence of pneumothorax on this supine\n radiograph. Previously-noted right pneumothorax is no longer visualized but\n the right hemidiaphragm appears unusually sharp. Cardiac and mediastinal\n contours are stable. Right lower lobe air- space opacity has nearly completely\n resolved. Left retrocardiac opacity is slightly improved. There is an\n increasing confluent somewhat rounded opacity in the left lower lobe.\n Moderate left layering left pleural effusion tracking to the left apex as well\n as a small amount of fluid at the right apex are noted. Fracture of the right\n second posterior rib is also demonstrated. Additional skeletal fractures of\n the clavicles and additional ribs are also noted.\n\n IMPRESSION: Previously noted pneumothorax no longer visualized. However, it\n is difficult to fully exclude residual basilar pneumothorax given the sharp\n appearance of right hemidiaphragm on the supine radiograph.\n\n Resolving air-space opacity in right lower lobe.\n\n Consolidation in left lower lobe which contains central lucencies, the latter\n consistent with areas of pulmonary laceration. The consolidation could be\n related to contusion, but superimposed aspiration or pneumonia are also\n considerations in the appropriate clinical setting.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-29 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 864253, "text": " 3:25 PM\n CHEST (SINGLE VIEW); -76 BY SAME PHYSICIAN # \n Reason: Radiologist had difficulty visualizing the tip of Picc line,\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with Aspiration pneumonia,s/p MVA, jaw wired,trach, mrsa\n precautions who needs picc line for 10 days of IV zosyn.\n REASON FOR THIS EXAMINATION:\n Radiologist had difficulty visualizing the tip of Picc line, pt needs repeat\n cxry with over exposer,please page at with wet read, thanks.\n ______________________________________________________________________________\n FINAL REPORT\n History: Repositioning of PICC line.\n\n The PICC line is in the right atrium and should be withdrawn approximately \n cm. No other change.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 863720, "text": " 10:19 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with ams\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: AMS.\n\n A tracheostomy tube remains in place. The heart size, mediastinal and hilar\n contours are normal. The lungs demonstrate a confluent rounded opacity within\n the left lower lobe with an oval configuration and relatively well-\n circumscribed margins, measuring about 5.5 cm in diameter. Scattered patchy\n and linear opacities are noted in the right mid and both lower lung zones and\n show interval improvement in the interval. Numerous skeletal fractures are\n noted, including a right clavicle and rib fractures. No definite pneumothorax\n is identified.\n\n IMPRESSION: Well-marginated oval-shaped left lower lobe opacity, most likely\n due to a pulmonary hematoma, which may have been previously partially obscured\n by more extensive superimposed areas of contusion. Followup radiographs are\n suggested to ensure resolution.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862245, "text": " 4:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Multiple traumas, right pneumothorax.\n\n CHEST: The position of the various lines and tubes remains unaltered. No\n pneumothorax is identified on either the right or the left side. Pulmonary\n contusions are again noted.\n\n IMPRESSION: No pneumothorax seen and no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "R FOREARM (AP & LAT) RIGHT", "row_id": 862246, "text": " 4:53 PM\n FOREARM (AP & LAT) RIGHT; -77 BY DIFFERENT PHYSICIAN # \n Reason: fx?\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n fx?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: The patient has a pneumothorax, pain and bruising in right\n arm.\n\n RIGHT FOREARM: A fracture is seen through the mid shaft of the right radius.\n No other fracture is present. No dislocations are seen either in the elbow or\n at the wrist.\n\n IMPRESSION: Comminuted fracture mid shaft of radius.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-13 00:00:00.000", "description": "T-SPINE", "row_id": 862330, "text": " 2:15 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: r/o fracture\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with MVA\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Thoracic spine, AP and lateral view.\n\n INDICATION: Motor vehicle accident, back pain. Evaluate for fracture.\n\n FINDINGS: AP and lateral view of the thoracic spine have been obtained with\n the boarded patient in the emergency room. A tracheal cannula is in place. An\n NG tube has passed below the diaphragm. A right subclavian approach central\n venous line is overlying the SVC, terminating 2 cm below the level of the\n carina. A right-sided chest tube terminates in the right apical area. There\n is evidence of bilateral clavicular fractures. No conclusive evidence for any\n pneumothorax but apical pleural thickening exists, slightly more on the left\n than the right side. The first and second ribs appear intact. The thoracic\n spine is straight in midline without evidence of fracture or dislocation. The\n lateral view obtained on the boarded patient demonstrates preserved vertebral\n bodies of the thoracic spine with ordinary kyphotic curvature. The lateral\n view, however, does not include the thoracic spine above the level of T4. AP\n view of the lumbosacral spine demonstrates normal bony structures without\n evidence of fracture or dislocation, and the intervertebral disc spaces are\n preserved. Cutaneous midline clips indicate recent abdominal intervention.\n Pelvis including SI joints grossly within normal limits. The lateral view of\n the lumbar spine demonstrates normal position of the vertebral column with\n preserved intervertebral disc spaces.\n\n IMPRESSION: No evidence of spine injury from T4 down to sacrum. Bilateral\n clavicular fractures, pleural apical caps bilaterally slightly more on left\n than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 862202, "text": " 6:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Trauma\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n Trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Axial noncontrast CT scans of the brain were obtained.\n\n No previous studies are available for comparison.\n\n FINDINGS: Brain parenchymal attenuation is preserved. No acute intracranial\n hemorrhage is visualized. The ventricles are normal in size and\n configuration. There is no shift of normally midline structures. A pressure-\n measuring device is visualized in the right frontal lobe parenchyma.\n\n No fractures of the calvarium or skull base are observed.\n\n There are numerous facial fractures. There is a comminuted fracture of the\n left lateral orbit, and there are multiple fractures of the left maxillary\n sinus and left pterygoid plates. There is also a fracture dislocation of the\n left mandibular condyle. There are some radiopaque foci along the margins of\n the globes, and there is orbital emphysema on the left. Please see the CT\n scan of the face for additional information.\n\n There is soft tissue swelling across the left side of the face and extending\n into the left lateral scalp soft tissues.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage or edema at this\n time. A right frontal pressure-monitoring device is in place. There are no\n skull fractures, but there are numerous facial fractures.\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2137-05-12 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 862203, "text": " 6:04 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma MVC\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with\n REASON FOR THIS EXAMINATION:\n trauma MVC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Noncontrast CT scans of the cervical spine were obtained and\n coronal and sagittal reformatted images are provided.\n\n FINDINGS: There are small bilateral apical pneumothoraces, and there is\n increased density in the right pulmonary apex. The patient has a tracheostomy\n and endotracheal tube in place. There is extensive edema in the soft tissues\n of the neck.\n\n Cervicovertebral alignment is normal. Vertebral body height is maintained.\n There are no cervical fractures observed. There are no findings to suggest\n impingement on the spinal cord in the upper cervical region, and the lower\n cervical spinal canal is not well seen due to artifact.\n\n IMPRESSION: No cervical spine fracture or malalignment is evident. There is\n extensive soft tissue swelling in the neck, especially on the left. Findings\n were discussed with Dr. . At this time (8 a.m.), he reports that the\n patient has a right hemiparesis. It is recommended that he have an MRI study\n of the brain and cervical spine, when clinically stable.\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2137-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 862266, "text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old s/p MVC with right PTX\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL HISTORY: MVA with multiple injuries and right pneumothorax.\n\n CHEST: Comparison to the prior film shows no significant change. No\n pneumothorax is seen on either side.\n\n IMPRESSION: No change.\n\n" }, { "category": "ECG", "chartdate": "2137-05-26 00:00:00.000", "description": "Report", "row_id": 191141, "text": "Normal sinus rhythm. J point elevation probably normal variant. Compared to the\nprevious tracing of no major change.\n\n" }, { "category": "ECG", "chartdate": "2137-05-12 00:00:00.000", "description": "Report", "row_id": 191142, "text": "Sinus tachycardia. Otherwise, normal ECG. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2170-02-02 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1229482, "text": " 9:25 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Evaluate for bowel perf, please use Gastrografin\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n Field of view: 45\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: On later review, the left lower lobe proximal basal and likely\n lateral basal pulmonary arteries contain partial filling defects, presumably\n related to resolving known pulmonary emboli.\n\n\n\n 9:25 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Evaluate for bowel perf, please use Gastrografin\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n Field of view: 45\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with DVT/PE on warfarin, UC flare and new abd free air with\n pneumomediastinum.\n REASON FOR THIS EXAMINATION:\n Evaluate for bowel perf, please use Gastrografin\n CONTRAINDICATIONS for IV CONTRAST:\n , would like to avoid IV contrast\n ______________________________________________________________________________\n WET READ: FRI 11:41 PM\n 1. No evidence of an intraabdominal leak or extraluminal orally administered\n contrast noted.\n\n 2. Moderate bilateral pleural effusions with associated atelectasis.\n\n 3. Unchanged pneumomediastinum and mild pneumoperitoneum.\n\n 4. Large amount of subcutaneous fluid and edema likely related to iatrogenic\n fluid overload.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with DVT/PE, on warfarin with ulcerative colitis\n flare, abdominal free air with pneumomediastinum, evaluate for bowel\n perforation.\n\n COMPARISON: Radiographs from and a CT of the chest from\n .\n\n TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with oral\n but without IV contrast. Multiplanar reformations were obtained and reviewed.\n\n FINDINGS:\n\n The partially imaged lungs show moderate bilateral pleural effusions.\n Pneumomediastinum is again noted. The partially imaged heart is unremarkable.\n Mild coronary artery calcifications are partially imaged.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST:\n\n Evaluation of the solid organs is limited due to lack of IV contrast. Within\n these limitations, the liver, spleen, both adrenals, both kidneys, pancreas\n and gallbladder are unremarkable. Evidence of vicarious excretion of contrast\n is noted within the gallbladder. An IVC filter is noted in appropriate\n position. There is retroperitoneal air on the left and possibly also a small\n amount of intraperitoneal free air. No evidence of a leak is identified.\n Contrast makes its way into the ascending colon but no extraluminal contrast\n is identified either. There is mild thickening of the transverse bowel wall\n consistent with known ulcerative colitis. No abdominal, retroperitoneal or\n (Over)\n\n 9:25 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Evaluate for bowel perf, please use Gastrografin\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n Field of view: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mesenteric lymphadenopathy by CT size criteria is present. No abdominal free\n fluid or free air is present. The small bowel loops are unremarkable.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n\n The rectum and sigmoid colon, both show a mildly thickened wall consistent\n with known ulcerative colitis. The bladder, prostate, and seminal vesicles\n are unremarkable. No pelvic or inguinal lymphadenopathy or pelvic free fluid\n is present.\n\n There is diffuse subcutaneous soft tissue stranding and subcutaneous edema\n likely related to fluid-fluid overload.\n\n OSSEOUS STRUCTURES:\n\n The visible osseous structures show no suspicious lytic or blastic lesions or\n fractures.\n\n IMPRESSION:\n\n 1. No evidence of an intraabdominal leak or extraluminal orally administered\n contrast noted.\n\n 2. Moderate bilateral pleural effusions with associated atelectasis.\n\n 3. Unchanged pneumomediastinum and retroperitoneal air.\n\n 4. Large amount of subcutaneous fluid and edema likely related to iatrogenic\n fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1229539, "text": " 11:26 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX, line position\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p new IJ placement on R\n REASON FOR THIS EXAMINATION:\n r/o PTX, line position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New right IJ placement, rule out pneumothorax and line position.\n\n CHEST, SINGLE AP PORTABLE VIEW\n\n An ET tube is present, tip approximately 4.1 cm above the carina. An NG tube\n is present, tip beneath diaphragm, extending off film. A right IJ sheath is\n present, tip overlying proximal SVC. A left-sided PICC line is present, tip\n over distal SVC. The uppermost tip of patient's known IVC filter is noted at\n the inferior edge of this film.\n\n There is upper zone redistribution, without other evidence of CHF. There are\n small bilateral layering effusions, likely accounting for the hazy opacity at\n both lung bases. Also minimal atelectasis is present at both lung bases. No\n pneumothorax is detected. However, there is subcutaneous emphysema in both\n supraclavicular fossae. The extensive mediastinal air seen on that study is\n less well appreciated radiographically, though some streaky opacities over the\n superior mediastinum likely correlate with that. Tiny right diaphragmatic\n calcifications noted, better depicted on chest CT.\n\n" }, { "category": "Radiology", "chartdate": "2170-01-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1228225, "text": " 9:54 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New left arm 45cm D.L. PICC. ? PICC tip location.\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new left 45cm D.L. PICC. ? PICC tip location\n REASON FOR THIS EXAMINATION:\n New left arm 45cm D.L. PICC. ? PICC tip location.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are normal. Normal appearance of the cardiac\n silhouette. No pleural effusions.\n\n The patient has received a left-sided PICC line. The tip of the line projects\n over the mid to low SVC. The course of the line is unremarkable. No evidence\n of complications, notably no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2170-01-22 00:00:00.000", "description": "B CT LOW WXT W/C BILAT", "row_id": 1227877, "text": " 11:24 PM\n CT LOW WXT W/C BILAT Clip # \n Reason: CT venogram from umbilicus to toes to eval for venous occlus\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with phlegmasia \n REASON FOR THIS EXAMINATION:\n CT venogram from umbilicus to toes to eval for venous occlusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa TUE 9:20 AM\n Extensive deep venous thrombosis beginning at the level of the IVC filter\n extending inferiorly. On the right, thrombus is seen throughout the lower\n extremity to the calf veins. On the left, thrombus extends through the iliac\n vein to the mid pelvis after which there is reconstitution with intermittent\n non-occlusive thrombus. Occlusive clot is again present within the popliteal\n vein extending into the calf veins on the left.\n WET READ VERSION #1 OXZa TUE 1:00 AM\n Extensive deep venous thrombosis beginning at the level of the IVC filter\n extending inferiorly. On the right, thrombus is seen throughout the lower\n extremity to the calf veins. On the left, thrombus extends through the iliac\n vein to the mid pelvis after which there is reconstitution. Thrombus is again\n present, however, within the popliteal vein extending into the calf veins on\n the left.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Phlegmasia . CT venogram to evaluate venous vessels\n from the level of the umbilicus to the toes.\n\n TECHNIQUE: Multidetector helical CT scan of the abdomen, pelvis, and lower\n extremities was obtained before and after the administration of 100 cc IV\n Omnipaque contrast. Coronal and sagittal reformations were prepared.\n\n COMPARISON: None available at the time of report.\n\n FINDINGS: The included portions of the lung bases are clear. There are\n diaphragmatic pleural calcifications on the right.\n\n The liver, gallbladder, spleen, pancreas, and adrenal glands appear grossly\n unremarkable. The kidneys contain multiple subcentimeter hypodensities too\n small to characterize. Loops of small and large bowel are normal in size and\n caliber.\n\n Within the pelvis, distal loops of large bowel and rectum are normal in size\n and caliber. There is mild wall thickening which could be due to\n underdistention or venous congestion. The bladder is non-distended with\n circumferential wall thickening which could be due to underdistention. There\n are coarse calcifications of the prostate gland. No free air or\n lymphadenopathy is identified. There is diffuse anasarca.\n\n No concerning osseous lesion is seen.\n\n (Over)\n\n 11:24 PM\n CT LOW WXT W/C BILAT Clip # \n Reason: CT venogram from umbilicus to toes to eval for venous occlus\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CTV: There is an IVC filter in place just inferior to the level of the renal\n arteries. Beginning at the IVC, there is thrombus causing filling defect and\n distention of the IVC extending inferiorly to the iliac veins. On the left,\n there does appear to be reconstitution of contrast within the iliac vein in\n the lower pelvis and contrast does appear to fill the femoral veins. Non-\n occlusive thrombus is likely present in a portion of common femoral and\n proximal superficial femoral veins. There is occlusive thrombus seen within\n the popliteal vein (3:279) with clot extending distally into the calf veins.\n On the right, distention of the vein with clot and filling defect persists\n throughout the iliac veins, to a lesser extent within the internal, however,\n persistent throughout the external iliac vein. Clot is present throughout\n both the deep and superficial femoral veins extending throughout the leg into\n the popliteal and calf veins. Again noted is diffuse anasarca.\n\n IMPRESSION: Extensive deep venous thrombosis beginning at the level of the\n IVC filter extending inferiorly. On the right, thrombus is seen throughout\n the lower extremity to the calf veins. On the left, thrombus extends through\n the common iliac vein after which there is reconstitution with intermittent\n non-occlusive thrombus in the common femoral an proximal superficial femoral\n vein. Occlusive clot is again present within the popliteal vein extending into\n the calf veins on the left.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229258, "text": " 10:21 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval for PTX, PATIENT MUST BE POSITIONED FULLY UPRIGHT FOR F\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with extensive DVTs, pt. HIT positive, bedbound, now with\n ?pneumomediastinum/PTX; PATIENT MUST BE POSITIONED FULLY UPRIGHT FOR FILM\n PLEASE\n REASON FOR THIS EXAMINATION:\n Eval for PTX, PATIENT MUST BE POSITIONED FULLY UPRIGHT FOR FILM PLEASE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Concern for pneumothorax and pneumomediastinum on prior chest\n radiograph repeat radiograph was recommended.\n\n COMPARISON: Comparison is made to chest radiograph performed 2 hours earlier.\n\n FINDINGS: On upright portable chest radiograph there is continued increased\n lucency of the right upper lung; however, the pleural fold is no longer\n evident. There is persistent bilateral subcutaneous gas in the soft tissues\n of the neck as well as persistent trace pneumomedistinum at the level of the\n trachea. Lungs are clear. No pleural effusion. Cardiac and hilar contours\n are unremarkable.\n\n IMPRESSION: Equivocal findings of right pneumothorax. Persistent\n pneumomediastinum or subcutaneous emphysema.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-01 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1229338, "text": " 7:23 PM\n CT CHEST W/CONTRAST Clip # \n Reason: Evaluate for esophageal perf\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Left lower lobe proximal basal and likely lateral basal pulmonary\n arteries contain partial filling defects, presumably related to resolving\n known pulmonary emboli.\n\n\n\n 7:23 PM\n CT CHEST W/CONTRAST Clip # \n Reason: Evaluate for esophageal perf\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with DVT/PE and UC flare who was found to have new\n pneumomediastinum and subcutaneous emphysema.\n REASON FOR THIS EXAMINATION:\n Evaluate for esophageal perf\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:14 PM\n Extensive subcutaneous, mediastinal, peritoneal and retroperitoneal air. No\n discrete leak points identified. Large bilateral non-hemorrhagic effusions\n with associated atelectasis. Diffuse esophageal wall thickening of uncertain\n significance. IVC filter is appropriate. High density along the right\n diaphragm likely represents calcifications. Colonic wall thickening with thumb\n printing in the ascending colon could be related to patients known UC. No\n pulmonary embolism. Diffuse subcutaneous fluid likely related to iatrogenic\n volume overload. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient being treated for DVT and PE and UC flare who was found\n to have pneumomediastinum and subcutaneous air on recent chest radiograph.\n Please evaluate for esophageal perforation.\n\n TECHNIQUE: Intravenous and esophageal contrast-enhanced axial images were\n acquired through the chest. Coronal and sagittal reformations were provided.\n\n FINDINGS: Subcutaneous, mediastinal, peritoneal and retroperitoneal air is\n extensive, but no leak is identified. Smooth, mild circumferential thickening\n of the mid and lower esophagus, is a nonspecific finding and there is no\n contrast leak. A large amount of intraperitoneal gas is present in the left\n upper abdomen, adjacent to the colon which may indicate a colonic source of\n gas. A solitary focus of air alongside the third portion of duodenum (4:257)\n is an unlikely source. The imaged part of the bowel is not distended, but its\n appearance distally is unknown.\n\n There is no supraclavicular, axillary, mediastinal or hilar lymphadenopathy.\n The central vasculature is unremarkable. Heart size is normal and without\n pericardial effusion. The tracheobronchial tree is normal to the subsegmental\n level. Centrilobular emphysema is mild. Aside from a calcified granuloma in\n the right upper lobe (4:106), the lungs are clear. Right diaphragmatic pleural\n calcifications could be due to any prior pleural insult. Large, layering\n nonhemorrhagic pleural effusions account for basal atelectasis. Of note, the\n right midlung pleural fold and right upper lobe lucency identified on the\n preceding chest radiograph are due to a pleural effusion layering behind the\n lower right lung and tracking along the major fissure.\n\n No areas of heterogenicity are present within the unenhanced liver to suggest\n mass. The right adrenal gland is unremarkable. The left adrenal gland has a\n non-fat density (26HU), 1.4 cm nodule. The inferior vena cava filter is in\n (Over)\n\n 7:23 PM\n CT CHEST W/CONTRAST Clip # \n Reason: Evaluate for esophageal perf\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the infrarenal position.\n\n No suspicious lytic or blastic lesions are evident. Multilevel degenerative\n changes are present in the thoracic spine but there are no bone lesions\n suspicious for malignancy.\n\n IMPRESSION:\n 1. Extensive subcutaneous mediastinal, peritoneal and retroperitoneal areas.\n No definitive leak points identified, though an intestinal source is most\n likely given large amount of left upper abdominal gas and history ulcerative\n colitis flare.\n 2. Large, layering nonhemorrhagic pleural effusions responsible for\n atelectasis.\n 4. Two diaphragmatic pleural calcifications, not necessarily\n asbestos-related.\n 5. 1.4 cm left adrenal nodule is statistically an adrenal adenoma.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229244, "text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infection or edema\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with DVT/PE and worsening shortness of breath\n REASON FOR THIS EXAMINATION:\n Evaluate for infection or edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with DVT and pneumonia with worsening shortness of\n breath. Please evaluate for infection or edema.\n\n COMPARISON: Comparison is made to chest radiograph dated .\n\n FINDINGS: Single upright portable chest radiograph demonstrates unremarkable\n mediastinal, hilar and cardiac contours. However, subcutaneous emphhysema\n identified in the soft tissues of the neck and bilateral supraclaviaular\n region. Linear lucency tracking along the trachea concerning for\n pneumomediastinum. There is a stable left PICC line with tip at the\n cavoatrial junction. There is suggestion of a pleural fold approximately 4.5\n cm from the apex with a paucity of lung markings in this region which may\n suggest a moderate-sized pneumothorax not evident on the prior study; however,\n there appears to be no evidence of the expected associated volume loss. Small\n rounded radiopaque density is noted projecting in the right mid lung and\n crossing a different bony structure than on prior study, indicating it is not\n within the bone and may represent a calcified granuloma. No pleural effusion\n evident. No osseous abnormality identified.\n\n IMPRESSION: Subcutaneous emphysema at thoracic inlet. Upper\n pneumomediastinum. Possible moderate right pneumothorax. Recommend repeat\n fully upright chest radiograph.\n\n communicated these findings to Dr via telephone\n at 09:30 on .\n\n" }, { "category": "Radiology", "chartdate": "2170-02-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1230801, "text": " 12:27 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 41cm Right picc, #\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new right picc\n REASON FOR THIS EXAMINATION:\n 41cm Right picc, #\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with new right-sided PICC.\n\n COMPARISON: Portable AP chest radiograph, .\n\n PORTABLE AP CHEST RADIOGRAPH: Portions of the left hemithorax are not\n included in the field of view. The cardiac, mediastinal, and hilar contours\n are unremarkable. Within this limitation, a right-sided PICC tip is noted to\n terminate within the lower SVC. A feeding tube passes into the stomach.\n Minimal calcification at the right hemidiaphragm cannot be completely\n excluded. Previously noted left pulmonary nodule is not visualized and may\n have not been included in the field of view.\n\n Findings were discussed with IV nurse, , at 13:11 on . Updated findings were also discussed with at 15:47pm on\n .\n\n" }, { "category": "Radiology", "chartdate": "2170-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230128, "text": " 10:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: acute process\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with acute onset of shortness of breath\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Acute shortness of breath.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n Large right pleural effusion is probably unchanged allowing the difference in\n positioning of the patient. There has been interval worsening of right lower\n lobe and right middle lobe atelectasis. There is no evident pneumothorax.\n Left pigtail catheter is in unchanged position at the base. NG tube tip is in\n the stomach. Cardiomediastinal contours are unchanged. Nodular lung\n opacities in the left upper lobe are new , could be superimposition of normal\n structures or focal areas of atelectasis. Attention in followup is\n recommended. Left PICC tip is in the mid-to-lower SVC.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1229769, "text": " 1:10 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? placement of LIJ and pigtail\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 M UC s/p subtotal colectomy end ileostomy, s/p placement of left pigtail for\n left pleural efussion and exchange of LIJ cortis\n REASON FOR THIS EXAMINATION:\n ? placement of LIJ and pigtail\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Subtotal colectomy, status post pigtail placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new left pigtail catheter. The catheter is well positioned. The previous\n left pleural effusion is almost completely drained. There is no evidence of\n pneumothorax.\n\n However, on the right, there might be a small pneumothorax with air in the\n minor fissure and in the apical lateral portions of the subpleural space. No\n evidence of tension, but close radiographic monitoring is required.\n\n The other monitoring and support devices are unchanged: right venous\n introduction sheath, left PICC line, endotracheal tube and nasogastric tube.\n\n At the time of dictation, 1:57 p.m. on , the referring\n physician, . , covered by Dr. was paged for notification.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229833, "text": " 8:47 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess interval change\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with left pigtail, right PTX\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n WET READ: MON 10:43 PM\n Previously seen small right pneumothorax is not well visualized on the present\n study. A moderate to large layering right pleural effusion persists, possibly\n slightly larger.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pigtail and right pneumothorax, to assess for changes.\n\n FINDINGS: In comparison with the earlier study of this date, the apparent\n small pneumothorax tracking along the minor fissure is not definitely\n appreciated. There is hazy opacification of the right hemithorax with poor\n definition of the hemidiaphragm, consistent with layering pleural effusion and\n compressive atelectasis at the base. Mild atelectatic changes are also seen\n on the left.\n\n The nasogastric tube has been removed. Right IJ catheter and left subclavian\n catheter remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230247, "text": " 4:37 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: upright please eval residual pneumothorax.\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with air leak on right pigtail placement\n REASON FOR THIS EXAMINATION:\n upright please eval residual pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 66-year-old male patient with air leak on right pigtail catheter.\n Evaluate for residual pneumothorax.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Comparison is made with the next preceding\n similar study obtained 12 hours earlier during the same day. There is marked\n improvement of the previously identified massive pleural effusion occupying\n major portions of the right hemithorax. New pigtail end small caliber\n catheter is now seen on the right base and explains the evacuation of the\n pleural effusion that occurred during the interval. No pneumothorax has\n developed. The lung parenchyma on the right side appears free as this can be\n identified by the single AP chest view. On the left side, there is also a\n small caliber pigtail end catheter in the basal space of the pleura but no\n evidence of pleural effusion is seen. A previously described left-sided\n advanced PICC line remain in unchanged appropriate position and terminating\n just 2 cm below the level of the carina.\n\n An NG tube remains and is seen to point with the Dobbhoff tip towards the\n pylorus.\n\n IMPRESSION: Bilateral small caliber pigtail and pleural drainage lines in\n place. Pleural effusions have practically been eliminated. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229859, "text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M w/UC flare, large B/L DVT/PE, HIT, coagulopathy now s/p subtotal colectomy\n and end ileostomy for transverse colon perforation.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Deep vein thrombosis, abdominal surgery.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Extensive right pleural effusion with areas of atelectasis and an\n unchanged left PICC line. Small nodular opacity, projecting over the border\n of the ventral aspect of the left fourth rib is unchanged since several\n examinations.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229922, "text": " 12:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: repositioned misplaced DHT, ? position now\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M w/UC flare, large B/L DVT/PE, HIT, coagulopathy now s/p subtotal colectomy\n and end ileostomy for transverse colon perforation.\n REASON FOR THIS EXAMINATION:\n repositioned misplaced DHT, ? position now\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with UC flare, bilateral DVTs, PEs, now with subtotal\n colectomy and end-ileostomy for transverse colon perforation. Repositioned\n Dobbhoff tube, please evaluate position.\n\n IMPRESSION: Interval repositioning of Dobbhoff tube with tip now in the\n stomach. Please note stylus wire is still in place. Otherwise, unchanged\n exam with moderate right pleural effusion layering in the minor fissure.\n Flattening and sclerosis of the left humeral greater tuberosity suggests\n shoulder impingement syndrome.\n\n IMPRESSION: Dobbhoff tube with tip in stomach. Stable right pleural\n effusion. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230150, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u pleural effusion\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p subtotal colectomy with end ileostomy with pleural effusion s/p chest\n tube placement\n REASON FOR THIS EXAMINATION:\n f/u pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Followup pleural effusion.\n\n Comparison is made with prior study performed a day earlier.\n\n Large right pleural effusion has increased. There are worsening opacities in\n the right lower lobe, and right perihilar region which could be due to\n worsening atelectasis, but in the appropriate clinical setting, superimposed\n infection is also possible. There is no evident pneumothorax or pleural\n effusion on the left side. Left pigtail catheter remains in place. NG tube\n tip is out of view below the diaphragm. Left PICC tip is in the lower SVC.\n There is minimal atelectasis in the left mid lung.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-15 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1231095, "text": " 2:22 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspiration\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with possible aspiration\n REASON FOR THIS EXAMINATION:\n eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with possible aspiration. Evaluate for\n aspiration.\n\n TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in\n conjunction with the speech and swallow team. Multiple consistencies of\n barium were administered.\n\n FINDINGS: Barium passes freely through the oropharynx and esophagus without\n evidence of obstruction. Penetration, but no gross aspiration was noted with\n both nectars and thin liquids. Moderate to large pharyngeal residues were\n present, particularly with pudding consistencies. For further details, please\n refer to speech and swallow division note.\n\n IMPRESSION: Penetration but no gross aspiration with thin and nectar thick\n liquids. Large pharyngeal residues, especially with pudding consistency.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230452, "text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate s/p placement of pigtails to H2O seal\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p b/l pigtail placements now placed to H20 seal\n REASON FOR THIS EXAMINATION:\n Evaluate s/p placement of pigtails to H2O seal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pigtails placed to waterseal.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with at 14:57 p.m., there is slight increased hazy opacity at\n right greater than left bases, ? atelectasis. Attention to these areas on\n followup films is recommended to exclude early pneumonic infiltrates.\n\n The cardiomediastinal silhouette and upper zone redistribution are unchanged.\n Bilateral pigtail type catheters are present. No pneumothorax or gross\n effusion is detected on either side. There is elevation of the right\n hemidiaphragm, more pronounced than on the earlier film. A Dobbhoff-type tube\n is present, radiopaque tip overlying the stomach. A left subclavian PICC line\n tip overlies the distal SVC.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230293, "text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u pleural effusion\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p subtotal colectomy with end ileostomy with pleural effusion s/p chest\n tube placement\n REASON FOR THIS EXAMINATION:\n f/u pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subtotal colectomy with end ileostomy with pleural effusion\n status post chest tube placement. Please assess for change in pleural\n effusion.\n\n COMPARISON: Comparison is made to multiple chest radiographs with most recent\n dated .\n\n FINDINGS: Portable chest radiograph demonstrates unremarkable mediastinal,\n hilar, and cardiac contours. Minimal stable atelectasis noted in the\n bilateral lower lungs, right greater than left. Bilateral chest tubes\n projecting over lung bases with no reaccumulation of pleural effusions or\n pneumothorax. Other lines and tubes in appropriate position.\n\n IMPRESSION: No pleural effusions bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1231075, "text": " 2:22 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for aspiration/pneumonia\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with dvt's, ivc filter, on argatroban, s/p colonic perf/total\n colectomy from UC, concern for aspiration, now with new fevers.\n REASON FOR THIS EXAMINATION:\n assess for aspiration/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, PA and lateral.\n\n INDICATION: 66-year-old male patient with deep vein thrombosis, IVC filter,\n on Argatroban, status post colonic perforation - total colectomy from UC,\n concern for aspiration now.\n\n FINDINGS: AP and lateral chest views were obtained with patient in sitting\n semi-upright position. Comparison is made with the next preceding similar\n portable chest examination of . Previously identified\n right-sided PICC line remains in unchanged position. On frontal view, lungs\n are clear. No evidence of new pulmonary infiltrates can be established.\n Noticed is a barium meal that has passed through the esophagus and now\n visualized in the stomach, as well the proximal small bowel. These findings\n are rather unremarkable on this single chest view examination.\n\n IMPRESSION: No evidence of new pulmonary abnormalities in comparison with\n next preceding chest examination of . Thus, no evidence of new\n aspiration pneumonitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230376, "text": " 3:06 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? post H20 seal CXR, pls do CXR at 1500\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 s/p b/l pigtail placements now placd to H20 seal\n REASON FOR THIS EXAMINATION:\n ? post H20 seal CXR, pls do CXR at 1500\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral chest tubes now on waterseal. Please evaluate for\n interval change.\n\n COMPARISON: Comparison is made to multiple chest radiographs, most recently\n dated the same day 10 hours earlier.\n\n FINDINGS: Portable chest radiograph demonstrates unremarkable mediastinal,\n hilar and cardiac contours. There is improved aeration of the lung bases\n particularly on the right. No reaccumulation of pleural effusions or\n development of pneumothorax. Dobbhoff tube is seen with tip in the mid\n stomach. left-sided PICC line tip terminates in the distal SVC.\n\n IMPRESSION: No reaccumulation of pleural fluid or development of\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229875, "text": " 8:53 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: is pneumothorax improved\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pneomthorax and plueral effusions\n REASON FOR THIS EXAMINATION:\n is pneumothorax improved\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumothorax, pleural effusion, has pneumothorax improved.\n\n COMPARISON: Comparison is made to chest radiograph performed four hours\n earlier.\n\n FINDINGS: Single portable chest radiograph demonstrates no evidence of\n pneumothorax. There is a stable large right layering pleural effusion as well\n as bibasilar atelectasis. No focal opacification concerning for pneumonia\n identified. Heart, mediastinal, and hilar borders are unremarkable. There is\n a left-sided PICC line with tip at the cavoatrial junction as well as a\n right-sided venous sheath catheter terminating in the upper SVC.\n\n IMPRESSION: No pneumothorax. Stable right large pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230008, "text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: F/u of pneumothorax\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66M s/p subtotal colectomy + end ileostomy w/pneumothorax s/p line exchange\n REASON FOR THIS EXAMINATION:\n F/u of pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative line exchange, to assess for pneumonia.\n\n FINDINGS: In comparison with the study of , the left subclavian catheter\n tip now lies probably within the right atrium. Long intestinal tube remains\n in place. There is increased opacification of the right hemithorax with\n preservation of pulmonary markings, consistent with substantial right layering\n pleural effusion. Underlying compressive atelectasis.\n\n The left lung is essentially clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229813, "text": " 4:02 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for PTX\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ETT and left pigtail, s/p colectomy\n REASON FOR THIS EXAMINATION:\n assess for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left pigtail catheter. Concern for pneumothorax.\n\n COMPARISON: Radiographs available from .\n\n FRONTAL CHEST RADIOGRAPH:\n A right IJ and left PICC are unchanged in position. An NGT terminates within\n the stomach. The heart size is normal. The hilar and mediastinal contours are\n unchanged since the 1:02 p.m. examination. Again seen is a lucency across the\n right minor fissure, representing a small pneumothorax, unchanged in\n appearance since the prior study. However, there has been an interval\n increase of a moderate-sized right pleural effusion. The left lung remains\n clear. A pigtail catheter is positioned at the left lung base.\n\n IMPRESSION:\n 1. Unchanged small right pneumothorax tracking along the minor fissure.\n 2. Interval increase of a moderate-sized right pleural effusion since the\n 1:02 p.m. study.\n 3. No left pneumothorax.\n\n The initial findings were discussed by Dr. with Dr. via telephone\n at 5:21 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2170-02-20 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1231635, "text": " 8:58 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ? aspiration\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with weakness, dysphagia\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Weakness and dysphagia, evaluate for aspiration.\n\n COMPARISON: .\n\n TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in\n conjunction with the speech and swallow team. Multiple consistencies of\n barium were administered.\n\n FINDINGS: Barium passes freely through the oropharynx and esophagus without\n evidence of obstruction. There was moderate residua within the valleculae and\n piriform sinuses. Penetration was observed during swallowing of thin liquids\n but there is no evidence of aspiration. For further details, please refer to\n speech and swallow note.\n\n IMPRESSION: Penetration but no gross aspiration with thin consistency liquid.\n Moderate pharyngeal residues.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230508, "text": " 5:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check to see if pleural effusions are reaccumulating\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man w/bilat pleural effusions. just dc'd the pigtails a few hours\n ago\n REASON FOR THIS EXAMINATION:\n check to see if pleural effusions are reaccumulating\n ______________________________________________________________________________\n WET READ: TXCf SAT 5:43 PM\n no evidence of pleural fluid reaacumulation following removal of pigtail\n catheters.\n chadashvili \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral effusions, DC'ed pigtails, question pleural effusions\n reaccumulating.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with at 5:54 a.m., the bilateral pigtail catheters have been\n removed. The Dobbhoff-type catheter is still present with radiopaque tip over\n stomach. The left subclavian PICC line is present, with tip over distal SVC.\n No reaccumulated effusions and no obvious pneumothorax is detected at this\n time.\n\n There is mild vascular plethora, without overt CHF. Minimal patchy\n atelectasis in the right cardiophrenic region and slight increased\n retrocardiac density is unchanged. A focal ~12.9 mm nodular density is seen\n in the left mid zone measuring immediately above the left anterior fourth rib,\n near its intersection with left posterior seventh rib. This is not fully\n characterized, but may correspond to an area of atelectasis seen on the\n chest CT (2:31). Attention to this area o n follow-up films is\n requested.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229705, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process?\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with bilateral PE\n REASON FOR THIS EXAMINATION:\n acute process?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:54 A.M., \n\n HISTORY: Bilateral pulmonary emboli. Question other acute process.\n\n IMPRESSION: AP chest compared to through 26:\n\n Greater opacification involving the left chest with a gradient from top\n increasing to the diaphragmatic surface is probably a large pleural effusion,\n increased since . Smaller right pleural effusion has also\n increased. The left lower lung is partially obscured and may be mildly\n atelectatic but otherwise unchanged. Right lung is grossly normal.\n Cardiomediastinal silhouette is unremarkable. ET tube in standard placement,\n left PIC line in the low SVC or at the superior cavoatrial junction. Enteric\n drainage tube passes into the stomach and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229900, "text": " 10:18 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assessment for pneumothorax s/p line removal\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66yo M s/p subtotal colectomy + end ileostomy with pneumothorax s/p line\n exchange. Need to assess for pneumo s/p line removal.\n REASON FOR THIS EXAMINATION:\n Assessment for pneumothorax s/p line removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subtotal colectomy and end ileostomy with pneumothorax, status\n post line exchange, need to assess for pneumo, status post line removal.\n\n COMPARISON: Comparison is made to chest radiograph performed the same day two\n hours earlier and , chest CT.\n\n FINDINGS: There has been interval placement of a Dobbhoff tube, which is\n coiled within the pharynx. There is a left-sided PICC line with tip\n terminating at the cavoatrial junction. There is interval removal of the\n right-sided central venous sheath. No pneumothorax evident. There is stable\n small right pleural effusion. Right lower lung opacification likely\n represents combination of atelectasis and layering pleural effusion. Stable\n calcified granuloma projects over right mid lung. A nodular opacity\n projecting over left upper lung corresponds with nipple evident on the\n , chest CT.\n\n IMPRESSION:\n 1. Dobbhoff tube coiled in esophagus with tip in pharynx. Recommend\n withdrawal.\n 2. No evidence of pneumothorax.\n 3. Stable right pleural effusion and basilar atelectasis.\n\n communicated these findings to Dr at 12:00 on\n via telephone.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1229616, "text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 M UC, b/l pleral efussions s/p subtotal colectomy\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: UC, bilateral pleural effusions, status post subtotal colectomy,\n question interval change.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Supine positioning.\n\n The carina is not well-delineated. The ET tube lies between 3.7 and 4.7 cm\n above the carina. An NG tube is present, tip extending beneath diaphragm off\n film. A right IJ sheath is present. Left subclavian PICC line tip overlies\n distal SVC, unchanged.\n\n Cardiomediastinal silhouette is unchanged. There are small to moderate\n bilateral effusions with underlying collapse and/or consolidation. Allowing\n for differences in patient position (supine today, erect on the prior film),\n there is no definite interval change.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230610, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: re-collection of fluids, other interval change\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with b/l pleural effusion s/p drainage\n REASON FOR THIS EXAMINATION:\n re-collection of fluids, other interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:04 A.M., \n\n HISTORY: Question reaccumulation of pleural effusion after drainage.\n\n IMPRESSION: AP chest compared to :\n\n There is no appreciable reaccumulation of pleural effusion and no\n pneumothorax. Left subclavian or PICC line ends low in the SVC and a\n nasogastric feeding tube passes into the stomach and out of view. A sharply\n marginated 10 mm wide round opacity projecting over the left third anterior\n interspace could be the left nipple, particularly since it is visible\n inconstantly on prior chest radiographs. If there is a legitimate concern for\n pulmonary nodule, CT scanning would be necessary.\n\n Left PICC line ends low in the SVC. Feeding tube passes into the stomach and\n out of view. Heart size and hilar silhouettes are normal and there is no\n indication of pleural effusion or pneumothorax. Feeding tube passes into the\n stomach and out of view. be right hemidiaphragmatic pleural\n calcification, a suggestion of prior asbestos exposure.\n\n" }, { "category": "ECG", "chartdate": "2170-02-07 00:00:00.000", "description": "Report", "row_id": 244743, "text": "Regular supraventricular rhythm, possibly sinus mechanism but baseline artifact\nprecludes definitive rhythm analysis. Compared to the previous tracing\nof regular supraventricular rhythm is now present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2170-02-05 00:00:00.000", "description": "Report", "row_id": 244744, "text": "Marked baseline artifact. Underlying rhythm is likely atrial fibrillation with\nrapid ventricular response. Diffuse low QRS voltage. Minor non-specific\nST-T wave abnormalities. Compared to the previous tracing of \nno diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2170-01-26 00:00:00.000", "description": "Report", "row_id": 244971, "text": "Sinus tachycardia with frequent premature ventricular contractions and\nnon-specific ST-T wave abnormalities. No diagnostic change from tracing\nof .\n\n" }, { "category": "ECG", "chartdate": "2170-01-24 00:00:00.000", "description": "Report", "row_id": 244972, "text": "Sinus tachycardia with ventricular premature beats. RSR' pattern in\nleads V1 and V2. ST-T wave abnormalities. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2170-02-08 00:00:00.000", "description": "Report", "row_id": 244742, "text": "Sinus bradycardia with baseline artifact. Compared to the previous tracing\nprobably no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2170-02-05 00:00:00.000", "description": "Report", "row_id": 244969, "text": "Probable atrial fibrillation with rapid ventricular response. Diffuse\nlow QRS voltage. Diffuse non-specific ST-T wave abnormalities. Compared to\nthe previous tracing of probable atrial fibrillation with a rapid\nventricular response is new. Suggest clinical correlation and repeat tracing.\nQRS voltage which was low before has diminished further suggesting a dynamic\nprocess. Suggest clinical correlation and repeat tracing.\n\n" }, { "category": "ECG", "chartdate": "2170-02-01 00:00:00.000", "description": "Report", "row_id": 244970, "text": "Sinus rhythm. Diffuse low voltage. Diffuse ST-T wave changes are\nnon-specific. Compared to the previous tracing of the rate has\ndecreased.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230534, "text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with bilateral CT\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Bilateral chest tubes removed. Assess for pneumothorax or\n increasing pleural effusions.\n\n Comparison is made with prior study .\n\n There is no evident pneumothorax or enlarging pleural effusions.\n Cardiomediastinal contours are unchanged. There are low lung volumes. Left\n PICC tip is in the mid SVC. NG tube tip is in the stomach. Bibasilar\n atelectases, larger on the right side, are stable. Calcified granulomas in\n the right upper lobe are again noted. Ill-defined rounded opacity in the left\n upper lobe is persistent. When clinically feasible CT is recommended for\n further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-15 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1231136, "text": " 8:41 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for source of fevers\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n Field of view: 36 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL ADDENDUM\n Thrombus is present throughout the iliac venous system and the caudad aspects\n of the IVC. A large burden of thrombus is also present within the IVC filter\n and extends 2mm cranial to the proximal tip of the filter.\n\n\n\n 8:41 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for source of fevers\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n Field of view: 36 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent bowel perforation, total colectomy, now with new\n fevers.\n REASON FOR THIS EXAMINATION:\n eval for source of fevers\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:18 PM\n - infrarenal IVC filter with extensive clot extending not bilateral common\n iliac veins into bilateral extenal and internal iliac veins and into bialteral\n common femoral veins. Thrombus has minimal superior extension beyond filter\n but bialteal renal veins are patent.21\n - pleurla based nodular consolidation, new since prior CT, likely round\n atelectasis, though warrants attention on follow-up (2:11)\n - known PEs note well seen\n - pt with total colectomy and ileostomy- no evidence of obstruciton or leak\n - anterior abd wall incision dehiscence with small bowel wall approximating\n overlying surgical staples. no defintive evidence of leak or fistula.\n - surgical sutures in pelvis with a small amount of surrounding simple fluid-\n no evidence of leak or abscess formation.\n - bladder partially collapsed around foley but with increased symmetric\n bladder wall thickness, may be related to colalpse but cannot exlcude\n infectous process\n - increased anasarca.\n PBishop d/w Dr at 23:15 on via telephone immediately findings\n were made.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fevers. Patient's history is significant for ulcerative colitis,\n with recent ruptured bowel and fecal peritonitis requiring colectomy performed\n .\n\n COMPARISON: CT of the abdomen from .\n\n TECHNIQUE: Axial CT images were acquired through the abdomen and pelvis\n following the uneventful intravenous administration of 130 cc of intravenous\n Omnipaque contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n DOSE: DLP 476 mGy-cm.\n\n CT ABDOMEN WITH CONTRAST: The lung bases are notable for subsegmental\n atelectasis, greater on the right than left as well as right basal pleural\n density, possibly a calcified pleural plaque. In the left lung base is a 13 x\n 8 mm nodule (2:11). The cardiac apex is notable for coronary arterial\n calcification. A nasogastric tube terminates in the stomach. The spleen,\n pancreas, right adrenal gland, gallbladder, and liver are normal. The left\n (Over)\n\n 8:41 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for source of fevers\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n Field of view: 36 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n adrenal gland is diffusely thickened (301A:46) in a pattern which is unchanged\n from the very recent comparison studies. The kidneys enhance and excrete\n contrast in a symmetric fashion, and contain bilateral hypodensities which are\n too small to characterize. Arterial structures are notable for\n atherosclerosis, without abdominal aortic aneurysm. The portal venous and\n mesenteric venous systems are patent. Note is made of an infrarenal IVC\n filter, with extensive IVC thrombus in the caudal aspects of the IVC,\n extending to both iliac veins, as well as the bilateral femoral venous\n vasculature. There is a small amount of free fluid remaining within the\n abdomen. Cutaneous staples are present along a right paramedian location\n reflecting the site of surgical scar. Along the cranial aspect of these\n staples is a small, incisional hernia. There is no evidence of\n intra-abdominal abscess.\n\n CT PELVIS WITH CONTRAST: The urinary bladder contains a Foley catheter. The\n prostate, seminal vesicles are unremarkable. The patient is status post\n colectomy and note is made of a rectal Hartmann pouch. There is a small\n amount of free fluid in the pelvis. There is no free gas in the pelvis. Note\n is made of diffuse severe anasarca.\n\n OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion.\n\n IMPRESSION:\n 1. Postoperative sequelae as described above, with a small amount of residual\n free fluid and severe anasarca, though no evidence of intra-abdominal or\n pelvic abscess.\n 2. Extensive severe deep venous thrombosis in the bilateral femoral\n vasculature, iliac vasculature in the lower portions of the IVC, below an\n infrarenal IVC filter. There is no evidence of more proximal venous thrombus.\n 3. Left lower lobe pulmonary nodular opacity. Unclear if true nodule or\n focal atelectasis/inflammation. Recommend repeat chest CT in 3months.\n\n Results and recommendations were discussed by Dr. with Dr.\n at 23:15 on via telephone.\n\n" }, { "category": "Radiology", "chartdate": "2170-02-14 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1230952, "text": " 1:22 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: assess clot burden prior to possible IVC filter removal\n Admitting Diagnosis: ISCHEMIC LEGS DVTS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with LE DVT's, IVC filter in place, on Argatroban.\n REASON FOR THIS EXAMINATION:\n assess clot burden prior to possible IVC filter removal\n ______________________________________________________________________________\n WET READ: MLHh WED 2:26 PM\n Continued extensive occlusive thrombus throughout majority of BLE. Minimal\n flow in the R CFV, DFV, GSV and L GSV.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with extensive bilateral DVT on argatroban,\n considering removal of IVC filter.\n\n COMPARISON: CT venogram from .\n\n BILATERAL LOWER EXTREMITY ULTRASOUND:\n On the right, there is markedly reduced flow and minimal pulsatility within\n the mostly thrombosed right common femoral vein. Partial inflow noted from\n the greater saphenous and deep femoral veins. Right superficial femoral,\n popliteal and below knee vdeep veins are completely thrombosed.\n\n On the left, the common femoral vein is completely thrombosed. There is mild\n flow within the greater saphenous vein, which drains via collaterals, and not\n into the occluded common femoral vein. Left superficial femoral, popliteal and\n below knee vdeep veins are completely thrombosed.\n\n IMPRESSION: Peristent near-complete occlusion of the deep bilateral lower\n extremity veins. Minimal flow in the right common femoral, deep femoral, and\n greater saphenous veins and left greater saphenous vein.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2141-03-06 00:00:00.000", "description": "Report", "row_id": 1514249, "text": "Respiratory Care\nPt. earlier in day after increasing respiratory distress and impending respiratory failure. MDI's administered as ordered. BS occ. coarse clear after Sx. of thick blood tinged secretions. Demonstrated a gool RBSI trial this a.m. RSBI - 60. appeared to tol. well.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-06 00:00:00.000", "description": "Report", "row_id": 1514250, "text": "BS coarse crackles. Weaned to CPAP 10/5 with NAD. CT of chest with results pending.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-06 00:00:00.000", "description": "Report", "row_id": 1514251, "text": "ccu nursing progress note\npls see carevue flowsheet for complete vs/data/events\ns: orally . able to mouth words, nod heads, follows commands.\no: id: afeb. levo added. vanco dosed per level. cont on zosyn for pna. all culture data pend or ngtd.\ncv: hr 60-80s sr. no vea. bp 140-160/60-80 now monitored via l radial aline. rec'd norvasc 10mg this afternoon but has since been dc'd. lopressor dose ^'d to 100mg tid from . isordil remains at 30mg tid. following cardiac enzymes, troponin elevated.\nresp: changed to ps 10/5. tv 500-600. rr 20s. abg: 7.36/25/172/15/-9. plan to continue ps wean. sxn'd for mod amt tan, thick bld tinged secretions. bs scatt coarse.\ngi: ogt in place. to start tf. no stool.\nheme: hct to 26.7, repeat confirmed. rec'ing 1unit prbcs ordered ^at 5pm.\ngu: foley to . uop 100cc/hr. cr 4.2(4.5).\nms: alert, v lightly sedated on propofol at 40mcg/kg. able to follow commands. mae w purpose. trying to communicate.\nskin: intact. freq repositioned w skin care. has bruising on r side of tongue from probable biting.\nsocial: family visiting throughout day. updated by rn and micu team. dtr plans to stay the night.\na: pna. tol ps wean. hd stable.\np: follow resp exam and wean as tolerated. pulm toilet. complete transfusion and monitor tolerance. cont supportive care and communication w family.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-07 00:00:00.000", "description": "Report", "row_id": 1514252, "text": "Respiratory CAre\nPt. on CPAP/PS tol well over night. BS coarse with abundent exp. wheezes inhaers adm. as ordered and pt. sx as per care vue for mod amounts of thick blood tinged secretions. BS remain with some fine exp. wheezes. Good RSBI but exp. increase in BP. (See CareVue) RSBI = 42\n" }, { "category": "Nursing/other", "chartdate": "2141-03-07 00:00:00.000", "description": "Report", "row_id": 1514253, "text": "CCU progress note 7p-7a\n\nNEURO: lightly sedated. family staying overnite in waiting room - checking every few hours on pt condition. PROPOFOL @ 40mcg/k/min. Became agitated at 5am w/ SBP 170s - holding onto foley, refusing to let go, given bolus propofol - settled, repositioned, foley moved out of way, + hand re-restrained. bilat soft wrist restraints.\n\nID: afebrile. 98.9. WBC 9.8. ABX: Zosyn + Levoflox + prn dosing of vanco.\n\nRESP: LS coarse. occ wheezes. nebs per RT. CPAP overnite 40%. am abg: 7.39/28/201 sats 100%. RR 20s. TV 5-700s.\n\nCARDIAC: SR 1'AVB 70-80s. L radial Aline. 150-170s/60. 3 PIV.\nTransfused 1u PRBCs last evening am HCT 28.6(26.7). Lopressor 100mg TID + Isordil 30mg TID.\n\nGI/GU: foley patent. good u/o. abd soft distended. +BS. no BM. OGT patent. TF started last nite - NEPRO @ 20cc/hr (goal rate). on RISS FS QID. On steroids. BUN/CR 65/4(61/4.2).\n\nPLAN: monitor HCT. con't abx. con't vent wean in am - continue to wean. cont' sedation. pulm toliet.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-09 00:00:00.000", "description": "Report", "row_id": 1514264, "text": "CCU NPN 3-11pm\nCV: HR 80-90's NSR, BP initially 170-180's/, given .1mg clonidine po inaddition to patch(12 hrs to take effect), to recieve 3 doses po, follow BP to determine if all 3 doses will be needed. cont on hydral and isordil. BP now 150-160's/60's.\n\nResp: remans on 40% PS 5/5PEEP with RR 14-16, VT's 600's, Sats 100%. LS clear with minimal wheezing, MDI's decreased to Q4hr from q2\nsuctioned for sm amt blood tinged sputum. Oral cavity with sm amt bleeding, tongue with sm laceration and bruised.\n\nNeuro: opens eyes, does not follow commands, remains sedated. Midaz decreased to 1mg/hr. will need to turn off early AM in prep for pot extubation.\n\nSkin: intact. Abd is oozing from hep injections, scrap on chin, cleansed and covered with 2x2. repositioned q 2-3 hrs.\n\nGI: cont on Nepro at 30cc/hr, BS (+), no stool.\n\nGU: cont with adequate UO, renal US ordered for tomorrow.\n\n: cont on SS reg cov, BS 266 at 1800, covered with 8 U reg.\n\nSoc: son in and out this eve. will be staying overnight. Wife and daughter went home.\n\nA/P: Pt near ready for extubation, weaning sedation. Check rsbi in AM, stop after MN. cont support and update family.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-10 00:00:00.000", "description": "Report", "row_id": 1514265, "text": "Resp CAre\nPt remains on the vent. with 7.5 @ 21, patent and secure. Suctioned mod amt of thick bloody secretions. no changes made. Rsbi 40. Plan to extubate in the am.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-10 00:00:00.000", "description": "Report", "row_id": 1514266, "text": "ccu progress note 7p-7a\n\nNEURO: lightly sedated on versed 1mg/hr. 1mg bolus x 2 versed overnite for ^BP d/t ?agitation. Haldol 1mg IVP given x 1 w/ little effect.\n\nID: Tmax 100.4 this morning. sputum cx obtained. BC obtained yesterday - pnd. on levofloxacin q48hrs. WBC 19.7(22.4).\n\nCARDIAC: SR 90s SBP 160-180s. Clonadine patch applied yesterday - po clonidine x3 doses to be given until patch takes effect (2 of 3 doses given). Remains on Isordil 40mg po TID + Norvasc 10mg qam.\n\nRESP: LS I/E wheezes, scattered coarsness. am ABG: 7.39/43/168/27/1 - sats 100%. remains on PS 5/5 40% w/ RR 8-14 TV 500-700s. ?extubate today. Sx small amts thick tan/bld tinged secretions. spec sent to lab.\n\nGI/GU: pt made NPO at 4am. TF off. min residuals while one. reglan 5mg qid. colace TID. no BM as yet. need to send stool for cx. foley patent dk amber urine w/ sediment. ~30cc/hr.\n: FS QID w/ RISS.\n\nPLAN: ?extubate today. con't cardiac meds. monitor temp - cultures pnd drawn yesterday. sputum sent this morning. FS qid.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-07 00:00:00.000", "description": "Report", "row_id": 1514254, "text": "ccu nursing progress note\ns: orally . nods head to ?s, follows commands\no: pls see flowsheet for complete vs/data/events\nid: afeb. zosyn dc'd. vanco level 20 today. not redosed at this time. remains on levo q 48hr.\nresp: rsbi 47 this am. on 10ps/5peep. weaned to . rr ^ slightly to low 30s. tv 350-450. abg ok. held on intubation d/t appeared to have ^'d wob on , and pt w^^'d sputum(loose, tan and bld tinged) and very wheezy. returned to ps 10. rr 24-30. bs scatt coarse, w diffuse exp wheezes.\ncv: hr 70s sr. no vea. bp 140-170/50-70 via l rad aline. lopressor dc'd d/t ^'s wheezyness today poss in response to ^'d lopressor yesterday. added hydralazine and restarted norvasc. remains on isordil.\ngi: tf ^'d to nepro at 30cc/hr. noted sm amt coffee grds in gi aspirate in am. no stool. abd distended w +bs. bs 140s.\ngu: uop 50-100cc/hr. cr 4.0.\nms: v alert and agitated at times. poorly controlled w propofol tho running at 40mcg/kg w occ boluses. after decision for pt to remain sedation switched to versed and fentanyl w some effect.\nsocial: family visiting, updated by rn.\naccess: rad aline. 3 peripheral ivs. seen by iv team for poss picc. site saved but deferred at this time as pt has adequate access at this time\na: ^'d sputum and wheezy, unable to extubate at this time.\np: follow resp exam. monitor hemodynamics w med changes. med for comfort.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-07 00:00:00.000", "description": "Report", "row_id": 1514255, "text": "Respiratory Care\nPt continues to be orally /ventilated at this time. BS: Exp wheeze throughout. MDI's administered Q4hrs. Suctioned for copious amounts of thick blood-tinged secretions. Pt tolerated PSV 5/5 for an hour until resp rate increased to low 30's and an increase in work of breathing noted. Despite normal abg's. PSV increased back to 10cm with rate decreasing to 15-20. Plan to continue antibiotics/pulmonary toliet in attempt for future extubation trials.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-08 00:00:00.000", "description": "Report", "row_id": 1514256, "text": "ccu progress note 7p-7a\n\nEVENTS: uneventful evening. BP elevated w/ agitation - increased fentanyl gtt w/ good effect. Increased wheezing thruout - increased albuterol to 6-8puffs q4h w/ some noted decrease. family in to see pt.\n\nNEURO: sedated on VERSED 2mg/hr + FENTANYL 100mcg/hr.\n\nID: afebrile. abx: levofloxacin. prn dosing of vanco per daily level.\nCONTACT PRECAUTIONS MRSA.\n\nRESP: LS diffuse I/E wheezing throughout. Coarse to bases. sx thick tan/yellow secretions. sats 100%. PS decreased to 40%. am labs pnd.\n\nCARDIAC: SR 70-80s. L radial aline patent. SBP 150-160s w/ increasing to 170-190s w/ agitation earlier in shift. ISORDIL increased to 40mg TID and HYDRALAZINE increased to 30mg QID. Now on Amlodipine 10mg qd.\n\nGI/GU: foley patent. good u/o. abd soft, distended. no BM. OGT patent - TF Nepro w/ promod @ GR 30cc/hr. RISS FS QID.\n\nPLAN: con't resp wean - con't steroids + inhalers to improve wheezing. con't cardiac meds + sedation. abx. TF. FS qid. support to family.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-08 00:00:00.000", "description": "Report", "row_id": 1514257, "text": "ccu progress note 7p-7a\n\nGI: TF residuals >120cc. TF on hold since 6am. Meds given. FS 233 - given 6u Regular insulin.\n\nRestart TF after 8am.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-10 00:00:00.000", "description": "Report", "row_id": 1514267, "text": "CCU NPN: MICU border see flowsheet for objective data\n\nCardiac:HR 95- no VEA. SBP has been high all day despite increasing doses of hydralazine and clonidine. BP 153-197/51-74\n\nResp: extubated at 12 today. Post extubation ABG 7.45/36/123 cont to have insp/exp wheezes. MDI's to be switched to nebs. on prednisone taper to receive 40mg tomorrow\n\nID: afebrile. cont on levoquin q 48 and renally dosing vanco by levels,24 today.WBC 19.1(19.6)\n\nGU: urine output 100-120/hr last BUN/Creat 98/4.6 K 3.4,ca 7.3 phosph 4.3\n\nGI: had very large liquid stool,spec sent for c-diff. FIB placed.no further stool\n\nEndocrine: FS 175-219 being covered by SSI\n\nNeuro: in early am not responding to commands,son asking him to squeeze hands,etc. by 12 was able to lift head off pillow when daughter asked. now following commands. initially not speaking just moaning. now speaking. though did tell family he was at home,tried to climb out of be once. a family member will spend the night to provide for safety. speech and swallow did an eval...fluids need to be thickened,pills to be crushed.\n\nA: improving resp status,renal function not improved,SBP remains difficult to control\n\nP: cont to assist family in assessing neuro status\n cont to follow FS and cover\n monitor BP and cont with medical plan\n emotional support pt and family\n" }, { "category": "Nursing/other", "chartdate": "2141-03-11 00:00:00.000", "description": "Report", "row_id": 1514268, "text": "CCU Nursing Note\nS-\"Thank you, thank you very much.\"\nO-See flowsheet for additional details.\n\nN-pt speaks several languages although none of which English. Family @ bedside throughout shift-per family a/ox1-needs reminders of place/time. More lucid as evening progressed per family. MAE, PERRL. Very copperative c care. cough/gag impaired. Thickened consistency diet per speech and swallow eval c pills crushed in custard.\n\nCV-NSR 80s-90s. BP remains elevated despite multiple anti-hypertensives c SBP 160-185 and MAP >90. Hydralazine dose increased last shift and clonidine patch remains intact. Left radial a-line remains sharp. 2 PIVs.\n\nResp-Txing for pna. Extubated 1200-tolerated well. Now weaned down to 2L NC c sats >97%. ABGs WNL. LS coarse c insp/exp wheezes-nebs dosed as ordered. Prednisone taper.\n\nID-Afebrile. Continues on Levofloxacin. WBCs 19.1. Contact for previous MRSA.\n\nGI/GU/-FIB intact c small amt liquid stool during shift. BS+. Tolerating thickened diet. Foley c pink tinged urine >60cc/hr. BUN/Crt remain elevated from baseline. SSI c regular coverage.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-05 00:00:00.000", "description": "Report", "row_id": 1514246, "text": "ADMIT NOTE 0930\nPT WAS SENT TO CCU FOR PNA/RESP DISTRESS AND PT NEEDED TO BE INTUBATED.ABG PH 7.07/PO263/PCO260/ K5. PT WAS FOUND IN HIS ROOM ON 3 IN RESP DISTRESS, LABORED BREATHING, TACHYPENIC RR 40'S. PT ARRIVED TO CCU INTUBATED AND IN DISTRESS PT WAS STARTED ON IV PROPOFOL 30MCG/KG/MIN.\nS/P INTUBATION ABG 7.26/41/178/-. PTS FIO2 WAS DROPPED TO .60 100%. AC/FIO2 60%/ TV 500/ SET FOR 14 PT OVERBREATHING ON HIS OWN BY 16-18. LS C EXP WHEEZES.\n\nCV: PT WAS IN ST ON ARRIVAL TO UNIT 'S. BP WAS IN THE 160'S. ONCE PT WAS STARTED ON SEDATION PT WAS IN NSR C A BP IN THE 140'S. A.M. BP MEDS ON HOLD UNTIL PT WAS STABLE. CPK 386/CPK-MB17. TROPONIN .07.\n\nID: PT AFEBRILE 98.7PO. PT ON MRSA PREC.\n\nGI: ABD DISTENDED (+)BS AND NO BM. OGT PLACED AND CONFIRMED BY X-RAY. ON INTERMITTEN SUCT.\n\nGU:CRI BASELINE CREAT IS HIGH 2S. BUN61,CREAT 4.7. MIN UO AT THIS TIME.\n\nENDO: PT ON A SS INSULIN ORDER.\n\nSOCIAL: PT HAS VERY SUPPORTIVE KIND FAMILY\n\nA:82YOM C H/O ASTHMA, HTN, CRI. NOW IN RESP FAILURE NEEDED INTUBATION.\n\nP: CONT TO MONITOR RSP STATUS VIA ABG'S ADJUST A NEEDED. CONT TO MONITOR RENAL IMPAIRMENT. PT NEEDS A ALINE PLACED. PNA MONITOR TEMP.KEEP FAMILY INVOLVED.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-05 00:00:00.000", "description": "Report", "row_id": 1514247, "text": "Respiratory Therapist\n82 years old Male diagnosed with pneumonia,CHF, got short of breath and restless on floor where he got intubated with ETT size 7.5, taped originally 22 at lips, then Doctor ordered to pull ETT back to 19 which is done, breath sounds coarse, suctioned for copious thick blood-tinged, now ordered to have nasopharyngeal sampling done to rule out influenza.Patient is on AC now.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-06 00:00:00.000", "description": "Report", "row_id": 1514248, "text": "CCU NPN\n\nCV: REMAINS IN NSR-SB WITH HR 59-75. SBP 126-137 WITH MAP'S 77-87. GIVEN LOPRESSOR AND ISORDIL WITH GOOD BP AND HR CONTROLS. INTIALLY TACHYCARDIAC, BUT IMPROVING HR'S WITH SEDATION INCREASE.\n\nRESP: MECH VENT # 7.5 ETT @ 21L. AC 50%,500X18,5 SATS 100%. ENCOURAGED TEAM TO INSERT A-LINE. DEFFERED AT THIS TIME. ABG DRAWN BY MD FROM VENOUS STICK. 7.30,40,55,20,-5. CON'T ON INHALERS AND STEROIDS FOR RLL PNA. BS COURSE/DIMINISHED IN BASES. HAS SM HEMATOMA NOTED ON TONGUE ON R LAT SIDE. IMPAIRED GAG AND COUGH.\n\nGI: OGT BRIEFLY CONECTED TO LIS. SCANT BILIOUS DRAINAGE NOTED. ABD SOFT/DISTENDED. NO STOOL. + BS ON PPI'S.\n\nGU: U/O > 75CC/HR LOS + 488\n\nSKIN: INTACT\n\nNEURO: AGITATED INITIALY. OPENS EYES TO NAME, RAISING UP BOTH ARMS, BUT ATTEMPTING TO PULL AT ETT. TACHYCARDIC AND RESTLESS. PROPOFOL ^ TO 40MCG/KG/MIN WITH VERY GOOD CONTROL. PUPILS 2MM BRISK.\n\nID: TEMP MAX 99.6 CON'T ON MRSA PRECAUTIONS. ON VANCO AND PIPERCILLIN FOR PNA. URINE, URINE LEGIONELLA, SPUTUM AND BLD CULT ALL PENDING.\n\nLABS: BS 174 COVERED WITH4 U REG INSULIN PER SS\n\nIVF: RECEIVED 1 L NS FOR SUSPECTED SEPSIS\n\nSOCIAL: MANY FAMILY MEMEBERS IN. SPOKE WITH MD AND UPDATED ON POC. FAMILY ENCOURAGED TO CALL BEFORE COMING INTO UNIT. FAMILY INSTRUCTED ON PROPER HAND WASHING AS PT IS ON PRECAUTIONS.\n\nA/P: 82 YR OLD ADM TO CCU ON WAS ON 3 BECAME SOB/COUGH HTN WITH BP 180/ RESP DITRESS. PT . PAN CULT SENT TO CCU AS MICU BORDER. R/I PNA. CON'T ON INHALERS,STEROIDS, AWAIT CULT RESULTS. SHARE POC WITH FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-08 00:00:00.000", "description": "Report", "row_id": 1514258, "text": "Respiratory CAre\nPt. remains on CPAP/PS. PS decreased during shift due to high Vt. BS very wheezy with pronounce prolonged exp. phase. Alb/atro MDIs adm as ordered with minimal benefit. Sx for large amounts of yellow and blood tinged secretions. RSBI = 14.6\n" }, { "category": "Nursing/other", "chartdate": "2141-03-08 00:00:00.000", "description": "Report", "row_id": 1514259, "text": "Respiratory Care\nPt continues to be orally inubated/ventilated at this time. BS: Profound expiratory wheeze bilaterally with a prolonged expiratory phase. MDI's administered Q2hrs. Suctioned for moderate amounts of blood-tinged secretions. Pt found have apnic periods this am/metabolic acidosis. Changed to A/C for a period of time/bicar drip started/abg's improved. Pt currently back on PSV 5/5/.40 with VT >1.0L and RR 8-12. Will contine to support at this time.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-08 00:00:00.000", "description": "Report", "row_id": 1514260, "text": "CCU NPN: MICU border,see flowsheet for objective data\n\nCardiac: HR 77-130's BP 130-180's/58-80 continues on isordil 40mg TID,norvasc 10mg po qd,hydralazine switched to 30mg IV q6.both HR and BP are better controlled when more sedated.\n\nGU/Renal/Volume: urine output dropped off to 10/hr this am. given 500cc NS bolus and started on D5W w/ 3 amps bicarb at 150/hr. urine output increased to 40-60/hr. + 1400 for day. am labs BUN/Creat 81/4.3,ca 7.0 phosph 7.1,serum bicarb 16.ionized calcium 0.88 repleted w/ 4gms IV. started on calcium carbonate and then amphojel to lower phopsh. repeat labs at 3pm BUN/Creat 79/4.2 calcium 7.7 Phos 6.3 serum bicarb still only 16.\n\nResp: at start of shift put on AC due to apnea. ABG on 40% 500 x 16 5 of peep 7.26/32/211. as sedation lightened placed back on PSV 8. repeat ABG 7.36/26/172 rr 7-16 large TV's 1 liter to 1.5 liters. sedation now back to 100mcg fentanyl and versed 2mg and now back on AC.concerns that CO2 may drop to low. cont on methylprensilone 80mg IV q8.\n\nGI: OGT aspirates greater than 120cc at 8am and again at 10am,reglan 5mg IV q6 started,colace TID started. able to restart TF's at 4pm. restarted at 20cc/hr. + BS no stool\n\nID: afebrile,on IV levoquin q 48hrs. WBC's up to 16.6 from 8 yest\n\nHeme: HCT this am 30 stable.epogen started today\n\nEndocrine: FS 232-272 being covered per sliding scale\n\nNeuro: unresponsive this am,pupils pinpoint. decreased sedation by half.no gradual waking,woke up agitated reaching for ETT. did nod head to questions but only nodded no no matter what was asked. HR and BP both very high at that time. sedation increased again\n\nSocial: various family members in and out of room. form social work checked in with family who maintain daily contact with MD. expressed that communication needs are currently being met.\n\nA: 82 yo admitted s/p intubation for rep distress ,R/I PNA,worsening renal failure and metabollic acidosis\n\nP:finish bicarb drip for total of 1.5 liters\n recheck ABG sedated and on AC\n cont to follow FS\n assess neuro status???? CT why large TV's with low rate\n emotional support pt and family\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-03-09 00:00:00.000", "description": "Report", "row_id": 1514261, "text": "CCU progress note 7p-7a (MICU boarder)\n\n82yo w/ NIDDM, ASTHMA, HTN, smoker, h/o pna, CRI- was admitted to CCU s/p resp distress/intubation. RI pneumonia. worsening renal failure. difficult wean.\n\nUneventful night. . Elevated BP w/ IV placement + then with repositioning in bed - given fentanyl 50mcg + 0.5mg versed w/ little effect on BP - given am dose of isordil 40mg po + Hydralazine 30mg IVP w/ some effect. back to normal BPs 150-160s.\n\nCARDIAC: SR/ST 96-120s. SBP 150s-190s - elevated w/ agitation (placed 2 new PIVs + changed Aline dsg then repositioned in bed). On Isordil 40mg TID, Hydralazine 30mg IV q6h. Amlodopine 10mg qam. HCT stable - 31.1 - on epoetin.\n\nACCESS: L radial aline, 2 newly placed PIVs (2 older in place).\nSKIN: 2 spots on lwr abd continue to bleed from heparin s/c shots - opstite applied x2 over nite.\n\nID: afebrile. Tmax 99.3. WBC elevated 22.4(16.6). remains on levofloxacin q48h. on Solumedrol 80mg IV q8h.\n MRSA Contact Precautions.\n: FS QID w/ RISS required.\n\nNEURO: remains lightly sedated on VERSED 2mg/hr + FENTANYL 100mcg/hr. given some boluses at beginning of shift + this morning. family very supportive - children taking shifts staying in waiting area overnite and during day.\n\nRESP: LS I/E wheezes. small amts bld tinged secretions. oral care q4h. pt was on AC at beginning of shift - but fighting against regulated breaths - would hold breath, cause apena/obstruction alarm to sound, more sedation given w/ some effect - but placed onto PS 5/5 40% w/ good effect. am abg while on all nite: 7.39/39/165/0/24.\n\nGI/GU: foley patent. dk amber/tea coloured urine w/ sediment. >30cc/hr. abd distended, using accessory muscles when breathing. +BS. no bm. obtain stool spec for cdiff if pt stools. OGT patent - low residuals now that pt on renal dosed reglan qid. TF Nepro @ GR 30cc/hr. RENAL: BUN/CR elevated 84/4.5(79/4.2).\n\n\nPLAN: con't sedation for comfort. con't vent wean. con't abx. con't cardiac meds. obtain stool spec. FS QID.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-09 00:00:00.000", "description": "Report", "row_id": 1514262, "text": "ccu nursing progress note\ns: orally \no: pls see carevue flowsheet for complete vs/data/events\nid: afeb. wbc^ 22. bld cultures sent, 1 peripheral, 1 off aline. urine also sent. remains on levo. vanco dosed today for level 14.6. other culture data pend or ngtd.\ncv: sr-st, rate hi 80s to 120. bp 170-210/60-70 via l rad aline, confirmed w auscultation. higher numbers when pt w eyes open and appearing to grimace. hydralizine ^'d to 40mg iv qid. team discussed adding clonidine patch or ace inhibitor but have not as yet.\nresp: remains on \r%. in am rr 5-10,\ntv 900-1000. abg: 7.34/44/161/25/-2.\nwith wean off fentanyl rr ^to w tv700-1000.\ngi: tf at goal 30cc/hr. residual 25-50cc today. cont rec'ing reglan q6hr. abd distended, hypoactive bs. no stool, remains on colace.\ngu: uop 40-70cc/hr. cr 4.5(4.2).\nskin: intact. some edema in upper extremities.\nms: opens eyes. grimaces w pain but barely moves to withdraw extremities. team concerned that fentanyl suppressing rr and compromising effort to extubate pt. fentanyl weaned off by 2pm. hr and bp ^, pt opening eyes, making mouth and swallowing movements but really nothing w any purpose or intent or to follow commands.\nsocial: wife, son and dtr visiting. need update from medical team.\na: weaning sedation. htn\np: follow ms/comfort. cont versed, bolus as needed. prn haldol for agitation. follow resp exam. adjust vent parameters as indicated. support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-09 00:00:00.000", "description": "Report", "row_id": 1514263, "text": "Respiratory Care\nPt continues to be orally /ventilated at this time. BS: Inspiratory/expiratory wheeze bilaterally R>L. Suctioned for small amounts of tan secretions. MDI's administered Q4hrs. Low grade fever noted. Pt is currently on PSV 5/5/.40 with tidal volumes ranging from 980-1.2L and a resp rate 6-15. ABG's acceptable. BP hypertensive at times. Questionable mental status persists. Will continue to closely monitor.\n" }, { "category": "Nursing/other", "chartdate": "2141-03-11 00:00:00.000", "description": "Report", "row_id": 1514269, "text": "CCU Nursing Note\nA/P-82y.o c PMHx asthma, HTN, CRI s/p resp distress c/b intubation. R/I pna. Successfully extubated . Continue anti-hypertensives, steroids, abxs, nebs. Update family and pt of POC per interdisiplinary rounds\n" }, { "category": "Nursing/other", "chartdate": "2141-03-11 00:00:00.000", "description": "Report", "row_id": 1514270, "text": "ccu npn\nsee transfer note for today's note.\n" }, { "category": "Echo", "chartdate": "2141-03-06 00:00:00.000", "description": "Report", "row_id": 103645, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Abnormal ECG.\nWeight (lb): 147\nBP (mm Hg): 145/63\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 11:34\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: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Calcified tips of\npapillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal 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 normal in size. 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 aortic stenosis is not present. Mild (1+) aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, mild mitral and mild aortic regurgitation are now identified (not\nreported previously). Mild symmetric left ventricular hypertrophy is also now\nidentified. Global biventricular systolic function remains preserved.\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": "2141-03-12 00:00:00.000", "description": "Report", "row_id": 298983, "text": "Sinus tachycardia\nConsider prior inferior myocardial infarction although is nondiagnostic\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , further ST-T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2141-03-05 00:00:00.000", "description": "Report", "row_id": 298984, "text": "Sinus rhythm. Borderline first degree A-V delay. Probable left atrial\nabnormality. Early precordial QRS transition is non-specific. ST-T wave\nconfiguration suggests early repolarization pattern/normal variant, but\nclinical correlation is suggested. Since the previous tracing earlier this date\nsinus tachycardia and the lasteral ST segment depressions are now present, and\npattern of early repolarization is now seen.\n\n" }, { "category": "ECG", "chartdate": "2141-03-03 00:00:00.000", "description": "Report", "row_id": 298985, "text": "Sinus tachycardia\nConsider old inferior infarct\nLateral ST changes are nonspecific\nSince previous tracing, lateral ST chnages less pronounced - consider ischemia\n\n" }, { "category": "ECG", "chartdate": "2141-03-04 00:00:00.000", "description": "Report", "row_id": 298986, "text": "Sinus rhythm\nBorderline first degree A-V block\nSince previous tracing, lateral ST-T waves normalized\n\n" }, { "category": "ECG", "chartdate": "2141-03-04 00:00:00.000", "description": "Report", "row_id": 298987, "text": "Sinus rhythm\nNormal ECG\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2141-03-05 00:00:00.000", "description": "Report", "row_id": 298988, "text": "Sinus tachycardia\nInferior/lateral ST-T changes suggest myocardial injury/ischemia\nRate and ST-T wave changes new from previous consider ischemia\n\n" }, { "category": "Radiology", "chartdate": "2141-03-10 00:00:00.000", "description": "DUPLEX DOP ABD/PEL LIMITED", "row_id": 905950, "text": " 9:10 AM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: hypertension. renal artery stenosis?\n Admitting Diagnosis: PNEUMONIA;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with severe hypertension despite maximal 3 dose regimen.\n REASON FOR THIS EXAMINATION:\n hypertension. renal artery stenosis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 82-year-old man with severe hypertension.\n\n COMPARISONS: .\n\n TECHNIQUE: Renal ultrasound examination with limited portable Doppler\n evaluation of the liver.\n\n FINDINGS: The right kidney measures 9.9 cm in length, the left measures 9.5\n cm. The cortices are somewhat thin bilaterally, which can be seen in\n parenchymal disease. Bilateral simple renal cysts are unchanged. Limited\n Doppler studies of both kidneys, with measurement of the resistive indices\n among multiple intralobar arteries bilaterally, show symmetric flow of the\n entirety of both kidneys, with resistive indices on the right ranging from\n 0.68-0.84 and on the left, from 0.77-0.80. There is a Foley catheter in the\n bladder, which is empty.\n\n IMPRESSION:\n\n 1. Somewhat thin cortices suggestive of parenchymal disease.\n\n 2. Bilateral simple renal cysts.\n\n 3. Symmetric appearance of color and spectral Doppler flow to both kidneys,\n with no suggestion of renal artery stenosis in this study.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2181-05-01 00:00:00.000", "description": "Report", "row_id": 1573073, "text": "PROB: S/P CABG\n\nCV: SR NO VEA NOTED, NTG STARTED AND TITRATED TO BP. CT DRAINING S/S DRAINAGE. PACER OFF. MED FOR PAIN X3 WITH MORPHINE, GOOD EFFECT. K AND CA REPLACED.\n\nRESP: ABGS ADEQUATE. SUCTION FOR SCANT WHITE. WEANING SLOWLY.\n\nGU: CLEAR YELLOW URINE.\n\nGI: NTG DRAINING COFFEE GROUND DRAINAGE, GUIAIC POSITIVE. NO BOWEL SOUNDS. NTG IRRIGATED WITH NSS, CLEARED.\n\nNEURO: PT RESTLESS AND AGITATED. MIDAZ 2MG X1 WHILE WAITING FOR PRECIDEX WITH GOOD EFFECT. PRECIDEX STARTED AT .4 AND TITRATED UP TO .6. PT STILL RESTLESS, NOT FOLLOWING COMMAnds. PERL.\n\nENDO: BS TREATED WITH 6U IV INSULIN WITH GOOD EFFECT. SEE FLOW SHEET.\n\nASSESMENT: RESTLESS AND AGITAATED\n\nPLAN: CONT PRECIDEX\nMONITOR BS/K/CA/HCT\nPROMOTE RESTFUL ENVIRONMENT.\n" }, { "category": "Nursing/other", "chartdate": "2181-05-02 00:00:00.000", "description": "Report", "row_id": 1573074, "text": " B:\n\nNeuro: alert, following commands, mae, oriented x 2 not oriented to place,paerl,ms04 for pain.\n\nCardiac: nsr in the 80's with occasional pvc, weened off neo gtt, sbp now in the one teen range, +2 edema in extremities, palpible pedial pulses, a-febrile, ci's all greater than 2, 2 a and 2 v wires, does not sense or capture correctly and box was shut off, ct's to sxn draining scant amount of sersang fluid.\n\nResp: lung sounds are dim in bases, on 5 liter nc satting at 94%, is coughing and deeep breathing, no leak in ct system.\n\nskin: chest with dsd with old serous drainage from or, medial stinal dsd cdi, right leg ace cdi, right fem site with dsd cdi.\n\nGi/Gu: tolerating ice chips presently will advance as tolerat, on and off insulin gtt, no bowel sounds presently, abd soft round and non-tender, making greater than 30 cc/hr of urine.\n\nPlan: start po's, start i/s, encourage to cough and deep breath, reorient as needed, monitor i/o's, monitor incision sites, monitor vital signs, transfer to floor later if stable.\n" }, { "category": "ECG", "chartdate": "2181-05-01 00:00:00.000", "description": "Report", "row_id": 140181, "text": "Sinus rhythm, rate 80. Right bundle-branch block. Possible inferior myocardial\ninfarction, age indeterminate. Compared to the previous tracing of the\nsinus rate is much faster. Right bundle-branch block is new (question possibly\nrate-related right bundle-branch block) and new Q waves have appeared in\nleads III and aVF raising the question of interval inferior myocardial\ninfarction.\n\n" }, { "category": "ECG", "chartdate": "2181-04-30 00:00:00.000", "description": "Report", "row_id": 140182, "text": "Sinus bradycardia, rate 41. Minor non-specific repolarization changes in\nleads III and aVF. Otherwise, normal tracing. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2171-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982856, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute cardiopulm proc\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hypoxia at \n REASON FOR THIS EXAMINATION:\n ? acute cardiopulm proc\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: Hypoxia.\n\n FINDINGS: The tracheostomy tube is approximately 5 cm above the carina. The\n left PICC line terminates in the upper SVC/brachiocephalic junction. There\n are persistent low lung volumes. There is increased right lower lobe linear\n opacities likely consistent with atelectasis. There is no pneumothorax. There\n are no focal consolidations or effusions.\n\n IMPRESSION: A left PICC line at the brachiocephalic-superior vena cava\n junction.\n\n These findings are communicated with Dr. at approximately 11:15\n a.m.\n\n" }, { "category": "Radiology", "chartdate": "2171-10-16 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 982917, "text": " 10:53 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for evidecne of acute cholecystits\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with elevated LFTs, AlkPhos, and fevers/hypotension\n REASON FOR THIS EXAMINATION:\n eval for evidecne of acute cholecystits\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Elevated LFTs, fevers, question cholecystitis.\n\n FINDINGS: Grayscale and color ultrasound imaging of the liver was performed\n with comparison made to CT examination of . Again seen are multiple\n shadowing stones within the gallbladder lumen. There is no gallbladder wall\n thickening or pericholecystic fluid. Son sign was not\n elicited. Body habitus limits thorough evaluation, however, no definite focal\n hepatic lesions are seen. There is no ascites. Two small hepatic cysts are\n seen, consistent with prior CT findings. Portal vein remains hepatopetal in\n flow direction.\n\n IMPRESSION: Cholelithiasis without son evidence for acute\n cholecystitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 983287, "text": " 3:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? change\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hypoxia at \n\n REASON FOR THIS EXAMINATION:\n ? change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia.\n\n FINDINGS: In comparison with the study of , there is little change. No\n definite atelectatic streaks are appreciated. No evidence of acute pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982833, "text": " 8:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate/edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hypoxia at \n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate/edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, evaluate for infiltrate or edema.\n\n Comparison is made to , radiograph.\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: Minimal amount of linear atelectasis is\n noted at the lung bases bilaterally with the lungs appearing otherwise clear.\n Cardiomediastinal silhouette, hilar contours, and pleural surfaces are within\n normal limits and unchanged. Tracheostomy tube terminates approximately 4.8 cm\n from the carina and left PICC terminates in the brachiocephalic\n junction/superior SVC. Previously identified surgical/drainage catheter\n projecting over the left upper quadrant is no longer visualized.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2171-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985185, "text": " 8:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EVal for pneumonia\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD c/b anoxic brain injury with trach and increased\n secretions\n REASON FOR THIS EXAMINATION:\n EVal for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:06 P.M., \n\n HISTORY: Coronary artery disease and occipital brain injury, and increased\n secretions.\n\n IMPRESSION: AP chest compared to and :\n\n Lungs are clear, heart size normal, widening of the upper mediastinum due to\n fat deposition chronic. No pneumothorax or pleural effusion. Lungs grossly\n clear. Tip of the left PIC line projects over the left brachiocephalic vein\n and a tracheostomy tube is in standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985219, "text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change, MICU rounds.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD c/b anoxic brain injury with trach and increased\n secretions\n REASON FOR THIS EXAMINATION:\n please assess for interval change, MICU rounds.\n ______________________________________________________________________________\n WET READ: KYg SUN 6:04 PM\n The lungs are clear. Trach in position. Left picc tip projects over left\n brachiocephalic vein. no change from 20:06.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:41 P.M.\n\n HISTORY: Increased secretions.\n\n IMPRESSION: AP chest compared to and 3:\n\n Lungs are fully expanded and clear. Tracheostomy tube tip abuts the left wall\n of the trachea and should be evaluated clinically to see if positioning is\n appropriate. Tip of the left PIC catheter projects over the mid left\n brachiocephalic vein. Borderline cardiomegaly is stable and fullness in the\n mediastinum is longstanding, probably due to fat deposition and tortuous head\n and neck vessels. There is no pleural abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985500, "text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD c/b anoxic brain injury with trach and increased\n secretions.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Anoxic brain injury with increasing secretions.\n\n FINDINGS: In comparison with the study of , there is no significant\n change. The lungs remain clear and a tracheostomy tube is again seen. No\n change in the appearance of the PICC line or borderline cardiomegaly and\n fullness of the mediastinum.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985029, "text": " 3:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for PICC placement and infiltrates.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD c/b anoxic brain injury with trach and L PICC that\n has migrated 5cm.\n REASON FOR THIS EXAMINATION:\n Please evaluate for PICC placement and infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Anoxic brain injury with tracheostomy, status post migration of\n PICC 5 cm.\n\n Portable AP chest dated is compared to the prior from .\n\n Tracheostomy tube is in stable position. The left PICC line has migrated\n approximately 2.5 cm and is now positioned in the distal left subclavian vein.\n The heart size and mediastinal contours are unchanged given patient\n positioning. Lung volumes are low, but there is no evidence of airspace\n consolidation, pleural effusion, or pneumothorax.\n\n IMPRESSION: Interval retraction of PICC approximately 2.5 cm, now terminating\n in the distal left subclavian vein.\n\n" }, { "category": "Radiology", "chartdate": "2171-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985808, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with likely PNA, psuedomonas on sputum.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Pseudomonas culture in scutum.\n\n Portable AP chest radiograph compared to . The tracheostomy\n tube is in unchanged central position. The mild-to-moderate cardiac\n enlargement is stable as well as the mediastinal widening. The lungs are\n overall clear except for right retrocardiac area where small opacity is\n demonstrated and might represent either atelectasis or pneumonia, unchanged\n since the previous study. There is no pleural effusion or pneumothorax. Left\n PICC line tip terminates in left brachiocephalic vein, unchanged since the\n previous study.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-11-11 00:00:00.000", "description": "UNCLOG G/GJ TUBE", "row_id": 986372, "text": " 11:52 AM\n PERC G/J TUBE CHECK Clip # \n Reason: please eval for tube function, change if necessary. preferab\n Admitting Diagnosis: HYPOXIA\n Contrast: OPTIRAY Amt: 75\n ********************************* CPT Codes ********************************\n * UNCLOG G/GJ TUBE UNCLOG G/GJ TUBE S&I *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with MMP- CAD c/b anoxic brain injury, urosepsis,\n osteomyelitis, trached, with PEG, non-functioning PEG\n REASON FOR THIS EXAMINATION:\n please eval for tube function, change if necessary. preferably today but if\n necessary tomorrow am.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Anoxic brain injury with nonfunctioning PEG. Please evaluate\n tube function and change if necessary.\n\n RADIOLOGIST: Dr. and Dr. , the attending physician,\n the procedure.\n\n PROCEDURE AND FINDINGS: The risks and benefits of the procedure were\n explained to the healthcare proxy and informed consent was obtained from the\n patient's brother. was placed supine on the angiographic table and the\n PEG was prepped and draped in usual sterile fashion. Initial spot film\n demonstrated G-tube catheter with a distended balloon in anticipated location\n overlying the stomach. Small amount of contrast was injected but could not be\n passed secondary to blockage. Vigorous aspiration and use of a Amplatz\n stiff wire with saline was able to dislodge the clog with subsequent rush of\n free- flowing saline. Approximately 25 cc of Optiray contrast was then\n injected via the G- tube and passed freely into the stomach with no\n resistance. The balloon was deflated and re-expanded with 5 cc saline.\n Reinjection of a small amount of contrast was performed demonstrating\n opacification of the stomach with good position of the balloon in situ. There\n was no extravasation.\n\n IMPRESSION: Successful declogging of G-tube using an Amplatz wire and\n saline. The tube is ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985314, "text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for changes in cardiopulmonary processes.\n Admitting Diagnosis: HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD c/b anoxic brain injury with trach and increased\n secretions.\n REASON FOR THIS EXAMINATION:\n Evaluate for changes in cardiopulmonary processes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Anoxic brain injury with increased secretions, to evaluate for\n pneumonia.\n\n FINDINGS: In comparison with the study of , there is no significant\n change. The lungs remain clear. Tracheostomy tube abuts the left wall of the\n trachea and the tip of the left PICC line projects over the mid to\n brachiocephalic vein. Borderline cardiomegaly is stable and the fullness in\n the mediastinum is longstanding, probably due to fat deposition and tortuous\n head and neck vessels.\n\n IMPRESSION: No significant interval change.\n\n\n\n ??\n\n ??\n\n ??\n\n ??\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-11-07 00:00:00.000", "description": "Report", "row_id": 1348626, "text": "Resp Care: Pt with 7.0 Portex; cuff inflated. Pt on 35% TM. SPO2 98-100% during night. Pt suctioned for moderate-large amounts of thick white secretions. MDI's given as ordered. PLAN: continue pulmonary hygiene.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-07 00:00:00.000", "description": "Report", "row_id": 1348627, "text": "Nursing Progress Note\nSee Carevue for specifics\n\nPt alert most of shift. Mouthing words, nods. Follows commands. MAE spontaneously in bed.\nNSR. HR 90's-tachy at times due to anxiety. BP 90's/50's.\nSecretions better today. Suctioned q 2 hours for thick white secretions. Sats 99-100% on 35% via trach .\nTolerating TF's at goal. Abdomen softly distended. +BS. Small soft formed BMx2.\n care done-see carevue.\nFBS well-controlled-RISS and fixed doses changed today.\n\nPlan: Continue pulm toilet, care, labs every other day, notify HO with changes.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-08 00:00:00.000", "description": "Report", "row_id": 1348628, "text": "RESPIRATORY CARE:\n\nFollowing for trache care protocol, equipment in place. Administering Tobramycin nebs , Xopenex as ordered. Sxing thick pale yellow secretions. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-08 00:00:00.000", "description": "Report", "row_id": 1348629, "text": "vss. plastics in to examine decubitus-suggest cont. w/ present regemin. sacral decubitus contaminated w/ stool-irrig w/ wd cleanser\nand alleyen applied.\npt suctioned q2hr mod. to copious thick white sputum. tol. trach collar.\npt w/ multiple scratch marks over body from scratching-very dry skin- oil and lotion applied very liberally.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-08 00:00:00.000", "description": "Report", "row_id": 1348630, "text": "Nursing Progress Note\nSee Carevue for specifics\n\nPt remains stable. Afebrile. Low BP to 80's x 1. Given fluid bolus with effect. HR 80's-tachy at times with agitation. Given Ativan prn with effect. Remains on Trach collar 35%. Sats 99-100%. Suctioned q 2-3 hours for moderate amts thick white secretions. Nebs given by RT as ordered.\nUrine cloudy with some sediment-UA/culture sent.\nDressings changed on coccyx and left hip as directed by plastics.\n\nPlan: Continue pulm toilet, follow labs, transfer to rehab facility when screened.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-16 00:00:00.000", "description": "Report", "row_id": 1348587, "text": "61 YR. OLD MAN WITH SEVERE CAD(MEDICAL MANAGEMENT), S/P CARDIAC ARREST\n& ANOXIC BRAIN INJURY , CHRONIC BRONCHITIS, OSTEOMYELITIS, TRACH'D & PEG'D & LIVING AT REHAB. RECENT ADMISSION() FOR FEVERS,\nTACHYCARDIA, TACHYPNEA, WAS DISCHARGED ON 5 WK. COURSE VANCO FOR OSTEO THAT WAS NEWLY DG BY MRI IMAGING OF HIP LOCATED AT ISCHEAL TUBEROSITY & COCCYX. IN USOH @ REHAB, WHEN HAD 2 EPISODED HYPOXIA->??MUCOUS PLUGS. PLACED ON NRB->ED. IN ED, WAS WEANED W/OUT DIFFICULTY TO TRACH . T 101.8(R) HR 130'S, BP 111/62. BC X2, U/A, URINE C&S SENT. GIVEN VANCO 1GM & TYLENOL 1 GM PR. ALSO, GIVEN 1L NS. TRANSFERRED TO CCU AS MICU BORDER.\n\nNEURO: APPEARS TO TRACK WITH EYES, BUT DOES NOT APPEAR TO UNDERSTAND OR ATTEMPT TO ENGAGE IN ANY WAY. LE CONTRACTED.\n\nRESP: O2 SATS 98-100% ON 50% TRACH COLLAR. RR 20-24. BS COARSE THROUGHOUT & VERY DIMINISHED. CXR DONE TO COMPARE WITH ONE TAKEN IN ED. RESULTS PENDING. SX FOR SM-MOD AMTS THICK WHITISH-YELLOW SPUTUM.\n\nCARDIAC: HR 115-130 ST->97-113 ST WITH FREQUENT PVC'S. BP 98-125/37-82\n2 EPISODES HYPOTENSION WITH SBP 70-80. TOTAL 750cc NS BOLUS WITH GOOD EFFECT. K 5.2, MG 2.6, LACTIC ACID 2.0, HCT 33.4.\n\nGI: PEG CLAMPED. NPO FOR ABD. US THIS AM. ABD. SL. DISTENDED BUT SOFT.\nBS +. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING YELLOW URINE WITH SEDIMENT. U/O 45-70\nCC/HR. BUN/CREAT 70/2.3.\n\nID: T 100.6(R)->98.5(PO). BC & URINE C&S PENDING. VANCO & ZOSYN STARTED. IV FLAGGYL ADDED.\n\nSKIN: ~8CM X 6 CM OPEN AREA @ COCCYX WITH YELLOWISH DRAINAGE. NS W->D DSG APPLIED. ALSO SMALLER OPEN AREA, BUT DEEP ON R. BUTT CHEEK. ALSO NS W->D DSG.\n\nPLAN: NPO->US THIS AM D/T ELEVATED LFT'S.\n SKIN CARE .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-10-16 00:00:00.000", "description": "Report", "row_id": 1348588, "text": "CCU Nursing note\nS-No verbal communication. Trach.\nO-61y.o male admitted from Rehab for hypoxia, febrile. Hypoxia attributed to mucos plug as was quickly resolved c suctioning and O2. Now 100% on 40% trach tent. Pan cultures pending c no growth as of yet. Differential for infx includes PICC line, foley, pressure ulcer c ? osteomyelitis, biliary obstruction c increased LFTs, cholyecysitis. Taken for Abd ultrasound to r/o obstruction/choly.. results pending. Skin care nurse ( ) -note in chart c full assessment and reccs.\n\nN- anoxic injury s/p cardiac arrest c minimal if any interaction. eyes open spontaneously, track, +corneal reflex, +cough, impaired gag. Moves upper extremities on occasion. LE contracted. Grimices c turning.\n\nCV-HR NSR to ST 90s-115, SBP 90-135 c MAP >60. pulses dopplerable. single lumen PICC, 1 piv. Small fluid bolus currently infusing 500cc over 2 hours.\n\nResp-trach (care done). sx'd small amts x3 for white/thick sputum. sats 100% on 40% trach tent. alb nebs done as ordered. LS diminished throughout.\n\nGI-NPO. Peg tube wnl. +BS. Reglan as ordered. small bowel movmts x2. cultures sent.\n\nGU-foley. yellow c sediment. adequate amts.\n\nID-tmax 100.3. cultures pending. dosed triple abxs as ordered. WBC decreased now 15.2.\n\nskin-please see detailed skin care nurse note for assessment and treatment. Pt now on air bed.\n\nsocial-brother called x2.\ndispo-confirmeed full code.\n\nplan-trach suctioning as needed. care per reccs-turn frequently. Monitor HR. gentle fluid boluses for BP (as EF low).\nFamily member updated on POC.\n\n" }, { "category": "Nursing/other", "chartdate": "2171-10-19 00:00:00.000", "description": "Report", "row_id": 1348597, "text": "Resp Care\n\nPt remains on 35% trach with cuff deflated. Suctioned for thick tan sputum; sent for culture.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-19 00:00:00.000", "description": "Report", "row_id": 1348598, "text": "CCU nursing progress note 0700-1900\nSee nursing transfer note. Also see flowsheet for objective data.\n\nPatient continues to be in NSR w/ PVC's. HR 72-91. BP 106-136/59-79. MICU team stated pt HIT neg. Heparin sq initiated. O2 sats 96-100% on CN Fio2 35%. Patient suctioned PRN- small-mod amounts of thick tan secretions. Coccyx, L hip, R heel, PICC line, trach, and PEG dressings changed as per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-20 00:00:00.000", "description": "Report", "row_id": 1348599, "text": "NURSING PROGRESS NOTE 7P-7A\nS: , NON COMMUNICATIVE\n\nO: NEURO: PT. ALERT, TRACKS WITH EYES. FOLLOWS SOME SIMPLE COMMANDS, IE, OPEN MOUTH, COUGH. TURNS EASILY IN BED WITH 2 ASSISTS. SLEEPING IN VERY SHORT NAPS .\n\nCV: HR 85 SR WITH FREQUENT PVC'S. BP 104-118/55.\n\nRESP: SUCTIONING VERY FREQUENTLY FOR COPIOUS AMTS OF THICK WHITE SECRETIONS. ABLE TO COUGH AND RAISE SECRETIONS AS WELL. COARSE BREATH SOUNDS. O2 SAT 99-100% ON 35% O2.\n\nGI: + BOWEL SOUNDS, INC X2 OF LARG AMT OF SOFT STOOL. CONT ON TF PROBALANCE FS @ 60 CC/HR (GOAL RATE).\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE IN GOOD AMTS. SEE FLOWSHEET FOR I/O TOTALS.\n\nSKIN: DRESSING CHANGED X2 D/T CONTAMINATION WITH STOOL. SEE CAREVUE FOR DATA.\n\nA: ADMIT FOR RESP DISTRESS.\n\nP: CONT WITH PULM TOILET, SUCTION . DRESSING CHANGES TO SACRAL AS ORDERED. FREQUENT POSITION CHANGE FOR PRESSURE RELIEF. FOLLOW LABS, REPLETE LYTES AS NEEDED. UPDATE PT. AND FAMILY ON PLAN OF CARE PER MICU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-20 00:00:00.000", "description": "Report", "row_id": 1348600, "text": "CCU nursing progress note 0700-1900\nSee nursing progress note. Also, see flowsheet for objective data.\n\nNSR w/ PVC's. HR 73-86. BP 109-120/58-89. O2 sats 99-100% CN Fio2 35%. Suctioned moderate amounts of white secretions from trach. Pt able to cough up most secretions. Patient attempted to communicate a few times throughout day. 2 Small hematomas on abd near sq heparin sites, MICU team aware. Inc sm amt of stool, dsg changed as per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-21 00:00:00.000", "description": "Report", "row_id": 1348601, "text": "CCU NPN\n61YO with severe CAD unable to vascularize, s/p cardiac arrest with severe anoxic brain injury on admitted from with hypoxia. Had recently been d/c on 5 week course of vanco for osteomyelitis of hip/coccyx. Also of note, sputum and decubs growing pseudomonas was started on zosyn but had large decrease in plts therefore changed to meropenem.\nID: Currently afebrile, conts on meropenem with expected 6 week course.\nCV: Hr 90's SR with pvc, ef approx 20%. BP 120-150's.\nResp: Conts to have ^^ secretions, but he is able to cough them up and out of trach. Requires suctioning approx q 2-3 hours. Secretions are white and thin. Lungs have course aeration scattered throughout. O2 at 35% trach , with sats in the high 90's to 100%.\nGI/GU: Abd soft with (+) bowel sounds. Probalance at 60cc/hr via PEG. Conts to have soft bm's. Foley drng adequate amts of clear yellow urine.\nMS: Alert on/off throughout night. At times seems to follow commands if exhibited for him, but this is inconsistent. Does not follow verbal commands. Is able to move upper extrems, have not seen him move lower extrems which are contracted up towards abdomen.\nSkin: Coccyx with full thickness approx 5.5 x 5 x 2.5 cm with 1.6 cm tunnel. The bed is pale /yellow tissue rimmed with reddened tissue. No drng noted. This area along with L hip were cleansed with soap and water followed by antimicrobial kerlix moistened with NS packed into area, ABD paid placed over and taped into place. Outer edges barrier cream applied. on R hip approx 1inch in diam but deeper than coccyx sore. His r outer ankle with escar intact duoderm placed over this area to prevent further breakdown. Area with no drng.\nAccess: Has L periph PICC line intact\nA: improved secretions from yesterday but conts to require ^ sxn'ing\n stable hemodynamically\n good sats on 35% trach \n cont with pressure \nP: prepare for d/c to \n cont with good pulm toilet, sxn'ing prn\n\n" }, { "category": "Nursing/other", "chartdate": "2171-11-09 00:00:00.000", "description": "Report", "row_id": 1348631, "text": "Resp Care\nPt remains with #7 Portex trach. BS coarse in upper aw's, wheezey at times. Pt suctioned for moderate- copious amounts of thin clear/white secretions, becoming thicker towards end of shift. Xopenex nebs given Q4 with improvement in wheezing. Atrovent and Tobramycin also given as ordered. Pt currently on 35% trach . See Carevue for details and specifics.\nPlan: Continue nebulizer treatments as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-09 00:00:00.000", "description": "Report", "row_id": 1348632, "text": "NPN (NOC):\n\n PROBLEM REMAINS SECRETIONS. HE ACTUALLY HAD A BED ON ONE OF THE MEDICAL FLOORS, BUT I DISCUSSED THE SITUATION WITH THE NURSING SUPERVISOR AND THE FLOORS CANNOT SX Q1-2 HRS AS WE HAVE BEEN DOING IN THE UNIT SO HE STAYED IN THE UNIT. RR TEENS TO 20'S, REG, UNLABORED. SX'D Q1-2 HRS FOR MOD TO COPIUOS AMTS OF THICK WHITE TO CLEAR SECRETIONS. NEBS Q 4 HRS FOR WHEEZING W/ GOOD EFFECT. SATS HIGH 90'S ON 35% TM.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-09 00:00:00.000", "description": "Report", "row_id": 1348633, "text": "Respiratory care\nPt with #7 portex trach, recieved Tobra neb at 0800, recieved xopen, and atrovent as ordered. Suctioned mod amts of thick yellow.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-18 00:00:00.000", "description": "Report", "row_id": 1348593, "text": "CCU NPN: MICU border,see flowsheet for objective data\n\n61 yo w/mult medical problems,CAD,hypoxic brain injury,chronic pressure ulcers stage IV,admitted from with hypoxia\n\nCardiac: HR 69-84 NSR with occ PVC's,brief burst of ST for unknown reason,now back in NSR, BP 96-131/54-78\n\nResp: remains on trach with sats 98-100.needing frequent suctioning every 30-45 minutes for clear-white thick -thin secretions.\nlungs clear/diminished at bases,upper airway noise,RR16-24\n\nGI: TF remain at 60/hr,+BS,no stool.now receiving carafate q6.\n\nGU/Volume:urine output 15-200/hr,+400\n\nEndocrine: covering FS with SSI,also receiving NPH insulin now increased to 5 units\n\nID: afebrile,vanco and zosyn d/ced and now on meripenum.\n\nHeme: Platlets down to 53 from 155 on admission,vanco and zosyn can both cause drop in platlets,now d/ced. labs sent for HIT\n\nSkin: care done at 11am on both stage IV pressure sores. barrier cream applied to macerated skin surrounding both. black eschared ulcer on rt ankle,cleaned and dry dsg applied and covered with kerlix. turning q2,on kinair bed.pillows under legs to keep heels off bed.\npneumo boots on .LE contractures\n\nNeuro: more awake,mouthing words,turning his head to direction of voice,grabbed my hand while suctioning,localizes to pain.\n\nSocial: brother, called today,plans to visit tomorrow\n\nA/P: hypoxia has resolved, need for suctioning\n platlet drop ?d/t abx or heparin,if due to heparin PICC line would need to be changed\n cont to follow FS and cover\n meripenum\n cont with turning q2 and skin care\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-10-18 00:00:00.000", "description": "Report", "row_id": 1348594, "text": "Resp Care\nPt remains with #7.0 portex cuff deflated on 35% TM satting >96%. BLBS diminished, suctioned for mod amt thick white secretions, Mdis given. will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-19 00:00:00.000", "description": "Report", "row_id": 1348595, "text": "Resp Care: Pt continues on 35% TM with cuff deflated. LS coarse and diminished bilaterally. Pt suctioned for moderate-large amounts of thick yellow secretions. MDI's given per . Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-19 00:00:00.000", "description": "Report", "row_id": 1348596, "text": "2300-0700\n61 YR. OLD MAN WITH H/O SEVERE CAD->S/P CARDIAC ARREST WITH ANOXIC BRAIN INJURY(), IDDM, CHRONIC PRESSURE ULCERS STAGE IV, WHO WAS ADMITTED FROM REHAB WITH HYPOXIA.\n\nNEURO: TRACKS WITH EYES, BUT DOES NOT ATTEMPT TO COMMUNICATE. MOVES UPPER EXTREMITIES, LE CONTRACTED.\n\nRESP: O2 SATS 100% ON 35% TRACH COLLAR. RR 14-22. BS COARSE BUT DIMINISHED AT BASES. SX FOR MOD. AMTS. THICK YELLOWISH-WHITE SPUTUM.\n\nCARDIAC: HR 78-85 SR WITH FREQUENT PVC'S. BP 99-120/55-79. +BPPP.\n\nGI: TF VIA PEG: FS PROBALANCE INFUSING AT GOAL RATE 60CC/HR. NO RESIDUALS. RECEIVING 250cc H20 Q4HRS VIA PEG. ABD. SL. DISTENDED. BS+.\nNO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING YELLOW URINE WITH SEDIMENT. U/O 60-75\nCC/HR.\n\nID: AFEBRILE. CONT. ON MEROPENUM. URINE C&S>100,000 GRAM(-)RODS,\n BCX2 PENDING, STOOL C DIFF (-), SPUTUM C&S->SPECIMEN CONTAMINATED WITH ORAL SECRETIONS, NEED NEW SPECIMEN.\n\nENDO: BS 133->108. NO COVERAGE REQUIRED.\n\nSKIN: DSGS TO COCCYX, L HIP, R. ANKLE D&I.\n\nAM LABS PENDING.\n\nPLAN: HAVE RPT OBTAIN NEW SPUTUM SPECIMEN\n REPLETE LYTES AS NEEDED.\n TRANSFER BACK TO REHAB.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-06 00:00:00.000", "description": "Report", "row_id": 1348622, "text": "Neuro alert, follows commands, mae, extremities contracted. Picking at skin and clothing continuously. Given ativan .5mg IV for sedation x1 with good effect. Patient sleeping on and off all night.\nResp sx q 1-2 hr for moderate amt of white thin secretions, bringing up the majority of secretions himself. 02 sat 97% lungs coarse throughout.\ncvs HR 100's ST occassional pvc bp 98/-127/63 hct 27.8 extremities without edema pp dopplerable\ngi TF probalance at 60cc q hr abd soft nontender peg small amt of soft golden stool\ngu foley > 35cc qhr mn to 0400 +140\nendo ss insulin scale not requiring\nskin decubitus ulcer unchanged extends to sacrum without signs of infection no drainage. Lt hip ischial decubitus ulcer alleyn dressing in place. Patient also has scratch marks all over upper body\naccess lt picc\na. trach h/o CAD nonsurg, anoxic brain damage from cardiac arrest chronic bronchitis, osteomyelitis, chronic sacral and ischial decubitis\np. PT and OT consults antecipated discharge , continue with vigorous pulm toliet\n\n" }, { "category": "Nursing/other", "chartdate": "2171-11-06 00:00:00.000", "description": "Report", "row_id": 1348623, "text": "Respiratory Care:\nPt remains with #7 portex. On aerosol trach 35%. Suctioning large amts thick white secretions. Received MDI's.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-06 00:00:00.000", "description": "Report", "row_id": 1348624, "text": "npn\n pt opens eyes spont and follows most commands. mae. mouthing words at times. continue to pick at skin and at times trach . ativan ordered prn none given this shift.\n\n\nResp- cont to require frequent suction approx q 1 hr of thick white secretions. nebs pr resp. therapy. Tobramycin nebs started this pm. Rehab case in this am- pt unable to go to rehab with current suctioning needs.\n\n\n/skin- cont stage 3-4 coccyx - cleansed with cleaner and covered with alleven drsg. small amount yellow drg from coccyx , no change from prevoius size. cont on air mattress.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-07 00:00:00.000", "description": "Report", "row_id": 1348625, "text": "Nsg shift summary\nAllergies:beta blocking agents and zosyn.\n\nNeuro:alert,unable to assess orientation,eye opens spontaneously,following commands.scratchng with long nails,having scratch marks all over the body.denies any pain.having lot of secretions,coughing out ,more when awake.slept well with 0.5mg inj.ativan.\n\nResp:trache collar,fio2 0.35% with 10lit O2.sats 98-100%.LS coarse throughout.suctioned copious white thick secretions.trache care given.\n\nCVS:HR 100-110'S,ST,no ectopics noted,BP 100-110's .\n\nGU/GI:Abdomen soft ,BS present.had BM X 2 this shift.PEG site looks clean.feed probalance 60cc/hr on progress.tolerated well.on foley cath ,urine output adequate.yellow clear urine.\n\nIntegu:impaired skin,stage 4 on buttocks and Rt upper thigh.dressing changed as per protocol.redness and escoriation on buttocks and around anal area,? due to frequent stool.bath given and postiond.\n\nIV Access:PICC on Lt hand,site looks clean and dressing intact.patent.\n\nsocial: by son early shift and updated.calm and co operative.on contact precautions.full code.\n\nEndo:RISS Q6H and covered.PM dose NPH also given.\n\nPlan:continue the present .pulmonary toileting and airway management. dressing PRN.frequent change of position to prevent further skin breakdown.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-04 00:00:00.000", "description": "Report", "row_id": 1348617, "text": "STATUS\nD: FOLLOWS SOME SIMPLE COMMANDS..MOVES ALL EXTREM'S PURPOSEFULLY\nA: REMAINS ON TRACH COLLAR @ 50%..SUCTIONED Q3H FOR LGE AMT THICK YELLOW C&R SAME..TRACH CARE X2..INCT LOOSE YELLOW STOOL>>DISEMPACKED FOR MOD AMT SOFT YELLOW STOOL..TOL TF'S WELL..ADQUATE AMT'S CLOUDY YELLOW URINE..ALLEVYN ON COCCYX CHANGED\nR: UNCHANGED\nP: ? TRANSFER BACK TO FLOOR..CONTINUE GOOD PULMONARY TOILET..NEED SKIN CARE NURSES TO EVALUATE 'S & WAYS TO PREVENT STOOL FROM ENTERING 'S\n" }, { "category": "Nursing/other", "chartdate": "2171-10-18 00:00:00.000", "description": "Report", "row_id": 1348592, "text": "NPN 7 AM--7 PM\n\nPt from after respiratory distress and desaturating thought to be due to plugging, hypotension. He has hx of cardiac arrest and CVA with anoxic brain injury, had PEG and trach and has been at until admission for hypotension, resp distress, tachycardia, fever. Treated with antibiotics, and aggressive suctioning. He has been hemodynamically stable, pan cultured. He has multiple sources of possible infection, Chronic foley catheter, colonization of Pseudomonas in resp tract, He has two large decubitus\none full thickness coccyx, and stage 3 left posterior gluteal.\nHe has improved BP wise, max temp 100.6 last night ( team, Dr. aware) still suctioning moderate amounts of thick yellow to thin white via trach. Requires suction Q 2-3 hours last night which is less often than previous 24 hours. Pt is alert and awake, grabs at trach collar and removes o2 sat probe, does not follow commands but does track, grimaces when turned. He has been weaned down to 35 percent trach collar and sats are 97-100 percent . CV wise- pt in SR with occasional PVC\"s, BP 96/54---100/66, HR 70-80. GI wise pt started probalance tube feeding at 60 cc per hour, tolerating. Had small soft BM last night quiac negative ( and control test was positive).\nendocrine: fs 158. then 122 on small dose NPH and SS coverage.\n pt has foley draining 30-80 cc per hour, urine has gram neg rods but team felt this was from chronic foley and did not change catheter.\nall other cultures pending.\n\nA: pt sp mucous plugging, fever, hypotension ( resolved), planning dc back to acute rehab.\n\np: follow culture data, continue monitor cv and resp status, suction Q 2-3 hours prn, and skin care ostomy RN orders in room.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-05 00:00:00.000", "description": "Report", "row_id": 1348618, "text": "Respiratory Care:\n\nPatient with 7.0 Portex. Cuff inflated with 7cc of air. Cuff pressure 25cm/H2O. Inner cannula put in trach. BS rhonchi bilaterally. Sx'd for moderate amounts of thick white secretions. Strong cough effort. Albuterol/Atrovent MDI's 4 puffs each x 2 this shift. Tolerated well with trach spacer/ambu. RR comfortable at rest. 35% Trach in use. O2 sats 100%.\nPlan: Will continue to follow for MDI's as ordered/trach management.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-05 00:00:00.000", "description": "Report", "row_id": 1348619, "text": "CONDITION UPDATE\nSEE CAREVIEW FOR DETAILS:\n\nALERT, FOLLOWS COMMANDS AND IS INTERACTIVE. ?PMV TRIAL WITH IMPROVING MS. TMAX 99.6. REQUIRES FREQEUNT SXN FOR THICK SECREATIONS THIS BECOMING FROTHY THIS AM. MICU RESIDENT AWARE, CXR ORDERED FOR THIS AM. AT TIMES AFTER SXN CONT TO COUGH AND IS UNABLE TO SETTLE OUT, HR UP TO 120-130'S, MICU RESIDENT AWARE GIVEN . 5 MG ATIVAN IV WITH VERY GOOD EFFECT. SEVERAL TIMES BP DOWN TO 70-80/40-50 BUT HYPOTENSION RESOLVES WHEN STIMULATED. MICU RESIDENT AWARE, NO INTERVENTION. ABD SOFT, TOL TUBEFEEDS. FOLEY WITH ADEQUATE URINE OUTPUT. ALLEVYN DSG CHANGED. PLAN TO CONT RESP SUPPORT, FREQUENT SUCTIONING, SKIN CARE. PROVIDE SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-05 00:00:00.000", "description": "Report", "row_id": 1348620, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nStatus unchanged. Follows commands and attempts to be interactive. ? PMV tomorrow. Remains with frequent sxn Q 1-2hrs. Lungs remain rhonchorus throughout. Sats 97-100% on trach . SBP stable 90's to 100's. Pt does become hypotensive while sleeping. MICU service is aware. PT with decubitus ulcers X2. Sore on coccyx requiring frequent changing pt stooling. Endo: RISS. Remains on TF at 60cc/hr. Plan: Pt needs to go to REHAB asap.\n\n" }, { "category": "Nursing/other", "chartdate": "2171-11-05 00:00:00.000", "description": "Report", "row_id": 1348621, "text": "Respiratory Care\nPatient received on 35% trach wearing a 7 Portex cuff inflated, breath sounds essentially clear but diminished, suctioned intermittently for moderate to small amount of thick white secretions, treated with Albuterol and atrovent inhalers, was afebrile and mostly into Sinus tachycardia, HR ranged 80 to 118, Blood-pressure stable, Creatine 1.8, hemoglobin 9.3, will continue to be followed.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-24 00:00:00.000", "description": "Report", "row_id": 1348610, "text": "61yo male c CAD c/b anoxic brain injury, pt admitted for hypoxia, tachycardiafevers and hypotension likely secondary to urosepsis. Pt is now improving and is waiting for nursing care facility placement. Insurance issues are delaying transfer.\n\nCV:HR 74 high 120 when pt is turned. bp 106/67(77) low bp systolic 79\n\nNeuro:alert unable to assess orientation. Pt will follow minimal commands. LE contracted moves upper extremities.\n\nResp:rr 18, ls coarse, trach care done, frequent suctioning for clear thin secretions.\n\nID:afebrile\n\nGU:urin output >30cc/hr clear yellow urin.\n\nGI: small smears of stool BS +. tube feed at goal 60cc/hr\n\nAccess:left PICC\n\nSkin: coccyx dressing changed hip dressing changed both ulcers appear not to be healing well.\n\nP:continue with frequent suctioning and trach care.\n dressing due to be changed dressing changes.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-11-02 00:00:00.000", "description": "Report", "row_id": 1348611, "text": "STATUS\nD: ADMITTED FROM CC7 FOR PULMONARY TOILETING..HST SEE FHP\nA: PT WITH INCREASED SECREATIONS FROM TRACH..IMPROVED WHEN CUFF INFLATED..'S ON LF HIP & COCCYX..PICC LF ARM..PEG ABD WITH TF'S AT GOAL..FOLEY WITH ADQUATE HUO\nR: STABLE\nP: GOOD PULMONARY TOILET..AWAITING TRANSFER ORDERS\n" }, { "category": "Nursing/other", "chartdate": "2171-11-03 00:00:00.000", "description": "Report", "row_id": 1348612, "text": "Resp Care Note, Pt remains on t-collar 50%. Suctioned for mod amts thick yellow secretions. MDI'S given prn.Temp febrile. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-03 00:00:00.000", "description": "Report", "row_id": 1348613, "text": "condition update\nS/P RESP distress/ multiple medical problems\nNEURO:Pt does not follow commands but has purposeful movement. reacts to stimulation but has blank stare.\nCARDIAC:HR is sinus tach(per EKG)/w-rate as high as 150's;pt does have a temp of 101. initially given 30 mg diltiazem(allergy to beta blocker) followed by 500ml fluid bolus and tylenol which brought rate < than 110.\nRESP:lots of secretions but has a strong cough and has required about 6 deep suctions. episode of low saturations which responded to an increased o2 to 50%.\n:dsg saturated w/feces and when removed staturated w/feces; washed aggressively w/ cleanser and allivyin applied for better security\n:/ ?V/Q SCAN\n reconsult\n" }, { "category": "Nursing/other", "chartdate": "2171-11-03 00:00:00.000", "description": "Report", "row_id": 1348614, "text": "STATUS\nD: ALERT..WILL FOLLOW SOME SIMPLE COMMANDS BUT DOESN'T ATTEMPT TO COMMUNICATE\nA: REMAINS ON TRACH COLLAR @ 50% FIO2 WITH GOOD SAT'S >96%..AMBUED & SUCTIONED FOR MOD AMT THICK YELLOW Q3-4H..GOOD HUO'S CLOUDY YELLOW URINE..INCT MED AMT LOOSE YELLOW STOOL..ALLEVYL CHANGED ON COCCYX & LF HIP..STAGE 4 ULCER ON COCCYX & STAGE 3 ON HIP..TOL TF'S WELL\nR: UNCHANGED\nP: CONTINUE WITH GOOD PULMONARY TOILET..HAVE WD CARE NURSE SEE PT IN AM re CARE PLAN..CONTINUE WITH GOOD SKIN CARE..KEEP OFF BACK AS MUCH AS POSSIBLE\n" }, { "category": "Nursing/other", "chartdate": "2171-11-04 00:00:00.000", "description": "Report", "row_id": 1348615, "text": "Respiratory care:\nPatient followed for trach checks. Breathsounds are coarse. Sx for copious amounts of thick yellow secretions. Albuterol/atrovent mdi given as ordered. Please see carevue for further data.\nPlan: Continue aggressive pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2171-11-04 00:00:00.000", "description": "Report", "row_id": 1348616, "text": "condition updated\ns/p RESP DISTRESS/ MULTIPLE MEDICAL PROBLEMS\nNEURO:\nseems more focused although minimal reaction to stimulation except suctioning. moves arms freely\nCARDIAC:\nHR down to 80-100 during sleep slightly higher when awake. BP lower but making good urine outs.\nRESP:\nsecretions copius and thick but lessening SAO2 97-100%\n:\n care per service, pulmonary toilet, pending cultures\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-10-17 00:00:00.000", "description": "Report", "row_id": 1348591, "text": "CCU Nursing note\nS-no attempts at communcation.\nO-see flowsheet for details. 61y.o male c multiple medical problems including inoperable CAD, hypoxic brain injury, chronic pressure ulcers. Admitted from rehab for hypoxia, febrile, brief hypotension. Hypoxia-suctioned/nebs resolved quickly and weaned to trach . Currently afebrile, pan cultures pending c sputum cx sent today. Urine cx c gram negative rods however chronic c indwelling foley. No other growth to date. Hypotension resolved c previous FB. Case manager involved as ready to transfer back to rehab.\n\nN-@ baseline (per disscussion c brother). Tracks, +Cough, impaired gag. Moves UE, LE contracted. Does not follow commands. Does not make any non-verbal/verbal attempts to communicate nor is there any indication that pt understands any verbal communication.\n\nCV-HR NSR 70s-90s c occasional PVC, SBP stable 90s-110. single lumen PICC left brachial. pulses dopplerable. SQ heprin d/c's c decrease in plts to 83. Heprin antibody test sent. Hct stable.\n\nResp-remains on 40% trach tent c sats 100%. Nebs as ordered. sx'd q2-3 for thick white/yellow secreations. However maintained sats >98%.\n\nGi-abd soft. tolerating TF. Nutrition reccomended change to Probalance (MDs to write order). no residuals. +BS. feeding tube intact. small stool x1.\n\nGU-foley c adequate CYU, sediment.\n\nEndo-standing dose + SS coverage as ordered.\n\nID-afebrile.\n\nSkin-no changes from skin care note written yesterday. Followed directions for dsg change (full thickness coccyx and stage lV left ischial). pt tolerated well. kinair bed. heal elevated.\n\nplan-Case management working on rehab placement c and insurance company. Continue suctioning as needed. skin care per note. turn q1-2. Monitor TF, BS, BP. F/U heprin antbdy test. Brother/HCP updated on .\n" }, { "category": "Nursing/other", "chartdate": "2171-10-22 00:00:00.000", "description": "Report", "row_id": 1348604, "text": "61yo male hx of CAD, s/p cardiac arrest c severe anoxic brain injury on admitted from c hypoxia.\n\nID:meropenem for osteomyelitis of hip/coccyx. temp 98.7 oral.\n\nSkin: coccyx and hip dressing changed per orders. right heal douderm intact.\n\naccess: l periph PICC intact.\n\nNeuro:lower extremities contracted bent up. alert pt will open his mouth when asked and will wave hello but does not follow command consistently.\n\nResp:frequent suction via trach for thick clear secretions. Pt does cough up secretions also. o2 at 35% trach maintaining o2 sats of 99%. LSC.\n\nCV:NSR/ST C PVC'S, HR 90-110, BP 113/70(74)\n\nGU:URIN VIA FOLEY CATH >20CC/HR CLEAR YELLOW URIN.\n\nA: PT CALLED OUT TO FLOOR WAITING FOR MRSA AVAILABLE BED.\n\nP:PT REQUIRES FREQUENT SUCTIONING, COCCXY DRESSING AND HIP DRESSINGS DUE TO BE CHANGED TONIGHT, PT GO BACK TO .\n\n" }, { "category": "Nursing/other", "chartdate": "2171-10-22 00:00:00.000", "description": "Report", "row_id": 1348605, "text": "Respiratory Care\nPt seen for trach check #7 portex cuff down. Suctioned for mod amts thick yellow. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-23 00:00:00.000", "description": "Report", "row_id": 1348606, "text": "NPN 7 PM -- 7 AM\n\ns: t non verbal, trach.\n\no: please see nursing transfer note for summary of stay and PMH.\nSee careview for vitals and other objective data.\n\nPT here from after resp distress and plugging. He Is also being treated for osteomylitis. He has hx of CAD and anoxic arrest\nand has been rehabing at pre admit.\n No events . Pt stable, only requires frequent turning due to skin breakdown, and very frequent suctioning for mostly tenacious\nwhite to clear sputum, suction Q 1/2 hour to 1 hr. He does cough up secreations at times but otherwise needs to be suctioned. CV wise pt in SR with occasional to frequent PVC's. No hypotesion. Lungs clear to rhonci and dim at bases. GI- tol tube feeding and 250 cc free water flush Q 4 hours, passing very soft non liquid quiac neg stool.\nSkin wise coccyx deep and putting out yellow foul smelling\ndischarge, yellow and red at base and excorriated all around area. we are dressing with antimicrobial wet to dry and crit care lotion at the edges. Cover with paper tape and then tape to protect from stool contamination. Same dressing with Hip - that is also putting out green drainage. Has trach and stoma looks well healed, trach care done no redness. neuro wise he is alert, cooperated\nwith care somewhat, hold side rails, opens mouth when instructed for mouth care. moves arms freely but legs contracted .\nsocial- Brother called last night, updated on pt condition, and he is\ncoming to visit today, I did mention that he should ask to speak with the DC planner today.\n\nA: Pt with Known CAD , sp respiratory arrest after plugging at , currently improved and planning discharge but delay due to insurance issues?\n\nP: continue to follow labs, CV and resp staus, frequent suctioning, continue follow glucose, NPH and SS insulin, tube feeding and flush\nwith free h2o. Have RN re eval and redness around cocyx . Keep family updated on pOVc as discussed in CCU rounds\n\n" }, { "category": "Nursing/other", "chartdate": "2171-10-23 00:00:00.000", "description": "Report", "row_id": 1348607, "text": "BS rhonchi improving with suction. Suctioned frequently for copious amounts of watery white secretions. Remains on 35% trach collar.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-23 00:00:00.000", "description": "Report", "row_id": 1348608, "text": "MICU NPN\n\nneuro: awake, not tracking, some purposeful movement, not following any commands\ncv: hr 89-103 sr occ- pvc's, bp 98-121/57-72\nresp: 35 % trach w/ sats 100%. copious amt thin, clear secretions from trach, sx q1 hr.\ngi: tolerating tf at 60cc/hr w/ 250 flush q4 hr, no stool\ngu: foley draining yellow urine w/ sediment 80-140cc/hr, + 700cc.\nid: afebrile, cont on merepenem\nsocial: no phone calls or visitors\nskin: on kinair bed, turned side to side q 2-4 hr, dsg intact.\nA: hemodynamically stable, copious amts thin secretions\nP: awaiting return to nursing home or floor\n" }, { "category": "Nursing/other", "chartdate": "2171-10-24 00:00:00.000", "description": "Report", "row_id": 1348609, "text": "ccu nsh progress note-micu border.\no:neuro=difficult to assess. @ times appears to be following with eyes, but does not follow simple commands.\n pulm=contin sxing for copious amts white secretions. sats upper 90's on 35% trach . breath sounds=course throughout.\n gi=tf-probalance @ goal. minimal residuals. sm loose stool x1. guiac neg.\n id=afebrile. abx as ordered.\n skin=dsg chged per care nurse suggestions.\n end=q6hr fs not requiring coverage w riss.\n\na:unchged.\n\np:contin present management. ?transfer to floor if nsg home bed not available in the near future. support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-17 00:00:00.000", "description": "Report", "row_id": 1348589, "text": "NPN 7 PM--7 Am\n\nS: Non verbal\n\no: please see careview for vitals and other objective data\n\nPt stable , did not spike fever, slept in long naps.\nHere with hypoxia and ? of sputum plugging at , Fever.\nSource of fever could be sputum, pt putting out large amounts thick, yellow to thin white sputum, suctioned 5-6 times or more ,\npt can be heard gurgling, requires suctioning at those times but can expectorate somewhat on his own ( stimulates coughing during suctioning). Another source of infection could be foley or UTI , urine yellow but threads of white and bloody mucousy threads in urine and\noozing around foley what could be purlent discharge. trach and skin care done, on coccyx close to bone and oozing green yellow dc ( pseudomonas) trach site looks like it is healing.\nTube feeding started at 0100 AM 10 CC then advanced to 30 cc, pt tolerating. NPH held PM dose as pt was NPO, BS at 0400- 110.\nCV wise pt was given 500 cc bolus change of shift for lower BP, he did respond to fluids and BP was stable . BP 102/60--120/68\nHR sinus tach 97-105. Respiratory wise - as above and lungs with rhonchi to clear anterior and very diminished posterior.\nNeuro- alert and tracking, raises both arms up left more than right, moving contracted legs somewhat, pulled out IV? Pivcc line in place.\nID- nPicc site looks OK, foley as above. Cultures pending. on vancomycin and zosyn. Afebrile .\n\nA/p- Pt with respiratory compromise at Nursing home, requires frequent suctioning here, continues on antibiotics. Plan is to follow lab, frequent suctioning, follow micro data /change foley? good skin care,\nfeet off bed at all times, keep family updated on POC as discussed\nin CCU rounds\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-10-21 00:00:00.000", "description": "Report", "row_id": 1348602, "text": "CCU NPN: MICU border,see flowsheet for objective data\n\nCardiac: HR 82-96 NSR with PVC's,BP 80-145/42-72 K 4.4 this afternoon\n\nResp: trach site cleaned,well healed. On 35% trach with good sats 95-100.rr 12-24,good cough clear-pale yellow thick to thin secretions,suctioning q1-2. breath sounds clear,diminished at bases.\n\nID: afebrile,cont on meripenum\n\nGU: urine output 75-100/hr, negative 360cc. BUN/Creat 38/2.0 stable.\n\nGI: TF's cont at 60/hr.very small amount of soft stool,brown,OB-,abd soft nondistended,+BS\n\nHeme:HCT 30 and plts 137,continuing to increase of zosyn\n\nSkin: decubitus on coccyx unchanged from Friday,pink base,cleansed with cleanser and gently packed with nonmicrobial kerlix barely moistened with saline. covered with 4x4,then softsorb,secured first with paper tape then 4\"hytape,same procedure with decubitus on left hip. skin surrounding both appears somewhat less macerated.turned q2.\non kinair bed.pillows under legs to keep heels off bed\n\nNeuro: primary MD came to see pt,MD felt pt recognized him as the pt smiled at the MD. pt very alert,turns head in direction of voice or other sound.moves upper extremities a lot,purposeful movement,holds on to side of bed,reaches for suction catheter.\n\nA/P: 61 yo man sig CAD,sp/ cardiac arrest w/anoxic brain injury,recently d/c to on 5 week course of vanco for osteomylitis for coccyx and hip,now being covered with meripenum\n\ncont with current med plan,emotional support pt and family\nd/c to pending insurance issues being resolved\n" }, { "category": "Nursing/other", "chartdate": "2171-10-22 00:00:00.000", "description": "Report", "row_id": 1348603, "text": "61 YR. OLD MAN WITH SEVERE CAD, S/P CARDIAC ARREST WITH SEVERE ANOXIC BRAIN INJURY . ADMITTED FROM REHAB WITH HYPOXIA. TRACH'D & PEG'D.\nOF NOTE, +MRSA IN URINE IN & PSEUDAMONAS IN SPUTUM & DECUBS. WAS ON ZOSYN->DRASTIC DECREASED IN PLATLET CT->CHANGED TO MEROPENUM, WITH INCREASED PLATLET CT.\n\nNEURO: APPEARED MORE ANIMATED. LOOKED AS HE WAS SMILING. FOLLOWING SIMPLE COMMANDS. MOVES UE. LE CONTRACTED.\n\nRESP: O2->35% TRACH . O2 SATS 99-100%. RR 13-17. BS CLEAR BUT DIMINISHED AT BASES. SX FOR SM-MOD. AMTS THICK PALE YELLOW SPUTUM.\n\nCARDIAC: HEMODYNAMICALLY STABLE.\n\nGI: TF: FS PROBALANCE INFUSING AT GOAL RATE 60CC/HR VIA PEG. NO RESIDUALS. ABD. SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELOW URINE. U/O 30-75CC/HR.\n\nID: T 99.6(R)->96.7(PO). CONT. ON IV MEROPENUM(6 WK COURSE).\n\nENDO: BS 117->111. NO INSULIN PER SLIDING SCALE.\n\nAM LABS: WBC 11.7, HCT 32.2, PLAT CT 157, PT 14.2, PTT 27.8, INR 1.3,\nK 4.1, BUN/CREAT 38/1.9, MG 2.8.\n\nPLAN: CALL OUT TO FLOOR->AWAITING BED--NEEDS PRIVATE D/T MRSA\n AWAITING TRANSFER BACK TO REHAB.\n" }, { "category": "Nursing/other", "chartdate": "2171-10-17 00:00:00.000", "description": "Report", "row_id": 1348590, "text": "respiratory care\npt was seen he is on 40% trach tol well. pt was also rx'ed with albuterol .5mg via HHN and trach . see respiratory page of carevue for more information.\n" }, { "category": "ECG", "chartdate": "2171-11-02 00:00:00.000", "description": "Report", "row_id": 212901, "text": "Sinus tachycardia\nProbable left anterior fascicular block\nAnterior myocardial infarct, age indeterminate - may be old unstable baseline\nmakes assessment difficult\nST-T wave abnormalities - are nonspecific but cannot exclude in part ischemia -\nclinical correlation is suggested\nSince previous tracing of , sinus tachycardia present but otherwise\nbaseline artifact makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2171-10-25 00:00:00.000", "description": "Report", "row_id": 213123, "text": "Baseline artifact. Sinus tachycardia. Leftward axis. Consider left\nventricular hypertrophy by voltage in lead aVL. Q waves in leads V2-V6.\nSince previous tracing of ventricular premature beats are no longer\nseen. The rate is somewhat faster. The axis is less leftward. The negative\ndeflection is no longer seen in lead II. The Q-T interval is shorter.\nOtherwise, as previously noted. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2171-10-16 00:00:00.000", "description": "Report", "row_id": 213124, "text": "Baseline artifact. Resting sinus tachycardia with frequent isolated\nventricular premature beats. Compared to the previous tracing of \nthe heart rate is not as fast with ventricular ectopy now seen. Multiple\nother abnormalities are as previously reported. QRS axis is more leftward\nconsistent with left anterior fascicular block which had been present on the\nprevious tracing of . P waves are less peaked. Clinical correlation is\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2171-10-15 00:00:00.000", "description": "Report", "row_id": 213125, "text": "Probable marked resting sinus tachycardia at about 136 beats per minute,\nalthough atrial tachycardia is not excluded. Borderline left axis deviation.\nPossible right or biatrial abnormality. Possible prior inferior wall\nmyocardial infarction. Left ventricular hypertrophy. Underlying anterior\nQ wave myocardial infarction. Non-specific ST-T wave changes. Compared to\nprevious tracing of the heart rate is markedly increased. QTc interval\nprolongation is not noted. Lateral T wave inversions are normalized.\nClinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2171-10-28 00:00:00.000", "description": "Report", "row_id": 213121, "text": "Sinus rhythm with slowing of the rate as compared with tracing of .\nVariation in precordial lead placement. However, the T waves are biphasic\nin lead V3 and inverted in leads V4-V6 consistent with recent or ongoing\nanterolateral ischemia. Rule out new myocardial infarction. Followup and\nclinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2171-10-27 00:00:00.000", "description": "Report", "row_id": 213122, "text": "Sinus tachycardia. Left axis deviation. Prior anteroseptal myocardial\ninfarction. Left ventricular hypertrophy. Compared to prior tracing\nof no diagnostic interim change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2164-11-10 00:00:00.000", "description": "Report", "row_id": 1677675, "text": "NPN 7AM-7PM\n\nNEURO~A=0 X3, NO C/O DISCOMFORT THIS AM. TORADOL AS ORDERED. ONCE OOB AND IN CHAIR C/O LBP. PERCOCET X2 W/ MINIMAL EFFECT. GIVEN 3PM TORADOL AND BACK RUB W/ RELIEF. FAMILY IN TO VISIT TODAY.\n\nCA 102-110. NEO OFF EARLY THIS AM MAINTAINING MAP >60. 1800 DROP IN MAP TO 50'S. WOULD NOT RESOLVE. NEO ON VERY BRIEFLY W/^ IN MAP TO 70'S.\nDR. AWARE. HESPAN 500ML X 2 ORDERED. HCT 25.5, NO BLOOD TO BE GIVEN PER DR. . POS PULSES BILAT W/ DOPPLER, VERY FAINT.\n\nRESP~ WEANED TO 2L NP, TOL WELL. SATS: 98%. LUNGS CLEAR UPPER DECREASED IN BASES.\n\nGI/GU~TOL PO FLUIDS AND CUSTARD WELL. U/O STARTING TO DWINDLE. HESPAN AS ABOVE.\n\nA/P~CONT TO MONITOR U/O. GIVE SECOND 500 CC'S OF HESPAN.AND ASSESS STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2164-11-11 00:00:00.000", "description": "Report", "row_id": 1677676, "text": "NEURO: Pt awake alert and cooperative able to comunicate needs.\nResp: o2 sats 92-95% o2 via np increased from 2l to 4l/min. pt coughing and deep breathing raising small amounts of sputum. Chest tubes patent draining small amounts of serous sang drainage ? d/c today.\nC/V: heart rate in the 100's pt started on lopressor 12.5mg tolerated well. blood pressure 90-100/50's with map >60. Hct down to 22 this am will discuss with team regarding tranfusion pt has not been transfused yet. GI: tolerating liquids without difficulty. Will advance diet today.\nGU: Foley patent draining yellow urine. weight still remains up 8kg from preop. Lasix 20mg iv started this am.\nSKin: incisions clean and dry no drainage.\nPain: pt having increasing amounts of pain. He had taking very little pain med during day and was active up to chair. Very discouraged overnight. pain initally treated with percocet 2tabs with minimal relief mso4 4mg sc given with more relief and pt was able to sleep.pt encouraged to take pain meds more frequently when he is active to prevent pain from getting ahead of him.\nPlan to transfer to floor this am.\n" }, { "category": "Nursing/other", "chartdate": "2164-11-11 00:00:00.000", "description": "Report", "row_id": 1677677, "text": "Neuro: intact.\n\nCV: A-febrile, VSS and WNL. NSR rate 90's. A-wires capture at 3mA but pacer turned off as no need for pacing. No ectopy.\n\nResp: Clear apexes and diminished bases. Strong productive cough with minimal thick clear/yellow secretions. Pt demonstrates use of incentive spirometer. CT's dc'd today.\n\nGI: Tol small amount of general diet. Minimal appetite. +Bowel sounds.\n\nGU: Adequate urine output. Foley MD's request.\n\nSkin: Incisions covered with clean, intact, occlusive dressing.\n\nPain: Percoset and SQ MSo4 for pain.\n\nSoc: Family visited at bedside and all questions answered.\n\nActivety: Up to chair with 1 assist. Tolerated move well.\n\nPlan: Transfer to 6 when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2164-11-11 00:00:00.000", "description": "Report", "row_id": 1677678, "text": "PT transfered to . PT and WNL. Report given to RN. Pt oriented to room. All questions answered.\n" }, { "category": "Nursing/other", "chartdate": "2164-11-09 00:00:00.000", "description": "Report", "row_id": 1677673, "text": "RECEIVED FORM O.R. TEMP. 97.8 ORALLY. EXTREMITIES COLD AND MOTTLED, UNABLE TO GET PEDAL PULSES BY DOPPLER, RESIDENTS AWARE ON ROUNDS. LR GIVEN FOR HYPOTENSION. AWOKE, RESTLESS. MAE ON COMMAND, BECAME HYPOTENSIVE AND SATS IN THE 80'S WHEN AWAKE. SATS 90'S WHEN SLEEPING. LABS PENDING. MINIMAL CT OUTPUT. LARGE U/O. SISTER CALLED AND WAS UPDATED.\n" }, { "category": "Nursing/other", "chartdate": "2164-11-10 00:00:00.000", "description": "Report", "row_id": 1677674, "text": " 7P-7A SHIFT SUMMARY;\n\nNEURO/RESP; INITALLY SLEEPY BUT EASILY ARROUSED BUT FEL BACK TO SLEEP ALMOST IMMEDIATELY. OPENS EYES SPONT. AND TO VOICE. NODS HEAD YES OR NO APPROP. TO SIMPLE QUESTIONS. FOLLOWS COMMANDS AND MAE'S WELL. ALERT AND ORIENTED AFTER EXTUBATION WHICH WAS HELD INITALLY D/T VERY SLEEPY AND UNABLE TO LIFT HEAD OFF OF PILLOW. PT ON CPAP FOR WHILE WITH STELLAR ABG. EXTUBATED WITHOUT EVENT WHEN PT MORE ALERT AND ABLE TO LIFT HEAD OFF OF PILLOW. PT PLACED ON N/C AT 2LM BUT POST EXTUBATION ABG P02 60'S SO PT PUT ON 50% OFM AND 2LN/C WITH 02 SAT'S 99-100 AND REPEAT ABG WNL WITH A P02 IN THE 100'S. BOTHERING PT SO PT THEN PLACED ON 5LN/C THIS AM AND 02 SAT'S ARE REMAINING 98-99%. POOR COUGH AND NOT RAISING ANY THING AT THIS TIME. CHEST TUBE DRAINING MINIMAL HOURLY SANQ. DRAINAGE.\n\nCARDIOVAS; SR-ST NO ECTOPY SEE CAREVIEW FLOWSHEET FOR VS. NEO ON FOR BP SUPPORT TO MAINTAIN MAP>60 AND <90. POTASSIUM, ION CA, AND MAGNESIUM REPLACE PER ORDERS. POST OP EKG DONE.\n\nGI; BOWEL SOUNDS HYPOACTIVE TAKING ICE CHIPS WITH NO C/O NAUSEA.\n\nGU; HOURLY URINE OP WNL.\n\nCOMFORT; C/O INCISIONAL DISCOMFORT STARTED ON TORADOL AND GIVEN MS04 IV FOR BREAKTHRU DISCOMFORT WITH GOOD EFFECT.\n\nSKIN; ABRASIONS NOTED ON PT'S THIGH THAT PT STATES IS FROM BEING SHAVED IN HOLDING AREA. LT GROIN DSD SAT. WITH SEROSANG. DRAINAGE AND NEW DSD APPLIED. LT LEG INCISION C+D NEW DSD APPLIED AND ACEWRAP REPLACED. BILATERAL FEET INITALLY COOL BUT WARMED AS SHIFT WENT ON LT COOLER THAN RT. BILATERAL PULSES PRESENT BY DOPPLER.\n\nSOCIAL; SISTER CALLED AND WAS UPDATED.\n\nPLAN; TRANSFER TO 6 THIS AM.\n\n" }, { "category": "Echo", "chartdate": "2164-11-14 00:00:00.000", "description": "Report", "row_id": 102064, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial/ventricular ectopy. Coronary artery disease. H/O cardiac surgery.\nHeight: (in) 68\nWeight (lb): 155\nBSA (m2): 1.84 m2\nBP (mm Hg): 108/67\nStatus: Inpatient\nDate/Time: at 15:33\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is dilated.\n\nLEFT VENTRICLE: There is mild regional left ventricular systolic dysfunction.\n\nRIGHT VENTRICLE: There is paradoxic septal motion consistent with prior\ncardiac surgery.\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\nthickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: Mild to moderate [+] tricuspid regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThere is biatrial enlargement. There is mild regional left ventricular\nsystolic dysfunction with hypokinesis of the inferior wall and abnormal septal\nmotion. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nmildly thickened. Moderate (2+) mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2164-11-09 00:00:00.000", "description": "Report", "row_id": 291663, "text": "Sinus tachycardia, rate 101\nNonspecific inferior ST-T abnormalities\nClinical correlation suggested\n\n" }, { "category": "Radiology", "chartdate": "2164-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744041, "text": " 7:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P CABG W/HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with S/P CABG\n REASON FOR THIS EXAMINATION:\n S/P CABG W/HYPOTENSION\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 53 year old man status post CABG. Hypertension.\n\n TECHNIQUE: Single AP view of the chest is provided.\n\n FINDINGS: The film was obtained with a low-volume technique. There are changes\n from a previous medial sternotomy. A focal area of increased density in the\n left base is most likely related to a subsegmental atelectasis in the left\n lower lobe. A chest tube is noted in the left hemithorax. There is no evidence\n of pneumothorax in this supine film. ETT is approximately 3 cm above the\n carina. A central line is also noted in the right jugular vein with the distal\n tip in the superior vena cava.\n\n IMPRESSION: Low volume film.\n\n 2. Subsegmental atelectasis in the left base.\n\n 3. Correct positioning of life supporting lines.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-11-08 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 743900, "text": " 8:08 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: 53 yo with old L CVA and new L carotid bruit for CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with old L CVA and new L carotid bruit with Coronary artery Dz\n for CABG\n REASON FOR THIS EXAMINATION:\n 53 yo with old L CVA and new L carotid bruit for CABG\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE:\n\n REASON: Stroke/bruit.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. On the\n right moderate plaque is identified in internal carotid artery. The peak\n systolic velocities are 152, 90, 88 in the ICA, CCA, ECA respectively. The\n ICA/CCA ratio is 1.68. This is consistent with a 60-69% stenosis. On the\n left mild plaque is evident. PSV are 85, 82, 260 in the ICA, CCA, ECA\n respectively. The ICA/CCA ratio is 1.03. This is consistent with less than\n 40% stenosis.\n\n There is antegrade flow in the left vertebral artery. The right vertebral\n artery was not visualized.\n\n IMPRESSION: Moderate plaque in the right internal carotid artery with a\n 60-69% stenosis. On the left there is less than 40% stenosis.\n\n" }, { "category": "Radiology", "chartdate": "2164-11-08 00:00:00.000", "description": "P CHEST (SINGLE VIEW) PORT", "row_id": 743976, "text": " 10:23 PM\n CHEST (SINGLE VIEW) PORT Clip # \n Reason: pre-op for CABG tomorrow\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with CAD, HTN, pre-op\n REASON FOR THIS EXAMINATION:\n pre-op for CABG tomorrow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op for CABG.\n\n AP UPRIGHT CHEST: The heart size is within normal limits. There is no\n evidence of vascular congestion, pleural effusions, or focal consolidations.\n\n IMPRESSION: No evidence of CHF or pneumonia.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2194-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701831, "text": "Anxiety\n Assessment:\n Pt still a little anxious this am so with the 8am infusing , He\n realizes it may\njust be all in my head\n Action:\n Ativan .5mg po given. Pt was reassured that while the PCN was infusing,\n he was not having any potentilally bad symptoms\n O2 sats good, no HR\n or BP changes\n Response:\n Much calmer\n Plan:\n Use ativan as needed Sent home with a prescription if needed\n Problem\n Anaphylactic Rsp\n Assessment:\n Pt received a total of 3 mores dose of PCN, all tol well with the only\n c/o the cont burning CP when infusing the meds\n Action:\n Pt given benadryl q6hrs, pepsid and ativan as ordered with the PCN\n infusing over 1 hour (vs 30 min). PICC line had TPA infused with better\n flow from white port and improved flow from blue port\n Response:\n Pt tolerated infusion well\n Plan:\n Will be sent home with services after 4pm dose. Home care plan\n /discharged papers given Home infusion unit faxed paper work and will\n see him in the morning\n" }, { "category": "Nursing", "chartdate": "2194-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701619, "text": "39 yo M with HIV CD4 354, viral load <75 as of , recent diagnosis\n of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP\n . Was electively admission for penicillin desensitization and\n sent home on IV PCN therapy, dosing q 4 hrs on programmable pump.\n Presented to ED complaint of chest burning and throat tightness on\n . Admitted to MICU to watch closely for anaphylaxis with next dose\n of PCN.\n Anxiety\n Assessment:\n Pt very anxious, began describing burning in upper chest at start of\n infusion of PCN(prior to med reaching his vein)\n Action:\n MD obtained history of present problem. Pointed out to pt that drug had\n not reached him yet when he began complaining of burning sensation. Pt\n offered ativan, but denied. S.O. with pt through onset of 1^st dose of\n PCN for support.\n Response:\n Slept after initiation of PCN without taking ativan.\n Plan:\n Pot for anaphylaxis\n Assessment:\n Pt presents with atypical symptoms, burning in chest, feeling flushed.\n Currently, patient c/o the same chest burning and throat tightness but\n it had improved slightly. He denied SOB, lightheadness, or tongue\n swelling. He also admits to feeling anxious, has a feeling of chest\n flushing but not facial flushing. He has sensitivity at the PICC site\n and a rash that consisted of 2 red papules, one on his right hand and\n one near his PICC site that were pruritic.\n Action:\n Pt premedicated with benadryl, protonix , epi pen at bedside. Infused\n PCN dose slowly(over 2 hrs)\n Response:\n Tolerated dose without change in vital signs.\n Plan:\n Cont PCN q 4 hrs and administer benadryl prn, monitor for signs of\n anaphylaxis\n" }, { "category": "Physician ", "chartdate": "2194-10-28 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 701735, "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:\n39yo man with a h/o HIV (CD4 354 and viral load <75 on ) with a recent diagn\nosis of anal HSV s/p treatment. He was found to have neurosyphillis on a LP \n/09 presenting electively for admission\nfor penicillin desensitization. He has a purported allergy to PCN and\ncephalosporins but the reaction is entirely unclear. was admitted for PCN \n last week without significant issues. He returned yesterday with co\nmplaints of vague chest tingling and ichiness over the past few days. He felt th\nat his symptoms were worsening and he returned to the ED for further evaluation.\n In the ED he was afebrile, HR 108, SBP 144, and Pox 100% on RA. He received mor\nphine. He was very anxious. Allergy and ID were called. Allergy didn\nt feel that\n this wasn\nt a legitimate anaphylactic reaction.\nLast night when the penicillin was hung (but not running) he complained of sympt\noms of vague chest pain and itching.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Pollen Extracts\n Unknown;\n Mold Extracts\n Unknown;\n Last dose of Antibiotics:\n Penicillin G potassium - 04:32 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Pepcid 20mg \n Heparin subQ TID\n PCN G 3M units q4\n Ritinovir\n Atenovir\n Atazovir\n Abacavir\n Ativan PRN\n Benadryl PRN\n Past medical history:\n Family history:\n Social History:\n-HIV last CD4 count 354\n-anal HSV \n-central serous retinopathy therefore stopped intranasal\nsteroids\n-Impetigo\n-Condyloma acuminatum\n-allergic rhinitis\n-esophageal reflux\n-sinusitis \n-hypertriglyceridemia\n-molluscum contagiosum\n-cellultis of finger\n-pterygium\n-Anal CIS\n-elbow pain/fracture\n-rective airway disease\n-chronic leg pain\n-back pain\n No history of lung disease in his family.\nCurrently works for in systems managing, non smoker, EtOH 3 times / \nh, admits to occasional recreational drug use. Not currently in a relationship b\nut MSM not always using protection.\n Flowsheet Data as of 07:44 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 80 (75 - 92) bpm\n BP: 127/87 {123/82 - 145/94} mmHg\n RR: 16 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 167 mL\n PO:\n TF:\n IVF:\n 167 mL\n Blood products:\n Total out:\n 500 mL\n 350 mL\n Urine:\n 500 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -500 mL\n -183 mL\n Respiratory\n SpO2: 97%\n ABG: ////\n Physical Examination\n General: NAD, non-toxic.\n HEENT: OP clear, no thrush or exudate. No cervical or clavicular\n adenopathy noted.\n CV: S1S2 RRR w/o m/r/g\ns. No heave.\n Lungs: CTA bilaterally without wheezing or crackles.\n Ab: Positive BS\ns. NT/ND.\n Ext: No rashes, bruising or lesions. No c/c/e.\n Neuro: No focal deficits on general exam.\n Labs / Radiology\n 216 K/uL\n 40.4 %\n 13.9 g/dL\n 6.4 K/uL\n [image002.jpg]\n 05:59 AM\n WBC\n 6.4\n Hct\n 40.4\n Plt\n 216\n Assessment and Plan\n 39yo man with a h/o HIV (CD4 354 and viral load <75 on ) with a\n recent diagnosis of anal HSV s/p treatment. He was found to have\n neurosyphillis on a LP now returning for vague symptoms that\n are likely to anxiety rather than a legitimate allergic /\n anaphylactic reaction.\n\n ANXIETY\n There has been no e/o an actual allergic reaction. That he experienced\n his vague chest pain and anxiety when the penicillin was hung but not\n running further implies that he is not experiencing a medical process,\n rather a psychological reaction to the medicine. Allergy and ID were\n contact by the and did not feel that he was having an actual\n allergic reaction. Further, he has never actually received penicillin\n in the past, and as such is would be extremely unusual for him to have\n pre-formed antibodies to this medicine. He was told he had an allergy\n by his mother when he was a child and the circumstances of it (his\n reaction, how he was told he had it) are very vague. Regardless, he\n will be discharged home with Ativan and Zyrtec to take with his\n penicillin.\n HIV\n Continue home meds. Out-patient f/u.\n NEUROSYPHILIS\n Continue penicillin for a total of 14 days (he is currently day #7.)\n ICU Care\n Nutrition: Regular diet.\n Glycemic Control:\n Lines / Intubation: PICC Line - 11:54 PM\n Comments:\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: Enteral feeds.\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Discharge to home with out-patient follow-up\n Total time spent:\n ------ Protected Section ------\n Patient seen and evaluated on rounds with fellow.\n Overnight Events: ? allergic response to PCN\n Agree substantially with plan as outlined in fellows note dated\n . Please see my additional comments below.\n On exam:\n P75 BP 125/84 RR 16 Sat 97% T 96.5\n Lungs - Clear\n Cor\n nl S1S2\n Abdomen\n soft BS active\n Extrem\n no edema\n Skin\n no rashes\n Neuro - alert\n Labs: All nl\n Radiology: Clear CXR\n Impression: Anxciety Reaction\n Time Spent: 30\n ------ Protected Section Addendum Entered By: , MD\n on: 14:10 ------\n" }, { "category": "Nursing", "chartdate": "2194-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701833, "text": "39 yo M with HIV CD4 354, viral load <75 as of , recent diagnosis\n of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP\n . Was electively admission for penicillin desensitization and\n sent home on IV PCN therapy, dosing q 4 hrs on programmable pump.\n Presented to ED complaint of chest burning and throat tightness on\n . Admitted to MICU to watch closely for anaphylaxis with next dose\n of PCN.\n Anxiety\n Assessment:\n Pt still a little anxious this am so with the 8am infusing , He\n realizes it may\njust be all in my head\n Action:\n Ativan .5mg po given. Pt was reassured that while the PCN was infusing,\n he was not having any potentilally bad symptoms\n O2 sats good, no HR\n or BP changes\n Response:\n Much calmer\n Plan:\n Use ativan as needed Sent home with a prescription if needed\n Problem\n Anaphylactic Rsp\n Assessment:\n Pt received a total of 3 mores dose of PCN, all tol well with the only\n c/o the cont burning CP when infusing the meds\n Action:\n Pt given benadryl q6hrs, pepsid and ativan as ordered with the PCN\n infusing over 1 hour (vs 30 min). PICC line had TPA infused with better\n flow from white port and improved flow from blue port\n Response:\n Pt tolerated infusion well\n Plan:\n Will be sent home with services after 4pm dose. Home care plan\n /discharged papers given Home infusion unit faxed paper work and will\n see him in the morning\n Pt d/c\nd to home at 6pm via taxi\n" }, { "category": "Nursing", "chartdate": "2194-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701614, "text": "39 yo M with HIV CD4 354, viral load <75 as of , recent diagnosis\n of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP\n s/p elective admission for penicillin desensitization who\n presented to ED complaint of chest burning and throat tightness.\n" }, { "category": "Nursing", "chartdate": "2194-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701618, "text": "39 yo M with HIV CD4 354, viral load <75 as of , recent diagnosis\n of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP\n . Was electively admission for penicillin desensitization and\n sent home on IV PCN therapy, dosing q 4 hrs on programmable pump.\n Presented to ED complaint of chest burning and throat tightness on\n . Admitted to MICU to watch closely for anaphylaxis with next dose\n of PCN.\n Anxiety\n Assessment:\n Pt very anxious, began describing burning in upper chest at start of\n infusion of PCN(prior to med reaching his vein)\n Action:\n MD obtained history of present problem. Pointed out to pt that drug had\n not reached him yet when he began complaining of burning sensation. Pt\n offered ativan, but denied. S.O. with pt through onset of 1^st dose of\n PCN for support.\n Response:\n Slept after initiation of PCN without taking ativan.\n Plan:\n Pot for anaphylaxis\n Assessment:\n Pt presents with atypical symptoms, burning in chest, feeling flushed.\n Action:\n Pt premedicated with benadryl, protonix , epi pen at bedside. Infused\n PCN dose slowly(over 2 hrs)\n Response:\n Tolerated dose without change in vital signs.\n Plan:\n" }, { "category": "Case Management ", "chartdate": "2194-10-28 00:00:00.000", "description": "Discharge Plan", "row_id": 701720, "text": "Case Management Discharge Plan\n The patient is a 39 yo M with HIV CD4 354, viral load <75 as of ,\n recent diagnosis of anal HSV s/p treatment and recent diagnosis of\n neurosyphillis on LP s/p elective admission for penicillin\n desensitization who presented to ED complaint of chest burning and\n throat tightness. He is known to this nurse case manager from his\n MICU admit earlier this month.\n The patient\ns nurse contact this and stated that the plan is for\n the patient to return home today to resume his q4h PCN infusions. Home Therapies (NEHT) provides the drug and IV supplies he\n needs to do this. He has been taught the administration of the drug\n and is independent in doing so. This has spoken with \n of NEHT, and she indicates that the patient has an adequate amount of\n the drug as well as the necessary supplies to resume administration at\n home. Per the patient\ns nurse, he will remain here for his 4 PM dose\n and be home in time for his 8 PM dose. will meet the patient in\n the ICU early this afternoon to facilitate the patient\ns discharge.\n Please page for any questions or if this discharge plan changes.\n , RN, BSN\n MICU Service Case Manager\n Phone: 7-0306 Pager: \n" }, { "category": "Physician ", "chartdate": "2194-10-28 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 701683, "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 History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Pollen Extracts\n Unknown;\n Mold Extracts\n Unknown;\n Last dose of Antibiotics:\n Penicillin G potassium - 04:32 AM\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 07:44 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 80 (75 - 92) bpm\n BP: 127/87(97) {123/82(70) - 145/94(103)} mmHg\n RR: 16 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 167 mL\n PO:\n TF:\n IVF:\n 167 mL\n Blood products:\n Total out:\n 500 mL\n 350 mL\n Urine:\n 500 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -500 mL\n -183 mL\n Respiratory\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 216 K/uL\n 40.4 %\n 13.9 g/dL\n 6.4 K/uL\n [image002.jpg]\n 05:59 AM\n WBC\n 6.4\n Hct\n 40.4\n Plt\n 216\n Assessment and Plan\n ANXIETY\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n PICC Line - 11:54 PM\n Comments:\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": "2194-10-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 701613, "text": "Chief Complaint: chest burning\n HPI:\n 39 yo M with HIV CD4 354, viral load <75 as of , recent\n diagnosis of anal HSV s/p treatment and recent diagnosis of\n neurosyphillis on LP s/p elective admission for penicillin\n desensitization who presented to ED complaint of chest burning and\n throat tightness. He had been getting home infusions of pcn and doing\n well. He started taking benadryl prophylactically 2 days ago because of\n fleeting chest burning that would come with each transfusion of pcn and\n then would go away after the transfusion was finishing. Today he\n noticed 2 red spots on his arm the were itching. He woke up feeling off\n and then when his transfusions started he felt chest burning that\n progressed to throat tightness that would not remit so he came to the\n ED. Of note, while in the MICU on prior admission patient experienced\n fleeting chest pain and burning in vein with PCN infusion. He also had\n a panic attack with PICC placement on . The day after discharge, he\n called his MD concerned about his panic attacks who prescribed him\n ativan.\n .\n In the ED, initial VS: 97.8 108 144/89 16 100% on RA. Given 4mg IV\n morphine. His PCP, and ID was consulted.\n .\n Currently, patient endorsed the same chest burning and throat tightness\n but it had improved slightly. He denied SOB, lightheadness, or tongue\n swelling. He endorsed anxiety and chest flushing but not facial\n flushing. He endorsed sensitivity at the PICC site and a rash that\n consisted of 2 red papules, one on his right hand and one near his PICC\n site that were pruritic.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, shortness of breath,\n abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,\n melena, hematochezia, dysuria, hematuria.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Penicillins\n Unknown;\n Pollen Extracts\n Unknown;\n Mold Extracts\n Unknown;\n Last dose of Antibiotics:\n Penicillin G potassium - 01:09 AM\n Infusions:\n Other ICU medications:\n Other medications:\n -Viread 300mg PO daily\n -Ziagen 600mg PO daily\n -Reyataz 300mg PO daily\n -Norvir 100mg PO daily\n -Astelin 137 mcg/spray \n -Guaifenesin 100mg PO BID\n -zyrtec 10mg PO daily\n -epipen\n -ativan prn\n -PCN G 3mil unit Iv q4 hrs day 6 of 14\n Past medical history:\n Family history:\n Social History:\n -HIV last CD4 count 354\n -anal HSV , s/p 10 day treatment with acyclovir\n -central serous retinopathy therefore stopped intranasal\n steroids\n -Impetigo\n -Condyloma acuminatum\n -allergic rhinitis\n -esophageal reflux\n -sinusitis \n -hypertriglyceridemia\n -molluscum contagiosum\n -cellultis of finger\n -pterygium\n -Anal CIS\n -elbow pain/fracture\n -rective airway disease\n -chronic leg pain\n -back pain\n father with CAD, aunt and uncle with diabetes\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Currently works for in systems managing, non smoker,\n ETOH 3times/month, admits to occasional recreational drug use. Not\n currently in a relationship but MSM not always using protection.\n Review of systems:\n Constitutional: anxiety\n Cardiovascular: Chest pain, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Headache\n / Immunology: Immunocompromised\n Flowsheet Data as of 01:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 90 (86 - 92) bpm\n BP: 127/94(96) {123/82(92) - 145/94(103)} mmHg\n RR: 22 (16 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 50 mL\n PO:\n TF:\n IVF:\n 50 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 50 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n T: 96.5 BP: 145/91 HR:86 RR: 23 02 sat: 98% on RA\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: No(t) Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n Rub, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n 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, Rash: 2 small pruritis papules on right arm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: PA and lateral views of the chest are obtained. A right\n upper extremity PICC line is seen with its tip in the expected location\n of the right atrium. Lungs are clear bilaterally. Cardiomediastinal\n silhouette is stable. No pneumothorax or pleural effusion is seen. Bony\n structures appear intact. No free air is seen below the right\n hemidiaphragm.\n IMPRESSION:\n PICC line with tip in the expected location of the right atrium.\n Correlate clinically for positional adequacy. Otherwise, unremarkable\n study.\n Microbiology: LP : colorless, clear, WBC 12 RBC 0 Neutrophils 0%\n Lymphocytes 84%, monocytes 16% eosinophils 0% total protein 92\n glucose 51\n VDRL: 1:2\n .\n RPR: 1:256, FTA-abs reactive\n GC culture/rectal: negative\n Rectal HSV swab: positive\n .\n ECG: NSR at 85, NA, NI, no acute STTW changes\n Assessment and Plan\n 39 yo M with HIV CD4 354, viral load <75 as of , recent diagnosis\n of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP\n s/p elective admission for penicillin desensitization who\n presented to ED complaint of chest burning and throat tightness.\n .\n # Throat/chest tightness: Given to pcn and cephalosporin\n concerning for anaphylaxis however has completed a desensitization\n protocol without complication. In addition, symptoms atypical even for\n early anaphylaxis. No peripheral eosinophilia. Likely anxiety\n component. EKG unchanged and enzymes unremarkable make ACS unlikely.\n -give pcn and monitor closely\n -premedicate with benadryl and famotidine and ativan prn\n -consider consult in am\n -start albuterol inhaler for symptoms represent bronchospasm\n .\n # Neurosyphilis: found on screening labs which prompted LP,\n asymptomatic, on day 6 of 14 of pcn\n -con pcn, consult ID in am issues overnight with pcn and need\n alternative meds\n .\n # Anxiety: recent diagnosis of panic attacks\n -ativan prn for anxiety\n -consider psych referral\n .\n # HIV: CD4 count 354 in \n -cont HAART\n .\n # FEN: noIVFs / replete lytes prn / regular diet\n # PPX: H2B, heparin SQ, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:54 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments: HCP \n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2194-10-28 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 701717, "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:\n39yo man with a h/o HIV (CD4 354 and viral load <75 on ) with a recent diagn\nosis of anal HSV s/p treatment. He was found to have neurosyphillis on a LP \n/09 presenting electively for admission\nfor penicillin desensitization. He has a purported allergy to PCN and\ncephalosporins but the reaction is entirely unclear. was admitted for PCN \n last week without significant issues. He returned yesterday with co\nmplaints of vague chest tingling and ichiness over the past few days. He felt th\nat his symptoms were worsening and he returned to the ED for further evaluation.\n In the ED he was afebrile, HR 108, SBP 144, and Pox 100% on RA. He received mor\nphine. He was very anxious. Allergy and ID were called. Allergy didn\nt feel that\n this wasn\nt a legitimate anaphylactic reaction.\nLast night when the penicillin was hung (but not running) he complained of sympt\noms of vague chest pain and itching.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Pollen Extracts\n Unknown;\n Mold Extracts\n Unknown;\n Last dose of Antibiotics:\n Penicillin G potassium - 04:32 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Pepcid 20mg \n Heparin subQ TID\n PCN G 3M units q4\n Ritinovir\n Atenovir\n Atazovir\n Abacavir\n Ativan PRN\n Benadryl PRN\n Past medical history:\n Family history:\n Social History:\n-HIV last CD4 count 354\n-anal HSV \n-central serous retinopathy therefore stopped intranasal\nsteroids\n-Impetigo\n-Condyloma acuminatum\n-allergic rhinitis\n-esophageal reflux\n-sinusitis \n-hypertriglyceridemia\n-molluscum contagiosum\n-cellultis of finger\n-pterygium\n-Anal CIS\n-elbow pain/fracture\n-rective airway disease\n-chronic leg pain\n-back pain\n No history of lung disease in his family.\nCurrently works for in systems managing, non smoker, EtOH 3 times / \nh, admits to occasional recreational drug use. Not currently in a relationship b\nut MSM not always using protection.\n Flowsheet Data as of 07:44 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 80 (75 - 92) bpm\n BP: 127/87 {123/82 - 145/94} mmHg\n RR: 16 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 167 mL\n PO:\n TF:\n IVF:\n 167 mL\n Blood products:\n Total out:\n 500 mL\n 350 mL\n Urine:\n 500 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -500 mL\n -183 mL\n Respiratory\n SpO2: 97%\n ABG: ////\n Physical Examination\n General: NAD, non-toxic.\n HEENT: OP clear, no thrush or exudate. No cervical or clavicular\n adenopathy noted.\n CV: S1S2 RRR w/o m/r/g\ns. No heave.\n Lungs: CTA bilaterally without wheezing or crackles.\n Ab: Positive BS\ns. NT/ND.\n Ext: No rashes, bruising or lesions. No c/c/e.\n Neuro: No focal deficits on general exam.\n Labs / Radiology\n 216 K/uL\n 40.4 %\n 13.9 g/dL\n 6.4 K/uL\n [image002.jpg]\n 05:59 AM\n WBC\n 6.4\n Hct\n 40.4\n Plt\n 216\n Assessment and Plan\n 39yo man with a h/o HIV (CD4 354 and viral load <75 on ) with a\n recent diagnosis of anal HSV s/p treatment. He was found to have\n neurosyphillis on a LP now returning for vague symptoms that\n are likely to anxiety rather than a legitimate allergic /\n anaphylactic reaction.\n\n ANXIETY\n There has been no e/o an actual allergic reaction. That he experienced\n his vague chest pain and anxiety when the penicillin was hung but not\n running further implies that he is not experiencing a medical process,\n rather a psychological reaction to the medicine. Allergy and ID were\n contact by the and did not feel that he was having an actual\n allergic reaction. Further, he has never actually received penicillin\n in the past, and as such is would be extremely unusual for him to have\n pre-formed antibodies to this medicine. He was told he had an allergy\n by his mother when he was a child and the circumstances of it (his\n reaction, how he was told he had it) are very vague. Regardless, he\n will be discharged home with Ativan and Zyrtec to take with his\n penicillin.\n HIV\n Continue home meds. Out-patient f/u.\n NEUROSYPHILIS\n Continue penicillin for a total of 14 days (he is currently day #7.)\n ICU Care\n Nutrition: Regular diet.\n Glycemic Control:\n Lines / Intubation: PICC Line - 11:54 PM\n Comments:\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: Enteral feeds.\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Discharge to home with out-patient follow-up\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2194-10-28 00:00:00.000", "description": "Physician Fellow / Attending Admission Note - MICU", "row_id": 701696, "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:\n39yo man with a h/o HIV (CD4 354 and viral load <75 on ) with a recent diagn\nosis of anal HSV s/p treatment. He was found to have neurosyphillis on a LP \n/09 presenting electively for admission\nfor penicillin desensitization. He has a purported allergy to PCN and\ncephalosporins but the reaction is entirely unclear. was admitted for PCN \n last week without significant issues. He returned yesterday with co\nmplaints of vague chest tingling and ichiness over the past few days. He felt th\nat his symptoms were worsening and he returned to the ED for further evaluation.\n In the ED he was afebrile, HR 108, SBP 144, and Pox 100% on RA. He received mor\nphine. He was very anxious. Allergy and ID were called. Allergy didn\nt feel that\n this wasn\nt a legitimate anaphylactic reaction.\nLast night when the penicillin was hung (but not running) he complained of sympt\noms.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Pollen Extracts\n Unknown;\n Mold Extracts\n Unknown;\n Last dose of Antibiotics:\n Penicillin G potassium - 04:32 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Pepcid 20mg \n Heparin subQ TID\n PCN G 3M units q4\n Ritinovir\n Atenovir\n Atazovir\n Abacavir\n Ativan PRN\n Benadryl PRN\n Past medical history:\n Family history:\n Social History:\n-HIV last CD4 count 354\n-anal HSV \n-central serous retinopathy therefore stopped intranasal\nsteroids\n-Impetigo\n-Condyloma acuminatum\n-allergic rhinitis\n-esophageal reflux\n-sinusitis \n-hypertriglyceridemia\n-molluscum contagiosum\n-cellultis of finger\n-pterygium\n-Anal CIS\n-elbow pain/fracture\n-rective airway disease\n-chronic leg pain\n-back pain\n No history of lung disease in his family.\nCurrently works for in systems managing, non smoker, EtOH 3 times / \nh, admits to occasional recreational drug use. Not currently in a relationship b\nut MSM not always using protection.\n Review of systems:\n Flowsheet Data as of 07:44 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 80 (75 - 92) bpm\n BP: 127/87(97) {123/82(70) - 145/94(103)} mmHg\n RR: 16 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 167 mL\n PO:\n TF:\n IVF:\n 167 mL\n Blood products:\n Total out:\n 500 mL\n 350 mL\n Urine:\n 500 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -500 mL\n -183 mL\n Respiratory\n SpO2: 97%\n ABG: ////\n Physical Examination\n General: NAD, non-toxic.\n Labs / Radiology\n 216 K/uL\n 40.4 %\n 13.9 g/dL\n 6.4 K/uL\n [image002.jpg]\n 05:59 AM\n WBC\n 6.4\n Hct\n 40.4\n Plt\n 216\n Assessment and Plan\n 39yo man with a h/o HIV (CD4 354 and viral load <75 on ) with a\n recent diagnosis of anal HSV s/p treatment. He was found to have\n neurosyphillis on a LP now returning for vague symptoms that\n are likely to anxiety rather than a legitimate allergic /\n anaphylactic reaction.\n\n ANXIETY\n There has been no e/o an actual allergic reaction. That he experienced\n his vague chest pain and anxiety when the penicillin was hung but not\n running further implies that he is not experiencing a medical process,\n rather a psychological reaction to the medicine. He will be discharged\n home with Ativan and Zyrtec to take with his penicillin.\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n PICC Line - 11:54 PM\n Comments:\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": "Nursing", "chartdate": "2194-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 701667, "text": "39 yo M with HIV CD4 354, viral load <75 as of , recent diagnosis\n of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP\n . Was electively admission for penicillin desensitization and\n sent home on IV PCN therapy, dosing q 4 hrs on programmable pump.\n Presented to ED complaint of chest burning and throat tightness on\n . Admitted to MICU to watch closely for anaphylaxis with next dose\n of PCN.\n Anxiety\n Assessment:\n Pt very anxious, began describing burning in upper chest at start of\n infusion of PCN(prior to med reaching his vein)\n Action:\n MD obtained history of present problem. Pointed out to pt that drug had\n not reached him yet when he began complaining of burning sensation. Pt\n offered ativan, but denied. S.O. with pt through onset of 1^st dose of\n PCN for support.\n Response:\n Slept after initiation of PCN without taking ativan.\n Plan:\n Discuss management of anxiety.\n Pot for anaphylaxis\n Assessment:\n Pt presents with atypical symptoms, burning in chest, feeling flushed.\n Currently, patient c/o the same chest burning and throat tightness but\n it had improved slightly. He denied SOB, lightheadness, or tongue\n swelling. He also admits to feeling anxious, has a feeling of chest\n flushing but not facial flushing. He has sensitivity at the PICC site\n and a rash that consisted of 2 red papules, one on his right hand and\n one near his PICC site that were pruritic. This AM pt states he was\n aware of symptoms during the night and felt that he could correlate\n them to seeing PCN dripping in. States symptoms have not gotten worse.\n He did sleep on and off during infusion of PCN.\n Action:\n Pt premedicated with benadryl, protonix , epi pen at bedside. Infused\n PCN dose slowly(over 2 hrs)\n Response:\n Tolerated dose without change in vital signs.\n Plan:\n Cont PCN q 4 hrs and administer benadryl prn, monitor for signs of\n anaphylaxis\n" }, { "category": "Physician ", "chartdate": "2194-10-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 701669, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:54 PM\n Allergies:\n Penicillins\n Unknown;\n Pollen Extracts\n Unknown;\n Mold Extracts\n Unknown;\n Last dose of Antibiotics:\n Penicillin G potassium - 04:32 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 80 (75 - 92) bpm\n BP: 127/87(97) {123/82(70) - 145/94(103)} mmHg\n RR: 16 (16 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 160 mL\n PO:\n TF:\n IVF:\n 160 mL\n Blood products:\n Total out:\n 500 mL\n 350 mL\n Urine:\n 500 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -500 mL\n -190 mL\n Respiratory support\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 216 K/uL\n 13.9 g/dL\n 40.4 %\n 6.4 K/uL\n [image002.jpg]\n 05:59 AM\n WBC\n 6.4\n Hct\n 40.4\n Plt\n 216\n Assessment and Plan\n 39 yo M with HIV CD4 354, viral load <75 as of , recent diagnosis\n of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP\n s/p elective admission for penicillin desensitization who\n presented to ED complaint of chest burning and throat tightness.\n # Throat/chest tightness: Given allergy to pcn and cephalosporin\n concerning for anaphylaxis however has completed a desensitization\n protocol without complication. In addition, symptoms atypical even for\n early anaphylaxis. No peripheral eosinophilia. Likely anxiety\n component. EKG unchanged and enzymes unremarkable make ACS unlikely.\n -give pcn and monitor closely\n -premedicate with benadryl and famotidine and ativan prn\n -consider allergy consult in am\n -start albuterol inhaler for symptoms represent bronchospasm\n # Neurosyphilis: found on screening labs which prompted LP,\n asymptomatic, on day 6 of 14 of pcn\n -con pcn, consult ID in am issues overnight with pcn and need\n alternative meds\n # Anxiety: recent diagnosis of panic attacks\n -ativan prn for anxiety\n -consider psych referral\n # HIV: CD4 count 354 in \n -cont HAART\n # FEN: noIVFs / replete lytes prn / regular diet\n # PPX: H2B, heparin SQ, bowel regimen\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:54 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments: HCP \n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:54 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "ECG", "chartdate": "2194-10-27 00:00:00.000", "description": "Report", "row_id": 115993, "text": "Sinus rhythm. Since the previous tracing the rate is slower.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2194-10-27 00:00:00.000", "description": "Report", "row_id": 115994, "text": "Sinus rhythm at upper limits of normal rate. Since the previous tracing\nof probably no significant change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2194-10-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1102218, "text": " 8:10 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pulm path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n ? pulm path\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n Comparison is made with prior study from .\n\n CLINICAL HISTORY: Chest pain.\n\n FINDINGS: PA and lateral views of the chest are obtained. A right upper\n extremity PICC line is seen with its tip in the expected location of the right\n atrium. Lungs are clear bilaterally. Cardiomediastinal silhouette is stable.\n No pneumothorax or pleural effusion is seen. Bony structures appear intact.\n No free air is seen below the right hemidiaphragm.\n\n IMPRESSION:\n\n PICC line with tip in the expected location of the right atrium. Correlate\n clinically for positional adequacy. Otherwise, unremarkable study.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2111-05-17 00:00:00.000", "description": "Report", "row_id": 1566621, "text": "CCU NPN 1900-0700\nS/O:\npt. lethargic, responds to voice. opens eyes to name and spontan. responding approp. to questions. sleeps when left alone.\ndenies pain.\nCV: HR 80-83AVpaced. no VEA. BP 90's-115/50's. falling to 78-80/ ~ 2300. levo titrated up to .098mcq/k/min and then able to wean to .055mcq/k/min. per HO: goal SBP>90 with MAP 60's.\n\nPAP 50/28->23. CVP 15-10.\nC.O. 7.3/3.2/658.\nmixed venous 71%.\n\nresp: 4lnc sats 95-97%. crackles bases. RR 24-28.\nGU: foley draining 35-40cc/hr. even fluid balance for .\nGI: TF at 35cc/hr. incontinent of liq. brown/green stool, guiac pos.\nFIB falling off. placed rectal tube instead and draining well. 150cc for the night.\n\nID: core temp 37C. contin. on flagyl and levo\nskin: reddened perianal area. skin protectant/anti fungal cream.\nendo: FS 208 at 12am. 4u reg.\n\nA: able to wean levo to keep map >60.\n good oxygenation, adaquate u/o per HO.\n MS stable. responding approp.\nP: follow PAP's, wean levo per perameters. follow u/o, AM lytes etc.\n" }, { "category": "Nursing/other", "chartdate": "2111-05-17 00:00:00.000", "description": "Report", "row_id": 1566622, "text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\ncv- Tele: AV paced rhythm- no ectopy- HR 80-84- L radial A-line- B/P 91-128/47-70- levo gtt weaned & D/C'd- Maps 58-62- NS fluid bolus given as ordered- R IJ PA line @ 55cm- PAS 32-47- PAD 18-23- CVP 4-10-\nunable to wedge- numbers lower this afternoon & Rx with fluid boluses- (losing large amts due to diarrhea)- CO/CI 6.9/3.08- SVR 823- labs drawn @ 1700 K 3.8- Mg 2.0- PTT 70.5- Heparin gtt @ 500u/hr.\n\nresp- In O2 4L via NC- ABG this am 7.43- 32- 103 sat 97%- lung sounds with crackles 1/3 up bilaterally- resp non-labored- SpO2 94-98%- mix venous sat 72%.\n\ngi- (+) ascites- abd distended (+) bowel sounds- large amt of grn liquid stool draining from mushroom cath (1700cc this shift)- stool for C diff sent to lab- perineum excoriated- freq skin care given- con't on TF @ 35cc/hr via feeding tube.\n\ngu- foley draining conc amber colored urine in small amts (15-20cc/hr)\nlast BUN 53- Crea 2.0- I&O 200cc (+) only due to large amt diarrhea.\n\nneuro- lethargic- oriented X2- confused @ times- moving all extremities- cooperative- follows command- c/o feeling jittery- ativan .25mg po ordered TID.\n\nid- afebrile- T max 98.2 Core- WBC 15.8- started on flagyl 500mg Po BID, in addition to IV & linezolid 600mg IV q12hr.\n\nA- successfully weaned off levo gtt\n\nP- monitor vs, lung sounds, I&O and labs- con't fld boluses/albumin PRN to maintain MAPs >60- ? D/C PA line- OOB tomorrow.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-05-15 00:00:00.000", "description": "Report", "row_id": 1566618, "text": "Respiratory Care Note\nPt was placed on niv for increased respiratory distress, due to increased girth. Pt. tolerated two-three hours with improvement, decreased rr, increased sats.\n" }, { "category": "Nursing/other", "chartdate": "2111-05-16 00:00:00.000", "description": "Report", "row_id": 1566619, "text": "CCU NURSING PROGRESS NOTE\nS\"I'M AT THAT THE \"\nO:PT LETHARGIC BUT EASILY , PT FOLLOWS COMMANDS, MAE. PUPILS EQUAL SLUGGISH, REACT AT 2MM. EYES REDDENED,SLT JUANDICE AND PHOTOSENSATIVE. FEQUENTLY SPEAKING/MUMBLING TO HIMSELF. SLIGHT DISORIENTED WHEN HE WAKES UP FROM SLEEP, BUT EASILY RE-ORIENTED.\nCV:MHR 80S, AP NO VEA. BRIEF HYPOTENSION, IMPROVED W/ INCREASE OF LEVOPHED. PAD 20-22. PCWP 15, SVR 669. CI 4.1. EXTREMITIES MOTTLED. BOTH KNEES ALSO MOTTLED. DP W/ WEAKLY PALP PULSES. +ANASARCA, VALVE CLICK AUDIBLE.\nRESP:LUNGS W/ COARSE BS IN UPPER LUNGFIELDS, BIB CRACKLES UP 2/3.\nDIMINISHED RIGHT BASE. REPEAT ABG WNL PAO2 80S ON 4L NC. PT SLT TACHYPNEIC RR 27, NO RESP DISTRESS.\nGI:ABD LARGE, DISTENDED, +BS. FEEDING TUBE PLACEMENT CONFIRMED BY MD W/ X RAY. PT STARTED ON FS NEPRO AT 15CC/HR. MUSHROOM CATH DRG GREEN LIQ STOOL.\nGU:F/C DRG AMBER, URINE >30CC/HR.\nSKIN:COCCYX REDDENED, BUT BLANCES. DUODERM APPLIED TO AREA. TRIPLE CREAM APPLIED TO PERIRECTAL AREA. PT TURNED AND REPOSITIONED.\nHEME:PTT REMAINS ELEVATED, HEPARIN GTT OFF X 1HR. AND RESTARTED AT 1/2 DOSE. COAGS REPORTED TO DR. .\nID:PT REMAINS ON LEVO/FLAGYL, PT AFEBRILE.\nA/P:SEPSIS VS DISTRIBUTIVE SHOCK REQUIRING VESOPRESSORS. LIVER FAILURE W/ PVT. CULTURES PENDING. CONTINUE PRESSORS AND FLUIDS AS NEEDED. MONITOR MENTAL STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2111-05-16 00:00:00.000", "description": "Report", "row_id": 1566620, "text": "CCU NPN 0700-1900\nS/O:\n\nCV: CONT IN AV PACED RHYTHM WITH NO VEA NOTED. LEVO WEANED DOWN TO .66 MCG BUT UNABLE TO GO LOWER BECAUSE SBP <100 AND U/O TO <30CC/HR. CARDIAC INDICES UNCHANGED FROM THIS AM. LYTES SENT AT 1800 WITH REPEAT PTT. HEP AT 500U/HR. PCWP INC FROM YESTERDAY IN MID 20'S. C/O UPPER ABD PAIN IN AM, EKG DONE SHOWING PCM RHYTHM. PAIN RESOLVED SPON, CK'S BEING CYCLED.\n\nRESP: CONT ON 4LNP WITH SATS IN MID 90'S. RR IN 20'S WITH KUSSMAUL BREATHING AT TIMES BUT PT DENIES SOB. LUNGS WITH CRACKLES BILAT AND COURSE THROUGHOUT.\n\nID: AFEB PER SWAN, WBC INC TO 14. FLAGYL CONT, LEVO INC TO 500MG QD TOMORROW.\n\nGI: CONT WITH WATERY DIARRHEA VIA FIB, CONVERTED TO BROWN BUT AFTERNOON, OB POS. ABD CONT WITH MARKED ASCITES, OCC SHARP LOWER ABD PAIN THAT RESOLVES SPONTANEOUSLY. NEPRO INC TO 35CC/HR BY 1800, UNABLE TO CHECK RESIDUALS B/C OF DOBHOFF TUBE. PT ALSO EATING SMALL AMOUNTS OF FOOD.\n\nGU: I=O'S FOR TODAY. URINE CLEAR. CREAT POINT FROM YESTERDAY UNTIL TODAY!\n\nMS: PT ORIENTED AT TIMES BUT MOSTLY ONLY ORIENTED TO PERSON AND PLACE, LETHARGIC, SLEEPING MOST OF DAY. WIFE, SISTER AND SONS IN TO VISIT, WILL INTERACT WITH THEM AND IS USUALLY APPROPRIATE.\n\nA/P: CHECK PTT RESULTS, IF 60-100 THEN WILL CHECK AGAIN WITH AM LABS. WANT TO RUN PTT IN THE LOWER END OF SCALE. WEAN LEVO AS TOL. CHECK LYTES. FOLLOW BS QID, NO INSULIN SS.\n" }, { "category": "Nursing/other", "chartdate": "2111-05-15 00:00:00.000", "description": "Report", "row_id": 1566617, "text": "Nursing Progress Note\n\nS: What's going on\"?\n\nO: See flow sheet for objective data. Levo continues at .09mcgs/kg/min with MAP's >60. Remains in paced rhythm. PTT elevated x's 2 heparin off 1hr and restarted at 1000u/hr. Repeat pending.\n\nResp: Early this am bibasilar crackles, O2 sat 88-94%. c/o increased difficulty breathing with RR 30's. Seen by house staff and placed on masked vent for approx 3hrs with improvement in oxygenation. See flow sheet for abgs. Much less short of breath.\n\nNeuro: Pt more lethargic today. Arousable, talking to himself, easily reoriented not combative. Has recieved Lactulose x's 2 today. PERRL.\n\nGU/GI: Taking sm amts of liquids this am. NGT to be placed for meds and tube feeding. Abd is very distended but nontender. Having multiple episodes of quiac neg brown loose to liquid stool. Mushroom catheter placed. Creat down to 2.6 today. Urine output > 30/hr. Given NS bolus 500x's 1.\n\nID: Remains afebrile. WBC 12,5. Continues on Levoflaxcin & Flagyl. Cultures pending.\n\nA&P: Possible sepsis with portal vein thrombosis. Continue antibiotic coverage. Mask vent if pt develops further resp distress. Lactulose prn until mental status improves. Continue to monitor coags. Possible repeat tap.\n" }, { "category": "Nursing/other", "chartdate": "2111-05-14 00:00:00.000", "description": "Report", "row_id": 1566615, "text": "Nursing Progress Note\n\n\n62 yo man transferred from with past medical hx which includes HTN, AF, placement of AICD & PPM, S/P AVR in , cardiomyopathy with EF of 15-20%. Admitted to OSH with c/o abd pain and distension with nausea. LFT's elevated. Abd CT shows ascites and portal vein thombosis. Paracentesis done with 6 liters removed, neg for cancer and hepatitis. transferred here for assessment of fluid status and management of ARF.\n\nO: See flow sheet for objective data. Tele AV paced. SBP 80's-low 90's. House staff aware. Given NS 500cc x's 2 with Albumin x's 1. Restarted on IV heparin at 1300u/hr. INR here 5.0 No further Vit K given. Cardiac meds held today.\n\nResp: Lungs with scattered rales in the bases. O2 sat 94-97% on 2l NP.\n\nGU/GI: Tolerating clear liquids well. Denies appetite. Abd is markedly distended, nontender. Inc of sm amt of soft brown stool. Foley placed today prior to transfer. Urine output thus far 28cc dark amber urine. Creat 2.9 K 5.1 Na 129.\n\nNeuro: Pt is alert and oriented, sleepy but easily arousable. Able to MAE.\n\nSocial: Pt is retired and lives with his wife. Wife in to visit and updated on pt status by MD's.\n\nA&P: Pt remains hypotensive in spite of fluid boluses. For placement of swan later tonight or tomorrow depending on coags. Continue to monitor creat, k & na.\n" }, { "category": "Nursing/other", "chartdate": "2111-05-15 00:00:00.000", "description": "Report", "row_id": 1566616, "text": "ccu nsg progress note-micu border.\no:procedures-rij paline & l-radial aline placed. dx paracentesis done w specimens sent.\n sl confused @ x's/talking to self-thinks he's @ home-very easily reoriented. breath sounds=deminished/clear. o2 increased nc 2 to 4l for po2 63. sats low 90's. rr mid 20's. hypotensive-initially rxed w ivf-post paline placement (septic #'s) rxed w levophed gtt w improvement in bp-see flow sheet for #'s. heparin restarted after paline placement-ptt pending. abx broadened due to septic #'s- levofloxacin & metronidazole. afebrile. kept essentially npo-sm sips to wet his mouth. am labs sent.\n\na:septic #'s rx w ivf/pressor/abx.\n\np:contin current management. ck am labs-rx as indicated. support as needed.\n" }, { "category": "Radiology", "chartdate": "2111-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821868, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess swan\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver and new ARF. sp swan\n\n REASON FOR THIS EXAMINATION:\n assess swan\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 62-year-old man with CHF, liver failure and renal failure.\n\n AP upright single view of the chest is compared to a similar view from the\n same six hours earlier.\n\n FINDINGS: ET tube, right IJ Swan-Ganz catheter, pacemaker and its leads,\n Dobhoff tube are unchanged in position. The patient is status post median\n sternotomy. There is slight worsening of the bilateral basilar atelectasis or\n consolidations. There are small bilateral pleural effusions. The cardiac,\n mediastinal and hilar contours are unchanged.\n\n IMPRESSION:\n 1. Slight worsening of the bibasilar atelectasis or consolidations.\n 2. Small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 820916, "text": " 4:52 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for CHF\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with pacer/ICD, h/o cardiomyopathy/low EF, presents with 1-2\n weeks increasing abd girth/LE edema.\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST OF .\n\n CLINICAL INDICATION: Increasing abdominal girth and lower extremity edema.\n Clinical suspicious for congestive heart failure.\n\n Comparison is made to previous study of .\n\n An ICD remains in place, with leads in the right atrium and right ventricle.\n The lung volumes are quite low. Allowing for this factor, there is stable\n cardiac enlargement. There has been interval development of hazy opacities in\n the mid and lower lung zones which are most prominent centrally. There are\n also linear areas of discoid atelectasis, also with a mid and lower lung zone\n predominance. No pleural effusions are identified. Skeletal structures\n reveal mild degenerative changes in the spine.\n\n IMPRESSION: Perihilar and basilar mid and lower lung zone opacities, most\n likely due to congestive heart failure. Follow-up radiographs may be helpful\n after diuresis to confirm resolution in order to exclude other underlying\n pulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821820, "text": " 12:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess swan\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver and new ARF. sp swan\n\n REASON FOR THIS EXAMINATION:\n assess swan\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Swan-Ganz catheter placement.\n\n Compared to .\n\n The exam is limited due to multiple overlying external structures. A SG\n catheter is identified, with the tip trminating in the right pulmonary artery.\n This is slightly more proximal in location than on the recent study. No\n pneumothorax is evident. The cardiac silhouette is enlarged but stable in\n size. There are areas of discoid atelectasis in both lower lobes. Mild\n elevation of the right hemidiaphragm is noted.\n\n IMPRESSION: SG catheter in satisfactory position. Cardiac enlargement but no\n evidence of CHF.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821738, "text": " 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess swan\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver and new ARF. sp swan\n\n REASON FOR THIS EXAMINATION:\n assess swan\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Swan-Ganz catheter placement. Comparison is made to\n previous study of one day earlier.\n\n A Swan-Ganz catheter has been respositioned and is now in the distal right\n pulmonary artery. There has otherwise been no significant change since recent\n study.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-18 00:00:00.000", "description": "P DUPLEX DOP ABD/PEL LIMITED PORT", "row_id": 821872, "text": " 8:01 AM\n DUPLEX DOP ABD/PEL LIMITED PORT Clip # \n Reason: assess for worsening portal thrombosis with dopplers\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with increasing ascites, CHF, cirrhosis, with new portal vein\n thrombosis, now with worsening of liver function. Please assess for worsening\n port thrombosis.\n REASON FOR THIS EXAMINATION:\n assess for worsening portal thrombosis with dopplers\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62 y/o man with increasing ascites, congestive heart failure,\n cirrhosis, presenting now with worsening liver function.\n\n Real time evaluation of the right upper quadrant was performed in multiple\n planes using grayscale, color and pulse Doppler imaging.\n\n The right and left hepatic arteries are patent and demonstrate normal wave\n forms. The measured resistive index at the left hepatic artery is 0.8 and the\n measured resistive index at the right hepatic artery is 0.6. The right,\n middle and left hepatic veins are patent and show normal wave forms.\n\n The main portal vein is patent but shows hepatopetal flow. The right and left\n portal veins are likewise patent.\n\n There is moderate to severe ascites.\n\n IMPRESSION: All visualized vessels within the liver are patent. The main\n portal vein however shows hepatopetal flow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-05-18 00:00:00.000", "description": "Report", "row_id": 1566623, "text": "CCU NPN 1900-0700\nS: \" I'm having an anxiety attack \"\nO: pt. awake, alert in eve. c/o anxiety and asking for ativan. had recieved first dose at 1500. pt. stating no effect. falling asleep on own and given second dose at 2200 as ordered. lethargic, wakes, opens eyes to name. responding approp. to questions. following commands. sleeps when left alone.\n\nCV: HR 80 AV paced. BP 90's-110/50-60. PAD 22-25. CVP 12-14. unable to wedge.\nheparin 500u/hr.\nResp: LS crackles 1/3 up bilat. 4lnc sats 92-95%. sats dropping to 90% in late eve, added face tent 50% with sats 95%. HO aware. RR 22-28, appearing labored at times, however pt. denies SOB. more comf. with HOB lower d/t distended abd.\n\nID: afeb. po flagyl added in addition to IV flagyl to cover for c.diff. also on levo and lisinozid IV\nGI: rectal tube draining liq. brown/green stool, guiac pos. over 2L for past 24hours. TF nepro/promod at goal 35cc/hr.\nGU: u/o 5-15cc/hr, given 250cc NS bolus in eve, no response.\n\nevent: pt. was seen 00-0020 , lucid, awake. at ~ 0045, noted change in breathing pattern, labored, forced breathing. eye, mouth, facial twitching. sats dropping. ABG sent. HO notified. BP dropping to 60's/ at ~ 0050. pt. having siezure. Rx with total 4mg ativan initially. started on levophed up to .22mcq/k/min with good responce. ABG 7.16/65/80. family called by intern. o.k'd intubation. pt. intubated at 0130, CXR done. given additional 4mg ativan and started on versed/fent gtt's. sats 100%. vent settings at 100%/AC 600x12. RR 20.\nhead/chest/abd CT done at 0200. showing bilat pl. effusions. large ascites. bilat lowerlobe atalectasis. no head bleed per resident.\ntransferred to MICU A at 0300 post CT. BP on transfer 110/60, HR 80PAced. pt. with no further sign of siezures.\n\nA/P: unclear etiology of new siezure/? sepsis/infection\nfollow neuro signs, contin. levo, heparin. contin. triple AB. family support. ? need for paracentesis. follow ABG/s. sedation.\n" }, { "category": "Nursing/other", "chartdate": "2111-05-18 00:00:00.000", "description": "Report", "row_id": 1566624, "text": "npn 4 a.m. - 7 a.m. transfer into MICU-A from CCU, s/p CT\n\ndx: cardiomyopathy; liver failure; new seizure; w/u sepsis\n\nneuro:\nreceived sedated on Versed and Fentanyl s/p intubation in CCU d/t resp distress, seizure;\n\nresp:\nchest CT showed bil pl effusions, bil atelectasis, likely d/t abdl ascites from liv failure;\n vent settings a/c rate 12/TV 600/peep 10; FIO2 100%, with 06:00 ABG on these settings 7.33/31/220/17, therefore FIO2 turned down to 60%; (previous ABG at time of sz on CCU was 7/16/65/80);\n lung sounds clear ant upper, decreased bases bilat;\n\nc-v:\nrequiring vasopressor to maintain adequate b/p thus organ perfusion, currently on norepi at .22 mcg/k/min; maintaining sbp goal of 90, and MAP goal of 60 with norepi at this dose; at 06:30, covering MD stated she desired vasopressin started, and preferred this to norepi;\n SCD calf cuffs in place; will obtain machine;\n on heparin (500 u/hr) for old AVR; also old a-v pacer, rate approx 80 (showing 81 on cardiac monitor);\n PAC 44/16, w/ cvp (RA) 11 (was 45/20, RA 10 at insertion )\n\ng-i:\nTF's off at arrival to MICU-A; 06:30 FS 143, no RISS coverage for this;\n on both IV and PO Flagyl, will re-check in a.m. MD rounds if both routes are to be continued;\n mushroom cath in place, for green liquid stool;\n\ng-u:\nvery small amt amber urine production; MD aware; per chart, written uop goal approx 40/hr;\n\ni.d.:\non triple abx; lactic acid noted to be elevated on a.m. labs;\n\nsocial:\nfamily present at transfer into MICU-A; asked approp questions;\n\nPLAN:\ncont POC\nstart vasopressin vs norepi\n" }, { "category": "Nursing/other", "chartdate": "2111-05-18 00:00:00.000", "description": "Report", "row_id": 1566625, "text": "NPN 7a -7p\nNeuro: Sedated on Fent and Midaz, reduced doses to Fent 50mcg/hr, and Midaz 3.0 mg/hr at 1630 - pt not responding to stimuli, no movement extr noted. PERL, 2mm, brsk.\n\nCV: Pt AV paced - 80-81 on monitor, no ectopy. BP 90-108/57-64, maintained c Vasopressin .04 u/min and Levophed, currently on .11mcg/kg/min ( was at .20 prior to FFP). PAP 43-59/26-28. Had transient increase to 82/36 during infusion of FFP. Reduced infusion rate reduced pressures quickly. Initially could not wedge, later obtained 18-20. CVP 14-16. CI 3.11, SVR 655. On heparin, 500units/hr in am due to mechanical valve, was d/c'd at 1000 for planned tap for ascites. 4 u ffp given for coags, INR from 7.4 to 2.4 post. Hct stable at 38.8.\n\nResp: Received on AC Tv 600 x 12, Peep 10, 60%. TV changed to 500, Good ABG. Peak pres 17. RR ~17, 5 over vent. LS coarse, diminished at bases c bibasilar rales. Atelectasis both lower lobes prob from ascites, bilat pleural effusions. O2 sat 95-96%. SX x1 c saline lavage for sputum cult, sm amt bld tinged sputum, could not obtain any secretions w/o saline.\n\nGI: neg BS. TF on hold, no stool since ~ 2am, mushroom cath in place. FS 170, 2u reg ins. Abd US at 1600 to observe portal venous thrombus.\n\nRenal/flds: uo improved on this shift, 15-65, prob from FFP. (many hours 0 output on nights). No cont IV fluid, but drips are giving > 100mls/hr. ?ARF due to liver failure and abd compression from ascites/decreased renal perfusion.\n\nID: Tmax 100. On tripple abx.\n\nSocial: Family in talking to mds. They made pt DNR. Continuing to discuss issues of continuing care vs. stopping treatment if pts condition not reversable.\n\nPlan: Keep sbp >90, map > 65.\n\n" }, { "category": "Echo", "chartdate": "2111-05-11 00:00:00.000", "description": "Report", "row_id": 66360, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Coronary artery disease. Dilated cardiomyopathy. Left ventricular function. S/p st. \nHeight: (in) 70\nWeight (lb): 205\nBSA (m2): 2.11 m2\nBP (mm Hg): 95/65\nStatus: Inpatient\nDate/Time: at 14:11\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is severely\ndepressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed. There is paradoxic septal motion\nconsistent with conduction abnormality/ventricular pacing.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: A bileaflet aortic valve prosthesis is present. The transaortic\ngradient is normal for this prosthesis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nOverall left ventricular systolic function is severely depressed (ejection\nfraction 15-20%). There is severe global hypokinesis with focal akinesis of\nthe anterior septum. The right ventricular chamber size is normal. Right\nventricular systolic function appears depressed. A bileaflet aortic valve\nprosthesis is present. The transaortic gradient is normal for this prosthesis\n(peak and mean gradients of 33 and 17 mmHg respectively). Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821716, "text": " 6:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess placement of dopoff tube. thank you.\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver and new ARF. sp swan\n\n REASON FOR THIS EXAMINATION:\n please assess placement of dopoff tube. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Congestive heart failure, acute renal failure.\n\n COMPARISON: Eighteen hours earlier.\n\n SINGLE VIEW CHEST, AP: The left hemithorax has been clipped off of the film.\n There has been interval placement of a Dobbhoff feeding tube with the tip\n lying within the proximal stomach. The right IJ Swan-Ganz catheter again\n appears to lie within the segmental branch of the right pulmonary artery. The\n pulmonary vasculature appears prominent with upper zone redistribution\n consistent with mild left ventricular heart failure. There has been interval\n improvement of left lower lung discoid atelectasis. The left-sided pacer wires\n appear in unchanged position.\n\n IMPRESSION: Interval placement of Dobbhoff tube which terminates within the\n stomach.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 821849, "text": " 2:06 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute onset of seizures, assess for bleed/stroke\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver failure, and renal failure, on anticoagulation\n for AVR.\n REASON FOR THIS EXAMINATION:\n acute onset of seizures, assess for bleed/stroke\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, liver failure, renal failure, on anticoagulation for AVR,\n acute onset of seizures, assess for intracranial hemorrhage or infarct.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE HEAD W/O IV CONTRAST: Examination is limited by patient motion\n despite multiple attempts to restrain patient. Allowing for this, no acute\n intracranial hemorrhage is identified. There is no shift of normally midline\n structures. The ventricles and sulci are prominent, consistent with brain\n atrophy. There is no loss of grey white differentiation identified to suggest\n acute minor or major vascular territorial infarct. Punctate calcifications\n within the basal ganglia bilaterally. The density values of the brain\n parenchyma are otherwise within normal limits. Scattered calcifications along\n the falx.\n\n Bone windows demonstrate no evidence of fracture within the surrounding\n osseous structures. The mastoid air cells and paranasal sinuses are normally\n pneumatized. Within the maxillary sinuses bilaterally, there is minimal\n mucosal thickening and rounded soft tissue density projection from the\n posterolateral wall bilaterally consistent with mucous retention cyst.\n\n IMPRESSION: 1) Limited examination due to patient motion. Allowing for this,\n no evidence of acute intracranial hemorrhage or mass effect. No definite\n evidence of loss of grey white differentiation to suggest acute minor or major\n vascular territorial infarct, although CT is limited in its sensitivity for\n detection of early infarct. 2) No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-18 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 821850, "text": " 2:07 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evidence of pulmonary disease\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with liver failure, CHF, and renal failure s/p extubation for\n respiratory distress in the setting of new-onset sz.\n REASON FOR THIS EXAMINATION:\n evidence of pulmonary disease\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver failure, congestive heart failure and renal failure status\n post extubation for respiratory distress in the setting of new onset seizures.\n Evaluate for evidence of pulmonary disease.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous helically acquired axial images were obtained through\n the chest without IV contrast due to elevated patient creatinine.\n\n CONTRAST: No contrast was administered due to elevated creatinine.\n\n CT CHEST W/O IV CONTRAST: There are small bilateral pleural effusions, right\n greater than left. There is atelectasis adjacent to the right-sided pleural\n effusion within the right lower lobe and more confluent consolidation and\n atelectasis at the right base. Fine detail within the upper lobes is obscured\n by prominent respiratory motion; allowing for this, there is a\n suggestion of scattered patchy ground- glass opacities within the right upper\n and middle lobes and left upper lobe. There is near- complete consolidation of\n the left lower lobe, with associated volume loss. The patient is intubated.\n There is partial compression of the left lower lobe bronchus proximally,\n likely related to compression in the setting of extensive collapse of the left\n lower lobe. The remainder of the airways are patent to the level of the\n subsegmental bronchi bilaterally. The patient is status post median\n sternotomy, and there are surgical clips within the mediastinum, as well as\n left-sided pacemaker. A central venous access catheter is seen within the\n SVC. The aorta is normal in caliber throughout. Scattered mural\n calcifications within the thoracic aorta. A NG tube is in place. There is no\n pathologic-appearing mediastinal or hilar adenopathy. Multiple small\n mediastinal and hilar nodes do not meet criteria for pathologic enlargement.\n Multiple small axillary nodes are present.\n\n Limited images of the upper abdomen demonstrate marked ascites. The liver\n appears small and irregular in contour. Feeding tube tip terminates within\n the stomach.\n\n BONE WINDOWS: Bone windows demonstrate no evidence of suspicious lytic or\n sclerotic osseous lesions.\n\n IMPRESSION:\n (Over)\n\n 2:07 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evidence of pulmonary disease\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Small bilateral pleural effusions, right greater than left. Atelectasis and\n consolidation within the right lower lobe inferiorly. Near-total atelectasis\n and consolidation of the left lower lobe. Findings are consistent with\n aspiration pneumonia and fluid overload.\n 2. Marked ascites and evidence of cirrhosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-05-12 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 821379, "text": " 1:30 PM\n ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL Clip # \n Reason: evaluate liver for cirrhosis, portal venous flow, e/o venous\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with increasing ascites, CHF, ?cirrhosis\n REASON FOR THIS EXAMINATION:\n evaluate liver for cirrhosis, portal venous flow, e/o venous thrombosis. With\n doppler flow.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing ascites and CHF.\n\n FINDINGS:\n\n The liver is small in size and nodular in contour consistent with cirrhosis.\n There is no focal suspicious lesion. The portal vein is thrombosed extending\n from the extrahepatic portal vein intrahepatically. No flow is seen within\n these regions of portal vein. Likely as a compensatory mechanism the hepatic\n artery is enlarged but demonstrates normal waveforms. The hepatic veins are\n patent.\n\n There is intra-abdominal ascites.\n\n There is no intra or extrahepatic biliary ductal dilatation.\n\n The right kidney measures 11.5 cm in length while the left kidney measures\n 11.1 cm in length. No hydronephrosis bilaterally.\n\n IMPRESSION:\n\n 1) Cirrhosis without focal liver lesions.\n\n 2) Thrombosis of the portal vein.\n\n 3) Intra-abdominal ascites.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821847, "text": " 1:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver and new ARF. sp swan now with\n hypercapnic respiratory failure\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, new renal failure. Status post Swan placement. Respiratory\n failure. Rule out pneumonia.\n\n FINDINGS: A single AP supine image. Comparison study dated . An\n ET tube is noted, in good position. The Swan catheter tip is now in the\n right interlobar pulmonary artery, also in good position. The heart shows\n moderate LV enlargement. A pacemaker with dual-chamber electrodes is noted,\n in good position. Sternal sutures are noted. The lungs show patchy\n atelectasis at both bases, associated with high diaphragm position. No\n definite pleural effusions are identified. A Dobhoff tube is present with its\n tip in the mid portion of the stomach.\n\n IMPRESSION: ET tube, Swan catheter and Dobhoff tube in good position.\n Bibasilar atelectasis/infiltrate. The atelectasis is more marked than on the\n previous day.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821628, "text": " 2:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess swan placement.\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver and new ARF.\n REASON FOR THIS EXAMINATION:\n assess swan placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62 y/o male with CHF, liver failure and acute renal failure.\n\n COMPARISON: .\n\n FINDINGS: AP semi-upright single view of the chest. The right IJ Swan-Ganz\n catheter tip is located in segmental branch of the right pulmonary artery.\n Recommend pulling it slightly back. Again noted are left chest wall pacemaker\n with the leads in unchanged position. Interval improvement of bilateral\n perihilar patchy opacities consistent with improvement of CHF or fluid\n overload. There is bibasilar discoid atelectasis. There are low lung volumes.\n No obvious focal consolidation or pleural effusion.\n\n IMPRESSION: 1) Interval improvement bilateral perihilar opacities. 2) Residual\n bibasilar discoid atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2111-05-14 00:00:00.000", "description": "CHEST FLUORO WITHOUT RADIOLOGIST", "row_id": 821625, "text": " 11:57 PM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: pt has AICD and needs to have swan placed under fluoro after\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with CHF, liver failure, and now acute renal failure.\n REASON FOR THIS EXAMINATION:\n pt has AICD and needs to have swan placed under fluoro after reversing\n coagulopathy\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST FLUOROSCOPY WAS PERFORMED WITHOUT A RADIOLOGIST PRESENT. 8 SECONDS OF\n FLUORO TIME WAS USED. No films were submitted.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2111-05-14 00:00:00.000", "description": "RENAL U.S.", "row_id": 821593, "text": " 2:58 PM\n RENAL U.S.; DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: OBSTRUCTION, R/O RENAL ARTERY STENOSIS\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with renal failure\n REASON FOR THIS EXAMINATION:\n any obstruction, please also assess the renal arteries with . thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal failure. Cirrhosis with portal venous thrombosis and ascites.\n\n COMPARISON: Abdominal ultrasound of .\n\n RENAL ULTRASOUND: The right kidney measures 11.3 cm. The left kidney\n measures 10.2 cm. There are no renal masses, stones or hydronephrosis.\n Ascites is again noted.\n\n LIMITED ABDOMINAL DOPPLER: The right and left renal arteries were sampled in\n the upper, mid, and lower portions of each kidney. They are patent with\n normal upstroke acceleration and systolic peaks. The right and left renal\n veins are also patent with normal waveforms.\n\n IMPRESSION:\n 1. Normal appearance of the kidneys.\n 2. Normal Doppler examination of the renal arteries and veins.\n 3. Ascites.\n\n" }, { "category": "ECG", "chartdate": "2111-05-16 00:00:00.000", "description": "Report", "row_id": 133949, "text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-05-12 00:00:00.000", "description": "Report", "row_id": 133950, "text": "A-V paced rhythm. Since the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2111-05-07 00:00:00.000", "description": "Report", "row_id": 133951, "text": "A-V sequentially paced rhythm. The rate is 80. Compared to the previous tracing\nof no diagnostic change.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2126-05-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 378440, "text": "Mr. is a 73 year-old man with DMII, HTN and extensive CAD s/p\n multiple PCIs including at least 11 stents, most recently , and\n capsule endoscopy last week for a history of anemia, who presents with\n 1 week of nausea, loose stools, diaphoresis and dizziness. He presented\n to his PCP today who found lower abdominal pain and referred him to the\n ED, where he was found to have EKG changes.\n He was in his USOH until 6 days ago when he underwent capsule endoscopy\n as part of a continuing GI investigation of previous anemia and guaiac\n positive stools, despite a recently normal hematocrit. He began to have\n loose stools the day before the procedure, while on a liquid-only diet\n for the procedure, and after the procedure noted nausea, diaphoresis\n and dizziness that has persisted until this admission. He reports loose\n stools about 3x per week. The \"dizziness\" is described as feeling faint\n when he would stand up. The symptoms waxed and waned during the course\n of each day. He also reports insomnia and anorexia. Of note, he reports\n that these symptoms are very different from any prior episodes of CP,\n GERD or esophageal spasm.\n His recent GI workup is for a h/o low Hct on prior admissions (to 34)\n and guaiac positive stools. Per patient, colonoscopy (), abdominal\n MRI and capsule endoscopy have all been unremarkable.\n He denies CP, palpitations, syncope, SOB or edema. He also denies\n vomiting, abdominal pain, black or bloody stools or urine, cough,\n fever, chills or night sweats. All of the other review of systems were\n negative. Denies prior history of stroke, TIA, DVT or PE. He notes\n regular use of stool softeners at home but no recent constipation. He\n also notes recent extensive dental work and antibiotic treatment due to\n an abscess.\n His PCP noted abdominal pain on deep palpation, which the patient\n says was reproduced in the ED. In the ED, he was hemodynamically\n stable, NAD with no CP. Initial vitals showed hypertension to SBP 190.\n He received Ondasetron 2mg, ASA 325 mg, Heparin, Nitroglycerin SL\n 0.4mg. EKG changes were concerning for STE in the inferior leads, over\n a territory of a known old infarct. CXR in the ED was negative for PNA.\n Cardiology was involved because of a question of ACS.\n H/O Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Patient in NSR to Sinus brady HR 50\ns-70\ns. SBP 120-140\ns. On 2 L NC,\n Heparin gtt at 1000 units/hr. Patient denies SOB, nausea, vomiting, or\n pain.\n Action:\n Patient kept on bed rest,\n ECG done,\n CCU team and Dr. in to assess patient,\n Heparin gtt discontinued,\n Echo done.\n Response:\n ECG unchanged from previous ECG\ns, no acute process per Dr. \n pt.\ns cardiologist.\n Echo unremarkable per preliminary report.\n Plan:\n Transfer to 3, continue to monitor, discharge tomorrow?\n Demographics\n Attending MD:\n \n Admit diagnosis:\n NAUSEA\n Code status:\n Full code\n Height:\n Admission weight:\n 95.9 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Demerol (Oral) (Meperidine Hcl)\n Unknown;\n Phenobarbital\n Unknown;\n Nsaids\n potassium level\n Precautions:\n PMH: Diabetes - Insulin, Diabetes - Oral \n CV-PMH: Angina, CAD, Hypertension, MI\n Additional history: Multiple PCI's including at least 11 stents. 6 days\n ago underwent capsule endoscopy & MRI of abdomen unremarkable. GERD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:69\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 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 2 L/min\n FiO2 set:\n 24h total in:\n 1,909 mL\n 24h total out:\n 2,020 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 01:16 AM\n Potassium:\n 3.8 mEq/L\n 01:16 AM\n Chloride:\n 101 mEq/L\n 01:16 AM\n CO2:\n 25 mEq/L\n 01:16 AM\n BUN:\n 23 mg/dL\n 01:16 AM\n Creatinine:\n 1.5 mg/dL\n 01:16 AM\n Glucose:\n 85 mg/dL\n 01:16 AM\n Hematocrit:\n 39.8 %\n 01:16 AM\n Finger Stick Glucose:\n 118\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 3\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2126-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 378411, "text": "Chief Complaint: Nausea/ EKG changes\n 24 Hour Events:\n 24-hr events:\n -No CP overnight\n -NPO for possible cath today \n -CE: CK trending down from 205-192, TnT still rising 0.07 - 0.09.\n -KUB: pending\n -Hct down slightly, 42.6 -> 39.8\n -Worsening ARF, Cre (1.2)->1.4->1.5\n Allergies:\n Penicillins\n Unknown;\n Demerol (Oral) (Meperidine Hcl)\n Unknown;\n Phenobarbital\n Unknown;\n Nsaids\n potassium level\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 59 (59 - 75) bpm\n BP: 144/72(90) {131/46(69) - 159/78(96)} mmHg\n RR: 17 (11 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 12 mL\n 884 mL\n PO:\n TF:\n IVF:\n 12 mL\n 884 mL\n Blood products:\n Total out:\n 0 mL\n 620 mL\n Urine:\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 264 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 336 K/uL\n 14.0 g/dL\n 85 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 101 mEq/L\n 137 mEq/L\n 39.8 %\n 8.5 K/uL\n [image002.jpg]\n 01:16 AM\n WBC\n 8.5\n Hct\n 39.8\n Plt\n 336\n Cr\n 1.5\n TropT\n 0.09\n Glucose\n 85\n Other labs: PT / PTT / INR:15.5/88.5/1.4, CK / CKMB /\n Troponin-T:192/8/0.09, Ca++:9.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ASSESSMENT AND PLAN\n This is a 73 yo man with DMII, HTN and an extensive cardiac history\n including known 3VD and multiple PCIs including 11 stents who now\n presents with 1 week of nausea, lightheadedness, diaphoresis and loose\n stools in the setting of recent capsule endoscopy for h/o anemia, found\n to have ST elevations in an area of prior ischemia.\n .\n # CORONARIES: EKG unchanged, known prior inferior infarct. The ST\n changes may represent a collateral vessel territory given known RCA\n occlusion. Given no CP and enzymes trending down from a low peak, not\n STEMI/NSTEMI but may represent cardiac strain in the setting of\n hypovolemia and likely tachycardia from diarrhea and nausea, c/w\n lightheadedness. No evidence of ACS\n - cycle enzymes\n - f/u with Dr. \n - d/c Heparin 900 units/hr on sliding scale for now\n - plavix at home dose; not loading given low suspicion for ACS at this\n point\n - lopressor 100 mg (home dose),lisinopril 5 mg (home dose)-\n holding off on incr ACE given rising Cre; full dose aspirin\n - will start atorva 80 mg daily instead of simva 40 home dose.\n - f/u EKG\n - monitor for CP\n .\n # PUMP: EF of 30% in . Clinically slightly hypovolemic, perhaps\n related to recent episodes of diarrhea.\n - monitor Is/Os\n - echo today to evaluate LV function vs past MIBI study, and r/o\n endocarditis given recent dental work\n .\n # RHYTHM: NSR\n - follow on tele\n .\n # Abdominal Pain and symptoms: Normal WBC and normal temps not\n suggestive of an acute infectious process. No abd pain overnight.\n - f/u KUB\n - f/u C.diff, O&P\n - f/u U/A\n .\n # ARF. Cre slightly up from baseline of 1.2. In the setting of diarrhea\n and lightheadedness, likely prerenal related to mild hypovolemia;\n received 1L bolus on admission.\n - follow Cre\n - renally dose meds\n - urine lytes\n .\n # Diabetes - Hold home glucophage and glyburide; continue home lantus\n and add SSI.\n - f/u A1c.\n .\n # Dyslipidemia - atorva 80 mg daily, as above\n .\n # GERD - Continue outpatient regimen of sucralfate and ranitidine.\n Holding prilosec due to potential interaction with plavix.\n .\n # Chronic back pain secondary to spinal stenosis s/p L3-L5\n laminectomy and an L4-L5 in situ fusion- PRN APAP for pain.\n .\n # Neuropathy - Continue home nortriptyline.\n - decreasing neurontin dose to 300 q12h due to increased creatinine\n - consider neurontin toxicity as underlying cause of mild renal\n failure, nausea, diarrhea.\n .\n # Overactive bladder - Continue home hytrin.\n .\n # Depression - Continue home effexor.\n .\n FEN: heart healthy diet if no cath; replete electrolytes as needed\n ACCESS: R PIV\n PROPHYLAXIS:\n -DVT ppx with heparin\n -Pain management with APAP\n -Bowel regimen with senna/colace\n CODE: Presumed full\n DISPO: transfer to floor, PT consult and possible d/c today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 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": "2126-05-14 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 378426, "text": "Mr. is a 73 year-old man with DMII, HTN and extensive CAD s/p\n multiple PCIs including at least 11 stents, most recently , and\n capsule endoscopy last week for a history of anemia, who presents with\n 1 week of nausea, loose stools, diaphoresis and dizziness. He presented\n to his PCP today who found lower abdominal pain and referred him to the\n ED, where he was found to have EKG changes.\n He was in his USOH until 6 days ago when he underwent capsule endoscopy\n as part of a continuing GI investigation of previous anemia and guaiac\n positive stools, despite a recently normal hematocrit. He began to have\n loose stools the day before the procedure, while on a liquid-only diet\n for the procedure, and after the procedure noted nausea, diaphoresis\n and dizziness that has persisted until this admission. He reports loose\n stools about 3x per week. The \"dizziness\" is described as feeling faint\n when he would stand up. The symptoms waxed and waned during the course\n of each day. He also reports insomnia and anorexia. Of note, he reports\n that these symptoms are very different from any prior episodes of CP,\n GERD or esophageal spasm.\n His recent GI workup is for a h/o low Hct on prior admissions (to 34)\n and guaiac positive stools. Per patient, colonoscopy (), abdominal\n MRI and capsule endoscopy have all been unremarkable.\n He denies CP, palpitations, syncope, SOB or edema. He also denies\n vomiting, abdominal pain, black or bloody stools or urine, cough,\n fever, chills or night sweats. All of the other review of systems were\n negative. Denies prior history of stroke, TIA, DVT or PE. He notes\n regular use of stool softeners at home but no recent constipation. He\n also notes recent extensive dental work and antibiotic treatment due to\n an abscess.\n His PCP noted abdominal pain on deep palpation, which the patient\n says was reproduced in the ED. In the ED, he was hemodynamically\n stable, NAD with no CP. Initial vitals showed hypertension to SBP 190.\n He received Ondasetron 2mg, ASA 325 mg, Heparin, Nitroglycerin SL\n 0.4mg. EKG changes were concerning for STE in the inferior leads, over\n a territory of a known old infarct. CXR in the ED was negative for PNA.\n Cardiology was involved because of a question of ACS.\n H/O Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Patient in NSR to Sinus brady HR 50\ns-70\ns. SBP 120-140\ns. On 2 L NC,\n Heparin gtt at 1000 units/hr. Patient denies SOB, nausea, vomiting, or\n pain.\n Action:\n Patient kept on bed rest,\n ECG done,\n CCU team and Dr. in to assess patient.\n Response:\n ECG unchanged from previous ECG\ns, no acute process per Dr. \n pt.\ns cardiologist.\n Plan:\n Transfer to 3\n" }, { "category": "Physician ", "chartdate": "2126-05-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 378389, "text": "Chief Complaint: Nausea/ EKG changes\n 24 Hour Events:\n 24-hr events:\n -No CP overnight\n -NPO for possible cath today \n -CE: CK trending down from 205-192, TnT still rising 0.07 - 0.09.\n -KUB: pending\n -Hct down slightly, 42.6 -> 39.8\n -Worsening ARF, Cre (1.2)->1.4->1.5\n Allergies:\n Penicillins\n Unknown;\n Demerol (Oral) (Meperidine Hcl)\n Unknown;\n Phenobarbital\n Unknown;\n Nsaids\n potassium level\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.5\n HR: 59 (59 - 75) bpm\n BP: 144/72(90) {131/46(69) - 159/78(96)} mmHg\n RR: 17 (11 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 12 mL\n 884 mL\n PO:\n TF:\n IVF:\n 12 mL\n 884 mL\n Blood products:\n Total out:\n 0 mL\n 620 mL\n Urine:\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 264 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 336 K/uL\n 14.0 g/dL\n 85 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 101 mEq/L\n 137 mEq/L\n 39.8 %\n 8.5 K/uL\n [image002.jpg]\n 01:16 AM\n WBC\n 8.5\n Hct\n 39.8\n Plt\n 336\n Cr\n 1.5\n TropT\n 0.09\n Glucose\n 85\n Other labs: PT / PTT / INR:15.5/88.5/1.4, CK / CKMB /\n Troponin-T:192/8/0.09, Ca++:9.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ASSESSMENT AND PLAN\n This is a 73 yo man with DMII, HTN and an extensive cardiac history\n including known 3VD and multiple PCIs including 11 stents who now\n presents with 1 week of nausea, lightheadedness, diaphoresis and loose\n stools in the setting of recent capsule endoscopy for h/o anemia, found\n to have ST elevations in an area of prior ischemia.\n .\n # CORONARIES: EKG findings are nonspecific because of known prior\n inferior infarct. The ST changes may represent a collateral vessel\n territory given known RCA occlusion. Given no CP and enzymes trending\n down from a low peak, likely not STEMI but may represent ACS or cardiac\n strain in the setting of hypovolemia and likely tachycardia from\n diarrhea and nausea, c/w lightheadedness.\n - f/u with Dr. \n - Heparin 900 units/hr on sliding scale\n - plavix at home dose; not loading given low suspicion for ACS at this\n point\n - lopressor 100 mg (home dose),lisinopril 5 mg (home dose)-\n holding off on incr ACE given rising Cre; full dose aspirin\n - will start atorva 80 mg daily instead of simva 40 home dose.\n - f/u EKG\n - monitor for CP\n .\n # PUMP: EF of 30% in . Clinically slightly hypovolemic, perhaps\n related to recent episodes of diarrhea.\n - monitor Is/Os\n - echo today to evaluate LV function vs past MIBI study, and r/o\n endocarditis given recent dental work\n .\n # RHYTHM: NSR\n - follow on tele\n .\n # Abdominal Pain and symptoms: Normal WBC and normal temps not\n suggestive of an acute infectious process. No abd pain overnight.\n - f/u KUB\n - f/u C.diff, O&P\n - f/u U/A\n .\n # ARF. Cre slightly up from baseline of 1.2. In the setting of diarrhea\n and lightheadedness, likely prerenal related to mild hypovolemia;\n received 1L bolus on admission.\n - follow Cre\n - renally dose meds\n .\n # Diabetes - Hold home glucophage and glyburide; continue home lantus\n and add SSI.\n - f/u A1c.\n .\n # Dyslipidemia - atorva 80 mg daily, as above\n .\n # GERD - Continue outpatient regimen of sucralfate and ranitidine.\n Holding prilosec due to potential interaction with plavix.\n .\n # Chronic back pain secondary to spinal stenosis s/p L3-L5\n laminectomy and an L4-L5 in situ fusion- PRN APAP for pain.\n .\n # Neuropathy - Continue home nortriptyline.\n - decreasing neurontin dose to 300 q12h due to increased creatinine\n - consider neurontin toxicity as underlying cause of mild renal\n failure, nausea, diarrhea.\n .\n # Overactive bladder - Continue home hytrin.\n .\n # Depression - Continue home effexor.\n .\n FEN: heart healthy diet if no cath; replete electrolytes as needed\n ACCESS: R PIV\n PROPHYLAXIS:\n -DVT ppx with heparin\n -Pain management with APAP\n -Bowel regimen with senna/colace\n CODE: Presumed full\n DISPO: Can likely go to floor today if stable from cardiac perspective\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 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": "2126-05-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 378347, "text": "Chief Complaint: nausea/EKG changes\n HPI:\n Mr. is a 73 year-old man with DMII, HTN and extensive CAD s/p\n multiple PCIs including at least 11 stents, most recently , and\n capsule endoscopy last week for a history of anemia, who presents with\n 1 week of nausea, loose stools, diaphoresis and dizziness. He presented\n to his PCP today who found lower abdominal pain and referred him to the\n ED, where he was found to have EKG changes.\n .\n He was in his USOH until 6 days ago when he underwent capsule endoscopy\n as part of a continuing GI investigation of previous anemia and guaiac\n positive stools, despite a recently normal hematocrit. He began to have\n loose stools the day before the procedure, while on a liquid-only diet\n for the procedure, and after the procedure noted nausea, diaphoresis\n and dizziness that has persisted until this admission. He reports loose\n stools about 3x per week. The \"dizziness\" is described as feeling faint\n when he would stand up. The symptoms waxed and waned during the course\n of each day. He also reports insomnia and anorexia. Of note, he reports\n that these symptoms are very different from any prior episodes of CP,\n GERD or esophageal spasm.\n .\n His recent GI workup is for a h/o low Hct on prior admissions (to 34)\n and guaiac positive stools. Per patient, colonoscopy (), abdominal\n MRI and capsule endoscopy have all been unremarkable.\n .\n He denies CP, palpitations, syncope, SOB or edema. He also denies\n vomiting, abdominal pain, black or bloody stools or urine, cough,\n fever, chills or night sweats. All of the other review of systems were\n negative. Denies prior history of stroke, TIA, DVT or PE. He notes\n regular use of stool softeners at home but no recent constipation. He\n also notes recent extensive dental work and antibiotic treatment due to\n an abscess.\n .\n His PCP noted abdominal pain on deep palpation, which the patient\n says was reproduced in the ED. In the ED, he was hemodynamically\n stable, NAD with no CP. Initial vitals showed hypertension to SBP 190.\n He received Ondasetron 2mg, ASA 325 mg, Heparin, Nitroglycerin SL\n 0.4mg. EKG changes were concerning for STE in the inferior leads, over\n a territory of a known old infarct. CXR in the ED was negative for PNA.\n Cardiology was involved because of a question of ACS.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Penicillins\n Unknown;\n Demerol (Oral) (Meperidine Hcl)\n Unknown;\n Phenobarbital\n Unknown;\n Nsaids\n potassium level\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: DM2 with peripheral neuropathy, Dyslipidemia,\n Hypertension\n 2. CARDIAC HISTORY: CAD s/p MI\n -PERCUTANEOUS CORONARY INTERVENTIONS: s/p multiple stents\n 3. OTHER PAST MEDICAL HISTORY:\n -Obstructive sleep apnea - uses CPAP occasionally\n -Esophageal spasm\n -GERD, symptomatic\n -Chronic back pain secondary to spinal stenosis s/p cervical\n laminectomy, s/p L3-5 laminectomy and L4-5 in situ fusion \n -Overactive bladder\n -Restless leg syndrome\n -s/p cholecystectomy ~\n No early history of heart disease. Brother with MI in 50s, died in 70s\n of MI. Both brothers underwent CABG in their mid 50s to 60s. No family\n history of sudden cardiac death. Father died of prostate cancer at 51.\n Occupation: Retired, worked as a medical research consultant.\n Drugs: denies\n Tobacco: denies\n Alcohol: social\n Other: Lives at home with his wife.\n Review of systems:\n Flowsheet Data as of 01:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 75 (70 - 75) bpm\n BP: 149/71(91) {139/71(90) - 154/78(93)} mmHg\n RR: 14 (12 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 12 mL\n 13 mL\n PO:\n TF:\n IVF:\n 12 mL\n 13 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 13 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 325\n 154\n 1.4\n 23\n 22\n 100\n 4.7\n 135\n 42.6\n 9.7\n [image002.jpg]\n Other labs: PT / PTT / INR:14.3/26.3/1.2, CK / CKMB /\n Troponin-T:205/9/0.07, ALT / AST:24/21, Alk Phos / T Bili:67/0.2\n Imaging: ETT: PMibi performed on demonstrated: Abnormal\n myocardial\n perfusion study showing a severe fixed defect in the inferior\n wall from mid-chamber to the base. The LVEF is 30% and the\n proximal inferior wall is akinetic. 51% MPRHR achieved; RPP 8470.\n CARDIAC CATH performed on demonstrated:\n 1. Coronary angiography of this right dominant system\n demonstrated 3 vessel coronary artery disease. The LMCA had a 20%\n distal stenosis. The LAD had moderate diffuse disease. The Diagonal-1\n had patent stents with an 80% stenosis at the distal edge of the most\n distal stent. The LCx had patent stents. There was a 50% stenosis in\n the mid-LCx. The RCA had a total occlusion with left-to-right\n collaterals.\n 2. Limited resting hemodynamics revealed severe systemic\n arterial hypertension with a central aortic pressure of 183/99 mmHg.\n 3. Successful PTCA of the distal Diagonal-1 using 2.0x12mm and\n 2.25x12mm Voyager balloons. Final angiography revealed TIMI III\n flow, no dissection, and a 10% residual stenosis\n ECG: -EKG ON ADMISSION (, 19:46): NSR 75; LAD; PR 200, QRS 120,\n QT 400; Q waves in II/III/aVF; PRWP, 1mm STE in III/aVF; STD in\n I/aVL/V5/V6.\n -EKG at PCP (, 16:35): NSR 75; LAD; QRS 120; Q in II/III/aVF;\n <1mm STE III,V2; <1mm STD I,aVL; PRWP; Twave flat V5-V6\n -EKG : NSR 70, PR 200, QRS 120, QT 360; Qs in III/aVF; no STT\n changes; normal R-wave progression.\n Assessment and Plan\n This is a 73 yo man with DMII, HTN and an extensive cardiac history\n including known 3VD and multiple PCIs with extensive stenting stents\n who now presents with 1 week of nausea, lightheadedness, diaphoresis,\n loose stools and intermittent abdominal pain in the setting of recent\n capsule endoscopy for h/o anemia, found to have ST elevations in an\n area of prior ischemia.\n # CORONARIES: EKG findings are likely nonspecific because of known\n prior inferior infarct. The ST changes may represent a collateral\n vessel territory given known RCA occlusion. Given no CP and low\n enzymes, likely not STEMI but may represent ACS in the setting of\n hypovolemia and/or tachycardia from diarrhea, nausea, c/w\n lightheadedness.\n - Heparin 900 units/hr on sliding scale\n - Plavix at home dose; not loading given low suspicion for ACS at this\n point\n - Lopressor 100 mg (home dose),lisinopril 5 mg (home dose) -\n may incr tomorrow pending creatinine trending down; full dose aspirin\n - will start atorvastatin 80 mg daily instead of simva 40 home dose.\n - recheck CE tonight\n - keep NPO after midnight for possible cath tomorrow\n - EKG in AM\n - monitor for CP overnight\n # PUMP: EF of 30% in . Clinically slightly hypovolemic, perhaps\n related to recent episodes of diarrhea.\n - Will give 1L NS overnight to replete volume\n - monitor Is/Os\n - echo tomorrow to evaluate LV function vs past MIBI study, and r/o\n endocarditis given recent dental work\n # RHYTHM: NSR\n - follow on tele\n # Abdominal pain and symptoms: No abd pain at home but c/o nausea,\n loose stools. be residual discomfort from endoscopy, possibly with\n a subacute viral enteritis. Given territory of pain, differential\n includes prostatitis or UTI, diverticulitis, infectious colitis or\n enteritis. Low suspicion for appendicitis or PUD given clinical\n picture. Recent endoscopy and colonoscopy were negative for sources of\n bleeding or diverticula (per patient). Normal WBC and normal temps not\n suggestive of an acute infectious process.\n - check KUB\n - Send C.diff, O&P\n - U/A\n -serial abdominal exams\n # Diabetes - Hold home glucophage and glyburide while in-house;\n continue home Lantus and add SSI.\n - check A1c\n # Dyslipidemia - Atorvastatin 80 mg daily, as above.\n # GERD - Continue outpatient regimen of sucralfate and ranitidine.\n Holding Prilosec due to potential interaction with Plavix.\n # Chronic back pain secondary to spinal stenosis s/p L3-L5 laminectomy\n and an L4-L5 in situ fusion:\n - PRN APAP for pain.\n # Neuropathy - Continue home nortriptyline.\n - decreasing neurontin dose to 300 q12h due to increased creatinine\n - consider neurontin toxicity as possible underlying cause of abdominal\n symptoms\n # Overactive bladder - Continue home terzosin.\n # Depression - Continue home Effexor.\n , MSIV\n *******************************************************\n CCU PGY-2 Addendum\n I have reviewed the note by MS above, interviewed and examined\n the patient and reviewed the relevent records. Briefly, this is a 73\n yoM with an extensive CAD history with associated depressed LVEF who\n presents after several weeks of abdominal symptoms following a dietary\n change for capsule endoscopy, found to have 1-2 mm STEs in leads III\n and aVL. As the patient denies any symptoms consistent with ACS, it is\n difficult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2126-05-14 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 378349, "text": "Chief Complaint: nausea/EKG changes\n HPI:\n Mr. is a 73 year-old man with DMII, HTN and extensive CAD s/p\n multiple PCIs including at least 11 stents, most recently , and\n capsule endoscopy last week for a history of anemia, who presents with\n 1 week of nausea, loose stools, diaphoresis and dizziness. He presented\n to his PCP today who found lower abdominal pain and referred him to the\n ED, where he was found to have EKG changes.\n He was in his USOH until 6 days ago when he underwent capsule endoscopy\n as part of a continuing GI investigation of previous anemia and guaiac\n positive stools, despite a recently normal hematocrit. He began to have\n loose stools the day before the procedure, while on a liquid-only diet\n for the procedure, and after the procedure noted nausea, diaphoresis\n and dizziness that has persisted until this admission. He reports loose\n stools about 3x per week. The \"dizziness\" is described as feeling faint\n when he would stand up. The symptoms waxed and waned during the course\n of each day. He also reports insomnia and anorexia. Of note, he reports\n that these symptoms are very different from any prior episodes of CP,\n GERD or esophageal spasm.\n His recent GI workup is for a h/o low Hct on prior admissions (to 34)\n and guaiac positive stools. Per patient, colonoscopy (), abdominal\n MRI and capsule endoscopy have all been unremarkable.\n He denies CP, palpitations, syncope, SOB or edema. He also denies\n vomiting, abdominal pain, black or bloody stools or urine, cough,\n fever, chills or night sweats. All of the other review of systems were\n negative. Denies prior history of stroke, TIA, DVT or PE. He notes\n regular use of stool softeners at home but no recent constipation. He\n also notes recent extensive dental work and antibiotic treatment due to\n an abscess.\n His PCP noted abdominal pain on deep palpation, which the patient\n says was reproduced in the ED. In the ED, he was hemodynamically\n stable, NAD with no CP. Initial vitals showed hypertension to SBP 190.\n He received Ondasetron 2mg, ASA 325 mg, Heparin, Nitroglycerin SL\n 0.4mg. EKG changes were concerning for STE in the inferior leads, over\n a territory of a known old infarct. CXR in the ED was negative for PNA.\n Cardiology was involved because of a question of ACS.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Penicillins\n Unknown;\n Demerol (Oral) (Meperidine Hcl)\n Unknown;\n Phenobarbital\n Unknown;\n Nsaids\n potassium level\n Home Medications:\n ASA 325 mg PO daily\n Clopidogrel 75 mg PO daily\n Terazosin 1 mg PO qhs\n Ranitidine 150 mg PO daily\n Nortriptyline 10 mg PO qhs\n Sucralfate 1g PO qid\n Nitroglycerin 0.4 mg SL PRN\n Simvastatin 40 mg PO daily\n Lopressor 100 mg PO bid\n Glucophage 1000 mg PO tid\n Prilosec EC 40 mg PO bid\n Effexor 75 mg PO daily\n Neurontin 800 mg PO bid\n Glyburide 5 mg PO daily\n Lantus 30 units SQ\n Zestril 5 mg PO daily\n Multivitamin PO daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: DM2 with peripheral neuropathy, Dyslipidemia,\n Hypertension\n 2. CARDIAC HISTORY: CAD s/p MI\n -PERCUTANEOUS CORONARY INTERVENTIONS: s/p multiple stents\n 3. OTHER PAST MEDICAL HISTORY:\n -Obstructive sleep apnea - uses CPAP occasionally\n -Esophageal spasm\n -GERD, symptomatic\n -Chronic back pain secondary to spinal stenosis s/p cervical\n laminectomy, s/p L3-5 laminectomy and L4-5 in situ fusion \n -Overactive bladder\n -Restless leg syndrome\n -s/p cholecystectomy ~\n No early history of heart disease. Brother with MI in 50s, died in 70s\n of MI. Both brothers underwent CABG in their mid 50s to 60s. No family\n history of sudden cardiac death. Father died of prostate cancer at 51.\n Occupation: Retired, worked as a medical research consultant.\n Drugs: denies\n Tobacco: denies\n Alcohol: social\n Other: Lives at home with his wife.\n Review of systems:\n Please see HPI.\n Flowsheet Data as of 01:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 75 (70 - 75) bpm\n BP: 149/71(91) {139/71(90) - 154/78(93)} mmHg\n RR: 14 (12 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 12 mL\n 13 mL\n PO:\n TF:\n IVF:\n 12 mL\n 13 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 12 mL\n 13 mL\n Physical Examination\n GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 4 cm at 20 degrees.\n CARDIAC: RR, normal S1, S2, 2/6 systolic murmur. No thrills, lifts. No\n S3 or S4.\n LUNGS: No chest wall deformities. Resp were unlabored, no accessory\n muscle use. Some crackles at L base, otherwise CTAB.\n ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No\n abdominial bruits. Tenderness in midline lower abdomen to deep\n palpation, but without guarding or peritoneal signs. -murphys.\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ DP 2+\n Left: Carotid 2+ DP 2+\n Labs / Radiology\n 325\n 154\n 1.4\n 23\n 22\n 100\n 4.7\n 135\n 42.6\n 9.7\n [image002.jpg]\n Other labs: PT / PTT / INR:14.3/26.3/1.2, CK / CKMB /\n Troponin-T:205/9/0.07, ALT / AST:24/21, Alk Phos / T Bili:67/0.2\n Imaging: ETT: PMibi performed on demonstrated: Abnormal\n myocardial\n perfusion study showing a severe fixed defect in the inferior\n wall from mid-chamber to the base. The LVEF is 30% and the\n proximal inferior wall is akinetic. 51% MPRHR achieved; RPP 8470.\n CARDIAC CATH performed on demonstrated:\n 1. Coronary angiography of this right dominant system\n demonstrated 3 vessel coronary artery disease. The LMCA had a 20%\n distal stenosis. The LAD had moderate diffuse disease. The Diagonal-1\n had patent stents with an 80% stenosis at the distal edge of the most\n distal stent. The LCx had patent stents. There was a 50% stenosis in\n the mid-LCx. The RCA had a total occlusion with left-to-right\n collaterals.\n 2. Limited resting hemodynamics revealed severe systemic\n arterial hypertension with a central aortic pressure of 183/99 mmHg.\n 3. Successful PTCA of the distal Diagonal-1 using 2.0x12mm and\n 2.25x12mm Voyager balloons. Final angiography revealed TIMI III\n flow, no dissection, and a 10% residual stenosis\n ECG: -EKG ON ADMISSION (, 19:46): NSR 75; LAD; PR 200, QRS 120,\n QT 400; Q waves in II/III/aVF; PRWP, 1mm STE in III/aVF; STD in\n I/aVL/V5/V6.\n -EKG at PCP (, 16:35): NSR 75; LAD; QRS 120; Q in II/III/aVF;\n <1mm STE III,V2; <1mm STD I,aVL; PRWP; Twave flat V5-V6\n -EKG : NSR 70, PR 200, QRS 120, QT 360; Qs in III/aVF; no STT\n changes; normal R-wave progression.\n Assessment and Plan\n This is a 73 yo man with DMII, HTN and an extensive cardiac history\n including known 3VD and multiple PCIs with extensive stenting stents\n who now presents with 1 week of nausea, lightheadedness, diaphoresis,\n loose stools and intermittent abdominal pain in the setting of recent\n capsule endoscopy for h/o anemia, found to have ST elevations in an\n area of prior ischemia.\n # CORONARIES: EKG findings are likely nonspecific because of known\n prior inferior infarct. The ST changes may represent a collateral\n vessel territory given known RCA occlusion. Given no CP and low\n enzymes, likely not STEMI but may represent ACS in the setting of\n hypovolemia and/or tachycardia from diarrhea, nausea, c/w\n lightheadedness.\n - Heparin 900 units/hr on sliding scale\n - Plavix at home dose; not loading given low suspicion for ACS at this\n point\n - Lopressor 100 mg (home dose),lisinopril 5 mg (home dose) -\n may incr tomorrow pending creatinine trending down; full dose aspirin\n - will start atorvastatin 80 mg daily instead of simva 40 home dose.\n - recheck CE tonight\n - keep NPO after midnight for possible cath tomorrow\n - EKG in AM\n - monitor for CP overnight\n # PUMP: EF of 30% in . Clinically slightly hypovolemic, perhaps\n related to recent episodes of diarrhea.\n - Will give 1L NS overnight to replete volume\n - monitor Is/Os\n - echo tomorrow to evaluate LV function vs past MIBI study, and r/o\n endocarditis given recent dental work\n # RHYTHM: NSR\n - follow on tele\n # Abdominal pain and symptoms: No abd pain at home but c/o nausea,\n loose stools. be residual discomfort from endoscopy, possibly with\n a subacute viral enteritis. Given territory of pain, differential\n includes prostatitis or UTI, diverticulitis, infectious colitis or\n enteritis. Low suspicion for appendicitis or PUD given clinical\n picture. Recent endoscopy and colonoscopy were negative for sources of\n bleeding or diverticula (per patient). Normal WBC and normal temps not\n suggestive of an acute infectious process.\n - check KUB\n - Send C.diff, O&P\n - U/A\n -serial abdominal exams\n # Diabetes - Hold home glucophage and glyburide while in-house;\n continue home Lantus and add SSI.\n - check A1c\n # Dyslipidemia - Atorvastatin 80 mg daily, as above.\n # GERD - Continue outpatient regimen of sucralfate and ranitidine.\n Holding Prilosec due to potential interaction with Plavix.\n # Chronic back pain secondary to spinal stenosis s/p L3-L5 laminectomy\n and an L4-L5 in situ fusion:\n - PRN APAP for pain.\n # Neuropathy - Continue home nortriptyline.\n - decreasing neurontin dose to 300 q12h due to increased creatinine\n - consider neurontin toxicity as possible underlying cause of abdominal\n symptoms\n # Overactive bladder - Continue home terzosin.\n # Depression - Continue home Effexor.\n , MSIV\n *******************************************************\n CCU PGY-2 Addendum\n I have reviewed the note by MS above, interviewed and examined\n the patient and reviewed the relevant records. Briefly, this is a 73\n yoM with an extensive CAD history with associated depressed LVEF who\n presents after several weeks of abdominal symptoms following a dietary\n change for capsule endoscopy, found to have 1-2 mm STEs in leads III\n and aVL. As the patient denies any symptoms classically consistent with\n ACS, it is difficult to know the significance of these findings,\n although they are certainly worrisome given his history. At the present\n time we will manage him medically with ASA, BB, heparin gtt, Plavix and\n high dose statin. We will obtain a repeat ECG and echocardiogram in a\n few hours and consider possible repeat cardiac cath, although if his\n cardiac biomarkers do not trend up in a significant manner, I currently\n would not favor an invasive strategy. Concerning his abdominal\n symptoms, this is difficult to pull together in the setting of his\n recent apparently negative work-up including colonoscopy and abdominal\n CT. We will obtain a KUB, UA, stool studies including C. Diff and\n abdominal labs and follow his status clinically. We may need to repeat\n an abdominal CT if he does not improve. Finally, I suspect his mild ARF\n is secondary to pre-renal azotemia in the setting of diarrhea and\n decreased PO intake. It appears he can tolerate IV hydration at this\n time, and thus will infuse 1L NS overnight. We will continue his ACEi\n for the moment, but will hold this if there is not marked improvement\n with his next lab draw, would discontinue this and consider further\n testing (renal ultrasound, urine eos, etc.).\n ICU Care\n Nutrition: PO cardiac diet\n Glycemic Control: insulin\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2126-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 378355, "text": "Chief Complaint: nausea/EKG changes\n HPI:\n Mr. is a 73 year-old man with DMII, HTN and extensive CAD s/p\n multiple PCIs including at least 11 stents, most recently , and\n capsule endoscopy last week for a history of anemia, who presents with\n 1 week of nausea, loose stools, diaphoresis and dizziness. He presented\n to his PCP today who found lower abdominal pain and referred him to the\n ED, where he was found to have EKG changes.\n He was in his USOH until 6 days ago when he underwent capsule endoscopy\n as part of a continuing GI investigation of previous anemia and guaiac\n positive stools, despite a recently normal hematocrit. He began to have\n loose stools the day before the procedure, while on a liquid-only diet\n for the procedure, and after the procedure noted nausea, diaphoresis\n and dizziness that has persisted until this admission. He reports loose\n stools about 3x per week. The \"dizziness\" is described as feeling faint\n when he would stand up. The symptoms waxed and waned during the course\n of each day. He also reports insomnia and anorexia. Of note, he reports\n that these symptoms are very different from any prior episodes of CP,\n GERD or esophageal spasm.\n His recent GI workup is for a h/o low Hct on prior admissions (to 34)\n and guaiac positive stools. Per patient, colonoscopy (), abdominal\n MRI and capsule endoscopy have all been unremarkable.\n He denies CP, palpitations, syncope, SOB or edema. He also denies\n vomiting, abdominal pain, black or bloody stools or urine, cough,\n fever, chills or night sweats. All of the other review of systems were\n negative. Denies prior history of stroke, TIA, DVT or PE. He notes\n regular use of stool softeners at home but no recent constipation. He\n also notes recent extensive dental work and antibiotic treatment due to\n an abscess.\n His PCP noted abdominal pain on deep palpation, which the patient\n says was reproduced in the ED. In the ED, he was hemodynamically\n stable, NAD with no CP. Initial vitals showed hypertension to SBP 190.\n He received Ondasetron 2mg, ASA 325 mg, Heparin, Nitroglycerin SL\n 0.4mg. EKG changes were concerning for STE in the inferior leads, over\n a territory of a known old infarct. CXR in the ED was negative for PNA.\n Cardiology was involved because of a question of ACS.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Penicillins\n Unknown;\n Demerol (Oral) (Meperidine Hcl)\n Unknown;\n Phenobarbital\n Unknown;\n Nsaids\n potassium level\n Home Medications:\n ASA 325 mg PO daily\n Clopidogrel 75 mg PO daily\n Terazosin 1 mg PO qhs\n Ranitidine 150 mg PO daily\n Nortriptyline 10 mg PO qhs\n Sucralfate 1g PO qid\n Nitroglycerin 0.4 mg SL PRN\n Simvastatin 40 mg PO daily\n Lopressor 100 mg PO bid\n Glucophage 1000 mg PO tid\n Prilosec EC 40 mg PO bid\n Effexor 75 mg PO daily\n Neurontin 800 mg PO bid\n Glyburide 5 mg PO daily\n Lantus 30 units SQ\n Zestril 5 mg PO daily\n Multivitamin PO daily\n" }, { "category": "Nursing", "chartdate": "2126-05-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 378356, "text": "Chief Complaint: nausea/EKG changes\n HPI:\n Mr. is a 73 year-old man with DMII, HTN and extensive CAD s/p\n multiple PCIs including at least 11 stents, most recently , and\n capsule endoscopy last week for a history of anemia, who presents with\n 1 week of nausea, loose stools, diaphoresis and dizziness. He presented\n to his PCP today who found lower abdominal pain and referred him to the\n ED, where he was found to have EKG changes.\n He was in his USOH until 6 days ago when he underwent capsule endoscopy\n as part of a continuing GI investigation of previous anemia and guaiac\n positive stools, despite a recently normal hematocrit. He began to have\n loose stools the day before the procedure, while on a liquid-only diet\n for the procedure, and after the procedure noted nausea, diaphoresis\n and dizziness that has persisted until this admission. He reports loose\n stools about 3x per week. The \"dizziness\" is described as feeling faint\n when he would stand up. The symptoms waxed and waned during the course\n of each day. He also reports insomnia and anorexia. Of note, he reports\n that these symptoms are very different from any prior episodes of CP,\n GERD or esophageal spasm.\n His recent GI workup is for a h/o low Hct on prior admissions (to 34)\n and guaiac positive stools. Per patient, colonoscopy (), abdominal\n MRI and capsule endoscopy have all been unremarkable.\n He denies CP, palpitations, syncope, SOB or edema. He also denies\n vomiting, abdominal pain, black or bloody stools or urine, cough,\n fever, chills or night sweats. All of the other review of systems were\n negative. Denies prior history of stroke, TIA, DVT or PE. He notes\n regular use of stool softeners at home but no recent constipation. He\n also notes recent extensive dental work and antibiotic treatment due to\n an abscess.\n His PCP noted abdominal pain on deep palpation, which the patient\n says was reproduced in the ED. In the ED, he was hemodynamically\n stable, NAD with no CP. Initial vitals showed hypertension to SBP 190.\n He received Ondasetron 2mg, ASA 325 mg, Heparin, Nitroglycerin SL\n 0.4mg. EKG changes were concerning for STE in the inferior leads, over\n a territory of a known old infarct. CXR in the ED was negative for PNA.\n Cardiology was involved because of a question of ACS.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Penicillins\n Unknown;\n Demerol (Oral) (Meperidine Hcl)\n Unknown;\n Phenobarbital\n Unknown;\n Nsaids\n potassium level\n Home Medications:\n ASA 325 mg PO daily\n Clopidogrel 75 mg PO daily\n Terazosin 1 mg PO qhs\n Ranitidine 150 mg PO daily\n Nortriptyline 10 mg PO qhs\n Sucralfate 1g PO qid\n Nitroglycerin 0.4 mg SL PRN\n Simvastatin 40 mg PO daily\n Lopressor 100 mg PO bid\n Glucophage 1000 mg PO tid\n Prilosec EC 40 mg PO bid\n Effexor 75 mg PO daily\n Neurontin 800 mg PO bid\n Glyburide 5 mg PO daily\n Lantus 30 units SQ\n Zestril 5 mg PO daily\n Multivitamin PO daily\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt alert and oriented X3\n Denies any chest pain\n Denies any dizziness / nausea\n Arrived from with EKG changes\n Heparin gtt a1200u/hr\n PTT 88.5\n CPK MB and Trop elevated\n Action:\n Heparin gtt decreased to 1000u/hr\n Response:\n Awaiting repeat PTT this am\n Plan:\n ? cardiac cath today\n Cont to monitor VS\n Serial PTT\n Serial CK\n" }, { "category": "Echo", "chartdate": "2126-05-14 00:00:00.000", "description": "Report", "row_id": 97770, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease.\nHeight: (in) 71\nWeight (lb): 210\nBSA (m2): 2.16 m2\nBP (mm Hg): 125/66\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 11:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mild regional LV systolic\ndysfunction. TDI E/e' >15, suggesting PCWP>18mmHg. Transmitral Doppler and TVI\nc/w Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral\n- hypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. RV function depressed.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification. Physiologic MR (within normal limits). LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. There is mild regional left ventricular systolic dysfunction with\ninferiora akinesis/hypokinesis and inferolateral hypokinesis. Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nTransmitral Doppler and tissue velocity imaging are consistent with Grade I\n(mild) LV diastolic dysfunction. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. Physiologic mitral regurgitation is seen (within\nnormal limits). The left ventricular inflow pattern suggests impaired\nrelaxation. The tricuspid valve leaflets are mildly thickened. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nNOTE: Report edited on to correct the name of the referring\nphysician. \n\n\n" }, { "category": "ECG", "chartdate": "2126-05-14 00:00:00.000", "description": "Report", "row_id": 269463, "text": "Sinus rhythm at lower limits of normal rate. Since the previous tracing\nno significant change in previously noted findings.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2126-05-13 00:00:00.000", "description": "Report", "row_id": 269464, "text": "Sinus rhythm. Left axis deviation. Intraventricular conduction delay.\nConsider inferior myocardial infarction. ST-T wave abnormalities.\nSince the previous tracing no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-05-13 00:00:00.000", "description": "Report", "row_id": 269465, "text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. Consider\ninferior myocardial infarction. ST-T wave abnormalities. Since the previous\ntracing of inferior R waves are less prominent. ST-T wave\nabnormalities are more prominent.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2173-09-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 875754, "text": " 8:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate known intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hemorrhagic stroke, intubated\n REASON FOR THIS EXAMINATION:\n evaluate known intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VK MON 10:01 PM\n Large lt frontoparietal intraparenchymal hemorrhage increased from outside\n study. New bilat. intraventricular hemorrhage. Lt frontal SAH. Mild left uncal\n herniation. Increase in rt medial parietal hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old with intracranial hemorrhage. By report, the patient\n drove himself to an outside hospital emergency room, and subsequently became\n lethargic and obtunded.\n\n TECHNIQUE: CT of the brain without IV contrast.\n\n Comparison is made to a study performed approximately 5:00 p.m. at an outside\n hospital, which was not available for review by the attending co-signing the\n report.\n\n FINDINGS: There is a large left frontal and parietal intraparenchymal\n hemorrhage with surrounding vasogenic edema. There is also subarachnoid\n hemorrhage seen superiorly in the left frontal lobe. Intraparenchymal\n hemorrhage is also seen medially within the right parietal lobe along the\n falx. There is hemorrhage layering bilaterally within the occipital horns of\n the lateral ventricles. The extensive intraparenchymal hemorrhage is larger\n than on the earlier outside study in both cerebral hemispheres. In addition,\n the intraventricular hemorrhage is new since the prior study.\n\n There is mild shift of midline structures to the right, including medial\n displacement of the left uncus. There is flattening of the left lateral\n ventricle due to mass effect. Other ventricles are not dilated. Marked sulcus\n effacement is seen within the left cerebral hemisphere. The patient is\n slightly rotated on the scout view.\n\n An endotracheal tube is present, as is an NG tube. Minimal mucosal thickening\n is seen in the ethmoid air cells. Soft tissues, osseous structures, and\n remaining paranasal sinuses are unremarkable in appearance.\n\n IMPRESSION: Large left cerebral intraparenchymal hemorrhage and right\n parietal lobe intraparenchymal hemorrhage with associated left frontal lobe\n subarachnoid hemorrhage and bilateral intraventricular hemorrhage. There is\n also mild left uncal herniation. These findings were communicated to Dr. \n at the completion of the examination.\n\n DFDgf\n (Over)\n\n 8:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate known intracranial bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2173-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 875752, "text": " 8:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p intubation for head bleed\n REASON FOR THIS EXAMINATION:\n eval tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation for intracranial hemorrhage, evaluate tube\n position.\n\n COMPARISON: None.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 5.2 cm from\n the carina. Nasogastric tube terminates in the gastric fundus. The heart\n size and mediastinal contours are within normal limits. Slight prominence of\n the upper zone pulmonary vasculature likely relates to supine positioning.\n There is partial atelectasis of the left lower lobe. No pneumothorax. The\n left costophrenic angle is excluded from the radiograph. The visualized\n osseous structures appear unremarkable.\n\n IMPRESSION:\n 1. Endotracheal tube and nasogastric tube in satisfactory position.\n 2. Partial atelectasis of the left lower lobe.\n\n\n" }, { "category": "ECG", "chartdate": "2173-09-06 00:00:00.000", "description": "Report", "row_id": 300582, "text": "Sinus rhythm. Within normal limits. No previous tracing available for\ncomparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-09-07 00:00:00.000", "description": "Report", "row_id": 1477754, "text": "SICU NPN\nSEE FHP FOR HPI AND PMH\nS-Unresponsive\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNS\n\nO-Intubated and repsonding to stimuli only by flexing all extremeties and withdrawing in LUE. Propofol stopped on arrival from ED since GCS of 3. Propofol at 5mcgs/kg/min prior. Pupil 2mms bilaterally and reactive, impaired corneas, delayed cough and gag absent. Dr. meeting with family prior to pt being transfered from ED and pt made . HR 60-90s, NSR with no viewed ectopy. SBP 70-130s. Goal initially to keep SBP < 180. Labetolol gtt if needed. Arriving on AC, later extubated without incident and left on RA. Breath sound clear, dim at right base. Foley patent and draining clear yellow urine, since made pt oliguric. Abd soft with hypoactive bowel sounds. OGT removed with extubation. Afebrile. No issues. Skin dry and intact. Family into see pt prior to extubation and spending time. Prior to family seeing given 2mg of Ativan for comfort and Morphine gtt started prior to extubation and titrated to comfort. Pt's ring with red stone and watch sent home with wife. band left on since unable to remove. RN explaining to wife that would be able to probably remove at funeral home. NEOB notified and pt not a canidate since recent diagnosis of cancer.\n\nA/P: s/p ICH now \nContinue to make comfortable\nWife and children not expected to call or visit\nNotify NEOB again once pt expires\n" }, { "category": "Nursing/other", "chartdate": "2173-09-07 00:00:00.000", "description": "Report", "row_id": 1477755, "text": "RESPIRATORY CARE: PT EXTUBATED PER FAMILY\nWISHES AND NOW STATUS. EXTUBATED TO\nROOM AIR.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-07 00:00:00.000", "description": "Report", "row_id": 1477756, "text": "NPN (SEE CAERVUE FOR SPECIFICS)\nPT UNRESPONSIVE, MORPHINE GTT CURRENTLY AT 20MG/HR WITH GOOD EFFECT, RESP 15-20. BP 80'S, (CHECKED INFREQUENTLY), HR 90'S, SAT 99% ON RA. ATIVAN PRN ALSO GIVEN WITH GOOD EFFECT. PERIODS OF APNEA, HOWEVER PT APPEARING COMFORTABLE, NO LABORED BREATHING. FAMILY AT THE BEDSIDE, UPDATED, PT CALLED OUT TO THE FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-07 00:00:00.000", "description": "Report", "row_id": 1477757, "text": "ADDENDUM\nPT EXPIRED AT 1837, FAMILY AT BEDSIDE\n" } ]

[ { "category": "Radiology", "chartdate": "2201-02-06 00:00:00.000", "description": "PERIPHERAL W/O PORT", "row_id": 952095, "text": " 2:36 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: s/p malpositioned US DL PICC placed by venous access; please\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with GI bleed now with IR placed PICC line that fell out\n overnight.\n REASON FOR THIS EXAMINATION:\n s/p malpositioned US DL PICC placed by venous access; please reposition.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 64-year-old man with gastrointestinal bleeding, now with\n malpositioned double-lumen PICC line. Revision requested.\n\n TECHNIQUE: PICC line replacement.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist was present and\n supervising throughout the procedure.\n\n PROCEDURE AND FINDINGS: At the site of the existing PICC line along the\n proximal right upper extremity, the site was prepped and draped in the usual\n sterile fashion. A pre-procedure timeout was performed to verify patient\n identity and the procedure to be performed. 3 mL of 1% lidocaine was applied\n subcutaneously for local anesthesia. Fluoroscopy showed that the existing\n catheter was placed via the right cephalic vein, but made a turn back towards\n the axilla into a tributary vein, rather than passing centrally into the\n subclavian vein. The catheter was retracted, cut, and cannulated with 0.018\n guidewire, which was advanced into the proximal cephalic vein using\n flouroscopic guidance. The existing catheter was replaced by a 4.5-French\n micropuncture sheath. A venogram with 8 mL of Optiray 320 via the sheath\n showed patency of the right axillary and cephalic veins. However, it was\n somewhat difficult initially to pass the 0.018 guidewire into the subclavian\n vein. The micropuncture sheath was exchanged for a 4-French vascular sheath,\n which was cannulated with a 0.035 angled glidewire, which was passed into the\n proximal cephalic vein. Using the glidewire and a 4-French C2 Cobra glide\n catheter, access to the superior vena cava was obtained. The catheter and\n vascular sheath were removed, and again replaced with the micropuncture\n sheath. Over the guidewire, a 55-cm length 5- French double-lumen Vaxcel PICC\n line was advanced into the superior vena cava. The wire was removed. The\n catheter was flushed. The PICC line was secured to the adjacent skin using a\n StatLock. A final fluoroscopic spot image shows that the tip of the PICC line\n lies in the superior vena cava. The patient tolerated the procedure well.\n There were no immediate complications.\n\n IMPRESSION: Successful revision of double-lumen PICC line, via the existing\n venous access in the right cephalic vein, terminating in the superior vena\n cava. Ready for use.\n (Over)\n\n 2:36 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: s/p malpositioned US DL PICC placed by venous access; please\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2201-02-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 952076, "text": " 1:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p 48cm DL right median PICC placement; please determine ti\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with GIB. Bleeding at PICC site\n\n REASON FOR THIS EXAMINATION:\n s/p 48cm DL right median PICC placement; please determine tip location.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST :\n\n COMPARISON: .\n\n INDICATION: PICC line placement.\n\n A right PICC line coils within the right axilla. The distal tip is not\n visualized but appears to be coursing back down the right arm rather than in\n the chest. Left PICC line has been removed. Cardiac silhouette is mildly\n enlarged but stable in size. No acute pulmonary findings are evident.\n\n IMPRESSION: Malpositioned right PICC line, as communicated by telephone to\n the PICC line nurse caring for the patient.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-02-06 00:00:00.000", "description": "FOLLOW-UP,REQUEST BY RAD.", "row_id": 952075, "text": " 1:05 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: replace PICC line\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ********************************* CPT Codes ********************************\n * FOLLOW-UP,REQUEST BY RAD. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with GI bleed now with IR placed PICC line that fell out\n overnight.\n REASON FOR THIS EXAMINATION:\n replace PICC line\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: This study was canceled. Please see clip# regarding\n placement of a PICC line on the same day.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-01-30 00:00:00.000", "description": "PICC W/O PORT", "row_id": 951111, "text": " 9:11 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: needs picc access\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 3\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with GI bleed\n REASON FOR THIS EXAMINATION:\n needs picc access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 64-year-old man with gastrointestinal bleeding, requiring PICC\n access.\n\n PROCEDURE: PICC line placement.\n\n RADIOLOGISTS: The procedure was performed by Drs. and \n . Dr. , the attending radiologist, was present and supervising\n throughout the procedure.\n\n PROCEDURE AND FINDINGS: Using ultrasound, the left basilic vein was found to\n be patent and compressible. A pre-procedure timeout was performed to verify\n patient identity and the procedure to be performed. The chosen site along the\n left upper arm was prepped and draped in the usual sterile fashion.\n Approximately 3 cc of 1% lidocaine was given subcutaneously for local\n anesthesia.\n\n Under ultrasound guidance, the left basilic vein was cannulated with a 21-\n gauge access needle, over which a 0.018 Glidewire was advanced into the left\n axillary vein. Hard copy ultrasound images were obtained prior to and\n following access, demonstrating venous patency. Because of mild initial\n difficulty traversing the left subclavian vein, fluoroscopic venography was\n performed by hand injection of 20 cc of Optiray-320, verifying patency of the\n left subclavian vein. A 0.018 Glidewire was then readily advanced into the\n superior vena cava. Over the wire, a 45 cm length double- lumen 5-French PICC\n line was advanced into the superior vena cava. The catheter was flushed and\n secured to the adjacent skin with a StatLock device. The patient tolerated the\n procedure well. There were no immediate complications.\n\n IMPRESSION: Successful placement of 45 cm length 5-French double-lumen PICC\n line, via the left basilic vein, terminating in the superior vena cava.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951319, "text": " 5:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check placement of PICC,\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with GIB. Bleeding at PICC site\n\n REASON FOR THIS EXAMINATION:\n check placement of PICC,\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Bleeding at PICC line site. Check position of PICC line.\n\n The tip of the PICC line lies in the left innominate in the midline. The\n heart remains enlarged. No failure or infiltrates are present.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2201-01-30 00:00:00.000", "description": "Report", "row_id": 1519495, "text": "PT TX TO FROM OSH FOR TO CHANGE MECH AV TO PORCINE-SEE FHP FOR DETAILS. SEE CAREVUE FOR VS, LABS.\nROS:\n\nNEURO: PT IS A&OX3, FOLLOWS COMMANDS. SLEPT WELL OVERNIGHT. AMBULATED ON OWN @ HOME & @ OSH. STANDS TO VOID IN URINAL, STEADY GAIT. LEGALLY BLIND. RT EYE SUNKEN, REMAINS CLOSED. LEFT EYE OPEN, PUPIL NR. DENIES PAIN.\n\nCV: AF 80s-90s WHEN RECEIVED. NO ECTOPY. HEPARIN DOSE ON ARRIVAL UNKNOWN, PTT DRAWN, HEPARIN RESTARTED. BP 110S WHEN ALERT, 90S-100S, AT REST. PALPABLE PULSES. EXTRS W/D. AFEBRILE.\n\nRESP: BILAT LS CLR. O2SATS >97% ON RA. RESP RATE 10S.\n\nGI/GU: PT CLR LIQS. NO C/O N/V. +BS. ABD SOFT, NT, ND. NO BM. VOIDING CLR YELLOW URINE.\n\nENDO: BS MONITORED PER PT OWN SS. COVERED W/HUMALOG X2 OVERNIGHT. LANTUS @ HS GIVEN.\n\nSOCIAL: NO CALLS FROM FAMILY THIS SHIFT. PT STATES SPOUSE IS AWARE OF TRANSFER TO .\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS. MONITOR LABS. ? PICC PLACEMENT, CENTRAL ACCESS. UPDATE PT/FAMILY RE: STATUS & PLAN OF CARE.\n" }, { "category": "Radiology", "chartdate": "2201-01-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951048, "text": " 9:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG/AVR admit w/GIB and h/o ?LUL opacity\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABG/AVR admit w/GIB and h/o ?LUL opacity\n ______________________________________________________________________________\n FINAL REPORT\n\n AP CHEST 9:34 P.M. .\n\n HISTORY: Status post CABG and AVR, question left upper lobe opacity.\n\n IMPRESSION: AP chest compared to chest radiographs since ,\n most recently :\n\n The patient has had median sternotomy. Mild cardiomegaly has been present\n without change since . Also unchanged is a prominent left upper lobe\n pulmonary artery which should not be mistaken for juxtahilar nodule. Lungs\n are essentially clear. Left posterior healed rib fractures are longstanding.\n No pleural abnormality or evidence of central adenopathy.\n\n" }, { "category": "Radiology", "chartdate": "2201-02-01 00:00:00.000", "description": "R SHOULDER 2-3 VIEWS NON TRAUMA RIGHT", "row_id": 951386, "text": " 10:37 AM\n SHOULDER VIEWS NON TRAUMA RIGHT Clip # \n Reason: eval for mal-alignment or occult fracture\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hx of shoulder dislocation now with pain and limited\n passive ROM\n REASON FOR THIS EXAMINATION:\n eval for mal-alignment or occult fracture\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT SHOULDER, \n\n Three views of the right shoulder are obtained and show no evidence of acute\n displaced fracture nor any evidence of dislocation on the current images. Mild\n degenerative changes are present.\n\n There is evidence of prior cardiac surgery with median sternotomy wires.\n\n IMPRESSION:\n\n No obvious acute displaced fracture or dislocation of the right shoulder on\n the current study.\n\n" }, { "category": "ECG", "chartdate": "2201-02-08 00:00:00.000", "description": "Report", "row_id": 112745, "text": "Atrial fibrillation with a rapid ventricular response. Intraventricular\nconduction defect. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of atrial fibrillation and intraventricular conduction\ndefect are new. Cannot exclude prior inferior myocardial infarction. Clinical\ncorrelation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2120-08-29 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1205390, "text": " 10:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, TACHY, FEVER. ? PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman pt not ambulatory pw SOB, tachycardia, and fever\n REASON FOR THIS EXAMINATION:\n PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw FRI 12:10 AM\n no pulmonary embolism.\n\n small filing defect in the left main bronchus with left lower lobe atlectesis.\n unable to distinguish between endoluminal mass and secretions. short term\n follow up chest CT could be performed to distinguish.\n\n right hemidiaphragm elevation with RLL atelectasis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and tachycardia and fever.\n\n CTA CHEST: MDCT imaging was performed from the thoracic inlet to the upper\n abdomen without IV contrast. Subsequently, after the uneventful intravenous\n administration of 100 mL of Optiray, MDCT imaging was again performed from the\n thoracic inlet to the upper abdomen. Sagittal, coronal and oblique reformats\n were performed.\n\n COMPARISON: Chest radiograph , .\n\n FINDINGS: No pulmonary embolism, or evidence for acute aortic injury is\n present. There is dense atherosclerotic disease of the coronary vessels. The\n mitral annulus is calcified. There is aortic valvular calcifications.\n\n There is marked elevation of the right hemidiaphragm resulting in atelectasis\n of the right lower lobe, which may be chronic. Left basilar atelectasis is\n also present. There is soft tissue partially filling the left main stem\n bronchus (3:41). No pneumothorax, or pleural effusion is present. No\n significant axillary, hilar, or mediastinal lymphadenopathy is present. The\n lobes of the thyroid appear normal.\n\n Limited views of the upper abdomen demonstrate a cyst in the upper pole of the\n right kidney.\n\n BONE WINDOWS: No suspicious bone lesions are identified.\n\n IMPRESSION:\n\n 1. No pulmonary embolism.\n\n 2. Marked right hemidiaphragm elevation with resulting marked atelectasis of\n (Over)\n\n 10:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, TACHY, FEVER. ? PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the right lower lobe, which may be chronic.\n\n 3. Soft tissue within the left main stem bronchus may be secretions, but an\n endobronchial mass is not excluded. A repeat CT of the chest could be\n performed after deep suction to distinguish between these two possibilities.\n Alternatively, bronchoscopy could be performed. This was discussed via phone\n with Dr. at 10AM on .\n\n" }, { "category": "Radiology", "chartdate": "2120-08-31 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1205584, "text": " 9:16 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 41 cm right basilic vein Picc text tip placement to \n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 41 cm right basilic vein Picc text tip placement to \n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON AT 9:16\n\n HISTORY: New PICC line.\n\n FINDINGS: The film was rotated and there is a moderately elevated right\n hemidiaphragm. There is a new right-sided PICC line with tip in the right\n atrium. This should be pulled back about 5 cm. This finding was discussed\n with the IV nurse, by Dr. at 11:45 a.m. on . There\n is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-08-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1205552, "text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare to previous\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n compare to previous\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Hypoxia.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is a small left effusion that is increased in size compared\n to prior. The right hemidiaphragm continues to be elevated. There is volume\n loss at both bases. There is no definite infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-08-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1205375, "text": " 8:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 2036 HOURS.\n\n HISTORY: Respiratory distress.\n\n COMPARISON: .\n\n FINDINGS: Please note the lateral lower left chest has been excluded from\n view. Again noted is a markedly elevated right hemidiaphragm occupying the\n inferior half of the right hemithorax. There is also significant volume loss\n of the left hemithorax as well. Ill-defined opacities project over the\n cardiac silhouette likely signifying left lower lobe atelectasis. Of the\n aerated lung seen, there is no consolidation or superimposed edema noted. The\n trachea is midline. There is marked aortic tortuosity. Mitral annulus\n calcification is incidentally noted. The cardiac silhouette size is difficult\n to assess but is grossly stable. Blunting of the right costophrenic angle is\n again noted and stable. There may be a small underlying effusion. No left\n effusion is noted. The bones are diffusely osteopenic.\n\n IMPRESSION: Numerous limitations but grossly stable x-ray examination. There\n is slight increased density in the retrocardiac left lower lobe, which may be\n due to atelectasis in light of even further volume loss.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-08-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1205392, "text": " 11:16 PM\n CHEST (PA & LAT) Clip # \n Reason: pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with fever and sob\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and shortness of breath.\n\n PA AND LATERAL CHEST RADIOGRAPH\n\n COMPARISON: chest radiograph and chest CT.\n\n FINDINGS: Lung volumes are markedly low with severe elevation of the right\n hemidiaphragm. These low lung volumes likely cause exaggeration of the\n pulmonary vasculature, but mild vascular congestion is likely still present.\n The aorta is markedly tortuous. No pleural effusions are present. Bibasilar\n atelectasis is present.\n\n IMPRESSION:\n 1. Low lung volumes with bibasilar atelectasis, and mild vascular congestion.\n Stable right hemidiaphragm elevation.\n\n" }, { "category": "ECG", "chartdate": "2120-08-30 00:00:00.000", "description": "Report", "row_id": 278548, "text": "Sinus rhythm.. Compared to the previous tracing of the same date multiple\nabnormalities are as previously reported without diagnostic change. Clinical\ncorrelation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2120-08-30 00:00:00.000", "description": "Report", "row_id": 278549, "text": "Sinus rhythm. Compared to the previous tracing of multiple abnormalities\nas previously reported. The heart rate is not as fast. QRS axis is less\nleftward. Right bundle-branch block persists with left ventricular hypertrophy\nand lateral ST-T wave changes which could be due to ischemia, left ventricular\nhypertrophy, etc. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2120-08-29 00:00:00.000", "description": "Report", "row_id": 278784, "text": "Resint sinus tachycardia. Left axis deviation. Right bundle-branch block. Left\nventricular hypertrophy. Non-specific ST-T wave changes could be due to left\nventricular hypertrophy, ischemia, etc. Compared to the previous tracing\nof the heart rate is minimally faster. QRS axis is slightly less\nleftward and ST-T wave changes are slightly less pronounced.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2175-06-26 00:00:00.000", "description": "BX-NEEDLE KIDNEY BY NEPHROLOGIST", "row_id": 1200935, "text": " 10:49 AM\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: biopsy for evaluation of DGF of transplanted kidney\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ********************************* CPT Codes ********************************\n * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p renal transplant with delayed graft function- needs\n biopsy\n REASON FOR THIS EXAMINATION:\n biopsy for evaluation of DGF of transplanted kidney\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post renal transplant with delayed graft function, needs\n biopsy.\n\n SON GUIDANCE FOR RENAL TRANSPLANT BIOPSY BY NEPHROLOGIST: Son\n guidance was provided to the nephrologist for biopsy of a transplanted kidney\n located in the pelvis. Two passes were made using an 18-gauge core biopsy\n needle. Please refer to nephrologist's note for details of the procedure.\n\n IMPRESSION: Son guidance for biopsy of transplant kidney by\n nephrologist.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-06-21 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1200208, "text": " 12:22 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman POD 5 from kidney transplant, poor urine output, increased\n incisional drainage and fluid seen on ultrasound around transplant kidney\n REASON FOR THIS EXAMINATION:\n assess for fluid collection\n CONTRAINDICATIONS for IV CONTRAST:\n kidney transplant\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST\n\n COMPARISON: Ultrasound and .\n\n CLINICAL HISTORY: 60-year-old woman post-op day 5 from kidney transplant,\n poor urine output, increased incisional drainage and fluid seen on ultrasound\n around transplant kidney. Assess for fluid collection.\n\n FINDINGS:\n An intra-abdominal right lower quadrant transplant kidney is visualized.\n There is a ureteral stent extending from the renal pelvis into the\n predominantly collapsed urinary bladder. Evaluation of the renal parenchyma\n is limited given lack of intravenous contrast. There is no significant\n hydronephrosis. Surrounding the kidney, there is a small amount of free\n fluid, likely similar in degree as seen on previous ultrasound. In addition,\n there is a moderate amount of subcutaneous fluid deep to the surgical staples\n and in the anterior right abdominal wall. There is no definite evidence of\n organized fluid collection or abscess.\n\n Lack of intravenous contrast limits evaluation of the solid abdominal viscera\n and vasculature. There is a small right pleural effusion. There is\n subcutaneous stranding of the soft tissues extending superiorly from the\n incision to the level of the anterior eighth rib.\n\n Trace pericardial fluid or minimal pericardial thickening is present. A\n partially imaged central venous catheter is seen, the tip terminating at the\n inferior cavoatrial junction. A catheter traversing the anterior abdominal\n subcutaneous tissues and entering the peritoneal cavity is evident consistent\n with reported VP shunt.\n\n Coronary artery calcifications are evident. The heart is normal in size.\n There is compressive atelectasis on the right and linear strands of\n atelectasis or scarring bilaterally at the bases.\n\n The native kidneys demonstrate innumerable hypodense lesions. In addition,\n there are scattered high-density lesions which may represent hemorrhagic or\n proteinaceous cyst. There are scattered renal calcifications on the left\n greater than right, measuring up to 8 mm in the mid left kidney. There is no\n hydronephrosis. The liver also demonstrates innumerable low-density lesions\n (Over)\n\n 12:22 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: assess for fluid collection\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with the lesions larger than 1 cm measuring near water density in Hounsfield\n units. These likely represent multiple cysts. The gallbladder, spleen,\n adrenal glands, and pancreas are grossly unremarkable. Atherosclerotic\n calcifications are present within the normal caliber infrarenal abdominal\n aorta as well as iliac arteries.\n\n There is no evidence of bowel obstruction. Multiple diverticula are seen\n within the sigmoid colon without surrounding inflammatory changes. Severe\n degenerative changes are present within the left hip with complete loss of\n joint space and osseous fusion of the femoral head and acetabulum. This is\n possibly post-traumatic or post infectious as it is an asymmetric finding.\n Significant facet arthropathy is noted in the lower lumbar spine. There are\n no suspicious osseous lesions.\n\n IMPRESSION:\n 1. Right lower quadrant intraperitoneal transplant with surrounding small\n perinephric fluid collection.\n 2. Unorganized fluid in the right anterior/lateral abdominal wall\n subcutaneous tissues.\n 3. Polycystic kidney and liver disease with scattered small hemorrhagic or\n proteinaceous cysts and non-obstructing renal calculi. Evaluation is limited\n for solid enhancing lesions given lack of intravenous contrast.\n\n" }, { "category": "Radiology", "chartdate": "2175-06-26 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 1201019, "text": " 9:05 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: duplex ultrasound of right kidney transplant to evaluate for\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p renal transplants complicated by delayed graft function\n pod 0 from kidney biopsy now with falling hematocrit.\n REASON FOR THIS EXAMINATION:\n duplex ultrasound of right kidney transplant to evaluate for AVF and hematoma\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc MON 11:02 PM\n No evidence of acute venous fistula. Stable fluid collection adjacent to the\n upper pole of the transplant kidney. No hydronephrosis. No new hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 60-year-old female status post renal transplant\n complicated by delayed graft function, postoperative day 0, now status post\n kidney biopsy postoperative day 10 with falling hematocrit. Evaluate for AV\n fistula or hematoma.\n\n EXAMINATION: Renal transplant ultrasound.\n\n COMPARISONS: , and .\n\n FINDINGS:\n\n The right lower quadrant transplant kidney was evaluated. The right lower\n quadrant transplant kidney measures 11.4 cm. Redemonstrated is a\n peri-transplant fluid collection adjacent to the upper pole, that within\n differences in technique, is stable to minimally increased in size and\n distribution since recent CT from measuring 4.3 x 3.1 x 5.1 cm. There is\n no evidence of arteriovenous fistula formation. The kidneys demonstrate\n symmetric flow. Limited views of the main renal artery and vein demonstrate\n patency and appropriate direction of flow. Full Doppler examination was not\n performed.\n\n IMPRESSION: No evidence of arteriovenous fistula. Stable to minimally\n increased fluid collection adjacent to the upper pole of the transplant\n kidney, given difference in modality. No hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2175-06-26 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 1201020, "text": ", R. FA10 9:05 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: duplex ultrasound of right kidney transplant to evaluate for\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p renal transplants complicated by delayed graft function\n pod 0 from kidney biopsy now with falling hematocrit.\n REASON FOR THIS EXAMINATION:\n duplex ultrasound of right kidney transplant to evaluate for AVF and hematoma\n ______________________________________________________________________________\n PFI REPORT\n No evidence of acute venous fistula. Stable fluid collection adjacent to the\n upper pole of the transplant kidney. No hydronephrosis. No new hematoma.\n\n" }, { "category": "Radiology", "chartdate": "2175-06-19 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1199948, "text": " 8:10 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ASSESS FOR HEMATOMA/SEROMA DRAINAGE\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with new sero-sanguinous incision drainage and what appears\n to be expanding area of hematoma. Area more painful and looks more swollen\n since this AM\n REASON FOR THIS EXAMINATION:\n Assess for hematoma/ seroma\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg MON 11:30 PM\n Small amount of hypoechoic fluid tracking lateral to the surgical staples with\n subcutaneous edema. Small unchanged peri-transplant fluid.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with new serosanguineous incisional drainage,\n status post transplant. Evaluate for expanding hematoma.\n\n COMPARISON: .\n\n FINDINGS: Lateral and superior to the line of surgical staples at 2 cm depth,\n there is a hypoechoic fluid tracking approximately 1.0 cm in maximal width.\n There is no internal vascularity. Subcutaneous edema is present. Small\n peri-transplant fluid collection is similar to prior. Limited evaluation of\n the transplant kidney is unremarkable.\n\n IMPRESSION:\n\n 1. Hypoechoic fluid lateral and superior to surgical incision.\n\n 2. Small perinephric fluid collection, similar to .\n\n" }, { "category": "Radiology", "chartdate": "2175-06-17 00:00:00.000", "description": "BLADDER US", "row_id": 1199690, "text": " 3:12 PM\n BLADDER US Clip # \n Reason: Confirm position of foley in bladder\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with post renal transplant\n REASON FOR THIS EXAMINATION:\n Confirm position of foley in bladder\n ______________________________________________________________________________\n WET READ: GMSj SAT 5:15 PM\n Focused ultrasound ~3 inches below the umbilicus demonstrates a round\n echogenic structure in the midline - c/w a foley catheter - likely within the\n bladder - though difficult to assess given lack of distension of the bladder.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old female status post renal transplant. Patient with\n decreasing drainage from Foley, evaluation of position.\n\n COMPARISON: Renal transplant ultrasound from .\n\n BLADDER ULTRASOUND: A focused ultrasound in the region of the bladder, ~3\n inches below the umbilicus in the midline, demonstrates a hypoechoic rounded\n region with thin hyperechoic walls, findings suggestive of Foley catheter.\n The catheter is likely within a decompressed bladder; however, complete\n evaluation is limited.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2175-06-22 00:00:00.000", "description": "RENAL SCAN", "row_id": 1200306, "text": "RENAL SCAN Clip # \n Reason: 60 YR OLD WOMAN WITH KIDNEY TRANSPLANT, MINIMAL URINE OUTPUT AND RISING CREATININE REQUIRING HEMODIALYSIS ASSESS F\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 5.4 mCi Tc-m MAG3 ();\n HISTORY: 60 y/o woman, 1 week s/p renal transplant. Now oliguric and rising\n creatinine.\n\n INTERPRETATION:\n\n Flow and dynamic images were obtained after intravenous administration of\n tracer.\n\n Blood flow images show normal flow to the renal transplant in the anterior\n pelvis.\n\n Renogram images show minimal excretion from the renal transplant.\n\n There is continuous increase in tracer activity after injection. In the setting\n of oliguria, good flow to the renal graft, and minimal excretion, this is most\n consistent with acute tubular necrosis.\n\n IMPRESSION:\n\n Acute tubular necrosis of kidney transplant.\n\n\n\n\n , MD\n , M.D. Approved: FRI 4:16 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": "2175-06-16 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1199452, "text": " 2:53 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: END STAGE RENAL FAILURE\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with end-stage renal disease, here for potential transplant\n REASON FOR THIS EXAMINATION:\n Please evaluate for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: End-stage renal disease, for potential transplant.\n\n TECHNIQUE: CHEST RADIOGRAPH, TWO VIEWS.\n\n COMPARISON: No prior.\n\n FINDINGS: A hemodialysis catheter ends in the right atrium. There is a tubing\n projecting over right lung, could be a VP shunt, correlate with history.\n There are low lung volumes and no pneumonia. Minimal bibasilar atelectasis\n are seen at the lung bases. There is no pleural effusion or pneumothorax.\n Hilar, mediastinal and cardiac silhouettes are within normal limits.\n\n IMPRESSION:\n 1. Low lung volumes.\n 2. Minimal bibasilar atelectasis.\n 3. No pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2175-06-16 00:00:00.000", "description": "P RENAL TRANSPLANT U.S. PORT", "row_id": 1199507, "text": " 10:18 AM\n RENAL TRANSPLANT U.S. PORT Clip # \n Reason: please perform renal duplex to assess vasculature\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with new R iliac renal txp (intra-peritoneal) & intra-op\n renal ischemia\n REASON FOR THIS EXAMINATION:\n please perform renal duplex to assess vasculature\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 60-year-old female with new right iliac renal transplant and\n intraop renal ischemia.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The transplant kidney is seen in the right lower quadrant and there\n is a small peri-transplant fluid collection seen at the upper pole.\n Transplant kidney measures 10.7 cm in length. No hydronephrosis is seen.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. Appropriate venous flow is seen in the main renal vein.\n Appropriate arterial waveforms with sharp upstrokes are seen in the main renal\n artery. Resistive indices of the intraparenchymal arteries are normal\n measuring from 55-66.\n\n IMPRESSION: Patent renal transplant vasculature with normal RIs. Small\n peri-transplant fluid collection seen at the upper pole. No hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2175-06-19 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1199949, "text": ", R. FA10 8:10 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ASSESS FOR HEMATOMA/SEROMA DRAINAGE\n Admitting Diagnosis: END STAGE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with new sero-sanguinous incision drainage and what appears\n to be expanding area of hematoma. Area more painful and looks more swollen\n since this AM\n REASON FOR THIS EXAMINATION:\n Assess for hematoma/ seroma\n ______________________________________________________________________________\n PFI REPORT\n Small amount of hypoechoic fluid tracking lateral to the surgical staples with\n subcutaneous edema. Small unchanged peri-transplant fluid.\n\n" }, { "category": "ECG", "chartdate": "2175-06-17 00:00:00.000", "description": "Report", "row_id": 200979, "text": "Sinus rhythm. Borderline non-specific ST-T wave changes. Compared to the\nprevious tracing of there is no change.\n\n" }, { "category": "ECG", "chartdate": "2175-06-16 00:00:00.000", "description": "Report", "row_id": 200980, "text": "Sinus rhythm. Non-specific ST-T wave changes, probably a normal variant.\nCompared to the previous tracing of no change.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446114, "text": "89 yo female w/ known history of hypertension w/ syncople episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental\n status. Per report, the patient appeared to lose consciousness and\n collapse while walking. She struck her head on the pavement when she\n fell. Her blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke.\n Action:\n Nutrition consult placed. IVF\ns. Labs sent. Frequent\n turning/repositioning required while sedated.\n Response:\n Plan:\n Await nutrition recs. Assess pts MS and ability to care for self once\n extubated and sedation removed. Freq turning/skin care provided.\n Altered mental status (not Delirium)\n Assessment:\n Pt arrived sedated on Propofol @ 30mcg/kg/min. Pt still restless and\n somewhat agitated in bed.\n Action:\n Propofol gtt has essentially stayed the same at this time. Shut off\n intermittently to try and assess MS.\n Response:\n Pt became increasingly restless and agitated.\n Plan:\n ? wean to extubate this am. Assess SBT/RSBI. ? f/u head CT is MS does\n not improve.\n Fall(s)\n Assessment:\n Pt has a known hx of multiple falls per son. today was witness and\n pt did hit head. C-Spine & TLS precautions have in essence been\n cleared.\n Action:\n ? ligament injury (will not be able to assess until MS has cleared, \n MD) -J\nstout\n collar. Social work cx placed.\n Response:\n Collar still appears to not fit adequately. Fall risk precautions.\n Plan:\n ? possible placement of collar for comfort and better fit.\n Assess safety/living circumstances.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears noted on BUE. Skin tear also noted on coccyx.\n Bilateral heels reddened. Hands notable for abrasions. Ecchymotic areas\n covering various parts of body\n Action:\n Skin tears cleansed w/ NS and covered with Mepilex dsgs. Abrasions OTA\n w/ bacitracin. Aloe vesta barrier cream applied to bilateral heels.\n Response:\n Plan:\n Improve nutrition status/caloric intake. Assess skin and reposition pt\n Q2hr. Keep all bony prominences elevated @ all times if possible.\n Pt has had a significant amt of bloody secretions via nose and oral\n cavity. Subglottal suctioning revealing impaired gag/cough reflex.\n Ventilator suction notable for thick/yellow secretions. At this time pt\n is hemodynamically stable w/ Hct 33. Lactate 1.8 as noted above. LS\n clear/dim @ bases with occasional rhonci.\n" }, { "category": "Respiratory ", "chartdate": "2196-02-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 446122, "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 Tube Type\n ETT:\n Position: 19 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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n Possible extubation in A.M.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2196-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 446596, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke but not eat.\n Action:\n Pt seen by S&S today. Able to take nectar thick liquids, ground solids.\n Requires supervision with meals to prevent aspiration. Repleted with\n K+, Mg+, Ca+.\n Response:\n Pt tolerating meals today. No s/s aspiration.\n Plan:\n Strongly encourage PO intake. Cont to provide supervision with meals.\n Replete electrolytes as needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox2 (does not know year but knows place/name). Obeys commands and\n able to move extremities. Remains calm/cooperative this shift. PERRLA.\n Impaired gag but productive/congested cough present. Able to clear\n secretions when reminded.\n Action:\n Response:\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. Mepilex\n dsgs to left elbow & coccyx CDI. Pt c/o mild pain in her right shoulder\n on movement but has remained comfortable w/ repositioning. Bilateral\n heels reddened. Hands notable for abrasions. Ecchymotic areas covering\n various parts of body. Right shoulder large reddened area collar\n placement.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as needed. Attempt to improve\n nutrition/caloric intake.\n" }, { "category": "Physician ", "chartdate": "2196-02-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 446600, "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 Called out to floor, became hypoxic to mid 80s on RA, started on\n levofloxacin, now on 4L.\n INVASIVE VENTILATION - STOP 11:54 AM\n ULTRASOUND - At 03:10 PM\n Carotid Ultra Sound\n CALLED OUT\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 AM\n Heparin Sodium (Prophylaxis) - 07:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (99\n HR: 70 (63 - 86) bpm\n BP: 143/51(74) {104/36(56) - 143/51(74)} mmHg\n RR: 20 (15 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,403 mL\n 1,750 mL\n PO:\n TF:\n IVF:\n 1,403 mL\n 1,750 mL\n Blood products:\n Total out:\n 1,708 mL\n 285 mL\n Urine:\n 1,683 mL\n 285 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -305 mL\n 1,465 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.3 g/dL\n 157 K/uL\n 89 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 110 mEq/L\n 143 mEq/L\n 29.9 %\n 6.8 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n 12:08 PM\n 07:16 PM\n 03:54 AM\n WBC\n 9.3\n 7.6\n 9.0\n 6.8\n Hct\n 33.0\n 31.0\n 33.1\n 29.9\n Plt\n 197\n 179\n 183\n 157\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TropT\n 0.02\n 0.04\n 0.03\n TCO2\n 30\n 29\n 28\n Glucose\n 101\n 106\n 103\n 89\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:596/8/0.03, ALT / AST:118/156, Alk Phos / T Bili:85/0.4,\n Lactic Acid:1.5 mmol/L, Albumin:3.5 g/dL, Ca++:7.4 mg/dL, Mg++:1.5\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 1. Resp failure: Appears to have aspiration PNA in RLL\n -levofloxacin for now\n -swallow eval\n -cont. O2 NC\n -advair 250/50 \n -spireva\n 2. Syncope: Extensive neg w/u\n 3. htn: Home meds being held\n 4. FEN: modify diet according to swallow eval\n 5. PT/OT consult\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 07:39 PM\n 20 Gauge - 06:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n ------ Protected Section ------\n 89 year old female with recurrent syncope presented after fall/syncope\n and intubated because agitated and needed emergent HCT/neck CT scan\n extubated and was slotted to go to the floor yesterday but developed\n hypoxia and right lower infiltrate consistent with pneumonia\n PE: T 100.3 P 82 121/43 Sat 95 on 3.5 liters NC\n Intubated/sedated\n Decreased BS on right\n S1 S2 reg\n Soft NT ND\n No edema\n A:\n 1) Fall/syncope\n 2) Pneumonia\n likely an aspiration pneumonitis\n Plan:\n 1) Can go to the floor\n 2) Will give antibiotics for pneumonia although this may be\n pneumonitis rather than actual pneumonia\n Time: 25 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 06:09 PM ------\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446199, "text": "89 yo female w/ known history of hypertension w/ syncople episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental\n status. Per report, the patient appeared to lose consciousness and\n collapse while walking. She struck her head on the pavement when she\n fell. Her blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke (does not eat)\n Action:\n Nutrition consult placed. IVF\ns. Labs sent. Frequent\n turning/repositioning required.\n Response:\n Rigid @ times. Otherwise tolerating activity.\n Plan:\n Await nutrition recs. Assess pts MS and ability to care for self once\n extubated and sedation removed. Freq turning/skin care provided.\n Altered mental status (not Delirium)\n Assessment:\n Pt arrived sedated on Propofol @ 30mcg/kg/min. Pt has remained\n comfortable and arousable.\n Action:\n Propofol gtt has essentially stayed the same at this time. RSBI 75.\n Successful SBT\n Response:\n Propofol remains for comfort until plan for extubation.\n Plan:\n ? wean to extubate this am. SBT/RSBI completed. ? f/u head CT if MS\n does not improve.\n Fall(s)\n Assessment:\n Pt has a known hx of multiple falls per son. today was witness and\n pt did hit head. C-Spine & TLS precautions have in essence been\n cleared.\n Action:\n ? ligament injury (will not be able to assess until MS has cleared, \n MD) -J\nstout\n collar. Social work cx placed.\n Response:\n Collar still appears to not fit adequately. Fall risk precautions.\n Plan:\n ? possible placement of collar for comfort and better\n fit. Assess safety/living circumstances.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears noted on BUE. Skin tear also noted on coccyx.\n Bilateral heels reddened. Hands notable for abrasions. Ecchymotic areas\n covering various parts of body. Right shoulder large reddened area \n collar placement.\n Action:\n Skin tears cleansed w/ NS and covered with Mepilex dsgs. Abrasions OTA\n w/ bacitracin. Aloe vesta barrier cream applied to bilateral heels.\n Response:\n Plan:\n Improve nutrition status/caloric intake. Assess skin and reposition pt\n Q2hr. Keep all bony prominences elevated @ all times if possible.\n Pt has had a significant amt of bloody secretions via nose and oral\n cavity. Subglottal suctioning revealing impaired gag/cough reflex.\n Ventilator suction notable for small thick/yellow secretions. At this\n time pt is hemodynamically stable w/ Hct 31. Lactate 1.5. K 3.1 (MD\n aware, awaiting replacement orders) LS clear/dim @ bases with\n occasional rhonci.\n" }, { "category": "Physician ", "chartdate": "2196-02-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 446236, "text": "Chief Complaint: Fall, Intubated\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:32 PM\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Intubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 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: 60 (60 - 76) bpm\n BP: 150/44(71) {124/41(63) - 150/58(80)} mmHg\n RR: 23 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 432 mL\n 666 mL\n PO:\n TF:\n IVF:\n 432 mL\n 666 mL\n Blood products:\n Total out:\n 500 mL\n 870 mL\n Urine:\n 500 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n -68 mL\n -204 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 365 (314 - 377) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 73\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: 7.38/45/46/27/0\n Ve: 7.7 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin\n Eyes / Conjunctiva: pinpoint pupils\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, No(t) NG tube, No(t) OG tube, abrasion above left eye\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: 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 Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting\n Skin: Warm, diffuse ecchymosis on arms\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 179 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 9 mg/dL\n 109 mEq/L\n 142 mEq/L\n 31.0 %\n 7.6 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n WBC\n 9.3\n 7.6\n Hct\n 33.0\n 31.0\n Plt\n 197\n 179\n Cr\n 0.6\n 0.5\n TropT\n 0.02\n 0.04\n TCO2\n 30\n 29\n 28\n Glucose\n 101\n 106\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:631/8/0.04, Lactic Acid:1.5 mmol/L, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 89 F with h/o of HTN, hyperlipidemia and syncope who was brought to the\n ED after a witnessed fall where her head struck the ground. Pt was\n intubated in the ED for altered mental status so that a thorough\n work-up could be conducted. Head CT was negative and patients labs\n were by-in-large unremarkable. She did have a mildly elevated lactate\n and acidemia that were attributed to the fact that she was violently\n thrashing around prior to sedation and intubation. With gentle fluids\n and time, her lactate has come back down. The patient's history was\n obtained from her son who reports that she falls quite frequently. She\n is normally seen at . Syncope work-ups have been\n unrevealing to date.\n .\n Altered Mental Status - Son reports that patient fully mentally\n competent at baseline with only mild senility. Etiologies of agitation\n and alteration today could include trauma fall, toxic metabolic,\n infection or delirium. Head CT negative for acute bleed. Pt had\n mildly elevated white blood cell count on admission, however, trended\n down to normal with gently fluids. CXR and UA negative for occult\n infection.\n - blood cx is spikes\n - no antibiotics for now in absence of signs of infection\n - decrease sedation and extubate in am\n - check B12, Thiamine and Folate, then replete\n - f/u urine cx\n - if agitated once extubated, consider Haldol only as needed\n - clear c-spine once awake and extubated, with a negative CT scan, low\n risk for ligamentous injury given mechanism of fall\n .\n Syncope/Fall - Per report, pt lost consciousness before she fell. Per\n son and friend, she falls often in the setting of a loss of\n consciousness. Etiologies include vaso-vagal, orthostatic hypotension,\n MI, or other neurologic cause such as seizure, TIA, etc. Extensive\n work-up at over the years has been unrevealing. Blood\n glucose 156 in field. Pt had ECHO in but report is not\n available in records. No evidence of arrhthymia on EKG,\n cardiac enzymes negative x1. Per notes, on B-Blocker to\n facilitate beta 2-receptor blockade and assist with some possible\n neurogenic causes of her symptoms. Per son's report, pt does not drink\n anything but coffee that he is aware of and is often light-headed when\n she stands up. BBlocker and/or CCB could be contributing to\n hypotension and or bradyarrhythmia\n - Check B12, Thimaine and Folate, then replete\n - ROMI, cardiac enzymes negative x1\n - consider carotid dopplers\n - continue gently volume resuscitation\n - hold BBlocker and calcium channel blocker for now\n - XRs negative\n .\n Resp Failure\n Intubated in setting of altered MS. acute pulmonary\n issues. On minimal settings.\n - Plan to extubate this AM if following commands off sedation\n .\n Elevated Lactate - Differential includes infection versus muscle\n exertion in setting of extreme agitation and combativeness. Likely due\n to the latter. With time and gentle fluids acidemia and elevated\n lactate have resolved.\n - normalized lactate by AM\n .\n Elevated troponin\n Trop is still in indeterminate range but has\n trended up from <0.01 to 0.04 this AM. CK also trending up but MD flat.\n - Repeat EKG\n - Cycle enzymes until trajectory is evident\n - Fluids for CKs\n .\n Hypertension - on HCTZ and amlodipine\n - will hold for now\n .\n Hyperlipidemia - on lescol at home\n - will restart when extubated\n .\n FEN - NPO, gentle fluids, replete lytes, replete B12, thiamine and\n folate\n .\n Proph - Heparin sq, VAP bundle, pneumoboots, PT/OT consult once\n extubated\n .\n Code Status - Full Code\n .\n Contact - , \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor once extubated\n" }, { "category": "Physician ", "chartdate": "2196-02-16 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 446237, "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 89 y/o f had a witnessed fall and hit head yesterday, taken to ED, was\n agitated and non-cooperative. Was intubated and sedated. Had a neg head\n CT, no ECG changes, lactate was 6.\n Was 100% on PS 15/5 0.4. Now placed on SBT overnight.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n lescol, amlodine, hctz\n Past medical history:\n Family history:\n Social History:\n htn\n hyperlipidemia\n nicotene use\n h/o DVT 1 y ago\n recurrent syncope with unrevealing w/u, suspected vasovagal, neg\n cartotid dopplers, neg EEG, Holter with PVCS and APBs\n B12 def\n h/o PNA\n lacunar infarcts\n brother w MI, sister \n Occupation:\n Drugs:\n Tobacco: ppd X70y\n Alcohol: never\n Other: son lives nearby, lives independently\n Review of systems:\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: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 65 (56 - 76) bpm\n BP: 123/47(66) {123/41(63) - 150/58(80)} mmHg\n RR: 21 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 432 mL\n 674 mL\n PO:\n TF:\n IVF:\n 432 mL\n 674 mL\n Blood products:\n Total out:\n 500 mL\n 950 mL\n Urine:\n 500 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -68 mL\n -276 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 288 (288 - 377) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 73\n PIP: 5 cmH2O\n SpO2: 100%\n ABG: 7.38/45/46/27/0\n Ve: 6.4 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: abrasion over L eyebrow\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 179 K/uL\n 31.0 %\n 11.2 g/dL\n 106 mg/dL\n 0.5 mg/dL\n 9 mg/dL\n 27 mEq/L\n 109 mEq/L\n 3.1 mEq/L\n 142 mEq/L\n 7.6 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n WBC\n 9.3\n 7.6\n Hct\n 33.0\n 31.0\n Plt\n 197\n 179\n Cr\n 0.6\n 0.5\n TropT\n 0.02\n 0.04\n TC02\n 30\n 29\n 28\n Glucose\n 101\n 106\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:631/8/0.04, Lactic Acid:1.5 mmol/L, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 89 y/o f with recurrent suncope.\n 1. AMS: Fully communicative at baseline and communicative, no clear\n infectious source, suspect lactate was elevated agitation\n -possible delirium, no clear cause\n -hold sedation\n 2. Syncope: Dx includes seizure vs CVA vs arrythmia vs. orthostasis\n -check orthostatics\n -B12 low, replete\n -cycle CE\n -carotid dopplers\n -uop 30-40/h\n -held BP meds\n -f/u trauma recs re: C. collar\n 3. htn: Hold antihypertensives\n 4. NPO\n 5. vent: shut off propofol and try to extubate\n -haldol prn for agitation\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2196-02-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 446238, "text": "Chief Complaint: Fall, Intubated\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:32 PM\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Intubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 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: 60 (60 - 76) bpm\n BP: 150/44(71) {124/41(63) - 150/58(80)} mmHg\n RR: 23 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 432 mL\n 666 mL\n PO:\n TF:\n IVF:\n 432 mL\n 666 mL\n Blood products:\n Total out:\n 500 mL\n 870 mL\n Urine:\n 500 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n -68 mL\n -204 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 365 (314 - 377) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 73\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: 7.38/45/46/27/0\n Ve: 7.7 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin\n Eyes / Conjunctiva: pinpoint pupils\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, No(t) NG tube, No(t) OG tube, abrasion above left eye\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: 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 Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting\n Skin: Warm, diffuse ecchymosis on arms\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 179 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 9 mg/dL\n 109 mEq/L\n 142 mEq/L\n 31.0 %\n 7.6 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n WBC\n 9.3\n 7.6\n Hct\n 33.0\n 31.0\n Plt\n 197\n 179\n Cr\n 0.6\n 0.5\n TropT\n 0.02\n 0.04\n TCO2\n 30\n 29\n 28\n Glucose\n 101\n 106\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:631/8/0.04, Lactic Acid:1.5 mmol/L, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 89 F with h/o of HTN, hyperlipidemia and syncope who was brought to the\n ED after a witnessed fall where her head struck the ground. Pt was\n intubated in the ED for altered mental status so that a thorough\n work-up could be conducted. Head CT was negative and patients labs\n were by-in-large unremarkable. She did have a mildly elevated lactate\n and acidemia that were attributed to the fact that she was violently\n thrashing around prior to sedation and intubation. With gentle fluids\n and time, her lactate has come back down. The patient's history was\n obtained from her son who reports that she falls quite frequently. She\n is normally seen at . Syncope work-ups have been\n unrevealing to date.\n .\n Altered Mental Status - Son reports that patient fully mentally\n competent at baseline with only mild senility. Etiologies of agitation\n and alteration today could include trauma fall, toxic metabolic,\n infection or delirium. Head CT negative for acute bleed. Pt had\n mildly elevated white blood cell count on admission, however, trended\n down to normal with gently fluids. CXR and UA negative for occult\n infection.\n - blood cx is spikes\n - no antibiotics for now in absence of signs of infection\n - decrease sedation and extubate in am\n - check B12, Thiamine and Folate, then replete\n - f/u urine cx\n - if agitated once extubated, consider Haldol only as needed\n - clear c-spine once awake and extubated, with a negative CT scan, low\n risk for ligamentous injury given mechanism of fall\n .\n Syncope/Fall - Per report, pt lost consciousness before she fell. Per\n son and friend, she falls often in the setting of a loss of\n consciousness. Etiologies include vaso-vagal, orthostatic hypotension,\n MI, or other neurologic cause such as seizure, TIA, etc. Extensive\n work-up at over the years has been unrevealing. Blood\n glucose 156 in field. Pt had ECHO in but report is not\n available in records. No evidence of arrhthymia on EKG,\n cardiac enzymes negative x1. Per notes, on B-Blocker to\n facilitate beta 2-receptor blockade and assist with some possible\n neurogenic causes of her symptoms. Per son's report, pt does not drink\n anything but coffee that he is aware of and is often light-headed when\n she stands up. BBlocker and/or CCB could be contributing to\n hypotension and or bradyarrhythmia\n - Check B12, Thimaine and Folate, then replete\n - ROMI, cardiac enzymes negative x1\n - consider carotid dopplers\n - continue gently volume resuscitation\n - hold BBlocker and calcium channel blocker for now\n - XRs negative\n .\n Resp Failure\n Intubated in setting of altered MS. acute pulmonary\n issues. On minimal settings.\n - Plan to extubate this AM if following commands off sedation\n .\n Elevated Lactate - Differential includes infection versus muscle\n exertion in setting of extreme agitation and combativeness. Likely due\n to the latter. With time and gentle fluids acidemia and elevated\n lactate have resolved.\n - normalized lactate by AM\n .\n Elevated troponin\n Trop is still in indeterminate range but has\n trended up from <0.01 to 0.04 this AM. CK also trending up but MD flat.\n - Repeat EKG\n - Cycle enzymes until trajectory is evident\n - Fluids for CKs\n .\n Hypertension - on HCTZ and amlodipine\n - will hold for now\n .\n Hyperlipidemia - on lescol at home\n - will restart when extubated\n .\n FEN - NPO, gentle fluids, replete lytes, replete B12, thiamine and\n folate\n .\n Proph - Heparin sq, VAP bundle, pneumoboots, PT/OT consult once\n extubated\n .\n Code Status - Full Code\n .\n Contact - , \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor once extubated\n" }, { "category": "Physician ", "chartdate": "2196-02-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 446215, "text": "Chief Complaint: Fall, Intubated\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:32 PM\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Intubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 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: 60 (60 - 76) bpm\n BP: 150/44(71) {124/41(63) - 150/58(80)} mmHg\n RR: 23 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 432 mL\n 666 mL\n PO:\n TF:\n IVF:\n 432 mL\n 666 mL\n Blood products:\n Total out:\n 500 mL\n 870 mL\n Urine:\n 500 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n -68 mL\n -204 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 365 (314 - 377) mL\n PS : 5 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 73\n PIP: 6 cmH2O\n SpO2: 100%\n ABG: 7.38/45/46/27/0\n Ve: 7.7 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin\n Eyes / Conjunctiva: pinpoint pupils\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, No(t) NG tube, No(t) OG tube, abrasion above left eye\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: 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 Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting\n Skin: Warm, diffuse ecchymosis on arms\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 179 K/uL\n 11.2 g/dL\n 106 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 9 mg/dL\n 109 mEq/L\n 142 mEq/L\n 31.0 %\n 7.6 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n WBC\n 9.3\n 7.6\n Hct\n 33.0\n 31.0\n Plt\n 197\n 179\n Cr\n 0.6\n 0.5\n TropT\n 0.02\n 0.04\n TCO2\n 30\n 29\n 28\n Glucose\n 101\n 106\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:631/8/0.04, Lactic Acid:1.5 mmol/L, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 89 F with h/o of HTN, hyperlipidemia and syncope who was brought to the\n ED after a witnessed fall where her head struck the ground. Pt was\n intubated in the ED for altered mental status so that a thorough\n work-up could be conducted. head CT was negative and patients labs\n were by-in-large unremarkable. She did have a mildly elevated lactate\n and and acidemia that were attributed to the fact that she was\n violently thrashing around prior to sedation and intubation. With\n gentle fluids and time, her lactate has come back down. The patient's\n histroy was obtained from her son who reports that she falls quite\n frequently. She is normally seen at . Syncope\n work-ups have been unrevealing todate.\n .\n Altered Mental Status - Son reports that patient fully mentally\n competent at baseline with only mild senility. Etiologies of agitation\n and alteration today could include trauma fall, toxic metabolic,\n infection or delirium. Head CT negative for acute bleed. Pt had\n mildly elevated white blood cell count on admission, however, trended\n down to normal with gently fluids. CXR and UA negative for occult\n infection.\n - blood cx is spikes\n - no antibiotics for now in absence of signs of infection\n - decrease sedation and extubate in am\n - check B12, Thiamine and Folate, then replete\n .\n Syncope - Per report, pt lost consiousness before she fell. Per son\n and friend, she falls often in the setting of a loss of consciousness.\n Etiologies include vaso-vagal, orthostatic hypotension, MI, or other\n neurologic cause such as seizure, TIA, etc. Extensive work-up at over the years has been unrevealing. Blood glucose 156 in\n field. Pt had ECHO in but report is not available in \n records. No evidence of arrhthymia on EKG, cardiac enzymes negative\n x1. Per notes, on B-Blocker to facilitate beta 2-receptor\n blockade and assist with some possible neurogenic causes of her\n symptoms. Per son's report, pt does not drink anything but coffee that\n he is aware of and is often light-headed when she stands up. BBlocke\n rnad/or CCB could be contributing to hypotension and or bradyarrhythmia\n - Check B12, Thimaine and Folate, then replete\n - ROMI, cardiac enzymes negative x1\n - consider carotid dopplers\n - conitnue gently volume resuscitation\n - hold BBlocker and calcium channel blocker for now\n .\n Elevated Lactate - Differential includes infection versus muscle\n exertion in setting of extreme agtation and combativeness. Liklely due\n to the latter. With time and gentle fluids acidemia and elevated\n lactate have resolved.\n - will recheck in am\n .\n Hypertension - on HCTZ and amlodipine\n - will hold for now\n .\n Hyperlipidemia - on lescol at home\n - will restart when extubated\n .\n FEN - NPO, gentle fluids, replte lytes, replete B12, thiamine and\n folate\n .\n Proph - Heparin sc, VAP bundle, pneumoboots, PT/OT consult\n .\n Code Status - Full Code\n .\n Contact - , \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446317, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Extubated this morning, pt remains NPO. Vomited 25ml of dark red blood\n prior to extubation. Last K was 3.1\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult obtained.\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening and\n encourage intake, Administer K per sliding scale\n Altered mental status (not Delirium)\n Assessment:\n Propofol d/c this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERL, A&O x 2. Has weak cough and mild difficulty\n clearing oral secretions.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Response:\n Increased alertness\n Plan:\n Continue to monitor MS, risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and bruises upon admission. No further skin\n impairments. Dressings dry and intact. Pt complained of pain in her\n neck with turning, pain was relieved by repositioning.\n Action:\n Turning with frequent position changes, Monitor pain\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 2L with Sats between 97-100%, No distress noted.\n" }, { "category": "Physician ", "chartdate": "2196-02-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 446474, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:54 AM\n ULTRASOUND - At 03:10 PM\n Carotid Ultra Sound\n CALLED OUT\n - Successfully extubated\n - Called out to floor but then developed new hypoxia to mid-80s\n - CXR with increased L lung opacity, poor cough and minimal gag, also\n worsened leukocytosis\n - Started Levofloxacin for CAP\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 AM\n Heparin Sodium (Prophylaxis) - 07:45 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 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 73 (63 - 86) bpm\n BP: 120/47(66) {104/36(56) - 152/50(75)} mmHg\n RR: 22 (15 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,403 mL\n 1,185 mL\n PO:\n TF:\n IVF:\n 1,403 mL\n 1,185 mL\n Blood products:\n Total out:\n 1,708 mL\n 285 mL\n Urine:\n 1,683 mL\n 285 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -305 mL\n 900 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 288 (288 - 288) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 5 cmH2O\n SpO2: 97%\n ABG: ///27/\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, diffuse ecchymosis\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 157 K/uL\n 10.3 g/dL\n 89 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 110 mEq/L\n 143 mEq/L\n 29.9 %\n 6.8 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n 12:08 PM\n 07:16 PM\n 03:54 AM\n WBC\n 9.3\n 7.6\n 9.0\n 6.8\n Hct\n 33.0\n 31.0\n 33.1\n 29.9\n Plt\n 197\n 179\n 183\n 157\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TropT\n 0.02\n 0.04\n 0.03\n TCO2\n 30\n 29\n 28\n Glucose\n 101\n 106\n 103\n 89\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:596/8/0.03, ALT / AST:118/156, Alk Phos / T Bili:85/0.4,\n Lactic Acid:1.5 mmol/L, Albumin:3.5 g/dL, Ca++:7.4 mg/dL, Mg++:1.5\n mg/dL, PO4:2.8 mg/dL\n Imaging: Carotid Dopplers -\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 89 F with h/o of HTN, hyperlipidemia and syncope who was brought to the\n ED after a witnessed fall where her head struck the ground. Pt was\n intubated in the ED for altered mental status so that a thorough\n work-up could be conducted. Head CT was negative and patients labs\n were by-in-large unremarkable. She did have a mildly elevated lactate\n and acidemia that were attributed to the fact that she was violently\n thrashing around prior to sedation and intubation. With gentle fluids\n and time, her lactate has come back down. The patient's history was\n obtained from her son who reports that she falls quite frequently. She\n is normally seen at . Syncope work-ups have been\n unrevealing to date.\n .\n Altered Mental Status - Son reports that patient fully mentally\n competent at baseline with only mild senility. Etiologies of agitation\n and alteration today could include trauma fall, toxic metabolic,\n infection or delirium. Head CT negative for acute bleed. Pt had\n mildly elevated white blood cell count on admission, however, trended\n down to normal with gently fluids. CXR and UA negative for occult\n infection.\n - blood cx is spikes\n - no antibiotics for now in absence of signs of infection\n - decrease sedation and extubate in am\n - check B12, Thiamine and Folate, then replete\n - f/u urine cx\n - if agitated once extubated, consider Haldol only as needed\n - clear c-spine once awake and extubated, with a negative CT scan, low\n risk for ligamentous injury given mechanism of fall\n .\n Syncope/Fall - Per report, pt lost consciousness before she fell. Per\n son and friend, she falls often in the setting of a loss of\n consciousness. Etiologies include vaso-vagal, orthostatic hypotension,\n MI, or other neurologic cause such as seizure, TIA, etc. Extensive\n work-up at over the years has been unrevealing. Blood\n glucose 156 in field. Pt had ECHO in but report is not\n available in records. No evidence of arrhthymia on EKG,\n cardiac enzymes negative x1. Per notes, on B-Blocker to\n facilitate beta 2-receptor blockade and assist with some possible\n neurogenic causes of her symptoms. Per son's report, pt does not drink\n anything but coffee that he is aware of and is often light-headed when\n she stands up. BBlocker and/or CCB could be contributing to\n hypotension and or bradyarrhythmia\n - Check B12, Thimaine and Folate, then replete\n - ROMI, cardiac enzymes negative x1\n - consider carotid dopplers\n - continue gently volume resuscitation\n - hold BBlocker and calcium channel blocker for now\n - XRs negative\n .\n Resp Failure\n Intubated in setting of altered MS. acute pulmonary\n issues. On minimal settings.\n - Plan to extubate this AM if following commands off sedation\n .\n Elevated Lactate - Differential includes infection versus muscle\n exertion in setting of extreme agitation and combativeness. Likely due\n to the latter. With time and gentle fluids acidemia and elevated\n lactate have resolved.\n - normalized lactate by AM\n .\n Elevated troponin\n Trop is still in indeterminate range but has\n trended up from <0.01 to 0.04 this AM. CK also trending up but MD flat.\n - Repeat EKG\n - Cycle enzymes until trajectory is evident\n - Fluids for CKs\n .\n Hypertension - on HCTZ and amlodipine\n - will hold for now\n .\n Hyperlipidemia - on lescol at home\n - will restart when extubated\n .\n FEN - NPO, gentle fluids, replete lytes, replete B12, thiamine and\n folate\n .\n Proph - Heparin sq, VAP bundle, pneumoboots, PT/OT consult once\n extubated\n .\n Code Status - Full Code\n .\n Contact - , \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor once extubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:39 PM\n 20 Gauge - 06:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-02-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 446096, "text": "Chief Complaint: Witnessed fall, Altered Mental Status\n HPI:\n 89F with history of hypertension and syncope s/p witnessed fall where\n she struck her head admitted to ICU intubated for agitation and altered\n mental status. Per report, the patient appeared to lose consciousness\n and collapse while walking. Per report, she struck her head on the\n pavement when she fell. Her blood glucose in the field was 156.\n .\n On arrival to the ED, her vitals were BP 190/83 HR 100 afib T 98.6.\n Her mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using etomidate and succ,\n then started on a propofol gtt. Her lactate was initially elevated but\n she was fighting violently when arrived. Repeat lactate was 4.4 after\n the patient was intubated. The patient also received 2L NS per report\n though not documented in the chart. The patient was afebrile with a\n white count of 11.3. UA negative. Head CT negative for bleed. EKG\n unremarkable, mild sinus tach at 101. CXR negative. Pt remained quite\n agitated requiring increased propofol for sedation.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Intubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hypertension\n Hyperlipidemia\n Chronic Obstructive Pulmonary Disease\n Nicotine Use\n s/p DVT\n Recurrent syncope last workup in at which time carotid\n ultrasounds, head CT and EEG were reported as normal\n B12 deficiency\n Pneumonia in and \n Old right basal ganglia lacunar infarct\n Brother died of a myocardial infarction at age 52. Sister died of\n disease.\n Occupation:\n Drugs: None\n Tobacco: 1.5 ppd x 70years\n Alcohol: None\n Other: Widow. Lives alone in . Independent in ADLs. Son\n lives nearby checks in with her daily. Has neighbors who check in with\n her daily. Son does report that she does not eat much despite having\n ample food. Has meals made for her 3 days a week and gets take out\n most others. Drinks 3-4 cups coffee per day. Friend, Sister \n , lives in building and looks in on her as well.\n Review of systems:\n Flowsheet Data as of 12:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 72 (63 - 76) bpm\n BP: 140/58(80) {124/49(69) - 150/58(80)} mmHg\n RR: 19 (16 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 416 mL\n PO:\n TF:\n IVF:\n 416 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -84 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 377 (377 - 377) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.39/46/246/28/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 615\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, Emaciated\n Eyes / Conjunctiva: No(t) Sclera edema, pupils pinpoint\n Head, Ears, Nose, Throat: Poor dentition, Endotracheal tube, No(t) NG\n tube, No(t) OG tube, abrasion over left eye, dried blood around mouth\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice, diffuse ecchymosis on\n bilateral upper extremities\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 197 K/uL\n 11.2 g/dL\n 101 mg/dL\n 0.6 mg/dL\n 14 mg/dL\n 28 mEq/L\n 110 mEq/L\n 3.3 mEq/L\n 145 mEq/L\n 33.0 %\n 9.3 K/uL\n [image002.jpg]\n \n 2:33 A3/9/ 09:15 PM\n \n 10:20 P3/9/ 09:44 PM\n \n 1:20 P3/9/ 10:06 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.3\n Hct\n 33.0\n Plt\n 197\n Cr\n 0.6\n TC02\n 30\n 29\n Glucose\n 101\n Other labs: CK / CKMB / Troponin-T:448//, Lactic Acid:1.1 mmol/L,\n Ca++:7.7 mg/dL, Mg++:1.6 mg/dL, PO4:2.6 mg/dL\n Imaging: Persantine Stress :\n CONCLUSION: After Persantine infusion there were no ST segment\n changes.\n .\n ECHO : LV systolic function is estimated 65%. Chamber sizes are\n normal. There is mild TR. PA pressures are elevated with an estimated\n PASP of 42 mmHg + CVP. There is no pericardial effusion noted.\n .\n Carotid Dopplers : There is no evidence of hemodynamically\n significant obstruction of flow in the internal carotid artery,\n bilaterally. There is no change compared to the prior exam of .\n .\n EEG : There are no definite focal or lateralized processes here.\n The record is suboptimal with loss of the digital signal toward the end\n of the recording at photic stimualtion. The EKG monitor is not always\n defined. The significance of the rsynchronous\n 5 to 6 hz. activity is not clear here. No definite abnormality is\n noted in this recording of the 83 year old individual.\n A record of (#) by report was borderline abnormal because\n of a slight excess of shifting anterior quadrant dysrhythmic slow. The\n same does not appear to be a prominent feature in this recording.\n There is just a hint of a minimally slowed wave form here. The\n background may be a half cycle per second slower in predominant\n frequency range but is in the same frequency realm. The difference is\n not a definite abnormality. The prior tracing is comparable only by\n report. The tracing itself is not available.\n .\n Holter : COMMENTS: Sinus rhythm throughout. Rare (39) SVPB's.\n One SV pair. Rare (5), unifocal VPB's.\n COMPARISON: Since monitoring done on , there are no changes.\n .\n CT Head :\n Prelim: No fracture or hemorrage. Parenchymal atrophy and chronic\n small vessel disease.\n .\n CT C-Spine : No fracture; expected degenerative change.\n .\n CXR: : ET tube well positioned, no obvious infiltrate\n .\n EKG : Sinus tachycardia, Low voltage in limb leads\n Assessment and Plan\n 89 F with h/o of HTN, hyperlipidemia and syncope who was brought to the\n ED after a witnessed fall where her head struck the ground. Pt was\n intubated in the ED for altered mental status so that a thorough\n work-up could be conducted. head CT was negative and patients labs\n were by-in-large unremarkable. She did have a mildly elevated lactate\n and and acidemia that were attributed to the fact that she was\n violently thrashing around prior to sedation and intubation. With\n gentle fluids and time, her lactate has come back down. The patient's\n history was obtained from her son who reports that she falls quite\n frequently, typically in the setting of a loss of\n consciousness/syncope. She is normally seen at .\n Syncope work-ups have been unrevealing todate.\n .\n Altered Mental Status - Son reports that patient fully mentally\n competent at baseline with only mild senility. Etiologies of agitation\n and alteration today could include trauma fall, toxic metabolic,\n infection or delirium. Head CT negative for acute bleed. Pt had\n mildly elevated white blood cell count on admission, however, trended\n down to normal with gently fluids. CXR and UA negative for occult\n infection.\n - blood cx is spikes\n - no antibiotics for now in absence of signs of infection\n - decrease sedation and extubate in am\n - check B12, Thiamine and Folate, then replete\n .\n Syncope - Per report, pt lost consiousness before she fell. Per son\n and friend, she falls often in the setting of a loss of consciousness.\n Etiologies include vaso-vagal, orthostatic hypotension, MI, or other\n neurologic cause such as seizure, TIA, etc. Extensive work-up at over the years has been unrevealing. Blood glucose 156 in\n field. Pt had ECHO in but report is not available in \n records. No evidence of arrhthymia on EKG, cardiac enzymes negative\n x1. Per notes, on B-Blocker to facilitate beta 2-receptor\n blockade and assist with some possible neurogenic causes of her\n symptoms. Per son's report, pt does not drink anything but coffee that\n he is aware of and is often light-headed when she stands up. BBlocke\n rnad/or CCB could be contributing to hypotension and or bradyarrhythmia\n - Check B12, Thimaine and Folate, then replete\n - ROMI, cardiac enzymes negative x1\n - consider carotid dopplers\n - conitnue gently volume resuscitation\n - hold BBlocker and calcium channel blocker for now\n .\n Elevated Lactate - Differential includes infection versus muscle\n exertion in setting of extreme agtation and combativeness. Liklely due\n to the latter. With time and gentle fluids acidemia and elevated\n lactate have resolved.\n - will recheck in am\n .\n Hypertension - on HCTZ and amlodipine\n - will hold for now\n .\n Hyperlipidemia - on lescol at home\n - will restart when extubated\n .\n FEN - NPO, gentle fluids, replte lytes, replete B12, thiamine and\n folate\n .\n Proph - Heparin sc, VAP bundle, pneumoboots, PT/OT consult\n .\n Code Status - Full Code\n .\n Contact - , \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 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: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446308, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Extubated this morning, pt remains NPO. Vomited 25ml of dark red blood\n prior to extubation. Last K was 3.1\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult obtained.\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening and\n encourage intake\n Altered mental status (not Delirium)\n Assessment:\n Propofol d/c this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERL, A&O x 2. Has weak cough and mild difficulty\n clearing oral secretions.\n Action:\n J collar removed, spine and neck were cleared.\n Response:\n Increased alertness\n Plan:\n Continue to monitor MS, risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and bruises upon admission. No further or new skin\n impairments. Dressings dry and intact. Pt complained of pain in her\n neck with turning, pain was relieved by repositioning.\n Action:\n Turning with frequent position changes, Monitor pain\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 2L with Sats between 97-100%, No distress noted.\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446311, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Extubated this morning, pt remains NPO. Vomited 25ml of dark red blood\n prior to extubation. Last K was 3.1\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult obtained.\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening and\n encourage intake,\n Altered mental status (not Delirium)\n Assessment:\n Propofol d/c this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERL, A&O x 2. Has weak cough and mild difficulty\n clearing oral secretions.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Response:\n Increased alertness\n Plan:\n Continue to monitor MS, risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and bruises upon admission. No further skin\n impairments. Dressings dry and intact. Pt complained of pain in her\n neck with turning, pain was relieved by repositioning.\n Action:\n Turning with frequent position changes, Monitor pain\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 2L with Sats between 97-100%, No distress noted.\n" }, { "category": "General", "chartdate": "2196-02-15 00:00:00.000", "description": "ICU Event Note", "row_id": 446094, "text": "Clinician: Attending\n Total time spent: 45 minutes\n Patient is critically ill.\n Pt seen and evaluated with HO\ns. Please seee their note dated \n for details of history and plan. I agree with the workout as outlined\n in \n MD\ns note.\n 89 year woman with hx of HBP, syncope who was witnessed to have fallen\n and hit head in . ? LOC prior to fall.\n Brought to ED and was combative in ED. BP 190/83. Unable to evaluate\n adequately so she was intubated to facilitate w/u.\n Intubated and put on Propafol, lactate fell with hydration to nl. WBC\n was 11.3.\n Head CT neg, CXR negative. Spine CT negative as well.\n Glucose 156, 138.\n PMH HBP, COPD, DVT , numerous episodes of syncope w/u\nd at \n with no clear etiology.\n Poor nutritional status is chronic.\n Meds in HO note.\n PE\n 98.2/124/51/69/15/ 100% on IPS with 50% FIO2\n Emaciated with abrasions on forehead, hands, ecchymoses, dried blood in\n mouth\n Clear Lungs, nl Heart exam, nl abdomen, no edema\n Responsive to noxious stimuli\n Syncope w/u has been repeatedly negative.\n Will monitor overnight, wean sedation and extubate in AM.\n No other interventions planned for this evening.\n" }, { "category": "Nursing", "chartdate": "2196-02-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446442, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke (does not eat) Extubated this morning, pt remains NPO. Vomited\n 25ml of dark red blood prior to extubation. AM K 3.1. Hct 33\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult placed. Frequent turning/repositioning required. PM\n Labs sent (awaiting results)\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening/early\n am secretions. Strongly encourage PO intake when allowed.\n Administer KCL per sliding scale.\n Altered mental status (not Delirium)\n Assessment:\n Propofol dc\nd this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERRLA. A&OX3 (does not have any remembrance of fall)\n Has congested/productive cough. Able to clear secretions when\n reminded.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Subglottal sx\ning and mouth care given.\n Response:\n Increased alertness. Following commands.\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. Mepilex\n dsgs to left elbow & coccyx CDI. Pt c/o mild pain in her right shoulder\n on movement but has remained comfortable w/ repositioning. Bilateral\n heels reddened. Hands notable for abrasions. Ecchymotic areas covering\n various parts of body. Right shoulder large reddened area collar\n placement.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as warranted. Improve nutrition/caloric\n intake.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 4L with O2 sats between 91-97%. Pt denies CP/SOB & is\n able to expectorate sputum @ times. Needs much encouragement. Low grade\n 100.3 @ 2100. Tylenol 650mg PR X 1.\n" }, { "category": "Nursing", "chartdate": "2196-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 446445, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke (does not eat) Extubated this morning, pt remains NPO. Vomited\n 25ml of dark red blood prior to extubation. AM K 3.1. Hct 33\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult placed. Frequent turning/repositioning required. PM\n Labs sent (awaiting results)\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening/early\n am secretions. Strongly encourage PO intake when allowed.\n Administer KCL per sliding scale.\n Altered mental status (not Delirium)\n Assessment:\n Propofol dc\nd this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERRLA. A&OX3 (does not have any remembrance of fall)\n Has congested/productive cough. Able to clear secretions when\n reminded.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Subglottal sx\ning and mouth care given.\n Response:\n Increased alertness. Following commands.\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. Mepilex\n dsgs to left elbow & coccyx CDI. Pt c/o mild pain in her right shoulder\n on movement but has remained comfortable w/ repositioning. Bilateral\n heels reddened. Hands notable for abrasions. Ecchymotic areas covering\n various parts of body. Right shoulder large reddened area collar\n placement.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as warranted. Improve nutrition/caloric\n intake.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 4L with O2 sats between 91-97%. Pt denies CP/SOB & is\n able to expectorate sputum @ times. Needs much encouragement. Low grade\n 100.3 @ 2100. Tylenol 650mg PR X 1.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n Admission weight:\n 41 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH: COPD, Smoker\n CV-PMH: Hypertension\n Additional history: Hyperlipidemia\n s/p DVT\n Recurrent syncope with multiple falls (last workup in at which\n time carotid ultrasounds, head CT and EEG were reported as normal)\n B12 deficiency\n Pneumonia in and \n Old right basal ganglia lacunar infarct\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:42\n Temperature:\n 100.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93 %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,278 mL\n 24h total out:\n 1,603 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 07:16 PM\n Potassium:\n 3.5 mEq/L\n 07:16 PM\n Chloride:\n 110 mEq/L\n 07:16 PM\n CO2:\n 26 mEq/L\n 07:16 PM\n BUN:\n 5 mg/dL\n 07:16 PM\n Creatinine:\n 0.5 mg/dL\n 07:16 PM\n Glucose:\n 103 mg/dL\n 07:16 PM\n Hematocrit:\n 33.1 %\n 07:16 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper, Lower )\n Other valuables: DENTURES SENT HOME W/ SON \n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: (SON)\n Jewelry: 2 rings on left hand\n Transferred from: MICU 7\n Transferred to: CC728\n Date & time of Transfer: 22:00 AM\n ------ Protected \n Pt called back in to MICU 7\n ------ Protected Section Error Entered By: \n on: 06:53 ------\n" }, { "category": "Nursing", "chartdate": "2196-02-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446453, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke (does not eat) Extubated this morning, pt remains NPO. Vomited\n 25ml of dark red blood prior to extubation. AM K 3.1. Hct 33\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult placed. Frequent turning/repositioning required. PM\n Labs sent (awaiting results)\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening/early\n am secretions. Strongly encourage PO intake when allowed.\n Administer KCL per sliding scale. Speech & swallow eval placed.\n Altered mental status (not Delirium)\n Assessment:\n Propofol dc\nd prior to extubation, noted increased alertness. Remained\n calm and cooperative. Obeys commands and able to move extremities.\n PERRLA. A&OX3 (does not have any remembrance of fall) Has\n congested/productive cough. Able to clear secretions when reminded.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Subglottal sx\ning and mouth care given.\n Response:\n Increased alertness. Following commands.\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. Mepilex\n dsgs to left elbow & coccyx CDI. Pt c/o mild pain in her right shoulder\n on movement but has remained comfortable w/ repositioning. Bilateral\n heels reddened. Hands notable for abrasions. Ecchymotic areas covering\n various parts of body. Right shoulder large reddened area collar\n placement.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as warranted. Improve nutrition/caloric\n intake.\n EVENTS:\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Pt had episode of desaturation to 86% prior to tx to floor. 4LNC & 70%\n OFM. Atrovent & Albuterol nebs given. LS extremely rhoncerous @ times.\n Much improved this am. Pt denies CP/SOB. Is able to expectorate sputum\n @ times. Needs much encouragement. Low grade 100.3 @ 2100. Tylenol\n 650mg PR X 1.\n AM Ca 7.4 (repleted w/ Calcium Gluconate 2gm) Mg 1.5 (repleted w/\n Magnesium Sulfate 2gm) K 3.3 (will need 60mEq IV per SS)\n" }, { "category": "Rehab Services", "chartdate": "2196-02-17 00:00:00.000", "description": "Bedside Swallow Evaluation", "row_id": 446519, "text": "TITLE: Bedside Swallow Evaluation\n Patient was seen for bedside swallow evaluation. Please see full\n evaluation in OMR or paper chart for details and recommendations.\n" }, { "category": "Respiratory ", "chartdate": "2196-02-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 446345, "text": "Pt received orally intubated and vented on PSV. Pt placed on SBT,\n passed SBT, neck cleared. Pt then extubated, good cuff leak heard prior\n to extubation. Placed on cool aerosol, fio2 35% via face tent, Spo2\n 98%.\n" }, { "category": "Physician ", "chartdate": "2196-02-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 446525, "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 Called out to floor, became hypoxic to mid 80s on RA, started on\n levofloxacin, now on 4L.\n INVASIVE VENTILATION - STOP 11:54 AM\n ULTRASOUND - At 03:10 PM\n Carotid Ultra Sound\n CALLED OUT\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 AM\n Heparin Sodium (Prophylaxis) - 07:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.2\nC (99\n HR: 70 (63 - 86) bpm\n BP: 143/51(74) {104/36(56) - 143/51(74)} mmHg\n RR: 20 (15 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,403 mL\n 1,750 mL\n PO:\n TF:\n IVF:\n 1,403 mL\n 1,750 mL\n Blood products:\n Total out:\n 1,708 mL\n 285 mL\n Urine:\n 1,683 mL\n 285 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -305 mL\n 1,465 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.3 g/dL\n 157 K/uL\n 89 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 110 mEq/L\n 143 mEq/L\n 29.9 %\n 6.8 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n 12:08 PM\n 07:16 PM\n 03:54 AM\n WBC\n 9.3\n 7.6\n 9.0\n 6.8\n Hct\n 33.0\n 31.0\n 33.1\n 29.9\n Plt\n 197\n 179\n 183\n 157\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TropT\n 0.02\n 0.04\n 0.03\n TCO2\n 30\n 29\n 28\n Glucose\n 101\n 106\n 103\n 89\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:596/8/0.03, ALT / AST:118/156, Alk Phos / T Bili:85/0.4,\n Lactic Acid:1.5 mmol/L, Albumin:3.5 g/dL, Ca++:7.4 mg/dL, Mg++:1.5\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 1. Resp failure: Appears to have aspiration PNA in RLL\n -levofloxacin for now\n -swallow eval\n -cont. O2 NC\n -advair 250/50 \n -spireva\n 2. Syncope: Extensive neg w/u\n 3. htn: Home meds being held\n 4. FEN: modify diet according to swallow eval\n 5. PT/OT consult\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 07:39 PM\n 20 Gauge - 06:30 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2196-02-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 446527, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:54 AM\n ULTRASOUND - At 03:10 PM\n Carotid Ultra Sound\n CALLED OUT\n - Successfully extubated\n - Called out to floor but then developed new hypoxia to mid-80s\n - CXR with increased L lung opacity, poor cough and minimal gag, also\n worsened leukocytosis\n - Started Levofloxacin for CAP\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n rash;\n Last dose of Antibiotics:\n Levofloxacin - 11:51 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:00 AM\n Heparin Sodium (Prophylaxis) - 07:45 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 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37\nC (98.6\n HR: 73 (63 - 86) bpm\n BP: 120/47(66) {104/36(56) - 152/50(75)} mmHg\n RR: 22 (15 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,403 mL\n 1,185 mL\n PO:\n TF:\n IVF:\n 1,403 mL\n 1,185 mL\n Blood products:\n Total out:\n 1,708 mL\n 285 mL\n Urine:\n 1,683 mL\n 285 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -305 mL\n 900 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 288 (288 - 288) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 5 cmH2O\n SpO2: 97%\n ABG: ///27/\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, diffuse ecchymosis\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 157 K/uL\n 10.3 g/dL\n 89 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 110 mEq/L\n 143 mEq/L\n 29.9 %\n 6.8 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n 12:08 PM\n 07:16 PM\n 03:54 AM\n WBC\n 9.3\n 7.6\n 9.0\n 6.8\n Hct\n 33.0\n 31.0\n 33.1\n 29.9\n Plt\n 197\n 179\n 183\n 157\n Cr\n 0.6\n 0.5\n 0.5\n 0.5\n TropT\n 0.02\n 0.04\n 0.03\n TCO2\n 30\n 29\n 28\n Glucose\n 101\n 106\n 103\n 89\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:596/8/0.03, ALT / AST:118/156, Alk Phos / T Bili:85/0.4,\n Lactic Acid:1.5 mmol/L, Albumin:3.5 g/dL, Ca++:7.4 mg/dL, Mg++:1.5\n mg/dL, PO4:2.8 mg/dL\n Imaging: Carotid Dopplers -\n Assessment and Plan\n 89 F with h/o of HTN, hyperlipidemia and syncope who was brought to the\n ED after a witnessed fall where her head struck the ground. Pt was\n intubated in the ED for altered mental status so that a thorough\n work-up could be conducted. Head CT was negative and patients labs\n were by-in-large unremarkable. She did have a mildly elevated lactate\n and acidemia that were attributed to the fact that she was violently\n thrashing around prior to sedation and intubation. With gentle fluids\n and time, her lactate has come back down. The patient's history was\n obtained from her son who reports that she falls quite frequently. She\n is normally seen at . Syncope work-ups have been\n unrevealing to date.\n # Altered Mental Status - Son reports that patient fully mentally\n competent at baseline with only mild senility. Etiologies of agitation\n and alteration today could include trauma fall, toxic metabolic,\n infection or delirium. Head CT negative for acute bleed. Pt had\n mildly elevated white blood cell count on admission, however, trended\n down to normal with gently fluids. CXR and UA negative for occult\n infection.\n - Follow-up blood cx\n - Levofloxacin for PNA\n - replete B12, Thiamine and Folate\n - f/u urine cx\n # Syncope/Fall - Per report, pt lost consciousness before she fell.\n Per son and friend, she falls often in the setting of a loss of\n consciousness. Etiologies include vaso-vagal, orthostatic hypotension,\n MI, or other neurologic cause such as seizure, TIA, etc. Extensive\n work-up at over the years has been unrevealing. Blood\n glucose 156 in field. Pt had ECHO in but report is not\n available in records. No evidence of arrhthymia on EKG,\n cardiac enzymes negative x1. Per notes, on B-Blocker to\n facilitate beta 2-receptor blockade and assist with some possible\n neurogenic causes of her symptoms. Per son's report, pt does not drink\n anything but coffee that he is aware of and is often light-headed when\n she stands up. BBlocker and/or CCB could be contributing to\n hypotension and or bradyarrhythmia\n - Check B12, Thimaine and Folate, then replete\n - Carotid dopplers\n follow-up final read\n - continue gently volume resuscitation\n - hold BBlocker and calcium channel blocker for now\n .\n Resp Failure\n Intubated in setting of altered MS. acute pulmonary\n issues. On minimal settings.\n - Extubated AM\n # Elevated Lactate - Differential includes infection versus muscle\n exertion in setting of extreme agitation and combativeness. Likely due\n to the latter. With time and gentle fluids acidemia and elevated\n lactate have resolved.\n - normalized lactate by AM\n # Elevated troponin\n Trop is still in indeterminate range but has\n trended up from <0.01 to 0.04 this AM. CK also trending up but MD flat.\n - Downward trending, will no longer cycle\n - Fluids for CKs\n # Hypertension - on HCTZ and amlodipine\n - will hold for now, check orthostatics today\n # Hyperlipidemia - on lescol at home\n - On Lescol\n FEN: Diet per Speech & Swallow; replete lytes, replete B12, thiamine\n and folate\n Ppx - Heparin sq, pneumoboots, PT/OT consult\n Code Status - Full Code\n Contact - , \n DISPO: Call out to floor, likely d/c home with services with weaning\n from O2 and PT/OT evaluation for home safety.\n Lines:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 PM\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446170, "text": "89 yo female w/ known history of hypertension w/ syncople episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental\n status. Per report, the patient appeared to lose consciousness and\n collapse while walking. She struck her head on the pavement when she\n fell. Her blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke (does not eat)\n Action:\n Nutrition consult placed. IVF\ns. Labs sent. Frequent\n turning/repositioning required.\n Response:\n Rigid @ times. Otherwise tolerating activity.\n Plan:\n Await nutrition recs. Assess pts MS and ability to care for self once\n extubated and sedation removed. Freq turning/skin care provided.\n Altered mental status (not Delirium)\n Assessment:\n Pt arrived sedated on Propofol @ 30mcg/kg/min. Pt has remained\n comfortable and arousable.\n Action:\n Propofol gtt has essentially stayed the same at this time. RSBI 75.\n Successful SBT\n Response:\n Propofol remains for comfort until plan for extubation.\n Plan:\n ? wean to extubate this am. SBT/RSBI completed. ? f/u head CT if MS\n does not improve.\n Fall(s)\n Assessment:\n Pt has a known hx of multiple falls per son. today was witness and\n pt did hit head. C-Spine & TLS precautions have in essence been\n cleared.\n Action:\n ? ligament injury (will not be able to assess until MS has cleared, \n MD) -J\nstout\n collar. Social work cx placed.\n Response:\n Collar still appears to not fit adequately. Fall risk precautions.\n Plan:\n ? possible placement of collar for comfort and better\n fit. Assess safety/living circumstances.\n Impaired Skin Integrity\n Assessment:\n Multiple skin tears noted on BUE. Skin tear also noted on coccyx.\n Bilateral heels reddened. Hands notable for abrasions. Ecchymotic areas\n covering various parts of body. Right shoulder large reddened area \n collar placement.\n Action:\n Skin tears cleansed w/ NS and covered with Mepilex dsgs. Abrasions OTA\n w/ bacitracin. Aloe vesta barrier cream applied to bilateral heels.\n Response:\n Plan:\n Improve nutrition status/caloric intake. Assess skin and reposition pt\n Q2hr. Keep all bony prominences elevated @ all times if possible.\n Pt has had a significant amt of bloody secretions via nose and oral\n cavity. Subglottal suctioning revealing impaired gag/cough reflex.\n Ventilator suction notable for small thick/yellow secretions. At this\n time pt is hemodynamically stable w/ Hct 33. Lactate 1.5. K 3.1. LS\n clear/dim @ bases with occasional rhonci.\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446290, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Extubated this morning, pt remains NPO. Vomited 25ml of dark red blood\n prior to extubation. Last K was 3.1\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult obtained.\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening and\n encourage intake\n Altered mental status (not Delirium)\n Assessment:\n Propofol d/c this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERL, A&O x 2. Has weak cough and mild difficulty\n clearing oral secretions.\n Action:\n J collar removed, spine and neck were cleared.\n Response:\n Increased alertness\n Plan:\n Continue to monitor MS, risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and bruises upon admission. No further or new skin\n impairments. Dressings dry and intact.\n Action:\n Turning with frequent position changes\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats. No distress noted.\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 446371, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke (does not eat) Extubated this morning, pt remains NPO. Vomited\n 25ml of dark red blood prior to extubation. AM K 3.1. Hct 33\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult placed. Frequent turning/repositioning required. PM\n Labs sent (awaiting results)\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening/early\n am secretions. Strongly encourage PO intake when allowed.\n Administer KCL per sliding scale.\n Altered mental status (not Delirium)\n Assessment:\n Propofol dc\nd this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERRLA. A&OX3 (does not have any remembrance of fall)\n Has congested/productive cough. Able to clear secretions when\n reminded.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Subglottal sx\ning and mouth care given.\n Response:\n Increased alertness. Following commands.\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. Mepilex\n dsgs to left elbow & coccyx CDI. Pt c/o mild pain in her right shoulder\n on movement but has remained comfortable w/ repositioning. Bilateral\n heels reddened. Hands notable for abrasions. Ecchymotic areas covering\n various parts of body. Right shoulder large reddened area collar\n placement.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as warranted. Improve nutrition/caloric\n intake.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 4L with O2 sats between 91-97%. Pt denies CP/SOB & is\n able to expectorate sputum @ times. Needs much encouragement. Low grade\n 100.3 @ 2100. Tylenol 650mg PR X 1.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n Admission weight:\n 41 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH: COPD, Smoker\n CV-PMH: Hypertension\n Additional history: Hyperlipidemia\n s/p DVT\n Recurrent syncope with multiple falls (last workup in at which\n time carotid ultrasounds, head CT and EEG were reported as normal)\n B12 deficiency\n Pneumonia in and \n Old right basal ganglia lacunar infarct\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:42\n Temperature:\n 100.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93 %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,278 mL\n 24h total out:\n 1,603 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 07:16 PM\n Potassium:\n 3.5 mEq/L\n 07:16 PM\n Chloride:\n 110 mEq/L\n 07:16 PM\n CO2:\n 26 mEq/L\n 07:16 PM\n BUN:\n 5 mg/dL\n 07:16 PM\n Creatinine:\n 0.5 mg/dL\n 07:16 PM\n Glucose:\n 103 mg/dL\n 07:16 PM\n Hematocrit:\n 33.1 %\n 07:16 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper, Lower )\n Other valuables: DENTURES SENT HOME W/ SON \n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: (SON)\n Jewelry: 2 rings on left hand\n Transferred from: MICU 7\n Transferred to: CC728\n Date & time of Transfer: 22:00 AM\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446286, "text": "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 Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-02-16 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 446364, "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 89 y/o f had a witnessed fall and hit head yesterday, taken to ED, was\n agitated and non-cooperative. Was intubated and sedated. Had a neg head\n CT, no ECG changes, lactate was 6.\n Was 100% on PS 15/5 0.4. Now placed on SBT overnight.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n lescol, amlodine, hctz\n Past medical history:\n Family history:\n Social History:\n htn\n hyperlipidemia\n nicotene use\n h/o DVT 1 y ago\n recurrent syncope with unrevealing w/u, suspected vasovagal, neg\n cartotid dopplers, neg EEG, Holter with PVCS and APBs\n B12 def\n h/o PNA\n lacunar infarcts\n brother w MI, sister \n Occupation:\n Drugs:\n Tobacco: ppd X70y\n Alcohol: never\n Other: son lives nearby, lives independently\n Review of systems:\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: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 65 (56 - 76) bpm\n BP: 123/47(66) {123/41(63) - 150/58(80)} mmHg\n RR: 21 (15 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 432 mL\n 674 mL\n PO:\n TF:\n IVF:\n 432 mL\n 674 mL\n Blood products:\n Total out:\n 500 mL\n 950 mL\n Urine:\n 500 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -68 mL\n -276 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 288 (288 - 377) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 73\n PIP: 5 cmH2O\n SpO2: 100%\n ABG: 7.38/45/46/27/0\n Ve: 6.4 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: abrasion over L eyebrow\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 179 K/uL\n 31.0 %\n 11.2 g/dL\n 106 mg/dL\n 0.5 mg/dL\n 9 mg/dL\n 27 mEq/L\n 109 mEq/L\n 3.1 mEq/L\n 142 mEq/L\n 7.6 K/uL\n [image002.jpg]\n 09:15 PM\n 09:44 PM\n 10:06 PM\n 03:41 AM\n 05:05 AM\n WBC\n 9.3\n 7.6\n Hct\n 33.0\n 31.0\n Plt\n 197\n 179\n Cr\n 0.6\n 0.5\n TropT\n 0.02\n 0.04\n TC02\n 30\n 29\n 28\n Glucose\n 101\n 106\n Other labs: PT / PTT / INR:11.7/22.3/1.0, CK / CKMB /\n Troponin-T:631/8/0.04, Lactic Acid:1.5 mmol/L, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FALL(S)\n IMPAIRED SKIN INTEGRITY\n 89 y/o f with recurrent suncope.\n 1. AMS: Fully communicative at baseline and communicative, no clear\n infectious source, suspect lactate was elevated agitation\n -possible delirium, no clear cause\n -hold sedation\n 2. Syncope: Dx includes seizure vs CVA vs arrythmia vs. orthostasis\n -check orthostatics\n -B12 low, replete\n -cycle CE\n -carotid dopplers\n -uop 30-40/h\n -held BP meds\n -f/u trauma recs re: C. collar\n 3. htn: Hold antihypertensives\n 4. NPO\n 5. vent: shut off propofol and try to extubate\n -haldol prn for agitation\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 16 Gauge - 07:38 PM\n 18 Gauge - 07:39 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n ------ Protected Section ------\n 89 year old female with recurrent syncope presented after fall/syncope\n and intubated because agitated and needed emergent HCT/neck CT scan.\n Overnight, HCT and neck CT are negative\n On PS and agitation improved\n PE: 37 P 82 121/43 Sat 100\n Intubated/sedated\n CTA bilat\n S1 S2 reg\n Soft NT ND\n No edema\n A:\n 1) Fall/syncope\n 2) Respiratory Failure\n Plan:\n 1) Hold sedation - > extubated\n 2) Re-assess for injuries after extubation\n 3) Continue to monitor tele for arrythmogenic cause of syncope\n Addendum: patient tolerated extubation without any complications. Neck\n cleared clinically with normal CT scan as above.\n Time: 30 minutes (patient is critically ill)\n ------ Protected Section Addendum Entered By: , MD\n on: 19:38 ------\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 446367, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Extubated this morning, pt remains NPO. Vomited 25ml of dark red blood\n prior to extubation. AM K 3.1. Hct 33\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult obtained.\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening/early\n am secretions. Strongly encourage PO intake when allowed.\n Administer KCL per sliding scale.\n Altered mental status (not Delirium)\n Assessment:\n Propofol dc\nd this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERRLA. A&OX3 (does not have any remembrance of fall)\n Has congested/productive cough. Able to clear secretions when reminded.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Subglottal sx\ning and mouth care given.\n Response:\n Increased alertness. Following commands.\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. No\n further skin impairments. Mepilex dsgs to left elbow & coccyx CDI. Pt\n c/o mild pain in her right shoulder on movement but has remained\n comfortable w/ repositioning.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as warranted.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 4L with O2 sats between 93-97%. Pt denies CP/SOB\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 446368, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke (does not eat) Extubated this morning, pt remains NPO. Vomited\n 25ml of dark red blood prior to extubation. AM K 3.1. Hct 33\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult placed. Frequent turning/repositioning required. PM\n Labs sent (awaiting results)\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening/early\n am secretions. Strongly encourage PO intake when allowed.\n Administer KCL per sliding scale.\n Altered mental status (not Delirium)\n Assessment:\n Propofol dc\nd this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERRLA. A&OX3 (does not have any remembrance of fall)\n Has congested/productive cough. Able to clear secretions when\n reminded.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Subglottal sx\ning and mouth care given.\n Response:\n Increased alertness. Following commands.\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. Mepilex\n dsgs to left elbow & coccyx CDI. Pt c/o mild pain in her right shoulder\n on movement but has remained comfortable w/ repositioning. Bilateral\n heels reddened. Hands notable for abrasions. Ecchymotic areas covering\n various parts of body. Right shoulder large reddened area collar\n placement.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as warranted. Improve nutrition/caloric\n intake.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 4L with O2 sats between 93-97%. Pt denies CP/SOB\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n Admission weight:\n 41 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH: COPD, Smoker\n CV-PMH: Hypertension\n Additional history: Hyperlipidemia\n s/p DVT\n Recurrent syncope with multiple falls (last workup in at which\n time carotid ultrasounds, head CT and EEG were reported as normal)\n B12 deficiency\n Pneumonia in and \n Old right basal ganglia lacunar infarct\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:46\n Temperature:\n 100.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 68 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,278 mL\n 24h total out:\n 1,603 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 07:16 PM\n Potassium:\n 3.5 mEq/L\n 07:16 PM\n Chloride:\n 110 mEq/L\n 07:16 PM\n CO2:\n 26 mEq/L\n 07:16 PM\n BUN:\n 5 mg/dL\n 07:16 PM\n Creatinine:\n 0.5 mg/dL\n 07:16 PM\n Glucose:\n 103 mg/dL\n 07:16 PM\n Hematocrit:\n 33.1 %\n 07:16 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper, Lower )\n Other valuables: DENTURES SENT HOME W/ SON \n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: (SON)\n Jewelry: 2 rings on left hand\n Transferred from: MICU 7\n Transferred to: CC728\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2196-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 446357, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Alteration in Nutrition\n Assessment:\n Extubated this morning, pt remains NPO. Vomited 25ml of dark red blood\n prior to extubation. Last K was 3.1\n Action:\n Administered 4mg of Zofran, receiving light K and Thiamine repletion.\n Nutrition consult obtained.\n Response:\n Denies N/V, no stool\n Plan:\n Will continue to assess ability to initiate PO later this evening and\n encourage intake, Administer K per sliding scale\n Altered mental status (not Delirium)\n Assessment:\n Propofol d/c this morning prior to extubation, noted increased\n alertness. Remained calm and cooperative. Obeys commands and able to\n move extremities. PERL, A&O x 2. Has weak cough and mild difficulty\n clearing oral secretions.\n Action:\n J collar removed, C-Spine & TLS precautions have been cleared.\n Response:\n Increased alertness\n Plan:\n Continue to monitor MS, risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and bruises upon admission. No further skin\n impairments. Dressings dry and intact. Pt complained of pain in her\n neck with turning, pain was relieved by repositioning.\n Action:\n Turning with frequent position changes, Monitor pain\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes.\n Extubated with no complications, placed on 35% face tent with 100% O2\n sats.\n Currently on NC 2L with Sats between 97-100%, No distress noted.\n" }, { "category": "Nursing", "chartdate": "2196-02-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 446605, "text": "89 yo female w/ known history of hypertension w/ syncope episode who\n presents s/p witnessed fall where she struck her head. Admitted to MICU\n from ED after being intubated for agitation and altered mental status.\n Per report, the patient appeared to lose consciousness and collapse\n while walking. She struck her head on the pavement when she fell. Her\n blood glucose in the field was 156.\n On arrival to the ED, her vitals were BP 190/83 HR 100 T 98.6. Her\n mental status was altered and she was extremely combative. GCS was\n . The patient was intubated in the ED using Eomidate and Sux and\n started on a propofol gtt. Her lactate was initially elevated @ 8.4\n but she was noted to be fighting violently when arrived. Repeat\n lactate was 4.4 after the patient was intubated. The patient also\n received 2L NS RN. The patient was afebrile with a white count\n of 11.3. UA negative. Head CT negative for bleed. EKG unremarkable,\n mild sinus tach at 101. CXR negative. Pt remained quite agitated\n requiring increased propofol for sedation. Repeat lactate 1.8 as of\n 2200.\n Access: Right #18G PIV, Left #20G PIV\n Code: FULL\n Social: Son involved in care\n ROS: Pt A&Ox2 (name, place), high fall risk as pt has had multiple\n falls in past loss of consciousness with unknown etiology. C/O\n generalized discomfort but denies need for pain meds. Satting 94-97% on\n 3L NC. Lungs were extremely ronchorous this AM but clearing this\n afternoon. Productive/congested cough present; pt may need reminding to\n clear secretions. BPs ranging 120s-140s systolic, HR 60s-80s, SR. Foley\n in place with CYU, QS. Abd S/NT/ND, BS+, no BM as of yet. Tol nectar\n thick liquids/ground solids; needs encouragement to eat. Pt was OOB to\n chair today with 1 assist, steady on feet.\n Alteration in Nutrition\n Assessment:\n Pt presenting @ ~ 41kg. Poor nutrition noted decreased skin turgor\n and healing process. Pt has multiple skin tears/abrasions along with\n various ecchymotic areas. Per son, pt does have meals delivered to her\n 3x\ns/wk but essentially drinks numerous amounts of coffee and continues\n to smoke but not eat.\n Action:\n Pt seen by S&S today. Able to take nectar thick liquids, ground solids.\n Requires supervision with meals to prevent aspiration. Repleted with\n K+, Mg+, Ca+.\n Response:\n Pt tolerating meals today. No s/s aspiration.\n Plan:\n Strongly encourage PO intake. Cont to provide supervision with meals.\n Replete electrolytes as needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&Ox2 (does not know year but knows place/name). Obeys commands and\n able to move extremities. Remains calm/cooperative this shift. PERRLA.\n Impaired gag but productive/congested cough present. Able to clear\n secretions when reminded.\n Action:\n Frequent checks to maintain safety.\n Response:\n Safety maintained. Pt remains A&Ox2, frequently reminded of year/date.\n Plan:\n Continue to monitor MS. risk for falls.\n Impaired Skin Integrity\n Assessment:\n Several skin tears and ecchymotic areas noted upon admission. Mepilex\n dsgs to left elbow & coccyx CDI. Pt c/o mild pain in her right shoulder\n on movement but has remained comfortable w/ repositioning. Bilateral\n heels reddened. Hands notable for abrasions. Ecchymotic areas covering\n various parts of body. Right shoulder large reddened area collar\n placement.\n Action:\n Frequent turning and skin care required. Aloe vesta barrier cream to\n elbows/feet. Bacitracin to fingers for abrasions.\n Response:\n No changes in skin integrity\n Plan:\n Continue to asses for further skin breakdown, continue with frequent\n turning and dressing changes as needed. Attempt to improve\n nutrition/caloric intake.\n" }, { "category": "Radiology", "chartdate": "2196-02-19 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1067669, "text": " 12:51 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate for mass, lesion, potential seizure focus\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with recurrent syncope followed by confusion and previously\n benign workup\n REASON FOR THIS EXAMINATION:\n evaluate for mass, lesion, potential seizure focus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recurrent syncope, followed by confusion. Previously benign\n workup. Please evaluate for mass or other lesion.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging, including\n diffusion-weighted imaging.\n\n FINDINGS: There is no sign of intracranial hemorrhage. There is no mass,\n mass effect, or edema. No diffusion abnormality is detected. Ventricles and\n sulci are normal in size and configuration for the patient's age.\n Periventricular white matter hypodensities are nonspecific, but most\n consistent with chronic small vessel ischemic disease. Mucosal thickening is\n noted in the sphenoid sinus, and in the ethmoid air cells and nasal passages.\n There is no leptomeningeal abnormality, or other evidence of meningitis or\n encephalitis.\n\n IMPRESSION: No evidence of mass. Moderate small vessel ischemic changes.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-15 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 1066875, "text": " 3:02 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval for acute abnormality\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fall from standingQ\n REASON FOR THIS EXAMINATION:\n eval for acute abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female with fall from standing. Evaluate for acute\n abnormality.\n\n COMPARISON: No prior study available for comparison.\n\n CHEST, SINGLE AP SUPINE VIEW: Evaluation is limited by underlying trauma\n board and radiopaque tubes and wires. Within this limitation, an endotracheal\n tube is noted at the inferior margin of the clavicles, approximately 4.7 cm\n from the carina.\n\n The lungs are hyperexpanded and demonstrate a reticular interstitial pattern.\n The hila contours are prominent suggesting pulmonary artery hypertension.\n These findings are consistent with a chronic interstitial lung disease.\n\n The left inferior- most portion of the costophrenic angle is excluded from\n view. The right costophrenic angle is normal without evidence of effusion.\n There is no evidence of pneumothorax or displaced rib fracture. The heart size\n and mediastinal contour are normal.\n\n SINGLE AP VIEW OF THE PELVIS: Allowing for oblique positioning of the\n patient, no overt fracture is identified. There is a lucency projecting over\n the left acetabulum, which is likely overlying bowel gas. There is no pubic\n symphysis diastasis. The sacroiliac joints are normal. Complete evaluation of\n the sacrum is limited by overlying bowel gas. A Foley catheter is noted\n projecting over the bladder. Note is made of vascular calcifications.\n\n IMPRESSION:\n 1. No evidence of acute intrathoracic abnormality.\n 2. Distal tip of endotracheal tube at the inferior margin of the clavicles,\n 4.7 cm above the carina.\n 3. Emphysema.\n 4. Limited view of the pelvis without overt fracture. If there is concern for\n pelvic fracture, repeat radiograph is recommended.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2196-02-15 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1066890, "text": " 3:14 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fall from standing and loc\n REASON FOR THIS EXAMINATION:\n eval for fx/dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc MON 4:19 PM\n No fracture; expected degenerative change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with fall from standing, loss of consciousness.\n\n COMPARISON: Concurrent head CT.\n\n TECHNIQUE: Axial imaging was performed from the skull base to the\n cervicothoracic junction without IV contrast. Multiplanar reformats were\n provided.\n\n CT C-SPINE WITHOUT IV CONTRAST: There is no fracture or malalignment. The\n normal cervical lordosis is maintained. The patient is intubated. Minimal\n degenerative change is noted with posterior osteophyte formation at C5-C6 and\n mild indentation of the thecal sac at this level. The visualized lung apices\n demonstrate severe emphysema. Soft tissues are unremarkable. ETT is noted\n with surrounding aerosolized secretions in the oro/hypo-pharynx. Carotid\n calcifications noted.\n\n IMPRESSION: No evidence of traumatic injury to the cervical spine. Severe\n emphysema.\n\n Findings posted in the ED dashboard.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1066889, "text": " 3:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH or abnormality\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fall from standing and loc\n REASON FOR THIS EXAMINATION:\n eval for ICH or abnormality\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc MON 4:19 PM\n No fracture or hemorrage. Parenchymal atrophy and chronic small vessel\n disease.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female, fall from standing and loss of consciousness.\n\n COMPARISON: Concurrent CT C-spine.\n\n TECHNIQUE: Axial imaging was performed from the cranial vertex to the foramen\n magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There is no fracture, hemorrhage, edema, mass\n effect, or shift of midline structures. The ventricles and sulci are\n prominent, consistent with age-related parenchymal involutional change. There\n is periventricular hypodensity consistent with chronic small vessel ischemic\n disease. The visualized paranasal sinuses and soft tissues are unremarkable.\n\n IMPRESSION:\n\n 1. No fracture, hemorrhage, or edema.\n 2. Chronic small vessel ischemic disease.\n 3. Age-related parenchymal involutional change.\n\n Findings posted to the ED dashboard.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1067155, "text": ", W. MED MICU-7 10:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: e/o evolving pulmonary process to explain new hypoxia.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with COPD, continued smoking, with unexplained fall,\n intubated in ED, now extubated with new hypoxia.\n REASON FOR THIS EXAMINATION:\n e/o evolving pulmonary process to explain new hypoxia.\n ______________________________________________________________________________\n PFI REPORT\n Right lower lobe opacity could be due to pneumonia or CHF. Emphysema. Mild\n cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-15 00:00:00.000", "description": "P PELVIS (AP ONLY) PORT", "row_id": 1066899, "text": " 4:02 PM\n PELVIS (AP ONLY) PORT; -76 BY SAME PHYSICIAN # \n Reason: eval for fracture, please repeat\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n eval for fracture, please repeat\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female, status post fall. Evaluate for fracture.\n\n COMPARISON: Two trauma views of the chest and pelvis same day.\n\n SINGLE PORTABLE SUPINE VIEW OF THE PELVIS: The position of the pelvis is\n somewhat oblique. However, the ilioischial lines are intact, and there is no\n evidence of pelvic fracture. Evaluation of the sacrum is somewhat limited by\n superimposed stool and gas. There is no evidence of hip fracture. Abundant\n vascular calcifications are identified. A Foley catheter has been placed.\n\n IMPRESSION: No evidence of fracture.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1067154, "text": " 10:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: e/o evolving pulmonary process to explain new hypoxia.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with COPD, continued smoking, with unexplained fall,\n intubated in ED, now extubated with new hypoxia.\n REASON FOR THIS EXAMINATION:\n e/o evolving pulmonary process to explain new hypoxia.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld WED 10:49 AM\n Right lower lobe opacity could be due to pneumonia or CHF. Emphysema. Mild\n cardiomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: New hypoxia.\n\n There are no prior studies available for comparison\n\n There is mild cardiomegaly. The lungs are hyperinflated. Atelectases are in\n the left base. Right lower lobe opacity could be due to pneumonia or\n aspiration. There is no pneumothorax or large pleural effusions.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2196-02-16 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 1067072, "text": " 1:47 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: UNEXPLAINED FALL\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with unexplained fall in , prior extensive\n work-up but no carotid u/s x 4 years\n REASON FOR THIS EXAMINATION:\n Please evaluate for stenosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRc WED 1:39 PM\n No stenosis in the internal carotid arteries bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID ULTRASOUND\n\n INDICATION: Unexplained fall.\n\n FINDINGS: RIGHT SIDE: There is no plaque identified. The peak systolic\n velocity in the common carotid artery 77 cm/sec, proximal ICA 80 cm/sec, mid\n ICA 97 cm/sec, distal ICA 82 cm/sec and external carotid artery 172 cm/sec.\n ICA/CCA ratio 1.25. The flow in the vertebral artery is in antegrade\n direction.\n\n LEFT SIDE: There is a mild plaque at the carotid bulb without increase in\n peak systolic velocities. The peak systolic velocity in the common carotid\n artery 105 cm/sec, proximal ICA 65 cm/sec, mid ICA 94 cm/sec, distal ICA 87\n cm/sec and external carotid artery 56 cm/sec. ICA/CCA ratio 0.89. The flow\n in the vertebral artery is in antegrade direction.\n\n IMPRESSION: No hemodynamically significant stenosis in the internal carotid\n arteries bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-16 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 1067073, "text": ", W. MED MICU-7 1:47 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: UNEXPLAINED FALL\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with unexplained fall in , prior extensive\n work-up but no carotid u/s x 4 years\n REASON FOR THIS EXAMINATION:\n Please evaluate for stenosis\n ______________________________________________________________________________\n PFI REPORT\n No stenosis in the internal carotid arteries bilaterally.\n\n" }, { "category": "ECG", "chartdate": "2196-02-15 00:00:00.000", "description": "Report", "row_id": 241459, "text": "Sinus tachycardia. Consider right atrial abnormality. Low limb lead voltage.\nST segment depression. Clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2142-07-19 00:00:00.000", "description": "Report", "row_id": 1539748, "text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTED, COOPERATIVE, PT IS TALKATIVE AND ASKING APPROPRIATE QUESTIONS. PEARL REACT BRISKLY, MAE ABLE TO TURN SELF. PT STILL RECEIVING MUCOMIST. PT HAS 1:1 SITTER AT BEDSIDE AT ALL TIMES.\n\nRESP: PT REMAINS EXTUBATED. RECEIVED ON NC BUT CHANGED TO OPEN FACE TENT TO ADD MOISTURE TO HELP LOOSEN SECRETIONS. LUNG SOUNDS WITH INSP/EXP WHEEZING AND VERY DIMINISHED AT THE BASES. PT RECEIVING NEBS BY RESP THERAPIST. O2 SAT'S 100%. PT'S VOICE IS HOARSE AND IS COUGHING FREQ TO CLEAR THROAT. PT RAISING SMALL AMT'S OF SECRETIONS.\n\nCV: PT HEMODYNAMICALLY STABLE. NSR WITHOUT ECTOPY. BP WITHIN NORMAL LIMITS. LOW GRADE TEMP 99.1. CONT ON CLINDAMYCIN FOR POSSIBLE ASP PNEUMONIA.\n\nGI: PT TAKING CLEAR LIQ'S WITHOUT DIFFICULTY. MUCOMIST MIXED WITH APPLE JUICE. PT HAS MUSHROOM CATH IN PLACE AND IS DRAINING SMALL AMT'S OF LIQ BLACK STOOL.\n\nGU: PT HAS FOLEY CATH WHICH IS DRAINING GOOD AMT'S OF YELLOW URINE OCC IS PINK TINGED. PT REQUESTING THAT IT COMES OUT SOON.\n\nSKIN: PT'S SKIN IS INTACT BUT VERY FLACKY FROM EXZEMA CONDITION.\n\nACCESS: PT HAS ONE #20 RIGHT ANTICUBE.\n\nIV FLUID D51/2NS AT 125/HR.\n\nENDO: FINGERSTICKS CHECKED Q 6/HR, NO SSRI REQUIRED TONIGHT.\n\nSOCIAL: SISTER AND AUNT AT BEDSIDE EARLIER IN THE NIGHT. ABLE TO TALK OPENLY WITH PT ABOUT HER PROBLEMS. PT IS FULL CODE AND WILL BE CALLED OUT TO THE FLOOR WHEN BED AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-19 00:00:00.000", "description": "Report", "row_id": 1539749, "text": "nursing note: 7a-7p\nneuro- pt alert and oriented x3. soft spoken and pleasant, cooperative with care. oob to chair and to commode with assistance. ciwa scale 8.\n\nresp- ls clear and diminished. ra sats high 90's. congested npc. remains on clinda for asp pneumonia.\n\ncv- hr 60-80's sr no ectopy noted. bp stable, please see flowsheet for vs.\n\ngi- abd soft + bs, small amount of liquid black stool, appears like charcoal. tolerating house diet.\n\ngu- foley d/c'd at 1300. dtv by 2100.\n\naccess- #20g piv in rac.\n\nsocial- aunt visited, sister phoned.\n\ndispo- remains in icu, full code, awaiting transfer to medical when bed available. one to one constant observer for safety.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 1539745, "text": "35 Y/O ADMITTED WITH SUICIDE ATTEMPT BY TYLENOL OD. HX OF DEPRESSION WITH MULTIPLE SUICIDE ATTEMPTS.\n\nNEURO: ORALLY INTUBATED. UNRESPONSIVE TO ANY STIMULATION WHEN CARE OF PT ASSUMED AT 2300 TO OPENING EYES TO VOICE, MAE, FOLLOWING COMMANDS BY 0300. HANDS RESTRAINED AND THIS NURSE CONSTANTLY AT BEDSIDE D/T SUICIDE PRECAUTIONS. NO SEDATIVES OR PAIN MEDS ADMINISTERED.\n\nPULM: ON CMV MODE WHEN UNAROUSABLE TO CPAP MODE AT 40%, 5 PEEP AND 5 PS AT 0400. VT > 350, RATE 20, SAT >98%. LUNGS COARSE THROUGHOUT, DIMINISHED L BASE. SXING SCANT TO SMALL AMTS THICK TAN SECRETIONS. T MAX 100.4.\n\nCV: NSR WITHOUT ECTOPY. HENODYNAMICALLY STABLE, SEE CAREVUE FOR Q1H VS. SEE CAREVUE LABS. LYTES REPLETED PER ORDERS.\n\nENDO: QID FSBS RANGE 150-254, COVERED WITH SLIDING SCALE INSULIN.\n\nGI: NGT INPLACE, 5000MG MUCOMYST Q4H. + BS, + LIQUID BLACK STOOLS.\n\nGU: FOLEY TO CD DRAINING QS AMTS URINE.\n\nSOCIAL: NO VISITORS OR PHONE CALLS.\n\nPLAN: SUICIDE PRECAUTIONS. WEAN AND EXTUBATE ASAP. REPLACE LYTES PER LABS. CLINDAMYCIN IV IF SPIKES TEMP FOR PROABLE ASP PNEUMONIA. CHEST XRAY DONE AT 0455.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 1539746, "text": "Resp: pt on a/c 12/650/.50/5+. Alarms on and functioning. Ambu/syringe @ hob. Ett 7.5 taped @ 19 lip. 02 sats 100%. Bs auscultated reveal bilateral coarse sounds. Suctioned for small amounts of tan thick secretions. Pt became arousable and following commands. RSBI=52,then placed on psv 5/5/50%. VT's 400, Ve 8-9L, rr 20-22. Fio2 decreased to 40%. Plan is to continue wean then extubate following rounds.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 1539747, "text": "MICU B Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. Pt. is a 35 y.o. woman admitted , hypotensive requiring pressors, resp. failure requiring intubation post trazadone/tylenol OD.\n\nRESP: Pt. successfully extubated at 1000. Lungs with diminished breath sounds throughout.Sats of >98% on 2lnc. Coughing well and expectorating small amounts of thin, white secretions. Clindamycin started for probable aspiration pneumonia.\n\nCNS: Pt. is lethargic, but cooperative and easily aroused by verbal stim. Slightly confused re:recent events, but remembers taking pills, knows she is in the hospital. MAE's. PEARL, 3mm.\n\nPSYCH/SOCIAL: Pt. seen by psych, awaiting their recommendations. Constant observer at the bedside. Pt. states she is \"happy\" that she was not successful in suicide attempt. Manager of group home, aunt and uncle all in to visit with pt's permission.\n\nCVS: Hemodynamically stable with heart rate of 80-90, NSR without VEA. B/P 100-120/syst.\n\nGI: Continues on mucomyst despite negative tylenol level at this point. Passing large amount of liquid, black (charcoal) stool via mushroom catheter. Hypoactive bowel sounds throughout. Able to take clear liquids without difficulty. LFT's WNL.\n\nID: Afebrile. As mentioned, clinda started for probable aspiration pneumonia. Sputum culture and one blood culture sent.\n\nVASCULAR: Left femoral line pulled and tip sent for culture. Site pulsatile post line dc. Pressure x 10min to site by H.O. to achieve hemostasis. Hct to be checked at 1600. Pt. to have left femoral u/s to assess for ?pseudoaneurysm. +DP/PT bilaterally. Legs are warm with appropriate sensation and movement.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 1539743, "text": "MICU Admission Note:\n35y.o. female with PMH anxiety disorder and severe exzema and also four past suicide attempts admitted today from EW with tylenol/barbituate OD. Pt was found unresponsive on porch of her group home where she resides. She was cold and EMT's were unable to get peripheral access or pulse. Carotid pulse was weak and BP was 70ish. Pt was intubated and transported to EW where groin line was inserted for access. Pt found to be acidotic with lactate 9.0. Treated with fluids/ventillation, charcoal and mucomist. Tylenol level was 267. Pt remained unresponsive in EW and was hypotensive and started on levophed. Her temp was 90 rectally and she was put on warming blanket with good results. Pt was transported to MICU for further care for tylenol OD.\n\nAllergies: Sulfa\n\nNeuro: Pt unresponsive upon arrival to MICU. +cough with stimulation. PEARL. No spontaneous movement noted.\n\nCV: Pt on levophed at .08mcg.kg/min. Wil attempt to get off as day progresses. NS bolus 1000cc's given upon arrival and pt put on 150cc/hr. BP 100-110. HR 70's NSR no ectopy. Labs drawn.\n\nResp: Arrivaed on AC 12, TV 600, FIO2 50% with 5cm peep and will need to have a-line inserted or intermittent blood gases drawn by team. Lungs coarse. Breathing over the set rate 2-5 breaths/min.\n\nGI: OGT in place for meds. +bs, passed small stool. Abdomen softly distended.\n\nEndo: Fingersticks ordered QID.\n\nGU: Foley in place with excellent amts clear urine draining.\n\nID: Temp 98.6 rectal on arrival. Blanket removed and pt covered with blankets, will follow. On no antibiotics currently.\n\nSocial: Has sister and aunt who were present in EW but have not arrived on unit yet. They were aware of the OD attempts in the past.\n" }, { "category": "Nursing/other", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 1539744, "text": "MICU NPN Update from admit note:\nNeuro: Pt remains unresponsive, no gag, +cough. PEARL 4mm bilaterally. Slightly tremulous briefly once today with turning but otherwise no movement noted. No withdrawal to pain. No grimace. Tylenol level back down. Found out the pt took fioricet OD ?how many tabs. She wrote a suicide note saying she was in too much pain and could not stand living any more.\n\nCV: Weaned off levophed this evening after 2 1000cc NS boluses. Currently BP 100-110. HR 70-80 NSR no ectopy. IVF d51/2NS at 125cc/hr. Received 40meq KCL, 3gm mag and 2gm calcium repletion and currently getting a dose of k-phos as ordered. Repeat K 4.0. Lactate down to 1.9 this eve.\n\nResp: Lungs coarse with occasional exp wheezes. Pt getting albuterol MDI's PRN. Blood gas on AC 12, TV 650, FIO2 50% w/5cm peep was adequate. No a-line inserted at this time. Is breathing over the vent 2-4breaths/min.\n\nGI: NPO except for meds, getting mucomist 5000mg Q4hrs for tylenol OD which is causing her to pass large amts foul smelling diarrhea. Fecal bag applied. OGT in place by auscultation/aspiration. Started on lansoprazole.\n\nGU: UO excellent via foley.\n\nID: Afebrile WBC 5.4\n\nEndo: Blood glucose 147 at 6PM. No coverage required but pt may need sliding scale written for if glucose goes back up.\n\nSocial: sister came in to visit and is her next-of-. Updated by myself and MD.\n\nPt down for unknown period of time and not waking up at present. Remains unresponsive at time of this note. Please continue to follow neuro status closely. Replete labs as needed. Continue with aggressive care. If wakes up plan to wean to extubate as soon as possible. Will need sitter for suicide watch when extubated.\n" }, { "category": "ECG", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 313335, "text": "Sinus rhythm\nProlonged Q-Tc interval with diffuse ST-T wave changes - clinical correlation\nis suggested for possible metabolic/drug effect\nSince previous tracing of the same date, probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2142-07-17 00:00:00.000", "description": "Report", "row_id": 313336, "text": "Sinus rhythm\nModest right ventricular conduction delay\nProlonged Q-Tc interval with diffuse ST-T wave changes - clinical correlation\nis suggested for possible metabolic/drug effect\nSince previous tracing of , prolonged Q-Tc interval with ST-T wave\nchanges present\n\n\n" }, { "category": "ECG", "chartdate": "2142-07-19 00:00:00.000", "description": "Report", "row_id": 313333, "text": "Sinus rhythm. Compared to the previous tracing of Q-T interval now\nwithin normal limits.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2142-07-18 00:00:00.000", "description": "Report", "row_id": 313334, "text": "Sinus rhythm. Non-diagnostic repolarization abnormalities. Prolonged\nQ-T interval. Compared to the previous tracing of no major change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2164-06-05 00:00:00.000", "description": "Report", "row_id": 1350985, "text": "npn\ns=i have a slight headache, but she gave me tylenol earlier.\n\no=awake, alert, moves all extremities. no neuro deficits. oriented x 3, pupils 3 mm and reactive.\n\ncv=monitor pattern initially a.fib, then apparently converted around 0300 to nsr. no ectopy noted. hr=60-80. sbp via non-invasive cuff 120--150's. consistently below 160 as desired. ivf off except for k+and mg repletion and antibiotics. taking water without nausea.\n\npulm=sats good on room air. resp. rate 10-20. breath sounds clear to bases.\n\ngi=positive bowel sounds. abdomen soft, non-distended. no stool this shift. asking if he may use commode if he feels urge to stool\n\n\ngu=voiding q.s. via urinal.\n\nskin=no open areas. antibiotic ointment to bridge of nose, upper lip and chin. no other open or abraded areas.\n\nendo=no issues.\n\nheme=hct 35.3. wbc 10.4.\n\nid=afebrile. continues on antibiotics as ordered.\n\nsocial=no family contact this shift.\n\na=stable overnight.\n\np=continue to monitor, possible transfer to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2164-06-05 00:00:00.000", "description": "Report", "row_id": 1350986, "text": "NURSING NOTE--DISCHARGE\nNeuro: Alert and oriented x 3, c/o mild headache, med with tylenol with relief. Strength 5/5 throughout, ambulating in the unit independently.\n\nCV: HR 50s-60s NSR-SB, no ectopy. BP 120-160/70s. Continues on atenolol and univasc.\n\nResp: Breath sounds clear throughout, sats 97-100% on RA\n\nGI: Abdomen soft, (+)bowel sounds. Tolerating regular diet without difficulty\n\nGU: Voiding via urinal adequate amounts.\n\nHeme: Hct stable at 35.\n\nID: Afebrile, clindamycin d/c'd\n\nSkin: Eccymosis/scabbed areas on face, cleansed with ns and covered with bacitracin and left open to air. Lip and nose lacs with sutures, ota, no drainage\n\nSocial: son in to visit, updated on plan. Pt to be d/c'd to son's home this evening\n\nA: Hemodynamically and neurologically stable\n\nP: D/C to home this evening with son, d/c instructions written\n" }, { "category": "Nursing/other", "chartdate": "2164-06-04 00:00:00.000", "description": "Report", "row_id": 1350983, "text": "Nursing Admit Note:\n\nPt is a 77 y.o. man who was riding his bike and fell off, went over the handle bars and hit face on cement per report. +LOC at scene, pt reports he can only remember parts of the event. Pt came to EW AAOx3 c/o pain in his mouth and face. Trauma series done. Head CT revealed small SDH vs SAH. Pt transferred to T/SICU for further management.\n\nPMhx: AF, Htn, CAD/AI, Recurrent prostatitis, cyst removal as child.\n\nMeds at home: ASA, univasc, atenelol, prozac, citrical, ciproflox prn prostatitis, and MVI\n\nAllergies: NKDA.\n\nReview of Systems:\n\nNeuro: Neuro status unchanged, Pt 3, follows commands and answers questions appropriately. Extremities strong and equal bilaterally. PERRL. Pt c/o headache, tylenol given with releif. Logroll precuations d/c'd by Dr . C spine precautions maintained.\n\nCV: hr=60-70s NSR, no ectopy. Pt hypertensive on arrival to T/SICU, given pm meds and hypertension resolved, currently sbp=120-140s. Color pink, skin warm and dry. Palpable pulses all extremities. Maintainance IVF.\n\nResp: LS CTA, SaO2=95-100% RA.\n\nGI: Abd soft, nontender. +BSx4. No BM. NPO x meds. IV pepcid started.\n\nGU: Indwelling foley intact and draining clear yellow urine, sufficient UO.\n\nHeme: HCT=34.0. Coags wnl. Venodynes in place.\n\nID: Tmax=100.4po. IV clindamycin started.\n\nEndo: No issues.\n\nSkin: Skin warm and dry. Mouth/lip c laceration, sutured in ED, draining sm sanguinous drainage. L side of chin contusion with swelling and ecchymosis. Sm amt of Periorbital ecchymosis noted.\n\nSOC: Pt lives alone, has 3 children. son ) it pt's HCP, lives locally and is a MD . Son very supportive and updated.\n\nPlan: Continue support as above, continue to monitor neuro status. Plan for repeat head CT today. ?transfer to floor if remains stable.\n" }, { "category": "Nursing/other", "chartdate": "2164-06-04 00:00:00.000", "description": "Report", "row_id": 1350984, "text": "3p-11p\nNeuro= A&O x 3. PERRL at 3mm with brisk response bilat. Neuro checks q 2 hours unchanged. MAE to command. C/O HA and given tylenol for relief.\n\nCV=chronic afib with brady rate in 50s/60s. no ectopy noted. Chronic HTN. sbp to be kept below 160. hydralazine 10mg iv given x2. bilat ac perph iv patent. pedal pulses 3+bilat. radial pulses 3+ bilat.\n\nlungs=clear with diminished at right base. strong nonproductive cough. sat 95-100% on room air. deep breathing encouraged.\n\nGI/GU=abd SNT with bowel sounds present. started on clear liquids today with no N/V. No stool this shift. foley dc'd and pt voiding per urinal clear yellow urine wnl.\n\nskin=contusion to abd. facial lac at left side of mouth with scant s/s drainage. Red/purple. Periorbital edema/bruising.\n\nendo=no issues.\n\nID=afebrile. abx continues.\n\nsoc= son, DR , phoned x3 and visited at 2200.\n\nplan=continue support.transfer when bed available.\n" } ]

[ { "category": "Radiology", "chartdate": "2107-07-17 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 974651, "text": " 2:41 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with murmur\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 3:17 P.M.\n\n HISTORY: Murmur.\n\n No comparisons. The lungs are well inflated. The lungs are clear.\n Curvilinear lucency running along the left mid clavicular line is likely a\n skinfold and not a pneumothorax, given that there are interstitial markings\n that projecting lateral to it. This could be confirmed with a repeat view.\n\n Heart size is normal. No pleural effusion.\n\n Bones and soft tissue structures are normal.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2107-07-17 00:00:00.000", "description": "Report", "row_id": 2066205, "text": "Respiratory Care\nPt rec'd hyperoxia test as part of cardiac w/u. TcO2 >300mmHg while rec'ing 100% O2. Attending and RN notified of results.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-17 00:00:00.000", "description": "Report", "row_id": 2066206, "text": "NICU NURSING NOTE\n\n Baby Girl was admitted to the NICU for cardiac evaluation.\nMurmur is soft. Pulses are wnl. Color is pink/jaundiced. Infant is very irritable. 4- ext. BP are wnl's ( systolics in 90's). Passed hyperoxia at 302. EKG wnl. Awaiting CXR. Examined by Dr. . Pending CXR will be transferred abck to NBN.\n" }, { "category": "Nursing/other", "chartdate": "2107-07-17 00:00:00.000", "description": "Report", "row_id": 2066207, "text": "Neonatology Attending\n36-6/7 week GA infant now DOL 11 transferred to NICU triage at request of Dr. for consultation regarding cardiac murmur\n\nMaternal Hx - 32 year old G7P4->5 woman with PMHx notable for hepatitis C carriage, endocarditis, positive PPD (s/p INH). Social history is notable for polysubstance abuse, on methadone maintenance with report of no recent illicit use in past 3 years. Family history is non-contributory. Prenatal screens were as follows: O positive, IAT negative, HBsAg negative, RPR non-reactive, rubella immune, GBS positive.\n\nAntenatal Hx - for EGA 36-6/7 weeks at delivery on at 1020. Pregnancy was complicated by above maternal social and medical issues. Spontaneous onset labor leading to SVD under epidural anesthesia. There was no intrapartum fever or other clinical evidence of chorioamnionitis. AROM occurred 9 hours prior to delivery and yielded clear amniotic fluid. Intrapartum antibiotics were initiated 12 hours prior to delivery.\n\nNeonatal course - Infant required only suctioning. Apgars were 9 at one minute and 9 at five minutes. Postaxial polydactyly noted at delivery (resected by plastic surgery service). She has been monitored in the regular nursery for neonatal withdrawal but has not required opiate replacement therapy. Infant has been feeding well without diaphoresis, cyanosis or respiratory distress. Murmur was noted on earlier examination and has persisted.\n\nPE\nagitated bot otherwise very well-appearing term infant\nhr 166 rr 40-50 SaO2 100% in room air\nBP: LA 91/47 (62)\n RA 97/58 (71)\n LL 93/47 (64)\n RL 94/48 (65)\nHEENT AFSF; non-dysmorphic; palate intact; neck/mouth normal; normocephalic; no nasal flaring\nCHEST no retractions; good bs bilat; no adventitious sounds\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; 1/6 SEM ULSB without radiation\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent\nGU normal female genitalia\nCNS active, hyperalert, resp to stim; irritable and somewhat difficult to console; tone moderately increased in symmetrical distribution; MAE symm; suck/root/gag intact; facies symm\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nINV\ntcPaO2 in 1.00 FiO2: 302\nEKG wnl\nCXR normal cardiac silhouette and pulmonary parenchyma\n\nIMPRESSION\n36-6/7 week GA infant with\n1. Cardiac murmur, without evidence of left sided obstruction, shunt, pulmonary edema or hypertrophy. Given normal screening investigations, critical congenital heart disease is highly unlikely, although less severe lesions such as VSD or ASD cannot be excluded. Findings are likely related to flow or PDA.\n2. Risk for neonatal withdrawal syndrome, based on maternal methadone use. Infant has had acceptable NAS , although current examination suggests some degree of irritability\n\nPLAN\n-In light of negative screening investigations and absence of clinical findings consistent with cardiorespiratory compromise, we will return infant to the regular nursery for continued observation and o\n" }, { "category": "Nursing/other", "chartdate": "2107-07-17 00:00:00.000", "description": "Report", "row_id": 2066208, "text": "Neonatology Attending\n(Continued)\ntherwise routine neonatal care\n-Continue NAS and institute DTO therapy per protocol if indicated\n" } ]

[ { "category": "Radiology", "chartdate": "2156-02-07 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 777850, "text": " 1:59 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: S/P TRAUMA, R/O DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pulmonary embolus\n REASON FOR THIS EXAMINATION:\n Bilateral lower extrem. to R/O DVT\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY; Pulmonary embolism.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: scale and doppler son of\n bilateral common femoral, superficial femoral and popliteal veins were\n obtained.\n\n There is normal flow, compressibility, and augmentation.\n\n IMPRESSION: No evidence of bilateral lower extremity DVT.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2156-02-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 778258, "text": " 1:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? progression of intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with known Right SDH and intraparenchymal hemorrhage.\n REASON FOR THIS EXAMINATION:\n ? progression of intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Follow up hemorrhages.\n\n The exam is compared to a prior studies of and .\n\n The right-sided convexity subdural collection is unchanged in size. There is\n some alteration in its density consistent with evolution and measures no\n greater than 3 mm in dimension. There is no change in the superficial left\n frontal and in the left temporal lobe contusions compared to the previous\n exam. There is opacification of the left maxillary sinus which appears\n increased compared to . Ethmoid sinus disease persists. There is no\n change in the alignment of the right zygomatic arch fracture which does not\n appear depressed.\n\n IMPRESSION: Increased sinus disease. Stable appearance of intracranial\n extra-axial hematoma and hemorrhagic contusions as described.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777857, "text": " 4:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please do at 3pm. r/o bilateral pneumothoraces. s/p remova\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall, acute MI, hemodynamically unstable, s/p bilateral\n chest tube placement\n REASON FOR THIS EXAMINATION:\n Please do at 3pm. r/o bilateral pneumothoraces. s/p removal right chest tube,\n air leak on the left.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for bilateral pneumothoraces following removal of chest\n tubes with air leak on left side.\n\n Comparison is made to the prior study from . A portable AP view of the\n chest reveals a left sided chest tube along the left lateral chest wall the\n sidehole of the tube is projected over the left lateral chest wall. No\n pneumothorax is noted on this side no pneumothorax is noted on the right side\n following chest tube removal. Swan-Ganz catheter tip terminates in the\n pulmonary outflow tract cardiac silhouette is unchanged in size and appearance\n bilateral effusions are noted ET tube tip terminates 5 cm above the carina.\n\n IMPRESSION: No pneumothorax on right side following right chest tube removal.\n 2. What appears to be a left sided chest tube is projected along the left\n lateral chest wall with the sidehole projected over the rib margin this may be\n a site of air leak.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777734, "text": " 7:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check PA catheter position, r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall, acute MI, hemodynamically unstable\n REASON FOR THIS EXAMINATION:\n Check PA catheter position, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: Status post fall. Acute MI. Check PA catheter.\n\n COMPARISON: at 06:30.\n\n PORTABLE SUPINE CHEST: There has been interval placement of a left suclavian\n SG catheter, with tip directed inferiorly into the intralobar artery. No\n pneumothorax. The ETT remains in satisfactory position. There is an NG tube\n extending below the level of the diaphragm. There is an external pacing device\n overlying the right hemithorax.\n\n The heart size is normal. The pulmonary vascularity is slightly indistinct.\n There is a hazy opacity within the left lower lobe with increased opacity in\n the left retrocardiac region. This is consistent with a probable small left\n pleural effusion. There is probable atelectasis at the left base.\n\n IMPRESSION:\n\n 1. Left subclavian PA catheter tip in the intralobar artery. No pneumothorax.\n 2. Mild CHF, unchanged in degree.\n 3. Probable small left effusion with left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777727, "text": " 6:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/o Pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall, desatting\n REASON FOR THIS EXAMINATION:\n R/o Pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P fall. Desaturation.\n\n COMPARISON: at 8:30 p.m.\n\n PORTABLE SUPINE CHEST @ 6:30 A.M.: The ETT is 2.0 cm above the\n carina. The tip of the NG tube extends below the level of the diaphragm. The\n heart size is normal. The pulmonary vascularity is prominent, consistent with\n CHF/volume overload. There is an external pacer pad obscuring a portion of the\n lateral aspect of the right hemithorax. There is biapical pleural thickening,\n right slightly greater than left. There are patchy bibasilar opacities, likely\n reflecting areas of atelectasis vs. aspiration. No pneumothorax.\n\n IMPRESSION: Worsening CHF/volume overload. Patchy bibasilar opacities may\n reflect areas of aspiration vs. atelectasis. Biapical pleural thickening.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777874, "text": " 11:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ETT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall, acute MI, hemodynamically unstable, s/p\n bilateral chest tube removal, near self-extubation, decreasing O2 sats\n\n REASON FOR THIS EXAMINATION:\n check ETT position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P fall, MI, with removal of bilateral chest tubes. Decreasing\n oxygen saturations.\n\n TECHNIQUE: Single portable AP view of the chest is compared with 1 day prior.\n\n FINDINGS: Again seen is the endotracheal tube, terminating at the thoracic\n inlet. A left-sided subclavian Swan-Ganz catheter terminates with the tip in\n the right main pulmonary artery. The cardiac silhouette remains slightly\n enlarged, with perihilar haziness and vascular redistribution. Additionally,\n there are probable bilateral small effusions. No pneumothorax. Osseous\n structures appear unremarkable.\n\n IMPRESSION:\n 1) Cardiomegaly with mild CHF.\n 2) Probable small bilateral effusions.\n 3) Lines and tubes in appropriate position.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 777718, "text": " 12:35 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: s/p trauma w/ ? r apical cap on CXR. please eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n s/p trauma w/ ? r apical cap on CXR. please eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma. ? right apical cap on chest x-ray.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet to the upper abdomen.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is no significant\n axillary, mediastinal, or hilar lymphadenopathy. The heart and great vessels\n are unremarkable on this non-contrast examination. There are bibasilar\n consolidations. Atelectasis is present posteriorly, in the dependent portion\n of both lungs. The ET tube tip terminates at the thoracic inlet. The NG tube\n tip is present within the stomach. The imaged portion of the upper abdomen is\n unremarkable. There are no pleural effusions or pneumothoraces. The osseous\n structures are normal. No fractures are identified.\n\n IMPRESSION: There are bibasilar consolidations, likely representing\n aspiration. There is bilateral minimal atelectasis along the posterior\n portions of the lungs extending to the lung apices. No pleural effusion or\n pneumothorax is present.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-05 00:00:00.000", "description": "C-SPINE, TRAUMA", "row_id": 777713, "text": " 9:21 PM\n C-SPINE, TRAUMA; T-SPINE Clip # \n L-SPINE (AP & LAT)\n Reason: patient s/p fall with head trauma, s/p fall\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n patient s/p fall with head trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P fall with head trauma.\n\n AP, LATERAL & ODONTOID VIEWS OF THE CERVICAL SPINE, AP & LATERAL VIEWS OF THE\n LUMBAR SPINE: The cervical vertebral bodies are normal in height and\n alignment. There is no prevertebral soft tissue swelling. No fractures are\n identified. The thoracic and lumbar vertebral bodies are normal in height and\n alignment. No fractures are identified. Note is made of an ETT and NG tube.\n The odontoid and lateral masses are unremarkable. Note is made of anterior\n osteophytic spurring at the L1/2 intervertebral level and L4/5 intervertebral\n levels.\n\n IMPRESSION: There is no evidence of a cervical spine fracture. The thoracic\n and lumbar vertebral bodies are unremarkable. Note is made of degenerative\n change of the lumbar spine.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-05 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 777714, "text": " 9:52 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: s/p found down, please repeat CXR w/ PA technique\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n s/p found down, please repeat CXR w/ PA technique\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down. Trauma.\n\n COMPARISON: \n\n PORTABLE SUPINE CHEST: The patient is on a trauma board. There is a external\n pacing pad overlying the right hemithorax. There is mild cardiomegaly. The\n pulmonary vascularity is slightly prominent, which could reflect supine\n positioning. There are patchy bibasilar opacities. The apices are not\n entirely included on this film. No definite pneumothorax is seen.\n\n IMPRESSION: Patchy bibasilar opacities may reflect areas of atelectasis or\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777756, "text": " 11:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check chest tube placement, r/o pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p fall, acute MI, hemodynamically unstable, s/p bilateral\n chest tube placement\n REASON FOR THIS EXAMINATION:\n Check chest tube placement, r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P fall bilateral chest tube placement.\n\n COMPARISON: \n\n SINGLE VIEW CHEST: There has been interval placement of bilateral chest tube.\n No definite pneumothorax is seen. The left subclavian PA catheter has been\n withdrawn and is now in the main pulmonary artery. The NG tube tip is just at\n the level of the GE junction and should be advanced. The ETT is in\n satisfactory position.\n\n Vascularity remains indistinct, consistent with CHF/volume overload. There is\n hazy opacity at the left base, probably reflecting a small amount of pleural\n fluid. There is increased left retrocardiac density, likely related to\n atelectasis.\n\n IMPRESSION: No pneumothorax. NG tube tip just at the level of the GE\n junction. Consider advancing. Stable, mild CHF, small left effusion and\n probable left lower lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 777707, "text": " 8:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P TRAUMA - ? BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with trauma\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Motion limits evaluation.\n There are foci of parenchymal hemorrhage within the left temporal lobe, in the\n brain adjacent to the petrous bone and in the more superior lateral temporal\n lobe. There is probably a small area of left posterior inferior frontal lobe\n contusion as well. There is mild surrounding hypodensity, indicating edema.\n The left temporal remains visible and the basal cisternal spaces are not\n narrowed.\n\n There is an acute right subdural hematoma with extends from the convexity,\n along the frontal and temporal lobes, into the right middle cranial fossa.\n This measures 4 mm. in thickness. There is obscuration of the sulcal pattern\n in the adjacent brain and narrowing of the right Sylvian fissure.\n\n There is a small amount of subarachnoid blood seen in some of the frontal lobe\n sulci.\n\n The ventricles are not dilated and retain their normal morphology.\n\n There is a scalp hematoma adjacent to the right parietal bone. No skull\n fractures are seen. There is a non- displaced fracture through the right\n zygomatic arch. Fluid and mucosal thickening is present in the sphenoid and\n ethmoid air cells. There is a small air- fluid level within the left maxillary\n sinus. The lamina papyraceae are intact. Facial bones and orbits are only\n partially viewed. The temporomandibular joints appear aligned.\n\n IMPRESSION:\n Left temporal lobe and frontal lobe contusions. Thin right subdural\n collection. Basal cisternal spaces remain well visualized; there is no\n appreciable shift of midline structures at this time. The ventricles are\n normal in size.\n No skull fractures are identified.\n The right zygomatic arch is fractured.\n - These findings were directly communicated to the clinicians caring for the\n patient at the time of the examination.\n\n (Over)\n\n 8:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P TRAUMA - ? BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2156-02-06 00:00:00.000", "description": "INTERUP IVC", "row_id": 777796, "text": " 5:37 PM\n IVC GRAM/FILTER Clip # \n Reason: High clinical suspicion PEpersitent hypoxia of sudden onsetP\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * IVC GRAM C1769 GUID WIRES INCL INF *\n * C1880 VENA CAVA FILTER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n High clinical suspicion PEpersitent hypoxia of sudden onsetPt cannot be\n anticoagulated secondary to head bleedWOuld require filter in PE present\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67 y/o man with intracranial injury and hypoxia.\n\n RADIOLOGISTS: The procedure was performed by Drs. and ,\n with the attending radiologist Dr. being present during the entire\n procedure.\n\n PROCEDURE AND FINDINGS: The risks and benefits were explained to the\n patient's family and consent was obtained.\n\n The patient was placed supine on the angiographic table and the right groin\n was prepped and draped in sterile fashion. Under local anesthesia using 1%\n Lidocaine, the right common femoral vein was accessed with a 19 gauge needle\n and 0.035 wire was advanced into the inferior vena cava. The needle\n was exchanged for a 4 FR Omniflush catheter with its tip just above the IVC\n bifurcation. Inferior vena cavogram was performed with injection of nonionic\n contrast diluted to half which demonstrated patent bilateral common iliac\n veins and IVC with no filling defect or anomalies visualized. Both renal vein\n openings were identified bilaterally. The catheter was removed and the venous\n entry site was dilated over a .035 wire with increasing sized dilators\n sequentially. A 15 FR long sheath was advanced over the wire into the upper\n inferior vena cava. Then, filter was deployed with tip at the\n level of bilateral renal vein openings. The final X-ray demonstrated the\n filter is in proper position. The sheath was removed and local hemostasis was\n achieved by manual compression.\n\n The patient tolerated the procedure well with no complications.\n\n IMPRESSION: Successful placement of a infrarenal IVC filter.\n Patent inferior vena cava. Reflux into the left common iliac vein compatible\n with increased right atrial pressure.\n (Over)\n\n 5:37 PM\n IVC GRAM/FILTER Clip # \n Reason: High clinical suspicion PEpersitent hypoxia of sudden onsetP\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2156-02-05 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 777708, "text": " 8:14 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with trauma\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Trauma.\n\n TECHNIQUE: AP view of the pelvis and AP chest.\n\n FINDINGS:\n\n Chest: The right CP angle is not included on the present study. Study is\n limited by trauma board. There is an endotracheal tube with the tip 8.3 cm\n above the carina. The tip of the NG tube is in the stomach. The heart size is\n in the upper limits of normal allowing for AP technique. The aorta is\n unfolded. There is an opacity in the right apical region and increased pleural\n opacity which may represent thickening or a small amount of fluid. No\n fractures are seen. There is no evidence of pneumothorax.\n\n IMPRESSION: Increased pleural opacity in the right apical region, may\n represent fluid or pleural thickening. Further evaluation with CT is\n recommended.\n\n AP pelvis: The lateral portions of the femurs and the right iliac bone are\n not included on the present study. The study is limited by trauma board. No\n fractures are seen. There are extensive degenerative changes in the lower\n lumbar spine.\n\n IMPRESSION: No fractures are seen.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-05 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 777709, "text": " 8:14 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: S/P TRAUMA - ? FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with trauma\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: Non-contrast axial images were obtained through the cervical\n spine.\n\n FINDINGS: There is degenerative change at the C1-2 articulation, with a 3-mm\n well- corticated ossification just to the left of the superior portion of the\n odontoid. There is narrowing of the interspace between the odontoid process\n and the anterior ring of C1. No fractures are identified.\n\n There is sclerosis of the left pedicle, facet and lamina of C3, perhaps\n related to old injury and healing. There are multlevel degenerative changes,\n involving facet joints, uncovertebral joints and endplates at the C3-4, C4-5,\n C5-6 and C6- 7 intervertebral levels. The patient is intubated and an NG\n tube is present. There is no significant prevertebral soft-tissue swelling.\n The posterior elements are normal.\n\n IMPRESSION:\n\n There is no fracture identified. Multilevel degenerative change is observed.\n\n A few left inferior mastoid air cells are opacified.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-05 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 777710, "text": " 8:15 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: S/P TRAUMA, ? INTERNAL INJURY\n Field of view: 46 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with trauma\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:12 PM\n bibasilar consolidation - probable aspiration. No acute intra-abdominal\n process.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma.\n\n TECHIQUE: Helically acquired images were obtained from the lung bases to the\n pubic symphysis after the administration of intravenous contrast.\n\n CONTRAST: 150 cc of Optiray was administered per trauma protocol.\n\n CT ABDOMEN WITH IV CONTRAST: There are bibasilar posterior consolidations.\n There are no pleural effusions. An NG tube is coiled within the gastric\n fundus. The spleen, liver, gallbladder, pancreas, adrenal glands and\n intraabdominal bowel loops are unremarkable. The kidneys enhance symmetrically\n and excrete normally. At the lower pole of the right kidney there is a 1.3 cm\n simple cyst. There is no free fluid or free air within the abdomen. There is\n no significant adenopathy.\n\n CT PELVIS WITH IV CONTRAST: A Foley catheter is present within the urinary\n bladder. The prostate and seminal vesicals are unremarkable. The interpelvic\n bowel loops are are normal. There is no free fluid or free air within the\n pelvis.\n\n The osseous structures demonstrate degenerative change throughout the lumbar\n spine. There is spiculation of the T12 vertebral body which is incompletely\n imaged. No fractures are identified.\n\n IMPRESSION:\n 1. There are bibasilar consolidations likely representing aspiration. There is\n no evidence of an acute intraabdominal process.\n 2. Probable hemangioma of the T12 vertebral body. Degenerative change of the\n lumbar spine without evidence of fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-02-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 777787, "text": " 3:57 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? worsening of intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with trauma\n REASON FOR THIS EXAMINATION:\n ? worsening of intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, prior bleed, evaluate for change.\n\n Comparison is made to the prior study from .\n\n TECHNIQUE: Contiguous axial images of the brain without IV contrast.\n\n FINDINGS: Previously seen acute intracranial hemorrhages are again\n identified, and are unchanged in appearance. There is no shift of normally\n mid-line structures. There is no new hydrocephalus. The pattern of \n white differentiation is unchanged.\n\n Again identified is a non-displaced fracture of the right zygomatic arch. A\n right-sided scalp hematoma is again demonstrated, unchanged. There is fluid\n within the ethmoid air cells, sphenoid sinuses, and maxillary sinuses.\n\n IMPRESSION: Previously identified areas of acute intracranial hemorrhage are\n unchanged in appearance. There is no new hydrocephalus or shift of normally\n mid-line structures. There is an increased amount of fluid within the\n maxillary sinuses.\n\n" }, { "category": "Radiology", "chartdate": "2156-02-06 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 777785, "text": " 3:54 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: hypoxia, question of PE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n\n REASON FOR THIS EXAMINATION:\n hypoxia, question of PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia.\n\n TECHNIQUE: Helically-acquired axial images were obtained throughout the chest\n with 100 cc Optiray. Non-ionic intravenous contrast was used secondary to the\n fast injection rate required for the study.\n\n COMPARISON: Prior CT on .\n\n FINDINGS: The heart and great vessels are unremarkable. There is no\n significant mediastinal, hilar or axillary lymphadenopathy. Again noted are\n bibasilar consolidations, most prominently in the posterior portion, the\n dependent portion of both lungs. The ET tube is again noted, which remains\n stable in position. The NG tube tip is present within the stomach.\n\n There are multiple small intraluminal filling defects noted bilaterally, right\n greater than left. The above findings are consistent with multiple small\n subsegmental pulmonary emboli in the appropriate clinical setting.\n\n There is no evidence of pneumothorax or pleural effusion. The visualized\n intraabdominal organs are unremarkable. Bone windows demonstrate no evidence\n of suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1) Multiple subsegmental pulmonary emboli noted bilaterally, predominantly in\n the right upper lobe and the left upper lobe.\n\n 2) Persistent bibasilar consolidations, likely representing aspiration.\n\n" }, { "category": "Echo", "chartdate": "2156-02-06 00:00:00.000", "description": "Report", "row_id": 74140, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction?\nHeight: (in) 72\nWeight (lb): 240\nBSA (m2): 2.30 m2\nBP (mm Hg): 113/54\nStatus: Inpatient\nDate/Time: at 11:23\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular systolic function is normal.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: Physiologic tricuspid regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\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 probably normal (LVEF>55%). The\nright ventricle may be dilated. Right ventricular systolic function is normal.\nThe aortic valve leaflets are mildly thickened. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. There is a trivial/physiologic pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2156-02-07 00:00:00.000", "description": "Report", "row_id": 171120, "text": "Sinus rhythm. No change since the previous tracing of .\n\n" }, { "category": "ECG", "chartdate": "2156-02-06 00:00:00.000", "description": "Report", "row_id": 171121, "text": "Sinus rhythm. Compared to tracing #1 no significant diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2156-02-05 00:00:00.000", "description": "Report", "row_id": 171122, "text": "Sinus rhythm. Non-specific anterior ST-T wave abnormalities. No previous\ntracing available for comparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2156-02-07 00:00:00.000", "description": "Report", "row_id": 1404404, "text": "TRAUMA SICU NPN\nO:\nNEURO: INITIALLY RESTLESS AND ON FENTANYL GTT. WOKE CALMER AND MAE, FOLLOWING COMMANDS. FENTANYL OFF AND PT REMAINED CALM. VERY SLEEPY BUT EASILY AROUSABLE. MOUTHING WORDS TO COMMUNICATE. 2 EPISODES OF PANICKED FEELING TXED W/ MIDAZ. WAKES FORGETFUL FROM MIDAZ BUT ABLE TO REORIENT EASILY.\n\nCV: SWAN REMAINS IN PLACE W/ STABLE HEMODYNAMICS. CO , SV02 77-80.\nHR 70'S-80'S NSR, RARE PVC. LEVO WEANED OFF ONCE FENTANYL OFF. EKG DONE W/ PANIC ATTACK SHOWING NO CHANGES.\n\nRESP: ATTEMPTED WEAN TO PSV ONCE FENTANYL OFF. PT APNEIC AND UNABLE TO TOLERATE SEVERAL ATTEMPTS. WEANED IMV TO 10 W/ MINIMAL OVERBREATHING AND C02 RETENTION. PLACCED BACK ON FULL VENTILATION, IMV 14 W/ STABLE ABG. SXNED FOR THICK TAN SECRETIONS. SPUTUM CX SENT.\n\nGI: ABD SOFT. OGT-. NO BM.\n\nHEME: HEMATOLOGY W/U SENT AND PND.\n\nID: TMAX 100.4\nWBC COMING DOWN.\n\nSKIN: INTACT.\n\nSOCIAL: WIFE IN AND V ATTENTIVE TO PT'S NEEDS. MORE ANXIOUS WHEN PT IS ANXIOUS.\n\nA: FAILURE TO WEAN D/T LETHARGY. HEMODYNAMICALLY STABLE.\n\nP: CONT TO MONITOR. HOLD SEDATION AS TOLERATED. REATTEMPT WEAN TOMORROW. CONT PULM TOILET. AWAIT HEME W/U. CONT TO MONITOR NVS. FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2156-02-08 00:00:00.000", "description": "Report", "row_id": 1404405, "text": "Altered Respiratory Status\n\n(Brief note-see transfer note for VSS.)\n\nPt agitated despite Midazolam. Tongued out ETT and OGT@ 1:30am. Pt alert and conversant. No neuro deficits. Strong cough. Sats 96% on 100% face tent with 4 L NP. Breath sounds diminished at bases. Bilateral chest tubes d/c. BP rising-started Lopressor q6hr. Lasix 20mg with good diuresis. Abd. soft, no stool.\nPt transferred to N/SICU.\n\n" }, { "category": "Nursing/other", "chartdate": "2156-02-06 00:00:00.000", "description": "Report", "row_id": 1404398, "text": "S/P FALL/HEAD TRAUMA-R SDH/L SAH(TRAUMATIC)\nT/SICU NSG ADMIT NOTE\n\nHPI:\nPT IS A 67 Y/O MAN WHO WAS FOUND NAKED ON A COT IN HIS BASEMENT .PT APPARENTLY HAD BEEN TAKING OF HIS WORK CLOTHES IN HIS BASEMENT AND FELL VS FAINTED VS ?.PT WAS APPARENTLY ABLE TO GET TO ROOM IN BASEMENT W/ COT AND GET BLANKET ON HIMSELF.PT WAS FOUND BY FAMILY INCOHERENT/INCONTINENT.PT BROUGHT BY EMS TO HOSPITAL-INTUBATED- R SDH NOTED ON CT SCAN.PT TO .PT HAD FURTHER CT SCAN WHICH SHOWED R SDH,L IPH,+L FRONTAL SAH(TRAUMATIC).PT BROUGHT TO T/SICU ~10:30PM.PT CHEST CT SCANNED ~1AM.\n\nPMHX-^^CHOLESTEROL\n HOH\n\nMEDS-LIPITOR\n\nTUBES LINES + DRAINS:#8.0 ETT,OGT,2 PERIPHERAL IV'S,R RAD A-LINE,+ INDWELLING FOLEY.\n\nEVENTS:@~6:30 AM PT WOKE UP AGGITATED THRASHING ATTEMPTING TO EXTUBATE SELF PULLING @ LINES HYPERTENSIVE 160-180'S HR>100.INCREASED PROPOFOL INFUSION W/O SUCCESS,SICU HO AND TRAUMA RESIDENTS IN TO EVAL,PROPOFOL CHANGED TO OTHER PERIPHERAL IV W/ SUCCESS-PT O2 SATS THEN DOWN TO 70%-SBP DOWN TO 60,CXR DONE,PROPOFOL GTT DECREASED,NEO GTT BACK ON,INDRODUCER + CCO PA CATH PLACED.TROPONIN 4A ^^23(8P 1.0).\n\nCURRENT REVIEW OF SYSTEMS:\n\nNEURO-PT SEDATED ON PROPOFOL GTT,WHEN PT LIGHTENED PT AS NOTED THRASHING NOT FOLLOWING COMMANDS,MAE'S.RUE SL STRONGER THAN LUE,MOVES TO NOXIOUS STIM.PERRLA 2MM,PROPOFOL GTT 0-80 MCG/KCG/MIN OVER NOC.PT DID OPEN EYES TO VOICE THIS AM.\n\nCV-SBP 60-180 RANGE,NEO GTT OFF+ ON,HR 70'S-90'S NSR,RARE VEA, + DP/PT ,IVF 75->100->150CC/HR,TOTAL 3L LR + 1L NS IN IVF BOLUS' DURING SHIFT.DOPA ADDED NEO OFF CHANGE OFF SHIFT.\n\nRESP-PT INITIALLY ON SIMV/PSV 800 X 14 80% 5PEEP/10PSV,ABG WNL PO2 ^200,VENT CHANGED TO SIMV 650 X 16 5PEEP/O PSV 50% FIO2,ABG OK,EVENTS AS NOTED THIS AM @ 6:30.PT Q2-3HRS FOR SM AMTS THICK LIGHT YELLOW SECRETIONS.STRONG COUGH EFFORT.\n\nGI/GU-PT ABD SOFT + HYPOACTIVE BS,OGT DRAINING SM-MOD BROWN,CARAFATE ADDED.U/O 17-80CC/HR CLEAR->TURBID YELLOW URINE VIA FOLEY CATH.NPO.\n\nSKIN-GROSSLY INTACT.\n\n MARRIED WIFE IN SUPPORTIVE STAYING @ BEST WESTERN,PT STEP DAUGHTER IN W/ HER HUSBAND.PT HAS DAUGHTER IN SHE PHONED X 1 OVER NOC.\n\nENDO-BS 160-170'S\n\nID-TMAX 101.3,PT PAN .\n\nA-PT HEMO AND NEURODYNAMICALLY UNSTABLE S/P SDH/SAH\n\nP-CONT NEURO CHECKS,REPEAT HEAD CT TODAY,VS,HEMODYNAMIC MONITORING,I+O,FAMILY SUPPORT PRN,SOC WORK CONSULT,MONITOR SKIN INTEGRITY QS AND PRN,MONITOR CX DATA QD AND PRN.\n" }, { "category": "Nursing/other", "chartdate": "2156-02-06 00:00:00.000", "description": "Report", "row_id": 1404399, "text": "SOCIAL WORK NOTE:\n\nNew trauma pt on T-SICU. Pt is a 67 year old married man who lives in , NH with his wife, . Pt was here from Hospital last night s/p presumed fall at home. wife stayed at Best Western last night. Her dtr (pt's step-dtr) is involved and supportive and pt's dtr is currently in but has been in contact by phone. This SW will try to meet pt's wife today if possible. Social work remains available as needed. Pager .\n" }, { "category": "Nursing/other", "chartdate": "2156-02-06 00:00:00.000", "description": "Report", "row_id": 1404400, "text": "3:45pm-6:30pm\nResp. Care note: Patient transported to Cat Scan, and\nSpecial procedures during this time period. He maintained\nSpo2's 99-100% and appeared to ventilate smoothly through\nthe trip.\n" }, { "category": "Nursing/other", "chartdate": "2156-02-06 00:00:00.000", "description": "Report", "row_id": 1404401, "text": "T-SICU NURSING PROGRESS NOTE\nNEURO: PT WITH ONE EPISODE OF EXTREME AGITATION THIS AM, REQUIRED 6 PEOPLE TO KEEP PT SAFE AND IN BED. BOLUSED WITH FENTANYL AND ATIVAN WITH EFFECT, STARTED ON FENTANYL GTT. AT 12:30PM, NEUROSURG UP FOR EXAM, PT OPENED EYES TO NAME, FOLLOWING COMMANDS CONSISTENTLY, MAE'S. PT REMAINS ON FENTANYL GTT BUT EASILY AROUSABLE. OCCASIONALLY WILL WAKE QUICKLY AND ATTEMPTS TO SIT UP IN BED BUT ABLE TO CALM AND REASSURE PT VERBALLY. PUPILS EQUAL AND REACTIVE. REPEAT HEAD CT THIS EVENING UNCHANGED PER REPORT.\n\nCV: HR 70S-80S, FREQUENT PVC'S EARLY IN SHIFT, LYTES REPLETED WITH IMPROVEMENT IN ECTOPY. HYPOTENSIVE EARLY IN THE SHIFT, STARTED ON DOPAMINE GTT, LEVO ADDED. CURRENTLY MAINTAINING SBP > 100 ON 2.5 OF DOPA AND 0.1 OF LEVO, PLAN TO WEAN DOPA TO OFF, LEVO TO KEEP SBP >100. S/P IVC FILTER PLACEMENT FOR PE'S AT 6PM, RIGHT GROIN SITE WITHOUT BLEEDING OR HEMATOMA, EASILY PALPABLE DISTAL PULSES. SEE CAREVUE FOR DETAILS OF HEMODYNAMICS.\n\nRESP: SATS 91-92% ON 100% FIO2 THIS AM, PA02 65-70, BILAT CHEST TUBES PLACED WITHOUT IMPROVEMENT IN SATS, PEEP INCREASED TO 15, PA02 SLOWLY IMPROVED TO 127 THIS AFTERNOON, FI02 WEANED TO 80%. PT TO REPEAT HEAD CT AND CT ANGIO AT 4PM, NOTED TO HAVE MULTIPLE PE'S BILAT, IVC FILTER PLACED. BREATH SOUNDS COARSE BILAT, SUCTIONED FOR SMALL TO MOD AMTS OF THICK BLOOD TINGED SECRETIONS. MINIMAL DRAINAGE FROM CHEST TUBES. CURRENT VENT SETTINGS IMV 750 X 18, 15 PEEP, 80% FIO2, SATS 98-99%.\n\nGI: ABD SOFT, HYPOACTIVE BOWEL SOUNDS. OGT TO LWS--MOD AMT OF BROWN DRAINAGE. REMAINS NPO, ON CARAFATE\n\nHEME: HCT STABLE, COAGS WNL.\n\nID: T. MAX 100.3, PAN CX'ED THIS AM, STARTED ON FLAGYL AND LEVAQUIN, HAS NOT RECEIVED LEVAQUIN DOSE D/T AWAITING ID APPROVAL.\n\nSKIN: ABRASIONS TO RIGHT TEMPLE AREA, RIGHT ELBOW AND FOREARM AND RIGHT KNEE, LEFT OTA. SKIN OTHERWISE INTACT\n\nENDO: BLOOD SUGARS 164-166 TODAY, COVERED WITH REGULAR INSULIN PER SLIDING SCALE\n\nSOCIAL: WIFE AND IN TO VISIT, UPDATED ON PT'S CONDITION, ALL QUESTIONS ANSWERED\n\nA: NEUROLOGICALLY IMPROVED, RESPIRATORY STATUS IMPROVING, S/P IVC FILTER PLACEMENT FOR BILAT PE'S\n\nP: WEAN DOPA/LEVO AS TOLERATED, FOLLOW NEUO STATUS, WEAN PEEP AS TOLERATED, FOLLOW UP ON RESULTS OF CULTURES, PROVIDE SUPPORT TO PT AND FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2156-02-08 00:00:00.000", "description": "Report", "row_id": 1404406, "text": "Nursing note:\nNEURO: Initially confused and agitated this am, oriented x1-2 only. Pulling at lines and yelling out frequently. Pt. calmer upon his wife's arrival this am - still confused at times but more appropriate. PERRLA. MAE on bed, lifts/holds all 4. Following commands. collar intact. No c/o's pain.\n\nRESP: Lung sounds diminished, encouraged to cough and deep breathe w/some effect. No SOB, RR 16-22. Strong non-productive cough. Sats 92-95% today w/occ. transient drops to 88-90% - sats improve w/coughing. Remains on shovel mask and NC. CPT done. Bilat. CT sites intact w/DSDs in place.\n\nCV: NSR, no ectopy. Rate in 60s-70s. Hypertensive at times, aline positional also. Given Lopressor ATC and extra dose of 5mg Lopressor w/effect for SBP to 190s. NBP 30 points lower at this time. No cardiac c/o's. PA catheter d/c'd.\n\nGI: +BS, abdomen soft, non-tender. +flatus, no stool. Begun on sips this am but pt. frequently coughing forcefully after drinking, so back to just ice chips for aspiration risk. Dr. aware. Pt. c/o thirst and hunger.\n\nGU: Foley patent adequate amount clear urine, +diuresis after 20mg IV Lasix this am.\n\nACT: Turn/reposition w/assist.\n\nA/P: Stable, hypertensive at times. Cotn. w/aggressive pulm. hygeine, monitor mental status, collar to remain in place, cont. w/current ICU care and treatments. ? transfer to floor in am.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-02-09 00:00:00.000", "description": "Report", "row_id": 1404407, "text": "NEURO; ALERT TO PERSON AND PLACE MOST OF SHIFT, FREQUENTLY CONFUSED AT OTHER TIMES AND CALLING OUT, AGITATED AND PULLED OUT FOLEY CATHETER, MAE, PT FREQUENTLY PULLING CLOTHING OFF\n\nCARDIOVASCULAR; HR 60'S SR, NO ECTOPY, BP 150'S-170'S-OCCAS UP TO 180'S WITH AGITATION, RECEIVING METOPOLOL AS ORDERED\n\nRESPIR LUNGS CLEAR, CHEST TUBE DSGS CHANGED BILAT, SMALL OPEN AREA RT LATERAL CHEST, STERI-STRIPS APPLIED, AND DSD, SOFT, MOVEABLE MASS IN RT AXILLA, REPORTED TO DR. AND DR. , 02 SATS 96 ON FACE TENT AND NASAL PRONGS BUT DESATS WHEN HE TAKES MASK OFF DOWN TO 88, A LINE DC'D-DAMPENED WAVEFORM ON PRIOR SHIFT AND ON THIS SHIFT, OCCLUDED AND NOT ABLE TO DRAW BACK OR OBTAIN TRACING,\n\nRENAL; PT PULLED OUT FOLEY CATH, RE-INSERTED, HEMATURIA, N CLOTS, CATHETER IRRIGATED X 1 FOR DECREASED U/O-NO PROBLEMS WITH IRRIGATION, U/O INCREASED, PT PLACED ON MAINTEN IV AT 50CC/HR SECONDARY TO NOT BEING ABLE TO TAKE LIQUIDS SUCCESSFULLY ON PREVIOUS SHIFT,\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-02-07 00:00:00.000", "description": "Report", "row_id": 1404402, "text": "S/P SDH/SAH ACUTE RESP FAILURE +PE-T/SICU NPN 7P-7A\nS-PT INTUBATED\n AWAKES STARTLED ORIENTS QUICKLY,CALMS,MAE'S,FOLLOWS COMMANDS,PERRLA 2-4MM.STRONG COUGH.SHOWS 2 FINGERS,NODS APPROPRIATLY.SEDATED ON FENT GTT 400MCG/HR.PRN MIDAZ IVP.\nCV-HR 70'S-80'S NSR,RARE VEA,LYTES REPLEATED PRN,SBP 90'S-120'S ON LEVO GTT @ .1-.16 MCG/KG/MIN TO KEEP SBP ~100,SVO2'S 60'S-70'S,CCO 7'S-8'S W/ CCI'S 3.5-4.5,EDVI 120'S-140'S.3+DP/PT .500CC NS BOLUS X 1 OVER NOC.\nRESP-MULT VENT CHANGES OVER NOC,SEE RESP FLOWSHEET FOR DETAILS OF CHANGES AND ABG DATA.PT X 1 OVER NOC FOR SM AMT THICK YELLOW SPUTUM.O2 SATS 96-100% OVER NOC.\nGI/GU-PT ABD SOFT HYPOACTIVE BS,U/O 35-80CC/HR VIA FOLEY.URINE CLEAR YELLOW,PT REMAINS NPO,OGT DRAINING SM AMTS BROWN.\nSKIN-NO NEW ISSUES.\nID-T MAX 100.2.\nENDO-BS 150-170'S COVERED W/ SS REG INSULIN/ORDERS\n WIFE X 1 OVER NOC.\nA-HEMODYNAMICALLY UNSTABLE ON LEVO GTT,IMPROVING RESP STATUS.\nP-CONT NEURO CHECKS,SEDATION/ORDERS,MONITOR EFFECT,VS AND HEMODYNAMICS,TITRATE LEVO/ORDERS,VENT/ORDERS,MONITOR LAB DATA PRN,I+O,MONITOR SKIN INTEGRITY QS AND PRN.FAMILY SUPPORT PRN.MONITOR CX DATA QD AND PRN.\n" }, { "category": "Nursing/other", "chartdate": "2156-02-07 00:00:00.000", "description": "Report", "row_id": 1404403, "text": "Resp Care: Pt continues intubated and on ventilatory support weaned to simv 750x14/+5 peep/fio2 .5 with improving abg; bs diminished throughout, minimal yell secretions, see carevue for details.\n" } ]

[ { "category": "Echo", "chartdate": "2133-02-02 00:00:00.000", "description": "Report", "row_id": 77976, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment. Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 90/64\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 10:41\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand/or RV.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Moderate regional\nLV systolic dysfunction. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; basal inferolateral - hypo; mid\ninferolateral - hypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. 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.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate regional left ventricular systolic\ndysfunction with focal severe hypokinesis of the inferior and inferolateral\nwalls. The remaining segments contract well. No masses or thrombi are seen in\nthe left ventricle. Right ventricular chamber size is normal with moderate\nglobal free wall hypokinesis. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. Mild (1+) aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. Mild\naortic 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": "Radiology", "chartdate": "2133-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 853996, "text": " 8:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for CHF, and for IABP placement\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with inferior STEMI, s/p stent and IABP\n REASON FOR THIS EXAMINATION:\n Please evaluate for CHF, and for IABP placement\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest dated .\n\n CLINICAL INDICATION: Intraaortic balloon pump placement.\n\n There are no prior radiographs for comparison.\n\n An intraaortic balloon pump is identified with the tip projecting cephalad to\n the top of the aortic arch, concerning for location within the left subclavian\n or common carotid artery. A Swan-Ganz catheter terminates within the right\n pulmonary artery, but it makes an unusual abrupt turn within the right atrium.\n Cardiac and mediastinal contours are within normal limits for technique. The\n lungs are grossly clear and there is no evidence of pneumothorax or pleural\n effusion.\n\n IMPRESSION:\n\n 1) Intraaortic balloon pump tip is above the level of the aortic knob, as\n communicated to clinical service caring for the patient.\n\n 2) Satisfactory tip location of Swan-Ganz catheter but unusual abrupt turn of\n catheter within the right atrium.\n\n" }, { "category": "Radiology", "chartdate": "2133-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 854051, "text": " 9:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess IABP position.\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with inferior STEMI, s/p stent and IABP. Assess IABP position.\n\n REASON FOR THIS EXAMINATION:\n Assess IABP position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Inferior STEMI, status post stent and IABP. Assess IABP\n position.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The intra-aortic balloon device tip is located at the upper\n contour of the aortic arch. Retraction of the device by approximately 3 cm is\n recommended to assure safe positioning. A Swan-Ganz catheter terminates in\n the right pulmonary artery. Cardiac and mediastinal contours are within\n normal limits for the technique. The lungs are grossly clear and there is no\n evidence of pneumothorax or pleural effusion.\n\n IMPRESSION:\n The intra-aortic balloon device tip is located at the upper contour of the\n aortic arch, and retraction of the device by approximately 3 cm is recommended\n to assure safe positioning.\n\n" }, { "category": "Radiology", "chartdate": "2133-02-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 854173, "text": " 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess IABP position and interval change.\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with inferior STEMI, s/p stent and IABP.\n\n REASON FOR THIS EXAMINATION:\n Assess IABP position and interval change.\n ______________________________________________________________________________\n FINAL REPORT\n Single view chest.\n\n INDICATION: MI.\n\n COMPARISON: .\n\n FINDINGS: There has been interval removal of the intra-aortic balloon pump\n and Swan-Ganz catheter. The heart size and mediastinal contours are normal.\n Lung volumes are slightly low, but there is no focal infiltrate, pleural\n effusion, or pneumothorax.\n\n IMPRESSION: Support tubes and lines removed. Unremarkable appearance of the\n chest.\n\n" }, { "category": "ECG", "chartdate": "2133-02-03 00:00:00.000", "description": "Report", "row_id": 190114, "text": "Sinus rhythm\nLeft axis deviation\nInferior infarct - age undetermined\nLeft ventricular hypertrophy\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2133-02-02 00:00:00.000", "description": "Report", "row_id": 190115, "text": "Sinus rhythm. Prior inferior myocardial infarction. Left ventricular\nhypertrophy. Compared to the previous tracing of the sinus rhythm has\nappeared and the rate has slowed. Followup and clinical correlation are\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-02-01 00:00:00.000", "description": "Report", "row_id": 190116, "text": "Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy. Prior inferior myocardial infarction. No previous tracing\navailable for comparison. Followup and clinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2133-02-01 00:00:00.000", "description": "Report", "row_id": 1496479, "text": "CCU NPN: please see flowsheet for objective data\n45 yo man,raking snow off his roof today.developed jaw pain,diaphoretic. went in to shower,then drove to the hospital with SSCP. -ST elevations inferiorly,hypotensive started aggrestat and dopa,med flight to cath lab, 2 stents to RCA,60%LAD and circ. rapid afib,10mg lopressor,then to CCU.\n\nCardiac: arrived in afib rate 114-130's IABP 1:1,PA line,PA diastolics 16-20. cardioverted with 200 converted to NSR rate 70-90's . on aggrestat,started on heparin 1800u/hr. pulses palpable. sites D&I.\n\nResp: on 2l NP,lungs clear abit distant\n\nGU: foley in place\n\nGI: abd soft non distended,+BS\n\nNeuro: alert and oriented\n\nHeme: labs sent on heparin\n\nSocial: lives with wife and three children.very active,has participated in Pan Mass bicycle race.\n\nA/P: s/p IMI c/b rapid afib requring cardioversion.\n follow labs\n monitor hemodynamics\n emotional support\n" }, { "category": "Nursing/other", "chartdate": "2133-02-02 00:00:00.000", "description": "Report", "row_id": 1496480, "text": "NSG NOTE\n\nCV: NO EPISODES A-FIB. REMAINS IN NSR WITH HR 75-92. HEPARIN @ 1800U/HR AND AGGRESTAT @ 0.15MCG/KG/MIN. CP,JAW PAIN. UNASSISITED SBP 87-100 WITH MAP'S 66-81. PAD'S INITIALY LOW 14-15. POST CATH FLUIDS RATES CHG TO 150CC/HR. PAD'S NOW 18-21. CI 2.52,SVR 758. CK 1342,1780 WITH MB 218. IABP VIA R FEM. 1:1 PLEASE SEE FLOW FOR GRAPHICS. CVP 14-17.\n\nRESP: O2 SATS TO RA 96-100%. PT C/O DRYNESS FROM NC O2. REMAINS ON RA WITH ADEQUATE SATS. DENIES SOB. BS CL/DIMINISHED AT BASES. APPEARS COMFORTABLE. RR-16-22. NO COUGH NOTED\n\nGI: REMAINS NPO, OCCASSIONAL ICE CHIPS. TOL PO MEDS WITH SIPS. + BS NO STOOL THIS SHIFT. DENIES NAUSEA. PPI\n\nGU; BUN 14 CREAT 0.8 U/O ADEQUATE > 90CC/HR DRAINING F/C YELLOW URINE WITHOUT SEDIMENT.\n\nSKIN: R GROIN SWAN/IABP C/D PULSES NOW PALP AND STRONG. R FT INITIALY, BUT WTT NOW.\n\nID: WBC 11.7 AFEBRILE.\n\nNEURO: A/O X3 FOLLOWS COMMANDS. VERY PLEASANT, BUT ANXIOUS GENTLEMAN, WHO IS CONCERNED FOR FAMILY AND JOB. HE STATES,\"I CAN'T BELIEVE THIS HAS HAPPENED TO ME. VOICEING CONCERN OVER JOB. ASKING FOR CELL PHONE TO MAKE CONTACT CALLS. SUPPORT GIVEN TO FAMILY AND PT. HIS WIFE,BROTHERS AND ALL IN TO VISIT. POC REVIEWED WITH FAMILY AND PT. TEACHING INITIATED WITH REGARDS TO NEW DIAGNOSIS AND PRE-OP CABG. PT CAN MAE. OLANZIPINE GIVEN ALONG WITH PERCOCET FOR BACK PAIN WITH EXCELLENT EFFECT. PT MORE CALM AND COMPLIENT WITH BR.\n\nLABS: K+ REPLACED OVER X2\n MG 1.6 GIVEN 2 GM MAG SULFATE\n CA GLUCONATE GIVEN 2 AMPS.\n HCT 39\n PLTS 218,199\n PTT 62.2\n\nIV: POST CATH FLUIDS INFUSING 1/2 NS @ 150CC/HR X 2500CC.\n\nA/P: 45 YR OLD MALE R/I INF. STEMI. HX LYMPHOMA S/P CHOP AND XRT. NO PRIOR CARDIAC HX. PRESENTS TO OSH WITH ACUTE ON SET JAW PAIN,SSCP. TRANSFERED TO CATH FOR 60% LM,95% LCX,RAMUS 80% PROX,RCA TOTAL PROX STENTS X2. POST PROCEDURE TRANSFERED TO CCU IN RAPID A-FIB. LOPRESSOR AND CARDIOVERTED WITH 200J X1 WITH RETURN TO NSR. NOW PT AWAITS BY CT . CON'T TO CYCLE CK'S FOLLOW PLT,LYTES. SUPPORT TO FAMILY AND PT. HEALTH CARE PROXY COMPLETED IN PT CHART. CON'T PER NSG JUDGEMENT.\n F/U EKG\n POSSIBLE ECHO ? TTE TODAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-02-02 00:00:00.000", "description": "Report", "row_id": 1496481, "text": "CCU Progress Note:\n\nS- \" I hate lying flat on my back. I have such a backache!\"\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SR occ PAC- HR 73-83 R fem IABP @ 1:3 MAPs 70-80's- augmenting well with good systolic unloading & fair diastolic unloading- ABP 84-93/58-65 R groin PA line PAS 25-34 PAD 13-21 CVP 11-17- heparin gtt @ 1400u/hr (PTT 107.5 on 1600u/hr & decreased to 1400u @ 1600)- echo done this am- last K 3.7 KCL 40meq IV given- last Mg 2.1- Hct 36.5- R groin dsg with small amt bloody oozing- feet = warm to touch- (+) palpable pulses bilaterally- bruise noted on L flank- aggrastat D/C'd this AM- enzymes trending down.\n\nresp- lung sounds diminished @ bases, otherwise clear- resp even, non-labored- SpO2 94-99% on room air.\n\nneuro- very anxious- awake, alert & oriented X3- moving all extremities- cooperative- follows command.\n\ngi- abd soft (+) bowel sounds- no BM today- NPO except for ice chips while weaning off If Pt develops CP tonight, plan is to recath\n\ngu- autodiuresing- IV fluids con't @ 100cc/hr- foley draining lg amts clear yellow colored urine- u/a sent to lab- BUN 12 Crea .7\n\nA- (+) IMI S/P cardiac cath stents X2 to RCA c/b rapid A fib post procedure requiring cardiovertion\n\nP- seen by CT - needs CABG, however will wait a few weeks because of RV infarct- tolerating IABP 1:3 ? D/C tonight- ? resuming diet- monitor vs, lung sounds, I&O and labs- offer emotional support to Pt & family- keep them updated on plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2133-02-03 00:00:00.000", "description": "Report", "row_id": 1496482, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 70-90's NSR BP 103-126/65-72 CK's peaked 11pm at 1780/218 yest 565/153 todays are pending. IABP d/ced 11pm.groin site D&I,pulses palpable,feet warm. echo yest showed regional left vent wall dysfunction c/w CAD,mild aortic regurgitation.heparin d/ced for line pull and then d/ced altogether.\n\nResp: lungs clear,on RA with sats in 90's\n\nGU: IV fluid finished last night,good urine output 60-300/hr -570. am labs are pending\n\nGI: ate sandwhich last evening. no nausea. abd non tender +BS\n\nID: afebrile\n\nNeuro: alert and oriented x3,given olanzapine and percocett last evening,then received fentanyl for balloon pull. asked for a sleeper around 12am,ambien 10mg. slept most of night\n\nA/P: s/p IMI RV involvement,2 stents to RCA. has 60% LMCA,95% prox LC,80% ramus int. plan is to return in 3 weeks for \n cont to follow I&0's\n replete lytes as needed\n PT consult\n" }, { "category": "Nursing/other", "chartdate": "2133-02-03 00:00:00.000", "description": "Report", "row_id": 1496483, "text": "See nursing transfer note- awaiting bed on telemetry floor- tele: SR no ectopy- HR 83-97 activity increased HR up 120's with exertion- started on lopressor- tolerating well- taking PO well- no BM today- foley D/C'd- voiding qs- Hct 37.3- K 4.1- Mg 2.0- saline lock X2 patent.\n" }, { "category": "Nursing/other", "chartdate": "2133-02-04 00:00:00.000", "description": "Report", "row_id": 1496484, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 70-80's NSR no VEA,BP 100-120/50-66 on lopressor 12.5mg ,plavix,ASA.\n\nResp: RA,sats 90's,rr 16-20.lungs clear\n\nID: afebrile\n\nNeuro: alert and oriented x3,sleeping all night.\n\nA/P: called out to floor,transfer note written\n" } ]

[ { "category": "Radiology", "chartdate": "2181-12-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1221116, "text": " 8:19 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with sob and recent pneumonia.\n REASON FOR THIS EXAMINATION:\n r/o infectious process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath. Assess for pneumonia.\n\n COMPARISONS: Chest radiograph of .\n\n FINDINGS: PA and lateral views of the chest demonstrate slight improvemen in\n aeration at the right lung base. Small right pleural effusion persists.\n There is persistent thickening along the minor fissure. Retrocardiac\n consolidation is noted with associated moderate left pleural effusion. Hilar\n and mediastinal silhouettes are unremarkable. Perihilar vascular congestion\n is noted. Heart size top normal. Compression deformity of lower thoracic\n vertebral body is seen with near complete loss of the vertebral body height.\n\n IMPRESSION: Left lung base consolidation with associated pleural effusion.\n Small right pleural effusion is present with improved aeration of the right\n lung.\n\n" }, { "category": "Radiology", "chartdate": "2181-12-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1221300, "text": " 11:32 AM\n CHEST (PA & LAT) Clip # \n Reason: Any acute cardiopulmonary process?\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with history of critical aortic stenosis, mod/severe MR,\n recent PNA (discharged ) s/p levofloxacin therapy, with intermittent\n right sided chest discomfort. No dyspnea.\n REASON FOR THIS EXAMINATION:\n Any acute cardiopulmonary process?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of critical aortic stenosis, recent pneumonia,\n right-sided chest discomfort.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is moderate\n improvement, with larger lung volumes and improved ventilation of the basal\n lung areas.\n\n On the right, a plate-like atelectasis along the minor fissure persists, but\n the pre-existing medial basal opacity has substantially decreased in extent\n and severity.\n\n On the left, the pre-existing retrocardiac atelectasis is also improved.\n\n The bilateral pleural effusions, better visualized on the lateral than on the\n frontal radiograph, are not substantially changed.\n\n The size of the cardiac silhouette is constant.\n\n No newly appeared parenchymal opacities.\n\n\n" }, { "category": "Echo", "chartdate": "2182-01-03 00:00:00.000", "description": "Report", "row_id": 79645, "text": "PATIENT/TEST INFORMATION:\nIndication: Focused study s/p aortic valvuloplasty to evaluate residual gradient and aortic insufficiency.\nHeight: (in) 66\nWeight (lb): 110\nBSA (m2): 1.55 m2\nBP (mm Hg): 137/68\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 11:34\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nAORTIC VALVE: Mild (1+) AR.\n\nMITRAL VALVE: Eccentric MR jet. Moderate to severe (3+) MR.\n\nConclusions:\nMild (1+) aortic regurgitation is seen. An eccentric, posteriorly directed jet\nof moderate to severe (3+) mitral regurgitation is seen.\n\nIMPRESSION: Limited study/Focused views. Mild aortic regurgitation. Mean\ntransaortic valvular gradient 30 mmHg. Moderate to severe posteriorly directed\nmitral regurgitation.\n\nCompared with the prior study (images reviewed) of , the mean\ntransaortic valvular gradient has decreased from 59 mmHg to 30 mmHg\nstatus-post aortic valvuloplasty. Given the limited nature of the current\nstudy a comprehensive comparison of all parameters could not be made.\n\n\n" }, { "category": "Echo", "chartdate": "2181-12-25 00:00:00.000", "description": "Report", "row_id": 79646, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 66\nWeight (lb): 110\nBSA (m2): 1.55 m2\nBP (mm Hg): 143/76\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 08:57\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: Normal RA size.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Overall normal LVEF (>55%). TDI E/e' >15, suggesting\nPCWP>18mmHg.\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: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Tissue Doppler imaging suggests an increased\nleft ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are severely\nthickened/deformed. There is critical aortic valve stenosis (valve area\n<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare moderately thickened. Moderate to severe (3+) mitral regurgitation is\nseen. There is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Critical calcific aortic stenosis. Symmetric LVH with normal\nglobal and regional biventricular systolic function. Moderate to severe mitral\nregurgitation. Moderate pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , aortic stenosis\nhas significantly progressed. Mitral regurgitation is more prominent and\nestimated pulmonary pressures are higher. Findings discussed with Dr. \nat 0945 hours on the day of the study.\n\n\n" }, { "category": "ECG", "chartdate": "2182-01-03 00:00:00.000", "description": "Report", "row_id": 209556, "text": "Normal sinus rhythm. Right bundle-branch block. Single ventricular premature\nbeat is noted. Left anterior fascicular block. Compared to tracing #2\nventricular premature beat is now noted. Peaked T waves are no longer seen.\nThe loss of R waves in leads V1-V3 previously seen is noted here as well.\nSuggest clinical correlation.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2182-01-03 00:00:00.000", "description": "Report", "row_id": 209802, "text": "Normal sinus rhythm. Marked P-R interval prolongation. Right bundle-branch\nblock. Left anterior fascicular block. Poor R wave progression in\nleads V1-V3. Peaked T waves in leads V4-V6. Compared to tracing #1 there is a\nloss of R waves in leads V1-V3. Criteria for left anterior fascicular block\nare now seen and the P-R interval has markedly prolonged. In addition, the\nT waves appear to be more peaked in leads V4-V5 raising the possibility of\nhyperkalemia versus lead placmenent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2182-01-03 00:00:00.000", "description": "Report", "row_id": 209803, "text": "Normal sinus rhythm. Left atrial enlargement. Right bundle-branch block.\nCompared to the previous tracing of criteria for left atrial\nenlargement are now seen. Otherwise, no significant diagnostic changes.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2181-12-31 00:00:00.000", "description": "Report", "row_id": 209804, "text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nthere is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2181-12-28 00:00:00.000", "description": "Report", "row_id": 209805, "text": "Sinus rhythm. Left atrial abnormality. Complete right bundle-branch block.\nLeft ventricular hypertrophy. Non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of multiple abnormalities as noted\npersist without major change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2181-12-23 00:00:00.000", "description": "Report", "row_id": 209806, "text": "Sinus rhythm. Right bundle-branch block. Compared to tracing #2 the findings\nare similar.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2181-12-23 00:00:00.000", "description": "Report", "row_id": 209807, "text": "Sinus rhythm. Right bundle-branch block. Left atrial abnormality. Compared to\ntracing #1 the rate is slower and ST segment changes have improved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2181-12-23 00:00:00.000", "description": "Report", "row_id": 209808, "text": "Sinus rhythm bordering on sinus tachycardia. Left atrial abnormality. Right\nbundle-branch block. Q waves in leads I, aVL and V4-V6. Cannot exclude prior\nanterolateral wall myocardial infarction of indeterminate age. ST segment\ndepression in the anteroseptal and anterolateral leads which may be related to\nmyocardial ischemia. Compared to the previous tracing of the heart rate\nis faster. ST segment depression is new.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2144-03-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177795, "text": " 3:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with a history of alcoholic cirrhosis s/p two transplants in\n , then in who presented with acute altered mental status on .\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:11 A.M. ON .\n\n HISTORY: 48-year-old woman with alcoholic cirrhosis. Acute mental status\n changes.\n\n IMPRESSION: AP chest compared to through 19:\n\n Worsening of diffuse opacification in the mid and lower portions of the left\n lung at the right lung base suggests development of edema in locations of\n previous pneumonia. ET tube is in standard placement. Nasogastric tube ends\n in the stomach. Right supraclavicular central venous line tip projects over\n the mid SVC and a left PICC line in the right atrium at or just beyond the\n estimated location of the superior cavoatrial junction. Heart is normal size.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177516, "text": " 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year-old female with alcoholic cirrhosis s/p OLT x2, failed, now with\n pneumonia and fluid overload - intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and fluid overload.\n\n FINDINGS: In comparison with the study of , there is little change in the\n diffuse parenchymal opacifications involving most of the left lung.\n Monitoring and support devices remain in place except for removal of the right\n IJ catheter. The patient has taken a substantially better inspiration. Right\n lung remains essentially clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-05 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1180004, "text": " 3:29 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? Fungal PNA versus Lung Abscess\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with OTL now with ? Lung abscess in LUL.\n REASON FOR THIS EXAMINATION:\n ? Fungal PNA versus Lung Abscess\n CONTRAINDICATIONS for IV CONTRAST:\n ATN, HD dependent trying to preserve remaining kidney function\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old female with orthotopic liver transplantation with\n left upper lobe pneumonia. Question abscess.\n\n TECHNIQUE: Multiple axial images were obtained of the chest from thoracic\n inlet through the upper abdomen without contrast. Coronal and sagittal images\n are reformatted and reviewed. Elevated creatinine precluded administration of\n contrast.\n\n Comparison is made with chest CT, .\n\n FINDINGS: There is coalescent consolidation in the anterior segment of left\n upper lobe with no evidence of cavitation to suggest abscess. Additionally,\n there are multifocal areas of ground-glass and more nodular parenchymal\n opacity seen in the right middle, right lower and left lower lobes. There are\n diffuse emphysematous changes. There are bilateral pleural effusions, larger\n on the left.\n\n There is no mediastinal lymphadenopathy. No large hilar mass on this\n non-contrast examination.\n\n Since the prior chest CT, there has been interval development of diffuse\n calcification involving the anterior wall of the left ventricle, portions of\n the interventricular septum and papillary muscles. The apex and inferior and\n free walls appear uninvolved. The distribution of this finding is consistent\n with LAD territory infarction. The rapid development of calcification is\n somewhat atypical given the relatively normal appearance of the myocardium on\n the comparison examination from . There is no pericardial effusion.\n\n Imaged portions of upper abdomen are stable with a small amount of pneumobilia\n (2:54) as has been seen in the past.\n\n IMPRESSION:\n\n 1. Multifocal areas of consolidation bilaterally with more confluent\n consolidation in the anterior segment of left upper lobe. No evidence of\n cavitation to suggest abscess formation. The findings are most consistent\n with multifocal pneumonia with associated bilateral pleural effusions.\n\n 2. There has been interval development of diffuse calcification involving the\n anterior wall of left ventricle, portions of the interventricular septum and\n (Over)\n\n 3:29 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? Fungal PNA versus Lung Abscess\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n papillary muscles. The distribution is consistent with LAD infarction with the\n rapid development of calcification being somewhat atypical.\n\n Findings were discussed with Dr. on at approximately 5:00 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-30 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1179038, "text": " 8:43 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Please assess for source of infection. If ascities please ma\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with EtoH cirrhosis s/p OTL in , CKD on HD, asthma, CAD\n s/p MI with fever.\n REASON FOR THIS EXAMINATION:\n Please assess for source of infection. If ascities please mark for para.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old woman with alcoholic cirrhosis status post liver\n transplant in , please assess for source of infection if ascites present,\n please mark for paracentesis.\n\n FINDINGS:\n\n No free fluid seen. The liver shows no focal or textural abnormalities.\n There is a tortuous course of the hepatic artery along the medial margin of\n the right hepatic lobe in keeping with the previously demonstrated post\n transplant anatomy, this is also seen on the prior CT of . A\n vascular stent is also seen in this region. The common duct is not dilated.\n Both right and left kidneys are normal without hydronephrosis or stones. The\n pancreas and spleen are unremarkable. There is a small peripancreatic node\n measuring 1.2 cm, which has also been present since . The portal\n vein is patent with normal hepatopetal flow. A full Doppler study was not\n performed as this was done on .\n\n IMPRESSION:\n 1. No ascites. No spot was marked for paracentesis.\n 2. Unchanged appearance of the transplanted liver.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177692, "text": " 3:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year-old female with alcoholic cirrhosis s/p OLT x2, failed, now with\n pneumonia and fluid overload - intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:15 A.M., \n\n HISTORY: Alcoholic cirrhosis. Two liver transplants failed. Pneumonia and\n fluid overload.\n\n IMPRESSION: AP chest compared to through 18:\n\n Interstitial abnormality always has been a problem in the left lung, and has\n not cleared. Given the relatively extensive involvement of the left lung, I\n think is probably residual asymmetric edema rather than pneumonia, although\n has not changed appreciably since . Previous right lower lobe\n atelectasis is improved. At least a small left pleural effusion is present.\n\n Tip of the ET tube is nearly at the carina and needs to be withdrawn 4 cm.\n Right jugular dual-channel dialysis catheter ends in the mid SVC and a left\n PICC line in the upper right atrium approximately 2 cm below the estimated\n location of the cavoatrial junction. Nasogastric tube ends in the stomach.\n Heart size normal. No pneumothorax. Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-26 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 1178418, "text": " 10:46 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: Please do bilateal upper extremity vein mapping for ? fistul\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with anuric renal failure requiring HD\n REASON FOR THIS EXAMINATION:\n Please do bilateal upper extremity vein mapping for ? fistula placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman with history of renal failure. Study requested\n prior to AV fistula placement.\n\n TECHNIQUE AND FINDINGS: Venous mapping of the upper extremities was performed\n with B-mode, color and spectral Doppler ultrasound.\n\n The subclavian veins present patent with normal flow.\n\n On the right side, the right cephalic vein is thrombosed from the distal\n portion of the upper arm to the level of the antecubital fossa. The proximal\n portion of this vessel is patent and compressible with diameters ranging\n between 0.12 and 0.21 cm.\n\n The right basilic vein is patent and compressible with diameters ranging\n between 0.1 and 0.53 cm.\n\n On the left side, the left cephalic vein is thrombosed and noncompressible\n from the distal segment of the upper arm to the level of the antecubital\n fossa. The proximal segment of the vessel was patent and compressible with\n diameters ranging between 0.29 and 0.35 cm.\n\n The left basilic vein is patent and compressible with diameters ranging\n between 0.15 and 0.34 cm.\n\n The brachial arteries present patent and single bilaterally, presenting with\n triphasic Doppler waveforms.\n\n COMPARISON: None available.\n\n IMPRESSION: Noncompressible cephalic veins from the level of the distal\n portion of the upper arm to the antecubital fossa bilaterally.\n\n Patent basilic veins bilaterally with diameters as described above.\n\n Single brachial arteries bilaterally, with triphasic Doppler waveforms.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-03 00:00:00.000", "description": "L US EXTREMITY NONVASCULAR LEFT", "row_id": 1179722, "text": " 11:29 AM\n US EXTREMITY NONVASCULAR LEFT Clip # \n Reason: Please evaluate L thigh for small abscess on anterior thigh.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with ARF/ATN and liver transplant on immuno suppresion\n REASON FOR THIS EXAMINATION:\n Please evaluate L thigh for small abscess on anterior thigh.\n ______________________________________________________________________________\n WET READ: KKgc FRI 5:23 PM\n No focal fluid collections are seen in the left thigh. There is diffuse\n swelling and induration of the subcutaneous tissues in the region.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old woman with acute renal failure and liver\n transplant, on immunosuppressive therapy; now has left anterior thigh\n swelling.\n\n COMPARISON: None available.\n\n FINDINGS: Limited grayscale and Doppler son of the area of concern in\n the left anterior thigh was performed. No focal fluid collections are seen.\n There is diffuse swelling and induration of the subcutaneous tissues in the\n left anterior mid thigh.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-08 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1180424, "text": " 10:45 AM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Pleace place tunneled HD catheter in L.\n Admitting Diagnosis: HYPERKALEMIA\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with EtOH cirrhosis s/p OTL in now with ATN on HD and on\n heparin.\n REASON FOR THIS EXAMINATION:\n Pleace place tunneled HD catheter in L.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48 year old woman with EtOH cirrhosis s/p OTL in , now with\n ATN.\n\n ANALGESIA: Moderate sedation was provided by administering divided doses of\n 100 mcg fentanyl and 2 mg Versed throughout the total intraservice time of 45\n minutes, during which the patient's hemodynamic parameters were continuously\n monitored. In addition, local anesthesia was administered with 1% lidocaine to\n the skin overlying the right internal jugular vein, and lidocaine with\n epinephrine to the right anterior chest wall.\n\n RADIOLOGISTS: Drs. , and Dr. , dircetly supervised by\n Dr. .\n\n PROCEDURE: Left IJ tunneled HD catheter:\n\n Although the requisition for the procedure suggested to use the left IJ, Dr.\n (radiology) and Dr. (ordering physician) agreed on going via the\n right IJ.\n\n Written informed consent was obtained outlining the benefits, risks, and\n alternatives of the procedure. Subsequently, the patient was brought to the\n angiography suite and placed supine on the imaging table. The right side of\n the neck and upper chest were prepped and draped in the usual sterile fashion.\n A preprocedure huddle and timeout were performed per protocol.\n Following administration of local anesthetic and under ultrasound guidance\n with hard copy images on file, the right internal jugular vein was accessed\n with a micropuncture needle. A 0.018 nitinol wire was advanced through the\n needle into the SVC under continuous fluoroscopic guidance. The needle was\n removed and replaced with a 4.5 French micropuncture sheath. The inner dilator\n and 0.018 wire were removed, and a 0.035 wire was advanced to the level\n of the right atrium. Appropriate measurements for catheter length were made at\n this time. The wire was then further advanced into the IVC for\n stability.\n Attention was then turned to creation of a subcutaneous tunnel. Following\n administration of 1% lidocaine and 1% lidocaine with epinephrine, a 3-mm\n incision was made in the right anterior chest wall. A 15.5 French x 19 cm tip-\n (Over)\n\n 10:45 AM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: Pleace place tunneled HD catheter in L.\n Admitting Diagnosis: HYPERKALEMIA\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to-cuff (24 cm total) dual-lumen hemodialysis catheter was then tunneled\n antegradely to exit at the venotomy site. The venotomy tract was sequentially\n dilated with 12 and 14 French dilators, and a 16 French peel-away sheath was\n advanced over the wire under continuous fluoroscopic guidance. The\n catheter was then passed through the peel-away sheath, with the tip optimally\n positioned in the right atrium.\n\n Final fluoroscopic image confirms satisfactory position. Fluoroscopic images\n also show a left apical consolidation and pleural thickening, better\n characterized on a chest CT from .\n\n Both lumens of the catheter were aspirated and flushed with saline. The\n catheter was capped and secured with 0-silk anchor sutures. Sterile dressing\n was applied. Venotomy incision was closed with 4-0 Vicryl subcuticular\n sutures.\n The patient tolerated the procedure well, with no immediate complications.\n\n\n IMPRESSION: Uncomplicated placement of a 15.5 French x 19 cm tip-to-cuff\n hemodialysis catheter via the right internal jugular vein, with tip in the\n right atrium. The line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-21 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1177765, "text": " 5:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Adjustment of ETT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with a history of alcoholic cirrhosis s/p two transplants in\n , then in who presented with acute altered mental status on .\n REASON FOR THIS EXAMINATION:\n Adjustment of ETT\n ______________________________________________________________________________\n WET READ: EAGg SAT 8:30 PM\n ETT terminates 5.1 cm above carina. Left PICC tip remains in right atrium and\n little change from CXR earlier the same day.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:20 P.M. \n\n HISTORY: Alcoholic cirrhosis. ET tube adjusted.\n\n IMPRESSION: AP chest compared to through 19:\n\n ET tube has been repositioned to standard placement, 5 cm from\n the carina. Asymmetric interstitial infiltration predominantly in the left\n lung continues to improve, could be due to asymmetric edema or more likely\n infection or hemorrhage. Small left pleural effusion is presumed. There is\n no pneumothorax. Nasogastric tube, right supraclavicular central venous line\n are in standard placements. Left PICC line ends in the upper right atrium, at\n least 2 cm below the estimated location of the superior cavoatrial junction,\n as before.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1179989, "text": " 11:11 AM\n CHEST (PA & LAT) Clip # \n Reason: atelectasis versus PNA\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with cough, DOE\n REASON FOR THIS EXAMINATION:\n atelectasis versus PNA\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Cough and dyspnea on exertion. Atelectasis or pneumonia.\n\n IMPRESSION: AP chest compared to through :\n\n A nearly round opacity has developed in a region of previous consolidation at\n the right lung apex, and could be a lung abscess. Pulmonary edema is mild,\n and relatively evenly distributed, somewhat improved since end of ,\n but stable since . Small bilateral pleural effusions, left greater\n than right are stable on the right and slightly decreased on the left. Heart\n size is normal.\n\n Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-06 00:00:00.000", "description": "LUNG SCAN", "row_id": 1180119, "text": "LUNG SCAN Clip # \n Reason: 48 YO F WITH ETOH CIRRHOSIS S/P LIVER TRANSPLANT IN NOW WITH FEVER; S/P PULLED RIJ HD LINE AND IMMEDIATELY AFTER\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 8.5 mCi Tc-m MAA ();\n 39.6 mCi Tc-99m DTPA Aerosol ();\n HISTORY: 48 year old female with multifocal pneumonia and shortness of breath.\n Evaluate for pulmonary embolus.\n\n Ventilation images obtained with Tc-m aerosol in 8 views demonstrate\n obstructive airways disease with central clumping of radiotracer. There are\n large ventilation defects in a non-segmental distribution, especially in the\n lung apices.\n\n Perfusion images in the same 8 views show large areas of perfusion defects in a\n non-segmental distribution, especially in the lung apices.\n\n Chest CT demonstrates multifocal pneumonia and left greater than right pleural\n effusions.\n\n The above findings are consistent with a low probability of PE.\n\n IMPRESSION: Matched perfusion and ventilation defects consistent with a low\n probability of PE, especially in the setting of multifocal pneumonia and pleural\n effusions.\n\n\n\n , M.D.\n , M.D. Approved: WED 2:36 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": "2144-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177908, "text": " 2:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p liver transplant x2 for alcoholic cirrhosis p/w altered\n mental status and respiratory failure.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Liver transplant with altered mental status.\n\n FINDINGS: In comparison with the study of , the endotracheal tube and\n nasogastric tubes have been removed. The central catheters remain in place.\n\n There is continued prominence of interstitial markings consistent with\n vascular congestion. More coalescent opacifications at the left mid lung\n zones and the right base could reflect consolidation in the appropriate\n clinical setting.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-19 00:00:00.000", "description": "NON-TUNNELED", "row_id": 1177388, "text": " 11:34 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Line placement\n Admitting Diagnosis: HYPERKALEMIA\n ********************************* CPT Codes ********************************\n * NON-TUNNELED US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 F w/ ETOH Cirrhosis s/p combined OLT/CRT who presented with altered mental\n status now with renal failure.\n REASON FOR THIS EXAMINATION:\n Line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48 year old female with alcoholic cirrhosis post orthotopic liver\n transplant x 2, worsening acute on chronic renal failure with marked volume\n overload requiring temporary dialysis.\n\n OPERATORS: Drs. and .\n\n ANESTHESIA: Local anesthesia with 1% lidocaine solution. Hemodynamic\n parameters were monitored continuously throughout.\n\n PROCEDURE AND FINDINGS: Written informed consent was obtained from the\n patient's husband and son after explaining the risks, benefits, and\n alternatives of the procedure. Subsequently, the patient was brought to the\n angiography suite and placed supine on the angiographic table. Pre-procedure\n ultrasound demonstrated patent right internal jugular vein. The right neck\n was prepped and draped in usual sterile fashion. A preprocedural timeout and\n huddle were performed per protocol.\n\n Under ultrasound guidance with hard copy images saved, the patent right\n internal jugular vein was accessed via a micropuncture needle. A guidewire\n was then passed into the SVC, and the needle was exchanged for a micropuncture\n sheath. The guidewire was then exchanged for wire, which was advanced\n into the IVC. The sheath was removed, and serial dilations were performed\n over the wire. Ultimately, a 14 French 15-cm long double-lumen central\n venous catheter was placed over the wire, with tip terminating at the\n cavoatrial junction. The wire was removed, and both ports were\n aspirated and flushed easily. The catheter was secured to the skin with 0\n silk sutures, and a sterile dressing was applied. Final spot fluoroscopic\n radiograph demonstrates satisfactory placement of the catheter. The patient\n tolerated the procedure well, with no immediate complications.\n\n IMPRESSION: Uncomplicated successful placement of a double-lumen 14 French\n temporary hemodialysis catheter from the right internal jugular venous\n approach, with tip at the superior cavoatrial junction. The line is ready to\n use.\n (Over)\n\n 11:34 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Line placement\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2144-03-25 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1178224, "text": " 9:54 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ? aspiration\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with aspiration pneumonia\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspiration pneumonia.\n\n SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was\n performed in conjunction with the speech and swallow division. Multiple\n consistencies of barium were administered.\n\n FINDINGS: Barium passed freely through the oropharynx and esophagus without\n evidence of obstruction. There was penetration with thin consistency.\n\n For details, please refer to the speech and swallow division note in the\n online medical record.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177108, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F with alcoholic cirrhosis s/p two transplants with AMS, now intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Alcoholic cirrhosis, status post transplants, intubation,\n evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing\n parenchymal opacities have decreased in severity. The lung volumes are\n unchanged. Unchanged position of the monitoring and support devices,\n unchanged size of the cardiac silhouette, no major pleural effusions. No\n newly appeared focal parenchymal opacities.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1176505, "text": " 7:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with fall and ams\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd FRI 8:24 PM\n Evaluation slightly limited by motion, but no evidence of acute intracranial\n hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman status post fall and altered mental status.\n Evaluate for intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Axially acquired images were obtained through the head without\n contrast. Coronal and sagittal reformatted images were also displayed.\n\n FINDINGS: Evaluation is slightly limited given slight motion artifact.\n However, there is no acute intracranial hemorrhage, large areas of edema, or\n mass effect. There is preservation of normal -white matter\n differentiation. Ventricles and sulci are normal in size and configuration.\n There is no fracture. There is calcification of the carotid siphons\n bilaterally. Soft tissues of the orbits are within normal limits.\n Calcification is again noted in the right upper eyelid, which was present in\n . The paranasal sinuses and left mastoid air cells are clear.\n There is partial opacification of the right mastoid air cells.\n\n IMPRESSION: Evaluation is slightly limited by motion artifact. However, no\n evidence of acute intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-13 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1176506, "text": " 7:45 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval c-spine fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n eval c-spine fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd FRI 9:08 PM\n no fracture. alignment maintained. 3mm pulmonary nodule at the left lung apex;\n if no known risk factors (ie smoking/underlying malignancy) no further\n evaluation needed. otherwise, follow up ct in 12 months is recommended.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman status post fall. Evaluate for C-spine\n fracture.\n\n COMPARISON: .\n\n TECHNIQUE: Axially acquired images were obtained through the cervical spine\n without contrast. Coronal and sagittal reformatted images were also\n displayed.\n\n FINDINGS: There is no fracture. Alignment is maintained. Please note that\n evaluation is slightly limited due to motion artifact. Prevertebral soft\n tissues are within normal limits. Soft tissue structures of the neck are\n within normal limits. CT does not provide intrathecal detail comparable to\n that of MRI. There is dense calcification of the carotid bulbs bilaterally.\n A 3-mm nodule at the left lung apex (2:67).\n\n IMPRESSION:\n 1) No fracture. Alignment maintained.\n 2) 3-mm pulmonary nodule at the left lung apex. Dedicated chest CT is\n recommended for further evaluation. At the time of this dictation, patient is\n ordered for a CT torso, as which time the lungs can be further evaluated and\n surveillance schedule established.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1176512, "text": " 8:04 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with fall and hypotension\n REASON FOR THIS EXAMINATION:\n eval for pna, ptx\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST AT HOURS.\n\n HISTORY: Fall with hypotension.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are mildly diminished. No consolidation or edema is\n evident. The mediastinum is unremarkable. The cardiac silhouette is within\n normal limits for size. No effusion or pneumothorax is noted. The osseous\n structures are unremarkable.\n\n IMPRESSION: No acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-14 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1176561, "text": " 9:50 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: SP LIVER TX WT ELAVATED ALK PHOS,EVAL FOR BUDD CHIARI ,OBSTRUCTION\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with ESLD presents with , somnolence, sepsis and acute\n hepatitis\n REASON FOR THIS EXAMINATION:\n Budd Chiari? Cholestatic obstruction?\n ______________________________________________________________________________\n WET READ: DLrc SAT 11:35 AM\n Echogenic liver. Patent hepatic vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 48-year-old female with end-stage liver disease\n presenting with kidney injury and acute hepatitis. Evaluate for Budd-Chiari\n or cholestatic obstruction.\n\n EXAMINATION: RIGHT UPPER QUADRANT ULTRASOUND.\n\n COMPARISONS: Comparison is made to examination from .\n\n FINDINGS:\n\n The liver demonstrates diffusely increased echogenicity. There are no focal\n liver lesions. There is no intra- or extra-hepatic biliary dilatation with\n the common bile duct measuring up to 4 mm.\n\n DOPPLER EXAMINATION: The left, middle and right hepatic veins are patent.\n The IVC is patent. The main portal vein and its major branches including the\n left portal, right anterior and posterior portal branches are patent with\n appropriate directions of flow and Doppler waveforms.\n\n\n IMPRESSION:\n 1. Echogenic liver compatible with diffuse fatty deposition. Other forms of\n liver disease including more significant liver disease such as advanced\n hepatic cirrhosis/fibrosis cannot be excluded on this examination.\n\n 2. Patent hepatic vasculature with no evidence of Budd-Chiari syndrome.\n\n 3. No biliary dilation.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176523, "text": " 10:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with new intubation\n REASON FOR THIS EXAMINATION:\n eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Check ET tube placement.\n\n There is an ET tube 4 cm above the carina. NG tube tip is in the stomach.\n The lungs are clear without infiltrate or effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-04 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1179866, "text": " 10:05 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please assess for clots.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with EtOH Cirrhossi s/o OTL in admitted for AMS and\n developed VAP; now better, but with fever of unknown origin.\n REASON FOR THIS EXAMINATION:\n Please assess for clots.\n ______________________________________________________________________________\n WET READ: SAT 2:59 PM\n no dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman with alcohol cirrhosis with fever of unknown\n origin. Assess for clot.\n\n COMPARISON: None.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: -scale and Doppler son of\n bilateral common femoral, superficial femoral, and popliteal veins show normal\n blood flow, compressibility, and augmentation. The bilateral calf veins show\n normal flow.\n\n IMPRESSION: No evidence of DVT in bilateral lower extremities.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176546, "text": " 3:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with , acidosis, hyperkalemia\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall, hypotension.\n\n FINDINGS:\n\n The ET tube and NG tube are unchanged. The heart is upper limits of normal in\n size. There is bilateral lower lobe volume loss. There is no definite\n infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1176530, "text": " 12:05 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval acute intrathoracic/intraabdominal process.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p fall hypotensive c/o abd pain.\n REASON FOR THIS EXAMINATION:\n eval acute intrathoracic/intraabdominal process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SAT 8:15 AM\n No acute intra-abdominal or pelvic abnormality to explain the patient's\n symptoms.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old female status post liver transplant, presents after a\n fall with hypotension. Evaluate for acute intrathoracic or intra-abdominal\n abnormality.\n\n COMPARISON: CT chest of and CT torso of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest,\n abdomen, and pelvis without IV contrast. Coronal and sagittal reformats were\n displayed.\n\n CT CHEST WITHOUT IV CONTRAST: There is dependent subsegmental atelectasis at\n the bilateral lung bases. There is no focal consolidation. Emphysematous\n changes are noted diffusely. There is no pleural effusion or pneumothorax.\n Heart size is normal without pericardial effusion. There is mild\n atherosclerotic calcification of the aortic arch and branch vessels. The great\n vessels are otherwise unremarkable. There is no axillary, mediastinal, or\n hilar lymphadenopathy meeting CT criteria for pathologic enlargement.\n Endotracheal and orogastric tubes are noted in situ.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Evaluation of the abdominal organs is limited\n without IV contrast. Within this limitation, there is geographic hypodensity\n within segments V and VIII of the liver with some capsular retraction that\n most likely represents fibrosis, but poorly evaluated on this single-phase CT.\n There is trace ascites. The gallbladder is surgically absent. There is fatty\n atrophy of the pancreas. The spleen has markedely decreased in size and\n demonstrates multiple calcifications. Bilateral adrenal glands are normal.\n The kidneys appear atrophic. A 2 mm nonobstructing stone is noted in the the\n right kidney. There is hydronephrosis or hydroureter. The aorta is of normal\n caliber throughout with atherosclerotic disease. There is a stent that is\n related to the celiac axis but it is not evaluated on this noncontrast study.\n The non-opacified stomach and intra-abdominal loops of small and large bowel\n are unremarkable. No mesenteric or retroperitoneal lymphadenopathy meeting CT\n criteria for pathologic enlargment is noted.\n\n CT PELVIS WITHOUT IV CONTRAST: The urinary bladder is collapsed around a\n Foley catheter. The distal ureters, uterus, adnexa, sigmoid colon, and rectum\n are unremarkable. There is no free fluid in the pelvis. No pelvic or\n (Over)\n\n 12:05 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval acute intrathoracic/intraabdominal process.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n inguinal lymphadenopathy is noted. Right femoral catheter is noted in situ.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\n Old right rib fracture is noted on the sagittal view only.\n\n IMPRESSION:\n\n 1. No acute intra-abdominal or pelvic abnormality to explain the patient's\n symptoms.\n\n 2. Poorly evaluated geographic hypodensity in the right lobe of the liver\n with capsular retraction is likely fibrosis; vascular problem as the\n underlying cause can not be assessed on this study.\n\n 3. Trace ascites.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176630, "text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for evidence of PNA\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with h/o liver txp who presents with ARF, now intubated.\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence of PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Liver transplant, acute renal failure, question pneumonia.\n\n REFERENCE EXAMINATION: .\n\n FINDINGS: There is no significant change in the ET tube or NG tube. There is\n increased opacity at both bases that may represent small infiltrates or volume\n loss. There is some mild pulmonary vascular redistribution and possible small\n left effusion. Compared to the prior exam, the appearance of the lower lobes\n is worse.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1176531, "text": ", MED SICU-A 12:05 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval acute intrathoracic/intraabdominal process.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p fall hypotensive c/o abd pain.\n REASON FOR THIS EXAMINATION:\n eval acute intrathoracic/intraabdominal process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute intra-abdominal or pelvic abnormality to explain the patient's\n symptoms.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176720, "text": " 7:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with a history of alcoholic cirrhosis s/p two transplants in\n , then in who presented with acute altered mental status on .\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n WET READ: JEKh SUN 8:28 PM\n 1. ETT 5-5.5 cm above carina\n 2. unchanged appearance of left lung base opacity\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of alcoholic cirrhosis, status post two transplants. ETT\n placements.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 5 cm above the carina.\n The tube could be advanced by 1-2 cm.\n\n No evidence of complications.\n\n Unchanged diffuse parenchymal opacities on the left as well as at the right\n lung base, concerning for pneumonia or, potentially, gravity-dependent edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176732, "text": " 9:23 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with a history of alcoholic cirrhosis s/p two transplants in\n , then in who presented with acute altered mental status on .\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of alcoholic cirrhosis. Nasogastric tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing\n parenchymal opacities and the position of the endotracheal tube are unchanged.\n Unchanged size of the cardiac silhouette. In the interval, the patient has\n received a nasogastric tube. The tip of the tube projects over the pyloric\n region. There is no evidence of complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177311, "text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year-old female with alcoholic cirrhosis s/p OLT x2, failed, now with\n pneumonia and fluid overload - intubated\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Alcoholic cirrhosis, pneumonia, fluid overload.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is increase of the\n pre-existing relatively severe parenchymal opacities in the left lung. The\n right lung looks better ventilated than on the previous image. Unchanged\n monitoring and support devices, unchanged size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176923, "text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F with alcoholic cirrhosis s/p two transplants with AMS, now intubated\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transplantation with intubation, to assess for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Bilateral pulmonary opacifications, more prominent\n at the left base, persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176714, "text": " 5:16 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Pulmonary Edema\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with a history of alcoholic cirrhosis s/p two transplants in\n , then in who presented with acute altered mental status on .\n Now post extubation desating with increased RR.\n REASON FOR THIS EXAMINATION:\n Pulmonary Edema\n ______________________________________________________________________________\n WET READ: JEKh SUN 7:41 PM\n 1. interval removal of support lines and tubes\n 2. worsening bibasilar opacities, L worse than R, concerning for early\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of alcoholic cirrhosis, parenchymal opacities.\n\n COMPARISON: , 3:43.\n\n FINDINGS: As compared to the previous radiograph, there is marked increase in\n extent of the bilateral parenchymal opacities. Rapid development of these\n opacities is edema over infection. In the interval, the patient has been\n extubated.\n\n The size of the cardiac silhouette is unchanged. The nasogastric tube has\n also been removed.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-01 00:00:00.000", "description": "EXCH CENTRAL NON-TUNNELED", "row_id": 1179368, "text": " 9:04 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place tunnelled line\n Admitting Diagnosis: HYPERKALEMIA\n ********************************* CPT Codes ********************************\n * EXCH CENTRAL NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with ARF requiring dialysis\n REASON FOR THIS EXAMINATION:\n Please place tunnelled line\n ______________________________________________________________________________\n FINAL REPORT\n TUNNELED DIALYSIS LINE PLACEMENT CHANGED TO EXCHANGE OF TEMPORARY DIALYSIS\n LINE MID PROCEDURE\n\n INDICATION: 48-year-old woman with acute renal failure requiring dialysis for\n tunneled line placement.\n\n PROCEDURES:\n 1. Pre-procedure fluoroscopic spot image.\n 2. Creation of subcutaneous tunnel in the right upper chest.\n 3. Exchange of 15 cm 14 French temporary hemodialysis catheter for same.\n 4. Post-procedure fluoroscopic spot image.\n\n OPERATORS: Dr. (fellow) and Dr. (attending\n interventional radiologist) who supervised and reviewed the images.\n\n ANESTHESIA: Moderate sedation was provided via administration of 50 mcg of\n fentanyl and 1 mg of midazolam throughout the total intra-service time of 30\n minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n\n TECHNIQUE AND FINDINGS: After discussion of the risks, benefits and\n alternatives to the procedure with the patient, written informed consent was\n obtained. The patient was brought to the angiography suite and placed supine\n on the imaging table. A pre-procedure timeout and huddle were performed per\n protocol.\n\n After appropriate measurements were made, the right upper chest was\n anesthetized with 1% lidocaine and 1% lidocaine with epinephrine. A 1-cm\n incision was made four fingerbreadths below the pre-existing venotomy site.\n The venopuncture site at the right lower neck was expanded. Next a 20 cm tip-\n to-cuff dual-lumen catheter was tunneled and brought out at the venotomy site.\n\n At this time, the team called with emergent news that the patient was infected\n and blood cultures were positive and requested the tunneled line to be aborted\n and the temporary line to be exchanged. Given the emergent nature of this\n communication, the informed consent was annulled and the procedure changed for\n a temporary line exchange.\n\n (Over)\n\n 9:04 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place tunnelled line\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n A 0.035 wire was advanced through the temporary catheter into the IVC\n under fluoroscopic guidance with spot fluoroscopic image on file. The sutures\n were released and the catheter removed. A similar double-lumen 14 French 15\n cm hemodialysis catheter was advanced over the wire with tip adjusted to\n be in the superior right atrium. The wire was removed. Both ports aspirated\n and flushed readily. Catheter was secured to the skin with 0 silk suture. The\n extended venotomy site was closed with 4-0 Vicryl suture. The incision for\n the creation of a tunneled line in the right upper chest was closed with 4-0\n Vicryl suture. Sterile dressings were applied. The patient tolerated the\n procedure well with no immediate complications.\n\n IMPRESSION: Change of procedure from tunneled hemodialysis catheter placement\n after the creation of a tunnel secondary to information from the team\n regarding infection. Team requested change of procedure for exchange of\n temporary catheter. The pre-existing 14 French 15 cm double-lumen\n hemodialysis catheter was exchanged for same. The tip is at the superior\n right atrium. The line is ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179895, "text": " 1:26 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please assess for pneumothorax.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with EtOH cirrhosis with fever, s/p line removal today and\n immediately afterwards developped SOb.\n REASON FOR THIS EXAMINATION:\n Please assess for pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:30 P.M., \n\n HISTORY: Alcoholic cirrhosis with fever. Shortness of breath after line\n removal.\n\n IMPRESSION: AP chest compared to .\n\n No pneumothorax. Small right pleural effusion stable. Left pleural effusion\n resolved. Diffuse infiltrative pulmonary abnormality, sparing the right upper\n lobe, which worsened between and 26 is less severe today. This\n could be recurrent or persistent pulmonary edema, but there is no evidence of\n cardiac decompensation. Consideration should be given to a transfusion or\n drug reaction.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176756, "text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with a history of alcoholic cirrhosis s/p two transplants in\n , then in who presented with acute altered mental status on .\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of alcoholic cirrhosis, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is unchanged position\n of the nasogastric tube and the endotracheal tube. Unchanged extent and\n severity of the bilateral areas of parenchymal opacities, affecting the entire\n lung parenchyma on the left and the basal parts of the lung parenchyma on the\n right. No other parenchymal changes. Presence of a minimal left pleural\n effusion cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-01 00:00:00.000", "description": "RENAL U.S.", "row_id": 1179363, "text": " 8:19 AM\n RENAL U.S. Clip # \n Reason: ? hydronephrosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with ATN s/p hypotension, MICU course\n REASON FOR THIS EXAMINATION:\n ? hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND\n\n CLINICAL INDICATION: 48-year-old with ATN to assess for hydronephrosis.\n\n Both kidneys are slightly small, but symmetrical in size measuring 9.6 cm in\n length on the right and 9.7 cm on the left. There is diffuse increase in\n cortical echogenicity throughout both kidneys. There are no signs of\n hydronephrosis or renal stones, nor are any masses seen. Limited views of the\n bladder are unremarkable.\n\n CONCLUSION: Slightly small and hyperechoic kidneys suggesting some form of\n diffuse parenchymal disease. No signs of obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-04 00:00:00.000", "description": "FOLLOW-UP,REQUEST BY RAD.", "row_id": 1179897, "text": " 1:39 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please remove temporal HD line given concern for infection.\n Admitting Diagnosis: HYPERKALEMIA\n ********************************* CPT Codes ********************************\n * FOLLOW-UP,REQUEST BY RAD. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with EtOH cirrhosis s/p liver transplant with fever.\n REASON FOR THIS EXAMINATION:\n Please remove temporal HD line given concern for infection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48 year old female with acute renal failure and alcoholic\n cirrhosis post liver transplant. Temporary right internal jugular\n hemodialysis line placed on . Tunneled line requested and performed on\n , but primary team requested change back to temporary line during\n procedure. Following multiple additional requests for line tunneling, the\n primary team requests removal for line holiday over the weekend in\n consideration of intermittent pyrexia.\n\n PROCEDURE AND FINDINGS: Verbal informed consent was obtained outlining the\n procedure, risks and benefits. The right upper chest and catheter were\n prepped and draped in the usual sterile fashion. The anchor sutures were cut\n and removed from the skin. The temporary catheter was easily removed with\n gentle traction. Pressure was applied to the venotomy site for 5 minutes, and\n good hemostasis was achieved. A sterile dressing was applied.\n\n The patient demonstrated significant anxiety, but tolerated the procedure\n well, without complications during or immediately after the procedure.\n However, a few minutes later, she reported mild dyspnea and chest pain. A\n portable chest radiograph revealed no evidence of pneumothorax or other acute\n process. Diffuse interstitial and airspace opacities are improved from\n , and may represent pulmonary edema. Underlying parenchymal\n abnormalities are consistent with known emphysema.\n\n IMPRESSION: Removal of right temporary hemodialysis catheter.\n\n" }, { "category": "Radiology", "chartdate": "2144-03-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1176801, "text": " 10:07 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 42cm DL L brachial PICC placed ? tip\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with new L PICC\n REASON FOR THIS EXAMINATION:\n 42cm DL L brachial PICC placed ? tip\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Alcoholic cirrhosis, intubated, new PICC line inserted, check\n position.\n\n TECHNIQUE: Portable semi-erect chest radiograph submitted for review.\n\n FINDINGS:\n\n Comparison is made to chest radiograph obtained at 0500 on .\n\n There has been interval insertion of a left-sided PICC line, the tip of which\n lies in the distal SVC. An endotracheal tube is unchanged in position. The\n NG tube lies in the stomach. There are persistent bilateral parenchymal\n opacities predominantly affecting the lung bases, more extensive on the left.\n Left lower lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-04-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1179914, "text": " 4:11 PM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for PNA.\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with EtOH Cirrhosis s/p OTL in admitted with new renal\n failure, AMS, developed VAP and now with fever of origin.\n REASON FOR THIS EXAMINATION:\n Please assess for PNA.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 4:24 P.M.\n\n HISTORY: Alcoholic cirrhosis. Liver transplant. New renal failure and\n altered mental status. Fever.\n\n IMPRESSION: PA and lateral chest compared to through :\n\n Small bilateral pleural effusions are larger now than they were earlier in the\n day, suggesting that the interstitial abnormality in both lungs is probably\n edema. Heart size is normal. The suggestion of small nodular opacities at\n the lung bases indicates followup is necessary to exclude sepsis, but I\n suspect these are areas of atelectasis. No pneumothorax. Distended bowel\n loops in the upper abdomen raises question about small-bowel obstruction. Dr.\n was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178872, "text": " 9:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of pna?\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with EtOH cirrhosis s/p liver transplants recovering from\n sepsis s/p intubation for respiratory failure now with fevers to 101.\n REASON FOR THIS EXAMINATION:\n evidence of pna?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 48-year-old woman with alcoholic cirrhosis status post\n liver transplant.\n\n FINDINGS: Comparison is made to previous study from .\n\n Bilateral central venous catheters are stable and unchanged in position.\n There is a persistent left retrocardiac opacity and areas of consolidation\n within the bases bilaterally and in the left upper lung field. These appear\n to have worsened since the study. No pneumothoraces are\n identified.\n\n" }, { "category": "Echo", "chartdate": "2144-04-07 00:00:00.000", "description": "Report", "row_id": 102347, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function\nHeight: (in) 61\nWeight (lb): 110\nBSA (m2): 1.47 m2\nBP (mm Hg): 120/70\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 15:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild to moderate (+)\nAR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. No MS. Mild to moderate (+) MR. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Mild to moderate [+] TR. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF 55-60%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion. There is no aortic valve stenosis. Mild to\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. Mild to moderate\n(+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity\nof mitral regurgitation may be significantly UNDERestimated.] There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , no major change.\n\n\n" }, { "category": "Echo", "chartdate": "2144-03-16 00:00:00.000", "description": "Report", "row_id": 102348, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Congestive heart failure.\nHeight: (in) 60\nWeight (lb): 119\nBSA (m2): 1.50 m2\nBP (mm Hg): 83/51\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 14:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\npt intubated on vent.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The patient is mechanically\nventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). Mild to moderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Moderate\n(2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Left pleural\neffusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded\n(?hypokinesis of the basal anterior septum) Right ventricular chamber size is\nnormal. with borderline normal free wall function. The aortic valve leaflets\n(?#) appear structurally normal with good leaflet excursion. Mild to moderate\n(+) aortic regurgitation is seen. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no mitral valve prolapse.\nModerate (2+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , global left\nventricular systolic function is less vigorous, and the severity of aortic\nregurgitation, mitral regurgitation, and tricuspid regurgitation have slightly\nincreased.\n\n\n" }, { "category": "ECG", "chartdate": "2144-04-04 00:00:00.000", "description": "Report", "row_id": 295820, "text": "Sinus rhythm. Occasional ventricular premature beats. Non-specific ST-T wave\nchanges in the precordial leads. Compared to the previous tracing of \nectopy is new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2144-03-24 00:00:00.000", "description": "Report", "row_id": 295821, "text": "Normal sinus rhythm. Left atrial abnormality. Compared to the previous tracing\nof atrial flutter is no longer appreciated. The diffuse ST-T wave\nabnormalities have resolved.\n\n" }, { "category": "ECG", "chartdate": "2144-03-21 00:00:00.000", "description": "Report", "row_id": 295822, "text": "Probable atrial flutter with 2:1 A-V conduction. Diffuse ST-T wave\nabnormalities. Compared to the previous tracing of probably no\nsignificant change, except rhythm is now more regular.\n\n" }, { "category": "ECG", "chartdate": "2144-03-19 00:00:00.000", "description": "Report", "row_id": 295823, "text": "Possible atrial flutter with uncontrolled ventricular response. Diffuse\nminimal ST segment depressions in the anterolateral leads. Compared to\ntracing #1 the patient is no longer in normal sinus rhythm.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-03-19 00:00:00.000", "description": "Report", "row_id": 295824, "text": "Sinus tachycardia. Mild ST segment depressions in the inferolateral leads\nwith minimal J point elevation in lead aVL. Compared to the previous tracing\nof the rate is faster and the other findings are similar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2144-03-18 00:00:00.000", "description": "Report", "row_id": 295825, "text": "Sinus rhythm. Compared to the previous tracing of the Q-T interval has\nnormalized while the rate has increased. Inferolateral ST segment changes\npersist.\n\n" }, { "category": "ECG", "chartdate": "2144-04-05 00:00:00.000", "description": "Report", "row_id": 295819, "text": "Sinus rhythm. Borderline prolonged Q-T interval. Compared to tracing #1\nQ-T interval is slightly increased. ST-T wave changes in the anterior\nprecordial leads are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-03-15 00:00:00.000", "description": "Report", "row_id": 295826, "text": "Sinus rhythm with a single ventricular premature beat. Borderline prolonged\nQ-T interval. Otherwise, tracing is within normal limits. Compared to the\nprevious tracing of the findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2144-03-14 00:00:00.000", "description": "Report", "row_id": 295827, "text": "Sinus rhythm with a ventricular premature beat. Non-specific lateral\nT wave flattening. Compared to tracing #3 ventricular rate is faster.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2144-03-13 00:00:00.000", "description": "Report", "row_id": 295828, "text": "Sinus rhythm. Compared to tracing #2 the QRS complex is narrower and the\ntall peaked T waves are now absent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2144-03-13 00:00:00.000", "description": "Report", "row_id": 295829, "text": "Baseline artifact. Sinus rhythm. Wide QRS complex with tall peaked T waves in\nthe inferior and lateral leads suggesting hyperkalemia. Compared to\ntracing #1 earlier the same date baseline artifact is more pronounced.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-03-13 00:00:00.000", "description": "Report", "row_id": 295830, "text": "Baseline artifact makes P wave interpretation difficult. Sinus rhythm.\nNon-specific intraventricular conduction delay. Consider left anterior\nfascicular block. Tall peaked T waves in the inferior and lateral leads.\nConsider hyperkalemia or ischemia. Poor R wave progression. Compared to the\nprevious tracing of bradycardia is absent. The QRS complex is wider\nwith tall peaked T waves suggesting the possibility of hyerkalemia.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2176-08-06 00:00:00.000", "description": "INTRO CATH TO PELVIS FOR DRAINAGE AND INJ", "row_id": 1244992, "text": " 3:09 PM\n PERC NEPHROSTO Clip # \n Reason: nephrostomy for decompression. please send UA/culture from n\n Admitting Diagnosis: RENAL FAILURE\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with bladder ca s/p resection with worsening renal function in\n setting of obstruction with fevers\n REASON FOR THIS EXAMINATION:\n nephrostomy for decompression. please send UA/culture from nephrostomy. Please\n perform nephrostogram during procedure to evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 year old man with bladder ca, s/p pelvic exenteration with\n ileal conduit, with single left functioning kidney, presenting with worsening\n renal function in setting of obstruction with fever. For placement of left\n percutaneous nephrostomy tube.\n\n OPERATORS: Dr (fellow) and Dr (attending\n radiologist). Dr was present and supervising throughout the whole\n procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n fentanyl (50 mcg) and Versed (1 mg) throughout the total intraservice time of\n 35 minutes, during which the patient's hemodynamic parameters were\n continuously monitored. 1g of Cefazolin was administered immediately prior to\n the procedure.\n\n PROCEDURE: Left percutaneous nephrostomy tube placement.\n\n FINDINGS: After the risks and benefits of the procedure were explained to the\n patient, written informed consent was obtained. The patient was placed prone\n on the table and his left flank was prepped and draped in standard sterile\n fashion. A pre-procedure timeout was performed.\n\n Under ultrasound and fluoroscopic guidance, a left mid pole calix was\n cannulated with a 21-gauge Cook needle through which a 0.018 wire was advanced\n into the renal pelvis. Small sample of urine was sent to the lab as requested.\n The needle was exchanged for an AccuStick sheath. The wire and inner portion\n of Accustick were removed. Cloudy urine drained from the catheter.\n Approximately 10 cc of contrast were administered into the collecting system\n demonstrating moderate to severe left hydronephrosis and hydroureter. A\n wire was advanced into the renal pelvis. An 8 French dilator was used\n to open the tract over the wire. 6F sheath was placed over the wire and 5F\n catheter advanced into the distal ureter. Antegrade pyelogram was then\n performed which showed high grade stenosis at the anastomosis with delayed\n passage of contrast into the ileal conduit and reflux into the moderately\n dilated right ureter. The system was drained and over the wire 8 French\n (Over)\n\n 3:09 PM\n PERC NEPHROSTO Clip # \n Reason: nephrostomy for decompression. please send UA/culture from n\n Admitting Diagnosis: RENAL FAILURE\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n nephrostomy tube was placed with pigtail locked within the renal pelvis.\n Contrast was injected confirming this location. The catheter was secured to\n the skin with 0 silk suture and StatLock. The catheter was placed to external\n bag drainage.\n\n Patient tolerated procedure well. There were no immediate complications.\n\n FINDINGS:\n 1. Severe left hydroneprosis and hydroureter with high grade stenosis at the\n anastomosis with ileal conduit. The stricture is amenable to percutaneous\n plasty.\n 2. Reflux into the moderately dilated right ureter.\n\n Findings were discussed on the phone by Dr with Dr during the\n procedure.\n\n IMPRESSION: Successful left percutaneous nephrostomy with 8 French\n nephrostomy tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-08-13 00:00:00.000", "description": "GUIDANCE FOR ABSCESS (75989)", "row_id": 1245807, "text": " 1:23 PM\n US HEMATOMA SUBCUT DRAIN INCISION; GUIDANCE FOR ABSCESS () Clip # \n Reason: Please drain fluid collections.\n Admitting Diagnosis: RENAL FAILURE\n ********************************* CPT Codes ********************************\n * US HEMATOMA SUBCUT DRAIN INCISION GUIDANCE FOR ABSCESS () *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with pelvic fluid collections, now with rising WBC.\n REASON FOR THIS EXAMINATION:\n Please drain fluid collections.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with pelvic fluid collection, presumably a seroma\n following bladder resection, who now presents with elevated white blood cell\n count.\n\n COMPARISONS: Renal ultrasound exam of .\n\n PROCEDURE:\n\n The procedure, risks, benefits, and alternatives were discussed with the\n patient, and written informed consent was obtained. A preprocedure timeout\n was performed discussing the planned procedure, confirming the patient's\n identity with three identifiers, and reviewing the checklist per \n protocol.\n\n Under ultrasound guidance, an entrance site was selected, and the skin was\n prepped and draped in the usual sterile fashion. Approximately 8 mL of 1%\n lidocaine buffered with sodium bicarbonate was instilled for local anesthesia.\n A 5-French catheter was advanced into the fluid pocket in the right\n pelvis, and 70 mL of clear fluid was removed. The catheter was removed and a\n dry sterile dressing placed. Samples were sent to the lab for further\n analysis.\n\n The patient tolerated the procedure well without immediate complications. Dr.\n , the attending radiologist, was present and supervising throughout the\n procedure.\n\n Post-procedural ultrasound exam demonstrates near complete resolution of the\n pelvic fluid collection.\n\n IMPRESSION:\n\n Successful ultrasound-guided aspiration of the pelvic fluid collection. Fluid\n samples were sent to the lab for further analysis.\n\n" }, { "category": "ECG", "chartdate": "2176-08-05 00:00:00.000", "description": "Report", "row_id": 275240, "text": "Sinus rhythm. Non-diagnostic Q waves inferiorly. Early R wave transition.\nCompared to the previous tracing of the ventricular rate is faster.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2103-01-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1228398, "text": " 9:03 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 45cm left picc. tip? \n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 45cm left picc. tip? \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: radiograph.\n\n FINDINGS: Tip of left PICC terminates in the lower superior vena cava just\n above the junction with the right atrium. Nasogastric tube has been\n repositioned, now terminating more distally within the stomach. Cardiac\n silhouette is mildly enlarged and accompanied by pulmonary vascular congestion\n and minimal perihilar edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-01-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1228628, "text": " 5:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval re-bleed\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with recent SAH with worsening mental status\n REASON FOR THIS EXAMINATION:\n eval re-bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: SAT 5:37 PM\n No significant interval change in degree in intracranial hemorrhage, allowing\n for redistribution. No new intracranial hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent subarachnoid hemorrhage with worsening mental status.\n Evaluate for re-bleed.\n\n TECHNIQUE: Sequential axial images were acquired through the head without the\n administration of intravenous contrast material.\n\n COMPARISON: CT head from .\n\n FINDINGS: Allowing for re-distribution, there is no significant interval\n change in the quantity of subarachnoid hemorrhage overlying both cerebral\n hemispheres. A few foci of SAh in the fronal lobes on both sides are more\n conspicious- se 2, im 19 and 20. The degree of hemorrhagic content layering in\n both occipital horns of the lateral ventricles is minimally increased.\n Subdural hemorrhage overlying the leaflets of the tentorium cerebelli is again\n seen. There are also stable bilateral parietal subdural hematomas.\n Hypodensities within the anterior aspects of both frontal lobes is not\n significantly changed, consistent with contusions. There is no definite new\n intracranial hemorrhage, hydrocephalus, shift of normally midline structures,\n or acute large vascular territorial infarction. There is no central\n herniation. Periventricular and subcortical white matter hypodensities are a\n nonspecific finding that can be seen in the setting of chronic small vessel\n ischemic disease. Slight prominence of the ventricles and sulci is consistent\n with age-related involutional change. Bilateral cavernous carotid and left\n vertebral artery calcifications are noted. A non-displaced fracture through\n the frontal bone is again seen. There is an air-fluid level with aerosolized\n secretions in the left frontal sinus, not significantly changed compared to\n the prior study. The remainder of the visualized portions of the paranasal\n sinuses and mastoid air cells are well aerated.\n\n IMPRESSION:\n\n 1. No significant interval change in the degree of multicompartmental\n intracranial hemorrhage, allowing for re-distribution. Increased conspicuity\n of a few foci in the frontal lobes and occipital - may relate to\n redistribution- attention on close followup to assess stability.\n\n (Over)\n\n 5:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval re-bleed\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. No new intracranial hemorrhage.\n\n 3. Non-displaced frontal bone fracture, as before.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1227595, "text": " 8:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n traumatic sah-worsening neuro exam\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf SAT 9:35 PM\n 1. Unchanged extensive predominantly frontal subarachnoid and subdural\n hemorrhage with possible frontal contusions.\n\n 2. Fracture of the frontal bone in the midline may extend into the frontal\n sinus and places the patient at risk for a CSF leak.\n WET READ VERSION #1 ASpf SAT 8:26 PM\n Unchanged, bifrontal subarachnoid and subdural hemorrhage layering into both\n middle cranial fossa with possible contusions of the frontal brain parenchyma.\n Unchanged midline fracture of the frontal bone with high density fluid in the\n left frontal sinus compatible with blood.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old male with traumatic subarachnoid hemorrhage and\n worsening clinical exam.\n\n COMPARISON: Outside hospital head CT from at 5:18 p.m. and\n a head CT from .\n\n TECHNIQUE: MDCT images were acquired through the head without IV contrast.\n Bone kernel reconstruction and multiplanar reformations were obtained and\n reviewed.\n\n FINDINGS: There are bilateral acute subdural and subarachnoid hematoma\n primarily along the frontoparietal lobes, which is unchanged in extent\n compared to the previous examination from . Given the pattern of\n hyperdense blood along the anterior cranial fossa, a component of parenchymal\n henmorrhagic contusion cannot be excluded. The ventricles and sulci are mildly\n prominent, likely representative of age-related atrophy. There is mild\n bihemispheric white matter hypoattenuation consistent with sequelae of small\n vessel ischemic disease. The visible paranasal sinuses show high-density\n fluid in the left frontal sinus. Leading into the left frontal sinus is a\n midline fracture of the frontal bone extending to the vertex.\n\n IMPRESSION:\n\n 1. Stable bilateral frontoparietal subarachnoid and subdural hemorrhage with\n possible bifrontal contusions.\n\n 2. Fracture of the frontal bone in the midline may extend into the frontal\n sinus and places the patient at risk for a CSF leak.\n SESHa\n (Over)\n\n 8:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2103-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228226, "text": " 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia?\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with cough and temp\n REASON FOR THIS EXAMINATION:\n pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cough and pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. No evidence of pneumonia. No pleural effusions. Normal size of the\n cardiac silhouette. Moderate tortuosity of the thoracic aorta. Unchanged\n appearance of the sternal wires and the clips after CABG.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-01-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1228269, "text": " 1:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 87 year old man s/p fall with mult contusions, SAH. Currentl\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man s/p fall with mult contusions, SAH. Currently in\n status/seizing. Eval for interval changes\n REASON FOR THIS EXAMINATION:\n 87 year old man s/p fall with mult contusions, SAH. Currently in\n status/seizing. Eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with a subarachnoid hemorrhage. Currently in\n status epilepticus.\n\n COMPARISONS: CT head . CT head . CT head\n of .\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without the administration of IV contrast.\n\n FINDINGS: Overall, there has been no significant change since prior study.\n Hyperdense foci in the bilateral frontal lobes represent a combination of\n frontal contusions as well as subarachnoid hemorrhage. Stable subarachnoid\n hemorrhages are present in the bilateral parietal lobes. Bilateral parietal\n subdural hematomas and layering subdural hematomas over the tentorium are\n unchanged. Layering hemorrhage is seen in the bilateral occipital horns.\n This is unchanged from prior exam. There is no evidence of new hemorrhage,\n edema, or large vascular territory infarction. There is no shift of the\n normally midline structures. There is no hydrocephalus. The sulci and\n ventricles remain prominent, suggesting age-related atrophy. There is\n evidence of chronic small vessel ischemic disease.\n\n A fracture of the frontal bone is unchanged. The visualized paranasal\n sinuses, mastoid air cells, and middle ear cavities are clear.\n\n IMPRESSION:\n 1. No significant change in the bifrontal contusions, subarachnoid\n hemorrhage, subdural hematoma, and intraventricular hemorrhage.\n 2. No evidence of new hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228337, "text": " 8:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? placement\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with recent NGT placement\n REASON FOR THIS EXAMINATION:\n ? placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Radiograph of earlier the same date.\n\n FINDINGS: A radiograph centered at the thoracoabdominal junction region was\n obtained for assessment of a nasogastric tube, which terminates within the\n fundus of the stomach. Within the imaged portion of the chest, crowding of\n bronchovascular structures is present at the lung bases with otherwise clear\n lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-01-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1227608, "text": " 1:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change PRIOR TO AM ROUNDS 0500 am\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with status post fall with SDH/SAH/skull fracture\n REASON FOR THIS EXAMINATION:\n interval change PRIOR TO AM ROUNDS 0500 am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with traumatic subarachnoid hemorrhage, for\n interval change.\n\n COMPARISON: CT head from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Multiplanar reformatted images were prepared and\n reviewed.\n\n FINDINGS: Again visualized are diffuse bilateral parietal subarachnoid and\n subdural hemorrhages with layering down into the middle cranial fossa with\n little change in comparison to prior study. Additionally, hyperdense foci in\n the parenchyma of the inferior frontal lobes are again noted and likely\n representative of frontal contusion. The ventricles and sulci remain\n prominent but stable, likely representative of age-related cortical atrophy.\n Bilateral periventricular white matter hypodensities are suggestive of chronic\n small vessel ischemic disease.\n\n Again noted is a fracture of the frontal bone reaching from the vertex all the\n way to the level of the left frontal sinus.\n\n IMPRESSION:\n 1. Little change in comparison to prior study. Extensive predominantly\n frontal subarachnoid hemorrhages and parietal subdural hemorrhages\n bilaterally.\n 2. Fracture of the frontal bone in the midline may extend to the frontal\n sinus.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-01-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1228150, "text": " 6:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 87 year old man with traumatic SAH, increased confusion\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with traumatic SAH, increased confusion\n REASON FOR THIS EXAMINATION:\n 87 year old man with traumatic SAH, increased confusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MXAk WED 8:49 PM\n 1. Improvement in bilateral parietal subdural as well as subarachnoid\n hemorrhages but with stable appearance of bifrontal subarachnoid hemorrhages\n and contusions.\n 2. Fracture of the frontal bone in the midline with extension into the\n frontal sinus as seen previously.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with traumatic subarachnoid hemorrhage with\n increased confusion.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Multiplanar reformatted images were prepared.\n\n FINDINGS:\n\n Overall, there is minimal improvement in comparison to prior study. Again\n visualized are bifrontal hyperdense foci representing a combination of\n subarachnoid hemorrhage as well as frontal contusions, stable compared to\n prior study from . Bilateral parietal foci of subarachnoid\n hemorrhage appear less conspicuous. Additionally, bilateral parietal subdural\n hemorrhages appear nearly resolved. Layering of hemorrhage is visualized in\n bilateral occipital lobes of the ventricles. There is no evidence of new\n hemorrhage, edema, large territorial infarction, or shift of normally midline\n structures.\n\n The sulci remain prominent, likely representative of age-related cortical\n atrophy. Bilateral white matter hypodensities are suggestive of chronic small\n vessel ischemic disease.\n\n Again visualized is a fracture of the frontal bone region from the vertex to\n the level of the left frontal sinus.\n\n IMPRESSION:\n 1. Improvement in bilateral parietal subdural as well as subarachnoid\n hemorrhages but with stable appearance of bifrontal subarachnoid hemorrhages\n and contusions.\n 2. Fracture of the frontal bone in the midline with extension into the\n frontal sinus as seen previously.\n\n (Over)\n\n 6:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 87 year old man with traumatic SAH, increased confusion\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n NOTE ADDED AT ATTENDING REVIEW: Although I agree with the rest of the\n interpretation, I note that the intraventricular hemorrhage has increased\n slightly since the study of . This may be seen in the setting of\n trauma and contusion, but it indicates the need for close follow up. The\n ventricles are mildly dilated, but unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1228248, "text": " 11:35 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with low sats\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Low saturation, evaluation for interval change.\n\n COMPARISON: , 9:46 a.m.\n\n As compared to the previous radiograph, there is no relevant change. No\n pneumothorax, no pleural effusions, no pulmonary edema. No pneumonia. Normal\n size of the cardiac silhouette. Status post CABG, tortuosity of the thoracic\n aorta.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227616, "text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with s/p fall with possible aspiration- vomiting coofee ground\n emesis upon arrival\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Vomiting, suspected aspiration.\n\n Portable AP radiograph of the chest was reviewed in comparison to , .\n\n The patient is after median sternotomy and CABG with stable appearance of the\n cardiomediastinal silhouette. Lungs are clear with no definitive evidence of\n pneumonia or aspiration. No appreciable pleural effusion is demonstrated.\n There is no pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2103-01-25 00:00:00.000", "description": "Report", "row_id": 248157, "text": "Sinus rhythm. Right bundle-branch block. Borderline low voltage across the\nprecordium. Low voltage across the limb leads. Compared to the previous\ntracing of no new changes are noted.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2103-01-25 00:00:00.000", "description": "Report", "row_id": 248158, "text": "Sinus rhythm. Incomplete right bundle-branch block. Right atrial enlargement.\nBorderline low voltage across the limb leads. Prolonged Q-T interval.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2103-01-23 00:00:00.000", "description": "Report", "row_id": 248159, "text": "Sinus bradycardia. Right bundle-branch block. Low voltage. Compared to the\nprevious tracing of QS voltages are less.\n\n" }, { "category": "ECG", "chartdate": "2103-01-22 00:00:00.000", "description": "Report", "row_id": 248160, "text": "Sinus rhythm with atrial premature beats. Right bundle-branch block.\nNon-specific inferior ST-T wave changes. Right axis deviation which may be due\nto left posterior fascicular block. Q-T interval prolongation. Compared to\nthe previous tracing of the findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2103-01-20 00:00:00.000", "description": "Report", "row_id": 248161, "text": "Baseline artifact precludes definite assessment. Sinus rhythm with possible\natrial ectopy versus sinus arrhythmia. Complete right bundle-branch block with\nright axis deviation. The latter could be due to left posterior fascicular\nblock if other causes of right axis deviation including right ventricular\noverload are excluded. Non-specific ST-T wave change with QTc interval\nprolongation. Compared to the previous tracing of QTc interval is not\nas long. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2178-12-14 00:00:00.000", "description": "Report", "row_id": 1534020, "text": "NSG ADMIT NOTE\nPT RECEIVED FROM OR DIRECT S/P PANCREAS TRANSPLANT-EXTUBATED, ALERT AND ORIENTED. GLUCOSE DONE Q1, CHEM STICK 70-118. ABD INCISION WITH SERROSANG DRG AT JP SITE. JP 50-100 SERROUS DRG Q1-2. IVF 100 CC HR. UO 55-100,HR. HEPARIN AT 300 UNITS/HR VIA RIGHT IJ TLC. NGT LIWS NOT TO BE MANIPULATED AND NOTHING PR NGT. PAIN RX DILAUDID IVP PRN. PT STATES MSO4 MAKES HER NAUSETED. PSH KIDNEY TRANSPLANT IN , INCREASED LIPIDS, NEUROPATHY, IDDM SINCE AGE 8. ADMITED TO SICU OVERNOC FOR Q1 GLUCOSE.\n" }, { "category": "Nursing/other", "chartdate": "2178-12-14 00:00:00.000", "description": "Report", "row_id": 1534021, "text": "FOCUS: STATUS UPDATE\nDATA:\nPT IS ALERT AND ORIENTED AND VERY PLEASANT. HER LUNGS ARE CLEAR. SHE HAS 2LNC WITH SATS HIGH 90'S. VSS UNTIL THIS AFTERNOON WHEN SHE BECAME HYPERTENSIVE TO 200SYS. LOPRESSOR IV WAS GIVEN TWICE FOR A TOT OF 5MG. SHE IS TO STAY IN SICU UNTIL BP STABLE. SHE HAD BEEN ON VASOTEC AT HOME. NGT TO LCWS CANNOT BE MANIPULATED AND NOTHING BE GIVEN THRU TUBE. SHE IS NPO. HER ABD DSG HAS BEEN REINFORCED D/T SLIGHT SEROSANG DRAINAGE STAIN WHEN TURNED. SHE HAS JPX1 WITH SEROSANG DRAINAGE. FOLEY IN PLACE WITH GOOD URINE OUTPUT. CREAT/BUN STABLE. HER GLUCOSES HAVE BEEN DONE FREQUENTLY 79-94. SHE HAS INCISIONAL PAIN ESPECIALLY WHEN COUGHING. SHE UTILIZES COUGH PILLOW AND DILAUDID PCA STARTED WITH GOOD EFFECT. HCT 26.1 THIS PM. DR. FROM TRANSPLANT SERVICE NOTIFIED AND WANTS NO TX AT THIS TIME. SHE CONTINUES ON HEPARIN GTT WITH PTT 35.\n\n\nPLAN:\nMAINTAIN BP 140-150 PER TRANSPLANT TEAM. D/C ALINE AND TRANSFER TO 7 WHEN STABLE. REPORT GIVEN VIA TELEPHONE TO 7 RN.\n\n\n" }, { "category": "ECG", "chartdate": "2178-12-13 00:00:00.000", "description": "Report", "row_id": 152294, "text": "Sinus rhythm\nNo previous report available for comparison\nNormal ECG\n\n" }, { "category": "Radiology", "chartdate": "2178-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 748568, "text": " 12:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check cvl placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with s/p pancreas transplant\n REASON FOR THIS EXAMINATION:\n check cvl placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Check line placement in patient who is S/P pancreatic transplant.\n\n COMPARISON: \n\n FINDINGS: The cardiomediastinal silhouette is unremarkable. There is no\n evidence of failure. There are no focal pulmonary opacities or pleural\n effusions.\n\n Since the prior study, a central line entering from the right neck has been\n positioned with its tip in the low right atrium. There is no pneumothorax.\n Additionally, since the prior study an NG tube has been placed and its tip is\n well-positioned in the stomach.\n\n IMPRESSION: Interval placement of central line and nasogastric tube. The\n central line tip is in the low right atrium. The NG tube is well placed.\n\n" }, { "category": "Radiology", "chartdate": "2178-12-13 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 748555, "text": " 1:21 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PANCREATIC TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman for pancreas transplant\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pre-op for pancreatic transplant.\n\n There are no prior chest x-rays for comparison.\n\n The heart and mediastinum are normal. There are no consolidations, pleural\n effusions or pneumothorax. The nipple shadow is seen in the left lower lobe.\n The bones are unremarkable.\n\n IMPRESSION: No evidence of heart failure or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2178-12-13 00:00:00.000", "description": "O ABDOMEN (SUPINE ONLY) IN O.R.", "row_id": 748563, "text": " 9:05 PM\n ABDOMEN (SUPINE ONLY) IN O.R. Clip # \n Reason: LOST NEEDLE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lost needle.\n\n Two supine films of the abdomen obtained portably, labeled Film 1 and Film 2\n are submitted for interpretation. On Film 1 and 2 NG tube extends into the\n stomach and midline pelvic drains are present. Surgical closing staples\n extend from the mid abdomen to the pubic symphysis. On film #1, two ribbon-\n like opacities, presumably drains or packing, are projected over the right\n upper quadrant and right pelvis respectively. These are not present on Film\n #2. Three curvilinear metallic densities are projected over the right lower\n quadrant on both projections. On Film #2, a faint curvilinear artifact is\n projected over the right upper quadrant. No other abnormality is\n demonstrated.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2154-01-03 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 1164858, "text": " 6:42 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Evaluate biliary tree\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: MAGNEVIST Amt: 26\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p RNY GBP admitted for pancreatitis\n REASON FOR THIS EXAMINATION:\n Evaluate biliary tree\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:19 PM\n No intra or extrahepatic biliary dilation. no filling defect seen within the\n biliary system. Diffuse edema of the pancreas with small amount of sparing of\n a portion of the tail and uncinate process; however, there is apparent\n hypoenhancement of a small portion of the head and uncinate process,\n concerning for a small area of necrosis. Patent portal, hepatic veins and\n hepatic arteries.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man status post Roux-en-Y gastric bypass, admitted\n with pancreatitis. Please evaluate biliary tree.\n\n COMPARISON: CT of the abdomen and pelvis, .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images acquired on a 1.5 Tesla\n magnet, including dynamic 3D imaging obtained prior to, during, and after the\n uneventful intravenous administration of 0.1 mmol/kg (24 mL) gadolinium-DTPA.\n\n Multiplanar 2D and 3D reformations and subtraction images were generated on an\n independent workstation.\n\n FINDINGS: The pancreas demonstrates diffuse relative T1 hypointensity and\n indistinct margins, consistent with diffuse edema. However, there are\n portions of the head and uncinate process of the pancreas that demonstrate T1\n hyperintensity on the pre-contrast T1-weighted images with corresponding\n hypoenhancement, consistent with areas of necrosis. The pancreatic duct is\n not well seen due to diffuse edema. There are no discrete fluid collections.\n\n The gallbladder is mildly distended with multiple small stones as seen on the\n recent CT but is otherwise normal in appearance. There is diffuse fatty\n infiltration of the liver. There is no intra- or extra-hepatic biliary\n dilatation. The portal, hepatic, superior mesenteric and splenic veins are\n patent. The hepatic arteries are also patent.\n\n The patient is status post Roux-en-Y gastric bypass. Again seen is the large\n ventral hernia containing portions of the excluded stomach and loops of large\n and small bowel. The adrenal glands and spleen are within normal limits.\n Small cysts are noted in the upper pole of the right kidney. The kidneys are\n otherwise normal in appearance. Small bilateral pleural effusions are\n present, new since the prior recent CT.\n\n (Over)\n\n 6:42 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Evaluate biliary tree\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: MAGNEVIST Amt: 26\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multiple 2D and 3D reformations and subtraction images were generated on an\n independent workstation (series 975).\n\n IMPRESSION:\n\n 1. Findings of acute pancreatitis with small areas of hypoenhancement within\n the head and uncinate process consistent with areas of necrosis.\n\n 2. No intra- or extra-hepatic biliary dilatation. Cholelithiasis but no\n evidence of choledocholithiasis.\n\n 3. Diffuse fatty infiltration of the liver.\n\n 4. Small bilateral pleural effusions, new since prior study of .\n\n 5. Large ventral hernia containing portions of the excluded stomach, small\n bowel and large bowel.\n\n Findings were discussed with Dr. at 9:15 p.m. on via\n telephone.\n\n" }, { "category": "Radiology", "chartdate": "2154-01-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1164843, "text": " 2:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 48 cm Picc placed in right basilic vein, need Picc tip place\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 48 cm Picc placed in right basilic vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line.\n\n FINDINGS: In comparison with study of , the right subclavian PICC line\n extends to the lower portion of the SVC. This information was discussed by\n the resident on call with the IV nurse.\n\n There are lower lung volumes with mild atelectatic changes at the bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-01-01 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1164464, "text": " 12:42 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval Gastric bypass complication, leak, abscess. Please do\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with hx of gastric bypass now with diffuse worsening abd\n pain.\n REASON FOR THIS EXAMINATION:\n eval Gastric bypass complication, leak, abscess. Please do PO prep to eval\n leak, obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd TUE 5:26 PM\n 1. Uncomplicated pancreatitis could be related to cholelithiasis. No definite\n e/o cholecystitis or choledocholithiasis by CT. 2. Gastric bypss anatomy\n within normal limits, with patent anastomosis and no e/o G-G fistula. 3.\n Large wide bore ventral hernia containing small, large bowel, and portion of\n excluded stomach without obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old male with history of gastric bypass, presents with\n diffuse worsening abdominal pain. Question leak, abscess, or obstruction.\n\n COMPARISON: Ultrasound from same day.\n\n TECHNIQUE: MDCT images were acquired from the lung bases through the pubic\n symphysis following administration of intravenous contrast as well as a small\n amount of Gastrografin immediately prior to scanning. Multiplanar\n reformations were generated.\n\n CT ABDOMEN: With the exception of linear atelectasis or scarring in the left\n lung base, the lung bases are clear. There is no pleural effusion. The heart\n is normal in size without pericardial effusion.\n\n Fatty liver is better demonstrated on prior ultrasound. There is no\n intrahepatic biliary dilatation. The common duct is mildly prominent,\n measuring up to 7 mm. There is no evidence of choledocholithiasis. Splenic\n vein is patent. The gallbladder is mildly distended, containing multiple\n stones. There is no pericholecystic stranding to indicate inflammation. The\n spleen, adrenal glands appear within normal limits. Bilateral kidneys are\n miniscule in size, but demonstrate symmetric nephrograms without\n hydronephrosis or hydroureter.\n\n There is marked stranding around the mildly enlarged pancreatic head with\n associated thickening of Gerota's fascia, consistent with pancreatitis. There\n is no focal parenchymal non-enhancement to indicate necrosis. There is no\n abscess or pseudocyst formation. There is no evidence of or arterial\n pseudoaneurysm or venous thrombosis.\n\n Patient is status post gastric bypass. There is contrast material within the\n gastric pouch, passing into proximal Roux limb via a patent anastomosis.\n There is no contrast opacifying the excluded portion of the stomach. Note is\n (Over)\n\n 12:42 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval Gastric bypass complication, leak, abscess. Please do\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n made of a large wide-necked left hemi-abdominal ventral hernia, containing\n loops of small and large bowel, as well as portion of the excluded stomach.\n There is no evidence of obstruction. There is no free air or extraluminal\n contrast.\n\n Great vessels are patent and normal in caliber. An IVC filter is in expected\n location. Small mesenteric and retroperitoneal lymph nodes do not meet CT\n size criteria for pathologic enlargement.\n\n CT PELVIS: The bladder, distal ureters, rectum, and prostate appear\n unremarkable. There is no inguinal or pelvic lymphadenopathy. There is no\n free fluid within the pelvis.\n\n BONE WINDOW: No focal concerning lesion.\n\n IMPRESSION:\n 1. Findings consistent with uncomplicated acute pancreatitis.\n 2. Cholelithiasis without definite evidence of cholecystitis or\n choledocholithiasis.\n 3. Large ventral hernia containing loops of collapsed small and large bowel\n loops as well as a portion of the excluded stomach without evidence of\n obstruction.\n 4. Unremarkable post-gastric bypass anatomy with patent Roux limb and no\n evidence of gastro-gastric fistula.\n\n Findings reported to Dr. , RAGAVAN verbally at 4:30 on .\n\n" }, { "category": "Radiology", "chartdate": "2154-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164466, "text": " 12:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with abd pain\n REASON FOR THIS EXAMINATION:\n evaluate for free air\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Abdominal pain, evaluate for free air.\n\n COMPARISON: CXR .\n\n FINDINGS: A single upright portable view of the chest was obtained. Again\n seen is a 6-mm right upper lobe calcified granuloma. The lungs are well\n expanded and clear without focal consolidation, effusion or pneumothorax.\n Linear atelectasis is seen at the right lung base. The cardiomediastinal\n silhouette is unremarkable. The osseous structures are intact. No free air\n is seen below the diaphragm.\n\n IMPRESSION: No free air.\n\n" }, { "category": "Radiology", "chartdate": "2154-01-01 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1164477, "text": " 1:46 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for cholecystitis, cbd stone\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with abd pain, elevated lfts\n REASON FOR THIS EXAMINATION:\n eval for cholecystitis, cbd stone\n ______________________________________________________________________________\n WET READ: MDAg TUE 2:43 PM\n fatty liver. gallstones without wall edema or pericholecystic fluid. CBD not\n dilated at 5mm. Pancreas not well seen due to bowel gas.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Abdominal pain, elevated LFTs.\n\n COMPARISON: Ultrasound .\n\n FINDINGS: The study is significantly limited by patient's body habitus. Again\n seen is diffuse increased echogenicity of the liver, unchanged from prior\n study. Doppler assessment of the main portal vein demonstrates patency with\n normal hepatopetal flow. There is no intrahepatic biliary duct dilatation.\n The gallbladder demonstrates multiple stones without distention, wall edema or\n pericholecystic fluid. Son sign is negative. The common duct\n is not dilated, measuring 5 mm. No stone is seen in the visible duct. Limited\n views of the right kidney are unremarkable. The pancreas is not well\n visualized due to overlying bowel gas. The spleen is unremarkable measuring\n 12 cm. No ascites is seen.\n\n IMPRESSION:\n 1. Cholelithiasis without findings of cholecystitis or choledocholithiasis.\n 2. 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" }, { "category": "ECG", "chartdate": "2154-01-01 00:00:00.000", "description": "Report", "row_id": 191415, "text": "Sinus rhythm. Non-specific anterolateral ST-T wave changes. Compared to the\nprevious tracing of anterolateral ST-T wave changes are new.\nClinical correlation is suggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532024, "text": "7am-13 update\npt alert and orientated x 3. MAE and able to follow commands. pt very HOH - hearing aide in right ear only. pt given percocet x 1 for c/o back pain. pt remains NSR, occasional PAC noted. HR 60-80's. SBP 90-160's. MAP 60-100's. nitro gtt titrated for BP control. pt given 5 mg iv lopressor x 1 and started on Lopressor PO - tolerating well. CI > 2.0. PA line dc'd and introducer left intact. pt with 2 A wires and 2 V wires. A wires capturing and sensing appropiately -> temp pacer on AAI at 60. V wires sensing appropiately, V wires do not capture appropiately. PP by doppler. hct stable. LS clear with dim bases bil. pt remains on 5 L nc, o2 sats 93-97%. pt with weak cough. pt using IS to 250. Pt OOB to chiar with 2 assist. with OOb to chiar -> CT drained 270 cc's serousanginous fluid ( ). CT with no airleak noted. pt with + hypoactive bs. pt tolerting clears. able to take pills with water without difficulty. foley draining clear yellow urine. UO adequate. pt started on lasix. pt continue on vanco, cipro and flagyl.\n\nplan: pulm toliet, pain management, BP control, continue antibiotics, monitor lyres, continue with duiresis\n" }, { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532025, "text": "Neuro: A&O x3, calm & cooperative, hard of hearing, hearing aide in R ear only; MAE's, follows commnad consistently\n\nCV: SR 70's at first, went into rapid afib 130's @ ~ 1500, 150 mg IV amio bolus given, rate slowed down to 100's-110's, started on PO amio 400mg , 1st dose given @ 1615; SBP 130's @ fisrt, on NTG gtt 0.5, SBP decreased 90's-100's during afib, NTG gtt off; PO lopressor changed to 25mg TID; Mg repleted\n\nResp: Lung sound clear, dim @ bases bilat; weak cough, non-productive; IS ~250, needs constant intrustion on how to use IS; originally on 3L NC, sat >92%, desat to 91% after afib started & went back to bed, O2 increased to 5L, sat 94%-96%; CT to suction, draining moderate amount serous drainage, -leak, -crepitus\n\nGI: Abd soft, hypo bowel sound; tolerating clear liquid, pt with poor appetite\n\nGU: Foley draining minimal amount clear yellow urine\n\nInteg: Intact; sternal drsg drainage, marked\n\nPain: c/o pain @ L lower back, managed with PO percocet with moderate effect\n\nActivity: Back to bed from chair with 2 assist, tolerated well\n\nPlan: monitor hemodynamics; monitor lytes; pain management; f/u with general surgery for plan for pt; pulm toilet; inc activity as tolerated per cardiac rehab; ABX treatment\n" }, { "category": "Nursing/other", "chartdate": "2153-10-29 00:00:00.000", "description": "Report", "row_id": 1532018, "text": "Resp Care\nPt from OR s/p CABG x 3. Pt remains intubated. Current vent settings: A/C 500 x 12 50% 5/5. Current ABG: 7.41/34/112/22. Pt placed on CPAP 10/5, but did not tolerate. Plan is to continue to try and wean to extubate. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532026, "text": "Addendum:\n2A 2V wires attached to pacer, pacer turned off d/t pacing inappropriately\n" }, { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532027, "text": "Addendum\n1800 pt continue to have hypotension, MD aware, 500 ml NS fluid bolus MD , continue to have afib 100's; lasix dose held for now, team aware of low UO; SBP slightly improved to 90's-100's after fluid bolus\n" }, { "category": "Nursing/other", "chartdate": "2153-10-31 00:00:00.000", "description": "Report", "row_id": 1532028, "text": "ROS:\n\nNeuro: A+O x's 3. MAE x's 4. Denies pain other then when coughing. Pain meds offered and refused. PERRLA\n\nCV: Afib rate 90's->120. Amio bolus given, metoprolol 2.5 mg iv x's 2 in addition to po metoprolol. VSS. Peripheral pulses in LE via doppler. Palpable in UE. Has RIJ cath. Sternal drsg w/scant old drng. Mediastinal drsg . Left lower leg drsgs removed and left open to air, no drng, sites intact w/steri strips. Ace wrap to LLE. Has 2 A and 2 V wires, sense and capt not checked d/t AFib. Has 2 Medistinal and 1 left pleural chest tubes to 20 cm of sx draining thin serosang fluid, dumped 150cc x's 1 hr w/repositioning, E. Nillson .\n\nResp: O2 5L NP. Sats 93->98%. Lungs clear. No resp distress noted, = rise and fall of chest. C+DB well, pulls ~ 300cc w/IS.\n\nGI: Abd soft w/active BS. H2 blocker for GI prophylaxis.\n\nGU: Foley patent draining clear yellow urine in marginal amt, E. Nillson . 1800 dose of lasix held last evening d/t hypotension.\n\nEndo: RSSI\n\nLytes: IC and Mag repleted.\n\nSocial: no contact this shift from family or friends.\n\nPlan: Mobilize. Pulmonary toileting. Rate and rhythm control. Monitor, tx, support, and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-29 00:00:00.000", "description": "Report", "row_id": 1532019, "text": "1200-1900:\nneuro: pt received from or s/p cabg x 3. sedated on propofol gtt, body temperature warmed and pt reversed per protocol. pupils pinpoint. following commands. morphine prn pain with good effect. very hard of hearing.\n\ncv: sb 50's, underlying. apaced at 88 for hemodynamic support. ci low initially, treated with volume. fick ci > 2.5. mixed venous 69. remains on amidarone gtt for svt post bypass. no ectopy noted. remains on nitro gtt to maintain map < 90. dopplerable pedal pulses bilaterally.\n\nresp: lungs clear, diminished bilateral bases. remains orally intubated on simv 50%, 500 x 12, peep 5. rr 20's. no secretions noted. abg wnl. ct to 20 cm sxn, no airleak. minimal drainage.\n\ngi/gu: abd soft, nd. bs absent. ogt to lws. lft's pending. foley to gravity, good huo. cr wnl.\n\nendo: regular insulin gtt started and titrated per protocol.\n\nplan: monitor hemodynamics, wake and wean.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532020, "text": "Skin: Sternal drsg w/scant old drng. Mediastinal drsg . Left groin and leg drsgs w/old drng sm drng. Back side neck to buttox w/scattered petechia, team aware.\n\nAmio gtt dc'd at 0645\n" }, { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532021, "text": "Skin: Sternal drsg w/scant old drng. Mediastinal drsg . Left groin and leg drsgs w/old drng sm drng. Back side neck to buttox w/scattered petechia, team aware.\n\nAmio gtt dc'd at 0645\n" }, { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532022, "text": "ROS:\n\nNeuro: A+O x's 3. MAE x's 4 to command. Pain mngt w/MSO4 and percocet w/fair effect. PERRLA. Extremly HOH making communication difficult at the best.\n\nCV: RSR w/o ectopy. Has 2 A and 2 V epicardial pacing wires, both sense and capture. Ntg gtt on and titrated to maintain MAP 60-90. Peripheral pulses palpable. Has right radial abp line. Has RIJ triple lumen trauma line w/PA line. CO 4.1 w/CI > 2.0 See flow record for detailed hemodynamic. Has 2 mediastinal and 1 left pleural chest tube to 20cm sx draining serosang fluid. CT out put ^ after extubation x's several hours, then decreases.\n\nResp: Lungs clear, O2 4 L NP. No resp distress noted, = rise and fall of chest. C+DB well. Chest tubes as noted above.\n\nGI: OG dc'd w/extubation. Abd soft w/o bowel sounds. H2 blocker to start this AM for GI prophylaxis.\n\nGU: foley patent draining clear amber urine in marginal amts.\n\nEndo: Insulin gtt titrated per CSRU protocol\n\nLytes: IC and K repleted w/good report.\n\nSocial: Son called for up date will be in after 11AM\n\nPlan: Pulmonary toileting. Start B blockers, Wean NTG. Wean insulin gtt as able. Deline. Monitor, tx, support, and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2153-10-30 00:00:00.000", "description": "Report", "row_id": 1532023, "text": "Resp: pt on psv 10/5/50% Ett 7.0 20 @ lip. Alarms on and functioning. Ambu/syringe @ hob. Bs are clear bilaterally. Wean psv to 5, abg's (see carview) notable cuff leak then extubated without incident. Placed on 4 lpm n/c.\n" }, { "category": "Echo", "chartdate": "2153-10-29 00:00:00.000", "description": "Report", "row_id": 70023, "text": "PATIENT/TEST INFORMATION:\nIndication: cabg\nStatus: Inpatient\nDate/Time: at 09:37\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Simple atheroma in aortic root. Normal\nascending aorta diameter. Simple atheroma in ascending aorta. Normal\ndescending aorta diameter. There are complex (>4mm) atheroma in the descending\nthoracic aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened aortic valve\nleaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The TEE probe was passed with assistance from the\nanesthesioology staff using a laryngoscope. The patient was under general\nanesthesia throughout the procedure.\n\nConclusions:\nPre-CPB: No spontaneous echo contrast is seen in the left atrial appendage.\nLeft ventricular wall thicknesses and cavity size are normal. Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the aortic root. There are simple atheroma in the ascending aorta.\nEpi-aortic scan showed no focal lesions. There are complex (>4mm) atheroma in\nthe descending thoracic aorta. There are 3 aortic valve leaflets with good\nleaflet excursion. The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. There is no pericardial effusion.\nPost-CPB: Preserved biventricular systolic fxn. Trivial MR, no AI. Aorta\nintact. Other parameters as pre-bypass.\n\n\n" }, { "category": "Echo", "chartdate": "2153-10-27 00:00:00.000", "description": "Report", "row_id": 70024, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pre-op CABG\nHeight: (in) 61\nWeight (lb): 129\nBSA (m2): 1.57 m2\nBP (mm Hg): 140/89\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 12:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Hyperdynamic LVEF. TVI E/e' < 8, suggesting\nnormal PCWP (<12mmHg).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Physiologic TR. Normal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1.The left atrium is mildly dilated. The left atrium is elongated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%). Tissue velocity\nimaging demonstrates an E/e' <8 suggesting a normal left ventricular filling\npressure (PCWP<12mmHg).\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The ascending aorta is mildly dilated. The aortic arch is mildly dilated.\n5.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen.\n6.The mitral valve leaflets are structurally normal. Trivial mitral\nregurgitation is seen.\n7.The estimated pulmonary artery systolic pressure is normal.\n8.There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2153-10-25 00:00:00.000", "description": "Report", "row_id": 151083, "text": "Sinus rhythm with an atrial premature beat. Since the previous tracing\nof there are fewer atrial premature beats. Otherwise, as previously\nnoted.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2153-10-26 00:00:00.000", "description": "Report", "row_id": 151325, "text": "Sinus rhythm. Since the previous tracing no atrial premature beats are present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2153-10-24 00:00:00.000", "description": "Report", "row_id": 151326, "text": "Sinus rhythm\nShort P-R interval\nConsider inferior infarct - age undetermined\nSince previous tracing, probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2153-10-25 00:00:00.000", "description": "Report", "row_id": 151327, "text": "Atrial fibrillation with rapid ventricular response\nInferior/lateral ST-T changes\nSince previous tracing, atrial fibrillation new\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2153-10-25 00:00:00.000", "description": "Report", "row_id": 151328, "text": "Technically difficult study\nAtrial fibrillation with rapid ventricular response\nInferior/lateral ST-T changes\nSince previous tracing, the rate has decreased\n\n" }, { "category": "ECG", "chartdate": "2153-10-25 00:00:00.000", "description": "Report", "row_id": 151329, "text": "Sinus rhythm with PACs\nPossible inferior infarct - age undetermined\nSince previous tracing, sinus rhythm restored\n\n" }, { "category": "ECG", "chartdate": "2153-11-07 00:00:00.000", "description": "Report", "row_id": 151080, "text": "Sinus rhythm. Other than a somewhat more rapid rate, no diagnostic change\ncompared to the previous tracing of .\n\n" }, { "category": "ECG", "chartdate": "2153-10-29 00:00:00.000", "description": "Report", "row_id": 151081, "text": "Sinus bradycardia. Non-specific inferior T wave changes. Low QRS voltage in the\nprecordial leads. Compared to the previous tracing of frequent atrial\nectopy has resolved. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2153-10-27 00:00:00.000", "description": "Report", "row_id": 151082, "text": "Sinus rhythm with PACs\nInferior infarct - age undetermined\nLow QRS voltages in precordial leads\nSince previous tracing, no significant change except for atrial premature\ncomplexes\n\n" }, { "category": "Radiology", "chartdate": "2153-10-21 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 938522, "text": " 11:08 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: R/O ACUTE PATHOLOGY, CHOLECYTITIS, PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with mid-epigastric abdominal pain to back and nausea\n REASON FOR THIS EXAMINATION:\n r/o acute pathology including cholecystitis\n ______________________________________________________________________________\n WET READ: MJGe SUN 11:59 PM\n small gallstone. no evidence of cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Midepigastric abdominal pain, nausea.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in appearance and\n echotexture. No focal liver lesions or biliary ductal dilatation is\n identified. The gallbladder is not distended and contains a 6-mm freely\n movable gallstone. There is no gallbladder wall edema, pericholecystic fluid,\n or son sign to suggest cholecystitis. Common bile duct\n measures 3 mm, which is normal. The pancreas is not well visualized due to\n overlying bowel gas. The imaged portion of the right kidney is normal. There\n is no ascites.\n\n IMPRESSION:\n 1. Cholelithiasis without evidence for cholecystitis. No biliary duct\n dilatation.\n 2. Pancreas not well visualized due to overlying bowel gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-10-27 00:00:00.000", "description": "R FEMORAL VASCULAR US RIGHT", "row_id": 939306, "text": " 10:27 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: eval for fistula s/p cath\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with CAD s/p cath via right femoral approach, now with bruit\n on exam\n REASON FOR THIS EXAMINATION:\n eval for fistula s/p cath\n ______________________________________________________________________________\n WET READ: AKSb SAT 11:18 AM\n Superficial right groin hematoma. No pseudoaneurysm of the femoral artery.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post catheterization via right femoral approach, now with\n bruit. Evaluate for fistula.\n\n RIGHT GROIN ULTRASOUND: There is a superficial hematoma in the right groin\n measuring 1.7 x 2.8 x 1.1 cm. No abnormal vascularity in or around the\n hematoma. No evidence of aneurysm or pseudoaneurysm in the right femoral\n artery or vein. There are normal waveforms in these vessels.\n\n" }, { "category": "Radiology", "chartdate": "2153-10-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 939830, "text": " 4:55 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate pneumothorax\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABGx3\n REASON FOR THIS EXAMINATION:\n evaluate pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY, PA AND LATERAL VIEWS.\n\n INDICATION: Status post CABG. Assess for pneumothorax.\n\n COMPARISONS: .\n\n There has been interval removal of the endotracheal and NG tubes. There are\n multiple median sternotomy wires overlying the midline of the thorax. On the\n left side, there is a new small-to-moderate size pneumothorax. There is\n associated left-sided atelectasis. The right hemidiaphragm is elevated\n mildly. A left-sided pleural effusion cannot be excluded on this exam.\n\n IMPRESSION: New left-sided small-to-moderate pneumothorax.\n\n Findings were communicated to Dr. by Dr. on the telephone at\n approximately 5:20 p.m. on the date of the examination.\n\n" }, { "category": "Radiology", "chartdate": "2153-10-23 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 938794, "text": " 2:53 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: r/o sludge, choledocolithiasis, etc\n Admitting Diagnosis: PANCREATITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with ?gallstone pancreatitis\n REASON FOR THIS EXAMINATION:\n r/o sludge, choledocolithiasis, etc\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with pancreatitis, evaluate for gallstones, sludge.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the pancreas were\n obtained on a 1.5 Tesla magnet, including dynamic 3D imaging obtained prior\n to, during, and after the intravenous administration of 0.1 mmol/kg of\n gadolinium-DTPA.\n\n COMPARISON: Findings are compared with prior liver/gallbladder ultrasound\n dated .\n\n Multiplanar 2D and 3D reformations as well as subtraction images were\n essential in demonstrating multiple perspectives for this dynamic series.\n Nonbreathhold imaging technique was utilized.\n\n FINDINGS:\n Evaluation of the lung bases demonstrates left lower lung atelectasis with a\n small amount of overlying fluid. The liver is normal in size and morphology.\n There is no intra- or extra- hepatic biliary dilatation, with the common bile\n duct measuring only 2 mm within the pancreatic head. There is no\n choledocholithiasis or CBD sludge. A small gallstone is visualized within the\n body of the gallbladder with a small amount of layering sludge. The\n gallbladder wall is slightly thickened. The pancreatic duct is unremarkable.\n There is slight enlargement of the pancreas with peripancreatic fluid. No\n peripancreatic collections are seen. There is normal enhancement of the\n pancreas without evidence for necrosis. Incidental note is made of three\n prominent duodenal diverticula arising from the second and third portion of\n the duodenum respectively.\n\n There is a 1-cm nodule within the right adrenal gland, incompletely\n characterized on this nontargeted examination. The left adrenal, kidneys, and\n spleen are unremarkable except for a simple left renal cyst.\n\n Evaluation of the abdominal aorta demonstrates a 4.0-cm infrarenal abdominal\n aortic aneurysm. There is no evidence for dissection or penetrating ulcer.\n The proximal extent of the aneurysm is 3 cm below the takeoff of the renal\n arteries, and the distal extent is 1.7 cm above the iliac bifurcation.\n\n There is a marked levoscoliosis with apex at L2/3.\n\n Multiplanar 2D as well as 3D reformations and subtraction images were\n (Over)\n\n 2:53 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: r/o sludge, choledocolithiasis, etc\n Admitting Diagnosis: PANCREATITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n essential in demonstrating multiple perspectives for this dynamic series.\n\n IMPRESSION:\n 1. Nondilated common bile duct and pancreatic duct without evidence for\n intrluminal stones or sludge. There is an enlarged, edematous pancreas\n compatible with mild pancreatitis. Single small gall stone and layering\n sludge; gallbladder wall edema likely from pancreatitis.\n\n 2. Three prominent duodenal diverticulum seen surrounding the head of the\n pancreas.\n\n 3. 4.0-cm infrarenal abdominal aortic aneurysm that does not extend into the\n iliac bifurcation.\n\n 4. Incompletely characterized 1-cm right adrenal nodule.\n\n" }, { "category": "Radiology", "chartdate": "2153-11-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 940430, "text": " 9:55 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate pleural effusion - please do early this am thank yo\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABGx3\n\n REASON FOR THIS EXAMINATION:\n evaluate pleural effusion - please do early this am thank you\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS.\n\n INDICATION: 84-year-old woman status post CABG, evaluate pleural effusion.\n\n CHEST, TWO VIEWS: Comparison is made to prior examination of . The\n lung volumes are low. The heart size is difficult to evaluate in the presence\n of bilateral pleural effusions. These are stable. A small left\n hydropneumothorax is noted. This is somewhat decreased in size. The\n pulmonary vasculatures is normal.\n\n IMPRESSION:\n 1. Small loculated hydropneumothorax on the left is decreased in size.\n\n 2. Moderate bilateral pleural effusions are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-11-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 940005, "text": " 4:28 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p MT removal still has left pleural tube - evaluate pneumo\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABGx3 ? rt sided ptx\n\n REASON FOR THIS EXAMINATION:\n s/p MT removal still has left pleural tube - evaluate pneumothorax and effusion\n left side\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of CABG.\n\n Status post CABG. Chest tube is present in the left lower hemithorax. There\n is a persistent small left pneumothorax with atelectasis in the left upper,\n mid, and lower zones. Small left pleural effusion. Elevation right\n hemidiaphragm with associated atelectasis at right lung base.\n\n IMPRESSION: Persistent small left pneumothorax. Linear/discoid atelectasis\n left lung. Atelectasis right lung base with elevated right hemidiaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2153-11-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 940152, "text": " 6:00 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for pneumothorax s/p chest tube removalFYI (aortic\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABGx3\n\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax s/p chest tube removalFYI (aortic notch with known\n calcification)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG and chest tube removal.\n\n PA and lateral chest x-ray dated at 18:01 is compared to the same\n examination from 4 hours earlier.\n\n The patient is status post median sternotomy and CABG, and the median\n sternotomy wires and CABG clips are stable. The left lung base chest tube has\n been removed. There is stable appearance of left pneumothorax with left lung\n base subsegmental atelectasis. There is some linear atelectasis noted at the\n right lung base. The right pleural effusion is stable. The cardiomediastinal\n and hilar contours are stable.\n\n IMPRESSION: Status post left chest tube removal with unchanged appearance of\n left pneumothorax. Stable appearance of the cardiomediastinal silhouette and\n lung fields.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-10-22 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 938757, "text": " 11:29 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: R/O CBD stones.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with abd pain and vomiting with elevated LFTs and amylase and\n lipase concerning for GS pancreatitis.\n ERCP performed , req sent \n REASON FOR THIS EXAMINATION:\n R/O CBD stones.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with abdominal pain, vomiting and elevated LFT\n and amylase and lipase concerning for gallstone pancreatitis. Evaluate with\n ERCP for CBD stones.\n\n ERCP:\n\n Five fluoroscopic spot film images were obtained without a radiologist\n present. There is no contrast entering the biliary tree consistent with\n reported history of inability to cannulate the common bile duct. The\n pancreatic duct is opacified demonstrating no filling defects or evidence of\n stricture.\n\n IMPRESSION:\n\n 1. Nonvisualization of the common bile duct.\n\n 2. Normal-appearing pancreatic duct.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-10-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 939848, "text": " 7:38 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess ptx\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABGx3 ? rt sided ptx\n\n REASON FOR THIS EXAMINATION:\n assess ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of pneumothorax in a patient after recent\n CABG.\n\n PA and lateral upright chest radiograph compared to .\n\n The left new small to moderate sized pneumothorax is demonstrated in both PA\n and lateral view is slightly decreased comparing to the previous film, which\n is better demonstrated on the lateral view. The bilateral small pleural\n effusion is unchanged. The right lung and the left upper lung is\n unremarkable. The left lower lobe retrocardiac atelectasis is again\n demonstrated. Mediastinal drains and left chest tube are in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-10-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 939509, "text": " 12:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with CAD s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CABG.\n\n Status post CABG. Endotracheal tube is 3 cm above carina. Tip of Swan-Ganz\n catheter overlies proximal right main pulmonary artery. Mediastinal and\n bilateral chest tubes in situ. NG tube is in stomach with distal end not\n included on film. No pneumothorax. There is a small left pleural effusion\n and opacity consistent with atelectasis in the left lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-11-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 940130, "text": " 1:52 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate pneumo\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABGx3\n REASON FOR THIS EXAMINATION:\n evaluate pneumo\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of CABG.\n\n Chest tube is present in the left lower hemithorax. There is a persistent\n small left pneumothorax, essentially unchanged since the prior study of\n . Linear atelectases are again noted in the left mid and\n lower zones as well as a right pleural effusion with associated atelectasis as\n previously demonstrated. A somewhat unusual appearance of the aortic knuckle\n in the PA film is of uncertain etiology and suggest revaluate on followup with\n oblique views to determine if any further workup such as CT as indicated.\n\n IMPRESSION: Unchanged left pneumothorax and left lung atelectases. Unchanged\n right pleural effusion. Unusual appearance of aortic knuckle in PA film as\n described. Oblique films may be helpful to further evaluate and determine if\n CT as indicated.\n Discussed by telephone with Dr \n\n" }, { "category": "Radiology", "chartdate": "2153-11-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 940205, "text": " 9:16 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate pneumothorax\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABGx3\n\n REASON FOR THIS EXAMINATION:\n evaluate pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, .\n\n HISTORY: Status post CABG.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small loculated left hydropneumothorax has decreased in overall volume and\n contains slightly more fluid than it did on . Cardiac apex is\n obscured. Remainder of the mediastinum is unchanged, including a generally\n large and tortuous thoracic aorta. Elevation of the right lung base is\n longstanding and view only in part to a small right pleural effusion,\n partially fissural. The upper lungs are clear. There is no right\n pneumothorax.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2126-05-01 00:00:00.000", "description": "Report", "row_id": 1310818, "text": "S/MICU Nursing Progress Note\n Pt is a y/o woman admitted for close observation after endoscopy finding an ulcer with clot over site, injected with epi.\n\n GI: abd soft with bs passing black tarry stools x3 tonight, some episodes of N/bleching. hct stable at 35-36 last one done at 4am Will need one drawn at 8-10 am this morning. Last stool at 6am melena, melena smelling. no change in VS. Pt does have 2 #18 angios in the left arm. NPO\n Cardiac: HR 70-80's NSR, BP inially 190-200/80's but once asleep down to 140-160/60's\n Respiratory: on Nasal cannula at 2liters O2 sat 99-100% lungs clear.\n Plan: if hct stable today may be transferred to med floor. will follow hct q4-6 hr till afternoon.\n" } ]

[ { "category": "Echo", "chartdate": "2175-01-17 00:00:00.000", "description": "Report", "row_id": 99800, "text": "PATIENT/TEST INFORMATION:\nIndication: Imaging during ethanol ablation\nHeight: (in) 65\nWeight (lb): 332\nBSA (m2): 2.46 m2\nBP (mm Hg): 164/66\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: Optison\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nThere is left ventricular hypertrophy with prominent interventricular septum\n(at least 30 mm thick at its base). (Parasternal views not obtained for\nstandard wall thickness measurements.\n\nOn baseline imaging, a resting left ventricular outflow gradient of at least\n26 mmHg was recorded. However the baseline survey was limited, so this is\nlikely an underestimate of the baseline gradient.\n\nWith injections of Optison into the first septal perforator , there was\nenhancement of the basal septum including the most prominent portion of the\nleft ventricular outflow obstruction at point of contact with the tip of the\nanterior mitral leaflet.\n\nEnhancement of the same basal septal region was noted following ethanol\ninjection into the septal perforator (3 injections total of 1cc each). The\nbasal septum appeared enhanced and hypokinetic following these injections and\nthere was no signfiicant residual left ventricular outflow gradient recorded\n(peak left ventricular outflow velocity of 1 m/s).\n\n\n" }, { "category": "Echo", "chartdate": "2175-01-06 00:00:00.000", "description": "Report", "row_id": 99692, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. CMP\nHeight: (in) 65\nWeight (lb): 341\nBSA (m2): 2.48 m2\nBP (mm Hg): 133/73\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 11:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Asymmetric LVH. Hyperdynamic LVEF >75%. Moderate resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial 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 moderately dilated. The right atrium is moderately dilated.\nThere is asymmetric left ventricular hypertrophy. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). There is a moderate resting left\nventricular outflow tract obstruction. Right ventricular chamber size and free\nwall motion are normal. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Asymmetric LVH with hyperdynamic systolic function, c/w\nhypertrophic cardiomyopathy. Moderate resting LVOT obstruction. Mild pulmonary\nhypertension.\n\nCompared with the prior study (images reviewed) of , measured LVOT\ngradient is lower. The other findings are similar.\n\n\n" }, { "category": "ECG", "chartdate": "2175-01-12 00:00:00.000", "description": "Report", "row_id": 284244, "text": "Sinus rhythm. Left ventricular hypertrophy. Inferolateral ST-T wave\nabnormality secondary to left ventricular hypertrophy. Compared to the previous\ntracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2175-01-05 00:00:00.000", "description": "Report", "row_id": 284245, "text": "ECG interpreted by ordering physician.\n see corresponding office note for interpretation.\n\n" }, { "category": "ECG", "chartdate": "2175-01-20 00:00:00.000", "description": "Report", "row_id": 284240, "text": "Sinus rhythm. A-V conduction delay. Right bundle-branch block. T wave\ninversions in lateral precordial leads. Cannot exclude myocardial ischemia.\nCompared to the previous tracing T wave inversions in leads V5-V6 are just as\nthey are in the inferior leads. The other findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2175-01-18 00:00:00.000", "description": "Report", "row_id": 284241, "text": "Sinus rhythm. Leftward axis. Right bundle-branch block. Since the previous\ntracing the axis is less leftward. Q-T interval prolongation and ST-T wave\nabnormalities persist. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2175-01-17 00:00:00.000", "description": "Report", "row_id": 284242, "text": "Sinus rhythm. Left anterior fascicular block. Right bundle-branch block.\nST-T wave abnormalities. Since the previous tracing of earlier on there\nis less artifact. Otherwise, findings are probably unchanged except that\nthe lateral precordial lead voltage is less prominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2175-01-17 00:00:00.000", "description": "Report", "row_id": 284243, "text": "Baseline artifact. Sinus rhythm. Borderline P-R interval prolongation. Left\naxis deviation. Left anterior fascicular block. Right bundle-branch block.\nQ-T interval prolongation. Since the previous tracing of the axis is\nmore leftward. QRS voltage is less prominent in the limb leads. Right\nbundle-branch block pattern is new with marked ST-T wave abnormalities.\nClinical correlation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2193-02-14 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 953674, "text": " 11:49 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: needs PICC access\n Admitting Diagnosis: DELERIUM\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with delirium, fungal infection\n REASON FOR THIS EXAMINATION:\n needs PICC access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 62-year-old woman with delirium and fungal infection, requiring\n intravenous access for antibiotics. Double lumen PICC requested.\n\n TECHNIQUE: PICC line placement.\n\n RADIOLOGISTS: The procedure was performed by Dr. , Dr. \n , and Dr. . Dr. , the attending radiologist, was\n present and supervising throughout the procedure.\n\n PROCEDURE AND FINDINGS: Using ultrasound, two brachial veins were found to be\n patent and compressible, as well as a patent basilic vein and at least one\n additional vein along the medial right upper arm. The left upper arm was\n prepped and draped in the usual sterile fashion. A pre-procedure timeout was\n performed to verify patient identity and the procedure to be performed. 10 cc\n of 1% lidocaine was applied locally for anesthesia.\n\n Using direct ultrasound visualization, the basilic vein was accessed using a\n 21-gauge needle. A 0.018 guide wire was passed easily into the vein distally.\n The wire, however, would not pass proximally by more than approximately 5-6 cm\n and appeared to enter multiple branching veins at that level, but would not\n pass into the proximal circulation. Accordingly, a small brachial vein was\n instead chosen for access, and again under direct ultrasound visualization,\n the more medial brachial vein was accessed using a 21-gauge needle. Initial\n passage of the wire into the vein was somewhat difficult, so a limited\n venogram was performed via the needle with gentle hand injection of 5 cc of\n Optiray-320, which showed two patent and straight brachial veins, the medial\n vein larger than the lateral brachial vein.\n\n A 0.018 nitinol wire was then readily passed into the left axillary vein, but\n initially would not pass more proximally. The needle was exchanged for a\n micropuncture sheath. Via the sheath, a 0.018 glidewire was used to pass into\n the superior vena cava under fluoroscopic guidance. The inner dilator of the\n sheath was removed, and a 5-French double- lumen PICC line was advanced into\n the left axillary vein, at which point there was some resistance. Accordingly,\n an additional limited venogram was performed via the sheath with hand\n injection of 10 cc of Optiray 320, which demonstrated patency of the left\n axillary and subclavian veins, but also showed collateral vessels and\n (Over)\n\n 11:49 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: needs PICC access\n Admitting Diagnosis: DELERIUM\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n significant narrowing of the distal left subclavian vein. The left axillary\n vein was also small in caliber. The left axillary and subclavian veins,\n however, appeared wide enough to accept a PICC line, and there were no abrupt\n turns in the pathway of access. Accordingly, it was again attempted to pass\n the PICC line into the central circulation over the glidewire, and on second\n attempt, this occurred easily without resistance, using fluoroscopic guidance.\n The sheath and guidewire were removed.\n\n A final fluoroscopic spot image shows that the 46-cm length double-lumen 5-\n French Vaxcel PICC line terminates in the distal superior vena cava. Hard\n copy ultrasound images were obtained of the left brachial vein, which was\n accessed both prior to and following obtaining access, demonstrating venous\n patency. Each catheter port was flushed, and the PICC line was secured to the\n adjacent skin using a StatLock device. The site was dressed with a Tegaderm.\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION:\n 1. Successful placement of double-lumen PICC line, via a left brachial vein,\n terminating in the superior vena cava. Ready for use.\n\n 2. Limited venography by hand ejection showing significant narrowing of the\n left axillary and distal veins, with evidence of collateral circulation.\n\n\n" }, { "category": "Echo", "chartdate": "2193-02-18 00:00:00.000", "description": "Report", "row_id": 64760, "text": "PATIENT/TEST INFORMATION:\nIndication: candidemia. Endocarditis\nHeight: (in) 66\nWeight (lb): 180\nBSA (m2): 1.91 m2\nBP (mm Hg): 198/61\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 15:48\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nLipomatous hypertrophy of the interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Symmetric LVH. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was monitored by a nurse throughout the\nprocedure. Local anesthesia was provided by benzocaine topical spray. The\npatient was sedated for the TEE. Medications and dosages are listed above (see\nviscous lidocaine. No TEE related complications. 0.1 mg of IV glycopyrrolate\nwas given as an antisialogogue prior to TEE probe insertion. The patient\nappears to be in sinus rhythm.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. There is symmetric\nleft ventricular hypertrophy. Overall left ventricular systolic function is\nnormal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. There are complex (>4mm) atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. No masses or vegetations are seen on the aortic valve. The\nmitral valve appears structurally normal with trivial mitral regurgitation. No\nmass or vegetation is seen on the mitral valve. The tricuspid valve leaflets\nare mildly thickened. There is no pericardial effusion.\n\nNo vegetation seen.\n\nCatheter seen entering right atrium via the SVC. The catheter tip visibile in\nthe right atrium near the tricuspid valve (contact with valve not clearly\ndocumented). Would consider pullback of catheter to RA/SVC junction if\nclinically indicated.\n\n\n" }, { "category": "Echo", "chartdate": "2193-02-15 00:00:00.000", "description": "Report", "row_id": 64761, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 67\nWeight (lb): 180\nBSA (m2): 1.94 m2\nBP (mm Hg): 124/50\nHR (bpm): 61\nStatus: Outpatient\nDate/Time: at 15:54\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild thickening of mitral valve chordae. Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No masses or vegetations are seen on the aortic\nvalve. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. No mass or vegetation is seen on the mitral valve. Trivial mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: No valvular vegetations seen. If clinically indicated, a TEE may\nbe better to exclude a small valvular vegetations/endocarditis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-02-13 00:00:00.000", "description": "Report", "row_id": 1609378, "text": "NPN Days 0700-1900\nPt had extremely difficult day w no break in her delerium.Hallucinating, frequent grimacing and yawning, rigidity of extremities. Haldol d/c'd ? negative impact on limb rigidity. Pt started on Precedex @ 1330 in attempt to comfortably sedate enough for trip to CT for head with contrast.\nNeuro: MAE, afebrile today. Remains delerious, intermittently agitated and hallucinating\nCV: ST, difficult to obtain accurate BP's agitation. See carevue for objective data.\nResp: Pt satting in high 90's on RA; LSCTAB\nGI: NPO aspiration risk delirium. RISS, see . No bm this shift, believed to have not had a bm for several days.\nGU: foley patent, draining clear yellow urine at >50cc/hr\nSkin: R shin lesion was biopsied yesterday by derm, came to assess today--CDI. R chest lesion Hickman removal , dressing intact, draining serosangious fluid in small amt.\nSocial: husband has already been in and spoken with team\nPlan: Continue to seek good sedation\n PICC placement in IR tomorrow\n Safety\n Head CT w/ contrast if agitation ceases and PIV remains patent\n" }, { "category": "Nursing/other", "chartdate": "2193-02-14 00:00:00.000", "description": "Report", "row_id": 1609379, "text": "Ms is 62 yo female with multiple medical problems, including metastatic thyroid cancer s/p radiation; spinl arachnoiditis, chronic pain syndrome on morphine PCA before and now presents with UTI, fungemia (7/8 bottles from all drawn from hickman grew out ) and altered mental status ( somnolence, agitation, hallucination).\n\nNeuro: Patient was dangerously agitated at start of shift, Haldol 5 mgs given with poor effect, clamed down for only 10-20 mins; patient is not on precedex sedation this time, extra dose requested from pharmacy. Climbing out of bed, kicking staff, moving all extremeties with rigid clenched fist; tense muscle, sweating. awake open eyes when name is loudly called, follows to simple command ( open eyes/ open mouth )but unable to assess orientation, doesn't follow through a conversation; appears to be looking and responding to stimuli not present in the room; incomprehensible and inappropriate words; Can be distracted with verbal stimuli but very poor attention span. High risk for fall, on restraints ( waist and both legs and R arm ) Pupils 2mm equal and briskly reactive. Precedex 0.9 mcgs/kg/hr restarted 2100 titrated up to maintain RAS 3; given Zyprexa 10mgs PO, tolerated well; Able to sleep comfortably since 2200 upto this time; CAT scan of head with contrast done 0030 no extra sedation needed during procedure; off of precedex sedation since 0100\n" }, { "category": "Nursing/other", "chartdate": "2193-02-12 00:00:00.000", "description": "Report", "row_id": 1609375, "text": "NPN Days 0700-1900\nNeuro: Pt continues to experience hallucinations and flight of ideas with intermittent, brief periods of improved mental clarity. Intermittent tremors, hand clenching observed. Rec'd Haldol 2.5mg IV this am but has not required additional sedation as she is cooperative and can be calmed. Remains in posey restraint with soft wrist restraints applied when RN not at bedside as pt is still at risk for OOB/fall. Rec'd 5mg morphine PO for c/o neck/back pain with good effect. MAE. Afebrile\nCV: NSR with HR 75-95. Difficult to assess ectopy near continuous UE activity. BP's 132-168/48-86. Repleted with 40mEq PO K and 3gm Mg Sulfate IV. Also rec'd FFP x2units INR=2.2 and scheduled removal of Hickman at bedside. Pt has denied any CP.\nResp:RR in teens, pt maintaining O2sats>95% on RA. LSCTAB/L\nGI/Endo: Abd s/nt; has been NPO but will be eating dinner. No BM today; husband reports that pt has not had BM in recent days @ . Remains on RISS as pt is .\nGU: Foley changed for a second time today as pt pulled urimeter apart from catheter this am. Patent foley draining clear light yellow urine @ consistently >100cc/hr\nSkin: 2cm x2cm shiny pink lesion on R shin biopsied by Derm this pm, awaiting result.\nSocial: Husband in to visit, remains concerned about the duration of her confused mental state\nPlan: Monitor and support hemodynamic/coagulation status\n RISS\n Reorient PRN, safety\n Monitor sutured site of Hickman removal for drainage, change dressing PRN as per surgeon Dr \n Replete lytes prn\n Monitor swallow esophageal thickening\n Encourage T/C/DB\n Emotional support\n" }, { "category": "Nursing/other", "chartdate": "2193-02-12 00:00:00.000", "description": "Report", "row_id": 1609376, "text": "Addendum to Day note:\nID: pt remains on Cefepime q12h, Caspofungin q24\n" }, { "category": "Nursing/other", "chartdate": "2193-02-13 00:00:00.000", "description": "Report", "row_id": 1609377, "text": "NPN 1900 -0700\n\nNEURO: TO SUNDOWN AS SOON AS HUSBAND LEFT. STATED \" I NEED TO GO DOWNSTAIRS\".UNABLE TO RE ORIENT FOR MORE THAN A FEW MINUTES. PT WAS ATTEMPTING TO CLIMB OOB AND PULL AT IV. UP TO 5 MG HALDOL AS WELL AS 1 MG ATIVAN , AND HS SEROQUEL GIVEN W/ POOR EFFECT. PT RESTRAINED FOR SAFETY, WAS ABUSIVE TO STAFF, SCRATCHED AND KICKED NURSES. HALDOL ORDER WAS INCREASED, PT BECAME LESS VERBAL BUT CONT TRYING TO GET OUT OF RESTRAINTS, HALLUCINATING, UNABLE TO RE ORIENT.MSO4 GIVEN FOR BACK PAIN\n\nRESP: LCTA, 98% ON RA.\n\nC/V:ST RARE PVC'S ,BP STABLE, HYPERTENSIVE DURING AGITATION.\n\nF/E/N: UO ~ 60-80CC HR, ABLE TO TAKE PO'S, NO STOOL OVERNOC.\n\nPLAN: HALDOL FOR DELIRIUM, RESTRAINTS FOR SAFETY, C/O TO FLOOR WHEN BED AVAILABLE.\n" }, { "category": "Nursing/other", "chartdate": "2193-02-12 00:00:00.000", "description": "Report", "row_id": 1609374, "text": "NARRATIVE NOTE: PT WAS ADM HERE FROM REHAB WITH ALTERED MENTAL STATUS AND BLOOD CULTERS POS FOR YEAST. PT WAS TREATED AT FOR SUSPECTED INFECTION. PT HAS HAD HALLUCINATIONS FOR THE PAST WEEK. PAIN AND PSYCHOTROPHIC MEDS WERE STOPPED BUT MENTAL STATUS DID NOT IMPROVE. PT HAS VERY EXTENSIVE HX OF ANEMIA, CHF IN THE PAST, DIABETES, HTN, SEIZURES, MRSA ? LOCATION, METASTATIC THYROID CA, RLE CELLULITIS, NEUROGENIC BLADDER WITH SELF CATH, CHRONIC BACK PAIN, DEPRESSION, CHRONIC ARACHNOIDITIS, ESAPHAGEASL DYSMOTILITY, DVT, PE WITH IVC FILTER, CHRONIC UTI'S WITH PSEUDOMONAS/KLEBSIELLA, OSA, OA, RIGHT ANKLE GRAFT, S/P ERCP FOR RETAINED STONE, R THUMB CELLULITIS, SPLENIC CYST, OSTEOMYLETITIS ON R SECOND TOE.\n\nCV: B/P HAS RANGED FROM 128/90-197/69. NSR/ST WITH HR RANGING FROM 80-100 WITH THE OCC RARE PVC. PPP BUT WEAK BIL. CURRENTLY LYTES PENDING BUT WILL CHECK AND REPLENISH AS NEEDED.\n\nRESP: LUNGS HAVE REMAINED CLEAR BUT SL DIM IN THE BASES. SAO2 99-100% ON N/C 2/L. RR 13-19, NO SOB NOTED.\n\nNEURO: PT HAS CHRONIC BACK PAIN BUT HAS NOT C/O BACK DISCOMFORT THROUGHOUT THE SHIFT. HAS REMAINED ALERT, HAS NOT SLEPT THROUGHOUT THE SHIFT. FOLLOWS SIMPLE COMMANDS. PERLA. ORIENTED TO PERSON AND CAN NAME FAMILY MEMBERS.. PT HAS BEEN HALLUCINATING THROUGHOUT THE SHIFT, CALLING OUT TO PEOPLE WHO ARE NOT THERE AND POINTING AT THE WALL OR WINDOW AND ASKING IF I SEE OBJECTS WHICH ARE NOT THERE. FORGETS WHERE SHE IS SHORTLY AFTER REORIENTATION.\n\nGU: FOLEY CATH WAS CHANGED AFTER PT ARRIVAL TO MICU.URINE IS LIGHT YELLOW IN COLOR AND CLEAR DRAINING IN GOOD AMTS.\n\nGI: ABD SOFT AND NON-TENDER WITH POS BS. ASKING FOR PO FOODS BUT PT IS NPO UNTIL AFTER CT OF THE CHEST.\n\nID: PT IS ON MULTIPLE ATB FOR POSSIBLE LINE INFECTION. PT HAS A HICKMAN AND TEAM IS PLANNING ON PULLING IT THIS AM.\n\nENDO: HAS SSIC AND SO FAR HAS NOT REQUIRED INSULIN.\n\nPLAN: HUSBAND IS VERY INVOLVED IN CARE OF PT. MLY GIVE OUT INFO TO THE SON PER HUSBAND WHO IS HCP. PROVIDE HUSBAND WITH ANY CHANGES IN PT CONDITION. REPLENISH LYTES AS NEEDED. MONITOR TEMPA\n" }, { "category": "Nursing/other", "chartdate": "2193-02-14 00:00:00.000", "description": "Report", "row_id": 1609382, "text": "MICU NPN\nNEURO: VERY LETHARGIC THIS AM BECAME MORE CLEARER AS DAY WENT ON, LESS AGITATED, HAS PEN ORDER OF . HAD WAIST POSEY AND WRIST RESTRAINTS, NOW ONLY WRIST RESTRAINTS WHICH ARE OFF WHEN HUSBAND IS IN THE ROOM. PSYCH. IN TO SEE PT. THIS AM ORDERED SITTER ONCE PT. GOES TO THE FLOOR.\n\nRESP: SATS ARE FINE ON ROOM AIR. LUNGS ARE FINE.\n\nCV: HR AND BP STABLE, HAS BEEN HYPOTENSIVE AT TIMES, MEDS. HAVE BEEN ADJUSTED.\n\nGI/GU: FOLEY PATENT U/O 30-50CC/HR. TAKING IN CLEAR LIQS AT PRESENT, ADVANCING TO SOFT.\n\nACCESS: DOUBLE LUMEN PICC PLACED IN IR WITH DIFFICULTY, SITE IS WNL.\n\nSOCIAL: HUSBAND IN VISITING, VERY SUPPORTIVE.\n\nPLAN: CALLED OUT TO FLOOR WITH SITTERS.\n" }, { "category": "Nursing/other", "chartdate": "2193-02-15 00:00:00.000", "description": "Report", "row_id": 1609383, "text": "NPN 1900-0700\nNeuro: Pt. alert and oriented x3. Pleasant and cooperative with care. C/o of feeling very sore all over her body. Medicated with Morphine x1 after which Pt. slept. Restraints off all night as Pt. slept.\n\nCV: VSS. HR 70's NSR with no ectopy noted. No edema. Antihypertensive meds held overnight as BP on the low side.\n\nResp: LS clear and dim. at bases. No cough noted. O2 sat 96-98% on RA.\n\nGI: C/O feeling constipated. Medicated with Bowel meds and fleet and SSE given with good result. Abd. soft, BS+. Tolerated diet well last evening. Cont. on Humalog SS.\n\nGU: Foley cath in place and ~20-30cc/hr of clear yellow urine.\n\nSkin: Intact,\n\nAccess: Double lumen PICC inserted in IR with some dificulties. NS at KVO.\n\nSocial: Pt. is a full code. Pt.'s husband called last night to check at his wife. Pt. called out to medical unit awaiting bed. ? if needs a sitter upon transfer as Pt. alert and appropriate.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-02-15 00:00:00.000", "description": "Report", "row_id": 1609384, "text": "MICU NPN for day shifts: Full Code\n\n\n Please see flowsheet for more details\n\nEvents: PT. dropped her BP to 80/30. symptomatic c/o dizziness, diaphoretic, and nausea w/o vomiting. Given NS bolus of 250 cc x 1 and 1 u prbc's w/ good response. Rest of the day uneventful.\n\nNeuro: AAOx2, some confusion at times, knows the year, but the day/month. Conts. to c/o \"pain everywhere\" w/ some relief after taking morphine 5mg elixir. PERLA. Weak movement of LL ext. Otherwise, she moves all other exts.\n\nRESP: RA w/ rr regular/unlabored. O2 sats stable. Lungs CTA. No cough noted.\n\nCV: NSR-SB w/ no ectopy. BP ranging from 80/30 - 171/64. meds adjustments made. Afebrile. EKC done during episode of hypotensive w/ no sign. changes noted per MICU resident except bradycardia. DL PICC in place.\n\nGI/GU: + bs noted. Abd is obese, nt, nd. Poor po intake on diet. Refused /senna today. Foley in place w/ adequate uo.\n\nPLAN: Cont. w/ current plan of care. Monitor per protocol Check HCT tonight post-1u prbc's transfusion. Repleting lytes as needed. Cardiac ECHO.\n\nSKIN: Sutures to right anterior lower leg from biopsy covered w/ 2x2. Old hickman site to right chest w/ sutures in place, dressing changed and site covered w/ 2 x 2.\n" }, { "category": "Nursing/other", "chartdate": "2193-02-16 00:00:00.000", "description": "Report", "row_id": 1609385, "text": "Neuro: oriented x 3 ( month and year only ) slept intermittently. Patient complained of sharp / aching back pain chronic due to arachnoiditis mediacted with morphine 5 mgs PO with fair - moderate effect; repositioned q2hrs help relieve her pain; refused to take tylenol when morphine was held related to RR < 8; patient verbalizes she unable to feel from waist down as well as on her both arms, moves all extremeties. pupils equally reactive, no hallucinations or agitation noted, asking appropriate questions.\n\nRespi: desatted 80% during sleep, placed on 2 lpm of O2 sats 99-100% from then on, patient have history of sleep apnea uses only O2 at OSH; lung sounds clear, dim at bases; RR 5-18, period of sleep apnea noted; not in respiratory distress, denies any shortness of breath\n\nCV: very labile BP 77-179/35-89 SB-SR 58-80 asymptomatic during hypotensive episode responded well with fluid bolus, received to of 750 cc overnight; clonidine patch off at midnight, placed back at 0400 when patient BP 170's denies any chest pain; pedal pulses dopplerable, no edema noted. Lopressor held due to tenious BP\n\nGI/GU: no BM tonight, bowel sounds present obese non-tender abdomen; +4L for LOS, urine output dropped with hypotension, responded with fluid bolus; UO ~ 0-60cc/hr\n\nID: afebrile, continues on caspofungin\n\nEndo: received 2 units of humalof for MN FS of 246\n\nHeme: repeat hct post transfusion 26.5, goal >21\n\nSocial: patient's husband called for updates on patient's condition and plan of care\n\nplan: echo today; replete lytes and transfuse blood for hct < 21; monitor for low RR/ apniec episode during sleep; morphine sulfate / repositioning for pain; transfer to once with available bed; fluid bolus for low BP and low UO\n" }, { "category": "Nursing/other", "chartdate": "2193-02-14 00:00:00.000", "description": "Report", "row_id": 1609380, "text": "CV: 81-142/37-91 MAP of 53-94; ST-SR 69-135 with rare PVC's; HR controlled with lessened agitation and lopressor given at 2200; clonidine patch taken off with BP dropped 80's; responded well with fluid bolus 500cc NS; pedal pulses very difficult to palpate, no edema noted; on maintenance fluid D51/2NS at 75cc/hr; PIV RFA inflitrated, dc'd. L hand site wnl, infusing well. For PICC line insertion at IR today if patient able to tolerate to lay still.\n\nRespi: tachypneic RR 30's at start of shift agitation; breathing regularly at 15-18 bpm during sleep, lung sounds clear, dim at bases but very difficult to assess, patient unable to follow command when awake. occasional non-productive cough noted. s/p chest CT showed nodular lesions with tiny cavitation ? fungal infection, inflammatory process or metastatic thyroid CA\n\nGI: NPO due to risk for aspiration agitation; sounds present, no BM this shift, with PRN bowel regimem but patient unable to tolerate PO's.\n\nGU: + 600 since MN, + 1200 for LOS urine output 14cc x 1 with BP drop; responded well with fluid bolus. foley patent, clear yellow urine. uirne culture negative though patient is positive for yeast at OSH\n\nEndo: on RISS no coverage for bedtime FS 163; metformin held.\n\nID: on Caspofungin, afebrile Tmax 98.1 blood culture pending.\n\nHeme: latest hct 28.1, will draw morning labs; transfuse if hct < 21, guiac stools; patient with history of guiac positive stools without bleeding source per previous endoscopy results. with IVC filter in place for h/o PE and DVT; plan to resume warfarin dose post PICC line insertion; INR 2.0\n\nSocial: full code; patient's husband called updated of patient's condition and plan of care; ? team's plan of calling out to depending on CAT scan result, pending at this time. Psych following patient, recommends to use of , far working well with patient.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-02-14 00:00:00.000", "description": "Report", "row_id": 1609381, "text": "patient continues to be off percedex sedation, sleeping upto this time; arouse to voice, coherent and follows directions; denies pain, stated she is cold and needs couple of blanket; oriented x 1 ( stated her name, when asked where she is answered \" \" and unable to state todays date; verbalizes she wants to get some sleep. Received PO meds with pudding and sips of water; morning FS 201 received 2 units humalog; head CT showed no remarkable findings; plan of transfer out to ? sitter if patient's hallucination and agitation comes back; patient's husband called this am, glad that her wife was able to get long sleep since 2200, verbalized that patient hasn't sleep for number of days.\n" }, { "category": "ECG", "chartdate": "2193-02-15 00:00:00.000", "description": "Report", "row_id": 134829, "text": "Sinus bradycardia. Otherwise, normal ECG. Compared to the previous tracing\nof bradycardia has appeared.\n\n" } ]

[ { "category": "Echo", "chartdate": "2189-02-26 00:00:00.000", "description": "Report", "row_id": 103622, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 120/74\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 11:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Low normal\nLVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo;\nmid anterolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. Indeterminate 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 mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is low normal (LVEF 50%) secondary to hypokinesis of the\nposterior and lateral walls. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion. There is an anterior space which\nmost likely represents a promient fat pad.\n\n\n" }, { "category": "ECG", "chartdate": "2189-02-27 00:00:00.000", "description": "Report", "row_id": 297690, "text": "Sinus rhythm. Right axis deviation. Non-specific ST-T wave changes, although\nischemia or infarction cannot be excluded. Low voltage in the limb leads.\nCompared to the previous tracing ST-T wave changes are more diffuse and more\nmarked.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2189-02-26 00:00:00.000", "description": "Report", "row_id": 297915, "text": "Artifact is present. Sinus rhythm. Non-specific ST-T wave changes. Compared\nto the previous tracing low voltage is no longer present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2189-02-26 00:00:00.000", "description": "Report", "row_id": 297916, "text": "Artifact is present. Sinus rhythm. Non-specific ST-T wave changes. Low\nvoltage in the limb leads. Compared to the previous tracing ST-T wave changes\nare less and low voltage is new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2189-02-26 00:00:00.000", "description": "Report", "row_id": 297917, "text": "Sinus rhythm. ST-T wave configuration consistent with acute ischemic injury\n(question posterolateral). Clinical correlation is suggested. No previous\ntracing available for comparison.\n\n" }, { "category": "Physician ", "chartdate": "2189-02-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 630094, "text": "Chief Complaint: chest pain\n HPI:\n Ms. is a generally healthy 54 yoF who is admitted to the CCU\n following emergent cardiac catheterization. On the afternoon prior to\n admission, the patient had acute onset of a burning substernal CP with\n a pressure sensation radiating to her left shoulder. She did not have\n associated symptoms such as nausea, SOB or diaphoresis. She thought\n this might have been indigestion or pain from her neck, and her\n symptoms did improve with antiacids. The discomfort then waxed and\n waned over the course of the day; the patient eventually felt well\n enough to go to sleep. Around 1AM she was awakened from sleep by an\n acute worsening of her symptoms. She presented to Hospital\n where her ECG was notable for STE in I, aVL, V5 and V6 as well as STD\n in III and V1 through V4. Initial TropI was elevated at 0.51 (initial\n CK not available). The patient was treated with ASA, IV heparin and IV\n NTG, which resulted in transient resolution of her pain. She was\n transferred to the ED, where she additionally received\n Integrillin and 600mg Plavix. As she was having recurrent discomfort in\n the ED, she was taken for urgent cardiac cath, performed with\n radial access, which demonstrated a tight OM lesion. This lesion was\n treated with a DES; a small proximal dissection was noted, and this was\n then treated with a second DES. The was excellent flow post-procedure.\n On arrival to the CCU, the patient reports being pain free and feeling\n entirely well.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Past medical history:\n Family history:\n Social History:\n 1. Upper back pain, s/p spinal fusion\n The patient's mother suffered an MI in her early 40s, but is now in her\n 80s and doing well. The patient's father required multi-vessle cardiac\n bypass surgery in his late 60s.\n Occupation: She works in HR for the Social Security Administration.\n Drugs: denies\n Tobacco: Prior smoker, quit for 14 years, now smoking a few ciggarettes\n per day.\n Alcohol: social\n Other: The patient reports being under a moderate amount of\n psychosocial stress recently.\n Review of systems:\n On review of systems, she denies any recent fever, chills, change in\n weight, nausea, vomiting, abdominal pain, change to bowel or bladder\n habbits, arthalgia, myaglia, dizziness, numbness or weakness. Cardiac\n review of systems is notable for absence of chest pain, dyspnea on\n exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\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: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 70) bpm\n BP: 147/89(102) {134/80(94) - 150/89(102)} mmHg\n RR: 18 (14 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\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 Physical Examination\n Gen: Well appearing adult female, no acute distress.\n HEENT: PERRL, EOMI. MMM. OP clear. Conjunctiva well pigmented.\n Neck: Supple, without adenopathy or JVD.\n Chest: Lungs clear to auscultation with normal respiratory effort.\n Cor: Normal S1, S2. RRR. No murmurs appreciated.\n Abdomen: Soft, non-tender and non-distended. +BS, no HSM.\n Extremity: Small hematoma at right radial access cath site. Otherwise\n warm, without edema. 2+ DP pulses bilaterally.\n Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all\n extremities. Sensation intact grossly.\n Labs / Radiology\n 224\n 117\n 0.7\n 17\n 23\n 108\n 4.0\n 142\n 41.6\n 11.5\n [image002.jpg]\n Assessment and Plan\n Ms. is a 54 yoF with few cardiac risk factors who is admitted to\n the CCU for ongoing managment after OM stenting for a posterior STEMI.\n # CORONARIES: Now s/p two DES to the OM. The remainder of the patient's\n cornary anatomy was reportedly without signficant abnormality.\n -Integrilling infusion x 18 hours\n -ASA 325 mg daily\n -clopidogrel 75 mg daily\n -check lipid profile; atorvastatin 80 mg daily\n -metoprolol 25 mg daily; consider uptitration\n -check echocardiogram\n -consider initiation of ACEi\n -check A1c\n -repeat ECG tomorrow\n -CCU monitoring x 24 hours\n # Leukocytosis: Likely a stress response. Will repeat in AM.\n ICU Care\n Nutrition: Cardiac diet\n Lines:\n 18 Gauge - 08:12 AM\n Prophylaxis:\n DVT: Heparin subq\n Stress ulcer:\n Communication: Comments:\n Code status: FULL\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2189-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 630197, "text": "Ms. is a 54 yr. old woman who is admitted to the CCU following\n emergent cardiac catheterization. On the afternoon prior to admission,\n the patient had acute onset of a burning substernal CP with a pressure\n sensation radiating to her left shoulder. She did not have associated\n symptoms such as nausea, SOB or diaphoresis. She thought this might\n have been indigestion or pain from her neck, and her symptoms did\n improve with antacids. The discomfort then waxed and waned over the\n course of the day; the patient eventually felt well enough to go to\n sleep. Around 1AM she was awakened from sleep by an acute worsening of\n her symptoms. She presented to Hospital where her ECG was\n notable for STE in I, aVL, V5 and V6 as well as STD in III and V1\n through V4. Initial Troponin was elevated at 0.51 (initial CK not\n available). The patient was treated with ASA, IV heparin and IV NTG,\n which resulted in transient resolution of her pain. She was transferred\n to the ED, where she additionally received Integrillin and 600mg\n Plavix. As she was having recurrent discomfort in the ED, she was\n taken for urgent cardiac cath, performed with radial access, which\n demonstrated a tight OM lesion. This lesion was treated with a DES; a\n small proximal dissection was noted, and this was then treated with a\n second DES. The was excellent flow post-procedure.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2189-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 630249, "text": "Ms. is a 54 yr. old woman who is admitted to the CCU following\n emergent cardiac catheterization. On the afternoon prior to admission,\n the patient had acute onset of a burning substernal CP with a pressure\n sensation radiating to her left shoulder. She did not have associated\n symptoms such as nausea, SOB or diaphoresis. She thought this might\n have been indigestion or pain from her neck, and her symptoms did\n improve with antacids. The discomfort then waxed and waned over the\n course of the day; the patient eventually felt well enough to go to\n sleep. Around 1AM she was awakened from sleep by an acute worsening of\n her symptoms. She presented to Hospital where her ECG was\n notable for STE in I, aVL, V5 and V6 as well as STD in III and V1\n through V4. Initial Troponin was elevated at 0.51 (initial CK not\n available). The patient was treated with ASA, IV heparin and IV NTG,\n which resulted in transient resolution of her pain. She was transferred\n to the ED, where she additionally received Integrillin and 600mg\n Plavix. As she was having recurrent discomfort in the ED, she was\n taken for urgent cardiac cath, performed with radial access, which\n demonstrated a tight OM lesion. This lesion was treated with a DES; a\n small proximal dissection was noted, and this was then treated with a\n second DES. The was excellent flow post-procedure.\n PMH: S/P spinal fusion for upper back pain. +smoker->quit 14yrs ago but\n currently smoking\na few\n cigarettes/day.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 61-80 SR, no ectopy.\n BP 88-126/51-75\n O2 sat 94-97% on Rm. Air. BS clear.\n R radial pulse easily palpable. Area with sm. hematoma & ecchymosis.\n Denies CP/SOB.\n Action:\n D51/2NS @ 100cc/hr x1L post-cath hydration.\n Integrellin 2mcg/kg x18hrs complete @ 0400.\n Started metoprolol 12.5mg po BID->tol. Well.\n Response:\n Hemodynamically stable post-stent to LCx.\n Plan:\n Call out to floor.\n" }, { "category": "Nursing", "chartdate": "2189-02-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 630253, "text": "Ms. is a 54 yr. old woman who is admitted to the CCU following\n emergent cardiac catheterization. On the afternoon prior to admission,\n the patient had acute onset of a burning substernal CP with a pressure\n sensation radiating to her left shoulder. She did not have associated\n symptoms such as nausea, SOB or diaphoresis. She thought this might\n have been indigestion or pain from her neck, and her symptoms did\n improve with antacids. The discomfort then waxed and waned over the\n course of the day; the patient eventually felt well enough to go to\n sleep. Around 1AM she was awakened from sleep by an acute worsening of\n her symptoms. She presented to Hospital where her ECG was\n notable for STE in I, aVL, V5 and V6 as well as STD in III and V1\n through V4. Initial Troponin was elevated at 0.51 (initial CK not\n available). The patient was treated with ASA, IV heparin and IV NTG,\n which resulted in transient resolution of her pain. She was transferred\n to the ED, where she additionally received Integrillin and 600mg\n Plavix. As she was having recurrent discomfort in the ED, she was\n taken for urgent cardiac cath, performed with radial access, which\n demonstrated a tight OM lesion. This lesion was treated with a DES; a\n small proximal dissection was noted, and this was then treated with a\n second DES. The was excellent flow post-procedure.\n PMH: S/P spinal fusion for upper back pain. +smoker->quit 14yrs ago but\n currently smoking\na few\n cigarettes/day.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 61-80 SR, no ectopy.\n BP 88-126/51-75\n O2 sat 94-97% on Rm. Air. BS clear.\n R radial pulse easily palpable. Area with sm. hematoma & ecchymosis.\n Denies CP/SOB.\n Action:\n D51/2NS @ 100cc/hr x1L post-cath hydration.\n Integrellin 2mcg/kg x18hrs complete @ 0400.\n Started metoprolol 12.5mg po BID->tol. Well.\n Response:\n Hemodynamically stable post-stent to LCx.\n Plan:\n Call out to floor.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n ACUTE CORONARY SYNDROME\n Code status:\n Full code\n Height:\n Admission weight:\n 73 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Smoker\n CV-PMH:\n Additional history: Spinal fusion\n Surgery / Procedure and date: Stented x 2 to left circ. Stable upon\n admission.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:94\n D:64\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 47 mL\n 24h total out:\n 300 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:22 AM\n Potassium:\n 4.1 mEq/L\n 04:22 AM\n Chloride:\n 105 mEq/L\n 04:22 AM\n CO2:\n 25 mEq/L\n 04:22 AM\n BUN:\n 14 mg/dL\n 04:22 AM\n Creatinine:\n 0.7 mg/dL\n 04:22 AM\n Glucose:\n 105 mg/dL\n 04:22 AM\n Hematocrit:\n 39.6 %\n 04:22 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: cell 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: \n Transferred to: F6\n Date & time of Transfer: 05:30 AM\n" }, { "category": "Nursing", "chartdate": "2189-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 630164, "text": "This is a 54 year old previously healthy woman who was admitted to the\n CCU from the cath lab after having two stents placed for an occluded\n circ. She presented to an outside hospital after complaining of chest\n pain for the entire day yesterday. She woke up at approximately 1 AM\n with 9 out of 10 chest pain and decided to seek treatment. She had\n lateral lead elevation on ECG. She was given heparin, asa, sublingual\n nitro and sent to for further management. She arrived in the CCU\n this morning, hemodynamically stable. She was denying pain\n consistently, she was hydrated with D5\n NS for 1 L for post dye\n hydration. She had an ECG and an ECHO post-cath. She has been on an\n integrlin infusion today which should be on it x 18 hours. She had an\n appreciable hematoma on her right radial artery access site. She had a\n TR band on the access site, throughout the morning, the hematoma has\n lessened, and the TR band was removed. She has no signs of bleeding in\n the area of her right radial artery and her hand appears warm and well\n perfused. She has been tolerating a regular diet. Anticipating floor\n transfer in the morning.\n" }, { "category": "Physician ", "chartdate": "2189-02-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 630144, "text": "Chief Complaint: chest pain\n HPI:\n Ms. is a generally healthy 54 yoF who is admitted to the CCU\n following emergent cardiac catheterization. On the afternoon prior to\n admission, the patient had acute onset of a burning substernal CP with\n a pressure sensation radiating to her left shoulder. She did not have\n associated symptoms such as nausea, SOB or diaphoresis. She thought\n this might have been indigestion or pain from her neck, and her\n symptoms did improve with antiacids. The discomfort then waxed and\n waned over the course of the day; the patient eventually felt well\n enough to go to sleep. Around 1AM she was awakened from sleep by an\n acute worsening of her symptoms. She presented to Hospital\n where her ECG was notable for STE in I, aVL, V5 and V6 as well as STD\n in III and V1 through V4. Initial TropI was elevated at 0.51 (initial\n CK not available). The patient was treated with ASA, IV heparin and IV\n NTG, which resulted in transient resolution of her pain. She was\n transferred to the ED, where she additionally received\n Integrillin and 600mg Plavix. As she was having recurrent discomfort in\n the ED, she was taken for urgent cardiac cath, performed with\n radial access, which demonstrated a tight OM lesion. This lesion was\n treated with a DES; a small proximal dissection was noted, and this was\n then treated with a second DES. The was excellent flow post-procedure.\n On arrival to the CCU, the patient reports being pain free and feeling\n entirely well.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Past medical history:\n Family history:\n Social History:\n 1. Upper back pain, s/p spinal fusion\n The patient's mother suffered an MI in her early 40s, but is now in her\n 80s and doing well. The patient's father required multi-vessle cardiac\n bypass surgery in his late 60s.\n Occupation: She works in HR for the Social Security Administration.\n Drugs: denies\n Tobacco: Prior smoker, quit for 14 years, now smoking a few ciggarettes\n per day.\n Alcohol: social\n Other: The patient reports being under a moderate amount of\n psychosocial stress recently.\n Review of systems:\n On review of systems, she denies any recent fever, chills, change in\n weight, nausea, vomiting, abdominal pain, change to bowel or bladder\n habbits, arthalgia, myaglia, dizziness, numbness or weakness. Cardiac\n review of systems is notable for absence of chest pain, dyspnea on\n exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\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: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 70) bpm\n BP: 147/89(102) {134/80(94) - 150/89(102)} mmHg\n RR: 18 (14 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\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 Physical Examination\n Gen: Well appearing adult female, no acute distress.\n HEENT: PERRL, EOMI. MMM. OP clear. Conjunctiva well pigmented.\n Neck: Supple, without adenopathy or JVD.\n Chest: Lungs clear to auscultation with normal respiratory effort.\n Cor: Normal S1, S2. RRR. No murmurs appreciated.\n Abdomen: Soft, non-tender and non-distended. +BS, no HSM.\n Extremity: Small hematoma at right radial access cath site. Otherwise\n warm, without edema. 2+ DP pulses bilaterally.\n Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all\n extremities. Sensation intact grossly.\n Labs / Radiology\n 224\n 117\n 0.7\n 17\n 23\n 108\n 4.0\n 142\n 41.6\n 11.5\n [image002.jpg]\n Assessment and Plan\n Ms. is a 54 yoF with few cardiac risk factors who is admitted to\n the CCU for ongoing managment after OM stenting for a posterior STEMI.\n # CORONARIES: Now s/p two DES to the OM. The remainder of the patient's\n cornary anatomy was reportedly without signficant abnormality.\n -Integrilling infusion x 18 hours\n -ASA 325 mg daily\n -clopidogrel 75 mg daily\n -check lipid profile; atorvastatin 80 mg daily\n -metoprolol 25 mg daily; consider uptitration\n -check echocardiogram\n -consider initiation of ACEi\n -check A1c\n -repeat ECG tomorrow\n -CCU monitoring x 24 hours\n # Leukocytosis: Likely a stress response. Will repeat in AM.\n ICU Care\n Nutrition: Cardiac diet\n Lines:\n 18 Gauge - 08:12 AM\n Prophylaxis:\n DVT: Heparin subq\n Stress ulcer:\n Communication: Comments:\n Code status: FULL\n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n ------ Protected Section Addendum Entered By: , MD\n on: 15:43 ------\n" } ]

[ { "category": "Radiology", "chartdate": "2135-06-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 792349, "text": " 8:05 AM\n CHEST (PA & LAT) Clip # \n Reason: resolution of right sided effusion; PLEASE PERFORM AM 6/10/0\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with ef 10-15% s/p pericardiocentesis and new right sided\n pain. possible new effusion on right per previous CXR. please eval\n REASON FOR THIS EXAMINATION:\n resolution of right sided effusion; PLEASE PERFORM AM \n ______________________________________________________________________________\n FINAL REPORT\n PA & LATERAL CHEST:\n\n INDICATION: S/P pericardiocentesis now with new right sided chest pain.\n\n Comparison is made to the prior examination of .\n\n FINDINGS: The heart is enlarged but stable in size. The pulmonary vasculature\n is normal. The lungs are clear. There is a right sided small effusion and a\n trace left sided effusion.\n\n IMPRESSION: Right small and left trace pleural effusions. No radiographic\n evidence of pneumonia or cardiac failure. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2135-06-03 00:00:00.000", "description": "CT FINE NEEDLE ASP", "row_id": 792057, "text": " 2:45 PM\n CT FINE NEEDLE ASP; CT GUIDANCE DRAINAGE Clip # \n CT CHEST W/O CONTRAST\n Reason: EVAL FLUID\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with cardiomyopathy with EF 10-15% p/w large pericardial\n effusion, spiking fevers. Please perform CT guided pericardial drainage. SEND\n FLUID FOR STUDIES ATTACHED TO CHART\n REASON FOR THIS EXAMINATION:\n drainage of pericardial effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiomyopathy with large pericardial effusion and spiking\n fevers.\n\n TECHNIQUE: Multiple contiguous slices were obtained through the lower chest\n and upper abdomen without administration of IV contrast.\n\n FINDINGS:\n\n CT OF THE CHEST WITHOUT CONTRAST: There is evidence of moderate pleural\n effusion on the left. There is a moderate amount of pericardial effusion noted\n on both lateral portions.\n\n CT PERICARDIAL CENTESIS: Informed consent was obtained from the patient after\n explaining the benefits and risks of the procedure. Using the usual prepping\n and draping, as well as local anesthesia, the needle was inserted under CT\n fluoroscopy guidance into the right precaudal area and 10 cc of bloody fluid\n was aspirated and sent for labaratory studies.\n\n Dr. performed the procedure. No immediate complications occurred.\n\n IMPRESSION: Successful pericardiocenthesis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2135-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 791735, "text": " 4:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: RIJ SWAN PLACEMENT.\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with dilated cardiomyopathy, hypothyroidism\n\n REASON FOR THIS EXAMINATION:\n RIJ SWAN PLACEMENT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right IJ catheter placement.\n\n TECHNIQUE: A single portable AP view of the chest is compared with a prior\n study from 4 days ago.\n\n FINDINGS: There has been interval placement of a right-sided IJ Swan-Ganz\n catheter, with the tip in the right pulmonary artery trunk. There is no\n evidence of pneumothorax. The cardiac silhouette remains enlarged, without\n evidence of overt failure. There is slight improvement of retrocardiac\n opacity, and left-sided pleural effusion is unchanged. The osseous structures\n remain unchanged.\n\n IMPRESSION: Right IJ Swan-Ganz catheter terminates in the right pulmonary\n artery; no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2135-06-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 791938, "text": " 2:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: RIJ line placement\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with dilated cardiomyopathy, hypothyroidism\n\n REASON FOR THIS EXAMINATION:\n RIJ line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of dilated cardiomyopathy and hypothyroidism. Status\n post line placement. Check position.\n\n Comparison is made to examination of .\n\n FINDINGS: As before, there is polychamber enlargement of the heart. The\n pulmonary vasculature is normal. The cardiomediastinal borders are unchanged.\n There has been interval removal of a Swan-Ganz catheter. A right internal\n jugular central venous line is now seen, however its tip is coiled on itself\n and heading cephalad within the proximal SVC and right brachiocephalic vein.\n There is no pneumothorax. The left hemidiaphragm is obscured, suggesting\n partial collapse of the left lower lobe.\n\n IMPRESSION: Unsatisfactory appearance to right internal jugular central\n venous line, as described above. No pneumothorax seen. The house staff was\n notified of the findings at the time of interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-06-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 791850, "text": " 2:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: R/O infection\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with nonischemic cardiomyopathy admitted with fevers,\n pericardial effusion, and appears septic on Swan ganz hemodynamics. No\n localizable source of infection. please evaluate for focus\n REASON FOR THIS EXAMINATION:\n R/O infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN, \n\n INDICATION: Cardiomyopathy with fevers, pericardial effusion and sepsis\n picture. Evaluate for source of infection.\n\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\n\n FINDINGS: There is encephalomalacia of the right occipital lobe and right\n frontal lobe, consistent with old infarction. There are also smaller\n infarctions in the cerebellum, right basal ganglia and a lacunar infarction in\n the left frontal lobe white matter. There are no signs of acute cortical\n edema or gyral swelling. There is no shift of intracranial structures. The\n ventricles are not dilated. There is no evidence of acute intracranial\n hemorrhage.\n\n Bone window images reveal clear mastoid air cells and visualized paranasal\n sinuses. There are no lytic or destructive changes of the skull.\n\n IMPRESSION: Chronic infarctions. No evidence of edema or shift of\n structures. No acute hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2135-06-01 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 791849, "text": " 2:37 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: FEVERS,ABDOMINAL PAIN, EVALUATE FOR SOURCE OF INFECTION\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with nonischemic cardiomyopathy admitted with fevers,\n pericardial effusion, and appears septic on Swan ganz hemodynamics. No\n localizable source of infection. please evaluate for focus of infection\n REASON FOR THIS EXAMINATION:\n evaluate for site of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Pericardial effusion, fever,.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung apices through the pubic symphysis after the administration of 150 cc of\n Optiray contrast intravenously. Optiray was used given patient's debility.\n\n COMPARISON: None.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The heart is enlarged and there is a Swan-\n Ganz catheter positioned with the tip in the right main pulmonary artery.\n There is a large pericardial effusion. The aorta and pulmonary arteries are\n unremarkable otherwise. There is a pathologically enlarged right tracheal\n lymph node measuring 1.8 x 2.1 cm and there are multiple other prominent right\n paratracheal lymph nodes as well as multiple subcentimeter prominent lymph\n nodes in the prevascular space, the aorticopulmonary window, as well as in the\n axilla and subpectoral regions bilaterally. There are small bilateral pleural\n effusions, left greater than right with associated atelectasis of the adjacent\n lung. Otherwise the lungs are clear without nodules.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: There are two simple cysts in the liver\n measuring between 1 and 1.5 cm, one in segment VIII of the liver and one in\n segment V of the liver. No other hepatic lesions are seen. There is no biliary\n ductal dilatation. There is a small stone in the gallbladder neck. There is no\n gallbladder wall thickening or pericholecystic fluid to suggest cholecystitis.\n The pancreas, spleen, adrenal glands, kidneys, ureters, and visualized loops\n of small and large bowel are normal. There is no mesenteric or retropertoneal\n lymphadenopathy. There are no abnormal fluid collections or abscesses. There\n is no free fluid or free air.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The sigmoid colon and rectum are normal.\n The uterus, adnexa, and urinary bladder with Foley catheter in place are\n unremarkable. There is no lymphadenopathy, free fluid, or evidence of abscess.\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. Cardiomegaly with a large pericardial effusion.\n 2. Multiple prominent mediastinal lymph nodes, the largest in the right\n (Over)\n\n 2:37 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: FEVERS,ABDOMINAL PAIN, EVALUATE FOR SOURCE OF INFECTION\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n paratracheal region measuring 1.8 x 2.1 cm. This lymphadenopathy is\n nonspecific. This largest lymph node would be amenable to mediastinoscopy/\n biopsy if indicated.\n 3. Small bilateral pleural effusions, left greater than right, with associated\n atelectasis.\n 4. No evidence of abscess or other inflammatory or infectious process within\n the abdomen or pelvis.\n 5. Two simple hepatic cysts.\n 6. Cholelithiasis without evidence of cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2135-06-06 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 792275, "text": " 1:11 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: RT SHOULDER PAIN, S/P SUBCL LINE, R/O DVT\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with right sided arm pain s/p subclavian line placement.\n please eval for dvt.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND DOPPLER OF THE RIGHT UPPER EXTREMITY.\n\n INDICATION: Patient after subclavian line placement with right side arm pain.\n\n FINDINGS: Grey-sclale, color and Doppler waveform analysis was performed on\n the right internal jugular vein, subclavian vein, axillary vein, cephalic and\n basilic veins. No filling defect is noticed in these vessels. There is normal\n color and waveform in these vessels. There is normal compressibility of all\n the vessels except for the subclavian vein which is not accessible for\n compression. Normal augmentation is noticed in all the stations.\n\n IMPRESSION: No DVT was noticed in the right internal jugular vein and the\n proximal part of the upper extremity on the right side.\n\n" }, { "category": "Radiology", "chartdate": "2135-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792105, "text": " 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for ptx, pulm edema after pericardiocentesis\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with dilated cardiomyopathy, hypothyroidism\n\n REASON FOR THIS EXAMINATION:\n please eval for ptx, pulm edema after pericardiocentesis\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON \n\n INDICATION: Pericardiocentesis-assess for PTX and edema.\n\n COMPARISON: at 14:36\n\n FINDINGS: Compared to the prior study the appearance of the cardiomegaly\n remains unchanged and it's configuration suggests pericardial fluid. The\n right CVL has been removed and there is no pneumothorax. The pulmonary\n vascular markings are mildly prominent but unchanged from prior study. There\n is no evidence for pulmonary edema. Some pleural fluid appears to layer out\n on the right.\n\n IMPRESSION:\n\n Right CVL removal - No pneumothorax. Right pleural fluid now identified, not\n seen previously - positioning differences could contribute.\n\n" }, { "category": "Radiology", "chartdate": "2135-06-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 792272, "text": " 12:59 PM\n CHEST (PA & LAT) Clip # \n Reason: eval change in right sided effusion\n Admitting Diagnosis: PERICARDIAL EFFUSION\\PERICARDIOCENTESIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with ef 10-15% s/p pericardiocentesis and new right sided\n pain. possible new effusion on right per previous CXR. please eval\n REASON FOR THIS EXAMINATION:\n eval change in right sided effusion\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATIONS: EF of 10% to 15% status post cardiocentesis compare to prior\n evaluate for change in right-sided effusion.\n\n Comparison is made to the chest radiograph from .\n\n PA AND LATERAL CHEST RADIOGRAPH: Again demonstrated is marked polychamber\n cardiac enlargement. There is interval improvement in the amount of congestive\n heart failure. A right-sided pleural effusion is again present. Allowing for\n differences in technique, it is difficult to compare the size of the effusion.\n The left hemidiaphragm is not completely visualized. No pneumonic\n consolidations are present. Osseous structures are unchanged.\n\n IMPRESSION: Improved CHF. Persistent right-sided pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2135-05-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 791358, "text": " 8:14 PM\n CHEST (PA & LAT) Clip # \n Reason: pneumonia, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with ef 10-15% p/w spiking temps to 104.\n REASON FOR THIS EXAMINATION:\n pneumonia, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia congestive heart failure.\n\n COMMENT: PA and lateral chest xrays are reviewed, and compared to the previous\n study of .\n\n There is consolidation in the left lower lobe, which indicates pneumonia\n versus atelectasis. Again note is made of marked dilatation of the heart\n consistent with the patient's history of cardiomyopathy.\n\n IMPRESSION: Left lower lobe consolidation: pneumonia versus atelectasis.\n Cardiomyopathy.\n\n" }, { "category": "Echo", "chartdate": "2135-05-27 00:00:00.000", "description": "Report", "row_id": 61963, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Dilated cardiomyopathy. Pericardial effusion.\nBP (mm Hg): 90/60\nStatus: Inpatient\nDate/Time: at 15:07\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 is severely dilated. Overall left ventricular systolic\nfunction is severely depressed.\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 are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nPERICARDIUM: There is a moderate sized pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is severely dilated. Overall left\nventricular systolic function is severely depressed. Right ventricular chamber\nsize is normal. Right ventricular systolic function appears depressed. The\naortic valve leaflets are mildly thickened. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is a moderate sized pericardial effusion. There are no\nechocardiographic signs of tamponade. Not clear if the anterior portion of the\npericardial fluid is loculated and echo dense. Otherwise, the rest of the\npericardial fluid is echolucent.\n\n\n" }, { "category": "Echo", "chartdate": "2135-06-04 00:00:00.000", "description": "Report", "row_id": 62012, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nStatus: Inpatient\nDate/Time: at 10:33\nTest: Portable TTE(Focused views)\nDoppler: Focused 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. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. There is severe\nglobal right ventricular free wall hypokinesis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate to\nsevere (3+) mitral regurgitation is seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Bilateral pleural effusions are present.\n\nConclusions:\nThe left atrium is normal in size. There is severe global left ventricular\nhypokinesis. The right ventricular cavity is dilated with severe global free\nwall hypokinesis. The mitral valve leaflets are mildly thickened. Moderate to\nsevere (3+) mitral regurgitation is seen. There is a small anterior partially\necho-filled space likely representing a fat pad, though cannot exclude an\norganized pericardial effusion. There is no 2D echo evidence for tamponade\nphysiology.\nCompared with the pre-pericadiectomy study of , the pericardial effusion\nhas largely resolved.\n\n\n" }, { "category": "Echo", "chartdate": "2135-05-31 00:00:00.000", "description": "Report", "row_id": 61961, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Dilated cardiomyopathy. Pericardial effusion. Pericarditis.\nHeight: (in) 66\nWeight (lb): 156\nBSA (m2): 1.80 m2\nBP (mm Hg): 88/56\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 11:39\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is dilated. There is severe global left ventricular\nhypokinesis. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed.\n\nMITRAL VALVE: Moderate (2+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPERICARDIUM: There is a small to moderate sized pericardial effusion. The\neffusion appears loculated. There are no echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: The echocardiographic results were reviewed by telephone\nwith the physician caring for the patient.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\ndilated with severe global left ventricular hypokinesis. No masses or thrombi\nare seen in the left ventricle. Right ventricular chamber size is normal.\nRight ventricular systolic function appears depressed. The mitral leaflets may\nbe mildly thickened. Moderate (2+) mitral regurgitation is seen. There is a\nsmall to moderate sized pericardial effusion measuring <1cm inferior to the\nleft ventricle, 1-1.5cm lateral to the left ventricle, <0.5cm around the LV\napex and anterior to the right ventricle, and >2cm anterior to the right\natrium. The asymmetric nature of the effusion suggests loculation. There are\nno echocardiographic signs of tamponade.\n\nCompared with the prior study (tape reviewed) of , there is no change.\n\n\n" }, { "category": "Echo", "chartdate": "2135-05-30 00:00:00.000", "description": "Report", "row_id": 61962, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Dilated cardiomyopathy. Pericardial effusion.\nHeight: (in) 66\nWeight (lb): 156\nBSA (m2): 1.80 m2\nBP (mm Hg): 96/60\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 08:59\nTest: TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is severely dilated. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate to\nsevere (3+) mitral regurgitation is seen.\n\nPERICARDIUM: There is a moderate sized pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is severely dilated. There is severe\nglobal left ventricular hypokinesis. Overall left ventricular systolic\nfunction is severely depressed. Right ventricular chamber size is normal.\nRight ventricular systolic function appears depressed. The aortic valve\nleaflets are mildly thickened. The mitral valve leaflets are mildly thickened.\nModerate to severe (3+) mitral regurgitation is seen. There is a moderate\nsized pericardial effusion. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study (tape reviewed) of , the pericardial\neffusion is smaller.\n\n\n" }, { "category": "ECG", "chartdate": "2135-06-04 00:00:00.000", "description": "Report", "row_id": 112326, "text": "Sinus tachycardia. Consider left atrial abnormality. Non-specific ST-T wave\nabnormalities - clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2135-05-31 00:00:00.000", "description": "Report", "row_id": 1275670, "text": "ccu nursing progress note\ns: i'm just not very hungry\no: pls see carevue flowsheet for complete vs/data/events\nid: low grade temp. no abx. wbc 12.4. cultures sent of bld x2 and urine.\ncv: denies cp. arrived to unit on 4.7mcg/kg of dopa. hr 90-100sr, occ pvc. bp 100-115/60 via r rad aline.\nr ij pa line placed. pad low 20s. cvp 11-14. mv sat 70. co 7, ci 3.8, svr 700.\nresp: no sob but color is poor w exertion, turning etc. sats low to mid 90s on 4l nc. drops quickly to 80s if o2 off. bilat cxs.\ngi: poor appetite. taking liquids. no stool.\ngu: foley placed. uop 30-50cc/hr. cr 0.8\nms: ox3. mae w purpose. pt c/o fatigue, falls asleep freq for brief periods, even during conversation.\nsocial: husband visited and updated.\na: ?septic physiology. bp stable on dopa.\np: follow temp, await cultures. ct scan tonoc for source of infection.\nmonitor for chf. support to pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-06-01 00:00:00.000", "description": "Report", "row_id": 1275672, "text": "CCU Nursing Progress Note\nS-\"My breathing is alittle beter\"\nO-Neuro alert and oriented x3, pleasant and cooperative.\nCV-VSS HR down 92 with occ PVC's, PAD elevated this am 28-30, with CVP 15. Received lasix 10mg IVB with fair response. Restarted captopril 12.5mg TID. Unable to draw mixed venous sat for hemodynamics. PT 16.1 pt had been on coumadin.No heparin d/t pericardial effusion. TEE scheduled for ?Thursday.\nResp- LS rales 1/2 up bilateral, with NPC upon deep breathing. 26-32 easily SOB at rest. O2 sat 97% on 5lnp. Improved O2 sats while in chair (92% on RA). O2 weaned to 4lnp.\nID afebrile 98.7po ID consult to see today.\nGU-foley draining 30-50cc/hr BUN/CR 9/.7\nGI-NPO for CT scan of head/chest/abd/pelvis this afternoon. HCT 27.9\nelevated sed rate Rheumatoid consult into see pt this am.\nActivity-OOB chair tolerated well.\nSocial-family lives in .\nA/P-CHF this am, improving PAD with lasix/captopril\nMonitor PAD and urine output.\nRecheck HCT at 1800\n" }, { "category": "Nursing/other", "chartdate": "2135-06-01 00:00:00.000", "description": "Report", "row_id": 1275673, "text": "CCU NPN \nCV: HR 90-111 NSR/ST occ PVC's, BP 106-128/50-60, tolerating Captopril 12.5mg. Diuresing well this evening after 10mg IV lasix earlier in the day. ~380cc pos. PAP 36/20, CVP 11.\n\nResp: 3L NC, sat 94-96%, denies SOB, RR 24. LS with crackles at bases bilaterally.\n\nID: afebrile. Had full body CT today, showed cholelithiasis(no signs of inflamation), bilateral pleural effusions, enlarged mediastinal lymph nodes.\n\nHeme: Hct 28 this eve, stable from 27.9\n\nGI: Inc of sm amt light colored stool, then up to toilet passed more. Appetite poor at dinner.\n\nA/P: hemodynamically stable, UO picked up this eve, PAD down to 20. Cont to follow fluid balance, resp status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-06-02 00:00:00.000", "description": "Report", "row_id": 1275674, "text": "CCU Nursing Progress Note 1900-0700\nS-My neck hurts.\"\nSEE CAREVUE FOR ALL OBJECTIVE DATA ANS VS\nMS: Sleeping most of night. Given ambien on previous shift. C/o of neck pain and given motrin with fair effect. OOB to bathroom on previous shift.\nCV: HR 90s to 100s. ST with some PVCs and PACs. SBPs 90s to 120s.\nTolerating Captopril well. PADs 18s to 20s. CVP 10-13. AM CO/CIs pending. Groin site CDI with palpable pulses distal. Denies CP.\nRESP: LS with crackles near bases. O2Sats 93-96% on 4LNP. Occasionally appearing dypsenic but improved since post diuressis. Overall pt rates breathing \"better.\"\nGU/GI: Foley draining CYU. HUOs > 30cc/hr. Diuresed with 10mg of Lasix overnight and thus far diuresing 240ccs and continues to diurese. (+) 300ccs as of MN. Abd soft with (+) BSs. Appetite fair.\nID: Tm 99.1. Currently on no ABx. ID continues to follow.\nA/P: Improved CHF and low grade fevers.\nPossible removal of Swan\nPossible call out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2135-06-01 00:00:00.000", "description": "Report", "row_id": 1275671, "text": "CCU Nursing Progress Note 1900-0700: Cardiomyopathy\nS-\"My neck is sore.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND VS\n\nMS: A/O/X/3. Very pleasant and cooperative. C/o being tired and wanting to rest. Asking for sleeping and sleeping well overnight.\nNeuro remaing intact overnight. In addition c/o of neck being sore \"on and off\" sine yesterday. Offering Tylenol but declining. MAEs.\nCV: 90s to 100s. ST with occasional PVCs. HR addressed with team and team stating pt baseline on floor 100s to 120s. HR as low 60s to 80s post procedure but increasing this shift. BB held low BPs. Dopa weaned to off and off since 10PM. PADs 18 to low 20s. Pt denying CP. Right groin CDI with no hematoma noted. Pulses palpable and extremeties warm to touch.\nRESP: LS with crackles way up bilateral. Occasional cough but NP.\nDenies SOB but appears dypsenic with conversing and turning in bed. RR 20s to 30s overnight with O2Sat 93-95%. Pt denying SOB throughout night and \"feels fine.\"\nGU/GI: Foley draining CYU. HUOs > 40cc/hr. Since MN (+) 200ccs. Abd soft-distended with (+) BSs. Taking POs well. No BM this shift.\nID: Tm 99.6 PO. Culture data pending. No source of temperture as of yet. Scheduled for total body CT today.\nA/P: Non-ischemic CM with no source of fever spikes.\nCT Scan today\nRe-starting cardiac meds ASAP\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2155-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 499257, "text": "83F with h/o myasthenia , presenting with three weeks of\n progressive ptosis, dysphagia, dysarthria, and generalized weakness.\n Ms. first noticed her eyelids drooping, worse on left compared to\n right and over the past week has had progressive difficulty swallowing\n solids. Over the past two days she has been unable to swallow solids\n or liquids and has reported her speech to be more nasal than baseline.\n Ms. was first diagnosed with myasthenia in when she\n had developed a similar constellation of symptoms. She was started on\n mestinon with a dramatic improvement.\n Allergies:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Past medical history:\n -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Myasthenia exacerbation\n Assessment:\n Alert, oriented, moves all extremities equally but c/o generalized\n weakness though had steady balance when using the commode. PERRLA\n though has obvious L eye ptosis (L eye red and irritated with\n discharge). Very talkative though speech is\nthick tongued\n. Has\n persistent cough and at times feels like she is choking. Denies pain.\n BP slightly elevated (150-160\ns). On 2l np with adequate saturation.\n Voiding concentrated urine per commode.\n Action:\n Mestinon given in applesauce (to aid swallowing) q 4 hours, labs\n obtained, q 4 hour nifs, q 1 hour neuro checks\n Spoke at length with pts. Daughter who was frustrated in trying to get\n appropriate care and treatment of her mom (mother had made previous\n visit to ER 2 days pta and was sent home).\n Response:\n Continued coughing and choking sensation though able to swallow\n applesauce puree, continued L eye ptosis though she says the eye is\n better (apparently was completely closed when she arrived in ER).\n States she feels stronger over all and the quality of her voice has\n improved. Difficulty obtaining NIF and vital capacity (pt states she\n had difficulty performing these also with previous MG exacerbation)\n Plan:\n Frequent neuro checks, bedside speech and swallow today. If passes,\n advance diet as tolerated. Continue mestinon q 4 hours while monitoring\n symptoms.\n" }, { "category": "Physician ", "chartdate": "2155-10-31 00:00:00.000", "description": "Intensivist Note", "row_id": 499254, "text": "TSICU\n HPI:\n 83F with h/o myasthenia , presenting with three weeks of\n progressive ptosis, dysphagia, dysarthria, and generalized\n weakness. Ms. first noticed her eyelids drooping, worse on left\n compared to right and over the past week has had progressive\n difficulty swallowing solids. Over the past two days she has been\n unable to swallow solids or liquids and has reported her speech to be\n more nasal than baseline. Ms. was first diagnosed with myasthenia\n in when she had developed a similar constellation of\n symptoms. At that time, an EMG demonstrated decrementing response to\n repetitive stimulation of facial nerves and a tensilon test did improve\n her ptosis. She was started on mestinon with a dramatic improvement.\n The patient received two sessions of\n plasmapheresis, but did not complete the entire course of five due to\n thrombus formation at the site of the catheter. She was discharged\n home on mestinon and was followed by Dr. for several years. She\n had been doing well and her mestinon was discontinued several years\n prior in the early (unsure of exact date) with no further\n recurrences of symptoms. She had never required immunosuppression or\n intubation.\n Chief complaint:\n generalized weakness, ptosis\n PMHx:\n -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1635\n 7. Heparin 5000 UNIT SC TID Order date: @ \n 2. 1000 mL NS\n Continuous at 75 ml/hr\n continue until patient tolerating PO Order date: @ 1635\n 8. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2127\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever Order date: @\n 1635\n 9. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 1630\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 2127\n 10. Pyridostigmine Bromide 60 mg PO/NG Q4H Order date: @ 1635\n 5. Famotidine 20 mg IV Q12H Order date: @ \n 11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1635\n 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 2127\n 24 Hour Events:\n Admitted to TSICU overnight for monitoring of respiratory status. NIFs\n stable from -18 to -22, VCs stable from 1.5 to 1.7. No overnight\n events.\n NASAL SWAB - At 08:39 PM\n Allergies:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.8\nC (98.2\n HR: 88 (82 - 100) bpm\n BP: 158/54(83) {134/40(68) - 187/102(114)} mmHg\n RR: 20 (16 - 41) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 71 kg\n Height: 56 Inch\n Total In:\n 493 mL\n 461 mL\n PO:\n Tube feeding:\n IV Fluid:\n 493 mL\n 461 mL\n Blood products:\n Total out:\n 250 mL\n 350 mL\n Urine:\n 250 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 243 mL\n 111 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: 7.43/45/95./30/4\n NIF: -22 cmH2O\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI, L ptosis. Voice mildly hoarse.\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE:\n Weakness)\n Labs / Radiology\n 180 K/uL\n 12.5 g/dL\n 92 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 104 mEq/L\n 143 mEq/L\n 37.1 %\n 7.3 K/uL\n [image002.jpg]\n 09:17 PM\n 12:32 AM\n WBC\n 7.3\n Hct\n 37.1\n Plt\n 180\n Creatinine\n 0.7\n TCO2\n 31\n Glucose\n 92\n Other labs: Ca:8.9 mg/dL, Mg:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Myasthenia exacerbation\n Assessment and Plan: Ms. is an 83-year-old female with history of\n myasthenia , presenting with three weeks of ptosis, nasal speech,\n dysphagia, and generalized weakness.\n Neurologic: Neuro checks Q: 4 hr, Generalized weakness, ptosis L > R\n now resolving; monitor for changes in neuro exam; pyridostigmine 60mg\n q4h; will consider IVIG vs steroids as needed depending on response to\n pyridostigmine\n Cardiovascular: Stable HR and BP\n Pulmonary: Stable on room air; q4h NIFs and VCs, low threshold for\n intubation if evidence of respiratory decline\n Gastrointestinal / Abdomen: NPO except meds, speech & swollow eval\n pending\n Nutrition: NPO, except meds\n Renal: UOP appropriate, monitor lytes and replete as needed\n Hematology: Hct 37.1, no issues\n Endocrine: RISS\n Infectious Disease: No evidence of infection, WBC normal / afebrile; no\n abx at this time\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids: NS, @75mL/hr\n Consults: Neurology\n Billing Diagnosis: Other: myasthenia exacerbation\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:59 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Nutrition", "chartdate": "2155-10-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 499370, "text": "Ht: 65\n Admit wt: 71 kg\n UBW: 68.2 kg (per patient)\n IBW: 59 kg\n Pmh: -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Diet Order: soft, nectar thick liquids\n Food allergies/ intolerances: lactose\n 83 year old female h/o myasthenia admitted with 3 weeks of\n progressive dysphagia, dysarthria, and weakness. Patient reports taking\n no pos 1 week PTA due to dysphagia and fear of choking, but reports no\n wt changes in this time period. SLP saw patient this morning and\n recommended above diet. Will add supplements to increase kcal intake.\n Potential for nutrition risk. Patient being monitored.\n Recommendations:\n 1. Encourage pos\n 2. Add ensure pudding TID\n 3. Will follow page with questions\n" }, { "category": "Rehab Services", "chartdate": "2155-10-31 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 499384, "text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for referring this 83 yo woman admitted via the Neuro\nclinic on p/w progressively worsening ptosis and\ndysarthria for 1 month, and worsening nonproductive cough and\ndysphagia with both liquids and solids for past week. Pt has a\nPMH remarkable for Myasthenia in , which pt reports\nwas c/b a similar set of symptoms. Per Neuro admission note on\n, pt's son suspected that her symptoms may be\ndue to myasthenia and gave her some 5 yr old Mestinon that he\nfound in her cabinet. Per note, her son reported that her\nsymptoms seemed to improve slightly following first dose, but\nsubsequently worsened as the week progressed. Consequently, she\nhad poor PO intake for past week at home per Neuro note. She is\ncurrently on a clear liquids diet. RN reports that pt tolerated\nice cream and jello, though refused broth and tea because the\nwere uncomfortable. We were consulted to eval oral and\npharyngeal swallow function to determine the safest diet.\nPMH:\nMyasthenia , diagnosed 10 years ago when she presented with\ndysarthria, dysphagia, and ptosis with Tensilon test and EMG\nindicating MG, son says were \"abnormal\" at Dr.\noffice, was given plasmapheresis c/b LUE DVT, not currently on\nmedications but previously on mestinion which she stopped 5 years\nago due to diarrhea (which she says is due to lactose in the\nformulation and not a mestinon side effect itself), has had no\nflares since diagnosis, has never been intubated\nIdiopathic colitis\nDiverticulosis\nTemporomandibular joint disease with secondary migraine headaches\nLower GI bleed\nLactose intolerant\ns/p bilateral total hip replacement\ns/p bladder suspension\ns/p appendectomy\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the TSICU.\nCognition, language, speech, voice:\nPt was awake upon entry to the room and oriented x3. However, pt\ndid become confused at times, reporting that her favorite MD was\nat another hospital, \"the .\" She was also forgetful,\nrequiring multiple repetitions of the same info. However, pt was\nable to follow simple motor commands. Expressive was\nfluent, mostly appropriate, and without paraphasias. Speech was\nmildly dysarthric. Vocal quality was WNL.\nTeeth: WNL\nSecretions: WNL\nORAL MOTOR EXAM:\nL ptosis and facial droop appreciated. Tongue protruded at\nmidline with adequate strength and ROM. Labial seal was reduced\ndue to L lip droop, however pt was still able to maintain\nadequate labial seal around straw. Palatal elevation was\nsymmetrical. Gag was hypersensitive.\nSWALLOWING ASSESSMENT:\nPt was offered ice chips, thin liquids (tsp, cup), nectar thick\nliquids (tsp, cup, straw), puree, and soft solids. Oral phase\nwas mildly prolonged for all trialed consistencies, generally\nrequiring 2 swallows per bite or sip. Laryngeal elevation was\nreduced. Pt had delayed cough/throat clear with ice chips and\napproximately 90% of trials of thin liquids. Wet vocal quality\nalso noted with thin liquids. Additionally, pt had delayed\nthroat clear with initial puree and nectar trials, but was\nwithout any s/sx of aspiration for many subsequent trials. No\nchoking or 02 desats observed throughout eval. However, pt noted\nthat she was \"unable\" to take whole meds because she \"would\nchoke.\" When meds were administered crushed in puree, pt was\nextremely hesitant and said she felt nauseous, but was able to\nclear. Pt also noted sensation of pharyngeal residue with puree,\nbut no sensation of aspiration or odynophagia.\nSUMMARY / IMPRESSION:\nPt presents with s/sx of aspiration with ice chips, thin liquids,\nand initial trials of puree and nectar. However, given that many\n(approx 6) subsequent trials of nectar were clear, a PO diet of\nsoft solids and nectar thick liquids is recommended. Meds may be\ncrushed in puree. 1:1 supervision is recommended to maintain\naspiration precautions. Please continue to consult with\nNutrition, given pt's poor PO intake for greater than 7 days. We\nwill f/u early next week to see if pt is eligible for diet\nupgrade.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5 out of 7.\nRECOMMENDATIONS:\n1.) PO diet of soft solids and nectar thick liquids.\n2.) Meds crushed in puree\n3.) TID oral care\n4.) 1:1 supervision with meals to maintain aspiration precautions\nincluding:\n -Consider 6 small meals in of 3 large ones\n -Provide supplements between meals rather than with meals\n -Eat tougher, chewier foods at the beginning of the meal,\nand end meal with softer foods.\n5.) Please continue to consult with Nutrition, given pt's poor PO\nintake for greater than 7 days.\n6.) We will f/u early next week\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , B.A., SLP/s\nPager #\n____________________________________\n Whitmill, M.S., CCC-SLP\nPager #\nFace time: 10:45-11:15\nTotal time: 75min\n" }, { "category": "Rehab Services", "chartdate": "2155-10-31 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 499386, "text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for referring this 83 yo woman admitted via the Neuro\nclinic on p/w progressively worsening ptosis and\ndysarthria for 1 month, and worsening nonproductive cough and\ndysphagia with both liquids and solids for past week. Pt has a\nPMH remarkable for Myasthenia in , which pt reports\nwas c/b a similar set of symptoms. Per Neuro admission note on\n, pt's son suspected that her symptoms may be\ndue to myasthenia and gave her some 5 yr old Mestinon that he\nfound in her cabinet. Per note, her son reported that her\nsymptoms seemed to improve slightly following first dose, but\nsubsequently worsened as the week progressed. Consequently, she\nhad poor PO intake for past week at home per Neuro note. She is\ncurrently on a clear liquids diet. RN reports that pt tolerated\nice cream and jello, though refused broth and tea because the\nwere uncomfortable. We were consulted to eval oral and\npharyngeal swallow function to determine the safest diet.\nPMH:\nMyasthenia , diagnosed 10 years ago when she presented with\ndysarthria, dysphagia, and ptosis with Tensilon test and EMG\nindicating MG, son says were \"abnormal\" at Dr.\noffice, was given plasmapheresis c/b LUE DVT, not currently on\nmedications but previously on mestinion which she stopped 5 years\nago due to diarrhea (which she says is due to lactose in the\nformulation and not a mestinon side effect itself), has had no\nflares since diagnosis, has never been intubated\nIdiopathic colitis\nDiverticulosis\nTemporomandibular joint disease with secondary migraine headaches\nLower GI bleed\nLactose intolerant\ns/p bilateral total hip replacement\ns/p bladder suspension\ns/p appendectomy\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the TSICU.\nCognition, language, speech, voice:\nPt was awake upon entry to the room and oriented x3. However, pt\ndid become confused at times, reporting that her favorite MD was\nat another hospital, \"the .\" She was also forgetful,\nrequiring multiple repetitions of the same info. However, pt was\nable to follow simple motor commands. Expressive was\nfluent, mostly appropriate, and without paraphasias. Speech was\nmildly dysarthric. Vocal quality was WNL.\nTeeth: WNL\nSecretions: WNL\nORAL MOTOR EXAM:\nL ptosis and facial droop appreciated. Tongue protruded at\nmidline with adequate strength and ROM. Labial seal was reduced\ndue to L lip droop, however pt was still able to maintain\nadequate labial seal around straw. Palatal elevation was\nsymmetrical. Gag was hypersensitive.\nSWALLOWING ASSESSMENT:\nPt was offered ice chips, thin liquids (tsp, cup), nectar thick\nliquids (tsp, cup, straw), puree, and soft solids. Oral phase\nwas mildly prolonged for all trialed consistencies, generally\nrequiring 2 swallows per bite or sip. Laryngeal elevation was\nreduced. Pt had delayed cough/throat clear with ice chips and\napproximately 90% of trials of thin liquids. Wet vocal quality\nalso noted with thin liquids. Additionally, pt had delayed\nthroat clear with initial puree and nectar trials, but was\nwithout any s/sx of aspiration for many subsequent trials. No\nchoking or 02 desats observed throughout eval. However, pt noted\nthat she was \"unable\" to take whole meds because she \"would\nchoke.\" When meds were administered crushed in puree, pt was\nextremely hesitant and said she felt nauseous, but was able to\nclear. Pt also noted sensation of pharyngeal residue with puree,\nbut no sensation of aspiration or odynophagia.\nSUMMARY / IMPRESSION:\nPt presents with s/sx of aspiration with ice chips, thin liquids,\nand initial trials of puree and nectar. However, given that many\n(approx 6) subsequent trials of nectar were clear, a PO diet of\nsoft solids and nectar thick liquids is recommended. Meds may be\ncrushed in puree. 1:1 supervision is recommended to maintain\naspiration precautions. Please continue to consult with\nNutrition, given pt's poor PO intake for greater than 7 days. We\nwill f/u early next week to see if pt is eligible for diet\nupgrade.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5 out of 7.\nRECOMMENDATIONS:\n1.) PO diet of soft solids and nectar thick liquids.\n2.) Meds crushed in puree\n3.) TID oral care\n4.) 1:1 supervision with meals to maintain aspiration precautions\nincluding:\n -Consider 6 small meals in of 3 large ones\n -Provide supplements between meals rather than with meals\n -Eat tougher, chewier foods at the beginning of the meal,\nand end meal with softer foods.\n5.) Please continue to consult with Nutrition, given pt's poor PO\nintake for greater than 7 days.\n6.) We will f/u early next week\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , B.A., SLP/s\nPager #\n____________________________________\n Whitmill, M.S., CCC-SLP\nPager #\nFace time: 10:45-11:15\nTotal time: 75min\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: Whitmill, SLP\n on: 01:20 PM ------\n" }, { "category": "Physician ", "chartdate": "2155-10-31 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 499488, "text": "Chief Complaint: genearalized weakness, ptosis\n HPI:\n 83F with h/o myasthenia , presenting with three weeks of\n progressive ptosis, dysphagia, dysarthria, and generalized weakness.\n Ms. first noticed her eyelids drooping, worse on left\n compared to right and over the past week has had progressive difficulty\n swallowing solids. Over the past two days she has been unable to\n swallow solids or liquids and has reported her speech to be more nasal\n than baseline. Ms. was first diagnosed with myasthenia in\n when she had developed a similar constellation of symptoms. At\n that time, an EMG demonstrated decrementing response to repetitive\n stimulation of facial nerves and a tensilon test did improve her\n ptosis. She was started on mestinon with a dramatic improvement. The\n patient received two sessions of plasmapheresis, but did not complete\n the entire course of five due to thrombus formation at the site of the\n catheter. She was discharged home on mestinon and was followed by Dr.\n for several years. She had been doing well and her mestinon was\n discontinued several years prior in the early (unsure of exact\n date) with no further recurrences of symptoms. She had never required\n immunosuppression or intubation.\n Post operative day:\n Allergies:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Past medical history:\n Family / Social history:\n -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Social History;\n -lives alone, has four children. Retired emergency room nurse.\n No history of tobacco or alcohol use.\n Family History;\n -no history of autoimmune disease or neurological diseases\n Flowsheet Data as of 09:48 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 87 (86 - 100) bpm\n BP: 166/78(100) {160/74(98) - 187/91(114)} mmHg\n RR: 21 (21 - 41) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71 kg (admission): 71 kg\n Height: 56 Inch\n Total In:\n 320 mL\n PO:\n TF:\n IVF:\n 320 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.43/45/95.//4\n NIF: -22 cmH2O\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, L eye ptosis\n Head, Ears, Nose, Throat: Normocephalic, voice mildly hoarse\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: slight L arm weakness; otherwise strength equal /\n intact\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person/place/time, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n [image002.jpg]\n 09:17 PM\n TCO2\n 31\n Assessment and Plan\n Assessment And Plan: Ms. is an 83-year-old female with history of\n myasthenia , presenting with three weeks of ptosis, nasal speech,\n dysphagia, and generalized weakness.\n Neurologic: Generalized weakness, ptosis L > R now resolving; monitor\n for changes in neuro exam; pyridostigmine 60mg q4h; will consider IVIG\n vs steroids as needed depending on response to pyridostigmine; q4h\n neuro checks\n Cardiovascular: Stable HR and BP\n Pulmonary: Stable on room air; q4h NIFs and VCs, low threshold for\n intubation if evidence of respiratory decline\n Gastrointestinal: NPO except meds, speech & swollow eval pending\n Renal: UOP appropriate, monitor lytes and replete as needed\n Hematology: Hct 42.2, no issues\n Infectious Disease: No evidence of infection, WBC normal / afebrile; no\n abx at this time\n Endocrine: RISS\n Fluids: NS @ 75mL/hr\n Electrolytes: replete as needed\n Nutrition: NPO except meds\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:59 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2155-10-31 00:00:00.000", "description": "Intensivist Note", "row_id": 499489, "text": "TSICU\n HPI:\n 83F with h/o myasthenia , presenting with three weeks of\n progressive ptosis, dysphagia, dysarthria, and generalized\n weakness. Ms. first noticed her eyelids drooping, worse on left\n compared to right and over the past week has had progressive\n difficulty swallowing solids. Over the past two days she has been\n unable to swallow solids or liquids and has reported her speech to be\n more nasal than baseline. Ms. was first diagnosed with myasthenia\n in when she had developed a similar constellation of\n symptoms. At that time, an EMG demonstrated decrementing response to\n repetitive stimulation of facial nerves and a tensilon test did improve\n her ptosis. She was started on mestinon with a dramatic improvement.\n The patient received two sessions of\n plasmapheresis, but did not complete the entire course of five due to\n thrombus formation at the site of the catheter. She was discharged\n home on mestinon and was followed by Dr. for several years. She\n had been doing well and her mestinon was discontinued several years\n prior in the early (unsure of exact date) with no further\n recurrences of symptoms. She had never required immunosuppression or\n intubation.\n Chief complaint:\n generalized weakness, ptosis\n PMHx:\n -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1635\n 7. Heparin 5000 UNIT SC TID Order date: @ \n 2. 1000 mL NS\n Continuous at 75 ml/hr\n continue until patient tolerating PO Order date: @ 1635\n 8. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2127\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever Order date: @\n 1635\n 9. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 1630\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 2127\n 10. Pyridostigmine Bromide 60 mg PO/NG Q4H Order date: @ 1635\n 5. Famotidine 20 mg IV Q12H Order date: @ \n 11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1635\n 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 2127\n 24 Hour Events:\n Admitted to TSICU overnight for monitoring of respiratory status. NIFs\n stable from -18 to -22, VCs stable from 1.5 to 1.7. No overnight\n events.\n NASAL SWAB - At 08:39 PM\n Allergies:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.8\nC (98.2\n HR: 88 (82 - 100) bpm\n BP: 158/54(83) {134/40(68) - 187/102(114)} mmHg\n RR: 20 (16 - 41) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 71 kg\n Height: 56 Inch\n Total In:\n 493 mL\n 461 mL\n PO:\n Tube feeding:\n IV Fluid:\n 493 mL\n 461 mL\n Blood products:\n Total out:\n 250 mL\n 350 mL\n Urine:\n 250 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 243 mL\n 111 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: 7.43/45/95./30/4\n NIF: -22 cmH2O\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI, L ptosis. Voice mildly hoarse.\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE:\n Weakness)\n Labs / Radiology\n 180 K/uL\n 12.5 g/dL\n 92 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 104 mEq/L\n 143 mEq/L\n 37.1 %\n 7.3 K/uL\n [image002.jpg]\n 09:17 PM\n 12:32 AM\n WBC\n 7.3\n Hct\n 37.1\n Plt\n 180\n Creatinine\n 0.7\n TCO2\n 31\n Glucose\n 92\n Other labs: Ca:8.9 mg/dL, Mg:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Myasthenia exacerbation\n Assessment and Plan: Ms. is an 83-year-old female with history of\n myasthenia , presenting with three weeks of ptosis, nasal speech,\n dysphagia, and generalized weakness.\n Neurologic: Neuro checks Q: 4 hr, Generalized weakness, ptosis L > R\n now resolving; monitor for changes in neuro exam; pyridostigmine 60mg\n q4h; will consider IVIG vs steroids as needed depending on response to\n pyridostigmine\n Cardiovascular: Stable HR and BP\n Pulmonary: Stable on room air; q4h NIFs and VCs, low threshold for\n intubation if evidence of respiratory decline. Good respiratory status\n at this point. NIF -22, VC 1600 mL.\n Gastrointestinal / Abdomen: Clears as tolerated, bedside speech and\n swallow.\n Nutrition: NPO, except meds\n Renal: UOP appropriate, monitor lytes and replete as needed\n Hematology: Hct 37.1, no issues\n Endocrine: RISS\n Infectious Disease: No evidence of infection, WBC normal / afebrile; no\n abx at this time\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids: NS, @75mL/hr\n Consults: Neurology\n Billing Diagnosis: Other: myasthenia exacerbation\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:59 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: na\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2155-10-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 499478, "text": "80yo female with hx of myasthenia , diagnosed in\n98 and received\n mestanon with dramatic improvement. Pt was at home and began to\n experience worsening weakess, ptosis (worse on the left eye),\n dysphagia, dysarthria. Pt was admitted to the TSICU for further care\n on .\n Myasthenia exacerbation\n Assessment:\n Pt is alert and oriented x3, appropriate, able to hold clear\n conversations, speech is slightly slurred, pt able to recognize when it\n feels more difficult to speak or swallow. Pt MAE\ns with good strength,\n seen by PT this AM and ambulated around unit, as well as OOB to chair\n multiple times today. Pt also boosts and shifts herself in the bed as\n needed. Pt able to get OOB to commode to urinate PRN. Pt is on RA, O2\n sat >94% when awake/sitting up in bed. Occasionally O2 sat drifts\n lower to 88% when sleeping-2L nc applied while sleeping rarely. Pt has\n strong, productive and occasional cough. Abdomen soft, pt able to take\n PO\ns but coughing frequently. Pt voids clear yellow urine, uses\n commode. Skin intact. Vital capacity is 1.6L and nifs are -22 per RT.\n Action:\n Q4 hr neuro checks done, speech and swallow eval completed. Physical\n therapy saw pt this AM-pt ambulated around unit and OOB to chair\n multiple times. Pt continues on PO mestanon (liquid) q4. Emotional\n support provided to pt and family. IgA level pending, type and cross\n pending-IV Ig not given, neuro med aware and ok if pt receives it on\n the floor. Nifs and vital capacities done by RT Q6hrs as ordered.\n Response:\n Pt\ns neuro exam remains intact, respiratory status and swallowing\n improving with mestanon. Ptosis of left eye improving. Pt is not\n allowed to have thin liquids per Speech and swallow exam, may have\n thickened liquids and soft foods.\n Plan:\n Continue Q4 mestanon, new speech and swallow exam planned for Monday\n morning. Monitor respiratory status, keep on telemetry, enforce diet\n recommendations. Give IV Ig tonight when on SDU per neuromed once\n pending labs are back. RT to check vital capacity and nifs Q6hrs.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n WEAKNESS\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 71 kg\n Daily weight:\n 71.2 kg\n Allergies/Reactions:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Precautions: No Additional Precautions\n PMH: GI Bleed\n CV-PMH:\n Additional history: myasthenia \n idiopathic colitis\n diveticular disease\n s/p appendectomy\n temporomandibular disease\n s/p total hip replacements\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:153\n D:71\n Temperature:\n 98.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 86 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 2,006 mL\n 24h total out:\n 1,050 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 12:32 AM\n Potassium:\n 3.5 mEq/L\n 12:32 AM\n Chloride:\n 104 mEq/L\n 12:32 AM\n CO2:\n 30 mEq/L\n 12:32 AM\n BUN:\n 13 mg/dL\n 12:32 AM\n Creatinine:\n 0.7 mg/dL\n 12:32 AM\n Glucose:\n 92 mg/dL\n 12:32 AM\n Hematocrit:\n 37.1 %\n 12:32 AM\n Finger Stick Glucose:\n 102\n 02:00 PM\n Additional pertinent labs:\n pending type & cross, pending IgA level in order to give IV Ig\n Lines / Tubes / Drains:\n PIV x1\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: pt wearing yellow watch, two yellow rings-one has clear\n stones, one white colored ring\n Transferred from: TSICU 561\n Transferred to: 1121 SDU\n Date & time of Transfer: 07:30 PM\n" }, { "category": "Nursing", "chartdate": "2155-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 499183, "text": "83F with h/o myasthenia , presenting with three weeks of\n progressive ptosis, dysphagia, dysarthria, and generalized weakness.\n Ms. first noticed her eyelids drooping, worse on left compared to\n right and over the past week has had progressive difficulty swallowing\n solids. Over the past two days she has been unable to swallow solids\n or liquids and has reported her speech to be more nasal than baseline.\n Ms. was first diagnosed with myasthenia in when she\n had developed a similar constellation of symptoms. She was started on\n mestinon with a dramatic improvement.\n Allergies:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Past medical history:\n Family / Social history:\n -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Social History;\n -lives alone, has four children. Retired emergency room nurse.\n No history of tobacco or alcohol use.\n Family History;\n -no history of autoimmune disease or neurological diseases\n Myasthenia exacerbation\n Assessment:\n Alert, oriented, moves all extremities equally but c/o generalized\n weakness though had steady balance when using the commode. PERRLA\n though has obvious L eye ptosis (L eye red and irritated with\n discharge). Very talkative though speech is\nthick tongued\n. Has\n persistent cough and at times feels like she is choking. Denies pain.\n BP slightly elevated (150-160\ns). On 2l np with adequate saturation.\n Voiding concentrated urine per commode.\n Action:\n Mestinon given in applesauce (to aid swallowing) q 4 hours, labs\n obtained, q 4 hour nifs, q 1 hour neuro checks\n Spoke at length with pts. Daughter who was frustrated in trying to get\n appropriate care and treatment of her mom (mother had made previous\n visit to ER 2 days pta and was sent home).\n Response:\n Continued coughing and choking sensation though able to swallow\n applesauce puree, continued L eye ptosis though she says the eye is\n better (apparently was completely closed when she arrived in ER).\n Difficulty obtaining NIF and vital capacity (pt states she had\n difficulty performing these also with previous MG exacerbation)\n Plan:\n Frequent neuro checks, bedside speech and swallow today. If passes,\n advance diet as tolerated.\n Continue mestinon q 4 hours while monitoring symptoms.\n" }, { "category": "Physician ", "chartdate": "2155-10-30 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 499174, "text": "Chief Complaint: genearalized weakness, ptosis\n HPI:\n 83F with h/o myasthenia , presenting with three weeks of\n progressive ptosis, dysphagia, dysarthria, and generalized weakness.\n Ms. first noticed her eyelids drooping, worse on left\n compared to right and over the past week has had progressive difficulty\n swallowing solids. Over the past two days she has been unable to\n swallow solids or liquids and has reported her speech to be more nasal\n than baseline. Ms. was first diagnosed with myasthenia in\n when she had developed a similar constellation of symptoms. At\n that time, an EMG demonstrated decrementing response to repetitive\n stimulation of facial nerves and a tensilon test did improve her\n ptosis. She was started on mestinon with a dramatic improvement. The\n patient received two sessions of plasmapheresis, but did not complete\n the entire course of five due to thrombus formation at the site of the\n catheter. She was discharged home on mestinon and was followed by Dr.\n for several years. She had been doing well and her mestinon was\n discontinued several years prior in the early (unsure of exact\n date) with no further recurrences of symptoms. She had never required\n immunosuppression or intubation.\n Post operative day:\n Allergies:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Past medical history:\n Family / Social history:\n -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Social History;\n -lives alone, has four children. Retired emergency room nurse.\n No history of tobacco or alcohol use.\n Family History;\n -no history of autoimmune disease or neurological diseases\n Flowsheet Data as of 09:48 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 87 (86 - 100) bpm\n BP: 166/78(100) {160/74(98) - 187/91(114)} mmHg\n RR: 21 (21 - 41) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71 kg (admission): 71 kg\n Height: 56 Inch\n Total In:\n 320 mL\n PO:\n TF:\n IVF:\n 320 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.43/45/95.//4\n NIF: -22 cmH2O\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, L eye ptosis\n Head, Ears, Nose, Throat: Normocephalic, voice mildly hoarse\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: slight L arm weakness; otherwise strength equal /\n intact\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person/place/time, Movement: Purposeful, Tone:\n Normal\n Labs / Radiology\n [image002.jpg]\n 09:17 PM\n TCO2\n 31\n Assessment and Plan\n Assessment And Plan: Ms. is an 83-year-old female with history of\n myasthenia , presenting with three weeks of ptosis, nasal speech,\n dysphagia, and generalized weakness.\n Neurologic: Generalized weakness, ptosis L > R now resolving; monitor\n for changes in neuro exam; pyridostigmine 60mg q4h; will consider IVIG\n vs steroids as needed depending on response to pyridostigmine; q4h\n neuro checks\n Cardiovascular: Stable HR and BP\n Pulmonary: Stable on room air; q4h NIFs and VCs, low threshold for\n intubation if evidence of respiratory decline\n Gastrointestinal: NPO except meds, speech & swollow eval pending\n Renal: UOP appropriate, monitor lytes and replete as needed\n Hematology: Hct 42.2, no issues\n Infectious Disease: No evidence of infection, WBC normal / afebrile; no\n abx at this time\n Endocrine: RISS\n Fluids: NS @ 75mL/hr\n Electrolytes: replete as needed\n Nutrition: NPO except meds\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:59 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Rehab Services", "chartdate": "2155-10-31 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 499319, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: MG / 358.01\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 83 yo F with h/o\n myasthenia p/w 3 weeks of progressive ptosis, dysphagia,\n dysarthria, and generalized weakness. Found to have poor NIF and VC in\n the ED, admitted to icu for respiratory monitoring.\n Past Medical / Surgical History: MG dx ', idiopathic colitis,\n diverticular dz, s/p appy, s/p bladder suspension, lower GIB, TMJ dz,\n s/p B THR\n Medications: tylenol, heparin, mestinon\n Radiology: CXR pending\n Labs:\n 37.1\n 12.5\n 180\n 7.3\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist\n Social / Occupational History: lives alone, has several children,\n supportive son lives nearby\n Living Environment: lives in multi-level home with steps to enter and\n flight of stairs to bedroom\n Prior Functional Status / Activity Level: I pta, no DME\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x3, pleasant and\n cooperative\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 88\n 161/76\n 18\n 95% on RA\n Activity\n 98\n 173/87\n 22\n 95% on RA\n Recovery\n 84\n 143/88\n 20\n 95% on RA\n Total distance walked: 125'\n Minutes:\n Pulmonary Status: mild rhonchi B upper BS, strong productive cough,\n non-labored breathing\n Integumentary / Vascular: skin intact, L eye erythema, tele\n Sensory Integrity: intact to light touch, denies parasthesias\n Pain / Limiting Symptoms: denies pain\n Posture: kyphotic posture\n Range of Motion\n Muscle Performance\n B LE's WNL\n B LE's grossly 4+/5 t/o\n Motor Function: no abnormal movement patterns, L eye ptosis\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: steady functional gait pushing w.c, slight c/o\n fatigue.\n Rolling:\n\n\n T\n\n\n\n Supine /\n Sidelying to Sit:\n\n T\n\n\n\n Transfer:\n\n T\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S static sitting, CG static/dynamic standing balance. No\n gross LOB with mobility\n Education / Communication: REviewed PT and d/c planning, encourated\n OOB and ambulation. Communicated with nsg re: status\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired strength\n Clinical impression / Prognosis: 83 yo F with myasthenia p/w\n above impairments a/w CNS dysfunction. She is most limited by general\n deconditioning and weakness a/w hospitalization and has not eaten solid\n food in > 1 week. She is just below her baseline level but is\n progressing well, anticipate safe d/c home following more PT tx to\n progress ambulation and assess on stairs.\n Goals\n Time frame: 1 week\n 1.\n Independent with all mobility\n 2.\n No LOB with mobility\n 3.\n Ambulate >/= 300' with stable HDR\n 4.\n Independent with home exercise program.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1-2x\n bed mobility, transfers, ambulation, stairs, balance, endurance,\n education, strengthening, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2155-10-31 00:00:00.000", "description": "Intensivist Note", "row_id": 499301, "text": "TSICU\n HPI:\n 83F with h/o myasthenia , presenting with three weeks of\n progressive ptosis, dysphagia, dysarthria, and generalized\n weakness. Ms. first noticed her eyelids drooping, worse on left\n compared to right and over the past week has had progressive\n difficulty swallowing solids. Over the past two days she has been\n unable to swallow solids or liquids and has reported her speech to be\n more nasal than baseline. Ms. was first diagnosed with myasthenia\n in when she had developed a similar constellation of\n symptoms. At that time, an EMG demonstrated decrementing response to\n repetitive stimulation of facial nerves and a tensilon test did improve\n her ptosis. She was started on mestinon with a dramatic improvement.\n The patient received two sessions of\n plasmapheresis, but did not complete the entire course of five due to\n thrombus formation at the site of the catheter. She was discharged\n home on mestinon and was followed by Dr. for several years. She\n had been doing well and her mestinon was discontinued several years\n prior in the early (unsure of exact date) with no further\n recurrences of symptoms. She had never required immunosuppression or\n intubation.\n Chief complaint:\n generalized weakness, ptosis\n PMHx:\n -myasthenia , diagnosed in \n -idiopathic colitis\n -diverticular disease\n -s/p appendectomy\n -s/p bladder suspension\n -lower GI bleed\n -lactose intolerance\n -temporomandibular disease with secondary headaches\n -s/p b/l total hip replacements\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1635\n 7. Heparin 5000 UNIT SC TID Order date: @ \n 2. 1000 mL NS\n Continuous at 75 ml/hr\n continue until patient tolerating PO Order date: @ 1635\n 8. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2127\n 3. Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever Order date: @\n 1635\n 9. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 1630\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 2127\n 10. Pyridostigmine Bromide 60 mg PO/NG Q4H Order date: @ 1635\n 5. Famotidine 20 mg IV Q12H Order date: @ \n 11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1635\n 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 2127\n 24 Hour Events:\n Admitted to TSICU overnight for monitoring of respiratory status. NIFs\n stable from -18 to -22, VCs stable from 1.5 to 1.7. No overnight\n events.\n NASAL SWAB - At 08:39 PM\n Allergies:\n Lactose Intolerance (Oral) (Lactase)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.8\nC (98.2\n HR: 88 (82 - 100) bpm\n BP: 158/54(83) {134/40(68) - 187/102(114)} mmHg\n RR: 20 (16 - 41) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.2 kg (admission): 71 kg\n Height: 56 Inch\n Total In:\n 493 mL\n 461 mL\n PO:\n Tube feeding:\n IV Fluid:\n 493 mL\n 461 mL\n Blood products:\n Total out:\n 250 mL\n 350 mL\n Urine:\n 250 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 243 mL\n 111 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: 7.43/45/95./30/4\n NIF: -22 cmH2O\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI, L ptosis. Voice mildly hoarse.\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE:\n Weakness)\n Labs / Radiology\n 180 K/uL\n 12.5 g/dL\n 92 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 104 mEq/L\n 143 mEq/L\n 37.1 %\n 7.3 K/uL\n [image002.jpg]\n 09:17 PM\n 12:32 AM\n WBC\n 7.3\n Hct\n 37.1\n Plt\n 180\n Creatinine\n 0.7\n TCO2\n 31\n Glucose\n 92\n Other labs: Ca:8.9 mg/dL, Mg:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Myasthenia exacerbation\n Assessment and Plan: Ms. is an 83-year-old female with history of\n myasthenia , presenting with three weeks of ptosis, nasal speech,\n dysphagia, and generalized weakness.\n Neurologic: Neuro checks Q: 4 hr, Generalized weakness, ptosis L > R\n now resolving; monitor for changes in neuro exam; pyridostigmine 60mg\n q4h; will consider IVIG vs steroids as needed depending on response to\n pyridostigmine\n Cardiovascular: Stable HR and BP\n Pulmonary: Stable on room air; q4h NIFs and VCs, low threshold for\n intubation if evidence of respiratory decline. Good respiratory status\n at this point. NIF -22, VC 1600 mL.\n Gastrointestinal / Abdomen: Clears as tolerated, bedside speech and\n swallow.\n Nutrition: NPO, except meds\n Renal: UOP appropriate, monitor lytes and replete as needed\n Hematology: Hct 37.1, no issues\n Endocrine: RISS\n Infectious Disease: No evidence of infection, WBC normal / afebrile; no\n abx at this time\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids: NS, @75mL/hr\n Consults: Neurology\n Billing Diagnosis: Other: myasthenia exacerbation\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:59 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: na\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Radiology", "chartdate": "2155-11-07 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1108516, "text": " 7:55 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o retroperitoneal hematoma\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with back pain, decreasing HCT\n REASON FOR THIS EXAMINATION:\n r/o retroperitoneal hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old woman with back pain, decreasing hematocrit. Rule\n out retroperitoneal hematoma.\n\n No studies are available for comparison.\n\n TECHNIQUE: This study was performed as a non-contrast study through the\n abdomen and pelvis. Coronal and sagittal reformations were also performed.\n\n FINDINGS: Visualized lung bases show increased interstitial markings in the\n right lower lobe. Also noted 0.2 subpleural pulmonary nodule in the right\n lower lobe. Additional dense probably calcified tiny pulmonary nodule is seen\n in the left lower lobe, series 2, image 22. There is no evidence of pleural\n or pericardial effusion. Coronary artery calcifications are noted. Moderate\n hiatal hernia is seen.\n\n Non-contrast view of the liver shows single hypodense lesion in the segment II\n measuring 0.9 cm, which is indeterminate on this study. There is no evidence\n of intrahepatic or extrahepatic bile dilatation.\n\n Gallbladder is elongated, mildly enlarged measuring 4.1 cm in its largest\n portion with stones in it. However, there is no thickening of the\n gallbladder wall. If clinically indicated, further evaluation should be\n performed by ultrasound.\n\n Pancreas is of normal size and attenuation on this non-contrast study. There\n is no evidence of pancreatic duct dilatation. Spleen is of normal size and\n attenuation. Adrenals are unremarkable bilaterally. Right kidney shows lower\n pole hypodensity, which may be consistent with cysts but is not fully\n evaluated by this non-contrast study. The left kidney shows also additional\n small cortical hypodensity series 2, image 36, which cannot be fully evaluated\n by this non-contrast study. Stomach is within normal limits.\n\n Duodenum shows diverticulum at the second part measuring 4 cm, with air-fluid\n level and small amount of fecal material in it.\n\n Diffuse atherosclerotic changes of abdominal aorta are noted with tortuosity\n but without abnormal dilatation.\n\n There is no evidence of retroperitoneal hematoma.\n\n There is no evidence of retroperitoneal or mesenteric lymphadenopathy. Small\n (Over)\n\n 7:55 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o retroperitoneal hematoma\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n umbilical hernia containing fat is noted. Diffuse diverticulosis of the\n ascending, transverse, descending and sigmoid colon is noted. Diverticulosis\n is extremely prominent in the sigmoid colon. There is no evidence of\n diverticulitis.\n\n PELVIS CT: Total hip replacement. Metallic artifacts on the pelvic\n structures impair proper evaluation of pelvic organs. As far as we can see\n there is no evidence of pelvic lymphadenopathy. There is no evidence of\n inguinal lymphadenopathy.\n\n OSSEOUS STRUCTURES: Total hip replacement bilaterally. There is no evidence\n of other worrisome lesions.\n\n IMPRESSION:\n 1. There is no evidence of retroperitoneal hematoma.\n 2. Gallbladder is distended up to 4.4 cm with stones in it. There is no\n evidence of inflammatory changes around it but if clinically indicated further\n evaluation should be performed by ultrasound.\n 3. Extensive diverticulosis of the colon, more prominent in the sigmoid\n colon.\n 4. Duodenal diverticulum.\n 5. Bilateral hypodensity within the kidneys, which cannot be fully evaluated\n by this non-contrast study.\n\n" }, { "category": "Radiology", "chartdate": "2155-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107598, "text": " 12:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o lung process\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with with new oxygen requirement\n REASON FOR THIS EXAMINATION:\n r/o lung process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 83-year-old female with myasthenia and new oxygen\n requirement.\n\n COMPARISON: Chest radiograph from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Lungs are hyperinflated. There is no\n evidence of pneumonia or congestive heart failure. There is no pneumothorax\n or pleural effusion. Slight amount of left costophrenic angle opacity may\n represent minimal atelectatic changes. Right paratracheal increased soft\n tissue density is again noted, which may be vascular. The aorta is severely\n calcified and tortuous. The heart is not enlarged. Osseous structures are\n osteopenic. A loose body inferior to the left shoulder joint is stable.\n\n IMPRESSION:\n 1. No pneumonia.\n 2. Stable prominent right paratracheal soft tissue may be vascular in nature.\n Given the history of myasthenia , we recommend correlation with prior\n studies. CT can be obtained if clinically warranted.\n\n" }, { "category": "Radiology", "chartdate": "2155-11-03 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1107940, "text": " 6:05 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for thymoma\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with myasthenia . please eval for thymoma.\n REASON FOR THIS EXAMINATION:\n eval for thymoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf MON 6:29 PM\n No evidence of thymoma. Bibasilar mild atelectasis. Small hypodensity at the\n left liver lobe, too small to characterize.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Myasthenia , query thymoma.\n\n COMPARISON: None available.\n\n TECHNIQUE: Multiple MDCT axial images were obtained through the chest using\n 1.25-mm axial collimation without intravenous contrast. Multiplanar reformats\n were derived using 5-mm collimation. A series of axial 5-mm collimated slices\n were processed using lung kernel algorithm.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: The visualized thyroid appears\n normal. No axillary or mediastinal nodes meet CT size criteria for pathologic\n enlargement. AP window and right paratracheal nodes measure to 9 mm and a\n subcarinal node measures to 9 mm. The pulmonary artery is normal in diameter.\n There is no thymoma. The aorta is normal in caliber and course. There are\n dense atherosclerotic calcifications including two-vessel coronary artery\n calcification. The aortic valve is slightly calcified. Ascending aorta is\n prominent to 3.6 cm. The heart is normal in size. There is no pericardial\n effusion. The esophagus appears normal. The diaphragm is incomplete\n anteriorly where distal fat is seen.\n\n Central airways are patent to the level of subsegmental bronchi. There is\n mild bibasal atelectasis. Lower lobe granulomata are seen. There is no\n pleural effusion, pulmonary mass, or pneumothorax.\n\n This study is not optimized to visualize the abdomen, but within this limit,\n there is a subcentimeter hypodensity in the left lobe of the liver,\n incompletely characterized. The spleen, pancreas, adrenals, and visualized\n kidneys appear normal. Incidental note is made of a splenule. There is no\n suspicious osteolytic or osteoblastic lesion. Degenerative changes are seen in\n the left shoulder where partly imaged opacites suggest calcific tendonitis.\n Multilevel degenerative changes are seen in the spine.\n\n IMPRESSION:\n 1. No evidence for thymoma.\n 2. Aortic and coronary artery calcification.\n 3. Morgagni fat-containing hernia.\n 4. Left lobe of the liver hypodensity, too small to characterize, likely a\n (Over)\n\n 6:05 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for thymoma\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n simple cyst or hemangioma.\n 5. Degenerative changes of the left shoulder and possilbe calcific\n tendonitis. Correlate clinically.\n\n" }, { "category": "Radiology", "chartdate": "2155-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1107410, "text": " 4:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with myasthenic crisis and dysphagia\n REASON FOR THIS EXAMINATION:\n evaluate for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old woman with myasthenia and dysphagia.\n\n Evaluate for aspiration.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: No images for comparison at the time of dictation.\n\n FINDINGS: Lungs are clear. No focal consolidation, pleural effusion or\n pneumothorax is seen. There is prominent right paratracheal soft tissue\n density which could be vascular in nature.\n\n IMPRESSION: No focal consolidation.\n\n Prominent right paratracheal soft tissue which may be vascular in nature.\n However, given history of myasthenia , recommend correlation with prior\n studies. CT or MRI can be obtained as clinically indicated for confirmation.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2158-07-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1245290, "text": " 5:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 28M with AMS, hematoma to occiput\n REASON FOR THIS EXAMINATION:\n Evaluate for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXCf FRI 6:37 AM\n no acute intracranial process\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with altered mental status, occipital hematoma. Assess\n for intracranial hemorrhage.\n\n COMPARISONS: None available.\n\n TECHNIQUE: MDCT-acquired contiguous images through the head was obtained\n without intravenous contrast. Coronally and sagittally reformatted images\n were displayed.\n\n FINDINGS:\n\n There is no evidence of acute intracranial hemorrhage, mass effect or shift of\n normal midline structures. There is no cerebral edema or loss of -white\n matter differentiation to suggest an acute ischemic event. The sulci and\n ventricles are prominent, is advanced for the patient. There is mild\n asymmetry of the frontal horns of the lateral ventricles, which is likely\n congenital. Basal cisterns are patent. Moderate right parietal subgaleal\n hematoma is noted. No underlying fracture is seen. Imaged paranasal sinuses\n and mastoid air cells are well aerated.\n\n IMPRESSION:\n\n No evidence of acute intracranial process.\n\n\n" }, { "category": "ECG", "chartdate": "2158-07-14 00:00:00.000", "description": "Report", "row_id": 305006, "text": "Artifact is present. Regular atrial pacing with native ventricular conduction.\nLeft bundle-branch block. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1970114, "text": "Neonatology Attending\n\nDay 5\n\nRemains in RA. Clear breath sounds. Sats > 95%. RR 30-50s. No murmur. Pink. HR 120-140s. Weight 3045 gms (-20). Ad lib E20. Taking 50-90 cc per feed. Waking every 2-4 hours on demand. Passing heme negative stool. EEG pending.\n\nAppears to be doing well with no further seizure activity reported. Plan to discharge to home if EEG normal.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1970115, "text": "Neonatology Fellow\nAlert and active. No distress. AFSOF. Nl facies. Bilateral red reflex. Lungs - clear and symmetric breath sounds. CV - s1s2, regular, no murmurs. Warm and well perfused. Abdomen - active bowel sounds, soft, flat. GU - well healing circ, bilaterally descended testes. Hips - stable. Skin - no rashes. Neuro - nonfocal.\nPlease see discharge dictation for further detail.\nEEG was normal. Discharge to home, follow up with Dr. , PHA at CH, on at 3:30 PM.\n\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1970116, "text": "Nursing Discharge Note\n\n\nPt. remains in RA, O2 sats >96%. RR 30-60's. LS clear/=,\nno increase work of breathing noted. No A&B's. HR\n120-140's, no murmur noted. He is pink/sl.mottly, well\nperfused. Weight today 3.045kg. He is ad lib demand of\nEnfamil 20 and takes ~50-90cc Q feed. Pt. is alert and\nactive but is irritable at times. He uses his pacifier well\nfor comfort, brings hands to face. Fontanelle soft/flat.\nTemps stable, swaddled. No signs of any seizure-like\nactivity noted. Discharge teaching done with mom. She\nappears to have a good understanding of infant care. Mom\nstates that she lives with several family members that have\nsmall children which offers her some extra support with\nchild care. Patient will have follow up with pedi on Friday\n@ 1530, . VNA identified, referral\nwritten and faxed. VNA plans to visit the home tomorrow am.\n Please refer to social work for further information r/t\nFOB. Pt. is stable and ready for D/C home.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-10-21 00:00:00.000", "description": "Report", "row_id": 1970108, "text": "Neonatology Attending\n\nDay 4\n\nRemains in RA. Saturations 97-100%. RR 40-60s. Clear breath sounds. No murmur. HR 150-160s. Weight 3065 gms (+50). On ad lib feeds of BM/E20. Benign abdomen. Circ site looks clear. Receiving acetominophen. NAS scores initiated last night- 6, 10, 7- for irritability. Toxicology screen pending. No seizure activity reported. Stable temperature.\n\nAppears to be doing well overall. No evidence of seizure activity. Will continue to monitor this afternoon. Will obtain EEG because of duration of episode. Will discharge if continues to do well and no issues with EEG findings.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-21 00:00:00.000", "description": "Report", "row_id": 1970109, "text": "Neonatology Note\nActive and alert. Pink in RA. AFSOF. CV - s1s2, regular, no murmurs. Warm and well perfused. Lungs - clear and symmetric breath sounds. Abdomen - soft, nontender, nondistended. Ext - no edema. Neuro - somewhat jittery, but no seizure-like activity. Slighty increased tone. Normal suck, grasp, and moro. Skin - no rashes.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-21 00:00:00.000", "description": "Report", "row_id": 1970110, "text": "SOCIAL WORK\nMet with mother again this am. She is hopeful that infant will be able to be d/c'd following final test. Have encouraged mother to address and take care of the legal issues with fob with the appropriate authorities. Though mother denies domestic violence to be an issue in their relationship, she was reminded that the B.I.D.M.C. Safe Transitions Program remains available to her following d/c. Mum focusing on infant, desire to go home with him. Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-21 00:00:00.000", "description": "Report", "row_id": 1970111, "text": "NPN 7a-7a\n\n\nNeuro: Infant alert and active, not sleeping longer than\n2hours today. Irritable when awake, rooting and sucking\nexcessively. Hypertonic, often kicks legs out straight.\nInfnat jittery at times and twitches and kicks legs when\nsleeping on occasion, not rythmic adn stops on own. No\nseizure activity noted. NAS score of 7 this am, tox screen\nnegative, not any further. EEG done this afternoon,\nresults will be read by 11am tomorrow, infant will remain on\nobservation until that time and then may be d/c'd home w/\nmom.\n\nFamily: Mom in and out all day. Holding and bottling well.\nIndependent w/ changing diaper. Asking questions. Has not\ndiscussed situations w/ FOB. Was hoping that paternal\ngrandparents could visit tonight, but she is aware they\ncan't visit without her. Mom went home for the night but\nwill be calling later. Left carseat. Con't to support and\nupdate as needed. Prepare for d/c home.\n\nInfant otherwise stable, no resp or CV issues. Feeding ad\nlib E20 and breastfeeding. Abd benign, voiding and stooling.\nAlert and active, temps stable. Will con't to monitor and\nsupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1970112, "text": "Co-Worker Note: \n\n\n1. NEURO: O: No signs on siezures thus far this shift. Pt.\nvigorous with binkie when awake. Slightly increased tone.\nAwaiting EEG results in morning. P: Continue to monitor.\n\n2. PAR: O: Mom called x1. updated A: Loving, invested\nmother. P: Support and educate.\n\n3. DEV: O: Pt's BW= 3065. Wt. tonight down 20g to 3045g.\nBottling adlib amounts on E20. TF yesterday = 131cc/k.\nRemains swaddled on open warmer, temps stable. Awake and\nalert with cares. vigorous with binkie and bottles. See\nflowsheet. A: AGA P: Support G&D. PKU to be drawn in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1970113, "text": "AGREE WITH ABOVE NOTE.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-20 00:00:00.000", "description": "Report", "row_id": 1970104, "text": "Neonatology Attending\n\n3 day old FT infant admitted to NICU for observation and evaluation after possible seizure activity.\n\nInfant born at 38 weeks to 26 yo G3P1 B+, Ab-, HBsAg-, RPR-NR, GBS- woman. Reported benign antepartum. Past history of asthma treated with albuterol prn. Admitted in labor. No fever. ROM 6 hours PTD. C/S for FTP with Apgars 9, 9.\n\nBenign nursery course with normal vital signs. Feeding well at breast as well as by bottle. Weight down 2 oz this morning.\n\nHad uncomplicated circumcision this morning with lidocaine dorsal penile block. Within minutes of return to mother, tonic-clonic movements of all four extremities noted- not responsive to holding. Episode, by report, lasted 3 minutes. No color change. Infant with eyes closed at time.\n\nPer social work, mother is obtaining restraining order against FOB. Alleged assault in post-partum room yesterday morning. By report, while holding the baby, he (infant) was pushed into mother who later was on top of baby briefly on the bed. Mother at the time denied that there was any significant impact on the infant reportedly slept through the event.\n\nExam here remarkable for pink, well-appearing term infant with mildly exaggerated response to stimuli with vital signs as noted, pink color, soft af, opposed sutures, PERRL, EOMI, nl facies, intact palate, no gfr, clear breath sounds, no murmur, present femoral pulses, flat soft n-t abdomen without hsm, circumcised penis, stable hips, fixes/follows, nl tone, present grasp, symmetric Moro.\n\nTook 45 cc formula. No further episodes seen since admission.\n\nWell-appearing, term infant with possible seizure. Will monitor and observe closely. Will do general search for contributors including, lytes, glc, Ca, cbc, urine toxicology screen. Given duration of event and description of events above, will also obtain CT scan. Sepsis unlikely, given well-appearance. Will hold off on anti-microbials for now.\n\nPrimary pediatrician is Dr. , CH PGA. In-house coverage by CNS.\n\nMother aware of clinical status and immediate plan of care. Not yet aware of plan for CT but will inform now.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-20 00:00:00.000", "description": "Report", "row_id": 1970105, "text": "SOCIAL WORK\nMet with mother today to sort out issues related to conflict that arose between mother and fob on Sat evening in mother's post partum room.\n Mother states that fob had been drinking, demanded to hold the baby, became physical with mother when she refused to give baby to him. Both security and Police were notified. Mother had plans to seek restraining order today following her d/c. PLans have changed due to infant's NICU admit and mother's decision to remain inpt., and she is unclear about persuing restraining order at this time. She states she has had a conversation with him in which he expressed his remorse for Sat's behavior.\n Mother has been informed that if fob should come to hospital security will be notified and Police will be called to arrest him for domestic abuse complaint. Mother understands this issue is now in the hands of the Police.\nHave notified NICU providers of above. Will continue to follow closely. Please call with questions/concerns. Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-20 00:00:00.000", "description": "Report", "row_id": 1970106, "text": "Nursing Note\nFT male infant () arrived in NICU for observation after possible seizure episode in NBN. See attending note for full hx.\n\nResp: Infant in RA, sats 97-100%, LS clear, no retractions. RR 40-50s. No apnea or bradies. No resp issues noted, will remain on CV monitor and pulse ox at this time. Con't to monitor.\n\nCV: ?soft murmor heard x1. HR 130-140s. Pink, well perfused, no jaundice noted. Pulses normal. BP means 50-54. Stable, con't to monitor.\n\nFEN: BW 3065, CW 3015. Ad lib breast feeding or bottling E20, took 40/40/60, waking ~q3hrs. Admission DS 70, then 115. Abd benign, BS active. Voiding and stooling. Circumsized this morning, site clean. Small amount of new blood noted, cleaning w/ water and applying vaseline as needed. Given tylenol for pain. Applied urine bag to obtain specimin for tox screen. Tolerating feeds, no spits. Con't to monitor and encourage Mom's plans to breastfeed.\n\nNeuro: Infant alert and active, sleepy upon arrival, but more active this afternoon. Fontanelles soft and flat. Jittery/hyperactive moro. Sucks, roots, and grasps appropriately. Easily startled. Occasionally twitches or kicks leg while sleeping. Motion not rythmic and easily stopped. No lip smacking or arm movements. Lytes w/ Ca, PO4, and MgSo4 sent, results benign. CBC also benign, Blood cx pending. Obtaining urine for tox screen. CT scan done this afternoon, also benign. Ifnant appears stable w/ no further signs of seizure activity. Nested on open warmer for further observation through the night.\n\nFamily: Mom in and out through the afternoon. Appropriate w/ baby, bottles well. Planning to BF. Mom had her sister call FOB to inform him of infant being in NICU. Dad called and I updated over the phone and gave him phone number to mothers room which was changed. later discovered note in chart re: domestic incident involving police yesterday in hospital. Pages social worker to clarify. AT this time, dad is not allowed in unit and security is to be called if he arrives. Dad called later and informed that I could not give him information over the phone he would have to get it from the mother. mom remains in house although had to leave to go to TCH where her 7yo daughter was brought today for asthma attack. Mom will be in later w/ family memebers. Mom aware of current plan of care including CT results and obtaining tox screen. con't to have nursing and social work follow this family closely. See Social work note as well.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-21 00:00:00.000", "description": "Report", "row_id": 1970107, "text": "Nursing Progress Note\n\n1 NEURO\n2 PARENTING\n3 DEVELOPMENT\n\n#1,#3. O: Infant remains in RA with O2 sats >97%. No spells\nnoted overnight. Infant awake and irritable this evening for\nabout 6 hours without sleeping. Urine tox screen sent. NAS\novernight 6,10,11,7. Higher scores significant for not\nsleeping after feeds, increased tone, loose stools and\ntremors when disturbed. Infant required tight swaddling and\nholding to keep calm. Temp stable. Infant slept undisturbed\nfor 3 hours later in shift. No seizure activity noted. PO\nfeeding well. A: Urine tox screen negative. Infant very\nirritable overnight but no seizures noted. P: Continue to\nobserve.\n\n#2. O: Mom up this evening. Held infant after feeding.\nAsking appropriate questions. Mom did not discuss Dad's\nsituation. A: Involved mother with social issues. P: SW to\nfollow closely.\n\n\n\nREVISIONS TO PATHWAY:\n\n 1 NEURO; added\n Start date: \n 2 PARENTING; added\n Start date: \n 3 DEVELOPMENT; added\n Start date: \n\n" } ]

[ { "category": "Radiology", "chartdate": "2176-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 790179, "text": " 11:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SP ct\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with\n REASON FOR THIS EXAMINATION:\n SP ct\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of CABG. Status post CABG.\n\n PORTABLE AP CHEST: Right jugular CV line is in proximal SVC. No\n pneumothorax. Atelectasis are present at both lung bases and in the left mid\n zone.\n\n" }, { "category": "ECG", "chartdate": "2176-05-17 00:00:00.000", "description": "Report", "row_id": 135171, "text": "Normal sinus rhythm. Compared to the previous tracing of multiple\nabnormalities persist without diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-05-16 00:00:00.000", "description": "Report", "row_id": 135172, "text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. J point\nelevation with early repolarization. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2176-05-19 00:00:00.000", "description": "Report", "row_id": 1455258, "text": "nursing\n\nPt continues on neo gtt. MP sinus rhythm with no ectopy. urine output had been minimal but improved significantly during the night. Alert and cooperative,minimal bleeding;taking liquids well.\n\nPlan: support BP while diuresing ,wean off neo as soon as possible\n advance diet and activity level,pulmonary toilet prn.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-05-19 00:00:00.000", "description": "Report", "row_id": 1455259, "text": "NEURO ALERT ORIENTED MOVES ALL EXTREMETIES NO DEFECITS NOTED\n\nC/V NSR PAC OCC EPI WIRES INTACT NOT APPROPRIATLY SENSING MA OFF LOPRESSOR 12.5MG STARTED TOL WELL B/P 90S IN CHAIR PALP PULSES\n\nRESP NC 2L 97% LUNGS CLEAR IS WELL CHEST TUBES REMOVED\n\nGU/GI TOL PO WELL ABD SOFT FOLEY OUT VOIDED 450CC X1\n\nPLAN INCREASE ACTIVITY AND DIET TX TO 2 IN AM\n" }, { "category": "Nursing/other", "chartdate": "2176-05-20 00:00:00.000", "description": "Report", "row_id": 1455260, "text": "EKG NSR, RARE PVCS. SBP STABLE. AFEBRILE. VOIDING QS IN URINAL. BREATH SOUNDS CLEAR BILAT, DEEP BREATHES AND COUGHS WELL, NEEDS REMINDER TO USE IS. NC AT 2L TO MAINTAIN SPO2 95-99%, DROPS TO 90% ON ROOM AIR. CHEST AND CT SITE DRESSING DRY. ACE BANDAGE DC/D, JP STILL IN PLACE, DRAINED 15CC. ABD SOFT, BOWEL SOUNDS PRESENT, TOLERATING FLUID AND SOLID FOOD. ALERT AND ORIENTED, DENIES PAIN WHEN ASKED. SLEPT IN NAPS.\n" }, { "category": "Nursing/other", "chartdate": "2176-05-17 00:00:00.000", "description": "Report", "row_id": 1455255, "text": "Post-op CABG X4\n\nWeaned propofol/reversal agents given pt weaned and extubated at 1545\nMultiple fluid boluses given for SBP<90 low CVP and massive diuresis HCT 33-35 CT output approx 25 cc/hr will rechekc HCT at 1700 neo titrated for BP\n\nNeuro-lethargic flat affect follows simple commands moves all extrem well slow to respond to questions one word answers PERL med with morphine for c/o pain PA updated on neuro cont to monitor closely\nCV-MP SR-ST CSM palp pulses ace wrap right leg DI with JP/ CT to 20 cms sx Pacer ademand at 60/ cont to monitor wean neo as tol\nResp-LS clear dim at bases enc pulm toilet\nGI-reg insulin gtt titrated for BS <125 absent BS\nGU-urine output great diuresis K repleted\nPlease see flow sheet\n" }, { "category": "Nursing/other", "chartdate": "2176-05-18 00:00:00.000", "description": "Report", "row_id": 1455256, "text": "csru update\nneuro: folllows commands. maew in bed. aaox3 though early in shift speaking nonsensical sentences. has been more appropriate in conversing this am.\n\ncv: vs as per flowsheet. 500cc fluid bolus x1 for cvp ~2 and sinus tachy. nsr w/ pac at times. remains on neo for bp support. min ct output except for this am w/ s->s w/ linen change ->150cc thin serosang dng. feet cool palp dp , toes dusky at times. pt states wnl for him.\n\nresp: lungs clear ct dng as noted. o2 sats 99% much of shift. using is to 1750cc.\n\ngi: abd soft. bsp. c/o thirst frequently. tol clears w/out diff.\n\ngu: uop qs\n\nassess: stable pm. conversing approp this am. cont to require neo.\n\nplan: monitor neuro status. wean neo as able. increase activity/diet.\n" }, { "category": "Nursing/other", "chartdate": "2176-05-18 00:00:00.000", "description": "Report", "row_id": 1455257, "text": "Shift Note\nPt is neurologically intact,MAE to command. Hemodynamically pt requires neo to maintain BP. Neo has been weaned down slowly throughout shift. Lungs are CTA but diminished, Pt encouraged to cough and deep breathe and use the IS. U/O qs, + bowel sounds, pt tolerating solid foods. Percocet given for pain with effect. See flowsheet for details.\n" } ]

[ { "category": "Radiology", "chartdate": "2159-09-29 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1214577, "text": " 5:31 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: pulmonary edema\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with pulmonary edema\n REASON FOR THIS EXAMINATION:\n pulmonary edema\n ______________________________________________________________________________\n WET READ: NATg SAT 6:39 PM\n More confluent bilateral perihilar opacities edema vs. atypical infection. No\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FILM\n\n CLINICAL INDICATION: 56-year-old woman with pulmonary edema.\n\n Comparison is made to the patient's prior study of at 1010.\n\n PA and lateral views of the chest dated at 1742 are submitted.\n\n IMPRESSION:\n\n 1. Left internal jugular central line with its tip in the superior vena cava.\n Stable cardiac and mediastinal contours with the heart remaining mildly\n enlarged. Bilateral perihilar and patchy airspace opacities at both bases\n which most likely represent pulmonary edema although a bilateral pneumonia\n cannot be excluded. No pleural effusions or pneumothorax. No acute bony\n abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214176, "text": " 9:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for free air, line placement, PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with septic shock\n REASON FOR THIS EXAMINATION:\n eval for free air, line placement, PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n COMPARISON: None.\n\n CLINICAL HISTORY: Septic shock, question free air, line placement, assess\n position of catheter.\n\n FINDINGS: Single AP portable chest radiograph was obtained. A left IJ\n central venous catheter is seen with its tip residing at the level of the\n superior vena cava. The lungs are clear and well expanded. No pneumothorax\n or pleural effusion. Cardiomediastinal silhouette appears normal. Bony\n structures are intact. No free air below the right hemidiaphragm.\n\n IMPRESSION: Appropriately positioned left IJ central venous catheter. No\n acute intrathoracic process or signs of free air.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-09-29 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1214542, "text": " 10:05 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: rule out DVT\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with new oxygen requirement, rule out DVT\n REASON FOR THIS EXAMINATION:\n rule out DVT\n ______________________________________________________________________________\n WET READ: NATg SAT 1:08 PM\n No DVT of the bilateral lower extremities, with note of non-visualization of\n the right calf veins.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 56-year-old female with new oxygen requirement,\n question DVT.\n\n COMPARISON: None available.\n\n TECHNIQUE: Son images were obtained of the bilateral lower\n extremities.\n\n FINDINGS: There is normal respirophasic waveform in the bilateral common\n femoral veins. There is normal compressibility, color Doppler flow, and\n response to augmentation within the bilateral common femoral, superficial\n femoral, and popliteal veins. The visualized posterior tibial and peroneal\n veins of the left calf are normal. The posterior tibial and peroneal veins of\n the right calf were not visualized.\n\n IMPRESSION: No DVT of the bilateral lower extremities, with note of\n non-visualization of the right calf veins.\n\n" }, { "category": "Radiology", "chartdate": "2159-09-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1214541, "text": " 10:02 AM\n CHEST (PA & LAT) Clip # \n Reason: pneumonia\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with new oxygen requirement\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n WET READ: NATg SAT 11:06 AM\n Developing bilateral airspace opacities, perihilar predominance concerning for\n edema more than atypical infection, consider developing ards in this patient\n with DIC. Heart size normal. No sig effusion. Line stable.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FILM AT 1010\n\n CLINICAL INDICATION: 56-year-old with new oxygen requirement, question\n pneumonia.\n\n Comparison is made to at 2100.\n\n PA and lateral views of the chest dated at 1010 are submitted.\n\n IMPRESSION:\n\n 1. Left internal jugular central line with its tip in the superior vena cava.\n Interval appearance of bilateral airspace process involving the right upper,\n right lower and left mid and lower lung which is concerning for pneumonia or\n ARDS, less likely edema. Possible small left pleural effusion. Stable\n cardiac and mediastinal contours. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2159-10-01 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1214692, "text": " 8:40 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Eval for stones/other\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with history stones who is s/p LEFT ESWL\n REASON FOR THIS EXAMINATION:\n Eval for stones/other\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for residual stones.\n\n COMPARISONS: CT abdomen and pelvis .\n\n FINDINGS:\n One upright and one supine image of the abdomen show residual irregular stones\n in the left kidney, which are unchanged in comparison to the CT on .\n There is no evidence of residual stones in the ureter. The bowel gas pattern\n is nonspecific without evidence of obstruction or ileus. There is no free\n air. The osseous structures are unremarkable. There are multiple pelvic\n phleboliths.\n\n IMPRESSION:\n 1. Unchanged residual left renal stones.\n 2. No evidence of residual stones in the left ureter.\n\n" }, { "category": "Radiology", "chartdate": "2159-10-01 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1214690, "text": " 8:40 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Eval pulm nodules and for acute process. PLEASE CALL PA \n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56F w/ hx pulm nodules (see prior studies). This admission pulmonary edema.\n REASON FOR THIS EXAMINATION:\n Eval pulm nodules and for acute process. PLEASE CALL PA pager .\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NMKa MON 12:28 PM\n PFI:\n\n 1. The study was suboptimal for evaluation of pulmonary artery embolism due\n to poor opacification secondary from poor IV access which precluded _____ of\n contrast material at an appropriate rate.\n\n 2. Within the limitation, there is no evidence of pulmonary embolism within\n the main pulmonary arteries; however, assessment of lobar, segmental and\n subsegmental arteries are limited.\n\n 3. Bilateral symmetric ground-glass opacities representing pulmonary edema.\n\n 4. Moderate right and mild left non-hemorrhagic posteriorly layered pleural\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT\n\n TECHNIQUE: Contrast-enhanced MDCT of thorax was performed using standard\n department protocol for evaluation of pulmonary embolism. Contiguous axial\n images at 5 mm and 5.25 mm slice thickness were reviewed concurrently with\n coronal and sagittal reformats. Due to the poor IV access, the contrast\n material could not be administered at desired rate which resulted in\n suboptimal opacification of the pulmonary arteries. Hence, the assessment of\n pulmonary embolism within the lobar, segmental and subsegmental vessels was\n limited.\n\n FINDINGS:\n\n PULMONARY ARTERY: The caliber of main pulmonary artery proximal to the\n bifurcation measures 33 mm and is mildly enlarged suggestive of pulmonary\n artery hypertension. No filling defects seen in the main pulmonary artery to\n suggest pulmonary embolism. Due to suboptimal opacification, evaluation of\n lobar, segmental and subsegmental pulmonary arteries was limited.\n\n AIRWAYS AND LUNGS: Airways are patent to subsegment brochi. Bilateral\n ground-glass opacities prominently in the perihilar and upper lobes on\n concurrently reviewing series of chest radiographs from to represent pulmonary edema. Mild-to-moderate amount of atelectasis is\n present in the middle lobe. Non-hemorrhagic, posteriorly layered, pleural\n (Over)\n\n 8:40 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Eval pulm nodules and for acute process. PLEASE CALL PA \n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n effusion is moderate on the right and minimal on the left side and is\n associated with adjacent lung atelectasis.\n\n MEDIASTINUM: There are small mediastinal and right hilar lymph nodes, but\n none meet the CT size criteria for pathological enlargement, likely reactive.\n There is no pathological enlargement of central mediastinal, supraclavicular\n or axillary lymph nodes. Heart is noraml size without pericardial effusion.\n The internal jugular line ends at upper SVC.\n\n ABDOMEN: The study is not designed for evaluation of abdomen although limited\n views were remarkable to reveal two, small (less than 6 mm) hypodense lesions\n in the left and right lobes of the liver which are incompletely characterized\n and mild hiatal hernia. Both adrenal glands are normal.\n\n BONES: There is no bone lesion suspicious for malignancy/infection.\n\n IMPRESSION:\n\n 1. Due to suboptimal opacification of the pulmonary artery, the study was\n limited for evaluation of pulmonary embolism within the lobar, segmental and\n subsegmental pulmonary arteries. However, no filling defect was seen in the\n main pulmonary artery to suggest pulmonary embolism.\n\n 2. Pulmonary artery hypertension.\n\n 3. Moderate-to-severe pulmonary edema.\n\n 4. Moderate right and minimal left non-hemorrhagic and non loculated pleural\n effusion.\n\n 5. Mild hiatal hernia.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2159-10-01 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1214691, "text": " , MED 12R 8:40 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Eval pulm nodules and for acute process. PLEASE CALL PA \n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56F w/ hx pulm nodules (see prior studies). This admission pulmonary edema.\n REASON FOR THIS EXAMINATION:\n Eval pulm nodules and for acute process. PLEASE CALL PA pager .\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. The study was suboptimal for evaluation of pulmonary artery embolism due\n to poor opacification secondary from poor IV access which precluded _____ of\n contrast material at an appropriate rate.\n\n 2. Within the limitation, there is no evidence of pulmonary embolism within\n the main pulmonary arteries; however, assessment of lobar, segmental and\n subsegmental arteries are limited.\n\n 3. Bilateral symmetric ground-glass opacities representing pulmonary edema.\n\n 4. Moderate right and mild left non-hemorrhagic posteriorly layered pleural\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2159-09-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1214656, "text": " 5:10 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: pulmonary edema\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with pulmonary edema\n REASON FOR THIS EXAMINATION:\n pulmonary edema\n ______________________________________________________________________________\n WET READ: SUN 5:24 PM\n No significant change in appearance of opacities at both lung bases as well as\n in a perihilar distribution, likely representing pulmonary edema.\n Tip of left IJV catheter is at the upper/mid svc.\n Small left pleural effusion is stable.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: 56-year-old woman with pulmonary edema.\n\n IMPRESSION: PA and lateral chest compared to through 6:\n\n Widespread somewhat heterogeneous pulmonary opacification that developed\n between and , probably pulmonary edema, has improved\n slightly since . More focal region of consolidation in the right\n lower lung could be concurrent pneumonia or pulmonary hemorrhage. Initial\n engorgement of mediastinal veins has resolved, and pleural effusion, if any,\n is minimal. There is persistent mild distention of upper lobe pulmonary\n vasculature, but there is likely to be more than one concurrent pulmonary\n abnormality.\n\n Left internal jugular line ends in the upper SVC. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2159-09-26 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1214170, "text": " 8:16 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for perinephric hematoma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with 5d s/p lithotripsy p/w pain and hypotension\n REASON FOR THIS EXAMINATION:\n eval for perinephric hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd WED 9:58 PM\n 1. Enlarged left kidney with perinephric stranding, most consistent with\n pyelonephritis. Multiple renal stones still present within the interpolar\n region and lower pole of the left kidney. While there is no hydronephrosis or\n hydroureter, there is a long segment of the distal left ureter filled with\n from the recent lithotripsy.\n\n Assessment for renal abscess limited given the lack of IV contrast.\n\n 2. No evidence of perinphric hematoma.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with five days status post lithotripsy, who\n presents with pain and hypertension. Evaluate for perinephric hematoma.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired images were obtained through the abdomen and pelvis\n without contrast. IV contrast was not administered due to renal patient's\n acute renal failure. Coronal and sagittal reformatted images were also\n displayed.\n\n FINDINGS:\n CT ABDOMEN: A 6 mm pulmonary nodule is seen in the left lower lobe (601:49).\n There is mild bibasilar atelectasis. Mild septal thickening is present, most\n consistent with pulmonary edema, likely from aggressive fluid resuscitation.\n The heart size is normal. The non-contrast appearance of the spleen, adrenal\n glands, pancreas, stomach, liver, and gallbladder are within normal limits.\n The right kidney is also normal in appearance.\n\n The left kidney is enlarged and demonstrates perinephric stranding. Multiple\n renal stones are noted within the renal hilum and also in the lower pole of\n the left kidney. The largest measures up to 7 mm. There is no hydronephrosis\n or hydroureter. However, there is a long segment of tiny stones in the left\n distal ureter consistent with debris from patient's recent lithotripsy\n (\"steinstrasse\"). Multiple small retroperitoneal lymph nodes are noted,\n likely reactive. There is no free air or free fluid.\n\n CT PELVIS: A Foley catheter is noted within a decompressed bladder. The\n rectum and intrapelvic loops of bowel are within normal limits. There is no\n free fluid. There is no inguinal or pelvic lymphadenopathy.\n\n (Over)\n\n 8:16 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for perinephric hematoma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: No concerning osseous lesions are identified. Note is made of\n SI joint sclerosis bilaterally; the SI joints remain preserved.\n\n IMPRESSION:\n 1. Enlarged left kidney with perinephric stranding, concerning for\n pyelonephritis. Multiple stones are present within the interpolar and lower\n pole of the left kidney. While there is no hydronephrosis or hydroureter,\n there is a long segment of tiny stones/debris from the recent lithotripsy\n within the distal ureter (\"steinstrasse\").\n\n 2. 6 mm pulmonary nodule in the left lower lobe. Follow up in months is\n recommended if patient is at increased risk for malignancy. Otherwise, follow\n up in 12 months is recommended.\n\n Findings were discussed with Dr. at 12:30 am on , via telephone.\n\n" }, { "category": "Radiology", "chartdate": "2159-09-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1214603, "text": " 7:25 AM\n CHEST (PA & LAT) Clip # \n Reason: pulmonary edema\n Admitting Diagnosis: URINARY TRACT INFECTION;PYELONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with pulmonary edema\n REASON FOR THIS EXAMINATION:\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FILM\n\n CLINICAL INDICATION: 56-year-old with pulmonary edema.\n\n Comparison is made to the patient's previous study dated at 17:42.\n\n PA and lateral views of the chest dated at7:44 is submitted.\n\n IMPRESSION:\n\n Left internal jugular central line has its tip in the superior vena cava.\n Overall, cardiac and mediastinal contours are stable. Persistent patchy\n opacities at both lung bases as well as in a perihilar distribution are again\n seen, which could reflect pulmonary edema, although a diffuse pneumonia could\n also have this appearance. Clinical correlation is advised. Probable small\n left effusion. No pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2159-09-26 00:00:00.000", "description": "Report", "row_id": 285197, "text": "Sinus tachycardia, rate 106. Consider left atrial abnormality. Slight\nnon-specific ST segment changes. No other diagnostic abnormality.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2165-06-14 00:00:00.000", "description": "Report", "row_id": 63368, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Prosthetic valve function. Shortness of breath.\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\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Normal regional\nLV systolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic\nfunction likely depressed given the severity of valvular regurgitation.]\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: Mildly dilated descending aorta. No atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPREBYPASS\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy. The left ventricular cavity is mildly\ndilated. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). [Intrinsic left\nventricular systolic function is likely more depressed given the severity of\nvalvular regurgitation.] Right ventricular chamber size and free wall motion\nare normal. The descending thoracic aorta is mildly dilated. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis. Mild (1+) aortic regurgitation is seen.Mild to moderate\n(+) mitral regurgitation is seen. After induction of general anesthesia..\nWith steep Trendelenberg, phenylephrine infusion to increase systolic BP to\n150 mm Hg the MR increased to 3+. The mitral valve leaflets are mildly\nthickened.\n\nPOSTBYPASS Biventricular systolic function remains normal. There is a ring\nprosthesis in the mitral position. No MR . The remaining study is\nunchanged from prebypass.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243929, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusion, hemothorax, pneumothorax\n Admitting Diagnosis: MITRAL STENOSIS\\MITRAL VALVE REPAIR ? REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p MVR now with dropping Hct\n REASON FOR THIS EXAMINATION:\n assess for effusion, hemothorax, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:23 A.M., ON \n\n HISTORY: 46-year-old man with dropping hematocrit after MVR.\n\n IMPRESSION: AP chest compared to through 17:\n\n Pleural effusion if any is small on both sides, but not appreciably changed.\n There is greater opacification at both lung bases today than on ,\n concerning for a developing pneumonia and/or worsening atelectasis, both\n pointing to aspiration. The upper lungs are clear. The heart is normal size.\n Right jugular line ends in the mid SVC. No pneumothorax. Dr. was paged\n at the time of this dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-06-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1243879, "text": " 1:16 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line position\n Admitting Diagnosis: MITRAL STENOSIS\\MITRAL VALVE REPAIR ? REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man\n REASON FOR THIS EXAMINATION:\n eval line position\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right IJ catheter tip is in the lower SVC. There is no pneumothorax.\n Compared to prior study performed seven hours earlier, there has been interval\n increase in left lower lobe opacities consistent with increasing atelectasis\n and small left pleural effusion . There are no other interval changes_.\n\n" }, { "category": "Radiology", "chartdate": "2165-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243856, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumo\n Admitting Diagnosis: MITRAL STENOSIS\\MITRAL VALVE REPAIR ? REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man\n REASON FOR THIS EXAMINATION:\n r/o pneumo\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess for pneumothorax after chest tube removal.\n\n Comparison is made with prior study, .\n\n There is no evident pneumothorax. There are low lung volumes. Left lower\n lobe atelectasis has increased. Small bilateral pleural effusions are\n unchanged. Cardiomediastinal contours are stable. Right IJ catheter sheath\n tip is in the proximal SVC. There is mild vascular congestion. Sternal wires\n are aligned.\n\n" }, { "category": "Radiology", "chartdate": "2165-06-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1243671, "text": " 11:15 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: MITRAL STENOSIS\\MITRAL VALVE REPAIR ? REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post MVR.\n\n Comparison is made with prior study .\n\n There is mild-to-moderate cardiomegaly. There is mild postoperative\n mediastinal widening. There is mild-to-moderate vascular congestion.\n Bibasilar atelectases are larger on the left side. There is a small left\n pleural effusion. The ET tube is in a standard position. Swan-Ganz catheter\n tip is in the right main pulmonary artery. NG tube tip is in the stomach and\n the side port is just distal to the EG junction and can be advanced for more\n standard position. Mediastinal and right chest tubes are in place. There is\n no evident pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-06-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1244236, "text": " 8:48 AM\n CHEST (PA & LAT) Clip # \n Reason: postop changes eval\n Admitting Diagnosis: MITRAL STENOSIS\\MITRAL VALVE REPAIR ? REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with s/p MVr\n REASON FOR THIS EXAMINATION:\n postop changes eval\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Post-op mitral valve replacement.\n\n IMPRESSION: AP chest compared to through 18:\n\n Right lung is clear. Left lower lobe atelectasis is improving. Small\n bilateral pleural effusions are stable. Cardiomediastinal silhouette has a\n normal post-operative appearance. Air in the pericardium and mediastinum seen\n on the lateral view at level of the xiphoid is not an uncommon post-operative\n finding this early.\n\n Right internal jugular line ends in the mid SVC.\n\n\n" }, { "category": "ECG", "chartdate": "2165-06-20 00:00:00.000", "description": "Report", "row_id": 126543, "text": "Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of the Q-T interval is now normal.\n\n" }, { "category": "ECG", "chartdate": "2165-06-14 00:00:00.000", "description": "Report", "row_id": 126544, "text": "Sinus rhythm. Left atrial abnormality. Prolonged Q-T interval. Delayed\nprecordial R wave progression. Compared to the previous tracing, the findings\nare similar.\n\n" } ]

[ { "category": "Echo", "chartdate": "2110-06-17 00:00:00.000", "description": "Report", "row_id": 94714, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Myocardial infarction. S/P Stent to RCA\nHeight: (in) 70\nWeight (lb): 174\nBSA (m2): 1.97 m2\nBP (mm Hg): 117/71\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 08:30\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: Normal RA size. No ASD by 2D or color\nDoppler. Normal IVC diameter (<=2.1cm) with >50% decrease with sniff\n(estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional\nLV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic;\nbasal inferolateral - akinetic; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\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\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 with normal cavity size. There is\nmoderate regional left ventricular systolic dysfunction with akinesis of the\nbasal inferior, inferolateral and inferoseptal segments and hypokinesis of the\nrest of the inferior wall. The remaining segments contract normally (LVEF =\n40%). There is some echogenicity of the basal inferior/inferolateral\nendocardium, consistent with myocardial edema. Right ventricular chamber size\nand free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The ascending aorta is mildly dilated. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal. Mild\n(1+) mitral regurgitation is seen. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular dysfunction, c/w recent\ninferoposterior infarction. Mild mitral regurgitation. No echocardiographic\nevidence of right ventricular infarction or mechanical complications of LV\ninfarction.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-06-17 00:00:00.000", "description": "R FEMORAL VASCULAR US RIGHT", "row_id": 1243311, "text": " 1:20 PM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: BRUIT ? AVF S/P CATH\n Admitting Diagnosis: CHEST PAIN;MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD s/p cardiac cath with femoral access and now with\n bruit not heard previously\n REASON FOR THIS EXAMINATION:\n ? AVF s/p cath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with recent cardiac cath. Assess for AV fistula.\n\n COMPARISONS: None available.\n\n FINDINGS/IMPRESSION:\n\n Right femoral vein and artery demonstrate appropriate waveforms and are\n patent. There is a 1.7 x 1.3 cm partially thrombosed saccular pseudoaneurysm\n arising from the right common femoral artery with a measuring\n approximately 6 mm. There is no evidence of AV fistula.\n\n" }, { "category": "Radiology", "chartdate": "2110-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1243218, "text": " 4:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evall for pulm / ;large vessel cause for chest pain\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 69M with new EKG chnages and chest pain\n REASON FOR THIS EXAMINATION:\n evall for pulm / ;large vessel cause for chest pain\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: EKG changes and chest pain.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, semi-upright AP portable.\n\n FINDINGS: The heart is at the upper limits of normal size. The mediastinal\n and hilar contours appear within normal limits. There is mild upper zone\n re-distribution of pulmonary vascularity and indistinctness, suggesting slight\n vascular congestion or fluid overload, although not striking. There is no\n pleural effusion or pneumothorax.\n\n IMPRESSION: Mild vascular prominence which could be seen with pulmonary\n venous hypertension or slight congestion.\n\n\n" }, { "category": "ECG", "chartdate": "2110-06-16 00:00:00.000", "description": "Report", "row_id": 271858, "text": "Sinus rhythm at lower limits of normal rate. Compared to tracing #2 there may\nbe a blocked atrial premature beat and the Q-T interval is longer. Otherwise,\nunchanged. Possible inferior myocardial infarction, age undetermined.\nClinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2110-06-16 00:00:00.000", "description": "Report", "row_id": 271859, "text": "Sinus rhythm as on tracing #1. No significant change on previously noted\nfindings.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2110-06-16 00:00:00.000", "description": "Report", "row_id": 271860, "text": "Baseline artifact. Sinus rhythm. Inferior wall myocardial infarction, age\nundetermined, with inferior ST segment elevation and T wave inversions - may be\nacute. Prominent precordial T waves. Since the previous tracing of \nthe inferior ST segment elevation and T wave inversions in leads II and aVF are\nnew and the rate is slower. Probable intervening inferior myocardial\ninfarction. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2110-06-18 00:00:00.000", "description": "Report", "row_id": 271857, "text": "Sinus rhythm. Normal ECG. Compared to the previous tracing of , no\nclear change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2150-05-26 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1134303, "text": " 4:46 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: carotid stenosis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with LM CAD\n REASON FOR THIS EXAMINATION:\n carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n\n Study: Carotid Series Complete\n\n Reason:88 year old man with LM and CAD.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is heterogeneous plaque in the ICA and CCA. On the left there\n is heterogeneous plaque in the ICA and CCA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 88/18, 84/18, 89/16cm/sec. CCA peak systolic velocity\n is 114 cm/sec. ECA peak systolic velocity is 87 cm/sec. The ICA/CCA ratio is\n 0.78. These findings are consistent with <40% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 49/8, 93/20, 85/19 cm/sec. CCA peak systolic velocity\n is 162 cm/sec. ECA peak systolic velocity is 69 cm/sec. The ICA/CCA ratio is\n ?. These findings are consistent with <40% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA stenosis <40%.\n Left ICA stenosis <40%.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2150-05-26 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1134315, "text": " 6:19 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD preop CABg\n REASON FOR THIS EXAMINATION:\n cardiopulmonary dz\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, pre-operative evaluation for CABG.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: The heart size is mildly enlarged. The\n aorta is tortuous with vascular calcifications of the knob present. Pulmonary\n vascularity is mildly prominent, suggestive of mild pulmonary vascular\n congestion, but no overt pulmonary edema is seen. There are low inspiratory\n lung volumes. Streaky opacities within the left lung base may reflect\n atelectasis. No pleural effusion or pneumothorax is visualized. No acute\n osseous abnormalities are seen.\n\n IMPRESSION: Mild cardiomegaly with mild pulmonary vascular congestion, but no\n overt pulmonary edema. Probable left basilar atelectasis.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2150-05-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1134450, "text": " 5:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact # if abnormal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man s/p cabg x3\n REASON FOR THIS EXAMINATION:\n postop film-contact # if abnormal\n ______________________________________________________________________________\n WET READ: 12:56 AM\n ETT 1.5 cm above carina, NGT with proximal port at GE junction, else support\n lines/tubes in expected locations. low lung volumes, bibasilar likely\n atelectasis, with small rt pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , there has been a CABG procedure\n performed with intact midline sternal wires. Endotracheal tube is only 1.5 cm\n above the carina and must be pulled back approximately 2 cm. Right IJ\n catheter extends to the lower portion of the SVC or upper portion of the right\n atrium. Nasogastric tube extends to the stomach with the side hole at the\n esophagogastric junction. Left chest tube is in place and there is no\n evidence of pneumothorax.\n\n Low lung volumes may account for much of the increased prominence of the\n transverse diameter of the heart. Mild bibasilar atelectatic change is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-05-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1134869, "text": " 9:14 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 9:22\n\n INDICATION: Recent CABG.\n\n COMPARISON: .\n\n FINDINGS: Compared to the prior study there is increased fluid in the minor\n fissure as well as increased prominence of subsegmental atelectatic changes.\n There are bilateral small effusions noted on the lateral view and the frontal\n view shows some blunting at the right CP angle. Heart size remains stable and\n the pulmonary vascular markings are within normal limits. A right CVL remains\n in place with tip in the SVC and no PTX.\n\n IMPRESSION: Slight increase in fluid since prior study and increased\n subsegmental atelectatic changes.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2150-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1134548, "text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chset tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chset tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old man status post CABG, now with chest tube removal,\n here to evaluate for pneumothorax.\n\n COMPARISON: .\n\n SINGLE PORTABLE CHEST RADIOGRAPH: There has been interval extubation with\n removal of a feeding tube and mediastinal drains as well as a left chest tube.\n Lung volumes remain low but without evidence of pneumothorax. Bibasilar\n atelectasis persists. Prominent cardiomediastinal silhouette is stable.\n Median sternotomy wires are intact.\n\n IMPRESSION: No evidence of pneumothorax status post extubation.\n\n" }, { "category": "Echo", "chartdate": "2150-05-27 00:00:00.000", "description": "Report", "row_id": 90989, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 189\nBSA (m2): 1.98 m2\nBP (mm Hg): 119/57\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 15:15\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo contrast or\nthrombus in the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferoseptal - hypo; mid inferior - hypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. 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: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) 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. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nPre-bypass:\nThe left atrium and right atrium are normal in cavity size. No spontaneous\necho contrast or thrombus is seen in the body of the left atrium or left\natrial appendage. No atrial septal defect is seen by 2D or color Doppler.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is low\nnormal (LVEF 50-55%). Right ventricular chamber size and free wall motion are\nnormal. There are simple atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta. The aortic valve leaflets (3) are\nmildly thickened. There is no aortic valve stenosis. Mild to moderate (+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is a trivial/physiologic\npericardial effusion.\n\nPost-bypass:\nThe patient is receiving no inotropic support post-CPB. Biventricular systolic\nfunction is preserved and all findings are consistent with pre-bypass\nfindings. The aorta is intact post-decannulation. All findings communicated to\nthe surgeon intraoperatively.\n\n\nPRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by\nthe Attending Echo Physician.\n\n\n" }, { "category": "Echo", "chartdate": "2150-05-27 00:00:00.000", "description": "Report", "row_id": 90990, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment CABG.\nHeight: (in) 67\nWeight (lb): 191\nBSA (m2): 1.98 m2\nBP (mm Hg): 135/82\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 09:15\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. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; basal inferolateral - hypo; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Mildly dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MS. Mild (1+) MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+]\nTR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size. There is mild regional left ventricular systolic\ndysfunction with infero-lateral hypokinesis. No masses or thrombi are seen in\nthe left ventricle. There is no ventricular septal defect. Right ventricular\nchamber size and free wall motion are normal. The ascending aorta is mildly\ndilated. The aortic arch is mildly dilated. 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 moderately thickened.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests impaired relaxation. The tricuspid\nvalve leaflets are mildly thickened. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2150-05-27 00:00:00.000", "description": "Report", "row_id": 232038, "text": "Sinus rhythm. P-R interval prolongation. Left axis deviation. Left anterior\nfascicular block. Mild ST segment elevations in leads V2-V3 and T wave\ninversions in the lateral precordial leads of uncertain significance. No\nprevious tracing available for comparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "ECG", "chartdate": "2203-04-01 00:00:00.000", "description": "Report", "row_id": 295453, "text": "Sinus rhythm. Low voltage across the limb leads. Non-specific ST-T wave\nchanges across the precordium, likely non-specific finding. However, extensive\nanterior ischemia should be considered. Compared to the previous tracing\nof new ST-T wave changes are noted.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2203-03-31 00:00:00.000", "description": "Report", "row_id": 295454, "text": "Sinus rhythm. Baseline artifact. Borderline low voltage across the limb\nleads. T wave inversions across the precordium, likely representing a\nnon-specific finding. However, anterior ischemia should be considered.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2125-09-01 00:00:00.000", "description": "Report", "row_id": 1621640, "text": "T-SICU nsg note\nEvents - art line inserted in L radial artery\n - repeat CT of head - unchanged per preliminary report\n - cerebral angiogram - very small narrowing of portion of artery - unlikely disection\n - changed nitroprusside drip to labetalol drip for BP control\n\n\n\n\n\nReview of Injuries - R subgaleal hematoma\n small R subdural hematoma\nMultiple facial fractures, including R temporal bone fx\n Sphenoid fx\n R lateral orbital wall fx\n multiple sinus hemorrhages\n C2 vertebral body defect\n possible widening of C5-C6 space\n\nPt followed by Dr. spine team,neurosurg, plastics, and opthamology\n\n\n\nNeuro - dozing frequently unless spoken to. Awakens easily to voice. Pt has sleep apnea, but pt not aware of diagnosis - \"My wife tells me my snoring wakes her up.\" Ox3, moves all limbs purposefully and to command. R arm motion limited by shoulder pain and pain from abrasions on upper and lower arm. Able to lift and hold all limbs. Has had headache most of day. Also pain around R eye and face. Pt reported pain in lumbar region to palpation this morning during exam by Dr. . Morphine 2mg IVP has relieved pain.\n\nCV - HR up to 115 on nitroprusside. Now on labetalol drip with HR 70 to 90, NSR. No ectopy noted all day. GOal sys BP < 150. Labetalol drip now at 0.5 mg/min with BP 100 to 135 sys.\n\nR groin angio site clean, dry, no contusion nor hematoma, DSD intact. DP pulses easily palpable bilaterally.\n\nResp - on 3 l NC. Pt has sleep apnea, so pauses and irregular resp rate. When pt asleep, O2 sats drop to 85% on room air, so NC re-applied.\n\nGU - urine output adequate via foley.\n\nGI - pt allowed to take ice chips. Abd softly distended, obese, bowel sounds present, no flatus nor stool this shift.\n\nHeme - Hct dropping - 40., 37.5, 35.0. Probably dilutional.\n\nID - WBC's dropping, last one 10.5. No antibiotics.\n\nEndo - insulin x 1, 4 units regular insulin SC.\n\nSkin - Contusion and edema to R eye and R face. superficial and painful abrasions L posterior arm, R anterior and posterior uppper and lower arm. R shoulder abrasion. Skin under cervical collar intact. @ lacs to R leg, dressed & dry.\n\nSocial - pt's wife in after angio and remains here visiting pt. T-SICU HO Dr. . updated pt and wife.\n\nA: Remains on log roll precautions pending MRI of lumbar spine. C- in place. Neuro status good. On small dose of labetalol to maintain sys BP < 150. Morphine effective pain relief.\n\nP: Medicate prn for pain. MRI of cervical and lumbar spine tonight. COntinue plan of care. Clear back. Continue informational support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2125-09-02 00:00:00.000", "description": "Report", "row_id": 1621641, "text": "t-sicu nsg note:\nneuro- remains intact, alert and oriented x3, follows commands consistently, mae's w/ gd strength.\n\nresp- cont to have sleep apnea, maintaining spo2 96-98% on 3lnc, rr 16-20, bs cta and diminished in basis. strong non-productive cough.\n\ncvs- min dose of labetalol iv gtt, maintaining hr 70's nsr, rare pvc, sbp 120's-130's sys. lr continues @100cc/hr, lytes repleted. angio site in r femoral c+d, pedal pulses present.\n\ngi- abd soft/obese +bs, no stool, will begin bowel regime.\n\ngu- foley patent for adeq amt clear yellow urine.\n\nskin- mult areas of abrasion on r arm amd shoulder, lesser amt on l arm, r leg sm lac c+d.\n\nendo- fs 130's rx w/ riss.\n\nsocial- wife very supportive.\n\nA: stable nvs and cvs\n\nP: awaiting MRI, cont pulm toileting, medicate prn for pain, ice packs to l shoulder. awaits clearing of c-spines and l-spines.\n" }, { "category": "Nursing/other", "chartdate": "2125-09-02 00:00:00.000", "description": "Report", "row_id": 1621642, "text": "T-SICU nsg note\nEvents - Labetalol drip weaned off.\n plain films of R shoulder - no fx per report.\n MRI of L and C spine\nart line came out with turning.\n Family in to visit and stayed with pt all afternoon\n Dr. looked at MRI and L spine cleared, so off log roll precautions. C5-C6 with herniated disc - plan is to continue collar.\nNeuro - continues intact, Ox3, sense of humor. Good limb strength. R arm movement limited due to shoulder pain. Closeness of MRI cramped pt's shoulders, much less pain after medicated and back in bed with room to stretch. Dilantin level low. Repeat level tomorrow.\nCV - labetalol drip off. Sys BP 100-130 off drip. NSR 70 -90, rare PVC's.\nResp - continues with resp pauses of 25 seconds consistent with sleep apnea. O2 sats drop with pauses with or without supplemental O2. Currently O2 off. Has worn face tent for hydration. Lung sounds clear, diminished at bases at times. Strong, non-productive cough.\nGu - adeuqate U/o via foley. IV fluids remain at 100cc/hr of LR.\nGI - pt now on clear liquid diet and may advance. No flatus nor stool.\nEndo - no exogenous insulin given this shift.\nA: less pain, dull to no headache. Shoulder pain less. Now off log roll precautions. Able to eat & drink.\nP: keep C-collar for now per Dr. . No further scans planned. Continue informational support to pt and family. Encourage movement now that back cleared.\n" }, { "category": "Nursing/other", "chartdate": "2125-09-03 00:00:00.000", "description": "Report", "row_id": 1621643, "text": "npn\n0700 foley dc'd, pt to dtv at 1300, ivf also dc'd at 0700\n" }, { "category": "Nursing/other", "chartdate": "2125-09-03 00:00:00.000", "description": "Report", "row_id": 1621644, "text": "npn\nneuro: pt aox3, at times needs to be reoriented to place but is able to say he is here due to accident on his motorcycle, seems to remember accident but not events following. perrla at 2mm\npain: c/o sore throat, states shoulder discomfort very mild.\ncad hr 80's sr no ectopy noted, nbp 126/82 to 144/74\nresp: ls clear pt has sign OSA with sats to high 70's during apnenic episodes, rr irregular 20-30's, will need sleep study after facial fx repair\ngi: abd obese, bs+, no flatus noted, tolerating water, small amt of broth and coke.\ngu: uo > 100cc/hr of light yellow urine, awaiting am lyte results. 870 negative at 5am\nid: temp max 99.3, wbc wnl\nendo: bs <150 no ssi given due to low po intake\nsocial wife called for update\nplan: inc activity as tolerated, collar ordered, advance diet as tolerated, transfer for continuation of care.\n" }, { "category": "Nursing/other", "chartdate": "2125-09-01 00:00:00.000", "description": "Report", "row_id": 1621639, "text": "NPN/ADMISSION NOTE:\n56YO MALE ADMITTED FROM OSH S/P MOTORCYCLE VS. PARKED CAR. +LOC, ? SEIZURE ACTIVITY AT SCENE. AT OSH, A+OX3. CT HEAD SHOWED SM R TEMPORAL SDH AND R SIDED BASILAR SKULL FX. TX TO FOR FURTHER MANAGEMENT.\nIMAGING AT : CT HEAD, SINUS, MANDIBLE, MAXILOFACIAL, TORSO, C-SPINE, CTA HEAD AND NECK. PLAIN FILMS OF R FEMUR, TIB/FIB, AND KNEE. AWAITING FINAL READS; WET READ OF CT SUGGESTING SIGNIFICANT CAROTID DAMAGE AND SM. C2 FX. PT TO HAVE MRI AND ANGIO FOR FURTHER PLAN OF CARE.\nROS:\nNEURO: A+OX3, MAE'S, FOLLOWS COMMANDS CONSISTENTLY, NO DEFICITS. C-COLLAR ON, LOGROLL PRECAUTIONS MAINTAINED, AWAITING CLEARANCE. DILANTIN LOAD GIVEN AT OSH.\nRESP: 2LNC, APPARENT SLEEP APNEA, UNDIAGNOSED. LS CLEAR, STRONG COUGH, NON-PRODUCTIVE. TOP DENTURES INSITU.\nCV: HX OF HTN. NEUROSURG. REQUESTING GOAL SBP 100-120, CURRENTLY ON NIPRIDE GTT AT 1.5MCG/KG/MIN. TO BE CHANGED TO LABETALOL PER AM ROUNDS. HR SR/ST 110'S.\nGI: NPO, BS PRESENT. SLIDING SCALE INSULIN.\nGU: ADEQUATE UO VIA FOLEY\nSKIN: LG HEMATOMA TO R EYE. LAC TO RLE SUTURED RASH AREAS TO ARMS AND LEGS. CONTS. LOGROLL, BACK/BUTTOCKS INTACT.\nPSYCH/SOCIAL: WIFE IN , UPDATED BY HO.\nPLAN: A-LINE TO BE PLACED. MRI THIS AM. NEUROSURG. TO ARRANGE ANGIO, ? LATER TODAY. TRANSITION TO LABETALOL. TLS TO BE CLEARED. MAINTAIN SBP 100-120. ENSURE PT COMFORT AND SAFETY.\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1025576, "text": " 12:45 PM\n CAROT/CEREB Clip # \n Reason: BILATERAL carotid artery and status\n Admitting Diagnosis: SKULL FRACTURE\n Contrast: OPTIRAY Amt: 43\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with traumatic head injury after MVC\n REASON FOR THIS EXAMINATION:\n BILATERAL carotid artery and status\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): HBSb SAT 3:04 PM\n Very slight narrowing of a portion of the right cavernous carotid artery\n without evidence of intimal flap or pseudoaneurysm formation. Although\n considered unlikely, dissection is not entirely excluded. The left internal\n carotid artery and left vertebral arteries are normal.\n ______________________________________________________________________________\n FINAL REPORT\n CEREBRAL ANGIOGRAM ON \n\n Correlation is made with recent CTA of the head dated .\n\n INDICATION: 56-year-old man with traumatic head injury after a motorcycle\n collision and skull base fractures. Angiography was requested by Dr. to\n assess for carotid injury\n\n CEREBRAL ANGIOGRAM TECHNIQUE: Informed consent was obtained from the patient\n after explaining the risks, benefits, and alternatives of the procedure. This\n explaining included stroke, hematoma, infection.\n\n The patient was brought to the interventional neuroradiology suite and placed\n on the biplane table in supine position. Both groins were prepped and draped\n in the usual sterile fashion. Access to the right common femoral artery was\n obtained using a micropuncture set under local anesthesia using 1% lidocaine\n mixed with sodium bicarb and with aseptic precautions. Through the needle, a\n wire was introduced and the needle taken out. Over the wire, a 5 French\n vascular sheath was placed. Through this sheath, a 4 French Berenstein\n catheter was introduced and connected to continuous saline infusion.\n The following blood vessels were selectively catheterized and arteriograms\n were obtained in AP and lateral projections:\n\n 1. Right common carotid artery.\n 2. Left common carotid artery.\n 3. Left vertebral artery.\n\n After review of the films, catheter and sheath were withdrawn and pressure was\n (Over)\n\n 12:45 PM\n CAROT/CEREB Clip # \n Reason: BILATERAL carotid artery and status\n Admitting Diagnosis: SKULL FRACTURE\n Contrast: OPTIRAY Amt: 43\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n applied to the groin until hemostasis was obtained. The procedure was\n uneventful, and the patient tolerated the procedure well without any\n complication. Patient was sent to the floor with orders.\n\n\n FINDINGS:\n The right common carotid artery injection opacifies the right internal and\n external carotid branches briskly. The cervical views show no evidence of\n carotid injury. The cerebral views show brisk filling of the MCA branches. The\n right ACA fills only minimally from this side due to a hypoplastic A1 segment.\n There is slight and smooth narrowing of the right cavernous carotid artery\n without an intimal flap identified to suggest definite dissection.\n\n The left common carotid artery injection opacifies the left MCA and ACA\n branches briskly. Cervical and cerebral views show no evidence of carotid\n injury.\n\n The left vertebral artery injection opacifies the vertebrobasilar circulation\n briskly without evidence of arterial injury.\n\n MODERATE SEDATION was provided by administering 25 mcg of Fentanyl and 1 mg\n of Versed for the 30 minute intraservice time during which the patient's\n hemodynamic parameters were continuously monitored.\n\n The Attending Neuroradiologist, Dr. , was present and supervising\n throughout the entire procedure.\n\n IMPRESSION: Slight narrowing of the right cavernous carotid artery without\n definite intimal flap or pseudoaneurysm identified. This may be congenital or\n due to mild external compression by clot. Dissection is much less likely.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CAROTID/CERVICAL BILAT", "row_id": 1025577, "text": ", J. TSICU 12:45 PM\n CAROT/CEREB Clip # \n Reason: BILATERAL carotid artery and status\n Admitting Diagnosis: SKULL FRACTURE\n Contrast: OPTIRAY Amt: 43\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with traumatic head injury after MVC\n REASON FOR THIS EXAMINATION:\n BILATERAL carotid artery and status\n ______________________________________________________________________________\n PFI REPORT\n Very slight narrowing of a portion of the right cavernous carotid artery\n without evidence of intimal flap or pseudoaneurysm formation. Although\n considered unlikely, dissection is not entirely excluded. The left internal\n carotid artery and left vertebral arteries are normal.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-02 00:00:00.000", "description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT", "row_id": 1025666, "text": " 10:13 AM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: assess for fracture, dislocation\n Admitting Diagnosis: SKULL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p motorcycle accident, shoulder pain, swelling, ecchymosis\n REASON FOR THIS EXAMINATION:\n assess for fracture, dislocation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pain. Motorcycle accident.\n\n Three radiographs of the right shoulder demonstrate marginal osteophyte\n formation about the glenohumeral joint. No fracture or dislocation.\n Acromioclavicular joint is unremarkable. Visualized ribs, lung, and regional\n soft tissues are unremarkable.\n\n IMPRESSION:\n\n Moderate glenohumeral joint osteoarthritis.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1025560, "text": " 10:22 AM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: bleeding right sided temporal\n Admitting Diagnosis: SKULL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n bleeding right sided temporal\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AKSb SAT 4:10 PM\n PFI: Unchanged right subgaleal hematoma and small right subdural hemorrhage\n in the middle cranial fossa.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right temporal bleeding. Evaluate for change.\n\n COMPARISON: .\n\n NONCONTRAST HEAD CT: The large right frontal subgaleal hematoma is stable in\n size with slight spreading out of the hyperacute blood. Two small foci of\n subdural hematoma in the right middle cranial fossa are stable measuring 5 mm\n in greatest diameter (2:8). No new intracranial hemorrhage and no\n hydrocephalus. Redemonstration of right greater sphenoid fracture\n extending to the sella, better appreciated on prior bone algorithm CT. Again,\n blood layers within the sphenoid and maxillary sinuses with fluid in the\n ethmoid air cells.\n\n IMPRESSION:\n\n 1. No change in right frontal subgaleal hematoma and small subdural hematoma\n within the right middle cranial fossa.\n\n 2. Unchanged minimally displaced fracture of the greater of the sphenoid\n bone extending to the sella.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1025561, "text": ", J. TSICU 10:22 AM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: bleeding right sided temporal\n Admitting Diagnosis: SKULL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n bleeding right sided temporal\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Unchanged right subgaleal hematoma and small right subdural hemorrhage\n in the middle cranial fossa.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1025522, "text": " 1:18 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: r/o dissection\n Admitting Diagnosis: SKULL FRACTURE\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p trauma with carotid canal injuries\n REASON FOR THIS EXAMINATION:\n r/o dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj SAT 6:38 AM\n Diminutive right A1 segment and irregular supraclinoid portion of the right\n carotid artery raise concern for acute injury. This area is also near to\n nondisplaced fracture of the sellae. Assessment overall is limited by contrast\n within the venous system from earlier CT studies. A repeat CTA may be\n helpful.\n Relatively right vetebral artery. Otherwise unremarkable Circle\n of .\n Right SDH middle cranial fossa.\n See concurrent CT reports for fractures.\n Final pending 3-D reconstructions. Findings discussed with Dr.\n of neurosurgery.\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE HEAD AND NECK\n\n HISTORY: Trauma with concern for dissection.\n\n A comparison is made with CT from the same day.\n\n The CT demonstrates multiple skull base fractures.\n\n A small extra-axial hematoma is seen in the anterior temporal lobe on the\n right. As noted on the previous facial bone CT, there are multiple skull base\n fractures. There is diminutive caliber of the right cavernous and\n supraclinoid ICA. Evaluation for CCF is limited due to venous contamination.\n\n There is a hypoplastic right A1 segment. The right distal vertebral artery is\n hypoplastic.\n\n In the neck, there is no evidence for hemodynamically significant stenosis.\n\n The right cervical vertebral artery is hypoplastic relative to the left. No\n hemodynamically significant stenosis is seen.\n\n Fluid levels in the paranasal sinuses are again identified.\n\n IMPRESSION:\n\n Irregular and diminutive caliber of the right cavernous and supraclinoid ICA\n concerning for vascular injury.\n (Over)\n\n 1:18 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: r/o dissection\n Admitting Diagnosis: SKULL FRACTURE\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Numerous skull base and facial fractures as detailed on the recent CT of the\n facial bones.\n\n Stable right middle fossa subdural hematoma without significant mass effect on\n the underlying brain.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-02 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1025674, "text": " 10:54 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: eval for disc herniation, cord compression\n Admitting Diagnosis: SKULL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p MVC, ? malalignment on CT\n REASON FOR THIS EXAMINATION:\n eval for disc herniation, cord compression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI of the cervical spine without gadolinium.\n\n History: Trauma\n\n No comparison studies\n\n Comparison is made to previous CT of the cervical spine from .\n\n The study is somewhat motion degraded. Within limits of this examination,\n there is no evidence for compression fracture or abnormal marrow signal. No\n evidence for ligamentous injury or cord contusion is seen.\n\n There is a left paracentral disk protrusion at C5- C6 which narrows the left\n neural foramen. There are and disk-osteophyte complexes at C3-C4 and C4-C5\n without significant stenosis.\n\n Impression:\n\n No evidence for acute posttraumatic injury to the cervical spine.\n\n Cervical spondylosis most prominent at C5-C6.\n\n" }, { "category": "Radiology", "chartdate": "2125-08-31 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1025515, "text": " 11:39 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable AP chest.\n\n INDICATION: 56-year-old male status post trauma.\n\n COMPARISONS: None.\n\n FINDINGS: The lung volumes are low. Allowing for AP technique, the\n cardiomediastinal silhouette is within normal limits. The lungs are probably\n clear without definite consolidation and there is no pleural effusion,\n pneumothorax or rib fracture.\n\n IMPRESSION: Slightly limited study secondary to low lung volumes. No acute\n cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1025516, "text": " 12:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with MCC\n REASON FOR THIS EXAMINATION:\n ?bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj SAT 5:46 AM\n Large right frontal subgaleal hematoma and preseptal thickening.\n Right greater sphenoid fracture extending into the sellae worrisome for\n carotid injury.\n 1.7 cm fragment fracture of the right temporal process.\n Small right SDH in the middle cranial fossa. No other intracranial\n hemorrhage.\n Layering hemorrhage within the maxillary and sphenoid sinuses.\n Right lateral wall maxillary sinus fracture.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n STUDY: CT of the head without contrast.\n\n INDICATION: 56-year-old male status post motorcycle crash.\n\n COMPARISONS: None.\n\n TECHNIQUE: 5-mm axial images of the head were acquired.\n\n FINDINGS: There is a large right frontal subgaleal hematoma with a hyperdense\n component measuring 3.9 x 1.6 cm (2:23). There is extensive stranding of the\n subcutaneous tissues overlying the right frontal cranium and face. Marked\n preseptal thickening is also noted. A small amount of hyperdensity along the\n posterior falx may be a small parafalcine subdural hematoma. A small right\n middle cranial fossa subdural hematoma is additionally noted. The right\n temporal lobe within the middle cranial fossa is mildly heterogeneous and it\n will be difficult to exclude a small amount of subarachnoid hemorrhage.\n Otherwise, 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.\n\n There is a free fragment of bone of the right temporal process of the\n zygomatic arch with minimal medial depression, measuring 1.7 cm in length.\n There are fractures through the lateral wall of the right maxillary sinus.\n There is a nondisplaced fracture involving the greater of the sphenoid.\n\n A fracture through the clivus extends into the left carotid canal, raising a\n concern of carotid artery injury. This fracture also extends across\n both optic canals, raising a concern of optic nerve injury.\n\n Hyperdense material layering within the sphenoid sinuses is consistent with\n hemorrhage. Hyperdense material layering within both maxillary sinuses is also\n consistent with hemorrhage.\n (Over)\n\n 12:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?bleed\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n A fracture through the greater of the sphenoid extends into the\n tuberculum sellae. Note is made of a defect in the anterior cortex of the\n vertebral canal of the C2 vertebral body. There is minimal mucosal thickening\n of the ethmoid sinuses.\n\n IMPRESSION:\n\n 1. Multiple right-sided facial fractures, small right subdural hematoma\n within the right middle cranial fossa. Extensive hemorrhage within the\n maxillary sinuses and sphenoid sinuses.\n\n 2. Fracture line extending into the sella turcica is concerning for injury to\n the carotid arteries.\n\n Please refer to the concurrent CT sinus report for a futher discussion of the\n facial fractures as they were better seen on that study.\n\n\n NOTE ADDED AT ATTENDING REVIEW: The optic canal fractures wree not mentioned\n in the preliminary report. Also, the right middle fossa hematoma may be\n epidural rather than subdural.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1025517, "text": " 12:05 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ?c spine injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with MCC\n REASON FOR THIS EXAMINATION:\n ?c spine injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj SAT 5:56 AM\n Very subtle widening of the anterior interspace at the C5-6 level. If there is\n concern for cervical spine injury, MRI is recommended.\n Probable fracture of the anterior portion of the vertebral artery canal at the\n C2 level on the left. CTA of the neck is recommended to exclude vertebral\n artery injury.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE C-SPINE\n\n INDICATION: 56-year-old male status post MCC.\n\n TECHNIQUE: MDCT axial images of the cervical spine were acquired. Coronal\n and sagittal reformatted images were then obtained.\n\n FINDINGS: Several ossified fragments noted along the inferior margins of the\n C3 and C5 vertebral bodies are likely degenerative in nature as they are well\n corticated. There is very subtle widening of the anterior interspace at the\n level of the C5-6 vertebral bodies. This may be degenerative in nature or\n reflect acute injury. There is apparent disruption of the anterior aspect of\n the left vertebral artery canal at the level of C2 (2:17). No other acute\n fracture is visualized. The visualized lung apices are clear. The visualized\n outline of the thecal sac is unremarkable. Please note, CT is unable to\n provide intrathecal detail comparable to MRI.\n\n IMPRESSION: Possible widening of the anterior interspace at the C5-6 level.\n If there is any concern for cervical spine injury, an MRI of the cervical\n spine is recommended.\n\n Apparent fracture of the anterior portion of the vertebral artery canal at the\n level of C2. CTA of the neck is recommended to exclude vertebral artery\n injury.\n\n Final Attending Comment:\n No fracture of the C2 transverse foramen is seen.\n\n\n\n\n\n\n (Over)\n\n 12:05 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ?c spine injuries\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1025518, "text": " 12:05 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?injuries\n Field of view: 48\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with MCC\n REASON FOR THIS EXAMINATION:\n ?injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj SAT 6:03 AM\n No acute intrathoacic, abdominal or pelvic injuries.\n Fatty liver.\n Diverticulosis.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n INDICATION: 56-year-old male status post motorcycle accident.\n\n COMPARISONS: None.\n\n TECHNIQUE: Following the administration of intravenous contrast, MDCT axial\n images were acquired from the thoracic inlet to the pubic symphysis. Coronal\n and sagittal reformatted images were then obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: The aorta is normal in caliber and contour\n without evidence of acute injury. The heart is normal in size and there is no\n pericardial effusion. No pathologically enlarged mediastinal or axillary\n lymph nodes are present. The lungs are clear aside from minimal bibasilar\n atelectasis.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver is diffusely low in attenuation\n consistent with fatty infiltration. The gallbladder, spleen, adrenal glands,\n kidneys, stomach and abdominal portions of the large and small bowel are\n unremarkable. There is mild fatty replacement of the pancreas. A few\n prominent retroperitoneal lymph nodes are noted, none of which meet criteria\n for pathology by CT. There is no free fluid or free air within the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: There are scattered colonic diverticula. A\n Foley balloon is present within the bladder which is decompressed. A small\n amount of air is noted superiorly, likely related to placement. The prostate,\n rectum, sigmoid colon are otherwise unremarkable. There is no free fluid\n within the pelvis.\n\n OSSEOUS STRUCTURES: No acute fracture of the thoracic or lumbar spine. No\n blastic or lytic lesions.\n\n IMPRESSION:\n 1. No acute intrathoracic, abdominal or pelvic injury.\n\n (Over)\n\n 12:05 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ?injuries\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Fatty infiltration of the liver.\n\n 3. Diverticulosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1025519, "text": " 12:07 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with MCC\n REASON FOR THIS EXAMINATION:\n ?fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj SAT 5:52 AM\n Right lateral orbital wall fracture with tiny foci of intraconal air.\n For other fractures please refer to head CT wet read.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE FACIAL BONES\n\n INDICATION: 56-year-old male status post MCC.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT axial images of the facial bones were acquired. Coronal and\n sagittal reformatted images were then obtained.\n\n FINDINGS: There is a fracture of the right temporal bone. There is a\n comminuted fracture involving the greater of the sphenoid bone. This\n fracture extends into the sella and cavernous sinus. There are fractures of\n the carotid canals bilaterally. There is a comminuted fracture involving the\n lateral wall of the right maxillary sinus and layering hemorrhage within the\n sinus is visualized. A small amount of layering hemorrhage is also visualized\n within the left maxillary sinus. Layering hemorrhage and several foci of\n pneumocephalus are present within the sphenoid sinuses. There is\n opacification of the ethmoid sinuses bilaterally and this may also represent\n acute hemorrhage.\n\n There is a nondisplaced fracture of the right lateral orbital wall and a tiny\n focus of intraconal pneumocephalus is visualized (400B:62). There is\n extensive right-sided preseptal swelling as well. Otherwise, the orbits\n appear intact.\n\n IMPRESSION:\n 1. Multiple facial fractures, predominantly right-sided. Concerning fracture\n to the sella and area of the cavernous sinus. This raises concern for carotid\n injury. Followup CTA of the head and neck is recommended.\n 2. Nondisplaced right lateral wall orbital fracture with tiny foci of\n intraorbital air.\n\n Final Attending Comment:\n Also noted are fractures of the right zygomatic arch and pterygoid plates.\n (Over)\n\n 12:07 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: ?fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2125-09-01 00:00:00.000", "description": "R KNEE (AP, LAT & OBLIQUE) RIGHT", "row_id": 1025520, "text": " 12:37 AM\n KNEE (AP, LAT & OBLIQUE) RIGHT; FEMUR (AP & LAT) RIGHT Clip # \n TIB/FIB (AP & LAT) RIGHT\n Reason: ?injury\n Admitting Diagnosis: SKULL FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with MCC\n REASON FOR THIS EXAMINATION:\n ?injury\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male with MCC, question injury.\n\n TECHNIQUE: Two views of the right hip, two views of the right femur, two\n views of the right knee and two views of the right tibia and fibula and an AP\n pelvis x-ray wer obtained.\n\n FINDINGS:\n RIGHT HIP: There is no evidence of fracture or dislocation. Note is made of\n mild osteophyte formation along the superior acetabulum. Soft tissues appear\n normal.\n\n RIGHT KNEE: Note is made of mild osteophyte formation, joint space narrowing\n and subchondral sclerosis of the tibiofemoral and patellofemoral joint spaces.\n No evidence of fracture or dislocation is appreciated. Soft tissues appear\n normal.\n\n RIGHT TIBIA AND FIBULA: No evidence of fracture or dislocation.\n There is osseous remodeling of the cortices of the tibia and fibula which may\n represent old trauma. In addition, note is made of lucencies within the\n cortices on the lateral views. These lucencies are of unclear etiology and\n may represent summation shadows from overlying soft tissues or clothing. A\n repeat xray of the tibia and fibula with the clothing removed is recommended.\n\n Limited views of the ankle joint demonstrate calcific densities which appear\n to be intrarticular. Marginal osteophytes are noted at the tibiotalar joint.\n\n PELVIS: There is contrast partially distending the bladder. A foley catheter\n is in the bladder. Note is made of contrast within the distal ureters\n bilaterally. No evidence of contrast extravasation.\n\n No evidence of fracture or dislocation. Degenerative changes are seen in the\n bilateral hip joints characterized by osteophyte formation and mild joint\n space narrowing.\n\n These findings were discussed with Dr. at 1 pm on .\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2182-07-16 00:00:00.000", "description": "Report", "row_id": 1339898, "text": "CCU Nursing adm/progress note\n56 yr old with extensive PMH including DM I, ESRD on HD, CAD, MI in past transferred from hosp for further management of CP and a.fib that he has experienced during dialysis.\n\nPlease see for details.\n\nPT arrived in no acute distress.\n\nCV: HR 65 NSR, no a.fib, BP 70's-80's/20, asymptomatic, mentating. Baseline BP runs in the 80-90's/. Pt c/o soreness in chest, ECG done, without changes.\n\nResp: LS clear with crackles at L base. O2 sat 95-100% on RA, arrived on 4L but prefers not to wear O2. Denies SOB. C/O pain on inspiration.\nDry cough.\n\nNeuro: A&Ox3, pleasant, cooperative.\n\nID: afebrile.\n\nGU: arrived with dialysis line accessed, flushed with 10cc NS followed by 2cc 5000U/cc hep, catheter labeled. Have attempted dialysis today and yesterday with episodes CP and a.fib each time.\n sent this eve.\n\nGI: ate for dinner.\n\nEndo: written for glargine and humalog.SS.\n\nSkin: has scratch on L arm from daughters dog, scabbed, with one open area, covered with triple AB oint and 2x2.\n\nSoc: wife and in, updated by MD.\n\nA/P: 56 yr old with extensive PMH, now with a.fib/CP during dialysis, to evaluated futher by EP, follow on tele, ?cath vs. stress test. NPO after MN for ?tests tomorrow. To be seen by renal also, follow , eval need for dialysis tomorrow. Support pt/family.\n" }, { "category": "Nursing/other", "chartdate": "2182-07-17 00:00:00.000", "description": "Report", "row_id": 1339899, "text": "Neuro slept most of the night easily aroused ox3\ncvs HR 58-62 sb to nsr bp 74/42-88/36 given 250cc ns bolus without change to bp, K+ 4.9 hct 32.8 skin w+d pulses doppler\nresp rm air lungs cta\ngi npo after mn abd snt bs+ no stool\ngu anuric\nendo ss and fixed insulin bs 177-140\naccess 22g periph rtsc HD line\nID afebrile wbc wnl lactic acid 1.7, bld cx x1 drawn\na. 56 yo with sign pmh IDDM, ESRD renal and pancreatic transplants in past now on hd, PAF, CM, CAD, PVD with multiple amputations, hep c and b, presents with PAF and cp with HD\n hypotension\np. ESRD poss. HD today lytes stable\n npo after mn for ? stress test ? need for AV nodal ablation and pacemaker\n" }, { "category": "Nursing/other", "chartdate": "2182-07-17 00:00:00.000", "description": "Report", "row_id": 1339900, "text": "CCU NPN 7a-7p\nPlease see transfer note for today's note\n" }, { "category": "Echo", "chartdate": "2182-07-17 00:00:00.000", "description": "Report", "row_id": 101415, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 140\nBSA (m2): 1.74 m2\nBP (mm Hg): 91/41\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 09:20\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.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function. TVI E/e' >15,\nsuggesting PCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderate mitral annular calcification. Calcified tips of\npapillary muscles. Mild (1+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Regional\nleft ventricular wall motion is normal. Tissue velocity imaging E/e' is\nelevated (>15) suggesting increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. Mild (1+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Elevated LVEDP. Pulmonary artery\nsystolic hypertension. Mild mitral regurgitation.\nCompared with the prior study (tape reviewed) of , left ventricular\nsystolic function is improved.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2182-07-23 00:00:00.000", "description": "Report", "row_id": 301967, "text": "Sinus bradycardia. Compared to the previous tracing of Q-T interval\nprolongation persists.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2182-07-22 00:00:00.000", "description": "Report", "row_id": 301968, "text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block.\nNon-diagnostic repolarization abnormalities. Prolonged Q-T interval. Compared\nto the previous tracing of multiple abnormalities persist without major\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2182-07-20 00:00:00.000", "description": "Report", "row_id": 301969, "text": "Normal sinus rhythm. Intraventricular conduction defect. Q-T interval\nprolongation. Compared to the previous tracing of normal sinus rhythm\nhas returned.\n\n" }, { "category": "ECG", "chartdate": "2182-07-19 00:00:00.000", "description": "Report", "row_id": 301970, "text": "Atrial fibrillation with a mean ventricular response, rate 96. Compared to the\nprevious tracing of no major change.\n\n" }, { "category": "ECG", "chartdate": "2182-07-17 00:00:00.000", "description": "Report", "row_id": 301971, "text": "Atrial fibrillation with a mean ventricular response, rate 113. Left axis\ndeviation. Left anterior fascicular block. Compared to the previous tracing\nof cardiac rhythm now atrial fibrillation. Other abnormalities as\npreviously noted persist without major change.\n\n\n\n" }, { "category": "ECG", "chartdate": "2182-07-17 00:00:00.000", "description": "Report", "row_id": 301972, "text": "Sinus rhythm\nBorderline first degree AV block\nintraventricular conduction defect with left axis deviation probably in part\nleft anterior fascicular block and additional intraventricular conduction delay\nConsider left atrial abnormality\nProlonged Q-Tc interval\nNonspecific ST-T wave changes\nClinical correlation is suggested is suggested for possible metabolic/drug\neffect\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2182-07-16 00:00:00.000", "description": "Report", "row_id": 301973, "text": "Sinus rhythm\nBorderline first degree A-V delay\nIntraventricular conduction defect with left axis deviation probably in part\nleft anterior fascicular block and additional intraventricular conduction delay\nLeft atrial abnormality\nProlonged Q-Tc interval\nNonspecific ST-T wave changes\nClinical correlation is suggested for possible metabolic/drug effect\nSince previous tracing of , first degree A-V delay absent\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2198-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982827, "text": " 7:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lung fields\n Admitting Diagnosis: TRACHEAL MALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man w/ tracheomalacia, tracheostomy, LLL pneumonia, L PICC s/p\n bronch, y-stent placement\n REASON FOR THIS EXAMINATION:\n assess lung fields\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:49 P.M., ON \n\n HISTORY: Tracheostomy. Tracheomalacia and left lower lobe pneumonia. Y\n stent and left PIC catheter.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n A roughly 6 cm long tracheostomy cannula ends at the level of the thoracic\n inlet at the upper margin of a tracheal stent which is seen to continue into\n the left main bronchus. A right bronchial component is not clearly\n identified, nor is the connection between the trachea and left bronchial\n components. Lung volumes are generally low and pulmonary vasculature is\n congested. Opacification at the base of the left lung could be atelectasis or\n pneumonia. Heart size is top normal. Tip of the left PIC catheter projects\n over the mid SVC. A left axillary power pack may be the source of a\n filamentous lead heading inferiorly, but the connection is not clear. Pleural\n effusion, if any, is small, on the left. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-11-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 983569, "text": " 1:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronchoscopy today, interval change\n Admitting Diagnosis: TRACHEAL MALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 y/o M with h/o diptheria static encephalitis @ 2 mo old, chronic seizure\n d/o, trachomalacia s/p y-stent/trach at , recent admission at\n for recurrent LLL MRSA, pseudomonal transferred to for stent\n placement/trach change. Patient was discharged on from after\n prolonged hospitalization for pseudomonas PNA and tracheomalacia requiring\n trach/G-tube placement. About a month following hospitalization, pt. had\n increased suctioning requirements and intermittent fevers and was admitted to\n CHB, where he was diagnosed with LLL pseudomonal and MRSA PNA and started on\n meropenem and gentamicin. He was also found to have granulation tissue and\n mucuous in his trach tube and was transferred to the for stent placement\n and trach change. Pt was taken to the OR on , then admitted to TSICU\n for airway management. O/N pt had desat to 80s not relieved with suctioning -\n brought to SICU where he was given 2 mg ativan and placed on propofol gtt.\n Uncuffed trach changed to cuffed trach and placed on ventilator.\n REASON FOR THIS EXAMINATION:\n s/p bronchoscopy today, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Stent placement for the trachea in a patient with diphtheria history\n\n FINDINGS: In comparison with the study of , the tracheal stent is seen\n extending to about 2.5 cm above the level of the carina. No evidence of acute\n pneumonia. The hugely dilated gas-filled stomach appears to have been\n reduced.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 983317, "text": " 11:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: difficulty breathing\n Admitting Diagnosis: TRACHEAL MALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man w/ tracheomalacia, tracheostomy, LLL pneumonia, L PICC s/p\n bronch, y-stent placement\n REASON FOR THIS EXAMINATION:\n difficulty breathing\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Tracheomalacia, left lower lobe pneumonia, Y-stent placement.\n\n One portable view. Comparison with the previous study done . The\n lungs now appear clear. The heart is normal in size. There is some\n prominence of the superior mediastinum, unchanged. Tracheal and left brachial\n stent are in place. On the current study there is overlap of the distal end\n of the tracheal stent and the small opening of the left brachial stent. A\n right brachial stent is not identified. A tracheostomy tube remains in place.\n The power pack overlies the left axilla, as before. A left PICC line is\n present, terminating in the region of the superior vena cava, unchanged.\n\n IMPRESSION: The lungs now appear clear. Tracheal and bronchial stents are in\n place as described. There is now overlap of the distal end of the tracheal\n stent and proximal lumen of the left bronchial stent which may limit\n airflow and clinical correlation is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2198-11-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 984346, "text": " 7:24 PM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval acute gastric distension\n Admitting Diagnosis: TRACHEAL MALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with gastric dilt on CXR\n REASON FOR THIS EXAMINATION:\n eval acute gastric distension\n ______________________________________________________________________________\n WET READ: KMcd SUN 10:30 PM\n No evidence for gastric or bowel distention. G-tube in place.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 23-year-old male with gastric dilatation on chest x-ray.\n Evaluate for gastric distention.\n\n COMPARISON: at 7:29 a.m.\n\n FINDINGS: Single supine abdominal radiograph. Limited exam secondary to\n respiratory motion. The bowel gas pattern is non-specific. A percutaneous G-\n tube is present. No gastric dilatation. Scoliosis of the thoracolumbar spine\n with rightward convexity.\n\n IMPRESSION: No gastric distension.\n\n" }, { "category": "Radiology", "chartdate": "2198-11-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 983862, "text": " 1:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute cardiopulmonary process and Bovonna position\n Admitting Diagnosis: TRACHEAL MALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23M with h/o diptheria static encephalitis @ 2 mo old, chronic seizure d/o,\n trachomalacia s/p Bovonna trach recently advanced.\n REASON FOR THIS EXAMINATION:\n eval acute cardiopulmonary process and Bovonna position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate position of tracheal stent and heart and lungs.\n\n FINDINGS: Comparison with study of , allowing for differences in\n obliquity of the patient, there is little change. The tracheal tube tip lies\n about 2.5 cm above the carina. No evidence of focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-11-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 984260, "text": " 8:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval ? acute Pulmonary process\n Admitting Diagnosis: TRACHEAL MALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23M with h/o diptheria static encephalitis @ 2 mo old, chronic seizure d/o,\n trachomalacia s/p Bovonna trach recently advanced.\n REASON FOR THIS EXAMINATION:\n Eval ? acute Pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 20:24\n\n INDICATION: Chronic seizures, encephalitis and tracheomalacia.\n\n COMPARISON: .\n\n FINDINGS:\n\n Compared to the prior study there is no evidence for new focal consolidation.\n Tip of the trach tube is 4.1 cm above the carina. The gastric fundus is\n distended with air. Pulmonary vascular markings are normal.\n\n IMPRESSION: No acute cardiopulmonary disease. Gastric fundus distended with\n air.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-11-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 984303, "text": " 7:57 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess for ileus. please perform erect / upright study\n Admitting Diagnosis: TRACHEAL MALACIA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with gastric dilt on CXR\n REASON FOR THIS EXAMINATION:\n assess for ileus. please perform erect / upright study\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON AT 07:29.\n\n INDICATION: Gastric dilatation on chest x-ray.\n\n FINDINGS:\n The patient was unable to sit upright, however, the previously demonstrated\n gastric distention is no longer visualized. The bowel gas pattern is\n nonspecific and nondistended. No evidence of pneumatosis, free air or\n ascites. Gastrostomy tube identified.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-11-20 00:00:00.000", "description": "Report", "row_id": 1635119, "text": "Resp: pt on 50% t/c with humidification. Pt has #7 air filled trach, cuff deflated, instilled 3 cc air to inflate cuff. bs are coarse bilaterally and suctioned frequently for thick yellow secretions. MDI's administered via trach combivent. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-20 00:00:00.000", "description": "Report", "row_id": 1635120, "text": "Neuro: Unchanged. No seizure activity but periods of wakefulness and restlessness. Medicated at 0130 w 1mg ativan for sleep good effect.\n\nCV/resp Hr ST w higher hr when awake and restless. O2 50% trach collar fitted for bovona trach. suctioned multiple times troughout the night for thick white sometimes blood tinged secretions. o2 sat maintained in the high 90's consistently.\n\ngi/gu no stools abdomen soft. foley to gravity. uop marginal clear yellow urine. tube feeds continue at goal with minimal residuals.\n\ninteg skin warm and dry coccyx reddened. peri area reddened. Skin around trach slightly reddened.\n\nPlan: Transfer to rehab today aprox 10 am. Update referrals.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-20 00:00:00.000", "description": "Report", "row_id": 1635121, "text": "Pt discharged. VSS, report given to nurse .\n" }, { "category": "Nursing/other", "chartdate": "2198-11-11 00:00:00.000", "description": "Report", "row_id": 1635089, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED ON PROPOFOL MOST OF THE SHIFT, ABLE TO WEAN DOWN FOLLOWING OR. AROUSABLE TO TOUCH, PT DOES NOT FOLLOW COMMANDS OR INTERACT AT BASELINE DUE TO MR. . SHORTLY AFTER OR, PT MOVING HEAD FROM SIDE TO SIDE, EYES DEVIATED TO UPPER LEFT, BECOMING AGITATED AND TACHYPNEIC, ? SEIZURE ACTIVITY. ATIVEN 1 MG GIVEN WITH EFFECT. MAE ON THE BED, EXT. CONTRACTED. FENTANYL IV GIVEN WITH EFFECT POST SURGERY FOR ? OF PAIN.\nCV- BP STABLE VIA A-LINE, OCCASIONALLY HYPOTENSIVE FOLLOWING PAIN MED OR ATIVAN. HR 70'S-80'S, NSR WITHOUT ECTOPY. PICC LINE WORKING WELL, HOWEVER ONLY ACCESS AT THIS TIME, PIV BECOMING PAINFUL AND APPEARED RED AT THE SITE. IV TEAM CALLED FOR POSSIBLE REPLACEMENT, IV RN DECLINED, STATING SHE HAS TRIED PT BEFORE, UNABLE TO GET ACCESS, RESIDENT NOTIFIED.\nRESP- LUNGS COARSE, SUCTIONED A FEW TIMES FOR THICK TAN TO BLOOD TINGED SPUTUM. WENT TO OR FOR TRACH REPLACEMENT, STENT REMOVAL WITHOUT DIFFICULTY. REMAINS ON AC, BEGIN TO WEAN WHEN PT RECOVERED FROM SURGERY. ABG WNL.\nGI/GU-- ABD SOFT, HYPO SOUNDS. TUBEFEED ON HOLD FOR NOW PENDING BRONCH IN AM, RESIDENT WILL FOLLOW UP IN AM. UOP ADEQUATE, MAINTENENCE FLUID CONTINUE AT 75CC/HR.\nID- AFEBRILE\n MOM CALLED BY MD, WILL BE IN TO VISIT THIS AFTERNOON.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-17 00:00:00.000", "description": "Report", "row_id": 1635112, "text": "Please See Carevue for Specifics.\n\nNeuro status per pt baseline. Lungs are coarse to clear. An occasional productive cough of thick yellow/tan secretions. Suctioned at times for thick yellow tan secretions as well. ABd is soft, +BSx4, No stool this shift. Foley with c/y/u. Buttock are pink, unbroken down, improving.\n\nPOC: Transfer to Rehab Monday or Tuesday. Continue to closely monitor respir status. Monitor skin integrity. Continue to offer emotional support to pt and pt family throughout hospital stay.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-18 00:00:00.000", "description": "Report", "row_id": 1635113, "text": "REspiratory Care\nPt seen for routine trach care x's 3. Sx for large amounts thick yellow/tan secretions, lessened as shift progressed. Exp. wheeze T/O greatly improved after MDIs. Neb jar filled as needed. T.M. @ FiO2 50%\n" }, { "category": "Nursing/other", "chartdate": "2198-11-18 00:00:00.000", "description": "Report", "row_id": 1635114, "text": "temp 100.9-100.1. @ beginning of shift hr 130's st w/ rr-high 30's-o2sat 97% on 50% trach collar. cxr done-no changed in lungs from previous film. ativan 1mg ivp pt much calmer rr down to 120's.\ncs-course w/ scattered rhonchi. suctioned thick yellow. coughing but not raising-cough very bronchial.\nabd. softly distended-no bm this shift. cxr showed dilated bowel-residual min. amt 5cc. t fdg stopped @ 0600 and peg put to depentent drge. no drge thus far.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-18 00:00:00.000", "description": "Report", "row_id": 1635115, "text": "Please See Carevue for Specifics.\n\nPt is at neuro baseline. ST, 110-120's, no ectopy. Lungs are coarse bil. Suctione infrequently for thick tan/yellow secretions. TF held this morning for increase abd distention. PEG to drainage with 200cc of clear/slight yellow drainage. TF to resume at MN. Large formed golden stool this evening. Foley with c/y/u. on buttock improving. Slight pink skin, unbroken, cleansed well with inc of stool.\n\nPOC: Repeat abd and chest XRay's tomorrow. Resume TF's. Monitor respir status and suction as needed. Transfer to Rehab/Hospital or . Continue to offer emotional support to pt and pt family throughout hospital stay.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-11-19 00:00:00.000", "description": "Report", "row_id": 1635116, "text": "Update\nSee careview for details...\nPt neuro status unchanged, no seizure activity noted, VSS, NSR-NST, K+ 3.6 this AM, Dr , no replacement ordered, cont to sx lrg amts thick tan/yellow secretions, lungs coarse, sats 100% on 50%TC, repeat abd X-ray done, TF's restarted at 60/hr, no residuals, abd soft, incont lrg formed BM, clear yellow urine via foley\nPlan: cont pulm toilet, rehab this week\n" }, { "category": "Nursing/other", "chartdate": "2198-11-19 00:00:00.000", "description": "Report", "row_id": 1635117, "text": "REspiratory Care\nPt seen for routine aerway care. Sx for sm to mod amounts yellow secretions in addition to being sx by nursing. BS coarse but clear with sx. No wheezing noted this shift. Pt appears more comfortable tonight and much less restless. MDIs adm as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-19 00:00:00.000", "description": "Report", "row_id": 1635118, "text": "Please See Carevue for Specifics.\n\nPt at neuro baseline. Lungs remain coarse, suctioning and coughing less secretions than yesterday. Tolerating TF at goal rate of 60cc/hr, no stool this shift.\n\nPOC: Page 1, 2, and discharge summary completed and located in front of pt chart. Pt to be transferred to tomorrow. Continue to closely monitor skin intergrity and respir status.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-07 00:00:00.000", "description": "Report", "row_id": 1635080, "text": "RESP CARE: Pt recieved from OR with 6.0 uncuffed Portex trach tube in place. (INNER CANNULA HAS REMAINED OUT OVERNIGHT MD). Is currently on 35% trach collar, 02 sats 100%. Lungs bilat coarse rhonchi upper lobes, sl dim LLL. Few whhezes bilat. Combivent MDI via spacer per POE, tol well, as well as Pulmozyne via high neb at 0200. Pt has strong prod cough thick bld tinged sputum. #10FR suction catheters at bedside though IP stated no deep sxing to be done at this time. Will continue to monitor pt per airway protocol. Maintain patent airway.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-07 00:00:00.000", "description": "Report", "row_id": 1635081, "text": "Admission and ROS\n23 y/o male w/ chonic tracheal malacia s/p rigid bronch, granulation debridement, left mainstem stent placement (old y stent removed) trach change. Transferred from for this procedure; ICU overnoc to monitor airway.\n\nPNH: static encephalopathy, profound MR, seizure disorder since diptheric encephalitis at 2 months old. homecare, doing well until recent months. Pseudomonal/MRSA pneumonia , tracheostomy and g-tube placement at that time. PICC placed .\n\nneuro: responds to voice w/ open eyes, does not track. Spastic UE movement, spastic contractures LE's. Does not follow commands, no means of communication. 2 witnessed global seizures, < 1 minute each, shortly after arrival from OR. No obvious pain per grimace/VS scale; no sedation required.\n\nCV: ST, no VEA, 100-150's; MAP 70-80's. Pulses palpable, no edema.\n\nPulm: #6 uncuffed Portex trach; humdified trach mask, 35% FiO2. Stoma red, ecchymotic, scant sang secretions peri-stomal. No inner cannula in situ per surgeon. Strong cough productive copious creamy pink secretions. BS rhonchorous throughout, very dim LLL. Med w/ codeine sulfate 15 mg x 1 for severe bronchospastic cough.\n\nGI: abd soft, hypo BS. G-tube in situ, pink slightly eroded borders, no exudate, flushes easily, bilious returns. No stool. NPO\n\nGU: incontinent large volume urine, diaper containment. D5.45S @ 70cc/hr\n\nSkin: grossly intact, no pressure areas. Mupirocin cream to g-tube site and trach stoma. PICC left AC, flushes easily.\n\nEndo: BG<150, no RISS.\n\nID: afebrile, WBC 8. Gent trough .3, peak pending from 2100. Meropenem single dose given pending ID approval.\n\nPsychosocial: attentive parents, appropriate concerns and ?s.\n\nP: monitor airway and humidify; do not sx below trach distal end, do not place inner cannula. Seizure precautions, prn ativan for sustained seizures, prn ativan for extreme spastic movements. Prn codeine for bronchospastic cough to prevent bleeding. Parents will be in early. D/C plans are unsure, either return to today or to floor w/ plans to d/c to for resbit care for parents.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-11-07 00:00:00.000", "description": "Report", "row_id": 1635082, "text": "Respiratory Care\n\n\n Pt continues on cool aerosol via T-mask. No sx'ing done pt has prod cough for thick yellow. 2 puffs combivent given Q4 Will continue to follow closely.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-11-07 00:00:00.000", "description": "Report", "row_id": 1635083, "text": "TSICU NPN 0700-1900\nPt remains hemodynamically stable, no respiratory distress noted. No major events this shift. Plan to transfer to 2 this evening. See transfer note for review of systems.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-10 00:00:00.000", "description": "Report", "row_id": 1635084, "text": "resp care\nCalled to see pt on floors due to inc resp distress and worsening sats. Attempted to ventilate with an ambu bag with great dificulty. Trach very positional. Transported to sicu and bronch done by anesthesia. Pt fully sedated and currently on a/c 500x12 35% 5peep. Suct for sml amts of loose bloody sput.Trach changed from a cuffless #6 portex to a Cuffed #6 portex. Trach very positional with inc pap at times.Will cont to follow and wean to trach collar today.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-10 00:00:00.000", "description": "Report", "row_id": 1635085, "text": "resp care\nremains with #6 portex cuffed trach tube. sedated and on ac mode. bronched by ip with evidence of migrating stent. plan to keep well sedated/vented and reevaluate tomorrow. suctioning to be kept as minimum as possible. bs rhonchorous but aerating well t/out.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-10 00:00:00.000", "description": "Report", "row_id": 1635086, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT SEDATED ON PROFOFOL, INCREASED THROUGHOUT THE DAY FOR COMFORT. FENTANYL AT ATIVAN ALSO GIVEN FOR BREAKTHROUGH AGITATION WITH EXCELLENT EFFECT. PT DOES NOT INTERACT AT BASELINE, COGNITIVELY DELAYED AND DOES NOT FOLLOW COMMANDS OR DIRECTION. PERRL. MAE ON THE BED.\nCV- BP STABLE, HR 80'S-90'S, NSR WITHOUT ECTOPY.\n PT THIS AM BY IP, STENT HAD MIGRATED. TRIED TO REPOSITION STENT WITHOUT SUCCESS, PT WILL NEED TO GO TO OR FOR REPLACEMENT ON . IMPERATIVE FOR PT TO REMAIN CALM AND SEDATED WITHOUT ANY VIGOROUS MOVEMENTS TO ENSURE THAT STENT REMAIN STABLE UNTIL PT GOES TO OR.\nGI/GU- ABD SOFT, G-TUBE CLAMPED AND USED FOR MEDS ONLY. UOP ADEQUATE VIA FOLEY.\nID- TMAX 99 AXILLARY.\n MOTHER AND GRANDMOTHER UPDATED BY MDS.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-11 00:00:00.000", "description": "Report", "row_id": 1635087, "text": "Resp Care: Pt continues on mechanical ventilation: AC 500x12 35%+5; no changes overnight. LS coarse bilaterally. Pt coughed up small amounts of thick tan secretions. MDI's given as ordered. RSBI not done secondary to unstable airway. PLAN: bronch today, ? OR\n" }, { "category": "Nursing/other", "chartdate": "2198-11-14 00:00:00.000", "description": "Report", "row_id": 1635099, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT MILDLY SEDATED ON PROPOFOL, ALERT MOST OF THE NIGHT. DOES NOT FOLLOW COMMANDS AT BASELINE, DOES NOT INTERACT OR COMMUNICATE. OCCASIONALLY APPEARS TO HAVE DISCOMFORT, RELIEVED BY REPOSITIONING. NO SEIZURE ACTIVITY NOTED.\nCV- BP STABLE, CYCLING CUFF DUE TO INTERMITTENT DAMPENING OF A-LINE. HR RISING TO 100-110 THROUGHOUT THE NIGHT, 120'S WHEN APPEARING UNCOMFORTABLE.\nRESP- LUNGS COARSE AT TIMES, SUCTIONED EVERY FEW HOURS FOR THICK YELLOW SPUTUM. PT HAS STRONG COUGH. BECOMING TACHYPNEIC AT TIMES TO HIGH 30'S, ? NEED FOR INCREASED SEDATION, DR. NOTIFIED. ABG SENT AND WNL, NO VENT CHANGES MADE, NO INCREASE IN SEDATION AT THIS TIME.\nGI/GU- ABD SOFT, TOLERATING TF AT GOAL. UOP ADEQUATE.\nID- TMAX 99.8 AX, UNABLE TO ACQUIRE ORAL TEMP, PT ALWAYS HAS OPEN MOUTH AND DOES NOT HOLD STILL FOR TEMP.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-14 00:00:00.000", "description": "Report", "row_id": 1635100, "text": "Respiratory Care:\nPatient continues with #7.0 extended length LPC trach. It is 10.5 cm marking at edge of stoma - app 11cm marking. He has bronchial BS bilat with scattered insp wheezing. He has a cuff leak around trach and leak seems worse when he is on his left side. Suctioned for thick, pale yellow secretions app Q4 and he received combivent MDI app Q6. Plan to wean off vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-14 00:00:00.000", "description": "Report", "row_id": 1635101, "text": "Resp. care note - Pt. remaines trached, weaned to CA, tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-14 00:00:00.000", "description": "Report", "row_id": 1635102, "text": "Please See Carevue for Specifics.\n\nPt at neuro baseline. Propofol weaned off, Trach advanced 0.5cm by IP, and weaned to trach collar at 1100. Pt has been tolerating trach collar throughout day, ABG WNL. Suctioned for thick yellow/tan secretions ?TF, SICU residents aware, and TF held for short period. TF restarted this afternoon per SICU resident. No stool this shift.\n\nPOC: Continue to closely monitor respir status. ?transfer to towards the end of the week. Continue TF. Continue to offer emotional support to pt and pt family throughout hospital stay.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-15 00:00:00.000", "description": "Report", "row_id": 1635103, "text": "nursing note\nPt at neuro baseline, no seizure activity noted, dilantin 400 mg given for low level. Pt cont to thrash in bed when stimulated and have foreceful cough. low grade temps cont. Suctioned q1-2 of thick yellow to white secretions, forceful, spastic cough. o2 weaned to 40%. GT found to have tear in plastic catheter that had been taped over, MD Do aware. tube feeds cont. as ordered. Duoderm intact to buttocks. to buttocks and groin improved. bacitracin to trach site and peg site as ordered.\n\nPLAN: ? transfer to rehab, pulm toilet, monitor trach secretions for tube feeds, ? change in GT prior to transfer. skin care.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-15 00:00:00.000", "description": "Report", "row_id": 1635104, "text": "Resp Care\nPt remains trached with #7 Bovina with adjustible flange. Pt received on T-Piece 50%, weaned to 40%. BS coarse throughout. Suctioning for copious thick yellow secretions. MDI's as ordered. Pt placed on Trach collar early this morning due to secretions continuously getting stuck in T-piece. Pt tolerate trach mask well at this time. RR= 25, Spo2=98%. Pt continues to get agitated with stimulation. See CareVue flowsheet for details.\nPlan: ? Rehab today.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-15 00:00:00.000", "description": "Report", "row_id": 1635105, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt remains at baseline neurologically. Dilantin level therapeutic this AM.\n\n Resp: LS clear to coarse bilat. Remains on trach collar, maintaining O2 sat >95%. Pt able to cough and raise mod amounts of thick white secretions, suctioned prn. Bovina trach remains intact, bacitracin to area around trach.\n\n CV: Remains NSR-NST, no ectopy noted. Skin W&D. No edema noted. SBP 100-120. Palp pedal pulses\n\n GI: Abd soft, pos bs, small BM, tol Tf @ goal via Gtube.\n\n GU: Adequate amounts of clear yellow urine via foley cath\n\n Social: Mother and father into visit, spoke with IP fellow as well as from the rehab center. Parents filled out authorization form to give their daughter information while they are away in Aruba. Parents aware of plan to d/c to rehab on Monday or Tuesday and are in agreement with plan.\n\nPlan: Pulm toileting, skincare, provide emotional support to pt and family, d/c to rehab early next week.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-11-15 00:00:00.000", "description": "Report", "row_id": 1635106, "text": "Patient remains off vent all day requires frequent suctioning.Treated with Dornase daily and combivent Q4.Plan to go to rehab soon.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-16 00:00:00.000", "description": "Report", "row_id": 1635107, "text": "Update\nSee careview for details...\nNeuro: At baseline, no seizure activity noted, no s/s pain\n\nCV: VSS, afebrile\n\nResp: tol 40% TC, sx Q 2hrs for thick yellow secretions, strong cough, lungs clear, sats 98-100%\n\nGI: tol TF via peg at 60/hr, no BM\n\nGU: clear yellow urine via foley\n\nSkin: duoderm intact to coccyx\n\nPlan: monitor resp status, frequent sx, rehab on Monday\n" }, { "category": "Nursing/other", "chartdate": "2198-11-16 00:00:00.000", "description": "Report", "row_id": 1635108, "text": "Respiratory Care:\nPt remains trached with #7 tube secured at 11cm. Aerosol mask on at 40%. Suctioning thick white secretions. MDI's given.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-16 00:00:00.000", "description": "Report", "row_id": 1635109, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n No change in pt's condition, small seizure noted at change of shift lasting <5sec, 1mg iv ativan given with pos effect, no further seizure activity noted, SICU MDs notified during rounds. Bovina trach remains intact, bacitracin to site, suctioned prn for mod amounts of thick yellow secretions. Maintaining O2 sat > 95% on trach collar. Tol Tf @ goal, no BM this shift. Adequate amounts of clear yellow urine via foley cath. (pt's sister) updated by this RN. rehab bed.\n\nPlan: pulm toileting, skincare, provide pt and family with emotional support, d/c to rehab when bed available\n" }, { "category": "Nursing/other", "chartdate": "2198-11-13 00:00:00.000", "description": "Report", "row_id": 1635095, "text": "Respiratory Care:\nPatient with #7.0 aircuff trach noted to be 10.5 cm at flange. BS = bilat, slightly coarse. Suctioned for small amounts of thick blood tinged secretions. He is on a heated circuit and receiving combivent MDI app Q6 hours. RSBI done with propofol decreased and was 80 but he became agitated and sedation was increased, weaning held at this time per Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2198-11-17 00:00:00.000", "description": "Report", "row_id": 1635110, "text": "Resp care: Pt continues trached with #7 @ mark 11 @ flange and on cool mist 40% maintaining spo2 95-100%, 3 ml in cuff for 24 cm press; bs rhonchorous, sxn, c/r thick white secretions, rx with mdi combivent via , cont pul toilet as tol.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-17 00:00:00.000", "description": "Report", "row_id": 1635111, "text": "vss. neurologically @ baseline. no sz noted.\ntol. trach collar 40% cool mist. rr-23-28 w/ 02sat 97-100%. c&r'ing\nfrom trach-needing assistance w/ suctioning q3-4hr thick yellow sputum.\ntol. t. fdg probalance @ 60cc/hr. lrge bm brown semi-solid stool.\nbuttuck area improving-turned q2-3. skin intact.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-13 00:00:00.000", "description": "Report", "row_id": 1635096, "text": "condition update\nD: pt is sedated on propofol and still thrashing head back and forth.\nafter phenobarb, dilantin and clonipin. pt resting on propofol at 75mcg/kg/min. pt appears very sedated not overbreathing vent and hr in the 60's nsr with abp 90-110/50-60. propofol decreased to 40mcgs/kg/min and pt woke up thrashing head and moving arms. Spoke with Dr. and would prefer pt to be more sedated than moving head and appearing uncomfortable to keep tube stable. propofol back up to 60mcgs. pt with positional air leak resolved after turning. no drop in o2 sats. and tv back to baseline with no intervention.\ncardiac: pt in nsr to sb rate 58-70 depending on sedation. sbp 90's -110/50-60/ aline positional and wave dampened difficult to draw off and going by cuff pressure at this time.\nresp: risbi this am 80. pt to stay on cmv per Dr. until rounds.\npt suctioned for thick blood tinged sputum. breath sounds coarse and clear in bases. see flowsheet for abg results\ngi: g tube clamped and pt npo at this time.\ngu: foley patent and draining clear yellow urine.\nskin: pt with on face and perineum fungal cream on perinuem and bactroban cream to g tube site. have md on face for ? staph.\na: continue to monitor resp. status. ? wean sedation today.\nr: pt sedated on propofol at 60mcgs. abgs good on cmv at this time.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-13 00:00:00.000", "description": "Report", "row_id": 1635097, "text": "Please See Carevue for Specifics.\n\nPt mental status at baseline. Does not follow commands, non-purposeful movement with all four ext. NSR, no ectopy. SBP 100-110's, aline dampening at times. Lungs are clear to coarse. Slowly weaned from AC to CPAP to trach collar. With trach collar, pt becomes increasingly tachycardic, tachypneic, and O2 sat slowly decrease. 2mg IV ativan adm priot to trach collar and mother at bedside to help comfort pt. With increased HR and RR breathing began to sound stridorous. SICU resident in to pt. Pt placed back on vent and IP was called by SICU. IP to pt this evening. Tolerating TF via PEG.\n\nPOC: COntinue to closely monitor respir status. ?bronch to trach and stents. Propofol as needed. Increase TF to goal rate of 60cc/hr. Continue to offer pt and pt family emotional support throughout hospital stay.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-13 00:00:00.000", "description": "Report", "row_id": 1635098, "text": "Patient weaned on PSV for many hors with good result then T-Piece for short period of time. Became very agitated, tachypneic with increase HR on T-Piece. Back on PSV to alleviate stress level.Patient treated with Dornase and combivent will continue to follow LUL improved.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-11 00:00:00.000", "description": "Report", "row_id": 1635090, "text": "Respiratory Therapy\n\nPt remains trached on full mechanical support. To OR this shift for removal of stent and trach change. Pt currently has #7.0 air cuff trach secured 11cm @ flange. Per IP tip of trach tube ~1cm above carina. Continues on A/C ventilation 500*12 w/ PIP/Pplat = 22/17. ABG WNL. SpO2 90s. I:E = 1:4. MDI/Nebulizer given as documented. Suctioned for moderate amounts of thick blood tinged/brown pluggy sputum. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support; wean to trach collar as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-12 00:00:00.000", "description": "Report", "row_id": 1635091, "text": "NURSING\n VSS OVERNIGHT. NSR, NO ECTOPY. AFEBRILE. REMAINS ON 50 MCG'S PROPOFOL FOR SEDATION. APPEARS COMFORTABLE.\n VENT SETTINGS UNCHANGED OVERNIGHT. REMAINS ON AC/35%/5 PEEP. SUCTIONED A FEW TIMES OVER THE NIGHT FOR MODERATE AMOUNTS OF THICK, BLOOD TINGED SPUTUM. ABG'S WNL. SEE CARE VUE FOR FULL ASSESSMENT.\n ONE EPISODE OF SEIZURS ACTIVITY. 2 MG ATIVAN GIVEN WITH GOOD EFFECT. SEIZURE LASTED <3 MINUTES.\n FOLEY INTACT WITH QS URINE OUTPUT. G TUBE REMAINS CLAMPED, MEDS VIA G TUBE. NO STOOL OUT.\n SKIN INTACT WITH THE EXCEPTION OF RASH IN GROIN AREA. BARRIER CREAM APPLIED. RASH WAS PRESENT ON ADMIT TO SICU. AREA OF BROKEN SKIN IN FOLD BETWEEN BUTTOCKS, DUODOERM APPLIED ON THE 21ST INTACT.\n REPEAT BRONCH TODAY TO CHECK PLACEMENT OF TRACH. TUBE FEEDS TO START AFTER BRONCH. CONTINUE TO MONITER FOR SEIZURE ACTIVITY. MONITER HEMODYNAMICS AND PAIN CONTROL.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-12 00:00:00.000", "description": "Report", "row_id": 1635092, "text": "Resp Care: Pt continues on mechanical ventilation; no changes made overnight. LS coarse rhonchi bilaterally. Pt suctioned for moderate amounts of thick blood-tinged secretions. RSBI this am: 73. Plan: bronch to evaluate trach, ? TM\n" }, { "category": "Nursing/other", "chartdate": "2198-11-12 00:00:00.000", "description": "Report", "row_id": 1635093, "text": "Please See Carevue for Specifics.\n\nPt at neuro status baseline. One 15sec seizure noted, recevied 1mg IV ativan and seizure subsided. Briefly weaned off Propofol for T-piece trial. After 30 minutes of T-piece trial pt became very anxious and O2 sat decreased to 55. Placed back on Assist Control and received at 2mg IV ativan. After trial pt pressure varied between 44-47, ST, SBP 140-150's. 50mcg IV fentanyl adm without effect. SICU team aware and IP aware. IP suggested giving 500cc NS bolus. ?Bronch this evening. Remains NPO. Foley with c/y/u. Slight pinkish rash on buttocks, duoderm on coccyx is intact.\n\nPOC: ?bronch tonight by SICU team and IP. Continue to closely monitor respir status. Ativan and Fentanyl as needed. Continue to offer emotional support to pt and pt family throughout hospital stay. Case Management updated with POC.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-12 00:00:00.000", "description": "Report", "row_id": 1635094, "text": "Patient switched from A/C to T-Piece 50% this afternoon.Did ok for a while then became very anxious with % sat promptly dropped to 58 and noted tachycardia.Placed back on vent,suctioned for moderate amount of thick yellow to white looking sputum. Almost use bronchoscope to visualize position of tube because of high Pressure.However high pressure event solved itself,bronchoscopic view place on hold.Has airway collapsed tube passed into such area to prevent air way failure.\n" }, { "category": "Nursing/other", "chartdate": "2198-11-11 00:00:00.000", "description": "Report", "row_id": 1635088, "text": "NPN 7p-7a B Shift\nSee CareVue for VS and other objective data.\nNeuro: Very sedated. When pt awakened and became agitated, rx'ed with 25mcg fentanyl given IVP w/ good effect. Pupils 2mm and sluggish, disconjugate gaze. Did have a brief generalized seizure with an upward gaze and bilateral flapping arm movements, this was broken with 2mg lorazepam 2mg in less than one minute. Plan to keep fent/lorazepam at bedside for immediate sedation prn, keep seizure pads on bed for safety.\nCV: BP is tolerating heavy sedation, distant heart sounds.\nResp: LS coarse and with rhonchi in all fields. Coughed and raised thick borwn sputum. Difficult to suction, as tracheal stent is close to the end of the tracheostomy tube. RT gave MDI's as ordered. Plan to do a bronchoscopy at bedside and perhaps go to OR as well to have tracheobronchial stents repositioned or replaced.\nGI: BS present, but no stool or flatus noted. GT remains clamped. No TF's in anticipation of IP procedures today.\nGU: Passing good amounts of CYU each hour.\nSkin: Intact, but inguinal areas are very erythematous and appears to have yeast infection. Antifungal cream applied. Plan to keep this area dry. When turned, a small maceration was found between buttocks, area cleaned and a duoderm was applied. Acne on face.\nSocial: Mother called late last night and updated on condition and plan for tomorrow. She will visit later today.\nPOC: Reassess respiratory status after IP procedures today. Continue ICU care and monitor.\n" } ]

[ { "category": "ECG", "chartdate": "2158-05-10 00:00:00.000", "description": "Report", "row_id": 130673, "text": "Sinus rhythm with sinus arrhythmia. Biatrial abnormality. Delayed precordial\nR wave progression. Right ventricular conduction delay consistent with\npulmonary disease. Compared to the previous tracing of the sinus rate\nis faster. The other findings are quite similar.\n\n" }, { "category": "Nursing", "chartdate": "2158-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577758, "text": "TITLE:\n She was seen on with her outpatient pulmonologist Dr. \n at which time she complained of persistently increased shortness of\n breath. Her O2 requirement increased from 2L to 3L O2 and was started\n on prednisone 5mg daily. Then one day prior to this admission, she\n developed increased shortness of breath, persistent cough with changed\n sputum production. Associated symptoms include chills,\n light-headedness, and decreased appetite. On the morning of admission,\n she was evaluated by her home health aide who recommended that she go\n to the hospital. She then presented to . CXR\n demonstrated chronic lung disease with RLL disease suggestive of\n pneumonia. While in the OSH ED, she received levofloxacin, lorazepam,\n solumedrol, and she was started on BiPap. Since she receives her\n medical care from primarily, she was transferred to .\n .\n Upon arrival to the ED, temp 99.5, HR 90, BP 107/52, RR 21, and\n pulse ox 90% RA. She received ceftriaxone 1 g IV x1, vancomycin 1g IV x\n 1, ativan 1mg IV x 1, aspirin 300mg PR x 1.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Patient received from ED On Non\nInvasive Bipap Mask on 100 %,\n Patient\ns O2 sats 100 % .\n Action:\n Bipap mask discontinued & connected to Nasal cannula on 3 lits. ABG\n done. Please see Metavision for details. AT 1 am Patient became\n unresponsive as she was talking to the Resident & Intern during the\n assessment, 0.2 mgs of IV Naloxone given stat with moderate effect.\n Patient awake & responding after naloxone, ABG done PC 2 in 130\n Tried BIPAP mask, Patient Not tolerating, became unresponsive as the\n mask was placed on her face & responsive again as the mask was taken\n off. Informed team by RT. O2 sats in high 90\ns to 100 % on 35 % O2 via\n High Flow neb on 15 lits- changed to Aerosol cool neb 35 5 on 10 lits.\n O 2sats in low to high 90\n Response:\n At 03 10 am HR in 80\ns, O 2sats dropped to 70\ns to 80\ns on 35 %,\n Patient is unresponsive, Heart Rate gradually dropped down to the 70\n then down to 30\ns ,Patient remained calm & unresponsive, MICU Team at\n bedside. Patient is a DNR/DNI. As per Patient\ns wishes resuscitation\n measures not initiated. Patient expired at 0322 am on .\n Informed Patient\ns Daughter & Son by Resident. Body packed & sent to\n the mortuary with her belongings.\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient complained of back pain & requested for 3 Vicodin tablets.\n Action:\n As per PRN Orders 1 tab given at midnight. Lidocaine patch applied to\n her back.\n Response:\n Patient continues to have pain but is acceptable as per patient at 0030\n hrs.\n Plan:\n Patient\ns belongings sent to the morgue with the body. Total cash of\n 265 dollars & 40 cents, Tablet ativan 0.5 mgs total of 171 tablets sent\n to Public safety in a sealed envelope. 1 copy kept in patient\ns purse,\n 1 copy sent to admitting & 1 copy kept in the chart.\n" }, { "category": "General", "chartdate": "2158-05-11 00:00:00.000", "description": "ICU Event Note", "row_id": 577839, "text": "TITLE:\n Clinician: Resident\n Called to see pt for unresponsiveness in the setting of progressive\n bradycardia. HR in 30s with associated hypoxia when reached bedside.\n Code status DNR/DNI; pt remained calm and unresponsive as rhythm\n progressed to asystole on telemetry. Exam notable for fixed dilated\n pupils, absence of spontaneous respirations or heart sounds, and warm\n extremities with no palpable pulses. Time of death pronounced at 3:23am\n on with chief cause respiratory failure, immediate cause\n pneumonia, and antecedent cause COPD. Attending, PCP, outpatient\n pulmonologist notified. Medical examiner's office waived autopsy.\n Family notified and declined autopsy.\n Total time spent: 60 minutes\n Patient is critically ill.\n" }, { "category": "Radiology", "chartdate": "2158-05-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081863, "text": " 7:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman sent from OSH with RLL PNA, h/o severe COPD, poor BS\n bilateral bases\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: 82-year-old woman sent from outside hospital with right\n lower lobe pneumonia, history of severe COPD, poor breath sounds bilateral\n bases. Evaluate for pneumonia.\n\n FINDINGS: Portable upright AP chest radiograph is obtained. When compared\n with prior study, there is increased bilateral lower lobe opacity, concerning\n for pneumonia. There is likely small bilateral pleural effusions as well. The\n upper lobes are well aerated, though hyperexpanded with lucent appearance and\n splaying of bronchovasculature compatible with underlying severe COPD. Heart\n size cannot be assessed. Mediastinal contour is grossly unremarkable. The\n visualized osseous structures appear grossly intact.\n\n IMPRESSION:\n\n Bilateral lower lobe pneumonia with small effusions.\n SESHa\n\n" }, { "category": "Nursing", "chartdate": "2158-05-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577741, "text": "TITLE:\n She was seen on with her outpatient pulmonologist Dr. \n at which time she complained of persistently increased shortness of\n breath. Her O2 requirement increased from 2L to 3L O2 and was started\n on prednisone 5mg daily. Then one day prior to this admission, she\n developed increased shortness of breath, persistent cough with changed\n sputum production. Associated symptoms include chills,\n light-headedness, and decreased appetite. On the morning of admission,\n she was evaluated by her home health aide who recommended that she go\n to the hospital. She then presented to . CXR\n demonstrated chronic lung disease with RLL disease suggestive of\n pneumonia. While in the OSH ED, she received levofloxacin, lorazepam,\n solumedrol, and she was started on BiPap. Since she receives her\n medical care from primarily, she was transferred to .\n .\n Upon arrival to the ED, temp 99.5, HR 90, BP 107/52, RR 21, and\n pulse ox 90% RA. She received ceftriaxone 1 g IV x1, vancomycin 1g IV x\n 1, ativan 1mg IV x 1, aspirin 300mg PR x 1.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n without acute exacerbation\n Assessment:\n Patient received from ED On Non\nInvasive Bipap Mask on 100 %,\n Patient\ns O2 sats 100 % .\n Action:\n Bipap mask discontinued & connected to Nasal cannula on 3 lits. ABG\n done. Please see Metavision for details. AT 1 am Patient became\n unresponsive as she was talking to the Resident & Intern during the\n assessment, 0.2 mgs of IV Naloxone given stat with moderate effect.\n Patient awake & responding after naloxone, ABG done PC 2 in 130\n Tried BIPAP mask, Patient Not tolerating, became unresponsive as the\n mask was placed on her face & responsive again as the mask was taken\n off. Informed team by RT. O2 sats in high 90\ns to 100 % on 35 % O2 via\n High Flow neb on 15 lits- changed to Aerosol cool neb 35 5 on 10 lits.\n O 2sats in low to high 90\n Response:\n At 03 10 am HR in 80\ns, O 2sats dropped to 70\ns to 80\ns on 35 %,\n Patient is unresponsive, Heart Rate gradually dropped down to the 70\n then down to 30\ns ,Patient remained calm & unresponsive, MICU Team at\n bedside. Patient is a DNR/DNI. As per Patient\ns wishes resuscitation\n measures not initiated. Patient expired at 0322 am on .\n Informed Patient\ns Daughter & Son by Resident. Body packed & will be\n send to the mortuary\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient complained of back pain & requested for 3 Vicodin tablets.\n Action:\n As per PRN Orders 1 tab given at midnight. Lidocaine patch applied to\n her back.\n Response:\n Patient continues to have pain but is acceptable as per patient at 0030\n hrs.\n Plan:\n Patient has her clothes, Wallet with money , purse, 1 black bag- will\n be sent to security safe .\n" }, { "category": "Physician ", "chartdate": "2158-05-11 00:00:00.000", "description": "MICU Attending Admission Note", "row_id": 577731, "text": "TITLE: MICU ATTENDING ADMISSION 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 would emphasize\n and add the following points: 82F severe COPD, 3L O2 x24h, recent\n steroids p/w fever, chills, productive cough. CXR at OSH c RLL\n infiltrate, transferred for further management. Eval notable for 20K c\n 60% bands.\n Exam notable for Tm 99.5 BP 100/60 HR 90 RR 17 with sat 95 on NPPV.\n Drowsy, cachectic. Distant BS, long exp phase. Rales R base. RRR s1s2.\n Soft +BS. No edema. Labs notable for WBC 20K, HCT 35, K+ 4.7, Cr 0.6,\n ABG 7.13/130/43. CXR as above.\n Agree with plan to manage severe CAP in a very delicate woman with\n advanced COPD with NPPV as tolerated, steroids, vanco/ CTX / levo. Will\n pan culture and check viral swab now. Most recent ABG with profound\n acute-on-chronic hypercarbic respiratory failure - will contact family\n as she is unlikely to survive this without intubation and has clearly\n expressed desire to Dr. and others to be DNR/I. Remainder of\n plan as outlined in Resident admission note.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Physician ", "chartdate": "2158-05-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 577732, "text": "Chief Complaint: dyspnea\n HPI:\n 82yo female with a history of COPD was admitted from the ED with\n dyspnea.\n .\n She was seen on with her outpatient pulmonologist Dr. \n at which time she complained of persistently increased shortness of\n breath. Her O2 requirement increased from 2L to 3L O2 and was started\n on prednisone 5mg daily. Then one day prior to this admission, she\n developed increased shortness of breath, persistent cough with changed\n sputum production. Associated symptoms include chills,\n light-headedness, and decreased appetite. On the morning of admission,\n she was evaluated by her home health aide who recommended that she go\n to the hospital. She then presented to . CXR\n demonstrated chronic lung disease with RLL disease suggestive of\n pneumonia. While in the OSH ED, she received levofloxacin, lorazepam,\n solumedrol, and she was started on BiPap. Since she receives her\n medical care from primarily, she was transferred to .\n .\n Upon arrival to the ED, temp 99.5, HR 90, BP 107/52, RR 21, and\n pulse ox 90% RA. She received ceftriaxone 1 g IV x1, vancomycin 1g IV x\n 1, ativan 1mg IV x 1, aspirin 300mg PR x 1.\n .\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Zithromax (Oral) (Azithromycin)\n Hives;\n Sorbitol\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Amlodipine 5mg PO daily\n 2. Aspirin 81mg PO daily\n 3. Tylenol / Codeine 30/300mg qid prn\n 4. Spiriva 18mcg inh daily\n 5. Synthroid 125mcg PO daily\n 6. Simvastatin 5mg daily\n 7. Pantoprazole 40mg daily\n 8. Lorazepam .5mg PO tid prn\n 9. Lasix 10mg PO daily\n 10. Advair discus inh \n 11. Albuterol 90mcg 1-2 puffs qid prn SOB\n 12. Lidoderm 5% \n 13. Mirapex .125mg qhs prn restless legs\n 14. Nitrostat .3mg SL NG\n 15. Hydrocortisone enemas prn\n 16. Colace 100mg qhs\n 17. Metamucil PO daily\n 18. MVI daily\n 19. Gas-X\n Past medical history:\n Family history:\n Social History:\n 1. COPD.\n 2. Coronary artery disease (CAD).\n 3. Congestive heart failure.\n 4. Anxiety.\n 5. Colitis.\n 6. Aspiration - documented on swallow studies.\n 7. Back and other pains.\n 8. Hyponatremia.\n noncontributory\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: denies\n Review of systems:\n Flowsheet Data as of 02:26 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: 68 (68 - 102) bpm\n BP: 101/61(70) {101/42(61) - 119/61(71)} mmHg\n RR: 13 (13 - 31) 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 140 mL\n 35 mL\n Urine:\n 140 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n -140 mL\n -35 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 92%\n ABG: 7.13/130/43//7\n PaO2 / FiO2: 119\n Physical Examination\n Gen: cachectic, fatigued appearing\n HEENT: Clear OP, dry mucous membranes\n NECK: Supple, No LAD, No JVD\n CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops\n LUNGS: poor effort, crackles at right lower bases, poor air movement\n throughout\n ABD: Soft, NT, ND. NL BS. No HSM\n EXT: No edema. 2+ DP pulses BL\n SKIN: No lesions\n NEURO: A&Ox3. frequently needs redirection to answer questions. CN 2-12\n grossly intact. Preserved sensation throughout. 5/5 strength\n throughout. + reflexes, equal BL. Normal coordination. Gait\n assessment deferred\n Labs / Radiology\n 95 mg/dL\n 79 mEq/L\n 4.3 mEq/L\n 128 mEq/L\n [image002.jpg]\n \n 2:33 A6/3/ 09:32 PM\n \n 10:20 P6/4/ 12:21 AM\n \n 1:20 P6/4/ 01:07 AM\n \n 11:50 P6/4/ 01:12 AM\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 42\n 48\n 43\n 46\n Glucose\n 84\n 95\n Other labs: Lactic Acid:3.9 mmol/L\n Fluid analysis / Other labs: \n WBC 26.8 / Hct 35.3 / Plt 280\n N 17 / Bands 34 / L 3 / M 3 / Meta 19 / Myelocytes 24\n Na 131 / K 3.5 / Cl 83 / CO2 41 / BUN 18 / Cr .5 / BG 82\n Ca 8.8 / TP 6.8 / Alb 3.7 / Alk Phos 66\n TB .6 / AST 37 / ALT 32\n CK 174 / MB 9.8 / Trop T . 1\n BNP \n .\n LABS:\n - 7:35pm\n Na 130 / K 4.7 / Cl 85 / CO2 35 / BUN 19 / Cr .6 / BG 51\n Ck 184 / MB 8 / Trop T . 07\n Ca 8.1 / Mg 1.5 / Phos 3.1\n ALT 34 / AST 64 / Alk Phos 54 / TB .7 / Alb 3.5 / Lipase 11\n WBC 20.4 / Hct 35 / Plt 248\n N 33 / Bands 60 / L 3 / E 0 / M 1\n INR 1.5 / PTT 31.1\n Imaging: OSH STUDIES:\n - CXR - per report - chronic lung disease with right lung\n disease suggestive of superimposed pneumonia\n .\n STUDIES:\n - CXR - - final read pending\n - Echo - EF 45-50% - normal LA; mild LV systolic dysfunction with\n inferior / inferolateral hypokinesis; mild global free wall HK;\n Significant pulmonic regurgitation is seen. There is no pericardial\n effusion.\n ECG: - ECG - sinus rhythm with occasional PBCs, normal axis,\n ~100bpm, no acute ST change\n Assessment and Plan\n 82yo female with multiple medical problems including COPD and CHF was\n admitted with dyspnea.\n .\n 1. Dyspnea\n Etiology of her dyspnea is most likely related to a pneumonia\n superimposed on her chronic and worsening lung disease. Pneumonia\n appears likely given the leukocytosis with remarkable bandemia. This is\n likely further worsened with a COPD exacerbation. Additional\n possibilities include cardiac ischemia and pulmonary embolism. Cardiac\n ischemia is possible given her slightly elevated MB fraction at the\n outside hospital, although she has had no chest pain and her ECG is\n unremarkable. PE is also possible, although she does not have\n tachycardia and we have additional diagnoses that appear more likely.\n CHF exacerbation is also possible given the elevated BNP, although she\n appears clinically hypovolemic on exam. Plan is the following:\n - broad coverage for pneumonia with vancomycin, ceftriaxone, and\n levofloxacin\n - send for DFA and rapid viral antigen panel for evaluation of\n influenza\n - sputum gram stain and culture\n - send urine legionella\n - treat for COPD exacerbation with steroids and standing albuterol /\n atrovent nebulizer treatments\n - BiPap as tolerated\n - if patient does not improve with BiPap, will need to consider\n transition to comfort measures only given her baseline severe lung\n disease and she is DNR/DNI\n - consider CTA to evaluate for PE if symptoms do not improve with\n pneumonia and COPD treatment\n .\n 2. Coronary Artery Disease\n She has a history of CAD and congestive heart failure but she appears\n hypovolemic today.\n - continue aspirin and statin\n - continue CCB for afterload reduction\n - hold diuretic for now, consider restarting in the AM\n .\n 3. Anxiety\n Stable\n - hold clonazepam in the setting of hypoxia and intermittent altered\n mental status\n .\n 4. COPD\n Patient has a history of severe and worsening COPD and her symptoms are\n worsening, requiring chronic low dose prednisone and an increase in her\n O2 requirement. Will treat for COPD exacerbation as described above\n with steroids and standing nebulizer treatments.\n .\n 5. Hypothyroidism\n Stable\n - continue synthroid\n .\n 6. GERD\n Stable\n - continue PPI\n .\n 7. Pain\n Patient has chronic pain, particularly in back and neck.\n - continue lidoderm patch with tylenol and percocet for breakthrough\n pain\n - continue mirapex for restless legs\n .\n 8. Aspiration\n Patient also has a history of aspiration in the past.\n - obtain speech and swallow in the AM if more awake\n - give medications crushed in applesauce\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control:\n Lines:\n 18 Gauge - 10:24 PM\n 20 Gauge - 10:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" } ]

[ { "category": "Nursing/other", "chartdate": "2141-01-23 00:00:00.000", "description": "Report", "row_id": 1924523, "text": "Neonatology Attending Admit Note\n\nInfant is a 5 day old, 36 week female (twin A ) who was admitted to the NICU for hypothermia.\n\nInfant was born to a 38 y.o. G1P0 mother. Serologies: A-, ab neg, hep neg, RPR NR, RI, GBS negative.\n\nPregnancy notable for:\n1. twins\n2. amniocentesis normal\n3. Prenatal fetal ultrasound demonstrating mild ventriculomegaly (WNL prior to birth), followed by Dr. , .\n\nLabor induced. Vaginal delivery. Apgars 8,9. No perinatal sepsis risk factors.\n\nBW 2175 (), discharge wt . Infants BT A+, coombs +. Newborn course unremarkable except for mild jaundice (bili 9.3). Infant discharged at day 3.\n\nToday, to NICU for bilirubin check. On assessment infant noted to be hypothermic w/ rectal temp of 94.8. Infant admitted along w/ brother for evaluation and monitoring.\n\nMother reports infant with wet diapers, + stools. Breast feeding well. No ill contacts.\n\nOn exam:\nWeight 2055 (). Infant comfortable in no distress under radiant warmer. AFSF. Palate intact. Observing resp pattern, she has exaggerated periodic breathing associated w/ occassional desaturations. Lungs CTA, +BS. CV RRR, no murmur, 2+FP. Abd soft, +BS. No HSM. GU nl female, +vaginal tag. Ext pink and well perfused. Neuro - sleepy but arousable w/ exam. Decreased tone. Mild jaundice.\n\nImpression:\n1. Preterm female twin.\n2. AGA.\n3. Hypothermia.\n4. Periodic breathing w/ desaturations.\n5. Sepsis evaluation.\n6. Mild jaundice. h/o coombs positive.\n7. h/o prenatal ventriculomegaly.\n\nInfant's hypothermia most likely due to immaturity. Respiratory pattern, decreased tone may be also be immaturity or due to low temp. As a precaution we will also evaluate for infection.\n\nPlan:\n1. Cardio-resp monitoring. If demonstrates apnea even with normal temperature will need to monitor till demonstrates respiratory maturity.\n2. Check bili.\n3. Check CBC w diff and bld cx. Hold unless clinical course changes or labs abnl.\n4. By report, is feeding well and has shown weight gain since discharge. Will con't BF ad lib. No supplemental feedings or IVF at this time.\n5. Check HC.\n\nParents have been updated at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2141-01-23 00:00:00.000", "description": "Report", "row_id": 1924524, "text": "Nursing 3pm-7pm\n\nInfant admitted from her private pedi's office with request for bili level. On admission patient sleepy, pale pink with HR-112 and rectal T-94.8! Radiant open warmer to warm patient. CBC and blood cx drawn. Ds-stable. Mom reports baby last BF well- at 3pm (10 min of eager nursing per mom) Abd loopy with + BS bilaterally. Not fed til Temp returned to nml range. Subsequent Attempt to BF- little interest.\nWill await CBC and diff results.\nParents updated at bedside by MD. Mom continues to pump BM.\n" }, { "category": "Nursing/other", "chartdate": "2141-01-24 00:00:00.000", "description": "Report", "row_id": 1924525, "text": "Nicu Nursing Note 1900-0700\n\n\n#1Potential sepsis. O: Pt. initially on servo control on\nwarmer, maintaining temp., pt. now swaddled on off warmer,\ncobedding with twin, maintaining temp. Pt well perfused, no\napnea. BP MAPs 44 and 54. A: Maintaining temp. No increased\nsigns of sepsis noted. P: Continue to monitor temp. Monitor\nfor signs of sepsis.\n\n#2G and D. O: Maintaining temp. in off warmer, swaddled and\ncobeddding with twin. Alert and active with cares, waking\nfor feeds. Taking pacifier, putting hands to face. A: AGA.\nP: Continue to support development.\n\n#3Parenting. O: Parents here during evening, mom BF infant.\nParents updated at bedside, asking appropriate questions.\nDad called x 1 tonight. Parents plan to visit in am. A:\nInvolved parents. P: Continue to orient parents to nicu\nenvironment.\n\n#4FEN. O: Pt. breastfed once well. Has taken two feeds of\n45-55cc of BM or enfamil 20. Voiding,urine output\n1.1cc/kg/hour tonight, plus one unmeasured void. stool x 3\ntonight, green, heme negative. Abd. soft, active bowel\nsounds, no loops, stable girth. No spits.A: Tolerating po\nfeeds and breastfeeding, awakes to feed. P: Continue to\nassess for interest in and tolerance of po feeds. Monitor\nurine output.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-24 00:00:00.000", "description": "Report", "row_id": 1924526, "text": "Neonatology\nDoing well. RA. Temp has been stable. Periodic breathing has resolved with temp normalization. WIll check HUS and state screens.\n\nContinue to monitor for at least 48 h before discharge.\n\nCorrdinate discharge with PMD.\n" }, { "category": "Nursing/other", "chartdate": "2141-01-24 00:00:00.000", "description": "Report", "row_id": 1924527, "text": "NPN\n\n\n#1 O: Bcx negative to date. Hr, resp rate, sats stable. Temp\nstable, double wrapped, with another blanket covering,\nco-bedding with brother. Lethargic at times this afternoon.\nA: Stable P: Conitnue to monitor for signs of sepsis. Folow\nup with blood cultur results.\n\n#2 O: Lethargic at times this afternoon. Awakened for feeds\nq 4 hrs. Attempting to breastfeed, having difficulty\nlatching on, bottling well. Temp stable double wrapped wtih\ncovering, co-bedding with brother. A: AGA P: Continue to\nawaken q 4 hours for feeds, monitor temp and provide for all\ndev. needs.\n\n#3 O: Mom and dad in most of day. Large amount of\ninformation reviewed with parents regarding temp stability,\nfeeding, bladder patterns and other pertinent discharge\ninstructions. Parents verbalizing understanding of\ninformation. A: Involved parents, needing further discharge\ninstructions. P: Continue to educate parents on appropriate\nactions to be taken at home regarding all aspects of infants\ncare.\n\n#4 O: Breastfeeding ad lib. Breastfed well this morning\nafter awakening for feeding. At 1230 baby awakened for feed,\nnot latching on properly, bottle of breastmilk offered, see\nflow sheet for details. Awakened again following 4 hour\nstretch at 1630, unwilling to breastfeed at that time,\nbottle offered with adequate amount taken in. Voiding,\nstooling, see flow sheet for details, abd. bengin, girth\nstable, no spits. Spoke with regarding\nappropriate volume, guideline of 60cc/kg/day established\nwith 4 hour limit on ad lib feeding. Parents aware of plan\nto offer bottle if unwilling to breastfeed, comfortable with\nplan. A: stable P: Continue to monitor intake and output.\nEncourage bottle feeds if unwilling to breastfeed following\n4 hour stretch.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-25 00:00:00.000", "description": "Report", "row_id": 1924528, "text": "Nicu Nursing Note 1900-0700\n\n\n#1 Potential sepsis. O: Temp. stable swaddled in off warmer,\npt. well perfused. No spells. Blood culture negative so\nfar. A: No noted signs of sepsis. P: Continue to monitor for\nsigns of sepsis.\n\n#2G and D.O: Maintaining temp. swaddled, cobedding with\ntwin. Pt. waking for feeds, alert with cares. Putting\nhands to face. A: AGA. P:Cotinue to support development.\n\n#3Parenting. O: Mom called x1, updated, asking appropriate\nquestions. P:Support parents.\n\n#4FEN. O: Wt. 2025gms(-30gms). on BM/E20 ad lib. Took 60cc\nat , took 35cc at 0030. No spits. Abd. soft, stable\ngirths, active bowel sounds, no loops.Urine output 3.2cc/kg\nfor last 24 hours, and 3.2cc/kg/hour for first 8 hours\ntonight. Had green heme negative stool. D stick 79. A:\nIncreased po feeds. Stable d stick. Urine output increased.\nP; Continue to encourage po feeds and breastfeeding.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-26 00:00:00.000", "description": "Report", "row_id": 1924535, "text": "Nursing Transfer note\n\n\n#1 O: Second BC neg. to date, active and , temp. stable\nin open crib, feeding well A: without signs of sepsis P:\ntransfer to reg. nursery to board for evening with pending\nd/c in a.m., to be followed by private pediatrician\n#2 O: Active and for cares, sleeping well between,\nhead u/s done today with neurology consult secondary to\nprenatal u/s with ventricularmegaly A: AGA P: cont. with\ndevelopmental care and intervention to be carried out with\nparents at home, follow up with neurology as arranged with\nVNA scheduled for home visits upon discharge\n#3 O: Mom in all shift and independant with care in family\nroom, teaching and information given to parents, parents\nunable to go to residence secondary to power outage with\ninfant ready for transfered to newborn\nnursery to board till a.m. A: Involved parents P: to be\nfollowed by private pediatrician with appt. on , VNA\nand neurology\n#4 O: Abdomen soft with active BS without loops, BF\nexcellent for mom, voiding and A: feeding well P:\ntransfer to newborn nursery with d/c in a.m.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-25 00:00:00.000", "description": "Report", "row_id": 1924529, "text": "addendum Nursing note 1900-0700\n\n\n#1Potential sepsis. O: Blood culture + this am for gram +\ncocci in pairs and clusters, , aware.\nCBC and blood culture drawn, results pending.A/P:Continue to\nmonitor for signs of sepsis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-25 00:00:00.000", "description": "Report", "row_id": 1924530, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, no audible murmru. Pink, jaundiced and well perfused. Abd benign, no HSm. active bowel sounds. Infant active and alert with exam.\n" }, { "category": "Nursing/other", "chartdate": "2141-01-25 00:00:00.000", "description": "Report", "row_id": 1924531, "text": "npn 0700-1900\n\n\n1 SEPSIS\nREPEAT BC PENDING. NO NEW SIGNS OR SYMPTOMS OF INFECTION\nNOTED.\n\n2. G & D\nTEMP STABLE IN OPEN WARMER WHILE WITH BROTHER.\nWAKES FOR FEEDS. ALERT AND ACTIVE WITH CARES. SLEEPS WELL\nBETWEEN CARES. BRINGS HANDS TO FACE.\n\n3. PARENTING\nMOM AND DAD IN FOR CARES. INDEPENDENT WITH FEEDING AND\nDIAPER CHANGE. PLAN TO DO BATH WITH PARENTS LATER IN SHIFT.\n\n\n4 FEN\nCURRENTLY ON A MIN OF 60/KILO/DAY OF BM OR ENFAMIL 20.\nBREAST FED WITH MOM FOR CARES. BOTTLE FEEDS WELL. ABD\nSOFT AND ROUND. NO LOOPS. VOIDING AND STOOLING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-26 00:00:00.000", "description": "Report", "row_id": 1924532, "text": "Nursing Progress Note\n\n\n#1 Potential Sepsis\nNo acute S/S of infection. No lethargy. No temp\ninstability. Good tone. P/ Follow-up bld culture result.\nCont to assess for s/s of infection.\n#2 G/D\n with brother. Active and with cares.\nSucking pacifier. Calms with bounderies. P/ Cont to support\nG/D\n#3 Parenting\n Dad called and updated. Aware of plan of care. P/ Cont to\nupdate and support family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-26 00:00:00.000", "description": "Report", "row_id": 1924533, "text": "Cont. NCP\n\n\n#4 FEN\nWt 2.040(up 15gm)Remains on BM/E20 cal for min.fluid 60cc/k.\nTaking PO well over min.Good suck-swallow coordination. No\nspells. Abdomen benign Voiding and stooling. P/ Cont to\nassess feeding tolerance and growth.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2141-01-26 00:00:00.000", "description": "Report", "row_id": 1924534, "text": "Neonatology Attending Progress Note\n\nNow day of life 8 for this 36 week gestation infant with history of hyperbilirubinemia, hypothermia, and rule out sepsis.\n\nBaby's temperature stable in crib.\n\nWt. 2040gm up 15gm feedings - ad lib demand breastfeeding are well tolerated.\n\nID - repeat blood culture is negative at 36 hours\n\nBili - on the 14th was 11.2\n\nNeuro - mild vmeg noted on ultrasound done today - discussed with Neurology and plan is for follow-up with Dr. on . Weekly head circumferences will be performed until this visit.\n\nAssessment/Plan:\nDoing well.\nWill transfer to the Newborn Nursery - possible dc to home tonight or in the morning if continues to do well with feedings and temp control.\nFu as noted with Neurology.\nVNA arranged.\nFU with Pediatrician on Monday.\n\n\nRepeat bili pending.\n" }, { "category": "Radiology", "chartdate": "2141-01-26 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 750568, "text": " 8:01 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT TWIN ASSESS VENTRICULAR SIZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with intrauterine ventriculomegaly by prenatal ultrasound\n REASON FOR THIS EXAMINATION:\n assess ventricular size\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 9 day old former 36 week premature twin who is re-admitted for apnea.\n According to the baby's mother, the child was noted to have mild\n ventriculomegaly on prenatal scan with ventricles measuring no greater than 11\n mm in size.\n\n Standard coronal and sagittal images of the brain were obtained through the\n anterior fontanelle with additional mastoid and posterior fontanelle views\n performed. There is mild ventriculomegaly with the left slightly larger than\n the right. This is just at the upper limits of normal in size. The extra-axial\n spaces are otherwise normal. There is no evidence for germinal matrix or\n intraventricular hemorrhage. The parenchyma is normal and no structural\n abnormalities are present. Doppler interrogation of the anterior cerebral\n artery demonstrates a resistive index of .73 which increases to .82 with\n compression of the anterior fontanelle.\n\n IMPRESSION: Borderline/mild enlargement of the lateral ventricles, left\n greater than right with an otherwise normal neonatal head ultrasound.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2157-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 702927, "text": "SICU\n HPI:\n 61M who presents with decreased visual acuity in right eye and history\n of difficulty with balance while ambulating since . He has\n had 3 falls since due to his difficulty with balance, the last\n fall was this week. He has noticed his balance becoming worse over the\n past week and has not gone to work for the past week. Significant\n medical history includes left testicular mass removal in that was\n diagnosed as malignant lymphoma, large B cell. He has been followed by\n the hemotology/oncology team routinely every 6 months for this. The\n patient reports that he last took Aspirin 325 mg and Plavix 75 mg this\n morning.\n Chief complaint:\n Visual acuity defecit in right eye, difficulty with balance\n PMHx:\n HTN, CAD, s/p MI , lymphoma since -testicular mass\n orchiectomy (Malignant lymphoma, predominantly large cell type of\n B-cell lineage) Blepharitis,i nguinal hernia repair, Hyperlipidemia,\n STEMI LAD drug eluting stent, leukocytosis (leukocyte counts between\n 11.3-18.5) kappa restricted B-cell lymphoproliferative disorder\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1445\n 9. Metoprolol Succinate XL 25 mg PO DAILY htn\n hold heart rate < 60 Order date: @ 1445\n 2. 1000 mL NS\n Continuous at 75 ml/hr Start: Midnight\n Change to peripheral lock when taking POs Order date: @ 1445\n 10. Nitroglycerin SL 0.3 mg SL PRN chest pain\n 1 tab sl q 5 mins prn for chest pain Order date: @ 1445\n 3. Acetaminophen 325-650 mg PO Q6H:PRN pain Order date: @ 1445\n 11. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1445\n 4. Atorvastatin 80 mg PO DAILY Order date: @ 1445\n 12. Pantoprazole 40 mg IV Q24H Order date: @ 1445\n 5. Bisacodyl 10 mg PO/PR DAILY Order date: @ 1445\n 13. Phenytoin 100 mg IV Q8H Order date: @ 1445\n 6. Docusate Sodium 100 mg PO BID Order date: @ 1445\n 14. Senna 1 TAB PO BID Order date: @ 1445\n 7. HydrALAzine 10 mg IV Q4H:PRN htn\n sbp goal < 140 Order date: @ 1445\n 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1445\n 8. Lisinopril 20 mg PO DAILY Order date: @ 1445\n 24 Hour Events:\n Admitted to SICU from ED, started dilantin and q1h neuro checks. Neuro\n exam intact / unchanged overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.7\nC (98\n HR: 63 (56 - 72) bpm\n BP: 104/62(72) {91/49(58) - 134/81(107)} mmHg\n RR: 21 (17 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 530 mL\n 363 mL\n PO:\n 280 mL\n Tube feeding:\n IV Fluid:\n 363 mL\n Blood products:\n Total out:\n 600 mL\n 0 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -70 mL\n 363 mL\n Respiratory support\n SPO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI, visual acuity in right eye impaired relative to\n left eye\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, cerebellar\n finger-nose-finger testing intact; gait deferred\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan:\n Neurologic: q1h neuro checks, dilantin 100mg TID; OR for biopsy\n Cardiovascular: h/o MI on plavix/ASA, currently held\n Pulmonary: stable, no issues\n Gastrointestinal / Abdomen: no issues, tolerates regular diet\n Nutrition: regular diet then NPO p MN for OR \n Renal: stable, follow UOP\n Hematology: stable, monitor Hct need platelets for OR.\n Endocrine: no issues, monitor glucose\n Infectious Disease: no antibiotics at this time\n Lines / Tubes / Drains: PIV\n Wounds: none\n Imaging: MRI with 6.7cm x 6.8 cm\n Fluids: NS @ 75mL/hr while NPO\n Consults: neurosurgery\n Billing Diagnosis: intracranial mass\n ICU Care\n Nutrition: NPO for OR today\n Glycemic Control: n/a\n Lines:\n 20 Gauge - 04:04 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI\n VAP bundle: n/a\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: neuro step-down\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2157-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 702904, "text": "SICU\n HPI:\n 50 year old female with T4A, N0, M0, stage moderately\n differentiated squamous cell carcinoma involving the left buccal fossa\n and overlying skin s/p left buccal tumor resection and neck dissection\n with and radial forarm free flap reconstruction.\n Chief complaint:\n Squamous cell carcinoma of left buccal fossa\n PMHx:\n Metastatic breast cancer to liver and bone, Hypothyroidism, arthritis,\n poor joint mobility left side, heart murmur\n Current medications:\n 1. IV access: Peripheral line, 1 ports Order date: @ 0004\n 13. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1003\n 2. IV access: PICC, heparin dependent Location: Right basilic, Date\n inserted: Order date: @ \n 14. Furosemide 10 mg IV ONCE Duration: 1 Doses Order date: @ 0942\n 3. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 0034\n 15. Heparin 5000 UNIT SC BID Order date: @ 0004\n 4. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees Order date:\n @ 0004\n 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ \n 5. Albumin 25% (12.5g / 50mL) 25 g IV Q8H Duration: 48 Hours Order\n date: @ 1219\n 17. IV access request: PICC Place Indication: Hydration Urgency:\n Routine Order date: @ 1032\n 6. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0004\n 18. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0533\n 7. Aspirin 121.5 mg PO DAILY\n after first PR dose in PACU. (121.5 mg = one and one half baby\n aspirin) Order date: @ 0004\n 19. Ketamine 5-15 mg/hr IV INFUSION Order date: @ 0938\n 8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 1032\n 20. Morphine Sulfate 2-4 mg IV Q2H:PRN breakthrough pain Order date:\n @ 1032\n 9. Docusate Sodium 100 mg PO BID\n When taking PO Order date: @ 0004\n 21. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting Order date: @\n 0004\n 10. Famotidine 20 mg IV Q12H Order date: @ 0034\n 22. Potassium Chloride PO Sliding Scale Duration: 24 Hours Order date:\n @ 0943\n 11. Fentanyl Citrate 25-100 mcg IV Q1H:PRN pain Order date: @\n 0231\n 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 0303\n 12. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 1032\n 24. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0004\n 24 Hour Events:\n Extubation again deferred, no cuff leak; facial edema greatly improved.\n Ketamine gtt for pain control.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.7\nC (98\n HR: 64 (56 - 72) bpm\n BP: 104/62(72) {91/49(58) - 134/81(107)} mmHg\n RR: 20 (17 - 24) insp/min\n SPO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 530 mL\n 396 mL\n PO:\n 280 mL\n Tube feeding:\n IV Fluid:\n 396 mL\n Blood products:\n Total out:\n 600 mL\n 350 mL\n Urine:\n 600 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -70 mL\n 46 mL\n Respiratory support\n SPO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, nasally intubated, sedated\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\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 Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, alert, nods \"yes\" and \"no\" to questions\n when sedation lightened; moves all extremeties to command\n Labs / Radiology\n 256 K/uL\n 14.4 g/dL\n 39.3 %\n 14.7 K/uL\n [image002.jpg]\n 03:54 AM\n WBC\n 14.7\n Hct\n 39.3\n Plt\n 256\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan:\n Neurologic: Fentanyl gtt/patch/prn (weaning) and ketamine for pain\n control. Propofol gtt.\n Cardiovascular: Stable; NO PRESSORS; follow O2 saturation of graft\n Pulmonary: Nasally intubated and sedated; weaned to CPAP, no air leak\n when cuff down\n Gastrointestinal / Abdomen: stable, OGT in place\n Nutrition: Tube feeds at full volume, nutrition consult pending. Will\n hold at midnight in anticipation of extubation tomorrow.\n Renal: Follow UOP; foley; lasix 10mg IV x1 given for gentle\n augmentation of diuresis\n Hematology: Follow AM CBC, stable; aspirin 121.5 mg PO DAILY to\n maintain microvascular patency of graft\n Endocrine: RISS\n Infectious Disease: Ampicillin-Sulbactam 3 g IV Q6H\n Lines / Tubes / Drains: ETT, A-line, PIV, foley, JP\n Wounds: facial flap clean / dry / intact; JP serosanguinous\n Imaging: none\n Fluids: LR KVO\n Consults: ENT, plastics\n Billing Diagnosis: squamous cell carcinoma of left buccal mucosa\n ICU Care\n Nutrition: NPO, tube feeds\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 04:04 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: SICU\n Total time spent: 31 min\n ------ Protected Section------\n Entered in error by MD.\n ------ Protected Section Error Entered By: , MD\n on: 06:29 ------\n" }, { "category": "Nursing", "chartdate": "2157-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702990, "text": "Brain Mass\n Assessment:\n Patient is alert and oriented x3, able to move all extremities with\n normal strength. Pupils 3-2mm both equally and briskly reactive to\n light. No n/v/ dizziness. C/O headache in afternoon 3 out of 10 pain.\n Action:\n Continued with q 1 hour neuro checks,\n Given po Tylenol for pain,\n Kept NPO for OR,\n Able to ambulate to commode well with supervision.\n Taken to OR for brain mass biopsy.\n Response:\n Patient stated pain subsided after Tylenol given.\n Neuro status unchanged.\n Plan:\n Due back from OR around 1900. continue to monitor.\n" }, { "category": "Physician ", "chartdate": "2157-12-06 00:00:00.000", "description": "Intensivist Note", "row_id": 703040, "text": "SICU\n HPI:\n 61M with history of lymphoma p/w decreased visual acuity R eye and h/o\n difficulty with balance while ambulating since now with R\n frontal lobe mass s/p stereotactic bx\n PMHx:\n HTN, CAD, s/p MI , lymphoma -testicular mass orchiectomy\n (Malignant lymphoma, predominantly large cell type of B-cell lineage)\n Blepharitis, ing hernia repair, HLD, STEMI LAD drug eluting stent,\n leukocytosis (leukocyte counts between 11.3-18.5) kappa restricted\n B-cell lymphoproliferative disorder\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS\n Acetaminophen\n Atorvastatin\n Bisacodyl\n CefazoLIN\n Dexamethasone\n Docusate Sodium\n Famotidine\n HYDROmorphone (Dilaudid)\n HydrALAzine\n Insulin\n Lisinopril\n Metoprolol Succinate XL\n Nitroglycerin SL\n Ondansetron\n Phenytoin\n Senna\n 24 Hour Events:\n OR SENT - At 05:07 PM\n s/p stereotactic bx\n Post operative day:\n POD 1 s/p stereotactic bx R frontal lobe\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:25 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:12 PM\n Dilantin - 12:04 AM\n Other medications:\n Flowsheet Data as of 04:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.4\nC (97.6\n HR: 67 (60 - 83) bpm\n BP: 95/54(64) {91/50(64) - 147/95(98)} mmHg\n RR: 19 (15 - 24) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,290 mL\n 354 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 1,930 mL\n 354 mL\n Blood products:\n 240 mL\n Total out:\n 1,900 mL\n 0 mL\n Urine:\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 390 mL\n 354 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent, No(t) Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 236 K/uL\n 13.5 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 140 mEq/L\n 36.9 %\n 13.2 K/uL\n [image002.jpg]\n 03:54 AM\n 12:52 PM\n 07:24 PM\n WBC\n 14.7\n 13.2\n Hct\n 39.3\n 36.9\n Plt\n \n Creatinine\n 0.8\n 0.8\n Glucose\n 111\n 115\n Other labs: PT / PTT / INR:13.6/21.2/1.2, Albumin:3.9 g/dL, Ca:9.0\n mg/dL, Mg:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), BRAIN, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS\n Assessment and Plan: Neuro: q 2h neuro checks, dilantin 100mg TID (f/u\n level), dexamethasone 4 q6\n CV: h/o MI on plavix/ASA, being held\n Resp: stable, no issues\n GI: regular diet; H2B\n Renal/GU: stable, follow UOP\n Endo: RISS, no issues, monitor glucose\n Heme: stable, monitor Hct\n ID: ancef periop x 3 doses\n FEN: Reg diet, HLIV\n Prophy: boots, H2B\n TLD: PIV\n Code: FULL\n Consults: nsurg\n Dispo: Tx to OMED\n Neurologic: Neuro checks Q: 2 hr\n Billing Diagnosis: Brain Tumor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: famotidine\n VAP bundle: n/a\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 Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2157-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702896, "text": "Brain mass\n Assessment:\n Neuro intact, perrla, stood at bedside to void, ambulated to sink for\n , gait was steady, requiring min assistance.\n Action:\n Neuro checks q 1 hr\n Npo after midnight for ? OR procedure\n Iv NS at 75/hr\n Dilantin q 8 hrs,\n Labs sent, u/a sent\n Response:\n Stable at present\n Dilantin level 10.7\n Pt elevated (pt took plavix at home yesterday)\n Plan:\n Platelets to be given in OR\n Check with Dr this am re: OR time\n Allow for pt and his wife to have quality time this am when she visits.\n" }, { "category": "Physician ", "chartdate": "2157-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 702889, "text": "SICU\n HPI:\n 50 year old female with T4A, N0, M0, stage moderately\n differentiated squamous cell carcinoma involving the left buccal fossa\n and overlying skin s/p left buccal tumor resection and neck dissection\n with and radial forarm free flap reconstruction.\n Chief complaint:\n Squamous cell carcinoma of left buccal fossa\n PMHx:\n Metastatic breast cancer to liver and bone, Hypothyroidism, arthritis,\n poor joint mobility left side, heart murmur\n Current medications:\n 1. IV access: Peripheral line, 1 ports Order date: @ 0004\n 13. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 1003\n 2. IV access: PICC, heparin dependent Location: Right basilic, Date\n inserted: Order date: @ \n 14. Furosemide 10 mg IV ONCE Duration: 1 Doses Order date: @ 0942\n 3. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 0034\n 15. Heparin 5000 UNIT SC BID Order date: @ 0004\n 4. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees Order date:\n @ 0004\n 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush\n PICC, heparin dependent: Flush with 10mL Normal Saline followed by\n Heparin as above daily and PRN per lumen. Order date: @ \n 5. Albumin 25% (12.5g / 50mL) 25 g IV Q8H Duration: 48 Hours Order\n date: @ 1219\n 17. IV access request: PICC Place Indication: Hydration Urgency:\n Routine Order date: @ 1032\n 6. Ampicillin-Sulbactam 3 g IV Q6H Order date: @ 0004\n 18. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0533\n 7. Aspirin 121.5 mg PO DAILY\n after first PR dose in PACU. (121.5 mg = one and one half baby\n aspirin) Order date: @ 0004\n 19. Ketamine 5-15 mg/hr IV INFUSION Order date: @ 0938\n 8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation Order date: @\n 1032\n 20. Morphine Sulfate 2-4 mg IV Q2H:PRN breakthrough pain Order date:\n @ 1032\n 9. Docusate Sodium 100 mg PO BID\n When taking PO Order date: @ 0004\n 21. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting Order date: @\n 0004\n 10. Famotidine 20 mg IV Q12H Order date: @ 0034\n 22. Potassium Chloride PO Sliding Scale Duration: 24 Hours Order date:\n @ 0943\n 11. Fentanyl Citrate 25-100 mcg IV Q1H:PRN pain Order date: @\n 0231\n 23. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 0303\n 12. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 1032\n 24. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0004\n 24 Hour Events:\n Extubation again deferred, no cuff leak; facial edema greatly improved.\n Ketamine gtt for pain control.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.7\nC (98\n HR: 64 (56 - 72) bpm\n BP: 104/62(72) {91/49(58) - 134/81(107)} mmHg\n RR: 20 (17 - 24) insp/min\n SPO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 530 mL\n 396 mL\n PO:\n 280 mL\n Tube feeding:\n IV Fluid:\n 396 mL\n Blood products:\n Total out:\n 600 mL\n 350 mL\n Urine:\n 600 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -70 mL\n 46 mL\n Respiratory support\n SPO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, nasally intubated, sedated\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\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 Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, alert, nods \"yes\" and \"no\" to questions\n when sedation lightened; moves all extremeties to command\n Labs / Radiology\n 256 K/uL\n 14.4 g/dL\n 39.3 %\n 14.7 K/uL\n [image002.jpg]\n 03:54 AM\n WBC\n 14.7\n Hct\n 39.3\n Plt\n 256\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan:\n Neurologic: Fentanyl gtt/patch/prn (weaning) and ketamine for pain\n control. Propofol gtt.\n Cardiovascular: Stable; NO PRESSORS; follow O2 saturation of graft\n Pulmonary: Nasally intubated and sedated; weaned to CPAP, no air leak\n when cuff down\n Gastrointestinal / Abdomen: stable, OGT in place\n Nutrition: Tube feeds at full volume, nutrition consult pending. Will\n hold at midnight in anticipation of extubation tomorrow.\n Renal: Follow UOP; foley; lasix 10mg IV x1 given for gentle\n augmentation of diuresis\n Hematology: Follow AM CBC, stable; aspirin 121.5 mg PO DAILY to\n maintain microvascular patency of graft\n Endocrine: RISS\n Infectious Disease: Ampicillin-Sulbactam 3 g IV Q6H\n Lines / Tubes / Drains: ETT, A-line, PIV, foley, JP\n Wounds: facial flap clean / dry / intact; JP serosanguinous\n Imaging: none\n Fluids: LR KVO\n Consults: ENT, plastics\n Billing Diagnosis: squamous cell carcinoma of left buccal mucosa\n ICU Care\n Nutrition: NPO, tube feeds\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 04:04 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2157-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703028, "text": "Cancer (Malignant Neoplasm), Brain\n Assessment:\n Neuro assessment without any deficits\n Family updated by RN (as well as Dr. \n Hemodynamically stable overnight\n Off O2 overnight\n Ate dinner\n Voided in urinal\n Denies headache\n Action:\n Head CT done at \n Maintenance fluids infusing until adequate PO\n Response:\n Head CT unremarkable per NSURG resident\n DTR and wife aware of plan to transfer to in am\n Tolerating PO\n Plan:\n Transfer to heme/onc in am\n" }, { "category": "Physician ", "chartdate": "2157-12-05 00:00:00.000", "description": "Intensivist Note", "row_id": 702883, "text": "SICU\n HPI:\n 61M who presents with decreased visual acuity in right eye and history\n of difficulty with balance while ambulating since . He has\n had 3 falls since due to his difficulty with balance, the last\n fall was this week. He has noticed his balance becoming worse over the\n past week and has not gone to work for the past week. Significant\n medical history includes left testicular mass removal in that was\n diagnosed as malignant lymphoma, large B cell. He has been followed by\n the hemotology/oncology team routinely every 6 months for this. The\n patient reports that he last took Aspirin 325 mg and Plavix 75 mg this\n morning.\n Chief complaint:\n Visual acuity defecit in right eye, difficulty with balance\n PMHx:\n HTN, CAD, s/p MI , lymphoma since -testicular mass\n orchiectomy (Malignant lymphoma, predominantly large cell type of\n B-cell lineage) Blepharitis,i nguinal hernia repair, Hyperlipidemia,\n STEMI LAD drug eluting stent, leukocytosis (leukocyte counts between\n 11.3-18.5) kappa restricted B-cell lymphoproliferative disorder\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1445\n 9. Metoprolol Succinate XL 25 mg PO DAILY htn\n hold heart rate < 60 Order date: @ 1445\n 2. 1000 mL NS\n Continuous at 75 ml/hr Start: Midnight\n Change to peripheral lock when taking POs Order date: @ 1445\n 10. Nitroglycerin SL 0.3 mg SL PRN chest pain\n 1 tab sl q 5 mins prn for chest pain Order date: @ 1445\n 3. Acetaminophen 325-650 mg PO Q6H:PRN pain Order date: @ 1445\n 11. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1445\n 4. Atorvastatin 80 mg PO DAILY Order date: @ 1445\n 12. Pantoprazole 40 mg IV Q24H Order date: @ 1445\n 5. Bisacodyl 10 mg PO/PR DAILY Order date: @ 1445\n 13. Phenytoin 100 mg IV Q8H Order date: @ 1445\n 6. Docusate Sodium 100 mg PO BID Order date: @ 1445\n 14. Senna 1 TAB PO BID Order date: @ 1445\n 7. HydrALAzine 10 mg IV Q4H:PRN htn\n sbp goal < 140 Order date: @ 1445\n 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1445\n 8. Lisinopril 20 mg PO DAILY Order date: @ 1445\n 24 Hour Events:\n Admitted to SICU from ED, started dilantin and q1h neuro checks. Neuro\n exam intact / unchanged overnight.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 12:05 AM\n Other medications:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.7\nC (98\n HR: 63 (56 - 72) bpm\n BP: 104/62(72) {91/49(58) - 134/81(107)} mmHg\n RR: 21 (17 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 530 mL\n 363 mL\n PO:\n 280 mL\n Tube feeding:\n IV Fluid:\n 363 mL\n Blood products:\n Total out:\n 600 mL\n 0 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -70 mL\n 363 mL\n Respiratory support\n SPO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI, visual acuity in right eye impaired relative to\n left eye\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, cerebellar\n finger-nose-finger testing intact; gait deferred\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan:\n Neurologic: q1h neuro checks, dilantin 100mg TID; OR for biopsy\n Cardiovascular: h/o MI on plavix/ASA, currently held\n Pulmonary: stable, no issues\n Gastrointestinal / Abdomen: no issues, tolerates regular diet\n Nutrition: regular diet then NPO p MN for OR \n Renal: stable, follow UOP\n Hematology: stable, monitor Hct\n Endocrine: no issues, monitor glucose\n Infectious Disease: no antibiotics at this time\n Lines / Tubes / Drains: PIV\n Wounds: none\n Imaging: MRI with 6.7cm x 6.8 cm\n Fluids: NS @ 75mL/hr while NPO\n Consults: neurosurgery\n Billing Diagnosis: intracranial mass\n ICU Care\n Nutrition: NPO for OR today\n Glycemic Control: n/a\n Lines:\n 20 Gauge - 04:04 PM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI\n VAP bundle: n/a\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: neuro step-down\n Total time spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2157-12-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 703144, "text": "HPI:\n 61M with history of lymphoma p/w decreased visual acuity R eye and h/o\n difficulty with balance while ambulating since now with R\n frontal lobe mass s/p stereotactic bx\n PMHx:\n HTN, CAD, s/p MI , lymphoma -testicular mass orchiectomy\n (Malignant lymphoma, predominantly large cell type of B-cell lineage)\n Blepharitis, ing hernia repair, HLD, STEMI LAD drug eluting stent,\n leukocytosis (leukocyte counts between 11.3-18.5) kappa restricted\n B-cell lymphoproliferative disorder\n Cancer (Malignant Neoplasm), Brain\n Assessment:\n Pt is pleasantly alert and oriented times three. PERL 3mm briskly\n reactive. Speech is clear, moves all ext. Denies head ache. OOB with\n one assist.\n Action:\n No repeat head CT today. Ophthalmology consult this morning. PT\n consult this morning.\n Response:\n Plan:\n Continue to closely monitor neuro status. Transfer to seven\n this afternoon. Pt awaiting Oncology consult. Continue to offer pt\n and pt family emotional support throughout hospital stay.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n HEAD MASS\n Code status:\n Height:\n Admission weight:\n 76.6 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension, MI\n Additional history: mass left testis had orchiectomy\n Surgery / Procedure and date: ->brain biopsy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:64\n Temperature:\n 96.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,635 mL\n 24h total out:\n 1,050 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:39 AM\n Potassium:\n 4.3 mEq/L\n 03:39 AM\n Chloride:\n 105 mEq/L\n 03:39 AM\n CO2:\n 26 mEq/L\n 03:39 AM\n BUN:\n 13 mg/dL\n 03:39 AM\n Creatinine:\n 0.8 mg/dL\n 03:39 AM\n Glucose:\n 140 mg/dL\n 03:39 AM\n Hematocrit:\n 38.0 %\n 03:39 AM\n Finger Stick Glucose:\n 229\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:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Rehab Services", "chartdate": "2157-12-06 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 703107, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: / 191\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: Pt. is 61 y.o. male\n with h/o lymphoma p/w vision impairment and recent falls, found to have\n R frontal lobe mass. Now POD #1 R frontal lobe stereotactic brain\n biopsy.\n Past Medical / Surgical History: HTN, CAD, s/p MI , lymphoma\n since -testicular mass orchiectomy, Blepharitis,inguinal hernia\n repair,hyperlipidemia, leukocytosis, lymphoproliferative disorder\n Medications: Atorvastatin, Lisinopril, Acetaminophen, Nitroglycerin,\n Hydromorphone, Dexamethasone, HydrALAzine, Phenytoin,\n Radiology: Head CT: Expected post-biopsy changes and\n redemonstration of a large right frontal lobe mass, without evidence of\n new intracranial hemorrhage.\n Labs:\n 38.0\n 13.9\n 263\n 11.2\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist\n Social / Occupational History: Married, Lives with wife of 57 years.\n Has daughter involved with care. Works as an engineer.\n Living Environment: Lives in 1 level apt. + elevator in bldg\n Prior Functional Status / Activity Level: PTA. Difficulty\n . Recent falls.\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x 3, pleasant and\n cooperative\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 /\n Sit\n 74\n 118/60\n 20\n 95 on Ra\n Activity\n /\n Stand\n /\n Recovery\n 82\n 132/62\n 20\n 95 on Ra\n Total distance walked:\n Minutes:\n Pulmonary Status: BS CTA\n Integumentary / Vascular: frontal dressing c/d/i, L UE PIV, telemetry\n Sensory Integrity: Sensation grossly intact to LT in UEs/\n / Limiting Symptoms: No c/o pain\n Posture: WNL\n Range of Motion\n Muscle Performance\n Bilat. UEs/LEs: WFL throughout\n Bilat. UEs/LEs: > throughout\n Motor Function: Finger to Finger: WNL bilat. Finger-Nose-Finger: WNL\n bilat. : UEs/LEs: WNL\n Proprioception in LEs: Appears intact\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt. amb 300 ft pushing w/c with S lines. Pt. amb\n 10 ft in room with S lines\n Rolling:\n T\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n\n Transfer:\n T\n\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n\n Ambulation:\n Pushing w/c and without\n\n T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: No LOB during ambulation\n Education / Communication: Pt. edu re: Role of PT, , d/c plan to\n home once medically stable, continued ambulation, visual scanning to R,\n RN comm re: pt. status\n Intervention:\n Other: Vision: Tracks to all visual quadrants. Unable to correctly\n identify objects in R visual field reports\nblurry vision\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Knowledge, Impaired\n Clinical impression / Prognosis: Pt. is 61 y.o. male with h/o lymphoma,\n s/p frontal lobe stereotactic biopsy that p/w above impairments\n associated with non-progressive d/o of the CNS. Pt. appears to be\n functioning close to baseline and has met all STGs. Anticipate d/c home\n once medically stable. No further acute PT needs.\n Goals\n Time frame: met on eval\n 1.\n supine to sit .\n 2.\n sit to stand .\n 3.\n Amb 300 ft pushing w/c with S\n 4.\n Amb 10 ft with S\n 5.\n Verbalize understanding of Role of PT\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration:\n d/c acute PT\n time: 9:30-10:00\n Nsg recs: Encourage Ambulation throughout day\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2157-12-06 00:00:00.000", "description": "Intensivist Note", "row_id": 703098, "text": "SICU\n HPI:\n 61M with history of lymphoma p/w decreased visual acuity R eye and h/o\n difficulty with balance while ambulating since now with R\n frontal lobe mass s/p stereotactic bx\n PMHx:\n HTN, CAD, s/p MI , lymphoma -testicular mass orchiectomy\n (Malignant lymphoma, predominantly large cell type of B-cell lineage)\n Blepharitis, ing hernia repair, HLD, STEMI LAD drug eluting stent,\n leukocytosis (leukocyte counts between 11.3-18.5) kappa restricted\n B-cell lymphoproliferative disorder\n Current medications:\n 20 mEq Potassium Chloride / 1000 mL NS\n Acetaminophen\n Atorvastatin\n Bisacodyl\n CefazoLIN\n Dexamethasone\n Docusate Sodium\n Famotidine\n HYDROmorphone (Dilaudid)\n HydrALAzine\n Insulin\n Lisinopril\n Metoprolol Succinate XL\n Nitroglycerin SL\n Ondansetron\n Phenytoin\n Senna\n 24 Hour Events:\n OR SENT - At 05:07 PM\n s/p stereotactic bx\n Post operative day:\n POD 1 s/p stereotactic bx R frontal lobe\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:25 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:12 PM\n Dilantin - 12:04 AM\n Other medications:\n Flowsheet Data as of 04:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 36.4\nC (97.6\n HR: 67 (60 - 83) bpm\n BP: 95/54(64) {91/50(64) - 147/95(98)} mmHg\n RR: 19 (15 - 24) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,290 mL\n 354 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 1,930 mL\n 354 mL\n Blood products:\n 240 mL\n Total out:\n 1,900 mL\n 0 mL\n Urine:\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 390 mL\n 354 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent, No(t) Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 236 K/uL\n 13.5 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 106 mEq/L\n 140 mEq/L\n 36.9 %\n 13.2 K/uL\n [image002.jpg]\n 03:54 AM\n 12:52 PM\n 07:24 PM\n WBC\n 14.7\n 13.2\n Hct\n 39.3\n 36.9\n Plt\n \n Creatinine\n 0.8\n 0.8\n Glucose\n 111\n 115\n Other labs: PT / PTT / INR:13.6/21.2/1.2, Albumin:3.9 g/dL, Ca:9.0\n mg/dL, Mg:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), BRAIN, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS\n Assessment and Plan: Neuro: q 2h neuro checks, dilantin 100mg TID (f/u\n level), dexamethasone 4 q6\n CV: h/o MI on plavix/ASA, being held\n Resp: stable, no issues\n GI: regular diet; H2B\n Renal/GU: stable, follow UOP\n Endo: RISS, no issues, monitor glucose\n Heme: stable, monitor Hct\n ID: ancef periop x 3 doses\n FEN: Reg diet, HLIV\n Prophy: boots, H2B\n TLD: PIV\n Code: FULL\n Consults: nsurg\n Dispo: Tx to OMED\n Neurologic: Neuro checks Q: 2 hr\n Billing Diagnosis: Brain Tumor\n ICU Care\n Nutrition: Regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: famotidine\n VAP bundle: n/a\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 Total time spent:\n" }, { "category": "Nursing", "chartdate": "2157-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 702871, "text": "Patient admitted via ed with a 4 month history of dizziness and visual\n disturbances.\n Found to have right frontal mass.\n Right frontal mass\n Assessment:\n Patient alert orientated x3\n Perrla\n Denies numbness/tingling\n Patient has blurred vision\n Mae equal strength\n Unsteady gait, at risk of falling\n Action:\n Monitored neuro checks Q1\n Bed rest with bed alarm on for patient safety\n Npo from midnight, iv fluids to start at midnight.\n Response:\n No change in neuro exam\n Plan:\n Patient for review by team with regard to possibility of surgery in am\n Npo midnight and iv fluids to start at 75cc hrly\n" }, { "category": "Nursing", "chartdate": "2157-12-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 703070, "text": "Cancer (Malignant Neoplasm), Brain\n Assessment:\n Neuro assessment without any deficits\n Family updated by RN (as well as Dr. \n Hemodynamically stable overnight\n Off O2 overnight\n Ate dinner\n Voided in urinal\n Denies headache\n Action:\n Head CT done at \n Maintenance fluids infusing until adequate PO\n Response:\n Head CT unremarkable per NSURG resident\n DTR and wife aware of plan to transfer to in am\n Tolerating PO\n Plan:\n Transfer to heme/onc in am\n" }, { "category": "ECG", "chartdate": "2157-12-05 00:00:00.000", "description": "Report", "row_id": 127147, "text": "Sinus rhythm. Normal tracing. Compared to tracing #1 there is no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2157-12-04 00:00:00.000", "description": "Report", "row_id": 127148, "text": "Sinus rhythm. Normal-appearing tracing. Compared to the previous tracing\nof anterior deep T wave inversions are no longer present.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2157-12-05 00:00:00.000", "description": "CT STEREOTAXIS W/ CONTRAST", "row_id": 1103394, "text": " 5:04 PM\n CT STEREOTAXIS W/ CONTRAST Clip # \n Reason: pre-op planning for steriotactic biopsy with frame in place\n Admitting Diagnosis: HEAD MASS\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with brain mass\n REASON FOR THIS EXAMINATION:\n pre-op planning for steriotactic biopsy with frame in place\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with brain mass, preoperative scan with IV\n contrast.\n\n TECHNIQUE: CT of the head with IV contrast.\n\n COMPARISON: MR available from .\n\n FINDINGS:\n\n The patient was scanned in a stereotactic head frame, resulting in multiple\n streak artifacts. This study is not intended for diagnostic purposes. The\n known large right frontal mass with central necrosis is again seen, with\n extensive mass effect as described in the MRI.\n\n IMPRESSION:\n\n The large right frontal mass is again demonstrated for operative planning.\n\n" }, { "category": "Radiology", "chartdate": "2157-12-04 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1103196, "text": " 9:18 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: metastatic disease to brain, unilateral loss of vision plus\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with metastatic disease to brain, unilaterl loss of vision plus\n vertigo\n REASON FOR THIS EXAMINATION:\n metastatic disease to brain, unilateral loss of vision plus vertigo\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg SUN 11:55 AM\n 6.7 X 6.8 CM MASS IN THE RIGHT FRONTAL LOBE WITH SURROUDING EDEMA. 8MM OF\n LEFTWARD SHIFT OF NORMALLY MIDLINE STRUCTURE. CENTRAL AREA OF HIGH T2 SIGNAL\n IN THE MASS IS C/W NECROSIS. THERE IS INVOLVMENT OF THE CORPUS CALLOSUM.\n PERIPHERAL AREA OF LOW SIGNAL ON THE GRE SEQUENCE INDICATE CALCIFICATION\n OR BLOOD PRODUCTS. THE DWI SEQUENCE SHOWS RESTRICTED DIFFUSION IN THE NON-\n NECROTIC PORTIONS OF THE MASS SUGGESTING INCREASED CELLULARITY. DIFFERENTIAL\n CONSIDERATION INCLUDE LYMPHOMA, GBM, MET. ALTHOUGH NECROSIS IS UNUSUAL IN A\n IMMUNOCOMPETANT PATIENT, LYMPHOMA IS FAVORED GIVEN PREVIOUS HISTORY OF\n LYMPHOMA, CORPUS CALLOSUM INVOLVMENT AND HIGH CELLUARITY. MILD ENHANCEMENT OF\n THE RIGHT OPTIC NERVE SUGGEST DISEASE INVOLVMENT. SMALL EQUIVOCAL AREA OF\n ENHANCEMENT IS NOTED IN THE VERMIS, BEST SEEN ON CORONAL POST (802:122). SINUS\n DISEASE. \n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITHOUT AND WITH CONTRAST, \n\n HISTORY: Metastatic disease to brain with unilateral loss of vision.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. After administration of 15 cc of Magnevist intravenous contrast,\n axial imaging was performed with long TR, long TE fast spin echo, FLAIR,\n gradient echo, diffusion, and short TR, short TE spin echo technique. Sagittal\n MP-RAGE imaging was performed and reformatted into axial and coronal\n orientations. No prior brain imaging studies are available for comparison.\n\n FINDINGS: The right frontal lobe contains a massive enhancing structure,\n likely neoplastic, with extensive surrounding edema. There is severe right-\n to-left midline shift and effacement of overlying sulci. There are extensive\n areas of signal loss on the gradient echo images around the periphery of this\n lesion, suggesting prior hemorrhage. The central portion of the mass is\n hyperintense on the long TR images and hypointense on the short TR images\n suggesting necrosis. There is thick irregular enhancement around the\n periphery of the mass including the component grossly infiltrating and\n enlarging the corpus callosum. The lesion is relatively hyperintense and is\n composed to cortex and white matter on the long TR images and contains\n extensive areas of relative hypointensity on the diffusion maps. The adjacent\n right frontl and ethomoid sinuses are opacified and there may be defects in\n the bone separating the sinuses from the cranial cavity.\n\n Overall, this appearance is most typical of a malignant glioma, such as a\n (Over)\n\n 9:18 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: metastatic disease to brain, unilateral loss of vision plus\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n glioblastoma. Extensive areas of necrosis are unusual in lymphoma, but in a\n patient with a known diagnosis of lymphoma, this would be a consideration.\n Primitive neuroectodermal tumors can have an identical appearance. If the\n sinus involvement reflects the source of the lesion, then infectious and\n inflammatory diagnoses could be considered, such as Wegners granulomatosis\n and fungal sinusitis with intracranial extension. The appearance would be\n unusual for a metastatsis.\n\n No other abnormalities are detected. There is no evidence of leptomeningeal\n seeding of this abnormality. No other areas of hemorrhage or mass effect are\n detected.\n\n Incidental note is made of partial opacification of the right ethmoid and\n frontal sinuses.\n\n This study was performed on and a preliminary report was issued that\n read \"6.7 x 6.8 cm mass in the right frontal lobe with surrounding edema. 8-mm\n of leftward shift of normally midline structure. Central area of high T2\n signal in the mass is consistent with necrosis. There is involvement of the\n corpus callosum. Peripheral area of low signal on the gradient echo sequence\n may indicate calcification or blood products. The diffusion-weighted image\n sequence shows restricted diffusion in the non-necrotic portion of the mass\n suggesting increased cellularity. Differential considerations include\n lymphoma, glioblastoma, metastasis. Although necrosis is unusual in an\n immunocompetent patient, lymphoma is favored given previous history of\n lymphoma, corpus callosum involvement and high cellularity. Mild enhancement\n of the right optic nerve may suggest disease involvement. Small equivocal\n area of enhancement is noted in the vermis, best seen on coronal series\n (802:122). Sinus disease\". .\n\n CONCLUSION: Right frontal mass with severe mass effect and midline shift. The\n differential diagnosis includes glioblastoma, lymphoma, and primitive\n neuroectodermal tumor. Non-neoplastic possiblitiies include wegner's and\n fungal sinusitis. The growth along the corpus callosum would be unusual for a\n metastasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-12-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1103422, "text": ", M. NSURG SICU-B 8:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for post-op hemorrhage. Please do within 4 h\n Admitting Diagnosis: HEAD MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with brain mass, s/p right stx brain biopsy\n REASON FOR THIS EXAMINATION:\n Please evaluate for post-op hemorrhage. Please do within 4 hours**\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Expected post-biopsy changes and redemonstration of a large right\n frontal lobe mass, without evidence of new intracranial hemorrhage.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2157-12-07 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1103665, "text": " 9:51 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Concern for lymphoma in the chest, abd, pelvis.\n Admitting Diagnosis: HEAD MASS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of lymphoma of the testis removed no other\n treatment. Now brain mass, early path appears to be lymphoma.\n REASON FOR THIS EXAMINATION:\n Concern for lymphoma in the chest, abd, pelvis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61 year-old man with history of lymphoma with new brain mass\n which likely represents lymphoma.\n\n COMPARISON: Multiple prior exams, the most recent performed .\n\n TECHNIQUE: MDCT-acquired images were obtained through the chest, abdomen, and\n pelvis after the uneventful administration of oral and IV Optiray contrast.\n Multiplanar reformats were reviewed.\n\n FINDINGS:\n\n\n CT CHEST: Prominent multinodular thyroid galnd containing several calcified\n nodules is similar to . Moderate predominantly paraseptal emphysema\n primarily involving the lung apices is similar to . Bibasilar\n atelectasis/scarring is similar to . There is no pulmonary nodule.\n Heart size is normal. There is no pleural or pericardial effusion. LAD stent\n is noted.\n\n CT ABDOMEN: The liver, spleen, adrenals, kidneys, and pancreas are\n unremarkable. The gallbladder demonstrates scattered calcified and\n noncalcified gallstones. There is no intra or extra- hepatic biliary\n dilatation. The abdominal loops of large and small bowel are unremarkable\n without evidence of pneumatosis, free air or obstruction. There is no\n mesenteric or retroperitoneal lymphadenopathy.\n\n CT PELVIS: The bladder, distal ureters, prostate, rectum, and sigmoid colon\n are unremarkable. There is no pelvic or inguinal lymphadenopathy.\n Sclerotic 3 x 1.5 cm lesion in the right iliac bone is unchanged since\n . There is no lesion concerning for metastasis or infection.\n\n\n IMPRESSION:\n No evidence of acute process or lymphoma recurrence.\n (Over)\n\n 9:51 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Concern for lymphoma in the chest, abd, pelvis.\n Admitting Diagnosis: HEAD MASS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2157-12-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1103421, "text": " 8:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for post-op hemorrhage. Please do within 4 h\n Admitting Diagnosis: HEAD MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with brain mass, s/p right stx brain biopsy\n REASON FOR THIS EXAMINATION:\n Please evaluate for post-op hemorrhage. Please do within 4 hours**\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc MON 9:56 PM\n PFI: Expected post-biopsy changes and redemonstration of a large right\n frontal lobe mass, without evidence of new intracranial hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right stereotactic brain biopsy.\n\n COMPARISON: CT from and MR from .\n\n TECHNIQUE: Axial CT images were acquired through the head in the absence of\n intravenous contrast.\n\n FINDINGS: The patient is status post biopsy of the large right frontal lobe\n mass, which was characterized in detail on the MRI. There is a small\n amount of pneumocephalus along the biopsy track. The extent of mass effect,\n leftward midline shift, and right subfalcine herniation are not significantly\n changed. There is no sign of new intracranial hemorrhage.\n\n Some of the posterior ethmoid air cells are opacified, right greater than\n left, as before.\n\n IMPRESSION: Expected postsurgical changes s/p right frontal mass biopsy.\n\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2157-12-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1103778, "text": " 6:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: new bleed, extension of tumor.\n Admitting Diagnosis: HEAD MASS\n ______________________________________________________________________________\n FINAL ADDENDUM\n Informed to by dr. on \n\n\n 6:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: new bleed, extension of tumor.\n Admitting Diagnosis: HEAD MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of lymphoma. right frontal lobe mass sp stereotactic\n brain biopsy. Developed some pressure behind the right eye this evening. Would\n like to evaluate for bleed, extension of tumor. No new neuro deficits on exam.\n Patient notes feeling a little more tired.\n REASON FOR THIS EXAMINATION:\n new bleed, extension of tumor.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc WED 8:12 PM\n PFI: Expected post-biopsy changes following a right frontal mass biopsy with\n no evidence of enlarging or evolving mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right frontal brain biopsy in a patient with history of lymphoma,\n now with right retro-orbital pressure.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images were acquired through the head in the absence of\n intravenous contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n FINDINGS: Overall there is minimal change from the comparison study. The\n patient is status post biopsy of the large mass centered in the right frontal\n lobe. A small amount of pneumocephalus persists along the biopsy tract. The\n overall extent of the mass with associated leftward shift of normal midline\n structures and effacement of the frontal of the right lateral ventricle\n is unchanged. There is no evidence of new or expanding mass effect. The\n included osseous structures redemonstrate a defect at the right aspect of the\n frontal bone from the biopsy tract. The paranasal sinuses reveal some\n circumferential mucosal thickening at the frontal sinuses as well as partial\n opacification in the ethmoid air cells as previous. The globes appear intact\n with no evidence of retrobulbar hematoma.\n\n IMPRESSION: Expected changes following a right frontal mass biopsy with no\n evidence of progressive mass effect.\n\n NOTE ON ATTENDING REVIEW:\n\n On bone windows, there is a defect in the inner table of the right side of\n the frontal bone at the level of the frontal sinus, (104b/28) where there is\n associated ipacification of the sinus. Similarly, the osseous intergrity of\n the cribriform plates is not well seen, more so on the right side. These raise\n the possibility of osseous erosion from the process within the sinuses and\n intracranially, which may relate to chronic sinus infection related to fungal,\n Wegener's or lymphoma, as described on MR.\n\n (Over)\n\n 6:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: new bleed, extension of tumor.\n Admitting Diagnosis: HEAD MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2157-12-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1103779, "text": ", D. OMED 7F 6:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: new bleed, extension of tumor.\n Admitting Diagnosis: HEAD MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of lymphoma. right frontal lobe mass sp stereotactic\n brain biopsy. Developed some pressure behind the right eye this evening. Would\n like to evaluate for bleed, extension of tumor. No new neuro deficits on exam.\n Patient notes feeling a little more tired.\n REASON FOR THIS EXAMINATION:\n new bleed, extension of tumor.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Expected post-biopsy changes following a right frontal mass biopsy with\n no evidence of enlarging or evolving mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2157-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1103216, "text": " 2:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op r/o pna\n Admitting Diagnosis: HEAD MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with large right frontal mass\n REASON FOR THIS EXAMINATION:\n pre-op r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Preop right frontal craniotomy.\n\n Cardiac size is normal. Aside from minimal linear atelectasis in the left\n base, the lungs are clear. There is no pleural effusion.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2188-02-13 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 1183404, "text": " 2:55 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: ? thrombus\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with LV thrombus\n REASON FOR THIS EXAMINATION:\n ? thrombus\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Left ventricular thrombus noted during CABG.\n\n FINDINGS: Duplex was performed of bilateral carotid arteries. The\n visualization on the right was limited due to the presence of a central venous\n line. There is no significant plaque seen in the visualized portion of the\n right CCA and ICA. CCA velocity is 62 with a normal upstroke and right\n proximal ICA velocity is 59. This is consistent with no stenosis but due to\n limited visualization I cannot rule out stenosis in the non-visualized portion\n of the carotid vessels.\n\n On the left there is no significant plaque seen. ICA velocity is 53/22. CCA\n velocity is 71. ECA velocity is 49. There is normal upstroke within the left\n CCA. This is consistent with no stenosis.\n\n IMPRESSION: Limited study particularly of the right carotid due to the\n central line but no evidence of stenosis seen bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-02-14 00:00:00.000", "description": "CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS", "row_id": 1183483, "text": " 7:16 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Clip # \n Reason: Ischemic R. foot s/p CABG. Please eval. R. LE arterial syste\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ischemic R. foot after CABG\n REASON FOR THIS EXAMINATION:\n Ischemic R. foot s/p CABG. Please eval. R. LE arterial system.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 1:37 PM\n PFI:\n\n 1. Occlusion of bilateral mid-to-distal deep femoral artery. Occlusion in\n mid-to-distal right popliteal artery. Multiple filling defects in right\n posterior tibial and peroneal arteries. Multiple filling defects in left\n anterior tibial and diminutive flow in the left distal peroneal artery.\n\n 2. Bilateral small pleural effusions and adjacent opacities at the lung\n bases, likely atelectasis. Patient is status post CABG with air within the\n mediastinum, post-surgical.\n\n 3. Ventral abdominal wall hernia with loops of bowel, however, no stranding\n and no evidence of bowel obstruction.\n\n 4. Colonic diverticulosis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG, thrombus present in the left ventricle prior CABG,\n not seen post-procedure and symptoms of ischemic right foot after CABG.\n\n TECHNIQUE: CTA through the abdominal aorta, iliac vessels and lower\n extremities with coronal and sagittal reformatted images. Oral contrast was\n not administered. Coronal and sagittal reformatted images provided.\n\n CT reconstructions are pending at the time of dictation.\n\n FINDINGS: There are bilateral opacities at the lung bases and bilateral small\n pleural effusions. There is air within the mediastinum status post CABG and\n coronary calcifications. There is heterogeneous perfusion in the liver;\n however, no focal abnormalities identified on a single-phase contrast. The\n gallbladder, spleen, and bilateral adrenal glands are normal. The kidneys\n enhance symmetrically and there is no evidence of hydronephrosis. There is a\n focal hypodensity in the interpolar region of the right kidney, too small to\n be characterized (3A:75). There is nonspecific perinephric stranding about\n both kidneys. There are scattered diverticula in the colon; however, there is\n no evidence of diverticulitis. The pancreas enhances homogeneously. There is\n no evidence of bowel obstruction. There is anterior abdominal wall hernia;\n however, no evidence of obstruction at this level. No free fluid or free air.\n\n CT PELVIS: The sigmoid is collapsed. There are scattered diverticula in the\n (Over)\n\n 7:16 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Clip # \n Reason: Ischemic R. foot s/p CABG. Please eval. R. LE arterial syste\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sigmoid. The urinary bladder contains a Foley catheter and focus of air,\n likely from placement of Foley. There are bilateral small fat-containing\n inguinal hernias. There is no free fluid in the pelvis. The prostate and\n seminal vesicles appear within normal limits.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion.\n\n CTA: The abdominal aorta is patent with mild atherosclerotic changes. The\n celiac axis and its branches are patent. There are mild atherosclerotic\n changes at the origin of SMA, however, branches of SMA are widely patent. The\n bilateral renal arteries are patent and kidneys are well perfused. The is\n patent.\n\n The bilateral iliac vessels are patent with mild atherosclerotic changes and\n scattered calcifications. The common femoral artery is patent bilaterally.\n\n RIGHT LEG: The right common femoral artery is patent. The right deep femoral\n artery is patent in its proximal portion; however, there is thrombus in the\n distal portion (3A:241). The right superficial femoral artery is patent; no\n filling defect in the right superficial femoral artery. The proximal portion\n of the right popliteal artery is patent; however, there is complete occlusion\n at the mid-to-lower portion of the right popliteal artery, posterior to\n proximal tibia (3A:370). The tibioperoneal trunk is occluded. There is flow\n distally in segments of the right peroneal artery and few small filling\n defects. There are multiple filling defects and minimal diminutive flow in\n the right posterior tibial artery. The right anterior tibial artery is\n patent; however, in the distal portion flow is diminutive, could be due to\n chronic changes.\n\n LEFT LEG: The left common femoral artery is patent. The proximal portion of\n the deep femoral artery is patent; however, there is small thrombus in the\n distal portion, less than right (3A:244). The left superficial femoral artery\n is patent along its length with mild atherosclerotic changes. The left\n popliteal artery is patent. The left posterior tibial artery has\n independent/higher origin from the popliteal artery and is patent. There are\n multiple filling defects in the left anterior tibial artery. The left\n peroneal artery is patent in its proximal portion with diminutive flow in the\n distal portion.\n\n IMPRESSION:\n 1. Thrombus in mid-to-distal right below-knee popliteal artery extending into\n the proximal right anterior tibial artery and filling the entire right common\n tibial-peroneal trunk. Multiple filling defects in right posterior tibial and\n peroneal arteries. Multiple filling defects in left anterior tibial artery\n and diminutive flow in the left distal peroneal artery.\n (Over)\n\n 7:16 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Clip # \n Reason: Ischemic R. foot s/p CABG. Please eval. R. LE arterial syste\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Bilateral small pleural effusions and adjacent opacities at the lung\n bases, likely atelectasis. Patient is status post CABG with air within the\n mediastinum post-surgical.\n\n 3. Ventral abdominal wall hernia with loops of bowel; however, no stranding\n and no evidence of bowel obstruction.\n\n 4. Colonic diverticulosis.\n\n Preliminary findings were discussed with at the time scan done\n on 9:30 a.m. in person and in more details at 11 am by phone.\n\n" }, { "category": "Radiology", "chartdate": "2188-02-14 00:00:00.000", "description": "CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS", "row_id": 1183484, "text": ", R. CSURG CSRU 7:16 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Clip # \n Reason: Ischemic R. foot s/p CABG. Please eval. R. LE arterial syste\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with ischemic R. foot after CABG\n REASON FOR THIS EXAMINATION:\n Ischemic R. foot s/p CABG. Please eval. R. LE arterial system.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Occlusion of bilateral mid-to-distal deep femoral artery. Occlusion in\n mid-to-distal right popliteal artery. Multiple filling defects in right\n posterior tibial and peroneal arteries. Multiple filling defects in left\n anterior tibial and diminutive flow in the left distal peroneal artery.\n\n 2. Bilateral small pleural effusions and adjacent opacities at the lung\n bases, likely atelectasis. Patient is status post CABG with air within the\n mediastinum, post-surgical.\n\n 3. Ventral abdominal wall hernia with loops of bowel, however, no stranding\n and no evidence of bowel obstruction.\n\n 4. Colonic diverticulosis.\n\n" }, { "category": "Radiology", "chartdate": "2188-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1183742, "text": " 3:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old male status post CABG. Patient status post recent chest\n tube removal, evaluation for pneumothorax.\n\n COMPARISON: Chest radiograph from .\n\n PORTABLE AP CHEST RADIOGRAPH: There has been interval removal of the\n endotracheal tube, nasogastric tube, Swan-Ganz catheter, and left chest tube.\n There is no pneumothorax. Bibasilar atelectasis and small pleural effusions\n are unchanged. Median sternotomy wires are intact. There is no vascular\n engorgement. Cardiomediastinal and hilar contours are unchanged.\n\n IMPRESSION:\n\n 1. Interval removal of multiple support devices. No pneumothorax.\n\n 2. Stable bibasilar atelectasis and small bilateral effusions.\n\n" }, { "category": "Radiology", "chartdate": "2188-02-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1183934, "text": " 12:05 PM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusions, atx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p cardiac surgery\n REASON FOR THIS EXAMINATION:\n f/u effusions, atx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac surgery, followup effusions.\n\n COMPARISON: .\n\n FRONTAL AND LATERAL CHEST RADIOGRAPH: Cardiomediastinal silhouette is\n unchanged. There are small bilateral pleural effusions with associated\n atelectasis, which is mildly decreased in extent accounting for differences in\n technique. Dense retrocardiac atelectasis is also noted. Remainder of the\n lung fields are clear without pneumothorax or new focal consolidation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2188-02-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1183400, "text": " 2:51 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, eval for ptx effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, eval for ptx effusions. icu provider is\n - page him if there is concern\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post CABG.\n\n Comparison is made with preop evaluation, .\n\n The ET tube tip is 3.1 cm above the carina. Swan-Ganz catheter tip is in the\n main pulmonary artery. Mediastinal and chest tubes are in place. NG tube tip\n is in the stomach but is not clearly visualized. Sternal wires are aligned.\n There are low lung volumes with large bibasilar atelectasis, right greater\n than left with problable collapse of the right lower lobe. There is no\n pneumothorax. Left pleural effusion is small. There is mild vascular\n congestion. Postoperative mediastinal widening is expected. There is mild\n cardiomegaly.\n\n" }, { "category": "Echo", "chartdate": "2188-02-13 00:00:00.000", "description": "Report", "row_id": 92816, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG\nStatus: Inpatient\nDate/Time: at 12:20\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mildly dilated LV cavity. Moderate regional LV systolic\ndysfunction. Moderately depressed LVEF. Large LV thrombus.\n\nRIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function. Prominent\nmoderator band/trabeculations are noted in the RV apex.\n\nAORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. No atheroma\nin ascending aorta. Normal descending aorta diameter. No atheroma in\ndescending aorta. No thoracic aortic dissection.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Physiologic\nTR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Pulmonic\nvalve not well seen. 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. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPRE-CPB:\nThe left atrium is mildly dilated. No thrombus is seen in the left atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler.\n\nThe left ventricular cavity is mildly dilated. The apical anterior and\nanteroseptal wall segments are thinned and akinetic. The apex is also\nakinetic. Overall left ventricular systolic function is moderately depressed\n(LVEF= 35-40 %). A large globular thrombus is seen in the apex of the left\nventricle, measuring 1.5cm x 1.7cm.\n\nThe right ventricular cavity is mildly dilated with normal free wall\ncontractility.\n\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. No thoracic aortic dissection is seen. There are three aortic\nvalve leaflets. There is no aortic valve stenosis. No aortic regurgitation is\nseen.\n\nThe mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen.\n\nPOST-CPB:\nThe LV thrombus is no longer seen.\n\nThe LV continues to have regional wall motion abnormalities as described\npre-bypass. The estimated EF is 40-45%. The RV systolic function is normal.\n\nThere is no evidence of aortic dissection.\n\nDr. was notified in person of the results at time of study.\n\n\n" }, { "category": "ECG", "chartdate": "2188-02-14 00:00:00.000", "description": "Report", "row_id": 256289, "text": "Sinus rhythm with first degree A-V delay. Possible anteroseptal myocardial\ninfarction of indeterminate age. Leftward axis. Low precordial QRS voltage.\nCompared to the previous tracing of the findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2188-02-13 00:00:00.000", "description": "Report", "row_id": 256290, "text": "Sinus rhythm with atrial premature beat. Left anterior fascicular block.\nMyocardial infarction of indeterminate age. Cannot exclude myocardial ischemia.\nLow precordial lead QRS voltage is non-specific. Since the previous tracing\nof the rate is faster and QRS voltage is lower.\n\n" } ]

[ { "category": "Echo", "chartdate": "2129-11-25 00:00:00.000", "description": "Report", "row_id": 78371, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Congestive heart failure. Left ventricular function. AS\nHeight: (in) 64\nWeight (lb): 220\nBSA (m2): 2.04 m2\nBP (mm Hg): 99/53\nHR (bpm): 99\nStatus: Inpatient\nDate/Time: at 11:19\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Beat-to-beat variability on LVEF due to\nirregular rhythm/premature beats. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Moderate AS (area 1.0-1.2cm2) Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Calcified tips of papillary muscles. No MS. Moderate\n(2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - patient unable to cooperate. The\nrhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%). There is considerable\nbeat-to-beat variability of the left ventricular ejection fraction due to an\nirregular rhythm/premature beats. Right ventricular chamber size and free wall\nmotion are normal. There is moderate to severe aortic valve stenosis (valve\narea 1.0 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen.\nThe tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Moderate to severe calcific aortic stenosis. Mild symmetric LVH\nwith normal global and regional biventricular systolic function. Moderate\nmitral and tricuspid regurgitation. Moderate pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , aortic\ntransvalvular gradients are higher. Estimated pulmonary pressures are also\nhigher. The other findings are similar.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-11-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1214440, "text": " 2:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 45cm SL R basilic power PICC - \n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with new R PICC\n REASON FOR THIS EXAMINATION:\n 45cm SL R basilic power PICC - \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate right PICC.\n\n FRONTAL RADIOGRAPH OF THE CHEST\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: There is a newly inserted right-sided PICC catheter with the tip in\n the right atrium and pullback by 4 cm with the tip of the catheter near the\n cavoatrial junction. Lung aeration has improved with decreased edema and\n bilateral effusions. Moderate cardiomegaly persists. No pneumothorax is\n present.\n\n IMPRESSION: Tip of the right-sided PICC in the right atrium and pullback by 4\n cm would be indicated. Decreased effusions and edema.\n\n Findings were discussed with IV nurse, at 3:30 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2129-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214351, "text": " 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for worsening infx, edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n Please eval for worsening infx, edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF exacerbation, evaluate for worsening infection or edema.\n\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiographs from and .\n\n FINDINGS: Since the study there is a progressive opacification of\n the right hemithorax likely due to increasing layering effusion. Pulmonary\n edema remains stable. Moderate cardiomegaly is unchanged. No pneumothorax is\n present. Hilar and mediastinal contours appear stable.\n\n IMPRESSION:\n\n 1. Progressive increase in pulmonary edema with increased size of a right\n effusion. Bibasilar atelectasis is present.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1214259, "text": " 12:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n please eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia.\n\n COMPARISON: Chest radiograph and chest CT .\n\n UPRIGHT AP VIEW OF THE CHEST: Moderate enlargement of the cardiac silhouette\n with left ventricular predominance is redemonstrated. The aorta is tortuous\n and calcified. There is perihilar haziness and vascular indistinctness\n compatible with pulmonary edema, mild in degree. Additionally, there are\n likely bilateral pleural effusions, a component opf which appears to be\n somewhat layering on the right. Retrocardiac opacity may reflect atelectasis,\n though infection cannot be excluded. No pneumothorax is identified. There\n are no acute osseous abnormalities, though degenerative changes are seen in\n the thoracic spine.\n\n IMPRESSION: Mild pulmonary edema. Bilateral pleural effusions, likely small\n and layering on the right side. Retrocardiac opacity may be due to compressive\n atelectasis, though infection cannot be excluded.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2129-11-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1214999, "text": " 9:01 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with CHF, ? pneumonia\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb WED 11:47 AM\n 1. Probable multilobar pneumonia of the right lung, stable from two days ago\n and much improved from .\n 2. A focal component of pneumonia versus pleural effusion tracking into the\n fissure on the right. Oblique views may help differentiate the two\n possibilities\n 3. Stable congestive heart failure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF and possible pneumonia, assess for interval change.\n\n COMPARISON: Multiple chest radiographs from to .\n\n PA AND LATERAL VIEWS OF THE CHEST: The diffuse heterogeneous opacification of\n the right lung with a denser perifissural component at the inferior upper lobe\n is unchanged from the prior study but considerably improved from . The left lung is clear. Moderate cardiomegaly and mediastinal vascular\n engorgement is stable. There is no pneumothorax. Possible small bilateral\n pleural effusions appear unchanged from two days ago. A right PICC terminates\n in the mid SVC and is also unchanged.\n\n IMPRESSION:\n 1. Probable multilobar pneumonia of the right lung, stable from two days ago\n and much improved from .\n 2. A focal remaining component of pneumonia versus pleural effusion tracking\n into the fissures on the right. Oblique views may help differentiate the two\n possibilities.\n 3. Stable congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2129-11-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1215000, "text": ", E. MED FA7A 9:01 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with CHF, ? pneumonia\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n PFI REPORT\n 1. Probable multilobar pneumonia of the right lung, stable from two days ago\n and much improved from .\n 2. A focal component of pneumonia versus pleural effusion tracking into the\n fissure on the right. Oblique views may help differentiate the two\n possibilities\n 3. Stable congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2129-11-28 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1214708, "text": " 10:04 AM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: please assess for dvt\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with swelling RUE after picc placement\n REASON FOR THIS EXAMINATION:\n please assess for dvt\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right upper extremity duplex son.\n\n INDICATION: 89-year-old female, status post PICC placement with swelling in\n the right upper extremity. Assess for DVT.\n\n COMPARISON: None.\n\n Duplex son evaluation of the deep veins of the right upper extremity\n was performed and reviewed.\n\n FINDINGS: There is normal flow, compressibility involving the right internal\n jugular, right subclavian, axillary and brachial veins. There is slight\n limited evaluation of the distal portions of the right brachial vein due to\n bandaging for the PICC line placement.\n\n There is normal flow within the cephalic and basilic veins.\n\n IMPRESSION: Negative study for right upper extremity deep vein thrombosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-11-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1214778, "text": " 4:22 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess for interval change, presence of pneumonia\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with CHF, COPD, ? pna\n REASON FOR THIS EXAMINATION:\n please assess for interval change, presence of pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 5:29 PM\n PFI: Persistent moderate right pleural effusion. Superimposed right mid lung\n opacity could reflect a developing pneumonia. PA and lateral radiographs may\n be helpful for further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old female with CHF and COPD. Evaluate for pneumonia.\n\n COMPARISON: .\n\n AP AND LATERAL CHEST:\n\n Right PICC is in unchanged position. The lung volumes remain low. There is a\n moderate right pleural effusion, resulting in a veiled opacity in the right\n hemithorax. A more focal ill-defined opacity in the periphery of the right\n upper lobe adjacent to the minor fissure could represent a developing\n pneumonia. There is no focal opacity identified on the left, and there is no\n left pleural effusion. There is no pneumothorax. Hilar and cardiomediastinal\n contours are unchanged. There is no pulmonary edema. Degenerative changes\n are noted in the thoracic spine.\n\n IMPRESSION: Persistent moderate layering right pleural effusion.\n Questionable developing pneumonia in periphery of right upper lobe. PA and\n lateral radiographs may be helpful for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2129-11-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1214779, "text": ", E. MED FA7A 4:22 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess for interval change, presence of pneumonia\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with CHF, COPD, ? pna\n REASON FOR THIS EXAMINATION:\n please assess for interval change, presence of pneumonia\n ______________________________________________________________________________\n PFI REPORT\n PFI: Persistent moderate right pleural effusion. Superimposed right mid lung\n opacity could reflect a developing pneumonia. PA and lateral radiographs may\n be helpful for further evaluation.\n\n" }, { "category": "ECG", "chartdate": "2129-11-26 00:00:00.000", "description": "Report", "row_id": 183837, "text": "Atrial fibrillation. Mild non-specific inferolateral ST-T wave abnormalities.\nUnchanged from previous tracing.\n\n" }, { "category": "ECG", "chartdate": "2129-11-24 00:00:00.000", "description": "Report", "row_id": 183838, "text": "Atrial fibrillation with rapid ventricular response with slowing of the rate\nas compared with previous tracing of . The inferolateral ST-T wave\nchanges have improved. Otherwise, no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2129-11-24 00:00:00.000", "description": "Report", "row_id": 183839, "text": "Atrial fibrillation with rapid ventricular response. Low precordial lead\nvoltage. Compared to the previous tracing of the ventricular response\nhas increased. There are non-specific inferolateral ST-T wave changes.\nOtherwise, no diagnostic interim change.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2156-03-23 00:00:00.000", "description": "EMBO EXTRACRAINIAL", "row_id": 757642, "text": " 12:24 PM\n CAROT/CEREB Clip # \n Reason: f/u angiogram for aneurysm\n Contrast: OPTIRAY Amt: 210\n ********************************* CPT Codes ********************************\n * EMBO EXTRACRAINIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CEREBRAL BILAT *\n * CAROTID/CEREBRAL BILAT EXT CAROTID BILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE SEL EA ADD'L *\n * SEL EA ADD'L SEL EA ADD'L *\n * SEL EA ADD'L SEL EA ADD'L *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n * IV CONSCIOUTIOUS SEDATION PRO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aneursym.\n REASON FOR THIS EXAMINATION:\n f/u angiogram for aneurysm\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Occipital sinus dural arteriovenous fistula status\n post embolization of a right posterior meningeal feeding artery.\n\n POSTOPERATIVE DIAGNOSIS: Persistent dural arteriovenous fistula with feeder\n vessels off of the bilateral occipital arteries status post embolization of\n transosseous feeder vessels using cyanoacrylate glue adhesive.\n\n ANESTHESIA: Nursing sedation with monitoring of hemodynamic parameters\n administered using divided doses of Versed and fentanyl and continuous\n hemodynamic monitoring and supervision by the operator.\n\n CONSENT: The patient was given a full and complete explanation of the\n procedure including the risks, benefits and possible complications. The\n patient and her family understood and wished to proceed with the operation.\n The risks include but are not limited to stroke, infection, bleeding, coma,\n death, as well as other unforeseen complications.\n\n INDICATION: This patient is a 72 year old woman who was previously noted to\n have dilated left cerebellar draining veins for which she underwent a previous\n diagnostic cerebral angiogram. The angiographic study at that time revealed\n the presence of a dural arteriovenous fistula located over the occipital sinus\n and draining mainly in a retrograde venous fashion through the cerebellar vein\n of the left cerebellum and then into the deep draining system via vein of\n and the straight sinus. The singular major feeder at the time of the\n initial angiographic study was a right posterior meningeal branch which was\n treated using proximal coil occlusion. The patient is returning now for a\n (Over)\n\n 12:24 PM\n CAROT/CEREB Clip # \n Reason: f/u angiogram for aneurysm\n Contrast: OPTIRAY Amt: 210\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n follow-up study to determine the status of the fistula and the need for\n additional embolization.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion. A 5-French femoral sheath\n was inserted into the right common femoral artery. Upon the return of brisk\n arterial blood, a 4-French Berenstein type II catheter was used to selectively\n catheterize the vessels in following succession: right vertebral artery,\n right occipital artery, right external carotid artery, right internal carotid\n artery, left common carotid artery, left occipital artery, left external\n carotid artery, left internal carotid artery, and finally, left vertebral\n artery. With the catheter in each of these positions, a biplane angiographic\n run was performed of the whole head. Review of this revealed a significant\n supply of the dural fistula via feeders off of the left greater than right\n occipital arteries. The decision was made to embolize these feeder arteries\n using N-butyl-cyanoacrylate adhesive glue. To that end, a microcatheter of\n type Target Excelsior SL-10 was primed over a Transcend floppy EX wire and a\n 5-French NPD Cordis guide catheter was then placed into the left occipital\n artery. With the catheter in this position, a biplane angiographic run was\n obtained of the head in visual roadmap fashion. The microcatheter was then\n used to selectively catheterize a distal transmastoid feeder to the dural\n arteriovenous fistula coming off the very distal part of the left occipital\n artery. With the microcatheter in this position, and after obtaining a number\n of angiographic runs through the microcatheter in superselective fashion, a\n decision was made to proceed with glue embolization and this was accomplished\n with .5 cc of 25% NBCA in order to impregnate the distal feeders and the\n fistula itself. At the end of the glue injection, the entire system with the\n microcatheter and the guide catheter was withdrawn from the patient and\n discarded. Examination of the patient in neurological fashion revealed no\n deficits associated with the injection. At this point, an additional\n microcatheter and microwire combination of the same manufacturer and\n additional guide catheter were then again used to selectively catheterize the\n left occipital artery and an additional more proximal branch feeding the dural\n fistula was superselectively catheterized and a biplane angiographic run was\n obtained and at this point, a glue injection was again performed of the\n separate feeder, again in same fashion with 25% mixture of glue and Lipiodol.\n Once again, the entire system was discarded after the glue injection. At this\n point, a 5-French MPD catheter was then used to selectively catheterize the\n right occipital artery and a microcatheter of the same manufacturer as\n previously was used to selectively catheterize the distal right occipital\n artery feeding the dural fistula and the microcatheter was then used to\n selectively catheterize that branch and a biplane angiographic run was\n performed. In addition, a .5 cc injection of N-butyl-cyanoacrylate was used\n to inject the dural fistula and with the termination of the glue injection the\n entire system was discarded. The patient was tested again and was found to be\n (Over)\n\n 12:24 PM\n CAROT/CEREB Clip # \n Reason: f/u angiogram for aneurysm\n Contrast: OPTIRAY Amt: 210\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n neurologically intact. At this point, diagnostic catheter was used to\n selectively catheterize the following vessels: right occipital artery, left\n occipital artery, right external carotid artery, left external carotid artery.\n With the catheter in each of these positions, a biplane angiographic run was\n obtained post embolization to document the extent of the residual fistula. At\n the end of the procedure, there appeared to be approximately 80% reduction of\n the flow compared to the beginning of the procedure to the dural arteriovenous\n fistula, and the decision was made then to terminate the procedure today and\n return the patient for additional angiography and possible additional\n embolization in the near future.\n\n RESULTS: Injection of the right vertebral artery reveals the previously\n embolized right posterior meningeal artery along with the coil mass and shows\n no evidence of flow to the fistula from the right vertebral artery. There is\n no evidence of distal abnormality other than a small 2-mm basilar tip aneurysm\n which was previously noted. This is unchanged in appearance. Injection of\n the left vertebral artery reveals no evidence of perfusion to the dural\n fistula off of the left vertebral artery or of the left posterior meningeal\n artery. Injection of the right occipital artery reveals the presence of at\n least feeder vessels with the most prominent being distal branch and to a\n lesser degree, a proximal transosseous perforator which is providing flow to\n the dural fistula which is located over the dural occipital sinus and which\n drains into the deep venous system. The right occipital transosseous branch\n was successfully embolized using N-butyl-cyanoacrylate with significant\n reduction in flow and complete occlusion of this feeder branch. Injection of\n the right external carotid artery reveals no evidence of either abnormality in\n the internal maxillary or other distribution other than the previously-noted\n feeding to the fistula from the right occipital artery. Injection of the\n right internal carotid artery reveals normal intracranial vasculature with no\n evidence of aneurysm or other arteriovenous malformation. In addition,\n injection of the right internal carotid artery reveals filling of both of the\n distal anterior cerebral territories. Injection of the left occipital artery\n reveals significant perfusion to the dural arteriovenous fistula again via two\n major feeders. Both of these were selectively catheterize using microcatheter\n technique and selectively embolized in separate fashion to complete occlusion\n of these feeders. Injection of the left external carotid artery reveals no\n evidence of other feeders to the fistula from the right posterior meningeal or\n other vessels at this point that are apparent. The major supply to the\n fistula appears to emanate off of branches of the left occipital artery.\n Injection of the left internal carotid artery reveals no evidence of\n intracranial aneurysm or arteriovenous malformation and reveals an aplastic A1\n segment of the left internal carotid artery. Injection of the left common\n carotid artery in the cervical region reveals no evidence of stenosis or\n dissection. Injection of the right common carotid artery in the cervical\n region reveals no evidence of stenosis or dissection. Injection of the right\n subclavian artery reveals no evidence of disease or stenosis or dissection of\n (Over)\n\n 12:24 PM\n CAROT/CEREB Clip # \n Reason: f/u angiogram for aneurysm\n Contrast: OPTIRAY Amt: 210\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n this segment or of the origin of the right vertebral artery. Injection of the\n left subclavian artery reveals no evidence of stenosis or dissection other\n than approximately 20% proximal stenosis and a somewhat tortuous take-off of\n the origin of the left vertebral artery, both of which are unchanged compared\n to previous study.\n\n IMPRESSION: Persistent occlusion of the right posterior meningeal feeder to\n the dural fistula with significant increased in flow from left greater than\n right occipital artery branches to the occipital dural arteriovenous fistula.\n Three of these feeders, two on the left and one on the right, were\n superselectively embolized using glue injection without complication.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2156-03-26 00:00:00.000", "description": "EMBO EXTRACRAINIAL", "row_id": 757880, "text": " 11:18 AM\n CAROT/CEREB Clip # \n Reason: S/P EMBO OF AVM\n Contrast: OPTIRAY Amt: 225\n ********************************* CPT Codes ********************************\n * EMBO EXTRACRAINIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT SEL EA ADD'L *\n * SEL EA ADD'L IV CONSCIOUTIOUS SEDATION PRO *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM (REVISED)\n ADDENDUM:\n\n Injection of the right common carotid artery reveals no significant\n atheroscleoris in the cervical region but shows some very faint dural\n shunting into the fistula. Injection of the right occipital artery reveals\n no detectable contribution to the fistula.\n\n\n\n 11:18 AM\n CAROT/CEREB Clip # \n Reason: S/P EMBO OF AVM\n Contrast: OPTIRAY Amt: 225\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Occipital sinus dural arteriovenous fistula with\n multiple feeders off of bilateral external carotid arteries.\n\n POSTOPERATIVE DIAGNOSIS: Same, status post embolization of the left occipital\n artery feeder using NBCA adhesive embolic .\n\n ANESTHESIA: Conscious sedation with continuous hemodynamic monitoring of the\n patient's vital signs and hemodynamic condition with divided doses of Versed\n and fentanyl under the operator's supervision.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion and vascular sheath was\n inserted into the common femoral artery of size 5 French. The catheter was\n then placed into the left common carotid artery where an angiographic run was\n performed, followed by placement into the left external carotid artery where\n an angiographic run was performed in biplane projection. Subsequently, an\n Excelsior SL-10 microcatheter was used coaxially into the guide catheter and\n placed into the left occipital artery. With the catheter in this position, an\n angiographic run was performed and then the catheter was used to selectively\n catheterize only the transosseous branches of the left occipital artery which\n provided significant blood flow to the dural arteriovenous fistula. With the\n catheter in this position, an NBCA embolic mixture was mixed and\n injected with complete stasis and occlusion and permeation of the dural\n arteriovenous fistula with the NBCA glue. At this point, following the\n embolization, an angiographic run was performed of the left occipital artery.\n The catheter was then withdrawn and a new guide catheter was used to\n selectively catheterize the right common carotid artery, followed by\n catheterization of the right external carotid artery, followed by\n catheterization of the right occipital artery, and the guide catheter was then\n withdrawn. With the catheter in each of these positions, an angiographic run\n was performed.\n\n RESULTS: Injection of the left external carotid artery revealed the presence\n of significant feeder off of the main trunk which was catheterized\n successfully and that component providing flow to the dural arteriovenous\n fistula was embolized to complete stasis using NBCA liquid adhesive .\n Injection of the left common carotid artery reveals no evidence of other\n stenosis or dissection at the bifurcation. Injection of the right external\n carotid artery revealed a small trickle of flow into the dural arteriovenous\n fistula representing probably less than 5% of the flow prior to the\n embolization on .\n\n IMPRESSION: Successful embolization using NBCA liquid adhesive of the left\n occipital artery feeder to the dural arteriovenous fistula with significant\n reduction in flow.\n (Over)\n\n 11:18 AM\n CAROT/CEREB Clip # \n Reason: S/P EMBO OF AVM\n Contrast: OPTIRAY Amt: 225\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Physician ", "chartdate": "2186-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 648620, "text": "TITLE:\n Chief Complaint:\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion.\n 24 Hour Events:\n He had a repeat TEE after he arrived at the CCU which showed a\n continued small, 1 cm, primarily anterior, partially echo filled\n pericardial effusion (no echographic signs of tamponade). EF >55%.\n Compared with the prior study of earlier in the afternoon, the findings\n are similar.\n This am the patient continues to have pleuritic CP which gets\n better when he sits up. This has gotten a little better since last\n night. No other or new CP. Denies SOB or dizziness.\n Allergies:\n Quinidine Gluconate\n Rash; Diarrhea;\n Amiodarone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Dofetilide 250 mcg \n Toprol 25 mg daily\n Lisinopril 20 mg \n ASA 325 mg daily\n Tylenol prn\n Ambien qhs prn\n AlOH prn\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.4\nC (97.6\n HR: 81 (75 - 92) bpm\n BP: 116/54(69) {91/27(46) - 142/74(116)} mmHg\n RR: 25 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,800 mL\n 360 mL\n PO:\n 600 mL\n 360 mL\n TF:\n IVF:\n 4,200 mL\n Blood products:\n Total out:\n 2,450 mL\n 500 mL\n Urine:\n 850 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,350 mL\n -140 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Middle-aged male in no acute distress lying in bed\n comfortably.\n Eyes / Conjunctiva: Sclera anicteric.\n Head, Ears, Nose, Throat: Normocephalic, OP clear.\n Cardiovascular: Irregularly irregular, no MRG heard.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Diminished), right\n PT diminshed; left PT 2+\n Respiratory / Chest: Patient breathing comfortably. CTAB.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Warm and well perfused with trace edema b/l.\n Groin: Right and left groin both with cath sites which are\n nonbleeding, no hematoma present, no femoral bruits present. Femoral\n pulses equal b/l. Small ecchymosis over the groin b/l.\n Neurologic: Alert and appropriate.\n Labs / Radiology\n 125 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 102 mEq/L\n 139 mEq/L\n [image002.jpg]\n 07:47 PM\n Cr\n 1.1\n Glucose\n 125\n Other labs: PT / PTT / INR:19.7/21.9/1.8, Ca++:9.0 mg/dL, Mg++:1.6\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion\n # RHYTHM: Patient has a history of afib and aflutter. Most recently on\n dofetilide but converted back to afib. s/p PVI yesterday complicated\n by a small pericardial effusion. Now in a.fib on telemetry.\n - Per EP recs will DC dofetilide and increase in toprol to 50 mg daily.\n - Will start diltiazem at 120 mg daily for rate control in addition to\n his toprol.\n - Restart warfarin for anticoagulation today at his home dose of 7.5 mg\n daily.\n # PUMP/pericardial effusion: normal EF; small pericardial effusion\n measured at less than 1 cm which was stable on repeat TTE yesterday.\n - Repeat TTE this am to evaluate for change.\n - Monitor for signs of tamponade; will call cardiology fellow if any\n clinical e/o tamponade for stat echo and ? pericardial drain if\n necessary.\n - Continue home lisinopril 20 mg and increase to toprol 50 mg daily\n # Hypertension: currently normotensive\n - Continue home lisinopril 20 mg and increase to toprol 50 mg\n daily. Diltiazem being added as above.\n # CORONARIES: no known coronary disease\n - cont b-blocker\n - ASA\n FEN: cardiac diet; replete electrolytes prn\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with pneumoboots for now; INR 1.9\n -Pain management with APAP prn\n -Bowel regimen PRN\n CODE: full\n DISPO: can consider calling the patient out to the floor if his\n pericardial effusion is stable on TTE today or even discharging the\n patient home.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:58 PM\n Prophylaxis:\n DVT: ppx with pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Echo", "chartdate": "2186-12-04 00:00:00.000", "description": "Report", "row_id": 69171, "text": "PATIENT/TEST INFORMATION:\nIndication: Asssess for pericardial effusion s/p EP PVI.\nHeight: (in) 70\nWeight (lb): 273\nBSA (m2): 2.38 m2\nBP (mm Hg): 85/62\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: 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\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. There is a small (~1cm), primarily\nanterior pericardial effusion around the right ventricle (seen on subcostal\nviews). There are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , a small\npericardial effusion is now identified.\n\n\n" }, { "category": "Echo", "chartdate": "2186-12-04 00:00:00.000", "description": "Report", "row_id": 68909, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/Atrial flutter pre-pulmonary vein isolation. History of prior ablations and electrical cardioversions.\nHeight: (in) 70\nWeight (lb): 273\nBSA (m2): 2.38 m2\nBP (mm Hg): 124/104\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 09:32\nTest: TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Mild spontaneous echo contrast in the body\nof the LA. Mild spontaneous echo contrast in the LAA. No thrombus in the LAA.\nAll four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast or thrombus in\nthe body of the RA or RAA. Left-to-right shunt across the interatrial septum\nat rest. Small secundum ASD.\n\nLEFT VENTRICLE: Normal LV cavity size.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). The patient was under general anesthesia throughout the procedure.\nNo TEE related complications. MD caring for the patient was notified of the\nechocardiographic results by e-mail.\n\nConclusions:\nThe left atrium is mildly dilated. Mild spontaneous echo contrast but no\nthrombus is seen in the body of the left atrium and left atrial appendage. No\nspontanous echocontrast or thrombus is seen in the body of the right\natrium/right atrial appendage. The interatrial septum is intact by 2D, but\nthere is a small color Doppler jet in the superior portion of the interatrial\nseptum c/w ASD with left-to-right flow. The left ventricular cavity size is\nnormal. There are simple atheroma in the descending thoracic aorta 45 cm to\nthe incisors. The aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen. The mitral leaflets are mildly thickened. There is no\nmitral valve prolapse. Mild mitral regurgitation and trace tricuspid\nregurgitation are seen. There is no pericardial effusion.\n\nIMPRESSION: Mild spontaneous echo contrast in the left atrium and left atrial\nappendage without evidence of thrombus. Small secundum type atrial septal\ndefect with left to right flow at rest. Simple plaque in the descending\nthoracic aorta.\n\n\n" }, { "category": "Echo", "chartdate": "2186-12-05 00:00:00.000", "description": "Report", "row_id": 69055, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 71\nWeight (lb): 275\nBSA (m2): 2.42 m2\nBP (mm Hg): 118/70\nHR (bpm): 126\nStatus: Inpatient\nDate/Time: at 13:37\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 VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left ventricular cavity size is normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. There is a small pericardial\neffusion. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n" }, { "category": "Echo", "chartdate": "2186-12-04 00:00:00.000", "description": "Report", "row_id": 69172, "text": "PATIENT/TEST INFORMATION:\nIndication: focused exam during EP ablation to assess for pericardial effusion and to verify catheter positions.\nHeight: (in) 70\nWeight (lb): 273\nBSA (m2): 2.38 m2\nBP (mm Hg): 113/70\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 10:53\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator. Emergency study.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Right\nventricular chamber size is normal. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2186-12-04 00:00:00.000", "description": "Report", "row_id": 69056, "text": "PATIENT/TEST INFORMATION:\nIndication: Serial effusion f/u. Assess for interval change 4 hrs s/p procedure.\nHeight: (in) 71\nWeight (lb): 275\nBSA (m2): 2.42 m2\nBP (mm Hg): 118/71\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 17:10\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\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\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Results were reviewed with the Cardiology Fellow involved\nwith the patient's care.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThere is a small (1cm), primarily anterior, partially echo filled pericardial\neffusion. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study of earlier in the afternoon, the findings are\nsimilar.\n\n\n" }, { "category": "ECG", "chartdate": "2186-12-07 00:00:00.000", "description": "Report", "row_id": 155775, "text": "Probable atrial flutter\nAnterolateral ST-T abnormalities suggest ischemia\nClinical correlation is suggested\nSince previous tracing of , rate slower and further ST-T wave\nabnormalities present\n\n" }, { "category": "ECG", "chartdate": "2186-12-05 00:00:00.000", "description": "Report", "row_id": 156000, "text": "Probable atrial fibrillation with rapid ventricular response\nNonspecific T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of the same date, atrial flutter now present\n\n" }, { "category": "ECG", "chartdate": "2186-12-05 00:00:00.000", "description": "Report", "row_id": 156001, "text": "Sinus rhythm with atrial premature beats with varying coupling intervals.\nST-T wave abnormalities with prominent lateral T wave inversions. Since the\nprevious tracing of atrial fibrillation is no longer present.\n\n" }, { "category": "Nursing", "chartdate": "2186-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648557, "text": "Patient is a 55 yo male with longstanding h/o atrial fibrillation and\n atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and\n multiple failed cardioversion attempts who was admitted today for a\n pulmonary vein isolation procedure. During his last admission, he\n underwent cardioversion and initiation of dofetilide and\n anticoagulation. After discharge, he went back into afib, despite\n dofetilide, therefore it was determined that he should undergo PVI.\n Today, he underwent PVI, and intially there was no evidence of\n pericardial effusion prior to procedure. A post procedure\n echocardiogram showed evidence of a 0.9 cm effusion anterior to the RV,\n without any echocardiographic evidence of tamponade. Post procedure,\n the patient was hemodynamically stable, in sinus rhythm, chest pain\n free, and was admitted to the CCU for further monitoring.\n Pericardial effusion (without tamponade)\n Assessment:\n Pt. w/ hx. Afib s/p ablation w/ CV as above today. Currently in SR w.\n frequent PAC\ns. Procedure c/b 0.9 cm pericardial effusion. Admitted CCU\n for monitoring for tamponade as well serial echo\n Action:\n Cardiac echo at 430 pm. Hemodynamic monitoring. Monitoring for c/o\n pain or discomfort. Monitoring bilateral groin sites and pedal pulses.\n Response:\n Echo showed no worsening of effusion. Hemodynamically stable and chest\n pain free. Right groin w. unchanged ooze and positive pedal pulses\n bilaterally.\n Plan:\n Continue medications as ordered- to restart dofotelide tonight.\n Continue to monitor for tamponade physiology. Repeat echo in am. Also,\n at risk for OSA. Bedrest complete at 730 pm.\n" }, { "category": "Nursing", "chartdate": "2186-12-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648555, "text": "Patient is a 55 yo male with longstanding h/o atrial fibrillation and\n atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and\n multiple failed cardioversion attempts who was admitted today for a\n pulmonary vein isolation procedure. During his last admission, he\n underwent cardioversion and initiation of dofetilide and\n anticoagulation. After discharge, he went back into afib, despite\n dofetilide, therefore it was determined that he should undergo PVI.\n Today, he underwent PVI, and intially there was no evidence of\n pericardial effusion prior to procedure. A post procedure\n echocardiogram showed evidence of a 0.9 cm effusion anterior to the RV,\n without any echocardiographic evidence of tamponade. Post procedure,\n the patient was hemodynamically stable, in sinus rhythm, chest pain\n free, and was admitted to the CCU for further monitoring.\n" }, { "category": "Physician ", "chartdate": "2186-12-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 648535, "text": "TITLE:\n Chief Complaint: s/p PVI c/b pericardial effusion\n HPI:\n Patient is a 55 yo male with longstanding h/o atrial fibrillation and\n atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and\n multiple failed cardioversion attempts who was admitted today for a\n pulmonary vein isolation procedure. During his last admission, he\n underwent cardioversion and initiation of dofetilide and\n anticoagulation. After discharge, he went back into afib, despite\n dofetilide, therefore it was determined that he should undergo PVI.\n Today, he underwent PVI, and intially there was no evidence of\n pericardial effusion prior to procedure. A post procedure\n echocardiogram showed evidence of a 0.9 cm effusion anterior to the RV,\n without any echocardiographic evidence of tamponade. Post procedure,\n the patient was hemodynamically stable, in sinus rhythm, chest pain\n free, and was admitted to the CCU for further monitoring.\n On admission to the CCU, the patient denies any chest pain or shortness\n of breath. He denies significant groin pain. He is otherwise without\n complaints.\n On review of systems, he denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n He denies recent fevers, chills or rigors. He denies exertional buttock\n or calf pain. All of the other review of systems were negative.\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n syncope or presyncope. He was experiencing palpitations at home when\n he went into afib.\n History obtained from Patient\n Allergies:\n Quinidine Gluconate\n Rash; Diarrhea;\n Amiodarone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Dofetilide 250 mcg \n Lisinopril 20 mg \n Metoprolol Succinate 25 mg daily\n Warfarin 7.5 mg daily\n ASA 81 mg daily\n MVI\n Omega-3\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension\n 2. CARDIAC HISTORY:\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS: none\n -PACING/ICD: s/p afib ablation x 1 and aflutter ablation x 2; multiple\n cardioversions most recently on \n 3. OTHER PAST MEDICAL HISTORY:\n Paroxysmal atrial fibrillation s/p ablation x 1\n Atrial flutter s/p ablation x 2\n S/P multiple DCCV\n HTN\n Hyperlipidemia\n Mild AI\n Father and brother with Afib.\n Occupation: engineer\n Drugs: none\n Tobacco: none\n Alcohol: 10 per week\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, Palpitations, No(t) Edema, No(t)\n Orthopnea, when in afib, no palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Numbness / tingling\n Flowsheet Data as of 04:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 78 (76 - 78) bpm\n BP: 119/65(78) {119/63(78) - 122/65(78)} mmHg\n RR: 20 (15 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,200 mL\n PO:\n TF:\n IVF:\n 4,200 mL\n Blood products:\n Total out:\n 0 mL\n 1,820 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,380 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Diminished), right\n PT diminshed; left PT 2+\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n EKG: NSR, HR 75, TWI in I, aVL, III and TWF in aVF. TWI in V2-V6. no\n significant ST segment changes\n .\n TELEMETRY: pending; NSR\n .\n 2D-ECHOCARDIOGRAM:\n TEE :\n The left atrium is mildly dilated. Mild spontaneous echo contrast but\n no thrombus is seen in the body of the left atrium and left atrial\n appendage. No spontanous echocontrast or thrombus is seen in the body\n of the right atrium/right atrial appendage. The interatrial septum is\n intact by 2D, but there is a small color Doppler jet in the superior\n portion of the interatrial septum c/w ASD with left-to-right flow. The\n left ventricular cavity size is normal. There are simple atheroma in\n the descending thoracic aorta 45 cm to the incisors. The aortic valve\n leaflets (3) are mildly thickened. No aortic regurgitation is seen. The\n mitral leaflets are mildly thickened. There is no mitral valve\n prolapse. Mild mitral regurgitation and trace tricuspid regurgitation\n are seen. There is no pericardial effusion.\n IMPRESSION: Mild spontaneous echocontrast without evidence of thrombus\n in the left atrium and left atrial appendage. Small secundum type\n atrial septal defect with left to right flow at rest. Simple plaque in\n the descending thoracic aorta.\n .\n 10:53 AM\n Left ventricular wall thicknesses and cavity size are normal. Right\n ventricular chamber size is normal. There is no pericardial effusion.\n .\n 13:00\n Left ventricular wall thickness, cavity size, and global systolic\n function are normal (LVEF>55%). Due to suboptimal technical quality, a\n focal wall motion abnormality cannot be fully excluded. There is a\n small (~1cm), primarily anterior pericardial effusion around the right\n ventricle (seen on subcostal views). There are no echocardiographic\n signs of tamponade.\n Compared with the prior study (images reviewed) of , a small\n pericardial effusion is now identified.\n .\n EP STUDY:\n \n Conclusions:\n 1. Verified right atrial cavotricuspid line of block, with single left\n to right interatrial breakthrough\n 2. Successful isolation of all three pulmonary veins, with additional\n inter-venous and -annular lines of lesions\n 3. Vein of potential noted\n 4. Left atrial atriopathy with diffuse low voltage\n 5. Successful internal cardioversion (20J) of atrial fibrillation\n .\n EP STUDY: report pending; pulmonary vein isolation procedure\n with NSR at end of study\n Assessment and Plan\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion\n # RHYTHM: h/o afib and aflutter. Most recently on dofetilide but\n converted back to afib. s/p PVI currently in NSR though c/b small\n pericardial effusion\n - cont dofetilide at home 250 mcg \n - hold warfarin tonight, restart tomorrow\n - cont b-blocker\n # CORONARIES: no known coronary disease\n - cont b-blocker\n - restart ASA in AM\n # PUMP: normal EF; small pericardial effusion measured at less than 1\n cm.\n - repeat ECHO today at 4 pm\n - repeat ECHO in AM\n - monitor for e/o tamponade; will call cardiology fellow if any\n clinical e/o tamponade for stat echo and ? pericardial drain if\n necessary\n - cont b-blocker and lisinopril\n # Hypertension: currently normotensive\n - cont home ace and b-blocker\n FEN: NPO for now; after repeat ECHO if no change in effusion size, can\n restart cardiac diet\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with pneumoboots for now; INR 1.9\n -Pain managment with APAP prn\n -Bowel regimen PRN\n CODE: full\n DISPO: CCU for now for monitoring\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2186-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 648586, "text": "TITLE:\n Chief Complaint:\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion.\n 24 Hour Events:\n He had a repeat TEE after he arrived at the CCU which showed a\n continued small, 1 cm, primarily anterior, partially echo filled\n pericardial effusion (no echographic signs of tamponade). EF >55%.\n Compared with the prior study of earlier in the afternoon, the findings\n are similar.\n Allergies:\n Quinidine Gluconate\n Rash; Diarrhea;\n Amiodarone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.4\nC (97.6\n HR: 81 (75 - 92) bpm\n BP: 116/54(69) {91/27(46) - 142/74(116)} mmHg\n RR: 25 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,800 mL\n 360 mL\n PO:\n 600 mL\n 360 mL\n TF:\n IVF:\n 4,200 mL\n Blood products:\n Total out:\n 2,450 mL\n 500 mL\n Urine:\n 850 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,350 mL\n -140 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\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: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Diminished), right\n PT diminshed; left PT 2+\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 125 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 102 mEq/L\n 139 mEq/L\n [image002.jpg]\n 07:47 PM\n Cr\n 1.1\n Glucose\n 125\n Other labs: PT / PTT / INR:19.7/21.9/1.8, Ca++:9.0 mg/dL, Mg++:1.6\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion\n # RHYTHM: h/o afib and aflutter. Most recently on dofetilide but\n converted back to afib. s/p PVI currently in NSR though c/b small\n pericardial effusion\n - cont dofetilide at home 250 mcg \n - hold warfarin tonight, restart tomorrow\n - cont b-blocker\n # CORONARIES: no known coronary disease\n - cont b-blocker\n - restart ASA in AM\n # PUMP: normal EF; small pericardial effusion measured at less than 1\n cm.\n - repeat ECHO today at 4 pm\n - repeat ECHO in AM\n - monitor for e/o tamponade; will call cardiology fellow if any\n clinical e/o tamponade for stat echo and ? pericardial drain if\n necessary\n - cont b-blocker and lisinopril\n # Hypertension: currently normotensive\n - cont home ace and b-blocker\n FEN: NPO for now; after repeat ECHO if no change in effusion size, can\n restart cardiac diet\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with pneumoboots for now; INR 1.9\n -Pain managment with APAP prn\n -Bowel regimen PRN\n CODE: full\n DISPO: CCU for now for monitoring\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2186-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648627, "text": "Patient is a 55 yo male with longstanding h/o atrial fibrillation and\n atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and\n multiple failed cardioversion attempts who was admitted for a\n pulmonary vein isolation procedure. During his last admission, he\n underwent cardioversion and initiation of dofetilide and\n anticoagulation. After discharge, he went back into afib, despite\n dofetilide, therefore it was determined that he should undergo PVI.\n : underwent PVI, with no evidence of pericardial effusion prior to\n procedure. A post procedure echocardiogram showed evidence of a 0.9 cm\n effusion anterior to the RV, without any echocardiographic evidence of\n tamponade. Post procedure, the patient was hemodynamically stable, in\n sinus rhythm, chest pain free, and was admitted to the CCU for further\n monitoring.\n Pericardial effusion (without tamponade)\n Assessment:\n Pt. w/ hx. Afib s/p ablation w/ CV as above procedure c/b 0.9 cm\n pericardial effusion. pm echo showed no change in effusion.\n Action:\n Cardiac echo at pm. Hemodynamic monitoring. Monitoring for c/o pain or\n discomfort. Monitoring bilateral groin sites and pedal pulses.\n Ibuprofen given for c/o headache. Monitoring for s/s tamponade.\n Response:\n Echo showed. Hemodynamically stable (in Afib w/ RVR to 130s) and chest\n pain free. Bilateral groin sites stable with positive pedal pulses\n bilaterally. No s/s tamponade.\n Plan:\n Continue medications as ordered. Continue to monitor for tamponade\n physiology.\n Atrial fibrillation (Afib)\n Assessment:\n Rhythm converted from SR to afib w. rvr at 9 am\n Action:\n 12 lead EKG obtained when converted to Afib from SR. attempted rate\n control w/ 5 mg iv lopressor and 25 mg po lopressor. Dofetolide d/c\n Toprol dose increased from 25 mg to 50 mg daily. 120 mg diltiazem\n started. Am K+ and Mg+ repleted.\n Response:\n Pt. rate remains 120s-130s. Pt. can feel that HR is fast, but feels\n asymptomatic.\n Plan:\n Continue to work with CCU team to titrate rate control medications.\n" }, { "category": "Nursing", "chartdate": "2186-12-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648636, "text": "Patient is a 55 yo male with longstanding h/o atrial fibrillation and\n atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and\n multiple failed cardioversion attempts who was admitted for a\n pulmonary vein isolation procedure. During his last admission, he\n underwent cardioversion and initiation of dofetilide and\n anticoagulation. After discharge, he went back into afib, despite\n dofetilide, therefore it was determined that he should undergo PVI.\n : underwent PVI, with no evidence of pericardial effusion prior to\n procedure. A post procedure echocardiogram showed evidence of a 0.9 cm\n effusion anterior to the RV, without any echocardiographic evidence of\n tamponade. Post procedure, the patient was hemodynamically stable, in\n sinus rhythm, chest pain free, and was admitted to the CCU for further\n monitoring.\n Pericardial effusion (without tamponade)\n Assessment:\n Pt. w/ hx. Afib s/p ablation w/ CV as above procedure c/b 0.9 cm\n pericardial effusion. pm echo showed no change in effusion.\n Action:\n Cardiac echo this afternoon. Hemodynamic monitoring. Monitoring for\n c/o pain or discomfort. Monitoring bilateral groin sites and pedal\n pulses. Ibuprofen given for c/o headache. Monitoring for s/s tamponade.\n Response:\n Echo results pending. Hemodynamically stable (in Afib w/ RVR to 130s)\n and chest pain free. Bilateral groin sites stable with positive pedal\n pulses bilaterally. No s/s tamponade.\n Plan:\n Continue medications as ordered. Continue to monitor for tamponade\n physiology.\n Atrial fibrillation (Afib)\n Assessment:\n Rhythm converted from SR to afib w. rvr at 9 am\n Action:\n 12 lead EKG obtained when converted to Afib from SR. attempted rate\n control w/ 5 mg iv lopressor and 25 mg po lopressor. Dofetolide d/c\n Toprol dose increased from 25 mg to 50 mg daily. 120 mg diltiazem\n started. Am K+ and Mg+ repleted. Add\nl 50 mg po lopressor give at 1530\n to further attempt rate control.\n Response:\n Pt. rate remains 100s-130s. Pt. can feel that HR is fast, but feels\n asymptomatic.\n Plan:\n Continue to work with CCU team to titrate rate control medications.\n" }, { "category": "Physician ", "chartdate": "2186-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 648603, "text": "TITLE:\n Chief Complaint:\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion.\n 24 Hour Events:\n He had a repeat TEE after he arrived at the CCU which showed a\n continued small, 1 cm, primarily anterior, partially echo filled\n pericardial effusion (no echographic signs of tamponade). EF >55%.\n Compared with the prior study of earlier in the afternoon, the findings\n are similar.\n This am the patient continues to have pleuritic CP which gets\n better when he sits up. This has gotten a little better since last\n night. No other or new CP. Denies SOB or dizziness.\n Allergies:\n Quinidine Gluconate\n Rash; Diarrhea;\n Amiodarone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Dofetilide 250 mcg \n Toprol 25 mg daily\n Lisinopril 20 mg \n ASA 325 mg daily\n Tylenol prn\n Ambien qhs prn\n AlOH prn\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.4\nC (97.6\n HR: 81 (75 - 92) bpm\n BP: 116/54(69) {91/27(46) - 142/74(116)} mmHg\n RR: 25 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,800 mL\n 360 mL\n PO:\n 600 mL\n 360 mL\n TF:\n IVF:\n 4,200 mL\n Blood products:\n Total out:\n 2,450 mL\n 500 mL\n Urine:\n 850 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,350 mL\n -140 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Middle-aged male in no acute distress lying in bed\n comfortably.\n Eyes / Conjunctiva: Sclera anicteric.\n Head, Ears, Nose, Throat: Normocephalic, OP clear.\n Cardiovascular: Irregularly irregular, no MRG heard.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Diminished), right\n PT diminshed; left PT 2+\n Respiratory / Chest: Patient breathing comfortably. CTAB.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Warm and well perfused with trace edema b/l.\n Groin: Right and left groin both with cath sites which are\n nonbleeding, no hematoma present, no femoral bruits present. Femoral\n pulses equal b/l. Small ecchymosis over the groin b/l.\n Neurologic: Alert and appropriate.\n Labs / Radiology\n 125 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 102 mEq/L\n 139 mEq/L\n [image002.jpg]\n 07:47 PM\n Cr\n 1.1\n Glucose\n 125\n Other labs: PT / PTT / INR:19.7/21.9/1.8, Ca++:9.0 mg/dL, Mg++:1.6\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion\n # RHYTHM: Patient has a history of afib and aflutter. Most recently on\n dofetilide but converted back to afib. s/p PVI yesterday complicated\n by a small pericardial effusion. Now in a.fib on telemetry.\n - Continue dofetilide at his home dose of 250 mcg \n - Continue b-blocker\n - Restart warfarin for anticoagulation today if his pericardial\n effusion is stable on TTE.\n # PUMP/pericardial effusion: normal EF; small pericardial effusion\n measured at less than 1 cm which was stable on repeat TTE yesterday.\n - Repeat TTE this am to evaluate for change.\n - Monitor for signs of tamponade; will call cardiology fellow if any\n clinical e/o tamponade for stat echo and ? pericardial drain if\n necessary.\n - Continue home lisinopril 20 mg and toprol 25 mg daily\n # Hypertension: currently normotensive\n - Continue home lisinopril 20 mg and toprol 25 mg daily\n # CORONARIES: no known coronary disease\n - cont b-blocker\n - restart ASA in AM\n FEN: cardiac diet; replete electrolytes prn\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with pneumoboots for now; INR 1.9\n -Pain management with APAP prn\n -Bowel regimen PRN\n CODE: full\n DISPO: can consider calling the patient out to the floor if his\n pericardial effusion is stable on TTE today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:58 PM\n Prophylaxis:\n DVT: ppx with pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2186-12-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 648617, "text": "TITLE:\n Chief Complaint:\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion.\n 24 Hour Events:\n He had a repeat TEE after he arrived at the CCU which showed a\n continued small, 1 cm, primarily anterior, partially echo filled\n pericardial effusion (no echographic signs of tamponade). EF >55%.\n Compared with the prior study of earlier in the afternoon, the findings\n are similar.\n This am the patient continues to have pleuritic CP which gets\n better when he sits up. This has gotten a little better since last\n night. No other or new CP. Denies SOB or dizziness.\n Allergies:\n Quinidine Gluconate\n Rash; Diarrhea;\n Amiodarone\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Dofetilide 250 mcg \n Toprol 25 mg daily\n Lisinopril 20 mg \n ASA 325 mg daily\n Tylenol prn\n Ambien qhs prn\n AlOH prn\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.4\nC (97.6\n HR: 81 (75 - 92) bpm\n BP: 116/54(69) {91/27(46) - 142/74(116)} mmHg\n RR: 25 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,800 mL\n 360 mL\n PO:\n 600 mL\n 360 mL\n TF:\n IVF:\n 4,200 mL\n Blood products:\n Total out:\n 2,450 mL\n 500 mL\n Urine:\n 850 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,350 mL\n -140 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Middle-aged male in no acute distress lying in bed\n comfortably.\n Eyes / Conjunctiva: Sclera anicteric.\n Head, Ears, Nose, Throat: Normocephalic, OP clear.\n Cardiovascular: Irregularly irregular, no MRG heard.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Diminished), right\n PT diminshed; left PT 2+\n Respiratory / Chest: Patient breathing comfortably. CTAB.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Warm and well perfused with trace edema b/l.\n Groin: Right and left groin both with cath sites which are\n nonbleeding, no hematoma present, no femoral bruits present. Femoral\n pulses equal b/l. Small ecchymosis over the groin b/l.\n Neurologic: Alert and appropriate.\n Labs / Radiology\n 125 mg/dL\n 1.1 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 102 mEq/L\n 139 mEq/L\n [image002.jpg]\n 07:47 PM\n Cr\n 1.1\n Glucose\n 125\n Other labs: PT / PTT / INR:19.7/21.9/1.8, Ca++:9.0 mg/dL, Mg++:1.6\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 55 yo male with atrial fibrillation with previous afib and aflutter\n ablations and multiple DCCV which has been unsuccessful admitted today\n for a pulmonary vein isolation procedure c/b small anterior pericardial\n effusion\n # RHYTHM: Patient has a history of afib and aflutter. Most recently on\n dofetilide but converted back to afib. s/p PVI yesterday complicated\n by a small pericardial effusion. Now in a.fib on telemetry.\n - Per EP recs will DC dofetilide and increase in toprol to 50 mg daily.\n - Restart warfarin for anticoagulation today if his pericardial\n effusion is stable on TTE.\n # PUMP/pericardial effusion: normal EF; small pericardial effusion\n measured at less than 1 cm which was stable on repeat TTE yesterday.\n - Repeat TTE this am to evaluate for change.\n - Monitor for signs of tamponade; will call cardiology fellow if any\n clinical e/o tamponade for stat echo and ? pericardial drain if\n necessary.\n - Continue home lisinopril 20 mg and increase to toprol 50 mg daily\n # Hypertension: currently normotensive\n - Continue home lisinopril 20 mg and increase to toprol 50 mg daily\n # CORONARIES: no known coronary disease\n - cont b-blocker\n - ASA\n FEN: cardiac diet; replete electrolytes prn\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with pneumoboots for now; INR 1.9\n -Pain management with APAP prn\n -Bowel regimen PRN\n CODE: full\n DISPO: can consider calling the patient out to the floor if his\n pericardial effusion is stable on TTE today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:58 PM\n Prophylaxis:\n DVT: ppx with pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2186-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648595, "text": "Pericardial effusion (without tamponade)\n Assessment:\n TMax 99.9po. HR NSR with PAC\ns. BP stable.\n Pt. contin. to c/o mild pain with inspiration- unchanged since post\n cath. HO aware.\n Bilat. Fem. Sites D/I. palp pulses.\n c/o sore throat\n Action:\n Foley d/c\nd. pt. OOB- stood at bedside and dangled.\n Tylenol x1. contin. on lisinopril and dofetilide- took evening doses.\n Asking for ice water and ate popsicle\n Response:\n Temp. down to 97.6. tolerated standing- BP stable. Remains in NSR.\n Lytes stable.\n Voiding with urinal.\n Voice hoarse. Strong nonprod. Cough. LS diminished. Good sats on RA.\n Plan:\n Monitor fever, plan repeat echo today. Contin. Beta blocker,\n lisinopril and dofetilide.\n OOB\n ambulate.\n" }, { "category": "Nursing", "chartdate": "2186-12-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 648667, "text": "Patient is a 55 yo male with longstanding h/o atrial fibrillation and\n atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and\n multiple failed cardioversion attempts who was admitted for a\n pulmonary vein isolation procedure. During his last admission, he\n underwent cardioversion and initiation of dofetilide and\n anticoagulation. After discharge, he went back into afib, despite\n dofetilide, therefore it was determined that he should undergo PVI.\n : underwent PVI, with no evidence of pericardial effusion prior to\n procedure. A post procedure echocardiogram showed evidence of a 0.9 cm\n effusion anterior to the RV, without any echocardiographic evidence of\n tamponade. Post procedure, the patient was hemodynamically stable, in\n sinus rhythm, chest pain free, and was admitted to the CCU for further\n monitoring. Now returned to afib, attempting rate control with\n medications.\n Pericardial effusion (without tamponade)\n Assessment:\n Pt. w/ hx. Afib s/p ablation w/ CV as above procedure c/b 0.9 cm\n pericardial effusion. pm echo showed no change in effusion.\n Action:\n Cardiac echo this afternoon. Hemodynamic monitoring. Monitoring for\n c/o pain or discomfort. Monitoring bilateral groin sites and pedal\n pulses. Ibuprofen given for c/o headache. Monitoring for s/s tamponade.\n Response:\n Echo results pending. Hemodynamically stable (in Afib w/ RVR to 130s)\n and chest pain free. Bilateral groin sites stable with positive pedal\n pulses bilaterally. No s/s tamponade.\n Plan:\n Continue medications as ordered. Continue to monitor for tamponade\n physiology.\n Atrial fibrillation (Afib)\n Assessment:\n Rhythm converted from SR to afib w. rvr at 9 am\n Action:\n 12 lead EKG obtained when converted to Afib from SR. attempted rate\n control w/ 5 mg iv lopressor and 25 mg po lopressor. Dofetolide d/c\n Toprol dose increased from 25 mg to 50 mg daily. 120 mg diltiazem\n started. Am K+ and Mg+ repleted. Add\nl 50 mg po lopressor give at 1530\n to further attempt rate control.\n Response:\n Pt. rate remains 100s-130s. Pt. can feel that HR is fast, but feels\n asymptomatic.\n Plan:\n Continue to work with CCU team to titrate rate control medications.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ATRIAL FIBRILLATION PULMONARY VEIN ISOLATION **REMOTE WEST*\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 129.6 kg\n Daily weight:\n Allergies/Reactions:\n Quinidine Gluconate\n Rash; Diarrhea;\n Amiodarone\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, Hypertension\n Additional history: PAfib s/p multiple ablations. s/p multiple dccv,\n hyperlipidemia, mild AI, h/o MR.\n Surgery / Procedure and date: afib ablation : procedure\n complicated by <1 cm pericardial effusion in anterior RV.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:73\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 127 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,010 mL\n 24h total out:\n 1,100 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 05:55 AM\n Potassium:\n 3.8 mEq/L\n 05:55 AM\n Chloride:\n 104 mEq/L\n 05:55 AM\n CO2:\n 24 mEq/L\n 05:55 AM\n BUN:\n 16 mg/dL\n 05:55 AM\n Creatinine:\n 1.1 mg/dL\n 05:55 AM\n Glucose:\n 129 mg/dL\n 05:55 AM\n Hematocrit:\n 31.4 %\n 05:55 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: computer and cell phone with chargers\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2186-12-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 648570, "text": "Pericardial effusion (without tamponade)\n Assessment:\n TMax 99.9po. HR NSR with PAC\ns. BP stable.\n Pt. contin. to c/o mild pain with inspiration- unchanged since post\n cath. HO aware.\n Bilat. Fem. Sites D/I. palp pulses.\n c/o sore throat\n Action:\n Foley d/c\nd. pt. OOB- stood at bedside and dangled.\n Tylenol x1. contin. on lisinopril and dofetilide- took evening doses.\n Asking for ice water and ate popsicle\n Response:\n Temp. down to 97.6. tolerated standing- BP stable. Remains in NSR.\n Lytes stable.\n Voiding with urinal.\n Voice hoarse. Strong nonprod. Cough. LS diminished. Good sats on RA.\n Plan:\n Monitor fever, plan repeat echo today. Contin. Beta blocker,\n lisinopril and dofetilide.\n OOB\n ambulate.\n" } ]

[ { "category": "Echo", "chartdate": "2130-10-09 00:00:00.000", "description": "Report", "row_id": 63994, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Pulmonary stenosis\nHeight: (in) 61\nWeight (lb): 130\nBSA (m2): 1.57 m2\nBP (mm Hg): 121/80\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 10:51\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n PV mean/peak gradient transposition measurement error corrected. No\nchanges made in fFndings or Conclusion.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Physiologic MR\n(within normal limits).\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Moderate PS. Mild PR.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Right ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Physiologic mitral regurgitation is seen (within normal\nlimits). The tricuspid valve leaflets are mildly thickened. There is mild\npulmonary artery systolic hypertension. There is moderate pulmonic valve\nstenosis. There is a very small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nIMPRESSION: Normal regional and global biventricular systolic function.\nModerate pulmonic stenosis. Mild pulmonic regurgitation.\n\nCompared with the prior study (images reviewed) of , the severity of\npulmonic stenosis has increased.\n\n\n" }, { "category": "ECG", "chartdate": "2130-10-06 00:00:00.000", "description": "Report", "row_id": 124949, "text": "Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2130-09-30 00:00:00.000", "description": "Report", "row_id": 124950, "text": "Sinus rhythm. Normal ECG. Compared to the previous tracing the findings are\nsimilar.\n\n" }, { "category": "ECG", "chartdate": "2130-09-29 00:00:00.000", "description": "Report", "row_id": 124951, "text": "Sinus tachycardia. Left atrial abnormality. Non-specific inferolateral\nrepolarization abnormalities. Compared to the previous tracing of \nthe rate is significantly faster and now tachycardic. Previously described\nanterior J point elevation is no longer apparent. Non-specific inferolateral\nrepolarization abnormalities are similar in the limb leads and more pronounced\nin the apical precordial leads.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1255661, "text": " 8:00 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for interval change, pt with L sided pleuritic CP (\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with asthma, pneumonia, worsening wheeze and chest pain\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, pt with L sided pleuritic CP (effusion?) and\n diffuse wheezing\n ______________________________________________________________________________\n WET READ: EHAb FRI 8:19 PM\n Compared to , right perihilar and left mid and lower lung opacities\n persist but are greatly improved. There is a small left pleural effusion,\n which was present on CT dated but not seen on radiograph dated\n . Enlarged pulmonary arteries suggest pulmonary arterial hypertension,\n as seen on recent chest CTA. Interval removal of right internal jugular\n catheter. Lung hyperinflation appears increased, with increased peribronchial\n cuffing, suggestive of small airways disease with obstructive physiology.\n Discussed with Dr. by phone at 8:15 p.m. on at time of\n initial review of the study.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FILM, AT 20:05.\n\n CLINICAL INDICATION: 57-year-old with asthma, pneumonia, worsening wheezing\n and chest pain, evaluate for interval change.\n\n Comparison is made to the patient's prior study of at 3:17.\n\n PA and lateral views of the chest, at 20:05, are submitted.\n\n IMPRESSION:\n\n Interval improvement in airspace opacities within the right perihilar/upper\n and middle lobe and left mid and lower lobe suggestive of an improving\n pneumonia. Small left pleural effusion. Bilateral large pulmonary arteries\n consistent with known pulmonary arterial hypertension. Coarsening of the\n interstitium bilaterally which likely reflects underlying small airways\n disease. No pneumothorax. Stable cardiac and mediastinal contours. Interval\n removal of the right internal jugular central line. No acute bony abnormality\n appreciated.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1255105, "text": " 3:17 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: placment\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with right cvl placed\n REASON FOR THIS EXAMINATION:\n placment\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Central venous line placement.\n\n Portable AP radiograph of the chest was reviewed in comparison to prior study\n obtained the same day earlier.\n\n Left mid and lower lung consolidations are demonstrated as well as most likely\n present right perihilar opacity. Findings are concerning for pneumonia. The\n right internal jugular line has been placed with its tip at the level of mid\n SVC. There is no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-09-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1255097, "text": " 12:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ICP, mass?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57F with headache, fever\n REASON FOR THIS EXAMINATION:\n ICP, mass?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PBec SAT 1:54 AM\n no acute intracranial process\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Headache, fever. Evaluate for intracranial hemorrhage or mass.\n\n COMPARISON: No prior studies available for comparison.\n\n TECHNIQUE: Non-contrast axial images were obtained through the brain.\n Coronal and sagittal reformations are provided.\n\n FINDINGS: There is no evidence of hemorrhage, edema, large masses, mass\n effect, or acute infarct. Ventricles and sulci are normal. No osseous\n abnormality present. The mastoid air cells, middle ear cavities, and\n visualized paranasal sinuses are clear. No soft tissue swelling present.\n\n IMPRESSION: No acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-09-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1255098, "text": " 12:43 AM\n CHEST (PA & LAT) Clip # \n Reason: PNA?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57F with CP and cough and fever\n REASON FOR THIS EXAMINATION:\n PNA?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain, cough, fever, evaluate for pneumonia.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Frontal and lateral chest radiograph demonstrates unremarkable\n cardiomediastinal and hilar contours. On a background of interstitial edema,\n there are dense opacifications noted in the left lower lobe as well as within\n the lingula. No opacification is noted in the right lung. No pleural\n effusion or pneumothorax present.\n\n IMPRESSION: Left lower lobe and lingular pneumonia with background\n interstitial edema.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-03 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1255367, "text": " 2:53 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate for worsening pneumonia, post-obstructive pna, mass\n Admitting Diagnosis: PNEUMONIA\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hemoptysis, pneumonia on chest xray, persistently\n febrile on broad-spectrum antibiotics\n REASON FOR THIS EXAMINATION:\n Evaluate for worsening pneumonia, post-obstructive pna, mass, PE, cavitation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n , \n\n HISTORY: Hemoptysis. Question pneumonia, mass, or pulmonary embolus.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed with\n low-dose technique prior to second series of the scans during intravenous\n infusion of 100 mL Omnipaque nonionic iodinated contrast timed for\n optimal opacification of the pulmonary arterial system. The non-contrast\n scans were reconstructed as contiguous 5-mm thick axial images. The\n contrast-enhanced scans as 5-, 2.5-, 1.25-mm thick axial and 5-mm thick\n coronal, parasagittal and oblique MIP images. There are no prior CT scans for\n comparison.\n\n FINDINGS: The aorta is normal, maximum caliber of the ascending is 24 mm.\n Main, right and left pulmonary arteries are severely enlarged, 40 mm, 25 mm\n and 30 mm, respectively. There are no pulmonary emboli.\n\n Very small nonhemorrhagic pleural effusions layer posteriorly. A very small,\n but high attenuation pericardial effusion is either partially hemorrhagic,\n exudative, or chronic. There is no calcification or infiltration of the\n epicardial fat or impingement on the right atrium to suggest either tamponade\n or constrictive physiology.\n\n In both upper lungs are several regions of peribronchovascular ground-glass\n opacification with septal thickening, either pulmonary hemorrhage or edema.\n Much higher attenuation is found in two well circumscribed areas of\n consolidation in the anteromedial and posterior basal segments of the left\n lower lobe. These regions are distal to segmental and subsegmental bronchi\n occluded by secretions or blood in the small airways.\n\n Lymph node enlargement in the left hilus is minimal. In the mediastinum,\n however, adenopathy is real, with lymph nodes ranging in diameter up to 10 mm\n in the right and left lower paratracheal stations, 13 mm in the subcarinal,\n and 11 mm in the right hilus where there is no bronchial impingement.\n\n Heart is generally enlarged, particularly the left atrium.\n\n IMPRESSION:\n 1. Pulmonary hypertension, but no evidence of acute or chronic pulmonary\n (Over)\n\n 2:53 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate for worsening pneumonia, post-obstructive pna, mass\n Admitting Diagnosis: PNEUMONIA\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n emboli.\n 2. Residual, multifocal edema or pulmonary hemorrhage.\n 3. Left lower lobe pneumonia or segmental atelectasis. Segmental and\n subsegmental bronchial lumens occluded by debris, not by mass. Lymph node\n enlargement restricted to the contralateral (right) hilus and paratracheal\n mediastinal stations.\n 4. Small, non-serous pericardial effusion. No evidence of cardiac tamponade\n or constrictive pericarditis.\n\n Dr. and I discussed these findings by telephone at the time of\n dictation.\n\n" }, { "category": "Radiology", "chartdate": "2130-10-03 00:00:00.000", "description": "ABDOMEN US (COMPLETE STUDY)", "row_id": 1255305, "text": " 8:10 AM\n ABDOMEN US (COMPLETE STUDY) Clip # \n Reason: eval gallbladder, cbd\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with severe abdominal pain, diarrhea\n REASON FOR THIS EXAMINATION:\n eval gallbladder, cbd\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe abdominal pain and diarrhea.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND:\n\n The liver is normal in echotexture. There is a large 3.9 x 3.0 x 4.3 cm\n echogenic lesion within the inferior right hepatic lobe without significant\n vascular flow most likely representing a hemangioma. The portal vein is\n patent. There is no intra- or extra-hepatic biliary dilatation. Common bile\n duct measures 4 mm which is normal. The gallbladder is unremarkable without\n wall edema or gallstones. The right kidney measures 10.1 cm. The left kidney\n measures 10.3 cm. No stones or hydronephrosis. The spleen is normal in size.\n The visualized portions of the pancreas are unremarkable. The visualized\n aorta and IVC are of normal caliber. There are trace bilateral pleural\n effusions.\n\n IMPRESSION:\n\n 1. Echogenic lesion within the right hepatic lobe most likely representing a\n hemangioma.\n\n 2. No gallstones.\n\n 3. Trace bilateral pleural effusions.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2143-12-14 00:00:00.000", "description": "Report", "row_id": 1333868, "text": ": AWOKE PT FROM NAP, WITH ASSESSMENT, PT STATED HE WAS AT \" STADIUM\", THOUGHT IT WAS , PT INITIALLY DID NOT KNOW HIS NAME,\" IT'S THE JETS, PT FOLLOWING COMMANDS, PT ABLE TO LIFT AND HOLD LEFT LEG, ABLE TO LIFT AND HOLD LEFT ARM, PT DOES MOVE RIGHT ARM ON BED, PT WITH SOME MOVEMENT OF RIGHT LEG, DR. , DR. CALLED AND AWARE AND INTO ASSESS PATIENT. CARDS: PT REMAIN IN SR, TO SB. NUEROSURGICAL RESIDENTS WANT BP TO B/W 130-150, PT WAS ON NIPRIDE SHORTLY AND SHUT OFF SECONDARY TO BP IN 120'S. DR. AWARE, DR. AWARE. RESP: PT CONTINUES ON 4LNP.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-15 00:00:00.000", "description": "Report", "row_id": 1333869, "text": "TRANSFER NOTE:\n\n\nPT IS57 YEAR OLD MALE WITH PMH: GERD,INCREASE CHOL, HTN, OA,KNEE SURGERY, CYST REMOVED OFF BACK, NEUROMA OFF FOOT. PT WITH 4 MONTH H/O OF LEFT ARM TINGLING, DIZZINESS, PT HAD L ICA ANUERSYM AT BIFURIATION OF MCA. PT HAD WITH ANUEYRSM CLIPPING. POST OP PT ON NEO FOR BP SUPPORT. PT DEVELOPED RIGHT SIDED WEAKNESS, PT WENT DOWN FOR CTSCAN AND ANGIO ON , SHOWED NO VASOSPASM, BUT DID SHOW SMALL FRONTAL INFARACT. PT ALSO WITH RIGHT FACIAL DROP. POST OP, PT DEVELOPED SLURRED SPEECH, AT TIMES DIFFICULTY WITH WORD SEARCHING. PT NIPRIDE SHORTLY YESTERDAY, BUT NIPRIDE HAS BEEN OFF YESTERDAY. PT AWOKEN FROM NAP, ALERT BUT WHEN ASKED WHERE HE WAS HE WOULD STATE STADIUM, AND DID NOT KNOW HIS NAME, PT FOLLOWING COMMANDS, DR. UP TO ASSESS PATIENT, THEN RESOLVED ON OWN.\n\n\n: PT ALERT AND ORIENTED X3, PT DOES KNOW HE IS IN THE HOSPITAL, AT TIMES PT DOES NOT KNOW THE NAME OF HOSPITAL. NO WORD FINDING PROBLEMS NOTED TODAY. PT HAS RIGHT FACIAL DROP, NO SLURRED SPEECH NOTED. PT ABLE TO MOVE LIFT AND HOLD LEFT ARM AND LEFT LEG. PT ONLY CAN SLIGHTLY MOVE RIGHT ARM AND RIGHT LEG ON BED. PT DOES FOLLOW COMMANDS. BOTH PUPILS ARE EQUAL AND REACTIVE TO LIGHT. PT WITH BOOT ON RIGHT LEG. DILANTIN LEVEL BAC AS 3.8 PT 200MG OF DILANTIN EVERY 2HOURS X3.\nCARDS: PT REMAINS IN SR TO SBP. ALINE D/C'D TODAY. SBP HAS BEEN AS LOW AS 117-119/52, DR. AWARE, NO TX ORDERED.\nRESP: LUNGS CLEAR, PT COUGHING AND DEEP BREATHING. PT ON RA 02SAT 95-96%. GI: LAST NOC, MUTIPLE ATTEMPTS MADE BY DR. TO PLACE FEEDING TUBE,BUT UNSUCCESSFUL. PT TOLERATING REGULAR DIET MUCH BETTER TODAY THAN YESTERDAY, YESTERDAY FOOD KEPT GETTING CAUGHT IN RIGHT CHEEK, PT STATES IF FEELS BETTER TODAY. GU: PT MAKING UP TO 300CC/HR DR. AWARE, IVF INCREASE BACK TO 100CC/HR. PT LG AMT OF LIQUID STOOL, SPEC SENT OFF FOR C-DIFF. ACTIVITY: PT NEEDS THREE ASSIST TO GET OOB TO CHAIR, PT HAS MINIMAL MOVEMENT OF RIGHT LEG. THIS AFTERNOON WHILE GETTING PT OOB TO CHAIR, PT LOWERED TO FLOOR WITH ASSISTANCE OF NURSE , PT NOT INJURED.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-15 00:00:00.000", "description": "Report", "row_id": 1333870, "text": "add: urine output has been 400cc/hr dr. aware.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-15 00:00:00.000", "description": "Report", "row_id": 1333871, "text": ": alert and orientedx3. THIS AFTERNOON PT HAD DIFFICULT FINDING APPROIATE WORD, DR. AWARE. PT CONTINUES TO DIUREISIS 400CC/HR OF URINE PER HOUR DR. AWARE. PLT IS BEING TRANSFER TO 5.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-13 00:00:00.000", "description": "Report", "row_id": 1333865, "text": "Condition update/Nursing note:\nNeuro: Alert, oriented x3, brief period of disorientation - unable to state hospital and date but easily reoriented. +slurring of speech and some mild word finding difficulty noted. Able to move left side normally but right side weak w/weak hand grasp. Able to move right leg a bit but not able to wiggle toes. follows commands. Pupils 3mm and brisk bilat. Remains fidgety and restless. +ecchymosis to back of neck and ear on left side.\n\nCV: NSR, no ectopy in 70s.Neo gtt titrated for SBP 140-150,gtt off much of afternoon but on while sleeping and SBP dropped to 130s. +pboots worn, no cardiac c/o's.\n\nRESP: Lung sounds clear. Sats 94-97% on 4L NC. Given I/S w/improvement in sats noted, using w/encouragement.\n\nGI: +bs, abdomen soft, +flatus. tolerated small amount regular diet w/o difficulty. +large formed stool x1. no n/v.\n\nGU: Foley patent adequate amount clear yellow urine.\n\nACT: Evalutated by PT/OT today. ? OOB .\n\nSkin: no areas of breakdown noted. crani inc. to left side of head w/DSD intact. no drainage.\n\nENDO: Good glycemic control, no insulin SS required.\n\nPlan: encourage pulm. hygeine, cont. to monitor neuro assessment, Neo gtt to keep SBP 140-150, increase activity level.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-14 00:00:00.000", "description": "Report", "row_id": 1333866, "text": "NEURO STATUS\nD: PT IS ALERT AND FOLLOWS COMMANDS. SPEECH CONTINUES TO BE SLURRED AND HAS DIFFICULTY WORD FINDING. PT STILL WITH RT FACIAL DROOP. RT SIDE CONTINUES TO BE WEAK. WEAK RT ARM GRASP AND UNABLE TO WIGGLE TOES ON RT SIDE. INCONSISTENT MOVEMENT OF RT LEG. PUPILS ARE EQUAL AND REACITVE TO LIGHT. NEO REMAINS OFF AT THIS TIME.\nA: CONTINUE WITH NERUO CHECKS. NEO AS NEEDED TO KEEP SBP 150-156.\nR: NEUUO STATUS IS UNCHANGED.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-14 00:00:00.000", "description": "Report", "row_id": 1333867, "text": "Nuero: PT ALERT AND ORIENTED X3, AT TIMES DOES NOT KNOW THE NAME OF HOSPITAL, BUT HE DOES KNOW HE IS IN THE HOSPITAL. AT TIMES PT HAD DIFFICULT TIMES FINDING WORDS. PT SPEECH NOT AS SLURRED AS IT WAS THIS MORNING, BUT PT DOES STATE IT DOES STILL SOUNDS SLURRED TO HIM, \"ITS NOT BACK TO NORMAL\". R PT IS ABLE TO MOVE RIGHT HAND ON BED PT WILL LIGHTLY SQUEEZE RIGHT HANDS. RIGHT LEG PT ABLE TO MOVE RIGHT LEG ON BED, AT TIMES WILL SLIGHTLY BEND RIGHT LEG. LEFT HAND GRASP STRONG, LEFT LEG PT ABLE TO LIFT AND HOLD LEFT LEG. PT PUPILS BOTH EQUAL AND REACTIVE TO LIGHT. CARDS: PT REMAIN IN SR, TO SB. IV NIPRIDE STARTED AT LOW DOSE(PLEASE SEE FLOW SHEET) TO KEEP SBP LESS THAN 150. RESP: PT ON 4LNP, PT COUGHING AND DEEP BREATHING. GI: PT ATTEMPT TO EAT REGULAR DIET, (I.E TUNA FISH ), FOOD KEPT BEING BUILD UP IN RIGHT CHEEK, DR. AWARE. PT ALSO COUGHING A LOT WHEN EATING. PT PUT BACK ON CLEAR LIQUID DIET. GU: PT MAKING 150-200CC/HR DR. AWARE. CHEM 7 TO BE CHECKED AT 1700. PT X2 OF STOOL(GUAIC NEG). ACITIVY: PT OOB TO CHAIR WITH 3 ASSIST TOLERATING FINE.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-11 00:00:00.000", "description": "Report", "row_id": 1333861, "text": "Nursing note\nAdmitted from PACU S/P craniotomy for clipping of aneurism (elective). Easily arousable to voice. Sl right facial droop noted. Some difficulty finding words noted. MAE's, with right side slightly delayed. Left head incision covered with DSD, small amt s/s drainage noted. LS clear bil. Sat 98-99 on 4L/NC. Abd soft with +BS. NSR HR 90's. SBP 125-130. Neo on, titrating for SBP 140-160. #20 IV in R AC. #20 IV in L AC. R radial Aline patent. Denies pain/headache. Monitor B/P. Titrate neo for SBP of 150. Monitor neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-12 00:00:00.000", "description": "Report", "row_id": 1333862, "text": "NPN-CONDITION SUMMARY SEE ICU FLOWSHEET\nNEURO: GOAL SBP 140-160. NEO USED FOR B/P SUPPORT. NEURO STATUS VERY SENSITIVE TO DROPS IN B/P. NEO WAS FOUND DISLODGED FROM LINE AND DISCONNECTED. SBP DROPPED TO 120'S AND WAS UNABLE TO LIFT RUE AND SPEECH WAS GARBLED. WHEN NEO RECONNECTED, SBP QUICKLY RETURNED TO THE 140-160 RANGE AND NEURO STATUS RETURNED TO PRIOR LEVEL. WITH SBP IN GOAL, ALERT WITH SPONTANEOUS CONVERSATION. DOES HAVE SOME WORD FINDING DIFFICULTY AT TIMES. ABLE TO LIFT RUE OFF BED FOR SHORT PERIODS.\nINCISION DRESSING INTACT.\n\nCV: NEO FOR B/P SUPPORT. PIV X 2 AND A-LINE.\n\nRESP: O2 PER NC-WNL\n\nGI: ABD WNL AND FOLEY IS PATENT OF CLEAR DILUTE YELLOW URINE.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-12 00:00:00.000", "description": "Report", "row_id": 1333863, "text": "Nursing note/Condition update:\n\nNeuro: Alert and oriented x3, speech slurred. Following all commands. Moving left arm and leg in bed ad lib, able to lift and hold. Less movement w/right side, weak hand grasp w/right hand, able to wiggle toes and abduct right leg only. Slightly restless. PERRLA, 2mm and briskly reactive bilat. Head CT this am.Angio negative for vasospasms this am, ? area of infarct. Begun on Decadron and Dilantin, receiving Albumin q8hrs.\n\nCV: NSR, no ectopy. Rate in 60s-70s. SBP maintained 140-160 w/neo gtt. +pulses after angio done. pboots on. knee immobilizer on to right leg and restraint on ankle to keep leg straight s/p angio. No hematoma at site. New IV placed to left hand.\n\nRESP: Lung sounds clear throughout. Encouraged to cough and deep breath. Sats 93-96% on L NC.\n\nGI: +bs, abdomen soft, non-tender and non-distended. +flatus. remains NPO. no further episodes of n/v.\n\nGU: Foley patent qs light yellow urine.\n\nACT: Pt. laying flat after angio x 6hours, able to assist w/turning side to side. Frequent position changes done secondary to discomfort related to chronic arthritis.\n\nPlan: Maintain SBP 140-160 w/neo gtt, continue to monitor neuro status for change, encourage pulm. toilet.\n" }, { "category": "Nursing/other", "chartdate": "2143-12-13 00:00:00.000", "description": "Report", "row_id": 1333864, "text": "FOCUS: NEUROLOGICAL STATUS\nDATA:\nPT ALERT AND ORIENTED X3. PT. CONFUSED ABOUT PLACE X1 ASSESSMENT BUT REORIENTED QUICKLY. HE CONTINUES TO HAVE SLURRED SPEECH. MOVES L SIDE WITH NORMAL STRENGTH. R SIDE MOVES IN BED BUT UNABLE TO LIFT THOSE EXTREMITIES. HE SQUEEZES WITH R HAND BUT UNABLE TO WIGGLE TOES. VERY FIDGETY ALL NIGHT AND SLEPT VERY LITTLE. HEAD DSG INTACT. ECCHYMOTIC L NECK AND BEHIND L EAR. HE CONTINUES ON NEO GTT. WEANING AS TOLERATED, MAINTAINING BP >150. R GROIN SITE CLEAN, NO BLEEDING OR HEMATOMA. STRONG PALPABLE PEDAL PULSES.\n\nPLAN:\nCONT TO WEAN NEO AS TOL.\n" }, { "category": "Radiology", "chartdate": "2143-12-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 748799, "text": " 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P Clipping of L MCA aneurysm. HAs persistant Right hemipar\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with\n REASON FOR THIS EXAMINATION:\n S/P Clipping of L MCA aneurysm. HAs persistant Right hemiparesis. Pl evaluate.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST:\n\n INDICATION: Clipping of left MCA aneuerysm with persistent headaches.\n\n Multiple axial images were obtained from base to vertex without IV contrast\n administration. No prior head CT's are available for comparison. The patient\n has undergone clipping of a left MCA aneurysm.\n\n There is a surgical clip seen in the region of the left middle cerebral artery\n with significant beam hardening artifact. The patient has underone recent\n aneurysm clipping. There is significant pneumocephalus due to the patient's\n recent surgery and craniotomy in the left frontal region. A tiny amount of\n gas is also seen along the anterior portion of the middle cranial fossa on the\n right. There is no intraparenchymal hemorrhage noted. No midline shift or\n mass effect is seen. There are no extra-axial fluid collections. Superficial\n soft tissue edema is seen overlying the left frontal craniotomy flap.\n\n IMPRESSION: S/P surgical recent clipping of a left MCA aneurysm.\n Pneumocephalus overlying the frontal lobes bilaterally. Surgical clip in\n position. No intraparenchymal hemorrhage is seen. Further follow up is\n recommended if the patient's headaches persist.\n\n" }, { "category": "Radiology", "chartdate": "2143-12-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 748824, "text": " 7:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed, edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p aneurysm clipping now w/ neuro exam change\n REASON FOR THIS EXAMINATION:\n r/o bleed, edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Change in neurological exam. Post-aneurysm clipping.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: In the interval since yesterday's exam, an area of low attenuation\n in the posterior limb and genu of the left internal capsule has become\n apparent. There is no significant mass effect seen surrounding this lesion.\n There has been interval decrease in degree of pneumocephalus. Craniotomy\n defect is again noted with high-density material along the convexity of the\n frontal lobe immediately subjacent to the surgical site. There is no\n parenchymal or extraaxial hemorrhage identified. There is no shift of\n normally midline structures or mass effect. -white differentiation is\n preserved. The visualized ventricles, cisterns and sulci are within normal\n limits. Aneurysm clip is again noted in the region of the origin of the\n internal carotid bifurcation with significant beam hardening artifact\n surrounding it.\n\n IMPRESSION:\n\n Interval appearance of low attenuation in the left internal capsule genu and\n posterior limb suggestive of developing infarct.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2143-12-12 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 748832, "text": " 8:32 AM\n CAROT/CEREB Clip # \n Reason: VASOSPASM\n Contrast: OPTIRAY Amt: 65\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER CAROTID/CEREBRAL UNILAT *\n * CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Left internal carotid artery bifurcation aneurysm\n status post clipping. New onset of right-sided weakness.\n\n POSTOPERATIVE DIAGNOSIS: Well-clipped aneurysm with no evidence of residual.\n Patent middle cerebral artery and anterior cerebral artery trunks and patent\n anterior choroidal artery.\n\n ANESTHESIA: Monitored anesthesia care, local infiltration of the right groin\n with 10 cc of 1% lidocaine.\n\n INDICATION FOR PROCEDURE: This patient underwent a left-sided craniotomy with\n clipping of a left internal carotid artery bifurcation aneurysm.\n Postoperatively, he was noted to be somewhat weaker on the right side,\n however, this fluctuated with his blood pressure and was discounted as being\n the result of either retraction injury or a transient ischemia. He was\n treated with hypertension hypervolemia with some improvement, however, on\n postoperative day 1 was noted to have a worsening of his examination. He was\n taken to the undergo this angiogram under emergency condition to rule out the\n possibility of a major branch occlusion.\n\n CONSENT: Consent was obtained from the patient's wife. She understood the\n indication and possible complications of the procedure and wished to proceed\n with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought to the Angiographic Suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion. An 18-gauge single-wall\n needle was used to puncture the right common femoral artery. Upon the return\n of brisk arterial blood, a 5-French vascular sheath was secured in position.\n At this point, a 5-French diagnostic angiographic catheter was used over a\n hydrophilic wire to selectively catheterize the left common carotid artery and\n then the left internal carotid artery. With the catheter in the left internal\n carotid artery, a series of multiple runs was obtained including a propeller\n run. At this point, examination of the vessels revealed no evidence of major\n anomaly, and the patient was returned back to the Intensive Care Unit.\n\n RESULTS: Injection of the left common carotid artery reveals no evidence of\n stenosis or dissection or anomaly. Injection of the left internal carotid\n artery reveals a well-clipped, previously-noted internal carotid artery\n bifurcation aneurysm with no evidence of residual with the use of two clips a\n large bayonetted one and a small , located anteriorly. There is no\n evidence of impingement of the middle cerebral artery or anterior cerebral\n artery and there is good filling of the anterior choroidal artery.\n (Over)\n\n 8:32 AM\n CAROT/CEREB Clip # \n Reason: VASOSPASM\n Contrast: OPTIRAY Amt: 65\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n IMPRESSION: Angiographically clipped aneurysm with no evidence of residual\n and no evidence of overt branch occlusion.\n\n , MD, Ph.D.\n\n\n\n\n\n\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2162-12-07 00:00:00.000", "description": "Report", "row_id": 179735, "text": "Sinus rhythm. Borderline P-R interval prolongation. Left atrial abnormality.\nLeft bundle-branch block. Consider inferior myocardial infarction. No previous\ntracing available for comparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2112-03-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1133372, "text": ", V. MED FA2 8:21 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please assess for any evidence of colitis or other etiology\n Admitting Diagnosis: AFIB/AFLUTTER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with 15-20 bloody bowel movements per day\n REASON FOR THIS EXAMINATION:\n Please assess for any evidence of colitis or other etiology of bloody BMs\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Chronic wall thickening and mild surrounding inflammatory change involving\n the ascending colon, transverse colon, and descending colon. The sigmoid\n colon and rectum are difficult to evaluate as they are collapsed. The\n terminal ileum also appears thickened. Findings are likely inflammatory or\n infectious in nature. There are no secondary signs of ischemia, although this\n cannot be fully excluded.\n\n 2. 6-mm non-obstructing proximal right ureteral stone. Mild dilatation of\n the right ureter in its mid portion, which may represent a passed stone.\n\n 3. Focal left renal cortical scarring and two punctate non-obstructing\n stones.\n\n" }, { "category": "Radiology", "chartdate": "2112-03-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1133334, "text": " 12:00 AM\n CHEST (PA & LAT) Clip # \n Reason: pnuemonia? signs of PE?\n Admitting Diagnosis: AFIB/AFLUTTER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with intermittent CP\n REASON FOR THIS EXAMINATION:\n pnuemonia? signs of PE?\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Intermittent chest pain, question pneumonia or any indication of\n pulmonary embolism.\n\n IMPRESSION: PA and lateral chest reviewed in the absence of prior chest\n radiographs:\n\n Mild-to-moderate cardiomegaly is exaggerated by a pectus deformity of the\n sternum. Aside from a band of linear atelectasis inferior to the left hilus,\n the lungs are clear. There is no pulmonary edema and no pleural effusion or\n evidence of central adenopathy and the hila are normal size. Findings do not\n suggest pulmonary embolism in order to exclude that diagnosis. Incidental\n note made of healed left lower lateral rib fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-03 00:00:00.000", "description": "RENAL U.S.", "row_id": 1134031, "text": " 6:59 PM\n RENAL U.S. Clip # \n Reason: PT WITH URETERAL STONE, PLEASE EVAL FOR HYDRONEPHROSIS\n Admitting Diagnosis: AFIB/AFLUTTER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with CRI, GI bleed, atrial flutter.\n REASON FOR THIS EXAMINATION:\n Please eval for hydronephrosis.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy SUN 8:01 PM\n PFI: Findings in keeping with recent CT, . There is\n non-obstructing 7-mm stone at the right UPJ, and a right extrarenal pelvis,\n without hydronephrosis. On the left, there is scarring in the interpolar\n region of the left kidney, with punctate non-obstructing stones. There is no\n hydronephrosis on the left _____. There are no renal mass lesions and there\n is no perinephric fluid collection identified. The bladder is normal.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old male with chronic renal insufficiency. Evaluate for\n hydronephrosis.\n\n COMPARISON: CT abdomen and pelvis dated .\n\n RENAL ULTRASOUND: The right kidney measures 13.2 cm. There is no\n hydronephrosis on the right. There is an extrarenal pelvis identified, as\n seen on recent CT. Additionally, a small, 7-mm stone is identified at the\n ureteropelvic junction. There is no renal mass lesion and no perinephric\n fluid collection.\n\n The left kidney measures 10.2 cm. There is a focal area of cortical thinning\n in the interpolar region of the left kidney, compatible with scarring. There\n is a small 9-mm cyst at the lower pole of the left kidney. There is no left\n hydronephrosis or mass lesion. There is no perinephric fluid collection.\n\n The bladder is distended and appears normal. Ureteral jets were not\n evaluated.\n\n IMPRESSION:\n\n 1. Non-obstructing 7-mm stone at the right UPJ, with a right extrarenal\n pelvis, with no evidence for right hydronephrosis.\n\n 2. Focal cortical thinning in the left kidney without hydronephrosis or\n obstructing nephrolithiasis on the left. Small cyst at the lower pole of the\n left kidney.\n\n" }, { "category": "Radiology", "chartdate": "2112-04-03 00:00:00.000", "description": "RENAL U.S.", "row_id": 1134032, "text": ", N. MED FA3 6:59 PM\n RENAL U.S. Clip # \n Reason: PT WITH URETERAL STONE, PLEASE EVAL FOR HYDRONEPHROSIS\n Admitting Diagnosis: AFIB/AFLUTTER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with CRI, GI bleed, atrial flutter.\n REASON FOR THIS EXAMINATION:\n Please eval for hydronephrosis.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Findings in keeping with recent CT, . There is\n non-obstructing 7-mm stone at the right UPJ, and a right extrarenal pelvis,\n without hydronephrosis. On the left, there is scarring in the interpolar\n region of the left kidney, with punctate non-obstructing stones. There is no\n hydronephrosis on the left _____. There are no renal mass lesions and there\n is no perinephric fluid collection identified. The bladder is normal.\n\n" }, { "category": "Radiology", "chartdate": "2112-04-04 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 1134104, "text": " 12:53 PM\n BILAT UP EXT VEINS US Clip # \n Reason: Please eval b/l UE's for DVT, superficial thrombophlebitis,\n Admitting Diagnosis: AFIB/AFLUTTER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with b/l antecubital TTP and erythema, also atrial flutter and\n GI bleed.\n REASON FOR THIS EXAMINATION:\n Please eval b/l UE's for DVT, superficial thrombophlebitis, fluid collection at\n prior IV sites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 46-year-old man with bilateral antecubital TTP and erythema,\n evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral IJ,\n subclavian, axillary, brachial, and basilic veins. Note is made that the\n cephalic vein could not be identified in either arm. There is occlusive\n thrombus seen within the right basilic vein extending throughout the forearm.\n Occlusive thrombus is also seen in the left basilic vein extending throughout\n the forearm and into the left antecubital fossa. Normal flow, compression,\n and augmentation is seen in all of the veins above the antecubital fossa\n bilaterally.\n\n IMPRESSION: Occlusive thrombus seen within the basilic veins bilaterally. On\n the right arm, the thrombus is in the forearm below the antecubital fossa. In\n the left arm, the thrombus is in the forearm and extends into the antecubital\n fossa.\n\n These findings were conveyed to Dr. at 2:05 p.m., .\n\n\n" }, { "category": "Radiology", "chartdate": "2112-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1133449, "text": " 3:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for CHF.\n Admitting Diagnosis: AFIB/AFLUTTER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with afib/flutter, CP.\n REASON FOR THIS EXAMINATION:\n Please eval for CHF.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain, to evaluate for congestive failure.\n\n FINDINGS: In comparison with the earlier study of this date, there is no\n interval change. Mild-to-moderate enlargement of the cardiac silhouette\n persists. Specifically, there is no evidence of pulmonary edema. No acute\n pneumonia or pleural effusion is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-03-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1133371, "text": " 8:21 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please assess for any evidence of colitis or other etiology\n Admitting Diagnosis: AFIB/AFLUTTER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with 15-20 bloody bowel movements per day\n REASON FOR THIS EXAMINATION:\n Please assess for any evidence of colitis or other etiology of bloody BMs\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AKPe WED 1:13 PM\n 1. Chronic wall thickening and mild surrounding inflammatory change involving\n the ascending colon, transverse colon, and descending colon. The sigmoid\n colon and rectum are difficult to evaluate as they are collapsed. The\n terminal ileum also appears thickened. Findings are likely inflammatory or\n infectious in nature. There are no secondary signs of ischemia, although this\n cannot be fully excluded.\n\n 2. 6-mm non-obstructing proximal right ureteral stone. Mild dilatation of\n the right ureter in its mid portion, which may represent a passed stone.\n\n 3. Focal left renal cortical scarring and two punctate non-obstructing\n stones.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Bloody bowel movements.\n\n TECHNIQUE: MDCT of the abdomen and pelvis was performed following the\n uneventful administration of nonionic intravenous contrast and oral contrast.\n There are no prior studies for comparison.\n\n FINDINGS:\n Limited images of the lung bases demonstrate minimal atelectasis.\n\n There is a subcentimeter hypodensity in segment VI of the liver, too small to\n characterize, but likely representing a small cyst or hemangioma. There are\n no other focal liver lesions, and there is no biliary dilatation. There is a\n 6-mm stone within the proximal right ureter, with proximal ureteral\n thickening, but no evidence of hydronephrosis. The remainder of the right\n ureter is free of stones, although mildly dilated in its mid portion. The left\n kidney demonstrates marked cortical scarring in the mid pole and two punctate\n stones are identified. There is no evidence of left hydronephrosis or left\n hydroureter. The left ureter is free of stones.\n\n The adrenal glands, spleen, pancreas, and gallbladder are normal. There are\n no pathologically enlarged lymph nodes by size criteria. There is no ascites.\n\n The colon is mildly diffusely thickened, with some areas of surrounding\n inflammatory change, especially along the descending colon. The anatomy of\n the ileocecal valve appears altered, consistent with history of appendectomy\n and partial bowel resection. The terminal ileum is thickened. The remainder\n (Over)\n\n 8:21 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please assess for any evidence of colitis or other etiology\n Admitting Diagnosis: AFIB/AFLUTTER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the small bowel is normal. The sigmoid colon and rectum are collapsed and\n difficult to evaluate. There is no focal fluid collection or perforation.\n There is no pneumatosis.\n\n PELVIS: There is atrophy of the lower left rectus muscle. The bladder and\n prostate are unremarkable. There is no pelvic free fluid or adenopathy.\n\n Bone windows demonstrate no focal suspicious lesions.\n\n IMPRESSION:\n 1. Colonic wall thickening and mild surrounding inflammatory change involving\n the ascending, transverse, and descending colon. The sigmoid colon and rectum\n are difficult to evaluate as they are collapsed. The terminal ileum also\n appears thickened. Findings are likely inflammatory or infectious in nature.\n There are no secondary signs of ischemia, although this cannot be fully\n excluded.\n\n 2. 6-mm non-obstructing proximal right ureteral stone with proximal ureteral\n thickening, likely reactive. Mild dilatation of the right ureter in its mid\n portion, which may be due to prior passed stone.\n\n 3. Focal left renal cortical scarring and two punctate non-obstructing\n stones.\n\n" }, { "category": "Radiology", "chartdate": "2112-04-05 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1134300, "text": " 4:44 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: needs iv access for hydration/blood\n Admitting Diagnosis: AFIB/AFLUTTER\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 yo M w/ aflutter s/p ablation, BRBPR plan for \n REASON FOR THIS EXAMINATION:\n needs iv access for hydration/blood\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT.\n\n INDICATION: IV access needed for hydration and blood transfusion.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure. Dr. ,\n the attending radiologist, reviewed the study.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access are on file. A peel-away sheath was then\n placed over a guidewire and a double-lumen PICC line measuring 41 cm in length\n was then placed through the peel-away sheath with its tip positioned in the\n SVC under fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest. The peel-away sheath and guidewire were\n then removed. The catheter was secured to the skin, flushed, and a sterile\n dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double-lumen PICC line placement via the right brachial venous approach.\n Final internal length is 41 cm, with the tip positioned in SVC. The line is\n ready to use.\n\n" }, { "category": "Echo", "chartdate": "2112-04-05 00:00:00.000", "description": "Report", "row_id": 90888, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial flutter. Pre-flutter ablation.\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nBP (mm Hg): 156/78\nHR (bpm): 125\nStatus: Inpatient\nDate/Time: at 14:49\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. RV function depressed.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. No TEE related complications. Results were reviewed\nwith the Cardiology Fellow involved with the patient's care.\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. The right atrium is dilated. Left ventricular wall thicknesses and\ncavity size are normal. LV systolic function appears mildly to moderately\ndepressed globally. Right ventricular chamber size is normal with depressed\nfree wall contractility. There are simple atheroma in the aortic arch. There\nare simple atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. No mass or vegetation is seen.\n\nIMPRESSION: No spontaneous echo contrast or thrombus in the left atrium/left\natrial appendage. Mildly to moderately depressed global left ventricular\nsystolic function. Depressed right ventricular systolic function. Mild aortic\nregurgitation. Simple atheroma in the aortic arch and descending thoracic\naorta.\n\nDr. was notified in person of the results on at 12:30pm.\n\n\n" }, { "category": "Echo", "chartdate": "2112-04-05 00:00:00.000", "description": "Report", "row_id": 90889, "text": "PATIENT/TEST INFORMATION:\nIndication: evaluate for effusion s/p a flutter ablation\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nStudy interpreted from the Vivid Q loaner machine due to difficulties in\ndownloading moving images to the\nEchoPAC vault.\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is no pericardial effusion. There is left ventricular hypertrophy. Left\nventricular systolic function appears mildly to moderately depressed (LVEF\n?40%) in focused views.\n\nCompared to the prior study of , views are limited but suggest that\nleft ventricular systolic function is now less vigorous.\n\n\n" }, { "category": "Echo", "chartdate": "2112-03-30 00:00:00.000", "description": "Report", "row_id": 90890, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Atrial flutter. Hypertension.\nHeight: (in) 72\nWeight (lb): 195\nBSA (m2): 2.11 m2\nBP (mm Hg): 116/70\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 16:00\nTest: Portable TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes. No LA mass/thrombus (best excluded\nby TEE).\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. Normal IVC\ndiameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure\n(0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Trabeculated LV apex. 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. Mild coarctation of distal aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No left atrial\nmass/thrombus seen (best excluded by transesophageal echocardiography). The\nestimated right atrial pressure is 0-5 mmHg. There is mild symmetric left\nventricular hypertrophy with normal cavity size and regional/global systolic\nfunction (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. There appears to be a mild coarctation of the distal aortic arch. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. Trace aortic regurgitation is seen. The\nmitral valve appears structurally normal with trivial mitral regurgitation.\nThe estimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. ?Mild coarctation of the distal\naortic arch.\nIf clinically indicated a thoracic CT or MR or a TEE would be better able to\nanatomically define the possible mild aortic coarctation.\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": "2112-03-29 00:00:00.000", "description": "Report", "row_id": 229044, "text": "Atrial fibrillation. Incomplete right bundle-branch block. Modest left axis\ndeviation is non-diagnostic. ST-T wave abnormalities. Findings are\nnon-specific. Clinical correlation is suggested. Since the previous tracing of\nsame date atrial fibrillation with slower ventricular response has replaced\nrapid atrial flutter, axis is less leftward and T wave changes are now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-04-05 00:00:00.000", "description": "Report", "row_id": 229035, "text": "Atrial flutter with rapid ventricular response. Right bundle-branch block.\nProbable left anterior fascicular block. Since the previous tracing of \nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2112-04-02 00:00:00.000", "description": "Report", "row_id": 229036, "text": "Atrial flutter. Right bundle-branch block with left anterior fascicular block.\nCompared to the previous tracing the rate and rhythm have changed.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2112-04-01 00:00:00.000", "description": "Report", "row_id": 229037, "text": "Sinus rhythm. Sinus rhythm. Right bundle-branch block. Left anterior fascicular\nblock. Compared to the previous tracing the rate and rhythm have changed.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-04-01 00:00:00.000", "description": "Report", "row_id": 229038, "text": "Atrial flutter with 2:1 block. Right bundle-branch block with left anterior\nfascicular block pattern. Compared to the previous tracing of there is\nno change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2112-03-31 00:00:00.000", "description": "Report", "row_id": 229039, "text": "Probable atrial flutter with 2:1 A-V block. Atrial rate 286, ventricular\nrate 143. Non-specific repolarization changes. Left anterior hemiblock.\nRight bundle-branch block. Compared to the previous tracing of \n4:1 A-V block with atrial flutter has given way to 2:1 A-V block and the\nventricular rate is nearly doubled.\n\n" }, { "category": "ECG", "chartdate": "2112-03-30 00:00:00.000", "description": "Report", "row_id": 229040, "text": "Atrial flutter with variable A-V block. Compared to tracing #1 ventricular\nresponse has slowed.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-03-30 00:00:00.000", "description": "Report", "row_id": 229041, "text": "Probable atrial flutter with rapid ventricular response. Modest left axis\ndeviation with left anterior fascicular block. Right bundle-branch block.\nNon-specific ST-T wave changes. Probable inferior myocardial infarction of\nindeterminate age. Compared to the previous tracing of atrial flutter\nis new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2112-03-30 00:00:00.000", "description": "Report", "row_id": 229042, "text": "Sinus rhythm. Right bundle-branch block. Modest left axis deviation may be due\nto left anterior fascicular block and possible prior inferior myocardial\ninfarction although is non-diagnostic. Anterolateral lead ST-T wave changes are\nnon-specific but cannot exclude myocardial ischemia. Clinical correlation is\nsuggested. Since the previous tracing of same date there is no significant\nchange.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2112-03-30 00:00:00.000", "description": "Report", "row_id": 229043, "text": "Sinus rhythm. Incomplete right bundle-branch block. Modest left axis deviation\nis non-diagnostic although may be left anterior fascicular block or possible\nprior inferior myocardial infarction. Anterolateral lead ST-T wave changes are\nnon-specific but cannot exclude myocardial ischemia. Clinical correlation is\nsuggested. Since the previous tracing of atrial fibrillation is absent\nand further T wave changes are seen.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2112-03-29 00:00:00.000", "description": "Report", "row_id": 229270, "text": "Atrial flutter with rapid ventricular response. Incomplete right bundle-branch\nblock. Left axis deviation may be due to left anterior fascicular block. No\nprevious tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2178-03-12 00:00:00.000", "description": "Report", "row_id": 172154, "text": "Artifact is present. Sinus rhythm. There is a late transition which is\nprobably normal. Non-specific ST-T wave changes. Compared to the previous\ntracing there is no significant change.\n\n" }, { "category": "Physician ", "chartdate": "2178-03-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 630126, "text": "TITLE:\n Chief Complaint: Throat swelling\n .\n Reason for MICU admission: Monitoring of angioedema\n HPI: 69 year-old man with a h/o DM2, CAD, CHF, GERD, chronic sinusitis,\n asthma, s/p esophageal dilatation who presents with uvular swelling.\n Pt reports that he was walking to the bathroom at midnight when he\n noted the onset of a swelling sensation in his throat with difficulty\n and mild pain on swallowing. He also notes mild lip swelling. No\n urticaria, flushing, pruritis, or lightheadedness. No fevers, cough,\n swollen lymph nodes, sore throat, or purulent sputum. He has stable\n rhinorrhea worst at night from chronic sinusitis. He denies any\n difficulty handling his secretions or dysphagia; these sx are\n dissimilar from those leading to his esophageal dilatation several\n years ago. The patient does recall one similar prior episode a few\n years ago after eating a . At an OSH ED, he was given some\n medications and the swelling resolved after several hours; this was\n attributed to mayonnaise. He has tolerated this fine since and denies\n mayonnaise or other new foods recently. He reports being on lisinopril\n for 2-3 years; he believes he was taking it at the time of this\n previous episode. His only new medication is ferrous sulfate, started\n yesterday AM. He has not taken ASA or NSAIDs in at least 4 months due\n to his renal failure. No insect stings or chemical exposures. No\n chronic abdominal pain or family history of angioedema.\n .\n In the ED, initial vs were: T 98, P 82, BP 161/66, RR 22, O2sat 100. Pt\n was without stridor or wheezing with minimal tongue and lip swelling\n but +uvular hydrops. He was given diphenhydramine 50mg IV, famotidine\n 20mg IV, and methylprednisolone 125mg IV. Pt stable but given absence\n of improvement, he is being admitted to the ICU. VS on transfer: T\n 98.0, P 83, BP 151/79, RR 14, O2sat 100% 2L.\n .\n On the floor, pt currently reports slight improvement in his swelling.\n No difficulty handling secretions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n ALBUTEROL SULFATE (on med list but not taking)\n CALCITRIOL 0.25 mcg daily\n FUROSEMIDE 80 mg \n GLYBURIDE 5 mg daily\n INSULIN GLARGINE [LANTUS] 8 units daily\n LISINOPRIL 40 mg \n METOPROLOL TARTRATE 25 mg \n NIFEDIPINE SR 90 mg daily\n SEVELAMER CARBONATE [RENVELA] 1600 mg tid w/ meals\n SIMVASTATIN 80 mg daily\n IRON 325 mg daily\n Past medical history:\n Family history:\n Social History:\n Diabetes mellitus 2\n Hypertension\n Hyperlipidemia\n CAD with \"mild MI\" in the past per patient\n CHF (EF 51% on stress MIBI)\n ESRD undergoing work-up for PD and transplant\n Chronic sinusitis\n H/o asthma (last exacerbation in )\n GERD\n S/p esophageal dilatation several years ago\n S/p removal of benign cyst under tongue at age 15\n No h/o angioedema. Strong family history of DM, ESRD(several siblings\n on HD), and CAD.\n Lives with wife and daughters and granddaughters. Retired, used to work\n for a cleaning company.\n - Tobacco: Quit tobacco 20 yrs ago\n - Alcohol: Denies\n - Illicits: Denies\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, stably fluctuating weights due\n to CHF. Denies headache. Chronic sinus tenderness, rhinorrhea, and\n congestion. Denies cough, shortness of breath, or wheezing. Denies\n chest pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, abdominal pain. 1 episode of diarrhea yesterday; none\n since. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 01:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 98 (90 - 99) bpm\n BP: 159/65(87) {159/65(73) - 188/75(97)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 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: 100%\n Physical Examination\n Vitals: T 96.9, P 90, BP 165/73, RR 14, O2sat 100% 2L\n General: Alert, oriented, no acute distress, stridor, or wheezing\n HEENT: Sclera anicteric, MMM, lips and tongue not noticeably swollen,\n uvular hydrops without exudates, no erythema, no parotitis\n Neck: Supple, JVP not elevated, no LAD, nontender\n Lungs: Minimal crackles at bilateral bases, otherwise clear without\n wheezes.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Soft, non-tender, obese but non-distended, bowel sounds\n present, no rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 2+ pulses, trace LE edema\n Skin: No flushing or rash\n Neuro: AAO x 3, nonfocal\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 69 yo man with DM, CAD, GERD, chronic sinusitis, asthma, s/p esophageal\n dilatation p/w angioedema.\n .\n # Angioedema: C/w angioedema. Most commonly associated with ACE-I.\n Does have a history of similar episode; acquired C1 inhibitor\n deficiency possible - familial less likely given age and absence of\n family hx. Did just start iron supplement and allergy to a component\n is possible, but time course not as consistent and more likely\n kinin-mediated rather than mast cell given absence of urticaria,\n prurutis. No inhalant abuse; not taking ASA or NSAIDS due to renal\n failure. Pharyngitis can cause uvular swelling but no fever, exudates,\n or sore throat to suggest acute infectious etiology.\n - Check C4, C1 inh levels\n - Discontinue ACE-I\n - Hold iron supplements for now; discuss with primary providers\n - Sips for now, advance diet as tolerated\n - Monitor airways; currently stable but may need IV steroids, H2B,\n antihistamines if acute worsening or intubation if airway compromise\n .\n # HTN: Hypertensive; did not take usual meds this AM.\n - Hydralazine IV prn for SBP >180\n - No lisinopril but restart other oral meds (metoprolol, nifedipine,\n lasix) when able to tolerate po, likely in PM\n .\n # DM:\n - FSG qid with HISS for now\n - Would consider discontinuation of glyburide given ESRD\n .\n # ESRD: In work-up for PD and transplant\n - Will make primary providers aware of admission\n - F/u labs\n - Resume sevelamer and calcitriol when able\n .\n # CAD: Stable\n - Baseline EKG\n - Restart simvastatin, metoprolol when able\n - No lisinopril\n .\n # CHF: Euvolemic\n - Restart po lasix when able; IV lasix for now if acutely fluid\n overloaded\n .\n # HL: Restart simvastatin when able\n ICU Care\n Nutrition: No IVF, replete electrolytes, sips - advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 10:01 AM\n Prophylaxis:\n DVT: Subcutaneous heparin\n Communication: Patient\n Code status: Full. HCP is daughter ()\n Disposition: ICU pending clinical improvement, likely discharge either\n this evening or tmrw AM\n" }, { "category": "Physician ", "chartdate": "2178-03-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 630128, "text": "TITLE:\n Chief Complaint: Throat swelling\n .\n Reason for MICU admission: Monitoring of angioedema\n HPI: 69 year-old man with a h/o DM2, CAD, CHF, GERD, chronic sinusitis,\n asthma, s/p esophageal dilatation who presents with uvular swelling.\n Pt reports that he was walking to the bathroom at midnight when he\n noted the onset of a swelling sensation in his throat with difficulty\n and mild pain on swallowing. He also notes mild lip swelling. No\n urticaria, flushing, pruritis, or lightheadedness. No fevers, cough,\n swollen lymph nodes, sore throat, or purulent sputum. He has stable\n rhinorrhea worst at night from chronic sinusitis. He denies any\n difficulty handling his secretions or dysphagia; these sx are\n dissimilar from those leading to his esophageal dilatation several\n years ago. The patient does recall one similar prior episode a few\n years ago after eating a . At an OSH ED, he was given some\n medications and the swelling resolved after several hours; this was\n attributed to mayonnaise. He has tolerated this fine since and denies\n mayonnaise or other new foods recently. He reports being on lisinopril\n for 2-3 years; he believes he was taking it at the time of this\n previous episode. His only new medication is ferrous sulfate, started\n yesterday AM. He has not taken ASA or NSAIDs in at least 4 months due\n to his renal failure. No insect stings or chemical exposures. No\n chronic abdominal pain or family history of angioedema.\n .\n In the ED, initial vs were: T 98, P 82, BP 161/66, RR 22, O2sat 100. Pt\n was without stridor or wheezing with minimal tongue and lip swelling\n but +uvular hydrops. He was given diphenhydramine 50mg IV, famotidine\n 20mg IV, and methylprednisolone 125mg IV. Pt stable but given absence\n of improvement, he is being admitted to the ICU. VS on transfer: T\n 98.0, P 83, BP 151/79, RR 14, O2sat 100% 2L.\n .\n On the floor, pt currently reports slight improvement in his swelling.\n No difficulty handling secretions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n ALBUTEROL SULFATE (on med list but not taking)\n CALCITRIOL 0.25 mcg daily\n FUROSEMIDE 80 mg \n GLYBURIDE 5 mg daily\n INSULIN GLARGINE [LANTUS] 8 units daily\n LISINOPRIL 40 mg \n METOPROLOL TARTRATE 25 mg \n NIFEDIPINE SR 90 mg daily\n SEVELAMER CARBONATE [RENVELA] 1600 mg tid w/ meals\n SIMVASTATIN 80 mg daily\n IRON 325 mg daily\n Past medical history:\n Family history:\n Social History:\n Diabetes mellitus 2\n Hypertension\n Hyperlipidemia\n CAD with \"mild MI\" in the past per patient\n CHF (EF 51% on stress MIBI)\n ESRD undergoing work-up for PD and transplant\n Chronic sinusitis\n H/o asthma (last exacerbation in )\n GERD\n S/p esophageal dilatation several years ago\n S/p removal of benign cyst under tongue at age 15\n No h/o angioedema. Strong family history of DM, ESRD(several siblings\n on HD), and CAD.\n Lives with wife and daughters and granddaughters. Retired, used to work\n for a cleaning company.\n - Tobacco: Quit tobacco 20 yrs ago\n - Alcohol: Denies\n - Illicits: Denies\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, stably fluctuating weights due\n to CHF. Denies headache. Chronic sinus tenderness, rhinorrhea, and\n congestion. Denies cough, shortness of breath, or wheezing. Denies\n chest pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, abdominal pain. 1 episode of diarrhea yesterday; none\n since. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 01:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 98 (90 - 99) bpm\n BP: 159/65(87) {159/65(73) - 188/75(97)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 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: 100%\n Physical Examination\n Vitals: T 96.9, P 90, BP 165/73, RR 14, O2sat 100% 2L\n General: Alert, oriented, no acute distress, stridor, or wheezing\n HEENT: Sclera anicteric, MMM, lips and tongue not noticeably swollen,\n uvular hydrops without exudates, no erythema, no parotitis\n Neck: Supple, JVP not elevated, no LAD, nontender\n Lungs: Minimal crackles at bilateral bases, otherwise clear without\n wheezes.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Soft, non-tender, obese but non-distended, bowel sounds\n present, no rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 2+ pulses, trace LE edema\n Skin: No flushing or rash\n Neuro: AAO x 3, nonfocal\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 69 yo man with DM, CAD, GERD, chronic sinusitis, asthma, s/p esophageal\n dilatation p/w angioedema.\n .\n # Angioedema: C/w angioedema. Most commonly associated with ACE-I.\n Does have a history of similar episode; acquired C1 inhibitor\n deficiency possible - familial less likely given age and absence of\n family hx. Did just start iron supplement and allergy to a component\n is possible, but time course not as consistent and more likely\n kinin-mediated rather than mast cell given absence of urticaria,\n prurutis. No inhalant abuse; not taking ASA or NSAIDS due to renal\n failure. Pharyngitis can cause uvular swelling but no fever, exudates,\n or sore throat to suggest acute infectious etiology.\n - Check C4, C1 inh levels\n - Discontinue ACE-I\n - Hold iron supplements for now; discuss with primary providers\n - Sips for now, advance diet as tolerated\n - Monitor airways; currently stable but may need IV steroids, H2B,\n antihistamines if acute worsening or intubation if airway compromise\n .\n # HTN: Hypertensive; did not take usual meds this AM.\n - Hydralazine IV prn for SBP >180\n - No lisinopril but restart other oral meds (metoprolol, nifedipine,\n lasix) when able to tolerate po, likely in PM\n .\n # DM:\n - FSG qid with HISS for now\n - Would consider discontinuation of glyburide given ESRD\n .\n # ESRD: In work-up for PD and transplant\n - Will make primary providers aware of admission\n - F/u labs\n - Resume sevelamer and calcitriol when able\n .\n # CAD: Stable\n - Baseline EKG\n - Restart simvastatin, metoprolol when able\n - No lisinopril\n .\n # CHF: Euvolemic\n - Restart po lasix when able; IV lasix for now if acutely fluid\n overloaded\n .\n # HL: Restart simvastatin when able\n ICU Care\n Nutrition: No IVF, replete electrolytes, sips - advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 10:01 AM\n Prophylaxis:\n DVT: Subcutaneous heparin\n Communication: Patient\n Code status: Full. HCP is daughter ()\n Disposition: ICU pending clinical improvement, likely discharge either\n this evening or tmrw AM\n ------ Protected Section ------\n PMH also notable for new dx of prostate cancer - score 6 (3+3),\n small focus involving less than 5% of the core tissue. Planned f/u with\n Dr. on as outpatient.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:44 ------\n" }, { "category": "Physician ", "chartdate": "2178-03-12 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 630133, "text": "TITLE:\n Chief Complaint: Throat swelling\n .\n Reason for MICU admission: Monitoring of angioedema\n HPI: 69 year-old man with a h/o DM2, CAD, CHF, GERD, chronic sinusitis,\n asthma, s/p esophageal dilatation who presents with uvular swelling.\n Pt reports that he was walking to the bathroom at midnight when he\n noted the onset of a swelling sensation in his throat with difficulty\n and mild pain on swallowing. He also notes mild lip swelling. No\n urticaria, flushing, pruritis, or lightheadedness. No fevers, cough,\n swollen lymph nodes, sore throat, or purulent sputum. He has stable\n rhinorrhea worst at night from chronic sinusitis. He denies any\n difficulty handling his secretions or dysphagia; these sx are\n dissimilar from those leading to his esophageal dilatation several\n years ago. The patient does recall one similar prior episode a few\n years ago after eating a . At an OSH ED, he was given some\n medications and the swelling resolved after several hours; this was\n attributed to mayonnaise. He has tolerated this fine since and denies\n mayonnaise or other new foods recently. He reports being on lisinopril\n for 2-3 years; he believes he was taking it at the time of this\n previous episode. His only new medication is ferrous sulfate, started\n yesterday AM. He has not taken ASA or NSAIDs in at least 4 months due\n to his renal failure. No insect stings or chemical exposures. No\n chronic abdominal pain or family history of angioedema.\n .\n In the ED, initial vs were: T 98, P 82, BP 161/66, RR 22, O2sat 100. Pt\n was without stridor or wheezing with minimal tongue and lip swelling\n but +uvular hydrops. He was given diphenhydramine 50mg IV, famotidine\n 20mg IV, and methylprednisolone 125mg IV. Pt stable but given absence\n of improvement, he is being admitted to the ICU. VS on transfer: T\n 98.0, P 83, BP 151/79, RR 14, O2sat 100% 2L.\n .\n On the floor, pt currently reports slight improvement in his swelling.\n No difficulty handling secretions.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n ALBUTEROL SULFATE (on med list but not taking)\n CALCITRIOL 0.25 mcg daily\n FUROSEMIDE 80 mg \n GLYBURIDE 5 mg daily\n INSULIN GLARGINE [LANTUS] 8 units daily\n LISINOPRIL 40 mg \n METOPROLOL TARTRATE 25 mg \n NIFEDIPINE SR 90 mg daily\n SEVELAMER CARBONATE [RENVELA] 1600 mg tid w/ meals\n SIMVASTATIN 80 mg daily\n IRON 325 mg daily\n Past medical history:\n Family history:\n Social History:\n Diabetes mellitus 2\n Hypertension\n Hyperlipidemia\n CAD with \"mild MI\" in the past per patient\n CHF (EF 51% on stress MIBI)\n ESRD undergoing work-up for PD and transplant\n Chronic sinusitis\n H/o asthma (last exacerbation in )\n GERD\n S/p esophageal dilatation several years ago\n S/p removal of benign cyst under tongue at age 15\n No h/o angioedema. Strong family history of DM, ESRD(several siblings\n on HD), and CAD.\n Lives with wife and daughters and granddaughters. Retired, used to work\n for a cleaning company.\n - Tobacco: Quit tobacco 20 yrs ago\n - Alcohol: Denies\n - Illicits: Denies\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, stably fluctuating weights due\n to CHF. Denies headache. Chronic sinus tenderness, rhinorrhea, and\n congestion. Denies cough, shortness of breath, or wheezing. Denies\n chest pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, abdominal pain. 1 episode of diarrhea yesterday; none\n since. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 01:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 98 (90 - 99) bpm\n BP: 159/65(87) {159/65(73) - 188/75(97)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 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: 100%\n Physical Examination\n Vitals: T 96.9, P 90, BP 165/73, RR 14, O2sat 100% 2L\n General: Alert, oriented, no acute distress, stridor, or wheezing\n HEENT: Sclera anicteric, MMM, lips and tongue not noticeably swollen,\n uvular hydrops without exudates, no erythema, no parotitis\n Neck: Supple, JVP not elevated, no LAD, nontender\n Lungs: Minimal crackles at bilateral bases, otherwise clear without\n wheezes.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Soft, non-tender, obese but non-distended, bowel sounds\n present, no rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 2+ pulses, trace LE edema\n Skin: No flushing or rash\n Neuro: AAO x 3, nonfocal\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 69 yo man with DM, CAD, GERD, chronic sinusitis, asthma, s/p esophageal\n dilatation p/w angioedema.\n .\n # Angioedema: C/w angioedema. Most commonly associated with ACE-I.\n Does have a history of similar episode; acquired C1 inhibitor\n deficiency possible - familial less likely given age and absence of\n family hx. Did just start iron supplement and allergy to a component\n is possible, but time course not as consistent and more likely\n kinin-mediated rather than mast cell given absence of urticaria,\n prurutis. No inhalant abuse; not taking ASA or NSAIDS due to renal\n failure. Pharyngitis can cause uvular swelling but no fever, exudates,\n or sore throat to suggest acute infectious etiology.\n - Check C4, C1 inh levels\n - Discontinue ACE-I\n - Hold iron supplements for now; discuss with primary providers\n - Sips for now, advance diet as tolerated\n - Monitor airways; currently stable but may need IV steroids, H2B,\n antihistamines if acute worsening or intubation if airway compromise\n .\n # HTN: Hypertensive; did not take usual meds this AM.\n - Hydralazine IV prn for SBP >180\n - No lisinopril but restart other oral meds (metoprolol, nifedipine,\n lasix) when able to tolerate po, likely in PM\n .\n # DM:\n - FSG qid with HISS for now\n - Would consider discontinuation of glyburide given ESRD\n .\n # ESRD: In work-up for PD and transplant\n - Will make primary providers aware of admission\n - F/u labs\n - Resume sevelamer and calcitriol when able\n .\n # CAD: Stable\n - Baseline EKG\n - Restart simvastatin, metoprolol when able\n - No lisinopril\n .\n # CHF: Euvolemic\n - Restart po lasix when able; IV lasix for now if acutely fluid\n overloaded\n .\n # HL: Restart simvastatin when able\n ICU Care\n Nutrition: No IVF, replete electrolytes, sips - advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 10:01 AM\n Prophylaxis:\n DVT: Subcutaneous heparin\n Communication: Patient\n Code status: Full. HCP is daughter ()\n Disposition: ICU pending clinical improvement, likely discharge either\n this evening or tmrw AM\n ------ Protected Section ------\n PMH also notable for new dx of prostate cancer - score 6 (3+3),\n small focus involving less than 5% of the core tissue. Planned f/u with\n Dr. on as outpatient.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:44 ------\n ICU 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: 69M DM, ESRD (not yet on HD, may start PD\n soon), CAD s/p MI, dCHF (EF >50%), asthma, esophageal strictures, GERD\n p/w angioedema of the upper airway in the setting of long-term ACEI\n therapy and newly started Fe rx.\n Exam notable for Tm 96.9 BP 160/70 HR 90 RR 18 with sat 99 on 2LNC. WD\n man, NAD, no wheeze. + uvular hydrops / OP crowded. CTA B. RRR s1s2.\n Soft +BS. No edema. Labs notable for WBC 6K, HCT 33, K+ 4.7, Cr 5.9.\n Agree with plan to manage likely ACEI-associated focal angioedema with\n airway monitoring in the ICU, will d/c ACEI as well as Fe, as this was\n just started yesterday and add both to allergy list. No clear role of\n steroids or H2 blockers, but will hold off for now, will check\n complement levels to r/o C1 esterase inhibitor disease, hold off on Ab\n testing. Will resume home regimen when taking POs, NPO for now. ESRD -\n making good urine. CAD / CHF - stable. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:38 PM ------\n" }, { "category": "Nursing", "chartdate": "2178-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 630153, "text": ".H/O Problem\nangio edema, swollen uvula and discharge planning\n Assessment:\n Patient admitted from ED this am for swollen uvula\n ?Due to lisinopril\n Patient able to swallow and no difficulty with airway protection\n Blood sugars elevated\ngiven steroids in ED\n Action:\n Diet slowly advanced during the day to regular diet\n No difficulty with this\n PM blod sugar of 315 treated with 8u humalog\n Response:\n Medical team will be by later this afternoon to assess if patient can\n be discharged to \n Plan:\n" } ]

[ { "category": "Radiology", "chartdate": "2166-11-07 00:00:00.000", "description": "EMBO TRANSCRANIAL", "row_id": 1256389, "text": " 10:53 AM\n CAROT/CEREB Clip # \n Reason: Stent assisted coiling of aneurysmAnesthesia has been booked\n Admitting Diagnosis: BRAIN ANEURYSM/SDA\n Contrast: OPTIRAY Amt: 146\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with known aneurysm\n REASON FOR THIS EXAMINATION:\n Stent assisted coiling of aneurysmAnesthesia has been booked for at 12pm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known aneurysm of the basilar artery near the vertebrobasilar\n junction. Patient is presenting for intervention.\n\n OPERATORS: Dr. (attending physician), Dr. , Dr.\n , and Dr. \n\n PROCEDURE PERFORMED:\n 1. Left vertebral artery angiography.\n 2. Deployment of Neuroform stent from left vertebral artery into basilar\n artery.\n 3. Coil embolization of basilar artery aneurysm.\n\n ANESTHESIA: Procedure performed under general anesthesia. Please see\n separate anesthesia report for details.\n\n DETAILS OF PROCEDURE: Written informed consent was obtained prior to the\n procedure explaining the risks, benefits, and alternatives. The patient was\n brought to the angiography suite and general anesthesia induced. Following\n this, both groins were prepped and draped in the usual sterile fashion. A\n preprocedure timeout was performed per protocol.\n\n Access was gained into the right femoral artery with a 5 French micropuncture\n set. A 0.035 wire was advanced to the thoracic aorta and a 6 French\n Terumo sheath placed. A 5 French 2 catheter with angled Glidewire was\n then used to access the left vertebral artery, where angiography was\n performed. An exchange length Glidewire was then used to replace the 2\n catheter with a 6 French straight Neuron catheter with tip positioned in the\n vertebral artery.\n\n Through this, an Excelsior XT-27 microcatheter with Synchro-2 0.014 guidewire\n was used to access the basilar artery distal to the observed aneurysm.\n Subsequently, a 3.5 mm x 30 mm Neuroform EZ stent was deployed crossing the\n aneurysm with distal struts in the basilar artery and proximal struts in the\n left vertebral artery.\n\n (Over)\n\n 10:53 AM\n CAROT/CEREB Clip # \n Reason: Stent assisted coiling of aneurysmAnesthesia has been booked\n Admitting Diagnosis: BRAIN ANEURYSM/SDA\n Contrast: OPTIRAY Amt: 146\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Subsequently the Synchro-2 guidewire was used to position the tip of an\n Excelsior SL-10 microcatheter within the aneurysm sac. Through this catheter,\n three coils were deployed: Target 360 Ultra 2 mm x 4 cm, Target 360 Ultra 1.5\n mm x 3 cm, and Target 360 Ultra 2 mm x 4 cm. Intermittent angiography was\n performed between coil deployments and subsequently after deployment of the\n final coil.\n\n Catheters and sheath were removed with deployment of a 6 French Angio-Seal\n closure device. A sterile dressing was applied.\n\n The patient tolerated the procedure well, and there were no immediate\n post-procedure complications.\n\n FINDINGS: Angiography of the left vertebral artery again demonstrated\n aneurysm of the basilar artery at the vertebrobasilar junction. The\n craniocaudal extent of the aneurysm measured approximately 7.6 mm with the\n transverse dimension approximately 1.9 mm. The aneurysm was eccentric to the\n left. The right vertebral artery was noted to be diminutive.\n\n A Neuroform stent was successfully deployed crossing the aneurysm with distal\n struts in the basilar artery and proximal struts in the left vertebral artery.\n The aneurysm was then successfully coiled with three detachable Target 360\n coils with post-coiling angiography demonstrating minimal residual flow within\n the aneurysm. Major branches of the vertebral and basilar artery and distal\n branches filled appropriately post coiling.\n\n IMPRESSION: underwent cerebral angiography demonstrating\n aneurysmal dilation of the basilar artery at the vertebrobasilar junction.\n This was successfully coil embolized with the aid of a Neuroform stent.\n\n" } ]

[ { "category": "Echo", "chartdate": "2204-11-15 00:00:00.000", "description": "Report", "row_id": 97709, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Hypotension. Pulmonary Hypertension?\nHeight: (in) 66\nWeight (lb): 156\nBSA (m2): 1.80 m2\nBP (mm Hg): 96/53\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 14:42\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.\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. Mild mitral annular\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality as the patient was difficult to position.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is moderately depressed. Anterior, distal septal and apical\nakinesis is present.\n2. The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2204-11-15 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 894084, "text": " 3:18 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please assess for infiltrate, effusion, pulmonary edema.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with shortness of breath, hypotension\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrate, effusion, pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath and hypotension.\n\n COMPARISON: Film performed at 3 a.m. the same day.\n\n Since the prior study there has been new opacification of the left lung base.\n Likely this represents a pleural effusion with possibly some degree of\n underlying atelectasis or infiltrate. The right lung remains clear.\n\n IMPRESSION: Interval development of left lower lobe opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2204-11-16 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 894199, "text": " 8:46 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ?evolution of pleural effusion v consolidation\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with shortness of breath, hypotension\n\n REASON FOR THIS EXAMINATION:\n ?evolution of pleural effusion v consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n FINDINGS: The heart size is normal. A tortuous thoracic aorta is unchanged\n in contour compared to . The right lung is clear. Left lower lobe\n atelectasis and an associated effusion are unchanged compared to .\n No pneumothorax is seen.\n\n IMPRESSION: Left basilar opacity representing effusion and probable\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2204-11-21 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 894802, "text": " 1:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC (IV Team failed PICC on )\n Admitting Diagnosis: CHEST 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 83 year old woman with short gut syndrome, needs hydration and electrolyte\n repletion (IV Team failed PICC on )\n REASON FOR THIS EXAMINATION:\n please place PICC (IV Team failed PICC on )\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 83-year-old woman with short gut syndrome, needs PICC\n line placement for hydration.\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. Dr. reviewed the case.\n\n The patient was placed supine on the angiographic table. The left arm was\n prepped and wrapped in the standard sterile fashion. Ultrasound confirmed the\n left basilic vein was patent and compressible. Ten cc of 1% lidocaine were\n given for local anesthesia. Under ultrasonographic guidance, a 21-gauge\n needle was used to access the left basilic vein. A 0.018 guidewire was placed\n through the needle under fluoroscopic guidance with the tip in the superior\n vena cava. The needle was exchanged for a 4 French peel-away sheath. The\n length of the PICC line was measured at 48 cm based on the markers on the\n wire. After the inner dilator was removed, a double lumen PICC line was\n placed over the wire with the tip in the superior vena cava. Peel-away sheath\n and wire were removed. The two lumens were flushed and the line was secured to\n the skin with Stat-Lock.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n Ultrasound images were obtained before and after the venous puncture\n documenting vessel patency.\n\n IMPRESSION: Successful placement of a 48 cm, double lumen PICC line through\n left basilic vein with the tip in the superior vena cava. The line is ready\n to use.\n\n" }, { "category": "ECG", "chartdate": "2204-11-29 00:00:00.000", "description": "Report", "row_id": 266502, "text": "Sinus rhythm with large P waves and alternating atrial pacemaker followed by\nectopic atrial tachycardia, rate 135. Prior inferior myocardial infarction.\nPrior anteroseptal myocardial infarction. Compared to the previous tracing\nof atrial ectopy as noted has appeared, T wave abnormalities are\nless prominent in the lateral leads and the rate is increased. Followup and\nclinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2204-12-03 00:00:00.000", "description": "Report", "row_id": 266500, "text": "Sinus rhythm.\nInferior infarct - age undetermined\nPossible anteroseptal infarct - age undetermined\nLateral T wave changes may be due to myocardial ischemia\nLow QRS voltages in precordial leads\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2204-11-30 00:00:00.000", "description": "Report", "row_id": 266501, "text": "Sinus rhythm. Q waves in the inferior leads consistent with prior myocardial\ninfarction. There is a late transition with anterior, anterolateral and lateral\nST-T wave changes consistent with ischemia or infarction. Compared to the\nprevious tracing ST-T wave changes are more extensive and the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2204-11-26 00:00:00.000", "description": "Report", "row_id": 266503, "text": "Sinus rhythm. Low precordial lead QRS voltage. Prior inferior wall myocardial\ninfarction. Anterior wall myocardial infarction, age indeterminate.\nAnterolateral T wave abnormalities suggest ischemia. Clinical correlation is\nsuggested. Since the previous tracing of atrial ectopy is absent,\nR wave progression appears more abnormal and T wave changes are more prominent.\n\n" }, { "category": "ECG", "chartdate": "2204-11-18 00:00:00.000", "description": "Report", "row_id": 266741, "text": "Baseline artifact\nSinus rhythm\nAtrial premature complexes\nLow QRS voltage\nPrior inferior myocardial infarction\nPoor R wave progression with late precordial QRS transition - is nonspecific\nAnterolateral T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , atrial ectopy present\n\n" }, { "category": "ECG", "chartdate": "2204-11-16 00:00:00.000", "description": "Report", "row_id": 266742, "text": "Sinus rhythm. Compared to the previous tracing of multiple\nabnormalities persist without major change.\n\n" }, { "category": "ECG", "chartdate": "2204-11-15 00:00:00.000", "description": "Report", "row_id": 266743, "text": "Sinus rhythm. Inferolateral myocardial infarction. Compared to tracing #4, no\ndefinite or diagnsotic change.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2204-11-15 00:00:00.000", "description": "Report", "row_id": 266744, "text": "Sinus rhythm. Inferolateral myocardial infarction. Compared to tracing #3, no\ndefinite change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2204-11-15 00:00:00.000", "description": "Report", "row_id": 266745, "text": "Sinus rhythm. Inferolateral myocardial infarction. Compared to tracing #2,\nungoing changes consistent with evolving acute inferolateral myocardial\ninfarction present.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2204-11-15 00:00:00.000", "description": "Report", "row_id": 266746, "text": "Sinus rhythm. Compared to the previous tracing of loss of lateral\nR wave amplitude suggesting extensive ischemic territory involvement.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2204-11-14 00:00:00.000", "description": "Report", "row_id": 266747, "text": "Sinus rhythm. Inferior myocardial infarction. Marked lateral repolarization\nabnormalities. Compared to the previous tracing of reinfarction in the\ninferior territory is now suggested. Marked lateral T wave inversions suggest\nthat a large territory is included in the ischemic zone.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2204-12-02 00:00:00.000", "description": "Report", "row_id": 1306754, "text": "CCU Nursing Admission Note 1830-1700\nS: c/o itchy eyes on admission, not problem, uses eye drops.\n\nO: Please see FHPA/Nursing Admission Note: briefly patient transferred to CCU (MICU service) for antibiotic desensitization to treat Klebsiella/e-coli UTI. PMH: CAD, COPD, Ostomy for short-gut syndrome. Pt. admitted to with CP, Rd/I, refusing further cardiac intervention. Intermittent periods of hypotension treated with IV fluids to keep SBP >90. Cr increased to 1.3, receiving IV hydration. Anemia, refusing transfusion. According to intern transfer note, patient's status is DNR/DNI\n\nCV: HR 74 NSR, BP 96/40.\n\nResp: lungs with rhonchi, exp wheezing. Comfortable at 30 degree angle. O2 decreased to 1 LNP with o2 sat 96%.\n\nGI: ostomy intact. Small amount of soft brown stool\n\nGU: wearing depends\n\nSkin: Upper back flushing, rest of skin intact. c/o itching with eyes, no redness.\n\nAccess: Left arm PICC cath site clean.\n\nNeuro: knows it's the hospital but B&WH, thinks it's .\n\nID: on contact precautions for MRSA, ? C-diff\n\nA: stable awaiting antibiotic desensitization therapy for UTI treatment.\n\nP: Awaiting desensitization orders. Plan for patient to return to CC-7 following desensitization\n" }, { "category": "Nursing/other", "chartdate": "2204-12-03 00:00:00.000", "description": "Report", "row_id": 1306755, "text": "CCU NPN\n\nS: \" I HOPE I CAN PASS THIS TEST\"\n\n83 YR OLD FEMALE INITIALLY ADM TO BIBCM ON C/O CP. R/I IMI, REFUSES CATH OR INTERVENTION. HOSPITAL STAY C/B PERIODS OF HYPOTENSION ? R/T SEPSIS. TX WITH FLUID CHALLENGES. + UTI KLEBSIELLA, E COLI. PT WITH HX PCN TO CCU AS MICU BORDER FOR MEREPENUM DESENSITIZATION TO TREAT UTI. + MRSA HX LOOSE STOOL VIA COLOSTOMY ? C-DIFF STILL PENDING. EF 35%. PT AS DNR/DNI\n\nCV: REMAINS IN NSR WITH HR 65-75. SBP 108-133 MAPS' 62-74. DENIES CP\n\nRESP: LONG HX COPD. ALB/ATRV NEBS Q6 HR WITH GOOD EFFECT. BS COURSE/ WXP WHEEZES PRIOR TO NEBS. COUGHING AND RAISING THICK YELLOW SECRETIONS. SPUTUM CUL SHOWS YEAST AND GM + RODS. RR-REG DENIES SOB. O2 VIA 1-2 L 96-99%.\n\nID: STARTED AND COMPLETED MEREPENUM DESENSITIZATION PROTOCOL. PROTOCOL DOSES AND FREQUENCY REVIEWED WITH MD PRIOR TO STARTING. TOL WELL BY PT WITH NO S/S OF REACTION NOTED. PT DID HAVE SOME MILD C/O ITCHY SKIN ON BILAT ARMS. TREATED WITH SARNA LOTION WITH GOOD EFFECT. NO S/S OR RASH OR HIVES NOTED. PT DOES HAVE SOME FLUSHING OF UPPER BACK AND FACE WHICH SHE HAD PRIOR TO STARTING MEREPENUM. EPI AT BEDSIDE, BUT NOT NEEDED. WBC 10.0 LINEZOLID D/CD. AFEBRILE.\n\nGI: TOL SIPS OF CL LIQ. ABD SOFT AND NO TENDER. COLOSTOMY DRAINING BROWN SOFT STOOL. CON'T ON IMODIUM. STOOL IS GUIAC NEG. C-DIF PENDING.\n\nGU: INCONT OF URINE, LG AMT'S DIFFICULT TO DOCUMENT ACUURATE I/O PT REFUSES CATH, MD AWARE. CON'T ON PYRIDIUM WITH GOOD EFFECT.\n\nSKIN: HEELS VERY RED BUT SKIN INTACT. WAFFLES ORDERED AND APPLIED BILAT. STOMA SITE PINK AND INTACT. SHE HAS BASELINE FLUSHING OF CHEST AND UPPER BACK. SKIN VERY DRY OIL APLLIED SARNA AS NEEDED. DOULBE GUARD APPLIED TO RECTALPERINIUM AREA.\n\nNEURO: A/O X2 TP PERSON AND TIME. PLEASANT AND COOPERATIVE. HOH. GOOD HISTORIAN DESPITE HER AGE. MAE.\n\nSOCIAL: NO FAMILY NEARBY. HAS ONE BROTHER WHICH SHE HAS NOT SPOKEN TO SINCE . HER HCP IS A CLOSE FAMILY FRIEND. PT HAS NEVER BEEN MARRIED. NO CHILDREN. PT IS RETIRED NAVY NURSE.\n\nACCESS: L ARM PICC INTACT AND PATENT\n\nIVF: TO FINISH NS @ 75CC/HR\n\nA/P: LIKLY SHE WILL RETURN BACK TO CC7 TO CON'T ABX\n NEEDS NUTRITION CONSULT\n FOLLOW AM LABS ( HCT HAS BEEN TRENDING DOWN BUT PT REFUSES BLOOD TRANSFUSION IN PAST) CON'T PER NSG JUDGEMENT\n\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2100-09-10 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1147758, "text": " 8:49 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for tube placement\n Admitting Diagnosis: T10 MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with COPD, recently malignancy diagonosis s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with COPD and recent\n diagnosis of malignancy.\n\n Portable AP chest radiograph was reviewed in comparison to prior study\n obtained on .\n\n The ET tube tip is 5 cm above the carina. There is no change in the\n cardiomediastinal silhouette and orthopedic hardware. There is increased\n opacity in the right lung base that might represent developing infectious\n process. Mild fluid overload cannot be entirely excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-09-04 00:00:00.000", "description": "SPINAL FLUORO WITHOUT RADIOLOGIST", "row_id": 1146951, "text": " 6:36 PM\n T-SPINE IN O.R.; SPINAL FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: T10 CORPECTOMY AND T8-T12 FUSION\n Admitting Diagnosis: T10 MASS\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Five intraoperative fluoroscopic images of the thoracic spine,\n .\n\n COMPARISON: CT .\n\n INDICATION: 83-year-old female, T10 corpectomy and T8 through T12 fusion.\n\n FINDINGS: Multiple fluoroscopic images of the thoracic spine\n intraoperatively. Surgical instruments as well as subsequently intervertebral\n cages and pedicle screws are noted.\n\n IMPRESSION: Five intraoperative fluoroscopic images of the thoracic spine\n from T10 corpectomy and T8 through T12 fusion. Please see operative report\n for further details.\n\n\n DR. M. DIDOLKAR\n" }, { "category": "Radiology", "chartdate": "2100-09-10 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1147775, "text": " 9:38 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Placement of new CVL\n Admitting Diagnosis: T10 MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n Placement of new CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Placement of central venous line.\n\n Portable AP chest radiograph was reviewed in comparison to multiple prior\n studies from the same day and a day ago.\n\n The ET tube tip is 4 cm above the carina. The right internal jugular line\n that has been recently inserted terminates at the level of mid SVC with no\n evidence of post-insertion complications. Cardiomediastinal silhouette is\n unchanged. There is slight interval improvement in interstitial opacities.\n\n" }, { "category": "Radiology", "chartdate": "2100-09-03 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 1146874, "text": " 11:02 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for mets, primary\n Admitting Diagnosis: T10 MASS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with T10 mass\n REASON FOR THIS EXAMINATION:\n eval for mets, primary\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EAGg SAT 12:43 AM\n Large T10 lytic lesion with soft tissue tumor extending into the epidural\n space with poor delineation of the thecal sac and concerning for cord\n compression, but better evaluated dedicated CT T-spine/ MRI T-spine from OSH.\n Multiple other concerning lesions including a 5.7 cm lung mass in the LLL, 2,6\n cm hypodense mass in segment IVb of the liver, destructive lytic lesion in the\n right posterior iliac bone, incompletely evaluated 2.6 cm left labial mass, 1\n cm nodule in the right lateral abdominal subcutaneous tissue and ?? mass in\n left upper chest wall (incompletely eval). Findings concerning for neoplasm\n with multiple metastases.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old female with T10 mass. Evaluate for metastatic\n lesions or primary malignancy.\n\n COMPARISON: No prior study available for comparison.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen\n without IV contrast. Subsequently, axial images were obtained through the\n chest, abdomen, and pelvis after administration of 130 cc of IV Optiray\n contrast. Coronal and sagittal reformats were displayed.\n\n CT CHEST WITH IV CONTRAST: There is a large well-circumscribed mass in the\n medial left upper lung measuring 4.6 x 3.9 x 5.4 cm. A smaller 1 cm rounded\n satellite lesion is noted just inferior to the larger mass. In the right\n lung, there is an 8 x 6 mm nodule in the upper lobe (3:15). There is\n nonspecific ground-glass opacity in the right upper lobe as well (3:21). Small\n left hilar nodes do not meet CT criteria for pathologic enlargement but\n measures 9 mm (3:19). No pleural effusion or pneumothorax. The heart is\n normal without pericardial effusion. There is dense atherosclerotic\n calcification of the aortic arch and descending thoracic aorta, which is\n otherwise unremarkable.\n\n CT ABDOMEN WITH IV CONTRAST: There is a 2.6 x 2.3 cm enhancing mass in\n segment IVb of the liver. This lesion is relatively hypodense compared to the\n remainder of the liver on the contrast-enhanced base. There is a 4-mm\n hypodense lesion in segment III of liver which is too small to further\n characterize (3:52). The gallbladder is surgically absent. The pancreas and\n bilateral adrenal glands are normal. A small hypodensity in the spleen could\n represent a cyst or hemangioma (3:54). The kidneys enhance and excrete\n (Over)\n\n 11:02 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for mets, primary\n Admitting Diagnosis: T10 MASS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n contrast symmetrically without evidence of hydronephrosis or hydroureter. No\n mesenteric or retroperitoneal lymphadenopathy meeting CT criteria for\n pathologic enlargement is noted. There is no free air or fluid in the\n abdomen. The non-opacified stomach and intra-abdominal loops of bowel are\n unremarkable. Incidentally noted is a soft tissue nodule along the right\n lateral abdominal wall measuring 8 mm (3:52) and of uncertain significance.\n\n CT PELVIS WITH IV CONTRAST: The urinary bladder is collapsed around a Foley\n catheter. The distal ureters, uterus, adnexa, sigmoid colon, and rectum are\n unremarkable. There is an incompletely evaluated enhancing mass in the left\n labia measuring 2.6 x 2.5 cm.\n\n BONE WINDOWS: At T10, there is a destructive lytic lesion with expansion of\n soft tissue density into the epidural space. The outline of the thecal sac is\n not well delineated at this level and it suggests cord compression. Tiny\n sclerotic hyperdensities in the T8, T9 and T7 vertebral bodies and left iliac\n could represent bone islands; however, a metastatic process is also a\n consideration. In addition, there is a lytic lesion causing erosion of the\n cortex in the posterior right iliac bone (3:87). A symmetric 2.0 x 1.9 cm\n soft tissue density is noted in the left upper chest wall, but incompletely\n evaluated and the significance of which is uncertain.\n\n IMPRESSION:\n\n 1. Large 4.6 cm left lower lobe mass concerning for a neoplastic process. At\n least two other nodules are identified within the lungs, one in the left lower\n lobe and a second in the right upper lobe.\n\n 2. Additional soft tissue lytic lesion in the posterior right iliac bone.\n\n 3. Multiple soft tissue masses, one along the left and right lateral\n abdominal wall, and a second in the left labia and possible third in the left\n upper chest wall. Lesions are concerning for neoplastic process. Hypodense\n lesion in segment IVb of the liver which is incompletely evaluated but may\n also represent a metastatic or neoplastic process.\n\n\n Conglomerate of findings raises concern for melanoma as a primary source.\n\n" }, { "category": "ECG", "chartdate": "2100-09-10 00:00:00.000", "description": "Report", "row_id": 238225, "text": "Sinus tachycardia. Non-specific T wave flattening in the inferior leads.\nPossible prior anteroseptal myocardial infarction. Compared to the previous\ntracing of there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2100-09-10 00:00:00.000", "description": "Report", "row_id": 238226, "text": "Sinus tachycardia. Probable prior anteroseptal myocardial infarction, age\nundetermined. Compared to the previous tracing of no diagnostic\ninterim change.\n\n" }, { "category": "ECG", "chartdate": "2100-09-03 00:00:00.000", "description": "Report", "row_id": 238227, "text": "Sinus rhythm. Anteroseptal myocardial infarction of indeterminate age.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2111-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173223, "text": " 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hemoptysis and pneumonia.\n REASON FOR THIS EXAMINATION:\n Any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hemoptysis.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 8 cm above the carina. The NG tube tip passes below the\n diaphragm, terminating in the stomach. There is no change in the right lower\n lobe consolidation, left lower lobe opacity and interstitial pulmonary edema.\n The right mediastinal shift is unchanged.\n\n Pulmonary nodules if present, would be definitely obscured by the multifocal\n consolidations.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173068, "text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement and evolution of vap\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with Hemoptysis and VAP s/p bronch yesterday\n REASON FOR THIS EXAMINATION:\n ett placement and evolution of vap\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:51 A.M., \n\n HISTORY: Hemoptysis. Bronchoscopy yesterday. ET tube placement.\n\n IMPRESSION: AP chest compared to through 18:\n\n Greater opacification at the base of the right lung is due to worsening\n consolidation and possible increase in moderate pleural effusion.\n Heterogeneous opacification in the left lung has improved slightly, perhaps\n the component of pulmonary edema, but there is still multifocal nodulation\n suggesting widespread dissemination of infection accompanied by at least a\n moderate left pleural effusion. The heart is large, probably unchanged. Tip\n of the endotracheal tube is several centimeters above the upper margin of the\n clavicles and no less than 7 cm from the carina. It should be advanced at\n least 3 cm. Nasogastric tube passes below the diaphragm and out of view. No\n pneumothorax. Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1173133, "text": " 12:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 38cm right picc. tip?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 38cm right picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC placement, assess position.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The ET tube ends 7.6 cm above the carina. The right PICC ends in\n the low SVC. Right basilar consolidation and moderate right pleural effusion\n are unchanged. Heterogeneous opacification of the left lower lung is\n unchanged. Mild cardiomegaly is unchanged. There is no pneumothorax seen.\n\n IMPRESSION:\n\n 1. Right PICC ends in the low SVC.\n\n 2. Unchanged bilateral pleural effusions and lower lung consolidations.\n\n" }, { "category": "Radiology", "chartdate": "2111-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172905, "text": " 2:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hemoptysis and aspiration PNA.\n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hemoptysis, aspiration pneumonia, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is a minimal increase\n in extent of the pre-existing bilateral parenchymal opacities. A small left\n pleural effusion might have newly occurred in the interval. No other changes,\n except for a slightly increasing retrocardiac atelectasis.\n\n Unchanged right upper lobe opacity. No change in position of the monitoring\n and support devices, including the endotracheal tube that is located\n relatively high and could be advanced by 2 to 3 cm.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-11 00:00:00.000", "description": "EMBO INTRACRANIAL/SPINAL CORD", "row_id": 1172564, "text": " 9:20 PM\n BRONCHIAL Clip # \n Reason: Bronchial artery embolization; bleeding RLL\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 220\n ********************************* CPT Codes ********************************\n * EMBO INTRACRANIAL/SPINAL CORD 1SR ORDER /BRACHIOCEPHALIC *\n * -51 MULTI-PROCEDURE SAME DAY 1SR ORDER /BRACHIOCEPHALIC *\n * -59 DISTINCT PROCEDURAL SERVICE THORACIC ANGIOGRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\n * F/U STATUS INFUSION/EMBO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with history of treated TB, bronchiectasis, with massive\n hemoptysis, bronch today demonstrating large clot in RLL with oozing.\n REASON FOR THIS EXAMINATION:\n Bronchial artery embolization; bleeding RLL\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 79-year-old woman with past history of tuberculosis and\n bronchiectasis, presenting with massive hemoptysis. Bronchoscopy revealed\n active bleeding in the right lower lobe. Request for bronchial artery\n embolization.\n\n RADIOLOGISTS: Dr. , Dr. and Dr. \n performed the procedure. Dr. , the attending radiologist, was\n present throughout the procedure.\n\n ANESTHESIA: The patient was intubated and brought sedated from the ICU. 1%\n lidocaine was used for local anesthesia.\n\n PROCEDURE AND FINDINGS: After explaining the risks, benefits and alternatives\n of the procedure, written informed consent was obtained from HCP. The patient\n was brought to the angiography suite and placed supine on the imaging table.\n The right groin was prepped and draped in standard sterile fashion. A\n preprocedure timeout and huddle were performed per protocol.\n\n Using fluoroscopic and palpatory guidance, the right common femoral artery was\n accessed at the level of the mid femoral head using a micropuncture needle\n through which a 0.018 guidewire was advanced to the left of the spine. The\n needle was exchanged for a micropuncture sheath and the wire was upsized to a\n 0.035 wire. The micropuncture sheath was then exchanged for a 5\n French x 11 cm -Tip sheath. A 5 French Omniflush catheter was advanced\n over the wire and positioned in the proximal descending thoracic\n aorta. An aortogram was performed- a right intercosto-bronchial trunk giving\n off a right bronchial artery and a separate common bronchial artery dividing\n in to right and left bronchial arteries were seen arising from the aorta at\n the level of tracheal bifurcation. Based on these findings of the aortogram,\n it was decided to embolize the right-sided bronchial arteries. The Omniflush\n catheter was then exchanged for a 5 French catheter, which was\n (Over)\n\n 9:20 PM\n BRONCHIAL Clip # \n Reason: Bronchial artery embolization; bleeding RLL\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 220\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n formed over the aortic arch. The catheter was first used to select\n the right intercosto-bronchial trunk. Selective arteriogram was performed.\n Multiple attempts were made to subselectively catheterize the bronchial artery\n coming off the intercostal bronchial trunk using a combination of Renegade\n Hi- and Renegade STC microcatheters and a 0.018 Transcend wire; however,\n this was unsuccessful. An SL-10 microcatheter was then advanced over a\n Synchro Standard 0.014 wire and used to selectively catheterize the right\n bronchial artery coming off the intercostal bronchial trunk. Embolization was\n performed using 300-500 micron Embospheres. Post-embolization angiography was\n performed. The microcatheter and wire were then removed and the \n catheter was then used to select the common bronchial artery coming off the\n aorta. The Renegade STC microcatheter and Transcend wire were used to\n subselectively catheterize the right bronchial artery. Embolization was\n performed using 300-500 micron Embospheres. Post-embolization arteriogram was\n performed. The catheters were removed. The vascular sheath was then removed\n and a 6 French Angio-Seal was deployed for arterial closure. Sterile\n dressings were applied. The patient tolerated the procedure well and there\n were no immediate complications.\n\n FINDINGS:\n 1. Enlarged and tortuous right intercosto-bronchial trunk giving off a right\n bronchial artery and a separate common bronchial artery dividing in to right\n and left bronchial arteries were seen arising from the aorta at the level of\n tracheal bifurcation and are seen supplying the right lower lobe.\n 2. No contribution was identified to the anterior spinal artery from the\n right bronchial arteries.\n 3. Successful particle embolization using two vials of 300-500 micron\n Embospheres for the right bronchial arteries with good angiographic result.\n 4. Post-embolization angiogram demonstrates adequate occlusion/embolization.\n\n IMPRESSION: Successful angiogram and embolization of bronchial artery\n branches to the right lung as described above.\n\n" }, { "category": "Radiology", "chartdate": "2111-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173662, "text": " 3:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with bronchiectasis here with hemoptysis now resolved, but\n with pseudomonal PNA unalbe to wean from vent.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Bronchiectasis, hemoptysis resolved, unable to wean from\n ventilation.\n\n FINDINGS: As compared to the previous radiograph, from ,\n patient rotation and image acquisition technique are slightly different. The\n technique leads apparent increase in density of the left pulmonary vessels.\n However, their diameter has not increased.\n\n Unchanged moderate cardiomegaly. Unchanged left basal atelectasis with signs\n of left overinflation. Unchanged extensive right lower lung consolidation\n with air bronchograms and bronchiectasis. Unchanged moderate right apical\n thickening.\n\n There is no evidence of newly appeared changes. The monitoring and support\n devices are in constant position.\n\n" }, { "category": "Radiology", "chartdate": "2111-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172671, "text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess cardiopulm status, line/tube placement\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hemoptysis, s/p double lumen ETT placement and\n embolization\n REASON FOR THIS EXAMINATION:\n assess cardiopulm status, line/tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Hemoptysis, ET tube placement.\n\n One view. Comparison with the previous study done . Bilateral\n pulmonary opacities persist. There is interval improvement in the lower right\n lung, though there appears to be slightly increased streaky density in the\n lingular region. The right costophrenic sulcus is blunted as before. There\n is right apical capping changed. Mediastinal structures are unchanged in\n appearance. Endotracheal tube and nasogastric tube remain in place.\n\n IMPRESSION: Persistent bilateral pulmonary opacities. There is interval\n improvement in the right mid lung. Ill-defined increased density in the\n lingular region may represent developing focal consolidation at that site.\n There is no other significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173814, "text": " 11:39 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please eval for NGT placement\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with new NGT placement.\n REASON FOR THIS EXAMINATION:\n Please eval for NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a nasogastric tube that extends well into the stomach with the\n side hole below the esophagogastric junction. Little change in the appearance\n of the heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172625, "text": " 1:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change in cardiopulm status, tu\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with recent IP intervention for hemoptysis, now desaturating\n to 80s\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change in cardiopulm status, tube/drain placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Evaluate for interval change. Hemoptysis.\n\n One AP portable view. Comparison with the previous study done earlier the\n same day. Patchy bilateral pulmonary opacities, most pronounced in the lower\n right lung and left suprahilar region persist. Right apical capping is\n unchanged. Blunting of the right costophrenic sulcus has improved. The left\n costophrenic sulcus is not included on the current study. Mediastinal\n structures are unchanged. An endotracheal tube and nasogastric tube remain in\n place.\n\n Allowing for differences in technique, there is little interval change.\n\n IMPRESSION: No significant change in persistent bilateral pulmonary\n opacities. There may be slight interval decrease in or redistribution of\n right pleural fluid.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1173761, "text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with VAP.\n REASON FOR THIS EXAMINATION:\n Any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ventilator-associated pneumonia.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices have been removed. Obliquity of the patient somewhat obscures detail.\n There is continued enlargement of the cardiac silhouette with diffuse\n prominence of interstitial markings that could reflect elevated pulmonary\n venous pressure, chronic pulmonary disease, or both. The right basilar\n opacification persists, consistent with lower lung pneumonia. Apical\n thickening on the right is also noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172830, "text": " 1:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Any interval change?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hematemsis, s/p IR guided bronchial artery embolization.\n REASON FOR THIS EXAMINATION:\n Any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post bronchial artery embolization, hemoptysis.\n\n CHEST:\n\n Allowing for differences in rotation, there has been little change since the\n prior chest x-ray. Diffuse opacities are present in both lungs with streaky\n densities which would be consistent with aspiration or pneumonia.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172549, "text": " 5:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hemoptysis, s/p ETT\n REASON FOR THIS EXAMINATION:\n ?ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old female with hemoptysis.\n\n STUDY: Supine portable frontal chest radiograph.\n\n COMPARISON: None.\n\n FINDINGS: The endotracheal tube has been placed, whose tip is approximately 6\n cm above the carina. Endogastric tube is placed with its side port just at\n the GE junction. The patient is rotated toward the right. The\n cardiomediastinal contours demonstrate mildly enlarged heart. The hila appear\n unremarkable. Scattered areas of patchy opacity may represent areas of\n aspiration or hemorrhage. There is prominent thickening at the right apex.\n No pneumothorax is seen.\n\n IMPRESSION:\n 1. ET tube 6 cm above carina.\n 2. Endogastric tube side port just at the GE junction, would recommend\n advancing approximately 5 more cm to ensure that it is within the stomach.\n 3. Patchy opacities throughout the lungs may represent aspiration or\n hemorrhage in this patient with hemoptysis.\n 4. Prominent right apical opacity may be prominent assymetic pleural\n thickening. Recommend correlation with history of malignancy and chest CT for\n further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2111-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1172593, "text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated, OGT placement\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with double ett\n REASON FOR THIS EXAMINATION:\n intubated, OGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: T-tube and orogastric tube placement.\n\n One view. Comparison with the previous study done . The patient is\n rotated to the left, as before. There are scattered focal areas of increased\n density in the right mid and lower lung and left suprahilar region, unchanged.\n Opacities in the lower right lung appear worse. The heart appears large\n although cardiac size may be exaggerated by AP technique. Right apical\n capping persists. There is interval blunting of the costophrenic sulci. An\n endotracheal tube and orogastric tube remain in place.\n\n IMPRESSION: Interval blunting of the costophrenic sulci consistent with\n development of small effusions. Persistent pulmonary opacities with interval\n worsening in the lower right lung.\n\n\n" }, { "category": "Echo", "chartdate": "2111-12-12 00:00:00.000", "description": "Report", "row_id": 92161, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 66\nWeight (lb): 145\nBSA (m2): 1.75 m2\nBP (mm Hg): 90/57\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 12:49\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. The patient is\nmechanically ventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Aortic valve not well\nseen. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Calcified tips of papillary muscles. Mild to moderate (+) MR.\n[Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left and right atria are moderately dilated. Left ventricular wall\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The right ventricular cavity is dilated. Free wall motion is\nlow normal. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. Mild (1+) aortic regurgitation is seen. Mild to moderate\n(+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity\nof mitral regurgitation may be significantly UNDERestimated.] Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\npreserved global biventricular systolic function. Pulmonary artery\nhypertension. Moderaet mitral regurgitation. Mild aortic regurgitation.\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": "2111-12-28 00:00:00.000", "description": "Report", "row_id": 255572, "text": "Atrial fibrillation with slow ventricular response and occasional single\nventricular premature beats. Non-specific ST-T wave abnormalities. Compared\nto the previous tracing of the rate is slower, ventricular premature\nbeats are present and precordial T wave inversions are more marked. Cannot\nexclude ischemia.\n\n" }, { "category": "ECG", "chartdate": "2111-12-23 00:00:00.000", "description": "Report", "row_id": 255573, "text": "Atrial fibrillation with a controlled ventricular response. Non-specific\nST-T wave changes. Compared to the previous tracing of there is no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2111-12-22 00:00:00.000", "description": "Report", "row_id": 255574, "text": "Artifact is present. Atrial fibrillation with a controlled ventricular\nresponse. Non-specific ST-T wave changes. Compared to the previous tracing\nof the same date ventricular ectopy is no longer present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2111-12-22 00:00:00.000", "description": "Report", "row_id": 255575, "text": "Probable atrial fibrillation with probable ventricular premature beats. Since\nthe previous tracing ventricular premature beats are fewer and are of the same\nmorphology. ST-T wave abnormalities persist.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2111-12-22 00:00:00.000", "description": "Report", "row_id": 255576, "text": "Atrial fibrillation with frequent ventricular premature beats. ST-T wave\nabnormalities. Since the previous tracing ventricular premature beats are new\nand not the same morphology as those on the prior tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2111-12-22 00:00:00.000", "description": "Report", "row_id": 255577, "text": "Atrial fibrillation with rapid ventricular response with a single wide complex\nbeat, aberration or ventricular premature beat. ST-T wave abnormalities. Since\nthe previous tracing of the wide complex beat is new. The rate is\nsomewhat slower. Otherwise, there is no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2111-12-21 00:00:00.000", "description": "Report", "row_id": 255578, "text": "Atrial fibrillation with rapid ventricular response. Diffuse ST-T wave\nabnormalities are non-specific. Since the previous tracing of \nventricular rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2111-12-11 00:00:00.000", "description": "Report", "row_id": 255579, "text": "Atrial fibrillation with slower ventricular rate. Occasional ventricular\npremature beats. ST segment changes are similar to those seen on tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2111-12-11 00:00:00.000", "description": "Report", "row_id": 255580, "text": "Atrial fibrillation with moderate ventricular response. Non-specific ST-T wave\nchanges. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2139-01-22 00:00:00.000", "description": "Report", "row_id": 2027382, "text": "Neonatology-NNP Progress Note\n\nPE: Remains in an open crib, in room air, bbs cl=m rrr s1s 2no murmur, abd soft, nontender, V&S, afos, gavage in place\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2139-01-23 00:00:00.000", "description": "Report", "row_id": 2027383, "text": "NPN 1900-0730\n\n\nSpells: Infant had one desat to 58%, HR to 90s. Required\nmild stim. No bradys. See flowsheet for further details.\nContinue to monitor respiratory status and document any\ndesats or A&B spells.\n\nFEN: Wt.=2740g, down 50g from last night. TF= 120/k/day\nBM20/Sim20 PO/PNGT= 58cc's q4h (with a birthweight of\n2915g). Infant was put to breast by mom, for first time, at\n care. Good latch and suck, at breast for more than 10\nminutes. Full feed gavaged. Full second feed gavaged. Abd\nbenign. No spits, no aspirates. Voiding. Trace-small yellow\nstool. Continue to monitor tolerance to feeds and ability to\nPO feed.\n\nDev: Stable temp, swaddled, in OAC. Waking for feeds.\nSleeping well between feeds. and active. Likes\npacifier. Circ site healing well, vaseline applied to site.\nHep B given and PKU done by RN. Continue to promote\ndevelopment.\n\nParenting: Mom in for care. Taught how to take\ntemperature, change diaper. Held and breastfed infant.\n mom. Updated by RN. Plans to be in tomorrow for\neither the 0800 or 1200 care. Continue to update and\nsupport.\n\nJaundice: Infant appears slightly jaundiced. Bili levels\ndrawn by RN this morning. At 0000 they were 12.2, 0.3.\nContinue to monitor for further signs of high bilirubin\nlevels.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-23 00:00:00.000", "description": "Report", "row_id": 2027384, "text": "NPNOte\nInfant ,active with acre, mild jaundice present, PKU done with bili,desatx1 thus far this shift.i agree with above note by PCA.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-23 00:00:00.000", "description": "Report", "row_id": 2027385, "text": "Neonatology NP Note\nswaddled in open crib\nAFOF, sutures opposed\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nruddy and jaundiced\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good \n" }, { "category": "Nursing/other", "chartdate": "2139-01-23 00:00:00.000", "description": "Report", "row_id": 2027386, "text": "Neonatology Attending Progress Note\nNow day of life 4, CA 2/7 weeks.\nIn RA with RR 40-60s.\n1 episode of desaturation overnight - to 58% during feeding.\n\nHR 130-170s, BP 78/46 58\n2740gm down 50gm on 120ml/kg/d of MM20 or - feedings almost all gavage.\n\nBili 12.5/0.3\n\nAssessment/plan:\nSteady progress though still with immaturity of feeding skills.\nWill continue to support with gavage feedings until feeding skills mature. Fluids up to 140ml/kg/d.\nFU bili tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-24 00:00:00.000", "description": "Report", "row_id": 2027389, "text": "Neonatology Attending Progress Note:\nDOl #5\n35 3/7 weeks PMA\nremains in RA, RR=30-50's\ndesat on Thursday, no spells\nHR=130-160's, no murmur,\nbili=12.5 (no change)\nwt=2710g ( 30g), TF=140cc/kg/d BM/ 20\nvoiding, \n\nPE: well appearing, slightly jaundiced, AFOF, normal S1S2, no murmur, breath sounds clear, abdomen soft, nontender, nondistended, ext well perfused aga\n\nImp/Plan:x-34 week infant twin learning to po feed.\n--encourage po feeds, monitor weight\n--continue rest of present management\n--increase TF to 150cc/kg/d\n" }, { "category": "Nursing/other", "chartdate": "2139-01-21 00:00:00.000", "description": "Report", "row_id": 2027376, "text": "NPN \n\n\n\n #2. RESP: Infdant conts in RA. RR 30-40. LS cl/=. No\nincrease WO B. Sating >94%. No desats or A/B's thus far\ntoday. P: Cont to monitor for AOP.\n\n #3. FEN: TF increased to 80cc /k BM/ 20 (39cc q4hr). Not\nmeeting req by bottle. Taking only 20-22cc then falling\nasleep. Gavage tube palced and infant pg'd remainder. Abd\nsoft w/active BS, no spits, voiding and meconium.\nP: Cont to support nutritional needs. Cont to offer po.\n\n #4. DEV: Temp stable swaddled in OC. Not waking for feeds.\nMAEW. AFSO. Sucks on pacifier for comfort. Circ to be done\ntoday. Hep B order signed. P: Cont to support dev needs.\n\n #5. : Mom up at 1200 to feed infants. Is planning on\nBF is currently pumping. Dad up w/GM at 1400. Both \nupdated at the bedside. Fam meeting planned after circs\ntoday. P: Cont support, keep updated and educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-21 00:00:00.000", "description": "Report", "row_id": 2027377, "text": "1 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-22 00:00:00.000", "description": "Report", "row_id": 2027378, "text": "NPNOte\n\n\n#2.In R air, BBS clear, equal, easy resp effort,no spells\nthus far this shift. A; stable in R air. P; cont to monitor\nfor desats/ spells.\n\n#3.Todays weight=2790 down 20gms, TF=80cc/kg/day, Sim20\npo/pg fed tolerated, BS+, no loops, voided, small spitx1. A;\nfeeds tolerated. P; cont current feeding plan.\n\n#4. Alert, active with care, temp stbale in a open crib,\nswaddled with blanket,mae. A;AGA p; cont dev support.\n\n#5.Dad visited with paternal grandmother, asking \nquestions, involved with care. A; loving P; cont dev\nsupport.\n\n#6. Trace of Jaundice present,alert,active with care. P;\ncont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-22 00:00:00.000", "description": "Report", "row_id": 2027379, "text": "6 Jaundice\n\nREVISIONS TO PATHWAY:\n\n 6 Jaundice; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-22 00:00:00.000", "description": "Report", "row_id": 2027380, "text": "Neonatology Attending Progress Note\n\nNow day of life 3, CA 1/7 weeks. In RA with RR 30-60s.\nNo apnea and bradycardia noted in past 24 hours.\nHR 120-130s BP 79/45 60\n\nWt. 2790 down 20gm - took in 80ml/kg/d of MM or Similac\nFeedings well tolerated overall - mostly by gavage.\nNormal urine output.\n\nCirc performed yesterday.\n\nAssessment/plan:\nVery nice progress continues though baby has immaturity of feeding skills.\nWill increase to 120ml/kg/d.\nBili to be checked in the morning.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-22 00:00:00.000", "description": "Report", "row_id": 2027381, "text": "Nursing Progress Notes.\n\n\n#2 O: No spells noted to time of report. A: No spells\ntoday. P: Continue to monitor.\n#3 O: Total fluids increased to 120cc/kg/day of BM/ 20.\nFeeds given every 4 hours by gavage over 1 hour. 1 x large\nspit. Abdomen benign, voiding and . Circ healing\nwell. Vaseline applied with each diaper change. D/stix 93.\n A: Occasional spits, otherwise tolerating feeds well. P:\nOffer bottles at alternate feeds and observe feeding\nmaturity.\n#4 O: Temp stable in open crib. Baby woke for one feeding\nand slept though the other. Baby is and active once\nawake. A: Appropriate for age. P: Continue to support\ndevelopment.\n#5 O: mother up to visit this afternoon. Mother is pumping\nbut has not milk yet. Mother held baby. A: Involved\nfamily. P: Continue to keep informed.\n#6 O: Baby is slightly jaundiced. A: No change noted over\nthe day. P: Check bili in the am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-28 00:00:00.000", "description": "Report", "row_id": 2027404, "text": "Neonatology Attending Progress Note\n\nNow day of life 9, CA weeks.\nCurrently in RA with RR 30-50s.\nHR - 110-140s\n\nNo apnea and bradycardia in the past 2 days.\n\nWt. 2855gm down 15gm on 150ml/kg/d of MM or Sim20.\nFeedings po/pg - still unable to take full volume by bottle.\nNormal urine and stool output.\n\nID - on Nystatin powder for monilial rash.\n\nAssessment/plan:\nSteady progress continues for this now 36 week corrected age infant - will continue with support of feedings with gavage as needed.\n\n updated at bedside yesterday.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-28 00:00:00.000", "description": "Report", "row_id": 2027405, "text": "Neonatology NP NOte\nPLease refer ttending note for details of evalaution and plan.\n\nPE: large well appearing preterm infant nestled in open crib.\nAFOF eyes clear, ng in place, MMMP\nChest is clear, equal; bs, comfortable resp pattern.\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs, NTND, cord dry.\nGU: circumcised penis, testes descended\nEXT: MAE, WWP\nNeuro: symmertic , reflexes. Wide awake, slow to po.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027363, "text": "Admission Note\nTwin A 34+5/7weeker admitted to NICU for Prematurity, placed on warmer bed,V/s as recorded,baby care meds given, cBC with def, blood culture sent, D'stix 65,78,started on Po adlib sim20,po fed 10cc x1.voided, no stool,WBC 5.8, Polys 18, Bands0, Lymps 59, NNP aware.Infant alert,active with care, temp stable,MAe.Parents visited.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027364, "text": "1 Infant with Potential Sepsis\n2 Spells due to Prematurity.\n3 Fluid/e/nutrition\n4 Developmental\n5 Parenting.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Spells due to Prematurity.; added\n Start date: \n 3 Fluid/e/nutrition; added\n Start date: \n 4 Developmental; added\n Start date: \n 5 Parenting.; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027365, "text": "NPNOte\n\n\n#1.CBC with def, blood culture sent on admission, cbc\nresults seen by NNP. Infant alert,active with care. A;\nasymptomatic. P; contto monitor for s/s of sepsis.\n\n#2, no spells or desats noted thus far this shift.Easy resp\nsupport.\n\n#3. Tf=po adlib, po fed slowly, BS+, no loops, voided, no\nstool thus far this shift.d'stix 65,78,93.A; Feeds\ntolerated.P; Continue current feeding plan.\n\n#4Alert,active with care, temp stable on a warmer bed, bath\ngiven,A; AGA P; cont dev support.\n\n#5.parents visited, asking app questions.A; loving P; cont\nupdate and teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027366, "text": "Case Management Note\nChart reviewed and events noted to date. I have placed lists of Early Intervention PRograms and VNA's in record. Will be providing clinical updates to HMO Blue insurance and assist w/any d'c planning needs.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027370, "text": "NPN (1500-2300)\n\n\n1. Sepsis: No S&S of sepsis noted. No growth on blood\ncultures. Will continue at monitor.\n\n2. A/B: No A's or B's noted this shift. No desats or color\nchanges with feeding or at rest. Will continue to monitor\nclosely as infant had a desat at rest earlier today.\n\n3. F/N: PO fed 38-24cc. Needed some encouragement toward\nend of last feeding after being weighed and then fed by Dad.\n and well. Abd exam benign.\n\n4. Dev: Alert and active with cares, waking on own prior to\nfeeds. Temp stable in open crib. Well coordinated with po\nfeeding.\n\n5. Parenting: Mom and Dad in for visits with exended family\nthroughout evening. Dad fed baby at feeding and did\nwell after some teaching about positioning and burping, etc.\nPArents are loving and involved. Mom was having some\ndiscomfort and is getting some rest.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-21 00:00:00.000", "description": "Report", "row_id": 2027371, "text": "NPN:\n\nRESP: Sats 95-98% in RA. RR=30-50s. BBS =/clear. No A&Bs thus far tonight. Desats (66-75) x 2 at rest w/quick recovery thus far tonight; desats x 3 over past 24 h. Occasional desats (75-85) w/bottle feeding.\n\nCV: No murmur. HR=120-130s. BP=60/36 (46). Color pink w/slight jaundice. Perfusion good.\n\nFEN: Wt=2810g (- 105g). Ad Lib feeds. Intake yesterday 40cc/kg/d. Bottle feeding slowly w/encouragement for 30cc -20 q 4 h\n(= 60cc/kg/d). Abd benign. Voiding; mec stool.\n\nG&D: CGA=35 wk. Temp stable in crib. Not waking for feeds. Active and alert, but bottle feeeding slowly w/encouragement. Swaddled, nested and resting well.\n\nSOCIAL: No contact w/.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-21 00:00:00.000", "description": "Report", "row_id": 2027372, "text": "Neonatology\nDoing well. Intermittent desats with apnea. Comfortable appearing. No murmur. RA. WIll follow spells.\n\nWT 2810 down 105. Ad lib feeds going well. Abdomen benign. SLow .\nAwiaitng maturation of resp control and feeds. Expectw ill require gavage as feeding volumes increase. TF to increase to 80 cc/k/d.\n\nActive alert. Moving all 4. Skin w/o leisons.\n\nTemp stable.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-21 00:00:00.000", "description": "Report", "row_id": 2027373, "text": "NEonatology-NNP Progress Note\nPE: in his open crib, in room air, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, testes in scrotum, nl phallus, afso, active, slightly jaundiced\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2139-01-21 00:00:00.000", "description": "Report", "row_id": 2027374, "text": "NEonatology-NNP Progress Note\nMet with to review clinical issues and criteria for discharge. Mom is recovering from delivery and pleased with 's progress. Would like VNA at discharge, undecided regarding pedi at this time\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-21 00:00:00.000", "description": "Report", "row_id": 2027375, "text": "NEonatology-NNP Progress Note\nMet with to review clinical issues and criteria for discharge. Mom is recovering from delivery and pleased with 's progress. Would like VNA at discharge, undecided regarding pedi at this time\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-28 00:00:00.000", "description": "Report", "row_id": 2027406, "text": "NPN 0700-1900\n\n#2 Alt. in Resp. Status\nO: In RA with sats 95-100. Breath sounds are clear, =. RR 20's-60's with easy respirations. No desats or spells noted today.\nA: Doing well in RA\nP: Continue close observation and monitoring in RA. Document any spells.\n\n#3 Alt. in Nutrition\nO: TF=150cc/kg=74cc Sim20 (no BM available) Q 4 hrs. Abd. is round, soft wuth + BS, no loops. Minimal aspirates, no spits. Voiding and . PO fed X 3 taking 25-35cc and gavage fed remainder.\nA: Tolerating feeds, poor PO intake\nP: Continue with present feeding plan. Follow daily wts and encourage POs as able.\n\n#4 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Not waking for feeds but with cares. Slow PO feeding, unable to take full volume. Requires gavage. Hx. of occasional spells. None today. Nystatin powder for monilial diaper rash.\nA: Immature feeding skills, maturing breathing regulation\nP: Continue to support developmental needs.\n\n#5 Alt. in Parenting\nO: Dad called X 1. Updated on phone. Unable to visit today d/t his feeling that he is developing a cold.\nA: Involved family\nP: Keep informed and support.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-29 00:00:00.000", "description": "Report", "row_id": 2027407, "text": "1900-0700 NPN\n\n\n#2A/B'S\nO:REMAINS IN RA WITH SATS 95-100%. BS CLEAR. RESP RATE 36-60\nWIHTOUT DISTRESS. NO SPELLS/DESATS OVERNIGHT\nA:STABLE\nP:CONTINUE TO MONITOR RESP STATUS\n\n#3F/E/N\nO:TF AT 150CC/KG BM/SIM20 73CC Q4HR PO/PG. BABY BOTTLING\n39-41CC, REMAINDER GAVAGE. ABDOMEN SOFT, ROUND WITH GOOD BS.\nNO SPITS AND <1CC ASPIRATES. VOIDING WELL; SMALL STOOL X1.\nWT UP 45GM TO 2900GM. SLOW BUT WELL COORDINATED PO'S WITHOUT\nSPELLS OR CHOKING\nA:TOELRATING FEEDS WELL; LEARNING TO PO\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS\n\n#4G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. STARTING TO WAKE PRIOR TO FEEDING\nTIME. FOTNANEL SOFT AND FLAT; SUTURES SMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nO:DAD X1 FOR UPDATE.\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027367, "text": "Neonatology Attending Progress Note\n\nNow day of life 1 for this 34 week gestation twin.\nBaby is in RA with RR 40s\n1 episode of apnea and desaturation this morning.\nHR 120-140s, BP 66/44 52\n\nWt. 2915gm on ad lib demand 20.\nFeedings 15-20ml Q4H.\nDS 65-93\nNormal urine and stool output.\n\nAssessment/plan:\nPreterm male twin with mild immaturity of cardiorespiratory control.\nWill continue with cardiorespiratory monitoring and advancement of feedings as tolerated.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027368, "text": "NPN 1330\n\n\n#1 ID: Temps wnl. Behavior appropriate for . age. CBC\nnot shifted, no antibiotics.\nA: No s/s of sepsis.\nP: D/C problem.\n#2 A/B: No brady spells. One desat to 73 w/ apnea, color\nchange to dusky and stim needed.\nA: One desat, no brady.\nP: Cont to monitor.\n#3 F/N: Infant bottled 15cc q 4 hrs today, 20. Infant\nvoiding well, passing mec. Abd soft, bowel snds active. Some\nsmall spits.\nA: Taking po's fairly well.\nP: Cont to encourage po's.\n#4 Dev.: Infant taken off servo heat and swaddled w/ hat and\nt-shirt on. Temps 98.9ax. Infant awake and alert w/ cares.\nA: AGA\nP: Cont dev. supports. Move to open crib.\n#5 Parents: Mom and Dad up at 11am. Held both babies. Asking\nappropriate questions. Mom still unsure of plan to breast\nfeed. Parents will return this eve. to visit.\nA: Invested loving parents.\nP: cont parent support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-20 00:00:00.000", "description": "Report", "row_id": 2027369, "text": "NNP ON-Call\nPhysical Exam\nInfant in open air crib; room air; no respiratory distress; breath sounds clear/=; no murmur; abdomen soft, no masses; normal male genitalia; symmetric and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2139-01-19 00:00:00.000", "description": "Report", "row_id": 2027362, "text": "Neonatology Attending\n\n2915 gram 34 week male admitted secondary to prematurity\n\n2915 gram 34 week male born to a 42 yo G8 P2->4 female\nPNS: A+/Ab-/RPR NR/RI/HBsAg-/GBS unknown\nPrevious Ob history remarkable for twin loss at 24 week secondary incompetent cervix, ectopic pregnancy x 2, SAb x 3, 2 NSVD.\nThis pregnancy c/b IVF pregnancy with donor egg, triplets reduced to twins (diamniotic/dichorionic), cerclage placement and gestational DM diet controlled. Betamethasone given at 32 weeks. Presented with labor. Cerclage removed. C/S secondary to breech of Twin B. This twin vertex. Vigorous. BBO2. Agars .\n\nExam LGA premature male pink and comfortable in RA\nT 98.6 P 147 R 50 BP 67/33 mean 48 O2 sat 98%\nWt 2915 grams (>90%) Lt 47 cm (~60%) HC 34.5 cm (>90%)\nAF soft, flat, nondysmorphic, intact palate, RR not done, clear bs, no distress, no murmur, normal pulses, soft abd, 3 vessel cord, no hsm, normal male genitalia, testes descended into scrotum, no hip click, no sacral dimple, normal , \n\nDS 65\n\nA: 34 week twin #1 male who is clinically well. No respiratory distress. IDM at risk for hypoglycemia. At risk for sepsis secondary to prematurity and GBS status unknown.\n\nP: Monitor\n Feed ad lib\n If unable to feed will gavage\n Monitor DS per protocol\n Check CBC, BC\n Hold antibiotics unless CBC abnormal or develops symptoms\n Support parents\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-27 00:00:00.000", "description": "Report", "row_id": 2027399, "text": "NPN 1900-0700\n\n\n2. A&B'S\nO: Infant has had no spells or drifts thus far this shift.\nLast documented spell was on . A: Resolving AOP. P: Cont\nto monitor for A&B's.\n\n3. FEN\nO: BW 2915g. Current wgt= 2870g (+65). TF 150cc/kg/day of\nBM20/S20. Offering PO's w/each feed. Bottling 15-27cc of\n73cc minimum when offered this shift, gavaging remainder.\nAbd exam benign. No spits thus far this shift. Max asp=\n4.2cc (nonbilious and refed). Voiding and (heme-).\nA: Tolerating feeds. P: Cont to monitor for s/s feeding\nintolerance, encourage PO's, monitor intake and wgt gain.\n\n4. G&D\nO: is /active with cares. Infant is not waking\nfor feeds this shift. Temps stable swaddled in OAC.\n,. Brings hands to face. Roots and sucks on pacifier.\nWill need hearing, car seat screening prior to discharge. A:\nAGA. P: Cont to provide dev appropriate care.\n\n5. \nNo contact w/family thus far this shift. Unable to assess.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-27 00:00:00.000", "description": "Report", "row_id": 2027400, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOf,sutures opposed\ncomfortable respirations in room air,lungs clear/=\nRRr, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with symmetric and reflexes\nresolving jaundice\n" }, { "category": "Nursing/other", "chartdate": "2139-01-27 00:00:00.000", "description": "Report", "row_id": 2027401, "text": "Neonatology Attending\n\nNow day of life 8, CA 6/7 weeks.\nIn RA with RR 40-60\nNo apnea an\nHR 130-160s BP 69/32 48\n\nWt. 2870 up 65gm on 150ml/kg/d of MM or Sim20 - feedings gradually improving by bottle - still getting gavage supplementation.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current management.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-27 00:00:00.000", "description": "Report", "row_id": 2027402, "text": "NPN 0700-1900\n\n\n#2: O: Infant remains in room air, maintaining sats >93%. RR\n30's-70's with no retractions. No spells or desats this\nshift. P: Continue to monitor.\n\n#3: O: TF 150cc/kg/day of bm/ 20, 73cc q4 hours. Infant\nis offered POs each feed and so far this shift has taken\n35cc and 33cc. Abdomen benign, voiding and , stools\nheme negative. Minimal aspirates, one small spit. A: Infant\ntolerating feeds. P: Continue with current feeding plan.\n\n#4: O: Temp stable in OAC. Infant wakes for feeds and is\n and active with cares. Brings hands to face for\ncomfort and calms with pacifier. Remains swaddled in crib.\nA: AGA. P: Continue to support growth and development.\n\n#5: O: in this shift. Independant with feeds and\ncares. A: . P: Continue to support in\nthe care of their infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-28 00:00:00.000", "description": "Report", "row_id": 2027403, "text": "NURSING PROGRESS NOTE\n\n\n2 - NO SA/BS NOTED THUS FAR TONIGHT, NO A/BS IN 24 HRS.\n\n3 - FEN - TF=150CC/K OF BM/SIM20. PT ALL FEEDS, NO\nSPITS, MIN ASPIRATES. TAKING 25CC PO X2, PT REMAINS\nUNCOORDINATED WITH BOTTLE FEDDING. REMAINING FEED VIA\nNG. ABD SOFT, +BS, NO LOOPS. PT DING, .\nWT=2.855(-15)\n\n4 - DEV = TEMP STABLE IN OPEN CRIB. SWADDLED. ,\nWAKING BEFORE CARES. AFOF. SUCKING ON PACIFIER\n\n5 - Parent - no family contact thus far tonight\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-03 00:00:00.000", "description": "Report", "row_id": 2027440, "text": "NSG NOTE\n\nInstructed mom and dad in infant CPR and Choking. viewed video and on practice doll by this RN. returned on doll. Time allowed for questions to be answered. Reviewed Back to Sleep protocol. state understanding of techniques for infant CPR and Choking.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-25 00:00:00.000", "description": "Report", "row_id": 2027394, "text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in open crib, room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds equal, clear\nCV: RRR, no murmur; normal S1 S2; pulses +2\nABd: soft; no masses; + bowel sounds; cord on/drying\nGU: circumcision well-healed; normal male; testes descended\nExt: moving all\nNeuro: + suck; + grasps; symmetric \n" }, { "category": "Nursing/other", "chartdate": "2139-01-26 00:00:00.000", "description": "Report", "row_id": 2027395, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH NO A&B'S OR DESATS NOTED TONIGHT. BS CL&=, COLOR PINK AND WELL PERFUSED. NO AUDIBLE MURMER. HR 120-140'S, BP WNL.\n\nFEN: WEIGHT UP 40GMS TO 2805GMS. TOTAL FLUIDS MAINTAINED AT 150CC/KG/D OF S20/BM20 PO/PG. BOTTLED 15CC X2 TONIGHT. NO EMESIS OR RESIDUALS NOTED. VOIDING AND WNL.\n\nDEV: CIRC HEALED AND PINK. TEMP STABLE IN CRIB. WAKING FOR FEEDS BUT WEAK SUCK NOTED.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-29 00:00:00.000", "description": "Report", "row_id": 2027408, "text": "Neonatology Attending\n\nNow day 10 of life, CA \nRR - 30-60\nHR 130-160s\nNo apnea and bradycardia.\n\nWt. 2900gm up 45gm on 150ml/kg/d of MM or Sim20\nFeedings po/pg - still getting about by gavage - well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nGood progress continues.\nWill continue with encouragement of oral feedings.\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-29 00:00:00.000", "description": "Report", "row_id": 2027409, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, , AFOF, sutures opposed, good . BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-29 00:00:00.000", "description": "Report", "row_id": 2027410, "text": "Nursing NICU Note\n\n\n#2. A&B's O: Pt. remains in RA, O2 sats >96%. RR\n~30-60's. No increase work of breathing noted. No A&B's\nnoted. Pulse oximetere D/C'd today. A: Pt. remains stable\nin RA. P: Continue to monitor.\n\n#3. FEN O: TF 150cc/kg/d of BM20/Sim20 =73cc Q 4hrs. He\nis offered a bottle Q feed and has taken ~30-35cc PO q feed\nwith the remainder gavaged each time. Abdomen is soft,\npink, +bs, no loops/spits noted. A: Pt. is tolerateing\ncurrent nutritional plan. P: Continue w/ current feeding\nplan. Monitor for s/s of intolerance. Plan to offer PO\nfeeds w/ each care as pt. looks interested and tolerates.\n\n#4. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. He is and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. He uses his\npacifier well for comfort. A: AGA P: Continue to provide\nenvironment approrpriate for growth and development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-29 00:00:00.000", "description": "Report", "row_id": 2027411, "text": "2 Spells due to Prematurity.\n\nREVISIONS TO PATHWAY:\n\n 2 Spells due to Prematurity.; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-30 00:00:00.000", "description": "Report", "row_id": 2027412, "text": "1900-0700 NPN\n\n\n#3F/E/N\nO:TF AT 150CC/KG BM/SIM20 73CC Q4HR PO/PG. ABDOMEN SOFT,\nFULL WITH GOOD BS. NO SPITS AND NO ASPIRATES. VOIDING WELL;\nNO STOOL THUS FAR. WT UP 30GM. BABY HAS BOTTLED 50-68CC\nOVERNIGHT WITH GOOD COORDINATION---NO SPELLS/CHOKING\nA:IMPROVING PO'S\nP:CONTINUE TO ENCOUARGE PO'S AS ABLE, MONITOR TOLERANCE TO\nFEEDS AND WT GAIN\n\n#4G&D\nO:IN OAC WITH STABLE TEMPERTURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. WAKING TO EAT Q4HR. FONTANEL SOFT AND\nFLAT; SUTURES SMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nO:NO CONTACT OVERNIGHT\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-30 00:00:00.000", "description": "Report", "row_id": 2027413, "text": "Neonatology Attending Progress Note\nNow day of life 11, CA 3/7 weeks.\n\nCardiorespiratory status stable in RA with RR 30-50s\nHR 140-150s\nNo apnea and bradycardia.\n\nWt. up to 2930gm up 30gm on 150ml/kg/d of MM or Sim20 - feedings po/pg - bottle feedings improving somewhat - taking 20-68ml.\nNormal urine and stool output.\n\nAssessment/plan:\nSteady progress continues with gradual improvement of feeding skills.\nWill continue with support with gavage feedings as skill mature.\nWill start discharge screening and preparations.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-26 00:00:00.000", "description": "Report", "row_id": 2027396, "text": "NPN 0700-1900\n\n\n#2: O: Infant in room air, maintaining sats >94%. RR\n20's-60's. LS c/=, no spells or desats this shift. P:\nContinue to monitor.\n\n#3: O: TF 150cc/kg/day of bm/ 20, 73cc q4 hours. Offering\nPOs each feed. So far this shift infant has bottled 15cc and\n18cc. Abdomen benign, voiding, no stools so far this shift.\nMinimal aspirates, no spits. A: Infant tolerating feeds. P:\nContinue with current feeding plan.\n\n#4: O: Temp stable in OAC. Infant wakes for feeds and is\n and active with cares. Brings hands to face for\ncomfort and calms with pacifier. Remains swaddled in crib.\nA: AGA. P: Continue to support growth and development.\n\n#5: O: Dad and grandmother in this shift. Independant with\nfeeds and cares. A: family. P: Continue to support\n in the care of their infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-26 00:00:00.000", "description": "Report", "row_id": 2027397, "text": "Neonatology Attending Progress Note\n\nNow day of life 7, CA 5/7 weeks.\nIn RA with RR 20-60s.\nNo apnea and bradycardia.\n\nHR 130-150s, BP 75/44 53\n\nWt. 2805gm up 40gm on 150ml/kg/d of MM or Sim20\nFeedings mostly gavage - po feedings 10-20ml by bottle\nNormal urine and stool output\n\nLast bili 12.9/0.3\n\nAssessment/plan:\nSteady progress continues.\nWill continue with support with gavage feedings as feedings mature.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-26 00:00:00.000", "description": "Report", "row_id": 2027398, "text": "NNP Physical Exam\nPE: pink, mild jaundice, AFOF, sutures slightly override, breath sounds clear/equal with easy wOB, no murmur, abd soft, non distended, + bowel sounds, circ healed, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2139-02-02 00:00:00.000", "description": "Report", "row_id": 2027433, "text": "NNP PHysical Exam\nPE: pink infant sleeping in crib, AFOF, sutures apoosed, breath sounds clear/equal with easy WOB, no murmur, abd soft, nondistended, active bowel sounds, circ healed, sleeping with flexed .\n" }, { "category": "Nursing/other", "chartdate": "2139-01-24 00:00:00.000", "description": "Report", "row_id": 2027390, "text": "NPN 0700-1500\n\n#2 Alt. in Resp. Function\nO: In RA with sats 94-99. Breath sounds clear and =. Easy respirations. RR 30's-50's. No desats or spells.\nA: Doing well in RA\nP: Continue observation and monitoring.\n\n#3 Alt. in Nutrition\nO: TF increased to 150cc/kg=73cc BM/Sim20 Q 4 hrs. Abd. is full, soft with + BS, no loops. Minimal asdpirates, no spits. Voiding and QS. PO fed X 1, took 20cc. Gavage fed remainder and full volume at other feeding.\nA: Slow PO feeder, requires gavage\nP: Continue to encourage PO feeding as able and gavage as needed. Follow daily wts.\n\n#4 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Not waking for feeds but with cares. Sucks on pacifier but unable to take full volume by bottle. Requires gavage.\nA: Immature feeding skills\nP: Continue to support developmental needs.\n\n#5 Alt. in Parenting\nO: and grandmother up for noontime feeding. Updated. Mom being D/C'd today. Grandmother fed and held infant.\nA: Involved, family\nP: Keep informed and support.\n\n#6 Bili\nO: Repeat bili today 12.9/0.3. Color is mild jaundice. On full feeds, passing stool QS.\nA: Stable bili on DOL #5\nP: No need for treatment at this time. Continue observation. D/C problem.\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-02 00:00:00.000", "description": "Report", "row_id": 2027434, "text": "PCA NOTE 7A-7p\n\n\nFEN:\nTF are @ 120cc/kg/day of BM/ 20. Infant is on an adlib\nschedule eating about 65cc's Q4 hrs with minimal chin\nsupport. Abdominal exam benign, no loops, BS+, no spits.\nInfant is voiding qs, and heme neg. Infant seems to\nbe tolerating feeds well.\nP: continue to support nutritional needs.\n\nG/D:\nTemps are stable while infant is swaddled in OAC. Infant\nwakes for feeds, is and active with cares, and sleeps\nwell in between cares. Fonts soft and flat. AGA. Passed car\nseat test today.\nP; continue to support developmental needs.\n\n:\nDad called and spoke with RN and was updated.\nP; continue to update and support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-02 00:00:00.000", "description": "Report", "row_id": 2027435, "text": "Nursing Progress Note\nThis RN examined baby , agree with above note written by , PCA. Infant is at min 120cc/kg/d for total fluids. Passed car seat test. Updated father over phone. Plan for d/c tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-03 00:00:00.000", "description": "Report", "row_id": 2027436, "text": "PCA\n\n\n#3FEN: wt 3060, no change. infant remains on ad lib demand\nschedule with a min of 120cc's/kg/d of BM/SIM20. infant\ntaking 70-75cc's thus far. abd benign, +bowel sounds, no\nloops, no spits, voiding and ; heme neg. A: feeds\nwell P:Cont to monitor infant\n\n#4DEVE: temp stable. infant swaddled in the oac. waking for\nfeedings. and active with cares. sleeps well. settles\nwell with binki. mae. font are soft and flat. brings hands\nto face. A:AGA P:cont to support\n\n#5PARENTING: no contact thus far A/P:cont to support\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-03 00:00:00.000", "description": "Report", "row_id": 2027437, "text": "Agree with above assessment.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-03 00:00:00.000", "description": "Report", "row_id": 2027438, "text": "Neonatology Attending Progress Note\n\nNow day of life 14, CA 6/7 weeks.\nIn RA with RR 30-60s.\nNo apnea and bradycardia.\nHR 130-150s BP 77/40 56\n\nWt. 3060gm - no change\nFeedings are going well with MM or Sim20 - bottling very well.\nNormal urine and stool output.\n\nDischarge screening done - passed hearing and carseat test.\n\nAssessment/plan:\nVery nice progress continues.\nReady for dc to home today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-03 00:00:00.000", "description": "Report", "row_id": 2027439, "text": "Nursing Discharge Note\n\n\nPt. remains in RA. LS clear/=. RR~30-60's. No increase\nwork of breathing noted. He is pink, warm and well\nperfused. HR ~130-150's, no murmur noted. BP WNL.\nDischarge weight is 3.060kg. He is ad lib demand of BM/\n20 and takes ~60-75cc PO Q 4hrs without any difficulty.\nAbdominal exam is benign. He is voiding/ QS. He\nremains swaddled in an open crib, temps are stable. He is\n and active w/ cares, wakeing independently to feed.\nFontanelle soft/flat. He loves to use his pacifier, brings\nhands to face. Discharge teaching done. VNA referral\nwritten and faxed. Patient is stable and ready for\ndischarge to home.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-25 00:00:00.000", "description": "Report", "row_id": 2027391, "text": "NPN:\n\nRESP: Sats 96-98% in RA. RR=40-60. BBS =/clear. No desats or A&Bs thus far tonight; no A&Bs over past 24 h.\n\nCV: No murmur. HR=140-160. BP=78/46 (57). Color pink w/slight jaundice. Perfusion good.\n\nFEN: Wt=2765g (+ 55g). TF=150cc/kg/d; 73cc BM/-20 q 4 h via PO/PG. Tolerating gavage fdgs well over1 h. Will attempt to bottle w/next feeding. Abd benign. Voiding qs; yellow stool.\n\nSKIN: Circ site healing well; vaseline applied w/diaper change. Miconazole pdr applied to diaper area for monilial rash.\n\nG&D: CGA=35 wk. Temp stable in crib. Active and w/cares. Bottle/gavage feeds. Swaddled. nested and resting well.\n\nSOCIAL: No contact w/.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-25 00:00:00.000", "description": "Report", "row_id": 2027392, "text": "Neonatology\nDoing well. REmains in RA. No spells. Comfortable apeparing.\n\nWt 2765 up 55. Tolerating feeds at 150 cc/k of 20 cal. ABdomen benign. Req gavage. Poing slowly.\n\nActive . Moving all 4. Skin w/o lesions except for diaper rash..\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-25 00:00:00.000", "description": "Report", "row_id": 2027393, "text": "NPN 0700-1900\n\n\n#2 O: Infant remains in RA. No spells. O2 sats 94-100%. RR\n40's-60's. LS clear and =. A: Stable in RA. P: Cont to\nmonitor for a's/b's.\n\n#3 O: TF= 150cc/kg/d. Infant taking 73cc's of BM20/Similac\n20 q 4h via po/pg. Bottled 10cc's at 1200. Abdomen benign;\nvoiding and . Miconazole to monilial rash on bottom.\nCirc healing well. A: Tolerating feeds. P: Cont to monitor.\n\n#4 O: Maintaining temp in oac. Awake and with cares;\nsleeping well between. Swaddled in blanket; brings hands to\nface for comfort. A: AGA. P: Cont to support development.\n\n#5 O: No contact as yet this shift. A/P: Cont to support and\nupdate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027420, "text": "NPN 1900-0700\nI have read above note by PCA . Correection to note, pt. was not weighed by PCA. Pt. new wt is 3000gms, up 70gms.\nI had no contact with .\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027421, "text": "NPN addendum 0600\nThe PCA note bt Jocclyn referenced above appears on previous day.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027422, "text": "Neonatology Attending Note\nDOL #12, CGA 36 wks.\n\nCVR: Remains in RA, comfortable. No spells (last ). Hemodynamically stable.\n\nFEN: Wt 3 kg, up 70 cc/kg/day. TF 150 cc/kg/day, /BM 20, PO/PG. Voiding/.\n\nPE: see other note.\n\nIMP: Overall stable growing premature infant. Still with significant feeding immaturity requiring PG feeds.\n\nPLANS:\n- monitor respiratory status.\n- will decrease TF to 130 cc/kg/day min given excellent weight gain in effort to improve PO intake.\n- monitor intake, growth.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027423, "text": "NPN 1900-0730\n\n\nFEN: TF=130/k/day minimum BM/Sim30 PO/PNGT= 65cc's q4h.\nChanged today from 150/k/day requirement. Infant bottled\n43cc's at first care and 50cc's at second care, with good\ncoordination. Remainder of each feed gavaged. Abd benign.\nMinimal aspirates, no spits. Voiding. Med stool x1. Continue\nto monitor tolerance to feeds and ability to PO feed.\n\nDev: Stable temp, swaddled, in OAC. and active. Wakes\nfor feeds. Sleeps well between feeds. Loves pacifier.\nDesitin applied to mild diaper rash. Continue to promote\ndevelopment.\n\nParenting: and grandmother in for 1200 care. \n, independant with care. Mom infant.\n will be in tomorrow to visit and to bring infant's\nsibling home. Continue to update and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027424, "text": "NPN 0700-1900\n I have read and agree w/ (PCA)'s assessment and plan for this infant, with the following exception: Infant is on or BM 20 ( not 30).\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027425, "text": "Neonatology - NNP PRogress Note\n\nInfant is active with good . AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating full volume feeds. Abd soft, active bowel sounds, no loops, voiding and . Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-01 00:00:00.000", "description": "Report", "row_id": 2027426, "text": "NPN 7pm-7am\n\n\nFEN: Current weight 3005gms up 5gms. TF min 130cc/kg/day of\nBM/ 20. Infant has bottled all feeds taking 70cc's q4hrs.\nAbd soft, +bs, no loops noted. Voiding and heme\nneg. Desitin applied with diaper change for red skin. No\nspits and no asp. A: Feeding well. P: Will cont to monitor\nweight and exam.\n\nG/D: Infant is stable in open crib, temp stable. and\nactive with cares. Sucks on pacifier. Sleeps well between.\nA: AGA P: Will cont to support dev needs.\n\n: No contact at this time in shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-01 00:00:00.000", "description": "Report", "row_id": 2027427, "text": "Neonatology Attending Progress Note\nDOL #13\nCGA 36 wk\n\nOn RA. RR 30-50s.\nNo spells.\nNo murmur.\nStable VS.\n\nWt 3005 (up 5 gm)\nOn min 130 cc/kg 20/MM20. Still working on POs.\n\nStill needs car seat, but passed hearing.\nReceived Hep B.\nSome eye drainage.\n\nA/P\nPlan to decrease min to 120 cc/kg and monitor POs.\nWatch eye drainage off tx for now.\nDischarge planning underway.\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-01 00:00:00.000", "description": "Report", "row_id": 2027428, "text": "Nursing Progress Note:\n\nFEN:\nO: Infant recieving min 130cc/kg of SC/BM 20, (60cc q4h),\n(45cc q3h), po. Infant taking 50-60cc, every 3 hours. Infant\npresents with a strong suck reflex, and is eager to feed.\nDifficulty with making seal around nipple; does well with\ncheek/chin support. No spits noted today. Abdominal exam\nbenign. Voiding and passing heme negative stool.\nA: Infant tolerating feeds well.\nP: Continue with nutrition plan.\n\nDev:\nO: Infant temp stable. Swaddled in an OAC. Infant waking for\nfeeds, and is and active with cares. within\nnormal limits. Infant brings hands to face, and sucks on\npacifier for consolement. L eye continues to drain clear.\nA: Appropriate behavior for gestational age.\nP: Continue to support development\n\nSoc:\nO: in this am. Updated regarding infant's plan of\ncare by RN. assissted in cares, and po fed infant.\nMom continues to pump. CPR class tues. Twin #2 d/c'd today.\nA: Interacting well with infant.\nP: Continue to suport and keep informed.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-01 00:00:00.000", "description": "Report", "row_id": 2027429, "text": "Neonatology NP Note\nPLease refer to attending note for details of evaluation and plan.\n\nPE: well apperaing well developed p[retermn infant nestled in open crib. AFOF, eyes clear, MMMP. NG removed today.\nChest is clear, equal bs, comfortable resp pattern\nCV: RRR, no murmur, pulses +2=\nAbd: soft, active bs, NTND\nGU: circ healed, testes descended\nEXT: MAE, \nNeuro: symmetric and reflexes.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-02 00:00:00.000", "description": "Report", "row_id": 2027430, "text": "PCA\n\n\n#3FEN: wt up 55 to 3060. infant remains on ad lib demand\nschedule with a min of 120cc's/kg/d of BM/SIM20. infant is\ntaking 58-65cc's thus far. abd benign, belly is soft and\nround, no loops, +bowel sounds, no spits thus far, voiding\nand ; heme neg. A: feeds well P:cont to monitor\n\n#4DEVE: temp stable. infant is swaddled in the oac. wakes\nfor feedings. and active with cares. settles well with\nbinki. sleeps well in between cares. mae. font are soft and\nflat. A:AGA P:cont to support\n\n#5PARENTING:no contact thus far A/P:cont to support\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-02 00:00:00.000", "description": "Report", "row_id": 2027431, "text": "NPN 7pm-7am\nI agree with above note by , PCA. Infant is stable. Feeding well.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-02 00:00:00.000", "description": "Report", "row_id": 2027432, "text": "Neonatology Attending\n\nNow day of life 13, CA 5/7 weeks.\n\nIn RA with RR 30-40s.\nNo apnea and bradycardia.\nHR 130-150s BP 75/39 45\n\nWt. up 55gm to 3060gm on ad lib feedings MM or 20 - took in more than minimum all po (120ml/kg/d) - feedings well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress with evidence of maturation of feeding skills.\nWill plan on discharge to home tomorrow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-23 00:00:00.000", "description": "Report", "row_id": 2027387, "text": "NPN 0700-1900\n\n#2 Alt. in Resp. Function\nO: In RA with sats 96-100. Breath sounds are clear and =. RR 30's-50's. One quick desat to 78 while bottle feeding, QSR when feeding stopped. No spontaneous spells.\nA: Doing well in RA\nP: Continue observtion and monitoring. Document any spells.\n\n#3 Alt. in Nutrition\nO: TF increased to 140cc/kg=68cc BM/E20 Q 4 hrs. Abd. exam is benign. Minimal aspirates, no spits. Voiding and . To breast X 1, w/o latch. Bottle fed X 3 taking 10-20cc. Gavage fed remainder.\nA: Tolerating feeds, poor PO feeder\nP: Continue to encourage PO feeding. Gavage as needed to acheive adequate intake. Follow daily wts.\n\n#4 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Not waking for feeds, but with cares. Sucks well on pacifier. No spontaneous spells. Requires gavage to acheive TFI.\nA: Immature feeding skills\nP: Continue to support developmental needs.\n\n#5 Alt. in Parenting\nO: up for all feeds. Updated and questions answered. took temps and changed diapers. Mom put infant to breast with assistance and offred bottle.\nA: Involved, \nP: Keep informed and support.\n\n#6 Hyperbili\nO: Color is mild/mod. jaundice. Increased TF to 140cc/kg. Passing stool. Last bili 12.5/0.3\nA: Mild hyperbili, not at treatment level\nP: Check bili in AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-24 00:00:00.000", "description": "Report", "row_id": 2027388, "text": "NPN 2300-0700\n\n\n2 Spells\nNone noted this far this shift.\n\n3 FEN\nCurrent weight 2.710 kg, down 30 grams. Below birth weight.\n TF remain at 140cc/kg/day. Alt po/pg. PO feed 25cc, out\nof 68. Tolerating feedings well. Abd soft, bs +. No\nspits, or asp. Voiding and .\n\n4 DEV\nTemp stable in open crib. Awake and active with cares.\nSleeps well between cares. Sucks vigorously on pacifier.\n\n5 \nNo contact thus far this shift,\n\n6 Jaundice\nBili sent results pending. Remains slightly jaundice.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-30 00:00:00.000", "description": "Report", "row_id": 2027414, "text": "NPN 0700-1500\n\n\n#3 O: TF= 150cc/kg/d. Infant taking 73cc's of similac 20 q\n4h via po/pg feeds. Bottled 20 and 50cc's this shift;\ngavaged remainder. Abdomen benign; voiding and . No\nspits, no aspirates. Circ has healed well. Desitin to\nreddened bottom. A: Tolerating feeds. P: Cont to monitor.\n\n#4 O: Maintaining temp in oac. Awake and with cares;\nsleeping well between. Awoke x2 for feeds today. Swaddled in\nblanket; brings hands to face for comfort and sucks on\npacifier when offered. Bilateral eye drainage; yellowish. A:\nAGA. P: Cont to support development. To get hearing test\nsoon.\n\n#5 O: No contact as yet this shift. are suppose to\nlet us know their choice of pedi. We need to tell to\nbring in car seat soon. A/P: Cont to support and update;\ncont d/c teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-30 00:00:00.000", "description": "Report", "row_id": 2027415, "text": "NPN 0700-1500\nMom in at 1400 for visit. Mom told of infant # 2's possible d/c for Sunday. Mom calling pedi today to make appt for Mon. Mom told of VNA referral. Mom told to bring in car seat ASAP to have test. Reviewed some d/c teahcing with mom. requesting family meeting Sun. before d/c to review with both together. Given \"Back to sleep\" brochure and signed up for CPR Tues. . Cont d/c teaching.\n" }, { "category": "Nursing/other", "chartdate": "2139-01-30 00:00:00.000", "description": "Report", "row_id": 2027416, "text": "Neonatology NP Note\nPlease refer to attending note for details of evaluation and plan.\n\nLarge well developed preterm infant nestled in open crib.\nPink, well perfused, comfortable in RA.\nAFOF, eyes clear, ng in place, MMMP.\nChest is clear, equal bs, comfortable resp pattern\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs cord area drying.\nGU: circ well healed\nEXT: , \nNeuro: symmetric , reflexes\n\nMother updated regarding infant's progress, acre, readiness for discharge.\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-30 00:00:00.000", "description": "Report", "row_id": 2027417, "text": "FEN O/A: 150cc/kilo BM20 or Sim20 Q4hours PO or PG. Bottled\nhalf feed each time, voiding/ heme negative. +BS, no\nspits, minimal aspirates, Weight 3.23kg, up 105 grams. P:\nContinue to monitor and encourage PO feeds.\n\nG&D O/A: Open air crib, and active with cares, waking\nfor feeds, self soothes with hand, A&P fontanells soft and\nflat, engages care taker. P: Continue to monitor.\n\n O/A: Mom and aunt in today for 1600 feed. Mom asked\nappropriate questions, aunt fed , seem like very\n family. P: Continue to encourage and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027418, "text": "PCA NOTE\n\n\nFEN: Current weight 3.000, ^ 70gm. TF 150cc/k/d of 20.\nPO/PG. Taking about half PO volume. is voiding and\n. Hem neg. Active bowel sounds. Benign abdomen.\nMinimal residuals. No spits. Tolerating feeds. P-Continue to\nencourage PO intake.\n\nDEV: Temp stable in OAC. Waking for feeds. and active.\nSleeps peacefully. MAE. AF-flat. Roots. Sucking on pacifier.\nAGA. P-Continue to support developmental milestones.\n\n: No contact over night.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-01-31 00:00:00.000", "description": "Report", "row_id": 2027419, "text": "NPN 1900-0700\nI have read and agree with above note by PCA . I have examined pt. at care times.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2138-01-14 00:00:00.000", "description": "Report", "row_id": 1329044, "text": "npn\nneuro: aox3 very pleasant man, perlla,\n\npain: c/o abd pain prior to bm around 4am which pt said resolved after., again at 5am put pt stated he felt better after being repositioned, tf not advanced beyond 20cc/hr\n\ncad; pt has pacer, hr 50 sb with no ectopy noted, b/p 96/31 while asleep to 124/34 while awake. cpk 115, hct at 6am 30.1, prior, 30.8 and then 34.5\n\nresp: ls clear, sats 98% on ra,\n'\ngi: abd soft bs+, pt had one maroonish liquid stool at 430am approx. 350cc. tf at 20cc/hr not advanced to due abd pain, pt letting ice shiips melt in mouth and then spitting out,\n\ngu: pt voiding clear yellow urine, cl 123\n\nid: afebrile, wbc 6.5\n\nPlan: ? transferrring to floor with liquid maroonish stool and hct at 30.1 overnight, cont to monitor hct, vs other labs\n\n\n" }, { "category": "Nursing/other", "chartdate": "2138-01-12 00:00:00.000", "description": "Report", "row_id": 1329041, "text": "Nursing progress notes\n yr old male w/ hx of cabg yrs ago, angioplasty w/ stent 3 yrs ago, htn, esoph. stricture and g-tube placement 6yrs ago, bleeding ulcer, demand pacer (set at 50), afib. had drk stools x 4 days had a near syncopal episode to ed hct 20.5 2 units of prbc given hct 20.3 3 units of prbc given hct 22.4. pt received 9 units total prbc. to for egd using pediscope d/t esoph stricture. Arrival to micu #8 &#9 units were finished by ems. pt pale alert no c/o pain- did receive fentanyl 25mcq iv x 2 for mid abd pain w/ good results. all labs drawn on arrival hct 31. gi consult in room to preform scope via peg tube d/t esoph stricture and risk for perferation. pt had maroon stool w/ marble size clots x1. AT 1830 pt bp dropped from 120s/60s to 90s/40s 2 units of prbc ordered to be given- 1st unit up at 1900.\n\nNeuro: alert and oriented x 3 mae.\n\nResp: 2l nc sat 100% ls clear\n\nCV: tele sr 70-80s no pacer spikes seen, ekg done protonix gtt at 8mg/hr.\n\nGi: npo abd flat soft bs hypoactive, pt has peg tube and feeds himself carnation breakfast drinks tid at home.\n\ngu: pt voiding in urinal 110cc since 1630.\n\nskin intact\n\nsoical: son contact person\n\ncode: full\n\nplan:\ncont scope of pt duodenum.\ncont finishing tx 2 units\nmonitor for acute bleeding\n" }, { "category": "Nursing/other", "chartdate": "2138-01-13 00:00:00.000", "description": "Report", "row_id": 1329042, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A Y/O ANESTHESIOLOGIST WITH A PMH OF CABG, ESOPHAGEAL STRICTURES, HTN AND CHF (EF 45%) WHO PRESENTED TO C/O OF FEELING TIRED, DIZZY AND WEAK. THE WEEK PRIOR TO ADMISSION, PT HAD NOTED MAHOGANY STOOLS. HE HAD STOPPED TAKING HIS ASA FOR THE WEEK BUT HAD BEEN TREATING A SORE FOOT WITH ADVIL. UPON ARRIVAL TO , HIS CRIT WAS NOTED TO BE 20. DUE TO ESOPHAGEAL PT TX TO FOR SCOPE VIAPEG TUBE SITE. RECEIVED TOTAL OF 9 UNITS PRIOR TO ARRIVAL AND ANOTHER 4 UNITS UPON ARRIVAL FOR A TOTAL OF 13U PRBCS. PT HAD SCOPE ON AT 1900- TOLERATED WELL. BLEEDER FOUND AND INJECTED WITH EPINEPHRINE. TRANSIENT EPISODE OF SBP IN THE 70'S- RESPONDED TO 500CC FLUID BOLUS. NO EPISODES OF MELENA SINCE SCOPE. CRIT HAS REMAINED STABLE- GOAL OF > OR = TO 30.\n\nDISPO: FULL CODE, CALL OUT TODAY. TRANSFER NOTE IS DONE.\n\nNEURO: PT IS ALERT AND ORIENTED X 3. SPEECH CLEAR, ABLE TO VOCALIZE NEEDS WITHOUT DIFFICULTY. FOLLOWS COMMANDS. MAE X 4 WITHOUT DIFFICULTY- ABLE TO REPOSITION AND ASSIST WITH CARE. PERRLA, 3/BRISK. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nRR: BBS= ESSENTIALLY CLEAR TO AUSCULTATION. RR 15-20. NO C/O SOB OR DIFFICULTY BREATHING. SP02 > OR = TO 95% ON 2L NC. BILATERAL CHEST EXPANSION NOTED. STRONG, PRODUCTIVE COUGH- THICK, WHITE SPUTUM NOTED.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, 80'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. DENIES ANY CHEST PAIN. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS.\n\nGI: ABD IS SOFT, NON-DISTENDED AND ON-TENDER TO PALPATION. BS X 4 QUADRANTS- FOLEY CATHETER SUBSTITUDED FOR PEG TUBE. PASSING LARGE AMOUNTS OF FLATUS. NO BM DURING THE SHIFT.\n\nGU: ABLE TO VOID IN URINAL. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nSOCIAL: SON WILL BE IN TO VISIT TODAY.\n\nPLAN: MONITOR CRIT Q 4 HOURS- 4 HOURS, NEXT CRIT DUE AT 0800 PLEASE. GOAL FOR CRIT > OR = TO 30. CALL OUT TO FLOOR- TRANSFER NOTE IS DONE- PLEASE UPDATE PRN. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2138-01-13 00:00:00.000", "description": "Report", "row_id": 1329043, "text": "PT IS A/O X3, PLEASANT AND COOPERATIVE. ABLE TO GET UP TO CHAIR WITH SUPERVISION. HR 47-55 SB, RARE PVC NOTED. BP STABLE. AFEBRILE. LS CTA, ON RA WITH O2 SATS IN HIGH 90'S TO 100%. PRODUCTIVE COUGH OF WHITE SPUTUM. NEPRO TF STARTED AT 10CC/HR, GOAL IS 35CC/HR VIA G-TUBE (WHICH IS ACTUALLY FOLEY CATHETER TUBE TEMPORARILY). NO STOOL TODAY. HCT STABLE. VOIDS PER URINAL. SEE CAREVUE AND TRANSFER NOTE FOR OBJECTIVE DATA.\n\nPLAN: PT IS CALLED OUT TO MEDICAL FLOOR, AWAITING BED PLACEMENT. CONT TO ADVANCE TF AS TOLERATES. NEW TUBE TO BE PLACED TO G-TUBE SITE PRIOR TO PTS DISCHARGE.\n" }, { "category": "Echo", "chartdate": "2138-01-13 00:00:00.000", "description": "Report", "row_id": 80252, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Coronary artery disease. Left ventricular function. Mitral valve disease. Murmur.\nHeight: (in) 68\nWeight (lb): 120\nBSA (m2): 1.65 m2\nBP (mm Hg): 122/39\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 10:41\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: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild-moderate\nregional LV systolic dysfunction. No resting LVOT gradient. No LV\nmass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Moderate AS. Mild (1+) AR. Eccentric AR jet directed toward the\nanterior mitral leaflet.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Moderate (2+) MR. LV\ninflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild to moderate regional left\nventricular systolic dysfunction with distal septal and apical hypokinesis as\nwell as basal inferior and infero-lateral hypokinesis. No masses or thrombi\nare seen in the left ventricle. Right ventricular chamber size and free wall\nmotion are normal. The number of aortic valve leaflets cannot be determined.\nThe aortic valve leaflets are moderately thickened. There is moderate aortic\nvalve stenosis. Mild (1+) aortic regurgitation is seen. The aortic\nregurgitation jet is eccentric, directed toward the anterior mitral leaflet.\nThe mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation. The tricuspid valve leaflets are mildly thickened. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2138-01-13 00:00:00.000", "description": "Report", "row_id": 203387, "text": "A-V paced rhythm\nSince previous tracing, A-V pacing is new\n\n" }, { "category": "ECG", "chartdate": "2138-01-12 00:00:00.000", "description": "Report", "row_id": 203388, "text": "Sinus rhythm. Left axis deviation. Poor R wave progression - consider old\nanterior wall myocardial infarction. Q waves in the inferior leads suggest old\ninferior wall myocardial infarction. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2138-01-15 00:00:00.000", "description": "R FOOT AP,LAT & OBL RIGHT", "row_id": 900014, "text": " 1:46 PM\n FOOT AP,LAT & OBL RIGHT Clip # \n Reason: fracture, inflammation\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with sudden onset R foot pain, erythema on dorsum of foot. No\n h/o trauma, but pain also occurred 2 weeks ago during golf\n REASON FOR THIS EXAMINATION:\n fracture, inflammation\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Right foot.\n\n HISTORY: Sudden onset right foot pain, erythema on dorsum of foot. No\n history of trauma.\n\n Right foot three views show marked osteoarthritic changes at the\n tarsometatarsal joints medially and there are subchondral cystic changes.\n There is also osteoarthritis of the navicular-cuneiform joint. The alignment\n of the tarsometatarsal joints is well maintained. There is also mild\n osteoarthritis of the great toe MTP joint. Osteopenia. There is mild soft\n tissue swelling at the dorsum of the mid foot.\n\n IMPRESSION: Osteoarthritis of tarsometatarsal and navicular-cuneiform joints\n with large subchondral cyst which may be secondary to old trauma.\n Tarsometatarsal joints are also a good site for gout arthropathy.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2163-06-08 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 962383, "text": " 7:51 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: HYPOXEMIA, ? PE/DISSECTION\n Field of view: 44 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with IPF, now more SOB, hypoxemic, +chest pain CXR infiltrates\n widened mediastinum\n REASON FOR THIS EXAMINATION:\n chest pain protocol for dissection? pe? infiltrates vs effusions vs volume\n overload?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl WED 9:24 PM\n Study somewhat limited by motion, but no evidence of PE or dissection.\n Marked interval worsening of ground glass opacity and interstitial thickening\n on top of the patient's baseline disease. Differential includes exacerbation\n of chronic lung disease and/or superimporsed infectiouis process. Absence of\n pleural effusions weighs against CHF.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: IPF, now with more shortness of breath and hypoxia. Chest pain.\n\n COMPARISON: CT chest dated .\n\n TECHNIQUE: MDCT acquired images of the chest were obtained before and after\n the administration of IV contrast with CT angiogram technique.\n\n CTA OF THE CHEST: Study is limited by motion. Within the limits of this\n study, no pulmonary embolism is identified. The aorta and great vessels\n appear intact. There are coronary artery calcifications. Enlarged anterior\n mediastinal, AP window, paratracheal, right hilar, and subcarinal lymph nodes\n are not significantly changed compared to the previous study. There is marked\n interval worsening of diffuse ground-glass opacity affecting all five lobes of\n the lungs. Peripheral interlobular septal thickening with honeycombing is\n also again demonstrated. Limited images of the upper abdomen are\n unremarkable.\n\n Bone windows reveal no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n\n 1. Study limited by motion with no evidence of pulmonary embolism or thoracic\n aortic dissection.\n\n 2. Continued demonstration of peripheral honeycombing and interlobular septal\n thickening with marked interval worsening of diffuse ground-glass opacity as\n well as interstitial thickening. The rapidity of progression would favor an\n acute process such as infection as opposed to solely an acute exacerbation of\n chronic lung disease. The absence of pleural effusions and cardiac enlargement\n may weigh against pulmonary edema.\n\n (Over)\n\n 7:51 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: HYPOXEMIA, ? PE/DISSECTION\n Field of view: 44 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Stable mediastinal and hilar lymph nodes, likely related to underlying\n IPF.\n\n" }, { "category": "Radiology", "chartdate": "2163-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 962373, "text": " 6:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for inflitrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with know pulm fibrosis with hypoxia and SOB\n REASON FOR THIS EXAMINATION:\n eval for inflitrate\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Known pulmonary fibrosis with hypoxia and shortness of breath.\n\n PORTABLE CHEST: Comparison is made to multiple priors, the most recent dated\n . Since that time, there has been substantial improvement in the\n focal scattered ill-defined opacities noted in the left apical region and the\n lower lobes, bilaterally with no new opacity identified. Increased\n interstitial markings consistent with patient's chronic lung process persist.\n Pleural thickening versus small effusion in the right costophrenic angle is\n unchanged. Evaluation of the cardiomediastial silohuette is again notable for\n borderline cardiac enlargement.\n\n IMPRESSION: Improvement in scatterred parenchymal opacities with no new\n opacity identified.\n\n" }, { "category": "ECG", "chartdate": "2163-06-08 00:00:00.000", "description": "Report", "row_id": 199151, "text": "Sinus rhythm\nEarly transition\nNonspecific inferolateral T wave flattening\nSince previous tracing of , T wave changes are noted\n\n" }, { "category": "Nursing/other", "chartdate": "2163-06-09 00:00:00.000", "description": "Report", "row_id": 1376690, "text": "Respiratory care\nPt recieving 100% NRB, + 8 l/m NC sat 86-92. Pt trialed on high-flow without success. Plan to continue on current fio2.\u0013\n" }, { "category": "Nursing/other", "chartdate": "2163-06-10 00:00:00.000", "description": "Report", "row_id": 1376691, "text": "respiratory care\npt was on NRB + NC 4l/min with sats in 80's.Nasal CPAP and NIPPV tried ,poorly tolerated.Condition discussed with family.Pt was made DNR/DNI earlier.Decision was made for comfort measures only.Pt was placed back on NRB+NC.Family in and out of pt's Room.\n" }, { "category": "Nursing/other", "chartdate": "2163-06-10 00:00:00.000", "description": "Report", "row_id": 1376692, "text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVUE FOR OTHER OBJ DATA\n\n61 YR OLD MALE WITH PULMONARY FIBROSIS, HTN, CAD, ADMITTED WITH SUDDEN ONSET WORSENING DYPSNEA, HYPOXEMIA, CHEST PRESSURE FOR 2 WEEKS AFTER A PNA TREATED WITH LEVOFLOXACIN.\n\nEVENT: PT CONT TO TO LOW 80S ON 15L /7LNC, UNABLE TO TOLERATE NON INASIVE VENT (BIPAP MASK). FAMILY (PT'S WIFE AND CHILDREN) REQUEST INITIATION OF COMFORT CARE/ MORPHINE GTT INITIATED.\n\nPT RECEIVED AGITATED AND DISORIENTED, PULLING LINES, ATTEMPTING TO GET OOB. LORAZEPAM AND MORPHINE GIVEN/ GTT AT 4MG/HR. PT SEDATED, DOES NOT RESPONSE TO VOICE STIMULATION, DOES NOT FOLLOW COMMANDS.\n\nHEART RYTHM SINUS WITH NO ECTOPIES/ HR 70S-80S/ SBP 100S-120S/MAP:70S.\n\nPT RECEIVED LABORED, TACHYPNEIC AND SOB. NOW, RESP EFFORT LESS LABORED AND EVEN/ LUNG SOUNDS DIMINISHED/ SATO2 80S ON 10L / 5L NC. ATTEMPTS TO WEAN OFF , PT RAPIDLY TO 60S AND BECOME VERY AGITATED/COMBATIVE. WILL REATTEMPT WHEN ADEQUATELY SEDATED.\n\nABD OBESE/ FIRM, POS BS. NO BM\n\nFOLEY DRAINING AMBER CLEAR URINE/ 30-50CC/HR\n\nSKIN W/M.\n\nFAMILY (WIFE, AT BEDSIDE FOR ENTIRE SHIFT. THEY FULLY UNDERSTOOD PT'S DISEASE PROCESS AND PROGNOSTIC. WIFE STATES:\" MY HUSBAND DOES NOT WANT TO BE KEPT IN VEGETATIVE STATE.\" FAMILY APPEAR VERY UPSET RE: PT'S SUDDEN DETORIORATION. FAMILY BENEFIT FROM SS AND PALIATIVE CARE CONSULT.\n\nCONT CURRENT POC\nPROVIDE EMOTIONAL SUPPORT FOR PT AND FAMILY\n\n" }, { "category": "Nursing/other", "chartdate": "2163-06-10 00:00:00.000", "description": "Report", "row_id": 1376693, "text": "Nursing 0700 - 1030:\nPt made CMO over night\n\nreceived pt on 4mg of IV morphine, @ 15L and NC at 6L, Pt unresponsive. PERLA/sluggish, CV NSR 70's with no ectopy. + PP skin cool and dry. Family at bedside. and NC removed pt given 1mg bolus and morphine GTT increased to 8mg/hr. Pt past away at 1030, Resident in room. Pt was sent to morgue with gold ring with diamonds on left hand. And a gold ring with a triangle on his right hand.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-06-09 00:00:00.000", "description": "Report", "row_id": 1376688, "text": "nsg admit note\n61 yo male with hx of intersitial pulm fibrosis on 2l np at home presented after developing increasing dyspnea and hypoxemia. He was in 3 weeks ago when he developed dyspnea, cough and sputum production. He was prescribed levofloxacin for 10 days which he finished. When he returned to he came into pulmonary clinic. He had a chest CT which showed worsening ground glass opacities. He was placed back on levofloxacin and given azithromycin. He began noticing increasing dyspnea and 1 day PTA he awoke with sudden dyspnea and intermittent cp which was relieved with 1 ntg. He went to osh and was transferred to where he receives his pulm care. PMH IPF diagnosed , HTN, CAD MI and PTCA , prior etoh abuse, PTSD, bipolar disorder. He is allergic to percocet. He lives with wife, smoked ppd x 30-40yr quit , etoh abuse also quit . He is a retired quality engineer.\nO. Neuro a/o x3 appearing very agitated, moving constantly c/o all the lines and restrictions, wanting to get oob to chair. He was given ativan 1mg po and clonazepam 1mg without effect. He was found oob standing bed alarm had gone off he was very unsteady on his feet but never fell. Oxygen saturation dropped to 65%. Patient placed back in bed both MD tried to explain his plan of care and why restrictions were in place. His oxygen saturation was slow in going back to low 90% on 100% NRB\nResp on 100% NRB unable to tolerate any activity, oxygen saturations drop quickly. Lungs crackles 3/4 up b/l. Given lasix 20mg IVP with good effect neg LOS mn to 0500 neg 1210\ncvs HR 80-96 nsr K+ 3.5 tx with 40 meq kcl po bp 93/60-153/90 Hct 36.8 skin warm and slightly diaphoretic pp+, denied cp cpk and troponin pending\ngu bun 9 cr .8 leaking around foley which is 14 fr patient felt insertion was very painful urine sent for cx and ua\ngi npo except meds abd obese soft bs+\nID afebrile on flagyl, vanco and ceftazidime\na. IPF in a research study on oxcarbazepine med in room,? chf ? infectious process, CAD, HTN, Leukocytosis, bipolar disease\np. given lasix 20mg ivp monitor I+o's, lung exam, tx antibx as ordered, follow cx, wbc ? using steroids, cardiac enzymes pnding first neg., cont atenolol, reassure patient and family, place patient back on psych meds give lorezapam, clonazepan ? increasing doses, ? if patient would benefit by either social worker or psych consult\n\n" }, { "category": "Nursing/other", "chartdate": "2163-06-09 00:00:00.000", "description": "Report", "row_id": 1376689, "text": "Nursing 0700-1900:61 Year old male with allergy to Percocet. Pt made a DNR/DNI today.\nCC:\nNeuro: Pt is alert and oriented X 3. PERLA, pt able to move all extremeties. Pt very anxious/agitated at times. Pt receiving PO ativan with very little effect. Pt has a one time dose for 0.5mg of IV Morphine MRX1.\n\nCV: Afebrile, NBP 108-120/60's with a mean in the 70's, BNP upon addmition = 579. Pt R/O for MI by enzymes. No edema, strong Pedal pulses. No chest pain or chest discomfort noted or stated by the pt. Capilary refill less than 3sec. Blood culture pending.\n\nRespiratory: lower lobes with crackles bilat and upper lobes clear and diminished bilat. Pt on NRB at 15L and NC @ 4L NC. Pt had one episode of O2 drop to 74%. Subsequently O2 took greater than 10 minutes to rise back to 88% with NC increased to 8L NC. Pt O2 dramatically drops when NRB is off or pt becomes excited. Pt is constantly reinforced to keep NRB in place, and to deep breath.\n\nGI: abdomen soft non-tender Bowel sounds present. Pt had a small brown semi-formed today guiac negative. Pt on a low sodium diet secondary to history of CAD. Also pt is on insulin sliding scale 2/2 steroid use.\n\nGU: foley inplace draing clear yellow urine. Urine culture pending.\n\nPlan: Provide emotional support to both Pt and family, continue antibiotics, Keep O2 85%<, Blood sugar QID cover with sliding scale.\n" } ]

[ { "category": "Echo", "chartdate": "2165-08-23 00:00:00.000", "description": "Report", "row_id": 64874, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 57\nWeight (lb): 120\nBSA (m2): 1.45 m2\nBP (mm Hg): 100/60\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 10:52\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Dilated LV cavity. Severe global LV hypokinesis. Severely\ndepressed LVEF.\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity is dilated. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n3. The right ventricular cavity is dilated. There is severe global right\nventricular free wall hypokinesis.\n4. The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\n\n" }, { "category": "ECG", "chartdate": "2165-08-29 00:00:00.000", "description": "Report", "row_id": 129492, "text": "Baseline artifact. Probable atrial fibrillation with variable ventricular\nresponse. Low limb lead voltage with vertical axis. Right bundle-branch block.\nST-T wave abnormalities including Q-T interval prolongation. Since the previous\ntracing of atrial fibrillation is new. Other features are probably\nunchanged. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2165-08-25 00:00:00.000", "description": "Report", "row_id": 129493, "text": "Probable \"fine\" atrial fibrillation. Right bundle-branch block. Posterolateral\nmyocardial infarction of indeterminate age which may be old. Borderline low\nQRS voltage. ST-T wave abnormalities. Since the previous tracing of no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2165-08-22 00:00:00.000", "description": "Report", "row_id": 129494, "text": "Fine atrial fibrillation. Low voltage in the limb leads, low normal voltage in\nthe precordial leads. Right bundle-branch block. Non-specific ST segment\ndepressions with T wave inversions in leads V3-V4. Compared to the previous\ntracing of ST segment depressions have newly appeared. Ischemia should\nbe excluded.\n\n" }, { "category": "Radiology", "chartdate": "2165-08-22 00:00:00.000", "description": "ERCP BILIARY ONLY BY GI UNIT", "row_id": 925292, "text": " 6:37 PM\n ERCP BILIARY ONLY BY GI UNIT Clip # \n Reason: r/o neoplastic biliary obstruction\n Admitting Diagnosis: EXCESSIVE LOSS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with obtructive jaundice and wt loss.\n REASON FOR THIS EXAMINATION:\n r/o neoplastic biliary obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old male with obstructive jaundice and weight loss.\n\n FINDINGS: Eight fluoroscopic spot images obtained during recent ERCP without\n a radiologist present are submitted for review. Images show cannulation and\n subsequent opacification with contrast of the common bile duct and biliary\n tree. An irregular filling defect is seen in the distal common bile duct\n consistent with a stone. There is no evidence of biliary ductal dilatation.\n By report, a sphincterotomy was performed and a 12-mm balloon was used to\n sweep the common bile duct with successful extrusion of sludge and bile.\n Subsequent images demonstrate successful placement of a 7 cm x 10 French\n biliary stent within the common bile duct.\n\n For further details, please refer to the dedicated ERCP report, which is\n available on the online CareWeb system.\n\n" }, { "category": "Radiology", "chartdate": "2165-08-26 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 925687, "text": " 11:43 AM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n Reason: Concern for other source of obstruction.\n Admitting Diagnosis: EXCESSIVE LOSS\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with 4 weeks of weight loss and painless jaundice, s/p ERCP\n with removal of single stone in CBD, no other dilation, now found to have\n increasing bilirubin.\n REASON FOR THIS EXAMINATION:\n Concern for other source of obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n This dictation included clip # (MRCP dated ), as well as\n clip # (continuation of the MRCP, performed on ).\n\n INDICATION: Four weeks of weight loss and painless jaundice, status post ERCP\n with removal of a single stone in common bile duct, no other dilation, now\n with increasing bilirubin. Evaluate for other source of obstruction.\n\n COMPARISON: No prior MRs for comparison. Comparison is made to CT\n dated .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the\n abdomen on a 1.5 Tesla magnet prior to, during, and following the\n administration of intravenous gadolinium-DTPA. Subtraction images are\n provided.\n\n Images were reviewed and multiplanar reformations generated on a separate\n workstation.\n\n FINDINGS: Multiple series are markedly limited by patient respiratory motion\n during image acquisitions. Within the right lobe of the liver, an 8-mm simple\n cyst is seen just superior to the gallbladder fossa. There is an additional,\n questionable, tiny cyst within the lateral aspect of the left lobe. A small\n amount of pneumobilia is seen within the left hepatic duct. There is no\n intra- or extra-hepatic biliary ductal dilatation. Hypointensity within the\n common bile duct on T1-weighted images is likely consistent with a plastic\n stent in place within the common duct. The gallbladder is nondistended. No\n stones are identified within the gallbladder or biliary tree. No enhancing\n lesions are identified within the liver. The pancreas appears unremarkable,\n without evidence of masses or ductal dilatation. The spleen and adrenal\n glands appear unremarkable. At the upper pole of the left kidney, a 7-mm\n peripheral, linear focus of hyperintensity on T1 pre-contrast images\n demonstrates non-enhancement post-contrast and likely represents a small\n proteinaceous or hemorrhagic cyst. A simple cyst within the interpolar region\n of the right kidney measures 5 mm in diameter. There is no hydronephrosis in\n either kidney. A small amount of ascites is seen about the liver. The portal\n vein is patent with flow in the appropriate direction.\n\n Note is made of cardiomegaly with marked enlargement of the right atrium and\n reflux of contrast into the hepatic veins on arterial phase images consistent\n (Over)\n\n 11:43 AM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n Reason: Concern for other source of obstruction.\n Admitting Diagnosis: EXCESSIVE LOSS\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with right heart failure.\n\n Oval, T2 hyperintense lesions are seen within the L4 and T8 vertebrae,\n incompletely imaged, but most likely representing hemangiomas.\n\n There is diverticulosis. The imaged loops of large and small bowel are normal\n in caliber.\n\n Multiplanar reformations are essential in providing multiple perspectives in\n the dynamic enhanced series.\n\n IMPRESSION:\n 1. No biliary dilation or evidence of obstructing hepatic or pancreatic mass.\n No gallstones.\n\n 2. Simple cyst within the right lobe of liver and probable additional tiny\n left lobe cyst.\n\n 3. Right renal cyst and hemorrhagic or proteinaceous cyst, upper pole of left\n kidney.\n\n 4. Cardiomegaly and evidence of right heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-08-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 926169, "text": " 6:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pneumonia\n Admitting Diagnosis: EXCESSIVE LOSS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with painless jaundice and hypotension\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n Painless jaundice, hypotension. Evaluate for pneumonia.\n\n chest, 1 vw\n\n The patient is status post sternotomy. There is moderately severe\n cardiomegaly. There is upper zone redistribution, without overt CHF. No\n definite pneumonia. However, there is patchy opacity at both bases -- it is\n unclear whether this lies outside the patient or within the lungs. The\n remainder of the lungs are grossly clear. A biliary stent in the right upper\n quadrant is noted.\n\n IMPRESSION: Hazy opacity at both bases -- question outside of patient. If\n clinically indicated, a lateral view could help for further assessment.\n\n" }, { "category": "Radiology", "chartdate": "2165-08-21 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 925128, "text": " 4:26 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: WEIGHT LOSS, JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with 30+ lb weight loss and jaundice over last month\n REASON FOR THIS EXAMINATION:\n bile duct/hepatic duct blockage\n ______________________________________________________________________________\n WET READ: JCT WED 5:04 PM\n Unchanged appearance of liver and gallbladder compared to yesterday's CT.\n\n no biliary ductal dilatation.\n\n marked distension of hepatic veins c/w right heart failure.\n\n nondistended gallbladder with thickened wall, stones, and adenomyomatosis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old man with 30-pound weight loss and jaundice over last\n month.\n\n COMPARISON: Abdominal CTA, and abdominal ultrasound, , .\n\n FINDINGS: The gallbladder is not distended. Again seen is a thickened\n gallbladder wall. Echogenic foci with comet tail appearance are consistent\n with adenomyomatosis. Rounded echogenic foci within the lumen are consistent\n with stones. The liver shows no focal or textural abnormalities. There is\n marked distention of the IVC and hepatic veins. The common duct is not\n dilated. Visualized portions of the pancreas are unremarkable. There is a\n small amount of ascites.\n\n IMPRESSION:\n 1. Stable appearance of the liver and gallbladder compared to the previous\n day's CT.\n 2. No biliary ductal dilatation.\n 3. Marked distention of the IVC and hepatic veins consistent with right heart\n failure.\n 4. Stable appearance of the nondistended gallbladder with thickened wall,\n cholelithiasis, and adenomyomatosis.\n 5. Ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-08-27 00:00:00.000", "description": "MRI ABDOMEN W/O CONTRAST", "row_id": 925730, "text": " 9:09 AM\n MRI ABDOMEN W/O CONTRAST; FOLLOW-UP,REQUEST BY RAD. Clip # \n Reason: CALL BACK BY RADIOLOGIST COR AND AXIAL SSFSE(HASTE) WITH RESP GATING,\n Admitting Diagnosis: EXCESSIVE LOSS\n ______________________________________________________________________________\n FINAL REPORT\n CLIP #: This clip was performed as the continuation of the MRCP\n performed , with clip #. The images included in this\n clip are described in the dictated report of the examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-08-23 00:00:00.000", "description": "DUPLEX DOP ABD/PEL LIMITED", "row_id": 925428, "text": " 3:55 PM\n DUPLEX DOP ABD/PEL LIMITED; US ABD LIMIT, SINGLE ORGAN Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: concern for thrombus of IVC.\n Admitting Diagnosis: EXCESSIVE LOSS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with 30+ lb weight loss and jaundice x 4 weeks, found to have\n markedly distended IVC on US.\n REASON FOR THIS EXAMINATION:\n concern for thrombus of IVC.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with 30-pound weight loss and jaundice found to\n have distended IVC on recent CT.\n\n COMPARISON: CT abdomen and pelvis, and right upper quadrant\n ultrasound, .\n\n LIVER DOPPLER ULTRASOUND: Multiple small echogenic foci scattered throughout\n the liver are consistent with pneumobilia in the setting of recent ERCP. Again\n demonstrated is marked distension of the hepatic veins and IVC. Normal\n waveforms and wall-to-wall blood flow are demonstrated within the main, right\n and left hepatic veins. Appropriate directionality wall-to-wall flow and\n waveform is demonstrated within the main, left, right anterior and right\n posterior portal vein. Wall-to-wall flow and appropriate waveform is noted\n within the IVC. Also demonstrated is patency of the splenic vein.\n\n IMPRESSION:\n 1. Hepatic veins and IVC are patent without evidence of thrombosis. Marked\n distention of these vessels is considered most likely due to right heart\n failure.\n 2. Expected pneumobilia in the setting of recent ERCP.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2165-08-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 925144, "text": " 6:21 PM\n CHEST (PA & LAT) Clip # \n Reason: possible right heart failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with 30+ lbs weight loss in last month\n REASON FOR THIS EXAMINATION:\n possible right heart failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with 30 pound weight loss in the last month.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST RADIOGRAPH: The patient is status post CABG and median\n sternotomy wires are again seen. The pulmonary vasculature is normal. The\n lungs are clear. There likely is a small right-sided pleural effusion. The\n osseous structures are unremarkable.\n\n IMPRESSION:\n\n No acute cardiopulmonary abnormality. Small right-sided pleural effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-08-31 00:00:00.000", "description": "Report", "row_id": 1441868, "text": "EVENTS PT REFUSING CARE THROUGHOUT SHIFT. Family spoke with team wanted pt to be on comfort measures All Abx D/C'd No lab draws . No IV fluids.Son felt he was not respecting father's wishes by giving him IV fluid. Wanted alarms shut off on monitor. off.Did not want B/P taken and wanted cuff removed. Pt was saying \"take this thing off me I don't want you to do anything\" Unable to turn monitor off completely since would not be able to monitor HR. Family agreed to have occasional B/p taken so as to monitor status of pt.\n\nNeuro pt incessantly talking beginning of shift. \"He is at gates of heaven seeing all the angels. Rambling for long periods of time, able to respond to some questions. Told me \"to get out \" Sclera yellow pupils are equal. Pt denies pain . Morphine PRn IV as needed\n\nCV HX of cardiomegaly EF @18 Last CXR showed heart is very enlarged. pt B/P dropping during beginning of shift Had rec's 2 bolus IV fluid in prev/shift. Family said he does not want any additional fluid. Has 2 PIV Hep/lock. Currently B/P in low 90/60 Hr 90-100 V/S has been moderatley stable with lowest B/P at 80 Afebrile. Pt in A-Fib with occasional PVC\"s\n\nResp pt is 86-100% on R/A RR 18 lungs bilaterally diminished\n\nGI/GU Pt did have some juice that family gave to him U/O now icteric and clear has dropped off but still passing adequate amts. No stool this shift EGD neg yesterday. Procedure done r/o GI bleed with his drop in HCt results negative\n\nFamily remained at bedside throughout night. Wife did go home to change etc. Will be back this AM> team to speak with palliative care for family consult. Family would benefit from social work consult and possible bridge to hospice if pt conts to refuse care. Possible c/o to floor?\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-08-31 00:00:00.000", "description": "Report", "row_id": 1441869, "text": "MICU Nursing Progress NOte\n pt is a 76y/o gentleman admitted to hospital on with c/o large weight loss(over 30lbs), fatique and jandice. admitted to medical floor and abd CT scan done, ERCP done on and had some post procedure bleeding, mild and would treat with occasional RBC tx however on during the night pt became hypotensive not responding to fluid boluses transferred to MICU for closer monitoring and possible endoscopy.\n PMH: CAD, EF18%; h/o pancreatits, afib,hypertension,dyslipidemia,h/o obesity, CABG '\n System Reveiw:\n Social: pt did agree for endoscopy yesterday but very reluctenly, told the family that he did not want any further procedures... pt refused bld draqs,vital signs. after numberous discussions with the family and pt pt is now comfort care only. all meds are D/C.\n Cardiac: Hr 90-100's afib, BP range 90-100/50's\n Respiratory: pt refuses to wear O2.\n GI: no futher stool abd soft.\n GU: foley in place, urine very icteric,was c/o the foley and pulling at it during the night now though has been comfortable with it. would d/c it if pt was unconfortable.\n Plan: transfer to medical floor, contact social service and hospice about care options. provide support for the family.\n" }, { "category": "Nursing/other", "chartdate": "2165-08-30 00:00:00.000", "description": "Report", "row_id": 1441866, "text": "76 yr old male CAD s/p CABG EF 18% presented with 50lb weight loss x 4 weeks jaundice Elevated LFT's and bili ERCp for small stone extraction and stent placed on on floor yesterday became hypotensive 80/90 dropping Hct and rising BUN with mild ascites on U/S HX of A fib with right bundle branch block\n\nNeuro pt alert throughout much of shift. Did sleep for period of time and said he was very tired. Will babble at times quotes from the bible and incessantly talking, appears to be some what confused at times\n\nResp lungs are diminshed throughout pt on RA no SOB noted sats high 90's\n\nCV Hypotensive currently lopressor held @ 6am 12.5 mg Pt was taking 50 mg at home. Low 90's to 100 map above 60. Pt baseline pressure 110-120. Pt HCt dropped after ERCP and was transfused. Hr ST with occasional PVC/s Pt will be given IVF bolus and put on levo if necessary Transfuse for Hct less than 30 Pt shown to have enlarged rt atrium cardiomegaly. stem test to be done CK and troponin sent. Pt has 2 PIV/s which have good blood draw on 18 gauge\n\nGI/GU jaundice bili elevated with urine icteric. Psoivive B/s sounds Rectal baag in place draining small amt brown loose stool. Pt had received barium for CT scan which was cancelled last evening. Had lg bowel movement after drinking part first bottle of barium. Will have CT possible today On flagyl, levo, broad spectrum abx.\n\nSkin dry intact\n\nSocial several family members in to visit will be back today Lives with wife and son live in area Pt is a DNR DNI according to family\n" }, { "category": "Nursing/other", "chartdate": "2165-08-30 00:00:00.000", "description": "Report", "row_id": 1441867, "text": " 4 ICU NPN 0700-1900\nS: \"I don't want you to do anything to me. Please respect my wishes\".\nRefusing care throuhout the day ie; temp, general assessment, blood draws, CT scan, CXR. Oriented . TAlking incesently about the bible, religion, and other times not appearing to make sense\nWhen family arrived. Family agreed this was a change in his baseline. Family agreed to have afternoon labs drawn.\nRepeat crit 31.8 (33.5). Family, HCP agreed to have EGD done with belief pt agreed to EGD when MS was better. EGD done. No bleeding noted. No stoool this shift.\nGiven midazolam 1mg, fentanyl 25mcg for EGD.\nHypotensive to 80's prior to EGD. Transiently improved with fld boluses 750 cc total. Presently receiving 250 bolus for SBP low 80's.\nRefusing PO's. Took 100 cc cranberry juice when offered by family.\nUO ~40 cc's hr. Min PO's.\nT-bili 18.4 (18.9). Skin intact,jaundiced, sclera yellow\nRemains in Af with no to rare VEA noted HR 90-109.\n\nA/P: Negative EGD with slight crit drop. Assess for bleeding. crits if pt, family consents\nHypotension with poor po in take, sedation for EGD. Fld boluses.( EF 18%)\n" }, { "category": "Nursing/other", "chartdate": "2165-08-29 00:00:00.000", "description": "Report", "row_id": 1441865, "text": "PMH: CAD, CABG . AF HTN. EF 18%.\nPT. ADMITTED TO F7 WITH WGT LOSS, LOSS OF APPETITE. INCREASED BILI, AND JAUNDICE. WHILE ON F7 PT. UNDERWENT AN ERCP AND A COMMON BILE DUCT STONE WAS REMOVED.\nPT'S HCT DROPPED 3 PTS AFTER THE PROCEDURE, REQUIRING TRANSFUSION OF PC'S. FOR POSSIBLE SLOW BLEED. PT. BECAME HYPOTENSIVE LAST NIGHT AND GIVEN SEVERAL 250CC FLUID BOLUSES, BUT PT. REMAINED HYPOTENSIVE THIS AM. CARDIAC MEDS WERE HELD. ? SEPSIS. STARTED ON ANTIBIOTICS-UNABLE TO GIVE D/T NO ACCESS. GIVEN 1U AND PT. TRANSF. TO THE MICU FOR ANOTHER ERCP, POSSIBLY TOMORROW. ON ARRIVAL PT. HEMODYNAMICALLY STABLE. NO HYPOTENSION SINCE ADM. PT. TACHY\nRESP: PT. ARRIVED ON NO O2. SATS 98-100%. NO C/O SOB. BS'S VERY DIMINISHED.\nGI: NPO. TAKING SIPS OF WATER WITH MEDS. NO C/O N/V. ? OF MELENA STOOLS. ABD SOFT. BS'S PRESENT.\nRENAL: INCONT. OF URINE WHILE ADMITTING PT. FOLEY PLACED. URINE ICTERIC.\nNEURO: ALERT AND SLIGHTLY DISORIENTATED. PT. SPEAKING ABOUT GOD AND THAT HE'S READY TO DIE AND SEE THE .\nID: GIVEN FLAGYL ON ARRIVAL. GIVEN 1X FLUID BOLUS. LACTATE 1.3 THIS AM. TEMP 99.8. CT OF ABD AND HEAD THIS EVENING.\nENDOC: LYTES SENT.\nHEM: CBC SENT. LFT;S SENT.\nACCESS: PERIPH LINE PLACED BY IV NURSE. PT. HAS POOR ACCESS.\nPLAN: CT SCAN OF ABD AND HEAD. AWAITING LAB RESULTS. ? ERCP IN AM.\nIV BOLUSES FOR HYPOTENSION.\n" } ]

[ { "category": "Radiology", "chartdate": "2131-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1161225, "text": " 12:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman transfer from OSH s/p fall with 17x4mm extra axial\n hemorrhage.\n REASON FOR THIS EXAMINATION:\n Eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 1:26 AM\n 5 x 26mm R parietooccipital lentiform extraaxialhemorrhage along superior\n extent of a nondisplaced posterior paramedian skull fx. This is minimally if\n at all larger as compared to preceding ref exam, with minimal mass effect and\n no herniation. Could represent SDH, EDH cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female transferred from outside hospital status post\n fall with 7 x 4 mm extra-axial hemorrhage. Question interval change.\n\n COMPARISON: Reference CT from at 2215 o'clock.\n\n TECHNIQUE: Non-contrast head CT with coronal and sagittal reconstructions.\n\n FINDINGS: There is a non-displaced posterior right paramedian skull fracture\n associated with a 5 x 26 mm lentiform extra-axial hemorrhage along the\n superior extent of the fracture in the posterior parieto-occipital junction,\n suggestive of subdural versus epidural hemorrhage. There is minimal mass\n effect, with mild if any sulcal effacement. There is no shift of normally\n midline structures or signs for herniation. There is no additional focus of\n hemorrhage. The ventricles and sulci are prominent, consistent with\n age-related involution. Periventricular white matter hypoattenuation likely\n represent small vessel ischemic disease.\n\n Paranasal sinuses and mastoid air cells appear clear. Globes are intact.\n Minimal scalp hematoma is noted on the right.\n\n IMPRESSION: 5 x 26 mm right parieto-occipital extra-axial hemorrhage. This\n appears somewhat lentiform, associated with superior extent of a non-displaced\n right posterior paramedian skull fracture, could represent epidural hematoma.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-10-25 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 1161226, "text": " 12:39 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: FALL, BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with low back pain s/p fall, h/o lumbar spine fx\n REASON FOR THIS EXAMINATION:\n eval fx/malalignment\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 1:57 AM\n Severe L1 wedge deformity with >80% loss of height anteriorly, age\n indeterminate. Sclerotic appearance chronic change,. Minimal posterior\n displacement of L1 posterior aspect without definite retropulsion. Comparison\n to prior study when available would be helpful.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with low back pain, status post fall.\n Question lumbar spine fracture. Question malalignment.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT of the lumbar spine was performed without contrast\n administration. Multiplanar reformations were generated.\n\n FINDINGS: The lumbar lordosis is preserved. There is severe diffuse osseous\n demineralization, limiting evaluation.\n\n There is a compression fracture with deformity of the L-1 vertebral body, with\n anterior wedging and loss of height greater than 80% at the narrowest point,\n associated with vacuum phenomenon. It is difficult to exclude superimposed\n acute worsening, without comparison to prior exam. There is minimal posterior\n displacement of L1 vertebral body, with mild narrowing of the spinal canal.\n Please note that CT cannot visualize intrathecal detail.\n\n Correlate clinically for need of MRI for evaluation of cord or ligamentous\n injury. There is relative preservation of vertebral body height and disc\n heights in the remainder of the lumbar spine. No significant paravertebral\n soft tissue swelling. Atherosclerotic calcification seen in the aorta.\n Gallstones are incidentally noted. Partially visualized kidneys and bowel\n loops appear unremarkable. A tiny sub-2-mm non-obstructive right renal stone\n may be present. There is no critical spinal canal or neural foraminal\n narrowing.\n\n IMPRESSION:\n 1. L-1 severe compression fracture, with areas of sclerosis, at least in part\n chronic. Supervening acute worsening cannot be excluded due to lack of prior\n exam for comparison. Mild retropulsion of the posterior margin of the body\n with mild narrowing of the spinal canal. Please correlate clinically for need\n of evaluation for the cord or ligamentous injury.\n 2. Diffuse osseous demineralization.\n 3. Cholelithiasis.\n 4. Non-obstructive 2-mm right renal stone.\n (Over)\n\n 12:39 AM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: FALL, BACK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2131-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1161243, "text": " 5:36 AM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with SDH vs. EDH; pls re-eval 6AM\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with subdural versus epidural hemorrhage here\n for reevaluation.\n\n COMPARISON: CT head from six hours ago.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: As compared to most recent preceding study, a 4 x 14 mm right\n parietooccipital extra-axial hemorrhage, most likely epidural hematoma, is not\n significantly changed. Please note that measurements may differ from the\n prior exam, where the measurement was taken from sagittal view. No\n reconstruction is available with the current examination.\n\n There is no increase in mass effect. Minimal if any sulcal effacement. No\n new focus of hemorrhage. Prominent ventricles and sulci are consistent with\n age-related involution. Periventricular white matter hypoattenuation\n indicates small vessel ischemic disease. Suprasellar and basilar cisterns are\n patent.\n\n A nondisplaced right paramedian skull fracture is redemonstrated. A small\n scalp hematoma is noted on the right posteriorly. Within limitation of\n motion, paranasal sinuses and mastoid air cells are clear. Globes and soft\n tissues are unremarkable.\n\n IMPRESSION: No significant interval change of a small right parietooccipital\n hemorrhage, most likely an epidural hematoma, with a nondisplaced posterior\n skull fracture. No new focus of hemorrhage.\n\n" } ]

[ { "category": "Echo", "chartdate": "2179-06-03 00:00:00.000", "description": "Report", "row_id": 75828, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 60\nWeight (lb): 154\nBSA (m2): 1.67 m2\nBP (mm Hg): 93/63\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 09:29\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: Moderate symmetric LVH. Normal LV cavity size. Moderately\ndepressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR. LV\ninflow pattern c/w restrictive filling abnormality, with elevated LA pressure.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Normal PA systolic pressure. Given severity of TR, PASP may be\nunderestimated due to elevated RA pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is moderately depressed (LVEF= 35-40%). The\nright ventricular cavity is moderately dilated with moderate global free wall\nhypokinesis. The diameters of aorta at the sinus, ascending and arch levels\nare normal. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. The mitral valve leaflets are mildly thickened.\nModerate (2+) mitral regurgitation is seen. The left ventricular inflow\npattern suggests a restrictive filling abnormality, with elevated left atrial\npressure. The tricuspid valve leaflets are mildly thickened. The estimated\npulmonary artery systolic pressure is normal. [In the setting of at least\nmoderate to severe tricuspid regurgitation, the estimated pulmonary artery\nsystolic pressure may be underestimated due to a very high right atrial\npressure.] There is no pericardial effusion.\n\nIMPRESSION: Moderate symmetric LVH with moderately depressed systolic\nfunction. Restrictive left ventricular filling. The appearance of the left\nventricular myocardium suggests infiltrative disease. Dilated and hypokinetic\nright ventricle. Moderate mitral regurgitation. Moderate to severe tricuspid\nregurgitation. While estimated pulmonary systolic pressures are normal, they\nare likely UNDERestimated (or the right ventricular function is so poor that\nit cannot elevate its pressure).\n\n\n" }, { "category": "Radiology", "chartdate": "2179-06-08 00:00:00.000", "description": "PYROPHOSPHATE SCAN", "row_id": 1245674, "text": "PYROPHOSPHATE SCAN Clip # \n Reason: RESTRICTIVE CARDIOMYOPATHY WITH ECHO VERY SUGGESTIVE OF AMYLOID, UNABLE TO GET CARDIAC MRI\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 20.4 mCi Tc-m Pyrophosphate ();\n HISTORY: 77 year old female with metastatic colon cancer, restrictive\n cardiomyopathy, and suggestion of amyloidosis on echo. Cannot receive cardiac\n MRI.\n\n INTERPRETATION: SPECT images -level, diffuse uptake of Tc-99\n pyrophosphate in the left ventricular myocardium.\n\n Multiple foci of avid osseous uptake are present, many with a linear pattern\n suggestive of compression fractures. Incidental note is made of intense\n activity within the central line, the route of injection.\n\n CT images show right chest wall port in the high right atrium. There is\n right-sided heart enlargement with flattening of the interventricular septum.\n Diffuse aortic and coronary calcifications. No pericardial effusion. There are\n moderate bilateral pleural effusions, with compressive atelectasis. Anasarca\n is present in the soft tissues. Bones demonstrate sternal and multilevel\n vertebral compression fractures\n\n IMPRESSION: 1. Relatively low-level pyrophosphate uptake in the heart. Often\n amyloid will show intense myocardial uptake; however pyrophosphate should not\n accumulate in the normal heart. 2. Multiple foci of uptake in the bones.\n Etiology of bony findings could be further evaluated with a dedicated CT. 3.\n Moderate bilateral pleural effusions.\n\n\n , M.D.\n , M.D. Approved: 3:14 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": "2179-06-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1245026, "text": " 1:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for hemorrhage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 77F with confusion\n REASON FOR THIS EXAMINATION:\n evaluate for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXCf WED 2:11 AM\n no acute intracranial process\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Confusion.\n\n COMPARISONS: None available.\n\n TECHNIQUE: MDCT-acquired contiguous images through the head were obtained at\n 5 mm slice thickness, without intravenous contrast. Coronal and sagittal\n reformatted images were displayed.\n\n FINDINGS:\n\n There is no evidence of acute intracranial hemorrhage, mass, mass effect or\n shift of normally midline structures. There is no cerebral edema or loss of\n -white matter differentiation to suggest an acute ischemic event.\n Confluent hypodensities in subcortical, deep white matter and periventricular\n distribution likely reflects small vessel ischemic disease. Sulci and\n ventricles are prominent, likely age related global atrophy. Basal cisterns\n are patent. There is extensive atherosclerotic calcification of the\n intracranial carotid and left vertebral arteries.\n\n Frontal sinuses are underpneumatized. Mild mucosal thickening of sphenoid\n sinuses is seen with secretions noted in the right sphenoid sinus. Otherwise,\n imaged paranasal sinuses and mastoid air cells are well-aerated. No acute\n fracture is seen.\n\n IMPRESSION:\n\n 1. No evidence of acute intracranial process.\n\n 2. Sequelae of chronic small vessel ischemic disease.\n\n 3. Prominent sulci and ventricles, likely age-related atrophy.\n\n" }, { "category": "Radiology", "chartdate": "2179-06-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1245023, "text": " 12:41 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pulmonary edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 77F with CHF, poor hisotrian, \"felt terrible\"\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of congestive heart failure, who now\n presents with chest pain.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n AP and lateral views of the chest demonstrate low lung volumes. Large left\n pleural effusion. Retrocardial consolidation. Right lung base is elevated,\n possibly due to subpulmonic pleural effusion There is moderate pulmonary\n edema. Heart size moderately enlarged. No pneumothorax. Port-A-Cath tip\n projects over cavoatrial junction. Chest CT is recommended to further\n assessment.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2179-06-03 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1245207, "text": " 1:05 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: please evaluate for obstruction\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p colectomy for colon cancer, now with (Cr 2.5 with 1.3\n baseline)\n REASON FOR THIS EXAMINATION:\n please evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old woman status post colectomy for colon cancer in\n , now with acute renal insufficiency and elevated LFTs.\n\n FINDINGS: The liver has an echogenic texture, but no focal liver lesions are\n identified. The main portal vein is patent with appropriate hepatopetal flow.\n There is no intra- or extra-hepatic biliary dilatation. The gallbladder is\n surgically absent. Visualized pancreatic head is homogeneous. The more\n distal portion of the pancreatic body and tail are obscured by overlying bowel\n gas. The spleen is not enlarged. The aorta and IVC are normal in caliber.\n The left kidney measures 8.6 cm. The right kidney measures 8.5 cm. No\n stones, masses, or hydronephrosis in either kidney. A small amount of ascites\n is seen in the right lower quadrant. A right pleural effusion is moderate.\n\n Focused ultrasound was performed with a high-resolution linear transducer\n along palpable subcutaneous nodules along the midline abdominal incision and\n laterally to the right. Along the midline abdominal incision, there are\n linear tracts of edema, but no fluid collection. More laterally, there are\n numerous anechoic lesions in the subcutaneous fat with increased through\n transmission. The largest measures 2.6 x 1 cm and contains several internal\n septations. Another lesion measures 1.3 x 1.9 cm and has a slightly\n hyperechoic rim. None of the lesions exhibit any vascularity on color and\n power Doppler imaging. Numerous smaller subcentimeter lesions are also\n visualized.\n\n IMPRESSION:\n 1. Echogenic liver compatible with fatty infiltration. More serious forms of\n steatohepatitis, fibrosis, and/or cirrhosis cannot be excluded on this study.\n 2. Normal kidneys without any explanation for acute renal insufficiency.\n 3. Moderate right pleural effusion.\n 3. Numerous anechoic ovoid lesions in the right lateral abdominal\n subcutaneous fat. These lesions are incompletely characterized by ultrasound.\n The location of these lesions should be correlated with history of prior\n subcutaneous injections that could represent incompletely absorbed injected\n medications. Abdominal wall metastases cannot be excluded on this study. A\n CT scan is recommended for further evaluation. Ideally, this would be with\n intravenous contrast; however, a non-contrast CT may still useful in the\n setting of acute renal failure.\n\n Findings were discussed with Dr. via telephone at 1400 on .\n (Over)\n\n 1:05 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: please evaluate for obstruction\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2179-06-04 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1245364, "text": " 3:54 PM\n PORTABLE ABDOMEN Clip # \n Reason: bowel obstruction? stool? ileus?\n Admitting Diagnosis: ACUTE CORONARY SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman sp colostomy for colon CA few months ago, now with abdominal\n on left side and minimal colostomy output\n REASON FOR THIS EXAMINATION:\n bowel obstruction? stool? ileus?\n ______________________________________________________________________________\n WET READ: RJab FRI 5:10 PM\n Non specific bowel gas pattern with no definite evidence for obstruction. No\n large free air. Effusion/atelectasis on the left.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMINAL PLAIN FILM, AT 16:34\n\n CLINICAL INDICATION: 77-year-old status post colostomy for colon cancer a few\n months ago, now with abdominal pain on the left side, question stool, question\n ileus.\n\n No comparison studies.\n\n A single portable plain film of the abdomen dated at 16:34\n submitted.\n\n There is scattered air within non-distended loops of bowel. There is no\n evidence of obstruction. No free air is seen, although the study was obtained\n in the supine position, so the sensitivity is diminished. There is patchy\n opacity at the left base which may represent an area of atelectasis and/or\n associated effusion versus pneumonia. Clinical correlation is advised.\n Several rounded calcifications in the pelvis likely are vascular in etiology.\n Degenerative changes are seen in the visualized thoracolumbar spine and\n sacroiliac joints. Rounded opacities project over the soft tissues lateral to\n the hip which may reflect stool near the colostomy site. Clinical correlation\n is advised.\n\n IMPRESSION:\n\n 1. No evidence of bowel obstruction. Nonspecific bowel gas pattern.\n Radiopaque densities lateral to the left hip may reflect stool within or near\n the area of colostomy. Clinical correlation is advised.\n\n" }, { "category": "ECG", "chartdate": "2179-06-04 00:00:00.000", "description": "Report", "row_id": 196226, "text": "Sinus rhythm. Premature ventricular contractions and a couplet. Low voltage.\nT wave inversions in the lateral leads. Possible old inferior myocardial\ninfarction. Compared to the previous tracing of no significant changes\nare noted.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2179-06-02 00:00:00.000", "description": "Report", "row_id": 196229, "text": "Sinus rhythm with frequent ventricular premature beats and atrial premature\nbeats. Possible inferior myocardial infarction of indeterminate age. Poor\nR wave progression, consider an anterior myocardial infarction of indeterminate\nage. ST-T wave abnormalities. Compared to tracing #2 of earlier the same day\nsinus rhythm appears to be the predominant rhythm in this tracing.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2179-06-02 00:00:00.000", "description": "Report", "row_id": 196230, "text": "Probable atrial fibrillation with rapid ventricular response, although there\nappear to be two sinus beats. Ventricular premature beats. Inferior wall\nmyocardial infarction of indeterminate age. Anterior wall myocardial\ninfarction of indeterminate age. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2179-06-02 00:00:00.000", "description": "Report", "row_id": 196231, "text": "Probable sinus rhythm with frequent ventricular ectopy, although atrial\nfibrillation cannot be excluded. Inferior wall myocardial infarction of\nindeterminate age. Anterior wall myocardial infarction of indeterminate age.\nCompared to tracing #1 of earlier the same day there probably is no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-06-02 00:00:00.000", "description": "Report", "row_id": 196227, "text": "Probable underlying sinus rhythm with predominantly ventricular ectopy and\nventricular tachycardia. Clinical correlation is suggested. Compared to the\nprevious tracing of the same date ventricular tachycardia is now predominant.\n\n" }, { "category": "ECG", "chartdate": "2179-06-02 00:00:00.000", "description": "Report", "row_id": 196228, "text": "Sinus rhythm with premature ventricular beats and premature atrial beats. The\nright bundle-branch block pattern in leads V1 and V2 is due to ventricular\nectopy. Anterior wall myocardial infarction of indeterminate age. ST-T wave\nabnormalities. Compared to tracing #3 of earlier the same day probably no\nsignificant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2179-06-13 00:00:00.000", "description": "Report", "row_id": 195977, "text": "Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave\nchanges. Compared to the previous tracing of ectopy is not seen and\nT wave inversions in the lateral apical leads have resolved.\n\n\n" }, { "category": "ECG", "chartdate": "2179-06-05 00:00:00.000", "description": "Report", "row_id": 195978, "text": "Sinus rhythm. Atrial premature beats. Ventricular premature beats.\nBorderline low voltage. T wave inversions in the lateral leads. Consider\nlateral wall ischemia.\nTRACING #2\n\n" } ]

[ { "category": "Echo", "chartdate": "2156-06-29 00:00:00.000", "description": "Report", "row_id": 65867, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 66\nWeight (lb): 300\nBSA (m2): 2.38 m2\nBP (mm Hg): 110/50\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 15:21\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: 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: Mildly dilated RV cavity. RV function depressed.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. The right ventricular cavity is mildly dilated with\nfree wall hypokinesis. The aortic valve leaflets appear structurally normal\nwith good leaflet excursion. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. The pulmonary\nartery systolic pressure could not be determined. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Preserved global and regional left ventricular systolic function.\nRight ventricular cavity enlargement with free wall hypokinesis c/w possible\nright ventricular infarction.\nIf more definitive information regarding a possible right ventricular\ninfarction is desired, a cardiac MRI () may be useful.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 872412, "text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneumonia\n Admitting Diagnosis: INTERIOR MYOCARDIAL INFARCTION;CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman admitted with inferior MI, new cough and CP, no ECG changes\n REASON FOR THIS EXAMINATION:\n ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-ERECT CHEST DATED .\n\n There are no prior films for comparison.\n\n INDICATION: Cough and chest pain.\n\n Cardiac silhouette is upper limits of normal in size. Mediastinal contours\n and pulmonary vascularity are normal. The lungs appear clear except for a\n small linear opacity at the left base.\n\n IMPRESSION:\n 1. No evidence of congestive heart failure or pneumonia.\n 2. Minimal linear discoid atelectasis versus scar left lung base.\n\n\n" }, { "category": "ECG", "chartdate": "2156-06-30 00:00:00.000", "description": "Report", "row_id": 140207, "text": "Sinus rhythm\nInferior T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , precordial T wave amplitude improved but may\nbe no significant change\n\n" }, { "category": "ECG", "chartdate": "2156-06-29 00:00:00.000", "description": "Report", "row_id": 140208, "text": "Sinus rhythm\nInferior T wave abnormalities - are nonspecific but consider ischemia\nModest nonspecific low amplitude precordial T waves\nClinical correlation is suggested\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2156-06-29 00:00:00.000", "description": "Report", "row_id": 140209, "text": "Sinus rhythm. Compared to tracing #1 anterolateral ST-T wave abnormalities\npersist but are resolving. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2156-06-28 00:00:00.000", "description": "Report", "row_id": 140210, "text": "Sinus rhythm. Q waves in leads II, III and aVF - consider old inferior wall\nmyocardial infarction. Anterolateral ST-T wave changes - consider myocardial\nischemia. Compared to the previous tracing of anterolateral ST-T wave\nabnormalities persist but are improved.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2156-06-27 00:00:00.000", "description": "Report", "row_id": 140211, "text": "Sinus rhythm. Compared to the previous tracing of anterolateral\nST-T wave abnormalities are more prominent. Consider myocardial ischemia.\nClinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2156-06-26 00:00:00.000", "description": "Report", "row_id": 140212, "text": "Sinus rhythm. Occasional blocked atrial premature beats. Anterolateral\nST-T wave abnormalities suggestive of myocardial ischemia. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2156-06-26 00:00:00.000", "description": "Report", "row_id": 1449861, "text": "CCU NPN: please see flowsheet and FHPA\n\n57yo woman presented to OH with 7/10 CP radiating to jaw and tongue burning. ST ^ inf,bradycardia to 50's,treated with ASA,heparin,aggrastat.due to contrast dye allergy given steroids,benedryl and pepcid prior to .cath lab drug-eluting stent to RCA,post dilation ballon,no flow,inf ST^,VFIB arrest,nipride improved flow and stent postdilated prox with good results.\n\nCardiac: arterial sheath d/ced in cath lab,angio seal. venous sheath in place.c/o chest burning .EKG taken no changes from post cath EKG.team notified. BP 180/80,IV NTG started and 2mg IV morphime given. BP gradually came down to 120-130/'s. HR 70-80's.CP now .IV NTG at 0.58mcg/kg/min.on aggrastat until tomorrow at 8am.venous sheath d/ced. site D&I pulses palpable.\n\nResp: on 2l NP,lungs clear,sats 93-96\n\nGU: foley placed with some difficulty. good urine output\n\nGI: abd obese,+BS\n\nID: afebrile\n\nNeuro: alert and oriented x3\n\nSocial: married no children,husband is health care proxy.copy in chart\n\nA/P: 57 s/p IMI with stenting of RCA. CB by brief Vfib.now on aggrastat and NTG\n cont to follow hemodynamics closely\n titrate NTG to comfort and BP\n emotional support pt and family\n" }, { "category": "Nursing/other", "chartdate": "2156-06-27 00:00:00.000", "description": "Report", "row_id": 1449862, "text": "CCU NURSING PROGRESS NOTE\nS:I'M SCARED TO FALL ASLEEP.\nO:PT IS 57YR OLD OBESE FEMALE, S/P IMI W/ RV INVOLVEMENT. S/P STENT TO RCA. ON AGRASTAT AND IV NTG FOR POST PCI CHEST PAIN EARLIER YESTERDAY AFTERNOON. PT ALERT AND ORIENTED X3, PT RECEIVED CLONAZEPAM BUT STILL FEELING ANXIOUS. AMBIEN ORDERED AND HAD GOOD EFFECT. PT DENIED CHEST PAIN, BURNING OR DISCOMFORT. IV NTG D/, PT REMAINS ON IV AGRASTAT UNTIL 0800 IN AM. MHR 80-90S SR, W/ ISSO RUN OF VT. PO LOPRESSOR INCREASED, CAPOTEN ALSO INCREASED AND TOLERATED WELL. R GROIN DSG D+I, NO BLEEDING OR HEMATOMA. DP PULSES PALP.\nRESP:SATS 96% AND >, LUNGS CLR BILAT. PT ON BIPAP FOR SLEEP. SKIN PINK WARM AND DRY.\nGI:OBESE, C/O BEING HUNGRY, ASKED FOR ICE CREAM. PT GIVEN FEW SNACKS THIS EVENING .\nENDO:HS POC 217, REPORTED TO MD, AND COVERED AS PER SS. PT WILL NEED FURTHER W/U.\nGU:CLR YELL URINE.\nSOC:PT SPOKE W/ FAMILY PER TELEPHONE.\nED:PT ANXIOUSLY ASKING MANY QUESTIONS RE: MED. TEACHING DONE, BUT PT NOT RETAINING ALL INFO D/T INCREASE ANXIETY. PROVIDE EMOTIONAL SUPPORT. ANSWER QUESTIONS. PROVIDE WRITTEN INFORMATION.\nA/P:S/P INF MI W/ RV INVOLVEMENT. D/C AGRESTAT AT 0800, INCREASE ACITIVIY, PROVIDE INFORMATION REGARDING LIFE STYLE CHANGES TO DECREASE RISK FACTORS.\n" }, { "category": "Nursing/other", "chartdate": "2156-06-27 00:00:00.000", "description": "Report", "row_id": 1449863, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 67-85 NSR,BP 100-139/47-70 had one episode of chest pressure this am,EKG obtained no ischemic changes,q's inf. captopril now at 25mg TID,lopressor 50mg . aggrastat off at 8am.most recent CK 5am 791/67 up from 481/44,new set sent at 6:30pm.\n\nResp: on RA with sats mid 90's,lungs clear\n\nGU:urine output 60-170/hr negative 700cc today.urine has become pink,pt is on keflex for chronic cystitis\n\nGI:good appetite,+BS\n\nID: afebrile\n\nEndocrine: FS 131 at 5am and 102 no needed coverage,lytes sent at 6:30pm\n\nA/P: hemodynamically stable tolerating increasing doses of captopril and lopressor\n cont to monitor hemodynamics\n follow FS and treat as needed\n notify team if urine becomes more pink or bloody\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2156-06-27 00:00:00.000", "description": "Report", "row_id": 1449864, "text": "CCU TRANSFER NOTE\nS\"DO I HAVE TO MOVE RIGHT NOW.\"\nO:PT NOTIFIED OF TRANSFER TO 3, NOTIFIED THAT SHE WILL BE PLACED ON CPAP BY RESP. SEE TRANSBER NOTE FOR ADDITIONAL INFORMATION.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2162-08-18 00:00:00.000", "description": "Report", "row_id": 1521967, "text": "Adm note 2300-0700\n87 yo fe adm from 12 R after return from pacu at 7pm. Pt had removal compression screw L hip c total hip replacement. Bld loss in OR 1200mls c cont oozing from dsg. Pt given 5L fld in OR & 3 units pc. Was hypotensive on floor after returning from pacu, sbp in 80s despite 1 500ml fld bolus. pt also febrile to 100.6 ax. See FHPA for PMH and reason for adm. Upon arrival to micu, pt hypotensive 89/51, hr 104, nsr, oozing lge amt from L hip dsg.\n\nROS:\n\nNeuro: Lethargic, oriented x2. Apparently pt is comfused at baseline, needs freq orientation. Only c/o pain is with movement of pt side to side. Med c .5mg versed for line placement.\n\nID: Tmax 101.1 ax, now 99.4. Being rx for UTI c ceftaz. also started on cipro, vanco and zosyn. bld cx sent. lactate 3.9.\n\nCV: Pt cont hypotensive during noc, gave 500ml ns boluses x5, brought bp up for time period, then dropped again to low 80s. team watching. HR 80s to 104, sr/st, no ectopy. central line placed at 0630, 2 pivs.\nhct during noc 29.7, down from 30, am labs pending.\n\nGU: U/o 18-45mls/hr clear, yellow urine. Team aware of sm volumes.\n\nSkin: L hip dsg saturated c blood, dsg reinforced, seen by surgeon. some bruises (ecchymosis and eschar) on arms and legs. No reddness noted on coccyx.\n\nSocial: Pt being followed by protective services for assault (see FHPA, phone # on front of chart). Daughter was called for consent for procedure. All visitors are to be supervised.\n\nPlan: F/u on am labs. Monitor bleeding, hct, ? need for tx. monitor for pain. follow bp, hr, flds as needed.\n\nGI: +BS, abd soft, nt. NPO. sm amt stool x3. OB neg.\n" }, { "category": "Nursing/other", "chartdate": "2162-08-19 00:00:00.000", "description": "Report", "row_id": 1521970, "text": "RESP: BS'S CLEAR. NO C/O SOB. O2 SATS 99-100% ON 4L NP, WITH A GOOD PLETH.\nNEURO: CONFUSED, HALLUCINATING, DELERIOUS-PICKING AT LINES, O2 AND FOLEY. PT. NEEDED MITTS AND RESTRAINTS WHEN PT. ALONE. GIVEN HALDOL 2.5MG IVP WITH NO EFFECT. SLEPT IN VERY SHORT NAPS.\nGI: INCONT. OF STOOL. GU -. SWALLOWING IMPROVED. TAKING AND JELLO WITHOUT DIFFICULTY. SWALLOW STUDY D/C'ED.\nRENAL: CONT. WITH POOR U/O'S. URINE AMBER. U/'S DID IMPROVED SLIGHTLY WITH FLUID BOLUSES, BUT PRESENTLY 20CC/OVER 2HRS.\nHEM: HCT 28.6 THIS AM. TRANSFUSED WITH 1 U PC'S. REPEAT HCT SENT AT 18PM.\nENDOC: K+ AND MG+ REPLETED THIS AM. LYTES SENT AT 18PM. PRESENTLY RECEIVING 2MG CA+ GLUC.\nCV: TROPONIN'S CONT. TO RISE. CARDIAC ECHO SHOWED ABNL. WALL MOTION. MITRAL REGURG. CONT. TO BE IN NSR-ST, RARE PVC. EKG SHOWED RBBB, ? OF NEW. NO C/O CHEST PAIN. PT. HAS HAD A PREVIOUS MI WITH HER GI BLEED. GIVEN 2.5MG LOPRESSOR IVP (BP PRE 132- POST 100). ALSO REQUIRED SEVERAL FLUID BOLUSES FOR LOW CVP.\nORTHO: HIP DRSG. CHANGED BY ORTHO RESIDENT. SOME BLOODY STAINING. MEDICATED 1X WITH OXYCODONE AND PT. FINALLY FELL ASLEEP.\nSKIN INTEGRITY: BOTH ARMS ECCHYMOTIC. DAUGHTERS SAYS SHE BRUISES EASILY.\nSOCIAL: BOTH AND (DAUGHTERS) INTO VISIT. (ATTORNEY). STATED THAT HER MOTHER PHYSICALLY ABUSED BY HER CARETAKER. BOTH DAUGHTERS AWARE OF PT.'S PRECARIOUS SITUATION AND AGREE WITH NO HEROIC MEASURES.\nPLAN: CONT. WITH BOLUSES AS NECESSARY FOR BP CONTROL.\nAWAIT HCT RESULTS.\nMEDICATE WITH OXYCODONE FOR COMFORT AND SLEEP.\nMITTS AND RESTRAINTS PRN.\n" }, { "category": "Nursing/other", "chartdate": "2162-08-20 00:00:00.000", "description": "Report", "row_id": 1521971, "text": "NPN 1900-0700:\nNeuro: Pt is confused, disoriented, agitated most of the time, screeming and pulling out her lines Central line and Foley), needed restrained, reoriented frequently, c/o pain in L hip, given Oxycodone PRN with good effect.\n\nResp: Breathing regularly on O2 NC 4 L/min, RR 14-29, SPO2 90-100%, LS CTA.\n\nCV: HR 73-102, no ectopies, BP 96-129/50-62, with Rt IJ line, received a unit of PRBCs, Hct increased from 27.6 to 31.2, palpable pulses.\n\nGI/GU: Tolerating fluids and taking pills, abdomen soft, BS present, passed 2 diarrheac BM, with Foley 20-25 cc/hr amber clear U/O.\n\nInteg: Dressing over hip minimal bleeding, T max 98.7.\n\nSocial: No visits/calls from family overnight. Pt is DNR.\n\nPlan: Continue same tx, monitor cardiac enzymes, transfuse for Hct less than 30, give oxycodone for pain, consider Ativan for agitation PRN.\n" }, { "category": "Nursing/other", "chartdate": "2162-09-01 00:00:00.000", "description": "Report", "row_id": 1521977, "text": "MICU NPN:\nNEURO: Pt. sleepy but easily arousable to voice and follows commands. Oriented to self and knows she is in the \"hospital\" but can't name it. Not oriented to time. Denies any pain. Tylenol suppository given x1 before turning but none since. Pt. consistently denies pain although moaning with turning at times. Moving UEs in bed and pulling at O2 mask so soft wrist restraints on loosely. Moving R leg in bed.\nCV: Afeb. Last dose of cefazolin given. HR 60s-80s SB/SR with occ. PACs. Post transfusion HCT 25 and am labs pending- ?need for another PRBCs due to cardiac history. MDs aware. NTG gtt off since 1030pm and SBP 110-140. Pt. denies any chest pain or discomfort. R radial a-line in place and not sutured. R TLC line intact with no further oozing. LR at 75cc/hr.\nRESP: Continues on 40% humidified face mask with O2 Sat >92%. Encouraged to cough and deep breathe. LS clear and diminished at bases. Strong cough.\nGI/GU: Abd. softly distended with hypoactive bowel sounds. No BM. No po meds given due to pt's somulence. Foley draining clear yellow urine 30cc/hr.\nSKIN: DSD with ace clean, dry and intact to L hip. Pt's legs need to be abducted at all times to prevent another hip dislocation. Pillow in place at all times with turning etc. Not to let L leg drift midline to prevent dislocation.\nOTHER: Pt. is DNR/DNI but full treat. Tow daughters involved in her care. Plan for eventual d/c to rehab.\n\n" }, { "category": "Nursing/other", "chartdate": "2162-08-18 00:00:00.000", "description": "Report", "row_id": 1521968, "text": "npn 0700-1500;\n87 yr old lady who is pod#2s/p compression screw removal and total lt hip replacement.transferred ti micu.for hypotension. pt has dementia and is being monitored for elder abuse.please see admission note for details.caretaker has been fired and gentleman who abused pt has not to be allowed to visit.picture of gentleman at desk.\n\nneuro;aoox2 mae equally min movement of lt leg with small contraction of lt knee.agitated and tearful at times usually inconnection with stooling. restless picking at things restrainrts removed and hand mitts applied wiwth improved comfort off when family members are in room.given tylenol for pain.\n\nresp; lungs clear upper diminished at bases sats 93-96 on ra strong productive cough encouraged to cdb rr 16-20;\n\ncvs; tmax 100.4ax. nsr94-105 no ectopy noted. bp87/45-106/50 after prbcx1.cvp 5-8.? r/o mi following cardiac enzymes next due at 2200.12 lead ecg unchanged from previous troponin .2\n\ngu passing small mounts amber urine via foley team aware.ua sent.\n\ngi; belly soft passing mod amounts of liquid stool with hard formed stool.with each reposition.guaiac neg.npo currently/no coverage onriss.\n\nheme; prbcx1 hct 27-29.2. to be checked at 1700;\n\nskin ;hip wound dsd stained with old sanquinous drainiage continues to drain mod amounts less than in am. ortho team aware,skin ecchymotic over arms,coccyx and heels intact.\n\nsoc; daughter in most of morning, daughter to visit this pm..s/b lisw and updated with pts current cndition and plan of care.\n\na/p; more stable main map around 65\ncontinue to follow urine output\nposs strt clear liquids and resume 0po meds if pt able to swallow.\ncontinue to liimit pts visitors to immediate family.\nfollow up on cardiac enzymes.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-08-19 00:00:00.000", "description": "Report", "row_id": 1521969, "text": "NPN 1900-0700\n87 yo fe post op day 2 s/p compression screw removal and total L hip replacement, transferred to micu for hypotension. Pt is r/i for MI, trop levels up to 1.24 at 10pm last noc, am labs pending. CPK up to 523. hypotension cont, was 84/42 last noc, started NS fld boluses, given 2L, CVP up from 1 to , sbp up to 90s-100s. Pt up 10L since surgery. Hct 28.6 down from 29.7 (hct following 1 unit pc yest). L hip dsg C&D overnoc.\n\nNeuro: Pt confused, oriented x1-2. Usually remembers she is in hosp. mae. contracture of L knee. Restless at times, but mostly slept well. Took mits off last noc, pt did well, left her o2 on, this am started to pull it off, reapplied x2.\n\nCV: As above. HR 90s,100s, nsr/st, no ectopy. held metoprolol 12.5 mg due to sbp 90s. EKG x2 unchanged from previous tracings. Tmax 99.1 WBC 15.9 down from 18.3. previous UTI, ? other source. On Zosyn, vanco.\n\nGI/GU: Cl liquids. gave water and one pill, some coughing. Did not give larger pills, suggest trying jello this am. Stooled x3, large and 2 med. soft and solid, brown, ob neg. Very large amt stooling post . abd soft, +bs. U/o scant, 10-20mls hr, team aware, amber clear urine.\n\nSkin: Dsg d&I. skin ecchymotic with bruises on arms, coccyx ok.\n\nSocial: Pt being followed by elder abuse, see social service notes in chart. may have visitors except for man who abused pt, picture was at front desk. Social service is working with 2 daughters re pts disposition.\n\nPlan: monitor BP, HR, maint map ~ 65. Follow u/o, cvp, temp. Monitor hct, ? tx. cont abx, monitor wbc.\n" }, { "category": "Nursing/other", "chartdate": "2162-08-20 00:00:00.000", "description": "Report", "row_id": 1521972, "text": "RESP: BS'S CLEAR. O2 SATS 98-100% ON 4L NP.\nGI: SWALLOWING WELL. FED PT. BREAKFAST WITHOUT DIFFICULTY. FAIR APPETITE. ABLE TO SWALLOW HER MEDS.\nRENAL: CONT. WITH POOR U/O'S. 2X FLUID BOLUSES OF 500CC GIVEN. NO INCREASED IN OUTPUT.\nCV: FLUID BOLUSES FOR LOW BP. BP THIS AM WAS 132-GIVEN HER LOPRESSOR, BUT WITHIN 2.5HRS. BP IN 70'S REQUIRING BOLUS. THIS NEED HAS CONTINUED. DOES RESPOND TO THE BOLUSES HOWEVER. CVP 9-6. TOPONIN CONT. TO RISE. ECHO SHOWED + MR, APICAL AKENISIS AND EF OF 45%.\nNEURO: REMAINS CONFUSED. STILL NITPICKING, BUT LESS SO THEN YESTERDAY. CONT. WITH RESTRAINTS. NO MITTS TODAY. SLEPT IN NAPS.\nID: ANTIBIOTICS CHANGED TO CIPRO FOR UTI. REMAINS AFEBRILE.\nHEM: WITH HYPOTENSION REPEAT HCT. STABLE AT 31.5. NEED TO RECHECK CBC ON 17PM.\nORTHO: CONT. TO OOZE FROM DRSG. DRSG CHANGED. LEFT FOOT MORE EDEMATOUS.\nSOCIAL: SPOKE WITH DAUGHTER AND UPDATED.\nPLAN: CONT. WITH FLUID BOLUSES. WILL HAVE TO ADDRESS LOPRESSOR DOSE AT 20PM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-08-21 00:00:00.000", "description": "Report", "row_id": 1521973, "text": "NPN 1900-0700:\nNeuro: Pt is confused, disoriented, delerious, dementic on Aricept, with occasional visual hallucination, asked for her mother and wanted to go for a walk and to the hair dressor during the night, agitated sometimes trying to pull out central line and Foley cath, c/o L hip pain especially with turning and movement, pt underwent THR and did well after that, yesterday CPT done and pt involved actively with ROM, did well, responding to Oxycodone well for pain, slept well.\n\nResp: Breathing regularly on O2 NC 4 L/min, SPO2 95-100%, RR 12-17, LS CTA.\n\nCV: NSR HR 78-95, BP 110-140/50-78, CVP 9-14, with RIJ line, on 2 KVOs, peripheral pulses palpable, didn't need blood transfusion yesterday as Hct >30, pt has an active MI and ischemia, troponin level increassing daily, didn't need any boluses with me, pt is on Aspirin and Lopressor, sometimes BP drops after Lopressor by 1-3 hours, could be due to blood loss from incisional site and from cardiogenic shock, responding well to fluid boluses.\n\nGI/GU: On house diet, eating salad, apple sauce, rice, chicken, ice cream with no aspiration, taking pills, however big ones like Ciprofloxacin needs to be crushed, abdomen soft, BS present, passed 3x loose BM, with Foley draining low amber U/O, HO aware, on Cipro PO for UTI, pt doesn't appear to be septic (no fever, falling WBCs).\n\nInteg: With dressing on incisional site bleeding moderately, changed yesterday by surgical team, T max 99.\n\nSocial: Visited by 2 daughters yesterday and updated on , pt is /DNR, family doesn't want much extensive treatment.\n\nPlan:Continue Oxygen, Aspirin, and Lopressor for MI, Monitor BP and bolus IVF if hypotension to keep CVP above , Oxycodone PRN for pain, consider Haldol if very agitated, continue monitoring cardiac enzymes and Hct, transfuse for Hct < 30, Social worker will F/U on and visit pt, possible family meeting to discuss disposition, pt is not to be discharged home from ICU, but to be transferred to a rehab center.\n\n" }, { "category": "Nursing/other", "chartdate": "2162-08-31 00:00:00.000", "description": "Report", "row_id": 1521974, "text": "MICU Nursing Admission Note to MICU/ 4:\n 87y.o. female received from OR today, intubated, at 11AM after undergoing left hip dislocatuion repair under general anesthesia. Transfer to MICU on NTG drip for hypertension, received morphine 4mg IV upon arrival to MICU.\n\n Pt originally admitted to with left hip ORIF done after which time she had NSTEMI. Pt has been DNR/DNI while on the floor and having cardiac problems, SVT/VT, for which her proxy has refused any further invasive procedures. She has also had problems with renal insufficiency which attending renal MD has stated less intervetion is better at this poiunt(Limit or d/c'd lisinopril and limit antibiotic administration) They have planned to maximize electrolytes and limit invasive intervention. Pt then dislocated her repaired hip and decision was made to go back to OR today to see if it could be put back into position. Pt was given 2 units FFP before procedure and will get two more post-op. Plan will be to maximize her medical care and extubate her ASAP.\n\nAllergies: NKA\n\nPMH: CVA with left sided weakness, dementia with restless agitated behavious this admission, frequent falls, UTI, depression, CAD, MI, RF. Pt has also been the victim of elder abuse and is under protective services care at this time and will not be allowed to go home from the hospital at this point.\n\nNeuro: Intubated on the vent, restless at times and does not follow commands. Shakes head yes and no to simple questions. Denies pain at this point. Bilateral soft wrist restraints on for safety as pt will pull lines/tubes given the chance.\n\nCV: BP 150-160's on NTG drip 1mcg/kg/min. HR 70-90 NSR with APC's. Currently awaiting chemistries sent at 1300. Denies chest pain. CVP 6-12. A-line in place is not sutured. IVF LR at 75cc/hr\n\nResp: Currently remains intubated on PSV 10 with 5cm peep. Plan to extubate this evening. Lungs clear.\n\nGI: NPO with no access for meds at this point. Abdomen is soft and slightly distended.\n\nGU: Foley inserted today in OR draining clear yellow urine.\n\nID: Pt getting three doses of cefazolin 1gm IV Q8hrs as ordered. Pt also on zosyn Q8hr. Temp 98.0 PO and WBC is up to 16 today from 13 on .\n\nHeme: Plan to receive two more units FFP here in MICU this evening. Hct 27 post-op and will most likely need blood transfusion. Will restart anticoagulation tomorrow if she is stable.\n\nAccess: Right arm peripheral IV is in place and clamped. Currenlty using quad lumen central line inserted in OR in right IJ.\n\nMobility: Pt must keep her legs abducted at all times because this hip can out of position easily. Turn pt with pillow in place and she can sit up for meds as long as pillow stays between legs. DO NOT LET HER LEFT LEG GO TO MIDLINE OR THE HIP WILL DISLOCATE AGAIN!\n\nSocial: Pt is DNR/DNI but full treat and family says it was OK to have pt intubated around her surgery. Pressors/inotropic meds OK also.\n" }, { "category": "Nursing/other", "chartdate": "2162-08-31 00:00:00.000", "description": "Report", "row_id": 1521975, "text": "Patient successfully extubated placed on 70% cool mist.S/P redo hip surgery.will soon move patient from cool mist to N/C.\n" }, { "category": "Nursing/other", "chartdate": "2162-08-31 00:00:00.000", "description": "Report", "row_id": 1521976, "text": "MICU NPN Update ROS:\nNeuro: Pt sleepy but wakes to name calling but falls right back to sleep. Does follow simple commands inconsistantly. Denies pain in her hip repair site but has significant moaning, crying with attempts to turn. Abduction pillow in place at all times/logroll her for turns. Prior to extubation pt given 25-50mcg IV fentanyl for turns but now that she is extubated she only has tylenol ordered which was given PR this evening.\n\nCV: Remains on NTG drip at 1.3mcg/kg/min and IV lopressor ordered as needed since pt not taking her PO meds due to somnolence. BP 135-160/60. HR 65-90 sinus with APC's. EKG done. Hct checked at 7PM was down to 24.9 so pt is being transfused with one unit PRBC's over four hours. K+, Mag and calcium repletion given as ordered.\n\nResp: Extubated at 1700 and weaned to 50% cool neb with good ABG's. Lungs remains clear with decreased breath osunds at bases. Weak non-productive cough noted. RR 14-18 non-labored.\n\nGI: NPO, too sleepy to take pills at this point. When more awake she apparently can take pills crushed and mixed with applesauce or pudding. Abdomen is soft w/positive bowel sounds.\n\nGU: Urine has become sedimented but remains light yellow in color.\n\nSkin: Slight red rash noted over part of her chest and legs, denies itch. Keep heels off the bed.\n\nID: Temp was up to 99.8 axillary at 7PM. Will follow closely. Continues on zosyn and cefazolin.\n\nSocial: Daughter was in to visit today and spoke to team and confirmed pt/family wishes for DNR/DNI. No compressions.shock. Plan will be to support pt overnight and transfer her back to surgical floor if stable tomorrow. Please restart meds PO when more awake and follow strict activity guidline as noted above. ABDUCTOR PILLOW IN PLACE AT ALL TIMES/NEVER LET LEFT LEG GO TO MIDLINE/LIMIT HIP FLEXION ALSO AS THIS DISLOCATE HIP\n" }, { "category": "Echo", "chartdate": "2162-08-19 00:00:00.000", "description": "Report", "row_id": 93517, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 65\nWeight (lb): 135\nBSA (m2): 1.68 m2\nBP (mm Hg): 145/73\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 15:16\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Depressed\nLVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\ndyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nSevere PA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. LV systolic function\nappears depressed. Resting regional wall motion abnormalities include apical\nhypokinesis/akinesis/dyskinesis; cannot exclude mid lateral hypokinesis. No\nleft ventricular thrombus identified; cannot exclude. Right ventricular\nchamber size and free wall motion are normal. The ascending aorta is mildly\ndilated. The aortic valve leaflets are moderately thickened. There is mild\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild to moderate (+) mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. Moderate [2+]\ntricuspid regurgitation is seen. There is severe pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , apical\nhypokinesis is new. Estimated pulmonary artery systolic pressure is now\nhigher.\n\n\n" }, { "category": "ECG", "chartdate": "2162-08-26 00:00:00.000", "description": "Report", "row_id": 245503, "text": "Baseline artifact. The rhythm is more regular. Atrial fibrillation versus\nsinus rhythm with atrial premature beats. Intraventricular conduction delay of\nleft bundle-branch block type persists. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2162-08-25 00:00:00.000", "description": "Report", "row_id": 245504, "text": "Baseline artifact. Probable sinus rhythm with an atrial premature beat.\nIntraventricular conduction delay of left bundle-branch block type. ST-T wave\nabnormalities. Since the previous tracing of the rate is slower and the\nQ-T interval is more prolonged.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2162-09-01 00:00:00.000", "description": "Report", "row_id": 245499, "text": "Normal sinus rhythm\nLeft bundle branch block\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2162-08-31 00:00:00.000", "description": "Report", "row_id": 245500, "text": "Sinus arrhythmia\nLeft bundle branch block\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2162-08-28 00:00:00.000", "description": "Report", "row_id": 245501, "text": "Sinus rhythm. Left bundle-branch block. Precordial lead T wave abnormalities\nmay be primary but cannot exclude ischemia. Clinical correlation is suggested.\nSince the previous tracing of precordial lead T wave abnormalities\nappear slightly less prominent.\n\n" }, { "category": "ECG", "chartdate": "2162-08-27 00:00:00.000", "description": "Report", "row_id": 245502, "text": "Sinus rhythm. Intraventricular conduction delay. Compared to the previous\ntracing of there is further evolution of ischemic appearing ST-T wave\nabnormalities in leads I, aVL and VI-V6. Followup and clinical correlation are\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2162-08-19 00:00:00.000", "description": "Report", "row_id": 245732, "text": "Sinus rhythm with underlying left bundle-branch block. No change compared to\nthe previous tracing of .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2162-08-18 00:00:00.000", "description": "Report", "row_id": 245733, "text": "Sinus tachycardia with underlying left bundle-branch block and secondary\nST-T wave abnormalities. Compared to the previous tracing of no\ndiagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2162-08-16 00:00:00.000", "description": "Report", "row_id": 245734, "text": "Normal sinus rhythm. Left bundle-branch block with secondary ST-T wave\nabnormalities. Left atrial abnormality. Compared to the previous tracing\nof no diagnostic interval change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2170-12-31 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 808416, "text": " 5:24 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for abscess; appendicitis, diverticulitis, pancreatitis\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with abd pain/n/v and elev wbc with bandemia\n REASON FOR THIS EXAMINATION:\n eval for abscess; appendicitis, diverticulitis, pancreatitis, other intra-abd\n infection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa MON 5:55 PM\n bilateral multifocal pyelonephritis\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Evaluate for abscess, elevated WBC, nausea and vomiting,\n abdominal pain.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases to the\n pubic symphysis after the administration of intravenous contrast.\n\n CONTRAST: 150 cc of Optiray was administered.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are trace bilateral\n pleural effusions. There is increased opacity in the basilar portions of the\n lower lobes consistent with pulmonary edema versus early consolidation. The\n liver, gallbladder, spleen, pancreas and adrenal glands are unremarkable.\n Note is made of a tiny splenule within the splenic hilum.\n\n There are multifocal areas of decreased enhancement within the kidney\n parenchyma bilaterally most prominently demonstrated within the mid-portion of\n the right kidney, yet the regions extend through both poles of both kidneys.\n The decreased enhancement extends to the cortex. The kidneys excrete\n normally. There is a minimal amount of fluid surrounding the right kidney\n tracking inferiorly.\n\n The intra-abdominal bowel loops are unremarkable. There is no free air within\n the abdomen. There is no significant abdominal adenopathy.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is a trace amount of free\n fluid within the right paracolic gutter. The intrapelvic bowel loops are\n unremarkable. Note is made of a moderate-sized fundal fibroid. The urinary\n bladder contains a Foley catheter.\n\n The osseous structures demonstrate degenerative changes at the L5/S1\n intervertebral level with multiple endplate lucencies and endplate sclerosis.\n\n IMPRESSION:\n 1. Multifocal bilateral pyelonephritis.\n 2. A 4.5 cm fundal fibroid.\n (Over)\n\n 5:24 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for abscess; appendicitis, diverticulitis, pancreatitis\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n 3. Trace free fluid within the abdomen.\n 4. There are trace bilateral pleural effusions and increased ground glass\n opacity at the lung bases. This is most likely consistent with pulmonary\n edema. However, early lower lobe consolidation cannot be excluded.\n\n" }, { "category": "Nursing/other", "chartdate": "2171-01-01 00:00:00.000", "description": "Report", "row_id": 1350369, "text": "pmicu nursing progress 7p-7a\npt is being tx as per the MUST protocol\nreview of systems\nCV-bp via nbp with MAP~58-initially tx with a 500 cc bolus then was started on a small dose of iv levo-0.03 mcgs/kg/min and her MAP has been 60- 75.her hr has come down to the 50's-60's sb/sr with no ectopy noted.\nRESP-has been breathing comfortably on 2L nasal cannula, lungs are clear throughout anteriorally. no cough. SVO2 has been 69-76. RR has been 16-20, no c/o SOB.\nID-afebrile. wbc elevated- pnd for this am. receiving ampi q6hrs. flagyl d/cd. micro called with gm negative rods in anaerobic bottle.\nGI-abd is soft and nontender, positive bowel sounds. no stool overnight. taking clear liqs-tolerating well. on po protonix\nNEURO- a+o x 3. cooperative. sleeping in naps.\nF/E- ivf decreased from 150--75 ccs/hr. was repleted with 3 gms Mag.is developing peripheral edema.has had multiple labs drawn overnight.\nENDO- stim test done--pnd\nIV access- has specific SVO2 catheter placed R IJ.\n nephew in to visit this evening.\na- stable night\nP-will continue as per sepsis protocol\n" }, { "category": "Nursing/other", "chartdate": "2171-01-01 00:00:00.000", "description": "Report", "row_id": 1350370, "text": "npn 7-7am\nPt no longer on sepsis protocol. Levophed weaned off at 11am. Remains afebrile. Continues on Levoflax for gram negative rod bacterimia.\n\nneuro: axox3, mae, follows commands. Pt appears anxious at times.She c/o back pain this afternoon and was given tylenol withhout effect. Re-evaluated by team and given Tylenol # 3.\n\nresp: No issues. LS with some crackles at bases. 2L O2.\n\nCV: SR in the 80's, no ectopy. BP wnl. Pt c/o back pain and nausea this afternoon--EKG done and was normal.\n\naccess: tlc and 2 piv.\n\ngi/gu: Pain in RLQ. Pelvic exam performed by Dr this afternoon was normal. Diet advanced to normal today and is being tolearted. Foley in place draining large amt of clear yellow urine.\n\nSkin: Intact\n\nDispo: Full code.\n\nPlan: Continue to monitor pain.\n" }, { "category": "Nursing/other", "chartdate": "2171-01-02 00:00:00.000", "description": "Report", "row_id": 1350371, "text": "Nursing Note-\nNo issues overnight.\n\nN- A&O x3, move all ext, very low tolerance for pain, winces when given heparin shot, No c/o abd pain or bac pain. Afebrile. Slept all shift.\n\nCV- Hr 60s sr, no ectopy, bp on the low side, 90/45 - , denies cp or sob. RIJ TLC intact and patent, cvp 12 - 16. Fluids kvo.\n\nResp- Clear bs bil, sats high 90s on ra, rr 16 - 22.\n\nGI/GU- +bs, abd soft, no stool, tol liquids. Foley draining cl yellow urine. Continue on po levoflox, wbc down to 8.\n\nSkin- Warm, dry and intact.\n\nSocial- No family contact overnight.\n\n Pt stable, ?dc today, No medical coverage, per case managers note Pt to be dc home without services.\n" }, { "category": "ECG", "chartdate": "2171-01-03 00:00:00.000", "description": "Report", "row_id": 196850, "text": "Sinus bradycardia. Diffuse non-diagnostic T wave flattening. No previous\ntracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2171-01-01 00:00:00.000", "description": "Report", "row_id": 196851, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2114-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162019, "text": " 7:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ET tube location\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with respiratory failure on ventilation\n REASON FOR THIS EXAMINATION:\n ET tube location\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:10 P.M. \n\n HISTORY: Respiratory failure. Check ET tube.\n\n IMPRESSION: AP chest compared to , 5:27 a.m.:\n\n ET tube is in standard placement, no less than 3 cm from carina, with the chin\n slightly flexed.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1161378, "text": " 6:05 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please evaluate for pneumonia, possible parapneumonic effusi\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CHF, AKA, recurrent UTI, h/o C.diff, presented with\n lethargy/dehydration, likely pneumonia and is aneuric.\n REASON FOR THIS EXAMINATION:\n please evaluate for pneumonia, possible parapneumonic effusion, renal stones,\n hydronephrosis, any signs of colitis, any scrotal fluid collections or\n abnormalities\n CONTRAINDICATIONS for IV CONTRAST:\n no urine output, Cr 3.8\n ______________________________________________________________________________\n WET READ: 9:13 PM\n 1) Dense consolidations primarily involving the bilateral lower lobes, right\n greater than left, compatible with multifocal pneumonia.\n 2) Bilateral double-J ureteral stents.\n 3) Some redundancy to the sigmoid colon with possible impacted stool however\n no obstruction is present.\n 4) Heterogeneous, nodular thyroid.\n 5) Vascular calcifications\n 6) Heterotopic calcifications and degenerative changes notable in shoulders\n and hips. Hetertopic bridging ossification between posterior chest wall and\n right scapula and bridging right shoulder. Osteopenia. Atrophy of muscular\n of right chest.\n 7) Though examination is not optimal for evaluation of scrotal contents,\n bilateral hydroceles are present. Foci of air are felt to be outside of the\n patient.\n 8) ETT approximately 2.2 cm above carina.\n 9) Right renal stone and cysts. Left small exophytic foci too small to\n characterize.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 79-year-old male with CHF, above-knee amputation,\n recurrent UTIs and history of C. difficile colitis, now presenting with\n lethargy. Evaluate for pneumonia, renal stones or hydronephrosis.\n\n EXAMINATION: CT of the torso without intravenous contrast.\n\n COMPARISON: No prior studies are available for direct comparison. Indirect\n comparison is made to chest radiographs from and .\n\n TECHNIQUE: Helically-acquired axial images were obtained from the thoracic\n inlet to the pubic symphysis with the administration of oral contrast only.\n Intravenous contrast was deferred secondary to renal failure and elevated\n creatinine. Coronal and sagittal reformations were obtained.\n\n FINDINGS:\n\n CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:\n (Over)\n\n 6:05 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please evaluate for pneumonia, possible parapneumonic effusi\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is dense lobe or parenchymal consolidation involving the right lower\n lobe and consolidation involving the left lower lobe compatible with\n pneumonia. The remainder of the lungs are clear with no pulmonary nodules\n identified. There are no pleural effusions or pneumothorax. An endotracheal\n tube terminates approximately 2.2 cm above the level of the carina. Note is\n made of posterior bowing of the trachea that is indicative of an expiratory\n phase. There is no axillary, hilar, or mediastinal lymphadenopathy. There is\n extensive atherosclerotic calcification involving the thoracic aorta and\n aortic valve. A left approach central venous catheter terminates within the\n lower SVC. Esophageal and nasoenteric tube courses through the esophagus with\n tip terminating within the gastric body.\n\n There is extensive heterogeneity involving the thyroid with multiple low-\n attenuation lesions compatible with nodules. The largest measures up to 1.0\n cm.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The liver, gallbladder, both\n adrenal glands, and visualized loops of intra-abdominal small and large bowel\n are unremarkable. There is no intra-abdominal free air or free fluid. There\n is no mesenteric or retroperitoneal lymphadenopathy. The spleen demonstrates\n peripheral calcification, likely related to prior granulomatous\n disease/trauma.\n\n The patient is status post bilateral double-J nephroureteral stents in\n standard positions. There are multiple right-sided renal calculi, the largest\n conglomerate seen in the medial interpolar region measuring up to 1.0 cm.\n There is no gross hydronephrosis or hydroureter.\n\n The pancreas demonstrates fatty atrophy.\n\n There is a moderate-to-large amount of stool distending the rectum and sigmoid\n colon, which is otherwise unremarkable in appearance. The bladder is\n collapsed without a Foley catheter with the distal aspects of the double-J\n nephroureteral stents noted. The prostate and seminal vesicles are\n unremarkable. There is no pelvic free fluid. There is no pelvic or inguinal\n lymphadenopathy.\n\n There is extensive atherosclerotic calcification involving the abdominal aorta\n and its major branches.\n\n Note is made of extensive simple fluid within the scrotal sac related to\n bilateral hydroceles.\n\n BONE WINDOWS: There is extensive heterotopic ossification, and diffuse\n (Over)\n\n 6:05 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please evaluate for pneumonia, possible parapneumonic effusi\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n osteopenia involving both hips (series 2:image 101). In addition, there is\n extensive heterotopic ossification and soft tissue seen in the region of the\n known right distal femur at site of known above-knee amputation. There is\n also extensive heterotopic bone formation involving the right shoulder\n relative atrophy of the right chest wall musculature.\n\n IMPRESSION:\n 1. Multifocal pneumonia with right greater than left parenchymal\n consolidation.\n 2. Bilateral double-J nephroureteral stents in standard positions. Right\n renal calculi measuring 1.0 cm in the right interpolar region.\n 3. Heterogeneous nodular thyroid.\n 4. Extensive heterotopic calcification and degenerative changes in the\n shoulders and hips.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1161379, "text": " 6:06 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for intracranial bleed and/or cerebral edema\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CHF, AKA, recurrent UTI, h/o C.diff, presented with\n lethargy/dehydration, hypernatremia, likely pneumonia, acute renal failure,\n intubated not sedated and not responding well\n REASON FOR THIS EXAMINATION:\n please evaluate for intracranial bleed and/or cerebral edema that might\n contribute to altered mental status\n CONTRAINDICATIONS for IV CONTRAST:\n no urine output, Cr 3.8-4\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:25 PM\n No evidence of acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nonresponsive.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast.\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect or\n recent infarction. Prominence of the ventricles and sulci likely reflects\n generalized atrophy, age related. Areas of periventricular and subcortical\n white matter hypodensity likely reflect sequela of chronic small vessel\n ischemic disease. There are extensive vascular calcifications. No concerning\n osseous lesion is seen. Mucosal thickening with aerosolized secretions and\n air-fluid level in the right sphenoid sinus and mucosal thickening within the\n left sphenoid sinus are seen. There is opacification of the mastoid air cells\n on the right. On the left, opacification of the mastoid air cells at the apex\n is seen.\n\n IMPRESSION: No evidence of acute intracranial process.\n\n Final Attending Comment:\n Also noted is an old left pontine infarct.\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1161380, "text": ", F. MED 6:06 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for intracranial bleed and/or cerebral edema\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CHF, AKA, recurrent UTI, h/o C.diff, presented with\n lethargy/dehydration, hypernatremia, likely pneumonia, acute renal failure,\n intubated not sedated and not responding well\n REASON FOR THIS EXAMINATION:\n please evaluate for intracranial bleed and/or cerebral edema that might\n contribute to altered mental status\n CONTRAINDICATIONS for IV CONTRAST:\n no urine output, Cr 3.8-4\n ______________________________________________________________________________\n PFI REPORT\n No evidence of acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1161270, "text": " 9:35 AM\n RENAL U.S. PORT Clip # \n Reason: obstruction, abscess\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo M w/ CHF, PVD, s/p AKA, s/p ureteral stents and s/p partial penisectomy\n (distal shaft of penis excised) with indwelling catheter transferred from\n hospital with fevers, bilateral rhonchi, and hypoxia, intubated in ED\n for respiratory distress, and transferred to concern for sepsis.\n REASON FOR THIS EXAMINATION:\n obstruction, abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 79-year-old male with congestive heart failure,\n peripheral vascular disease, and with concern for sepsis. Please evaluate for\n obstruction or abscess.\n\n EXAMINATION: Renal ultrasound.\n\n COMPARISONS: None available.\n\n FINDINGS: The right kidney measures 8.0 cm.\n\n Left kidney measures 11.7 cm.\n\n Within the limitations of poor acoustic windows, note is made of multiple\n renal calculi within the upper pole region of the right kidney with\n conglomeration of renal calculi measuring up to 2.9 cm. The right kidney is\n otherwise unremarkable with no evidence of hydronephrosis or discrete renal\n masses. Within the left kidney, there are also multiple renal calculi, the\n largest being in the lower pole measuring up to 6 mm. In addition, there is\n mild hydronephrosis involving the left kidney. There are no discrete renal\n masses.\n\n IMPRESSION:\n 1. Bilateral multiple renal calculi, with largest conglomeration in the right\n upper pole measuring up to 2.9 cm.\n 2. Mild left hydronephrosis. No evidence of right-sided hydronephrosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "P SCROTAL U.S. PORT", "row_id": 1161316, "text": " 1:02 PM\n SCROTAL U.S. PORT Clip # \n Reason: ? abscess\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo M w/ CHF, PVD, s/p AKA, s/p ureteral stents and s/p partial penisectomy\n (distal shaft of penis excised) with indwelling catheter transferred from\n hospital with fevers, bilateral rhonchi, and hypoxia, intubated in ED\n for respiratory distress, and transferred to concern for sepsis.\n REASON FOR THIS EXAMINATION:\n ? abscess\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Very complicated patient with concern for sepsis, history\n of partial penectomy, ureteral stents, lower extremity amputations, peripheral\n vascular disease, indwelling catheter. Enlarged scrotum. Please assess for\n abscess.\n\n STUDY: Scrotal/testicular ultrasound.\n\n FINDINGS:\n\n There are large bilateral hydroceles which are simple in appearance. There is\n no definite thickening of the about the hydrocele or about the testes.\n There is no hyperemia about the hydrocele of either.\n\n Testes are within normal limits in size bilaterally with the right testis 3.5\n x 2.5 x 2.0 and the left testis 3.0 x 2.0 x 2.1 cm. There is minimal\n parenchymal heterogeneity within both testes, but no focal mass or definite\n evidence of ischemic injury. A small coarse calcification is seen within the\n right testis. Bilateral epididymides are within normal limits in size.\n Within the right epididymis, there are three subcentimeter simple cystic\n lesions. No definite lesion within the left epididymis. There is diffuse\n skin thickening noted.\n\n IMPRESSION:\n 1. Large bilateral hydroceles without evidence of superinfection. Mild skin\n thickening is noted which could be related to cellulitis, though this is\n uncertain.\n 2. Testes within normal limits. No masses.\n 3. Right epididymal cysts are simple in appearance.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1161359, "text": " 4:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for left CVL placement\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CHF, PVD, s/p AKA presented with lethargy, found to have\n likely pneumonia and dehydration, intubated and central line just placed\n REASON FOR THIS EXAMINATION:\n please evaluate for left CVL placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:32 PM\n 1. Left internal jugular catheter ending in right atrium, recommend\n withdrawal by 4 cm.\n 2. Stable right-sided consolidation and small pleural effusion with interval\n increase in left lower lobe consolidation concerning for aspiration pneumonia.\n 3. Stable position of endotracheal tube and nasogastric tube.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New central line placement.\n\n TECHNIQUE: Portable AP upright radiograph of the chest.\n\n COMPARISONS: Multiple prior chest radiographs, most recently .\n\n FINDINGS: There has been interval placement of a left internal jugular\n central venous catheter which ends in the right atrium. Stable position of\n endotracheal and nasogastric tubes. There is stable appearance of the right\n basilar consolidation representing aspiration pneumonia with slight increase\n in consolidation within the left base concerning for a similar process. The\n remainder of the lungs are normal in appearance. The cardiomediastinal\n contour is unchanged. There is stable right pleural effusion.\n\n IMPRESSION:\n 1. Left internal jugular catheter ending in right atrium, recommend\n withdrawal by 4 cm.\n 2. Stable right-sided consolidation and small pleural effusion with interval\n increase in left lower lobe consolidation concerning for aspiration pneumonia.\n 3. Stable position of endotracheal tube and nasogastric tube.\n\n These findings were relayed by Dr. to Dr. at 1700 on .\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1161360, "text": ", F. MED 4:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for left CVL placement\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CHF, PVD, s/p AKA presented with lethargy, found to have\n likely pneumonia and dehydration, intubated and central line just placed\n REASON FOR THIS EXAMINATION:\n please evaluate for left CVL placement\n ______________________________________________________________________________\n PFI REPORT\n 1. Left internal jugular catheter ending in right atrium, recommend\n withdrawal by 4 cm.\n 2. Stable right-sided consolidation and small pleural effusion with interval\n increase in left lower lobe consolidation concerning for aspiration pneumonia.\n 3. Stable position of endotracheal tube and nasogastric tube.\n\n" }, { "category": "Radiology", "chartdate": "2114-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161266, "text": " 9:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA?\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo M w/ CHF, PVD, s/p AKA, s/p ureteral stents and s/p partial penisectomy\n (distal shaft of penis excised) with indwelling catheter transferred from\n hospital with fevers, bilateral rhonchi, and hypoxia, intubated in ED\n for respiratory distress, and transferred to concern for sepsis.\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with CHF, PVD, fevers, rhonchi, hypoxemia,\n intubated for respiratory distress.\n\n COMPARISON: Chest radiograph one day prior.\n\n SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: An endotracheal tube terminates\n 2.8 cm above the carina and a nasogastric tube terminates in the stomach. The\n heart size is top normal. A rapidly developing right lower lobe ill-defined\n opacification most likely represents aspiration. The remainder of the lungs\n appear relatively well aerated. There is likely a small right pleural\n effusion. The bony thorax is unremarkable. The right shoulder is only\n partially visualized but demonstrates severe deformity. Proximal end of\n nephroureteral stents are seen.\n\n IMPRESSION: Right lower lobe aspiration pneumonia with likely small right\n effusion.\n\n Paged Dr. to discuss at 11:45 a.m. .\n\n" }, { "category": "Radiology", "chartdate": "2114-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161429, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumonia vs pulm edema\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo M w/ CHF, PVD, s/p AKA, s/p ureteral stents and s/p partial penisectomy\n (distal shaft of penis excised) with indwelling catheter transferred from\n hospital with fevers, bilateral rhonchi, and hypoxia, intubated in ED\n for respiratory distress\n REASON FOR THIS EXAMINATION:\n ? pneumonia vs pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory distress, intubation in the ED.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the left internal jugular\n catheter has been pulled back. The other monitoring and support devices are\n in unchanged position. Mildly increasing pleural effusions that cause\n homogeneous loss in transparency at the lung bases. Tips of renal internal\n drains are visible bilaterally. No newly appeared focal parenchymal opacities\n in the lung parenchyma. Known right shoulder pathology. Unchanged size of\n the cardiac silhouette.\n\n" }, { "category": "Radiology", "chartdate": "2114-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161851, "text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in infiltrate and pulmon\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with 79 yo M w/ CHF, PVD, s/p AKA, presented w/ fevers,\n bilateral rhonchi, and hypoxia, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in infiltrate and pulmonary edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MON 12:16 PM\n 1. Bilateral moderate-sized pleural effusions with increasing pulmonary\n vascular congestion which limit the ability to characterize the previously\n described consolidations in the lower lobe.\n 2. Endotracheal tube at the level of carina should be withdrawn 2-3 cm and\n cuff should be suggested as it is slightly overinflated.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral rhonchi, hypoxia and fevers, intubated. Assess for\n change in consolidation and pulmonary edema.\n\n TECHNIQUE: Portable supine radiograph of the chest.\n\n COMPARISON: Multiple prior chest radiographs, most recently .\n\n FINDINGS: Small-to-moderate sized bilateral pleural effusions are stable with\n slight increase in bilateral pulmonary vascular congestion. On this\n background, the bibasilar consolidations described previously are somewhat\n indistinct and difficult to appreciate. Cardiac size is unremarkable with\n normal cardiomediastinal silhouette.\n\n Endotracheal tube is at the level of the carina approaching the right mainstem\n bronchus and should be withdrawn 2-3 cm and the cuff should be somewhat\n deflated as it appears to be expanded outwards. Stable appearance of the left\n internal jugular catheter and nasogastric tube which courses into the stomach\n and out of view with bilateral ureteral pigtail stents, incompletely imaged.\n\n IMPRESSION:\n 1. Bilateral moderate-sized pleural effusions with increasing pulmonary\n vascular congestion which limit the ability to characterize the previously\n described consolidations in the lower lobe.\n 2. Endotracheal tube at the level of carina should be withdrawn 2-3 cm and\n cuff should be suggested as it is slightly overinflated.\n 3. Stable appearance of the left IJ and nasogastric tubes.\n\n These findngs were relayed to Dr. by Dr. at 1100 on .\n (Over)\n\n 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in infiltrate and pulmon\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2114-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161643, "text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening pneumonia\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo M w/ CHF, PVD, s/p AKA, s/p ureteral stents and s/p partial penisectomy\n (distal shaft of penis excised) with indwelling catheter transferred from\n hospital with fevers, bilateral rhonchi, and hypoxia, intubated in ED\n for respiratory distress\n REASON FOR THIS EXAMINATION:\n worsening pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient for respiratory distress with fevers,\n hypoxia, status post ureteral stents and partial penectomy.\n\n ET tube tip is 3.1 cm above the carina. Left IJ catheter tip is in the\n upper-to-mid SVC. Compared to prior study performed a day earlier. Vascular\n congestion has improved. Cardiomediastinal contours are unchanged. Bilateral\n pleural effusions with adjacent atelectasis are probably unchanged allowing\n the difference in positioning of the patient. There is no pneumothorax.\n Bilateral ureteral catheters are in place. NG tube tip is in the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2114-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161753, "text": " 4:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any improvement of underlying process?\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with multifocal PNA, on ventilator\n REASON FOR THIS EXAMINATION:\n Any improvement of underlying process?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient with multifocal pneumonia.\n\n Comparison is made with prior study performed a day earlier.\n\n Allowing the difference in positioning of the patient and the technique of the\n study, bilateral pleural effusions with adjacent atelectases,\n cardiomediastinal silhouette, and vascular congestion are stable. Lines and\n tubes remain in place in standard position.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161217, "text": " 8:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with hx of resp failure.\n REASON FOR THIS EXAMINATION:\n eval ETT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON \n\n COMPARISON: None.\n\n CLINICAL HISTORY: Respiratory failure, question ET tube position.\n\n FINDINGS: AP supine portable view of the chest is obtained. An endotracheal\n tube is seen with its tip located approximately 1.8 cm above the carina.\n Bilateral ureteral stents are seen in the upper abdomen. Low lung volumes\n limit evaluation, though the imaged portions of both lungs appear essentially\n clear. Heart size cannot be assessed. The aorta appears unfolded. There is\n sclerotic appearance of the right shoulder, incompletely assessed.\n\n IMPRESSION: Slightly low position of endotracheal tube located 1.8 cm above\n the carina. Consider minimal retraction.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2114-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1161852, "text": ", F. MED 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in infiltrate and pulmon\n Admitting Diagnosis: RESPIRATORY FAILURE;ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with 79 yo M w/ CHF, PVD, s/p AKA, presented w/ fevers,\n bilateral rhonchi, and hypoxia, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in infiltrate and pulmonary edema\n ______________________________________________________________________________\n PFI REPORT\n 1. Bilateral moderate-sized pleural effusions with increasing pulmonary\n vascular congestion which limit the ability to characterize the previously\n described consolidations in the lower lobe.\n 2. Endotracheal tube at the level of carina should be withdrawn 2-3 cm and\n cuff should be suggested as it is slightly overinflated.\n\n\n" }, { "category": "Echo", "chartdate": "2114-11-02 00:00:00.000", "description": "Report", "row_id": 90133, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Endocarditis.\nBP (mm Hg): 115/53\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: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor\nsubcostal views. Suboptimal image quality - poor suprasternal views.\nSuboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThere is no ventricular septal defect. Right ventricular chamber size and free\nwall motion are normal. 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. Mild (1+) mitral regurgitation is\nseen. The pulmonary artery systolic pressure could not be determined. There is\nno pericardial effusion.\n\nIMPRESSION: Normal global biventricular systolic function. Mild mitral and\naortic regurgitation. Limited study.\n\n\n" }, { "category": "ECG", "chartdate": "2114-11-01 00:00:00.000", "description": "Report", "row_id": 237660, "text": "Sinus tachycardia. Limb leads are misplaced. Left ventricular hypertrophy with\nsecondary repolarization abnormality. Compared to the previous tracing\nof the limb leads are misplaced on the current tracing and the\nventricular premature beats are not seen.\n\n" }, { "category": "ECG", "chartdate": "2114-11-01 00:00:00.000", "description": "Report", "row_id": 237661, "text": "Sinus tachycardia with ventricular preamture beat. Consider left atrial\nabnormality. Left ventricular hypertrophy with ST-T wave abnormalities.\nNo previous tracing available for comparison.\n\n" } ]