R. No PTX.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Catheter placement.\\n\\n FINDINGS: In comparison with the study of earlier in this date, there has\\n been placement of a left IJ catheter that extends to the mid to lower portion\\n of the SVC. ET tube tip is approximately 3.6 cm above the carina. Diffuse\\n bilateral pulmonary opacifications persist.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1201913,\n \"text\": \" 10:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Are there any infiltrates or enlarging pleural effusions?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with recent ICU stay secondary to severe sepsis, likely\\n secondary to MRSA infection. Would like to obtain chest x-ray as patient still\\n on 4L NC.\\n REASON FOR THIS EXAMINATION:\\n Are there any infiltrates or enlarging pleural effusions?\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:46 A.M., \\n\\n HISTORY: Severe sepsis. Question enlarging pleural effusion or new\\n pneumonia.\\n\\n IMPRESSION: AP chest compared to through :\\n\\n New 2.5 cm wide nodular lesion in the right mid lung has developed from a less\\n well-defined region of vague radiopacity on and may contain a cavity.\\n As such, septic embolus should be considered, alternatively a small\\n aspiration-related lung abscess, but because of the rapid development, not\\n tuberculosis, and probably not fungal infection. Moderate right basal\\n atelectasis is longstanding. A much larger region of consolidation in the\\n left lower lobe, has progressed since . Much of this is probably\\n atelectasis, but concurrent pneumonia could be present and either could\\n explain a moderate left pleural effusion, which has also increased in size\\n since . Mediastinal vascular engorgement indicates elevated central\\n venous pressure or volume, and moderate cardiomegaly is unchanged. No\\n pneumothorax.\\n\\n The physician at pager and I discussed these findings.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-08-22 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1201987,\n \"text\": \" 5:17 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: lung abscess/ embolus/ pneumonia\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL s/p SCT, complicated by GVHD, now with MRSA bullous\\n skin lesions/abscess, recovering from septic shock, now with new nodular lesion\\n on CXR concerning for abscess/emboli\\n REASON FOR THIS EXAMINATION:\\n lung abscess/ embolus/ pneumonia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe MON 6:36 PM\\n 1. Right upper lobe rounded ground glass opacity (4 x 3 cm) without central\\n necrosis or cavity formation corresponds to the finding on a previous CXR and\\n likely represents pneumonia, less likely GVHD or leukemic infiltrate.\\n 2. Interval increase of a small to moderate left pleural effusion. Stable\\n small right effusion.\\n 3. Slight increase of left lower lobe and stable right lower peribronchial\\n opacities, likely atelectasis.\\n 4. Slight increase of the anasarca.\\n 5. Stable small pericardial effusion and T9 superior endplate compression fx.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old male with CLL, status post stem cell transplant\\n complicated by graft-versus-host disease, now with multiple MRSA skin lesions.\\n For evaluation of recent nodular opacification on radiograph.\\n\\n EXAMINATION: CT of the chest without intravenous contrast.\\n\\n COMPARISONS: Portable radiograph from , CT examinations from \\n and .\\n\\n TECHNIQUE: Helically acquired axial images from the thoracic inlet to the\\n upper abdomen were obtained at 1.25 and 5-mm collimation. In addition coronal\\n and sagittal reformations are provided for review.\\n\\n FINDINGS:\\n\\n A right internal jugular approach central venous catheter tip terminates\\n within the low SVC. A subcutaneous tissue defect in the right anterior chest\\n wall, site of the removed infusion, has no associated fluid collection.\\n\\n A round, 3.5 x 3.1cm, ground glass opacity in the anterior segment of the\\n right upper lobe corresponds to a lesion that was new on yesterday's\\n conventional chest radiograph, but less radiodense than expected. There is no\\n cavitation. Mild bibasilar peribronchiolar opacification is greater on the\\n left than the right. Bilateral pleural effusions are small.\\n\\n Moderate cardiomegaly is stable and a small pericardial effusion has\\n increased. The great vessels are unremarkable on this non-contrast\\n examination. The tracheobronchial tree is patent to the subsegmental level.\\n (Over)\\n\\n 5:17 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: lung abscess/ embolus/ pneumonia\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n There is no axillary, mediastinal or hilar lymphadenopathy.\\n\\n This examination is not tailored for subdiaphragmatic evaluation. The\\n visualized colon is relatively decompressed. The visualized upper abdomen is\\n otherwise unremarkable.\\n\\n Diffuse anasarca is unchanged since the recent examination.\\n\\n BONE WINDOWS: There are no bone lesions are suspicious for malignancy or\\n infection; several thoracic vertebral compression fractures are chronic,\\n including the most severe at T9.\\n\\n IMPRESSION:\\n 1. 3.5-cm area of ground-glass lesion in the right upper lobe may be\\n resolving since it first appeared on . Given the decrease in density,\\n differential diagnosis includes atypical infection, hemorrhage or infarction.\\n\\n 2. Interval increase since in lower lobe opacification, particularly\\n on the left, probable atelectasis, less likely pneumonia.\\n\\n 3. Small bilateral pleural effusions.\\n\\n 4. Increased small pericardial effusion.\\n\\n The right upper lobe opacification can be monitored with radiographs, though\\n if the clinical picture suggests infarction, CTA is recommended to look for\\n pulmonary embolism.\\n\\n Findings were discussed with Dr. at 12:15PM via telephone by Dr.\\n .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1211018,\n \"text\": \" 11:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with worsening resp status, intubated\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n WET READ: EHAd TUE 4:24 PM\\n Bibasilar heterogeneous opacities, increased on right, compatible with\\n atelectasis, but in the appropriate clinical setting, superimposed pneumonia\\n may be considered.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 27-year-old man with worsening respiratory status. Evaluate for\\n interval change.\\n\\n COMPARISON: . . .\\n\\n FINDINGS: Single frontal view of the chest was obtained. The heart size and\\n cardiomediastinal silhouette are stable. Bibasilar hazy opacities, slightly\\n increased at the right base, compatible with atelectasis, but in the\\n appropriate clinical setting, multifocal pneumonia should be considered.\\n Endotracheal tube is in satisfactory position. No change in the position of\\n left and right central catheters. No pneumothorax.\\n\\n IMPRESSION: Bibasilar heterogeneous opacities, increased on right, compatible\\n with atelectasis, but in the appropriate clinical setting, superimposed\\n pneumonia may be considered.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-24 00:00:00.000\",\n \"description\": \"R MR WRIST W/O CONTRAST RIGHT\",\n \"row_id\": 1210949,\n \"text\": \" 8:30 PM\\n MR WRIST W/O CONTRAST RIGHT Clip # \\n Reason: to evaluate right wrist. Is there evidence of deep tissue or\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with neutropenia, respiratory failure, and invasive fungal\\n disease on biopsy of R wrist. Concern for deeper invasion that would make\\n surgery or amputation necessary. pt with fluctuating renal\\n function and currently on intermittent dialysis\\n REASON FOR THIS EXAMINATION:\\n to evaluate right wrist. Is there evidence of deep tissue or bone invations?\\n CONTRAINDICATIONS for IV CONTRAST:\\n intemittently on dialysis with fluctuating renal function\\n\\n Yes to Choyke questions.\\n ______________________________________________________________________________\\n WET READ: CMDk MON 11:08 PM\\n the study is limited due to lack of IV contrast. There is no evidence of\\n marrow replacement to suggest bone marrow involvement. There is extensive soft\\n tissue edema as well as extensive edema involving the muscles. pt has known\\n mucor involving the wrist. D/W Dr at 11pm \\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Invasive fungal disease seen on right wrist biopsy in a patient\\n with neutropenia.\\n\\n COMPARISON: Ultrasound from \\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\\n Tesla magnet. Contrast was not administered related to history of\\n intermittent dialysis. Note that the patient's wrist was edematous,\\n precluding scanning an atypical wrist coil. Acquired sequences include proton\\n density axial, STIR axial and coronal, T1-weighted axial and coronal, and\\n T2-weighted axial and sagittal sequences through the right wrist.\\n\\n FINDINGS: Bony structures reveal no cortical disruption or periostitis. Bone\\n marrow signal is notable for serpiginous areas of edema involving the base of\\n the first metacarpal, the distal radius (series 8, image 9) and the radial\\n aspect of the distal ulna adjacent to the distal radioulnar joint. Areas of\\n mild edema are also visualized at the base of the fourth and fifth metacarpals\\n (series 8, image 12), though this is mild in contrast to the extensive\\n surrounding soft tissue edema. Assessment of the intrinsic ligaments of the\\n wrist is limited, given the technique though the scapholunate and\\n lunotriquetral ligaments appear intact, as does the TFCC. There is no fluid\\n in the distal radioulnar joint.\\n\\n The flexor tendons and contents of the carpal tunnel are normal as is the\\n median nerve. Of the extensor tendons, note is made of tenosynovitis of the\\n extensor carpi radialis brevis and longus tendons (series 14, image 15).\\n Additionally, there is minimal tenosynovitis of the fourth digit extensor\\n (Over)\\n\\n 8:30 PM\\n MR WRIST W/O CONTRAST RIGHT Clip # \\n Reason: to evaluate right wrist. Is there evidence of deep tissue or\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n tendons.\\n\\n There is striking edema involving all visualized muscles of the proximal hand.\\n In addition, note is made of extensive subcutaneous edema surrounding the\\n wrist and proximal hand. There is no fluid collection.\\n\\n IMPRESSION:\\n 1. Marked muscular edema involving all visualized muscles as well as\\n extensive subcutaneous edema without focal fluid collection. Given the\\n history of positive biopsy, these findings are consistent with extensive\\n cellulitis and myositis.\\n 2. Serpiginous bone marrow signal abnormalities involving the base of the\\n first metacarpal, distal radius and portions of the distal ulna, concerning\\n for bone infarctions given the history of infectious vascular invasion.\\n\\n These results were discussed via telephone by Dr. with Dr. \\n at 10:54 on \\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210213,\n \"text\": \" 5:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: post intubation CXR\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with resp distress. intubated\\n REASON FOR THIS EXAMINATION:\\n post intubation CXR\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Post-intubation.\\n\\n FINDINGS: In comparison with the study of , the tip of the endotracheal\\n tube measures approximately 5 cm above the carina. Little change in the\\n appearance of the central catheter and hemodialysis catheter. Again, there\\n are low lung volumes with stable cardiomediastinal silhouette. Increasing\\n pulmonary vascular congestion with progression of opacification in the\\n retrocardiac region. This is consistent with volume loss in the left lower\\n lobe, though the air bronchogram pattern raises the possibility of\\n superimposed pneumonia in this region. There is also a more focal area of\\n opacification in the right upper and left mid zone, worrisome for possible\\n supervening infection.\\n\\n If clinically possible, a repeat study with better inspiration would be most\\n helpful.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210875,\n \"text\": \" 5:44 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o intrathoracic process, interval change, ETT placement.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL/SLL s/p SCT currently with VRE bacteremia, CMV\\n viremia, mucor and respiratory distress requiring intubation.\\n REASON FOR THIS EXAMINATION:\\n r/o intrathoracic process, interval change, ETT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST AT 0600\\n\\n HISTORY: 27-year-old man with CLL/SLL with bacteremia and respiratory\\n distress.\\n\\n COMPARISON: at 0543.\\n\\n Endotracheal tube and catheters remain in satisfactory position. The lung\\n volumes are low. The bilateral patchy pulmonary infiltrates do not appear\\n significantly changed. There is no pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210367,\n \"text\": \" 5:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o intrathoracic process, interval change and evaluation of\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL s/p SCT currently in ICU for respiratory distress,\\n currently intubated.\\n REASON FOR THIS EXAMINATION:\\n r/o intrathoracic process, interval change and evaluation of ETT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: CLL, currently intubated, evaluation for endotracheal tube.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the monitoring and support\\n devices are unchanged. The tip of the endotracheal tube projects 4.3 cm above\\n the carina. The lung volumes have minimally increased, potentially result of\\n increased ventilatory pressures. The overall extent and distribution of the\\n pre-existing bilateral parenchymal consolidations and opacities are unchanged.\\n No new parenchymal opacities.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1211463,\n \"text\": \" 5:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o interval change, intrathoracic process, ETT placement.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL s/p SCT currently with multiple infections and\\n intubated for respiratory distress.\\n REASON FOR THIS EXAMINATION:\\n r/o interval change, intrathoracic process, ETT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE FRONTAL VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess ET tube. Patient with respiratory distress with\\n multiple infections.\\n\\n Comparison is made with prior study performed a day earlier.\\n\\n The ET tube tip is 3.7 cm above the carina. Bilateral central catheters are\\n in the cavoatrial junction and upper right atrium, unchanged. There is no\\n pneumothorax. Cardiomegaly and widened mediastinum arew stable.\\n\\n There are low lung volumes. Moderate pulmonary edema with bibasilar\\n atelectasis larger on the left side and unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1211292,\n \"text\": \" 6:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with respiratory distress\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old man with respiratory distress.\\n\\n COMPARISON: , , . CT chest .\\n\\n FINDINGS: Frontal view of the chest was obtained. Mild cardiomegaly is\\n stable. Low lung volumes persist with unchanged pulmonary vascular\\n congestion, pulmonary edema, and bibasilar atelectasis. Left lower lobe\\n consolidation, particularly of the retrocardiac area, is stable. Endotracheal\\n tube, right hemodialysis catheter, and left PICC are all unchanged in\\n appropriate position.\\n\\n IMPRESSION:\\n 1. Unchanged pulmonary vascular congestion and pulmonary edema.\\n 2. Unchanged left lower lobe consolidation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-22 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1210733,\n \"text\": \" 5:51 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Eval for disseminated mucor\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL c/b VRE bacteremia, renal failure, and respiratory\\n failure now with mucormycosis on wrist.\\n REASON FOR THIS EXAMINATION:\\n Eval for disseminated mucor\\n CONTRAINDICATIONS for IV CONTRAST:\\n Dialysis dependent renal failure\\n ______________________________________________________________________________\\n WET READ: SHSf SAT 8:24 PM\\n No acute intracranial process with sinuses better assessed on accompanying\\n sinus CT. Opacification of bilateral mastoid air cells.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: CLL with VRE bacteremia and renal failure with mucormycosis on\\n the wrist. Assess for disseminated Mucor.\\n\\n TECHNIQUE: Contiguous axial images were obtained through the brain without\\n intravenous contrast. Coronal and sagittal reformations were prepared.\\n\\n COMPARISONS: CT of the head from .\\n\\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\\n major vascular territorial infarction. -white matter differentiation\\n appears preserved. There is no shift of normally midline structures.\\n Ventricles and sulci are normal in size and configuration. There is no\\n fracture. There is opacification of the bilateral mastoid air cells, which is\\n new since the prior study. The paranasal sinuses are better assessed on the\\n sinus CT. There is no bony destruction seen to suggest mucormycosis.\\n\\n IMPRESSION: No acute intracranial pathological process, with sinuses better\\n assessed on accompanying sinus CT. Opacification of bilateral mastoid air\\n cells.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-22 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1210734,\n \"text\": \" 5:51 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: Eval for disseminiated mucor\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL c/b VRE bacteremia, renal failure, and respiratory\\n failure now with mucormycosis on wrist.\\n REASON FOR THIS EXAMINATION:\\n Eval for disseminiated mucor\\n CONTRAINDICATIONS for IV CONTRAST:\\n Dialysis dependend renal failure\\n ______________________________________________________________________________\\n WET READ: SHSf SAT 8:23 PM\\n Interval increase in degree of sinus disease with mucosal thickening and\\n secretions present in the ethmoid air cells and nasal cavity along with\\n mucosal thickening increased in the bilateral maxillary sinuses. Moderate\\n sphenoid sinus thickening as before. Much of this increased secretion could be\\n related to intubation. No bony destruction to suggest invasive mucormycosis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: CLL complicated by VRE bacteremia, renal failure and respiratory\\n failure with mucormycosis on wrist. Assess for disseminated mucor.\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the paranasal\\n sinuses without intravenous contrast. Coronal reformations were prepared.\\n\\n COMPARISONS: CT sinus from .\\n\\n FINDINGS: The frontal sinuses display only minimal mucosal thickening.\\n There is mild mucosal thickening in the anterior and middle ethmoid air cells,\\n with more pronounced mucosal thickening and aerosolized secretions in the\\n posterior ethmoid air cells bilaterally. There is mucosal thickening and\\n mucus retention cysts versus polyps in the maxillary sinuses, without\\n air-fluid levels seen. There is moderate-to-severe mucosal thickening\\n demonstrated again, as before, in the sphenoid sinus. There is also extensive\\n secretion in the nasal cavity. These abnormalities, at least in part, could be\\n due to the patient's intubated status. No bony destruction is seen. The\\n lamina papyracea appear intact. The cribriform plats are also intact. The\\n anterior clinoid processes are not pneumatized. There is no fracture. The\\n brain is better assessed on the accompanying head CT scan.\\n\\n IMPRESSION: Interval increase in degree of sinus disease, with mucosal\\n thickening and secretions present in the ethmoid air cells and nasal cavity,\\n along with mucosal thickening increased in the bilateral maxillary sinuses.\\n Moderate sphenoid sinus thickening as before. Much of this increased secretion\\n could be related to intubation. No bony destruction to suggest invasive\\n mucormycosis.\\n (Over)\\n\\n 5:51 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: Eval for disseminiated mucor\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1211129,\n \"text\": \" 4:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with intubation\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 5:08 A.M., \\n\\n HISTORY: 27-year-old man intubated.\\n\\n IMPRESSION: AP chest compared to through 11:\\n\\n Moderate-to-severe pulmonary edema has recurred worsening the appearance of\\n pre-existing left lower lobe consolidation. Heart is moderately enlarged,\\n unchanged. Pleural effusions are presumed, but small. ET tube is in standard\\n placement. Dual-channel hemodialysis line ends just above and just below the\\n level of the superior cavoatrial junction alongside the left subclavian line\\n in the right atrium. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1209880,\n \"text\": \" 5:12 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for interval change, fluid vs infection vs blood\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with worsening hypoxia, known bacteremia\\n REASON FOR THIS EXAMINATION:\\n Eval for interval change, fluid vs infection vs blood\\n ______________________________________________________________________________\\n WET READ: SHSf SUN 6:55 PM\\n Markedly low lung volumes.\\n Dense bibasilar opacities increased since the prior likely atelectasis.\\n\\n Right upper lung opacity is new and could reflect atelectasis as well given\\n the low lung volumes though supervening pneumonia cannot be fully excluded.\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 5:32 P.M \\n\\n HISTORY: Worsening hypoxia and known bacteremia.\\n\\n IMPRESSION: AP chest compared to chest radiographs since , most\\n recently :\\n\\n Pulmonary vascular congestion has been present since , unchanged\\n today since , accompanied by a moderate to severe cardiomegaly and\\n mediastinal vascular engorgement also unchanged. Low lung volumes have been\\n present throughout, accompanied by bibasilar consolidation, most likely\\n atelectasis. A dual-channel right supraclavicular central venous line ends in\\n the right atrium, alongside a left PIC catheter. No pneumothorax. Pleural\\n effusions are presumed but not large.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-22 00:00:00.000\",\n \"description\": \"CT ABD & PELVIS W/O CONTRAST\",\n \"row_id\": 1206377,\n \"text\": \" 9:46 PM\\n CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: Is there compression fracture? Kidney Stone?\\n Admitting Diagnosis: SEPSIS\\n Field of view: 45\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL, chronic steroid therapy, and acute renal failure\\n recovering from toxic shock syndrome with new right flank pain and unable to\\n stand for x-ray.\\n REASON FOR THIS EXAMINATION:\\n Is there compression fracture? Kidney Stone?\\n CONTRAINDICATIONS for IV CONTRAST:\\n dialysis-dependent acute kidney injury\\n ______________________________________________________________________________\\n WET READ: 11:20 PM\\n -Non-contrast examination done per ordering clinician\\n\\n -No calculi within the kidneys, ureters or bladder. No hydronephrosis.\\n -Non-contrast images of abdominopelvic viscera within normal limits.\\n -Loss of vertebral body height of T9 - though unchanged from prior. No acute\\n compression fracture.\\n -Multiple healed rib fractures bilaterally.\\n -Central line in low SVC\\n -Bibasilar patchy lung opacities unchanged from prior - likely\\n scarring/atelectasis.\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST\\n\\n DATE: .\\n\\n COMPARISON: and multiple prior examinations.\\n\\n CLINICAL INDICATION: 27-year-old man with CLL, chronic steroid therapy, and\\n acute renal failure recovering from toxic shock syndrome, now with new right\\n flank pain and unable to stand for x-ray. Is there compression fracture?\\n Kidney stone?\\n\\n TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained without\\n the use of intravenous contrast. Coronal and sagittal reformatted images were\\n constructed.\\n\\n FINDINGS:\\n\\n ABDOMEN: There are no renal calculi or ureteral calculi.\\n\\n There is no hydronephrosis. Central venous catheter tip terminates at the\\n superior cavoatrial junction. The heart is borderline enlarged. There is no\\n pericardial or pleural effusion. Mild bronchiectasis and linear stranding at\\n bilateral bases is similar to the prior examination, if not slightly improved.\\n\\n (Over)\\n\\n 9:46 PM\\n CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: Is there compression fracture? Kidney Stone?\\n Admitting Diagnosis: SEPSIS\\n Field of view: 45\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Non-contrast technique limits evaluation of the solid abdominal viscera. The\\n collapsed gallbladder, liver, spleen, adrenal glands and pancreas are grossly\\n unremarkable. There is no upper abdominal, mesenteric or retroperitoneal\\n lymphadenopathy. Aortocaval lymph node measuring 6 mm is noted along with\\n smaller retroperitoneal lymph nodes. Just inferior to the aortic bifurcation,\\n there is a new area of fat stranding with a 5-mm lymph node. Ill-defined\\n margins makes this area difficult to measure, however, area measures\\n approximately 4.5 x 2.6 cm in transverse and craniocaudal dimensions\\n respectively.\\n\\n Loops of small and large bowel are grossly unremarkable. The appendix is\\n within normal limits. Multiple pills are present within the cecum and\\n descending colon. There is a small 1.9 x 2.5 cm paraumbilical hernia with\\n mesenteric fat. There is asymmetric subcutaneous fat stranding along the left\\n flank (2:53). This may relate to positional anasarca. There is significant\\n muscle atrophy given the patient's age.\\n\\n PELVIS: The bladder, seminal vesicles, rectum and prostate are grossly\\n unremarkable. There is no pelvic lymphadenopathy or free fluid.\\n\\n MUSCULOSKELETAL: T9 compression fracture is unchanged from the prior\\n examination. Multiple additional thoracic and lumbar vertebral bodies\\n demonstrate superior endplate deformities, most prominent at T11, T12, L2 and\\n L4 are also unchanged from the prior examination. There is no new compression\\n deformity.\\n\\n IMPRESSION:\\n 1. No renal or ureteral calculi or hydronephrosis.\\n 2. No acute vertebral compression deformity. Stable multilevel compression\\n deformities.\\n 3. New ill-defined fat stranding in the retroperitoneum, just inferior to the\\n aortic bifurcation with a probable 5 mm associated lymph node. Lymphatic\\n involvement of known CLL is considered.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-13 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1205003,\n \"text\": \" 9:54 AM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval for lesions, tumor\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with GVHD and epistaxis - PLEASE NO CONTRAST !\\n REASON FOR THIS EXAMINATION:\\n eval for lesions, tumor\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n WET READ: PRib TUE 1:25 PM\\n 1. No evidence of masses or bony dehiscence.\\n\\n 2. Mild mucosal thickening of left anterior and right posterior ethmoid air\\n cells. Mucosal retention cyst in right and left maxillary sinuses. Moderate\\n to severe mucosal thickening in right sphenoid sinus.\\n\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Graft-versus-host disease, CLL status post stem cell transplant,\\n epistaxis, evaluate for lesions or tumor.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.\\n Coronal reformatted images were prepared.\\n\\n FINDINGS: The frontal sinuses are well aerated. There is mild mucosal\\n thickening in a left anterior ethmoid air cell and in a right posterior\\n ethmoid air cell. There is moderate to severe mucosal thickening of the right\\n sphenoid sinus. The left sphenoid sinus is hypoplastic and well aerated.\\n There is a mucus retention cyst in the left and right maxillary sinuses. The\\n ostiomeatal units are patent. The nasal septum is deviated to the left with a\\n bone spur. The nasal cavities are well aerated, without evidence of polyps\\n or masses. The lamina papyracea are intact. The cribriform plate is intact.\\n There is no other bone erosion or sclerosis. There is no evidence of\\n periapical lucency in the maxillary alveolar ridge. The orbits are\\n unremarkable on this non-contrast study. This study is not technically\\n optimal for assessment of intracranial structures, but mild diffuse atrophy is\\n seen in the imaged portion of the brain.\\n\\n IMPRESSION:\\n\\n 1. Moderate to severe mucosal thickening in the right sphenoid sinus. Milder\\n mucosal changes in maxillary and ethmoid sinuses. No osseous erosion or\\n remodeling.\\n\\n 2. No evidence of a mass on noncontrast evaluation.\\n (Over)\\n\\n 9:54 AM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval for lesions, tumor\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-13 00:00:00.000\",\n \"description\": \"CT NECK W/O CONTRAST (EG: PAROTIDS)\",\n \"row_id\": 1205004,\n \"text\": \" 9:54 AM\\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \\n Reason: neck lesions\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with GVHD and epistaxis, coughing up blood - PLEASE NO\\n CONTRAST !\\n REASON FOR THIS EXAMINATION:\\n neck lesions\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: PRib TUE 1:36 PM\\n 1. No exophytic mucosal masses or areas of focal mass effect.\\n\\n 2. 2.3cm x 1.8cm x 2.1cm enlarged level 2 lymph node on the left, new compared\\n to neck CT from . No necrosis or surrounding inflammatory changes. No\\n other areas of pathological lymphadenopathy by imaging criteria.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Graft versus host disease, coughing up blood, evaluate for neck\\n lesions.\\n\\n COMPARISON: CT neck on .\\n\\n TECHNIQUE: Routine non-enhanced multidetector CT study of the neck was\\n performed with images obtained from the skull base to the thoracic inlet using\\n 2.5-mm thick sections. Coronal and axial reformations were performed. No iv\\n contrast was administered due to renal failure.\\n\\n FINDINGS: There is no evidence of an exophytic mucosal mass. Compared to the\\n study on , there is a new 2.3 cm x 1.8 cm x 2.1 cm enlarged left\\n level 2, without evidence of necrosis or surrounding inflammatory change. The\\n thyroid gland is unremarkable. The sublingual and submandibular salivary\\n glands are unremarkable.\\n\\n There is opacification of the right and left mastoid tip air cells. The\\n paranasal sinuses are better assessed on the concurrent dedicated sinus CT.\\n\\n There are no lytic or sclerotic bone lesions.\\n\\n There is bilateral pulmonary opacities, described in the concurrent chest CT\\n report.\\n\\n IMPRESSION:\\n\\n New enlarged left level 2 lymph node. No evidence of an exophytic mucosal\\n mass.\\n\\n (Over)\\n\\n 9:54 AM\\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \\n Reason: neck lesions\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2112-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79354,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Tachycardia/abnormal ekg (h/o CLL s/p allogenic stem cell transplant/MRSA sepsis/increased hypoxia.\\nHeight: (in) 66\\nWeight (lb): 190\\nBSA (m2): 1.96 m2\\nBP (mm Hg): 108/62\\nHR (bpm): 104\\nStatus: Inpatient\\nDate/Time: at 11:10\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mildly dilated LV cavity. Mild global LV hypokinesis. LV\\ndysnchrony is present.\\n\\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\\n\\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\\nsystolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: Very small pericardial effusion. There is an anterior space which\\nmost likely represents a fat pad, though a loculated anterior pericardial\\neffusion cannot be excluded.\\n\\nConclusions:\\nThe left atrium is normal in size. The left ventricular cavity is mildly\\ndilated. There is mild global left ventricular hypokinesis (LVEF = 40%). Left\\nventricular dysnchrony is present. Right ventricular chamber size is normal.\\nwith mild global free wall hypokinesis. The aortic root is mildly dilated at\\nthe sinus level. The aortic valve leaflets (3) appear structurally normal with\\ngood leaflet excursion and no aortic stenosis or aortic regurgitation. The\\nmitral valve appears structurally normal with trivial mitral regurgitation.\\nThere is no mitral valve prolapse. The estimated pulmonary artery systolic\\npressure is normal. There is a very small pericardial effusion. There is an\\nanterior space which most likely represents a prominent fat pad.\\n\\nIMPRESSION: Mild global biventricular systolic dysfunction. Very small\\npericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , the findings are\\nsimilar.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2112-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79355,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Endocarditis.\\nHeight: (in) 66\\nWeight (lb): 182\\nBSA (m2): 1.92 m2\\nBP (mm Hg): 131/78\\nHR (bpm): 86\\nStatus: Inpatient\\nDate/Time: at 14:19\\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: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC was not visualized.\\nThe RA pressure could not be estimated.\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\\nquality, a focal LV wall motion abnormality cannot be fully excluded. Mildly\\ndepressed LVEF. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis.\\nAbnormal septal motion/position.\\n\\nAORTA: Moderately dilated aorta at sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: ?# aortic valve leaflets. No masses or vegetations on aortic\\nvalve, but cannot be fully excluded due to suboptimal image quality. No AS. No\\nAR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No masses or vegetations\\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\\nTrivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No masses or\\nvegetations are seen on the tricuspid valve, but cannot be fully excluded due\\nto suboptimal image quality. Borderline PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Very small pericardial effusion. There is an anterior space which\\nmost likely represents a fat pad, though a loculated anterior pericardial\\neffusion cannot be excluded. No echocardiographic signs of tamponade.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - poor subcostal views. Suboptimal image quality - poor\\nsuprasternal views. Suboptimal image quality as the patient was difficult to\\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\\npatient unable to cooperate.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses and\\ncavity size are normal. Due to suboptimal technical quality, a focal wall\\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\\nfunction is mildly depressed (LVEF= 45 %). The right ventricular cavity is\\ndilated with mild global free wall hypokinesis. There is abnormal septal\\nmotion/position. The aortic root is moderately dilated at the sinus level. The\\nnumber of aortic valve leaflets cannot be determined. No masses or vegetations\\nare seen on the aortic valve, but cannot be fully excluded due to suboptimal\\nimage quality. There is no aortic valve stenosis. No aortic regurgitation is\\nseen. The mitral valve leaflets are mildly thickened. No masses or vegetations\\nare seen on the mitral valve, but cannot be fully excluded due to suboptimal\\nimage quality. Trivial mitral regurgitation is seen. No masses or vegetations\\nare seen on the tricuspid valve, but cannot be fully excluded due to\\nsuboptimal image quality. There is borderline pulmonary artery systolic\\nhypertension. There is a very small pericardial effusion. There is an anterior\\nspace which most likely represents a prominent fat pad. There are no\\nechocardiographic signs of tamponade.\\n\\nIMPRESSION: Normal left ventricular cavity size and wall thickness with mildly\\ndepressed left ventricular systolic function. Moderately dilated aortic root.\\nNo clinically significant valvular regurgitation or stenosis. Borderline\\npulmonary artery systolic hypertension. Very small percicardial effusion.\\n\\nCompared with the prior study (images reviewed) of , the overall left\\nventricular systolic function appears to have minimally improved, although the\\npreviously reported ejection fraction may have been an underestimate.\\n\\nThe absence of valvular vegetations/abscesses on transthoracic echocardiogram\\ndoes not preclude its presence. If clinical suspicion for endocarditis is\\nhigh, consider transesophageal echocardiogram.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2112-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79356,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHeight: (in) 66\\nWeight (lb): 217\\nBSA (m2): 2.07 m2\\nBP (mm Hg): 128/98\\nHR (bpm): 124\\nStatus: Inpatient\\nDate/Time: at 14:10\\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 wall thickness and cavity size. Moderately depressed\\nLVEF. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis.\\n\\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: ?# aortic valve leaflets.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\\n\\nTRICUSPID VALVE: Normal PA systolic pressure.\\n\\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\\ntamponade.\\n\\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\\nelectrodes. Suboptimal image quality as the patient was difficult to position.\\nSuboptimal image quality - body habitus. Suboptimal image quality - patient\\nunable to cooperate. Resting tachycardia (HR>100bpm). Left pleural effusion.\\n\\nConclusions:\\nLeft ventricular wall thicknesses and cavity size are normal. Overall left\\nventricular systolic function is moderately depressed (LVEF= 35-40%). The\\nright ventricular cavity is dilated with mild global free wall hypokinesis.\\nThe aortic root is mildly dilated at the sinus level. The number of aortic\\nvalve leaflets cannot be determined. The mitral valve leaflets are mildly\\nthickened. The estimated pulmonary artery systolic pressure is normal. There\\nis a small pericardial effusion. There are no echocardiographic signs of\\ntamponade.\\n\\nCompared with the prior study (images reviewed) of , image quality on\\nboth studies is sub-optimal making direct comparisons difficult. The function\\nof the more distal left ventricular segments is probably marginally better.\\nThe other findings are similar.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2112-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79357,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Endocarditis.\\nHeight: (in) 66\\nWeight (lb): 217\\nBSA (m2): 2.07 m2\\nBP (mm Hg): 142/92\\nHR (bpm): 106\\nStatus: Inpatient\\nDate/Time: at 10:27\\nTest: Portable TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT VENTRICLE: Moderate global LV hypokinesis.\\n\\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\\nfunction.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\\nvegetations on aortic valve.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\\nvalve. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\\nvegetation on tricuspid valve.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. No vegetation/mass on pulmonic valve.\\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.\\nSuboptimal image quality. Suboptimal image quality - patient unable to\\ncooperate. Bilateral pleural effusions.\\n\\nConclusions:\\nThere is moderate global left ventricular hypokinesis (LVEF = 30-35%). Right\\nventricular chamber size is normal with borderline normal free wall function.\\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\\nexcursion and no aortic stenosis or aortic regurgitation. No masses or\\nvegetations are seen on the aortic valve. The mitral valve leaflets are\\nstructurally normal. No mass or vegetation is seen on the mitral valve.\\nTrivial mitral regurgitation is seen. No vegetation/mass is seen on the\\npulmonic valve. There is no pericardial effusion.\\n\\nIMPRESSION: No vegetations or clinically-significant valvular disease seen.\\nModerate global left ventricular systolic dysfunction.\\n\\nCompared with the prior study (images reviewed) of , LV function has\\nslightly improved. The other findings are similar.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2112-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79358,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: R/O Tamponade\\nHeight: (in) 66\\nWeight (lb): 217\\nBSA (m2): 2.07 m2\\nBP (mm Hg): 94/42\\nHR (bpm): 124\\nStatus: Inpatient\\nDate/Time: at 07:56\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\\ndepressed LVEF. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. RV function\\ndepressed.\\n\\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\\nmitral valve supporting structures. No MS.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\\ntricuspid valve supporting structures. No TS.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Dilated main PA.\\n\\nPERICARDIUM: Very small pericardial effusion. Effusion circumferential.\\nEffusion echo dense, c/w blood, inflammation or other cellular elements. No\\nechocardiographic signs of tamponade.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - body habitus. Suboptimal image quality - ventilator.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity size is normal. Overall left ventricular\\nsystolic function is severely depressed (LVEF= 25 %), with regional variation.\\nThe right ventricular free wall is hypertrophied. Right ventricular chamber\\nsize is normal. with depressed free wall contractility. The aortic root is\\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\\nstructurally normal with good leaflet excursion and no aortic stenosis or\\naortic regurgitation. The mitral valve appears structurally normal with\\ntrivial mitral regurgitation. There is no mitral valve prolapse. The main\\npulmonary artery is dilated. There is a very small pericardial effusion. The\\neffusion appears circumferential. The effusion is echo dense, consistent with\\nblood, inflammation or other cellular elements. There are no echocardiographic\\nsigns of tamponade.\\n\\nCompared to the prior study of , contractile function of both\\nventricles is markedly reduced. Consider therapy for acute cardiac\\ngraft-versus host disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1205471,\n \"text\": \" 12:03 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infection and line imaging\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man w cll, gvhd, with new HD line, on abx for bacteremia (VRE)\\n REASON FOR THIS EXAMINATION:\\n infection and line imaging\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: 27-year-old man with history of graft-versus-host disease with\\n new HD line.\\n\\n TECHNIQUE: Semi-upright portable radiograph of chest.\\n\\n Comparisons were made with prior chest radiographs through ,\\n with the most recent from .\\n\\n IMPRESSION: The HD line through left internal jugular approach is new with tip\\n terminating approximately at cavoatrial junction. Bilateral lung volumes are\\n very low. Bibasilar atelectases, left side more than right side are unchanged\\n since . Pleural effusion, if any, appears minimal on the\\n left side. Wide cardiomediastinal silhouette is likely from low lung volumes.\\n There are lung opacities concerning for pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-13 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1204999,\n \"text\": \" 9:32 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: lung lesions\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with GVHD and epistaxis, coughing up blood - PLEASE NO\\n CONTRAST !\\n REASON FOR THIS EXAMINATION:\\n lung lesions\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n COMPUTED TOMOGRAPHY OF THE THORAX\\n\\n INDICATION: Hemoptysis, graft-versus-host disease.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,\\n no administration of intravenous contrast material, multiplanar\\n reconstructions.\\n\\n FINDINGS: The examination is compared to . In the interval,\\n the patient has been extubated. There is mild lipomatosis of the mediastinum.\\n No incidental thyroid findings. In the mediastinal fat, no enlarged or\\n pathological lymph nodes are detected.\\n\\n The large mediastinal vessels appear unremarkable.\\n\\n As on the previous examination, severe motion artifacts due to aspiration\\n substantially limit the assessment of the lung parenchyma. The pre-existing\\n bilateral upper lobe parenchymal opacities are overall unchanged in extent and\\n severity.\\n\\n A pre-existing left lower lobe parenchymal opacity with air bronchograms is\\n slightly more extensive than on the previous examination. Newly appeared is a\\n right lower lobe basal opacity of similar morphology. The location and\\n appearance of the opacities would be consistent with atelectasis, aspiration,\\n or pneumonia, or a combination of these.\\n\\n There are no substantial pleural effusions.\\n\\n Within the limits of the examination, there is no evidence for intrabronchial\\n or intratracheal lesions.\\n\\n No changes in the upper abdominal organs.\\n\\n IMPRESSION: As compared to the previous examination, there are newly appeared\\n right lower lobe opacities and a slightly more extensive left lower lobe\\n opacity. Both opacities have air bronchograms. The pre-existing bilateral\\n upper lobe opacities are stable. The changes could correspond to atelectasis,\\n (Over)\\n\\n 9:32 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: lung lesions\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n aspiration, or pneumonia. No pleural effusions. No mediastinal lymph node\\n enlargement.\\n\\n The entire examination is limited by severe respiratory motion artifacts.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-17 00:00:00.000\",\n \"description\": \"NON-TUNNELED\",\n \"row_id\": 1205602,\n \"text\": \" 2:13 PM\\n TEMP DIALYSIS LINE PLCT Clip # \\n Reason: Needs hemodialysis\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * NON-TUNNELED -79 UNRELATED PROCEDURE/SERVICE DURI *\\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with anuric\\n REASON FOR THIS EXAMINATION:\\n Needs hemodialysis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient needs hemodialysis and current line accidentally pulled\\n out.\\n\\n OPERATORS: Dr. and Dr. performed the\\n procedure.\\n\\n ANALGESIA: Analgesia was provided by 25 mcg of fentanyl and 1% local\\n lidocaine was used.\\n\\n PROCEDURE: Written informed consent was obtained from the patient after the\\n procedure was explained in detail along with the risks, benefits and\\n alternatives. The patient was brought to the angiographic suite and laid\\n supine on the table. The right side of the neck was prepped and draped in a\\n sterile fashion. A preprocedural huddle and a timeout was performed per \\n protocol.\\n\\n The right internal jugular vein was imaged by ultrasound. There appeared to\\n be a small amount of clot in the right IJ and it was partially compressible.\\n This was accessed with a needle and a wire was passed through the needle which\\n was confirmed fluoroscopically to be in the SVC. The needle was taken out and\\n a sheath was threaded in. The guidewire was then exchanged with ,\\n which was threaded into the IVC. Multiple dilations were performed with 12\\n and 14 French dilators, after which the temporary dialysis line was threaded\\n over the wire and the tip was confirmed to be in the right atrium\\n fluoroscopically. Then, the wire was pulled out and the line was stitched in\\n place with 0 silk and sterile dressings were applied. The patient tolerated\\n the procedure well and had no immediate complications.\\n\\n IMPRESSION: Uncomplicated placement of a 14.4 French temporary dialysis line\\n in the right IJ. The line length is 15 cm. The tip is in the right atrium.\\n The line is ready to use.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-23 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1210814,\n \"text\": \" 3:21 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Is there evidence of invasive fungal disease on chest imagin\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with neutropenia, respiratory failure, and invasive fungal\\n disease on biopsy of R wrist. Concern that may be systemic manifestation of\\n process in lungs as well since pt had worsened respiratory status since last\\n chest CT which was before he was diagnosed with cutaneous fungal disease.\\n REASON FOR THIS EXAMINATION:\\n Is there evidence of invasive fungal disease on chest imaging in patient with\\n cutaneous disease?\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST CT\\n\\n INDICATION: Patient with neutropenia, respiratory failure, to assess for\\n invasive fungal disease\\n\\n TECHNIQUE: Unenhanced MDCT of thorax was performed using a standard\\n department protocol. Contiguous axial images at 5-mm and 1.25-mm slice\\n thickness were reviewed concurrently with coronal and sagittal reformats.\\n Comparisons were made with prior chest CTs through , with the most\\n recent one from .\\n\\n FINDINGS:\\n\\n AIRWAYS AND LUNGS: Airways are patent to subsegmental level. Minimal\\n secretions are seen in trachea and left main bronchus. Since the prior study\\n dated , diffuse ground-glass opacities in the bilateral\\n lungs, predominantly in the upper lobes, have worsened. However, bilateral\\n lower lung consolidations have improved. Severity of bilateral lung\\n bronchiectasis, right side more than left side, is unchanged. There are no\\n findings to suggest an invasive fungal infection.\\n\\n MEDIASTINUM: Right internal jugular line and left Port-A-Cath ends at\\n cavoatrial junction. Tip of the endotracheal tube terminates approximately\\n 1.2 cm above the carina. Caliber of main pulmonary artery proximal to\\n bifurcation measures 33 mm and is top normal. Heart size is mildly prominent\\n without any pericardial effusion. There is no pathological enlargement of\\n mediastinal, supraclavicular, or axillary lymph nodes.\\n\\n ABDOMEN: The study is not tailored for evaluation of abdomen; however,\\n limited views were unremarkable. Both adrenal glands are normal in\\n morphology.\\n\\n BONES: There is no bone lesion suspicious for malignancy/infection. Wedge\\n compression of multiple lower thoracic vertebral bodies is stable.\\n\\n\\n (Over)\\n\\n 3:21 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Is there evidence of invasive fungal disease on chest imagin\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION:\\n\\n 1. Since , bilateral upper lobe predominant ground-glass\\n opacities, right side more than left side, have progressed, bilateral lower\\n lung consolidations have improved and severity of bronchiectasis is unchanged.\\n The interval progression of the ground-glass opacities suggests a worsening\\n infection and is nonspecific for particular etiology but not consistent with\\n invasive fungal infection. Improved bilateral lower lobe consolidation\\n represented combination of infection, atelectasis and aspiration.\\n\\n 2. Mild cardiomegaly and top normal size pulmonary artery.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1205340,\n \"text\": \" 2:42 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?PNA vs. effusion vs. atalectasis\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with increased O2 req (GVHD s/p SLL/CLL)\\n REASON FOR THIS EXAMINATION:\\n ?PNA vs. effusion vs. atalectasis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old male with history of CLL with recent respiratory\\n distress, now extubated with increased O2 requirement.\\n\\n TECHNIQUE: Single frontal radiograph of the chest.\\n\\n COMPARISON: Multiple prior examinations, most recent radiograph dated , . Correlation with CT of the chest dated .\\n\\n FINDINGS: Lung volumes remain low. Bibasilar atelectasis/consolidation are\\n not significantly changed. As compared to the prior examination, a perihilar\\n opacities appear improved consistent with a component of edema. No\\n pneumothorax is seen. The cardiomediastinal silhouette is unchanged. A\\n right-sided central line is unchanged with tip reaching the right atrium.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-11 00:00:00.000\",\n \"description\": \"R US EXTREMITY NONVASCULAR RIGHT\",\n \"row_id\": 1204760,\n \"text\": \" 2:21 PM\\n US EXTREMITY NONVASCULAR RIGHT Clip # \\n Reason: PT WITH NEW RIGHT WRIST LESION, EVAL FOR ABSCESS\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with MRSA scalded skin syndrome now with new R wrist lesion\\n REASON FOR THIS EXAMINATION:\\n eval for abscess\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh SUN 4:55 PM\\n 10 x 20 x 2 mm subcutaneous fluid collection adjacent to but not involving the\\n nearby tendon sheath.\\n PFI VERSION #1 JEKh SUN 4:52 PM\\n 10 x 20 x 2 mm fluid collection adjacent to the tendon sheath.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 27-year-old male with MRSA scalded skin syndrome, now with right\\n wrist lesion.\\n\\n STUDY: Ultrasound of the right wrist.\\n\\n COMPARISON: .\\n\\n FINDINGS: Transverse and sagittal views over the medial aspect of the right\\n wrist were obtained. Subcutaneous edema is demonstrated. A hypoechoic region\\n measuring 1 x 2 cm that is 2 mm in thickness is demonstrated just over but not\\n involving the adjacent tendon sheath. There is not appreciable surrounding\\n hyperemia.\\n\\n IMPRESSION: 10 x 20 x 2 mm subcutaneous fluid collection adjacent/superficial\\n to but not involving the nearby tendon sheath.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204972,\n \"text\": \" 3:53 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: stat\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with resp distress\\n REASON FOR THIS EXAMINATION:\\n stat\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old male with respiratory distress, now status post\\n extubation.\\n\\n TECHNIQUE: Single frontal radiograph of the chest.\\n\\n COMPARISON: Prior examinations, ranging from to .\\n\\n FINDINGS: Lung volumes remain low. The patient is in anti-lordtic\\n positioning. Focal opacities at the bases are felt to likely represent\\n atelectasis, increased on the right. No large pneumothorax is seen, though\\n the lung apices are excluded from the field of view of the radiograph. The\\n cardiomediastinal silhouette is unchanged. A right central venous catheter is\\n unchanged with tip reaching the right atrium.\\n\\n IMPRESSION: Low lung volumes with increased right lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210674,\n \"text\": \" 5:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o intrathoracic process, interval change, ETT placement.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL/SLL s/p SCT currenting in ICU and intubated for\\n respiratory distress.\\n REASON FOR THIS EXAMINATION:\\n r/o intrathoracic process, interval change, ETT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST\\n\\n HISTORY: 27-year-old man with CLL, respiratory distress.\\n\\n COMPARISON: at 05:35.\\n\\n Endotracheal tube is 2.4 cm above the carina. Left and right central\\n catheters remain in satisfactory position. Cardiomegaly is unchanged. The\\n heterogeneous infiltrates in both lower lung zones are not significantly\\n changed. The infiltrate in the axillary portion of the right lung may be\\n slightly improved. There is no evidence of pneumothorax.\\n\\n IMPRESSION: Minimal if any change, favor pneumonia over asymmetric pulmonary\\n edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210537,\n \"text\": \" 5:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o intrathoracic process, interval change, ETT placement\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL s/p SCT c/b viremia and bacteremia transfered to ICU\\n for resipratory distress, currently intubated.\\n REASON FOR THIS EXAMINATION:\\n r/o intrathoracic process, interval change, ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 5:35 A.M., \\n\\n HISTORY: CLL. Viremia and bacteremia. Respiratory distress.\\n\\n IMPRESSION: AP chest compared to through :\\n\\n Given chronic moderate-to-severe cardiomegaly and mediastinal vascular\\n engorgement it is possible that multifocal heterogeneous pulmonary\\n opacification is asymmetric edema but I am more concerned about pneumonia,\\n particularly at the lung bases and in the axillary region of the right lung.\\n Pleural effusion is small if any. No pneumothorax. ET tube ends above the\\n upper margin of the clavicles no less than 5.5 cm above the carina, and should\\n be advanced 2-3 cm for more secured seating.\\n\\n A left internal jugular line ends alongside the dual-channel right\\n supraclavicular central venous dialysis catheter in the upper right atrium.\\n No mediastinal widening to suggest active bleeding.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-16 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1205458,\n \"text\": \" 10:37 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: ?gallstones, liver inflammation\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with elevated alk phos /VRE in blood\\n REASON FOR THIS EXAMINATION:\\n ?gallstones, liver inflammation\\n ______________________________________________________________________________\\n FINAL REPORT\\n LIMITED ABDOMINAL ULTRASOUND\\n\\n DATE: .\\n\\n COMPARISON: CT torso, .\\n\\n CLINICAL HISTORY: 27-year-old man with elevated alk phos/VRE in blood.\\n Question gallstones, liver inflammation.\\n\\n TECHNIQUE: Multiple son grayscale images of the abdomen were\\n obtained. Select images were supplemented with color Doppler and spectral\\n waveform analysis.\\n\\n Examination is limited by mobile technique and patient's body habitus. The\\n left lobe of the liver is poorly visualized, as is the pancreas. In the\\n visualized portions of the liver, there is mildly coarsened echotexture\\n without focal lesion identified. There is no evidence of fatty deposition.\\n The gallbladder is within normal limits without cholelithiasis or\\n pericholecystic fluid. There is no intrahepatic or extrahepatic biliary\\n dilatation. The common hepatic duct measures 3-4 mm.\\n\\n The spleen is partially visualized, measuring 9.1 cm. Limited sagittal views\\n of the kidneys reveal no hydronephrosis.\\n\\n There is no ascites.\\n\\n IMPRESSION:\\n 1. Limited mobile examination without cholelithiasis.\\n 2. Coarsened echotexture of the liver without fatty deposition. Underlying\\n hepatocellular disease cannot be excluded on this exam.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-09 00:00:00.000\",\n \"description\": \"US EXTREMITY NONVASCULAR\",\n \"row_id\": 1204567,\n \"text\": \" 4:24 PM\\n US EXTREMITY NONVASCULAR Clip # \\n Reason: please assess for abscess/hematoma\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL, chronic GVHD, now with MRSA scalded skin syndrome\\n with new erythematous/warm area on right wrist at area of previous IV. Of note,\\n on Vanco for 2 weeks.\\n REASON FOR THIS EXAMINATION:\\n please assess for abscess/hematoma\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc FRI 5:16 PM\\n PFI: Complex fluid tracking along fascial planes without discrete drainable\\n fluid collection or hematoma.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old male with CLL, chronic graft versus host disease with\\n new erythematous warm area involving the right wrist at the site of previous\\n IV. Evaluate for discrete abscess or hematoma.\\n\\n EXAMINATION: Focused ultrasound examination of the right wrist.\\n\\n COMPARISONS: None available.\\n\\n FINDINGS: A focused ultrasound examination was performed at the site of\\n clinical concern in the right wrist. In this region, there is fluid with\\n internal echoes tracking tracking along the subcutaneous soft tissue planes,\\n extending approximately 2.6 cm in length, without a discrete drainable fluid\\n collection or hematoma identified. There is generalized subcutaneous edema\\n and skin thickening. The underlying vein in the region of interest\\n demonstrates normal venous flow.\\n\\n IMPRESSION: Subcutaneous edema and fluid tracking along the soft tissue\\n planes, but no discrete abscess identified.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204401,\n \"text\": \" 1:34 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: baseline CXR\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL, MRSA scalded skin syndrome, extubated today\\n REASON FOR THIS EXAMINATION:\\n baseline CXR\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old male with chronic lymphocytic leukemia and MRSA, now\\n status post extubation.\\n\\n TECHNIQUE: Single frontal radiograph of the chest.\\n\\n COMPARISON: Multiple prior examinations, most recent radiographs dated , and correlation with CT of the chest dated .\\n\\n FINDINGS: As compared to the prior radiographs, there is improved aeration of\\n both lungs with improved edema. Atelectasis at the left base remains.\\n Cardiomegaly is unchanged. No pneumothorax is seen. Right internal jugular\\n venous catheter reaches the right atrium. Endotracheal tube, left central\\n line and esophageal catheter has been removed.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-09 00:00:00.000\",\n \"description\": \"US EXTREMITY NONVASCULAR\",\n \"row_id\": 1204568,\n \"text\": \", S. OMED 4:24 PM\\n US EXTREMITY NONVASCULAR Clip # \\n Reason: please assess for abscess/hematoma\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL, chronic GVHD, now with MRSA scalded skin syndrome\\n with new erythematous/warm area on right wrist at area of previous IV. Of note,\\n on Vanco for 2 weeks.\\n REASON FOR THIS EXAMINATION:\\n please assess for abscess/hematoma\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Complex fluid tracking along fascial planes without discrete drainable\\n fluid collection or hematoma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-16 00:00:00.000\",\n \"description\": \"EXCH CENTRAL NON-TUNNELED\",\n \"row_id\": 1205514,\n \"text\": \" 5:09 PM\\n TUNNELED CENTRAL LINE PLACEMEN Clip # \\n Reason: please place new HD line on right side\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * EXCH CENTRAL NON-TUNNELED -79 UNRELATED PROCEDURE/SERVICE DURI *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL s/p BMT complicated by GVHD, in need of HD tomorrow;\\n line placed yesterday didn't work\\n REASON FOR THIS EXAMINATION:\\n please place new HD line on right side\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old man with CLL status post BMT complicated by GVHD in\\n need of HD tomorrow. The line placed yesterday did not work.\\n\\n OPERATORS: Dr. performed the procedure. Dr. \\n (attending physician), was present and supervised the procedure\\n throughout.\\n\\n ANESTHESIA: Moderate sedation was administered via divided doses of 75 mg of\\n fentanyl throughout the total intraservice time of 30 minutes, during which\\n the patient's cardiovascular status was continuously monitored.\\n\\n PROCEDURE: Written informed consent was taken from the patient after\\n explaining the procedure, its benefits, risks and alternatives. The patient\\n was brought into the angio suite and laid supine on the table. The exisitng HD\\n line and area around it were preped and draped in a sterile fasion. A pre\\n procedural huddle and timeout was performed per protocol.\\n\\n A scout image was taken of the existing hemodialysis line which looked to be\\n in place. All the lumens were withdrawing blood but with a little bit of\\n resistance. There were flushing without any resistance. wire was\\n advanced down the VIP port into the IVC. Once the was confirmed to be\\n in the IVC fluoroscopically, the existing hemodialysis line was pulled over\\n the wire and a new 20-cm temporary hemodialysis line with a VIP port was\\n inserted. The tip was confirmed to be in the right atrium. The wire was\\n taken out and all the lumens withdrew and flushed without any resistance. The\\n catheter was sutured in place. Sterile dressing was applied on the catheter.\\n The patient tolerated the procedure well. He did not have any complications.\\n\\n IMPRESSION: Uncomplicated exchange of a temporary hemodialysis line with a\\n VIP port over the wire. The renal fellow Dr. was notified by a page at\\n 6:15 PM.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1204978,\n \"text\": \" 6:33 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with ASPIRATION, HYPOXEMIA\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old male with history of aspiration and hypoxemia.\\n Interval evaluation.\\n\\n TECHNIQUE: Single frontal radiograph of the chest.\\n\\n COMPARISON: Prior examinations, ranging from to .\\n\\n FINDINGS: Lung volumes are extremely low, causing vascular crowding. Right\\n perihilar and infrahilar opacity is unchanged. New left perihilar opacity is\\n seen. No focal parenchymal opacity to suggest pneumonia is seen. No pleural\\n effusion or pneumothorax is present.\\n\\n IMPRESSION: Increased left perihilar and stable right perihilar\\n consolidations versus edema.\\n\\n Findings discussed with Dr. at 11:30 am .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-15 00:00:00.000\",\n \"description\": \"NON-TUNNELED\",\n \"row_id\": 1205347,\n \"text\": \" 3:08 PM\\n TEMP DIALYSIS LINE PLCT Clip # \\n Reason: temporary dialysis line placement\\n Admitting Diagnosis: SEPSIS\\n ********************************* CPT Codes ********************************\\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS MOD SEDATION, FIRST 30 MIN. *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with renal failure on HD\\n REASON FOR THIS EXAMINATION:\\n temporary dialysis line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old man with renal failure, on HD, temporary dialysis\\n line placement requested.\\n\\n OPERATORS: Dr. and Dr. performed the\\n procedure.\\n\\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\\n 50 mcg of fentanyl and 0.5 mg of Versed throughout the intraservice time of 20\\n minutes, during which the patient's hemodynamic parameters were continuously\\n monitored.\\n\\n PROCEDURE: Written informed consent was obtained from the patient after\\n explaining the indications, risks, benefits and alternatives to the procedure.\\n The patient was laid supine in the angio suite. The left neck and anterior\\n chest wall were prepped in the sterile fashion. A preprocedural timeout and\\n huddle were performed per protocol.\\n\\n Under son guidance, a patent left IJ was accessed using a\\n micropuncture needle and a guidewire was passed through the needle. The\\n needle was then exchanged for a micropuncture sheath, through which \\n was passed into the right atrium and appropriate measurements were taken. The\\n was then passed into the IVC for stability. The micropuncture sheath\\n was taken out and the tract was serially dilated. Then, the 20-cm temporary\\n dialysis line with a VIP port was threaded over the with the tip in the\\n right atrium.\\n\\n All ports were withdrawing blood and flushed easily. The catheter was sutured\\n to the skin and sterile dressing was applied. The patient tolerated the\\n procedure well. There were no immediate complications.\\n\\n IMPRESSION: Uncomplicated placement of a 20-cm, three-lumen temporary\\n hemodialysis line with a VIP port.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-23 00:00:00.000\",\n \"description\": \"TUNNELED W/O PORT\",\n \"row_id\": 1206493,\n \"text\": \" 4:13 PM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: please exchange temp HD line for tunnelled HD line and also\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 60\\n Type of Port: None\\n ********************************* CPT Codes ********************************\\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\\n * -59 DISTINCT PROCEDURAL SERVICE *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n \\\"This procedure was done under fluoroscopic and ultrasound guidance with hard\\n copy images on file.\\\"\\n\\n\\n DR. \\n\\n 4:13 PM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: please exchange temp HD line for tunnelled HD line and also\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 60\\n Type of Port: None\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with ESRD and need for access\\n REASON FOR THIS EXAMINATION:\\n please exchange temp HD line for tunnelled HD line and also please place\\n tunnelled double lumen power access line, with questions. Thanks\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURES:\\n 1. Conversion of a temporary double-lumen hemodialysis line inserted by the\\n right internal jugular vein approach into a tunneled double-lumen hemodialysis\\n line,\\n 2. De insertion of a tunneled Power double-lumen central line by the\\n left internal jugular vein approach,\\n 3. Superior vena cava venogram via the left brachiocephalic vein: .\\n\\n INDICATION: 27 year-old man with ESRD requiring access for hemodialysis and\\n medications.\\n\\n PHYSICIANS: , MD; , MD.\\n\\n MEDICATIONS: The procedure was performed under monitored conscious sedation.\\n The patient received a total quantity of 2 mg of midazolam and 200 mcg of\\n fentanyl intravenously during the total procedural time of 2 hours and 50\\n minutes while his hemodynamic parameters and pulse oximetry were continuously\\n monitored by a trained radiology nurse.\\n\\n TECHNIQUE/FINDINGS:\\n\\n Informed consent for both procedures was obtained after risks and potential\\n complications had been discussed with the patient. The patient was positioned\\n on the angiography table in usual supine position. The huddle and timeout\\n protocol were carried out prior to all procedures according to the \\n Hospital policy.\\n\\n Skin of the right anterior neck around the insertion site of the temporary\\n right-sided internal jugular dialysis line was prepped and draped in a sterile\\n fashion. Local anesthesia was effected with 1% lidocaine. Heparin was\\n removed from both ports of the dialysis line prior to advancement of a\\n guidewire. Silk suture securing the line to the skin was cut, and a 0.035\\n inch guidewire was successfully advanced into the suprarenal inferior\\n vena cava through one of the ports of the central line. Attention was then\\n turned to the anterior chest wall. Subcutaneous soft tissues were\\n anesthetized with 1% lidocaine with epinephrine. A small skin incision was\\n made with a scalpel, and subcutaneous soft tissue tunnel connecting to the\\n venipuncture site was created by blunt preparation. The tunnel was placed\\n more laterally secondary to a previous port pocket that was being packed. A\\n (Over)\\n\\n 4:13 PM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: please exchange temp HD line for tunnelled HD line and also\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 60\\n Type of Port: None\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 19-cm long tip-to-cuff hemodialysis catheter was pulled through the soft\\n tissue tunnel and advanced through an appropriate peel-away sheath into the\\n right atrium. The skin over the venipuncture was sutured using 4-0 Vicryl\\n suture. The line was secured to the skin outside the tunnel using 0 silk\\n sutures. Sterile dressings were applied.\\n\\n Attention was then turned to the left anterior neck, where the skin was\\n prepped and draped in sterile fashion. Son interrogation of the left\\n anterior neck demonstrated a predominantly thrombosed left internal jugular\\n vein, which was only partially compressible. Local anesthesia was effected\\n with 1% lidocaine. Due to partial compressibility and demonstration of a\\n patent left internal jugular vein on recent cross-sectional imaging studies of\\n the neck in , the procedure of insertion of the central line was\\n deemed feasible, and the left internal jugular vein was punctured under\\n ultrasound visualization using a 21-gauge micropuncture needle. Blood return\\n was obtained, and 0.018 inch guidewire was advanced into the superior vena\\n cava. The micropuncture needle was then exchanged for an appropriate\\n peel-away sheath. A digital subtraction venogram was then performed through\\n the peel-away sheath by injection of 10 mL of undiluted Omnipaque 220, which\\n demonstrated high-grade stenosis of the central left brachiocephalic vein with\\n partial thrombosis of the left brachiocephalic and left internal jugular veins\\n more peripherally. The superior vena cava is widely patent. To facilitate\\n advancement of a PICC, a 0.018 Glidewire was advanced into the right atrium\\n through the peel-away sheath. However, attempts to advance the PICC over the\\n Glidewire were met with resistance at the level of mid left brachiocephalic\\n vein. A 4 French MPA-1 catheter was then successfully advanced over the\\n Glidewire into the superior vena cava paving the way for advancement of a\\n double-lumen PowerPICC into the right atrium. The PICC was tunneled through a\\n subcutaneous soft tissue tunnel inferior and lateral to the venipuncture site.\\n At the conclusion of the procedure, the tip of the Power double-lumen central\\n line was in the superior third of the right atrium. At the conclusion of the\\n procedure, the tip of the hemodialysis in the superior third of the right\\n atrium. The line flushed and aspirated well and was instilled with heparined\\n saline. Sterile dressings were applied.\\n\\n IMPRESSION:\\n\\n 1. Successful conversion of a temporary right internal jugular hemodialysis\\n line into a tunneled right internal jugular hemodialysis line with tip in the\\n right atrium under fluoroscopic guidance. The hemodialysis line is ready to\\n use.\\n 2. High-grade stenosis of the central left brachiocephalic vein near the\\n junction with the superior vena cava with partial thrombosis of the left\\n brachiocephalic vein and left internal jugular vein more peripherally. Due to\\n (Over)\\n\\n 4:13 PM\\n TUNNELED DIALYSIS LINE PLACEME Clip # \\n Reason: please exchange temp HD line for tunnelled HD line and also\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 60\\n Type of Port: None\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n soft consistency and recent age of the thrombus, placement of the left\\n internal jugular central line through the clot was deemed feasible and was\\n successful. The left internal jugular central venous line is ready to use.\\n 3. The clinical team was advised not remove the left internal jugular central\\n venous line without consulting interventional radiology.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-11 00:00:00.000\",\n \"description\": \"R US EXTREMITY NONVASCULAR RIGHT\",\n \"row_id\": 1204761,\n \"text\": \", M 27 () \\n , S. OMED 2:21 PM\\n US EXTREMITY NONVASCULAR RIGHT Clip # \\n Reason: PT WITH NEW RIGHT WRIST LESION, EVAL FOR ABSCESS\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with MRSA scalded skin syndrome now with new R wrist lesion\\n REASON FOR THIS EXAMINATION:\\n eval for abscess\\n ______________________________________________________________________________\\n PFI REPORT\\n 10 x 20 x 2 mm subcutaneous fluid collection adjacent to but not involving the\\n nearby tendon sheath.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-17 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 1205618,\n \"text\": \" 4:07 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: PICC for HD\\n Admitting Diagnosis: SEPSIS\\n Contrast: OPTIRAY Amt: 8\\n ********************************* CPT Codes ********************************\\n * PICC W/O PORT -79 UNRELATED PROCEDURE/SERVICE DURI *\\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with HD dependent renal failure\\n REASON FOR THIS EXAMINATION:\\n PICC for HD\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old man with hemodialysis-dependent renal failure, needs\\n a PICC for IV access, for medication and fluids.\\n\\n OPERATORS: Dr. performed the procedure and Dr. \\n reviewed the images.\\n\\n ANALGESIA: It was provided by 1% lidocaine.\\n\\n PROCEDURE AND FINDINGS: Verbal informed consent was obtained from the patient\\n after explaining the procedure, risks, benefits and alternatives. Patient was\\n brought to the angiographic suite and laid supine on the table. The right arm\\n was prepped and draped in a sterile fashion. Preprocedural timeout and huddle\\n were performed per protocol.\\n\\n Under ultrasound guidance, the patent right brachial vein was accessed and a\\n wire was tried to be threaded in, but there was a stenosis at the subclavian\\n vein and the wire was not feeding in. This was confirmed angiographically and\\n by contrast injection. So it was decided to leave a midline venous access. A\\n 16 cm long single-lumen 4 French PICC was threaded over the wire into the\\n brachial vein. The guidewire was removed and sterile dressing was applied at\\n the PICC line.\\n\\n The patient tolerated the procedure well. She did not have any immediate\\n complications.\\n\\n IMPRESSION: Uncomplicated successful placement of a midline venous line in\\n the mid axillary vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1209088,\n \"text\": \" 6:08 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o intrathoracic process and compare with prior.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with 27 yo male with h/o CLL s/p allogenic stem cell transplant\\n complicated by chronic GVHD of his gut with icreased hypoxia.\\n REASON FOR THIS EXAMINATION:\\n r/o intrathoracic process and compare with prior.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n TECHNIQUE: Portable supine radiograph of chest.\\n\\n Comparisons were made with prior chest radiographs from \\n with the most recent from .\\n\\n FINDINGS:\\n Previously seen supporting and monitoring devices are in standard position.\\n Bilateral lung volumes remain low and there are no new relevant findings.\\n Assessment of the left lung was limited as most of it was obscured by the\\n widened mediastinum presumably from the low lung volumes and due to flexed\\n position of the neck obscuring most of the lung apices. Increased\\n retrocardiac density on the left side suggesting left lower lung volumes is no\\n different to the prior radiograph.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1207833,\n \"text\": \" 4:28 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for infiltrates\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with new cough and chest pain\\n REASON FOR THIS EXAMINATION:\\n please evaluate for infiltrates\\n ______________________________________________________________________________\\n WET READ: MDAg SUN 9:51 PM\\n Low lung volumes. Increased opacity at left base may be crowding of vessels vs\\n increased atelectasis. Unchanged right basilar atelectasis. Support devices in\\n unchanged positions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: New cough and chest pain.\\n\\n Portable AP chest radiograph was reviewed in comparison to .\\n\\n Right central venous line and left subclavian line are in unchanged position\\n terminating at the low SVC/cavoatrial junction. Cardiomediastinal silhouette\\n is unchanged. Bibasal linear opacities are unchanged, most likely\\n representing atelectasis although in the right lung the opacity is relatively\\n and might reflect infectious process. There is no apparent pleural\\n effusion noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-03 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1207922,\n \"text\": \" 9:02 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: evaluate for pneumonia\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL s/p allo SCT complicatedby chronic GVHD, with fevers\\n and new onset hypoxia\\n REASON FOR THIS EXAMINATION:\\n evaluate for pneumonia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient with CLL, status post allo stem cell transplant,\\n compatibility complicated by chronic graft-versus-host disease. Fever and new\\n onset hypoxia, evaluate for pneumonia.\\n\\n TECHNIQUE: Unenhanced MDCT of thorax was performed using a standard\\n department protocol.\\n\\n Comparisons were made with prior chest CTs through , with most\\n recent from .\\n\\n FINDINGS:\\n\\n LUNGS AND AIRWAYS: Central airways are patent till subsegmental level. Since\\n , revious multifocal pneumonic consolidation and ground glass\\n opacities in both upper lobes, lingula and middle lobe have significantly\\n decreased. Opacities in the dependent portions of the bilateral lower lungs\\n representing either aspiration, atelectasis, or pneumonic consolidation have\\n also minimally improved. Bilateral pleural effusion is trace.\\n\\n MEDIASTINUM: Bilateral central line terminates at the cavoatrial junction.\\n There is no pathological enlargement of mediastinal, supraclavicular, or\\n axillary lymph nodes. Thyroid gland is normal. Heart is normal size without\\n pericardial effusion.\\n\\n ABDOMEN: The study is not tailored for evaluation of the abdomen; however,\\n limited views were unremarkable.\\n\\n BONES: Mild wedge compression deformities of sixth and ninth vertebral body\\n are unchanged. Degenerative changes at multiple vertebral body levels are\\n seen. There is no bone lesion suspicious for malignancy/infection.\\n\\n\\n IMPRESSION:\\n\\n Since , bilateral multifocal pneumonia and ground glass\\n opacification as well as bilateral lower lobes opacities representing either\\n atelectasis, aspiration, or pneumonia have decreased.\\n (Over)\\n\\n 9:02 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: evaluate for pneumonia\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1207569,\n \"text\": \" 2:49 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pulmonary edema? pleural effusions? pneumonia?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL and recovering HD-dependent and 4 pound weight\\n gain from yesterday. Now with 2L oxygen requirement new from yesterday.\\n REASON FOR THIS EXAMINATION:\\n pulmonary edema? pleural effusions? pneumonia?\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Patient with 4-pound weight gain in one day with new oxygen\\n requirement.\\n\\n Comparison is made with prior study .\\n\\n There persist unchanged low lung volumes with bibasilar atelectasis. There is\\n no evident pneumothorax or large pleural effusion. The chin of the patient\\n obscures the apices of the lungs. Bilateral central catheters are unchanged\\n in standard position. Cardiomediastinal contours are unchanged with\\n cardiomegaly accentuated by the low lung volumes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-06 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1208459,\n \"text\": \" 10:16 AM\\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: please eval for PNA or intraabdominal or RP bleed\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with GVHD of gut and neutropenic fevers and dropping HCT on\\n heparin GTT\\n REASON FOR THIS EXAMINATION:\\n please eval for PNA or intraabdominal or RP bleed\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n WET READ: 4:18 PM\\n 1. No acute intra-abdominal or intrapelvic process. Specifically, there is\\n no evidence of RP bleed.\\n 2. Interval increase in patchy ground-glass opacities throughout the upper\\n lung zones since the CT examination concerning for\\n worsening multifocal pneumonia.\\n\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old male with graft-versus-host disease of GI tract with\\n neutropenic fevers and decreasing hematocrit values.\\n\\n COMPARISON: Chest CT available from and abdominal CT from\\n .\\n\\n TECHNIQUE: MDCT-acquired 5-mm axial images of the chest, abdomen, and pelvis\\n were obtained without the use of IV or oral contrast. Coronal and sagittal\\n reformations were performed at 5-mm slice thickness.\\n\\n CHEST: A left IJ catheter terminates at the cavoatrial junction. A larger\\n right IJ catheter terminates within the right atrium. The heart size is top\\n normal. The left ventricle is enlarged. There is no pericardial effusion.\\n The main pulmonary artery is enlarged. Scattered axillary and mediastinal\\n lymph nodes do not meet CT criteria for lymphadenopathy.\\n\\n Moderate atelectasis is present at the posterior aspect of both lungs. In\\n comparison to examination, there has been an interval\\n increase in patchy ground-glass opacities and focal consolidations within the\\n upper zones, which may reflect worsening multifocal pneumonia. There is no\\n effusion. No discrete mass is detected.\\n\\n ABDOMEN: Non-contrast enhanced views of the liver, gallbladder, pancreas,\\n adrenal glands, kidneys, spleen, and stomach are normal. There is no\\n mesenteric or retroperitoneal lymphadenopathy, and no free air or free fluid.\\n A moderate amount of fluid is seen throughout the distal colon extending to\\n the rectal vault.\\n\\n PELVIS: The urinary bladder and prostate are within normal limits. No\\n intrapelvic free fluid or lymphadenopathy.\\n\\n (Over)\\n\\n 10:16 AM\\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: please eval for PNA or intraabdominal or RP bleed\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or\\n lytic lesions are identified. Wedge compression deformities are seen from\\n T7-12, L1, L2, and L4 over the background of severe osteopenia, all unchanged.\\n\\n\\n IMPRESSION:\\n 1. No acute intra-abdominal or intrapelvic process. Specifically, there is\\n no evidence of RP bleed.\\n 2. Interval increase in patchy ground-glass opacities throughout the upper\\n lung zones since the CT examination concerning for\\n worsening multifocal pneumonia.\\n\\n The initial findings were discussed by Dr. with Dr. at 2:20 p.m. on\\n .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-09 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1208835,\n \"text\": \" 10:20 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Is there interval worsening of infiltrates compared to \\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with significant hypoxia and worsning chest CT imaging on \\n and . There is concern for viral pneumonia, pulmonary hemorrhage, and PCP\\n pneumonia as well as typical HAP.\\n REASON FOR THIS EXAMINATION:\\n Is there interval worsening of infiltrates compared to and and is\\n there evidence of hemorrhage?\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n WET READ: KKgc SUN 3:21 PM\\n Multifocal ground-glass opacities and pulmonary consolidation in the upper\\n lobes are unchanged. Mild interval progression of the dense consolidation in\\n the right lower lobe, likely reflecting a combination of atelectasis,\\n infection, and or aspiration. New small right pleural effusion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 27-year-old man with significant hypoxia and worsening pulmonary\\n abnormalities on CT imaging of and . Clinical concern for viral\\n pneumonia, pulmonary hemorrhage, and PCP .\\n\\n COMPARISON: CT torso without contrast and CT chest without contrast\\n .\\n\\n TECHNIQUE: MDCT helical images were acquired through the chest without\\n intravenous contrast. Sagittal and coronal reformats were generated and\\n reviewed.\\n\\n FINDINGS: Multifocal areas of ground-glass opacity and patchy consolidation\\n in both upper lobes and right middle lobe, are unchanged since the prior\\n study. Also seen are dense consolidations involving the dependent portion of\\n both lower lobes, right greater than left. There is mild interval progression\\n of the consolidation in the right lower lobe. These consolidations likely\\n reflect a combination of atelectasis, infection, and superimposed aspiration.\\n Small right pleural effusion is new since the prior study. No pneumothorax is\\n identified. No significant mediastinal, hilar, or axillary adenopathy is\\n seen. Within the limitations of a non-contrast study, the thoracic aorta is\\n unremarkable. The heart is mildly enlarged. There is no pericardial\\n effusion.\\n\\n Bilateral internal jugular approach central venous catheters are seen, with\\n the left terminating in the cavoatrial junction and the right terminating in\\n the right atrium. Main pulmonary artery is mildly enlarged measuring 3.4 cm,\\n suggestive of pulmonary arterial hypertension.\\n\\n This study is not tailored for evaluation of the subdiaphragmatic organs.\\n Within this limitation, the imaged portion of the upper abdomen including the\\n liver, spleen, adrenal glands are unremarkable.\\n (Over)\\n\\n 10:20 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Is there interval worsening of infiltrates compared to \\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n BONES AND SOFT TISSUES: No bone lesion concerning for infection or malignancy\\n are detected. Mild compression of T6, T7, T9 and T12 vertebral bodies, are\\n unchanged since the prior study.\\n\\n IMPRESSION:\\n Multifocal ground-glass opacities and pulmonary consolidation in the upper\\n lobes are unchanged. Mild interval progression of the dense consolidation in\\n the right lower lobe, likely reflecting a combination of atelectasis,\\n infection, and or aspiration. New small right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208429,\n \"text\": \" 4:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with ?PNA\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 27-year-old with pneumonia. Please evaluate for interval\\n change.\\n\\n COMPARISON: .\\n\\n FINDINGS: Left and right central venous lines are in unchanged correct\\n position. Cardiomediastinal silhouette is unchanged. The lung volumes are\\n very low. In comparison to the prior study there appears to be little\\n interval change with the left retrocardiac densities and the right perihilar\\n density still visible and unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-09-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1207431,\n \"text\": \" 7:18 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pulmonary edema? effusions? pneumonia?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27yo male with 3 pound weight gain and increasing oxygen requirement. Just\\n d/c'd HD this week and UOP improving but still in positive fluid balance.\\n REASON FOR THIS EXAMINATION:\\n pulmonary edema? effusions? pneumonia?\\n ______________________________________________________________________________\\n WET READ: 9:26 PM\\n\\n Right IJ HD line extends to cavoatrail jxn. Left IJ catheter extends to\\n distal SVC. persistently low lung volumes but slightly improved aeration at\\n the lung bases. stable heat size. no pulmonary edema or pleural effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Incresed oxygen requirement.\\n\\n Portable AP radiograph of the chest was reviewed in comparison with , .\\n\\n The left central venous line tip is at the cavoatrial junction. The right\\n central venous line has been inserted terminating in the right\\n atrium/cavoatrial junction. Cardiomediastinal silhouette is unchanged. There\\n is interval improvement of bibasilar atelectasis. Small amount of pleural\\n effusion is most likely present. Within the limitations of this examination,\\n no evidence of pneumothorax is seen.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208207,\n \"text\": \" 4:35 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pna\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 yo male with h/o CLL s/p allogenic stem cell transplant complicated by\\n chronic GVHD of his gut, recent MRSA sepsis, in MICU twice this admission,\\n first , and second admission , who now has increased hypoxia\\n REASON FOR THIS EXAMINATION:\\n pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n DATE: .\\n\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: 27-year-old male patient with history of chronic lymphatic\\n leukemia status post allogenic stem cell transplant complicated by chronic\\n GVHD of his gut, recent MRSA sepsis, in MICU twice during this admission. Now\\n with increased hypoxia.\\n\\n FINDINGS: AP single view of the chest has been obtained with patient in\\n supine position. Comparison is made with the next preceding similar study\\n dated . Previously identified right-sided internal jugular\\n approach double-lumen catheter remains in unchanged position terminating in\\n the upper portion of the right atrium. A left-sided subclavian approach\\n central venous line is also in unchanged position terminating to the right of\\n the midline in the area of the mid portion of the SVC. No pneumothorax has\\n developed. The on previous examination identified pulmonary density on the\\n left base in retrocardiac position persists and may have increased slightly.\\n There is no new evidence of pneumothorax or pleural effusion. On the right\\n base, a plate atelectasis has developed but no other new abnormalities are\\n seen and the right lateral pleural sinus remains free. During the latest\\n examination interval, the patient underwent a chest CT on .\\n The bilateral patchy densities on the bases and plate atelectases were shown\\n in greater detail. It is concluded that no major interval change has occurred\\n as can be identified on this portable single view chest examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1209280,\n \"text\": \" 5:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o intrathoracic process\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL/SLL s/p allo SCT with increased hypoxia.\\n REASON FOR THIS EXAMINATION:\\n r/o intrathoracic process\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Increased hypoxia. Patient is status post allo transplant.\\n\\n Comparison is made with prior study .\\n\\n Bilateral central lines remain in standard unchanged position. There are\\n persistent low lung volumes. Cardiomegaly and widened mediastinum are stable.\\n Bibasilar opacities larger on the left side are unchanged consistent with\\n atelectasis but pneumonia cannot be excluded. Right upper lobe opacity has\\n improved.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208777,\n \"text\": \" 5:24 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for O2 desaturation\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with new onset O2 desaturation\\n REASON FOR THIS EXAMINATION:\\n eval for O2 desaturation\\n ______________________________________________________________________________\\n WET READ: MLHh SAT 8:05 PM\\n Low lung vols. Slight in bilat streaky opacities = interstitial PNA +\\n atelectasis based on CT. Bilat lines in RA as before.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: New onset of O2 desaturation, evaluate for cause.\\n\\n CHEST\\n\\n The position of the various lines remains unchanged. The heart is enlarged.\\n Perihilar opacities are still present, perhaps a little less marked. No\\n effusions are identified.\\n\\n IMPRESSION: Mild improvement since prior chest x-ray.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208919,\n \"text\": \" 4:26 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with increased O2 req and GVHD\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Increased oxygen requirement.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change. Monitoring and support devices remain in place. Continued low lung\\n volumes with bibasilar atelectasis, especially in the retrocardiac region\\n consistent with volume loss in the left lower lobe.\\n\\n IMPRESSION: Little change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1209573,\n \"text\": \" 5:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess lung fields for acute process\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL, aspirating blood intermittently\\n REASON FOR THIS EXAMINATION:\\n Assess lung fields for acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n Semi-erect portable radiograph of chest.\\n\\n Comparisons were made with prior chest radiographs through ,\\n with the most recent from .\\n\\n FINDINGS: Left porta catheter and dual-lumen right central line catheter end\\n in the upper right atrium. Bilateral lung volumes are low. Bilateral lower\\n lung atelectasis, left side more than right side, are unchanged.\\n Cardiomediastinal silhouette and hilar contours are stable. There are no new\\n lung opacities of concern.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208813,\n \"text\": \" 5:04 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with GVHD of gut and shortness of breath w/ ? CMV pneumotitis\\n vs. pulm hemoorhage\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Graft-versus-host disease.\\n\\n Shortness of breath.\\n\\n CHEST:\\n\\n Lung volumes are very low and fluid is likely present in the minor fissure in\\n addition to costophrenic angles. There is loss of the left hemidiaphragm and\\n this could be due to atelectasis and/or pneumonia in this region.\\n\\n IMPRESSION: Increasing pleural effusions and opacification of left lower\\n lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208258,\n \"text\": \" 4:59 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval progression\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with CLL/SLL, new hypoxia\\n REASON FOR THIS EXAMINATION:\\n interval progression\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: New hypoxia.\\n\\n Portable AP radiograph of the chest was reviewed in comparison to , .\\n\\n Left and right central venous lines are in unchanged position. Bibasilar\\n atelectasis is unchanged. Comparison with the prior study is difficult since\\n the patient was imaged in significant lordotic projection and his head is\\n obscuring upper lungs. Within those limitations, no substantial change since\\n the prior study demonstrated.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1208585,\n \"text\": \" 5:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pna?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with possible pna\\n REASON FOR THIS EXAMINATION:\\n pna?\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n TECHNIQUE: AP semi-upright portable radiograph of chest.\\n\\n Comparisons were made with prior chest radiographs through \\n with the most recent from .\\n\\n FINDINGS: Bilateral central venous lines terminate in the right atrium. Both\\n lung volumes remain low. Since , there is no difference in\\n bilateral predominantly mid and lower lung opacities. In an appropriate\\n clinical setting, these may either reflect atelectasis or pneumonic\\n consolidation. On concurrent comparison with the recent CT torso study, it\\n appears that most of the lower lung opacity is attributed to the lung\\n atelectasis, whereas patchy mid and upper lobe opacities are suggestive of\\n multifocal pneumonic consolidation. cardiomediastinal and hilar contours are\\n unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-03 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1207954,\n \"text\": \", OMED 7F 11:22 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: acute head bleed?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with extensive clots of central nenous system and falling\\n platelets on heparin gtt\\n REASON FOR THIS EXAMINATION:\\n acute head bleed?\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal\\n ______________________________________________________________________________\\n PFI REPORT\\n No acute intracranial process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-10-03 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1207953,\n \"text\": \" 11:22 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: acute head bleed?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 27 year old man with extensive clots of central nenous system and falling\\n platelets on heparin gtt\\n REASON FOR THIS EXAMINATION:\\n acute head bleed?\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRAf MON 12:01 PM\\n No acute intracranial process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Extensive clot of the central nervous system and falling platelet on\\n heparin drip, evaluate for acute bleed.\\n\\n TECHNIQUE: Contiguous axial sections of the brain without IV contrast.\\n\\n COMPARISON: CT of the neck without contrast from .\\n\\n FINDINGS: No hemorrhage, edema or shift of normally midline structures.\\n Study is limited by motion, but overall appears normal. The ventricles and\\n sulci are normal in size and caliber. No suspicious osseous lesions. The\\n mastoid air cells are well aerated. Again seen is moderate mucosal thickening\\n within the sphenoid sinus, unchanged from prior exams. Scattered white matter\\n abnormalities from the MRI are not appreciated on this study.\\n\\n\\n IMPRESSION: No acute intracranial process.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203953,\n \"text\": \"Sinus tachycardia. Diffuse T wave abnormalities likely secondary to rate.\\nCompared to the previous tracing there is no change.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203954,\n \"text\": \"Sinus tachycardia. Diffuse non-specific T wave abnormalities likely secondary\\nto rate.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203955,\n \"text\": \"Sinus tachycardia. Diffuse non-specific T wave abnormalities likely secondary\\nto rate. Compared to the previous tracing there is no change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203956,\n \"text\": \"Sinus tachycardia. Diffuse non-specific T wave abnormalities likely secondary\\nto rate. Compared to the previous tracing no diagnostic changes.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203957,\n \"text\": \"Normal sinus rhythm with ventricular premature beats. Left atrial abnormality.\\nPoor R wave progression in leads V1-V6 raises the possibility of old\\nanterolateral myocardial infarction. Non-specific ST-T wave abnormalities in\\nthe inferior and lateral leads. Compared to the previous tracing of \\nventricular premature beats are now noted and lateral T wave abnormalities are\\nslightly more prominent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203958,\n \"text\": \"Sinus rhythm. Leftward axis. Late R wave proression. T wave abnormalities.\\nSince the previous tracing of the rate is slower. ST-T wave\\nabnormalities may be less prominent. Otherwise, unchanged.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203959,\n \"text\": \"Sinus tachycardia. Compared to tracing #1 the rate is faster. Non-specific\\nanteroseptal ST-T wave changes persist.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-08-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203960,\n \"text\": \"Sinus tachycardia. Delayed R wave transition in the anterior precordial leads.\\nCompared to the previous tracing of the rate is faster. Ventricular\\npremature beats are no longer seen. Non-specific anteroseptal ST-T wave changes\\npersist.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203717,\n \"text\": \"Compared to tracing #1 the patient has gone from atrial flutter with a rapid\\nventricular response to normal sinus rhythm with frequent ventricular premature\\nbeats. There is marked baseline artifact on the current tracing. J point\\nelevation. Non-specific ST-T wave changes in the right precordial leads may\\nhave been present to some degree in tracing #1 as well, although obscured by\\nthe baseline artifact due in part to atrial flutter.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203718,\n \"text\": \"Atrial flutter with a rapid ventricular rate of 160 beats per minute.\\nModerate baseline artifact. Non-specific ST-T wave changes. Compared to the\\nprevious tracing of no diagnostic interval change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203719,\n \"text\": \"Atrial flutter with 2:1 A-V block. There are non-specific ST segment changes.\\nCompared to the previous tracing there is considerable baseline\\nartifact but there are no longer frequent ventricular premature beats and the\\nrhythm has gone from sinus tachycardia to atrial flutter with an increase in\\nrate from 121 to 158. The non-specific ST-T wave changes persist but are\\nsomewhat less prominent in leads I and aVL. No other diagnostic interval\\nchange.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-10-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203720,\n \"text\": \"Sinus tachycardia with ventricular premature beats and baseline artifact.\\nPossible biatrial enlargement. Left axis deviation. Poor R wave progression.\\nPossible left ventricular hypertrophy. Non-specific ST-T wave changes could\\nbe due to left ventricular hypertrophy but cannot exclude ischemia. Compared\\nto the previous tracing of artifact is new.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203721,\n \"text\": \"Sinus tachycardia with ventricular premature beats. Possible biatrial\\nenlargement. Leftward axis. Left ventricular hypertrophy with lateral\\nST-T wave abnormalities. Compared to the previous tracing of lateral\\nST-T wave abnormalities are new.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-10-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203722,\n \"text\": \"Normal sinus rhythm with occasional ventricular premature beats. T wave\\ninversions in leads V1-V3 suggest the possibility of anteroseptal myocardial\\nischemia. Voltage criteria for left ventricular hypertrophy. Compared to the\\nprevious tracing of the T wave inversions in the right precordial leads\\nare less prominent and the ventricular ectopic activity has diminished.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203723,\n \"text\": \"Normal sinus rhythm with frequent ventricular premature beats in a bigeminal\\npattern. There is T wave inversion in the conducted beats in leads V1-V4 with\\npoor R wave progression. Compared to the previous tracing of the\\npatient is no longer in sinus tachycardia with occasional ventricular\\npremature beats. Non-specific ST-T wave changes noted at that time in\\nleads I and aVL are not present on the current tracing. Poor R wave progression\\nin leads V1-V6 is no longer seen on the current tracing. Marked T wave\\ninversion in leads V1-V4 is new, however. These changes are non-specific and\\nnon-diagnostic.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203724,\n \"text\": \"Sinus tachycardia with ventricular premature beats. Possible biatrial\\nenlargement. Leftward axis. Poor R wave progression of uncertain\\nsignificance. Diffuse non-specific ST-T wave abnormalities. Compared to the\\nprevious tracing of heart rate and non-specific ST-T wave abnormalities\\nhave increased. Axis is more leftward and loss of R wave in the lateral\\nprecordial leads may reflect lead placement but suggest clinical correlation\\nand repeat tracing.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 203725,\n \"text\": \"Sinus tachycardia with ventricular premature beats and significant baseline\\nartifact. Non-specific T wave changes. Compared to the previous tracing\\nof artifact persists. Ventricular premature beats are seen on the\\ncurrent tracing.\\n\\n\"\n }\n]"}}},{"rowIdx":23090,"cells":{"subject_id":{"kind":"number","value":30593,"string":"30,593"},"hadm_id":{"kind":"number","value":187958,"string":"187,958"},"target_text":{"kind":"string","value":"Pt was admitted to the hospital following the above mentioned procedure - please see op report for details. Postoperatively, pt had low urine output and bleeding, and pt was admitted to the ICU for serial Hcts and monitoring. On POD1, pt was transfused 2U PRBCs, and on POD2 he received another 2U PRBCs for persistent bleeding; he was hemodynamically stable during this period. While he was in the ICU, he worked some with PT, but was limited secondary to pain. Pt's Hct was stable throughout the remainder of POD2 (following the transfusion) and on POD3, after 4 stable serial Hcts, he was transferred to the floor, and lovenox was started on in the AM. TLD: Pt's CVL was d/c'd on POD3, foley was d/c'd on POD4, and his hemovac was d/c'd on POD1. Pain: Pt's pain was initially trteated with a PCA, but this was changed to po oxycodone post-operatively, and his pain was treated with this an tylenol while in-house ID: pt received perio-op ancef for 24 hrs Activity: Pt was 50% WB with posterior precautions (for 6 weeks post-op)"},"extractive_notes_summ":{"kind":"string","value":"Chief Complaint: s 24 Hour Events: - Remained hemodynamically stable - Hct trended: 34.5 -> 26.4 -> 21.4 - Patient currently being transfused 2 units Allergies: Lisinopril Cough; Aspirin Anemia; Last dose of Antibiotics: Cefazolin - 02:00 AM Infusions: Other ICU medications: Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 06:30 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.9C (100.2 Tcurrent: 37.1C (98.7 HR: 73 (73 - 106) bpm BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg RR: 14 (10 - 17) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Total In: 525 mL 1,518 mL PO: TF: IVF: 525 mL 1,288 mL Blood products: 230 mL Total out: 105 mL 85 mL Urine: 55 mL 85 mL NG: Stool: Drains: 50 mL Balance: 420 mL 1,433 mL Respiratory support O2 Delivery Device: Face tent SpO2: 100% ABG: ///24/ Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 21.4 % [image002.jpg] 03:30 AM Hct 21.4 Microbiology: No new Assessment and Plan 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated post-op bleeding. Anticipated Discharge: Rehab Plan: Ther-Ex, transfers, ambulation w/ RW, balance, inc. endurance, wean O2. peripheral pulse assessment done q4hr as needed. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. - Will continue to monitor pm CBC, if platelets lower, will consider platelet tx at that time # Osteoarthritis s/p THA: now POD#1 from surgery. Response: Some general non pitting edema noted. Bladder pressure is WNL.. Hct stable. - Will continue to monitor pm CBC, if decreasing, can consider plt tx, no need at this time # Osteoarthritis s/p THA: now POD#1 from surgery. - Will continue to monitor pm CBC, if decreasing, can consider plt tx, no need at this time # Osteoarthritis s/p THA: now POD#1 from surgery. Central line care per protocol being maintained.VSS being done Q1hr. received 2uPRBC, w/ appropriate bump in Hct to 28.2. - Hold oral meds for now (metformin, actos, glipizide) - RISS # Hypertension: hold anti-hypertensives until Hct stable # FEN: Replete lytes prn, IVF as above, PO as tolerated ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 09:30 PM Multi Lumen - 11:35 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Continue ICU monitoring for now, can consider c/o later today He was transfered to the MICU for further monitoring Problem - Description In Comments Assessment: Pt with noted swelling of right hip, area is warm and skin taught to the touch, right foot cool though equally so to left, pedal pulses palpable, pt able to wiggle toes, hemovac in place in right hip, surgical dsg d&I, repeat hct this am with 4 point drop, u/o ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP: 94-122/42-57 Action: Overnight pt received 2 500cc fluid boluses, ordered to receive 2 UPRBC, first of two started at 0445, pt is a difficult venipuncture, this RN unable to obtain morning labs, HO attempted arterial stick, only able to obtain enough blood for 0330 hct, pt also receiving maintenance LR at 125/hr Response: Pt with some response in u/o with second FB, HR decreased with fluid adm, VSS Plan: Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip and dsg, PT consult tomorrow to obtain wedge pillow if appropriate, continue to provide fluid for goal u/o of 30cc/hr Pain control (acute pain, chronic pain) Assessment: Obtained pt very lethargic, as noted above while in PACU there was difficulty maintaining good pain control w/o over sedation, pts mental status improving throughout the shift, able to report pain scored at , pain located in right hip Action: Minimizing pt turns and movements in bed, keeping right hip straight with pillow between legs, pt received 2 5mg doses of oxycodone with good effect Response: Pt sleeping comfortably throughout the shift, PRN pain medications with good effect Plan: Continue to monitor pain control, pt will likely require larger doses of pain medication with increased activity during the day Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Intervention: Supine ther-ex x 10 reps: AP, hip rolls, hip AB/AD, SAQ, HS Other: Diagnosis: 1. peripheral pulse assessment done q4hr as needed. Hypertension - hold meds for now as was hypotensive and bleeding 4. Plan: Transfuse for Hct <24. Plan: Transfuse for Hct <24. - Will continue to monitor pm CBC, if platelets lower, will consider platelet tx at that time # Osteoarthritis s/p THA: now POD#1 from surgery. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT."},"n_notes":{"kind":"number","value":43,"string":"43"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2178-05-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":322918,"text":"Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units,\n but said it's expected after such a bloody case. will need to\n re-address in AM\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\n unchanged. Mild interstitial edema which was present on has\n resolved and there is no appreciable pleural effusion. Thoracic aorta\n is generally large and tortuous but not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - CVL today for more definitive access as patient with only one working\n PIV at this time (also very hard peripheral stick). Will also aid with\n overall volume monitoring\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Touch base with orthopedics later this morning to confirm they do not\n want further imaging/? If they would like to assess pressure in right\n thigh with probe\n - Awaiting am labs until CVL placed as unable to draw blood\n peripherally\n - IVF/blood prn volume; patient appears dry on exam\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, additional morphine being careful to avoid\n sedation/somnolence\n - Ortho recs\n - PA/lat hip films final read\n - Continue peri-op prophylactic antibiotics.\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 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":"2178-05-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":322920,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units,\n but said it's expected after such a bloody case. will need to\n re-address in AM\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\n unchanged. Mild interstitial edema which was present on has\n resolved and there is no appreciable pleural effusion. Thoracic aorta\n is generally large and tortuous but not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - CVL today for more definitive access as patient with only one working\n PIV at this time (also very hard peripheral stick). Will also aid with\n overall volume monitoring\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Touch base with orthopedics later this morning to confirm they do not\n want further imaging/? If they would like to assess pressure in right\n thigh with probe\n - Awaiting am labs until CVL placed as unable to draw blood\n peripherally\n - IVF/blood prn volume; patient appears dry on exam\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, additional morphine being careful to avoid\n sedation/somnolence\n - Ortho recs\n - PA/lat hip films final read\n - Continue peri-op prophylactic antibiotics.\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: PO\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2178-05-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":322933,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr period with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n INR 1.0\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of the trachea to suggest a hematoma. Heart\n size is mildly enlarged and unchanged. Mild interstitial edema which\n was present on has resolved and there is no appreciable\n pleural effusion. Thoracic aorta is generally large and tortuous but\n not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct trend over 24 hours is\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\nd a total of 6\n units prbcs over 24 hours and is currently receiving 2 more units\n PRBCs. Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\n be done to rule out other areas of bleed (such as RP)\n - IVF/blood prn volume; patient appears dry on exam\n - As it is still not entirely clear if patient is bleeding anywhere\n other than his thigh, will check bladder pressure to monitor abdominal\n pressures as a measure to follow along with thigh diameter\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets.\n - Will continue to monitor pm CBC, if platelets lower, will consider\n platelet tx at that time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"ECG","chartdate":"2178-05-26 00:00:00.000","description":"Report","row_id":124465,"text":"Sinus rhythm. P-R interval prolongation. Since the previous tracing\nof there is no significant change.\n\n"},{"category":"Physician ","chartdate":"2178-05-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":322800,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n - Remained hemodynamically stable\n - Hct trended: 34.5 -> 26.4 -> 21.4\n - Patient currently being transfused 2 units\n - Ortho attending this am: requesting CVL for CVP monitoring\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 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 06:30 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: 37.1\nC (98.7\n HR: 73 (73 - 106) bpm\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,518 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 230 mL\n Total out:\n 105 mL\n 85 mL\n Urine:\n 55 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 1,433 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Gen: NAD\n CV: RRR, no m/r/g\n Pulm: CTAB anteriorly\n Abd: Soft, NTND, obese\n Ext: L thigh with tense skin, much larger than right, wound dressed and\n intact, peripheral pulses full and symmetric bilat\n Labs / Radiology\n 222\n 1.0\n 24\n 4.6\n 19\n 105\n 138\n 21.4 %\n [image002.jpg] Ca 7.7 Mag 1.4 Phos 3.7\n AM Labs pending\n 03:30 AM\n Hct\n 21.4\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - CVL today for more definitive access as patient with only one working\n PIV at this time (also very hard peripheral stick). Will also aid with\n overall volume monitoring\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Touch base with orthopedics later this morning to confirm they do not\n want further imaging/? If they would like to assess pressure in right\n thigh with probe\n - Awaiting am labs until CVL placed as unable to draw blood\n peripherally\n - IVF/blood prn volume; patient appears dry on exam\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, additional morphine being careful to avoid\n sedation/somnolence\n - Ortho recs\n - PA/lat hip films final read\n - Continue peri-op prophylactic antibiotics.\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO as tolerated\n Glycemic Control: ISS, holding oral meds\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker (famotidine)\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Case Management ","chartdate":"2178-05-27 00:00:00.000","description":"Case Managment Initial Patient Assessment","row_id":322809,"text":"Insurance information\n Primary insurance: EverCare\n Secondary insurance:\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None known prior to admission\n DME / Home O[2]: none prior to admission\n Functional Status / Home / Family Assessment:\n Pt. lives with his family in . He is independent with all\n personal care ADL's. His primary language is Portugese\n Primary Contact(s): (son) \n Health Care Proxy: .\n Dialysis: Yes\n Referrals Recommended: Physical Therapy, Occupational Therapy\n Current plan: Undetermined\n Unclear what level of services will be required at discharge. Case\n Management will follow for DC needs, The patient did have a stay at\n in .\n Patient (s) to Discharge:\n Patient discussed with multidisciplinary team: No\n"},{"category":"Physician ","chartdate":"2178-05-29 00:00:00.000","description":"Physician Resident and Attending Progress Note","row_id":323055,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n -Post Hct check up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -Ortho recs: Hold lovenox, WBAT\n -bladder pressure 14->7->6\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Gen: NAD, AAOx3\n CV: RRR, no m/r/g\n Pulm: CTAB anteriorly\n Abd: Soft, NTND, obese\n Ext: L thigh with tense skin, larger than right, wound dressed and\n intact, peripheral pulses full and symmetric bilat, pain on deep\n palpation of R thigh, though improved from prior\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6 today\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable\n - IVF/blood prn volume; patient is tolerating PO\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor, if decreasing, can consider plt tx, no need\n at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated, aggressive\n bowel regimen\n ICU Care\n Nutrition:\n PO, diabetic diet\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: c/o to ortho today\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n Key points:\n - hct stable now, rose with transfusions. Plt count higher on repeat\n check.\n - pain much better controlled\n - safe for transfer to floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:58 ------\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Transfer Note","row_id":323064,"text":"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\n limb girth 23in\n Action:\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\n Response:\n No s/s of bleeding, repeated Hct-28.2\n Plan:\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\n w/pain meds\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain- distention and rt hip pain, unable to score due to\n language barrier.\n Action:\n prn oxycodone, Tylenol q6hr, reposition and support the limb\n Response:\n Intermittent pain as low as 0/10.\n Plan:\n Continue w/ pain assessment, pain meds prn, and reposition and ambulate\n when possible.\n Neuro: a/oX , speaking, understands some English, Right\n lower extremity: Partial weight bearing.\n Resp: NC 2L sats at 96-98%, bil LS clear, diminished at the bases, IS\n use and DB/coughing encouraged.\n Cardio: denies CP or SOB, pneumoboots on, LE edema, peripheral pulses\n present w/Doppler.\n GU: foley w/clear yellow urine w/adequate amnt of urine.\n GI. Abd soft distended, positive for BS and flatus, started on bowel\n regimen., regular diabetic diet- tolerates well no N?V.\n Pain: c/o abd discomfort\nbloated\n and intermittent RT hip pain- on\n Tylenol q6hr and oxycodone prn.\n Skin: rat hip incision w/staples, mild-moderate serosang drainage. 2\n skin tears over rt thigh and RLQ abd w/dsd and tegaderm.\n Patient due to have Xray of his hip prior to discharge. Will be done on\n the floor.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n RIGHT HIP OSTEOARTHRITIS/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 109 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Precautions:\n PMH: Anemia, Diabetes - Oral , GI Bleed\n CV-PMH: Hypertension\n Additional history: prostate ca s/p xrt from 99-00, BPH, gastritis,\n esophagitis, doudentitis, gastric ulcers in stomach body and antrum,\n hemmorrhoids, h pylori, GIB, vertigo, osteoarthritis\n Surgery / Procedure and date: EGD 06\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:59\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 580 mL\n 24h total out:\n 2,685 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 99 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 8 mg/dL\n 02:57 AM\n Creatinine:\n 0.7 mg/dL\n 02:57 AM\n Glucose:\n 114 mg/dL\n 02:57 AM\n Hematocrit:\n 28.2 %\n 08:50 AM\n Finger Stick Glucose:\n 152\n 12:00 PM\n Valuables / Signature\n Patient valuables: sent w/patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/\n Transferred to: R12\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2178-05-28 00:00:00.000","description":"Nursing Progress Note","row_id":322967,"text":"Electrolyte & fluid disorder, other\n Assessment:\n Trend lab values, monitor for change in hemodynamics and v/s.\n Action:\n Patient given calcium carbonate x3 dose for low Ca. MgSO4 x1 today.\n Response:\n Patient remains free of arrhythmia or any other symptoms at this time\n urinary output has been adequate and v/s remain stable. Patient denies\n any discomfort at this time.\n Plan:\n Monitor lab values and treated as order by other health care provider.\n , acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n V/S being doing q1hr and prn. Urinary output checked hourly and trends\n evaluated. Lab values also being monitored.\n Action:\n Received 2units of blood today with pending checks for improvement.\n Response:\n Patient\ns v/s remains stable for client. Continues on O2 via NC and\n saturating welll. No obvious signs of bleeding noted. No BM this shift.\n Plan:\n Continue with blood transfusions as ordered by physician and monitor\n /s and fluid status.\n Problem - Hip surgery\n Assessment:\n Observe wound dressing for drainage, measure limb for increase in\n diameter. Monitor pulses\n Action:\n Dressing to right hip changed, area cleansed and dressed with ABD and\n mepore tape\n Response:\n Patient tolerated procedure well. Has had moderate amount of drainage\n from incision site. Dressing dry and intact at this time.\n Plan:\n Continue to monitor for fluid loss and observe limb for increase in\n size. Monitor pulses distal to wound. Monitory v/s\n"},{"category":"Physician ","chartdate":"2178-05-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":322775,"text":"Chief Complaint: s\n 24 Hour Events:\n - Remained hemodynamically stable\n - Hct trended: 34.5 -> 26.4 -> 21.4\n - Patient currently being transfused 2 units\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 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 06:30 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: 37.1\nC (98.7\n HR: 73 (73 - 106) bpm\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,518 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 230 mL\n Total out:\n 105 mL\n 85 mL\n Urine:\n 55 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 1,433 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 21.4 %\n [image002.jpg]\n 03:30 AM\n Hct\n 21.4\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n # Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - monitor peripheral pulses\n - PT consult requested for POD 2 or 3\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker (famotidine)\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2178-05-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":323042,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n -Post Hct check up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -Ortho recs: Hold lovenox, WBAT\n -bladder pressure 14->7->6\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Gen: NAD, AAOx3\n CV: RRR, no m/r/g\n Pulm: CTAB anteriorly\n Abd: Soft, NTND, obese\n Ext: L thigh with tense skin, larger than right, wound dressed and\n intact, peripheral pulses full and symmetric bilat, pain on deep\n palpation of R thigh, though improved from prior\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6 today\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable\n - IVF/blood prn volume; patient is tolerating PO\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor, if decreasing, can consider plt tx, no need\n at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated, aggressive\n bowel regimen\n ICU Care\n Nutrition:\n PO, diabetic diet\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: c/o to ortho today\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Transfer Note","row_id":323044,"text":"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\n limb girth 23in\n Action:\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\n Response:\n No s/s of bleeding, repeated Hct-28.2\n Plan:\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\n w/pain meds\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain- destantion and rt hip pain , unable to score due to\n language barrier.\n Action:\n prn oxycodone, Tylenol q6hr, reposition and support the limb\n Response:\n Intermittent pain as low as 0/10.\n Plan:\n Continue w/ pain assessment, pain meds prn, reposition and ambulate\n when possible.\n Neuro: a/\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Transfer Note","row_id":323046,"text":"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\n limb girth 23in\n Action:\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\n Response:\n No s/s of bleeding, repeated Hct-28.2\n Plan:\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\n w/pain meds\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain- distention and rt hip pain, unable to score due to\n language barrier.\n Action:\n prn oxycodone, Tylenol q6hr, reposition and support the limb\n Response:\n Intermittent pain as low as 0/10.\n Plan:\n Continue w/ pain assessment, pain meds prn, and reposition and ambulate\n when possible.\n Neuro: a/oX , speaking, understands some English, Right\n lower extremity: Partial weight bearing.\n Resp: NC 2L sats at 96-98%, bil LS clear, diminished at the bases, IS\n use and DB/coughing encouraged.\n Cardio: denies CP or SOB, pneumoboots on, LE edema, peripheral pulses\n present w/Doppler.\n GU: foley w/clear yellow urine w/adequate amnt of urine.\n GI. Abd soft distended, positive for BS and flatus, started on bowel\n regimen., regular diabetic diet- tolerates well no N?V.\n Pain: c/o abd discomfort\nbloated\n and intermittent RT hip pain- on\n Tylenol q6hr and oxycodone prn.\n Skin: rat hip incision w/staples, mild-moderate serosang drainage. 2\n skin tears over rt thigh and RLQ abd w/dsd and tegaderm.\n Patient due to have Xray of his hip prior to discharge. Will be done on\n the floor.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n RIGHT HIP OSTEOARTHRITIS/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 109 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Precautions:\n PMH: Anemia, Diabetes - Oral , GI Bleed\n CV-PMH: Hypertension\n Additional history: prostate ca s/p xrt from 99-00, BPH, gastritis,\n esophagitis, doudentitis, gastric ulcers in stomach body and antrum,\n hemmorrhoids, h pylori, GIB, vertigo, osteoarthritis\n Surgery / Procedure and date: EGD 06\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:59\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 580 mL\n 24h total out:\n 2,685 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 99 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 8 mg/dL\n 02:57 AM\n Creatinine:\n 0.7 mg/dL\n 02:57 AM\n Glucose:\n 114 mg/dL\n 02:57 AM\n Hematocrit:\n 28.2 %\n 08:50 AM\n Finger Stick Glucose:\n 152\n 12:00 PM\n Valuables / Signature\n Patient valuables: sent w/patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/\n Transferred to:\n Date & time of Transfer:\n"},{"category":"Physician ","chartdate":"2178-05-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":322776,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n - Remained hemodynamically stable\n - Hct trended: 34.5 -> 26.4 -> 21.4\n - Patient currently being transfused 2 units\n - Ortho attending this am: requesting CVL for CVP monitoring\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 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 06:30 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: 37.1\nC (98.7\n HR: 73 (73 - 106) bpm\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,518 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 230 mL\n Total out:\n 105 mL\n 85 mL\n Urine:\n 55 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 1,433 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 222\n 1.0\n 24\n 4.6\n 19\n 105\n 138\n 21.4 %\n [image002.jpg] Ca 7.7 Mag 1.4 Phos 3.7\n AM Labs pending\n 03:30 AM\n Hct\n 21.4\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n # Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - monitor peripheral pulses\n - PT consult requested for POD 2 or 3\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker (famotidine)\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322780,"text":"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the MICU\n for further monitoring\n Problem - Description In Comments\n Assessment:\n Pt with noted swelling of right hip, area is warm and skin taught to\n the touch, right foot cool though equally so to left, pedal pulses\n palpable, pt able to wiggle toes, hemovac in place in right hip,\n surgical dsg d&I, repeat hct this am with 4 point drop, u/o\n ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP:\n 94-122/42-57\n Action:\n Overnight pt received 2 500cc fluid boluses, ordered to receive 2\n UPRBC, first of two started at 0445, pt is a difficult venipuncture,\n this RN unable to obtain morning labs, HO attempted arterial stick,\n only able to obtain enough blood for 0330 hct, pt also receiving\n maintenance LR at 125/hr\n Response:\n Pt with some response in u/o with second FB, HR decreased with fluid\n adm, VSS\n Plan:\n Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip\n and dsg, PT consult tomorrow to obtain wedge pillow if appropriate,\n continue to provide fluid for goal u/o of 30cc/hr\n Pain control (acute pain, chronic pain)\n Assessment:\n Obtained pt very lethargic, as noted above while in PACU there was\n difficulty maintaining good pain control w/o over sedation, pt\ns mental\n status improving throughout the shift, able to report pain scored at\n , pain located in right hip\n Action:\n Minimizing pt turns and movements in bed, keeping right hip straight\n with pillow between legs, pt received 2 5mg doses of oxycodone with\n good effect\n Response:\n Pt sleeping comfortably throughout the shift, PRN pain medications with\n good effect\n Plan:\n Continue to monitor pain control, pt will likely require larger doses\n of pain medication with increased activity during the day\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322782,"text":"------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 07:14 ------\n"},{"category":"Physician ","chartdate":"2178-05-27 00:00:00.000","description":"Physician Attending Progress Note","row_id":322794,"text":"Chief Complaint: Postop bleeding\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 77 yo man s/p total hip arthroplasty. H/O GIB. EBL intraop 1.5L in OR\n got 3L LR, 2U PRBC. No known CAD. Normotensive in OR. Hct 34.5--> 24 in\n PACU (though different techniques).\n 24 Hour Events:\n Hemodynamically stable- no episodes of hypotension.\n Hct 34.5--> 26.4--> 21.4.\n Hemovac removed, site oozing.\n RN noted apneic episodes while sleeping.\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Neurologic: No(t) Numbness / tingling\n Pain: Moderate\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.8\nC (98.2\n HR: 70 (70 - 106) bpm\n BP: 113/53(67) {94/41(56) - 134/57(74)} mmHg\n RR: 13 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,663 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 375 mL\n Total out:\n 105 mL\n 180 mL\n Urine:\n 55 mL\n 150 mL\n NG:\n Stool:\n Drains:\n 50 mL\n 30 mL\n Balance:\n 420 mL\n 1,483 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, dry mucosa\n Cardiovascular: (S1: Normal), (S2: Distant), distant HS\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Tight and enlarged right thigh\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): all, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 21.4 %\n [image002.jpg]\n 03:30 AM\n Hct\n 21.4\n Assessment and Plan\n BLOOD LOSS\n 20% Hct drop postop. Hemodynamically stable but poor urine output.\n H/O GI bleed.\n No known significant cardiac history.\n Has received total of 4U PRBC and 4.6L crystalloid.\n Pending repeat hct to check response to transfusion. Needs more fluid\n resuscitation.\n Will place CVC.\n Obviously holding antihypertensive meds.\n Guaiac all stools.\n RISK OF COMPARTMENT SYNDROME\n Discuss with ortho. Exam difficult to guage.\n POSTOP PAIN MANAGEMENT\n PO diet.\n H2 blocker.\n Pneumoboots.\n FULL CODE.\n ICU Care\n Nutrition:\n Comments: PO diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 40\n"},{"category":"Rehab Services","chartdate":"2178-05-28 00:00:00.000","description":"Physical Therapy Progress Note","row_id":322952,"text":"Subjective:\n \", I'm better today.\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: Hct 24.2 after 6 units of pRBC. Getting 2\n additional units of pRBC today.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n T\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n PWB R LE, RW\n\n\n\n T\n\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 112\n 129/p\n 18\n 94% RA\n Activity\n Sit\n 115\n 142/78\n Recovery\n Sit\n 106\n 114/50\n 21\n 96%RA\n Total distance walked: N/A\n Minutes:\n Gait: Took few small steps with RW with min A x 1 and CG x 1, decreased\n cadence, decreased step length\n Balance: Seated: initially required max A at EOB 2' lateral and\n posterior LOB; with proper positioning and verbal cues, pt able to\n maintain with B UE support and CG.\n Standing: required B UE support and CG x 2.\n Education / Communication: Educated patient as to role of PT, transfer\n technique.\n Communicated with RN.\n Other: Clarification of Functional Status: Rolled with mod A x 1, sup\n to sit with mod A x 2, sit to stand with mod A x 2, trasferred via\n stand pivot with min A x 2 with RW.\n Assessment: Patient was more alert and able to participate with therapy\n today. Anticipate continued improvement as patients hematocrit rises\n and energy level improves. Patient continues to need aggressive rehab\n with PT/OT on d/c.\n Anticipated Discharge: Rehab\n Plan: Transfer train with RW, gait train with RW, ther-ex with PT co-op\n student, hip ROM, patient education.\n OOB to chair daily with RN with gait belt (can order through\n distribution #7711) and 2 person assist.\n"},{"category":"Physician ","chartdate":"2178-05-28 00:00:00.000","description":"Physician Resident and Attending Progress Note","row_id":322956,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr period with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n INR 1.0\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of the trachea to suggest a hematoma. Heart\n size is mildly enlarged and unchanged. Mild interstitial edema which\n was present on has resolved and there is no appreciable\n pleural effusion. Thoracic aorta is generally large and tortuous but\n not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct trend over 24 hours is\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\nd a total of 6\n units prbcs over 24 hours and is currently receiving 2 more units\n PRBCs. Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\n be done to rule out other areas of bleed (such as RP)\n - IVF/blood prn volume; patient appears dry on exam\n - As it is still not entirely clear if patient is bleeding anywhere\n other than his thigh, will check bladder pressure to monitor abdominal\n pressures as a measure to follow along with thigh diameter\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets.\n - Will continue to monitor pm CBC, if platelets lower, will consider\n platelet tx at that time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n Key issue is hct remains 24% despite 6U PRBC transfusion. Undergoing 2U\n more now. No change in thigh circumference and exam thigh seems less\n tight than yesterday. Pt c/o extreme pain, but on exam localizes to hip\n area. Will check bladder pressure just to have a baseline and continue\n to check thigh measurement if hct does not rise appropriately. Also\n check plt count with next hct. No indication for platelet transfusion\n now.\n Critically ill with persistent blood loss requiring close observation\n in MICU.\n Time: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:16 ------\n"},{"category":"Physician ","chartdate":"2178-05-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":323020,"text":"Chief Complaint:\n 24 Hour Events:\n -delay in getting second unit of PRBCs, awaiting repeat HCT/PLT,\n transfusion goal for PLTs <50K.\n -post Hct check is up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -ortho recs: if Hct not bumping, ok with imaging, hold lovenox, WBAT\n -bladder pressure 14\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable.\n - IVF/blood prn volume; patient appears dry on exam\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor pm CBC, if decreasing, can consider plt tx,\n no need at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Continue ICU monitoring for now, can consider c/o later\n today\n"},{"category":"Physician ","chartdate":"2178-05-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":323021,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n -delay in getting second unit of PRBCs, awaiting repeat HCT/PLT,\n transfusion goal for PLTs <50K.\n -post Hct check is up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -ortho recs: if Hct not bumping, ok with imaging, hold lovenox, WBAT\n -bladder pressure 14\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable.\n - IVF/blood prn volume; patient appears dry on exam\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor pm CBC, if decreasing, can consider plt tx,\n no need at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Continue ICU monitoring for now, can consider c/o later\n today\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322866,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Drainage from right lateral hip and thigh incision being monitored.\n Continuous hemodynamic monitoring in progress. Right IJ triple lumen\n central line insitu with CVP monitoring. Assess right thigh for extreme\n distention, thigh circumference measured for comparison, and distal\n pulses being assessed. Trending lab valve monitoring with necessary\n interventions.\n Action:\n Right IJ central line placed this am to facilitate monitoring of\n hemodynamic values. Central line care per protocol being maintained.VSS\n being done Q1hr. peripheral pulse assessment done q4hr as needed.\n Consented Blood transfusions given in relevance to lab values. Pad\n beneath right leg assessed frequently and changed as needed. Continue\n IV therapy as ordered.\n Response:\n No adverse reaction noted to blood transfusion, VSS remain within\n acceptable limits for patient. Dressing to right thigh soiled but\n intact. Two pads moderately saturated with bloody drainage changed over\n the last 12hours. Peripheral pulses remain weak but palpable with\n regular rate and rhythm. Urinary output has picked up and is within\n acceptable limits.\n Plan:\n Continue CVP monitoring and other hemodynamic assessments. IVF as\n ordered. Monitor urinary output and follow lab trends with appropriate\n interventions as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Monitor skin integrity, VSS and CVP values. Trend lab values\n comparatively. Monitor Mg, Na, k, and Ca levels. Observe for abnormal\n EKG rhythms.\n Action:\n Given Magnesium sulfate for Mg of 1.4 Also received Calcium gluconate\n for Ca of 7.7.\n Response:\n Some general non pitting edema noted. Urinary output remains adequate.\n Lab value have not deteriorated.\n Plan:\n Continue se\n Diabetes Mellitus (DM), Type II\n Assessment:\n Random blood sugar being monitored q4hr. Observe for signs of hyper or\n hypoglycemia.\n Action:\n Blood sugar being managed per sliding scale oral hypoglycemic on hold\n Response:\n Blood sugars have been within normal limits and pt has shown no signs\n of hyper or hypoglycemia\n Plan:\n Continue q4hr. blood glucose level and manage per sliding scale orders.\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":323008,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure .\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is\n WNL.. Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): 24in. B DP\ns & PT\ns are weakly palpable (no\n change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Thigh girth may be increased as different person is measuring it.\n Thigh girth up by 0.25in.\n Plan:\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\n etc.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n ------ Protected Section ------\n 0300 Hct 28.5, still stable.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:36 ------\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322833,"text":"Pain control (acute pain, chronic pain)\n Assessment:\n Patient able to verbalize discomfort. Noted increase pain with movement\n and to touch of the right thigh and hip. Obvious swelling to area\n surrounding incision evident same is warn too touch.\n Action:\n Physicians aware of patients pain issue. Currently receives Oxycodone\n 5-10mg po as needed. Can also have morphine IV, however patient\n reluctant to have same. States it makes him\nfunny in the head\n Response:\n Tolerating oral analgesic well, VSS remain WNL for client, and he is\n able to sleep intermittently. Can consider medicating prior to activity\n with clients consent.\n Plan:\n Continue to assess for discomfort through verbal inquiry and monitor\n for changes in V/S.\n"},{"category":"Rehab Services","chartdate":"2178-05-29 00:00:00.000","description":"Physical Therapy Progress Note","row_id":323061,"text":"Subjective:\n \"Today was better.\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: Pt. received 2uPRBC, w/ appropriate bump in Hct\n to 28.2. Pt called out and awaiting bed.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n PWB R LE\n\n\n\n\n T\n\n Ambulation:\n PWB R LE\n\n\n\n\n T\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 94\n 134/62\n 98% 2L\n Activity\n Stand\n 112\n 116/61\n 98% 2L\n Recovery\n Sit\n 96\n 125/56\n 96% 2L\n Total distance walked: 4 steps forwards and backwards, x2\n Minutes:\n Gait: Pt. ambulated w/ Mod A x1 and Min A x1- 4 steps forward and\n backward, x2. Pt. independently advanced BLE. Absent heel strike B,\n minimal circumduction of RLE to clear from floor, decreased step length\n and wide BOS.\n Pt. maintained WBing status w/o cues self limitations of pain.\n Pt. performed sit to stand transfer 3x, w/ Min A x2.\n Balance: -LOB during ambulation, increased postural sway during static\n standing, likely in pt. attempt to shift weight from RLE.\n Education / Communication: Pt: Role of PT, goals of treatment session,\n technique and sequencing w/ RW.\n Other:\n Assessment: 77 yo M s/p RTHR c/b diffuse blood loss post operatively is\n now progressing slowly, but well w/ PT. Pt. tolerated multiple sit to\n stand transfers today w/ decreased support since yesterday. Pt. also\n now advancing RLE w/o assist. Anticipate as medical stability\n improves, pt. will continue to progress daily with PT. Pt. remains a\n strong rehab canddate.\n Anticipated Discharge: Rehab\n Plan: Ther-Ex, transfers, ambulation w/ RW, balance, inc. endurance,\n wean O2.\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322756,"text":"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the MICU\n for further monitoring\n Problem - Description In Comments\n Assessment:\n Pt with noted swelling of right hip, area is warm and skin taught to\n the touch, right foot cool though equally so to left, pedal pulses\n palpable, pt able to wiggle toes, hemovac in place in right hip,\n surgical dsg d&I, repeat hct this am with 4 point drop, u/o\n ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP:\n 94-122/42-57\n Action:\n Overnight pt received 2 500cc fluid boluses, ordered to receive 2\n UPRBC, first of two started at 0445, pt is a difficult venipuncture,\n this RN unable to obtain morning labs, HO attempted arterial stick,\n only able to obtain enough blood for 0330 hct, pt also receiving\n maintenance LR at 125/hr\n Response:\n Pt with some response in u/o with second FB, HR decreased with fluid\n adm, VSS\n Plan:\n Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip\n and dsg, PT consult tomorrow to obtain wedge pillow if appropriate,\n continue to provide fluid for goal u/o of 30cc/hr\n Pain control (acute pain, chronic pain)\n Assessment:\n Obtained pt very lethargic, as noted above while in PACU there was\n difficulty maintaining good pain control w/o over sedation, pt\ns mental\n status improving throughout the shift, able to report pain scored at\n , pain located in right hip\n Action:\n Minimizing pt turns and movements in bed, keeping right hip straight\n with pillow between legs, pt received 2 5mg doses of oxycodone with\n good effect\n Response:\n Pt sleeping comfortably throughout the shift, PRN pain medications with\n good effect\n Plan:\n Continue to monitor pain control, pt will likely require larger doses\n of pain medication with increased activity during the day\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322750,"text":"Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322865,"text":"Pain control (acute pain, chronic pain)\n Assessment:\n Patient able to verbalize discomfort. Noted increase pain with movement\n and to touch of the right thigh and hip. Obvious swelling to area\n surrounding incision evident same is warn too touch.\n Action:\n Physicians aware of patients pain issue. Currently receives Oxycodone\n 5-10mg po as needed. Can also have morphine IV, however patient\n reluctant to have same. States it makes him\nfunny in the head\n Response:\n Tolerating oral analgesic well, VSS remain WNL for client, and he is\n able to sleep intermittently. Can consider medicating prior to activity\n with clients consent.\n Plan:\n Continue to assess for discomfort through verbal inquiry and monitor\n for changes in V/S.\n"},{"category":"Physician ","chartdate":"2178-05-26 00:00:00.000","description":"Physician Resident Admission Note","row_id":322739,"text":"TITLE:\n Chief Complaint: post-op bleeding\n HPI:\n 77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the \n for further monitoring after discussing with the ortho attending. The\n drainage in the hip drain was considered normal.\n Denies pain except for hip pain. no difficulty with breathing. other\n ROS not obtainable due to sedation.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Infusions:\n Cefazolin in PACU\n Other ICU medications:\n Other medications:\n amlodopine 10 mg daily\n diovan 160 mg daily\n glipizide 10 mg daily\n metformin 1000 mg \n actos 30 mg daily\n simvastatin 20 mg daily\n Past medical history:\n Family history:\n Social History:\n hypertension\n diabetes mellitus type 2\n hypercholesterolemia\n prostate cancer s/p XRT\n osteoarthritis\n GI bleed - Dieulafoy lesion \n diabetes\n Occupation:\n Drugs: none\n Tobacco: quit in after 20yrs of smoking\n Alcohol: 1 glass of wine per night\n Other: He is from , retired. He is married.\n Review of systems:\n Constitutional: No(t) Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Edema\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: Foley\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Jaundice\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: Headache\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: right hip\n Flowsheet Data as of 11:20 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 88 (88 - 106) bpm\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\n RR: 17 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 516 mL\n PO:\n TF:\n IVF:\n 516 mL\n Blood products:\n Total out:\n 0 mL\n 95 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 421 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, right hip wound pressure\n dressing, drain in place\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 8:17pm\n Na 138 Cl 105 BUN 19 Gluc 222 AGap=9\n K 4.6 CO2 24 Cr 1.0\n Ca: 7.7 Mg: 1.4 P: 3.7\n WBC 14.1 Hb 8.3 Hct 26.4 Plt179 MCV 85\n 11:41a\n Na 141 Cl 107 BUN 13 Gluc 113 AGap=8\n K 4.6 CO2 27 Cr 0.9\n estGFR: >75 (click for details)\n Ca: 8.3 Mg: 1.7 P: 4.0\n WBC 9.9 Hb 11.5 Hct 34.5 Plt 155 MCV 82\n Imaging: AP port CXR - low lung volumes. large heart. stable RLL\n opacity. mild increased pulmonary markings\n Microbiology: none\n ECG: sinus\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. currently appears to be\n stabilizing Hct over past 4 hours.\n - cycle Hct q6 for now\n - transfuse for <24% as this would likely suggest significant\n re-bleeding\n - guaiac all stools\n .\n Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - PT consult requested for POD 2 or 3\n DM2: adequate control for now.\n - hold metformin for now\n - hold actos for now\n - continue glipizide\n - RISS\n Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2178-05-26 00:00:00.000","description":"Physician Resident Admission Note","row_id":322740,"text":"TITLE: PGY2 Admit Note\n Chief Complaint: post-op bleeding\n HPI:\n 77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the \n for further monitoring after discussing with the ortho attending. The\n drainage in the hip drain was considered normal.\n Denies pain except for hip pain. no difficulty with breathing. other\n ROS not obtainable due to sedation.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Infusions:\n Cefazolin in PACU\n Other ICU medications:\n Other medications:\n amlodopine 10 mg daily\n diovan 160 mg daily\n glipizide 10 mg daily\n metformin 1000 mg \n actos 30 mg daily\n simvastatin 20 mg daily\n Past medical history:\n Family history:\n Social History:\n hypertension\n diabetes mellitus type 2\n hypercholesterolemia\n prostate cancer s/p XRT\n osteoarthritis\n GI bleed - Dieulafoy lesion \n diabetes\n Occupation:\n Drugs: none\n Tobacco: quit in after 20yrs of smoking\n Alcohol: 1 glass of wine per night\n Other: He is from , retired. He is married.\n Review of systems:\n Constitutional: No(t) Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Edema\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: Foley\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Jaundice\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: Headache\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: right hip\n Flowsheet Data as of 11:20 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 88 (88 - 106) bpm\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\n RR: 17 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 516 mL\n PO:\n TF:\n IVF:\n 516 mL\n Blood products:\n Total out:\n 0 mL\n 95 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 421 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present. Heme negative brown\n stool in vault\n Extremities: Right: Absent, Left: Absent, right hip wound pressure\n dressing, drain in place\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 8:17pm\n Na 138 Cl 105 BUN 19 Gluc 222 AGap=9\n K 4.6 CO2 24 Cr 1.0\n Ca: 7.7 Mg: 1.4 P: 3.7\n WBC 14.1 Hb 8.3 Hct 26.4 Plt179 MCV 85\n 11:41a\n Na 141 Cl 107 BUN 13 Gluc 113 AGap=8\n K 4.6 CO2 27 Cr 0.9\n estGFR: >75 (click for details)\n Ca: 8.3 Mg: 1.7 P: 4.0\n WBC 9.9 Hb 11.5 Hct 34.5 Plt 155 MCV 82\n Imaging: AP port CXR - low lung volumes. large heart. stable RLL\n opacity. mild increased pulmonary markings\n Microbiology: none\n ECG: sinus\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. currently appears to be\n stabilizing Hct over past 4 hours.\n - cycle Hct q6 for now\n - transfuse for <24% as this would likely suggest significant\n re-bleeding\n - guaiac all stools\n .\n Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - monitor peripheral pulses\n - PT consult requested for POD 2 or 3\n DM2: adequate control for now.\n - hold metformin for now\n - hold actos for now\n - continue glipizide\n - RISS\n Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2178-05-27 00:00:00.000","description":"Physician Attending Admission Note","row_id":322743,"text":"Chief Complaint: post-operative hct drop\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 77 year old man who came in today for an elective R THR and was found\n to have a drop in his hct from 44.3 (in ) to 34.5 (initial in the\n PACU) to 24. EBL 1500cc, 2 units PRBC given and 3 liters of LR.\n Operative course was uncomplicated but in the PACU received multiple\n pain meds. Drain output is not excessive. No BRBPR. No melena.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n amlopipine, glipizide, metformin, actose, simvastatin\n Past medical history:\n Family history:\n Social History:\n Prostate CA - s/p XRT\n h/o GIB - iulefoy's\n HTN\n DM\n OA\n DM\n Occupation: retired\n Drugs:\n Tobacco: stopped in , 20+ pack years\n Alcohol: 1 drink/night\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\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, Foley\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Rash\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 01:07 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: 37.3\nC (99.2\n HR: 88 (88 - 106) bpm\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\n RR: 17 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 8 mL\n PO:\n TF:\n IVF:\n 525 mL\n 8 mL\n Blood products:\n Total out:\n 105 mL\n 0 mL\n Urine:\n 55 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 8 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, sleepy but\n arousable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, guaiac negative\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: R hip with dressing and drain\n minimal amount of\n blood in drain\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): person, place, location, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 179\n 26.4\n 222\n 1.0\n 24\n 25\n 95\n 4.6\n 138\n 14.1\n [image002.jpg]\n Imaging: CXR - Low lung volumes, opacity in RRR, deviated trachea\n CT (pre-op) - + mediastinal nodes, patchy ground glass\n ECG: NSR, PR slightly prolonged, small volts in precordial leads, no\n acute ST/T wave changes\n Assessment and Plan\n Assessment - 77 year old man with low hct after R THR. Suspect much of\n this was actually intraoperative loss and then re-equilibration from\n IVF.\n 1. Anemia - Will need to be careful to watch for true post-operative\n bleeding - follow drain output, exam. Will follow hct q6 hours.\n Guaiac stools. Will call ortho if hct falls again and give more blood.\n 2. Post-op pain - will use dilaudid PCA when awake. For now, seems\n quite sedate and comfortable.\n 3. Hypertension - hold meds for now as was hypotensive and bleeding\n 4. DM - hold metformin & glyburide until eating, ISS but may need NPH\n 5. R THR - will talk to them about when to restart anticoagulation -\n will hold for now.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 09:30 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2178-05-28 00:00:00.000","description":"Nursing Progress Note","row_id":322900,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt cont to have moderate amounts of oozing from right hip dressing.\n Site appears to be the same in size and color.\n Action:\n Dressing reinforced, Pt received 1 unit PRBCs\n Response:\n No appropriate bump in Hct, but it remains stable at 24.\n Plan:\n Monitor Q6H Hcts, ? transfusing one more unit of blood. Surgery to\n change dressing.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o less pain overnight, only with movement and turning.\n Action:\n Pt medicated with 1mg IV Dilaudid x2\n Response:\n Pt slept comfortably between doses, easily arousable to voice. Pt able\n to turn better after medicating.\n Plan:\n Cont to monitor pain, prn Dilaudid or Oxycodone.\n"},{"category":"Physician ","chartdate":"2178-05-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":322932,"text":"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units,\n but said it's expected after such a bloody case. will need to\n re-address in AM\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\n unchanged. Mild interstitial edema which was present on has\n resolved and there is no appreciable pleural effusion. Thoracic aorta\n is generally large and tortuous but not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct trend over 24 hours is\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\nd a total of 6\n units prbcs over 24 hours and is currently receiving 2 more units\n PRBCs. Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\n be done to rule out other areas of bleed (such as RP)\n - IVF/blood prn volume; patient appears dry on exam\n - As it is still not entirely clear if patient is bleeding anywhere\n other than his thigh, will check bladder pressure to monitor abdominal\n pressures as a measure to follow along with thigh diameter (which has\n been stable).\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets.\n - Will continue to monitor pm CBC, if platelets lower, will consider\n platelet tx at that time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322988,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure .\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is WNL..\n Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): 24in. B DP\ns & PT\ns are weakly palpable (no\n change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Thigh girth may be increased as different person is measuring it.\n Thigh girth up by 0.25in.\n Plan:\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\n etc.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"},{"category":"Rehab Services","chartdate":"2178-05-27 00:00:00.000","description":"Physical Therapy Evaluation Note","row_id":322845,"text":"Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 715.95 / hip OA\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 77 y/o male adm \n for R THR 2' OA. Course was c/b post-operative bleeding. Received 6\n units of pRBC in the .\n Past Medical / Surgical History: DM2, increased chol, HTN, prostate CA,\n BPH, GIB, CHF\n Medications: insulin, oxycodone, morphine\n Radiology: CXR : borderine cardiac decompensation\n Labs:\n 22.8\n 8.3\n 179\n 14.1\n [image002.jpg]\n Other labs:\n Activity Orders: bedrest, R LE PWB\n Social / Occupational History: Married, supportive dtr\n Environment: Lives with wife and dtr, 1 level home, 1 FOS to\n enter\n Prior Functional Status / Activity Level: I PTA, amb without AD but\n with physical assist of another person, assist for ADLs, 1 fall 2 weeks\n ago\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, pleasant,\n cooperative, primary language is portuguese\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 89\n 119/65\n 17\n 100%\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n 90\n 134/56\n 17\n 97%\n Total distance walked: N/A\n Minutes:\n Pulmonary Status: NARD\n Integumentary / Vascular: R lateral hip incision covered with\n elastoplast, saturated with sanguinous drainage, foley, central line\n Sensory Integrity: grossly intact to LT\n Pain / Limiting Symptoms: c/o severe pain R hip with ROM\n Posture: supine in bed\n Range of Motion\n Muscle Performance\n WFL B UE except R shoulder flexion 100 degrees (limited by pain which\n started after surgery); WFL L LE; R LE ankle and knee WFL; R hip\n flexion 0-60 degrees flexion, IR to neutral\n B UE > except R shoulder flexors 3-/5\n L LE > , R LE: DF , quads \n Motor Function: moves all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Clarification: All mobility deferred 2' bedrest order, hematocrit of\n 22.8 with significant continued post-op bleeding and pain.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: N/A\n Education / Communication: Educated patient as to role of PT, PT plan\n of care.\n Communicated with RN.\n Intervention: Supine ther-ex x 10 reps: AP, hip rolls, hip AB/AD, SAQ,\n HS\n Other:\n Diagnosis:\n 1.\n Gait, Impaired\n 2.\n Muscle Performace, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Range of Motion, Impaired\n 5.\n Transfers, Impaired\n Clinical impression / Prognosis: Patient is a 77 y/o male adm for R THR\n c/b postoperative bleeding. Patient presents with above defecits\n consistent with joint arthroplasty. Anticipate that patient will need\n rehab on d/c despite limited evaluation today. Will follow up for\n further mobility assessment and to further assist with d/c planning\n Goals\n Time frame: 1 week\n 1.\n Roll with mod A\n 2.\n Sup to sit with mod A\n 3.\n Assess OOB\n 4.\n R hip ROM 0-90 degrees flexion, 25% IR, 10 degrees ER, 10 degrees AB\n 5.\n Independent with HEP\n 6.\n Indepently state hip precautions\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 5-7x/week x 1 week\n Assess mobility\n Transfer train\n R hip ROM\n ther-ex\n Patient education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322989,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure .\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is\n WNL.. Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): 24in. B DP\ns & PT\ns are weakly palpable (no\n change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Thigh girth may be increased as different person is measuring it.\n Thigh girth up by 0.25in.\n Plan:\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\n etc.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"},{"category":"Nursing","chartdate":"2178-05-27 00:00:00.000","description":"Nursing Progress Note","row_id":322841,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Drainage from right lateral hip and thigh incision being monitored.\n Continuous hemodynamic monitoring in progress. Right IJ triple lumen\n central line insitu with CVP monitoring. Assess right thigh for extreme\n distention, thigh circumference measured for comparison, and distal\n pulses being assessed. Trending lab valve monitoring with necessary\n interventions.\n Action:\n Right IJ central line placed this am to facilitate monitoring of\n hemodynamic values. Central line care per protocol being maintained.VSS\n being done Q1hr. peripheral pulse assessment done q4hr as needed.\n Consented Blood transfusions given in relevance to lab values. Pad\n beneath right leg assessed frequently and changed as needed. Continue\n IV therapy as ordered.\n Response:\n No adverse reaction noted to blood transfusion, VSS remain within\n acceptable limits for patient. Dressing to right thigh soiled but\n intact. Two pads moderately saturated with bloody drainage changed over\n the last 12hours. Peripheral pulses remain weak but palpable with\n regular rate and rhythm. Urinary output has picked up and is within\n acceptable limits.\n Plan:\n Continue CVP monitoring and other hemodynamic assessments. IVF as\n ordered. Monitor urinary output and follow lab trends with appropriate\n interventions as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Monitor skin integrity, VSS and CVP values. Trend lab values\n comparatively. Monitor Mg, Na, k, and Ca levels. Observe for abnormal\n EKG rhythms.\n Action:\n Given Magnesium sulfate for Mg of 1.4 Also received Calcium gluconate\n for Ca of 7.7.\n Response:\n Some general non pitting edema noted. Urinary output remains adequate.\n Lab value have not deteriorated.\n Plan:\n Continue se\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322982,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Plan:\n Transfuse for Hct <24.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322983,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is mildly\n elevated (in range).\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Plan:\n Transfuse for Hct <24.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322984,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is mildly\n elevated (in range). Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Plan:\n Transfuse for Hct <24.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322979,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.5 (up from 24. ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Response:\n Plan:\n Continue to check thigh girths & monitor for compartment syndrome.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 6 units PC\n since that time. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p\n XRT.\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322980,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Response:\n Plan:\n Continue to check thigh girths & monitor for compartment syndrome.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 6 units PC\n since that time. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p\n XRT.\n"},{"category":"Nursing","chartdate":"2178-05-29 00:00:00.000","description":"Nursing Progress Note","row_id":322981,"text":"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Response:\n Plan:\n Continue to check thigh girths & monitor for compartment syndrome.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.2 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 322918,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n MULTI LUMEN - START 11:35 AM\\n tripple lumen central line placed successfully with normal f/u Xray\\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\\n effect, then did not require any more pain meds till midnight. pulses\\n good. thigh diameter mainatined at 23.75 inches\\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\\n HCT. Ortho aware that there was no significant increase after 2 units,\\n but said it's expected after such a bloody case. will need to\\n re-address in AM\\n - Had CVL placed\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37\\nC (98.6\\n HR: 82 (66 - 118) bpm\\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\\n RR: 12 (8 - 21) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 5 (0 - 11)mmHg\\n Total In:\\n 4,421 mL\\n 268 mL\\n PO:\\n 480 mL\\n 100 mL\\n TF:\\n IVF:\\n 2,463 mL\\n 168 mL\\n Blood products:\\n 1,478 mL\\n Total out:\\n 1,460 mL\\n 1,630 mL\\n Urine:\\n 1,430 mL\\n 1,630 mL\\n NG:\\n Stool:\\n Drains:\\n 30 mL\\n Balance:\\n 2,961 mL\\n -1,362 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 97 K/uL\\n 8.7 g/dL\\n 123 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 104 mEq/L\\n 139 mEq/L\\n 24.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n WBC\\n 9.7\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n Plt\\n 97\\n Cr\\n 0.8\\n Glucose\\n 123\\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\\n mg/dL, PO4:2.3 mg/dL\\n Imaging: IMPRESSION: AP chest compared to :\\n New right internal jugular central venous line ends at the superior\\n cavoatrial junction. Mild widening of the mediastinum to the right of\\n the midline is probably venous engorgement since there is no\\n contralateral displacement of\\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\\n unchanged. Mild interstitial edema which was present on has\\n resolved and there is no appreciable pleural effusion. Thoracic aorta\\n is generally large and tortuous but not focally dilated.\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\\n stool output yet to suggest GI source. Hct with acute drop overnight\\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\\n Orthopedics aware this morning.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - CVL today for more definitive access as patient with only one working\\n PIV at this time (also very hard peripheral stick). Will also aid with\\n overall volume monitoring\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - Touch base with orthopedics later this morning to confirm they do not\\n want further imaging/? If they would like to assess pressure in right\\n thigh with probe\\n - Awaiting am labs until CVL placed as unable to draw blood\\n peripherally\\n - IVF/blood prn volume; patient appears dry on exam\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, additional morphine being careful to avoid\\n sedation/somnolence\\n - Ortho recs\\n - PA/lat hip films final read\\n - Continue peri-op prophylactic antibiotics.\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT consult requested for POD 2 or 3 once acute issues resolved\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 322920,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n MULTI LUMEN - START 11:35 AM\\n tripple lumen central line placed successfully with normal f/u Xray\\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\\n effect, then did not require any more pain meds till midnight. pulses\\n good. thigh diameter mainatined at 23.75 inches\\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\\n HCT. Ortho aware that there was no significant increase after 2 units,\\n but said it's expected after such a bloody case. will need to\\n re-address in AM\\n - Had CVL placed\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37\\nC (98.6\\n HR: 82 (66 - 118) bpm\\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\\n RR: 12 (8 - 21) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 5 (0 - 11)mmHg\\n Total In:\\n 4,421 mL\\n 268 mL\\n PO:\\n 480 mL\\n 100 mL\\n TF:\\n IVF:\\n 2,463 mL\\n 168 mL\\n Blood products:\\n 1,478 mL\\n Total out:\\n 1,460 mL\\n 1,630 mL\\n Urine:\\n 1,430 mL\\n 1,630 mL\\n NG:\\n Stool:\\n Drains:\\n 30 mL\\n Balance:\\n 2,961 mL\\n -1,362 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Gen:\\n CV:\\n PULM:\\n ABD:\\n EXT:\\n Labs / Radiology\\n 97 K/uL\\n 8.7 g/dL\\n 123 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 104 mEq/L\\n 139 mEq/L\\n 24.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n WBC\\n 9.7\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n Plt\\n 97\\n Cr\\n 0.8\\n Glucose\\n 123\\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\\n mg/dL, PO4:2.3 mg/dL\\n Imaging: IMPRESSION: AP chest compared to :\\n New right internal jugular central venous line ends at the superior\\n cavoatrial junction. Mild widening of the mediastinum to the right of\\n the midline is probably venous engorgement since there is no\\n contralateral displacement of\\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\\n unchanged. Mild interstitial edema which was present on has\\n resolved and there is no appreciable pleural effusion. Thoracic aorta\\n is generally large and tortuous but not focally dilated.\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\\n stool output yet to suggest GI source. Hct with acute drop overnight\\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\\n Orthopedics aware this morning.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - CVL today for more definitive access as patient with only one working\\n PIV at this time (also very hard peripheral stick). Will also aid with\\n overall volume monitoring\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - Touch base with orthopedics later this morning to confirm they do not\\n want further imaging/? If they would like to assess pressure in right\\n thigh with probe\\n - Awaiting am labs until CVL placed as unable to draw blood\\n peripherally\\n - IVF/blood prn volume; patient appears dry on exam\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, additional morphine being careful to avoid\\n sedation/somnolence\\n - Ortho recs\\n - PA/lat hip films final read\\n - Continue peri-op prophylactic antibiotics.\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT consult requested for POD 2 or 3 once acute issues resolved\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition: PO\\n Glycemic Control: PO\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Famotidine\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 322933,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n MULTI LUMEN - START 11:35 AM\\n tripple lumen central line placed successfully with normal f/u Xray\\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\\n effect, then did not require any more pain meds till midnight. pulses\\n good. thigh diameter mainatined at 23.75 inches\\n - Received 4 units of pRBC in 24 hr period with only 1.5 pt increase in\\n HCT. Ortho aware that there was no significant increase after 2 units\\n - Had CVL placed\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37\\nC (98.6\\n HR: 82 (66 - 118) bpm\\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\\n RR: 12 (8 - 21) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 5 (0 - 11)mmHg\\n Total In:\\n 4,421 mL\\n 268 mL\\n PO:\\n 480 mL\\n 100 mL\\n TF:\\n IVF:\\n 2,463 mL\\n 168 mL\\n Blood products:\\n 1,478 mL\\n Total out:\\n 1,460 mL\\n 1,630 mL\\n Urine:\\n 1,430 mL\\n 1,630 mL\\n NG:\\n Stool:\\n Drains:\\n 30 mL\\n Balance:\\n 2,961 mL\\n -1,362 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Gen:\\n CV:\\n PULM:\\n ABD:\\n EXT:\\n Labs / Radiology\\n 97 K/uL\\n 8.7 g/dL\\n 123 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 104 mEq/L\\n 139 mEq/L\\n 24.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n INR 1.0\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n WBC\\n 9.7\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n Plt\\n 97\\n Cr\\n 0.8\\n Glucose\\n 123\\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\\n mg/dL, PO4:2.3 mg/dL\\n Imaging: IMPRESSION: AP chest compared to :\\n New right internal jugular central venous line ends at the superior\\n cavoatrial junction. Mild widening of the mediastinum to the right of\\n the midline is probably venous engorgement since there is no\\n contralateral displacement of the trachea to suggest a hematoma. Heart\\n size is mildly enlarged and unchanged. Mild interstitial edema which\\n was present on has resolved and there is no appreciable\\n pleural effusion. Thoracic aorta is generally large and tortuous but\\n not focally dilated.\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\\n output yet to suggest GI source. Hct trend over 24 hours is\\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\\nd a total of 6\\n units prbcs over 24 hours and is currently receiving 2 more units\\n PRBCs. Orthopedics aware this morning.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - Continue to monitor thigh diameter, has been stable\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\\n be done to rule out other areas of bleed (such as RP)\\n - IVF/blood prn volume; patient appears dry on exam\\n - As it is still not entirely clear if patient is bleeding anywhere\\n other than his thigh, will check bladder pressure to monitor abdominal\\n pressures as a measure to follow along with thigh diameter\\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\\n platelets.\\n - Will continue to monitor pm CBC, if platelets lower, will consider\\n platelet tx at that time\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, oxycodone and dilaudid being careful to\\n avoid sedation/somnolence\\n - Ortho recs\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT consult requested for POD 2 or 3 once acute issues resolved\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition: PO\\n Glycemic Control: ISS\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Famotidine\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-05-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 124465,\n \"text\": \"Sinus rhythm. P-R interval prolongation. Since the previous tracing\\nof there is no significant change.\\n\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 322800,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n - Remained hemodynamically stable\\n - Hct trended: 34.5 -> 26.4 -> 21.4\\n - Patient currently being transfused 2 units\\n - Ortho attending this am: requesting CVL for CVP monitoring\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 02:00 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 06:30 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: 37.1\\nC (98.7\\n HR: 73 (73 - 106) bpm\\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\\n RR: 14 (10 - 17) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 525 mL\\n 1,518 mL\\n PO:\\n TF:\\n IVF:\\n 525 mL\\n 1,288 mL\\n Blood products:\\n 230 mL\\n Total out:\\n 105 mL\\n 85 mL\\n Urine:\\n 55 mL\\n 85 mL\\n NG:\\n Stool:\\n Drains:\\n 50 mL\\n Balance:\\n 420 mL\\n 1,433 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n Gen: NAD\\n CV: RRR, no m/r/g\\n Pulm: CTAB anteriorly\\n Abd: Soft, NTND, obese\\n Ext: L thigh with tense skin, much larger than right, wound dressed and\\n intact, peripheral pulses full and symmetric bilat\\n Labs / Radiology\\n 222\\n 1.0\\n 24\\n 4.6\\n 19\\n 105\\n 138\\n 21.4 %\\n [image002.jpg] Ca 7.7 Mag 1.4 Phos 3.7\\n AM Labs pending\\n 03:30 AM\\n Hct\\n 21.4\\n Microbiology: No new\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\\n stool output yet to suggest GI source. Hct with acute drop overnight\\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\\n Orthopedics aware this morning.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - CVL today for more definitive access as patient with only one working\\n PIV at this time (also very hard peripheral stick). Will also aid with\\n overall volume monitoring\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - Touch base with orthopedics later this morning to confirm they do not\\n want further imaging/? If they would like to assess pressure in right\\n thigh with probe\\n - Awaiting am labs until CVL placed as unable to draw blood\\n peripherally\\n - IVF/blood prn volume; patient appears dry on exam\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, additional morphine being careful to avoid\\n sedation/somnolence\\n - Ortho recs\\n - PA/lat hip films final read\\n - Continue peri-op prophylactic antibiotics.\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT consult requested for POD 2 or 3 once acute issues resolved\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition: PO as tolerated\\n Glycemic Control: ISS, holding oral meds\\n Lines:\\n 18 Gauge - 09:30 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker (famotidine)\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Case Management \",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Case Managment Initial Patient Assessment\",\n \"row_id\": 322809,\n \"text\": \"Insurance information\\n Primary insurance: EverCare\\n Secondary insurance:\\n Insurance reviewer::\\n Free Care application: N/A\\n Status:\\n Medicaid application: N/A\\n Pre-Hospitalization services: None known prior to admission\\n DME / Home O[2]: none prior to admission\\n Functional Status / Home / Family Assessment:\\n Pt. lives with his family in . He is independent with all\\n personal care ADL's. His primary language is Portugese\\n Primary Contact(s): (son) \\n Health Care Proxy: .\\n Dialysis: Yes\\n Referrals Recommended: Physical Therapy, Occupational Therapy\\n Current plan: Undetermined\\n Unclear what level of services will be required at discharge. Case\\n Management will follow for DC needs, The patient did have a stay at\\n in .\\n Patient (s) to Discharge:\\n Patient discussed with multidisciplinary team: No\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Physician Resident and Attending Progress Note\",\n \"row_id\": 323055,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n -Post Hct check up to 27.6 from 24, a bump but not appropriate for 2\\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\\n 28.4\\n -Ortho recs: Hold lovenox, WBAT\\n -bladder pressure 14->7->6\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:28 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: 37.2\\nC (99\\n HR: 83 (83 - 114) bpm\\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\\n RR: 16 (13 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 14 (5 - 15)mmHg\\n Bladder pressure: 7 (6 - 14) mmHg\\n Total In:\\n 2,194 mL\\n 40 mL\\n PO:\\n 1,060 mL\\n TF:\\n IVF:\\n 384 mL\\n 40 mL\\n Blood products:\\n 750 mL\\n Total out:\\n 5,580 mL\\n 1,020 mL\\n Urine:\\n 5,580 mL\\n 1,020 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,386 mL\\n -980 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///34/\\n Physical Examination\\n Gen: NAD, AAOx3\\n CV: RRR, no m/r/g\\n Pulm: CTAB anteriorly\\n Abd: Soft, NTND, obese\\n Ext: L thigh with tense skin, larger than right, wound dressed and\\n intact, peripheral pulses full and symmetric bilat, pain on deep\\n palpation of R thigh, though improved from prior\\n Labs / Radiology\\n 125 K/uL\\n 9.9 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 8 mg/dL\\n 99 mEq/L\\n 137 mEq/L\\n 28.5 %\\n 9.5 K/uL\\n [image002.jpg]\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n 06:45 PM\\n 11:54 PM\\n 02:57 AM\\n WBC\\n 9.7\\n 9.5\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n 27.6\\n 27.8\\n 28.5\\n Plt\\n 97\\n 121\\n 125\\n Cr\\n 0.8\\n 0.7\\n Glucose\\n 123\\n 114\\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:1.6 mg/dL\\n Imaging: No new\\n Microbiology: No new\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\\n output yet to suggest GI source. Hct increased to 28.4 this morning\\n from 24 after 2 units. Has been stable over two measurements. Patient\\n has rec\\nd a total of 8 units prbcs since admission. Orthopedics saw\\n patient this morning, recommended continue monitoring, WBAT.\\n - Continue to cycle Hct q6 today\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - Continue to monitor thigh diameter, has been stable at 24in.\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - No need for further imaging at this point as Hct stable\\n - IVF/blood prn volume; patient is tolerating PO\\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\\n platelets. Improved without transfusion.\\n - Will continue to monitor, if decreasing, can consider plt tx, no need\\n at this time\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, oxycodone and dilaudid being careful to\\n avoid sedation/somnolence\\n - Ortho recs\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT recommending rehab\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated, aggressive\\n bowel regimen\\n ICU Care\\n Nutrition:\\n PO, diabetic diet\\n Glycemic Control: ISS\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Famotidine\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: c/o to ortho today\\n ------ Protected Section ------\\n I saw and examined the patient, and was physically present with the ICU\\n resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan. PMH, SH, FH and ROS are\\n unchanged from admission except where noted above and below.\\n Key points:\\n - hct stable now, rose with transfusions. Plt count higher on repeat\\n check.\\n - pain much better controlled\\n - safe for transfer to floor.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 14:58 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 323064,\n \"text\": \"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\\n and GI bleed presents following right total hip arthroplasty\\n complicated by post-operative bleeding\\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\\n limb girth 23in\\n Action:\\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\\n Response:\\n No s/s of bleeding, repeated Hct-28.2\\n Plan:\\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\\n w/pain meds\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n c/o abd pain- distention and rt hip pain, unable to score due to\\n language barrier.\\n Action:\\n prn oxycodone, Tylenol q6hr, reposition and support the limb\\n Response:\\n Intermittent pain as low as 0/10.\\n Plan:\\n Continue w/ pain assessment, pain meds prn, and reposition and ambulate\\n when possible.\\n Neuro: a/oX , speaking, understands some English, Right\\n lower extremity: Partial weight bearing.\\n Resp: NC 2L sats at 96-98%, bil LS clear, diminished at the bases, IS\\n use and DB/coughing encouraged.\\n Cardio: denies CP or SOB, pneumoboots on, LE edema, peripheral pulses\\n present w/Doppler.\\n GU: foley w/clear yellow urine w/adequate amnt of urine.\\n GI. Abd soft distended, positive for BS and flatus, started on bowel\\n regimen., regular diabetic diet- tolerates well no N?V.\\n Pain: c/o abd discomfort\\nbloated\\n and intermittent RT hip pain- on\\n Tylenol q6hr and oxycodone prn.\\n Skin: rat hip incision w/staples, mild-moderate serosang drainage. 2\\n skin tears over rt thigh and RLQ abd w/dsd and tegaderm.\\n Patient due to have Xray of his hip prior to discharge. Will be done on\\n the floor.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n RIGHT HIP OSTEOARTHRITIS/SDA\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 109 kg\\n Daily weight:\\n Allergies/Reactions:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Precautions:\\n PMH: Anemia, Diabetes - Oral , GI Bleed\\n CV-PMH: Hypertension\\n Additional history: prostate ca s/p xrt from 99-00, BPH, gastritis,\\n esophagitis, doudentitis, gastric ulcers in stomach body and antrum,\\n hemmorrhoids, h pylori, GIB, vertigo, osteoarthritis\\n Surgery / Procedure and date: EGD 06\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:151\\n D:59\\n Temperature:\\n 99.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 89 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 99% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 50% %\\n 24h total in:\\n 580 mL\\n 24h total out:\\n 2,685 mL\\n Pertinent Lab Results:\\n Sodium:\\n 137 mEq/L\\n 02:57 AM\\n Potassium:\\n 3.7 mEq/L\\n 02:57 AM\\n Chloride:\\n 99 mEq/L\\n 02:57 AM\\n CO2:\\n 34 mEq/L\\n 02:57 AM\\n BUN:\\n 8 mg/dL\\n 02:57 AM\\n Creatinine:\\n 0.7 mg/dL\\n 02:57 AM\\n Glucose:\\n 114 mg/dL\\n 02:57 AM\\n Hematocrit:\\n 28.2 %\\n 08:50 AM\\n Finger Stick Glucose:\\n 152\\n 12:00 PM\\n Valuables / Signature\\n Patient valuables: sent w/patient\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU/\\n Transferred to: R12\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322967,\n \"text\": \"Electrolyte & fluid disorder, other\\n Assessment:\\n Trend lab values, monitor for change in hemodynamics and v/s.\\n Action:\\n Patient given calcium carbonate x3 dose for low Ca. MgSO4 x1 today.\\n Response:\\n Patient remains free of arrhythmia or any other symptoms at this time\\n urinary output has been adequate and v/s remain stable. Patient denies\\n any discomfort at this time.\\n Plan:\\n Monitor lab values and treated as order by other health care provider.\\n , acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n V/S being doing q1hr and prn. Urinary output checked hourly and trends\\n evaluated. Lab values also being monitored.\\n Action:\\n Received 2units of blood today with pending checks for improvement.\\n Response:\\n Patient\\ns v/s remains stable for client. Continues on O2 via NC and\\n saturating welll. No obvious signs of bleeding noted. No BM this shift.\\n Plan:\\n Continue with blood transfusions as ordered by physician and monitor\\n /s and fluid status.\\n Problem - Hip surgery\\n Assessment:\\n Observe wound dressing for drainage, measure limb for increase in\\n diameter. Monitor pulses\\n Action:\\n Dressing to right hip changed, area cleansed and dressed with ABD and\\n mepore tape\\n Response:\\n Patient tolerated procedure well. Has had moderate amount of drainage\\n from incision site. Dressing dry and intact at this time.\\n Plan:\\n Continue to monitor for fluid loss and observe limb for increase in\\n size. Monitor pulses distal to wound. Monitory v/s\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 322775,\n \"text\": \"Chief Complaint: s\\n 24 Hour Events:\\n - Remained hemodynamically stable\\n - Hct trended: 34.5 -> 26.4 -> 21.4\\n - Patient currently being transfused 2 units\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 02:00 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 06:30 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: 37.1\\nC (98.7\\n HR: 73 (73 - 106) bpm\\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\\n RR: 14 (10 - 17) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 525 mL\\n 1,518 mL\\n PO:\\n TF:\\n IVF:\\n 525 mL\\n 1,288 mL\\n Blood products:\\n 230 mL\\n Total out:\\n 105 mL\\n 85 mL\\n Urine:\\n 55 mL\\n 85 mL\\n NG:\\n Stool:\\n Drains:\\n 50 mL\\n Balance:\\n 420 mL\\n 1,433 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 21.4 %\\n [image002.jpg]\\n 03:30 AM\\n Hct\\n 21.4\\n Microbiology: No new\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: likely secondary to surgical bleeding. no\\n stool output yet to suggest GI source. Hct with acute drop overnight\\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\\n Orthopedics aware.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n # Osteoarthritis s/p THA: now POD#O from surgery.\\n pain control with tylenol, additional morphine\\n - ortho recs\\n - PA/lat hip films\\n - peri-op prophylactic antibiotics.\\n - hold LMWH for now\\n - monitor peripheral pulses\\n - PT consult requested for POD 2 or 3\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:30 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker (famotidine)\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 323042,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n -Post Hct check up to 27.6 from 24, a bump but not appropriate for 2\\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\\n 28.4\\n -Ortho recs: Hold lovenox, WBAT\\n -bladder pressure 14->7->6\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:28 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: 37.2\\nC (99\\n HR: 83 (83 - 114) bpm\\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\\n RR: 16 (13 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 14 (5 - 15)mmHg\\n Bladder pressure: 7 (6 - 14) mmHg\\n Total In:\\n 2,194 mL\\n 40 mL\\n PO:\\n 1,060 mL\\n TF:\\n IVF:\\n 384 mL\\n 40 mL\\n Blood products:\\n 750 mL\\n Total out:\\n 5,580 mL\\n 1,020 mL\\n Urine:\\n 5,580 mL\\n 1,020 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,386 mL\\n -980 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///34/\\n Physical Examination\\n Gen: NAD, AAOx3\\n CV: RRR, no m/r/g\\n Pulm: CTAB anteriorly\\n Abd: Soft, NTND, obese\\n Ext: L thigh with tense skin, larger than right, wound dressed and\\n intact, peripheral pulses full and symmetric bilat, pain on deep\\n palpation of R thigh, though improved from prior\\n Labs / Radiology\\n 125 K/uL\\n 9.9 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 8 mg/dL\\n 99 mEq/L\\n 137 mEq/L\\n 28.5 %\\n 9.5 K/uL\\n [image002.jpg]\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n 06:45 PM\\n 11:54 PM\\n 02:57 AM\\n WBC\\n 9.7\\n 9.5\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n 27.6\\n 27.8\\n 28.5\\n Plt\\n 97\\n 121\\n 125\\n Cr\\n 0.8\\n 0.7\\n Glucose\\n 123\\n 114\\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:1.6 mg/dL\\n Imaging: No new\\n Microbiology: No new\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\\n output yet to suggest GI source. Hct increased to 28.4 this morning\\n from 24 after 2 units. Has been stable over two measurements. Patient\\n has rec\\nd a total of 8 units prbcs since admission. Orthopedics saw\\n patient this morning, recommended continue monitoring, WBAT.\\n - Continue to cycle Hct q6 today\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - Continue to monitor thigh diameter, has been stable at 24in.\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - No need for further imaging at this point as Hct stable\\n - IVF/blood prn volume; patient is tolerating PO\\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\\n platelets. Improved without transfusion.\\n - Will continue to monitor, if decreasing, can consider plt tx, no need\\n at this time\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, oxycodone and dilaudid being careful to\\n avoid sedation/somnolence\\n - Ortho recs\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT recommending rehab\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated, aggressive\\n bowel regimen\\n ICU Care\\n Nutrition:\\n PO, diabetic diet\\n Glycemic Control: ISS\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Famotidine\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: c/o to ortho today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 323044,\n \"text\": \"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\\n and GI bleed presents following right total hip arthroplasty\\n complicated by post-operative bleeding\\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\\n limb girth 23in\\n Action:\\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\\n Response:\\n No s/s of bleeding, repeated Hct-28.2\\n Plan:\\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\\n w/pain meds\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n c/o abd pain- destantion and rt hip pain , unable to score due to\\n language barrier.\\n Action:\\n prn oxycodone, Tylenol q6hr, reposition and support the limb\\n Response:\\n Intermittent pain as low as 0/10.\\n Plan:\\n Continue w/ pain assessment, pain meds prn, reposition and ambulate\\n when possible.\\n Neuro: a/\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 323046,\n \"text\": \"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\\n and GI bleed presents following right total hip arthroplasty\\n complicated by post-operative bleeding\\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\\n limb girth 23in\\n Action:\\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\\n Response:\\n No s/s of bleeding, repeated Hct-28.2\\n Plan:\\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\\n w/pain meds\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n c/o abd pain- distention and rt hip pain, unable to score due to\\n language barrier.\\n Action:\\n prn oxycodone, Tylenol q6hr, reposition and support the limb\\n Response:\\n Intermittent pain as low as 0/10.\\n Plan:\\n Continue w/ pain assessment, pain meds prn, and reposition and ambulate\\n when possible.\\n Neuro: a/oX , speaking, understands some English, Right\\n lower extremity: Partial weight bearing.\\n Resp: NC 2L sats at 96-98%, bil LS clear, diminished at the bases, IS\\n use and DB/coughing encouraged.\\n Cardio: denies CP or SOB, pneumoboots on, LE edema, peripheral pulses\\n present w/Doppler.\\n GU: foley w/clear yellow urine w/adequate amnt of urine.\\n GI. Abd soft distended, positive for BS and flatus, started on bowel\\n regimen., regular diabetic diet- tolerates well no N?V.\\n Pain: c/o abd discomfort\\nbloated\\n and intermittent RT hip pain- on\\n Tylenol q6hr and oxycodone prn.\\n Skin: rat hip incision w/staples, mild-moderate serosang drainage. 2\\n skin tears over rt thigh and RLQ abd w/dsd and tegaderm.\\n Patient due to have Xray of his hip prior to discharge. Will be done on\\n the floor.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n RIGHT HIP OSTEOARTHRITIS/SDA\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 109 kg\\n Daily weight:\\n Allergies/Reactions:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Precautions:\\n PMH: Anemia, Diabetes - Oral , GI Bleed\\n CV-PMH: Hypertension\\n Additional history: prostate ca s/p xrt from 99-00, BPH, gastritis,\\n esophagitis, doudentitis, gastric ulcers in stomach body and antrum,\\n hemmorrhoids, h pylori, GIB, vertigo, osteoarthritis\\n Surgery / Procedure and date: EGD 06\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:151\\n D:59\\n Temperature:\\n 99.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 89 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 99% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 50% %\\n 24h total in:\\n 580 mL\\n 24h total out:\\n 2,685 mL\\n Pertinent Lab Results:\\n Sodium:\\n 137 mEq/L\\n 02:57 AM\\n Potassium:\\n 3.7 mEq/L\\n 02:57 AM\\n Chloride:\\n 99 mEq/L\\n 02:57 AM\\n CO2:\\n 34 mEq/L\\n 02:57 AM\\n BUN:\\n 8 mg/dL\\n 02:57 AM\\n Creatinine:\\n 0.7 mg/dL\\n 02:57 AM\\n Glucose:\\n 114 mg/dL\\n 02:57 AM\\n Hematocrit:\\n 28.2 %\\n 08:50 AM\\n Finger Stick Glucose:\\n 152\\n 12:00 PM\\n Valuables / Signature\\n Patient valuables: sent w/patient\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU/\\n Transferred to:\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 322776,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n - Remained hemodynamically stable\\n - Hct trended: 34.5 -> 26.4 -> 21.4\\n - Patient currently being transfused 2 units\\n - Ortho attending this am: requesting CVL for CVP monitoring\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 02:00 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 06:30 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: 37.1\\nC (98.7\\n HR: 73 (73 - 106) bpm\\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\\n RR: 14 (10 - 17) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 525 mL\\n 1,518 mL\\n PO:\\n TF:\\n IVF:\\n 525 mL\\n 1,288 mL\\n Blood products:\\n 230 mL\\n Total out:\\n 105 mL\\n 85 mL\\n Urine:\\n 55 mL\\n 85 mL\\n NG:\\n Stool:\\n Drains:\\n 50 mL\\n Balance:\\n 420 mL\\n 1,433 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 222\\n 1.0\\n 24\\n 4.6\\n 19\\n 105\\n 138\\n 21.4 %\\n [image002.jpg] Ca 7.7 Mag 1.4 Phos 3.7\\n AM Labs pending\\n 03:30 AM\\n Hct\\n 21.4\\n Microbiology: No new\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: likely secondary to surgical bleeding. no\\n stool output yet to suggest GI source. Hct with acute drop overnight\\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\\n Orthopedics aware.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n # Osteoarthritis s/p THA: now POD#O from surgery.\\n pain control with tylenol, additional morphine\\n - ortho recs\\n - PA/lat hip films\\n - peri-op prophylactic antibiotics.\\n - hold LMWH for now\\n - monitor peripheral pulses\\n - PT consult requested for POD 2 or 3\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:30 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker (famotidine)\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322780,\n \"text\": \"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\\n and GI bleed presents following right total hip arthroplasty\\n complicated by post-operative bleeding.\\n .\\n He underwent elective right THA earlier today. Estimated intra-op blood\\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\\n At 7:45pm his spun hematocrit was 24. He was transfered to the MICU\\n for further monitoring\\n Problem - Description In Comments\\n Assessment:\\n Pt with noted swelling of right hip, area is warm and skin taught to\\n the touch, right foot cool though equally so to left, pedal pulses\\n palpable, pt able to wiggle toes, hemovac in place in right hip,\\n surgical dsg d&I, repeat hct this am with 4 point drop, u/o\\n ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP:\\n 94-122/42-57\\n Action:\\n Overnight pt received 2 500cc fluid boluses, ordered to receive 2\\n UPRBC, first of two started at 0445, pt is a difficult venipuncture,\\n this RN unable to obtain morning labs, HO attempted arterial stick,\\n only able to obtain enough blood for 0330 hct, pt also receiving\\n maintenance LR at 125/hr\\n Response:\\n Pt with some response in u/o with second FB, HR decreased with fluid\\n adm, VSS\\n Plan:\\n Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip\\n and dsg, PT consult tomorrow to obtain wedge pillow if appropriate,\\n continue to provide fluid for goal u/o of 30cc/hr\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Obtained pt very lethargic, as noted above while in PACU there was\\n difficulty maintaining good pain control w/o over sedation, pt\\ns mental\\n status improving throughout the shift, able to report pain scored at\\n , pain located in right hip\\n Action:\\n Minimizing pt turns and movements in bed, keeping right hip straight\\n with pillow between legs, pt received 2 5mg doses of oxycodone with\\n good effect\\n Response:\\n Pt sleeping comfortably throughout the shift, PRN pain medications with\\n good effect\\n Plan:\\n Continue to monitor pain control, pt will likely require larger doses\\n of pain medication with increased activity during the day\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322782,\n \"text\": \"------ Protected Section------\\n ------ Protected Section Error Entered By: , RN\\n on: 07:14 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 322794,\n \"text\": \"Chief Complaint: Postop bleeding\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 77 yo man s/p total hip arthroplasty. H/O GIB. EBL intraop 1.5L in OR\\n got 3L LR, 2U PRBC. No known CAD. Normotensive in OR. Hct 34.5--> 24 in\\n PACU (though different techniques).\\n 24 Hour Events:\\n Hemodynamically stable- no episodes of hypotension.\\n Hct 34.5--> 26.4--> 21.4.\\n Hemovac removed, site oozing.\\n RN noted apneic episodes while sleeping.\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 02:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever\\n Cardiovascular: No(t) Chest pain\\n Respiratory: No(t) Dyspnea\\n Neurologic: No(t) Numbness / tingling\\n Pain: Moderate\\n Flowsheet Data as of 09:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.2\\n Tcurrent: 36.8\\nC (98.2\\n HR: 70 (70 - 106) bpm\\n BP: 113/53(67) {94/41(56) - 134/57(74)} mmHg\\n RR: 13 (10 - 17) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 525 mL\\n 1,663 mL\\n PO:\\n TF:\\n IVF:\\n 525 mL\\n 1,288 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 105 mL\\n 180 mL\\n Urine:\\n 55 mL\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n 50 mL\\n 30 mL\\n Balance:\\n 420 mL\\n 1,483 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic, dry mucosa\\n Cardiovascular: (S1: Normal), (S2: Distant), distant HS\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Tight and enlarged right thigh\\n Musculoskeletal: No(t) Muscle wasting\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): all, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 21.4 %\\n [image002.jpg]\\n 03:30 AM\\n Hct\\n 21.4\\n Assessment and Plan\\n BLOOD LOSS\\n 20% Hct drop postop. Hemodynamically stable but poor urine output.\\n H/O GI bleed.\\n No known significant cardiac history.\\n Has received total of 4U PRBC and 4.6L crystalloid.\\n Pending repeat hct to check response to transfusion. Needs more fluid\\n resuscitation.\\n Will place CVC.\\n Obviously holding antihypertensive meds.\\n Guaiac all stools.\\n RISK OF COMPARTMENT SYNDROME\\n Discuss with ortho. Exam difficult to guage.\\n POSTOP PAIN MANAGEMENT\\n PO diet.\\n H2 blocker.\\n Pneumoboots.\\n FULL CODE.\\n ICU Care\\n Nutrition:\\n Comments: PO diet\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 09:30 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: H2 blocker\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : ICU\\n Total time spent: 40\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 322952,\n \"text\": \"Subjective:\\n \\\", I'm better today.\\\"\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for patient education\\n Updated medical status: Hct 24.2 after 6 units of pRBC. Getting 2\\n additional units of pRBC today.\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n T\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n T\\n\\n Transfer:\\n PWB R LE, RW\\n\\n\\n\\n T\\n\\n\\n Sit to Stand:\\n\\n\\n\\n T\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Supine\\n 112\\n 129/p\\n 18\\n 94% RA\\n Activity\\n Sit\\n 115\\n 142/78\\n Recovery\\n Sit\\n 106\\n 114/50\\n 21\\n 96%RA\\n Total distance walked: N/A\\n Minutes:\\n Gait: Took few small steps with RW with min A x 1 and CG x 1, decreased\\n cadence, decreased step length\\n Balance: Seated: initially required max A at EOB 2' lateral and\\n posterior LOB; with proper positioning and verbal cues, pt able to\\n maintain with B UE support and CG.\\n Standing: required B UE support and CG x 2.\\n Education / Communication: Educated patient as to role of PT, transfer\\n technique.\\n Communicated with RN.\\n Other: Clarification of Functional Status: Rolled with mod A x 1, sup\\n to sit with mod A x 2, sit to stand with mod A x 2, trasferred via\\n stand pivot with min A x 2 with RW.\\n Assessment: Patient was more alert and able to participate with therapy\\n today. Anticipate continued improvement as patients hematocrit rises\\n and energy level improves. Patient continues to need aggressive rehab\\n with PT/OT on d/c.\\n Anticipated Discharge: Rehab\\n Plan: Transfer train with RW, gait train with RW, ther-ex with PT co-op\\n student, hip ROM, patient education.\\n OOB to chair daily with RN with gait belt (can order through\\n distribution #7711) and 2 person assist.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Physician Resident and Attending Progress Note\",\n \"row_id\": 322956,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n MULTI LUMEN - START 11:35 AM\\n tripple lumen central line placed successfully with normal f/u Xray\\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\\n effect, then did not require any more pain meds till midnight. pulses\\n good. thigh diameter mainatined at 23.75 inches\\n - Received 4 units of pRBC in 24 hr period with only 1.5 pt increase in\\n HCT. Ortho aware that there was no significant increase after 2 units\\n - Had CVL placed\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37\\nC (98.6\\n HR: 82 (66 - 118) bpm\\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\\n RR: 12 (8 - 21) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 5 (0 - 11)mmHg\\n Total In:\\n 4,421 mL\\n 268 mL\\n PO:\\n 480 mL\\n 100 mL\\n TF:\\n IVF:\\n 2,463 mL\\n 168 mL\\n Blood products:\\n 1,478 mL\\n Total out:\\n 1,460 mL\\n 1,630 mL\\n Urine:\\n 1,430 mL\\n 1,630 mL\\n NG:\\n Stool:\\n Drains:\\n 30 mL\\n Balance:\\n 2,961 mL\\n -1,362 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Gen:\\n CV:\\n PULM:\\n ABD:\\n EXT:\\n Labs / Radiology\\n 97 K/uL\\n 8.7 g/dL\\n 123 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 104 mEq/L\\n 139 mEq/L\\n 24.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n INR 1.0\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n WBC\\n 9.7\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n Plt\\n 97\\n Cr\\n 0.8\\n Glucose\\n 123\\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\\n mg/dL, PO4:2.3 mg/dL\\n Imaging: IMPRESSION: AP chest compared to :\\n New right internal jugular central venous line ends at the superior\\n cavoatrial junction. Mild widening of the mediastinum to the right of\\n the midline is probably venous engorgement since there is no\\n contralateral displacement of the trachea to suggest a hematoma. Heart\\n size is mildly enlarged and unchanged. Mild interstitial edema which\\n was present on has resolved and there is no appreciable\\n pleural effusion. Thoracic aorta is generally large and tortuous but\\n not focally dilated.\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\\n output yet to suggest GI source. Hct trend over 24 hours is\\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\\nd a total of 6\\n units prbcs over 24 hours and is currently receiving 2 more units\\n PRBCs. Orthopedics aware this morning.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - Continue to monitor thigh diameter, has been stable\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\\n be done to rule out other areas of bleed (such as RP)\\n - IVF/blood prn volume; patient appears dry on exam\\n - As it is still not entirely clear if patient is bleeding anywhere\\n other than his thigh, will check bladder pressure to monitor abdominal\\n pressures as a measure to follow along with thigh diameter\\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\\n platelets.\\n - Will continue to monitor pm CBC, if platelets lower, will consider\\n platelet tx at that time\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, oxycodone and dilaudid being careful to\\n avoid sedation/somnolence\\n - Ortho recs\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT consult requested for POD 2 or 3 once acute issues resolved\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition: PO\\n Glycemic Control: ISS\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Famotidine\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n ------ Protected Section ------\\n I saw and examined the patient, and was physically present with the ICU\\n resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan. PMH, SH, FH and ROS are\\n unchanged from admission except where noted above and below.\\n Key issue is hct remains 24% despite 6U PRBC transfusion. Undergoing 2U\\n more now. No change in thigh circumference and exam thigh seems less\\n tight than yesterday. Pt c/o extreme pain, but on exam localizes to hip\\n area. Will check bladder pressure just to have a baseline and continue\\n to check thigh measurement if hct does not rise appropriately. Also\\n check plt count with next hct. No indication for platelet transfusion\\n now.\\n Critically ill with persistent blood loss requiring close observation\\n in MICU.\\n Time: 30 minutes.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:16 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 323020,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n -delay in getting second unit of PRBCs, awaiting repeat HCT/PLT,\\n transfusion goal for PLTs <50K.\\n -post Hct check is up to 27.6 from 24, a bump but not appropriate for 2\\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\\n 28.4\\n -ortho recs: if Hct not bumping, ok with imaging, hold lovenox, WBAT\\n -bladder pressure 14\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:28 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: 37.2\\nC (99\\n HR: 83 (83 - 114) bpm\\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\\n RR: 16 (13 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 14 (5 - 15)mmHg\\n Bladder pressure: 7 (6 - 14) mmHg\\n Total In:\\n 2,194 mL\\n 40 mL\\n PO:\\n 1,060 mL\\n TF:\\n IVF:\\n 384 mL\\n 40 mL\\n Blood products:\\n 750 mL\\n Total out:\\n 5,580 mL\\n 1,020 mL\\n Urine:\\n 5,580 mL\\n 1,020 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,386 mL\\n -980 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///34/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 125 K/uL\\n 9.9 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 8 mg/dL\\n 99 mEq/L\\n 137 mEq/L\\n 28.5 %\\n 9.5 K/uL\\n [image002.jpg]\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n 06:45 PM\\n 11:54 PM\\n 02:57 AM\\n WBC\\n 9.7\\n 9.5\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n 27.6\\n 27.8\\n 28.5\\n Plt\\n 97\\n 121\\n 125\\n Cr\\n 0.8\\n 0.7\\n Glucose\\n 123\\n 114\\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:1.6 mg/dL\\n Imaging: No new\\n Microbiology: No new\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\\n output yet to suggest GI source. Hct increased to 28.4 this morning\\n from 24 after 2 units. Has been stable over two measurements. Patient\\n has rec\\nd a total of 8 units prbcs since admission. Orthopedics saw\\n patient this morning, recommended continue monitoring, WBAT.\\n - Continue to cycle Hct q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - Continue to monitor thigh diameter, has been stable at 24in.\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - No need for further imaging at this point as Hct stable.\\n - IVF/blood prn volume; patient appears dry on exam\\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\\n platelets. Improved without transfusion.\\n - Will continue to monitor pm CBC, if decreasing, can consider plt tx,\\n no need at this time\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, oxycodone and dilaudid being careful to\\n avoid sedation/somnolence\\n - Ortho recs\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT recommending rehab\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Continue ICU monitoring for now, can consider c/o later\\n today\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 323021,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n -delay in getting second unit of PRBCs, awaiting repeat HCT/PLT,\\n transfusion goal for PLTs <50K.\\n -post Hct check is up to 27.6 from 24, a bump but not appropriate for 2\\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\\n 28.4\\n -ortho recs: if Hct not bumping, ok with imaging, hold lovenox, WBAT\\n -bladder pressure 14\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:28 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: 37.2\\nC (99\\n HR: 83 (83 - 114) bpm\\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\\n RR: 16 (13 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 14 (5 - 15)mmHg\\n Bladder pressure: 7 (6 - 14) mmHg\\n Total In:\\n 2,194 mL\\n 40 mL\\n PO:\\n 1,060 mL\\n TF:\\n IVF:\\n 384 mL\\n 40 mL\\n Blood products:\\n 750 mL\\n Total out:\\n 5,580 mL\\n 1,020 mL\\n Urine:\\n 5,580 mL\\n 1,020 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,386 mL\\n -980 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///34/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 125 K/uL\\n 9.9 g/dL\\n 114 mg/dL\\n 0.7 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 8 mg/dL\\n 99 mEq/L\\n 137 mEq/L\\n 28.5 %\\n 9.5 K/uL\\n [image002.jpg]\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n 06:45 PM\\n 11:54 PM\\n 02:57 AM\\n WBC\\n 9.7\\n 9.5\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n 27.6\\n 27.8\\n 28.5\\n Plt\\n 97\\n 121\\n 125\\n Cr\\n 0.8\\n 0.7\\n Glucose\\n 123\\n 114\\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:1.6 mg/dL\\n Imaging: No new\\n Microbiology: No new\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\\n output yet to suggest GI source. Hct increased to 28.4 this morning\\n from 24 after 2 units. Has been stable over two measurements. Patient\\n has rec\\nd a total of 8 units prbcs since admission. Orthopedics saw\\n patient this morning, recommended continue monitoring, WBAT.\\n - Continue to cycle Hct q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - Continue to monitor thigh diameter, has been stable at 24in.\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - No need for further imaging at this point as Hct stable.\\n - IVF/blood prn volume; patient appears dry on exam\\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\\n platelets. Improved without transfusion.\\n - Will continue to monitor pm CBC, if decreasing, can consider plt tx,\\n no need at this time\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, oxycodone and dilaudid being careful to\\n avoid sedation/somnolence\\n - Ortho recs\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT recommending rehab\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Famotidine\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Continue ICU monitoring for now, can consider c/o later\\n today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322866,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Drainage from right lateral hip and thigh incision being monitored.\\n Continuous hemodynamic monitoring in progress. Right IJ triple lumen\\n central line insitu with CVP monitoring. Assess right thigh for extreme\\n distention, thigh circumference measured for comparison, and distal\\n pulses being assessed. Trending lab valve monitoring with necessary\\n interventions.\\n Action:\\n Right IJ central line placed this am to facilitate monitoring of\\n hemodynamic values. Central line care per protocol being maintained.VSS\\n being done Q1hr. peripheral pulse assessment done q4hr as needed.\\n Consented Blood transfusions given in relevance to lab values. Pad\\n beneath right leg assessed frequently and changed as needed. Continue\\n IV therapy as ordered.\\n Response:\\n No adverse reaction noted to blood transfusion, VSS remain within\\n acceptable limits for patient. Dressing to right thigh soiled but\\n intact. Two pads moderately saturated with bloody drainage changed over\\n the last 12hours. Peripheral pulses remain weak but palpable with\\n regular rate and rhythm. Urinary output has picked up and is within\\n acceptable limits.\\n Plan:\\n Continue CVP monitoring and other hemodynamic assessments. IVF as\\n ordered. Monitor urinary output and follow lab trends with appropriate\\n interventions as needed.\\n Electrolyte & fluid disorder, other\\n Assessment:\\n Monitor skin integrity, VSS and CVP values. Trend lab values\\n comparatively. Monitor Mg, Na, k, and Ca levels. Observe for abnormal\\n EKG rhythms.\\n Action:\\n Given Magnesium sulfate for Mg of 1.4 Also received Calcium gluconate\\n for Ca of 7.7.\\n Response:\\n Some general non pitting edema noted. Urinary output remains adequate.\\n Lab value have not deteriorated.\\n Plan:\\n Continue se\\n Diabetes Mellitus (DM), Type II\\n Assessment:\\n Random blood sugar being monitored q4hr. Observe for signs of hyper or\\n hypoglycemia.\\n Action:\\n Blood sugar being managed per sliding scale oral hypoglycemic on hold\\n Response:\\n Blood sugars have been within normal limits and pt has shown no signs\\n of hyper or hypoglycemia\\n Plan:\\n Continue q4hr. blood glucose level and manage per sliding scale orders.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 323008,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\\n Bladder pressure .\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM. Bladder pressure is\\n WNL.. Hct stable.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): 24in. B DP\\ns & PT\\ns are weakly palpable (no\\n change).\\n Action:\\n Thigh girths checked for potential compartment syndrome.\\n Response:\\n Thigh girth may be increased as different person is measuring it.\\n Thigh girth up by 0.25in.\\n Plan:\\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\\n etc.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 8 units PC\\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\\n prostate CA s/p XRT.\\n ------ Protected Section ------\\n 0300 Hct 28.5, still stable.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 06:36 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322833,\n \"text\": \"Pain control (acute pain, chronic pain)\\n Assessment:\\n Patient able to verbalize discomfort. Noted increase pain with movement\\n and to touch of the right thigh and hip. Obvious swelling to area\\n surrounding incision evident same is warn too touch.\\n Action:\\n Physicians aware of patients pain issue. Currently receives Oxycodone\\n 5-10mg po as needed. Can also have morphine IV, however patient\\n reluctant to have same. States it makes him\\nfunny in the head\\n Response:\\n Tolerating oral analgesic well, VSS remain WNL for client, and he is\\n able to sleep intermittently. Can consider medicating prior to activity\\n with clients consent.\\n Plan:\\n Continue to assess for discomfort through verbal inquiry and monitor\\n for changes in V/S.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Physical Therapy Progress Note\",\n \"row_id\": 323061,\n \"text\": \"Subjective:\\n \\\"Today was better.\\\"\\n Objective:\\n Follow up PT visit to address goals of: . Patient seen today\\n for patient education\\n Updated medical status: Pt. received 2uPRBC, w/ appropriate bump in Hct\\n to 28.2. Pt called out and awaiting bed.\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Rolling:\\n\\n\\n\\n\\n\\n Supine/\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n PWB R LE\\n\\n\\n\\n\\n T\\n\\n Ambulation:\\n PWB R LE\\n\\n\\n\\n\\n T\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Aerobic Activity Response:\\n Position\\n HR\\n BP\\n RR\\n O[2] sat\\n RPE\\n Rest\\n Sit\\n 94\\n 134/62\\n 98% 2L\\n Activity\\n Stand\\n 112\\n 116/61\\n 98% 2L\\n Recovery\\n Sit\\n 96\\n 125/56\\n 96% 2L\\n Total distance walked: 4 steps forwards and backwards, x2\\n Minutes:\\n Gait: Pt. ambulated w/ Mod A x1 and Min A x1- 4 steps forward and\\n backward, x2. Pt. independently advanced BLE. Absent heel strike B,\\n minimal circumduction of RLE to clear from floor, decreased step length\\n and wide BOS.\\n Pt. maintained WBing status w/o cues self limitations of pain.\\n Pt. performed sit to stand transfer 3x, w/ Min A x2.\\n Balance: -LOB during ambulation, increased postural sway during static\\n standing, likely in pt. attempt to shift weight from RLE.\\n Education / Communication: Pt: Role of PT, goals of treatment session,\\n technique and sequencing w/ RW.\\n Other:\\n Assessment: 77 yo M s/p RTHR c/b diffuse blood loss post operatively is\\n now progressing slowly, but well w/ PT. Pt. tolerated multiple sit to\\n stand transfers today w/ decreased support since yesterday. Pt. also\\n now advancing RLE w/o assist. Anticipate as medical stability\\n improves, pt. will continue to progress daily with PT. Pt. remains a\\n strong rehab canddate.\\n Anticipated Discharge: Rehab\\n Plan: Ther-Ex, transfers, ambulation w/ RW, balance, inc. endurance,\\n wean O2.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322756,\n \"text\": \"77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\\n and GI bleed presents following right total hip arthroplasty\\n complicated by post-operative bleeding.\\n .\\n He underwent elective right THA earlier today. Estimated intra-op blood\\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\\n At 7:45pm his spun hematocrit was 24. He was transfered to the MICU\\n for further monitoring\\n Problem - Description In Comments\\n Assessment:\\n Pt with noted swelling of right hip, area is warm and skin taught to\\n the touch, right foot cool though equally so to left, pedal pulses\\n palpable, pt able to wiggle toes, hemovac in place in right hip,\\n surgical dsg d&I, repeat hct this am with 4 point drop, u/o\\n ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP:\\n 94-122/42-57\\n Action:\\n Overnight pt received 2 500cc fluid boluses, ordered to receive 2\\n UPRBC, first of two started at 0445, pt is a difficult venipuncture,\\n this RN unable to obtain morning labs, HO attempted arterial stick,\\n only able to obtain enough blood for 0330 hct, pt also receiving\\n maintenance LR at 125/hr\\n Response:\\n Pt with some response in u/o with second FB, HR decreased with fluid\\n adm, VSS\\n Plan:\\n Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip\\n and dsg, PT consult tomorrow to obtain wedge pillow if appropriate,\\n continue to provide fluid for goal u/o of 30cc/hr\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Obtained pt very lethargic, as noted above while in PACU there was\\n difficulty maintaining good pain control w/o over sedation, pt\\ns mental\\n status improving throughout the shift, able to report pain scored at\\n , pain located in right hip\\n Action:\\n Minimizing pt turns and movements in bed, keeping right hip straight\\n with pillow between legs, pt received 2 5mg doses of oxycodone with\\n good effect\\n Response:\\n Pt sleeping comfortably throughout the shift, PRN pain medications with\\n good effect\\n Plan:\\n Continue to monitor pain control, pt will likely require larger doses\\n of pain medication with increased activity during the day\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322750,\n \"text\": \"Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322865,\n \"text\": \"Pain control (acute pain, chronic pain)\\n Assessment:\\n Patient able to verbalize discomfort. Noted increase pain with movement\\n and to touch of the right thigh and hip. Obvious swelling to area\\n surrounding incision evident same is warn too touch.\\n Action:\\n Physicians aware of patients pain issue. Currently receives Oxycodone\\n 5-10mg po as needed. Can also have morphine IV, however patient\\n reluctant to have same. States it makes him\\nfunny in the head\\n Response:\\n Tolerating oral analgesic well, VSS remain WNL for client, and he is\\n able to sleep intermittently. Can consider medicating prior to activity\\n with clients consent.\\n Plan:\\n Continue to assess for discomfort through verbal inquiry and monitor\\n for changes in V/S.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-26 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 322739,\n \"text\": \"TITLE:\\n Chief Complaint: post-op bleeding\\n HPI:\\n 77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\\n and GI bleed presents following right total hip arthroplasty\\n complicated by post-operative bleeding.\\n .\\n He underwent elective right THA earlier today. Estimated intra-op blood\\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\\n At 7:45pm his spun hematocrit was 24. He was transfered to the \\n for further monitoring after discussing with the ortho attending. The\\n drainage in the hip drain was considered normal.\\n Denies pain except for hip pain. no difficulty with breathing. other\\n ROS not obtainable due to sedation.\\n Patient admitted from: OR / PACU\\n History obtained from Medical records\\n Patient unable to provide history: Sedated\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Infusions:\\n Cefazolin in PACU\\n Other ICU medications:\\n Other medications:\\n amlodopine 10 mg daily\\n diovan 160 mg daily\\n glipizide 10 mg daily\\n metformin 1000 mg \\n actos 30 mg daily\\n simvastatin 20 mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n hypertension\\n diabetes mellitus type 2\\n hypercholesterolemia\\n prostate cancer s/p XRT\\n osteoarthritis\\n GI bleed - Dieulafoy lesion \\n diabetes\\n Occupation:\\n Drugs: none\\n Tobacco: quit in after 20yrs of smoking\\n Alcohol: 1 glass of wine per night\\n Other: He is from , retired. He is married.\\n Review of systems:\\n Constitutional: No(t) Fatigue\\n Ear, Nose, Throat: Dry mouth\\n Cardiovascular: Edema\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Tachypnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Diarrhea, No(t)\\n Constipation\\n Genitourinary: Foley\\n Musculoskeletal: Joint pain\\n Integumentary (skin): No(t) Jaundice\\n Endocrine: Hyperglycemia\\n Heme / Lymph: Anemia\\n Neurologic: Headache\\n Signs or concerns for abuse : No\\n Pain: Mild\\n Pain location: right hip\\n Flowsheet Data as of 11:20 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.2\\n Tcurrent: 37.9\\nC (100.2\\n HR: 88 (88 - 106) bpm\\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\\n RR: 17 (10 - 17) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 516 mL\\n PO:\\n TF:\\n IVF:\\n 516 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 95 mL\\n Urine:\\n 45 mL\\n NG:\\n Stool:\\n Drains:\\n 50 mL\\n Balance:\\n 0 mL\\n 421 mL\\n Respiratory\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent, right hip wound pressure\\n dressing, drain in place\\n Skin: Warm, No(t) Rash:\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: 8:17pm\\n Na 138 Cl 105 BUN 19 Gluc 222 AGap=9\\n K 4.6 CO2 24 Cr 1.0\\n Ca: 7.7 Mg: 1.4 P: 3.7\\n WBC 14.1 Hb 8.3 Hct 26.4 Plt179 MCV 85\\n 11:41a\\n Na 141 Cl 107 BUN 13 Gluc 113 AGap=8\\n K 4.6 CO2 27 Cr 0.9\\n estGFR: >75 (click for details)\\n Ca: 8.3 Mg: 1.7 P: 4.0\\n WBC 9.9 Hb 11.5 Hct 34.5 Plt 155 MCV 82\\n Imaging: AP port CXR - low lung volumes. large heart. stable RLL\\n opacity. mild increased pulmonary markings\\n Microbiology: none\\n ECG: sinus\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n Acute blood loss anemia: likely secondary to surgical bleeding. no\\n stool output yet to suggest GI source. currently appears to be\\n stabilizing Hct over past 4 hours.\\n - cycle Hct q6 for now\\n - transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - guaiac all stools\\n .\\n Osteoarthritis s/p THA: now POD#O from surgery.\\n pain control with tylenol, additional morphine\\n - ortho recs\\n - PA/lat hip films\\n - peri-op prophylactic antibiotics.\\n - hold LMWH for now\\n - PT consult requested for POD 2 or 3\\n DM2: adequate control for now.\\n - hold metformin for now\\n - hold actos for now\\n - continue glipizide\\n - RISS\\n Hypertension: hold anti-hypertensives until Hct stable\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 09:30 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-26 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 322740,\n \"text\": \"TITLE: PGY2 Admit Note\\n Chief Complaint: post-op bleeding\\n HPI:\\n 77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\\n and GI bleed presents following right total hip arthroplasty\\n complicated by post-operative bleeding.\\n .\\n He underwent elective right THA earlier today. Estimated intra-op blood\\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\\n At 7:45pm his spun hematocrit was 24. He was transfered to the \\n for further monitoring after discussing with the ortho attending. The\\n drainage in the hip drain was considered normal.\\n Denies pain except for hip pain. no difficulty with breathing. other\\n ROS not obtainable due to sedation.\\n Patient admitted from: OR / PACU\\n History obtained from Medical records\\n Patient unable to provide history: Sedated\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Infusions:\\n Cefazolin in PACU\\n Other ICU medications:\\n Other medications:\\n amlodopine 10 mg daily\\n diovan 160 mg daily\\n glipizide 10 mg daily\\n metformin 1000 mg \\n actos 30 mg daily\\n simvastatin 20 mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n hypertension\\n diabetes mellitus type 2\\n hypercholesterolemia\\n prostate cancer s/p XRT\\n osteoarthritis\\n GI bleed - Dieulafoy lesion \\n diabetes\\n Occupation:\\n Drugs: none\\n Tobacco: quit in after 20yrs of smoking\\n Alcohol: 1 glass of wine per night\\n Other: He is from , retired. He is married.\\n Review of systems:\\n Constitutional: No(t) Fatigue\\n Ear, Nose, Throat: Dry mouth\\n Cardiovascular: Edema\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Tachypnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Diarrhea, No(t)\\n Constipation\\n Genitourinary: Foley\\n Musculoskeletal: Joint pain\\n Integumentary (skin): No(t) Jaundice\\n Endocrine: Hyperglycemia\\n Heme / Lymph: Anemia\\n Neurologic: Headache\\n Signs or concerns for abuse : No\\n Pain: Mild\\n Pain location: right hip\\n Flowsheet Data as of 11:20 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.9\\nC (100.2\\n Tcurrent: 37.9\\nC (100.2\\n HR: 88 (88 - 106) bpm\\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\\n RR: 17 (10 - 17) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 516 mL\\n PO:\\n TF:\\n IVF:\\n 516 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 95 mL\\n Urine:\\n 45 mL\\n NG:\\n Stool:\\n Drains:\\n 50 mL\\n Balance:\\n 0 mL\\n 421 mL\\n Respiratory\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present. Heme negative brown\\n stool in vault\\n Extremities: Right: Absent, Left: Absent, right hip wound pressure\\n dressing, drain in place\\n Skin: Warm, No(t) Rash:\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Movement: Not assessed, Sedated, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: 8:17pm\\n Na 138 Cl 105 BUN 19 Gluc 222 AGap=9\\n K 4.6 CO2 24 Cr 1.0\\n Ca: 7.7 Mg: 1.4 P: 3.7\\n WBC 14.1 Hb 8.3 Hct 26.4 Plt179 MCV 85\\n 11:41a\\n Na 141 Cl 107 BUN 13 Gluc 113 AGap=8\\n K 4.6 CO2 27 Cr 0.9\\n estGFR: >75 (click for details)\\n Ca: 8.3 Mg: 1.7 P: 4.0\\n WBC 9.9 Hb 11.5 Hct 34.5 Plt 155 MCV 82\\n Imaging: AP port CXR - low lung volumes. large heart. stable RLL\\n opacity. mild increased pulmonary markings\\n Microbiology: none\\n ECG: sinus\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n Acute blood loss anemia: likely secondary to surgical bleeding. no\\n stool output yet to suggest GI source. currently appears to be\\n stabilizing Hct over past 4 hours.\\n - cycle Hct q6 for now\\n - transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - guaiac all stools\\n .\\n Osteoarthritis s/p THA: now POD#O from surgery.\\n pain control with tylenol, additional morphine\\n - ortho recs\\n - PA/lat hip films\\n - peri-op prophylactic antibiotics.\\n - hold LMWH for now\\n - monitor peripheral pulses\\n - PT consult requested for POD 2 or 3\\n DM2: adequate control for now.\\n - hold metformin for now\\n - hold actos for now\\n - continue glipizide\\n - RISS\\n Hypertension: hold anti-hypertensives until Hct stable\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 09:30 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note\",\n \"row_id\": 322743,\n \"text\": \"Chief Complaint: post-operative hct drop\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 77 year old man who came in today for an elective R THR and was found\\n to have a drop in his hct from 44.3 (in ) to 34.5 (initial in the\\n PACU) to 24. EBL 1500cc, 2 units PRBC given and 3 liters of LR.\\n Operative course was uncomplicated but in the PACU received multiple\\n pain meds. Drain output is not excessive. No BRBPR. No melena.\\n Patient admitted from: OR / PACU\\n History obtained from Medical records\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n amlopipine, glipizide, metformin, actose, simvastatin\\n Past medical history:\\n Family history:\\n Social History:\\n Prostate CA - s/p XRT\\n h/o GIB - iulefoy's\\n HTN\\n DM\\n OA\\n DM\\n Occupation: retired\\n Drugs:\\n Tobacco: stopped in , 20+ pack years\\n Alcohol: 1 drink/night\\n Other:\\n Review of systems:\\n Constitutional: No(t) Fever\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\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, Foley\\n Musculoskeletal: Joint pain\\n Integumentary (skin): No(t) Rash\\n Heme / Lymph: Anemia\\n Neurologic: No(t) Headache\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\\n Allergy / Immunology: No(t) Immunocompromised\\n Flowsheet Data as of 01:07 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: 37.3\\nC (99.2\\n HR: 88 (88 - 106) bpm\\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\\n RR: 17 (10 - 17) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 525 mL\\n 8 mL\\n PO:\\n TF:\\n IVF:\\n 525 mL\\n 8 mL\\n Blood products:\\n Total out:\\n 105 mL\\n 0 mL\\n Urine:\\n 55 mL\\n NG:\\n Stool:\\n Drains:\\n 50 mL\\n Balance:\\n 420 mL\\n 8 mL\\n Respiratory\\n O2 Delivery Device: Face tent\\n SpO2: 100%\\n ABG: ///24/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, sleepy but\\n arousable\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\\n (Murmur: No(t) Systolic)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, guaiac negative\\n Extremities: Right: Absent, Left: Absent\\n Musculoskeletal: R hip with dressing and drain\\n minimal amount of\\n blood in drain\\n Skin: Not assessed\\n Neurologic: Follows simple commands, Responds to: Not assessed,\\n Oriented (to): person, place, location, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 179\\n 26.4\\n 222\\n 1.0\\n 24\\n 25\\n 95\\n 4.6\\n 138\\n 14.1\\n [image002.jpg]\\n Imaging: CXR - Low lung volumes, opacity in RRR, deviated trachea\\n CT (pre-op) - + mediastinal nodes, patchy ground glass\\n ECG: NSR, PR slightly prolonged, small volts in precordial leads, no\\n acute ST/T wave changes\\n Assessment and Plan\\n Assessment - 77 year old man with low hct after R THR. Suspect much of\\n this was actually intraoperative loss and then re-equilibration from\\n IVF.\\n 1. Anemia - Will need to be careful to watch for true post-operative\\n bleeding - follow drain output, exam. Will follow hct q6 hours.\\n Guaiac stools. Will call ortho if hct falls again and give more blood.\\n 2. Post-op pain - will use dilaudid PCA when awake. For now, seems\\n quite sedate and comfortable.\\n 3. Hypertension - hold meds for now as was hypotensive and bleeding\\n 4. DM - hold metformin & glyburide until eating, ISS but may need NPH\\n 5. R THR - will talk to them about when to restart anticoagulation -\\n will hold for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines / Intubation:\\n 18 Gauge - 09:30 PM\\n Comments:\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 35 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322900,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Pt cont to have moderate amounts of oozing from right hip dressing.\\n Site appears to be the same in size and color.\\n Action:\\n Dressing reinforced, Pt received 1 unit PRBCs\\n Response:\\n No appropriate bump in Hct, but it remains stable at 24.\\n Plan:\\n Monitor Q6H Hcts, ? transfusing one more unit of blood. Surgery to\\n change dressing.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o less pain overnight, only with movement and turning.\\n Action:\\n Pt medicated with 1mg IV Dilaudid x2\\n Response:\\n Pt slept comfortably between doses, easily arousable to voice. Pt able\\n to turn better after medicating.\\n Plan:\\n Cont to monitor pain, prn Dilaudid or Oxycodone.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-05-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 322932,\n \"text\": \"Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\\n cancer s/p XRT, and GI bleed presents following right total hip\\n arthroplasty complicated by post-operative bleeding\\n 24 Hour Events:\\n MULTI LUMEN - START 11:35 AM\\n tripple lumen central line placed successfully with normal f/u Xray\\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\\n effect, then did not require any more pain meds till midnight. pulses\\n good. thigh diameter mainatined at 23.75 inches\\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\\n HCT. Ortho aware that there was no significant increase after 2 units,\\n but said it's expected after such a bloody case. will need to\\n re-address in AM\\n - Had CVL placed\\n Allergies:\\n Lisinopril\\n Cough;\\n Aspirin\\n Anemia;\\n Last dose of Antibiotics:\\n Cefazolin - 08:04 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:30 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.1\\nC (100.6\\n Tcurrent: 37\\nC (98.6\\n HR: 82 (66 - 118) bpm\\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\\n RR: 12 (8 - 21) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n CVP: 5 (0 - 11)mmHg\\n Total In:\\n 4,421 mL\\n 268 mL\\n PO:\\n 480 mL\\n 100 mL\\n TF:\\n IVF:\\n 2,463 mL\\n 168 mL\\n Blood products:\\n 1,478 mL\\n Total out:\\n 1,460 mL\\n 1,630 mL\\n Urine:\\n 1,430 mL\\n 1,630 mL\\n NG:\\n Stool:\\n Drains:\\n 30 mL\\n Balance:\\n 2,961 mL\\n -1,362 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 99%\\n ABG: ///31/\\n Physical Examination\\n Gen:\\n CV:\\n PULM:\\n ABD:\\n EXT:\\n Labs / Radiology\\n 97 K/uL\\n 8.7 g/dL\\n 123 mg/dL\\n 0.8 mg/dL\\n 31 mEq/L\\n 4.1 mEq/L\\n 13 mg/dL\\n 104 mEq/L\\n 139 mEq/L\\n 24.0 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:30 AM\\n 11:33 AM\\n 07:22 PM\\n 01:38 AM\\n 03:57 AM\\n WBC\\n 9.7\\n Hct\\n 21.4\\n 22.8\\n 24.6\\n 24.2\\n 24.0\\n Plt\\n 97\\n Cr\\n 0.8\\n Glucose\\n 123\\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\\n mg/dL, PO4:2.3 mg/dL\\n Imaging: IMPRESSION: AP chest compared to :\\n New right internal jugular central venous line ends at the superior\\n cavoatrial junction. Mild widening of the mediastinum to the right of\\n the midline is probably venous engorgement since there is no\\n contralateral displacement of\\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\\n unchanged. Mild interstitial edema which was present on has\\n resolved and there is no appreciable pleural effusion. Thoracic aorta\\n is generally large and tortuous but not focally dilated.\\n Assessment and Plan\\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\\n post-op bleeding.\\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\\n output yet to suggest GI source. Hct trend over 24 hours is\\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\\nd a total of 6\\n units prbcs over 24 hours and is currently receiving 2 more units\\n PRBCs. Orthopedics aware this morning.\\n - Post-tx Hct and cycle q6\\n - Transfuse for <24% as this would likely suggest significant\\n re-bleeding\\n - Guaiac all stools\\n - Continue to monitor thigh diameter\\n - Will continue to monitor for signs of compartment syndrome (ie pain\\n out of proportion to exam)\\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\\n be done to rule out other areas of bleed (such as RP)\\n - IVF/blood prn volume; patient appears dry on exam\\n - As it is still not entirely clear if patient is bleeding anywhere\\n other than his thigh, will check bladder pressure to monitor abdominal\\n pressures as a measure to follow along with thigh diameter (which has\\n been stable).\\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\\n platelets.\\n - Will continue to monitor pm CBC, if platelets lower, will consider\\n platelet tx at that time\\n # Osteoarthritis s/p THA: now POD#1 from surgery.\\n - Pain control with tylenol, oxycodone and dilaudid being careful to\\n avoid sedation/somnolence\\n - Ortho recs\\n - Hold LMWH for now in the setting of bleed, will discuss\\n anticoagulation with ortho once Hct stabilized\\n - Monitor peripheral pulses\\n - PT consult requested for POD 2 or 3 once acute issues resolved\\n # DM2: Adequate control for now.\\n - Hold oral meds for now (metformin, actos, glipizide)\\n - RISS\\n # Hypertension: hold anti-hypertensives until Hct stable\\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\\n ICU Care\\n Nutrition: PO\\n Glycemic Control: ISS\\n Lines:\\n 18 Gauge - 09:30 PM\\n Multi Lumen - 11:35 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Famotidine\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322988,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\\n Bladder pressure .\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM. Bladder pressure is WNL..\\n Hct stable.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): 24in. B DP\\ns & PT\\ns are weakly palpable (no\\n change).\\n Action:\\n Thigh girths checked for potential compartment syndrome.\\n Response:\\n Thigh girth may be increased as different person is measuring it.\\n Thigh girth up by 0.25in.\\n Plan:\\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\\n etc.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 8 units PC\\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\\n prostate CA s/p XRT.\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Physical Therapy Evaluation Note\",\n \"row_id\": 322845,\n \"text\": \"Attending Physician: \\n Referral date: \\n Medical Diagnosis / ICD 9: 715.95 / hip OA\\n Reason of referral: eval and treat\\n History of Present Illness / Subjective Complaint: 77 y/o male adm \\n for R THR 2' OA. Course was c/b post-operative bleeding. Received 6\\n units of pRBC in the .\\n Past Medical / Surgical History: DM2, increased chol, HTN, prostate CA,\\n BPH, GIB, CHF\\n Medications: insulin, oxycodone, morphine\\n Radiology: CXR : borderine cardiac decompensation\\n Labs:\\n 22.8\\n 8.3\\n 179\\n 14.1\\n [image002.jpg]\\n Other labs:\\n Activity Orders: bedrest, R LE PWB\\n Social / Occupational History: Married, supportive dtr\\n Environment: Lives with wife and dtr, 1 level home, 1 FOS to\\n enter\\n Prior Functional Status / Activity Level: I PTA, amb without AD but\\n with physical assist of another person, assist for ADLs, 1 fall 2 weeks\\n ago\\n Objective Test\\n Arousal / Attention / Cognition / Communication: Alert, pleasant,\\n cooperative, primary language is portuguese\\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 89\\n 119/65\\n 17\\n 100%\\n Sit\\n /\\n Activity\\n /\\n Stand\\n /\\n Recovery\\n 90\\n 134/56\\n 17\\n 97%\\n Total distance walked: N/A\\n Minutes:\\n Pulmonary Status: NARD\\n Integumentary / Vascular: R lateral hip incision covered with\\n elastoplast, saturated with sanguinous drainage, foley, central line\\n Sensory Integrity: grossly intact to LT\\n Pain / Limiting Symptoms: c/o severe pain R hip with ROM\\n Posture: supine in bed\\n Range of Motion\\n Muscle Performance\\n WFL B UE except R shoulder flexion 100 degrees (limited by pain which\\n started after surgery); WFL L LE; R LE ankle and knee WFL; R hip\\n flexion 0-60 degrees flexion, IR to neutral\\n B UE > except R shoulder flexors 3-/5\\n L LE > , R LE: DF , quads \\n Motor Function: moves all extremities in isolation\\n Functional Status:\\n Activity\\n Clarification\\n I\\n S\\n CG\\n Min\\n Mod\\n Max\\n Clarification: All mobility deferred 2' bedrest order, hematocrit of\\n 22.8 with significant continued post-op bleeding and pain.\\n Rolling:\\n\\n\\n\\n\\n\\n\\n Supine /\\n Sidelying to Sit:\\n\\n\\n\\n\\n\\n Transfer:\\n\\n\\n\\n\\n\\n Sit to Stand:\\n\\n\\n\\n\\n\\n Ambulation:\\n\\n\\n\\n\\n\\n Stairs:\\n\\n\\n\\n\\n\\n Balance: N/A\\n Education / Communication: Educated patient as to role of PT, PT plan\\n of care.\\n Communicated with RN.\\n Intervention: Supine ther-ex x 10 reps: AP, hip rolls, hip AB/AD, SAQ,\\n HS\\n Other:\\n Diagnosis:\\n 1.\\n Gait, Impaired\\n 2.\\n Muscle Performace, Impaired\\n 3.\\n Knowledge, Impaired\\n 4.\\n Range of Motion, Impaired\\n 5.\\n Transfers, Impaired\\n Clinical impression / Prognosis: Patient is a 77 y/o male adm for R THR\\n c/b postoperative bleeding. Patient presents with above defecits\\n consistent with joint arthroplasty. Anticipate that patient will need\\n rehab on d/c despite limited evaluation today. Will follow up for\\n further mobility assessment and to further assist with d/c planning\\n Goals\\n Time frame: 1 week\\n 1.\\n Roll with mod A\\n 2.\\n Sup to sit with mod A\\n 3.\\n Assess OOB\\n 4.\\n R hip ROM 0-90 degrees flexion, 25% IR, 10 degrees ER, 10 degrees AB\\n 5.\\n Independent with HEP\\n 6.\\n Indepently state hip precautions\\n Anticipated Discharge: Rehab\\n Treatment Plan:\\n Frequency / Duration: 5-7x/week x 1 week\\n Assess mobility\\n Transfer train\\n R hip ROM\\n ther-ex\\n Patient education\\n T Patient agrees with the above goals and is willing to participate in\\n the rehabilitation program.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322989,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\\n Bladder pressure .\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM. Bladder pressure is\\n WNL.. Hct stable.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): 24in. B DP\\ns & PT\\ns are weakly palpable (no\\n change).\\n Action:\\n Thigh girths checked for potential compartment syndrome.\\n Response:\\n Thigh girth may be increased as different person is measuring it.\\n Thigh girth up by 0.25in.\\n Plan:\\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\\n etc.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 8 units PC\\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\\n prostate CA s/p XRT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322841,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Drainage from right lateral hip and thigh incision being monitored.\\n Continuous hemodynamic monitoring in progress. Right IJ triple lumen\\n central line insitu with CVP monitoring. Assess right thigh for extreme\\n distention, thigh circumference measured for comparison, and distal\\n pulses being assessed. Trending lab valve monitoring with necessary\\n interventions.\\n Action:\\n Right IJ central line placed this am to facilitate monitoring of\\n hemodynamic values. Central line care per protocol being maintained.VSS\\n being done Q1hr. peripheral pulse assessment done q4hr as needed.\\n Consented Blood transfusions given in relevance to lab values. Pad\\n beneath right leg assessed frequently and changed as needed. Continue\\n IV therapy as ordered.\\n Response:\\n No adverse reaction noted to blood transfusion, VSS remain within\\n acceptable limits for patient. Dressing to right thigh soiled but\\n intact. Two pads moderately saturated with bloody drainage changed over\\n the last 12hours. Peripheral pulses remain weak but palpable with\\n regular rate and rhythm. Urinary output has picked up and is within\\n acceptable limits.\\n Plan:\\n Continue CVP monitoring and other hemodynamic assessments. IVF as\\n ordered. Monitor urinary output and follow lab trends with appropriate\\n interventions as needed.\\n Electrolyte & fluid disorder, other\\n Assessment:\\n Monitor skin integrity, VSS and CVP values. Trend lab values\\n comparatively. Monitor Mg, Na, k, and Ca levels. Observe for abnormal\\n EKG rhythms.\\n Action:\\n Given Magnesium sulfate for Mg of 1.4 Also received Calcium gluconate\\n for Ca of 7.7.\\n Response:\\n Some general non pitting edema noted. Urinary output remains adequate.\\n Lab value have not deteriorated.\\n Plan:\\n Continue se\\n Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Diabetes Mellitus (DM), Type II\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322982,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\\n Bladder pressure 14-15.\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): B DP\\ns & PT\\ns are weakly palpable (no change).\\n Action:\\n Thigh girths checked for potential compartment syndrome.\\n Response:\\n Plan:\\n Transfuse for Hct <24.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 8 units PC\\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\\n prostate CA s/p XRT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322983,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\\n Bladder pressure 14-15.\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM. Bladder pressure is mildly\\n elevated (in range).\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): B DP\\ns & PT\\ns are weakly palpable (no change).\\n Action:\\n Thigh girths checked for potential compartment syndrome.\\n Response:\\n Plan:\\n Transfuse for Hct <24.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 8 units PC\\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\\n prostate CA s/p XRT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322984,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\\n Bladder pressure 14-15.\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM. Bladder pressure is mildly\\n elevated (in range). Hct stable.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): B DP\\ns & PT\\ns are weakly palpable (no change).\\n Action:\\n Thigh girths checked for potential compartment syndrome.\\n Response:\\n Plan:\\n Transfuse for Hct <24.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 8 units PC\\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\\n prostate CA s/p XRT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322979,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.5 (up from 24. ) @ 1800. Hct @ 00. No BM since .\\n Bladder pressure 14-15.\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): B DP\\ns & PT\\ns are weakly palpable (no change).\\n Action:\\n Response:\\n Plan:\\n Continue to check thigh girths & monitor for compartment syndrome.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 6 units PC\\n since that time. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p\\n XRT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322980,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\\n Bladder pressure 14-15.\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): B DP\\ns & PT\\ns are weakly palpable (no change).\\n Action:\\n Response:\\n Plan:\\n Continue to check thigh girths & monitor for compartment syndrome.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 6 units PC\\n since that time. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p\\n XRT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-05-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 322981,\n \"text\": \"Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\\n Assessment:\\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\\n Bladder pressure 14-15.\\n Action:\\n Given senna, bisacodyl, colace & MOM to induce BM.\\n Response:\\n Unable to guiac stool until patient has BM.\\n Plan:\\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\\n possible.\\n Problem\\n R total hip replacement \\n Assessment:\\n R hip drsg : scant sanguinous drainage noted. Thigh girth\\n (from 23.75 in): B DP\\ns & PT\\ns are weakly palpable (no change).\\n Action:\\n Response:\\n Plan:\\n Continue to check thigh girths & monitor for compartment syndrome.\\n This is a 77 yr old man from who had R total hip surgery\\n . He lost 1500cc blood intra-op. He has received 8 units PC\\n since that time. Dropped Hct from 34.2 to 24 in PACU, & Hct has only\\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\\n prostate CA s/p XRT.\\n\"\n }\n]"}}},{"rowIdx":23091,"cells":{"subject_id":{"kind":"number","value":24357,"string":"24,357"},"hadm_id":{"kind":"number","value":111518,"string":"111,518"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"EKG exhibited st^ in anterolateral leads which lead to recatheterization. However, T waves now appeawr to bebiphasic in leads V4-V6 suggesting lateral ischemia compared to the previoustracing of . Prior inferiormyocardial infarction. Mild (1+) mitral regurgitation is seen.Conclusions:1. Pt went to cath on found to of proximal LAD & proximal LCX. WENT FOR ROUTINE ETT C/O CP. Prior inferior myocardial infarction. Compared to the previous tracing of there ismore prominent downsloping ST segment depression in leads I and aVL and theappearance of frequent ventricular ectopy. CP resolved after inferior pole was reopened. There is severeglobal left ventricular hypokinesis. O2 SATS 95+ ON 3.0 L VIA NC.ID: AFEBRILE. Sinus bradycardiaPrior inferior myocardial infarctionDiffuse ST-T abnormalitiesSince previous tracing of : Lateral ST-T changes decreased Mild (1+) mitral regurgitation is seen. HR 69-77 W/ PVC'S RARE-OCCASSIONAL. Compared to the previous tracing of nodiagnostic change.TRACING #1 2nd PCI revealed stent patency but occlusion of inferior pole. SVG-D1 known occl. LV dilation @ stress, suggestive of ischemia. Overall left ventricular systolicfunction is severely depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. MAX PO TEMP 97.4. Severe partial reversible defect in the inferior LV wall. Left atrial abnormality. The SVG & OM1 was stented but infer pole outflow vessel of the OM had mod slow flow after intervention & was recrossed & dilated restoring flow. TRANS DSG APPLIED C&D. CABG ' WITH LIMA TO LAD, SVG TP D2, SVG TO OM. DP +2, PT +1. C/O BACK PAIN D/T CATH PROCEDURE. Sinus bradycardia. - OOZE OR HEMATOMA PRESENT. There is more prominent ST segmentdepression in leads I and aVL, while the biphasic T waves, previously recordedin leads V4-V6, have resolved. AM GLUC 144HCT 35.2. There is mildmitral annular calcification. K+ 3.6, CA 8.5, phos 5.0, MG 1.7, CK 825. C/O NAUSEA UPON ADMISSION. Left ventricular function.S/p VF arrestHeight: (in) 64Weight (lb): 182BSA (m2): 1.88 m2BP (mm Hg): 118/59HR (bpm): 85Status: InpatientDate/Time: at 16:40Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity is mildly dilated. USING URINAL @ 0600 W/OUT DIFFICULTY. Pt entered V-fib arrest on floor secondary to thrombosis fo OM inferior pole vessel., defib X1, IVB amiod. ST DEPRESSIONS SEEN IN V5, V6,I & aFL with max st depressions in V5. NBP 87-118/40-59. Clinical correlation issuggested.TRACING #3 Overall left ventricular systolic function isseverely depressed.2. There is severe global leftventricular hypokinesis. Arrived w/ no C/O CP but nausea. CATH WITH STENT PLACEMENT TO NATIVE MID RCA 3VD PATENT SVG TO OM2- OCCLUSIVE SVG TO DIAG, PATENT LIMA TO LAD, PATENT STENT TO THE MID RCA, PROX RCA HAD A FOCAL 80% STENOSIS & DISTAL RCA HAD A SEVERE FOCAL 90% STENOSIS PRIOR TO ORIGIN OF THE rPDA s/p stent placement to prox & distal RCA.ADMITTING HX: PT RECENTLY C/O ^SOB WITH EXERTION. The left ventricular cavity is mildly dilated. WBC 14.4.GI/GU: NPO EXCEPT WITH MEDS. Sinus tachycardia with frequent ventricular ectopy and couplets. Diffuse non-specificST-T wave abnormalities. Rule out active lateral ischemia.Clinical correlation is suggested. PT ON 2 MCG/KG/MIN. GIVEN 5TH MG & SERAX @ 0100. GIVEN 2MG MORE WITH MOD EFFECT. ABP 124-140/55-66. Given 320cc of contrast. +BS ALL 4 QUADRANTS, -BM. Clinical correlation is suggested.TRACING #2 SVG to OM1 midsegment w/ 80% focal lesion LIMALAD was patent w/LAD after touchdown TO. - COMPLICATIONS.P: FOLLOW CURRENT MEDICAL MANAGEMENT & C/O PT TO FLOOR. The aortic valve leaflets are mildly thickened. 60% midsegment stenosis in prev stented RCA. RR 12-19. GIVEN MORPHINE 1MG X2 WITH MINIMAL EFFECT. RECEIVING 2 LITER OF 2 OF IVF. The mitral valve leafletsare mildly thickened. SUPPORT PT WHERE INDICATED. SHEATH PULLED @ 2300. Sinus rhythm with increase in raste compared to the previous tracingof . Nuclear medicine revealed severe reversible defect in distal anterior & apical walls. Superior pole was dilated and restored as well. CK/MB 128RESP: NO C/O SOB. RECEIVED 320 CC OF CONTRAST DURING STUDY- BUN/CR 11/0.7.SKIN: WNLACCESS: LEFT WRIST #20G.DISP: FULL CODESOCIAL: FAMILY VISITED.A: POST CATH TOLERATED WELL. INITIAL LITER D5 1/2NS GLUCOSE 238, 2ND BAG CHANGED TO 1/2 NS 125CC/HR. COOPERATIVE & APPROPRIATE. CCU ADMITTING NOTE(Continued)S ALONE PROVIDE AT HOME RESOURCES. LUNG SOUNDS CLEAR. PATIENT/TEST INFORMATION:Indication: H/O cardiac surgery with CABG . Sinus rhythm withi increase in rate compared to the previous tracingof . No vomiting occurred.NEURO: A&OX3. Technically limited study. PRESSURE APPLIED FOR 20 MIN. PT SLEPT SOUNDLY UNTIL 0500.CV: NO C/O CP. SHEATH PULLED TOLERATED WELL. Global HK with sn EF of 40% noted. CCU ADMITTING NOTE58 YEAR OLD MALE ADMITTED TO CCU POST CATHETERIZATION & SHEATH PLACEMENT.ALLERGIES: NKDAPMH: Interior wall MI, CAD-(MULTIPLE SIBLINGS DIED OF PREMATURE CAD), HTN, +CHOL, HYPERLIPIDEMIA, TOB USE 2-3PPDX30YRS> QUIT 10 YRS AGO. Otherwise, no change. SOCIAL WORKER PT"},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2111-07-17 00:00:00.000","description":"Report","row_id":1579027,"text":"CCU ADMITTING NOTE\n58 YEAR OLD MALE ADMITTED TO CCU POST CATHETERIZATION & SHEATH PLACEMENT.\n\nALLERGIES: NKDA\n\nPMH: Interior wall MI, CAD-(MULTIPLE SIBLINGS DIED OF PREMATURE CAD), HTN, +CHOL, HYPERLIPIDEMIA, TOB USE 2-3PPDX30YRS> QUIT 10 YRS AGO.\n CABG ' WITH LIMA TO LAD, SVG TP D2, SVG TO OM.\n CATH WITH STENT PLACEMENT TO NATIVE MID RCA\n 3VD PATENT SVG TO OM2- OCCLUSIVE SVG TO DIAG, PATENT LIMA TO LAD, PATENT STENT TO THE MID RCA, PROX RCA HAD A FOCAL 80% STENOSIS & DISTAL RCA HAD A SEVERE FOCAL 90% STENOSIS PRIOR TO ORIGIN OF THE rPDA s/p stent placement to prox & distal RCA.\n\nADMITTING HX: PT RECENTLY C/O ^SOB WITH EXERTION. WENT FOR ROUTINE ETT C/O CP. ST DEPRESSIONS SEEN IN V5, V6,I & aFL with max st depressions in V5. Nuclear medicine revealed severe reversible defect in distal anterior & apical walls. Severe partial reversible defect in the inferior LV wall. LV dilation @ stress, suggestive of ischemia. Global HK with sn EF of 40% noted. Pt went to cath on found to of proximal LAD & proximal LCX. 60% midsegment stenosis in prev stented RCA. SVG-D1 known occl. SVG to OM1 midsegment w/ 80% focal lesion LIMA_LAD was patent w/LAD after touchdown TO. The SVG & OM1 was stented but infer pole outflow vessel of the OM had mod slow flow after intervention & was recrossed & dilated restoring flow. Superior pole was dilated and restored as well. Pt entered V-fib arrest on floor secondary to thrombosis fo OM inferior pole vessel., defib X1, IVB amiod. EKG exhibited st^ in anterolateral leads which lead to recatheterization. 2nd PCI revealed stent patency but occlusion of inferior pole. CP resolved after inferior pole was reopened. Given 320cc of contrast. Arrived w/ no C/O CP but nausea. No vomiting occurred.\n\nNEURO: A&OX3. COOPERATIVE & APPROPRIATE. C/O BACK PAIN D/T CATH PROCEDURE. GIVEN MORPHINE 1MG X2 WITH MINIMAL EFFECT. GIVEN 2MG MORE WITH MOD EFFECT. GIVEN 5TH MG & SERAX @ 0100. PT SLEPT SOUNDLY UNTIL 0500.\n\nCV: NO C/O CP. HR 69-77 W/ PVC'S RARE-OCCASSIONAL. NBP 87-118/40-59. ABP 124-140/55-66. SHEATH PULLED @ 2300. PRESSURE APPLIED FOR 20 MIN. - OOZE OR HEMATOMA PRESENT. TRANS DSG APPLIED C&D. DP +2, PT +1. PT ON 2 MCG/KG/MIN. RECEIVING 2 LITER OF 2 OF IVF. INITIAL LITER D5 1/2NS GLUCOSE 238, 2ND BAG CHANGED TO 1/2 NS 125CC/HR. AM GLUC 144\nHCT 35.2. K+ 3.6, CA 8.5, phos 5.0, MG 1.7, CK 825. CK/MB 128\n\nRESP: NO C/O SOB. LUNG SOUNDS CLEAR. RR 12-19. O2 SATS 95+ ON 3.0 L VIA NC.\n\nID: AFEBRILE. MAX PO TEMP 97.4. WBC 14.4.\n\nGI/GU: NPO EXCEPT WITH MEDS. C/O NAUSEA UPON ADMISSION. +BS ALL 4 QUADRANTS, -BM. CONDOM CATH DRAINING CLEAR YELLOW URINE. USING URINAL @ 0600 W/OUT DIFFICULTY. RECEIVED 320 CC OF CONTRAST DURING STUDY- BUN/CR 11/0.7.\n\nSKIN: WNL\n\nACCESS: LEFT WRIST #20G.\n\nDISP: FULL CODE\nSOCIAL: FAMILY VISITED.\n\nA: POST CATH TOLERATED WELL. SHEATH PULLED TOLERATED WELL. - COMPLICATIONS.\n\nP: FOLLOW CURRENT MEDICAL MANAGEMENT & C/O PT TO FLOOR. SUPPORT PT WHERE INDICATED. SOCIAL WORKER PT \n"},{"category":"Nursing/other","chartdate":"2111-07-17 00:00:00.000","description":"Report","row_id":1579028,"text":"CCU ADMITTING NOTE\n(Continued)\nS ALONE PROVIDE AT HOME RESOURCES.\n\n"},{"category":"Echo","chartdate":"2111-07-17 00:00:00.000","description":"Report","row_id":94901,"text":"PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery with CABG . Left ventricular function.\nS/p VF arrest\nHeight: (in) 64\nWeight (lb): 182\nBSA (m2): 1.88 m2\nBP (mm Hg): 118/59\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 16:40\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity is mildly dilated. There is severe\nglobal left ventricular hypokinesis. Overall left ventricular systolic\nfunction is severely depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nConclusions:\n1. The left ventricular cavity is mildly dilated. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n2. The aortic valve leaflets are mildly thickened. The mitral valve leaflets\nare mildly thickened. Mild (1+) mitral regurgitation is seen.\n\n\n"},{"category":"ECG","chartdate":"2111-07-18 00:00:00.000","description":"Report","row_id":272646,"text":"Sinus tachycardia with frequent ventricular ectopy and couplets. Prior inferior\nmyocardial infarction. Compared to the previous tracing of there is\nmore prominent downsloping ST segment depression in leads I and aVL and the\nappearance of frequent ventricular ectopy. Rule out active lateral ischemia.\nClinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2111-07-17 00:00:00.000","description":"Report","row_id":272647,"text":"Sinus rhythm with increase in raste compared to the previous tracing\nof . Left atrial abnormality. There is more prominent ST segment\ndepression in leads I and aVL, while the biphasic T waves, previously recorded\nin leads V4-V6, have resolved. Otherwise, no change. Clinical correlation is\nsuggested.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2111-07-16 00:00:00.000","description":"Report","row_id":272648,"text":"Sinus rhythm withi increase in rate compared to the previous tracing\nof . Technically limited study. However, T waves now appeawr to be\nbiphasic in leads V4-V6 suggesting lateral ischemia compared to the previous\ntracing of . Clinical correlation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2111-07-16 00:00:00.000","description":"Report","row_id":272649,"text":"Sinus bradycardia. Prior inferior myocardial infarction. Diffuse non-specific\nST-T wave abnormalities. Compared to the previous tracing of no\ndiagnostic change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2111-07-15 00:00:00.000","description":"Report","row_id":272650,"text":"Sinus bradycardia\nPrior inferior myocardial infarction\nDiffuse ST-T abnormalities\nSince previous tracing of : Lateral ST-T changes decreased\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1579027,\n \"text\": \"CCU ADMITTING NOTE\\n58 YEAR OLD MALE ADMITTED TO CCU POST CATHETERIZATION & SHEATH PLACEMENT.\\n\\nALLERGIES: NKDA\\n\\nPMH: Interior wall MI, CAD-(MULTIPLE SIBLINGS DIED OF PREMATURE CAD), HTN, +CHOL, HYPERLIPIDEMIA, TOB USE 2-3PPDX30YRS> QUIT 10 YRS AGO.\\n CABG ' WITH LIMA TO LAD, SVG TP D2, SVG TO OM.\\n CATH WITH STENT PLACEMENT TO NATIVE MID RCA\\n 3VD PATENT SVG TO OM2- OCCLUSIVE SVG TO DIAG, PATENT LIMA TO LAD, PATENT STENT TO THE MID RCA, PROX RCA HAD A FOCAL 80% STENOSIS & DISTAL RCA HAD A SEVERE FOCAL 90% STENOSIS PRIOR TO ORIGIN OF THE rPDA s/p stent placement to prox & distal RCA.\\n\\nADMITTING HX: PT RECENTLY C/O ^SOB WITH EXERTION. WENT FOR ROUTINE ETT C/O CP. ST DEPRESSIONS SEEN IN V5, V6,I & aFL with max st depressions in V5. Nuclear medicine revealed severe reversible defect in distal anterior & apical walls. Severe partial reversible defect in the inferior LV wall. LV dilation @ stress, suggestive of ischemia. Global HK with sn EF of 40% noted. Pt went to cath on found to of proximal LAD & proximal LCX. 60% midsegment stenosis in prev stented RCA. SVG-D1 known occl. SVG to OM1 midsegment w/ 80% focal lesion LIMA_LAD was patent w/LAD after touchdown TO. The SVG & OM1 was stented but infer pole outflow vessel of the OM had mod slow flow after intervention & was recrossed & dilated restoring flow. Superior pole was dilated and restored as well. Pt entered V-fib arrest on floor secondary to thrombosis fo OM inferior pole vessel., defib X1, IVB amiod. EKG exhibited st^ in anterolateral leads which lead to recatheterization. 2nd PCI revealed stent patency but occlusion of inferior pole. CP resolved after inferior pole was reopened. Given 320cc of contrast. Arrived w/ no C/O CP but nausea. No vomiting occurred.\\n\\nNEURO: A&OX3. COOPERATIVE & APPROPRIATE. C/O BACK PAIN D/T CATH PROCEDURE. GIVEN MORPHINE 1MG X2 WITH MINIMAL EFFECT. GIVEN 2MG MORE WITH MOD EFFECT. GIVEN 5TH MG & SERAX @ 0100. PT SLEPT SOUNDLY UNTIL 0500.\\n\\nCV: NO C/O CP. HR 69-77 W/ PVC'S RARE-OCCASSIONAL. NBP 87-118/40-59. ABP 124-140/55-66. SHEATH PULLED @ 2300. PRESSURE APPLIED FOR 20 MIN. - OOZE OR HEMATOMA PRESENT. TRANS DSG APPLIED C&D. DP +2, PT +1. PT ON 2 MCG/KG/MIN. RECEIVING 2 LITER OF 2 OF IVF. INITIAL LITER D5 1/2NS GLUCOSE 238, 2ND BAG CHANGED TO 1/2 NS 125CC/HR. AM GLUC 144\\nHCT 35.2. K+ 3.6, CA 8.5, phos 5.0, MG 1.7, CK 825. CK/MB 128\\n\\nRESP: NO C/O SOB. LUNG SOUNDS CLEAR. RR 12-19. O2 SATS 95+ ON 3.0 L VIA NC.\\n\\nID: AFEBRILE. MAX PO TEMP 97.4. WBC 14.4.\\n\\nGI/GU: NPO EXCEPT WITH MEDS. C/O NAUSEA UPON ADMISSION. +BS ALL 4 QUADRANTS, -BM. CONDOM CATH DRAINING CLEAR YELLOW URINE. USING URINAL @ 0600 W/OUT DIFFICULTY. RECEIVED 320 CC OF CONTRAST DURING STUDY- BUN/CR 11/0.7.\\n\\nSKIN: WNL\\n\\nACCESS: LEFT WRIST #20G.\\n\\nDISP: FULL CODE\\nSOCIAL: FAMILY VISITED.\\n\\nA: POST CATH TOLERATED WELL. SHEATH PULLED TOLERATED WELL. - COMPLICATIONS.\\n\\nP: FOLLOW CURRENT MEDICAL MANAGEMENT & C/O PT TO FLOOR. SUPPORT PT WHERE INDICATED. SOCIAL WORKER PT \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1579028,\n \"text\": \"CCU ADMITTING NOTE\\n(Continued)\\nS ALONE PROVIDE AT HOME RESOURCES.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2111-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 94901,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: H/O cardiac surgery with CABG . Left ventricular function.\\nS/p VF arrest\\nHeight: (in) 64\\nWeight (lb): 182\\nBSA (m2): 1.88 m2\\nBP (mm Hg): 118/59\\nHR (bpm): 85\\nStatus: Inpatient\\nDate/Time: at 16:40\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\\n\\nLEFT VENTRICLE: The left ventricular cavity is mildly dilated. There is severe\\nglobal left ventricular hypokinesis. Overall left ventricular systolic\\nfunction is severely depressed.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\\n\\nConclusions:\\n1. The left ventricular cavity is mildly dilated. There is severe global left\\nventricular hypokinesis. Overall left ventricular systolic function is\\nseverely depressed.\\n2. The aortic valve leaflets are mildly thickened. The mitral valve leaflets\\nare mildly thickened. Mild (1+) mitral regurgitation is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2111-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 272646,\n \"text\": \"Sinus tachycardia with frequent ventricular ectopy and couplets. Prior inferior\\nmyocardial infarction. Compared to the previous tracing of there is\\nmore prominent downsloping ST segment depression in leads I and aVL and the\\nappearance of frequent ventricular ectopy. Rule out active lateral ischemia.\\nClinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2111-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 272647,\n \"text\": \"Sinus rhythm with increase in raste compared to the previous tracing\\nof . Left atrial abnormality. There is more prominent ST segment\\ndepression in leads I and aVL, while the biphasic T waves, previously recorded\\nin leads V4-V6, have resolved. Otherwise, no change. Clinical correlation is\\nsuggested.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2111-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 272648,\n \"text\": \"Sinus rhythm withi increase in rate compared to the previous tracing\\nof . Technically limited study. However, T waves now appeawr to be\\nbiphasic in leads V4-V6 suggesting lateral ischemia compared to the previous\\ntracing of . Clinical correlation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2111-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 272649,\n \"text\": \"Sinus bradycardia. Prior inferior myocardial infarction. Diffuse non-specific\\nST-T wave abnormalities. Compared to the previous tracing of no\\ndiagnostic change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2111-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 272650,\n \"text\": \"Sinus bradycardia\\nPrior inferior myocardial infarction\\nDiffuse ST-T abnormalities\\nSince previous tracing of : Lateral ST-T changes decreased\\n\\n\"\n }\n]"}}},{"rowIdx":23092,"cells":{"subject_id":{"kind":"number","value":2040,"string":"2,040"},"hadm_id":{"kind":"number","value":124831,"string":"124,831"},"target_text":{"kind":"string","value":"In short, this is a 63-year-old mostly Spanish-speaking male with a history of end-stage renal disease on hemodialysis who presents with a question of seizures, intubated, now transferred to the floor with probable SVC syndrome and access issues. 1. NEUROLOGY: It is unlikely that the patient ever had a seizure. During this episode, trembling, the patient was noted to have a fingerstick of 36. In addition, he was continually talking through the rhythmic motions. It is much more likely that the patient was simply having symptomatic hypoglycemia. The patient was intubated after receiving loading doses of Ativan and Dilantin. His head CT was negative, and his MRI was negative for bleed but showed only old bilateral lacunar disease. No lumbar puncture was performed because of a low index of suspicion for infectious sources of mental status changes. The patient continued to be delirious, especially at night. However, as the Ativan came out of his system, he became less delirious and more oriented. He was continued on olanzapine 5 mg p.o. q.d. At this time, there still is an EEG pending from from which he was transferred. However, given the low likelihood for seizure activity, this may not need to be further followed. 2. HEMATOLOGY: The patient has known right and left-sided upper extremity clots, and as of , had 40% occlusion of the SVC. The patient was admitted on Coumadin. This was held and the patient was started on heparin. Given the new upper torso pitting edema and concern for SVC, it is probable that some of these clots have migrated into the path of the SVC. The patient was also sent for hypercoagulability workup. Many of these results are still pending. The patient was noted to have a protein S deficiency, but this may not be significant in the presence of active clotting. On , the patient received an ultrasound vein mapping. This showed the presence of only left-sided internal jugular clots. However, the SVC could not be assessed. The plan at this point is to visualize the upper torso venous system through angiography while performing a fistulogram. This is scheduled for . For now, the patient is maintained on a heparin drip. 3. ACCESS: On admission, the patient had an old left EJ versus subclavian that was inserted on this past admission about two weeks ago. This line is used for temporary dialysis. The patient also has a right midline catheter that was used for infusion of IV Oxacillin. However, this was found to be nonfunctioning. The patient received a left femoral central line for both Oxacillin and heparin infusion. The patient also has a left AV fistula with positive thrill, however, poor blood flow was noted during hemodialysis on . The patient is status post fistulogram and angioplasty of that same AV fistula about a week and a half ago. As already noted, the patient is scheduled for an AV fistulogram on . If this is found to be operational, the left EJ versus the subclavian line should be taken out, especially as the patient has been spiking fevers. If AV fistula is not viable, Transplant Surgery will need to reassess the fistula, and a temporary Perma-Cath will need to be placed. From past admissions, the patient is a big access problem, and placement of even a will be very difficult in this patient. The right midline catheter was removed on . 4. INFECTIOUS DISEASE: The patient is currently being treated for presumed osteomyelitis in the setting of MSSA bacteremia that was noted on past admissions. He is receiving Oxacillin IV, 1 gram q. four hours. This is to be continued through . Of note, the patient started spiking again on this admission, up to 102 degrees Fahrenheit. All of the patient's blood cultures have been negative. The patient is essentially anuric. His chest x-ray initially indicated the presence of opacity, but the final read was read as atelectasis. The patient was initially placed on levo and Flagyl for aspiration pneumonia. However, once the chest x-ray was confirmed, this combination was stopped. The most likely source of the fever is the left-sided EJ versus subclavian that was placed on the last admission. However, because the patient is such an access issue, there was a decision to treat through this infection as long as the blood cultures remained negative. 5. CARDIOVASCULAR: The patient has a history of atrial fibrillation. On , the patient was noted to be in atrial flutter, hemodynamically stable. The patient received IV Lopressor and IV Diltiazem and converted to normal sinus rhythm. The patient had an echocardiogram on , which showed an EF of 60-70%, bidirectional stent, ASD, normal free wall motion, and mild pulmonary artery hypertension. The patient was continued on his Lopressor, Captopril, aspirin. 6. RENAL: The patient continues hemodialysis on Mondays, Wednesdays, and Fridays. Continue on PhosLo, Nephrocaps, Epogen, sodium bicarbonate. 7. HEMATOLOGY: The patient has anemia secondary to renal failure. His baseline hematocrit runs around 28. Hematocrit has been stable. 8. PROPHYLAXIS: The patient is to continue Protonix. 9. CODE STATUS: The patient is a full code. DR., 12-927 Dictated By: MEDQUIST36 D: 14:34 T: 11:18 JOB#: "},"extractive_notes_summ":{"kind":"string","value":"Grossly normal flow can be seen within the internal carotid and right vertebral arteries Images of the circle of are degraded by motion artifact. IMPRESSION: 1) Vascath terminates in the mid-SVC, and right-sided PICC line terminates within the axilla. FINDINGS: There has been interval removal of the ET tube. PATIENT/TEST INFORMATION:Indication: Reassess for LV function and shunt.Height: (in) 66BP (mm Hg): 142/74Status: InpatientDate/Time: at 11:51Test: TTE(Complete)Doppler: Focused pulse and color flowContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. 8:01 AM AV FISTULOGRAM SCH Clip # Reason: functioning AVF, clots in upper torso? FINDINGS: A left sided central venous line is present with tip in the SVC. AnterolateralST-T wave changes suggestive of myocardial ischemia persist. There is near-complete thrombus of the left internal jugular vein with a tiny amount of flow through this vessel. A right-sided PICC line again terminates in the axilla. A small secundum atrial septal defect (ASD)is present. FINDINGS: Again seen is a left subclavian hemodialysis catheter, terminating in the mid-SVC. A small secundumatrial septal defect (ASD) is present.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. REASON FOR THIS EXAMINATION: functioning AVF, clots in upper torso? There is nomitral valve prolapse. There is nomitral valve prolapse. UNABLE TO GET GOOD IMAGES DESPITE MEDICATED WITH VERSED. Left external jugular dialysis cath intact. Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) Thereafter, an 0.035 wire was placed through the sheath and advanced under fluoroscopy until its tip was in the inferior vena cava. There are anterolateral ST-T wave abnormalities suggestive ofanterolateral myocardial ischemia. REASON FOR THIS EXAMINATION: does pt have intracranial bleed No contraindications for IV contrast FINAL REPORT INDICATION: Seizures, intubated. Major, symptomatic stenosis of the superior vena cava. There isa bidirectional shunt across the interatrial septum at rest. Atrial fibrillation with a moderate ventricular response. Additionally, the right cephalic vein was evaluated. Sinus rhythmAnterolateral ST-T changes may be due to myocardial ischemiaCompared to previous tracing of , sinus rhythm has appeared. There ismild thickening of the mitral valve chordae.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Bilateral hemidiaphragms are less distinct on today's exam suggesting increased bibasilar atelectasis. (Over) 8:01 AM AV FISTULOGRAM SCH Clip # Reason: functioning AVF, clots in upper torso? There are focalcalcifications in the ascending aorta.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is a bidirectional shunt across theinteratrial septum at rest (left-to-right on color-flow imaging; right-to-leftby air bubble contrast imaging). The aortic valve leaflets (3) are mildly thickened butnot stenotic. Mediastinal contours are unchanged allowing for differences in patient positioning. IMPRESSION: Worsening bibasilar atelectasis with probable left pleural effusion. PERIPHERAL PULSES PRESENT WITH DOPPLER. Probable small left pleural effusion. Mild tricuspid [1+] regurgitation is seen.There is mild pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Contrast study was performed with one iv injection of 8 ccsof agitated normal saline at rest.Conclusions:The left atrium is normal in size. There is mild mitral annular calcification. IMPRESSION: Chronic near-complete thrombus of the left internal jugular vein. Evaluate for upper-extremity DVT. MRI HEAD DONE, CHEST UNABLE TO OBTAIN. REASON FOR THIS EXAMINATION: pleave eval ett placement FINAL REPORT INDICATION: Intubated after seizure. Multiple T1 low attenuation lesions within the thalami, internal capsule and basal ganglia suggest multiple prior chronic lacunes. Left AV fistula with faint thrill and bruit. ST-T wave abnormalities are more marked.TRACING #1 Resolution of the narrowing was shown on a follow-up venogram. pt does not open eyes, and pt pupils are equal but not reactive, Dr. aware.Resp: pt remains intubated on vent AC/12/650/.50/5. It revealed patency of the arteriovenous anastomosis and the brachial artery proximally and distally to the anastomosis with no significant stenosis. There is normal respiratory variation throughout the veins of both the right and left upper extremities excluding the left internal jugular vein. Pt has H/O DVT, pt sup vena cava in belived to be clottted, pt head and swollen due to this clot. There are focal calcificationsin the aortic root. Pt has hematuria due to pt pulling on foley HO aware. There is mild thickening of the walls of the left internal jugular vein. Baseline artifactSinus rhythmModest lateral T wave changes are nonspecificLow limb leads voltageSince previous tracing of : probably no significant change CT BRAIN WITHOUT IV CONTRAST: The ventricles, cisterns and sulci are normal. Again seen are lacunar infarcts in the caudate nucleus bilaterally and the right cerebellar hemisphere."},"n_notes":{"kind":"number","value":19,"string":"19"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2145-11-24 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":776236,"text":" 11:36 AM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: please eval for acute stroke\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with AMS, ?seizure (new) with upgoing babinskis bilaterally\n REASON FOR THIS EXAMINATION:\n please eval for acute stroke\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Confusion. Question of new seizure.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain were obtained\n with and without IV contrast. 2D and 3D multiplanar reformatted images were\n created.\n\n MRI OF THE BRAIN W/O CONTRAST: The study is extremely limited by patient\n motion. In particular, the susceptibility and FLAIR images are somewhat\n degraded. Multiple T1 low attenuation lesions within the thalami, internal\n capsule and basal ganglia suggest multiple prior chronic lacunes. There are\n no abnormal signal intensities on diffusion weighted imaging to suggest acute\n ischemia. No shift of normally midline structures or mass effect is seen. The\n ventricles, cisterns, and sulci are symmetric without significant enlargement\n or effacement. No acute hemorrhage is identified.\n\n MRA OF THE BRAIN AND CAROTID ARTERIES: These images are degraded by motion\n artifact. Grossly normal flow can be seen within the internal carotid and\n right vertebral arteries\n\n Images of the circle of are degraded by motion artifact. Fine vascular\n detail is not obtained. There is normal flow within the basilar and\n intracranial carotid arteries. Branch vessels are not well evaluated.\n\n IMPRESSION:\n\n No evidence of acute brain infarction. Limited study due to motion artifact\n with significant degradation of MRA sequences.\n\n\n\n"},{"category":"Radiology","chartdate":"2145-11-25 00:00:00.000","description":"B UNILAT UP EXT VEINS US BILAT","row_id":776386,"text":" 4:12 PM\n UNILAT UP EXT VEINS US BILAT Clip # \n Reason: please perform vein mapping of entire upper extremity includ\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with h/o ESRD on HD p/w MS changes, b/l UE swelling concerning\n for SVC syndrome. Pt. has h/o numerous b/l UE clots.\n REASON FOR THIS EXAMINATION:\n please perform vein mapping of entire upper extremity including SVC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of end-stage renal disease, on hemodialysis, with mental\n status changes and bilateral upper extremity swelling concerning for SVC\n syndrome. Evaluate for upper-extremity DVT.\n\n BILATERAL UPPER EXTREMITY ULTRASOUND: -scale, color, and Doppler\n son of both internal jugular, subclavian, axillary and brachial veins\n were performed. Additionally, the right cephalic vein was evaluated. There\n is near-complete thrombus of the left internal jugular vein with a tiny amount\n of flow through this vessel. There is mild thickening of the walls of the\n left internal jugular vein. No thrombus is identified within the right\n internal jugular vein, both subclavians, axillary and brachial veins. No\n thrombus is identified within the right cephalic vein. There is neointimal\n thickening within the right subclavian vein where the PICC line enters with\n normal color flow through this area. There is normal respiratory variation\n throughout the veins of both the right and left upper extremities excluding\n the left internal jugular vein. The left upper extremity fistula was not\n evaluated.\n\n IMPRESSION: Chronic near-complete thrombus of the left internal jugular vein.\n No occlusive thrombus in the other veins evaluated.\n\n"},{"category":"Radiology","chartdate":"2145-11-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":776289,"text":" 7:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p extubation airway protection s/p seizure now w/\n tachycardia and fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Extubated. Now with tachycardia and fever.\n\n COMPARISON: .\n\n FINDINGS: There has been interval removal of the ET tube. Left-sided central\n venous line remains in unchanged position. The cardiac and mediastinal\n contours are unchanged allowing for patient rotation. Bilateral\n hemidiaphragms are less distinct on today's exam suggesting increased\n bibasilar atelectasis. Probable small left pleural effusion. Left-sided PICC\n line tip is in the axillary vein.\n\n IMPRESSION: Worsening bibasilar atelectasis with probable left pleural\n effusion.\n\n"},{"category":"Radiology","chartdate":"2145-11-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":776473,"text":" 3:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESRD on HD presents with fever.\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemodialysis with fever.\n\n TECHNIQUE: A single portable AP view of the chest is compared with 2 days\n prior.\n\n FINDINGS: Again seen is a left subclavian hemodialysis catheter, terminating\n in the mid-SVC. A right-sided PICC line again terminates in the axilla. The\n cardiomediastinal silhouette is unremarkable. No focal pulmonary opacities,\n pleural effusions, or pneumothorax. Pulmonary vasculature is unremarkable.\n\n IMPRESSION:\n 1) Vascath terminates in the mid-SVC, and right-sided PICC line terminates\n within the axilla.\n\n 2) No evidence of focal pneumonia.\n\n"},{"category":"Radiology","chartdate":"2145-11-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":776070,"text":" 10:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleave eval ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with intubation for airway protection s/p seizure.\n REASON FOR THIS EXAMINATION:\n pleave eval ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated after seizure.\n\n COMPARISON: .\n\n FINDINGS: A left sided central venous line is present with tip in the SVC.\n Endotracheal tube is in good position several cm above the carina. The heart\n is top normal in size with slight left ventricular enlargement. Mediastinal\n contours are unchanged allowing for differences in patient positioning. There\n is interval worsening of left lower lobe consolidation and collapse. No\n definite pleural effusion. No pneumothorax. The soft tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: Good placement of ET tube. Increased left lower lobe\n consolidation and collapse.\n\n"},{"category":"Radiology","chartdate":"2145-11-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":776074,"text":" 12:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: does pt have intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with report of seizure, now intubated.\n REASON FOR THIS EXAMINATION:\n does pt have intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizures, intubated.\n\n TECHNIQUE: Axial images of the brain were obtained without IV contrast.\n\n COMPARISON: .\n\n CT BRAIN WITHOUT IV CONTRAST: The ventricles, cisterns and sulci are normal.\n There is no shift of normal midline structures or mass affect. The /white\n matter differentiation is normal. There are no pathologic extra-axial fluid\n collections. Again seen are lacunar infarcts in the caudate nucleus\n bilaterally and the right cerebellar hemisphere. There are vascular\n calcifications. There is soft tissue and fluid in the left maxillary sinus,\n bilateral ethmoidal air cells and bilateral sphenoid sinuses. The patient is\n intubated. There is also a small fluid level in the posterior right mastoid.\n Dense carotid calcifications are present.\n\n IMPRESSION:\n\n 1.No evidence of intracranial hemorrhage. If clinically indicated, contrast-\n enhanced MR imaging may be useful for further evaluation of seizures.\n 2.Sinus disease.\n\n\n\n"},{"category":"Radiology","chartdate":"2145-11-30 00:00:00.000","description":"PTA VENOUS","row_id":776845,"text":" 8:01 AM\n AV FISTULOGRAM SCH Clip # \n Reason: functioning AVF, clots in upper torso?\n Contrast: OPTIRAY Amt: 150\n ********************************* CPT Codes ********************************\n * PTA VENOUS PTA VENOUS *\n * -59 DISTINCT PROCEDURAL SERVICE INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PTA VENOUS *\n * PTA VENOUS -59 DISTINCT PROCEDURAL SERVICE *\n * ART VENEOUS SHUNT -22 EXTRA CHARGE *\n * CATH, TRANSLUM ANGIO NONLASER CATH, TRANSLUM ANGIO NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 150 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with h/o ESRD on HD with new SVC syndrome, poorly functioning\n L AVF.\n REASON FOR THIS EXAMINATION:\n functioning AVF, clots in upper torso?\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 63 year old male with end stage renal disease on dialysis through\n left arm brachiocephalic arteriovenous (AV) fistula, now presents with\n significant swelling of left face and both arms with left side being worse.\n\n RADIOLOGISTS: Drs. and , with the attending\n radiologist Dr. being present for the entire procedure. Dr.\n reviewed the exam.\n\n PROCEDURE AND FINDINGS: The risks and benefits were explained to the patient\n and consent was obtained. The patient was placed supine on the angiographic\n table and the right arm was prepped and draped in sterile fashion. Local\n anesthesia using 1% Lidocaine was applied to the puncture site. Under\n son guidance, the left cephalic vein near the arteriovenous fistula\n was accessed using a 21 gauge needle and an 0.018 wire was placed into the\n vein toward the venous side. The needle was exchanged for a micropuncture\n sheath which was connected to the power injector.\n AV fistulogram was performed along the course of the cephalic vein to the\n level of the right atrium. The venograms demonstrated a focal stenosis in the\n dilated cephalic vein at the level of the mid arm and also confirmed the\n known, severe stenosis of the superior vena cava (SVC). There is a left\n internal jugular dialysis catheter with its tip in the SVC. This might be\n related to the development of the stenosis. No intrathoracic collateral is\n seen; there is, however, collateral filling from the left mid-arm towards the\n axilla and then left lateral thoracic wall caudally.\n Pressure measurements were performed through a 5-French straight catheter.\n They demonstrated mean pressures of 13 mmHg in the right atrium and 31 mmHg in\n the left brachiocephalic vein (i.e., gradient of 18 mmHg).\n A pressure cuff was insufflated over the upper arm and a venogram was\n repeated. It revealed patency of the arteriovenous anastomosis and the\n brachial artery proximally and distally to the anastomosis with no significant\n stenosis.\n (Over)\n\n 8:01 AM\n AV FISTULOGRAM SCH Clip # \n Reason: functioning AVF, clots in upper torso?\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Thereafter, an 0.035 wire was placed through the sheath and advanced\n under fluoroscopy until its tip was in the inferior vena cava. The\n micropuncture sheath was exchanged for a 6 French sheath. The focal stenosis\n in the cephalic vein was dilated using a 6 mm X 4 cm balloon. Resolution of\n the narrowing was shown on a follow-up venogram.\n The sheath was removed and a 18 mm X 4 cm balloon was placed over the wire\n into the stenotic SVC and dilated repeatedly under fluoroscopy up to 5\n atmospheres. Follow up venograms through the sidearm of the sheath showed\n significant improvement of the diameter of the SVC. Repeat pressure\n measurements through a 4 French multiside hole straight catheter showed\n complete resolution of pressure gradient across the superior vena cava.\n The catheter and sheath were then removed and local hemostasis was achieved by\n manual compression. The patient tolerated the procedure well with no\n complications.\n\n MEDICATIONS: For conscious sedation, a total of 75 micrograms of Fentanyl was\n given in small divided intravenous doses under continuous hemodynamic\n monitoring. Total of 165 ml IV Optiray 320 dilated by half.\n\n IMPRESSION:\n\n 1. Major, symptomatic stenosis of the superior vena cava. Low-pressure\n balloon venoplasty (18 mm) resulted in highly satisfactory immediate\n angiographic and manometric results.\n\n 2. Focal stenosis in the left cephalic vein at the mid-arm level. This was\n dilated to 6 mm in diameter with no immediate complication.\n\n"},{"category":"Radiology","chartdate":"2145-12-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":777219,"text":" 4:34 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with fever and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n History of cough and fever.\n\n Heart size is borderline for technique. No evidence for CHF. There is a small\n ill-defined area of air space consolidation in the right upper lobe, new since\n the prior study of . No definite pleural effusions.\n\n IMPRESSION: Small area of right upper lobe pneumonia, new since the prior\n study of .\n\n"},{"category":"Echo","chartdate":"2145-11-25 00:00:00.000","description":"Report","row_id":69269,"text":"PATIENT/TEST INFORMATION:\nIndication: Reassess for LV function and shunt.\nHeight: (in) 66\nBP (mm Hg): 142/74\nStatus: Inpatient\nDate/Time: at 11:51\nTest: TTE(Complete)\nDoppler: Focused pulse and color flow\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. There is\na bidirectional shunt across the interatrial septum at rest. A small secundum\natrial septal defect (ASD) is present.\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: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is normal in diameter. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. The tricuspid valve\nsupporting structures are normal. Mild tricuspid [1+] regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension.\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: Contrast study was performed with one iv injection of 8 ccs\nof agitated normal saline at rest.\n\nConclusions:\nThe left atrium is normal in size. There is a bidirectional shunt across the\ninteratrial septum at rest (left-to-right on color-flow imaging; right-to-left\nby air bubble contrast imaging). A small secundum atrial septal defect (ASD)\nis present. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF 60-70%). Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\nnot stenotic. The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared to the previous study of , the left ventricular\nejection fraction is significantly increased.\n\n\n"},{"category":"ECG","chartdate":"2145-12-10 00:00:00.000","description":"Report","row_id":154724,"text":"Sinus rhythm. There are anterolateral ST-T wave abnormalities suggestive of\nanterolateral myocardial ischemia. Compared to the previous tracing of \nanterolateral ST-T wave changes are new.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2145-11-28 00:00:00.000","description":"Report","row_id":154725,"text":"Baseline artifact\nSinus rhythm\nModest lateral T wave changes are nonspecific\nLow limb leads voltage\nSince previous tracing of : probably no significant change\n\n"},{"category":"ECG","chartdate":"2145-11-24 00:00:00.000","description":"Report","row_id":154726,"text":"Sinus rhythm. Since the previous tracing of the rhythm is again sinus\nand the rate is slower. There is no other diagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2145-11-24 00:00:00.000","description":"Report","row_id":154727,"text":"There is a rapid supraventricular rhythm most probably atrial flutter.\nSince the previous tracing of the rhythm is new and the rate is more\nrapid. ST-T wave abnormalities are more marked.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2145-12-12 00:00:00.000","description":"Report","row_id":154722,"text":"Sinus rhythm\nAnterolateral ST-T changes may be due to myocardial ischemia\nCompared to previous tracing of , sinus rhythm has appeared. Otherwise\nno change.\n\n"},{"category":"ECG","chartdate":"2145-12-10 00:00:00.000","description":"Report","row_id":154723,"text":"Atrial fibrillation with a moderate ventricular response. Anterolateral\nST-T wave changes suggestive of myocardial ischemia persist. Clinical\ncorrelation is suggested.\n\n"},{"category":"Nursing/other","chartdate":"2145-11-23 00:00:00.000","description":"Report","row_id":1288080,"text":"S-\"I have something in my mouth!\"\n\nO-Extubated at 1600 after successfully weaned to PS. Hoarse voice but moving adequate air with strong cough. Sats 97-99% on face shovel.\nVSS. BP non-labile. NSR. No ectopy. Extremely agitated-trying to get OOB and yelling. Verbal reassurance not helpful. Haldol 0.5 mg IV given at 1810 with minimal effect. Hemodialysis this afternoon and 3.3 KG were taken off. Pt received one unit PRBC's during dialysis for a HCT of 25.Tolerated well. FSBS remained stable-no episiodes of hypoglycemia. Heparin started IV and present rate is 1150U/Hr. Current PTT pending. Left groin TLC oozing moderate amts of blood.\nTeam aware. Left AV fistula with faint thrill and bruit. Left external jugular dialysis cath intact. Hematuria noted from foley catheter. ? pt agitated and pulling at it.\n\nA-Extubated-tolerated shovel mask well\n\nP-MRI/MRA later this evening when pt has settled down, monitor respiratort status, FSBS to assess for hypoglycemia, m seizure activity and reassure pt and provide a safe environment.\n\n"},{"category":"Nursing/other","chartdate":"2145-11-24 00:00:00.000","description":"Report","row_id":1288081,"text":"review of systems:\n\nNeuro: UTA pts neuro status fully, pt speaks only spanish and is aggitated. pt trying to get out of bed and trashing around in bed. Pt MAE well. pt pupils equal and reactive but sluggish. Pt has recived a couple of doses of haldol which has not seemed to work. pt has + babinski bilaterally.\n\nResp: pt remains on 50% face tent and sao2 > 92%. pt has had no secreations, but pts lungs sound very coarse.\n\nCV: pt BP has remained stable WNL, currently 147/45 in a normal ST with no ectopy noted. pt remains on hep gtt, PTT was hight @ 2300, so gtt turned off and then decreased per hep protocol. pt recived 1 unit of blood due to a HCT of 28. ptt and post tranfusion HCT pending. Pt is oozing ALOT of blood around left fem TLC, pressure dressing changed many times, HO made aware.\n\nGI/GU: Pt has a few loose brown stools tonight. Pt has hematuria due to pt pulling on foley HO aware.\n\n\n"},{"category":"Nursing/other","chartdate":"2145-11-24 00:00:00.000","description":"Report","row_id":1288082,"text":"NURSING NOTE: 7A-1300\n PT SPANISH SPEAKING ONLY. WITH HELP OF TRANSLATOR, FOLOWS SOME SIMPLE COMMANDS. PER TRANSLATOR PT'S SPANISH IS NOT CLEAR. MAE. NORMAL EQUAL STRENGTHS. BECOMES AGGITATED AT TIMES CALLING OUT AND FIDGETY. SOFT WRIST RESTRANITS AND FREQUENT CHECKS. FAMILY AT BEDSIDE IS HELPFUL FOR PT'S AGITATION. PUPILS FIXED AT 3MM WITH DOWNWARD PALSY NOTED. LARGE AMOUNT OF NECK AND HEAD SWELLING, PERI-ORBITAL EDEMA ALSO PRESENT.\n\nRESP- O2 TITRATED TO 4L N/C WITH SATS 97-100%. RR 16-24. NPC. LUNG SOUNDS COARSE.\n\nCV- HR ST 100-110'S NO ECTOPY OBSERVED. SBP 130-150'S. PERIPHERAL PULSES PRESENT WITH DOPPLER. HEPARIN INFUSION WAS OFF AT 7AM FOR PTT 140. PTT RECHECKED AT 1130 WAS 41.8 AND GTT WAS RESTARTED AT 600U/H. NEXT PTT DUE AT 1730.\n\nGI- ABD SOFT NT ND +BS 2 SMALL BM'S TODAY. SPEC SENT FOR CDIFF TODAY PENDING. NO PO MEDS GIVEN YET AS PT WOULD NOT COOPERATE WITH ASSESSING SWALLOWING. TEAM AWARE.\n\nGU- FOLEY PATENT FOR SMALL AMOUNTS OF BLOODY URINE. PT WENT TO HD TODAY AT APPROX 1300.\n\nACCESS- L FEMORAL TLCL BLEEDING AT SITE MODERATE AMOUNTS, TEAM MADE AWARE AND PTT THIS AM WAS SUPERTHERAPEUTIC. PRESSURE DSG APPLIED. L PICC CLOOTED PER REPORT FROM NOC SHIFT. L EJ DIALYSIS CATHETER, AND HAS L UPPER ARM AV FISTULA.\n\nSOCIAL-WIFE AT BEDSIDE THIS AM, DR ASSISTED IN TRANSLATING.\n\n PT WENT TO MRI TODAY. UNABLE TO GET GOOD IMAGES DESPITE MEDICATED WITH VERSED. MRI HEAD DONE, CHEST UNABLE TO OBTAIN. TEAM AWARE. FROM MRI PT WAS TRANSFERRED TO HD UNIT. PT IS TO TRANSFER TO 723 AFTER HD COMPLETE. TRANSFER NOT FAXED TO FLOOR, FOLLOW-UP REPORT TO BE CALLED.\n\n"},{"category":"Nursing/other","chartdate":"2145-11-23 00:00:00.000","description":"Report","row_id":1288079,"text":"Review of systems:\n\nNeuro: pt came to MICU and was sedated from OSH, after about 1 hour pt woke up and became very aggitated, pt recived adivan and fentanyl for sedation. After head CT pt was started on propofol gtt to sedate pt. pt is currently sedated on 10 mcg/kg/min of propofol. pt will grimase and flex to painful stim. pt does not open eyes, and pt pupils are equal but not reactive, Dr. aware.\n\nResp: pt remains intubated on vent AC/12/650/.50/5. pt sao2 is > 965. pt requires q 4 hour suctioning for scant amount of thick tan secreations. plan is to attempt to extubate pt this morning.\n\nCV: pt BP is stable WNL, currently 133/47, pt is in NSR with no ectopy noted. pt takes PO BP meds at home, PO meds currently on hold for extubation in AM. Pt has H/O DVT, pt sup vena cava in belived to be clottted, pt head and swollen due to this clot. Pt PICC line has since clotted.\n\nGI/GU: Pt has ESRD, with HD MWF, he missed HD and will recive HD this morning. pt has a L SC HD cath as well as a fistula in left arm with a + bruit and thrill.\n\nLines: pt had a left fem TLC placed.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-11-24 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 776236,\n \"text\": \" 11:36 AM\\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \\n Reason: please eval for acute stroke\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with AMS, ?seizure (new) with upgoing babinskis bilaterally\\n REASON FOR THIS EXAMINATION:\\n please eval for acute stroke\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: Confusion. Question of new seizure.\\n\\n TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain were obtained\\n with and without IV contrast. 2D and 3D multiplanar reformatted images were\\n created.\\n\\n MRI OF THE BRAIN W/O CONTRAST: The study is extremely limited by patient\\n motion. In particular, the susceptibility and FLAIR images are somewhat\\n degraded. Multiple T1 low attenuation lesions within the thalami, internal\\n capsule and basal ganglia suggest multiple prior chronic lacunes. There are\\n no abnormal signal intensities on diffusion weighted imaging to suggest acute\\n ischemia. No shift of normally midline structures or mass effect is seen. The\\n ventricles, cisterns, and sulci are symmetric without significant enlargement\\n or effacement. No acute hemorrhage is identified.\\n\\n MRA OF THE BRAIN AND CAROTID ARTERIES: These images are degraded by motion\\n artifact. Grossly normal flow can be seen within the internal carotid and\\n right vertebral arteries\\n\\n Images of the circle of are degraded by motion artifact. Fine vascular\\n detail is not obtained. There is normal flow within the basilar and\\n intracranial carotid arteries. Branch vessels are not well evaluated.\\n\\n IMPRESSION:\\n\\n No evidence of acute brain infarction. Limited study due to motion artifact\\n with significant degradation of MRA sequences.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-11-25 00:00:00.000\",\n \"description\": \"B UNILAT UP EXT VEINS US BILAT\",\n \"row_id\": 776386,\n \"text\": \" 4:12 PM\\n UNILAT UP EXT VEINS US BILAT Clip # \\n Reason: please perform vein mapping of entire upper extremity includ\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with h/o ESRD on HD p/w MS changes, b/l UE swelling concerning\\n for SVC syndrome. Pt. has h/o numerous b/l UE clots.\\n REASON FOR THIS EXAMINATION:\\n please perform vein mapping of entire upper extremity including SVC.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of end-stage renal disease, on hemodialysis, with mental\\n status changes and bilateral upper extremity swelling concerning for SVC\\n syndrome. Evaluate for upper-extremity DVT.\\n\\n BILATERAL UPPER EXTREMITY ULTRASOUND: -scale, color, and Doppler\\n son of both internal jugular, subclavian, axillary and brachial veins\\n were performed. Additionally, the right cephalic vein was evaluated. There\\n is near-complete thrombus of the left internal jugular vein with a tiny amount\\n of flow through this vessel. There is mild thickening of the walls of the\\n left internal jugular vein. No thrombus is identified within the right\\n internal jugular vein, both subclavians, axillary and brachial veins. No\\n thrombus is identified within the right cephalic vein. There is neointimal\\n thickening within the right subclavian vein where the PICC line enters with\\n normal color flow through this area. There is normal respiratory variation\\n throughout the veins of both the right and left upper extremities excluding\\n the left internal jugular vein. The left upper extremity fistula was not\\n evaluated.\\n\\n IMPRESSION: Chronic near-complete thrombus of the left internal jugular vein.\\n No occlusive thrombus in the other veins evaluated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-11-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 776289,\n \"text\": \" 7:51 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: FEVER\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man s/p extubation airway protection s/p seizure now w/\\n tachycardia and fever\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Extubated. Now with tachycardia and fever.\\n\\n COMPARISON: .\\n\\n FINDINGS: There has been interval removal of the ET tube. Left-sided central\\n venous line remains in unchanged position. The cardiac and mediastinal\\n contours are unchanged allowing for patient rotation. Bilateral\\n hemidiaphragms are less distinct on today's exam suggesting increased\\n bibasilar atelectasis. Probable small left pleural effusion. Left-sided PICC\\n line tip is in the axillary vein.\\n\\n IMPRESSION: Worsening bibasilar atelectasis with probable left pleural\\n effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-11-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 776473,\n \"text\": \" 3:06 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pna?\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with ESRD on HD presents with fever.\\n REASON FOR THIS EXAMINATION:\\n pna?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hemodialysis with fever.\\n\\n TECHNIQUE: A single portable AP view of the chest is compared with 2 days\\n prior.\\n\\n FINDINGS: Again seen is a left subclavian hemodialysis catheter, terminating\\n in the mid-SVC. A right-sided PICC line again terminates in the axilla. The\\n cardiomediastinal silhouette is unremarkable. No focal pulmonary opacities,\\n pleural effusions, or pneumothorax. Pulmonary vasculature is unremarkable.\\n\\n IMPRESSION:\\n 1) Vascath terminates in the mid-SVC, and right-sided PICC line terminates\\n within the axilla.\\n\\n 2) No evidence of focal pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-11-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 776070,\n \"text\": \" 10:48 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pleave eval ett placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with intubation for airway protection s/p seizure.\\n REASON FOR THIS EXAMINATION:\\n pleave eval ett placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intubated after seizure.\\n\\n COMPARISON: .\\n\\n FINDINGS: A left sided central venous line is present with tip in the SVC.\\n Endotracheal tube is in good position several cm above the carina. The heart\\n is top normal in size with slight left ventricular enlargement. Mediastinal\\n contours are unchanged allowing for differences in patient positioning. There\\n is interval worsening of left lower lobe consolidation and collapse. No\\n definite pleural effusion. No pneumothorax. The soft tissue and osseous\\n structures are unremarkable.\\n\\n IMPRESSION: Good placement of ET tube. Increased left lower lobe\\n consolidation and collapse.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-11-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 776074,\n \"text\": \" 12:36 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: does pt have intracranial bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with report of seizure, now intubated.\\n REASON FOR THIS EXAMINATION:\\n does pt have intracranial bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Seizures, intubated.\\n\\n TECHNIQUE: Axial images of the brain were obtained without IV contrast.\\n\\n COMPARISON: .\\n\\n CT BRAIN WITHOUT IV CONTRAST: The ventricles, cisterns and sulci are normal.\\n There is no shift of normal midline structures or mass affect. The /white\\n matter differentiation is normal. There are no pathologic extra-axial fluid\\n collections. Again seen are lacunar infarcts in the caudate nucleus\\n bilaterally and the right cerebellar hemisphere. There are vascular\\n calcifications. There is soft tissue and fluid in the left maxillary sinus,\\n bilateral ethmoidal air cells and bilateral sphenoid sinuses. The patient is\\n intubated. There is also a small fluid level in the posterior right mastoid.\\n Dense carotid calcifications are present.\\n\\n IMPRESSION:\\n\\n 1.No evidence of intracranial hemorrhage. If clinically indicated, contrast-\\n enhanced MR imaging may be useful for further evaluation of seizures.\\n 2.Sinus disease.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-11-30 00:00:00.000\",\n \"description\": \"PTA VENOUS\",\n \"row_id\": 776845,\n \"text\": \" 8:01 AM\\n AV FISTULOGRAM SCH Clip # \\n Reason: functioning AVF, clots in upper torso?\\n Contrast: OPTIRAY Amt: 150\\n ********************************* CPT Codes ********************************\\n * PTA VENOUS PTA VENOUS *\\n * -59 DISTINCT PROCEDURAL SERVICE INTRO CATH SVC/IVC *\\n * -51 MULTI-PROCEDURE SAME DAY PTA VENOUS *\\n * PTA VENOUS -59 DISTINCT PROCEDURAL SERVICE *\\n * ART VENEOUS SHUNT -22 EXTRA CHARGE *\\n * CATH, TRANSLUM ANGIO NONLASER CATH, TRANSLUM ANGIO NONLASER *\\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 150 CC *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with h/o ESRD on HD with new SVC syndrome, poorly functioning\\n L AVF.\\n REASON FOR THIS EXAMINATION:\\n functioning AVF, clots in upper torso?\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n HISTORY: 63 year old male with end stage renal disease on dialysis through\\n left arm brachiocephalic arteriovenous (AV) fistula, now presents with\\n significant swelling of left face and both arms with left side being worse.\\n\\n RADIOLOGISTS: Drs. and , with the attending\\n radiologist Dr. being present for the entire procedure. Dr.\\n reviewed the exam.\\n\\n PROCEDURE AND FINDINGS: The risks and benefits were explained to the patient\\n and consent was obtained. The patient was placed supine on the angiographic\\n table and the right arm was prepped and draped in sterile fashion. Local\\n anesthesia using 1% Lidocaine was applied to the puncture site. Under\\n son guidance, the left cephalic vein near the arteriovenous fistula\\n was accessed using a 21 gauge needle and an 0.018 wire was placed into the\\n vein toward the venous side. The needle was exchanged for a micropuncture\\n sheath which was connected to the power injector.\\n AV fistulogram was performed along the course of the cephalic vein to the\\n level of the right atrium. The venograms demonstrated a focal stenosis in the\\n dilated cephalic vein at the level of the mid arm and also confirmed the\\n known, severe stenosis of the superior vena cava (SVC). There is a left\\n internal jugular dialysis catheter with its tip in the SVC. This might be\\n related to the development of the stenosis. No intrathoracic collateral is\\n seen; there is, however, collateral filling from the left mid-arm towards the\\n axilla and then left lateral thoracic wall caudally.\\n Pressure measurements were performed through a 5-French straight catheter.\\n They demonstrated mean pressures of 13 mmHg in the right atrium and 31 mmHg in\\n the left brachiocephalic vein (i.e., gradient of 18 mmHg).\\n A pressure cuff was insufflated over the upper arm and a venogram was\\n repeated. It revealed patency of the arteriovenous anastomosis and the\\n brachial artery proximally and distally to the anastomosis with no significant\\n stenosis.\\n (Over)\\n\\n 8:01 AM\\n AV FISTULOGRAM SCH Clip # \\n Reason: functioning AVF, clots in upper torso?\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n Thereafter, an 0.035 wire was placed through the sheath and advanced\\n under fluoroscopy until its tip was in the inferior vena cava. The\\n micropuncture sheath was exchanged for a 6 French sheath. The focal stenosis\\n in the cephalic vein was dilated using a 6 mm X 4 cm balloon. Resolution of\\n the narrowing was shown on a follow-up venogram.\\n The sheath was removed and a 18 mm X 4 cm balloon was placed over the wire\\n into the stenotic SVC and dilated repeatedly under fluoroscopy up to 5\\n atmospheres. Follow up venograms through the sidearm of the sheath showed\\n significant improvement of the diameter of the SVC. Repeat pressure\\n measurements through a 4 French multiside hole straight catheter showed\\n complete resolution of pressure gradient across the superior vena cava.\\n The catheter and sheath were then removed and local hemostasis was achieved by\\n manual compression. The patient tolerated the procedure well with no\\n complications.\\n\\n MEDICATIONS: For conscious sedation, a total of 75 micrograms of Fentanyl was\\n given in small divided intravenous doses under continuous hemodynamic\\n monitoring. Total of 165 ml IV Optiray 320 dilated by half.\\n\\n IMPRESSION:\\n\\n 1. Major, symptomatic stenosis of the superior vena cava. Low-pressure\\n balloon venoplasty (18 mm) resulted in highly satisfactory immediate\\n angiographic and manometric results.\\n\\n 2. Focal stenosis in the left cephalic vein at the mid-arm level. This was\\n dilated to 6 mm in diameter with no immediate complication.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2145-12-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 777219,\n \"text\": \" 4:34 PM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with fever and cough\\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n History of cough and fever.\\n\\n Heart size is borderline for technique. No evidence for CHF. There is a small\\n ill-defined area of air space consolidation in the right upper lobe, new since\\n the prior study of . No definite pleural effusions.\\n\\n IMPRESSION: Small area of right upper lobe pneumonia, new since the prior\\n study of .\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2145-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 69269,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Reassess for LV function and shunt.\\nHeight: (in) 66\\nBP (mm Hg): 142/74\\nStatus: Inpatient\\nDate/Time: at 11:51\\nTest: TTE(Complete)\\nDoppler: Focused pulse and color flow\\nContrast: Saline\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. There is\\na bidirectional shunt across the interatrial septum at rest. A small secundum\\natrial septal defect (ASD) is present.\\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: The aortic root is normal in diameter. There are focal calcifications\\nin the aortic root. The ascending aorta is normal in diameter. There are focal\\ncalcifications in the ascending aorta.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\\nstenotic.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\\nmitral valve prolapse. There is mild mitral annular calcification. There is\\nmild thickening of the mitral valve chordae.\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. The tricuspid valve\\nsupporting structures are normal. Mild tricuspid [1+] regurgitation is seen.\\nThere is mild pulmonary artery systolic hypertension.\\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: Contrast study was performed with one iv injection of 8 ccs\\nof agitated normal saline at rest.\\n\\nConclusions:\\nThe left atrium is normal in size. There is a bidirectional shunt across the\\ninteratrial septum at rest (left-to-right on color-flow imaging; right-to-left\\nby air bubble contrast imaging). A small secundum atrial septal defect (ASD)\\nis present. Left ventricular wall thickness, cavity size, and systolic\\nfunction are normal (LVEF 60-70%). Right ventricular chamber size and free\\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\\nnot stenotic. The mitral valve leaflets are mildly thickened. There is no\\nmitral valve prolapse. There is mild pulmonary artery systolic hypertension.\\nThere is no pericardial effusion.\\n\\nCompared to the previous study of , the left ventricular\\nejection fraction is significantly increased.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2145-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 154724,\n \"text\": \"Sinus rhythm. There are anterolateral ST-T wave abnormalities suggestive of\\nanterolateral myocardial ischemia. Compared to the previous tracing of \\nanterolateral ST-T wave changes are new.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2145-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 154725,\n \"text\": \"Baseline artifact\\nSinus rhythm\\nModest lateral T wave changes are nonspecific\\nLow limb leads voltage\\nSince previous tracing of : probably no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2145-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 154726,\n \"text\": \"Sinus rhythm. Since the previous tracing of the rhythm is again sinus\\nand the rate is slower. There is no other diagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2145-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 154727,\n \"text\": \"There is a rapid supraventricular rhythm most probably atrial flutter.\\nSince the previous tracing of the rhythm is new and the rate is more\\nrapid. ST-T wave abnormalities are more marked.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2145-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 154722,\n \"text\": \"Sinus rhythm\\nAnterolateral ST-T changes may be due to myocardial ischemia\\nCompared to previous tracing of , sinus rhythm has appeared. Otherwise\\nno change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2145-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 154723,\n \"text\": \"Atrial fibrillation with a moderate ventricular response. Anterolateral\\nST-T wave changes suggestive of myocardial ischemia persist. Clinical\\ncorrelation is suggested.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2145-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1288080,\n \"text\": \"S-\\\"I have something in my mouth!\\\"\\n\\nO-Extubated at 1600 after successfully weaned to PS. Hoarse voice but moving adequate air with strong cough. Sats 97-99% on face shovel.\\nVSS. BP non-labile. NSR. No ectopy. Extremely agitated-trying to get OOB and yelling. Verbal reassurance not helpful. Haldol 0.5 mg IV given at 1810 with minimal effect. Hemodialysis this afternoon and 3.3 KG were taken off. Pt received one unit PRBC's during dialysis for a HCT of 25.Tolerated well. FSBS remained stable-no episiodes of hypoglycemia. Heparin started IV and present rate is 1150U/Hr. Current PTT pending. Left groin TLC oozing moderate amts of blood.\\nTeam aware. Left AV fistula with faint thrill and bruit. Left external jugular dialysis cath intact. Hematuria noted from foley catheter. ? pt agitated and pulling at it.\\n\\nA-Extubated-tolerated shovel mask well\\n\\nP-MRI/MRA later this evening when pt has settled down, monitor respiratort status, FSBS to assess for hypoglycemia, m seizure activity and reassure pt and provide a safe environment.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2145-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1288081,\n \"text\": \"review of systems:\\n\\nNeuro: UTA pts neuro status fully, pt speaks only spanish and is aggitated. pt trying to get out of bed and trashing around in bed. Pt MAE well. pt pupils equal and reactive but sluggish. Pt has recived a couple of doses of haldol which has not seemed to work. pt has + babinski bilaterally.\\n\\nResp: pt remains on 50% face tent and sao2 > 92%. pt has had no secreations, but pts lungs sound very coarse.\\n\\nCV: pt BP has remained stable WNL, currently 147/45 in a normal ST with no ectopy noted. pt remains on hep gtt, PTT was hight @ 2300, so gtt turned off and then decreased per hep protocol. pt recived 1 unit of blood due to a HCT of 28. ptt and post tranfusion HCT pending. Pt is oozing ALOT of blood around left fem TLC, pressure dressing changed many times, HO made aware.\\n\\nGI/GU: Pt has a few loose brown stools tonight. Pt has hematuria due to pt pulling on foley HO aware.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2145-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1288082,\n \"text\": \"NURSING NOTE: 7A-1300\\n PT SPANISH SPEAKING ONLY. WITH HELP OF TRANSLATOR, FOLOWS SOME SIMPLE COMMANDS. PER TRANSLATOR PT'S SPANISH IS NOT CLEAR. MAE. NORMAL EQUAL STRENGTHS. BECOMES AGGITATED AT TIMES CALLING OUT AND FIDGETY. SOFT WRIST RESTRANITS AND FREQUENT CHECKS. FAMILY AT BEDSIDE IS HELPFUL FOR PT'S AGITATION. PUPILS FIXED AT 3MM WITH DOWNWARD PALSY NOTED. LARGE AMOUNT OF NECK AND HEAD SWELLING, PERI-ORBITAL EDEMA ALSO PRESENT.\\n\\nRESP- O2 TITRATED TO 4L N/C WITH SATS 97-100%. RR 16-24. NPC. LUNG SOUNDS COARSE.\\n\\nCV- HR ST 100-110'S NO ECTOPY OBSERVED. SBP 130-150'S. PERIPHERAL PULSES PRESENT WITH DOPPLER. HEPARIN INFUSION WAS OFF AT 7AM FOR PTT 140. PTT RECHECKED AT 1130 WAS 41.8 AND GTT WAS RESTARTED AT 600U/H. NEXT PTT DUE AT 1730.\\n\\nGI- ABD SOFT NT ND +BS 2 SMALL BM'S TODAY. SPEC SENT FOR CDIFF TODAY PENDING. NO PO MEDS GIVEN YET AS PT WOULD NOT COOPERATE WITH ASSESSING SWALLOWING. TEAM AWARE.\\n\\nGU- FOLEY PATENT FOR SMALL AMOUNTS OF BLOODY URINE. PT WENT TO HD TODAY AT APPROX 1300.\\n\\nACCESS- L FEMORAL TLCL BLEEDING AT SITE MODERATE AMOUNTS, TEAM MADE AWARE AND PTT THIS AM WAS SUPERTHERAPEUTIC. PRESSURE DSG APPLIED. L PICC CLOOTED PER REPORT FROM NOC SHIFT. L EJ DIALYSIS CATHETER, AND HAS L UPPER ARM AV FISTULA.\\n\\nSOCIAL-WIFE AT BEDSIDE THIS AM, DR ASSISTED IN TRANSLATING.\\n\\n PT WENT TO MRI TODAY. UNABLE TO GET GOOD IMAGES DESPITE MEDICATED WITH VERSED. MRI HEAD DONE, CHEST UNABLE TO OBTAIN. TEAM AWARE. FROM MRI PT WAS TRANSFERRED TO HD UNIT. PT IS TO TRANSFER TO 723 AFTER HD COMPLETE. TRANSFER NOT FAXED TO FLOOR, FOLLOW-UP REPORT TO BE CALLED.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2145-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1288079,\n \"text\": \"Review of systems:\\n\\nNeuro: pt came to MICU and was sedated from OSH, after about 1 hour pt woke up and became very aggitated, pt recived adivan and fentanyl for sedation. After head CT pt was started on propofol gtt to sedate pt. pt is currently sedated on 10 mcg/kg/min of propofol. pt will grimase and flex to painful stim. pt does not open eyes, and pt pupils are equal but not reactive, Dr. aware.\\n\\nResp: pt remains intubated on vent AC/12/650/.50/5. pt sao2 is > 965. pt requires q 4 hour suctioning for scant amount of thick tan secreations. plan is to attempt to extubate pt this morning.\\n\\nCV: pt BP is stable WNL, currently 133/47, pt is in NSR with no ectopy noted. pt takes PO BP meds at home, PO meds currently on hold for extubation in AM. Pt has H/O DVT, pt sup vena cava in belived to be clottted, pt head and swollen due to this clot. Pt PICC line has since clotted.\\n\\nGI/GU: Pt has ESRD, with HD MWF, he missed HD and will recive HD this morning. pt has a L SC HD cath as well as a fistula in left arm with a + bruit and thrill.\\n\\nLines: pt had a left fem TLC placed.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":23093,"cells":{"subject_id":{"kind":"number","value":26027,"string":"26,027"},"hadm_id":{"kind":"number","value":127906,"string":"127,906"},"target_text":{"kind":"string","value":"38 M with h/o epilepsy, alcoholism, alcohol withdrawal seizures, and delirium tremens (per pt report) who presents in alcohol withdrawal requesting treatment. . 1. EtOH Withdrawal: Patient presented to the emergency department requesting detox. His last drink was approx 6 hours prior to arrival. He typically drinks gallon on Vodka daily. His EtOH level on arrival was 317. Tox screen was otherwise negative. Patient became increasingly hypertensive, tachycardic, and tremulous. He was given Ativan 2mg IV and Valium for a total of 40mg IV over 3 hours though he continued to show signs of withdrawal. He was admitted to the ICU Continues and required approx 200mg of Valium over 6 hour period to control his symptoms of withdrawal. He was given a banana bag and started on Thiamine, Folate, and MVT. The morning after discharge the patient left AMA. . 2. Anion Gap Acidosis: Likely starvation versus alcoholic ketoacidosis. Resolved after two liters of IVF. . 3. H/0 Epilepsy: No longer on meds. Reports seizure prior to presentation. Not clear if this was a alcohol withdrawal seizure. Patient was monitored on seizure precautions. AED were not restarted prior to presentation. . 4. Scabies: Patient with evidence of scabies on exam. Contact precautions applied. Treated with both Permethrin and Ivermectin x one. Bendaryl and Sarna as needed for itching."},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: In comparison with the study of , there is little change and no evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. The outermost portion of the left hemithorax has been excluded from the image."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2204-12-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1165770,"text":" 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new infiltrate\n Admitting Diagnosis: ETOH WITHDRAWL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with alcoholism and new mental status\n REASON FOR THIS EXAMINATION:\n new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Alcoholism with new mental status changes.\n\n FINDINGS: In comparison with the study of , there is little change and no\n evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,\n or pleural effusion. The outermost portion of the left hemithorax has been\n excluded from the image.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2204-12-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1165770,\n \"text\": \" 2:40 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: new infiltrate\\n Admitting Diagnosis: ETOH WITHDRAWL\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 38 year old man with alcoholism and new mental status\\n REASON FOR THIS EXAMINATION:\\n new infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Alcoholism with new mental status changes.\\n\\n FINDINGS: In comparison with the study of , there is little change and no\\n evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,\\n or pleural effusion. The outermost portion of the left hemithorax has been\\n excluded from the image.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":23094,"cells":{"subject_id":{"kind":"number","value":31495,"string":"31,495"},"hadm_id":{"kind":"number","value":188823,"string":"188,823"},"target_text":{"kind":"string","value":"Patient is a 73 yo woman with PMH of brain tumor s/p VP shunt , near deafness, hypothyroid and colon CA last year who presented to ED yesterday at 2300 with mental status changes. According to the daughter, the patient has in town from for the alst 2 weeks visiting for a graduation. Last night she had had 3 glasses of wine the of her MS changes. Last night during the graduation party said that she was feeling tired and that she was going to go upstairs to go to bed. About an hour later, she came down the stares and had notable face/eye trauma as if she had fallen. Her speech was dysarthric and she was mumbling. She said \"I don't know what happened\" and could not give explanation. Taken to ED. She was found to have bilateral SDH L >R and was transferred here. Here in the ICU, would open eyes and intermittently seemed to follow commands. She is very hard of hearing per daughter and nearly deaf. She was noted by ICU team to be moving x 4 but not speaking, and sleepy. She was obeserved in the ICU for 24 hours, and started on Folate, Thiamine, and Dilantin prophylactically. Subsequent CT scans revealved stability of SDH, and no worsening such to indicate surgical evacuation. Given her medical history a MRI/MRA was obtained(results included previously in this summary). Patient had inquired about receving her ongoing care in her come country of . Discharge planning has been moving toward that goal. She has a neurologist who follows her in , Dr. . This is acceptable per Dr. , and case managment has been working with the daughter to make arrangements to this effect. Physical therapy has continued to work with the patient in-house pending the finalization of these plans. The PT and OT felt that she did not require rehab but that she did need continued therapy after discharge. The patient will be discharged with the plan to go back home to with home PT and OT services."},"extractive_notes_summ":{"kind":"string","value":"Unchanged position of shunt catheter, with collapsed ventricles which may reflect intracranial hypotension or overshunting. LUNG SOUNDS DIMINISHED ON RT THROUGH NOC, THOUGH CLEAR BILATERALLY THIS AM.NEURO: LOC RANGES ALERT->LETHARGIC. TECHNIQUE: Non-contrast head CT. FINDINGS: Small bilateral convexity subdural hematomas are little changed, with subarachnoid blood again seen tracking along the tentorium, and upwards towards the vertex. Otherwise, little interval change in the bilateral convexity subdural hemorrhages, and bilateral subarachnoid blood. Normal flow void signal is identified in the vascular structures. Shunt catheter is unchanged in position, tip near the foramen of . The remainder of the visualized paranasal sinuses remain normally aerated. NURSING UPDATECV: HR NSR, NO ECTOPY. NURSING UPDATECV: HR NSR, NO ECTOPY. REASON FOR THIS EXAMINATION: eval No contraindications for IV contrast WET READ: KYg SAT 2:26 AM biconvexity subdural hematoma. IMPRESSION: No significant new interval change in the previously described subdural hematomas and subarachnoid hemorrhage. Slight interval increase in size of subdural hemorrhage in the inferior left frontal lobe, with minimal edema and mass effect on regional sulci. Paranasal sinuses remain normally aerated. The shunt catheter is unchanged in position with the tip near to the foramen of . The heart size and the mediastinal contours are within normal limits. REASON FOR THIS EXAMINATION: eval acute process No contraindications for IV contrast WET READ: KN SAT 4:02 AM Agree. Lungs are diminished at bases, clear upper lobes. FINDINGS: In comparison with the prior study, again there is evidence of bilateral subdural hematomas along the convexity with associated subarachnoid hemorrhage, no significant change is noted in the size and configuration of these collections. TECHNIQUE: Non-contrast MDCT-acquired axial images of the facial bones. Subdural hemorrhage in the left inferior frontal lobe has slightly increased, with minimal edema and mass effect seen on subjacent sulci. Pontine calcification is unchanged. NON-CONTRAST HEAD CT: There are bilateral cerebral convexity subdural hematoma with additional foci of subarachnoid blood noted within the left vertex and right temporal lobe. No intraparenchymal diffusion abnormalities are detected, the hematomas demonstrate mild restricted diffusion. Diffuse non-specific T wave flattening. Subarachnoid blood seen predominantly in the high left frontal sulci, left greater than right is little changed. There is a somewhat shallow level of inspiration and there is some blunting of the left CP angle suggesting some pleural fluid. A shunt catheter is seen via a right posterior occiput approach and terminates within the right frontal of the lateral ventricle adjacent to the septum pellucidum. FINDINGS: The cervical spine maintains a normal alignment without fracture or subluxation. REASON FOR THIS EXAMINATION: eval No contraindications for IV contrast WET READ: KYg SAT 2:29 AM no fractures. Note is made of biconvexity subdural hematoma, which is evaluated on head CT. SOFT, BOWEL SOUNDS +.GU: HUO MARGINAL, CLEAR YELLOW->AMBER VIA F/CATH.PT MONITORED .DR IN CLOSE ICU ATTENDANCE.SEE CAREVUE FLOWSHEETS FOR DETAILED DATA. Mild mucosal thickening is noted in the ethmoidal air cells. Note is made of collapsed ventricle suggesting the presence of intracranial hypotension or overshunting. IMPRESSION: No facial fracture. UE'S NORMAL STRENGTH, LIFT AND HOLDING BLE'S. TEMP RESOLVED WITHOUT INTERVENTION. small foci of sa blood at the left vertex and right temporal lobe. Right occipital burr hole. TECHNIQUE: Non-contrast MDCT-acquired axial images of the cervical spine from the skull base to the level of T2. A shunt catheter is seen via a right occipital approach terminating within the right frontal of the lateral ventricle adjacent to the septum pellucidum. Punctate low signal areas are identified in the pons related with previously described calcifications. Abd is soft, +BSX4. Bilateral cerebral convexity subdural hematomas with small foci of subarachnoid blood within the left vertex and right temporal lobe. TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained, axial T2, axial FLAIR, axial magnetic susceptibility, the T1-weighted sequences were repeated after the administration of gadolinium contrast in axial, sagittal, and coronal projections. Dr WET READ VERSION #1 KYg SAT 2:51 AM no fracture or subluxation. Please See Carevue for Specifics.Pt is arousable to name and stimuli, opens eyes, pt is aphasic, does not follow commands, PERL, withdraws all ext to nailbed pressure. No prevertebral soft tissue abnormality is detected. NSR, no ectopy, SBP 130-140's. After the administration of contrast, there is evidence of diffuse leptomeningeal enhancement possibly related with the recent fractures and hematomas. NEURO; MAE, DOES NOT FOLLOW COMMANDS, PERL AND BRISK, EOM'S INTACT, WITHDRAWS TO NOXIOIUS STIMULI, TAKEN FOR HEAD CAT AND MRI TODAY, MEDIC IN MRI SUITE FOR AGITATION, LETHARGIC THIS PM BUT EASILY AROUSEABLE,CARDIOVASCULAR; HR 60'S-70'S SR, GOA IS TO KEEP SYS 100-140 PER DR. , TEMP 100.6, LABS DRAWN THIS PM BUT PT DIFFICULT TO OBTAIN LAB DRAWS, ? COMPARISON: Prior CTs of the head dated . Ventricles remain collapsed. foley with c/y/u. IMPRESSION: No fracture or subluxation. FINDINGS: No fracture is detected. Basal cisterns are normal. The - white matter differentiation is preserved. Diffuse leptomeningeal enhancement, likely related with the recent fractures and subdural hematomas. FUTURE ATTEMPT AT A LINE INSERTIONRESPIR; LUNGS CLEAR, 02 SAT 98% ON R/A, FEW EXPIR WHEEZES THIS PM, EXPECTORATED SMALL AMT THICK YELLOW MUCOUS, REPOSITIONED FREQUENTLY AND CHEST PT DONEGI; DOBOFF FEEDING TUBE PLACED FOR MEDS AND CONFIRMED BY X RAY PER SICU HO, ? Hypodensity is seen within the left basal ganglia which likely represents old lacunar infarct. STOOL SOFTENERS IF NEEDEDPLAN; KEEP SYS < 160, FREQUENT NEURO CHECKS, PT FREQUENTLY TO SURROUNDINGS, SPEECH/SWALLOWING EVAL TOMORROW, ? Sinus rhythm. the ventricles are collapsed suggesting intracranial hypotension. The ventricles are collapsed which is suggestive of intracranial hypotension or overshunting. REMAINS NPO AT THIS TIME.GU: ADEQUATE HUO > 30CC/H.PLAN: SPEECH AND SWALLOW EXAM.TRANSFER TO HOSPITAL WHEN MD/MD AND TRANSPORT ARRANGEMENTS MADE.PT MONITORED .DR IN CLOSE ICU ATTENDANCE.SEE CAREVUE FLOWSHEETS FOR DETAILED DATA."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2117-06-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1015682,"text":" 9:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pos Dobhoff\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with SDH s/p Dobhoff placement\n REASON FOR THIS EXAMINATION:\n ?pos Dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 9:58\n\n INDICATION: Dobbhoff positioning.\n\n FINDINGS:\n\n There are no relevant comparison films. An NG tube extends below the level of\n the diaphragm cannot be seen with tube extends beyond the confines of the\n image. There is a somewhat shallow level of inspiration and there is some\n blunting of the left CP angle suggesting some pleural fluid. There is no\n patchy consolidation visualized. The heart size and the mediastinal contours\n are within normal limits.\n\n\n"},{"category":"Radiology","chartdate":"2117-06-26 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1015694,"text":" 12:13 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: T1 w/ gadolinium 3 planes\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with brain tumor & b/l SDH\n REASON FOR THIS EXAMINATION:\n T1 w/ gadolinium 3 planes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MRI of the head with and without contrast and MRA of the head.\n\n CLINICAL INDICATION: 73-year-old woman with history of subdural hematoma and\n facial fractures.\n\n COMPARISON: Prior CTs of the head dated .\n\n TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,\n axial T2, axial FLAIR, axial magnetic susceptibility, the T1-weighted\n sequences were repeated after the administration of gadolinium contrast in\n axial, sagittal, and coronal projections.\n\n FINDINGS: In comparison with the prior study, again there is evidence of\n bilateral subdural hematomas along the convexity with associated subarachnoid\n hemorrhage, no significant change is noted in the size and configuration of\n these collections. There is no evidence of shift of normally midline\n structures. Multiple lacunar ischemic changes are noted in the basal ganglia,\n more evident on the left side, prominent perivascular space is identified on\n the right external capsule. After the administration of contrast, there is\n evidence of diffuse leptomeningeal enhancement possibly related with the\n recent fractures and hematomas. No intraparenchymal diffusion abnormalities\n are detected, the hematomas demonstrate mild restricted diffusion. Normal\n flow void signal is identified in the vascular structures. Mild mucosal\n thickening is noted in the ethmoidal air cells. Punctate low signal areas are\n identified in the pons related with previously described calcifications.\n\n IMPRESSION: No significant new interval change in the previously described\n subdural hematomas and subarachnoid hemorrhage. There is no evidence of\n diffusion abnormalities or acute ischemic changes. Diffuse leptomeningeal\n enhancement, likely related with the recent fractures and subdural hematomas.\n Hyperintensity areas noted on FLAIR located in the subcortical white matter\n and basal ganglia consistent with chronic lacunar ischemic changes and small-\n vessel disease. The shunt catheter is unchanged in position with the tip near\n to the foramen of . There is no evidence of hydrocephalus. Right\n occipital burr hole.\n\n (Over)\n\n 12:13 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: T1 w/ gadolinium 3 planes\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2117-06-26 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1015653,"text":" 1:41 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with tx with subdurals and SA, ? facial fx.\n REASON FOR THIS EXAMINATION:\n eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN SAT 4:02 AM\n Agree. Dr \n WET READ VERSION #1 KYg SAT 2:51 AM\n no fracture or subluxation.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 72-year-old female with subdural and subarachnoid\n hemorrhage. 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 T2. Multiplanar reformatted images were\n obtained.\n\n FINDINGS: The cervical spine maintains a normal alignment without fracture or\n subluxation. Multilevel degenerative changes are seen involving the cervical\n spine, most notably disc space narrowing and endplate osteophytes at C5-C6. No\n prevertebral soft tissue abnormality is detected. A catheter is seen coursing\n through the right lateral neck. Mucosal thickening is seen within the\n sphenoid sinuses.\n\n IMPRESSION: No fracture or subluxation.\n\n"},{"category":"Radiology","chartdate":"2117-06-26 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1015651,"text":" 1:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with tx with subdurals and SA, ? facial fx.\n REASON FOR THIS EXAMINATION:\n eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg SAT 2:26 AM\n biconvexity subdural hematoma. small foci of sa blood at the left vertex and\n right temporal lobe. shunt catheter is present. the ventricles are collapsed\n suggesting intracranial hypotension.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 73-year-old female with subdural and subarachnoid\n hemorrhage.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: There are bilateral cerebral convexity subdural\n hematoma with additional foci of subarachnoid blood noted within the left\n vertex and right temporal lobe. There is no shift of normally midline\n structures. The - white matter differentiation is preserved. Hypodensity\n is seen within the left basal ganglia which likely represents old lacunar\n infarct. A shunt catheter is seen via a right occipital approach terminating\n within the right frontal of the lateral ventricle adjacent to the septum\n pellucidum. The ventricles are collapsed which is suggestive of intracranial\n hypotension or overshunting. Calcification is noted within the pons. Mucosal\n thickening is seen within the ethmoid and sphenoid sinuses. The remainder of\n the visualized paranasal sinuses remain normally aerated. No fracture is\n identified.\n\n IMPRESSION:\n 1. Bilateral cerebral convexity subdural hematomas with small foci of\n subarachnoid blood within the left vertex and right temporal lobe.\n\n 2. A shunt catheter is seen via a right posterior occiput approach and\n terminates within the right frontal of the lateral ventricle adjacent to\n the septum pellucidum. Note is made of collapsed ventricle suggesting the\n presence of intracranial hypotension or overshunting.\n\n\n"},{"category":"Radiology","chartdate":"2117-06-26 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":1015652,"text":" 1:40 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Q. FX.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with tx with subdurals and SA, ? facial fx.\n REASON FOR THIS EXAMINATION:\n eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg SAT 2:29 AM\n no fractures.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 73-year-old female with subdural and subarachnoid\n hemorrhage. Evaluate for facial fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the facial bones.\n Multiplanar reformatted images were obtained.\n\n FINDINGS: No fracture is detected. Mucosal thickening is seen within the\n sphenoid sinuses and ethmoid air cells. Note is made of biconvexity subdural\n hematoma, which is evaluated on head CT.\n\n IMPRESSION: No facial fracture.\n\n"},{"category":"Radiology","chartdate":"2117-06-26 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1015690,"text":" 10:55 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval changeplease perform at noon \n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with B SDH, SAH, brain tumor s/p fall\n REASON FOR THIS EXAMINATION:\n interval changeplease perform at noon \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old female with bilateral subdural and subarachnoid\n hemorrhages, and known brain tumor, status post fall. Please evaluate for\n interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Small bilateral convexity subdural hematomas are little changed,\n with subarachnoid blood again seen tracking along the tentorium, and upwards\n towards the vertex. Subdural hemorrhage in the left inferior frontal lobe has\n slightly increased, with minimal edema and mass effect seen on subjacent\n sulci. Subarachnoid blood seen predominantly in the high left frontal sulci,\n left greater than right is little changed. There is no new hemorrhage.\n\n Shunt catheter is unchanged in position, tip near the foramen of .\n Ventricles remain collapsed. Basal cisterns are normal. Pontine\n calcification is unchanged. Paranasal sinuses remain normally aerated.\n\n IMPRESSION:\n\n 1. Slight interval increase in size of subdural hemorrhage in the inferior\n left frontal lobe, with minimal edema and mass effect on regional sulci.\n Otherwise, little interval change in the bilateral convexity subdural\n hemorrhages, and bilateral subarachnoid blood.\n\n 2. Unchanged position of shunt catheter, with collapsed ventricles which may\n reflect intracranial hypotension or overshunting.\n\n\n"},{"category":"Nursing/other","chartdate":"2117-06-27 00:00:00.000","description":"Report","row_id":1663642,"text":"NEURO; MORE AWAKE AND INTERACTIVE THAN YESTERDAY, FOLLOWS SIMPLE COMMANDS, ABLE TO SHOW TWO FINGERS AND HOLD BOTH LEGS UP OFF MATTRESS, SPEECH IS GARBLED BUT FREQUENTLY ABLE TO INTERPRET WHAT PT IS SAYING, CONFUSED TO SURROUNDINGS AND REASON SHE IS HERE, UP IN CHAIR WITH ASSIST OF TWO, SLIGHTLY UNSTEADY GAIT BUT PT ASSISTED WITH TRANSFER OOB\nHYDRALAZINE X 1 THIS PM TO KEEP SYS < 160 (NEW GOAL PER DR.)\nEEG AT BEDSIDE TODAY\n\nCARDIOVASCULAR; HR 60'S-50'S SR-SB, TEMP 98.3,\nA LINE INTACT LEFT RADIAL,\nRESPIR; LUNGS CLEAR, CHEST\nPT Q FEW HRS, PT WELL BUT NOT RAISING SPUTUM AT PRESENT, 02 SAT 96% ON R/A, ENCOURAGED WITH COUGHING AND DEEP BREATHING BUT NEEDS REINFORCEMENT\n\nGI; TUBE FEEDS STARTED VIA DOBOFF FEEDING TUBE AM, PT PULLED TUBE OUT AND FEEDS ON HOLD FOR NOW, PER SICU HO, SPEECH/SWALLOWING EVAL TOMORROW\nNO BM THIS SHIFT, ? STOOL SOFTENERS IF NEEDED\n\nPLAN; KEEP SYS < 160, FREQUENT NEURO CHECKS, PT FREQUENTLY TO SURROUNDINGS, SPEECH/SWALLOWING EVAL TOMORROW, ? TRANSFER OUT OF SICU\n\n"},{"category":"Nursing/other","chartdate":"2117-06-28 00:00:00.000","description":"Report","row_id":1663643,"text":"NURSING UPDATE\nCV: HR NSR, NO ECTOPY. HYDRALAZINE 10MG IV X1 FOR SBP 164 EARLY NOC, SBP SINCE MAINTAINED @ GOAL<160.\n\nRESP: SATS IN LOW 90'S EARLY NOC, O2 2L APPLIED, HAS MAINTAINED 95-98 SINCE. LUNG SOUNDS DIMINISHED ON RT THROUGH NOC, THOUGH CLEAR BILATERALLY THIS AM.\n\nNEURO: LOC RANGES ALERT->LETHARGIC. ORIENTED TO PERSON AND SOMETIMES PLACE. BACK TO SLEEP QUICKLY AFTER EXAM. NORMAL STRENGTH ALL EXTREMITIES, TURNING IN BED INDEPENDANTLY. PUPILS EQUAL IN SIZE AND REACTIVITY. C/O HEADACHE X2, MORPHINE 1MG IV WITH MOD EFFECT, BUT NAUSEA FOLLOWED, ZOFRAN 4MG WITH GOOD EFFECT, TYLENOL 650MG PR FOR PERSISTANT HEADACHE, THIS TIME WITH GOOD EFFECT.\n\nGI: SOFT, BOWEL SOUNDS PRESENT, NO BM. REMAINS NPO AT THIS TIME.\n\nGU: ADEQUATE HUO > 30CC/H.\n\nPLAN: SPEECH AND SWALLOW EXAM.\nTRANSFER TO HOSPITAL WHEN MD/MD AND TRANSPORT ARRANGEMENTS MADE.\n\nPT MONITORED .\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"},{"category":"Nursing/other","chartdate":"2117-06-26 00:00:00.000","description":"Report","row_id":1663639,"text":"Please See Carevue for Specifics.\n\nPt is arousable to name and stimuli, opens eyes, pt is aphasic, does not follow commands, PERL, withdraws all ext to nailbed pressure. NSR, no ectopy, SBP 130-140's. Lungs are diminished at bases, clear upper lobes. Abd is soft, +BSX4. foley with c/y/u. Right side face and eye swollen and bruising.\n\nPOC: EEG to due out seizure activity, ?repeat head CT, continue to closely monitor neuro status. Family meeting to discuss pt plan of care. Continue to offer emotional support to pt and pt family throughout hospital stay.\n"},{"category":"Nursing/other","chartdate":"2117-06-26 00:00:00.000","description":"Report","row_id":1663640,"text":"NEURO; MAE, DOES NOT FOLLOW COMMANDS, PERL AND BRISK, EOM'S INTACT, WITHDRAWS TO NOXIOIUS STIMULI, TAKEN FOR HEAD CAT AND MRI TODAY, MEDIC IN MRI SUITE FOR AGITATION, LETHARGIC THIS PM BUT EASILY AROUSEABLE,\n\nCARDIOVASCULAR; HR 60'S-70'S SR, GOA IS TO KEEP SYS 100-140 PER DR. , TEMP 100.6, LABS DRAWN THIS PM BUT PT DIFFICULT TO OBTAIN LAB DRAWS, ? FUTURE ATTEMPT AT A LINE INSERTION\n\nRESPIR; LUNGS CLEAR, 02 SAT 98% ON R/A, FEW EXPIR WHEEZES THIS PM, EXPECTORATED SMALL AMT THICK YELLOW MUCOUS, REPOSITIONED FREQUENTLY AND CHEST PT DONE\n\nGI; DOBOFF FEEDING TUBE PLACED FOR MEDS AND CONFIRMED BY X RAY PER SICU HO, ? TUBE FEEDS IN FUTURE\n\nPLAN; HRLY NEURO CHECKS, KEEP SYS 100-140, CHEST PT AND REPOSITION, EMOTIONAL SUPPORT TO FAMILY\n"},{"category":"Nursing/other","chartdate":"2117-06-27 00:00:00.000","description":"Report","row_id":1663641,"text":"NURSING UPDATE\nCV: HR NSR, NO ECTOPY. BP @ GOAL<140. ARTERIAL LINE INSERTED BY DR AND MED STUDENT WITHOUT DIFFICULTY.\n\nRESP: BREATH SOUNDS CLEAR, NTS FOR SMALL THICK YELLOW. SATS 92% EARLY SHIFT, O2 APPLIED VIA NASAL PRONGS AND INCREASED TO 4L TO KEEP SPO2>95%.\n\nNEURO: VERY LETHARGIC AND DIFFICULT TO ROUSE EARLY NOC. LIGHTENED UP SLIGHTLY OVERNOC, ATTEMPTED TO SAY \"GOODMORNING\" @ 0400, STARTED FOLLOWING COMMANDS, SQUEEZED HANDS BILATERALLY ON COMMAND. UE'S NORMAL STRENGTH, LIFT AND HOLDING BLE'S. PUPILS EQUAL IN SIZE AND REACTIVITY. DILANTINAMBER VIA F/CATH.\n\nPT MONITORED .\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"},{"category":"ECG","chartdate":"2117-06-26 00:00:00.000","description":"Report","row_id":213973,"text":"Sinus rhythm. Diffuse non-specific T wave flattening. No previous tracing\navailable for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1015682,\n \"text\": \" 9:37 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?pos Dobhoff\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old woman with SDH s/p Dobhoff placement\\n REASON FOR THIS EXAMINATION:\\n ?pos Dobhoff\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST ON AT 9:58\\n\\n INDICATION: Dobbhoff positioning.\\n\\n FINDINGS:\\n\\n There are no relevant comparison films. An NG tube extends below the level of\\n the diaphragm cannot be seen with tube extends beyond the confines of the\\n image. There is a somewhat shallow level of inspiration and there is some\\n blunting of the left CP angle suggesting some pleural fluid. There is no\\n patchy consolidation visualized. The heart size and the mediastinal contours\\n are within normal limits.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1015694,\n \"text\": \" 12:13 PM\\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: T1 w/ gadolinium 3 planes\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old woman with brain tumor & b/l SDH\\n REASON FOR THIS EXAMINATION:\\n T1 w/ gadolinium 3 planes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: MRI of the head with and without contrast and MRA of the head.\\n\\n CLINICAL INDICATION: 73-year-old woman with history of subdural hematoma and\\n facial fractures.\\n\\n COMPARISON: Prior CTs of the head dated .\\n\\n TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,\\n axial T2, axial FLAIR, axial magnetic susceptibility, the T1-weighted\\n sequences were repeated after the administration of gadolinium contrast in\\n axial, sagittal, and coronal projections.\\n\\n FINDINGS: In comparison with the prior study, again there is evidence of\\n bilateral subdural hematomas along the convexity with associated subarachnoid\\n hemorrhage, no significant change is noted in the size and configuration of\\n these collections. There is no evidence of shift of normally midline\\n structures. Multiple lacunar ischemic changes are noted in the basal ganglia,\\n more evident on the left side, prominent perivascular space is identified on\\n the right external capsule. After the administration of contrast, there is\\n evidence of diffuse leptomeningeal enhancement possibly related with the\\n recent fractures and hematomas. No intraparenchymal diffusion abnormalities\\n are detected, the hematomas demonstrate mild restricted diffusion. Normal\\n flow void signal is identified in the vascular structures. Mild mucosal\\n thickening is noted in the ethmoidal air cells. Punctate low signal areas are\\n identified in the pons related with previously described calcifications.\\n\\n IMPRESSION: No significant new interval change in the previously described\\n subdural hematomas and subarachnoid hemorrhage. There is no evidence of\\n diffusion abnormalities or acute ischemic changes. Diffuse leptomeningeal\\n enhancement, likely related with the recent fractures and subdural hematomas.\\n Hyperintensity areas noted on FLAIR located in the subcortical white matter\\n and basal ganglia consistent with chronic lacunar ischemic changes and small-\\n vessel disease. The shunt catheter is unchanged in position with the tip near\\n to the foramen of . There is no evidence of hydrocephalus. Right\\n occipital burr hole.\\n\\n (Over)\\n\\n 12:13 PM\\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: T1 w/ gadolinium 3 planes\\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1015653,\n \"text\": \" 1:41 AM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: eval acute process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old woman with tx with subdurals and SA, ? facial fx.\\n REASON FOR THIS EXAMINATION:\\n eval acute process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KN SAT 4:02 AM\\n Agree. Dr \\n WET READ VERSION #1 KYg SAT 2:51 AM\\n no fracture or subluxation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 72-year-old female with subdural and subarachnoid\\n hemorrhage. 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 T2. Multiplanar reformatted images were\\n obtained.\\n\\n FINDINGS: The cervical spine maintains a normal alignment without fracture or\\n subluxation. Multilevel degenerative changes are seen involving the cervical\\n spine, most notably disc space narrowing and endplate osteophytes at C5-C6. No\\n prevertebral soft tissue abnormality is detected. A catheter is seen coursing\\n through the right lateral neck. Mucosal thickening is seen within the\\n sphenoid sinuses.\\n\\n IMPRESSION: No fracture or subluxation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1015651,\n \"text\": \" 1:39 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: FX\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old woman with tx with subdurals and SA, ? facial fx.\\n REASON FOR THIS EXAMINATION:\\n eval\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KYg SAT 2:26 AM\\n biconvexity subdural hematoma. small foci of sa blood at the left vertex and\\n right temporal lobe. shunt catheter is present. the ventricles are collapsed\\n suggesting intracranial hypotension.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 73-year-old female with subdural and subarachnoid\\n hemorrhage.\\n\\n COMPARISON: None.\\n\\n NON-CONTRAST HEAD CT: There are bilateral cerebral convexity subdural\\n hematoma with additional foci of subarachnoid blood noted within the left\\n vertex and right temporal lobe. There is no shift of normally midline\\n structures. The - white matter differentiation is preserved. Hypodensity\\n is seen within the left basal ganglia which likely represents old lacunar\\n infarct. A shunt catheter is seen via a right occipital approach terminating\\n within the right frontal of the lateral ventricle adjacent to the septum\\n pellucidum. The ventricles are collapsed which is suggestive of intracranial\\n hypotension or overshunting. Calcification is noted within the pons. Mucosal\\n thickening is seen within the ethmoid and sphenoid sinuses. The remainder of\\n the visualized paranasal sinuses remain normally aerated. No fracture is\\n identified.\\n\\n IMPRESSION:\\n 1. Bilateral cerebral convexity subdural hematomas with small foci of\\n subarachnoid blood within the left vertex and right temporal lobe.\\n\\n 2. A shunt catheter is seen via a right posterior occiput approach and\\n terminates within the right frontal of the lateral ventricle adjacent to\\n the septum pellucidum. Note is made of collapsed ventricle suggesting the\\n presence of intracranial hypotension or overshunting.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1015652,\n \"text\": \" 1:40 AM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: Q. FX.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old woman with tx with subdurals and SA, ? facial fx.\\n REASON FOR THIS EXAMINATION:\\n eval\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KYg SAT 2:29 AM\\n no fractures.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 73-year-old female with subdural and subarachnoid\\n hemorrhage. Evaluate for facial fracture.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the facial bones.\\n Multiplanar reformatted images were obtained.\\n\\n FINDINGS: No fracture is detected. Mucosal thickening is seen within the\\n sphenoid sinuses and ethmoid air cells. Note is made of biconvexity subdural\\n hematoma, which is evaluated on head CT.\\n\\n IMPRESSION: No facial fracture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1015690,\n \"text\": \" 10:55 AM\\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \\n Reason: interval changeplease perform at noon \\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old woman with B SDH, SAH, brain tumor s/p fall\\n REASON FOR THIS EXAMINATION:\\n interval changeplease perform at noon \\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 73-year-old female with bilateral subdural and subarachnoid\\n hemorrhages, and known brain tumor, status post fall. Please evaluate for\\n interval change.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: Small bilateral convexity subdural hematomas are little changed,\\n with subarachnoid blood again seen tracking along the tentorium, and upwards\\n towards the vertex. Subdural hemorrhage in the left inferior frontal lobe has\\n slightly increased, with minimal edema and mass effect seen on subjacent\\n sulci. Subarachnoid blood seen predominantly in the high left frontal sulci,\\n left greater than right is little changed. There is no new hemorrhage.\\n\\n Shunt catheter is unchanged in position, tip near the foramen of .\\n Ventricles remain collapsed. Basal cisterns are normal. Pontine\\n calcification is unchanged. Paranasal sinuses remain normally aerated.\\n\\n IMPRESSION:\\n\\n 1. Slight interval increase in size of subdural hemorrhage in the inferior\\n left frontal lobe, with minimal edema and mass effect on regional sulci.\\n Otherwise, little interval change in the bilateral convexity subdural\\n hemorrhages, and bilateral subarachnoid blood.\\n\\n 2. Unchanged position of shunt catheter, with collapsed ventricles which may\\n reflect intracranial hypotension or overshunting.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663642,\n \"text\": \"NEURO; MORE AWAKE AND INTERACTIVE THAN YESTERDAY, FOLLOWS SIMPLE COMMANDS, ABLE TO SHOW TWO FINGERS AND HOLD BOTH LEGS UP OFF MATTRESS, SPEECH IS GARBLED BUT FREQUENTLY ABLE TO INTERPRET WHAT PT IS SAYING, CONFUSED TO SURROUNDINGS AND REASON SHE IS HERE, UP IN CHAIR WITH ASSIST OF TWO, SLIGHTLY UNSTEADY GAIT BUT PT ASSISTED WITH TRANSFER OOB\\nHYDRALAZINE X 1 THIS PM TO KEEP SYS < 160 (NEW GOAL PER DR.)\\nEEG AT BEDSIDE TODAY\\n\\nCARDIOVASCULAR; HR 60'S-50'S SR-SB, TEMP 98.3,\\nA LINE INTACT LEFT RADIAL,\\nRESPIR; LUNGS CLEAR, CHEST\\nPT Q FEW HRS, PT WELL BUT NOT RAISING SPUTUM AT PRESENT, 02 SAT 96% ON R/A, ENCOURAGED WITH COUGHING AND DEEP BREATHING BUT NEEDS REINFORCEMENT\\n\\nGI; TUBE FEEDS STARTED VIA DOBOFF FEEDING TUBE AM, PT PULLED TUBE OUT AND FEEDS ON HOLD FOR NOW, PER SICU HO, SPEECH/SWALLOWING EVAL TOMORROW\\nNO BM THIS SHIFT, ? STOOL SOFTENERS IF NEEDED\\n\\nPLAN; KEEP SYS < 160, FREQUENT NEURO CHECKS, PT FREQUENTLY TO SURROUNDINGS, SPEECH/SWALLOWING EVAL TOMORROW, ? TRANSFER OUT OF SICU\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-06-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663643,\n \"text\": \"NURSING UPDATE\\nCV: HR NSR, NO ECTOPY. HYDRALAZINE 10MG IV X1 FOR SBP 164 EARLY NOC, SBP SINCE MAINTAINED @ GOAL<160.\\n\\nRESP: SATS IN LOW 90'S EARLY NOC, O2 2L APPLIED, HAS MAINTAINED 95-98 SINCE. LUNG SOUNDS DIMINISHED ON RT THROUGH NOC, THOUGH CLEAR BILATERALLY THIS AM.\\n\\nNEURO: LOC RANGES ALERT->LETHARGIC. ORIENTED TO PERSON AND SOMETIMES PLACE. BACK TO SLEEP QUICKLY AFTER EXAM. NORMAL STRENGTH ALL EXTREMITIES, TURNING IN BED INDEPENDANTLY. PUPILS EQUAL IN SIZE AND REACTIVITY. C/O HEADACHE X2, MORPHINE 1MG IV WITH MOD EFFECT, BUT NAUSEA FOLLOWED, ZOFRAN 4MG WITH GOOD EFFECT, TYLENOL 650MG PR FOR PERSISTANT HEADACHE, THIS TIME WITH GOOD EFFECT.\\n\\nGI: SOFT, BOWEL SOUNDS PRESENT, NO BM. REMAINS NPO AT THIS TIME.\\n\\nGU: ADEQUATE HUO > 30CC/H.\\n\\nPLAN: SPEECH AND SWALLOW EXAM.\\nTRANSFER TO HOSPITAL WHEN MD/MD AND TRANSPORT ARRANGEMENTS MADE.\\n\\nPT MONITORED .\\nDR IN CLOSE ICU ATTENDANCE.\\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663639,\n \"text\": \"Please See Carevue for Specifics.\\n\\nPt is arousable to name and stimuli, opens eyes, pt is aphasic, does not follow commands, PERL, withdraws all ext to nailbed pressure. NSR, no ectopy, SBP 130-140's. Lungs are diminished at bases, clear upper lobes. Abd is soft, +BSX4. foley with c/y/u. Right side face and eye swollen and bruising.\\n\\nPOC: EEG to due out seizure activity, ?repeat head CT, continue to closely monitor neuro status. Family meeting to discuss pt plan of care. Continue to offer emotional support to pt and pt family throughout hospital stay.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663640,\n \"text\": \"NEURO; MAE, DOES NOT FOLLOW COMMANDS, PERL AND BRISK, EOM'S INTACT, WITHDRAWS TO NOXIOIUS STIMULI, TAKEN FOR HEAD CAT AND MRI TODAY, MEDIC IN MRI SUITE FOR AGITATION, LETHARGIC THIS PM BUT EASILY AROUSEABLE,\\n\\nCARDIOVASCULAR; HR 60'S-70'S SR, GOA IS TO KEEP SYS 100-140 PER DR. , TEMP 100.6, LABS DRAWN THIS PM BUT PT DIFFICULT TO OBTAIN LAB DRAWS, ? FUTURE ATTEMPT AT A LINE INSERTION\\n\\nRESPIR; LUNGS CLEAR, 02 SAT 98% ON R/A, FEW EXPIR WHEEZES THIS PM, EXPECTORATED SMALL AMT THICK YELLOW MUCOUS, REPOSITIONED FREQUENTLY AND CHEST PT DONE\\n\\nGI; DOBOFF FEEDING TUBE PLACED FOR MEDS AND CONFIRMED BY X RAY PER SICU HO, ? TUBE FEEDS IN FUTURE\\n\\nPLAN; HRLY NEURO CHECKS, KEEP SYS 100-140, CHEST PT AND REPOSITION, EMOTIONAL SUPPORT TO FAMILY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663641,\n \"text\": \"NURSING UPDATE\\nCV: HR NSR, NO ECTOPY. BP @ GOAL<140. ARTERIAL LINE INSERTED BY DR AND MED STUDENT WITHOUT DIFFICULTY.\\n\\nRESP: BREATH SOUNDS CLEAR, NTS FOR SMALL THICK YELLOW. SATS 92% EARLY SHIFT, O2 APPLIED VIA NASAL PRONGS AND INCREASED TO 4L TO KEEP SPO2>95%.\\n\\nNEURO: VERY LETHARGIC AND DIFFICULT TO ROUSE EARLY NOC. LIGHTENED UP SLIGHTLY OVERNOC, ATTEMPTED TO SAY \\\"GOODMORNING\\\" @ 0400, STARTED FOLLOWING COMMANDS, SQUEEZED HANDS BILATERALLY ON COMMAND. UE'S NORMAL STRENGTH, LIFT AND HOLDING BLE'S. PUPILS EQUAL IN SIZE AND REACTIVITY. DILANTINAMBER VIA F/CATH.\\n\\nPT MONITORED .\\nDR IN CLOSE ICU ATTENDANCE.\\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 213973,\n \"text\": \"Sinus rhythm. Diffuse non-specific T wave flattening. No previous tracing\\navailable for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":23095,"cells":{"subject_id":{"kind":"number","value":46034,"string":"46,034"},"hadm_id":{"kind":"number","value":170420,"string":"170,420"},"target_text":{"kind":"string","value":"42 year old man with ETOH cirrhosis admitted with altered mental status in the setting of cellulitis. Brief hospital course by problem: . # Altered mental status: CT head neg for acute process. No evidence of hypercarbia on VBG. No meningismus on exam to raise concern for encephalitis or meningitis. Paracentesis negative for SBP. Most likely secondary to hyponatremia and encephalopathy in the setting of infection. Mental status improved with antibiotics, lactulose, and rifaximin. . # LLE cellulitis: Pt was initially treated with vancomycin, however he had a bad reaction to the vancomycin (possibly red man's syndrome), and received solumedrol and benadryl, and was switched to IV clindamycin. Wound culture grew Staph aureus. Pt MRSA negative. The patient remained afebrile with stable vitals and improving , he was switched to PO clindamycin to complete a 7-day course. . # : Creatinine was 1.8 on admission. Urine sodium <10, fractional excretion of urea 25%, c/w pre-renal physiology. Patient was fluid overloaded, so he was diuresed with IV lasix and spironolactone, and creatinine normalized. Pt was discharged on 60mg PO lasix QD and 100mg spironolactone QD. . # Hyponatremia: Sodium was 125 on admission, likely secondary to cirrhosis. Sodium normalized. . # ETOH Cirrhosis: RUQ ultrasound without evidence of portal vein thrombosis. Treated with diuretics, lactulose and rifaximin. . # Painful left 2nd toe: Pt states that he had a recent fall and has since had pain in the second toe on the left foot. Foot x-ray was negative for fracture. . # Code status: Full code. . # Outstanding issues: - F/u RUQ ultrasound final read"},"extractive_notes_summ":{"kind":"string","value":"At the porta hepatis, there is an apparently nonocclusive filling defect within the main portal vein. Mild (1+) mitralregurgitation is seen. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. Mild tomoderate [+] TR. QRS axis is not as leftwardand repolarization prolongation is again noted. The aortic valve leaflets (3) are mildly thickened but aortic stenosisis not present. IMPRESSION: No acute fracture identified. Mild talonavicular dorsal spurring. IMPRESSION: No evidence of left lower extremity DVT. Non-specific ST-T wave change with QTc intervalprolongation. Moderate ascites. Mild degenerative changes noted in dorsal mid-foot. Mild (1+)MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The diameters of aorta at the sinus, ascending and arch levels arenormal. There is noventricular septal defect. Moderate amount of ascites. Mild degenerative changes of the tibiotalar joint with joint space narrowing and tiny osteophytes. The visualized portal vein is patent, with no definite thrombus seen. Normal waveforms demonstrated. No definite fractures. No acute intracranial abnormality. IMPRESSION: No convincing evidence of a portal vein thrombus. Sinus rhythm with borderline sinus bradycardia. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Small mucus retention cyst is seen inferiorly in the right maxillary sinus and there is a small amount of aerosolized secretions seen in the frontal sinus on the right. Compared to the previous tracing of voltage criteria forleft ventricular hypertrophy are not as apparent. There is no appreciable pleural effusion. Trace aortic regurgitation is seen. Right ventricular chamber size and free wall motionare normal. Cardiomediastinal silhouette is stable. Focal, apparently nonocclusive filling defect in the main portal vein at the porta hepatis, with hepatopetal flow just proximal, with a velocity of 40 cm/sec. There is a moderate amount of ascites. WET READ VERSION #1 CXWc FRI 3:22 PM Targeted evaluation of the main portal vein shows nonocclusive filling defect at the porta hepatis, with a normal waveform and velocity 40 cm/s just before the thrombus. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No ankle effusion identified. PATIENT/TEST INFORMATION:Indication: Volume overloadHeight: (in) 75Weight (lb): 240BSA (m2): 2.37 m2BP (mm Hg): 120/58HR (bpm): 98Status: InpatientDate/Time: at 13:51Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. There is normal compressibility, flow and augmentation. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. This could represent nonocclusive thrombus, or could be artifact. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , no major change. Clinical correlation issuggested. The tricuspid valve leaflets are mildly thickened.There is mild pulmonary artery systolic hypertension. No resting LVOT gradient. No AS. No MVP. There is no mitral valve prolapse. COMPARISON: None. COMPARISON: None. No dislocations. Lung volumes remain low, but the lungs are otherwise clear. Possibleleft ventricular hypertrophy. Evaluate for portal venous thrombus. Baseline artifact. IMPRESSION: 1. TECHNIQUE: Axial CT images were acquired through the head without intravenous contrast. Ventricles and sulci are normal in size and in configuration. There is interval development of left retrocardiac opacity that is worrisome for interval development of infectious process. IMPRESSIONS: 1. Limited visualization of the liver. No TS. FINDINGS: There is no intracranial hemorrhage, edema, mass effect or vascular territorial infarction. There is no pneumothorax. Overall the study is not adequate for evaluation of the hepatic vasculature and dedicated liver Doppler ultrasound recommended. No MS. No atrial septal defect is seen by 2D orcolor Doppler. Small amounts of gas are seen in the cavernous sinus bilaterally, presumably related to intravenous catheter. Paranasal sinus disease. INDICATION: Concern for fracture of second digit. The mitral valve leafletsare mildly thickened. Portable AP chest radiograph was compared to . Small locules of gas in the cavernous sinus bilaterally. There is no fracture. FINDINGS: Dorsal soft tissue swelling. This is most likely related to peripheral intravenous catheter. A well-corticated ossific fragment is seen lateral to the second toe PIP joint, likely representing sequelae from prior trauma. COMPARISON: . 1:59 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: Eval for portal venous thrombosis MEDICAL CONDITION: 41 y/o M end stage liver disease REASON FOR THIS EXAMINATION: Eval for portal venous thrombosis WET READ: CXWc FRI 4:02 PM Targeted, limited evaluation of the main portal vein shows the suggestion of nonocclusive filling defect at the porta hepatis, although with a normal waveform and velocity 40 cm/s just before the filling defect. Left ventricular wall thickness, cavity size andregional/global systolic function are normal (LVEF >55%). There is lateral subluxation of the distal phalanx of the 2nd toe relative to the middle phalanx. 2. 2. There is a lateral subluxation of the distal phalanx in the 2nd toe relative to the middle phalanx. 7:34 PM FOOT AP,LAT & OBL LEFT Clip # Reason: Concern for fracture of 2nd digit. 3. REASON FOR THIS EXAMINATION: Concern for fracture of 2nd digit. TARGETED RIGHT UPPER QUADRANT ULTRASOUND TO EVALUATE THE MAIN PORTAL VEIN: Grayscale, color, and Doppler ultrasound was used to assess the main portal vein as requested. WET READ: SPfc SUN 8:10 PM No fracture."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2169-07-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1148856,"text":" 9:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with alcoholic cirrhosis, admitted with altered mental status,\n possible evolving sepsis\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with alcoholic cirrhosis.\n\n Portable AP chest radiograph was compared to .\n\n There is interval development of left retrocardiac opacity that is worrisome\n for interval development of infectious process. Lung volumes remain low, but\n the lungs are otherwise clear. There is no appreciable pleural effusion.\n There is no pneumothorax. Cardiomediastinal silhouette is stable.\n\n\n"},{"category":"Radiology","chartdate":"2169-07-07 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1148800,"text":" 2:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver disease, mental status changes, fall\n REASON FOR THIS EXAMINATION:\n Acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc FRI 4:03 PM\n no acute abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change in a patient with liver disease.\n\n TECHNIQUE: Axial CT images were acquired through the head without intravenous\n contrast. Coronal and sagittal reformatted images were also reviewed.\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect or vascular\n territorial infarction. Ventricles and sulci are normal in size and in\n configuration. There is no fracture. Small amounts of gas are seen in the\n cavernous sinus bilaterally, presumably related to intravenous catheter.\n Small mucus retention cyst is seen inferiorly in the right maxillary sinus and\n there is a small amount of aerosolized secretions seen in the frontal sinus on\n the right.\n\n IMPRESSION:\n 1. No acute intracranial abnormality.\n 2. Small locules of gas in the cavernous sinus bilaterally. This is most\n likely related to peripheral intravenous catheter.\n 3. Paranasal sinus disease.\n\n"},{"category":"Radiology","chartdate":"2169-07-07 00:00:00.000","description":"L UNILAT LOWER EXT VEINS LEFT","row_id":1148791,"text":" 1:58 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LLE SWELLING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver dx, swollen left leg\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n WET READ: CXWc FRI 3:19 PM\n No LLE DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man with end-stage liver disease and swollen left\n leg.\n\n COMPARISON: None.\n\n LEFT LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler ultrasound was\n used to evaluate the left common femoral, superficial femoral, popliteal and\n calf veins. There is normal compressibility, flow and augmentation.\n\n IMPRESSION: No evidence of left lower extremity DVT.\n\n"},{"category":"Radiology","chartdate":"2169-07-07 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1148792,"text":" 1:59 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Eval for portal venous thrombosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 y/o M end stage liver disease\n REASON FOR THIS EXAMINATION:\n Eval for portal venous thrombosis\n ______________________________________________________________________________\n WET READ: CXWc FRI 4:02 PM\n Targeted, limited evaluation of the main portal vein shows the suggestion of\n nonocclusive filling defect at the porta hepatis, although with a normal\n waveform and velocity 40 cm/s just before the filling defect. Overall the\n study is not adequate for evaluation of the hepatic vasculature and dedicated\n liver Doppler ultrasound recommended.\n WET READ VERSION #1 CXWc FRI 3:22 PM\n Targeted evaluation of the main portal vein shows nonocclusive filling defect\n at the porta hepatis, with a normal waveform and velocity 40 cm/s just before\n the thrombus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with end-stage liver disease. Evaluate for\n portal venous thrombus.\n\n COMPARISON: .\n\n TARGETED RIGHT UPPER QUADRANT ULTRASOUND TO EVALUATE THE MAIN PORTAL VEIN:\n Grayscale, color, and Doppler ultrasound was used to assess the main portal\n vein as requested. At the porta hepatis, there is an apparently nonocclusive\n filling defect within the main portal vein. There is wall-to-wall color flow\n just proximal to the focus of thrombus, with a velocity of 40 cm/sec,\n demonstrating hepatopetal flow.\n\n There is a moderate amount of ascites.\n\n IMPRESSIONS:\n 1. Focal, apparently nonocclusive filling defect in the main portal vein at\n the porta hepatis, with hepatopetal flow just proximal, with a velocity of 40\n cm/sec. This could represent nonocclusive thrombus, or could be artifact.\n Recommend dedicated liver Doppler evaluation.\n\n 2. Moderate ascites.\n\n Change in wet read discussed with at 3:45pm.\n\n"},{"category":"Radiology","chartdate":"2169-07-09 00:00:00.000","description":"L FOOT AP,LAT & OBL LEFT","row_id":1149057,"text":" 7:34 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: Concern for fracture of 2nd digit.\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with LLE cellulitis.\n REASON FOR THIS EXAMINATION:\n Concern for fracture of 2nd digit.\n ______________________________________________________________________________\n WET READ: SPfc SUN 8:10 PM\n No fracture. There is a lateral subluxation of the distal phalanx in the 2nd\n toe relative to the middle phalanx. Mild degenerative changes noted in dorsal\n mid-foot.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Three views of the left foot .\n\n COMPARISON: None.\n\n INDICATION: Concern for fracture of second digit.\n\n FINDINGS: Dorsal soft tissue swelling. No ankle effusion identified. No\n definite fractures. No dislocations. There is lateral subluxation of the\n distal phalanx of the 2nd toe relative to the middle phalanx. A\n well-corticated ossific fragment is seen lateral to the second toe PIP joint,\n likely representing sequelae from prior trauma. Mild talonavicular dorsal\n spurring. Mild degenerative changes of the tibiotalar joint with joint space\n narrowing and tiny osteophytes.\n\n IMPRESSION: No acute fracture identified.\n\n"},{"category":"Echo","chartdate":"2169-07-08 00:00:00.000","description":"Report","row_id":88172,"text":"PATIENT/TEST INFORMATION:\nIndication: Volume overload\nHeight: (in) 75\nWeight (lb): 240\nBSA (m2): 2.37 m2\nBP (mm Hg): 120/58\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 13:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: 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. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. Trace aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , no major change.\n\n\n"},{"category":"ECG","chartdate":"2169-07-07 00:00:00.000","description":"Report","row_id":232880,"text":"Baseline artifact. Sinus rhythm with borderline sinus bradycardia. Possible\nleft ventricular hypertrophy. Non-specific ST-T wave change with QTc interval\nprolongation. Compared to the previous tracing of voltage criteria for\nleft ventricular hypertrophy are not as apparent. QRS axis is not as leftward\nand repolarization prolongation is again noted. Clinical correlation is\nsuggested.\n\n"},{"category":"Radiology","chartdate":"2169-07-08 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1148893,"text":" 7:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: ALCOHOLIC CIRRHOSIS,ABD PAIN,EVAL FOR PV THROMBOSIS\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n WET READ: ENYa SAT 8:39 AM\n Unchanged exam from yesterday.\n ______________________________________________________________________________\n FINAL REPORT\n DUPLEX DOPPLER ABDOMEN\n\n INDICATION: Alcoholic cirrhosis, abdominal pain, evaluate for PV thrombosis.\n\n FINDINGS: This study was performed on . Surveillance showed\n there was no dictation attached to this study, therefore it was dictated on\n .\n\n Moderate amount of ascites. Limited visualization of the liver. The\n visualized portal vein is patent, with no definite thrombus seen. Normal\n waveforms demonstrated.\n\n IMPRESSION:\n No convincing evidence of a portal vein thrombus.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-07-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1148856,\n \"text\": \" 9:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for infiltrate\\n Admitting Diagnosis: CELLULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 42 year old man with alcoholic cirrhosis, admitted with altered mental status,\\n possible evolving sepsis\\n REASON FOR THIS EXAMINATION:\\n please eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient with alcoholic cirrhosis.\\n\\n Portable AP chest radiograph was compared to .\\n\\n There is interval development of left retrocardiac opacity that is worrisome\\n for interval development of infectious process. Lung volumes remain low, but\\n the lungs are otherwise clear. There is no appreciable pleural effusion.\\n There is no pneumothorax. Cardiomediastinal silhouette is stable.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-07-07 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1148800,\n \"text\": \" 2:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Acute process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 42 year old man with end stage liver disease, mental status changes, fall\\n REASON FOR THIS EXAMINATION:\\n Acute process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SPfc FRI 4:03 PM\\n no acute abnormality\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Mental status change in a patient with liver disease.\\n\\n TECHNIQUE: Axial CT images were acquired through the head without intravenous\\n contrast. Coronal and sagittal reformatted images were also reviewed.\\n\\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect or vascular\\n territorial infarction. Ventricles and sulci are normal in size and in\\n configuration. There is no fracture. Small amounts of gas are seen in the\\n cavernous sinus bilaterally, presumably related to intravenous catheter.\\n Small mucus retention cyst is seen inferiorly in the right maxillary sinus and\\n there is a small amount of aerosolized secretions seen in the frontal sinus on\\n the right.\\n\\n IMPRESSION:\\n 1. No acute intracranial abnormality.\\n 2. Small locules of gas in the cavernous sinus bilaterally. This is most\\n likely related to peripheral intravenous catheter.\\n 3. Paranasal sinus disease.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-07-07 00:00:00.000\",\n \"description\": \"L UNILAT LOWER EXT VEINS LEFT\",\n \"row_id\": 1148791,\n \"text\": \" 1:58 PM\\n UNILAT LOWER EXT VEINS LEFT Clip # \\n Reason: LLE SWELLING\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 42 year old man with end stage liver dx, swollen left leg\\n REASON FOR THIS EXAMINATION:\\n eval for DVT\\n ______________________________________________________________________________\\n WET READ: CXWc FRI 3:19 PM\\n No LLE DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 42-year-old man with end-stage liver disease and swollen left\\n leg.\\n\\n COMPARISON: None.\\n\\n LEFT LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler ultrasound was\\n used to evaluate the left common femoral, superficial femoral, popliteal and\\n calf veins. There is normal compressibility, flow and augmentation.\\n\\n IMPRESSION: No evidence of left lower extremity DVT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-07-07 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1148792,\n \"text\": \" 1:59 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: Eval for portal venous thrombosis\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 y/o M end stage liver disease\\n REASON FOR THIS EXAMINATION:\\n Eval for portal venous thrombosis\\n ______________________________________________________________________________\\n WET READ: CXWc FRI 4:02 PM\\n Targeted, limited evaluation of the main portal vein shows the suggestion of\\n nonocclusive filling defect at the porta hepatis, although with a normal\\n waveform and velocity 40 cm/s just before the filling defect. Overall the\\n study is not adequate for evaluation of the hepatic vasculature and dedicated\\n liver Doppler ultrasound recommended.\\n WET READ VERSION #1 CXWc FRI 3:22 PM\\n Targeted evaluation of the main portal vein shows nonocclusive filling defect\\n at the porta hepatis, with a normal waveform and velocity 40 cm/s just before\\n the thrombus.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 41-year-old man with end-stage liver disease. Evaluate for\\n portal venous thrombus.\\n\\n COMPARISON: .\\n\\n TARGETED RIGHT UPPER QUADRANT ULTRASOUND TO EVALUATE THE MAIN PORTAL VEIN:\\n Grayscale, color, and Doppler ultrasound was used to assess the main portal\\n vein as requested. At the porta hepatis, there is an apparently nonocclusive\\n filling defect within the main portal vein. There is wall-to-wall color flow\\n just proximal to the focus of thrombus, with a velocity of 40 cm/sec,\\n demonstrating hepatopetal flow.\\n\\n There is a moderate amount of ascites.\\n\\n IMPRESSIONS:\\n 1. Focal, apparently nonocclusive filling defect in the main portal vein at\\n the porta hepatis, with hepatopetal flow just proximal, with a velocity of 40\\n cm/sec. This could represent nonocclusive thrombus, or could be artifact.\\n Recommend dedicated liver Doppler evaluation.\\n\\n 2. Moderate ascites.\\n\\n Change in wet read discussed with at 3:45pm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-07-09 00:00:00.000\",\n \"description\": \"L FOOT AP,LAT & OBL LEFT\",\n \"row_id\": 1149057,\n \"text\": \" 7:34 PM\\n FOOT AP,LAT & OBL LEFT Clip # \\n Reason: Concern for fracture of 2nd digit.\\n Admitting Diagnosis: CELLULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 42 year old man with LLE cellulitis.\\n REASON FOR THIS EXAMINATION:\\n Concern for fracture of 2nd digit.\\n ______________________________________________________________________________\\n WET READ: SPfc SUN 8:10 PM\\n No fracture. There is a lateral subluxation of the distal phalanx in the 2nd\\n toe relative to the middle phalanx. Mild degenerative changes noted in dorsal\\n mid-foot.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Three views of the left foot .\\n\\n COMPARISON: None.\\n\\n INDICATION: Concern for fracture of second digit.\\n\\n FINDINGS: Dorsal soft tissue swelling. No ankle effusion identified. No\\n definite fractures. No dislocations. There is lateral subluxation of the\\n distal phalanx of the 2nd toe relative to the middle phalanx. A\\n well-corticated ossific fragment is seen lateral to the second toe PIP joint,\\n likely representing sequelae from prior trauma. Mild talonavicular dorsal\\n spurring. Mild degenerative changes of the tibiotalar joint with joint space\\n narrowing and tiny osteophytes.\\n\\n IMPRESSION: No acute fracture identified.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2169-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 88172,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Volume overload\\nHeight: (in) 75\\nWeight (lb): 240\\nBSA (m2): 2.37 m2\\nBP (mm Hg): 120/58\\nHR (bpm): 98\\nStatus: Inpatient\\nDate/Time: at 13:51\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\\nNo ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: 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. Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+)\\nMR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\\nmoderate [+] TR. Mild PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\\ncolor Doppler. Left ventricular wall thickness, cavity size and\\nregional/global systolic function are normal (LVEF >55%). There is no\\nventricular septal defect. Right ventricular chamber size and free wall motion\\nare normal. The diameters of aorta at the sinus, ascending and arch levels are\\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\\nis not present. Trace aortic regurgitation is seen. The mitral valve leaflets\\nare mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\\neffusion.\\n\\nCompared with the prior study (images reviewed) of , no major change.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 232880,\n \"text\": \"Baseline artifact. Sinus rhythm with borderline sinus bradycardia. Possible\\nleft ventricular hypertrophy. Non-specific ST-T wave change with QTc interval\\nprolongation. Compared to the previous tracing of voltage criteria for\\nleft ventricular hypertrophy are not as apparent. QRS axis is not as leftward\\nand repolarization prolongation is again noted. Clinical correlation is\\nsuggested.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-07-08 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1148893,\n \"text\": \" 7:16 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \\n Reason: ALCOHOLIC CIRRHOSIS,ABD PAIN,EVAL FOR PV THROMBOSIS\\n Admitting Diagnosis: CELLULITIS\\n ______________________________________________________________________________\\n WET READ: ENYa SAT 8:39 AM\\n Unchanged exam from yesterday.\\n ______________________________________________________________________________\\n FINAL REPORT\\n DUPLEX DOPPLER ABDOMEN\\n\\n INDICATION: Alcoholic cirrhosis, abdominal pain, evaluate for PV thrombosis.\\n\\n FINDINGS: This study was performed on . Surveillance showed\\n there was no dictation attached to this study, therefore it was dictated on\\n .\\n\\n Moderate amount of ascites. Limited visualization of the liver. The\\n visualized portal vein is patent, with no definite thrombus seen. Normal\\n waveforms demonstrated.\\n\\n IMPRESSION:\\n No convincing evidence of a portal vein thrombus.\\n\\n\"\n }\n]"}}},{"rowIdx":23096,"cells":{"subject_id":{"kind":"number","value":7939,"string":"7,939"},"hadm_id":{"kind":"number","value":125516,"string":"125,516"},"target_text":{"kind":"string","value":"The patient was admitted to the TSICU s/p his motorcycle crash. He was emergently taken to the operating room on for incision and drainage of his right tibial plateau and spanning ex-fix. See operative note for details. He returned to the TSICU post-operatively. He remained intubated secondary to his poor respiratory status. On he was taken to the operating room for ORIF of his right acetabulum and R gamma nail. See operative note for details. He returned to the TSICU post-op and remained intubated. On he was brought to the operating room for ORIF of his right tibial plateau. He returned to the TSICU post-op. The patient developed fevers in the TSICU. This was attributed to pneumonia. He was placed on vancomycin and ceftazidime as recommended by infectious disease. On he was extubated without incident and transferred later in the day to the floor without incident. On he was transferred to the orthopedic service from the trauma service. On he was taken to the operating room with spine service for fixation of his sacral fractures and L4 fracture. See operative note for details. He was extubated and brought to the recovery room in stable condition. Once stable in the PACU he was transferred to the floor. On an IVC filter was placed by vascular surgery. On the floor he did well. He worked with physical therapy and progressed well. He received tranfusions for post-operative anemia and his electrolytes were repleted. On he was brought to the operating room for revision of his right gamma nail and VAC placement of his . He tolerated this well. His labs and vitals remained stable. His hospital course was otherwise without incident. He is being discharged today to rehab in stable condition."},"extractive_notes_summ":{"kind":"string","value":"clear with minimal secreations.abgs:hyperoxygenated with otherwise normal parameters.PlaN: to OR for right leg/pelvis fx. Vented/sedated/stabilized. +cap refill, csm. Resp CarePt. Abd soft non tender.GU- u/o adeqSkin- RLE in splint with DSD, externally rotated.Drsg by . Mod general edema. Palp pedal and PT pulses with good CSM to BLEs. Right DP pulse dopplerable and Right PT, DP and PT palpable. Has left sublcavian cordis w/CCO swan. See carevue for exacts. ABP stable, drsg . Hypo BS. NIL SUCTIONED VIA OG IN OR. Mild (1+) mitralregurgitation is seen.3. Tube moved and reCV: Temp up to 102.3 orally. Promote w/ fiber via OGT started and advanced slowly R/T hypo BS. #8.0 ETT 24 @lip. Using IS with RN. Foley patent with adeq UO. ON PROPOFOL AND FENTANYL.RESP: VENTILATED. BS sl decreased, rel clear bilat. Right radial arterial line dampened, highly positional; d/c'd. Chest CT from reveals \"bilat opacities\".plan: cont vent support. F/U with TEE report. Tylenol administered via OGT. Gaze is deviated up and left: PERRLA.CV: NSR, ST freq MFVEA, 80's-100's. Using PCA with effective relief.Resp: Lung sounds clear, equal bilaterally, diminished bibasilar. LS CTA. PAS/D 36/18 -> 44/28, Wedge pressure this a.m. 3. Repositioned and re-taped. Anterior, septal, apical and inferior hypokinesis ispresent with some preservation of lateral wall motion.2. Right triple lumen CVL in place, CVP transducing sharply, generally . and Crt wnl.Endo: Bld sugars 120-160's corrected with RISS. PT STABLE. follow hct, cont sedation, awaiting or. Adeq amts of output. EPi off immediatly. ABG -resp alkalosis with normal oxygenation.Lungs dim LLL, coarse on R consistent with new opacity on R per CXR.Sxd mod amts thick tan sputum. ABGs consistent with resp alkolosis. LOWER ABD INCISION WITH STAPLES INTACT. 07-1400See carevue for objective data.Remains sedated on proprofol/fentanyl gtt. Left fields CTA.GI: abd softly distended; BS hypoactive. Repeat Pan cultured.OR with Dr cancelled.RESP:Remains orally intubated tolerating minimal settings. abg acceptable, slightly hypercarbic, compensated.cv: bp labile w/ stimulus, settles quickly at rest. Right a-line, RSC T/L clean. ANTERIOR LOWER LEG SUTURED SITE CLEAN- APPLIED XEROFORM/DSD. lytes repleted prn.gi: belly large, soft, bs present. Right leg remains in immobilizer; sang ooze lateral lower leg. TSICU NSG PROGRESS NOTE 11P-7A/ S/P MVAS- INTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE- HR- 100-114 ST, MINIMAL VEA. SX FOR THICK WHITISH SPUTUM- SMALL AMT.LUNG SOUNDS CL- DIM AT BASES.ID- AFEBRILE THIS SHIFT- 100.6-99.9 PO- REMAINS ON KEFZOL/GENT FOR (+) SPUTUM CULTURE AND S/P OR. Agressive bronchial hygeine...? ABG's cont resp alkalosis, adequate oxygenation. HCT 23.8 , UNCHANGED FROM THIS AM.RESP--SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. Right leg dsg D/I; splint maintained in place. Will squeeze and release and repeat, and is spontaneously localizing to ETT when not restrained.HEMODYNAMICS:ST most of day. TO GO TO OR TODAY FOR INTERNAL FIXATION OF TIB/FIB AND REMOVAL OF EXTERNAL DEVICE.PT HCT DOWN TO 23.3 FROM 24-25- HO AWARE- NO TRANSFUSION CURRENTLY.LOWER EXTREMITY PULSES (+) PALP OR DOPPLERABLE BILATERALLY.MS/ PT SLIGHTLY LIGHTER ON LESS SEDATION AS COMPARED WITH PREVIOUS NEURO ASSESSMENT BY REPORT, PREVIOUS SHIFT.- REQUIRING SOME BOLUS WITH TURNING/PIN CARE/PAINFUL INTERVENTIONS. suprapubic dsg d+i, rle immobilizer in place, dg serous dge from dsg, hemovac in placeID- temp to 102, pan cx. Right hip with small to mod amt of serous drainage. minimal residualsGU- foley indwelling/patent. Sinus rhythm with ventricular premature complexesLeft atrial abnormalityEarly precordial QRS transition - is nonspecificModest nonspecific low amplitude lateral T wave changesSince previous tracing of , lateral T wave amplitude lower filling pressures stable, co/ci . reinforced scheduled visiting hours.a: hemodynamics stable, comfortable w/ fentanyl, sedation. Sinus tachycardiaVentricular premature complexLeft atrial abnormalityModest low amplitude lateral T waves - are nonspecific and may be within normallimitsSince previous tracing of , ST-T wave changes decreased good strength in upper extremities, resists movement .CV- SR-ST w/pain, BP up to 170's w/pain, 120-140's @rest. Resp Care Note, Pt remains on current vent settings. Aline dampened, better after dsg change- gd waveform. cardiac meds restarted yest. Wean sedation as tolerated. ^ ectopy towards end of shift, mgso4 2 gm for mg=1.9pulses positive, palpable despite edema.boots in place.TLC in place, site unremarkable. Resp CarePt. to monitor filling pressures, vs, hct. lytes repleted prn. Again seen are right sacral fractures, comminuted right femoral, iliac, and superior pubic ramus fractures, and fixation hardware, which somewhat obscures evaluation of the lower pelvis structures. cont to w/u temps, follow cx Tiny foci of air are identified in the region of the hardware, related to expected postoperative change, if recent. CT PELVIS WITH IV CONTRAST: Sigmoid diverticulosis is seen, without diverticulitis. Continues on kefzol, clinda and gentamycinSkin: RLE dressing changed by ortho, hemovac d/c'd. abnormality FINAL REPORT INDICATION: Trauma, extubated, not diaphoretic and tachycardic. (Over) 11:58 CT LOW EXT W/O C RIGHT Clip # Reason: r/o fx tib plateau FINAL REPORT (Cont) There is a comminuted fracture of the proximal diaphysis of the fibula. Right sacral fracture and rt L5 transverse process fracture. Fracture of the right side of the sacrum and transverse process of L5 is noted. Proximal fibular diaphyseal fracture. The location of hematoma is extraperitoneal. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # Reason: ORIF RT.TIBIAL PLATEU FX FINAL REPORT HISTORY: Fracture fixation. These demonstrate portions of an right femoral intramedullary rod and extensive hardware in the proximal right tibia, which is incompletely visualized."},"n_notes":{"kind":"number","value":72,"string":"72"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2152-06-13 00:00:00.000","description":"Report","row_id":78180,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 69\nWeight (lb): 230\nBSA (m2): 2.19 m2\nBP (mm Hg): 103/51\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Moderately\ndepressed LVEF.\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. Mild (1+) MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition.\n\nConclusions:\n1. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is\nmoderately depressed. Anterior, septal, apical and inferior hypokinesis is\npresent with some preservation of lateral wall motion.\n2. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen.\n3. There is no pericardial effusion.\n4. Compared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-12 00:00:00.000","description":"Report","row_id":1368044,"text":"Admission note:\n\nInvolved in Motor cycle crash earlier this evening. Alert and oriented in ED. Right open tib/fib, right acetabular and femoral neck fxs.\n\nReceived from OR post Xfix application to right open tib/fib fx. Became hemodynamicly unstable in OR, case ended and brought to room. Still needs to have right acetabular fx and femoral neck repair done.\nOn epi w/SBP >200 and HR 130's. EPi off immediatly. Anasthesia admin 100 mcg of fentanyl and SBP lowers to 150-160.\n\nROS:\n\nNeuro: Sedated on propofol. Fentanyl gtt at 100 mcg. Prior to starting fentanyl was beginning to awaken, eyes opened to voice, lifted head off bed, and some movement of both arms noted before fentanyl begins to work. PEARRLA. C collar inplace. Log roll and spine recautions maintained.\n\nCV: Sinus tach w/PVCs, pairs, multifocal. S1S2. Has left sublcavian cordis w/CCO swan. PAs 35-40s/20's. CVP 3. SVO2 75 or >. Has left radial abp line. Peripheral pulses palpable w/great ease in all 4 extremities. P boots and heparin sub q for DVT prophylaxis.\n\nResp: Orally intubated and on vent. Fio2 weaned to 40%. ABGs w/metabolic acidosis. Tx w/1 liter of NS, with improving acidosis.\nLung sounds clear. No resp distress noted, = rise and fall of chest. Sats 100%.\n\nGI: Oral sump placed, positioned verified to be correct via instillation and auscultation of air bolus. H2 blocer orderd for GI prophylaxis.\n\nGu: Foley patent draining clear yellow urine in QS.\\\n\nENDO: FSG covered w/RSSI.\n\nLabs: Mag and IC need repletion, awaiting orders.\n\nSocial: Mother waiting to visit.\n\nPlan: Correct metobolic acidosis. Monitor CMS checks to RLE. Pulmonary toileting. Clear TLS and C spine. Mobilization. Pain control. Monitor, tx, support, and comfort.\n"},{"category":"Nursing/other","chartdate":"2152-06-12 00:00:00.000","description":"Report","row_id":1368045,"text":"Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS sl decreased, rel clear bilat. Sx'd for small amts thick yellow sputum. Most recent ABG reveals metabolic acidosis w/ hyperoxia. No vent changes made this shift. Chest CT from reveals \"bilat opacities\".\nplan: cont vent support. Pt to return to OR possibly tomorrow. Please see carevue for further vent inquiries.\n"},{"category":"Nursing/other","chartdate":"2152-06-12 00:00:00.000","description":"Report","row_id":1368046,"text":"NPN 7a-7p \n\n41 y.o. male s/p MCC -> Pt struck by car on right side, thrown over handle bars, noted to have landed on his back. No LOC, but known confusion after accident. Admitted to OSH (), then transfer to . DX: Tib/Fib fracture, and acetabular/femoral neck fracture, with L 5 transverse process fx.\n\nROS:\n\nNeuro: Pt sedated throughout day on Propofol 40mcg/kg/min and fentanyl gtt at 50mcg/hr. Lightened for daily wakeup/neuro checks. Pt opening his eyes to verbal stim, pupils equal and briskly reactive @ 2-3mm. Pt following commands consistently, appropriately nodding yes and no to questions asked by this RN. Pt is able to lift and hold UE's and LLE. Moves RLE on the bed d/t injury. At times agitated with wakeups, pt settles with verbal reassurance. Pt on Fentanyl for pain. Increased as able to tolerate for adequate pain control. Currently at 75 mcg/hr of Fentanyl with adeq pain relief. Cerv collar on, logroll dc'd by ortho team.\n\nCV: ST 105-113 with frequent ectopy, multiple PVC's. Was seen here back in for possible ICD plcment. s/p cardiomyopathy with low EF 10%, 35% at last follow up appt. with cardiology. Arterial Line to left hand, zero'd and re-leveled. SBP 99-121/60-70's correlating well with NBP. PAS/D 36/18 -> 44/28, Wedge pressure this a.m. 3. Dr. aware of difficulty wedging. SVO2 70's. PA line measured at 56. EDVI 90-140. Positive pulses bilaterally, easily palpable. +cap refill, csm. sc heparin and PB's for DVT prophylaxis.\n\nResp: O2 sats 97-99% on 40% FIO2. #8.0 ETT 24 @lip. Repositioned and re-taped. Current vent settings-> AC 40% FIO2/ 5 Peep/700x12, pt is breathing up to 3 breaths over the settings. Sux'd today for min amts of thick white/yellow secretions. Oral mucosa intact, frequent mouth care. LS CTA. Pt initially with metabolic acidosis, improved throughout shift. Last ABG's 7.34/40/160/23\n\nHem: HCT 31.9 PLT 173 WNL PT 12.6/PTT 23/INR1.1\n\nAccess: Left 16 gauge PIV / L-art line/ LSC PA line with Cordis/ Right 16 gauge PIV. Field Iv's d/c'd\n\nGI: Pt is on Pepcid q12 hrs. OGT to LCWS with very minimal output. Plcmt checked via air injection/auscultation. Abd softly distended. No bowel sounds present this a.m. now very hypoactive. No feeds started as of yet. No stool.\n\nGU: U/o via catheter, yellow with no sediment. Adeq amts of output. Last Potassium 4.5, Mag 2.4 after 4gm repletion. Lactic acid trending down since admission currently 2.3 from 2.8. Calcium Gluc 2 gms repleted. and Crt wnl.\n\nEndo: Bld sugars 120-160's corrected with RISS. No hx of diabetes\n\nID: Tmax 100.3 via swan. No anbx ordered at this time. WBC 14.4\n\nSKIN: Skin intact. No breakdown to buttocks. X-FIX to RLE with 10 lb wt added to traction. Ex-fix draining mod-lg amts of sanguinous drainage, wrapped with ace wrap. Aspen collar on at all times. Collar care completed.\n\nSocial: Pt lives with his girlfriend. Family in to visit today. Mom is the next of , in to visit today, calls for updates. Affect/quest\n"},{"category":"Nursing/other","chartdate":"2152-06-12 00:00:00.000","description":"Report","row_id":1368047,"text":"(Continued)\nions appropriate. Emotional support provided.\n\nAct: Pt was clr'd from logroll per Icu/ortho team. Pt is able to have hob no > than 45 degrees (for comfort reasons with acetabular fx). Turn and position through day.\n\nA: 41 y.r. old male s/p MCC. Vented/sedated/stabilized. Hemodynamically stable. Ex fix for tib/fib fx this am, awaiting OR for acetabular/femoral head fx\n\nP: Pt to have surgery for unstable femoral neck fx, possibly tues/wed. Monitor neuro, hemodynamics, pain. Initiate vent wean post surgery. Monitor hemodynamics/resp status. Monitor ex-fix/surgical site. CSM. Maintain safety. Provide emotional support to patient and family. Social work to consult in a.m.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-13 00:00:00.000","description":"Report","row_id":1368048,"text":"Resp Care\nPt. remains intubated overnight w/o change.\nBs: ess. clear with minimal secreations.\nabgs:hyperoxygenated with otherwise normal parameters.\nPlaN: to OR for right leg/pelvis fx.\n"},{"category":"Nursing/other","chartdate":"2152-06-13 00:00:00.000","description":"Report","row_id":1368049,"text":"t-sicu nsg note:\nneuro- pt remains sedated on fentanyl gtt @ 75mcg/hr and propofol gtt @ 40mcg/kg/min, he responds to voice, follows commands occ becomes restless to voice and care but quickly settles w/ reassurance. perrla 3mm brisk, strong cough, lifts ue's and lle off bed, moves rle on bed.\n\nresp- sxn infreq for sm amts of thick yellow secretions, vent settings unchanged a/c 40% 700x12 peep of 5, spont resp . bs cta, met acidosis resolved.\n\ncvs- fp's wnl, ci>3.5, svo2=71-73% pcwp 9, cvp 5-11, sbp 106-130's, hr 102-110 nt w/ up to 28 pvc's per min multifocal and in triplets.lytes wnl K+ 4.1, mg 2.0, Lr infusing @ 125cc/hr. hct 22\n\n\ngi- ogt drained scant amt clear fluid, abd soft,obese, no flatus, no stool, bs hypoactive.\n\ngu- foley patent for ~60cc cyu/hr\n\nskin- intact behind collar and back side, sm abrasion to r shin covered w/ bacitracin and 2x2, rle in 10 lbs skeletal traction via xfix, ace wrap soaked and draining mod amt sanguinous drainage.\n\nendo- no riss required.\n\nsocial- mother called twice, looking for info regarding or plans for today.\n\na: stable on present settings\n\np: monitor cvs/nms per routine, cont to assess volume and electrolyte status. follow hct, cont sedation, awaiting or.\n"},{"category":"Nursing/other","chartdate":"2152-06-13 00:00:00.000","description":"Report","row_id":1368050,"text":"Respiratory care\npt on the vent tol well no changes made. see respiratory page of carevue for more information.\n"},{"category":"Nursing/other","chartdate":"2152-06-13 00:00:00.000","description":"Report","row_id":1368051,"text":"NPN 0700-1900\n Pt is a 41 yo s/p MCC hit on R side by car and thrown over handlebars per report.\n Injuries included: R extensive communicated and displaced R fem neck fracture, multiple fractures of acetabulum and pubi rami, transverse process L5 fx, fracture line through sacrum. Hematoma and soft tissue swelling around fractures, hematoma anterior bladder, right open tib/fib. compression fx of T4.\n Hospital course complicated by preexsisting cardiomyopathy.\n\n Pt is sedated on fentanyl and propofol with good effect. When lightened on propofol he FCs and MAEs consistently. Lifts arms and head off bed. Nods no to pain and follows voice with gaze. PERLA.\n\nResp- No vent changes made and ABGs WNL. Small thick yellow ETT secretions. Lungs clear to auscultation. No signs/symptoms pulm edema.\n\nCV- SR-ST with freq ventricular ectopy. Swan in place, see carevue for #s. TEE done, final report pending. Afebrile. HCT dropped from 22.4 to 20.9. BG 105x2. Received 2u PRBCs over several hours. Palp pedal and PT pulses with good CSM to BLEs. Cap refill<3s. Mod general edema. Skin w/d. dressing changed on R calf. Suture intact. Had been oozing mod amt sang drainage throughout day. After dressing change at 1600 no further drainage.\n\nGI/GU- Abd soft, distended. Hypo BS. OGT to LWS with scant drainage, auscultate air in abd. Foley patent with adeq UO.\n\n Mother at bedside most of day. Updated by RN, Dr and ortho team. Asking appropriate questions and support provided.\n\nPlan- Cont serial HCts. Monitor resp status for s/s pulm edema. F/U with TEE report. Cont to provide support to family. Plan for OR in am tomorrow with Dr .\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-16 00:00:00.000","description":"Report","row_id":1368064,"text":"1445-1900\nSEE CAREVUE FOR VITAL SIGNS.\n\nPT WENT TO OR @ 1455 RETURNING @ 1820. PT STABLE. NO SIGNIFICANT EVENTS IN OR.\n\nNEURO: SEDATED ON PROPOFOL.\n\nCV: HYPERTENSIVE. ON PROPOFOL AND FENTANYL.\n\nRESP: VENTILATED. +++ GREEN/BROWN SECRETIONS SUCTIONED. SATS 99-100% SINCE RETURN.\n\nGI: TUBE FEED TO BE RECOMMENCED. NIL SUCTIONED VIA OG IN OR. NOW TO LWS.\n\nGU: ADEQUATE U/O.\n\nSOCIAL: PTS MOTHER UPDATED BY RN RE: SURGERY AND IS VISITING PT AT PRESENT. SHE HAS NOT SPOKEN WITH MD .\n\n"},{"category":"Nursing/other","chartdate":"2152-06-17 00:00:00.000","description":"Report","row_id":1368065,"text":"RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes made overnight. BS's coarse at times, diminished on LLL. Sxing thick tan/bloody secretions. See flowsheet for further pt data. Will follow.\n"},{"category":"Nursing/other","chartdate":"2152-06-17 00:00:00.000","description":"Report","row_id":1368066,"text":"Respiratory Care (Addendum):\nChanged to CPAP/PSV support mode per team. ABG's to follow.\n"},{"category":"Nursing/other","chartdate":"2152-06-17 00:00:00.000","description":"Report","row_id":1368067,"text":"NPN, 1900-0700\nneuro: lightly sedated on propofol and fentanyl gtts. Arouses to voice w/ open eyes. Follows commands slowly. MAE. Gaze is deviated up and left: PERRLA.\n\nCV: NSR, ST freq MFVEA, 80's-100's. K+ repleted aggressively. Pulses + by Doppler signal.\n\nPulm: orally intubated on AC overnoc; weaned to CPAP/PS 5/5 x 50% w/ excellent ABG's. Copious thick tan secretions. Weak cough and gag.\nBS course through, distant bases.\n\nGI: abd softly distended, hypo BS. No flatus or stool. Promote w/ fiber via OGT started and advanced slowly R/T hypo BS. Min residuals.\n\nGU: F/C urine clear amber, adequate OP. RF labs WNL\n\nskeletal: No pressure areas; skin grossly intact. Right hip stapled incisions C/D, Clear serous drainage from most distal. Right leg encased in aces and immobilizer, draining large amount serous from hemovac site, which is draining bloody fluid. CSM right leg intact.\n\nEndo: RISS, no coverage needed.\n\nID: WBC WNL; Tmax 100.7, po. Cont on gentamycin and cefazolin.\n\nP: wean and extubate. Restart pre-adm cardiac meds. Maintain right leg immobilizer at all times..DO NOT REMOVE or manipulate at all, per Ortho. Advance TF to goal. aggressive pulm toilet.\n"},{"category":"Nursing/other","chartdate":"2152-06-17 00:00:00.000","description":"Report","row_id":1368068,"text":"Respiratory Care Note\nPt received on PSV 5/5 as noted with VT 700-1000 and RR 15-25. BS essentially clear with good aeration. SBT 5/0 done VT 722 and RR 18 with a RSBI of 25. Pt taken to CT scan for head secondary to Pt weaned off sedation, but not waking. Plan to remain intubated on PSV at this time.\n"},{"category":"Nursing/other","chartdate":"2152-06-22 00:00:00.000","description":"Report","row_id":1368089,"text":"NPN 7a-7pm \n\nROS:\n\nN- A & Ox3, generalized weakness from decreased activity to ext's but moves all except RLE. RLE-> Injured leg. Pupils = reactive at 4mm\nDenies HA. Pt weaned off Propofol and Fentanyl. Pt started on Morphine PCA 1.5/6/15. Cerv collar clr'd this evening\n\nCV- SR-ST, Hr occasionally up to 110-120 with agitation/increasing temps. See carevue for exacts. Ocassional PVC's. ABP stable, drsg . Pos pulses, good CSM, warm/nml in color. Venodynne to LLE only.\n\n Pt extubated, on a humidified shovel mask with adeq saturation. Lungs clr in upper airways, decreased in bases. Using IS with RN.\n\n PT on a house diet. Tolerating Liquids no aspiration noted. Positive BS, denies n/v. Abd soft non tender.\n\nGU- u/o adeq\n\nSkin- RLE in splint with DSD, externally rotated.Drsg by . Site to right hip and abd with staples.\n\nSoc: family in to visit patient.\n\nEndo- RISS, no insulin needed.\n\n Pt spiked over noc, low grade temps today. Plan for OR when temps decreased. Pt on vanco and Ceftaz.\n\nLytes: WNL no repletion needed\n\nA: Pt extubated today, tolerating extubation. Stable. Collar clr'd\n\nP: Monitor overnight, monitor resp status, possible transfer to floor if stable tomorrow. Provide emotional support.\n"},{"category":"Nursing/other","chartdate":"2152-06-23 00:00:00.000","description":"Report","row_id":1368090,"text":"T/SICU Nursing 19-07\nNeuro: Alert, oriented to hospital, accident, self; disoriented to exact date, city. At times makes bizarre statements. Pupils 4mm, equal, round, briskly reactive. MAE purposefully and to command; can only wiggle toes on injured RLE.\n\nPain: Complaining of pain in RLE with movement only. Using PCA with effective relief.\n\nResp: Lung sounds clear, equal bilaterally, diminished bibasilar. Coughs but swallows sputum. Using IS with encouragement. SPO2 high 90's on 4L NC. Denies dyspnea.\n\nCV: Sinus tachycardia with rate 98-119, frequent VEA including bigeminy. SBP generally low 100's-one teens. 5mg lopressor given x1 as ordered with no effect on HR, however did lower SBP temporarily to high 80's. Palpable pulses in all extremities. Right radial arterial line dampened, highly positional; d/c'd. Right triple lumen CVL in place, CVP transducing sharply, generally . Pboot on left leg, on lovenox sc. Stable anemia hct 24.7.\n\nGI: Abdomen softly distended vs obese; complaining of constipation, given dulcolax PR and colace; had one large soft brown BM at 4am. Diminished appetite.\n\nGU: Foley to gravity draining clear yellow urine in adequate amounts.\n\nEndo: RISS with no coverage required.\n\nLytes: No repletions indicated.\n\nSkin: Intact, surgical incisions clean and dry with staples OTA.\n\nID: Tmax 101.5->100.0 **WBC 26.1 from 18.4**\n\nSocial: Numerous family visitors in early evening.\n\nPlan:\nMaintain safety\nPain management\nPulmonary toileting\nAdvance diet as tolerated\nNotify team of acute changes\nAwaiting surgery with orthopedics.\n"},{"category":"Nursing/other","chartdate":"2152-06-15 00:00:00.000","description":"Report","row_id":1368058,"text":"NPN: Review of Systems\nNeuro: Sedated w/ propofol and pain managed w/ fentanyl. Doses increased over the coarse of the day. Pt had nodded \"yes\" when asked if he was in pain. Propofol turned off to assess neuro status-> Pt followed commands; wiggled toes, stuck out tongue and squeezed hands. Strong productive cough.\n\nResp: Secretions increased throughout the day. Copious amts of thick yellow secretions. Sao2 dropped to low 90s, HR up to 140s-> relieved after suctioning and PS increased to 10. Gentamicin started for gram (-) rods in sputum. Oral sore present on left corner of mouth. Tube moved and re\n\nCV: Temp up to 102.3 orally. Blood and urine cultures sent. Sputum pending. Tylenol administered via OGT. Sinus tach w/ PVCs. Blood pressure has been stable this shift. Please see flowsheet for further data and assessment. Right DP pulse dopplerable and Right PT, DP and PT palpable. to touch. PA line rewired to triple lumen. Tip cultured. X-ray confirmed placement. A-line changed d/t clotting of previous one.\n\nGI: D51/2 NS w/ 20meq KCl infusing at 80cc/hr. Promote w/ fiber to be started at 20cchr. Green fluid via OGT.\n\nEndo: Blood sugar=132-> no insulin coverage per sliding scale.\n\nHeme: HCT=24.7 from 25.\n\nID: Febrile as noted above and cultures pending. Continue w/ antibiotics.\n\nSkin: No presssure wounds present. Abdominal and hip dressing dry and intact. RLE dressings changed d/t serous drainage.\n\nSocial: Mother in by bedside. Provided consent for Dr. surgery which is anticipated to occur on monday.\n\nA: Febrile.? lungs source. Hemodynamics stable.\n\nP: Or tomorrow for leg to be fixed and monday for lower back. Start TF at 20cc/hr and make NPO after MN. Suction as needed. Sedate/maintain comfort. F/U w/ culture results. gentamicin trough level prior to 2nd dose. HCT to be drawn at 6pm.\n\n"},{"category":"Nursing/other","chartdate":"2152-06-15 00:00:00.000","description":"Report","row_id":1368059,"text":"Respiratory Care: Pt remains on current vent settings, see carevue for details. Sxing tan/rusty secretions. No vent changes made this shift.\n"},{"category":"Nursing/other","chartdate":"2152-06-15 00:00:00.000","description":"Report","row_id":1368060,"text":"T/SICU NPN: 1500-2300\nS/O: System Review:\n\nNeuro: sedated on propofol and fentanyl drips overall more sedated\nno eye opening to stimuli pupils pinpoint no gag no cough\nwithdrawing all extremities to nailbed pressure fentanyl decreased to 100mcg/hr(from 140mcg/hr) and propofol weaned to 35mcg/kg/min(from 50mcg/kg/min) now, opening eyes to voice/stimuli eyes deviated upwards pupils 2mm with brisk reaction continues to withdrawl to nailbed pressure not following commands tends to stiffen extremities/body with stimulation gag/cough minimal c-collar remains on\n\nCVS: HR 120's>>>100's NST with multi-focal PVC's SBP 100's\nSBP up with stimulation as high as 170's a-line wired over by\nDr. CVP 8-11 LE: + palpable pedal pulses skin warm to touch with brisk capillary refill\n\nRespiratory: remains orally intubated and ventilated on PSV PS=10\nPeep=10 Fio2 50% RR 8-12 TV's 900-1200's Sao2 > 96%\nABG: 140-46-7.40-30+3 lungs clear, decreased at bases suctioned\nfor scant to small amounts of thick yellow-tan secretions\n\nRenal: foley patent and draining clear yellow urine 80-250cc/hr\nK+ 3.7 repleted with 20meq kcl D51/2NS w/20meq KCL at 80cc/hr\nMg++ 2.0\n\nGI: abdomen obese no bowel sounds no bm started on fs promote/fiber at 20cc/hr via ogt last residual 40cc(2hrs after starting tf's) on pepcid\n\nEndrocrine: fs q6hrs fingersticks 112>>104 no insulin required\n\nHeme: HCT q8hr last HCT 25.7 started on lovenox heparin d/c\non pnuemoboots\n\nID: tmax 102.4 sent second set of blood cultures for re-wired a-line\ncontinues on kefzol and gentamycin gnr's in sputum\n\nSkin: right leg>>ex-fix on pin sites draining serous fluid pin care\ndone right shin laceration>>>sutured red with small amt of bloody drainage right hip and low pelvic dsg's dry/intact back and buttocks intact with no redness\n\nPyschosocial: mother called and updated on clinical situation and questions answered\n\nOR tomorrow: anesthesia/surgical consents obtained NPO after mid-night\n\nA: febrile awaiting culture results more sedated weaning sedatives\n\nP: continue to monitor above parameters check culture results\nto OR tomorrow for further orthopedic surgeries\n\n"},{"category":"Nursing/other","chartdate":"2152-06-16 00:00:00.000","description":"Report","row_id":1368061,"text":"TSICU NSG PROGRESS NOTE 11P-7A/ S/P MVA\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE- HR- 100-114 ST, MINIMAL VEA. AM K- 3.9- TO RECEIVED 20 KCL PER PROTOCOL. BP- 95/50-107/60.\nNO ISSUES CURRENTLY.\n\n PT REMAINS ON PRESSURE SUPPORT- 10/10 PEEP 50%- TIDAL VOLUMES 1 L - 1.3 LITERS, RESP RATE- . ADEQUATE VENTILATION/OXYGENATION-\nAM ABG- 7.39-49-148. SX FOR THICK WHITISH SPUTUM- SMALL AMT.\nLUNG SOUNDS CL- DIM AT BASES.\n\nID- AFEBRILE THIS SHIFT- 100.6-99.9 PO- REMAINS ON KEFZOL/GENT FOR (+) SPUTUM CULTURE AND S/P OR. TYLENOL X 1. WC- 11.2.\n\nGU- GOOD UO- 60-200CC/HOUR- (+) 1575 OVERALL I/O.\nCLEAR YELLOW URINE. REMAINS ON IVF AT 80CC/HOUR.\n\nGI- NPO AFTER MN- FOR OR TO FOLLOW CASE TODAY.\nHYPO TO ABSENT ABD SOUNDS-- BLOOD SUGARS Q 6 HOUR- NO INSULIN THIS SHIFT.\n\nLINES- NEW ALINE OVER WIRE FROM 6/1 L RADIAL, TLC LEFT IJ AS WELL.\n\nORTHO- S/P EXTERNAL FIXATION OF TIB FIB FX- PIN SITES CLEAN, MINIMAL REDNESS. ANTERIOR LOWER LEG SUTURED SITE CLEAN- APPLIED XEROFORM/DSD\n. TO GO TO OR TODAY FOR INTERNAL FIXATION OF TIB/FIB AND REMOVAL OF EXTERNAL DEVICE.\nPT HCT DOWN TO 23.3 FROM 24-25- HO AWARE- NO TRANSFUSION CURRENTLY.\nLOWER EXTREMITY PULSES (+) PALP OR DOPPLERABLE BILATERALLY.\n\n\nMS/ PT SLIGHTLY LIGHTER ON LESS SEDATION AS COMPARED WITH PREVIOUS NEURO ASSESSMENT BY REPORT, PREVIOUS SHIFT.- REQUIRING SOME BOLUS WITH TURNING/PIN CARE/PAINFUL INTERVENTIONS. , .\nREMAINS ON PROPOFOL GTT AND FENT GTT- NO CHANGE IN DOSES- SEE FLOWSHEET.\n\nA/ PT S/P FX OF MVA C/B FX TIB/FIB CURRENTLY REMAINS HEMODYNAMICALLY STABLE , ON VENTILATORY SUPPORT.\nNPO FOR AM OR PLANNED FOR INTERNAL FIXATION OF FX.\n\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS ESP IN SETTING OF UNDERLYING CARDIOMYOPATHY. HOLDING OFF TRANSFUSION CURRENTLY. CONSIDER GENTLE DIURESIS AS HEMODYNAMICS ALLOW IF I/O TRENDS TOO (+) OVERALL.\nPULM TOILET, SX/MAINTAIN AIRWAY AS NECESSARY.\nCONTINUE ANTIBX AS ORDERED.\nRESUME NUTRITION POST OP ONCE MEDICALLY APPROPRIATE.\nSKIN CARE/PIN CARE/COLLAR CARE PER T SICU STANDARD OF CARE.\nKEEP PT COMFORTABLE, FREE OF PAIN. FENT/PROPOFOL GTT CONTINUE.\nKEEP FAMILY AWARE OF CURRENT PROGRESS AND PLAN OF CARE.\nOR THIS MORNING/AFTERNOON AS PLANNED.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-16 00:00:00.000","description":"Report","row_id":1368062,"text":"Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Latest abg results determined a compensated respiraotry acidemia with excellent oxygenation on the current settings.\n\nNo RSBI measured due to the level of PEEP currently required and the fact that the patient is scheduled for the OR.\n"},{"category":"Nursing/other","chartdate":"2152-06-16 00:00:00.000","description":"Report","row_id":1368063,"text":"07-1400\n\nSee carevue for objective data.\n\nRemains sedated on proprofol/fentanyl gtt. Opens eyes intermittingly\nto name being called.\nNo vent changes. Maintaining O2 sats. Minimal suctioning required.\nNSR/ST with frequent PVC's.\nNPO for OR this afternoon. SSRI per FSBS. Maintenance fluid continues.\nPin care done to lower extremities-large amount of serous fluid from pin sites. Both extremities swollen but with palpable pulses.\nGrimacing when turned with hypertension/tachycardia-fentanyl gtt increased to 150 mcg/kg/min with good effect.\nO/C to OR.\n\nContinue current POC.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-21 00:00:00.000","description":"Report","row_id":1368083,"text":"NPN, 1900-0700\nneuro: lightly sedated on propofol following eve of resp distres secretions w/ tachypnea, freq MFVEA. Responds to verbal when lightened. , . Follows commands inconsisitently. Med w/ ativan and morphine q4-5 hrs.\n\nCV: ST, freq MFVEA, mult brief salvos vtach, freq bigeminy. 12 lead EKG unchanged. HR 90's-140; CVP 9-14. SBP 90's-140's. Pulses palpable throughout.\n\nPulm: orally intubated on CMV 650 x 50% x 14 x 5. RSBI > 200. Copious thick tan secretions w/ sang clots. BS rhonchorous anteriorly, bronchial posteriorly w/ I/E wheezes. No vent changes. ABG's cont resp alkalosis, adequate oxygenation. Pt was labored, tachypneic, fatiguing until sedation restarted.\n\nGI: abd softly distended; BS hypo. +flatus, no stool despite dulcolax pr, MOM, colace. w/ fiber at goal, 85 cc/hr w/ min residuals.\n\nGU: F/C urine amber-->>clear yellow, adequate OP. RF labs cont WNL.\n\nskeletal: no pressure areas. Groins moist, pink, intact-->>miconazole powder. Hip wounds C/D. Right leg dsg D/I; splint maintained in place. Right a-line, RSC T/L clean. C-collar remains in place.\n\nEndo: RISS, no coverage required.\n\nID: Tmax 103.6, rectal, down to 100.2 after ice compresses, tylenol, ect. Started on vanco and ceftaz. WBC 15\n\nSocial: mult family members have vs and called.\n\nA: worsening resp failure..?ARDS bil pneumonia. ? septic picture evolving. Sluggish GI function.\n\nP: ?bronch. ? maintain sedation until weanable. ?start reglan.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-21 00:00:00.000","description":"Report","row_id":1368084,"text":"T/SICU NURSING PROGRESS NOTE 0700-1900\nNeuro--remains sedated on propofol 30 mcg/kg/min. Medicated with 6-10 mg iv MSO4 q2hr for leg pain. Facial grimace with increase in HR,RR with any movement of BLE. Pt nods head inconsistently to simple questions. Squeezes hands and wiggles toes to command. Pupils 4-5mm and reactive. Also received Ativan 2mg x1.\n\nCardiac--HR SR/ST with frequent multifocal PVC's. SBP 120-150/80's. CVP-.\n\nResp--No vent changes done. Bilateral breath sounds range from clear to bronchial->rhoncherous. Sx q2 hrs for moderate amts of tan thick sputum. No ABG's drawn as pt's VS have not changed and SaO2 is >98% on 50% FiO2. CPT given x2. No bronch done today.\n\nGI--Tolerating tube feeds at goal. HO disimpacted pt today and pt has stooled x2 in small amts. Hypoactive BS. Min. tube feed residuals.\n\nGU--foley cath patent draining >80 cc hr of yellow urine.\n\nENDO--SSRI coverage given and needed x2. Last BS 120. No lytes drawn at this time.\n\nSKIN--R leg brace removed and dressing changed by ortho. Sutures are intact. There is a couple of areas of maceration around bone puncture site. DSD applied and brace placed back on. Buttocks and back without breakdown. Turned q2 hrs. Oral membranes are dry. R leg noted this am to be more externally rotated than yesterday. HO and ortho notified and leg films done downstairs. COllar care given. Neck intact. Lower abd incision with staples intact and dry.\n\nID--T max 100.5. Pt received tylenol at 0800, 1200 and has not received since. Temp at 1700 100.1. Remains on Vanco and Ceftazadine.\n\nPAIN--Medicated with 6-10 mg IV q2hrs. Pt grimaces with any touch to RLE. He nods head yes when asked if he is in pain. At 1700, pt was given 10mg SC mso4 for good relief. Also given 2mg iv Ativan.\n\n, girlfriend (who was in accident with pt) and sister-in-law in to visit. They have been updated regarding pt's condition. They are happy about fever coming down. Asking questions regarding how long tube will be in and will they put a trach in.\n father and brother have not been in to visit.\n\nA--No temp spike today. Increase need for pain med. DOwn for leg films for increased external rotation.\n\nP--Con't to monitor, con't pulm toilet. Check am labs. COn't to medicate and assess relief. Offer support to pt and family. Attempt to wean vent tomorrow if tolerated.\n"},{"category":"Nursing/other","chartdate":"2152-06-21 00:00:00.000","description":"Report","row_id":1368085,"text":"Resp CAre\n\nPt remains intubated and on full vent support. MV is being maintained in the 17-20L range. Spo2 100%. BS with occasional rhonchi and wheezing and suctioning thick tan sputum\n"},{"category":"Nursing/other","chartdate":"2152-06-22 00:00:00.000","description":"Report","row_id":1368086,"text":"RESP CARE: Pt remains intubated/on vent per carevue. No changes this shift. Lungs dim bibasilar. Sxd thick tan sputum. RSBI-81. Pt remains febrile.\n"},{"category":"Nursing/other","chartdate":"2152-06-22 00:00:00.000","description":"Report","row_id":1368087,"text":"ASSESSMENT AS NOTED\n\nRES: NO CHANGES IN SETTINGS, ON 5PEEP, MAINTAINS PO2>120, SATS 100, LS CLEAR/DIM, SUCTIONED SM AMNT THICK ,\n\nCV: IN S/TACH WITH MULTIPLE PVCS AT TIMES, SEDATED WITH SBP >100, WHEN AWAKE UP TO 140S, + WEAK PULSES, +PERIPHERAL EDEMA\n\nNEURO: ON PROPOFOL AND FENTANYL GTT, FOLLOW COMMANDS, MOVES BOTH ARMS, FENTANYL UP TO 150 TO CONTROL PAIN, R/LEG EXTERNALY ROTATED 90 DEG ANGLE, CER COLLAR IS ON\n\nID: LOW GRADE TEMP 99-101.5, NO TYLENOL WAS GIVEN , FAN IS ON, CONT ON VANCO, CEFTAZIDIME\n\nGI: TOL TF AT 85/H W/O RESIDUALS, NO BM YET, +BS,\n\nGU: BRISK U/O,\n\nSKIN: R/LEG SPLINT AND DSD INTACT, BACK IS INTACT, SWEATING A LOT\n\nSOCIAL: FAMILY CALLED TWICE DURING THE NIGHT\n\nPLAN: CLEARFY IVF ORDER, MONITOR RES, PAIN CONTROL,ID, WEAN OFF WENT IF POSSIBLE, ?DATE OF SURGERY FOR R/HIP REDUCTION IN FUTURE\n"},{"category":"Nursing/other","chartdate":"2152-06-22 00:00:00.000","description":"Report","row_id":1368088,"text":"RESPIRATORY CARE: PT. EXTUBATED TO A 50 AEROSOL MASK\nAFTER HAVING AN RSBI OF BETWEEN 40-50 AND A GOOD ABG\nON A PS 5/5. C + R THICK BLOOD-TINGED SPUTUM. SPO2\n97-100 %. DOING WELL. WILL ENCOURAGE C+DBING AND\nWILL MONITOR RESPIRATORY STATUS CLOSELY.\n"},{"category":"Nursing/other","chartdate":"2152-06-19 00:00:00.000","description":"Report","row_id":1368076,"text":"Resp Care: Pt remains intubated via #8 ETT rotated and secured 24cm at lip. BS coarse bilat. Sx'd for mod amts thick yellow sputum. MDI's given as ordered. ABG WNL. No vent changes made this shift. Plan: awaiting OR when afebrile. Cont vent support. Please see carevue for further vent inquiries.\n"},{"category":"Nursing/other","chartdate":"2152-06-19 00:00:00.000","description":"Report","row_id":1368077,"text":"Nursing Progress Note:\nPlease refer to CareVue for specifics.\n\nEVENTS TODAY:\nFebrile to 102.7. Repeat Pan cultured.\nOR with Dr cancelled.\n\nRESP:\nRemains orally intubated tolerating minimal settings. Has spontaneous cough and copious thick tan secretions. Requires aggressive pulmonary tolieting. Also has clear oral secretions and has required frequent oral care. Chest clear to coarse. CXR attended.\n\nNEURO:\nAlert, looking around room, regarding and tracking examiner. Obeys commands intermittantly but uncooperative with some interventions such as turning. Denying pain but given morphine prn for grimacing and turning. Does not move legs until he is resisting our attempt to reposition him. Will squeeze and release and repeat, and is spontaneously localizing to ETT when not restrained.\n\nHEMODYNAMICS:\nST most of day. Has multifocal PVCs. Maintaining BP within range of normal most of day but has hypertension with interventions, promptly returning to baseline when left alone. Grossly diaphoretic most of day, and hot on palpation, now feet are cold and moist. A-line is intermittantly positional.\n\nENDOCRINE:\nBlood sugars in 120s. No coverage per sliding scale.\n\nFLUIDS/LYTES:\nMaintenance fluids at 50mls /hr. Magnesium for repletion.\n\nGI:\nAbd obese. Bowel sounds present. Tube feeds recommenced as not for OR today. No BM today.\n\nID:\nPt has spiked to 103.7 at report time. Pt pan cultured earlier this afternoon. Antibiotics as charted. At this time pt is spiking and also agitated and tachypneic, so was given morphine and ativan to help settle.\n\nRENAL:\nSatisfactory urine output. Urine is amber at times. Cr within range of normal.\n\nSKIN:\nDiaphoretic and skin marks easily but it is intact. Dr took Rt leg dressing down this am. There are several wounds, some surgical and one mid anterior lower leg which was the site of the open fracture per Dr . The wounds are clean with minimal ooze. There are puncture sites to legs which are oozing a small amount of hemoserous ooze. Dr want these free to drain.\n\nSOCIAL:\nMother visiting, reminded of ICU visitation policy. Questions addressed.\n\nPLAN:\nWatch fever.\nFOllow cultures.\nPulmonary toilet.\nAdd bowel regime.\nPossible OR at later date.\nTitrate tube feeds to goal.\nPossible change to assist control if continues to labor while febrile.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-20 00:00:00.000","description":"Report","row_id":1368078,"text":"RESP CARE: Pt remains intubateed/on vent with settings per carevue flowsheet. No changes made this shift.Pt had been placed back on rate during the day due to tachypnea,T max 103.9. ABG -resp alkalosis with normal oxygenation.Lungs dim LLL, coarse on R consistent with new opacity on R per CXR.Sxd mod amts thick tan sputum. RSBI-98.\n"},{"category":"Nursing/other","chartdate":"2152-06-20 00:00:00.000","description":"Report","row_id":1368079,"text":"NPN, 1900-0700\nneuro: arouses to voice w/ open eyes; follows commands inconsisitently. Moves UE's w/ near normal strength, moves LLE on bed. Min spontaneous movement noted RLE, withdraws from pain. Med w/ ativan + morphine q 4-5 hrs w/ adeqaute sedation/analgesia.\n\nCV: ST, MFVEA, 100-140's. MAP 80-100's. CVP 10-14. Pulses palpable throughout. Pboots in place.\n\nPulm: orally intubated on CMV 650 x 50% x 14 x 5 w/ resp. alkalosis, adequate oxygenation. RR 20's at rest, 30-40's w/ agitation. Strong cough, weak gag. Copious creamy tan secretions. BS rhonchorous right anterior and mid posterior fields, diminished bibasilar. Left fields CTA.\n\nGI: abd softly distended; BS hypoactive. Promote w/ fiber via oral sump advanced to goal, 85cc; min residuals. +flatus, no BM.\n\nGU: F/C urine clear amber; OP 80+/hr. Renal function labs cont WNL.\n\nskeletal: No pressure areas; skin grossly intact except for surgical sites. Right hip stapled wounds C/D. Right leg remains in immobilizer; sang ooze lateral lower leg. CSM intact RLE. A-line pink, positional; LSC T/L pink, nl wave. C-collar in place.\n\nEndo: RISS, no coverage required.\n\nID: WBC up to 12; Tmax 103.9, rectally. Cooling blanket, tylenol, sponge baths-->>T this am 101 po. Cont on clindamycin, cefazolin, gentamycin; started on levofloxacin.\n\nSocial: mother called x 3 during noc, very anxious.\n\nA: worsening respiratory failure pneumonia (gm+/- rods & gr+ cocci from ) Stable HD, GI, renal, neuro functions.\n\nP: ? adequste coverage for pulm cxs. New pulm cx pending. ? re-line a-line and central lines in setting of fever and line sites. Agressive bronchial hygeine...? rotating bed. Emotional support for mother.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-20 00:00:00.000","description":"Report","row_id":1368080,"text":"T/SICU NURSING PROGRESS NOTE 0700-1900\nCARDIAC--MULTIFOCAL PVC'S BUT NO RUNS. HR ST >100'S. SBP 120-140'S. HCT 23.8 , UNCHANGED FROM THIS AM.\n\nRESP--SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. ETT ROTATED. BREATH SOUNDS CLEAR IN UPPER LOBES BILATERALLY. CRACKLES IN R LOWER BASE THIS AM NOW JUST DIMINISHED. LLL IS COARSE. SAO2>97%. PT RESISTS WITH ANY TYPE OF CPT AND SUCTIONING.\n\nGI--TUBE FEEDS AT GOAL. RESIDUALS 70-80 CC. NO STOOL. ABD OBESE AND FIRM BUT PT DOES NOT GRIMACE WITH BELLY IS PALPATED. NO STOOL.\n\nGU--FOLEY CATH PATENT DRAINING >100 CC HR OF YELLOW URINE.\n\nENDO--UNREMARKABLE. NO SSRI COVERAGE.\n\nSKIN--L CORNER OF MOUTH WITH BREAKDOWN. ETT ROTATED. BUTTOCKS WITHOUT BREAKDOWN. LOWER ABD INCISION WITH STAPLES INTACT. RLE HAS SUTURES AND OLD PIN HOLE SITES WHICH HAVE DRAINED SEROUS DRAINAGE. AREA ON ANTERIOR TIB SITE THAT APPEARS MACERATED. DSD APPLIED WITH KLING LEG PLACED BACK IN KNEE IMMOBILIZER. R HIP WITH DSD. SCROTUM IS EDEMATOUS. ORAL MEMBRANES ARE DRY.COLLAR CARE GIVEN. NECK INTACT.\n\nID--FEBRILE TO 102.2 ABX CHANGED TO CEFTAZADINE AND VANCO WHICH HE HAS RECEIVED 1ST DOSE OF EACH TODAY. DOWN FOR CT OF PELVIS, CHEST AND ABD TO SEE IF THERE IS ANYTHING UNUSUAL. PT HAS CONSOLIDATIONS IN BLL.\n\nPAIN--NODS HEAD WHEN ASKED IF HE IS IN PAIN. MEDICATED WITH MSO4 AND ATIVAN SEVERAL TIMES THROUGHOUT THE DAY.\n\nCOPING--MOTHER IN TO VISIT ALL DAY. SHE HAS BEEN UPDATED ABOUT PLAN OF CARE. FATHER BE IN LATER TODAY. PER PT'S MOM, GIRLFRIEND , WAS RELEASED FROM THE HOSPITAL OVER THE WEEKEND.\n\nNEURO--OCCASIONALLY OPENS EYES TO NAME. INCONSISTENTLY FOLLOWS SIMPLE COMMANDS. MOVES ALL EXTR. ON BED AND BUE WILL LIFT AND HOLD AS WILL LLE. PEARL AT 2-3 MM.\n\nA--REMAINS WITH INCREASE IN TEMP AND ECTOPY.\n\nP--CON'T PULM TOILET. CHECK LYTES . CON'T ABX. OFFER SUPPORT TO PT AND FAMILY. NEXT DATE FOR OR IF ALL IS OK IS FRIDAY. IF PT HAS EMERGENCY, IT BE PERFORMED SOONER BUT PLAN IS FOR FRIDAY.\n"},{"category":"Nursing/other","chartdate":"2152-06-20 00:00:00.000","description":"Report","row_id":1368081,"text":"Resp Care\n\nPt remains intubated on A/C. Pt transported to CT w/o incident. PT suctioned for thick tan secretions and plugs. No other changes noted.\n"},{"category":"Nursing/other","chartdate":"2152-06-21 00:00:00.000","description":"Report","row_id":1368082,"text":"RESP CARE: Pt remains intubated/on vent settings per carevue. Pt tachypneic early in shift with RR 30s/vent asynchrony/increased cardiac ectopy.Pt started on propofol with good effect noted. More reg resp pattern, RR 20s. Lungs coarse bilat Sxd copious amts tenacious tan sputum. ABGs consistent with resp alkolosis. RSBI>200. Pt remains febrile.\n"},{"category":"Nursing/other","chartdate":"2152-06-15 00:00:00.000","description":"Report","row_id":1368056,"text":"nursing progress note\n\nneuro: pt remains intubated, sedated. propofol weaned slightly w/ change to cpap, pt at times resistent to any stimulus, opening eyes spont. perrla, 2mm. inconsist. follows commands. fentanyl boluses given prn for turns w/ good effect.\n\nresp: cpap+ps tol well, o2 sats 96-100%. ls coarse throughout. sx mod amts thick yellow secretions. cough, gag intact. abg acceptable, slightly hypercarbic, compensated.\n\ncv: bp labile w/ stimulus, settles quickly at rest. sinus tachy, much ventric. ectope noted (baseline). filling pressures stable, cvp remains mid teens. unable to wedge pa cath, icu team aware. co elevated, svo2 mid 80s-low 90s. note persistent low grade fever. lytes repleted prn.\n\ngi: belly large, soft, bs present. og to lws, mod amts bilious output.\n\ngu: foley patent clear yellow urine, qs.\n\nendo: bg's stable.\n\nid: tmax 101.5, less than 24h post op, icu team aware. tylenol given for comfort. wbc stable at 10.\n\nskin: ex fix pin sites clean, serosang drainage. open tibia lac sutured, mod amt serosang drainage as well. pelvic repair incisions all w/ post op dsgs, dry.\n\nsocial: family in last evening, supportive. called overnight for updates.\n\na: s/p pelvic repair, I+D right tibia, stable intra/post op course. hemodynamics stable, filling pressures unchanged. low grade febrile. hct holding at 25.\n\np: cont aggressive pulm toilet, d/c pa catheter, change to triple lumen access. cont current pain management, sedation while intub. await OR trip for ORIF of right tib/fib, sacral pinning. will need MRI in near future to f/u w/ T4 injury.\n"},{"category":"Nursing/other","chartdate":"2152-06-15 00:00:00.000","description":"Report","row_id":1368057,"text":"Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results revealed a compensated respiratory acidemia with excellent oxygenation on the current settings.\n\nRSBI = 16.7 on 0-PEEP and ATC off.\n"},{"category":"Nursing/other","chartdate":"2152-06-18 00:00:00.000","description":"Report","row_id":1368072,"text":"T-SICU NURSING PROGRESS NOTE\nNeuro: Opens eyes to name, continues with eyes rolled back slightly but turns toward person calling his name. Intermittently following commands, MAEs weakly. Pupils equal and reactive. Med with MS04 Q4H for pain.\n\nCV: HR 110s, ST up to 130s with pain and fevers, occas to freq PVCs. BP running 120s-140s systolic. Between 4-5pm pt more tachycardic and hypertensive, lighter, med with Ms04 for pain with effect. BP now running 130s systolic. Skin warm to touch, diaphoretic after receiving tylenol and defervescing. (+)palpable distal pulses bilat.\n\nResp: Remains on PSV 5/5, 40% Fi02. Breath sounds coarse on right, clear to diminished on the left. Strong cough, productive of moderate amt of thick tan secretions. Also with moderate amt of tan oral secretions.\n\nGI: Abdomen soft, (+)bowel sounds, no stool, no flatus. Tolerating tube feeds, advanced to 70cc/hr at 1600, residuals < 20cc.\n\nGU: Adequate urine output, see I & O for details\n\nEndo: Blood sugar 140-150 this shift, covered with regular insulin per sliding scale\n\nID: Remains febrile throughout the day, t. max 102.2. Cultures sent this am pending. Continues on kefzol, clinda and gentamycin\n\n\nSkin: RLE dressing changed by ortho, hemovac d/c'd. Right knee and RLL incis with sutures, small to mod amt of serosang drainage, no redness. Right hip with small to mod amt of serous drainage. Suprapubic incis OTA with staples, no redness or drainage. Back/buttocks and heels intact.\n\nSocial: Pt's family in to visit today, updated on patient's condition, all questions answered.\n\nA: 41 yo male s/p MCA with multiple ortho injuries, persistent fevers\n\nP: Continue to monitor neuro status, medicate for pain prn, advance tube feeds to goal of 85cc/hr. Follow culture results. ? Hold TF at MN for OR tomorrow. Provide support to patient and family\n"},{"category":"Nursing/other","chartdate":"2152-06-18 00:00:00.000","description":"Report","row_id":1368073,"text":"Resp Care: Pt remains intubated via #8 ETT retaped and secured at 24cm at lip. BS coarse bilat. Sx'd for small amt thick tan sputum. ABG WNL. No vent changes made this shift. Plan: cont vent support. Please see carevue for further vent inquiries.\n"},{"category":"Nursing/other","chartdate":"2152-06-19 00:00:00.000","description":"Report","row_id":1368074,"text":"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions.Started on atrovent mdi's.Temp 101.5. Agitated when awake.Given some morphine.HR-ST with PVC'S.RSBI done ON 0 PEEP/5 IPS 43.Will cont to monitor resp status.\n"},{"category":"Nursing/other","chartdate":"2152-06-14 00:00:00.000","description":"Report","row_id":1368052,"text":"nursing progress note\n\nneuro: pt remains intubated, sedated. lightened last eve for exam. mae, strong to bue. following commands, perrla, 2-3mm bilat. nods to pain when awake, given bolus fentanyl prn for turns, sx, etc w/ good effect.\n\nresp: ac mode continued, no changes made overnight. pt overbreathing vent when stimulated, volumes becoming very high during these times. o2 sats stable, abg wnl. ls clear, slightly dimin to bases. cough, gag intact. sx sm amts thick tan secretions.\n\ncv: cont w/ much ventric. ectope, rate 80s-100. bp stable, map consist. >65. filling pressures stable, co/ci . cvp 10-14. extrem warm, edematous. ppp bilat. lytes repleted prn. given 2u prbc overnight for hct 23.4, little improvement noted post transfusion, 25. repeat hct pending.\n\ngi: ogt repositioned last eve, draining mod amt bilious output. belly large, soft. bs present. remains npo.\n\ngu: u/o dropped last night, mod sized clot removed w/ irrigation. urimeter changed, draining clear yellow urine qs since.\n\nendo: bg's stable.\n\nid: low grade temps persist, tmax 100.8. ancef dosing continued.\n\nskin: open fx site to right tibia clean, large amt serosang drainage noted. pin sites clean, sm amts sanguinous drainage. ecchymotic areas to inner thigh, right hip.\n\nsocial: family in last eve, updates provided, all ques answered. reinforced scheduled visiting hours.\n\na: hemodynamics stable, comfortable w/ fentanyl, sedation. neuro exam intact, pulses remain intact to ble, extrem remain warm.\n\np: cont. to monitor filling pressures, vs, hct. replete lytes as needed, await OR today for pelvic, L5 repairs.\n"},{"category":"Nursing/other","chartdate":"2152-06-14 00:00:00.000","description":"Report","row_id":1368053,"text":"Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning abg results determined a compensated respiratory acidemia with very good oxygenation on the current settings.\n\nNo RSBI measured due to scheduled OR procedure.\n"},{"category":"Nursing/other","chartdate":"2152-06-14 00:00:00.000","description":"Report","row_id":1368054,"text":"nursing progress note\nevents- to or today from 9-3pm. screws placed in r femur and r femoral head, fib not fixed, ? friday.will need eventual hip replacement,\ntibia cleaned/ debrided\n\nneuro- pt remains sedated on propofol and fentanyl, arouses to voice, family at bedside. pre-op nodding ,obeying commands, postop very sleepy, mae.\n cv- sr-st, freq pvc's. bp stable by aline, pa pressures up w/stimuli\nswan now at 50 cm (was at 56cm preop), waveform adequate.svo2 re-cal, running in 70's.co had 1u pc's in or, hct now 27. boots on pulses +, good cap refill\n\nresp- placed on cpap 5/5 at 1830, tol well, mv . ls sl. coarse postop,pt to stay tubed- anticipating or on friday\n\ngi- sump to lws, bilious secretions. no bs heard\n\ngu- foley qs, clear yellow, no further clots\n\nid- remp 99, no issues\n\nskin- external fixation remains in place, pin sites clean, multiple surgical incisions with dressings intact. Sang draiange from tib/fib wound.\n\nsocial- mother, daughter-in-law at bedside, updated by Dr and RN\n\nplan-To OR on friday for ORIF fibia, most likily remain intubated til then, cont on ps as tolerated. Wean sedation as tolerated. Provide ongoing support to family. D/c swan in am and rewire to TLC. Start TF in am.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2152-06-14 00:00:00.000","description":"Report","row_id":1368055,"text":"Respiratory Care: Pt continues on ventilatory support. Initially on AC when back from OR today. Changed to PS 5/5 60% this eve, and tolerating well at this time.\n"},{"category":"Nursing/other","chartdate":"2152-06-19 00:00:00.000","description":"Report","row_id":1368075,"text":"nursing progress note\nNeuro- more awake, looks to speaker, obeys commands inconsistently.\nHas 4+ strength to resist turning! mso4 4mg w/effect for discomfort.\n\nCV- ST,occ-freq pvc's, aline bp 130's, up to 170's w/pain.hct 20's, color good, all pulses +, boots in place. tlc,aline in place, sites wnl.\n\nResp- remains on cpap, , 50%, oxygenation good, sao2 99-100.sxn copious thick yellow/tan secretions from mouth and ett.? extubation after or today.\n\nGI- tf off @ 0500- on call to or. bs+, no flatus or stool. minimal residuals\n\nGU- foley indwelling/patent. u/o clr yellow, qs\n\nID- cont w/ temp 101-102, pt has not been afebrile in>24hrs. pan cx , results pending, + sinusitis by head ct. on ancef, genta,clinda\n\nPlan- on call to or today for fusion of back by Dr. . ? extubation post op, pain cosult for chronic pain meds.? ortho to change dressing to rle. cont to w/u temps, follow cx\n\n"},{"category":"Nursing/other","chartdate":"2152-06-17 00:00:00.000","description":"Report","row_id":1368069,"text":"7a-7p\nneuro: pt sedated on propofol & fentanyl gtts, pt with eyes rolled back this am, ho aware, propofol off, pt still with eyes rolled back & not following commands, withdrawing to pain, PERL, moving all xtremites except R leg, fentanyl gtt decreased throughout day & down to only 25 mcg/hr by this afternoon, pt still not responding to commands & eyes continued to roll back so pt for head ct scan @ 1730, result negative\n\ncv: hr st(106-118), occasional pvc's, sbp stable, po lopressor, zestril & carvedilol started today\n\nresp: on 50% cpap 5/5 ps, tol well, lg amt tan thick secretions, bs+ all lobes & course, clears with sux, RSBI(25) & abg good but pt not extubated due to mental status & lg amt secretions, sat 99-100, rr 12-18\n\ngi: tf on hold today due to ? of extubation, tf resumed this pm after ct scan(fs promote @ 20 cc/hr, do not advance) no stool, iv pepcid\n\ngu: foley patent, clear yellow urine, good uo\n\nother: family in & updated on pt's condition, R leg with knee immobilizer @ all times, sm amt serou drainaged from R leg, bilat distal pulses by doppler, sm amt serous drainage from R hip suture line, ivf continue @ 80cc/hr, temp spike to 101.7 @ 1600, tylenol given, pt needs to be pan cultured, K+ & MG+ repleated\n\nplan: continue to monitor mental status, plan to extubate tomorrow when pt more awake, pan culture\n"},{"category":"Nursing/other","chartdate":"2152-06-18 00:00:00.000","description":"Report","row_id":1368070,"text":"Resp Care\nPt. remains intubated on minimal vent. support . Vt's 600-700cc/ MV 8-12lpm.\nBs: CEB, with minimal secreations.\nabgs:hyperoxygenated with slight metabolic alkalosis.\nPlan: rsbi 35.4 however MS may continue to prevent pt. from being extubated/protecting airway.\n"},{"category":"Nursing/other","chartdate":"2152-06-18 00:00:00.000","description":"Report","row_id":1368071,"text":"nursing progress note\nNeuro- off propofol and fentanyl, sl. more responsive now, nods yes to pain, obey commands slowly. mso4 w/effect. good strength in upper extremities, resists movement .\n\nCV- SR-ST w/pain, BP up to 170's w/pain, 120-140's @rest. cardiac meds restarted yest. ^ ectopy towards end of shift, mgso4 2 gm for mg=1.9\npulses positive, palpable despite edema.boots in place.TLC in place, site unremarkable. Aline dampened, better after dsg change- gd waveform. ivf . to 50cc/hr\n\n\nResp- remains on cpap 50%, 5+5. sao2>95%. rr20's, ls diminished, esp @ bases. sxn thick tan/ sputum, also from mouth- ct head shows severe sinusitis.ett not moved d/t ulcer @l side of mouth.\n\nGI- tf to increase to goal of 85- currently at 50cc/hr, tol well, min residuals.no stool.\nGU- foley indwelling/patent, u/o qs\nSkin- intact, r hip sutures intact, dg sm amt serous fluid. suprapubic dsg d+i, rle immobilizer in place, dg serous dge from dsg, hemovac in place\n\nID- temp to 102, pan cx. currently on genta and ancef\nplan- prn pain meds to optimize wakefulness, investigate source of temps ? sinuses.optimize nutritional status, ivf as able\n? extubate..\n\n\n\n"},{"category":"ECG","chartdate":"2152-07-03 00:00:00.000","description":"Report","row_id":192063,"text":"Sinus tachycardia with frequent ventricular premature beats. Left atrial\nabnormality. Intraventricular conduction defect. Compared to the previous\ntracing of the ventricular ectopic activity has increased. Otherwise, no\ndiagnostic change.\n\n"},{"category":"ECG","chartdate":"2152-06-23 00:00:00.000","description":"Report","row_id":192064,"text":"Sinus rhythm with ventricular premature complexes\nLeft atrial abnormality\nEarly precordial QRS transition - is nonspecific\nModest nonspecific low amplitude lateral T wave changes\nSince previous tracing of , lateral T wave amplitude lower\n\n"},{"category":"ECG","chartdate":"2152-06-21 00:00:00.000","description":"Report","row_id":192065,"text":"Sinus tachycardia\nVentricular premature complex\nLeft atrial abnormality\nModest low amplitude lateral T waves - are nonspecific and may be within normal\nlimits\nSince previous tracing of , ST-T wave changes decreased\n\n"},{"category":"ECG","chartdate":"2152-06-12 00:00:00.000","description":"Report","row_id":192066,"text":"Sinus tachycardia with frequent ventricular premature beats. Modest\nnon-specific inferolateral ST-T wave changes. Compared to the previous tracing\nof rate is faster but there are no other significant diagnostic\nchanges.\n\n"},{"category":"Radiology","chartdate":"2152-06-20 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":914847,"text":" 10:15 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: evaluate R sided opacity on prior CXR as recommended by atte\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate R sided opacity on prior CXR as recommended by attending radiologist\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right-sided opacity on prior chest x-rays, further evaluation\n recommended.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the thoracic\n inlet to the pubic symphysis after administration of IV contrast only. This\n study was compared with chest x-ray of and CT torso .\n\n CT CHEST WITH IV CONTRAST: These images are somewhat limited by motion. The\n low-density nodule on the left thyroid lobe is again identified. The patient\n is intubated. There is a left subclavian central venous line terminating in\n the distal SVC. A nasogastric tube is seen coursing below the diaphragm and\n into the stomach. Bilateral fluffy airspace opacities are identified in both\n upper lobes, consistent with contusion. Additionally, there are bilateral\n lower lobe dense consolidations corresponding to the unusual contour seen on\n chest x-ray of . There is no pericardial or pleural effusion. No\n hilar, axillary, or mediastinal lymphadenopathy is identified. Heart and\n great vessels are normal.\n\n CT ABDOMEN: Liver, spleen, pancreas, adrenals, kidneys, stomach and small\n bowel loops are normal given lack of oral contrast. The gallbladder is\n surgically absent. There is no free fluid or free air. There is no evidence\n of traumatic organ injury.\n\n CT PELVIS WITH IV CONTRAST: Sigmoid diverticulosis is seen, without\n diverticulitis. A Foley is present in the bladder. There is stranding\n surrounding the anterior aspect of the bladder wall and the posterior to the\n rectum. Stranding in the subcutaneous tissues is seen, consistent with some\n edema. Soft tissue density material representing hemorrhage is seen layering\n anterior and lateral to the left psoas muscle and along the right ureter.\n\n Again seen are right sacral fractures, comminuted right femoral, iliac, and\n superior pubic ramus fractures, and fixation hardware, which somewhat obscures\n evaluation of the lower pelvis structures. No new fractures are identified.\n Transverse process fracture of L5 is also noted.\n\n IMPRESSION:\n 1. Multifocal airspace opacities concentrated in both upper lobes, consistent\n with pulmonary contusions. Right hemithorax density seen on chest x-ray is\n accounted for consolidations in both lower lobes, probably related to\n (Over)\n\n 10:15 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: evaluate R sided opacity on prior CXR as recommended by atte\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aspiration.\n\n 2. Status post fixation of comminuted right femoral fracture and pelvic\n fractures. Small amount of hematoma along left paracolic gutter. Improved\n bladder wall hematoma in association with right pelvic fractures.\n\n 3. Sigmoid diverticulosis without diverticulitis.\n\n 4. Thyroid nodule which can be further evaluated by thyroid ultrasound on a\n non-emergent basis.\n\n"},{"category":"Radiology","chartdate":"2152-07-02 00:00:00.000","description":"CT PELVIS W/O CONTRAST","row_id":916429,"text":" 2:33 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: **Please extend views to knee*** evaluate hip fracture anato\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41M s/p Left hip fx\n REASON FOR THIS EXAMINATION:\n **Please extend views to knee*** evaluate hip fracture anatomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE PELVIS AND RIGHT LOWER EXTREMITY WITHOUT CONTRAST DATED .\n\n CLINICAL HISTORY: Please evaluate hip fracture in a 41-year-old male status\n post MVC.\n\n TECHNIQUE: Non-contrast CT scan of the pelvis and right femur was performed\n using 2.5 mm collimation. Images were reformatted in the coronal and sagittal\n planes.\n\n COMPARISON: Prior CT scan dated and plain films dated .\n\n FINDINGS: Posterior spinal fixation hardware is seen spanning the L5-S1\n level. This is a new finding when compared to prior CT examination. Tiny\n foci of air are identified in the region of the hardware, related to expected\n postoperative change, if recent. Hardware are also seen within both iliac\n bones. The hardware appears to be in good position. Previously identified\n sacral fractures are not significantly changed.\n\n There is a rod transfixing a comminuted superior right pubic ramus fracture.\n There is significant comminution of the anterior right acetabulum resulting in\n at least an 18 mm gap. An intramedullary rod with gamma nail fixes the right\n proximal femur fracture. The proximal right femur fracture is severely\n comminuted. Fracture is also identified within the right inferior pubic\n ramus.\n\n There is a severely comminuted fracture of the right kne tibial plateau. A\n side plate and multiple screws are unchanged in position when compared to\n prior examination.\n\n IMPRESSION: Status post ORIF for multiple fractures, as described above.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2152-06-17 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":914564,"text":" 5:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: cause for decreased mental status?\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with s/p motorcycle accident w/ decreased responsiveness.\n REASON FOR THIS EXAMINATION:\n cause for decreased mental status?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm SAT 6:56 PM\n no mass effect or hemorrhage. Severe sinusitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident, unresponsiveness.\n\n TECHNIQUE: Head CT without contrast.\n\n FINDINGS: There is no mass effect, hydrocephalus, shift of normally midline\n structures or infarction. The density values of the brain parenchyma are\n within normal limits.\n\n A severe opacification of the sphenoid and frontal sinuses as well as the\n ethmoid air cells with moderate to severe opacification of the maxillary\n sinuses. No fractures are present.\n\n IMPRESSION: No mass effect or hemorrhage. Severe sinusitis.\n\n"},{"category":"Radiology","chartdate":"2152-07-01 00:00:00.000","description":"R FEMUR (AP & LAT) RIGHT","row_id":916324,"text":" 11:46 AM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: pre-op eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle accident, multiple RLE fractures\n\n REASON FOR THIS EXAMINATION:\n pre-op eval\n ______________________________________________________________________________\n FINAL REPORT\n 41-year-old male with motorcycle accident and multiple right lower extremity\n fractures.\n\n COMPARISON: .\n\n RIGHT FEMUR, FIVE VIEWS: Again demonstrated is a comminuted intertrochanteric\n fracture of the right proximal femur. There is a fixation screw fixating the\n anterior column and medial wall of the acetabulum. An intramedullary rod with\n a gamma nail fixes the right proximal femoral fracture. Ghost tracks from\n prior fixation hardware are noted in the distal femur. A lateral plate and\n multiple screws fixate the comminuted tibial plateau fracture. There is no\n evidence of hardware complication.\n\n"},{"category":"Radiology","chartdate":"2152-06-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":915378,"text":" 7:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for cardiopulm. abnormality\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, just extubated, now diaphoretic and tachycardic.\n\n REASON FOR THIS EXAMINATION:\n Eval. for cardiopulm. abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, extubated, not diaphoretic and tachycardic. Evaluate for\n cardiopulmonary abnormality.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH\n\n There has been interval removal of the endotracheal tube, right subclavian\n line, and left subclavian line. Cardiomediastinal hilar contours appear\n unchanged. No focal consolidation is seen within the lungs. There are low\n lung volumes limiting complete assessment of the pulmonary vasculature.\n\n IMPRESSION: No focal consolidations.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-20 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":914862,"text":" 11:54 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check CVL\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, intubated, fevers\n\n REASON FOR THIS EXAMINATION:\n check CVL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, intubated, fevers.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: The endotracheal tube, left subclavian central\n venous catheter, and feeding tube are in standard positions. A new right\n subclavian central venous catheter tip is positioned within the lower SVC.\n There is no pneumothorax. Heart is mildly enlarged, unchanged. There is\n worsening consolidation within the left lower lobe with loss of the\n diaphragmatic contour, consistent with worsening atelectasis and/or\n infiltrate. Small left pleural effusion persists. There is improved aeration\n within the right base with residual atelectasis identified. There is no\n pneumothorax. No lower lung volumes are present on the current study, and\n there is crowding of the pulmonary vasculature at the bases with a\n perivascular haze present bilaterally suggestive of possible volume overload.\n\n IMPRESSION:\n\n 1. Satisfactory placement of right subclavian central venous catheter. No\n pneumothorax.\n\n 2. Worsening left lower lobe consolidation with persistent small left pleural\n effusion.\n\n 3. Possible mild volume overload.\n\n 4. Improved aeration within the right lung base.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":915445,"text":" 4:19 PM\n CHEST (PA & LAT) Clip # \n Reason: pna\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with questionable pna / fevers persistant\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest performed on .\n\n HISTORY: 41-year-old man with questionable pneumonia and fevers.\n\n FINDINGS: Comparison is made to prior study from .\n\n There are low lung volumes that limit evaluation. The lateral radiograph is\n suboptimal due to patient's large body habitus and overlying arm as well as\n the poor inspiratory effort. Allowing for this, however, there is no focal\n consolidation, signs for pulmonary edema or pleural effusions. The cardiac\n silhouette and mediastinum are prominent but may be secondary to the AP\n technique and low lung volumes. Bony structures are intact.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":914765,"text":" 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, intubated, fevers\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old male with trauma, intubated, fever.\n\n Portable AP chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: Endotracheal tube and left subclavian venous catheter are unchanged\n compared to the prior study. The distal nasogastric tube is terminating in\n left upper quadrant. Cardiac and mediastinal contours are unchanged, with\n somewhat prominent cardiac shadows. Note is made of new rounded opacity\n overlying the right hilum, which may represent consolidation, however, the\n etiology is uncertain. Note is made of atelectasis in left lower lobe.\n\n IMPRESSION: Tubes and lines as described above. New rounded opacity\n overlying the right hilum, of unknown etiology. This can represent early\n pneumonia, however, given the history of trauma, other process should be\n considered, and clinical correlation and close followup is recommended. If\n necessary, please perform CT scan.\n\n The finding was discussed with the referring physician, . , by\n telephone at the time of interpretation.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-11 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":913820,"text":" 11:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: cuts through upper right femur to eval for Fx\n Field of view: 47 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle accident\n REASON FOR THIS EXAMINATION:\n cuts through upper right femur to eval for Fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa MON 2:02 AM\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded by\n hematoma.\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\n extravasion on delayed scan.)\n 3. No aortic injury.\n 4. Lt thyroid nodule.\n 5. Right sacral fracture and rt L5 transverse process fracture.\n WET READ VERSION #1 MNIa MON 12:35 AM\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded\n by hematoma.\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\n extravasion on delayed scan.)\n 3. No aortic injury.\n WET READ VERSION #2 MNIa MON 12:59 AM\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded by\n hematoma.\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\n extravasion on delayed scan.)\n 3. No aortic injury.\n 4. Lt thyroid nodule.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old woman with motor cycle accident.\n\n TECHNIQUE: Contiguous axial CT images of the abdomen, chest, abdomen, and\n pelvis were obtained with the administration of IV contrast . Multiplanar\n reformation images are reconstructed.\n\n No comparison.\n\n FINDINGS:\n\n CHEST: There is no evidence of acute aortic injury. No mediastinal hematoma.\n No pericardial or pleural effusion. No evidence of pneumothorax. There are\n bilateral dependent opacities, however, no suspicious mass or consolidation is\n noted.\n\n (Over)\n\n 11:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: cuts through upper right femur to eval for Fx\n Field of view: 47 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ABDOMEN: The patient is status post cholecystectomy. No free air. No\n ascites. The liver, spleen, pancreas, adrenal glands and kidneys, the\n visualized portions of large and small intestines are within normal limits.\n\n PELVIS: The visualized portions of large and small intestines are within\n normal limits. No free air. No lymphadenopathy.\n\n Note is made of hyperdense hematoma with fat stranding anterior to the urinary\n bladder, tracking down along the anterior abdominal wall. On the delayed\n scan, the urinary bladder is distended with contrast, however, there is no\n evidence of extravasation. The hematoma appears to be located in the\n extraperitoneal space on sagittal reformation. Hematoma along the right psoas\n muscle is noted.\n\n Note is made of extensively comminuted displaced fracture of the right femoral\n neck with bone fragment and medial angulation of the femoral head, associated\n with multiple fracture lines in the acetabulum with bone fragment anteriorly,\n as well as fracture lines through the right pubic rami and right side of the\n sacrum. There is associated soft tissue fat stranding and hematoma\n surrounding the right hip joint. There is a hematoma medial to the right\n acetabulum, with some mass effect to the urinary bladder. Iliac arteries are\n patent and no evidence of active extravasation is noted. No rib fracture is\n seen. Fracture of the right side of the sacrum and transverse process of L5 is\n noted.\n\n IMPRESSION:\n\n 1. Extensive comminuted and displaced fracture of the right femoral neck with\n medial angulation of the head, as well as multiple fractures involving\n acetabulum, pubic rami. The fracture line through the right side of the\n sacrum as well as fracture of the right transverse process of L5.\n\n 2. Hematoma and soft tissue swelling surrounding the above-mentioned\n fracture. Hematoma anterior to the bladder, tracking just beneath the\n abdominal wall. No evidence for bladder injury. Hematoma along the psoas\n muscle.\n The location of hematoma is extraperitoneal.\n\n The information was communicated with the trauma team in person at the time of\n examination, and was also discussed with the referring physician, . \n by telephone, and was also flagged to ED dashboard.\n\n\n (Over)\n\n 11:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: cuts through upper right femur to eval for Fx\n Field of view: 47 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2152-06-11 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":913821,"text":" 11:52 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o Fx\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: The findings regarding T4 fracture was communicated to the covering\n physician, . , by telephone at 9:30 p.m. on . We tried to\n reach the ordering physician, . , however, was not successful, and\n therefore, the information was also sent to Dr. by e-mail.\n\n\n 11:52 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o Fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle\n REASON FOR THIS EXAMINATION:\n r/o Fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DBH MON 5:04 PM\n Scoliosis, no gross fracture.\n\n NOTE ADDED AT ATTENDING REVIEW: There is a compression fracture of T4\n with a retropulsed fragment into the spinal canal. The bone does not appear to\n produce severe canal narrowing, but cannot rule out disk protrusion or\n hematoma.\n WET READ VERSION #1 MNIa MON 12:08 AM\n Scoliosis, no gross fracture.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 41-year-old male with motorcycle.\n\n C-SPINE CT WITHOUT CONTRAST.\n\n No comparison.\n\n FINDINGS: Note is made of severe scoliosis, however, there is no gross\n fracture or dislocation. No prevertebral soft tissue swelling.\n\n IMPRESSION: Marked scoliosis. No gross fracture or dislocation.\n\n\n NOTE ADDED AT ATTENDING REVIEW: There is a compression fracture of T4, with\n retropulsion of an inferior endplate fragment. CT is extremely limited for\n analyzing canal narrowing. There appears to be only mild osseous encroachment\n on the canal, but the possibility of soft tissue abnormality, such as disk\n protusion or hematoma, cannot be evaluated. If clinically indicated, recommend\n CT of the thoracic and lumbar spine and perhaps an MR of the spine.\n\n Findings discussed with Dr. at 5:30 pm on .\n\n\n\n\n\n\n\n\n (Over)\n\n 11:52 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o Fx\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2152-06-11 00:00:00.000","description":"R CT LOW EXT W/O C RIGHT","row_id":913822,"text":" 11:58\n CT LOW EXT W/O C RIGHT Clip # \n Reason: r/o fx tib plateau\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle\n REASON FOR THIS EXAMINATION:\n r/o fx tib plateau\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa MON 12:30 AM\n Extensively comminuted tibial plateau fracture with hematoma and deep tissue\n air. Comminuted fracture of prox. fibula.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle accident, rule out tibial plateau fracture.\n\n TECHNIQUE:\n\n Thin section axial images were obtained from the distal femur through the mid\n calf and reconstructed using both bone and soft tissue algorithm. Coronal and\n sagittal reconstructions were also generated. The patient's leg is imaged in\n slight flexion, resulting in some distortion of the axial images\n presently available.\n\n RIGHT LOWER EXTREMITY, WITHOUT CONTRAST:\n\n PRELIMINARY WET :\n\n Please note that a wet was provided by the radiology resident on the\n PACS requisition as follows: \"extensively comminuted tibial plateau fracture\n involving joint surface with hematoma and deep tissue air. Comminuted\n proximal fibular fracture (spiral). Discussed with trauma team (by resident\n , M,\"\n\n FINAL REPORT:\n\n There is a markedly comminuted fracture of the proximal tibia, extending into\n the tibial plateau, with considerable axial dispersion of the fracture\n fragments. The articular surface components extend into the lateral plateau,\n into the tibial eminence, and into the medial tibial plateau. The distal\n major fracture lines exit in the medial and lateral metaphyses, with\n comminution. There is dispersion of fragments posteriorly, with small\n fragments lying adjacent to the popliteal vessels, though they do not appear\n to directly impinge on the vessels (series 2, images 139-117). The main\n longitudinal axis of the tibial shaft is displaced posteriorly with respect to\n the markedly comminuted proximal tibia, best appreciated on sagittal views.\n The tibial tubercle (insertion site of patellar tendon) is avulsed. There is\n also considerable comminution at the expected insertion site of the posterior\n cruciate ligament. The ACL is not effectively evaluated here.\n\n There is a joint effusion, with air within the joint. There is extensive\n surrounding soft tissue edema as well as some subcutaneous emphysema.\n (Over)\n\n 11:58\n CT LOW EXT W/O C RIGHT Clip # \n Reason: r/o fx tib plateau\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is a comminuted fracture of the proximal diaphysis of the fibula. The\n proximal tibiofibular joint remains congruent.\n\n IMPRESSION:\n\n 1. Markedly comminuted and impacted fracture of the proximal tibia, with\n extensive involvement of the tibial plateau and posterior displacement of the\n main shaft of the tibia. Avulsion of patellar tendon from tibial tubercle.\n Comminution at expected site of PCL insertion. Bony fragments abutting the\n popliteal vessels.\n\n 2. Proximal fibular diaphyseal fracture.\n\n\n\n"},{"category":"Radiology","chartdate":"2152-06-12 00:00:00.000","description":"R TIB/FIB (AP & LAT) RIGHT","row_id":913825,"text":" 4:06 AM\n TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: RT TIB FIB FX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with right tib/fib fracture.\n\n Three fluoroscopic images obtained during fixation of comminuted tibial\n plateau fracture and proximal fibular fracture, without the radiologist\n present. Rod is noted only on AP view, and neither end is seen. Please also\n refer to the official surgical report.\n\n"},{"category":"Radiology","chartdate":"2152-06-16 00:00:00.000","description":"RO KNEE (AP, LAT & OBLIQUE) RIGHT IN O.R.","row_id":914446,"text":" 3:21 PM\n KNEE (AP, LAT & OBLIQUE) RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: ORIF RT.TIBIAL PLATEU FX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture fixation.\n\n 2 minutes 8 seconds of fluoroscopy time. Exam consists of five AP and lateral\n intraoperative radiographs of the right knee and proximal leg. Since last\n exam the markedly comminuted and displaced fracture of the proximal\n tibia and lateral tibial plateau has been fixated by a curved lateral plate\n and multiple screws. A second small anterior plate and screws is also\n present. Again noted is the fracture of the adjacent proximal fibula. Bone\n detail obscured for technical reasons.\n\n"},{"category":"Radiology","chartdate":"2152-06-15 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":914287,"text":" 12:59 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check CVL\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, s/p Line placement\n\n REASON FOR THIS EXAMINATION:\n check CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the new central venous line placement.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 3.3 cm above the carina. The Swan-Ganz catheter was\n exchanged by a subclavian central venous line with its tip at the junction of\n the brachiocephalic vein with the superior vena cava. The NG tube now is\n properly inserted with its tip in the stomach.\n\n The heart size is normal. There is no evidence of congestive heart failure.\n There are bibasilar lower lobe atelectases, left more than right, which are\n worsening seen the previous film.\n\n IMPRESSION:\n\n 1. Normal position of the left central venous line with no evidence of\n pneumothorax.\n\n 2. Worsening bibasilar atelectases.\n\n"},{"category":"Radiology","chartdate":"2152-06-27 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":915785,"text":" 2:30 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: possible IVC filter placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with\n REASON FOR THIS EXAMINATION:\n possible IVC filter placement\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VEINS.\n\n INDICATION: 41-year-old man with possible IVC filter placement.\n\n BILATERAL LOWER EXTREMITY VEINS: Grayscale and color Doppler ultrasound were\n performed. There is normal compressibility, color flow, and Doppler signal\n within the common femoral, superficial femoral, and popliteal veins.\n\n IMPRESSION: No evidence of DVT.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-21 00:00:00.000","description":"R HIP UNILAT MIN 2 VIEWS RIGHT","row_id":915041,"text":" 1:52 PM\n HIP UNILAT MIN 2 VIEWS RIGHT; FEMUR (AP & LAT) RIGHT Clip # \n KNEE (2 VIEWS) RIGHT; TIB/FIB (AP & LAT) RIGHT\n PELVIS (AP ONLY)\n Reason: assess alignment of fractures\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, multiple RLE fx's\n REASON FOR THIS EXAMINATION:\n assess alignment of fractures\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right hip, two views. .\n\n HISTORY: 41-year-old man with trauma and multiple lower extremity fractures.\n\n FINDINGS: There is a single screw seen fixating the anterior column and\n medial wall of the acetabulum. There is an intramedullary rod with a gamma\n nail seen, fixating a comminuted intertrochanteric fracture of the right\n proximal femur. There are no signs of hardware complications. Ghost pin\n tracks are seen in the distal femur. The patient has a comminuted tibial\n plateau fracture, which is fixated by lateral plate and multiple screws, seen\n through the tibial plateau. The patient has a brace, which limits soft tissue\n detail. Visualization of the distal ankle is within normal limits.\n\n\n\n"},{"category":"Radiology","chartdate":"2152-06-26 00:00:00.000","description":"O L-SPINE (AP & LAT) IN O.R.","row_id":915656,"text":" 5:13 PM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: L5 TO ILIUM FUSION IN OR FOR L5-S1 FACET JOINT FX AND SACRAL FX\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fusion.\n\n Two intraoperative lateral radiographs of the lumbar spine were obtained\n without a radiologist present. These demonstrate fusion hardware overlying\n L5-S2. For additional details, please consult the operative report.\n\n\n"},{"category":"Radiology","chartdate":"2152-07-03 00:00:00.000","description":"R HIP UNILAT MIN 2 VIEWS RIGHT","row_id":916537,"text":" 9:50 AM\n HIP UNILAT MIN 2 VIEWS RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: REVISION RT HIP HARDWARE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right hip hardware revision.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Fluoro time recorded as 1.48 minutes on the electronic\n requisition. Nine spot views were obtained. These demonstrate portions of an\n right femoral intramedullary rod and extensive hardware in the proximal right\n tibia, which is incompletely visualized. A proximal fibular fracture is also\n demonstrated. A proximal femur fracture is also seen. Assessment of fine\n bony detail is limited due to RF technique.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-14 00:00:00.000","description":"PELVIS WITH JUDET VIEWS","row_id":914150,"text":" 2:16 PM\n PELVIS WITH JUDET VIEWS; HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT\n Reason: TRAUMA, DHS HIP, ORIF OF RIGHT ACETABULUM, FRACTURE\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Pelvis with Judet view.\n\n HISTORY: Trauma.\n\n Eight intraoperative fluoroscopic views of the femur and hemipelvis without\n right and left label were obtained during the open reduction and internal\n fixation of intertrochanteric fracture with an intramedullary nail and\n proximal and distal screws as well as internal fixation of anterior acetabular\n fracture with a cancellous screw. An inferior pubic ramus fracture is also\n noted. The final films are not available.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-13 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":913916,"text":" 4:04 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Position of line, pneumothorax\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, s/p Line placement\n REASON FOR THIS EXAMINATION:\n Position of line, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:38 A.M. .\n\n HISTORY: Trauma. Line placement. Possible pneumothorax.\n\n IMPRESSION: AP chest _____ with the only prior chest imaging, CT scan from\n :\n\n ET tube is in standard placement, nasogastric tube is looped in the\n hypopharynx and ends in the lower esophagus. The course of the Swan-Ganz\n catheter is distorted by cardiac motion, but the tip projects over the right\n pulmonary artery. Repeat examination should be performed to document\n continuity of the line.\n\n Lungs are very low in volume, but aside from mild left infrahilar atelectasis,\n probably clear. Supine positioning is probably responsible for distention of\n mediastinal veins. The heart is normal in size. No pneumothorax. Dr. \n was paged to discuss these findings, at the time of dictation.\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2152-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 78180,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHeight: (in) 69\\nWeight (lb): 230\\nBSA (m2): 2.19 m2\\nBP (mm Hg): 103/51\\nHR (bpm): 101\\nStatus: Inpatient\\nDate/Time: at 10:30\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\\nis seen in the RA and extending into the RV.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Moderately\\ndepressed LVEF.\\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. Mild (1+) MR. LV inflow pattern\\nc/w impaired relaxation.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\\nposition.\\n\\nConclusions:\\n1. There is mild symmetric left ventricular hypertrophy. The left ventricular\\ncavity size is normal. Overall left ventricular systolic function is\\nmoderately depressed. Anterior, septal, apical and inferior hypokinesis is\\npresent with some preservation of lateral wall motion.\\n2. The mitral valve leaflets are structurally normal. Mild (1+) mitral\\nregurgitation is seen.\\n3. There is no pericardial effusion.\\n4. Compared with the prior study (images reviewed) of , there is no\\nsignificant change.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368044,\n \"text\": \"Admission note:\\n\\nInvolved in Motor cycle crash earlier this evening. Alert and oriented in ED. Right open tib/fib, right acetabular and femoral neck fxs.\\n\\nReceived from OR post Xfix application to right open tib/fib fx. Became hemodynamicly unstable in OR, case ended and brought to room. Still needs to have right acetabular fx and femoral neck repair done.\\nOn epi w/SBP >200 and HR 130's. EPi off immediatly. Anasthesia admin 100 mcg of fentanyl and SBP lowers to 150-160.\\n\\nROS:\\n\\nNeuro: Sedated on propofol. Fentanyl gtt at 100 mcg. Prior to starting fentanyl was beginning to awaken, eyes opened to voice, lifted head off bed, and some movement of both arms noted before fentanyl begins to work. PEARRLA. C collar inplace. Log roll and spine recautions maintained.\\n\\nCV: Sinus tach w/PVCs, pairs, multifocal. S1S2. Has left sublcavian cordis w/CCO swan. PAs 35-40s/20's. CVP 3. SVO2 75 or >. Has left radial abp line. Peripheral pulses palpable w/great ease in all 4 extremities. P boots and heparin sub q for DVT prophylaxis.\\n\\nResp: Orally intubated and on vent. Fio2 weaned to 40%. ABGs w/metabolic acidosis. Tx w/1 liter of NS, with improving acidosis.\\nLung sounds clear. No resp distress noted, = rise and fall of chest. Sats 100%.\\n\\nGI: Oral sump placed, positioned verified to be correct via instillation and auscultation of air bolus. H2 blocer orderd for GI prophylaxis.\\n\\nGu: Foley patent draining clear yellow urine in QS.\\\\\\n\\nENDO: FSG covered w/RSSI.\\n\\nLabs: Mag and IC need repletion, awaiting orders.\\n\\nSocial: Mother waiting to visit.\\n\\nPlan: Correct metobolic acidosis. Monitor CMS checks to RLE. Pulmonary toileting. Clear TLS and C spine. Mobilization. Pain control. Monitor, tx, support, and comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368045,\n \"text\": \"Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS sl decreased, rel clear bilat. Sx'd for small amts thick yellow sputum. Most recent ABG reveals metabolic acidosis w/ hyperoxia. No vent changes made this shift. Chest CT from reveals \\\"bilat opacities\\\".\\nplan: cont vent support. Pt to return to OR possibly tomorrow. Please see carevue for further vent inquiries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368046,\n \"text\": \"NPN 7a-7p \\n\\n41 y.o. male s/p MCC -> Pt struck by car on right side, thrown over handle bars, noted to have landed on his back. No LOC, but known confusion after accident. Admitted to OSH (), then transfer to . DX: Tib/Fib fracture, and acetabular/femoral neck fracture, with L 5 transverse process fx.\\n\\nROS:\\n\\nNeuro: Pt sedated throughout day on Propofol 40mcg/kg/min and fentanyl gtt at 50mcg/hr. Lightened for daily wakeup/neuro checks. Pt opening his eyes to verbal stim, pupils equal and briskly reactive @ 2-3mm. Pt following commands consistently, appropriately nodding yes and no to questions asked by this RN. Pt is able to lift and hold UE's and LLE. Moves RLE on the bed d/t injury. At times agitated with wakeups, pt settles with verbal reassurance. Pt on Fentanyl for pain. Increased as able to tolerate for adequate pain control. Currently at 75 mcg/hr of Fentanyl with adeq pain relief. Cerv collar on, logroll dc'd by ortho team.\\n\\nCV: ST 105-113 with frequent ectopy, multiple PVC's. Was seen here back in for possible ICD plcment. s/p cardiomyopathy with low EF 10%, 35% at last follow up appt. with cardiology. Arterial Line to left hand, zero'd and re-leveled. SBP 99-121/60-70's correlating well with NBP. PAS/D 36/18 -> 44/28, Wedge pressure this a.m. 3. Dr. aware of difficulty wedging. SVO2 70's. PA line measured at 56. EDVI 90-140. Positive pulses bilaterally, easily palpable. +cap refill, csm. sc heparin and PB's for DVT prophylaxis.\\n\\nResp: O2 sats 97-99% on 40% FIO2. #8.0 ETT 24 @lip. Repositioned and re-taped. Current vent settings-> AC 40% FIO2/ 5 Peep/700x12, pt is breathing up to 3 breaths over the settings. Sux'd today for min amts of thick white/yellow secretions. Oral mucosa intact, frequent mouth care. LS CTA. Pt initially with metabolic acidosis, improved throughout shift. Last ABG's 7.34/40/160/23\\n\\nHem: HCT 31.9 PLT 173 WNL PT 12.6/PTT 23/INR1.1\\n\\nAccess: Left 16 gauge PIV / L-art line/ LSC PA line with Cordis/ Right 16 gauge PIV. Field Iv's d/c'd\\n\\nGI: Pt is on Pepcid q12 hrs. OGT to LCWS with very minimal output. Plcmt checked via air injection/auscultation. Abd softly distended. No bowel sounds present this a.m. now very hypoactive. No feeds started as of yet. No stool.\\n\\nGU: U/o via catheter, yellow with no sediment. Adeq amts of output. Last Potassium 4.5, Mag 2.4 after 4gm repletion. Lactic acid trending down since admission currently 2.3 from 2.8. Calcium Gluc 2 gms repleted. and Crt wnl.\\n\\nEndo: Bld sugars 120-160's corrected with RISS. No hx of diabetes\\n\\nID: Tmax 100.3 via swan. No anbx ordered at this time. WBC 14.4\\n\\nSKIN: Skin intact. No breakdown to buttocks. X-FIX to RLE with 10 lb wt added to traction. Ex-fix draining mod-lg amts of sanguinous drainage, wrapped with ace wrap. Aspen collar on at all times. Collar care completed.\\n\\nSocial: Pt lives with his girlfriend. Family in to visit today. Mom is the next of , in to visit today, calls for updates. Affect/quest\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368047,\n \"text\": \"(Continued)\\nions appropriate. Emotional support provided.\\n\\nAct: Pt was clr'd from logroll per Icu/ortho team. Pt is able to have hob no > than 45 degrees (for comfort reasons with acetabular fx). Turn and position through day.\\n\\nA: 41 y.r. old male s/p MCC. Vented/sedated/stabilized. Hemodynamically stable. Ex fix for tib/fib fx this am, awaiting OR for acetabular/femoral head fx\\n\\nP: Pt to have surgery for unstable femoral neck fx, possibly tues/wed. Monitor neuro, hemodynamics, pain. Initiate vent wean post surgery. Monitor hemodynamics/resp status. Monitor ex-fix/surgical site. CSM. Maintain safety. Provide emotional support to patient and family. Social work to consult in a.m.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368048,\n \"text\": \"Resp Care\\nPt. remains intubated overnight w/o change.\\nBs: ess. clear with minimal secreations.\\nabgs:hyperoxygenated with otherwise normal parameters.\\nPlaN: to OR for right leg/pelvis fx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368049,\n \"text\": \"t-sicu nsg note:\\nneuro- pt remains sedated on fentanyl gtt @ 75mcg/hr and propofol gtt @ 40mcg/kg/min, he responds to voice, follows commands occ becomes restless to voice and care but quickly settles w/ reassurance. perrla 3mm brisk, strong cough, lifts ue's and lle off bed, moves rle on bed.\\n\\nresp- sxn infreq for sm amts of thick yellow secretions, vent settings unchanged a/c 40% 700x12 peep of 5, spont resp . bs cta, met acidosis resolved.\\n\\ncvs- fp's wnl, ci>3.5, svo2=71-73% pcwp 9, cvp 5-11, sbp 106-130's, hr 102-110 nt w/ up to 28 pvc's per min multifocal and in triplets.lytes wnl K+ 4.1, mg 2.0, Lr infusing @ 125cc/hr. hct 22\\n\\n\\ngi- ogt drained scant amt clear fluid, abd soft,obese, no flatus, no stool, bs hypoactive.\\n\\ngu- foley patent for ~60cc cyu/hr\\n\\nskin- intact behind collar and back side, sm abrasion to r shin covered w/ bacitracin and 2x2, rle in 10 lbs skeletal traction via xfix, ace wrap soaked and draining mod amt sanguinous drainage.\\n\\nendo- no riss required.\\n\\nsocial- mother called twice, looking for info regarding or plans for today.\\n\\na: stable on present settings\\n\\np: monitor cvs/nms per routine, cont to assess volume and electrolyte status. follow hct, cont sedation, awaiting or.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368050,\n \"text\": \"Respiratory care\\npt on the vent tol well no changes made. see respiratory page of carevue for more information.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368051,\n \"text\": \"NPN 0700-1900\\n Pt is a 41 yo s/p MCC hit on R side by car and thrown over handlebars per report.\\n Injuries included: R extensive communicated and displaced R fem neck fracture, multiple fractures of acetabulum and pubi rami, transverse process L5 fx, fracture line through sacrum. Hematoma and soft tissue swelling around fractures, hematoma anterior bladder, right open tib/fib. compression fx of T4.\\n Hospital course complicated by preexsisting cardiomyopathy.\\n\\n Pt is sedated on fentanyl and propofol with good effect. When lightened on propofol he FCs and MAEs consistently. Lifts arms and head off bed. Nods no to pain and follows voice with gaze. PERLA.\\n\\nResp- No vent changes made and ABGs WNL. Small thick yellow ETT secretions. Lungs clear to auscultation. No signs/symptoms pulm edema.\\n\\nCV- SR-ST with freq ventricular ectopy. Swan in place, see carevue for #s. TEE done, final report pending. Afebrile. HCT dropped from 22.4 to 20.9. BG 105x2. Received 2u PRBCs over several hours. Palp pedal and PT pulses with good CSM to BLEs. Cap refill<3s. Mod general edema. Skin w/d. dressing changed on R calf. Suture intact. Had been oozing mod amt sang drainage throughout day. After dressing change at 1600 no further drainage.\\n\\nGI/GU- Abd soft, distended. Hypo BS. OGT to LWS with scant drainage, auscultate air in abd. Foley patent with adeq UO.\\n\\n Mother at bedside most of day. Updated by RN, Dr and ortho team. Asking appropriate questions and support provided.\\n\\nPlan- Cont serial HCts. Monitor resp status for s/s pulm edema. F/U with TEE report. Cont to provide support to family. Plan for OR in am tomorrow with Dr .\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368064,\n \"text\": \"1445-1900\\nSEE CAREVUE FOR VITAL SIGNS.\\n\\nPT WENT TO OR @ 1455 RETURNING @ 1820. PT STABLE. NO SIGNIFICANT EVENTS IN OR.\\n\\nNEURO: SEDATED ON PROPOFOL.\\n\\nCV: HYPERTENSIVE. ON PROPOFOL AND FENTANYL.\\n\\nRESP: VENTILATED. +++ GREEN/BROWN SECRETIONS SUCTIONED. SATS 99-100% SINCE RETURN.\\n\\nGI: TUBE FEED TO BE RECOMMENCED. NIL SUCTIONED VIA OG IN OR. NOW TO LWS.\\n\\nGU: ADEQUATE U/O.\\n\\nSOCIAL: PTS MOTHER UPDATED BY RN RE: SURGERY AND IS VISITING PT AT PRESENT. SHE HAS NOT SPOKEN WITH MD .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368065,\n \"text\": \"RESPIRATORY CARE:\\n\\nPt remains intubated, vent supported. No changes made overnight. BS's coarse at times, diminished on LLL. Sxing thick tan/bloody secretions. See flowsheet for further pt data. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368066,\n \"text\": \"Respiratory Care (Addendum):\\nChanged to CPAP/PSV support mode per team. ABG's to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368067,\n \"text\": \"NPN, 1900-0700\\nneuro: lightly sedated on propofol and fentanyl gtts. Arouses to voice w/ open eyes. Follows commands slowly. MAE. Gaze is deviated up and left: PERRLA.\\n\\nCV: NSR, ST freq MFVEA, 80's-100's. K+ repleted aggressively. Pulses + by Doppler signal.\\n\\nPulm: orally intubated on AC overnoc; weaned to CPAP/PS 5/5 x 50% w/ excellent ABG's. Copious thick tan secretions. Weak cough and gag.\\nBS course through, distant bases.\\n\\nGI: abd softly distended, hypo BS. No flatus or stool. Promote w/ fiber via OGT started and advanced slowly R/T hypo BS. Min residuals.\\n\\nGU: F/C urine clear amber, adequate OP. RF labs WNL\\n\\nskeletal: No pressure areas; skin grossly intact. Right hip stapled incisions C/D, Clear serous drainage from most distal. Right leg encased in aces and immobilizer, draining large amount serous from hemovac site, which is draining bloody fluid. CSM right leg intact.\\n\\nEndo: RISS, no coverage needed.\\n\\nID: WBC WNL; Tmax 100.7, po. Cont on gentamycin and cefazolin.\\n\\nP: wean and extubate. Restart pre-adm cardiac meds. Maintain right leg immobilizer at all times..DO NOT REMOVE or manipulate at all, per Ortho. Advance TF to goal. aggressive pulm toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368068,\n \"text\": \"Respiratory Care Note\\nPt received on PSV 5/5 as noted with VT 700-1000 and RR 15-25. BS essentially clear with good aeration. SBT 5/0 done VT 722 and RR 18 with a RSBI of 25. Pt taken to CT scan for head secondary to Pt weaned off sedation, but not waking. Plan to remain intubated on PSV at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368089,\n \"text\": \"NPN 7a-7pm \\n\\nROS:\\n\\nN- A & Ox3, generalized weakness from decreased activity to ext's but moves all except RLE. RLE-> Injured leg. Pupils = reactive at 4mm\\nDenies HA. Pt weaned off Propofol and Fentanyl. Pt started on Morphine PCA 1.5/6/15. Cerv collar clr'd this evening\\n\\nCV- SR-ST, Hr occasionally up to 110-120 with agitation/increasing temps. See carevue for exacts. Ocassional PVC's. ABP stable, drsg . Pos pulses, good CSM, warm/nml in color. Venodynne to LLE only.\\n\\n Pt extubated, on a humidified shovel mask with adeq saturation. Lungs clr in upper airways, decreased in bases. Using IS with RN.\\n\\n PT on a house diet. Tolerating Liquids no aspiration noted. Positive BS, denies n/v. Abd soft non tender.\\n\\nGU- u/o adeq\\n\\nSkin- RLE in splint with DSD, externally rotated.Drsg by . Site to right hip and abd with staples.\\n\\nSoc: family in to visit patient.\\n\\nEndo- RISS, no insulin needed.\\n\\n Pt spiked over noc, low grade temps today. Plan for OR when temps decreased. Pt on vanco and Ceftaz.\\n\\nLytes: WNL no repletion needed\\n\\nA: Pt extubated today, tolerating extubation. Stable. Collar clr'd\\n\\nP: Monitor overnight, monitor resp status, possible transfer to floor if stable tomorrow. Provide emotional support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368090,\n \"text\": \"T/SICU Nursing 19-07\\nNeuro: Alert, oriented to hospital, accident, self; disoriented to exact date, city. At times makes bizarre statements. Pupils 4mm, equal, round, briskly reactive. MAE purposefully and to command; can only wiggle toes on injured RLE.\\n\\nPain: Complaining of pain in RLE with movement only. Using PCA with effective relief.\\n\\nResp: Lung sounds clear, equal bilaterally, diminished bibasilar. Coughs but swallows sputum. Using IS with encouragement. SPO2 high 90's on 4L NC. Denies dyspnea.\\n\\nCV: Sinus tachycardia with rate 98-119, frequent VEA including bigeminy. SBP generally low 100's-one teens. 5mg lopressor given x1 as ordered with no effect on HR, however did lower SBP temporarily to high 80's. Palpable pulses in all extremities. Right radial arterial line dampened, highly positional; d/c'd. Right triple lumen CVL in place, CVP transducing sharply, generally . Pboot on left leg, on lovenox sc. Stable anemia hct 24.7.\\n\\nGI: Abdomen softly distended vs obese; complaining of constipation, given dulcolax PR and colace; had one large soft brown BM at 4am. Diminished appetite.\\n\\nGU: Foley to gravity draining clear yellow urine in adequate amounts.\\n\\nEndo: RISS with no coverage required.\\n\\nLytes: No repletions indicated.\\n\\nSkin: Intact, surgical incisions clean and dry with staples OTA.\\n\\nID: Tmax 101.5->100.0 **WBC 26.1 from 18.4**\\n\\nSocial: Numerous family visitors in early evening.\\n\\nPlan:\\nMaintain safety\\nPain management\\nPulmonary toileting\\nAdvance diet as tolerated\\nNotify team of acute changes\\nAwaiting surgery with orthopedics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368058,\n \"text\": \"NPN: Review of Systems\\nNeuro: Sedated w/ propofol and pain managed w/ fentanyl. Doses increased over the coarse of the day. Pt had nodded \\\"yes\\\" when asked if he was in pain. Propofol turned off to assess neuro status-> Pt followed commands; wiggled toes, stuck out tongue and squeezed hands. Strong productive cough.\\n\\nResp: Secretions increased throughout the day. Copious amts of thick yellow secretions. Sao2 dropped to low 90s, HR up to 140s-> relieved after suctioning and PS increased to 10. Gentamicin started for gram (-) rods in sputum. Oral sore present on left corner of mouth. Tube moved and re\\n\\nCV: Temp up to 102.3 orally. Blood and urine cultures sent. Sputum pending. Tylenol administered via OGT. Sinus tach w/ PVCs. Blood pressure has been stable this shift. Please see flowsheet for further data and assessment. Right DP pulse dopplerable and Right PT, DP and PT palpable. to touch. PA line rewired to triple lumen. Tip cultured. X-ray confirmed placement. A-line changed d/t clotting of previous one.\\n\\nGI: D51/2 NS w/ 20meq KCl infusing at 80cc/hr. Promote w/ fiber to be started at 20cchr. Green fluid via OGT.\\n\\nEndo: Blood sugar=132-> no insulin coverage per sliding scale.\\n\\nHeme: HCT=24.7 from 25.\\n\\nID: Febrile as noted above and cultures pending. Continue w/ antibiotics.\\n\\nSkin: No presssure wounds present. Abdominal and hip dressing dry and intact. RLE dressings changed d/t serous drainage.\\n\\nSocial: Mother in by bedside. Provided consent for Dr. surgery which is anticipated to occur on monday.\\n\\nA: Febrile.? lungs source. Hemodynamics stable.\\n\\nP: Or tomorrow for leg to be fixed and monday for lower back. Start TF at 20cc/hr and make NPO after MN. Suction as needed. Sedate/maintain comfort. F/U w/ culture results. gentamicin trough level prior to 2nd dose. HCT to be drawn at 6pm.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368059,\n \"text\": \"Respiratory Care: Pt remains on current vent settings, see carevue for details. Sxing tan/rusty secretions. No vent changes made this shift.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368060,\n \"text\": \"T/SICU NPN: 1500-2300\\nS/O: System Review:\\n\\nNeuro: sedated on propofol and fentanyl drips overall more sedated\\nno eye opening to stimuli pupils pinpoint no gag no cough\\nwithdrawing all extremities to nailbed pressure fentanyl decreased to 100mcg/hr(from 140mcg/hr) and propofol weaned to 35mcg/kg/min(from 50mcg/kg/min) now, opening eyes to voice/stimuli eyes deviated upwards pupils 2mm with brisk reaction continues to withdrawl to nailbed pressure not following commands tends to stiffen extremities/body with stimulation gag/cough minimal c-collar remains on\\n\\nCVS: HR 120's>>>100's NST with multi-focal PVC's SBP 100's\\nSBP up with stimulation as high as 170's a-line wired over by\\nDr. CVP 8-11 LE: + palpable pedal pulses skin warm to touch with brisk capillary refill\\n\\nRespiratory: remains orally intubated and ventilated on PSV PS=10\\nPeep=10 Fio2 50% RR 8-12 TV's 900-1200's Sao2 > 96%\\nABG: 140-46-7.40-30+3 lungs clear, decreased at bases suctioned\\nfor scant to small amounts of thick yellow-tan secretions\\n\\nRenal: foley patent and draining clear yellow urine 80-250cc/hr\\nK+ 3.7 repleted with 20meq kcl D51/2NS w/20meq KCL at 80cc/hr\\nMg++ 2.0\\n\\nGI: abdomen obese no bowel sounds no bm started on fs promote/fiber at 20cc/hr via ogt last residual 40cc(2hrs after starting tf's) on pepcid\\n\\nEndrocrine: fs q6hrs fingersticks 112>>104 no insulin required\\n\\nHeme: HCT q8hr last HCT 25.7 started on lovenox heparin d/c\\non pnuemoboots\\n\\nID: tmax 102.4 sent second set of blood cultures for re-wired a-line\\ncontinues on kefzol and gentamycin gnr's in sputum\\n\\nSkin: right leg>>ex-fix on pin sites draining serous fluid pin care\\ndone right shin laceration>>>sutured red with small amt of bloody drainage right hip and low pelvic dsg's dry/intact back and buttocks intact with no redness\\n\\nPyschosocial: mother called and updated on clinical situation and questions answered\\n\\nOR tomorrow: anesthesia/surgical consents obtained NPO after mid-night\\n\\nA: febrile awaiting culture results more sedated weaning sedatives\\n\\nP: continue to monitor above parameters check culture results\\nto OR tomorrow for further orthopedic surgeries\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368061,\n \"text\": \"TSICU NSG PROGRESS NOTE 11P-7A/ S/P MVA\\n\\nS- INTUBATED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n PT REMAINS HEMODYNAMICALLY STABLE- HR- 100-114 ST, MINIMAL VEA. AM K- 3.9- TO RECEIVED 20 KCL PER PROTOCOL. BP- 95/50-107/60.\\nNO ISSUES CURRENTLY.\\n\\n PT REMAINS ON PRESSURE SUPPORT- 10/10 PEEP 50%- TIDAL VOLUMES 1 L - 1.3 LITERS, RESP RATE- . ADEQUATE VENTILATION/OXYGENATION-\\nAM ABG- 7.39-49-148. SX FOR THICK WHITISH SPUTUM- SMALL AMT.\\nLUNG SOUNDS CL- DIM AT BASES.\\n\\nID- AFEBRILE THIS SHIFT- 100.6-99.9 PO- REMAINS ON KEFZOL/GENT FOR (+) SPUTUM CULTURE AND S/P OR. TYLENOL X 1. WC- 11.2.\\n\\nGU- GOOD UO- 60-200CC/HOUR- (+) 1575 OVERALL I/O.\\nCLEAR YELLOW URINE. REMAINS ON IVF AT 80CC/HOUR.\\n\\nGI- NPO AFTER MN- FOR OR TO FOLLOW CASE TODAY.\\nHYPO TO ABSENT ABD SOUNDS-- BLOOD SUGARS Q 6 HOUR- NO INSULIN THIS SHIFT.\\n\\nLINES- NEW ALINE OVER WIRE FROM 6/1 L RADIAL, TLC LEFT IJ AS WELL.\\n\\nORTHO- S/P EXTERNAL FIXATION OF TIB FIB FX- PIN SITES CLEAN, MINIMAL REDNESS. ANTERIOR LOWER LEG SUTURED SITE CLEAN- APPLIED XEROFORM/DSD\\n. TO GO TO OR TODAY FOR INTERNAL FIXATION OF TIB/FIB AND REMOVAL OF EXTERNAL DEVICE.\\nPT HCT DOWN TO 23.3 FROM 24-25- HO AWARE- NO TRANSFUSION CURRENTLY.\\nLOWER EXTREMITY PULSES (+) PALP OR DOPPLERABLE BILATERALLY.\\n\\n\\nMS/ PT SLIGHTLY LIGHTER ON LESS SEDATION AS COMPARED WITH PREVIOUS NEURO ASSESSMENT BY REPORT, PREVIOUS SHIFT.- REQUIRING SOME BOLUS WITH TURNING/PIN CARE/PAINFUL INTERVENTIONS. , .\\nREMAINS ON PROPOFOL GTT AND FENT GTT- NO CHANGE IN DOSES- SEE FLOWSHEET.\\n\\nA/ PT S/P FX OF MVA C/B FX TIB/FIB CURRENTLY REMAINS HEMODYNAMICALLY STABLE , ON VENTILATORY SUPPORT.\\nNPO FOR AM OR PLANNED FOR INTERNAL FIXATION OF FX.\\n\\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS ESP IN SETTING OF UNDERLYING CARDIOMYOPATHY. HOLDING OFF TRANSFUSION CURRENTLY. CONSIDER GENTLE DIURESIS AS HEMODYNAMICS ALLOW IF I/O TRENDS TOO (+) OVERALL.\\nPULM TOILET, SX/MAINTAIN AIRWAY AS NECESSARY.\\nCONTINUE ANTIBX AS ORDERED.\\nRESUME NUTRITION POST OP ONCE MEDICALLY APPROPRIATE.\\nSKIN CARE/PIN CARE/COLLAR CARE PER T SICU STANDARD OF CARE.\\nKEEP PT COMFORTABLE, FREE OF PAIN. FENT/PROPOFOL GTT CONTINUE.\\nKEEP FAMILY AWARE OF CURRENT PROGRESS AND PLAN OF CARE.\\nOR THIS MORNING/AFTERNOON AS PLANNED.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368062,\n \"text\": \"Respiratory Care:\\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Latest abg results determined a compensated respiraotry acidemia with excellent oxygenation on the current settings.\\n\\nNo RSBI measured due to the level of PEEP currently required and the fact that the patient is scheduled for the OR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368063,\n \"text\": \"07-1400\\n\\nSee carevue for objective data.\\n\\nRemains sedated on proprofol/fentanyl gtt. Opens eyes intermittingly\\nto name being called.\\nNo vent changes. Maintaining O2 sats. Minimal suctioning required.\\nNSR/ST with frequent PVC's.\\nNPO for OR this afternoon. SSRI per FSBS. Maintenance fluid continues.\\nPin care done to lower extremities-large amount of serous fluid from pin sites. Both extremities swollen but with palpable pulses.\\nGrimacing when turned with hypertension/tachycardia-fentanyl gtt increased to 150 mcg/kg/min with good effect.\\nO/C to OR.\\n\\nContinue current POC.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368083,\n \"text\": \"NPN, 1900-0700\\nneuro: lightly sedated on propofol following eve of resp distres secretions w/ tachypnea, freq MFVEA. Responds to verbal when lightened. , . Follows commands inconsisitently. Med w/ ativan and morphine q4-5 hrs.\\n\\nCV: ST, freq MFVEA, mult brief salvos vtach, freq bigeminy. 12 lead EKG unchanged. HR 90's-140; CVP 9-14. SBP 90's-140's. Pulses palpable throughout.\\n\\nPulm: orally intubated on CMV 650 x 50% x 14 x 5. RSBI > 200. Copious thick tan secretions w/ sang clots. BS rhonchorous anteriorly, bronchial posteriorly w/ I/E wheezes. No vent changes. ABG's cont resp alkalosis, adequate oxygenation. Pt was labored, tachypneic, fatiguing until sedation restarted.\\n\\nGI: abd softly distended; BS hypo. +flatus, no stool despite dulcolax pr, MOM, colace. w/ fiber at goal, 85 cc/hr w/ min residuals.\\n\\nGU: F/C urine amber-->>clear yellow, adequate OP. RF labs cont WNL.\\n\\nskeletal: no pressure areas. Groins moist, pink, intact-->>miconazole powder. Hip wounds C/D. Right leg dsg D/I; splint maintained in place. Right a-line, RSC T/L clean. C-collar remains in place.\\n\\nEndo: RISS, no coverage required.\\n\\nID: Tmax 103.6, rectal, down to 100.2 after ice compresses, tylenol, ect. Started on vanco and ceftaz. WBC 15\\n\\nSocial: mult family members have vs and called.\\n\\nA: worsening resp failure..?ARDS bil pneumonia. ? septic picture evolving. Sluggish GI function.\\n\\nP: ?bronch. ? maintain sedation until weanable. ?start reglan.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368084,\n \"text\": \"T/SICU NURSING PROGRESS NOTE 0700-1900\\nNeuro--remains sedated on propofol 30 mcg/kg/min. Medicated with 6-10 mg iv MSO4 q2hr for leg pain. Facial grimace with increase in HR,RR with any movement of BLE. Pt nods head inconsistently to simple questions. Squeezes hands and wiggles toes to command. Pupils 4-5mm and reactive. Also received Ativan 2mg x1.\\n\\nCardiac--HR SR/ST with frequent multifocal PVC's. SBP 120-150/80's. CVP-.\\n\\nResp--No vent changes done. Bilateral breath sounds range from clear to bronchial->rhoncherous. Sx q2 hrs for moderate amts of tan thick sputum. No ABG's drawn as pt's VS have not changed and SaO2 is >98% on 50% FiO2. CPT given x2. No bronch done today.\\n\\nGI--Tolerating tube feeds at goal. HO disimpacted pt today and pt has stooled x2 in small amts. Hypoactive BS. Min. tube feed residuals.\\n\\nGU--foley cath patent draining >80 cc hr of yellow urine.\\n\\nENDO--SSRI coverage given and needed x2. Last BS 120. No lytes drawn at this time.\\n\\nSKIN--R leg brace removed and dressing changed by ortho. Sutures are intact. There is a couple of areas of maceration around bone puncture site. DSD applied and brace placed back on. Buttocks and back without breakdown. Turned q2 hrs. Oral membranes are dry. R leg noted this am to be more externally rotated than yesterday. HO and ortho notified and leg films done downstairs. COllar care given. Neck intact. Lower abd incision with staples intact and dry.\\n\\nID--T max 100.5. Pt received tylenol at 0800, 1200 and has not received since. Temp at 1700 100.1. Remains on Vanco and Ceftazadine.\\n\\nPAIN--Medicated with 6-10 mg IV q2hrs. Pt grimaces with any touch to RLE. He nods head yes when asked if he is in pain. At 1700, pt was given 10mg SC mso4 for good relief. Also given 2mg iv Ativan.\\n\\n, girlfriend (who was in accident with pt) and sister-in-law in to visit. They have been updated regarding pt's condition. They are happy about fever coming down. Asking questions regarding how long tube will be in and will they put a trach in.\\n father and brother have not been in to visit.\\n\\nA--No temp spike today. Increase need for pain med. DOwn for leg films for increased external rotation.\\n\\nP--Con't to monitor, con't pulm toilet. Check am labs. COn't to medicate and assess relief. Offer support to pt and family. Attempt to wean vent tomorrow if tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368085,\n \"text\": \"Resp CAre\\n\\nPt remains intubated and on full vent support. MV is being maintained in the 17-20L range. Spo2 100%. BS with occasional rhonchi and wheezing and suctioning thick tan sputum\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368086,\n \"text\": \"RESP CARE: Pt remains intubated/on vent per carevue. No changes this shift. Lungs dim bibasilar. Sxd thick tan sputum. RSBI-81. Pt remains febrile.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368087,\n \"text\": \"ASSESSMENT AS NOTED\\n\\nRES: NO CHANGES IN SETTINGS, ON 5PEEP, MAINTAINS PO2>120, SATS 100, LS CLEAR/DIM, SUCTIONED SM AMNT THICK ,\\n\\nCV: IN S/TACH WITH MULTIPLE PVCS AT TIMES, SEDATED WITH SBP >100, WHEN AWAKE UP TO 140S, + WEAK PULSES, +PERIPHERAL EDEMA\\n\\nNEURO: ON PROPOFOL AND FENTANYL GTT, FOLLOW COMMANDS, MOVES BOTH ARMS, FENTANYL UP TO 150 TO CONTROL PAIN, R/LEG EXTERNALY ROTATED 90 DEG ANGLE, CER COLLAR IS ON\\n\\nID: LOW GRADE TEMP 99-101.5, NO TYLENOL WAS GIVEN , FAN IS ON, CONT ON VANCO, CEFTAZIDIME\\n\\nGI: TOL TF AT 85/H W/O RESIDUALS, NO BM YET, +BS,\\n\\nGU: BRISK U/O,\\n\\nSKIN: R/LEG SPLINT AND DSD INTACT, BACK IS INTACT, SWEATING A LOT\\n\\nSOCIAL: FAMILY CALLED TWICE DURING THE NIGHT\\n\\nPLAN: CLEARFY IVF ORDER, MONITOR RES, PAIN CONTROL,ID, WEAN OFF WENT IF POSSIBLE, ?DATE OF SURGERY FOR R/HIP REDUCTION IN FUTURE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368088,\n \"text\": \"RESPIRATORY CARE: PT. EXTUBATED TO A 50 AEROSOL MASK\\nAFTER HAVING AN RSBI OF BETWEEN 40-50 AND A GOOD ABG\\nON A PS 5/5. C + R THICK BLOOD-TINGED SPUTUM. SPO2\\n97-100 %. DOING WELL. WILL ENCOURAGE C+DBING AND\\nWILL MONITOR RESPIRATORY STATUS CLOSELY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368076,\n \"text\": \"Resp Care: Pt remains intubated via #8 ETT rotated and secured 24cm at lip. BS coarse bilat. Sx'd for mod amts thick yellow sputum. MDI's given as ordered. ABG WNL. No vent changes made this shift. Plan: awaiting OR when afebrile. Cont vent support. Please see carevue for further vent inquiries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368077,\n \"text\": \"Nursing Progress Note:\\nPlease refer to CareVue for specifics.\\n\\nEVENTS TODAY:\\nFebrile to 102.7. Repeat Pan cultured.\\nOR with Dr cancelled.\\n\\nRESP:\\nRemains orally intubated tolerating minimal settings. Has spontaneous cough and copious thick tan secretions. Requires aggressive pulmonary tolieting. Also has clear oral secretions and has required frequent oral care. Chest clear to coarse. CXR attended.\\n\\nNEURO:\\nAlert, looking around room, regarding and tracking examiner. Obeys commands intermittantly but uncooperative with some interventions such as turning. Denying pain but given morphine prn for grimacing and turning. Does not move legs until he is resisting our attempt to reposition him. Will squeeze and release and repeat, and is spontaneously localizing to ETT when not restrained.\\n\\nHEMODYNAMICS:\\nST most of day. Has multifocal PVCs. Maintaining BP within range of normal most of day but has hypertension with interventions, promptly returning to baseline when left alone. Grossly diaphoretic most of day, and hot on palpation, now feet are cold and moist. A-line is intermittantly positional.\\n\\nENDOCRINE:\\nBlood sugars in 120s. No coverage per sliding scale.\\n\\nFLUIDS/LYTES:\\nMaintenance fluids at 50mls /hr. Magnesium for repletion.\\n\\nGI:\\nAbd obese. Bowel sounds present. Tube feeds recommenced as not for OR today. No BM today.\\n\\nID:\\nPt has spiked to 103.7 at report time. Pt pan cultured earlier this afternoon. Antibiotics as charted. At this time pt is spiking and also agitated and tachypneic, so was given morphine and ativan to help settle.\\n\\nRENAL:\\nSatisfactory urine output. Urine is amber at times. Cr within range of normal.\\n\\nSKIN:\\nDiaphoretic and skin marks easily but it is intact. Dr took Rt leg dressing down this am. There are several wounds, some surgical and one mid anterior lower leg which was the site of the open fracture per Dr . The wounds are clean with minimal ooze. There are puncture sites to legs which are oozing a small amount of hemoserous ooze. Dr want these free to drain.\\n\\nSOCIAL:\\nMother visiting, reminded of ICU visitation policy. Questions addressed.\\n\\nPLAN:\\nWatch fever.\\nFOllow cultures.\\nPulmonary toilet.\\nAdd bowel regime.\\nPossible OR at later date.\\nTitrate tube feeds to goal.\\nPossible change to assist control if continues to labor while febrile.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368078,\n \"text\": \"RESP CARE: Pt remains intubateed/on vent with settings per carevue flowsheet. No changes made this shift.Pt had been placed back on rate during the day due to tachypnea,T max 103.9. ABG -resp alkalosis with normal oxygenation.Lungs dim LLL, coarse on R consistent with new opacity on R per CXR.Sxd mod amts thick tan sputum. RSBI-98.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368079,\n \"text\": \"NPN, 1900-0700\\nneuro: arouses to voice w/ open eyes; follows commands inconsisitently. Moves UE's w/ near normal strength, moves LLE on bed. Min spontaneous movement noted RLE, withdraws from pain. Med w/ ativan + morphine q 4-5 hrs w/ adeqaute sedation/analgesia.\\n\\nCV: ST, MFVEA, 100-140's. MAP 80-100's. CVP 10-14. Pulses palpable throughout. Pboots in place.\\n\\nPulm: orally intubated on CMV 650 x 50% x 14 x 5 w/ resp. alkalosis, adequate oxygenation. RR 20's at rest, 30-40's w/ agitation. Strong cough, weak gag. Copious creamy tan secretions. BS rhonchorous right anterior and mid posterior fields, diminished bibasilar. Left fields CTA.\\n\\nGI: abd softly distended; BS hypoactive. Promote w/ fiber via oral sump advanced to goal, 85cc; min residuals. +flatus, no BM.\\n\\nGU: F/C urine clear amber; OP 80+/hr. Renal function labs cont WNL.\\n\\nskeletal: No pressure areas; skin grossly intact except for surgical sites. Right hip stapled wounds C/D. Right leg remains in immobilizer; sang ooze lateral lower leg. CSM intact RLE. A-line pink, positional; LSC T/L pink, nl wave. C-collar in place.\\n\\nEndo: RISS, no coverage required.\\n\\nID: WBC up to 12; Tmax 103.9, rectally. Cooling blanket, tylenol, sponge baths-->>T this am 101 po. Cont on clindamycin, cefazolin, gentamycin; started on levofloxacin.\\n\\nSocial: mother called x 3 during noc, very anxious.\\n\\nA: worsening respiratory failure pneumonia (gm+/- rods & gr+ cocci from ) Stable HD, GI, renal, neuro functions.\\n\\nP: ? adequste coverage for pulm cxs. New pulm cx pending. ? re-line a-line and central lines in setting of fever and line sites. Agressive bronchial hygeine...? rotating bed. Emotional support for mother.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368080,\n \"text\": \"T/SICU NURSING PROGRESS NOTE 0700-1900\\nCARDIAC--MULTIFOCAL PVC'S BUT NO RUNS. HR ST >100'S. SBP 120-140'S. HCT 23.8 , UNCHANGED FROM THIS AM.\\n\\nRESP--SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. ETT ROTATED. BREATH SOUNDS CLEAR IN UPPER LOBES BILATERALLY. CRACKLES IN R LOWER BASE THIS AM NOW JUST DIMINISHED. LLL IS COARSE. SAO2>97%. PT RESISTS WITH ANY TYPE OF CPT AND SUCTIONING.\\n\\nGI--TUBE FEEDS AT GOAL. RESIDUALS 70-80 CC. NO STOOL. ABD OBESE AND FIRM BUT PT DOES NOT GRIMACE WITH BELLY IS PALPATED. NO STOOL.\\n\\nGU--FOLEY CATH PATENT DRAINING >100 CC HR OF YELLOW URINE.\\n\\nENDO--UNREMARKABLE. NO SSRI COVERAGE.\\n\\nSKIN--L CORNER OF MOUTH WITH BREAKDOWN. ETT ROTATED. BUTTOCKS WITHOUT BREAKDOWN. LOWER ABD INCISION WITH STAPLES INTACT. RLE HAS SUTURES AND OLD PIN HOLE SITES WHICH HAVE DRAINED SEROUS DRAINAGE. AREA ON ANTERIOR TIB SITE THAT APPEARS MACERATED. DSD APPLIED WITH KLING LEG PLACED BACK IN KNEE IMMOBILIZER. R HIP WITH DSD. SCROTUM IS EDEMATOUS. ORAL MEMBRANES ARE DRY.COLLAR CARE GIVEN. NECK INTACT.\\n\\nID--FEBRILE TO 102.2 ABX CHANGED TO CEFTAZADINE AND VANCO WHICH HE HAS RECEIVED 1ST DOSE OF EACH TODAY. DOWN FOR CT OF PELVIS, CHEST AND ABD TO SEE IF THERE IS ANYTHING UNUSUAL. PT HAS CONSOLIDATIONS IN BLL.\\n\\nPAIN--NODS HEAD WHEN ASKED IF HE IS IN PAIN. MEDICATED WITH MSO4 AND ATIVAN SEVERAL TIMES THROUGHOUT THE DAY.\\n\\nCOPING--MOTHER IN TO VISIT ALL DAY. SHE HAS BEEN UPDATED ABOUT PLAN OF CARE. FATHER BE IN LATER TODAY. PER PT'S MOM, GIRLFRIEND , WAS RELEASED FROM THE HOSPITAL OVER THE WEEKEND.\\n\\nNEURO--OCCASIONALLY OPENS EYES TO NAME. INCONSISTENTLY FOLLOWS SIMPLE COMMANDS. MOVES ALL EXTR. ON BED AND BUE WILL LIFT AND HOLD AS WILL LLE. PEARL AT 2-3 MM.\\n\\nA--REMAINS WITH INCREASE IN TEMP AND ECTOPY.\\n\\nP--CON'T PULM TOILET. CHECK LYTES . CON'T ABX. OFFER SUPPORT TO PT AND FAMILY. NEXT DATE FOR OR IF ALL IS OK IS FRIDAY. IF PT HAS EMERGENCY, IT BE PERFORMED SOONER BUT PLAN IS FOR FRIDAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368081,\n \"text\": \"Resp Care\\n\\nPt remains intubated on A/C. Pt transported to CT w/o incident. PT suctioned for thick tan secretions and plugs. No other changes noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368082,\n \"text\": \"RESP CARE: Pt remains intubated/on vent settings per carevue. Pt tachypneic early in shift with RR 30s/vent asynchrony/increased cardiac ectopy.Pt started on propofol with good effect noted. More reg resp pattern, RR 20s. Lungs coarse bilat Sxd copious amts tenacious tan sputum. ABGs consistent with resp alkolosis. RSBI>200. Pt remains febrile.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368056,\n \"text\": \"nursing progress note\\n\\nneuro: pt remains intubated, sedated. propofol weaned slightly w/ change to cpap, pt at times resistent to any stimulus, opening eyes spont. perrla, 2mm. inconsist. follows commands. fentanyl boluses given prn for turns w/ good effect.\\n\\nresp: cpap+ps tol well, o2 sats 96-100%. ls coarse throughout. sx mod amts thick yellow secretions. cough, gag intact. abg acceptable, slightly hypercarbic, compensated.\\n\\ncv: bp labile w/ stimulus, settles quickly at rest. sinus tachy, much ventric. ectope noted (baseline). filling pressures stable, cvp remains mid teens. unable to wedge pa cath, icu team aware. co elevated, svo2 mid 80s-low 90s. note persistent low grade fever. lytes repleted prn.\\n\\ngi: belly large, soft, bs present. og to lws, mod amts bilious output.\\n\\ngu: foley patent clear yellow urine, qs.\\n\\nendo: bg's stable.\\n\\nid: tmax 101.5, less than 24h post op, icu team aware. tylenol given for comfort. wbc stable at 10.\\n\\nskin: ex fix pin sites clean, serosang drainage. open tibia lac sutured, mod amt serosang drainage as well. pelvic repair incisions all w/ post op dsgs, dry.\\n\\nsocial: family in last evening, supportive. called overnight for updates.\\n\\na: s/p pelvic repair, I+D right tibia, stable intra/post op course. hemodynamics stable, filling pressures unchanged. low grade febrile. hct holding at 25.\\n\\np: cont aggressive pulm toilet, d/c pa catheter, change to triple lumen access. cont current pain management, sedation while intub. await OR trip for ORIF of right tib/fib, sacral pinning. will need MRI in near future to f/u w/ T4 injury.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368057,\n \"text\": \"Respiratory Care:\\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results revealed a compensated respiratory acidemia with excellent oxygenation on the current settings.\\n\\nRSBI = 16.7 on 0-PEEP and ATC off.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368072,\n \"text\": \"T-SICU NURSING PROGRESS NOTE\\nNeuro: Opens eyes to name, continues with eyes rolled back slightly but turns toward person calling his name. Intermittently following commands, MAEs weakly. Pupils equal and reactive. Med with MS04 Q4H for pain.\\n\\nCV: HR 110s, ST up to 130s with pain and fevers, occas to freq PVCs. BP running 120s-140s systolic. Between 4-5pm pt more tachycardic and hypertensive, lighter, med with Ms04 for pain with effect. BP now running 130s systolic. Skin warm to touch, diaphoretic after receiving tylenol and defervescing. (+)palpable distal pulses bilat.\\n\\nResp: Remains on PSV 5/5, 40% Fi02. Breath sounds coarse on right, clear to diminished on the left. Strong cough, productive of moderate amt of thick tan secretions. Also with moderate amt of tan oral secretions.\\n\\nGI: Abdomen soft, (+)bowel sounds, no stool, no flatus. Tolerating tube feeds, advanced to 70cc/hr at 1600, residuals < 20cc.\\n\\nGU: Adequate urine output, see I & O for details\\n\\nEndo: Blood sugar 140-150 this shift, covered with regular insulin per sliding scale\\n\\nID: Remains febrile throughout the day, t. max 102.2. Cultures sent this am pending. Continues on kefzol, clinda and gentamycin\\n\\n\\nSkin: RLE dressing changed by ortho, hemovac d/c'd. Right knee and RLL incis with sutures, small to mod amt of serosang drainage, no redness. Right hip with small to mod amt of serous drainage. Suprapubic incis OTA with staples, no redness or drainage. Back/buttocks and heels intact.\\n\\nSocial: Pt's family in to visit today, updated on patient's condition, all questions answered.\\n\\nA: 41 yo male s/p MCA with multiple ortho injuries, persistent fevers\\n\\nP: Continue to monitor neuro status, medicate for pain prn, advance tube feeds to goal of 85cc/hr. Follow culture results. ? Hold TF at MN for OR tomorrow. Provide support to patient and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368073,\n \"text\": \"Resp Care: Pt remains intubated via #8 ETT retaped and secured at 24cm at lip. BS coarse bilat. Sx'd for small amt thick tan sputum. ABG WNL. No vent changes made this shift. Plan: cont vent support. Please see carevue for further vent inquiries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368074,\n \"text\": \"Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions.Started on atrovent mdi's.Temp 101.5. Agitated when awake.Given some morphine.HR-ST with PVC'S.RSBI done ON 0 PEEP/5 IPS 43.Will cont to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368052,\n \"text\": \"nursing progress note\\n\\nneuro: pt remains intubated, sedated. lightened last eve for exam. mae, strong to bue. following commands, perrla, 2-3mm bilat. nods to pain when awake, given bolus fentanyl prn for turns, sx, etc w/ good effect.\\n\\nresp: ac mode continued, no changes made overnight. pt overbreathing vent when stimulated, volumes becoming very high during these times. o2 sats stable, abg wnl. ls clear, slightly dimin to bases. cough, gag intact. sx sm amts thick tan secretions.\\n\\ncv: cont w/ much ventric. ectope, rate 80s-100. bp stable, map consist. >65. filling pressures stable, co/ci . cvp 10-14. extrem warm, edematous. ppp bilat. lytes repleted prn. given 2u prbc overnight for hct 23.4, little improvement noted post transfusion, 25. repeat hct pending.\\n\\ngi: ogt repositioned last eve, draining mod amt bilious output. belly large, soft. bs present. remains npo.\\n\\ngu: u/o dropped last night, mod sized clot removed w/ irrigation. urimeter changed, draining clear yellow urine qs since.\\n\\nendo: bg's stable.\\n\\nid: low grade temps persist, tmax 100.8. ancef dosing continued.\\n\\nskin: open fx site to right tibia clean, large amt serosang drainage noted. pin sites clean, sm amts sanguinous drainage. ecchymotic areas to inner thigh, right hip.\\n\\nsocial: family in last eve, updates provided, all ques answered. reinforced scheduled visiting hours.\\n\\na: hemodynamics stable, comfortable w/ fentanyl, sedation. neuro exam intact, pulses remain intact to ble, extrem remain warm.\\n\\np: cont. to monitor filling pressures, vs, hct. replete lytes as needed, await OR today for pelvic, L5 repairs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368053,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning abg results determined a compensated respiratory acidemia with very good oxygenation on the current settings.\\n\\nNo RSBI measured due to scheduled OR procedure.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368054,\n \"text\": \"nursing progress note\\nevents- to or today from 9-3pm. screws placed in r femur and r femoral head, fib not fixed, ? friday.will need eventual hip replacement,\\ntibia cleaned/ debrided\\n\\nneuro- pt remains sedated on propofol and fentanyl, arouses to voice, family at bedside. pre-op nodding ,obeying commands, postop very sleepy, mae.\\n cv- sr-st, freq pvc's. bp stable by aline, pa pressures up w/stimuli\\nswan now at 50 cm (was at 56cm preop), waveform adequate.svo2 re-cal, running in 70's.co had 1u pc's in or, hct now 27. boots on pulses +, good cap refill\\n\\nresp- placed on cpap 5/5 at 1830, tol well, mv . ls sl. coarse postop,pt to stay tubed- anticipating or on friday\\n\\ngi- sump to lws, bilious secretions. no bs heard\\n\\ngu- foley qs, clear yellow, no further clots\\n\\nid- remp 99, no issues\\n\\nskin- external fixation remains in place, pin sites clean, multiple surgical incisions with dressings intact. Sang draiange from tib/fib wound.\\n\\nsocial- mother, daughter-in-law at bedside, updated by Dr and RN\\n\\nplan-To OR on friday for ORIF fibia, most likily remain intubated til then, cont on ps as tolerated. Wean sedation as tolerated. Provide ongoing support to family. D/c swan in am and rewire to TLC. Start TF in am.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368055,\n \"text\": \"Respiratory Care: Pt continues on ventilatory support. Initially on AC when back from OR today. Changed to PS 5/5 60% this eve, and tolerating well at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368075,\n \"text\": \"nursing progress note\\nNeuro- more awake, looks to speaker, obeys commands inconsistently.\\nHas 4+ strength to resist turning! mso4 4mg w/effect for discomfort.\\n\\nCV- ST,occ-freq pvc's, aline bp 130's, up to 170's w/pain.hct 20's, color good, all pulses +, boots in place. tlc,aline in place, sites wnl.\\n\\nResp- remains on cpap, , 50%, oxygenation good, sao2 99-100.sxn copious thick yellow/tan secretions from mouth and ett.? extubation after or today.\\n\\nGI- tf off @ 0500- on call to or. bs+, no flatus or stool. minimal residuals\\n\\nGU- foley indwelling/patent. u/o clr yellow, qs\\n\\nID- cont w/ temp 101-102, pt has not been afebrile in>24hrs. pan cx , results pending, + sinusitis by head ct. on ancef, genta,clinda\\n\\nPlan- on call to or today for fusion of back by Dr. . ? extubation post op, pain cosult for chronic pain meds.? ortho to change dressing to rle. cont to w/u temps, follow cx\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368069,\n \"text\": \"7a-7p\\nneuro: pt sedated on propofol & fentanyl gtts, pt with eyes rolled back this am, ho aware, propofol off, pt still with eyes rolled back & not following commands, withdrawing to pain, PERL, moving all xtremites except R leg, fentanyl gtt decreased throughout day & down to only 25 mcg/hr by this afternoon, pt still not responding to commands & eyes continued to roll back so pt for head ct scan @ 1730, result negative\\n\\ncv: hr st(106-118), occasional pvc's, sbp stable, po lopressor, zestril & carvedilol started today\\n\\nresp: on 50% cpap 5/5 ps, tol well, lg amt tan thick secretions, bs+ all lobes & course, clears with sux, RSBI(25) & abg good but pt not extubated due to mental status & lg amt secretions, sat 99-100, rr 12-18\\n\\ngi: tf on hold today due to ? of extubation, tf resumed this pm after ct scan(fs promote @ 20 cc/hr, do not advance) no stool, iv pepcid\\n\\ngu: foley patent, clear yellow urine, good uo\\n\\nother: family in & updated on pt's condition, R leg with knee immobilizer @ all times, sm amt serou drainaged from R leg, bilat distal pulses by doppler, sm amt serous drainage from R hip suture line, ivf continue @ 80cc/hr, temp spike to 101.7 @ 1600, tylenol given, pt needs to be pan cultured, K+ & MG+ repleated\\n\\nplan: continue to monitor mental status, plan to extubate tomorrow when pt more awake, pan culture\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368070,\n \"text\": \"Resp Care\\nPt. remains intubated on minimal vent. support . Vt's 600-700cc/ MV 8-12lpm.\\nBs: CEB, with minimal secreations.\\nabgs:hyperoxygenated with slight metabolic alkalosis.\\nPlan: rsbi 35.4 however MS may continue to prevent pt. from being extubated/protecting airway.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1368071,\n \"text\": \"nursing progress note\\nNeuro- off propofol and fentanyl, sl. more responsive now, nods yes to pain, obey commands slowly. mso4 w/effect. good strength in upper extremities, resists movement .\\n\\nCV- SR-ST w/pain, BP up to 170's w/pain, 120-140's @rest. cardiac meds restarted yest. ^ ectopy towards end of shift, mgso4 2 gm for mg=1.9\\npulses positive, palpable despite edema.boots in place.TLC in place, site unremarkable. Aline dampened, better after dsg change- gd waveform. ivf . to 50cc/hr\\n\\n\\nResp- remains on cpap 50%, 5+5. sao2>95%. rr20's, ls diminished, esp @ bases. sxn thick tan/ sputum, also from mouth- ct head shows severe sinusitis.ett not moved d/t ulcer @l side of mouth.\\n\\nGI- tf to increase to goal of 85- currently at 50cc/hr, tol well, min residuals.no stool.\\nGU- foley indwelling/patent, u/o qs\\nSkin- intact, r hip sutures intact, dg sm amt serous fluid. suprapubic dsg d+i, rle immobilizer in place, dg serous dge from dsg, hemovac in place\\n\\nID- temp to 102, pan cx. currently on genta and ancef\\nplan- prn pain meds to optimize wakefulness, investigate source of temps ? sinuses.optimize nutritional status, ivf as able\\n? extubate..\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192063,\n \"text\": \"Sinus tachycardia with frequent ventricular premature beats. Left atrial\\nabnormality. Intraventricular conduction defect. Compared to the previous\\ntracing of the ventricular ectopic activity has increased. Otherwise, no\\ndiagnostic change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192064,\n \"text\": \"Sinus rhythm with ventricular premature complexes\\nLeft atrial abnormality\\nEarly precordial QRS transition - is nonspecific\\nModest nonspecific low amplitude lateral T wave changes\\nSince previous tracing of , lateral T wave amplitude lower\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192065,\n \"text\": \"Sinus tachycardia\\nVentricular premature complex\\nLeft atrial abnormality\\nModest low amplitude lateral T waves - are nonspecific and may be within normal\\nlimits\\nSince previous tracing of , ST-T wave changes decreased\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192066,\n \"text\": \"Sinus tachycardia with frequent ventricular premature beats. Modest\\nnon-specific inferolateral ST-T wave changes. Compared to the previous tracing\\nof rate is faster but there are no other significant diagnostic\\nchanges.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-20 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 914847,\n \"text\": \" 10:15 AM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\\n Reason: evaluate R sided opacity on prior CXR as recommended by atte\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with\\n REASON FOR THIS EXAMINATION:\\n evaluate R sided opacity on prior CXR as recommended by attending radiologist\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right-sided opacity on prior chest x-rays, further evaluation\\n recommended.\\n\\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the thoracic\\n inlet to the pubic symphysis after administration of IV contrast only. This\\n study was compared with chest x-ray of and CT torso .\\n\\n CT CHEST WITH IV CONTRAST: These images are somewhat limited by motion. The\\n low-density nodule on the left thyroid lobe is again identified. The patient\\n is intubated. There is a left subclavian central venous line terminating in\\n the distal SVC. A nasogastric tube is seen coursing below the diaphragm and\\n into the stomach. Bilateral fluffy airspace opacities are identified in both\\n upper lobes, consistent with contusion. Additionally, there are bilateral\\n lower lobe dense consolidations corresponding to the unusual contour seen on\\n chest x-ray of . There is no pericardial or pleural effusion. No\\n hilar, axillary, or mediastinal lymphadenopathy is identified. Heart and\\n great vessels are normal.\\n\\n CT ABDOMEN: Liver, spleen, pancreas, adrenals, kidneys, stomach and small\\n bowel loops are normal given lack of oral contrast. The gallbladder is\\n surgically absent. There is no free fluid or free air. There is no evidence\\n of traumatic organ injury.\\n\\n CT PELVIS WITH IV CONTRAST: Sigmoid diverticulosis is seen, without\\n diverticulitis. A Foley is present in the bladder. There is stranding\\n surrounding the anterior aspect of the bladder wall and the posterior to the\\n rectum. Stranding in the subcutaneous tissues is seen, consistent with some\\n edema. Soft tissue density material representing hemorrhage is seen layering\\n anterior and lateral to the left psoas muscle and along the right ureter.\\n\\n Again seen are right sacral fractures, comminuted right femoral, iliac, and\\n superior pubic ramus fractures, and fixation hardware, which somewhat obscures\\n evaluation of the lower pelvis structures. No new fractures are identified.\\n Transverse process fracture of L5 is also noted.\\n\\n IMPRESSION:\\n 1. Multifocal airspace opacities concentrated in both upper lobes, consistent\\n with pulmonary contusions. Right hemithorax density seen on chest x-ray is\\n accounted for consolidations in both lower lobes, probably related to\\n (Over)\\n\\n 10:15 AM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\\n Reason: evaluate R sided opacity on prior CXR as recommended by atte\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n aspiration.\\n\\n 2. Status post fixation of comminuted right femoral fracture and pelvic\\n fractures. Small amount of hematoma along left paracolic gutter. Improved\\n bladder wall hematoma in association with right pelvic fractures.\\n\\n 3. Sigmoid diverticulosis without diverticulitis.\\n\\n 4. Thyroid nodule which can be further evaluated by thyroid ultrasound on a\\n non-emergent basis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-07-02 00:00:00.000\",\n \"description\": \"CT PELVIS W/O CONTRAST\",\n \"row_id\": 916429,\n \"text\": \" 2:33 PM\\n CT PELVIS W/O CONTRAST Clip # \\n Reason: **Please extend views to knee*** evaluate hip fracture anato\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41M s/p Left hip fx\\n REASON FOR THIS EXAMINATION:\\n **Please extend views to knee*** evaluate hip fracture anatomy\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE PELVIS AND RIGHT LOWER EXTREMITY WITHOUT CONTRAST DATED .\\n\\n CLINICAL HISTORY: Please evaluate hip fracture in a 41-year-old male status\\n post MVC.\\n\\n TECHNIQUE: Non-contrast CT scan of the pelvis and right femur was performed\\n using 2.5 mm collimation. Images were reformatted in the coronal and sagittal\\n planes.\\n\\n COMPARISON: Prior CT scan dated and plain films dated .\\n\\n FINDINGS: Posterior spinal fixation hardware is seen spanning the L5-S1\\n level. This is a new finding when compared to prior CT examination. Tiny\\n foci of air are identified in the region of the hardware, related to expected\\n postoperative change, if recent. Hardware are also seen within both iliac\\n bones. The hardware appears to be in good position. Previously identified\\n sacral fractures are not significantly changed.\\n\\n There is a rod transfixing a comminuted superior right pubic ramus fracture.\\n There is significant comminution of the anterior right acetabulum resulting in\\n at least an 18 mm gap. An intramedullary rod with gamma nail fixes the right\\n proximal femur fracture. The proximal right femur fracture is severely\\n comminuted. Fracture is also identified within the right inferior pubic\\n ramus.\\n\\n There is a severely comminuted fracture of the right kne tibial plateau. A\\n side plate and multiple screws are unchanged in position when compared to\\n prior examination.\\n\\n IMPRESSION: Status post ORIF for multiple fractures, as described above.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-17 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 914564,\n \"text\": \" 5:36 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: cause for decreased mental status?\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with s/p motorcycle accident w/ decreased responsiveness.\\n REASON FOR THIS EXAMINATION:\\n cause for decreased mental status?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: AZm SAT 6:56 PM\\n no mass effect or hemorrhage. Severe sinusitis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Motor vehicle accident, unresponsiveness.\\n\\n TECHNIQUE: Head CT without contrast.\\n\\n FINDINGS: There is no mass effect, hydrocephalus, shift of normally midline\\n structures or infarction. The density values of the brain parenchyma are\\n within normal limits.\\n\\n A severe opacification of the sphenoid and frontal sinuses as well as the\\n ethmoid air cells with moderate to severe opacification of the maxillary\\n sinuses. No fractures are present.\\n\\n IMPRESSION: No mass effect or hemorrhage. Severe sinusitis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-07-01 00:00:00.000\",\n \"description\": \"R FEMUR (AP & LAT) RIGHT\",\n \"row_id\": 916324,\n \"text\": \" 11:46 AM\\n FEMUR (AP & LAT) RIGHT Clip # \\n Reason: pre-op eval\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with motorcycle accident, multiple RLE fractures\\n\\n REASON FOR THIS EXAMINATION:\\n pre-op eval\\n ______________________________________________________________________________\\n FINAL REPORT\\n 41-year-old male with motorcycle accident and multiple right lower extremity\\n fractures.\\n\\n COMPARISON: .\\n\\n RIGHT FEMUR, FIVE VIEWS: Again demonstrated is a comminuted intertrochanteric\\n fracture of the right proximal femur. There is a fixation screw fixating the\\n anterior column and medial wall of the acetabulum. An intramedullary rod with\\n a gamma nail fixes the right proximal femoral fracture. Ghost tracks from\\n prior fixation hardware are noted in the distal femur. A lateral plate and\\n multiple screws fixate the comminuted tibial plateau fracture. There is no\\n evidence of hardware complication.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 915378,\n \"text\": \" 7:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval. for cardiopulm. abnormality\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with trauma, just extubated, now diaphoretic and tachycardic.\\n\\n REASON FOR THIS EXAMINATION:\\n Eval. for cardiopulm. abnormality\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Trauma, extubated, not diaphoretic and tachycardic. Evaluate for\\n cardiopulmonary abnormality.\\n\\n COMPARISON: .\\n\\n AP CHEST RADIOGRAPH\\n\\n There has been interval removal of the endotracheal tube, right subclavian\\n line, and left subclavian line. Cardiomediastinal hilar contours appear\\n unchanged. No focal consolidation is seen within the lungs. There are low\\n lung volumes limiting complete assessment of the pulmonary vasculature.\\n\\n IMPRESSION: No focal consolidations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-20 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 914862,\n \"text\": \" 11:54 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: check CVL\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with trauma, intubated, fevers\\n\\n REASON FOR THIS EXAMINATION:\\n check CVL\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Trauma, intubated, fevers.\\n\\n COMPARISON: .\\n\\n SUPINE AP VIEW OF THE CHEST: The endotracheal tube, left subclavian central\\n venous catheter, and feeding tube are in standard positions. A new right\\n subclavian central venous catheter tip is positioned within the lower SVC.\\n There is no pneumothorax. Heart is mildly enlarged, unchanged. There is\\n worsening consolidation within the left lower lobe with loss of the\\n diaphragmatic contour, consistent with worsening atelectasis and/or\\n infiltrate. Small left pleural effusion persists. There is improved aeration\\n within the right base with residual atelectasis identified. There is no\\n pneumothorax. No lower lung volumes are present on the current study, and\\n there is crowding of the pulmonary vasculature at the bases with a\\n perivascular haze present bilaterally suggestive of possible volume overload.\\n\\n IMPRESSION:\\n\\n 1. Satisfactory placement of right subclavian central venous catheter. No\\n pneumothorax.\\n\\n 2. Worsening left lower lobe consolidation with persistent small left pleural\\n effusion.\\n\\n 3. Possible mild volume overload.\\n\\n 4. Improved aeration within the right lung base.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 915445,\n \"text\": \" 4:19 PM\\n CHEST (PA & LAT) Clip # \\n Reason: pna\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with questionable pna / fevers persistant\\n REASON FOR THIS EXAMINATION:\\n pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: PA and lateral chest performed on .\\n\\n HISTORY: 41-year-old man with questionable pneumonia and fevers.\\n\\n FINDINGS: Comparison is made to prior study from .\\n\\n There are low lung volumes that limit evaluation. The lateral radiograph is\\n suboptimal due to patient's large body habitus and overlying arm as well as\\n the poor inspiratory effort. Allowing for this, however, there is no focal\\n consolidation, signs for pulmonary edema or pleural effusions. The cardiac\\n silhouette and mediastinum are prominent but may be secondary to the AP\\n technique and low lung volumes. Bony structures are intact.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 914765,\n \"text\": \" 5:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pneumonia\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with trauma, intubated, fevers\\n REASON FOR THIS EXAMINATION:\\n eval for pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 41-year-old male with trauma, intubated, fever.\\n\\n Portable AP chest radiograph.\\n\\n COMPARISON: Chest radiograph dated .\\n\\n FINDINGS: Endotracheal tube and left subclavian venous catheter are unchanged\\n compared to the prior study. The distal nasogastric tube is terminating in\\n left upper quadrant. Cardiac and mediastinal contours are unchanged, with\\n somewhat prominent cardiac shadows. Note is made of new rounded opacity\\n overlying the right hilum, which may represent consolidation, however, the\\n etiology is uncertain. Note is made of atelectasis in left lower lobe.\\n\\n IMPRESSION: Tubes and lines as described above. New rounded opacity\\n overlying the right hilum, of unknown etiology. This can represent early\\n pneumonia, however, given the history of trauma, other process should be\\n considered, and clinical correlation and close followup is recommended. If\\n necessary, please perform CT scan.\\n\\n The finding was discussed with the referring physician, . , by\\n telephone at the time of interpretation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-11 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 913820,\n \"text\": \" 11:47 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\\n Reason: cuts through upper right femur to eval for Fx\\n Field of view: 47 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with motorcycle accident\\n REASON FOR THIS EXAMINATION:\\n cuts through upper right femur to eval for Fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MNIa MON 2:02 AM\\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded by\\n hematoma.\\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\\n extravasion on delayed scan.)\\n 3. No aortic injury.\\n 4. Lt thyroid nodule.\\n 5. Right sacral fracture and rt L5 transverse process fracture.\\n WET READ VERSION #1 MNIa MON 12:35 AM\\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded\\n by hematoma.\\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\\n extravasion on delayed scan.)\\n 3. No aortic injury.\\n WET READ VERSION #2 MNIa MON 12:59 AM\\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded by\\n hematoma.\\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\\n extravasion on delayed scan.)\\n 3. No aortic injury.\\n 4. Lt thyroid nodule.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 41-year-old woman with motor cycle accident.\\n\\n TECHNIQUE: Contiguous axial CT images of the abdomen, chest, abdomen, and\\n pelvis were obtained with the administration of IV contrast . Multiplanar\\n reformation images are reconstructed.\\n\\n No comparison.\\n\\n FINDINGS:\\n\\n CHEST: There is no evidence of acute aortic injury. No mediastinal hematoma.\\n No pericardial or pleural effusion. No evidence of pneumothorax. There are\\n bilateral dependent opacities, however, no suspicious mass or consolidation is\\n noted.\\n\\n (Over)\\n\\n 11:47 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\\n Reason: cuts through upper right femur to eval for Fx\\n Field of view: 47 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n ABDOMEN: The patient is status post cholecystectomy. No free air. No\\n ascites. The liver, spleen, pancreas, adrenal glands and kidneys, the\\n visualized portions of large and small intestines are within normal limits.\\n\\n PELVIS: The visualized portions of large and small intestines are within\\n normal limits. No free air. No lymphadenopathy.\\n\\n Note is made of hyperdense hematoma with fat stranding anterior to the urinary\\n bladder, tracking down along the anterior abdominal wall. On the delayed\\n scan, the urinary bladder is distended with contrast, however, there is no\\n evidence of extravasation. The hematoma appears to be located in the\\n extraperitoneal space on sagittal reformation. Hematoma along the right psoas\\n muscle is noted.\\n\\n Note is made of extensively comminuted displaced fracture of the right femoral\\n neck with bone fragment and medial angulation of the femoral head, associated\\n with multiple fracture lines in the acetabulum with bone fragment anteriorly,\\n as well as fracture lines through the right pubic rami and right side of the\\n sacrum. There is associated soft tissue fat stranding and hematoma\\n surrounding the right hip joint. There is a hematoma medial to the right\\n acetabulum, with some mass effect to the urinary bladder. Iliac arteries are\\n patent and no evidence of active extravasation is noted. No rib fracture is\\n seen. Fracture of the right side of the sacrum and transverse process of L5 is\\n noted.\\n\\n IMPRESSION:\\n\\n 1. Extensive comminuted and displaced fracture of the right femoral neck with\\n medial angulation of the head, as well as multiple fractures involving\\n acetabulum, pubic rami. The fracture line through the right side of the\\n sacrum as well as fracture of the right transverse process of L5.\\n\\n 2. Hematoma and soft tissue swelling surrounding the above-mentioned\\n fracture. Hematoma anterior to the bladder, tracking just beneath the\\n abdominal wall. No evidence for bladder injury. Hematoma along the psoas\\n muscle.\\n The location of hematoma is extraperitoneal.\\n\\n The information was communicated with the trauma team in person at the time of\\n examination, and was also discussed with the referring physician, . \\n by telephone, and was also flagged to ED dashboard.\\n\\n\\n (Over)\\n\\n 11:47 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\\n Reason: cuts through upper right femur to eval for Fx\\n Field of view: 47 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-11 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 913821,\n \"text\": \" 11:52 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o Fx\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n ADDENDUM: The findings regarding T4 fracture was communicated to the covering\\n physician, . , by telephone at 9:30 p.m. on . We tried to\\n reach the ordering physician, . , however, was not successful, and\\n therefore, the information was also sent to Dr. by e-mail.\\n\\n\\n 11:52 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o Fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with motorcycle\\n REASON FOR THIS EXAMINATION:\\n r/o Fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DBH MON 5:04 PM\\n Scoliosis, no gross fracture.\\n\\n NOTE ADDED AT ATTENDING REVIEW: There is a compression fracture of T4\\n with a retropulsed fragment into the spinal canal. The bone does not appear to\\n produce severe canal narrowing, but cannot rule out disk protrusion or\\n hematoma.\\n WET READ VERSION #1 MNIa MON 12:08 AM\\n Scoliosis, no gross fracture.\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: 41-year-old male with motorcycle.\\n\\n C-SPINE CT WITHOUT CONTRAST.\\n\\n No comparison.\\n\\n FINDINGS: Note is made of severe scoliosis, however, there is no gross\\n fracture or dislocation. No prevertebral soft tissue swelling.\\n\\n IMPRESSION: Marked scoliosis. No gross fracture or dislocation.\\n\\n\\n NOTE ADDED AT ATTENDING REVIEW: There is a compression fracture of T4, with\\n retropulsion of an inferior endplate fragment. CT is extremely limited for\\n analyzing canal narrowing. There appears to be only mild osseous encroachment\\n on the canal, but the possibility of soft tissue abnormality, such as disk\\n protusion or hematoma, cannot be evaluated. If clinically indicated, recommend\\n CT of the thoracic and lumbar spine and perhaps an MR of the spine.\\n\\n Findings discussed with Dr. at 5:30 pm on .\\n\\n\\n\\n\\n\\n\\n\\n\\n (Over)\\n\\n 11:52 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o Fx\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-11 00:00:00.000\",\n \"description\": \"R CT LOW EXT W/O C RIGHT\",\n \"row_id\": 913822,\n \"text\": \" 11:58\\n CT LOW EXT W/O C RIGHT Clip # \\n Reason: r/o fx tib plateau\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with motorcycle\\n REASON FOR THIS EXAMINATION:\\n r/o fx tib plateau\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MNIa MON 12:30 AM\\n Extensively comminuted tibial plateau fracture with hematoma and deep tissue\\n air. Comminuted fracture of prox. fibula.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Motorcycle accident, rule out tibial plateau fracture.\\n\\n TECHNIQUE:\\n\\n Thin section axial images were obtained from the distal femur through the mid\\n calf and reconstructed using both bone and soft tissue algorithm. Coronal and\\n sagittal reconstructions were also generated. The patient's leg is imaged in\\n slight flexion, resulting in some distortion of the axial images\\n presently available.\\n\\n RIGHT LOWER EXTREMITY, WITHOUT CONTRAST:\\n\\n PRELIMINARY WET :\\n\\n Please note that a wet was provided by the radiology resident on the\\n PACS requisition as follows: \\\"extensively comminuted tibial plateau fracture\\n involving joint surface with hematoma and deep tissue air. Comminuted\\n proximal fibular fracture (spiral). Discussed with trauma team (by resident\\n , M,\\\"\\n\\n FINAL REPORT:\\n\\n There is a markedly comminuted fracture of the proximal tibia, extending into\\n the tibial plateau, with considerable axial dispersion of the fracture\\n fragments. The articular surface components extend into the lateral plateau,\\n into the tibial eminence, and into the medial tibial plateau. The distal\\n major fracture lines exit in the medial and lateral metaphyses, with\\n comminution. There is dispersion of fragments posteriorly, with small\\n fragments lying adjacent to the popliteal vessels, though they do not appear\\n to directly impinge on the vessels (series 2, images 139-117). The main\\n longitudinal axis of the tibial shaft is displaced posteriorly with respect to\\n the markedly comminuted proximal tibia, best appreciated on sagittal views.\\n The tibial tubercle (insertion site of patellar tendon) is avulsed. There is\\n also considerable comminution at the expected insertion site of the posterior\\n cruciate ligament. The ACL is not effectively evaluated here.\\n\\n There is a joint effusion, with air within the joint. There is extensive\\n surrounding soft tissue edema as well as some subcutaneous emphysema.\\n (Over)\\n\\n 11:58\\n CT LOW EXT W/O C RIGHT Clip # \\n Reason: r/o fx tib plateau\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n There is a comminuted fracture of the proximal diaphysis of the fibula. The\\n proximal tibiofibular joint remains congruent.\\n\\n IMPRESSION:\\n\\n 1. Markedly comminuted and impacted fracture of the proximal tibia, with\\n extensive involvement of the tibial plateau and posterior displacement of the\\n main shaft of the tibia. Avulsion of patellar tendon from tibial tubercle.\\n Comminution at expected site of PCL insertion. Bony fragments abutting the\\n popliteal vessels.\\n\\n 2. Proximal fibular diaphyseal fracture.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-12 00:00:00.000\",\n \"description\": \"R TIB/FIB (AP & LAT) RIGHT\",\n \"row_id\": 913825,\n \"text\": \" 4:06 AM\\n TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \\n Reason: RT TIB FIB FX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 41-year-old man with right tib/fib fracture.\\n\\n Three fluoroscopic images obtained during fixation of comminuted tibial\\n plateau fracture and proximal fibular fracture, without the radiologist\\n present. Rod is noted only on AP view, and neither end is seen. Please also\\n refer to the official surgical report.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-16 00:00:00.000\",\n \"description\": \"RO KNEE (AP, LAT & OBLIQUE) RIGHT IN O.R.\",\n \"row_id\": 914446,\n \"text\": \" 3:21 PM\\n KNEE (AP, LAT & OBLIQUE) RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \\n Reason: ORIF RT.TIBIAL PLATEU FX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Fracture fixation.\\n\\n 2 minutes 8 seconds of fluoroscopy time. Exam consists of five AP and lateral\\n intraoperative radiographs of the right knee and proximal leg. Since last\\n exam the markedly comminuted and displaced fracture of the proximal\\n tibia and lateral tibial plateau has been fixated by a curved lateral plate\\n and multiple screws. A second small anterior plate and screws is also\\n present. Again noted is the fracture of the adjacent proximal fibula. Bone\\n detail obscured for technical reasons.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-15 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 914287,\n \"text\": \" 12:59 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: check CVL\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with trauma, s/p Line placement\\n\\n REASON FOR THIS EXAMINATION:\\n check CVL\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the new central venous line placement.\\n\\n Portable AP chest radiograph compared to .\\n\\n The ET tube tip is 3.3 cm above the carina. The Swan-Ganz catheter was\\n exchanged by a subclavian central venous line with its tip at the junction of\\n the brachiocephalic vein with the superior vena cava. The NG tube now is\\n properly inserted with its tip in the stomach.\\n\\n The heart size is normal. There is no evidence of congestive heart failure.\\n There are bibasilar lower lobe atelectases, left more than right, which are\\n worsening seen the previous film.\\n\\n IMPRESSION:\\n\\n 1. Normal position of the left central venous line with no evidence of\\n pneumothorax.\\n\\n 2. Worsening bibasilar atelectases.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-27 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 915785,\n \"text\": \" 2:30 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: possible IVC filter placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with\\n REASON FOR THIS EXAMINATION:\\n possible IVC filter placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n BILATERAL LOWER EXTREMITY VEINS.\\n\\n INDICATION: 41-year-old man with possible IVC filter placement.\\n\\n BILATERAL LOWER EXTREMITY VEINS: Grayscale and color Doppler ultrasound were\\n performed. There is normal compressibility, color flow, and Doppler signal\\n within the common femoral, superficial femoral, and popliteal veins.\\n\\n IMPRESSION: No evidence of DVT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-21 00:00:00.000\",\n \"description\": \"R HIP UNILAT MIN 2 VIEWS RIGHT\",\n \"row_id\": 915041,\n \"text\": \" 1:52 PM\\n HIP UNILAT MIN 2 VIEWS RIGHT; FEMUR (AP & LAT) RIGHT Clip # \\n KNEE (2 VIEWS) RIGHT; TIB/FIB (AP & LAT) RIGHT\\n PELVIS (AP ONLY)\\n Reason: assess alignment of fractures\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with trauma, multiple RLE fx's\\n REASON FOR THIS EXAMINATION:\\n assess alignment of fractures\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Right hip, two views. .\\n\\n HISTORY: 41-year-old man with trauma and multiple lower extremity fractures.\\n\\n FINDINGS: There is a single screw seen fixating the anterior column and\\n medial wall of the acetabulum. There is an intramedullary rod with a gamma\\n nail seen, fixating a comminuted intertrochanteric fracture of the right\\n proximal femur. There are no signs of hardware complications. Ghost pin\\n tracks are seen in the distal femur. The patient has a comminuted tibial\\n plateau fracture, which is fixated by lateral plate and multiple screws, seen\\n through the tibial plateau. The patient has a brace, which limits soft tissue\\n detail. Visualization of the distal ankle is within normal limits.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-26 00:00:00.000\",\n \"description\": \"O L-SPINE (AP & LAT) IN O.R.\",\n \"row_id\": 915656,\n \"text\": \" 5:13 PM\\n L-SPINE (AP & LAT) IN O.R. Clip # \\n Reason: L5 TO ILIUM FUSION IN OR FOR L5-S1 FACET JOINT FX AND SACRAL FX\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Fusion.\\n\\n Two intraoperative lateral radiographs of the lumbar spine were obtained\\n without a radiologist present. These demonstrate fusion hardware overlying\\n L5-S2. For additional details, please consult the operative report.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-07-03 00:00:00.000\",\n \"description\": \"R HIP UNILAT MIN 2 VIEWS RIGHT\",\n \"row_id\": 916537,\n \"text\": \" 9:50 AM\\n HIP UNILAT MIN 2 VIEWS RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \\n Reason: REVISION RT HIP HARDWARE\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Right hip hardware revision.\\n\\n Fluoroscopic assistance provided to the surgeon in the OR without the\\n radiologist present. Fluoro time recorded as 1.48 minutes on the electronic\\n requisition. Nine spot views were obtained. These demonstrate portions of an\\n right femoral intramedullary rod and extensive hardware in the proximal right\\n tibia, which is incompletely visualized. A proximal fibular fracture is also\\n demonstrated. A proximal femur fracture is also seen. Assessment of fine\\n bony detail is limited due to RF technique.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-14 00:00:00.000\",\n \"description\": \"PELVIS WITH JUDET VIEWS\",\n \"row_id\": 914150,\n \"text\": \" 2:16 PM\\n PELVIS WITH JUDET VIEWS; HIP UNILAT MIN 2 VIEWS RIGHT Clip # \\n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT\\n Reason: TRAUMA, DHS HIP, ORIF OF RIGHT ACETABULUM, FRACTURE\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM ORDER: Pelvis with Judet view.\\n\\n HISTORY: Trauma.\\n\\n Eight intraoperative fluoroscopic views of the femur and hemipelvis without\\n right and left label were obtained during the open reduction and internal\\n fixation of intertrochanteric fracture with an intramedullary nail and\\n proximal and distal screws as well as internal fixation of anterior acetabular\\n fracture with a cancellous screw. An inferior pubic ramus fracture is also\\n noted. The final films are not available.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-13 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 913916,\n \"text\": \" 4:04 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Position of line, pneumothorax\\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 41 year old man with trauma, s/p Line placement\\n REASON FOR THIS EXAMINATION:\\n Position of line, pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 4:38 A.M. .\\n\\n HISTORY: Trauma. Line placement. Possible pneumothorax.\\n\\n IMPRESSION: AP chest _____ with the only prior chest imaging, CT scan from\\n :\\n\\n ET tube is in standard placement, nasogastric tube is looped in the\\n hypopharynx and ends in the lower esophagus. The course of the Swan-Ganz\\n catheter is distorted by cardiac motion, but the tip projects over the right\\n pulmonary artery. Repeat examination should be performed to document\\n continuity of the line.\\n\\n Lungs are very low in volume, but aside from mild left infrahilar atelectasis,\\n probably clear. Supine positioning is probably responsible for distention of\\n mediastinal veins. The heart is normal in size. No pneumothorax. Dr. \\n was paged to discuss these findings, at the time of dictation.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":23097,"cells":{"subject_id":{"kind":"number","value":11772,"string":"11,772"},"hadm_id":{"kind":"number","value":165749,"string":"165,749"},"target_text":{"kind":"string","value":"Blood gas in the Emergency Department revealed a pH of 7.44, PCO2 of 32, PO2 of 211, bicarbonate of 22, and lactate of 1.9. The patient had a small left temporal laceration which was cleaned and repaired with three 3-0 nylon sutures. The patient underwent numerous studies (see below). The patient was admitted to the Trauma Cardiothoracic Intensive Care Unit in stable condition. The patient was admitted and admitted to the Cardiothoracic Intensive Care Unit for observation. She self-extubated on arrival to the floor. She did well, breathing spontaneously with a clear airway with an alert and oriented mental status. No issues through the following morning. In the Emergency Department, the patient underwent radiologic evaluation including a head CT, chest x-ray, abdominal and pelvic CT; all of which were negative. A CT of the cervical spine was negative as well. The patient's collar was removed, and her cervical spine clinically cleared. On examination in the morning of hospital day one (and the day of discharge), the patient's vital signs revealed a temperature current of 37.8, a temperature maximum of 37.8, blood pressure of 108/45, a heart rate of 83, breathing 17 times per minute with an oxygen saturation of 97% on room air, and in no distress. Physical examination revealed the patient to be alert and oriented times three with a clear sensorium. Her heart was regular in rate and rhythm. No murmurs, rubs or gallops. Her lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, and nondistended, with positive bowel sounds. Her extremities were warm with palpable dorsalis pedis pulses and posterior tibialis pulses. She moved all extremities spontaneously. Neurologic examination revealed strength was throughout. Cranial nerves II through XII were intact. No sensory deficits."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: Central venous line placement without pneumothorax. IMPRESSION: No intracerebral hemorrhage. TECHNIQUE: Noncontrast head CT. IMPRESSION: 1) No evidence of intra-abdominal injury. Otherwise normal trauma chest and pelvis. Only the medial aspects of the clavicles are visualized and no fracture is seen in this region. SICU NPN 11p-7aS/o- Pt neurologically intact throughout the shift, PERL, denies dizziness/blurry vision, states that she has a HA yet that it is only a . FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally midline structures, or enlargement of the ventricles. GU- voiding w/o diff via foley, IVF con't at 100cc's hr overnoc. No cervical spine fracture. TSICU Nursing Progress NOte-Discharge Note-Neuro-Alert and oriented x3, no c/o dizziness, h/a, double/blurred vision. There is no duodenal hematoma. The SI joints and pubic symphysis are not widened. There is no loss of vertebral body or disc height. There is no abnormal adenopathy within the mesentery or retroperitoneum. No cervical spine fractures are visualized. MAE's w/ full strengths, no pronator drift, facial movements symetrical. on a scale of for pain, took no pain med over . There is no prevertebral soft tissue swelling. The mediastinum is not widened. No fractures are seen within the visualized osseous structures. VSS - DENIES CARDIAC C/O'S OR PAIN ISSUES - ALERT/ORIENTED X3 - AFFECT/QUESTIONS/CONCERNS APPROPRIATE. EXTUBATED UPON ARRIVAL, MAINTAINING ADEQUATE OXYGENATION - DENIES SOB. A trace amount of free fluid is seen within the pelvis adjacent to a normal appearing uterus and adnexa. No fractures are identified. No apical capping or shift of the trachea is seen. The small bowel is nonopacified but adequately visualized and there are no areas of wall thickening or luminal dilatation. The vasculature is within normal limits. There are no major or minor vascular territorial infarcts. No rib fractures are identified. There is normal alignment of the cervical vertebral bodies. The patient is intubated but the tip of the endotracheal tube is no visualized and is therefore likley above the thoracic inlet. There is no effusion. There are no pelvic masses or enlarged inguinal lymph nodes. There is no pneuomothorax. Nonionic contrast was administered in accordance with the trauma protocol. No fractures or malalignments are seen. TRAUMA CHEST: The apices are not included. Right upper lobe tiny pulmonary nodule. The heart size is normal given technique. No pneumothorax is seen and no focal consolidations to suggest pulmonary contusions are seen. GI- abd soft nondistended, took small sips H2O this AM. The heart size is normal. T/SICU 15:00:PT ARRIVED TO UNIT FROM EW/CTS ->STABLE. The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys have a normal appearance. Hemodynamically stable in SR w/ BP 100-110/40-50, resp- lungs clear, RR 12-16, sat 98-100% on RA. No subcapsular hematomas are seen along the liver or spleen. ET tube tip at the level of the thoracic inlet. C/O SEVERE HA WITH N/V,TX WITH ZOFRAN/MS IV WITH GOOG EFFECT,REPEATED WHEN SYMPTOMS REOCCURED.CARDIAC- VSS,IN NSR.SHE HAS A RT SUBCLAVIAN TRAUMA LINE INFUSING LR AT 100CC/HR.IN ADDITION SHE HAS THREE PERIPHERAL #18G IV'S WHICH FLUSH WELL.RESP-LS CLEAR,NO RESP DISTRESS NOTED.WEANED TO RA. PERLA @ 4mm/, , oob to chair independently w/o dizziness.CV -HR 70 SR, BP 120/70.Skin- Head Lac, no new d/c, old blood cleaned off as able. r/o ptx, confirm position. TLS AND C-SPINE CLEARED BY TEAM - CERVICAL COLLAR D/C'D. No comparison studies. AP PELVIS ON TRAUMA BOARD: The right greater trochanter is not completely included on this study. Soft tissue swelling over the right parieto-frontal calvarium. The endotracheal tube (seen on CT examination) has been removed and the NG tube has also been removed. Nausea improved, no need for antiemetics over as well. Coronal and sagittal reformatted images were obtained. The remainder of the large intestine is collapsed but there is no evidence of wall thickening or luminal dilatation. CHEST, PORTABLE: A right sided subclavian central venous line terminates in the central most aspect of the right subclavian vein. cvl placement. cvl placement. cvl placement. On lung windows incidental note is made of a small pleural-based pulmonary nodule in the right upper lobe posteriorly. There is no free air or free fluid within the abdomen. r/o ptx. The orbits, sinuses and osseous structures are normal; however, there is an area of soft tissue swelling over the right parieto-frontal skull, within the scalp. The ET tube tip is at the thoracic inlet. TECHNIQUE: Helically acquired contiguous axial images were obtained through the cervical spine. IMPRESSION: 1. IMPRESSION: 1. The lung fields are clear. The lung fields are clear. There is no prior study for comparison. confirm position. There is no free air within the pelvis. The soft tissues of the neck are symmetric. Central line placement. FINDINGS: C1 through T2 are visualized. CT ABDOMEN AFTER IV CONTRAST: There is some dependent atelectasis at the left lung base. The line tip is located at the central most aspect of the subclavian vein. Pager . Reformatted images support the above findings. If patient is intubated endotracheal tube should be advanced. TECHNIQUE: Helically acquired CT images were obtained from the lung bases through the pubic symphysis after the administration of 150 cc Optiray contrast. CT PELVIS AFTER IV CONTRAST: The rectum and sigmoid colon are full of stool. Trace erythema @ site, 1+ tenderness.Stable --probable concussion.Plan--Discharged to home w/ parents.Concussion, Laceration, Suture Care discharge instructions reviewed w/ patient and mother, stating good understanding of documents. The bladder contains a Foley and is collapsed. Results were discussed with the Trauma Team. 2. 2. 3. COMPARISON: Trauma chest radiograph from 90 minutes previously. FINAL REPORT INDICATION: Fall from bike. PT REMAINS NPO.N/V RELIVED WITH MEDICATION AS ABOVE PT CLEAR,YELLOW URINE VIA FOLEY CATHETER.PARENTS HAVE BEEN IN WITH PT MUCH OF THE EVENING. SOCIAL WORK NOTE:Pt and family known to this SW from pt's ED arrival. Please see my printed OMR note for further information."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2108-06-19 00:00:00.000","description":"CT EMERGENCY HEAD W/O CONTRAST","row_id":764181,"text":" 12:58 PM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: bike accident\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old with bike accident with loc\n REASON FOR THIS EXAMINATION:\n bike accident\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Fall from bike with loss of consciousness.\n\n No comparison studies.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally\n midline structures, or enlargement of the ventricles. There are no major or\n minor vascular territorial infarcts. The orbits, sinuses and osseous\n structures are normal; however, there is an area of soft tissue swelling over\n the right parieto-frontal skull, within the scalp.\n\n IMPRESSION: No intracerebral hemorrhage. Soft tissue swelling over the right\n parieto-frontal calvarium.\n\n"},{"category":"Radiology","chartdate":"2108-06-19 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":764182,"text":" 12:59 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: bike accident\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old with bike accident with loc\n REASON FOR THIS EXAMINATION:\n bike accident\n ______________________________________________________________________________\n WET READ: DCsc TUE 2:21 PM\n NO ABD INJURY\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST, AT 13:50:\n\n INDICATION: Bike accident with loss of consciousness.\n\n TECHNIQUE: Helically acquired CT images were obtained from the lung bases\n through the pubic symphysis after the administration of 150 cc Optiray\n contrast. Nonionic contrast was administered in accordance with the trauma\n protocol.\n\n There is no prior study for comparison.\n\n CT ABDOMEN AFTER IV CONTRAST: There is some dependent atelectasis at the left\n lung base. The liver, gallbladder, pancreas, spleen, adrenal glands, and\n kidneys have a normal appearance. There is no abnormal adenopathy within the\n mesentery or retroperitoneum. There is no free air or free fluid within the\n abdomen. The small bowel is nonopacified but adequately visualized and there\n are no areas of wall thickening or luminal dilatation. No subcapsular\n hematomas are seen along the liver or spleen. There is no duodenal hematoma.\n\n CT PELVIS AFTER IV CONTRAST: The rectum and sigmoid colon are full of stool.\n The remainder of the large intestine is collapsed but there is no evidence of\n wall thickening or luminal dilatation. There is no free air within the\n pelvis. The bladder contains a Foley and is collapsed. A trace amount of\n free fluid is seen within the pelvis adjacent to a normal appearing uterus and\n adnexa. There are no pelvic masses or enlarged inguinal lymph nodes.\n\n No fractures are seen within the visualized osseous structures.\n\n IMPRESSION:\n 1) No evidence of intra-abdominal injury.\n\n"},{"category":"Radiology","chartdate":"2108-06-19 00:00:00.000","description":"TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)","row_id":764184,"text":" 12:59 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: bike accident\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old with bike accident with loc\n REASON FOR THIS EXAMINATION:\n bike accident\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fell off bike then hit by car.\n\n TRAUMA CHEST: The apices are not included. The patient is intubated but the\n tip of the endotracheal tube is no visualized and is therefore likley above\n the thoracic inlet. An NG tube is seen looping in the stomach with tip in the\n fundus. The heart size is normal given technique. The mediastinum is not\n widened. No apical capping or shift of the trachea is seen. The lung fields\n are clear. No pneumothorax is seen and no focal consolidations to suggest\n pulmonary contusions are seen. No rib fractures are identified. Only the\n medial aspects of the clavicles are visualized and no fracture is seen in this\n region.\n\n AP PELVIS ON TRAUMA BOARD: The right greater trochanter is not completely\n included on this study. No fractures or malalignments are seen. The SI joints\n and pubic symphysis are not widened.\n\n IMPRESSION:\n 1. If patient is intubated endotracheal tube should be advanced.\n 2. Otherwise normal trauma chest and pelvis.\n\n Results were discussed with the Trauma Team.\n\n"},{"category":"Radiology","chartdate":"2108-06-19 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":764187,"text":" 1:24 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: bike accident with loc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old woman with bike accident and loc\n REASON FOR THIS EXAMINATION:\n bike accident with loc\n ______________________________________________________________________________\n WET READ: NTo TUE 2:39 PM\n no c-spine fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bicyclist hit by car with loss of consciousness.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained through\n the cervical spine. Coronal and sagittal reformatted images were obtained.\n\n FINDINGS: C1 through T2 are visualized. There is no prevertebral soft tissue\n swelling. There is normal alignment of the cervical vertebral bodies. There\n is no loss of vertebral body or disc height. No cervical spine fractures are\n visualized. The soft tissues of the neck are symmetric. The ET tube tip is\n at the thoracic inlet. On lung windows incidental note is made of a small\n pleural-based pulmonary nodule in the right upper lobe posteriorly.\n\n Reformatted images support the above findings.\n\n IMPRESSION:\n\n 1. No cervical spine fracture.\n\n 2. ET tube tip at the level of the thoracic inlet.\n\n 3. Right upper lobe tiny pulmonary nodule.\n\n"},{"category":"Radiology","chartdate":"2108-06-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":764188,"text":" 1:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p fall from bike. cvl placement. r/o ptx, confirm position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old woman s/p fall. cvl placement. r/o ptx. confirm position.\n REASON FOR THIS EXAMINATION:\n s/p fall from bike. cvl placement. r/o ptx, confirm position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall from bike. Central line placement.\n\n COMPARISON: Trauma chest radiograph from 90 minutes previously.\n\n CHEST, PORTABLE: A right sided subclavian central venous line terminates in\n the central most aspect of the right subclavian vein. The heart size is\n normal. The vasculature is within normal limits. The lung fields are clear.\n There is no effusion. There is no pneuomothorax. No fractures are identified.\n The endotracheal tube (seen on CT examination) has been removed and the NG\n tube has also been removed.\n\n IMPRESSION: Central venous line placement without pneumothorax. The line tip\n is located at the central most aspect of the subclavian vein.\n\n"},{"category":"Nursing/other","chartdate":"2108-06-20 00:00:00.000","description":"Report","row_id":1416147,"text":"SICU NPN 11p-7a\nS/o- Pt neurologically intact throughout the shift, PERL, denies dizziness/blurry vision, states that she has a HA yet that it is only a . on a scale of for pain, took no pain med over . Nausea improved, no need for antiemetics over as well. MAE's w/ full strengths, no pronator drift, facial movements symetrical. Hemodynamically stable in SR w/ BP 100-110/40-50, resp- lungs clear, RR 12-16, sat 98-100% on RA. GI- abd soft nondistended, took small sips H2O this AM. GU- voiding w/o diff via foley, IVF con't at 100cc's hr overnoc. Hct 34.6 yest afternoon , stable at 33.8 this AM.\nA/P- stable , advance DAT, activity, D/C foley and probable discharge to floor or home this PM.\n"},{"category":"Nursing/other","chartdate":"2108-06-20 00:00:00.000","description":"Report","row_id":1416148,"text":"TSICU Nursing Progress NOte-Discharge Note-\nNeuro-\nAlert and oriented x3, no c/o dizziness, h/a, double/blurred vision. PERLA @ 4mm/, , oob to chair independently w/o dizziness.\nCV -HR 70 SR, BP 120/70.\nSkin- Head Lac, no new d/c, old blood cleaned off as able. Trace erythema @ site, 1+ tenderness.\nStable --probable concussion.\nPlan--\nDischarged to home w/ parents.\n\nConcussion, Laceration, Suture Care discharge instructions reviewed w/ patient and mother, stating good understanding of documents. Trauma Clinic number provided, and instructed to call in next 24 hours and make F/U appt for 1 week.\n\n"},{"category":"Nursing/other","chartdate":"2108-06-19 00:00:00.000","description":"Report","row_id":1416144,"text":"SOCIAL WORK NOTE:\nPt and family known to this SW from pt's ED arrival. Please see my printed OMR note for further information. Met with pt and her parents this afternoon to offer continued support. Pt has been extubated and is alert, fully oriented, and able to answer questions and engage pleasantly in conversation. This SW will f/u tomorrow with pt and family if pt remains on T-SICU. Family has contact information for this SW and I encouraged parents and pt to be contact if further support needed. Pager .\n"},{"category":"Nursing/other","chartdate":"2108-06-19 00:00:00.000","description":"Report","row_id":1416145,"text":"T/SICU 15:00:\n\nPT ARRIVED TO UNIT FROM EW/CTS ->STABLE. EXTUBATED UPON ARRIVAL, MAINTAINING ADEQUATE OXYGENATION - DENIES SOB. TLS AND C-SPINE CLEARED BY TEAM - CERVICAL COLLAR D/C'D. VSS - DENIES CARDIAC C/O'S OR PAIN ISSUES - ALERT/ORIENTED X3 - AFFECT/QUESTIONS/CONCERNS APPROPRIATE. PARENTS IN ROOM W/PT - RESTING COMFORTABLY.\n"},{"category":"Nursing/other","chartdate":"2108-06-19 00:00:00.000","description":"Report","row_id":1416146,"text":"T/SICU\nPT IS A 19 YO WOMEN WHO FELL VS WAS STRUCK WHILE RIDING HER BICYCLE.SHE WAS WEARING A HELMET.SHE HAD LOC AT THE SCENE,VOMITING,WAS INTUBATED AND SEDATED,MEDFLIGHTED TO .SHE HAS NO PMH,NO ALLERGIES AND TAKES NO MEDS AT HOME.PEARL AT THE SCENE\n\nAT ,SHE WAS CLEARED BOTH BY XRAY AND PHYSICAL EXAM FOR HER TLS.C-SPINE CLEARED.INJURIES INCLUDE A LAC TO HER SCALP.UPON ARRIVAL TO T/SICU, SHE WAS EXTUBATED TO NC.\n\nROS:\n\n PT IS ON Q 2HR NEURO CHECKS.SHE HAS BEEN ALERT AND ORIENTED X 3,PEARL,GRASPS EQUAL. C/O SEVERE HA WITH N/V,TX WITH ZOFRAN/MS IV WITH GOOG EFFECT,REPEATED WHEN SYMPTOMS REOCCURED.\n\nCARDIAC- VSS,IN NSR.SHE HAS A RT SUBCLAVIAN TRAUMA LINE INFUSING LR AT 100CC/HR.IN ADDITION SHE HAS THREE PERIPHERAL #18G IV'S WHICH FLUSH WELL.\n\nRESP-LS CLEAR,NO RESP DISTRESS NOTED.WEANED TO RA.\n\n PT REMAINS NPO.N/V RELIVED WITH MEDICATION AS ABOVE\n\n PT CLEAR,YELLOW URINE VIA FOLEY CATHETER.\n\nPARENTS HAVE BEEN IN WITH PT MUCH OF THE EVENING.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"CT EMERGENCY HEAD W/O CONTRAST\",\n \"row_id\": 764181,\n \"text\": \" 12:58 PM\\n CT EMERGENCY HEAD W/O CONTRAST Clip # \\n Reason: bike accident\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old with bike accident with loc\\n REASON FOR THIS EXAMINATION:\\n bike accident\\n ______________________________________________________________________________\\n FINAL REPORT (REVISED)\\n INDICATION: Fall from bike with loss of consciousness.\\n\\n No comparison studies.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally\\n midline structures, or enlargement of the ventricles. There are no major or\\n minor vascular territorial infarcts. The orbits, sinuses and osseous\\n structures are normal; however, there is an area of soft tissue swelling over\\n the right parieto-frontal skull, within the scalp.\\n\\n IMPRESSION: No intracerebral hemorrhage. Soft tissue swelling over the right\\n parieto-frontal calvarium.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 764182,\n \"text\": \" 12:59 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: bike accident\\n Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old with bike accident with loc\\n REASON FOR THIS EXAMINATION:\\n bike accident\\n ______________________________________________________________________________\\n WET READ: DCsc TUE 2:21 PM\\n NO ABD INJURY\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST, AT 13:50:\\n\\n INDICATION: Bike accident with loss of consciousness.\\n\\n TECHNIQUE: Helically acquired CT images were obtained from the lung bases\\n through the pubic symphysis after the administration of 150 cc Optiray\\n contrast. Nonionic contrast was administered in accordance with the trauma\\n protocol.\\n\\n There is no prior study for comparison.\\n\\n CT ABDOMEN AFTER IV CONTRAST: There is some dependent atelectasis at the left\\n lung base. The liver, gallbladder, pancreas, spleen, adrenal glands, and\\n kidneys have a normal appearance. There is no abnormal adenopathy within the\\n mesentery or retroperitoneum. There is no free air or free fluid within the\\n abdomen. The small bowel is nonopacified but adequately visualized and there\\n are no areas of wall thickening or luminal dilatation. No subcapsular\\n hematomas are seen along the liver or spleen. There is no duodenal hematoma.\\n\\n CT PELVIS AFTER IV CONTRAST: The rectum and sigmoid colon are full of stool.\\n The remainder of the large intestine is collapsed but there is no evidence of\\n wall thickening or luminal dilatation. There is no free air within the\\n pelvis. The bladder contains a Foley and is collapsed. A trace amount of\\n free fluid is seen within the pelvis adjacent to a normal appearing uterus and\\n adnexa. There are no pelvic masses or enlarged inguinal lymph nodes.\\n\\n No fractures are seen within the visualized osseous structures.\\n\\n IMPRESSION:\\n 1) No evidence of intra-abdominal injury.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)\",\n \"row_id\": 764184,\n \"text\": \" 12:59 PM\\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \\n Reason: bike accident\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old with bike accident with loc\\n REASON FOR THIS EXAMINATION:\\n bike accident\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fell off bike then hit by car.\\n\\n TRAUMA CHEST: The apices are not included. The patient is intubated but the\\n tip of the endotracheal tube is no visualized and is therefore likley above\\n the thoracic inlet. An NG tube is seen looping in the stomach with tip in the\\n fundus. The heart size is normal given technique. The mediastinum is not\\n widened. No apical capping or shift of the trachea is seen. The lung fields\\n are clear. No pneumothorax is seen and no focal consolidations to suggest\\n pulmonary contusions are seen. No rib fractures are identified. Only the\\n medial aspects of the clavicles are visualized and no fracture is seen in this\\n region.\\n\\n AP PELVIS ON TRAUMA BOARD: The right greater trochanter is not completely\\n included on this study. No fractures or malalignments are seen. The SI joints\\n and pubic symphysis are not widened.\\n\\n IMPRESSION:\\n 1. If patient is intubated endotracheal tube should be advanced.\\n 2. Otherwise normal trauma chest and pelvis.\\n\\n Results were discussed with the Trauma Team.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 764187,\n \"text\": \" 1:24 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: bike accident with loc\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 18 year old woman with bike accident and loc\\n REASON FOR THIS EXAMINATION:\\n bike accident with loc\\n ______________________________________________________________________________\\n WET READ: NTo TUE 2:39 PM\\n no c-spine fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Bicyclist hit by car with loss of consciousness.\\n\\n TECHNIQUE: Helically acquired contiguous axial images were obtained through\\n the cervical spine. Coronal and sagittal reformatted images were obtained.\\n\\n FINDINGS: C1 through T2 are visualized. There is no prevertebral soft tissue\\n swelling. There is normal alignment of the cervical vertebral bodies. There\\n is no loss of vertebral body or disc height. No cervical spine fractures are\\n visualized. The soft tissues of the neck are symmetric. The ET tube tip is\\n at the thoracic inlet. On lung windows incidental note is made of a small\\n pleural-based pulmonary nodule in the right upper lobe posteriorly.\\n\\n Reformatted images support the above findings.\\n\\n IMPRESSION:\\n\\n 1. No cervical spine fracture.\\n\\n 2. ET tube tip at the level of the thoracic inlet.\\n\\n 3. Right upper lobe tiny pulmonary nodule.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 764188,\n \"text\": \" 1:57 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p fall from bike. cvl placement. r/o ptx, confirm position\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 18 year old woman s/p fall. cvl placement. r/o ptx. confirm position.\\n REASON FOR THIS EXAMINATION:\\n s/p fall from bike. cvl placement. r/o ptx, confirm position.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fall from bike. Central line placement.\\n\\n COMPARISON: Trauma chest radiograph from 90 minutes previously.\\n\\n CHEST, PORTABLE: A right sided subclavian central venous line terminates in\\n the central most aspect of the right subclavian vein. The heart size is\\n normal. The vasculature is within normal limits. The lung fields are clear.\\n There is no effusion. There is no pneuomothorax. No fractures are identified.\\n The endotracheal tube (seen on CT examination) has been removed and the NG\\n tube has also been removed.\\n\\n IMPRESSION: Central venous line placement without pneumothorax. The line tip\\n is located at the central most aspect of the subclavian vein.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2108-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416147,\n \"text\": \"SICU NPN 11p-7a\\nS/o- Pt neurologically intact throughout the shift, PERL, denies dizziness/blurry vision, states that she has a HA yet that it is only a . on a scale of for pain, took no pain med over . Nausea improved, no need for antiemetics over as well. MAE's w/ full strengths, no pronator drift, facial movements symetrical. Hemodynamically stable in SR w/ BP 100-110/40-50, resp- lungs clear, RR 12-16, sat 98-100% on RA. GI- abd soft nondistended, took small sips H2O this AM. GU- voiding w/o diff via foley, IVF con't at 100cc's hr overnoc. Hct 34.6 yest afternoon , stable at 33.8 this AM.\\nA/P- stable , advance DAT, activity, D/C foley and probable discharge to floor or home this PM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2108-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416148,\n \"text\": \"TSICU Nursing Progress NOte-Discharge Note-\\nNeuro-\\nAlert and oriented x3, no c/o dizziness, h/a, double/blurred vision. PERLA @ 4mm/, , oob to chair independently w/o dizziness.\\nCV -HR 70 SR, BP 120/70.\\nSkin- Head Lac, no new d/c, old blood cleaned off as able. Trace erythema @ site, 1+ tenderness.\\nStable --probable concussion.\\nPlan--\\nDischarged to home w/ parents.\\n\\nConcussion, Laceration, Suture Care discharge instructions reviewed w/ patient and mother, stating good understanding of documents. Trauma Clinic number provided, and instructed to call in next 24 hours and make F/U appt for 1 week.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416144,\n \"text\": \"SOCIAL WORK NOTE:\\nPt and family known to this SW from pt's ED arrival. Please see my printed OMR note for further information. Met with pt and her parents this afternoon to offer continued support. Pt has been extubated and is alert, fully oriented, and able to answer questions and engage pleasantly in conversation. This SW will f/u tomorrow with pt and family if pt remains on T-SICU. Family has contact information for this SW and I encouraged parents and pt to be contact if further support needed. Pager .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416145,\n \"text\": \"T/SICU 15:00:\\n\\nPT ARRIVED TO UNIT FROM EW/CTS ->STABLE. EXTUBATED UPON ARRIVAL, MAINTAINING ADEQUATE OXYGENATION - DENIES SOB. TLS AND C-SPINE CLEARED BY TEAM - CERVICAL COLLAR D/C'D. VSS - DENIES CARDIAC C/O'S OR PAIN ISSUES - ALERT/ORIENTED X3 - AFFECT/QUESTIONS/CONCERNS APPROPRIATE. PARENTS IN ROOM W/PT - RESTING COMFORTABLY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2108-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416146,\n \"text\": \"T/SICU\\nPT IS A 19 YO WOMEN WHO FELL VS WAS STRUCK WHILE RIDING HER BICYCLE.SHE WAS WEARING A HELMET.SHE HAD LOC AT THE SCENE,VOMITING,WAS INTUBATED AND SEDATED,MEDFLIGHTED TO .SHE HAS NO PMH,NO ALLERGIES AND TAKES NO MEDS AT HOME.PEARL AT THE SCENE\\n\\nAT ,SHE WAS CLEARED BOTH BY XRAY AND PHYSICAL EXAM FOR HER TLS.C-SPINE CLEARED.INJURIES INCLUDE A LAC TO HER SCALP.UPON ARRIVAL TO T/SICU, SHE WAS EXTUBATED TO NC.\\n\\nROS:\\n\\n PT IS ON Q 2HR NEURO CHECKS.SHE HAS BEEN ALERT AND ORIENTED X 3,PEARL,GRASPS EQUAL. C/O SEVERE HA WITH N/V,TX WITH ZOFRAN/MS IV WITH GOOG EFFECT,REPEATED WHEN SYMPTOMS REOCCURED.\\n\\nCARDIAC- VSS,IN NSR.SHE HAS A RT SUBCLAVIAN TRAUMA LINE INFUSING LR AT 100CC/HR.IN ADDITION SHE HAS THREE PERIPHERAL #18G IV'S WHICH FLUSH WELL.\\n\\nRESP-LS CLEAR,NO RESP DISTRESS NOTED.WEANED TO RA.\\n\\n PT REMAINS NPO.N/V RELIVED WITH MEDICATION AS ABOVE\\n\\n PT CLEAR,YELLOW URINE VIA FOLEY CATHETER.\\n\\nPARENTS HAVE BEEN IN WITH PT MUCH OF THE EVENING.\\n\"\n }\n]"}}},{"rowIdx":23098,"cells":{"subject_id":{"kind":"number","value":23061,"string":"23,061"},"hadm_id":{"kind":"number","value":194030,"string":"194,030"},"target_text":{"kind":"string","value":"1) Gram negative bacteremia: patient presented with symptoms suspicious for rigor but she was afebrile. Blood cultures were drawn and the anaerobic bottle grew gram negative rods, which are consistent with possible anaerobic gut organisms. She was treated with levofloxacin and flagyl while in the hospital and asymptomatic since presentation. CT of the abdomen/pelvis and MRCP were negative for identifying a source of infection. The ERCP service was contact and felt that without symptoms and with a normal MRCP, that ERCP was not necessary. Her LFT's were stable at discharge. She was discharged on 14 day total course of antibiotics. 2) Atrial fibrillation: She was noted to go into A fib two days into hospitalization, with rapid response to 150-180's and associated hypotension. She was transferred to the CCU and spontaneously converted a few hours after entering A fib following fluid boluses, metoprolol, and 150 mg of amiodarone. TSH/free T4 were normal. She was in NSR since that time, and will be set up with an event monitor at her cardiologist's office the day following discharge. Her propranolol daily dose was changed to atenolol for longer duration of action and to avoid multiple doses during the day. She was also maintained on heparin while hospitalized and started on coumadin for CHADS2 score of at least 2 at discharge, which will be managed by her PCP's office. She was not felt to need a bridge to coumadin and the heparin was discontinued at discharge. 3) Chest pain/CAD: CTA of the chest, EKG, and cardiac enzymes are negative. Her chest pain was felt to possibly be secondary to stable angina, or was possibly secondary to paroxysmal A fib. She was maintained on statin, Imdur (changed to once daily), atenolol, and started on a low dose of lisinopril. 4) Hypothyroidism: she was continued on synthroid. TSH/free T4 were normal. 5) Code - She was DNR/DNI"},"extractive_notes_summ":{"kind":"string","value":"Focal calcifications in aortic root.Normal ascending aorta diameter. There is no pericardial effusion.IMPRESSION: Preserved global and regional biventricular systolic function.Mild-moderate mitral regurgitation. Normal regional LV systolic function. Hypertension.Height: (in) 56Weight (lb): 154BSA (m2): 1.59 m2BP (mm Hg): 142/63HR (bpm): 74Status: InpatientDate/Time: at 11:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. moves all extrem, OOB to commode with steady gate.CV- remains in SR, rare PVc, rate 60-70 BP 110/43--143/60. ModeratePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. Moderate [2+]tricuspid regurgitation is seen. abx: levoflox + flagyl.RESP: LS clear. The common bile duct and pancreatic duct taper normally up to the ampulla, which appears unremarkable. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. No LA mass/thrombus (best excluded by TEE).RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Trace aortic regurgitation is seen. There is mild central biliary ductal dilatation. The spleen appears within normal limits. Mild to moderate (+) mitral regurgitation is seen. Dynamic volumetric images were acquired before, during, and after intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. Slight dry cough, not expectorating any sputum.CV:- Monitored in NSR, rare ectopics seen, rate 70-85bpm. ERCP '-> biliary dilitation. Pulmonary vascularity appears within normal limits. Portal venous flow is hepatopetal. Sinus rhythmAtrial premature complexesNonspecific precordial/anterior T wave abnormalitiesSince previous tracing of the same date, no significant change To observe RT AC site.ID:- Afebrile, given antibitics as needed, No obvious signs of infection known to be bacrteremic.SKIN:- Pressure areas intact, however whilcst using cammode rt buttock did get pinched slightly,r esulting in a small blood blister, duoderm applied. There is moderate pulmonary artery systolichypertension. ekg obtained - HO notified - assessed pt. Mild to moderate (+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mildly prominent mediastinal lymph nodes, and right hilar lymph nodes. Tollerated atenolol and lisinorpil well, without major drop in prssure. CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: The bladder, distal ureters, uterus are normal. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. pt with positive BC, source unknown , continues on antibiotics, afebrile, normotensive.P: NPO for MRI, follow rhythm, bp, resp status, assess for pain, support pt, OOB to chair with assist. Pneumobilia without evidence of a dependent biliary filling defect. A usual screening mammography is recommended. The common bile duct is within normal limits status post cholecystectomy measuring 9 mm. Bowels open x1, good amount.ACCESS:- Peripheral lines patent, sites satisfactory.ID:- Afebrile, antibiotics given as ordered. Moderate tricuspid regurgitation.Pulmonary artery systolic hypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). NPN 7 Pm - 7 AMs: \" I really feel fine, can you take this IV out? Slightly prominent infundibulum along the medial aortic arch, apparently the origin of a small vessel, of doubtful clinical significance. Started empirically on abx. TECHNIQUE: Axial non-contrast and contrast images through the abdomen and pelvis. Regionalleft ventricular wall motion is normal. She came to reg floor but later was found to be hypotensive and in rapid A- Fib, to unit yesterday where she received loading dose of amiodarone and converted to SR. Pt stable overnight, remains in SR, BP stable and no chest discommfort. am PTT 150- infusion on hold at 630 to 730am - restart gtt @ 800u/hr at 730amGI/GU: voiding well. Clinical decisions regarding the needfor prophylaxis should be based on clinical and echocardiographic data.Conclusions:The left atrium is normal in size. Atrial fibrillation with rapid ventricular responseDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in partischemia - clinical correlation is suggestedSince previous tracing of , rapid atrial fibrillation and further ST-Twave changes now present Usual mammographic screening is recommended. Abdomen soft and non tender, bowel sounds heard.ACCESS:- All 3 PIVs', removed as infilrated within hours of each other, IV placed new PIV. cont cardiac meds. Has continued to be in sr, pain free.resp: Initially pt on 100% NRB w/ sats high90's, after conversion to sr, sats 100% on 2lnp. Bedside AP chest radiograph dated compared to the prior chest radiograph dated . (Over) 4:22 PM CTA CHEST W&W/O C &RECONS Clip # Reason: eval PE, dissection Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) 3. Abdomen soft and non tender, continues on stool softener. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There are small bilateral pleural effusions and bibasilar atelectasis. Small bilateral breast calcifications are noted. Normal aortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). No left atrial mass/thrombus seen (bestexcluded by transesophageal echocardiography). Given lopressor 2.5 mg iv x3 w/ no appreciable change in hr, then given a150 mg amiodarone load, after which pt converted to sr rate 70's, no vea. Right ventricular chamber size andfree wall motion are normal. No c/o abd discomfort since CCU admit.gu: vdg qsid: afebrile, cont on abxskin: intactsocial: has been living in senior housing, scheduled to move to , daughter in with pt most of afternoon.Pt has macular degeneration and has very poor eyesight.A: RAF w/ hypotension, converted to sr after lopressor and amiodaroneP: NPO for MRCP this eve, monitor rhythm, bp Transferred to floor, c/o abd tenderness and fever w/ unknown source. There is bibasilar atelectasis, but otherwise the lungs are clear. Sinus rhythmAtrial premature complexesNonspecific precordial/anterior T wave abnormalitiesNo previous tracing available for comparison"},"n_notes":{"kind":"number","value":19,"string":"19"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2130-09-28 00:00:00.000","description":"Report","row_id":1563757,"text":"CCU Progress note 0700-1900\nRESP:- On room air for most of the day, Sa02 96-100%, RR 12-16, bilateral air entry haerd to all lungfields. Slight dry cough, not expectorating any sputum.\n\nCV:- Monitored in NSR, rare ectopics seen, rate 70-85bpm. SBP 100-120s'. Tollerated atenolol and lisinorpil well, without major drop in prssure. Peripherally warm to touch. Heparin re-stated at 850 units/hr, PTT collected late as had to wait for phebotomy to collect as very difficult stick.\n\nNEURO:- A&O x3, able to change own position from bed to chair as needed. and chatty. Walking to bathroom with assitance. PT seen and assessed.\n\nGU:- walking to bathrom and voiding in the bathroom, good amounts of clear yellow urine.\n\nGI:- Eaten very little today, had 1 x slice of toast only despite freequent encourgment from family. Refused neutraphos. Abdomen soft and non tender, continues on stool softener. Bowels open x1, good amount.\n\nACCESS:- Peripheral lines patent, sites satisfactory.\n\nID:- Afebrile, antibiotics given as ordered. Not coughing/expectorating sputum. NO other signs of infection. Awaiting rest of culture data.\n\nSKIN:- Pressure areas inatact, blister on RT buttock much better, just appaers as a bruise now. Able to change own position as needed. Full bedbath and sheet change given, feet soaked.\n\nFAMILY:- Daughter telephoned and today, updated on plan of care. No other enquires from family as yet today.\n\nPLAN:- For possible discahrge today/tomorrow, called out to the floor when bed avalible. To continue with heaprin as ordered and titrate as needed-> to convert to oral when discharge date organised. For possible home saftey evalutaion on discharged as movinmg into new home at . To continue to give full explination of care to patient and family.\n\n\n"},{"category":"Nursing/other","chartdate":"2130-09-28 00:00:00.000","description":"Report","row_id":1563758,"text":"CCU Progress note 0700-1900\nADDENDUM:- Pt able to go home today, heparin stopped started oral warfarin and antibiotics, tollerated well. All vitals within normal limits. Discahrged home with services at . All information given and explinated to both patient and daughter.\n"},{"category":"Nursing/other","chartdate":"2130-09-27 00:00:00.000","description":"Report","row_id":1563755,"text":"CCU Progress Note 0700-\nRESP:- Has remained on room air during the day, Sa02 94-96%, RR 14-16 and regular. Bilateral air entry heard to all lungfields. Not coughing/expectorating sputum.\n\nCV:- Monitored in NSR 70-80bpm, no ectopics seen. SBP 119-130s', MAP 60-70s'. Tollerated cardiac meds well, propanaolol given before order picked up for atenolol, so to start that in the am. Peripherally warm to touch. MG replaeted with IV mag, will take PO K+ once had MRI. Commenced heparin at 1200 units/hr at 1300.\n\nNEURO:- A&O x3, lady, a little angry this morning as she could not eat and she wanted to go home. For MRI this afternoon. Able to teransfer self with minimal assistance from bed to chair. Has short nap this afternoon. PERL 2-3mm.\n\nGU:- Using cammode as needed, voiding good amounts of clear yellow urine.\n\nGI:- Ate a small amount for breakfast, NPO for procdure since. Bowels not moved, taking colase, not had bowel movement since monday. Abdomen soft and non tender, bowel sounds heard.\n\nACCESS:- All 3 PIVs', removed as infilrated within hours of each other, IV placed new PIV. Possibly need second line placed later today. To observe RT AC site.\n\nID:- Afebrile, given antibitics as needed, No obvious signs of infection known to be bacrteremic.\n\nSKIN:- Pressure areas intact, however whilcst using cammode rt buttock did get pinched slightly,r esulting in a small blood blister, duoderm applied. Able to change own position in the bed as needed.\n\nFAMILY:- Daughter into visited this morning, eagerly awaiting MRI! also. Updated on plan of care, has spoken to her also on the phone.\n\nPLAN:- for MRI at somepoint this aftertoon, to continue with the antibiotics as ordered. To continue to give fulle xplination of care to aptient and family.\n"},{"category":"Nursing/other","chartdate":"2130-09-28 00:00:00.000","description":"Report","row_id":1563756,"text":"ccu progress note 7p-7a\n\nEVENTS: episode of CP at 5am this morning - maalox + crackers given with some relief to . ekg obtained - HO notified - assessed pt. O2 in place 2L. Ntg 0.3mg SL given total of 3 times with cessation of CP at 6am.\n\nNEURO: A+Ox3. OOB to chair + BSC. family in in the evening - updated by CCU team re plan of care + treatment/meds/tests. walking well under supervision. parkinson-like intentional tremors.\n\nID: afebrile. abx: levoflox + flagyl.\n\nRESP: LS clear. ra sats 93-95%. placed on O2 2L during CP episode this morning.\n\nCARDIAC: SR 60-70s. SBP 120-130s. To start increased dose atenolol 50mg in am. started dose captopril 6.25mg last nite - to start on lisinopril 2.5mg po today. Isordil 60mg qd. rec'd ntg s/l x3 this morning. Heparin 1050u/hr. am PTT 150- infusion on hold at 630 to 730am - restart gtt @ 800u/hr at 730am\n\nGI/GU: voiding well. BM x1 this morning. poor appetite. had toast and tea after MRI - took oral KCL replacements at that time (ordered in am). encourage po intake - poor appetite - \"everything is tasteless, I am not hungry\"\n\nPLAN: please restart HEPERIN gtt @ 730am @ 800u/hr. cont cardiac meds. monitor for CP, encourage pt to notify nurse for any discomfort or CP as she waited to say anything to nurse overnight. \"It was only a little pain, I get it in the past\" \" last 30 years, little pains are nothing.\" transfer to floor when bed available.\n"},{"category":"Nursing/other","chartdate":"2130-09-26 00:00:00.000","description":"Report","row_id":1563751,"text":"CCU NSG ADMIT\n76 yo woman presented to ew w/ chest pressure and nausea while walking at the mall. In EW EKG-> frequent pvd's no st changes, pain lasted several hrs not relieved w/ ntg. negative ck and troponin. Transferred to floor, c/o abd tenderness and fever w/ unknown source. Started empirically on abx. + BC . ERCP '-> biliary dilitation. CT central buliary ductal dilatation, hepatic cyst.\n\nThis am pt c/o feeling dizzy, palpatations. Found to be in rapid af w/ rate ~ 160, hypotensive w/ sbp 50. Transferred to CCU for further evaluation and tx.\n\nPt arrived to CCU ~ 1100, awake, alert, oriented x3, mentating well, cooperative.\nHR 140-160 RAF.bp 80-96/40-50 IVF 200cc/hr, given ~ 2 liters ivf on floor. Given lopressor 2.5 mg iv x3 w/ no appreciable change in hr, then given a150 mg amiodarone load, after which pt converted to sr rate 70's, no vea. sbp up to mid teens. Has continued to be in sr, pain free.\nresp: Initially pt on 100% NRB w/ sats high90's, after conversion to sr, sats 100% on 2lnp. lungs cta\ngi: poor appitite. NPO at this time for MRCP this evening. MRI checklist done. No c/o abd discomfort since CCU admit.\ngu: vdg qs\nid: afebrile, cont on abx\nskin: intact\nsocial: has been living in senior housing, scheduled to move to , daughter in with pt most of afternoon.\nPt has macular degeneration and has very poor eyesight.\nA: RAF w/ hypotension, converted to sr after lopressor and amiodarone\nP: NPO for MRCP this eve, monitor rhythm, bp\n\n\n"},{"category":"Nursing/other","chartdate":"2130-09-27 00:00:00.000","description":"Report","row_id":1563752,"text":"NPN 7 Pm - 7 AM\n\ns: \" I really feel fine, can you take this IV out? I can't stand all these wires.\"\n\no: please see careview for vitals and other objective data\n\nPt with PMH of CAD, GERD, macular degeneration, recent neg stress test\nadmitted to CCU with RAF. She originally experienced CP & dizzyness in the mall and CP here in ER, which did not respond to ntg. she had negative troponin and EKG. Pt also spiked a fever to 101 and BC was drawn ( GNR, origin unknown), she received fluid bolus and IV antibiotics. Pt was transferred here yesterday from floor with rapid A fib, txed with 500 ns bolus, Iv lopressor and Loading dose of amiodarone. Pt converted to SR after amiodarone and has remained in SR overnight and she is pain free.\n\nNeuro: Alert ox3, communicates well in english. moves all extrem, OOB to commode with steady gate.\n\nCV- remains in SR, rare PVc, rate 60-70 BP 110/43--143/60. No complaints of chest pain.\n\nRespiratory: lungs clear, sats 98-100 on 2L, down to 93-94 on room air. denies SOB.\n\nGI: pt has hx of billiary stent, and had elevated liver enzymes. She is due for MRI tomorrow nad is NPO. abd soft. denies discomfort.\n\nGU: voids clear yellow urine, good amounts 1600 cc overnight.\n\nsocial; dtr is supportive, visiting all day until 9 PM. Pt is moving to tomorrow. Pt is anxious to go back home, but has her dtr and professional movers to help her.\n\nA: pt sp event of rapid atrail fib, treated with IV amio load with good effect as well as fluids, remains in SR since yesterday afternoon. pt with positive BC, source unknown , continues on antibiotics, afebrile, normotensive.\n\nP: NPO for MRI, follow rhythm, bp, resp status, assess for pain, support pt, OOB to chair with assist. keep pt and family updated on POC as discussed in ccu rounds.\nshe has positive BC on\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n pt stared on levo and metrondiazole. She came to reg floor but later was found to be hypotensive and in rapid A- Fib, to unit yesterday where she received loading dose of amiodarone and converted to SR. Pt stable overnight, remains in SR, BP stable and no chest discommfort. afebrile.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2130-09-27 00:00:00.000","description":"Report","row_id":1563753,"text":"(Continued)\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2130-09-27 00:00:00.000","description":"Report","row_id":1563754,"text":"CCU Progress Note 0700-\nADDENDUM:- Pt taken to MRI for scan at 1830, nurse escort not needed, oreder written. heparin infusion continues at 12units/hr for PTT on return from MRI. Small blister/briuse on rt buttock, sustained when sitting on cammode, duoderm dressing inplace, to observe for bleeding as on heparin. Very upset prior to scan, reassurance given by medical and nursing staff.\n"},{"category":"Echo","chartdate":"2130-09-27 00:00:00.000","description":"Report","row_id":69336,"text":"PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Hypertension.\nHeight: (in) 56\nWeight (lb): 154\nBSA (m2): 1.59 m2\nBP (mm Hg): 142/63\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No LA mass/thrombus (best excluded by TEE).\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. No resting LVOT gradient.\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. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Based on AHA\nendocarditis 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 normal in size. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). Left ventricular wall\nthickness, cavity size, and systolic function are normal (LVEF>55%). Regional\nleft ventricular wall motion is normal. Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion. Trace aortic regurgitation is seen. The\nmitral valve leaflets are structurally normal. There is no mitral valve\nprolapse. Mild to moderate (+) mitral regurgitation is seen. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Preserved global and regional biventricular systolic function.\nMild-moderate mitral regurgitation. Moderate tricuspid regurgitation.\nPulmonary artery systolic hypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"},{"category":"ECG","chartdate":"2130-09-28 00:00:00.000","description":"Report","row_id":164627,"text":"Technically difficult study\nSinus rhythm\nQT interval prolonged for rate\nSince previous tracing, atrial fibrillation resolved\n\n"},{"category":"ECG","chartdate":"2130-09-26 00:00:00.000","description":"Report","row_id":164628,"text":"Atrial fibrillation with rapid ventricular response\nDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , rapid atrial fibrillation and further ST-T\nwave changes now present\n\n"},{"category":"ECG","chartdate":"2130-09-24 00:00:00.000","description":"Report","row_id":164629,"text":"Sinus rhythm\nAtrial premature complexes\nNonspecific precordial/anterior T wave abnormalities\nSince previous tracing of the same date, no significant change\n\n"},{"category":"ECG","chartdate":"2130-09-24 00:00:00.000","description":"Report","row_id":164630,"text":"Sinus rhythm\nAtrial premature complexes\nNonspecific precordial/anterior T wave abnormalities\nNo previous tracing available for comparison\n\n"},{"category":"Radiology","chartdate":"2130-09-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":933962,"text":" 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with hypoxia following A fib\n\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia following atrial fibrillation.\n\n Bedside AP chest radiograph dated compared to the prior chest\n radiograph dated . In the interval, there has been no change\n in the radiographic appearance of the chest, including probable mild\n cardiomegaly, normal pulmonary vascularity, clear lungs, absence of sizable\n pleural effusions.\n\n IMPRESSION: No CHF, no change since previous examination.\n\n"},{"category":"Radiology","chartdate":"2130-09-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":933606,"text":" 3:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with near syncope, intermittent CP, hypoxia\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Near syncope, intermittent chest pain and hypoxia.\n\n COMPARISON: None.\n\n PORTABLE CHEST: Cardiac and mediastinal contours appear unremarkable.\n Pulmonary vascularity appears within normal limits. Linear opacities at the\n left base likely represent atelectasis. No evidence of pleural effusion.\n\n IMPRESSION: Linear opacity at the left base likely represents atelectasis.\n\n"},{"category":"Radiology","chartdate":"2130-09-24 00:00:00.000","description":"CTA CHEST W&W/O C &RECONS","row_id":933609,"text":" 4:22 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: eval PE, dissection\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with chest pain radiating to back, hypoxic\n REASON FOR THIS EXAMINATION:\n eval PE, dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SUN 6:02 PM\n no pe or dissection; small infundibulum at origin or arch vessel of doubtful\n significance; pneumobilia with slight prominent central bile ducts, suggest\n clinical correlation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76-year-old woman with chest pain and near syncope.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial non-contrast CT images of the chest were first obtained,\n followed by a CT angiogram of the chest with intravenous contrast. Sagittal,\n coronal, and bilateral posterior oblique projection reconstructions were also\n performed.\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There are multiple subcentimeter\n slightly prominent mediastinal lymph nodes, the largest an upper medistinal\n nodes, of borderline size measuring 11 mm in diameter. There are also mildly\n prominent subcentimeter right hilar nodes. The heart, great vessels, and\n pericardium are unremarkable. There is a small medial infundibulum along the\n medial aortic arch associated with a small branch vessel. This is of doubtful\n clinical significance and measures up to 4 mm in diameter. There are a few\n calcifications in the aortic arch. There is no evidence of pulmonary\n embolism. There is bibasilar atelectasis, but otherwise the lungs are clear.\n\n Small bilateral breast calcifications are noted. A usual screening\n mammography is recommended.\n\n There are several subcentimeter hypoattenuating foci in the liver which are\n too small to characterize. The visualized left lobe shows pneumobilia with a\n slightly prominent duct. This may relate to prior cholecystectomy, but\n correlation with clinical history is recommended. Otherwise limited views of\n the upper abdomen are unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism or aortic dissection.\n\n 2. Slightly prominent infundibulum along the medial aortic arch, apparently\n the origin of a small vessel, of doubtful clinical significance.\n (Over)\n\n 4:22 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: eval PE, dissection\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Mildly prominent mediastinal lymph nodes, and right hilar lymph nodes.\n\n 4. Bibasilar atelectasis.\n\n 5. Pneumobilia, with slight prominence of the visualized central hepatic bile\n ducts. Correlation with clinical history and laboratory data is recommended.\n\n 6. Breast calcifications. Usual mammographic screening is recommended.\n\n"},{"category":"Radiology","chartdate":"2130-09-25 00:00:00.000","description":"CT ABD W&W/O C","row_id":933738,"text":" 2:33 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: eval source of fever\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with hx of biliary stones p/w fever, abdominal tenderness\n REASON FOR THIS EXAMINATION:\n eval source of fever\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of biliary stones, abdominal pain, and fever.\n\n TECHNIQUE: Axial non-contrast and contrast images through the abdomen and\n pelvis. Multiplanar reformats were performed.\n\n CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There are small bilateral\n pleural effusions and bibasilar atelectasis. There are multiple low\n attenuations within the dome of the liver, too small to characterize. There\n is a 6-mm right hepatic cyst. There is pneumobilia in this patient status\n post cholecystectomy. There is mild central biliary ductal dilatation. The\n common bile duct is within normal limits status post cholecystectomy measuring\n 9 mm. The pancreas, spleen, splenule, adrenal glands, kidneys, ureters, and\n large and small bowel are normal. There is no free air, free fluid, or\n lymphadenopathy. There is atherosclerotic calcification of the descending\n aorta.\n\n CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: The bladder, distal ureters,\n uterus are normal. There is no free fluid or lymphadenopathy.\n\n BONE WINDOWS: No suspicious lesions.\n\n REFORMATTED IMAGES: These show no fluid collections.\n\n IMPRESSION:\n 1. No explanation of the patient's symptoms.\n 2. Central biliary ductal dilatation and pneumobilia.\n 3. Hepatic cyst. Small low attenuations in the liver, too small to\n characterize.\n 4. Small bilateral pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2130-09-27 00:00:00.000","description":"MRCP (MR ABD W&W/OC)","row_id":934059,"text":" 6:59 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: eval for filling defects\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with h/o CAD, s/p cholecystectomy and biliary\n stenting/removal presents with epigastric pain, GNR bacteremia of unclear\n source\n REASON FOR THIS EXAMINATION:\n eval for filling defects\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old lady with history of coronary artery disease,\n cholecystectomy, and biliary stenting (removed in ) with Gram-negative rod\n bacteremia of unknown origin.\n\n TECHNIQUE:\n\n Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet.\n Dynamic volumetric images were acquired before, during, and after intravenous\n administration of 0.1 mmol/kg of gadolinium-DTPA. Subtraction images and\n multidimensional reformatted images were created and reviewed on an\n independent workstation.\n\n The liver shows no evidence of intrahepatic biliary duct dilatation or focal\n hepatic mass. There are a few scattered tiny simple cysts. Portal venous\n flow is hepatopetal.\n\n Air is identified within the biliary system (pneumobilia), which impacts the\n quality of the biliary imaging. Nevertheless, no dependent filling defect is\n identified. The gallbladder is surgically absent. The common bile duct and\n pancreatic duct taper normally up to the ampulla, which appears unremarkable.\n The extrahepatic biliary system, notably the common bile duct, is mildly\n dilated with a maximum diameter of approximately 11.5 mm.\n\n The pancreas appears unremarkable. There is no evidence of pancreas divisum.\n The adrenal glands and kidneys appear unremarkable. Incidental note is made\n of bibasilar atelectasis. The spleen appears within normal limits.\n\n IMPRESSION:\n 1. Pneumobilia without evidence of a dependent biliary filling defect.\n 2. Cholecystectomy.\n\n\n"},{"category":"Radiology","chartdate":"2130-09-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":933853,"text":" 10:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out PNA or pulm edema\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with sudden onset CP/SOB this am\n\n REASON FOR THIS EXAMINATION:\n rule out PNA or pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath and chest pain.\n\n Portable AP chest radiograph compared to .\n\n The heart size is mildly enlarged, but stable. The mediastinum is in normal\n position, contour, and width. The lungs are clear. The pleural surfaces are\n smooth with no pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563757,\n \"text\": \"CCU Progress note 0700-1900\\nRESP:- On room air for most of the day, Sa02 96-100%, RR 12-16, bilateral air entry haerd to all lungfields. Slight dry cough, not expectorating any sputum.\\n\\nCV:- Monitored in NSR, rare ectopics seen, rate 70-85bpm. SBP 100-120s'. Tollerated atenolol and lisinorpil well, without major drop in prssure. Peripherally warm to touch. Heparin re-stated at 850 units/hr, PTT collected late as had to wait for phebotomy to collect as very difficult stick.\\n\\nNEURO:- A&O x3, able to change own position from bed to chair as needed. and chatty. Walking to bathroom with assitance. PT seen and assessed.\\n\\nGU:- walking to bathrom and voiding in the bathroom, good amounts of clear yellow urine.\\n\\nGI:- Eaten very little today, had 1 x slice of toast only despite freequent encourgment from family. Refused neutraphos. Abdomen soft and non tender, continues on stool softener. Bowels open x1, good amount.\\n\\nACCESS:- Peripheral lines patent, sites satisfactory.\\n\\nID:- Afebrile, antibiotics given as ordered. Not coughing/expectorating sputum. NO other signs of infection. Awaiting rest of culture data.\\n\\nSKIN:- Pressure areas inatact, blister on RT buttock much better, just appaers as a bruise now. Able to change own position as needed. Full bedbath and sheet change given, feet soaked.\\n\\nFAMILY:- Daughter telephoned and today, updated on plan of care. No other enquires from family as yet today.\\n\\nPLAN:- For possible discahrge today/tomorrow, called out to the floor when bed avalible. To continue with heaprin as ordered and titrate as needed-> to convert to oral when discharge date organised. For possible home saftey evalutaion on discharged as movinmg into new home at . To continue to give full explination of care to patient and family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563758,\n \"text\": \"CCU Progress note 0700-1900\\nADDENDUM:- Pt able to go home today, heparin stopped started oral warfarin and antibiotics, tollerated well. All vitals within normal limits. Discahrged home with services at . All information given and explinated to both patient and daughter.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563755,\n \"text\": \"CCU Progress Note 0700-\\nRESP:- Has remained on room air during the day, Sa02 94-96%, RR 14-16 and regular. Bilateral air entry heard to all lungfields. Not coughing/expectorating sputum.\\n\\nCV:- Monitored in NSR 70-80bpm, no ectopics seen. SBP 119-130s', MAP 60-70s'. Tollerated cardiac meds well, propanaolol given before order picked up for atenolol, so to start that in the am. Peripherally warm to touch. MG replaeted with IV mag, will take PO K+ once had MRI. Commenced heparin at 1200 units/hr at 1300.\\n\\nNEURO:- A&O x3, lady, a little angry this morning as she could not eat and she wanted to go home. For MRI this afternoon. Able to teransfer self with minimal assistance from bed to chair. Has short nap this afternoon. PERL 2-3mm.\\n\\nGU:- Using cammode as needed, voiding good amounts of clear yellow urine.\\n\\nGI:- Ate a small amount for breakfast, NPO for procdure since. Bowels not moved, taking colase, not had bowel movement since monday. Abdomen soft and non tender, bowel sounds heard.\\n\\nACCESS:- All 3 PIVs', removed as infilrated within hours of each other, IV placed new PIV. Possibly need second line placed later today. To observe RT AC site.\\n\\nID:- Afebrile, given antibitics as needed, No obvious signs of infection known to be bacrteremic.\\n\\nSKIN:- Pressure areas intact, however whilcst using cammode rt buttock did get pinched slightly,r esulting in a small blood blister, duoderm applied. Able to change own position in the bed as needed.\\n\\nFAMILY:- Daughter into visited this morning, eagerly awaiting MRI! also. Updated on plan of care, has spoken to her also on the phone.\\n\\nPLAN:- for MRI at somepoint this aftertoon, to continue with the antibiotics as ordered. To continue to give fulle xplination of care to aptient and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563756,\n \"text\": \"ccu progress note 7p-7a\\n\\nEVENTS: episode of CP at 5am this morning - maalox + crackers given with some relief to . ekg obtained - HO notified - assessed pt. O2 in place 2L. Ntg 0.3mg SL given total of 3 times with cessation of CP at 6am.\\n\\nNEURO: A+Ox3. OOB to chair + BSC. family in in the evening - updated by CCU team re plan of care + treatment/meds/tests. walking well under supervision. parkinson-like intentional tremors.\\n\\nID: afebrile. abx: levoflox + flagyl.\\n\\nRESP: LS clear. ra sats 93-95%. placed on O2 2L during CP episode this morning.\\n\\nCARDIAC: SR 60-70s. SBP 120-130s. To start increased dose atenolol 50mg in am. started dose captopril 6.25mg last nite - to start on lisinopril 2.5mg po today. Isordil 60mg qd. rec'd ntg s/l x3 this morning. Heparin 1050u/hr. am PTT 150- infusion on hold at 630 to 730am - restart gtt @ 800u/hr at 730am\\n\\nGI/GU: voiding well. BM x1 this morning. poor appetite. had toast and tea after MRI - took oral KCL replacements at that time (ordered in am). encourage po intake - poor appetite - \\\"everything is tasteless, I am not hungry\\\"\\n\\nPLAN: please restart HEPERIN gtt @ 730am @ 800u/hr. cont cardiac meds. monitor for CP, encourage pt to notify nurse for any discomfort or CP as she waited to say anything to nurse overnight. \\\"It was only a little pain, I get it in the past\\\" \\\" last 30 years, little pains are nothing.\\\" transfer to floor when bed available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563751,\n \"text\": \"CCU NSG ADMIT\\n76 yo woman presented to ew w/ chest pressure and nausea while walking at the mall. In EW EKG-> frequent pvd's no st changes, pain lasted several hrs not relieved w/ ntg. negative ck and troponin. Transferred to floor, c/o abd tenderness and fever w/ unknown source. Started empirically on abx. + BC . ERCP '-> biliary dilitation. CT central buliary ductal dilatation, hepatic cyst.\\n\\nThis am pt c/o feeling dizzy, palpatations. Found to be in rapid af w/ rate ~ 160, hypotensive w/ sbp 50. Transferred to CCU for further evaluation and tx.\\n\\nPt arrived to CCU ~ 1100, awake, alert, oriented x3, mentating well, cooperative.\\nHR 140-160 RAF.bp 80-96/40-50 IVF 200cc/hr, given ~ 2 liters ivf on floor. Given lopressor 2.5 mg iv x3 w/ no appreciable change in hr, then given a150 mg amiodarone load, after which pt converted to sr rate 70's, no vea. sbp up to mid teens. Has continued to be in sr, pain free.\\nresp: Initially pt on 100% NRB w/ sats high90's, after conversion to sr, sats 100% on 2lnp. lungs cta\\ngi: poor appitite. NPO at this time for MRCP this evening. MRI checklist done. No c/o abd discomfort since CCU admit.\\ngu: vdg qs\\nid: afebrile, cont on abx\\nskin: intact\\nsocial: has been living in senior housing, scheduled to move to , daughter in with pt most of afternoon.\\nPt has macular degeneration and has very poor eyesight.\\nA: RAF w/ hypotension, converted to sr after lopressor and amiodarone\\nP: NPO for MRCP this eve, monitor rhythm, bp\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563752,\n \"text\": \"NPN 7 Pm - 7 AM\\n\\ns: \\\" I really feel fine, can you take this IV out? I can't stand all these wires.\\\"\\n\\no: please see careview for vitals and other objective data\\n\\nPt with PMH of CAD, GERD, macular degeneration, recent neg stress test\\nadmitted to CCU with RAF. She originally experienced CP & dizzyness in the mall and CP here in ER, which did not respond to ntg. she had negative troponin and EKG. Pt also spiked a fever to 101 and BC was drawn ( GNR, origin unknown), she received fluid bolus and IV antibiotics. Pt was transferred here yesterday from floor with rapid A fib, txed with 500 ns bolus, Iv lopressor and Loading dose of amiodarone. Pt converted to SR after amiodarone and has remained in SR overnight and she is pain free.\\n\\nNeuro: Alert ox3, communicates well in english. moves all extrem, OOB to commode with steady gate.\\n\\nCV- remains in SR, rare PVc, rate 60-70 BP 110/43--143/60. No complaints of chest pain.\\n\\nRespiratory: lungs clear, sats 98-100 on 2L, down to 93-94 on room air. denies SOB.\\n\\nGI: pt has hx of billiary stent, and had elevated liver enzymes. She is due for MRI tomorrow nad is NPO. abd soft. denies discomfort.\\n\\nGU: voids clear yellow urine, good amounts 1600 cc overnight.\\n\\nsocial; dtr is supportive, visiting all day until 9 PM. Pt is moving to tomorrow. Pt is anxious to go back home, but has her dtr and professional movers to help her.\\n\\nA: pt sp event of rapid atrail fib, treated with IV amio load with good effect as well as fluids, remains in SR since yesterday afternoon. pt with positive BC, source unknown , continues on antibiotics, afebrile, normotensive.\\n\\nP: NPO for MRI, follow rhythm, bp, resp status, assess for pain, support pt, OOB to chair with assist. keep pt and family updated on POC as discussed in ccu rounds.\\nshe has positive BC on\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n pt stared on levo and metrondiazole. She came to reg floor but later was found to be hypotensive and in rapid A- Fib, to unit yesterday where she received loading dose of amiodarone and converted to SR. Pt stable overnight, remains in SR, BP stable and no chest discommfort. afebrile.\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563753,\n \"text\": \"(Continued)\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2130-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1563754,\n \"text\": \"CCU Progress Note 0700-\\nADDENDUM:- Pt taken to MRI for scan at 1830, nurse escort not needed, oreder written. heparin infusion continues at 12units/hr for PTT on return from MRI. Small blister/briuse on rt buttock, sustained when sitting on cammode, duoderm dressing inplace, to observe for bleeding as on heparin. Very upset prior to scan, reassurance given by medical and nursing staff.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2130-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 69336,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Atrial fibrillation. Hypertension.\\nHeight: (in) 56\\nWeight (lb): 154\\nBSA (m2): 1.59 m2\\nBP (mm Hg): 142/63\\nHR (bpm): 74\\nStatus: Inpatient\\nDate/Time: at 11:59\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size. No LA mass/thrombus (best excluded by TEE).\\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. No resting LVOT gradient.\\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. Normal aortic arch diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\\nMR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\\nPA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Based on AHA\\nendocarditis 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 normal in size. No left atrial mass/thrombus seen (best\\nexcluded by transesophageal echocardiography). Left ventricular wall\\nthickness, cavity size, and systolic function are normal (LVEF>55%). Regional\\nleft ventricular wall motion is normal. Right ventricular chamber size and\\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\\nnormal with good leaflet excursion. Trace aortic regurgitation is seen. The\\nmitral valve leaflets are structurally normal. There is no mitral valve\\nprolapse. Mild to moderate (+) mitral regurgitation is seen. Moderate [2+]\\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Preserved global and regional biventricular systolic function.\\nMild-moderate mitral regurgitation. Moderate tricuspid regurgitation.\\nPulmonary artery systolic hypertension.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164627,\n \"text\": \"Technically difficult study\\nSinus rhythm\\nQT interval prolonged for rate\\nSince previous tracing, atrial fibrillation resolved\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164628,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in part\\nischemia - clinical correlation is suggested\\nSince previous tracing of , rapid atrial fibrillation and further ST-T\\nwave changes now present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164629,\n \"text\": \"Sinus rhythm\\nAtrial premature complexes\\nNonspecific precordial/anterior T wave abnormalities\\nSince previous tracing of the same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164630,\n \"text\": \"Sinus rhythm\\nAtrial premature complexes\\nNonspecific precordial/anterior T wave abnormalities\\nNo previous tracing available for comparison\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-09-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 933962,\n \"text\": \" 9:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for CHF\\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with hypoxia following A fib\\n\\n REASON FOR THIS EXAMINATION:\\n eval for CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hypoxia following atrial fibrillation.\\n\\n Bedside AP chest radiograph dated compared to the prior chest\\n radiograph dated . In the interval, there has been no change\\n in the radiographic appearance of the chest, including probable mild\\n cardiomegaly, normal pulmonary vascularity, clear lungs, absence of sizable\\n pleural effusions.\\n\\n IMPRESSION: No CHF, no change since previous examination.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 933606,\n \"text\": \" 3:37 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with near syncope, intermittent CP, hypoxia\\n REASON FOR THIS EXAMINATION:\\n infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Near syncope, intermittent chest pain and hypoxia.\\n\\n COMPARISON: None.\\n\\n PORTABLE CHEST: Cardiac and mediastinal contours appear unremarkable.\\n Pulmonary vascularity appears within normal limits. Linear opacities at the\\n left base likely represent atelectasis. No evidence of pleural effusion.\\n\\n IMPRESSION: Linear opacity at the left base likely represents atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-09-24 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C &RECONS\",\n \"row_id\": 933609,\n \"text\": \" 4:22 PM\\n CTA CHEST W&W/O C &RECONS Clip # \\n Reason: eval PE, dissection\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with chest pain radiating to back, hypoxic\\n REASON FOR THIS EXAMINATION:\\n eval PE, dissection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: AEBc SUN 6:02 PM\\n no pe or dissection; small infundibulum at origin or arch vessel of doubtful\\n significance; pneumobilia with slight prominent central bile ducts, suggest\\n clinical correlation\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 76-year-old woman with chest pain and near syncope.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Axial non-contrast CT images of the chest were first obtained,\\n followed by a CT angiogram of the chest with intravenous contrast. Sagittal,\\n coronal, and bilateral posterior oblique projection reconstructions were also\\n performed.\\n\\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There are multiple subcentimeter\\n slightly prominent mediastinal lymph nodes, the largest an upper medistinal\\n nodes, of borderline size measuring 11 mm in diameter. There are also mildly\\n prominent subcentimeter right hilar nodes. The heart, great vessels, and\\n pericardium are unremarkable. There is a small medial infundibulum along the\\n medial aortic arch associated with a small branch vessel. This is of doubtful\\n clinical significance and measures up to 4 mm in diameter. There are a few\\n calcifications in the aortic arch. There is no evidence of pulmonary\\n embolism. There is bibasilar atelectasis, but otherwise the lungs are clear.\\n\\n Small bilateral breast calcifications are noted. A usual screening\\n mammography is recommended.\\n\\n There are several subcentimeter hypoattenuating foci in the liver which are\\n too small to characterize. The visualized left lobe shows pneumobilia with a\\n slightly prominent duct. This may relate to prior cholecystectomy, but\\n correlation with clinical history is recommended. Otherwise limited views of\\n the upper abdomen are unremarkable.\\n\\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\\n\\n IMPRESSION:\\n\\n 1. No evidence of pulmonary embolism or aortic dissection.\\n\\n 2. Slightly prominent infundibulum along the medial aortic arch, apparently\\n the origin of a small vessel, of doubtful clinical significance.\\n (Over)\\n\\n 4:22 PM\\n CTA CHEST W&W/O C &RECONS Clip # \\n Reason: eval PE, dissection\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n 3. Mildly prominent mediastinal lymph nodes, and right hilar lymph nodes.\\n\\n 4. Bibasilar atelectasis.\\n\\n 5. Pneumobilia, with slight prominence of the visualized central hepatic bile\\n ducts. Correlation with clinical history and laboratory data is recommended.\\n\\n 6. Breast calcifications. Usual mammographic screening is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-09-25 00:00:00.000\",\n \"description\": \"CT ABD W&W/O C\",\n \"row_id\": 933738,\n \"text\": \" 2:33 PM\\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \\n Reason: eval source of fever\\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with hx of biliary stones p/w fever, abdominal tenderness\\n REASON FOR THIS EXAMINATION:\\n eval source of fever\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: History of biliary stones, abdominal pain, and fever.\\n\\n TECHNIQUE: Axial non-contrast and contrast images through the abdomen and\\n pelvis. Multiplanar reformats were performed.\\n\\n CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There are small bilateral\\n pleural effusions and bibasilar atelectasis. There are multiple low\\n attenuations within the dome of the liver, too small to characterize. There\\n is a 6-mm right hepatic cyst. There is pneumobilia in this patient status\\n post cholecystectomy. There is mild central biliary ductal dilatation. The\\n common bile duct is within normal limits status post cholecystectomy measuring\\n 9 mm. The pancreas, spleen, splenule, adrenal glands, kidneys, ureters, and\\n large and small bowel are normal. There is no free air, free fluid, or\\n lymphadenopathy. There is atherosclerotic calcification of the descending\\n aorta.\\n\\n CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: The bladder, distal ureters,\\n uterus are normal. There is no free fluid or lymphadenopathy.\\n\\n BONE WINDOWS: No suspicious lesions.\\n\\n REFORMATTED IMAGES: These show no fluid collections.\\n\\n IMPRESSION:\\n 1. No explanation of the patient's symptoms.\\n 2. Central biliary ductal dilatation and pneumobilia.\\n 3. Hepatic cyst. Small low attenuations in the liver, too small to\\n characterize.\\n 4. Small bilateral pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-09-27 00:00:00.000\",\n \"description\": \"MRCP (MR ABD W&W/OC)\",\n \"row_id\": 934059,\n \"text\": \" 6:59 PM\\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: eval for filling defects\\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with h/o CAD, s/p cholecystectomy and biliary\\n stenting/removal presents with epigastric pain, GNR bacteremia of unclear\\n source\\n REASON FOR THIS EXAMINATION:\\n eval for filling defects\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 76-year-old lady with history of coronary artery disease,\\n cholecystectomy, and biliary stenting (removed in ) with Gram-negative rod\\n bacteremia of unknown origin.\\n\\n TECHNIQUE:\\n\\n Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet.\\n Dynamic volumetric images were acquired before, during, and after intravenous\\n administration of 0.1 mmol/kg of gadolinium-DTPA. Subtraction images and\\n multidimensional reformatted images were created and reviewed on an\\n independent workstation.\\n\\n The liver shows no evidence of intrahepatic biliary duct dilatation or focal\\n hepatic mass. There are a few scattered tiny simple cysts. Portal venous\\n flow is hepatopetal.\\n\\n Air is identified within the biliary system (pneumobilia), which impacts the\\n quality of the biliary imaging. Nevertheless, no dependent filling defect is\\n identified. The gallbladder is surgically absent. The common bile duct and\\n pancreatic duct taper normally up to the ampulla, which appears unremarkable.\\n The extrahepatic biliary system, notably the common bile duct, is mildly\\n dilated with a maximum diameter of approximately 11.5 mm.\\n\\n The pancreas appears unremarkable. There is no evidence of pancreas divisum.\\n The adrenal glands and kidneys appear unremarkable. Incidental note is made\\n of bibasilar atelectasis. The spleen appears within normal limits.\\n\\n IMPRESSION:\\n 1. Pneumobilia without evidence of a dependent biliary filling defect.\\n 2. Cholecystectomy.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-09-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 933853,\n \"text\": \" 10:35 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: rule out PNA or pulm edema\\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 76 year old woman with sudden onset CP/SOB this am\\n\\n REASON FOR THIS EXAMINATION:\\n rule out PNA or pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Shortness of breath and chest pain.\\n\\n Portable AP chest radiograph compared to .\\n\\n The heart size is mildly enlarged, but stable. The mediastinum is in normal\\n position, contour, and width. The lungs are clear. The pleural surfaces are\\n smooth with no pleural effusion.\\n\\n IMPRESSION: No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":23099,"cells":{"subject_id":{"kind":"number","value":32059,"string":"32,059"},"hadm_id":{"kind":"number","value":105207,"string":"105,207"},"target_text":{"kind":"string","value":"Patient is an 82 year old male with past medical history significant for prior CVA with resultant left-sided hemi-paresis, coronary artery disease, and renal insufficiency who presented with hypotension and fever, found to have urosepsis secondary to e. coli infection. . # Septic shock: At time of admission, patient met SIRS criteria. He was initially continued on levophed and intravenous fluids with a goal mean arterial pressure of over 60. Levophed was quickly weaned off and the patient remained hemodynamically stable. Urine and blood cultures returned positive for e. coli. Antibiotic treatment was initiated with vancomycin and zosyn, but was changed to ceftriaxone when sensitivites returned. At time of admission, there was evidence of end-organ injury with an elevated lactate of 4.7 on admission, which normalized following resuscitation. He remained hemodynamically stable during after admission to the intensive care unit, and was transferred to the regular medical floor. Surveillance cultures demonstrated no growth at time of discharge. His foley was discontinued. He will need to complete 14 days total of antibiotic therapy (ceftriaxone)-- will be his last day of treatment. * Cultures will need to be followed up from Rehab. . # Renal failure: Patient's creatinine was elevated to 3.8 at time of admission, with a BUN of 118. This was felt to likely pre-renal in setting of sepsis and hypotension, likely leading to acute tubular necrosis. His creatinine continued to trend downward during his admission, and was 2.4 at time of discharge. He continue to have good urine output. A renal ultrasound demonstrated no evidence of obstruction or hydronephrosis. His foley was discontinued and he was able to void without difficulty. * He will need a basic chemistry panel checked on the day after discharge to ensure that his creatinine is stable or improving. He will also need a basic chemistry panel checked 4-5 days after discharge as well. * He may benefit from gentle intravenous fluids if his creatinine does not continue to improve or rises. . # Elevated troponin: Patient's cardiac enzymes bumped during his stay. An EKG showed no acute changes. The bump in cardiac enzymes was felt to be demand ischemia in setting of sepsis and hypotension. His cardiac enzymes were trended and his troponin peaked at 0.22. The elevated troponin may also have been due to his acute renal failure. He reported no chest pain or other symptoms. - He was continued on an aspirin and statin. - His beta-blocker was re-introduced at a low dose and titrated up to his home dose once his blood pressure normalized. - He was kept on telemetry but this was stopped after there were no significant abnormalities. . # Anemia: By report to the intensive care team, patient was anemic prior to his admission, though his baseline hematocrit was unknown. There was no clear source of evidence of bleeding, although there was a question of possible blood tinged vomitus at rehab. He had no emesis during his stay. He was transfused two units of packed red blood cells for a hematocrit of 22, with appropriate bump in his hematocrit, which remained stable during his stay. His stools were guaiac negative. * Appropriate work up, if desired and not previously completed, should be done on an outpatient basis. * He should have a complete blood count checked with his labs at one and 4-5 days after admission. . # History of clostridium difficile infection: Patient had history of c. difficile infection, but had completed treatment prior to admission. He was started on flagyl during his stay given concerns about c. difficile infection, however his stool was found to be c. difficile negative. His significant leukocytosis was concerning for possible recurrent infection, but he had no diarrhea, and his abdominal exam remained benign. * Given that he is on ceftriaxone for his urinary and blood stream infection, he should be monitored carefully for any evidence of c. difficile recurrence and re-started on flagyl in that event. . # Diabetes Mellitus: Patient was hypoglycemic at time of admission, and initially did not require very much insulin. After his tube feeds were re-started, his blood sugars then rose to the 200's to 300's. His lantus was re-started at about half of his home dose, 20 units, on the day prior to discharge. A sliding scale of humalog was also used. * His finger sticks should be monitored closely, and his lantus dose will likely need to be increased as his infection improves. . # Leukocytosis: Patient developed significant leukocytosis during his stay, with a WBC elevated to 40. At time of discharge, it had trended downward to 28. This was felt to be multifactorial due to his e. coli infection, and cortisol stimulation testing that was completed while in the intensive care unit. C. difficile infection was also considered, and he should be monitored carefully for evidence of his. A differential also revealed a few bands, however much improved from time of admission. * A complete blood count should be drawn the day and 4-5 days after discharge to monitor his leukocytosis to ensure that it is trending downward. . # Anxiety, depression: Patient's home doses of zoloft and xanax were restarted prior to discharge. . # Gout: Patient's home medications of allopurinol and colchinine were helding during his admission and may be re-started when indicated. . # Hypernatremia, fluid status: Patient became markedly hypernatremic during his stay, likely due to insensible losses and aggressive normal saline resuscitation during his intensive care unit stay. He was given D5 fluids to treat his hypernatremia, and free water flushes were increased to 300 mL q4 hours. His sodium improved slowly to 146 at time of admission. * He will need a basic chemistry panel checked the day after admission, and again in days to ensure that his sodium is stable and within a normal range. . # Prophylaxis: A proton pump inhibitor was continued, and heparin subcutaneous was used for DVT prophylaxis. Mouth care was maintained with mouth swabs and moisturing agents. . # Nutrition: Nutrition was consulted and tube feeds were re-started at their recommendation. Speech and swallow was consulted, and it was felt that he should continue his NPO status. A video swallow may be of assistance to further evaluate this if desired, on an outpatient basis. His tubefeeding was as follows: Nutren Renal Full strength, 45 ml/hr, with free water flush 300 mL water every 4 hours. . # Access: A right internal jugular line was pulled prior to discharge, and peripheral IV was kept in place. . # Code: Patient's code status was DNR/DNI based on discussions with family."},"extractive_notes_summ":{"kind":"string","value":"CK 159 (268)MB 18, Troponin 0.14. REMAINS A DNR/DNI.PT. FINDINGS: The right IJ line is in the mid SVC. LS clear Bilat.CVS: Sinus tach w/ occasional PVC's HR/ B/P and pressors as above. CVP 10-12.Access: R arm PIV x2, R IJ TL CVL.GI: abd soft , tube in abd Clamped, sm amt bilious residual noted, pt had sm amt soft brown stool x1. Left anteriorfascicular block. remains NPO at this time.GU: foley cath placed in ED w/ 1200ml immediate output. Hct was noted to be 22.2 w/ no obvious s/s of bleeding. Peripheral pulses 3+ DP/2+DT neg edema. Consider left atrial abnormality. Left anterior fascicular block. IMPRESSION: Right IJ line in standard position. Marked left axisdeviation. HAS NKDA.PT. BAD soft, BS +. K+ 5.1 IV access R IJ CVP 13-17. pressors/abx/ etc.pt arrived in the MICU on levophed 0.03mcg/kg/min w/ sbp's in the 80's and map in the 50's HR 110's. IS NSR 60-80'S WITH NO NOTED ECTOPY. pt transferred to ED where his temp was 102, sbp 70's-80's. New right IJ. Otherwise, no change.TRACING #1 Moves R side well, mod str. PT. PT. PT. PT. PT. PT. PT. REMAINS ON FLAGYL, VANCOMYCIN, AND ZOSYN.PLAN IS FOR POSSIBLE C/O TO THE FLOOR. There is a square radioopaque density over the left clavicle, of uncertain clinical significance. source, and hypotensive w/ sbp's in the 60's at NH. Baseline artifact. RESIDUALS ARE LOW AND WNL'S. Cards consult EKG NSTEMI, Demand ischemia. L side no movement r/t CVA. ; prostate Ca; CRI; DMII; CAD; and anemia who became febrile to 103 ? Right IJ catheter again is seen in place. HCT after PC 28.neuro: pt speaking, confused( per family confused at baseline), opens eyes spont, does not follow commands.moves R side, no movment on left side (s/p CVA).at time pt becomes agitation.resp: 5L NC, sat 98-100%, SL clear.cv: recived with HR 120's, overnight down to 93-98,with agitation up to 110's.cont NEO, recived NEO 0.5 mcg/kg/min, dropped BP to 82/50, increased NEO titrate to MAP>60 SBP >90. Moves LE on bed Left sided hemiparesis.CV: HR 100-110 ST no ectopy, @1600 started lopressor 12.5mg HR 90's NSR. Lungs clear fine crackles @ basesID: Contact precautions + c-diff, afebrile WBC 35.8 (42), Blood cx GNR, +U/A, Vanco, Zosyn, flagylGU: foley u/o 50-140cc/hr autodiuresis. Right bundle-branch block. pt is DNR/DNI per family, but may rec. Left axis deviation. ATN BUN/creat 122/3.5GI: abd soft + BS inplace clamped awaiting nutrition eval to resume TF. @ times will respond appropriately 1-2word. PERRLS.Pulm: pt recieved on 100% NRB 02 sat 98-100%, ABG 7.39/29/129/18, will wean 02 as tol. The QRS complexis narrower. HAS PEGTUBE WHICH TUBE FEEDS WERE STARTED LAST HS. NBP 110-128/56-70 MAPS>65. B/P REMAINS STABLE RANGING 103-140'S/60-80'S. HAS REMAINS AFEBRILE THROUGHOUT THIS SHIFT.PT. IMPRESSION: Little change. pt NPO. Passing soft stool x5.Derm: skin impaired coccyx abrasion duoderm applied.Social: DNR/DNI. pt received total 6L fluids, start on Levo , became tachy 120's, changed to NEo. IMPRESSION: Limited study. No obvious hydronephrosis. The right costophrenic angle is not visualized; however, the remaining lungs are clear. trending down. 500ml n/s bolus x 2, IV Zosyn, Vanco, and is now recieving 1st of 2 units PRBC's. pressor switched to Neo at 0.5mcg/kg/min, titrated to 1mcg/kg/min w/ maps in the 70's and HR in the 100's. REMAINS ON CONTACT PRECAUTIONS FOR CDIFF IN STOOL. O2 SATS REMAIN >96% WHILE ON 3L/MIN VIA NASAL CANNULA.PT. seriel Cardiac Enzymes. ABD IS OTHERWISE BENIGN AND PT. This discordance suggests the possibility of cardiomyopathy or pericardial effusion. WITH NO COVERAGE REQUIRED. Sinus tachycardia. Sinus tachycardia. Since the previous tracingno significant change.TRACING #2 no evidence of bleeding via G-tube.id:contact precaution for pos C.diff. BLOOD SUGARS ARE WNL'S RANGING 120'S. 3:19 PM RENAL U.S. levophed titrated to 0.09mcg/kg/min w/ maps increasing to 65-70's however pt became agitated and tachycardic w/ HR in the 120's. afebriel, cont Zocyn/flagylaccess: RIJ, 2piv.skin: abrasion on coccyx area, duoderm aplleid.social: DNR/DNI,pressors ok. pt'd daughter visited/updated.plan: cont monitoirng resp/cardio status wean NEO to keep MAP>60 follow HCT ,signs of bleedign cont ABX, follow temp. DOES NOT MOVE LEFT UPPER EXTREMITY. PULSES ARE VERY WEAK BUT PALPABLE. CVP MONITORED AND RANGES .RESP STATUS REMAINS CLEAR THROUGHOUT WITH RESP RATE CONTROLLED. NO EDEMA NOTED. HAS BEEN OFF NEO FOR ALMOST 24HRS. ABD IS SOFT WITH BOWELS SOUNDS EASILY AUDIBLE AND PT. IS SPEAKING ONLY, SPEAKS FEW ENGLISH WORDS AND HAS BASELINE DEMENTIA. FINDINGS: In comparison with the study of , there is little overall change. dropped HCT to 22, recieved 2 unit PC. RENAL ULTRASOUND: There is no comparison. 9:30 AM CHEST PORT. MICU7 RN Note 0700-1900Events: FB 500cc Tacychardic, later in day resumed Lopressor.Neuro: Responsive to verbal stimulation. Moves RUE random, LUE no movement. Please evaluate. lactate has trended down to 3.5.ROS:Neuro: pt awake, Russian speaking only and per family confused, non communicative at baseline. MICU Nurse admission/progress note 1300-1900Pt is an 82yo M, PMH: Alzhiemers; s/p R CVA w/ L hemi. Enlargement of the cardiac silhouette persists with relatively mild elevation of pulmonary venous pressure. Language barrier speaking, repetatively, Confusion. COMPARISON: None available. Maintenance IV D5NS 80cc/hr.resp: RR 16-20 O2 wean to 3L/Min, Sats 95-98%. CVP 10-14, start on D%NS 80cc/hr.cardiac ensymes sent, morning labs pending. Lactate 4.5 pt started on levophed and given IV abx in ED, then transferred to MICU for further management. Left kidney measures 10.6 cm, and the right kidney measures 11.6 cm. 1900-0700 rn notes micu82 y.o m with h/o of CVA in , L isded hemiparesis,dementia, DM CAD, s/p G-tube presented to ED from rehab with fever, hypotension to 70's, vomiting ?coffee ground, eleveted lactate. ALSO HAS GNR IN BLOOD AND IN URINE. eyes open not following commands. In addition to pressors, pt rec."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2107-03-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1006108,"text":" 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for vol overload\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n eval for vol overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis, to evaluate for volume overload.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Enlargement of the cardiac silhouette persists with relatively mild\n elevation of pulmonary venous pressure. This discordance suggests the\n possibility of cardiomyopathy or pericardial effusion. Tortuosity of the\n aorta is seen, but no evidence of pleural effusion or acute pneumonia.\n\n Right IJ catheter again is seen in place.\n\n IMPRESSION: Little change.\n\n\n"},{"category":"Radiology","chartdate":"2107-03-14 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1006014,"text":" 9:30 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placement, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with fever, hypoTN, new R IJ\n REASON FOR THIS EXAMINATION:\n eval for line placement, pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE FOR LINE PLACEMENT\n\n INDICATION: 82-year-old man with fever, hypotension. New right IJ. Please\n evaluate.\n\n COMPARISON: None available.\n\n FINDINGS: The right IJ line is in the mid SVC. There is no pneumothorax. The\n right costophrenic angle is not visualized; however, the remaining lungs are\n clear. The cardiomediastinal silhouette is enlarged, but this appears due to\n technical factors as the patient is markedly rotated. The hila are also\n enlarged; however, this is also likely due to technical factors. There are no\n pleural effusions. There is a square radioopaque density over the left\n clavicle, of uncertain clinical significance.\n\n IMPRESSION: Right IJ line in standard position. No evidence of pneumonia.\n\n"},{"category":"Radiology","chartdate":"2107-03-14 00:00:00.000","description":"P RENAL U.S. PORT","row_id":1006069,"text":" 3:19 PM\n RENAL U.S. PORT Clip # \n Reason: please check for obstruction\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with renal failure and sepsis\n REASON FOR THIS EXAMINATION:\n please check for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with renal failure and sepsis.\n\n RENAL ULTRASOUND: There is no comparison. The study is limited due to\n limited cooperation from the patient. Left kidney measures 10.6 cm, and the\n right kidney measures 11.6 cm. There is no hydronephrosis or obvious mass or\n stone identified on this ultrasound.\n\n IMPRESSION: Limited study. No obvious hydronephrosis.\n\n"},{"category":"Nursing/other","chartdate":"2107-03-16 00:00:00.000","description":"Report","row_id":1668854,"text":"PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. IS SPEAKING ONLY, SPEAKS FEW ENGLISH WORDS AND HAS BASELINE DEMENTIA. PT. DOES NOT MOVE LEFT UPPER EXTREMITY. PT. HAS REMAINS AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. IS NSR 60-80'S WITH NO NOTED ECTOPY. B/P REMAINS STABLE RANGING 103-140'S/60-80'S. PULSES ARE VERY WEAK BUT PALPABLE. NO EDEMA NOTED. PT. HAS BEEN OFF NEO FOR ALMOST 24HRS. CVP MONITORED AND RANGES .\n\nRESP STATUS REMAINS CLEAR THROUGHOUT WITH RESP RATE CONTROLLED. O2 SATS REMAIN >96% WHILE ON 3L/MIN VIA NASAL CANNULA.\n\nPT. HAS PEGTUBE WHICH TUBE FEEDS WERE STARTED LAST HS. NUTREN PULMONARY STARTED AT 10CC/HR, ADVANCE 10CC Q4HRS FOR A GOAL RATE OF 40CC/HR. RESIDUALS ARE LOW AND WNL'S. BLOOD SUGARS ARE WNL'S RANGING 120'S. WITH NO COVERAGE REQUIRED. ABD IS OTHERWISE BENIGN AND PT. ABD IS SOFT WITH BOWELS SOUNDS EASILY AUDIBLE AND PT. HAS HAD FOUR SOFT COLORED STOOLS. FOLEY CATHETER REMAINS INTACT WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.\n\nSKIN EXHIBTIS DUODERM TO COCCYX AREA WITH TWO SMALL AREAS JUST ABOVE DUODERM WHICH ARE ALL OLD AND HEALING PER DAUGHTER. TLC REMAINS INTACT WITH ALL PORTS FUNCTIONING WELL.\n\nPT. REMAINS ON CONTACT PRECAUTIONS FOR CDIFF IN STOOL. PT. ALSO HAS GNR IN BLOOD AND IN URINE. PT. REMAINS ON FLAGYL, VANCOMYCIN, AND ZOSYN.\n\nPLAN IS FOR POSSIBLE C/O TO THE FLOOR. PT. DAUGHTER STRESSED CONCERN OVER HIS INFECTION AND THE POSSIBLITY THAT THEY WON'T GO AWAY. PT'S DAUGHTER STRESSED THAT SHE JUST WANTED WHAT WAS BEST FOR HER FATHER WITHOUT CAUSING HIM DISTRESS.\n"},{"category":"Nursing/other","chartdate":"2107-03-14 00:00:00.000","description":"Report","row_id":1668851,"text":"MICU Nurse admission/progress note 1300-1900\nPt is an 82yo M, PMH: Alzhiemers; s/p R CVA w/ L hemi.; prostate Ca; CRI; DMII; CAD; and anemia who became febrile to 103 ? source, and hypotensive w/ sbp's in the 60's at NH. pt transferred to ED where his temp was 102, sbp 70's-80's. Hct was noted to be 22.2 w/ no obvious s/s of bleeding. Lactate 4.5 pt started on levophed and given IV abx in ED, then transferred to MICU for further management. pt is DNR/DNI per family, but may rec. pressors/abx/ etc.\n\npt arrived in the MICU on levophed 0.03mcg/kg/min w/ sbp's in the 80's and map in the 50's HR 110's. levophed titrated to 0.09mcg/kg/min w/ maps increasing to 65-70's however pt became agitated and tachycardic w/ HR in the 120's. pressor switched to Neo at 0.5mcg/kg/min, titrated to 1mcg/kg/min w/ maps in the 70's and HR in the 100's. In addition to pressors, pt rec. 500ml n/s bolus x 2, IV Zosyn, Vanco, and is now recieving 1st of 2 units PRBC's. lactate has trended down to 3.5.\n\nROS:\nNeuro: pt awake, Russian speaking only and per family confused, non communicative at baseline. Moves R side well, mod str. L side no movement r/t CVA. PERRLS.\n\nPulm: pt recieved on 100% NRB 02 sat 98-100%, ABG 7.39/29/129/18, will wean 02 as tol. LS clear Bilat.\n\nCVS: Sinus tach w/ occasional PVC's HR/ B/P and pressors as above. CVP 10-12.\n\nAccess: R arm PIV x2, R IJ TL CVL.\n\nGI: abd soft , tube in abd Clamped, sm amt bilious residual noted, pt had sm amt soft brown stool x1. remains NPO at this time.\n\nGU: foley cath placed in ED w/ 1200ml immediate output. now draining clody yellow urine w/ sediment. UOP 80-100ml/hr.\n\nSkin: Sm Stg II decub on coccyx, cleaned, moisture vbarrier applied.\n\nsocial: family spoke to MD, updated r/t pt cond/ POC, geriatric fellow also involved and will speak w/ family in am to reassess situation and plan going forward.\n\nPlan:wean 02 as tol\nwean pressors as tol\ncont IV abx, blood products as ordered\nmonitor lytes, hct, replete/tx as needed.\nreaddress POC w/ family in am.\n"},{"category":"Nursing/other","chartdate":"2107-03-15 00:00:00.000","description":"Report","row_id":1668852,"text":"1900-0700 rn notes micu\n\n82 y.o m with h/o of CVA in , L isded hemiparesis,dementia, DM CAD, s/p G-tube presented to ED from rehab with fever, hypotension to 70's, vomiting ?coffee ground, eleveted lactate. pt received total 6L fluids, start on Levo , became tachy 120's, changed to NEo. dropped HCT to 22, recieved 2 unit PC. HCT after PC 28.\n\nneuro: pt speaking, confused( per family confused at baseline), opens eyes spont, does not follow commands.moves R side, no movment on left side (s/p CVA).at time pt becomes agitation.\n\nresp: 5L NC, sat 98-100%, SL clear.\n\ncv: recived with HR 120's, overnight down to 93-98,with agitation up to 110's.cont NEO, recived NEO 0.5 mcg/kg/min, dropped BP to 82/50, increased NEO titrate to MAP>60 SBP >90. CVP 10-14, start on D%NS 80cc/hr.cardiac ensymes sent, morning labs pending. start on hydrocortison IV.\n\ngi/gu: foley drainged yellow clear urine 35-80cc/hr. BAD soft, BS +. pt NPO. no evidence of bleeding via G-tube.\n\nid:contact precaution for pos C.diff. afebriel, cont Zocyn/flagyl\n\naccess: RIJ, 2piv.\n\nskin: abrasion on coccyx area, duoderm aplleid.\n\nsocial: DNR/DNI,pressors ok. pt'd daughter visited/updated.\n\nplan: cont monitoirng resp/cardio status\n wean NEO to keep MAP>60\n follow HCT ,signs of bleedign\n cont ABX, follow temp.\n\n"},{"category":"Nursing/other","chartdate":"2107-03-15 00:00:00.000","description":"Report","row_id":1668853,"text":"MICU7 RN Note 0700-1900\n\nEvents: FB 500cc Tacychardic, later in day resumed Lopressor.\n\nNeuro: Responsive to verbal stimulation. eyes open not following commands. @ times will respond appropriately 1-2word. Language barrier speaking, repetatively, Confusion. Moves RUE random, LUE no movement. Moves LE on bed Left sided hemiparesis.\n\nCV: HR 100-110 ST no ectopy, @1600 started lopressor 12.5mg HR 90's NSR. NBP 110-128/56-70 MAPS>65. Cards consult EKG NSTEMI, Demand ischemia. seriel Cardiac Enzymes. trending down. CK 159 (268)MB 18, Troponin 0.14. Peripheral pulses 3+ DP/2+DT neg edema. K+ 5.1 IV access R IJ CVP 13-17. Maintenance IV D5NS 80cc/hr.\n\nresp: RR 16-20 O2 wean to 3L/Min, Sats 95-98%. Lungs clear fine crackles @ bases\n\nID: Contact precautions + c-diff, afebrile WBC 35.8 (42), Blood cx GNR, +U/A, Vanco, Zosyn, flagyl\n\nGU: foley u/o 50-140cc/hr autodiuresis. ATN BUN/creat 122/3.5\n\nGI: abd soft + BS inplace clamped awaiting nutrition eval to resume TF. Passing soft stool x5.\n\nDerm: skin impaired coccyx abrasion duoderm applied.\n\nSocial: DNR/DNI. Daughter called updated on status.\n\nplan: resume Betablockers\n Cardiac echo \n call out to floor\n\n"},{"category":"ECG","chartdate":"2107-03-15 00:00:00.000","description":"Report","row_id":135676,"text":"Baseline artifact. Sinus tachycardia. Left axis deviation. Left anterior\nfascicular block. Right bundle-branch block. Since the previous tracing\nno significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2107-03-14 00:00:00.000","description":"Report","row_id":135677,"text":"Sinus tachycardia. Consider left atrial abnormality. Marked left axis\ndeviation. Left anterior fascicular block. Right bundle-branch block.\nSince the previous tracing of the rate has increased. The QRS complex\nis narrower. Otherwise, no change.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-03-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1006108,\n \"text\": \" 3:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for vol overload\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with sepsis\\n REASON FOR THIS EXAMINATION:\\n eval for vol overload\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Sepsis, to evaluate for volume overload.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change. Enlargement of the cardiac silhouette persists with relatively mild\\n elevation of pulmonary venous pressure. This discordance suggests the\\n possibility of cardiomyopathy or pericardial effusion. Tortuosity of the\\n aorta is seen, but no evidence of pleural effusion or acute pneumonia.\\n\\n Right IJ catheter again is seen in place.\\n\\n IMPRESSION: Little change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-03-14 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1006014,\n \"text\": \" 9:30 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: eval for line placement, pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with fever, hypoTN, new R IJ\\n REASON FOR THIS EXAMINATION:\\n eval for line placement, pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PORTABLE FOR LINE PLACEMENT\\n\\n INDICATION: 82-year-old man with fever, hypotension. New right IJ. Please\\n evaluate.\\n\\n COMPARISON: None available.\\n\\n FINDINGS: The right IJ line is in the mid SVC. There is no pneumothorax. The\\n right costophrenic angle is not visualized; however, the remaining lungs are\\n clear. The cardiomediastinal silhouette is enlarged, but this appears due to\\n technical factors as the patient is markedly rotated. The hila are also\\n enlarged; however, this is also likely due to technical factors. There are no\\n pleural effusions. There is a square radioopaque density over the left\\n clavicle, of uncertain clinical significance.\\n\\n IMPRESSION: Right IJ line in standard position. No evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-03-14 00:00:00.000\",\n \"description\": \"P RENAL U.S. PORT\",\n \"row_id\": 1006069,\n \"text\": \" 3:19 PM\\n RENAL U.S. PORT Clip # \\n Reason: please check for obstruction\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old man with renal failure and sepsis\\n REASON FOR THIS EXAMINATION:\\n please check for obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 83-year-old male with renal failure and sepsis.\\n\\n RENAL ULTRASOUND: There is no comparison. The study is limited due to\\n limited cooperation from the patient. Left kidney measures 10.6 cm, and the\\n right kidney measures 11.6 cm. There is no hydronephrosis or obvious mass or\\n stone identified on this ultrasound.\\n\\n IMPRESSION: Limited study. No obvious hydronephrosis.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-03-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1668854,\n \"text\": \"PT. REMAINS A DNR/DNI.\\n\\nPT. HAS NKDA.\\n\\nPT. IS SPEAKING ONLY, SPEAKS FEW ENGLISH WORDS AND HAS BASELINE DEMENTIA. PT. DOES NOT MOVE LEFT UPPER EXTREMITY. PT. HAS REMAINS AFEBRILE THROUGHOUT THIS SHIFT.\\n\\nPT. IS NSR 60-80'S WITH NO NOTED ECTOPY. B/P REMAINS STABLE RANGING 103-140'S/60-80'S. PULSES ARE VERY WEAK BUT PALPABLE. NO EDEMA NOTED. PT. HAS BEEN OFF NEO FOR ALMOST 24HRS. CVP MONITORED AND RANGES .\\n\\nRESP STATUS REMAINS CLEAR THROUGHOUT WITH RESP RATE CONTROLLED. O2 SATS REMAIN >96% WHILE ON 3L/MIN VIA NASAL CANNULA.\\n\\nPT. HAS PEGTUBE WHICH TUBE FEEDS WERE STARTED LAST HS. NUTREN PULMONARY STARTED AT 10CC/HR, ADVANCE 10CC Q4HRS FOR A GOAL RATE OF 40CC/HR. RESIDUALS ARE LOW AND WNL'S. BLOOD SUGARS ARE WNL'S RANGING 120'S. WITH NO COVERAGE REQUIRED. ABD IS OTHERWISE BENIGN AND PT. ABD IS SOFT WITH BOWELS SOUNDS EASILY AUDIBLE AND PT. HAS HAD FOUR SOFT COLORED STOOLS. FOLEY CATHETER REMAINS INTACT WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.\\n\\nSKIN EXHIBTIS DUODERM TO COCCYX AREA WITH TWO SMALL AREAS JUST ABOVE DUODERM WHICH ARE ALL OLD AND HEALING PER DAUGHTER. TLC REMAINS INTACT WITH ALL PORTS FUNCTIONING WELL.\\n\\nPT. REMAINS ON CONTACT PRECAUTIONS FOR CDIFF IN STOOL. PT. ALSO HAS GNR IN BLOOD AND IN URINE. PT. REMAINS ON FLAGYL, VANCOMYCIN, AND ZOSYN.\\n\\nPLAN IS FOR POSSIBLE C/O TO THE FLOOR. PT. DAUGHTER STRESSED CONCERN OVER HIS INFECTION AND THE POSSIBLITY THAT THEY WON'T GO AWAY. PT'S DAUGHTER STRESSED THAT SHE JUST WANTED WHAT WAS BEST FOR HER FATHER WITHOUT CAUSING HIM DISTRESS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1668851,\n \"text\": \"MICU Nurse admission/progress note 1300-1900\\nPt is an 82yo M, PMH: Alzhiemers; s/p R CVA w/ L hemi.; prostate Ca; CRI; DMII; CAD; and anemia who became febrile to 103 ? source, and hypotensive w/ sbp's in the 60's at NH. pt transferred to ED where his temp was 102, sbp 70's-80's. Hct was noted to be 22.2 w/ no obvious s/s of bleeding. Lactate 4.5 pt started on levophed and given IV abx in ED, then transferred to MICU for further management. pt is DNR/DNI per family, but may rec. pressors/abx/ etc.\\n\\npt arrived in the MICU on levophed 0.03mcg/kg/min w/ sbp's in the 80's and map in the 50's HR 110's. levophed titrated to 0.09mcg/kg/min w/ maps increasing to 65-70's however pt became agitated and tachycardic w/ HR in the 120's. pressor switched to Neo at 0.5mcg/kg/min, titrated to 1mcg/kg/min w/ maps in the 70's and HR in the 100's. In addition to pressors, pt rec. 500ml n/s bolus x 2, IV Zosyn, Vanco, and is now recieving 1st of 2 units PRBC's. lactate has trended down to 3.5.\\n\\nROS:\\nNeuro: pt awake, Russian speaking only and per family confused, non communicative at baseline. Moves R side well, mod str. L side no movement r/t CVA. PERRLS.\\n\\nPulm: pt recieved on 100% NRB 02 sat 98-100%, ABG 7.39/29/129/18, will wean 02 as tol. LS clear Bilat.\\n\\nCVS: Sinus tach w/ occasional PVC's HR/ B/P and pressors as above. CVP 10-12.\\n\\nAccess: R arm PIV x2, R IJ TL CVL.\\n\\nGI: abd soft , tube in abd Clamped, sm amt bilious residual noted, pt had sm amt soft brown stool x1. remains NPO at this time.\\n\\nGU: foley cath placed in ED w/ 1200ml immediate output. now draining clody yellow urine w/ sediment. UOP 80-100ml/hr.\\n\\nSkin: Sm Stg II decub on coccyx, cleaned, moisture vbarrier applied.\\n\\nsocial: family spoke to MD, updated r/t pt cond/ POC, geriatric fellow also involved and will speak w/ family in am to reassess situation and plan going forward.\\n\\nPlan:wean 02 as tol\\nwean pressors as tol\\ncont IV abx, blood products as ordered\\nmonitor lytes, hct, replete/tx as needed.\\nreaddress POC w/ family in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1668852,\n \"text\": \"1900-0700 rn notes micu\\n\\n82 y.o m with h/o of CVA in , L isded hemiparesis,dementia, DM CAD, s/p G-tube presented to ED from rehab with fever, hypotension to 70's, vomiting ?coffee ground, eleveted lactate. pt received total 6L fluids, start on Levo , became tachy 120's, changed to NEo. dropped HCT to 22, recieved 2 unit PC. HCT after PC 28.\\n\\nneuro: pt speaking, confused( per family confused at baseline), opens eyes spont, does not follow commands.moves R side, no movment on left side (s/p CVA).at time pt becomes agitation.\\n\\nresp: 5L NC, sat 98-100%, SL clear.\\n\\ncv: recived with HR 120's, overnight down to 93-98,with agitation up to 110's.cont NEO, recived NEO 0.5 mcg/kg/min, dropped BP to 82/50, increased NEO titrate to MAP>60 SBP >90. CVP 10-14, start on D%NS 80cc/hr.cardiac ensymes sent, morning labs pending. start on hydrocortison IV.\\n\\ngi/gu: foley drainged yellow clear urine 35-80cc/hr. BAD soft, BS +. pt NPO. no evidence of bleeding via G-tube.\\n\\nid:contact precaution for pos C.diff. afebriel, cont Zocyn/flagyl\\n\\naccess: RIJ, 2piv.\\n\\nskin: abrasion on coccyx area, duoderm aplleid.\\n\\nsocial: DNR/DNI,pressors ok. pt'd daughter visited/updated.\\n\\nplan: cont monitoirng resp/cardio status\\n wean NEO to keep MAP>60\\n follow HCT ,signs of bleedign\\n cont ABX, follow temp.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1668853,\n \"text\": \"MICU7 RN Note 0700-1900\\n\\nEvents: FB 500cc Tacychardic, later in day resumed Lopressor.\\n\\nNeuro: Responsive to verbal stimulation. eyes open not following commands. @ times will respond appropriately 1-2word. Language barrier speaking, repetatively, Confusion. Moves RUE random, LUE no movement. Moves LE on bed Left sided hemiparesis.\\n\\nCV: HR 100-110 ST no ectopy, @1600 started lopressor 12.5mg HR 90's NSR. NBP 110-128/56-70 MAPS>65. Cards consult EKG NSTEMI, Demand ischemia. seriel Cardiac Enzymes. trending down. CK 159 (268)MB 18, Troponin 0.14. Peripheral pulses 3+ DP/2+DT neg edema. K+ 5.1 IV access R IJ CVP 13-17. Maintenance IV D5NS 80cc/hr.\\n\\nresp: RR 16-20 O2 wean to 3L/Min, Sats 95-98%. Lungs clear fine crackles @ bases\\n\\nID: Contact precautions + c-diff, afebrile WBC 35.8 (42), Blood cx GNR, +U/A, Vanco, Zosyn, flagyl\\n\\nGU: foley u/o 50-140cc/hr autodiuresis. ATN BUN/creat 122/3.5\\n\\nGI: abd soft + BS inplace clamped awaiting nutrition eval to resume TF. Passing soft stool x5.\\n\\nDerm: skin impaired coccyx abrasion duoderm applied.\\n\\nSocial: DNR/DNI. Daughter called updated on status.\\n\\nplan: resume Betablockers\\n Cardiac echo \\n call out to floor\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-03-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 135676,\n \"text\": \"Baseline artifact. Sinus tachycardia. Left axis deviation. Left anterior\\nfascicular block. Right bundle-branch block. Since the previous tracing\\nno significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-03-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 135677,\n \"text\": \"Sinus tachycardia. Consider left atrial abnormality. Marked left axis\\ndeviation. Left anterior fascicular block. Right bundle-branch block.\\nSince the previous tracing of the rate has increased. The QRS complex\\nis narrower. Otherwise, no change.\\nTRACING #1\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":230,"numItemsPerPage":100,"numTotalItems":24993,"offset":23000,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMTkyNzAwMSwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMTkzMDYwMSwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.RdRjn6-6I-cBMLdxm0Seg-o60ky1qc2RRgBuRtSvKuYBQFWSUVuOgesPrQQOR3VjKzkREsZIcu22NylW2qcgAA","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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1,180 | 131,713 | 82yo woman with complex PMH as above, with no known dementia, transferred from OSH with altered mental status, acute renal failure, hyperkalemia, and acidosis in the setting of UTI and hypovolemia. | Assessment and Plan ALTERED MENTAL STATUS (NOT DELIRIUM) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) Acute on Chronic Renal Failure, s/p fistula placement. inferior Q waves; peaked T waves resolved. inferior Q waves; peaked T waves resolved. Ceftriaxone 1 g was given for a suspected UTI. Ceftriaxone 1 g was given for a suspected UTI. Renal was called and suggested possible HD. Renal was called and suggested possible HD. Pt has generalized edema. Holding diuretics. Not yet at baseline RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - creat has stabilized. Abd: Normoactive BS, NT, slightly distended. BUN/Creat down from admit. BUN/Creat down from admit. BUN/Creat down from admit. BUN/Creat down from admit. Response: Afebrile. Pt received haldol in ew which helped with combativeness. Plan: Cont with d10 and sodium bicarb. Compared to the previous tracing of the anterior and inferior abnormalities consistent with prior infarction arenew. Q waves in leads II, III and aVFsuggest the possibility of prior inferior myocardial infarction. Side rails up Renal failure, acute (Acute renal failure, ARF) Assessment: BUN CR improved. Possible prior anteriormyocardial infarction. Renal failure, acute (Acute renal failure, ARF) Assessment: Bun and creat are currently pending. Action: IVFs infusing. Action: IVFs infusing. Action: IVFs infusing. Action: IVFs infusing. Probableleft ventricular hypertrophy. Suggestion of biapical traction bronchiectasis. Suggestion of biapical traction bronchiectasis. Renal failure, acute (Acute renal failure, ARF) Assessment: UO gd. Renal failure, acute (Acute renal failure, ARF) Assessment: UO gd. Renal failure, acute (Acute renal failure, ARF) Assessment: UO gd. Renal failure, acute (Acute renal failure, ARF) Assessment: UO gd. Action: Cont to monitor u/o and bun/creat. Plan: Cont to reorient pt and remind her of limitations. Delayed R wave transition. Clips in left axilla suggesting nodal dissection. Clips in left axilla suggesting nodal dissection. EKG at : NSR with LAD, a lot of artifact in the baseline, LVH by aVL criteria, poor R wave progression, ? EKG at : NSR with LAD, a lot of artifact in the baseline, LVH by aVL criteria, poor R wave progression, ? Plan: Cont to reorient prn. Plan: Cont to reorient prn. Plan: Cont to reorient prn. Plan: Cont to reorient prn. ECG: OSH EKG: NSR, peaked T waves. ECG: OSH EKG: NSR, peaked T waves. Cri, creat 3.9/bun 55. combative in ew. On SSInsulin. PM labs ordered. PM labs ordered. PM labs ordered. PM labs ordered. She had a R TLC placed supraclavicularly, which had to be pulled back. She had a R TLC placed supraclavicularly, which had to be pulled back. Currently has a R SC but it was placed in an OSH and needs to be changed ASAP. Response: pending Plan: Cont with bicarb until ph is normal. There is some flattening of the calcaneus with irregularity of the insertion of the plantar aponeurosis. There is some flattening of the calcaneus with irregularity of the insertion of the plantar aponeurosis. There is some flattening of the calcaneus with irregularity of the insertion of the plantar aponeurosis. Very agitation when transported to radiolody for xrays of L arm and R leg. Very agitation when transported to radiolody for xrays of L arm and R leg. Very agitation when transported to radiolody for xrays of L arm and R leg. Very agitation when transported to radiolody for xrays of L arm and R leg. Altered mental status (not Delirium) Assessment: A&O x2-3. Action: D10 with sodium bicarb. Monitor RFTs and UO. Afebrile. Afebrile. Afebrile. Afebrile. Action: Bicarb IVB given x1. Action: Bicarb IVB given x1. Action: Bicarb IVB given x1. Action: Followed by renal. In meantime we are bolusing her with D5/NaHCO3. Response: Pt is drinking, acidosis is corrected. Probable left anterior fascicular block.Compared to the previous tracing of the findings are similar. Altered mental status (not Delirium) Assessment: Pt cont moaning and only oriented to person. Treated w/bicarb gtt, and antibiotics. Plan: Check chem. Plan: Check chem. Plan: Check chem. Plan: Check chem. Marked osteoarthritic changes are seen involving the first carpometacarpal joint, as on the study of . Marked osteoarthritic changes are seen involving the first carpometacarpal joint, as on the study of . Marked osteoarthritic changes are seen involving the first carpometacarpal joint, as on the study of . Sinus rhythm. A timeout was performed. Acute absence of history - Obviously has significant CRF as she has dialysis vascular access. If these areas are of clinical concern, repeat films would be essential. If these areas are of clinical concern, repeat films would be essential. If these areas are of clinical concern, repeat films would be essential. Plan: Pnd labs. Plan: Pnd labs. Plan: Pnd labs. Plan: Pnd labs. All of this could well be the sequela of previous injury. All of this could well be the sequela of previous injury. All of this could well be the sequela of previous injury. Cont to monitor RFTs and UO. Cont to monitor RFTs and UO. | 20 | [
{
"category": "Radiology",
"chartdate": "2130-03-13 00:00:00.000",
"description": "R ANKLE (AP, MORTISE & LAT) RIGHT",
"row_id": 998431,
"text": " 11:03 AM\n KNEE (AP, LAT & OBLIQUE) RIGHT; ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n Reason: EVAL FOR FX PAIN S/P FALL\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with fall and right leg pain\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall with pain.\n\n FINDINGS: No previous images available. In the knee, there has been a total\n knee prosthesis. No evidence of acute bone abnormality or hardware-associated\n abnormality. In the ankle, no true frontal view has been presented, so that\n the ankle mortise is not adequately evaluated. Although there is substantial\n overlap, no evidence of acute fracture is appreciated. There is some\n flattening of the calcaneus with irregularity of the insertion of the plantar\n aponeurosis. This raises the possibility of some previous trauma. Extensive\n calcification is seen. Although poorly visualized, there appears to be fusion\n between the distal calcaneus and the cuboid as well as between the cuboid and\n the base of the fifth metatarsal. All of this could well be the sequela of\n previous injury.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-16 00:00:00.000",
"description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE",
"row_id": 998962,
"text": " 9:51 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: needs IV access for abx, fluids\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with UTI & hypotension, central line placed in , needs to\n be removed; please place on Left, pt has AVF on Right\n REASON FOR THIS EXAMINATION:\n needs IV access for abx, fluids\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for antibiotics.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. with Dr. performed the procedure. Dr.\n , teh Attending Radiologist, was present and supervised the entire\n procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left cephalic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a single-lumen PICC line measuring 41 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4 French\n single-lumen PICC line placement via the left cephalic venous approach. Final\n internal length is 41 cm, with the tip positioned in SVC. The line is ready\n to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-13 00:00:00.000",
"description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT",
"row_id": 998412,
"text": " 10:21 AM\n WRIST(3 + VIEWS) LEFT; SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFTClip # \n ELBOW (AP, LAT & OBLIQUE) LEFT\n Reason: EVAL FO FX PAIN S/P FALL\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with fall and left arm pain\n REASON FOR THIS EXAMINATION:\n eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall, to evaluate for fracture.\n\n FINDINGS: In the shoulder, the examination is inadequate to properly evaluate\n the humoral head and glenoid region. If these areas are of clinical concern,\n repeat films would be essential. Multiple surgical clips are seen in the\n axillary region. Views of the elbow are also somewhat limited in that a true\n lateral view is not obtained. This makes it impossible to properly evaluate\n for a posterior fat pad. No gross evidence of fracture or dislocation is\n identified. There is some irregularity of the base of the radial head, though\n this may not represent a true fracture.\n\n In the wrist, there is no evidence of acute fracture or dislocation. Marked\n osteoarthritic changes are seen involving the first carpometacarpal joint, as\n on the study of . There appears to be some increasing amorphous\n calcification in the region of the triangular cartilage.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2130-03-14 00:00:00.000",
"description": "Report",
"row_id": 192721,
"text": "Sinus rhythm. Left axis deviation. Probable left anterior fascicular block.\nCompared to the previous tracing of the findings are similar. The\ninferior complexes are not as suggestive of prior inferior myocardial\ninfarction as on the prior tracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2130-03-12 00:00:00.000",
"description": "Report",
"row_id": 192722,
"text": "Normal sinus rhythm. Delayed R wave transition. Possible prior anterior\nmyocardial infarction. Left axis deviation. Q waves in leads II, III and aVF\nsuggest the possibility of prior inferior myocardial infarction. Probable\nleft ventricular hypertrophy. Compared to the previous tracing of \nthe anterior and inferior abnormalities consistent with prior infarction are\nnew. Clinical correlation is suggested.\n\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 315968,
"text": "Chief Complaint: mental status change; acidosis\n 24 Hour Events:\n Seen by renal who think mental status changes too acute for uremia\n OSH nephrologist away but should return \n Had multiple trauma films given fall prior to admission. No definite\n fracuture of left upper or lower extremity but views limited overall\n Improved mental status with ability to communicate her needs; able to\n remember nurse's name throughout night\n Allergies:\n Sulfa (Sulfonamides)\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 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 105 (83 - 105) bpm\n BP: 115/87(94){100/26(50) - 155/111(114)} mmHg\n RR: 13 (11 - 17) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 16 (16 - 20)mmHg\n Total In:\n 2,172 mL\n 273 mL\n PO:\n 270 mL\n TF:\n IVF:\n 2,172 mL\n 3 mL\n Blood products:\n Total out:\n 1,120 mL\n 135 mL\n Urine:\n 1,040 mL\n 135 mL\n NG:\n 80 mL\n Stool:\n Drains:\n Balance:\n 1,052 mL\n 138 mL\n Respiratory support\n SpO2: 96%\n ABG: ///19/\n Physical Examination\n General Appearance: Calm, makes eye contact\n , Ears, Nose, Throat: R subclavian line with bruising, no hematoma\n felt\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n radiates to axilla\n Peripheral 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), scattered crackles; good\n air movement\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace\n Skin: Not assessed, bandaged left arm and right leg\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n \"hospital\" and to the nurse; not to time, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 274 K/uL\n 7.6 g/dL\n 109 mg/dL\n 3.4 mg/dL\n 19 mEq/L\n 2.9 mEq/L\n 49 mg/dL\n 102 mEq/L\n 135 mEq/L\n 23.3 %\n 6.8 K/uL\n [image002.jpg]\n 12:38 AM\n 05:21 AM\n 11:35 AM\n 04:45 PM\n 03:53 AM\n WBC\n 9.4\n 6.8\n Hct\n 26.2\n 23.3\n Plt\n 299\n 274\n Cr\n 3.9\n 4.0\n 3.6\n 3.4\n 3.4\n Glucose\n 94\n 160\n 128\n 129\n 109\n Other labs: PT / PTT / INR:14.1/37.8/1.2, ALT / AST:, Alk Phos / T\n Bili:52/0.1, Differential-Neuts:88.5 %, Lymph:6.5 %, Mono:4.5 %,\n Eos:0.2 %, Lactic Acid:1.3 mmol/L, LDH:177 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:4.9 mg/dL\n Imaging: Left Shoulder, elbow, wrist X-Ray:\n In the shoulder, the examination is inadequate to properly evaluate\n the humoral head and glenoid region. If these areas are of clinical\n concern,\n repeat films would be essential. Multiple surgical clips are seen in\n the\n axillary region. Views of the elbow are also somewhat limited in that\n a true\n lateral view is not obtained. This makes it impossible to properly\n evaluate\n for a posterior fat pad. No gross evidence of fracture or dislocation\n is\n identified. There is some irregularity of the base of the radial head,\n though\n this may not represent a true fracture.\n In the wrist, there is no evidence of acute fracture or dislocation.\n Marked\n osteoarthritic changes are seen involving the first carpometacarpal\n joint, as on the study of . There appears to be some increasing\n amorphous calcification in the region of the triangular cartilage.\n Right knee and ankle:\n No previous images available. In the knee, there has been a total\n knee prosthesis. No evidence of acute bone abnormality or\n hardware-associated\n abnormality. In the ankle, no true frontal view has been presented, so\n that\n the ankle mortise is not adequately evaluated. Although there is\n substantial\n overlap, no evidence of acute fracture is appreciated. There is some\n flattening of the calcaneus with irregularity of the insertion of the\n plantar\n aponeurosis. This raises the possibility of some previous trauma.\n Extensive\n calcification is seen. Although poorly visualized, there appears to be\n fusion\n between the distal calcaneus and the cuboid as well as between the\n cuboid and the base of the fifth metatarsal. All of this could well be\n the sequela of\n previous injury.\n Microbiology: Urine Cx : GNR > 100,000\n BCx pending\n Assessment and Plan\n 82yo woman with h/o CKD and Cr 2.5-3.0 admitted with ARF,\n acidosis, and mental status change.\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n - mental status somewhat improved, though still not at\n \n - unlikely to be due to uremia given that her renal function\n is not much worse than and that her mental status change\n occurred very acutely\n - suspect UTI is largely responsible\n - TSH normal\n - B12 at low end of normal range; will check methylmalonic\n acid levels\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Acute on Chronic Renal Failure, s/p fistula placement. Cr\n 2.5-3.0; current Cr 3.4\n - Most likely had prerenal renal failure from dehydration\n (excessive diuretics and UTI)\n - Will continue to hydrate with D5 with 2 amps of bicarb and\n monitor Cr; use HR and urine output to gauge hydration need\n - Continue renagel\n - Foley to closely monitor I/O\n - Appreciate renal recs\n ANEMIA, OTHER\n - Hct drop from 30 to 23 since admission; per PCP, \n Hct is 30-33\n - Suspect she was hemoconcentrated on admission; stool is\n guaiac negative\n - Active type and screen\n - Follow Hct and transfuse for Hct < 21\n - Check iron studies and methylmalonic acid\n - Continue Epogen\n ACIDOSIS, METABOLIC\n - resolving; continue hydration with HCO3-\n URINARY TRACT INFECTION (UTI)\n - urine growing enterobacter resistant to cipro\n - pt has sulfa allergy, so will start cefepime today\n HYPERTENSION, BENIGN\n - continue to hold diuretics and give other home BP meds\n .H/O FALL(S):\n - fall precautions\n - no fracture on X-Rays\n - appreciate input from plastics re: hand wound\n - appreciate wound care recs\n .H/O ARTHRITIS, RHEUMATOID (RA)\n - continue home meds, including prednisone 5mg daily\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - continue plavix, isosorbide, beta blocker\n - unclear why not on ASA or statin\n # Depression/Anxiety:\n - continue home meds but hold sedating medications, such as\n nortriptyline\n ICU Care\n Nutrition:\n Comments: cardiac, renal diet\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 12:00 AM\nremove TLC and ask son\ns permission\n for PICC in left arm despite prior mastectomy\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 315984,
"text": "Altered mental status (not Delirium)\n Assessment:\n A&O x2-3. More interactive but sleeps when undisturbed.\n Action:\n Re-orient. Correct met imbalances\n Response:\n Improved.\n As above. Side rails up\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN CR improved. UO marginal.\n Action:\n Followed by renal.\n Response:\n .improved.\n Plan:\n Cont current mgmt. Monitor RFTs and UO.\n Acidosis, Metabolic\n Assessment:\n Electrolytes improved.\n Action:\n Bicarb gtt infusing.\n Response:\n Plan:\n Follow chem. 7.Demographics\n Attending MD:\n \n Admit diagnosis:\n Code status:\n full\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions: sulfa\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money: no\n Cash / Credit cards sent home with:\n Jewelry: no\n Transferred from: micu east\n Transferred to: 11r\n Date & time of Transfer: \n 79 yo NH resident admitted w/UTI, acute on chronic renal failure.\n Treated w/bicarb gtt, and antibiotics. MS cleared as metabolic\n derangement and kidney function improved. Pt had R fistula placed in\n but it is not mature per renal team. She has never had HD. She\n also had a L mastectomy in the distant past which makes line access a\n challenge. Currently has a R SC but it was placed in an OSH and needs\n to be changed ASAP. Also has a L AC placed in OSH. Pt\ns son is her HCP.\n is very supportive and pt defers most decision making to him. \n MICU MD he has agreed with placement of L PICC.\n She is A&O x2-3. Occ periods of yelling and refusing care unless her\n son says it\ns ok.\n Skin is a major concern d/t fall in NH. Prior to hospitalization she\n had been using walker with wheels. She has RA. See skin care RN recs\n for skin care descriptions of Lg wound on RLE and LUE. LUE examined by\n plastics this afternoon. Currently care is clean wound w/wound\n cleanser, pat dry, cover w/adaptic then abd pad and wrap in kerlix qd.\n On SSInsulin. No coverage needed x>24hrs.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 315860,
"text": "Altered mental status (not Delirium)\n Assessment:\n Knows she is in the hospital and it is winter. Very agitation when\n transported to radiolody for xrays of L arm and R leg. Screaming out\nhelp me\n. Able to take pills crushed in custard. Can\nt sip though\n straw. Can take sips out of medicine cup.\n Action:\n Son arrived after xrays but pt calmer by then. Still son does have a\n calming affect on pt. Of note, his cell phone has a Fla. Area code and\n it can only be reached by specific phones in MICU.\n Response:\n Pt calmer and more communicative this afternoon, especially in presence\n of son and .\n Plan:\n Cont to reorient prn. Son is available if his mother needs him.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO gd. BUN/Creat down from admit.\n Action:\n Cont to assess. PM labs ordered.\n Response:\n Renal function sl improved.\n Plan:\n Pnd labs. Cont to monitor RFTs and UO. Renal team following.\n Urinary tract infection (UTI)\n Assessment:\n Urine lt yellow w/some sediment. Afebrile.\n Action:\n IVFs infusing. On PO Cipro.\n Response:\n T max 99.4 ax.\n Plan:\n Cont as above.\n Acidosis, Metabolic\n Assessment:\n Acidosis.\n Action:\n Bicarbgtt IV of 500ccs given x1. On bicarb gtt @ 150cc/hr x 1L.\n Response:\n Acidosis improving. PH 7.22. CO2 up to 13.\n Plan:\n Check chem. 7 at 1800. Cont to follow lytes. Reassess w/team for\n ?another bicarb gtt when present one finishes.\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 315958,
"text": "Chief Complaint: Acidosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n More alert\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamides)\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 Constitutional: Fatigue\n Pain: Mild\n Pain location: diffuse\n Flowsheet Data as of 12:17 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 36.7\nC (98.1\n HR: 86 (83 - 105) bpm\n BP: 140/36(61){100/26(50) - 155/111(114)} mmHg\n RR: 13 (11 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 13 (13 - 18)mmHg\n Total In:\n 2,172 mL\n 490 mL\n PO:\n 390 mL\n TF:\n IVF:\n 2,172 mL\n 100 mL\n Blood products:\n Total out:\n 1,120 mL\n 200 mL\n Urine:\n 1,040 mL\n 200 mL\n NG:\n 80 mL\n Stool:\n Drains:\n Balance:\n 1,052 mL\n 290 mL\n Respiratory support\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : scattered)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\n Not assessed\n Labs / Radiology\n 7.6 g/dL\n 274 K/uL\n 109 mg/dL\n 3.4 mg/dL\n 19 mEq/L\n 2.9 mEq/L\n 49 mg/dL\n 102 mEq/L\n 135 mEq/L\n 23.3 %\n 6.8 K/uL\n [image002.jpg]\n 12:38 AM\n 05:21 AM\n 11:35 AM\n 04:45 PM\n 03:53 AM\n WBC\n 9.4\n 6.8\n Hct\n 26.2\n 23.3\n Plt\n 299\n 274\n Cr\n 3.9\n 4.0\n 3.6\n 3.4\n 3.4\n Glucose\n 94\n 160\n 128\n 129\n 109\n Other labs: PT / PTT / INR:14.1/37.8/1.2, ALT / AST:, Alk Phos / T\n Bili:52/0.1, Differential-Neuts:88.5 %, Lymph:6.5 %, Mono:4.5 %,\n Eos:0.2 %, Lactic Acid:1.3 mmol/L, LDH:177 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM) improving as volume status and\n acidosis improve. Not yet at baseline\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - creat has\n stabilized. No urgent indication for dialysis\n Acute on Chronic Renal Failure, s/p fistula placement.\n ACIDOSIS, METABOLIC - much better as chloride comes down. Not clear\n what happened but not attributable to worsening renal fxn.\n receiving bicarbonate\n ANEMIA, OTHER - no apparent blood loss but hct is down. Will\n continue to follow but may need replacement and a plan to support as an\n outpatient\n FALL(S)\n DEPRESSION\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 315917,
"text": "Chief Complaint: mental status change; acidosis\n 24 Hour Events:\n Seen by renal who think mental status changes too acute for uremia\n OSH nephrologist away but should return \n Had multiple trauma films given fall prior to admission. No definite\n fracuture of left upper or lower extremity but views limited overall\n Improved mental status with ability to communicate her needs; able to\n remember nurse's name throughout night\n Allergies:\n Sulfa (Sulfonamides)\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 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 105 (83 - 105) bpm\n BP: 115/87(94){100/26(50) - 155/111(114)} mmHg\n RR: 13 (11 - 17) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 16 (16 - 20)mmHg\n Total In:\n 2,172 mL\n 273 mL\n PO:\n 270 mL\n TF:\n IVF:\n 2,172 mL\n 3 mL\n Blood products:\n Total out:\n 1,120 mL\n 135 mL\n Urine:\n 1,040 mL\n 135 mL\n NG:\n 80 mL\n Stool:\n Drains:\n Balance:\n 1,052 mL\n 138 mL\n Respiratory support\n SpO2: 96%\n ABG: ///19/\n Physical Examination\n General Appearance: Calm, makes eye contact\n , Ears, Nose, Throat: R subclavian line with bruising, no hematoma\n felt\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n radiates to axilla\n Peripheral 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), scattered crackles; good\n air movement\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace\n Skin: Not assessed, bandaged left arm and right leg\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n \"hospital\" and to the nurse; not to time, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 274 K/uL\n 7.6 g/dL\n 109 mg/dL\n 3.4 mg/dL\n 19 mEq/L\n 2.9 mEq/L\n 49 mg/dL\n 102 mEq/L\n 135 mEq/L\n 23.3 %\n 6.8 K/uL\n [image002.jpg]\n 12:38 AM\n 05:21 AM\n 11:35 AM\n 04:45 PM\n 03:53 AM\n WBC\n 9.4\n 6.8\n Hct\n 26.2\n 23.3\n Plt\n 299\n 274\n Cr\n 3.9\n 4.0\n 3.6\n 3.4\n 3.4\n Glucose\n 94\n 160\n 128\n 129\n 109\n Other labs: PT / PTT / INR:14.1/37.8/1.2, ALT / AST:, Alk Phos / T\n Bili:52/0.1, Differential-Neuts:88.5 %, Lymph:6.5 %, Mono:4.5 %,\n Eos:0.2 %, Lactic Acid:1.3 mmol/L, LDH:177 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:4.9 mg/dL\n Imaging: Left Shoulder, elbow, wrist X-Ray:\n In the shoulder, the examination is inadequate to properly evaluate\n the humoral head and glenoid region. If these areas are of clinical\n concern,\n repeat films would be essential. Multiple surgical clips are seen in\n the\n axillary region. Views of the elbow are also somewhat limited in that\n a true\n lateral view is not obtained. This makes it impossible to properly\n evaluate\n for a posterior fat pad. No gross evidence of fracture or dislocation\n is\n identified. There is some irregularity of the base of the radial head,\n though\n this may not represent a true fracture.\n In the wrist, there is no evidence of acute fracture or dislocation.\n Marked\n osteoarthritic changes are seen involving the first carpometacarpal\n joint, as on the study of . There appears to be some increasing\n amorphous calcification in the region of the triangular cartilage.\n Right knee and ankle:\n No previous images available. In the knee, there has been a total\n knee prosthesis. No evidence of acute bone abnormality or\n hardware-associated\n abnormality. In the ankle, no true frontal view has been presented, so\n that\n the ankle mortise is not adequately evaluated. Although there is\n substantial\n overlap, no evidence of acute fracture is appreciated. There is some\n flattening of the calcaneus with irregularity of the insertion of the\n plantar\n aponeurosis. This raises the possibility of some previous trauma.\n Extensive\n calcification is seen. Although poorly visualized, there appears to be\n fusion\n between the distal calcaneus and the cuboid as well as between the\n cuboid and the base of the fifth metatarsal. All of this could well be\n the sequela of\n previous injury.\n Microbiology: Urine Cx : GNR > 100,000\n BCx pending\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Acute on Chronic Renal Failure, s/p fistula placement.\n ACIDOSIS, METABOLIC\n URINARY TRACT INFECTION (UTI)\n HYPERTENSION, BENIGN\n .H/O FALL(S)\n .H/O ARTHRITIS, RHEUMATOID (RA)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ANEMIA, OTHER\n ICU Care\n Nutrition:\n Comments: cardiac, renal diet\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 315853,
"text": "Altered mental status (not Delirium)\n Assessment:\n Knows she is in the hospital and it is winter. Very agitation when\n transported to radiolody for xrays of L arm and R leg. Screaming out\nhelp me\n. Able to take pills crushed in custard. Can\nt sip though\n straw. Can take sips out of medicine cup.\n Action:\n Son arrived after xrays but pt calmer by then. Still son does have a\n calming affect on pt. Of note, his cell phone has a Fla. Area code and\n it can only be reached by specific phones in MICU.\n Response:\n Pt calmer and more communicative this afternoon, especially in presence\n of son and .\n Plan:\n Cont to reorient prn. Son is available if his mother needs him.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO gd. BUN/Creat down from admit.\n Action:\n Cont to assess. PM labs ordered.\n Response:\n Renal function sl improved.\n Plan:\n Pnd labs. Cont to monitor RFTs and UO. Renal team following.\n Urinary tract infection (UTI)\n Assessment:\n Urine lt yellow w/some sediment. Afebrile.\n Action:\n IVFs infusing. On PO Cipro.\n Response:\n Afebrile.\n Plan:\n Cont as above.\n Acidosis, Metabolic\n Assessment:\n Acidosis.\n Action:\n Bicarb IVB given x1. On bicarb gtt @ 150cc/hr x 1L.\n Response:\n Acidosis improving. PH 7.22. CO2 up to 13.\n Plan:\n Check chem. 7 at 1800. Cont to follow lytes. Reassess w/team for\n ?another bicarb gtt when present one finishes.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 315857,
"text": "Altered mental status (not Delirium)\n Assessment:\n Knows she is in the hospital and it is winter. Very agitation when\n transported to radiolody for xrays of L arm and R leg. Screaming out\nhelp me\n. Able to take pills crushed in custard. Can\nt sip though\n straw. Can take sips out of medicine cup.\n Action:\n Son arrived after xrays but pt calmer by then. Still son does have a\n calming affect on pt. Of note, his cell phone has a Fla. Area code and\n it can only be reached by specific phones in MICU.\n Response:\n Pt calmer and more communicative this afternoon, especially in presence\n of son and .\n Plan:\n Cont to reorient prn. Son is available if his mother needs him.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO gd. BUN/Creat down from admit.\n Action:\n Cont to assess. PM labs ordered.\n Response:\n Renal function sl improved.\n Plan:\n Pnd labs. Cont to monitor RFTs and UO. Renal team following.\n Urinary tract infection (UTI)\n Assessment:\n Urine lt yellow w/some sediment. Afebrile.\n Action:\n IVFs infusing. On PO Cipro.\n Response:\n T max 99.4 ax.\n Plan:\n Cont as above.\n Acidosis, Metabolic\n Assessment:\n Acidosis.\n Action:\n Bicarb IVB given x1. On bicarb gtt @ 150cc/hr x 1L.\n Response:\n Acidosis improving. PH 7.22. CO2 up to 13.\n Plan:\n Check chem. 7 at 1800. Cont to follow lytes. Reassess w/team for\n ?another bicarb gtt when present one finishes.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 315858,
"text": "Altered mental status (not Delirium)\n Assessment:\n Knows she is in the hospital and it is winter. Very agitation when\n transported to radiolody for xrays of L arm and R leg. Screaming out\nhelp me\n. Able to take pills crushed in custard. Can\nt sip though\n straw. Can take sips out of medicine cup.\n Action:\n Son arrived after xrays but pt calmer by then. Still son does have a\n calming affect on pt. Of note, his cell phone has a Fla. Area code and\n it can only be reached by specific phones in MICU.\n Response:\n Pt calmer and more communicative this afternoon, especially in presence\n of son and .\n Plan:\n Cont to reorient prn. Son is available if his mother needs him.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO gd. BUN/Creat down from admit.\n Action:\n Cont to assess. PM labs ordered.\n Response:\n Renal function sl improved.\n Plan:\n Pnd labs. Cont to monitor RFTs and UO. Renal team following.\n Urinary tract infection (UTI)\n Assessment:\n Urine lt yellow w/some sediment. Afebrile.\n Action:\n IVFs infusing. On PO Cipro.\n Response:\n T max 99.4 ax.\n Plan:\n Cont as above.\n Acidosis, Metabolic\n Assessment:\n Acidosis.\n Action:\n Bicarb IVB given x1. On bicarb gtt @ 150cc/hr x 1L.\n Response:\n Acidosis improving. PH 7.22. CO2 up to 13.\n Plan:\n Check chem. 7 at 1800. Cont to follow lytes. Reassess w/team for\n ?another bicarb gtt when present one finishes.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 315906,
"text": "Altered mental status (not Delirium)\n Assessment:\n Much more oriented than 24 hrs ago, still confused to date at times and\n place. Speech no longer garbled and is able to state needs clearly.\n Follows simple commands, opens mouth. Became agitated with bath and\n yelled out throughout entire bath but calmed down when finished. Pt\n also requesting lax and supp to move bowels.\n Action:\n Reoriented pt to place and time. Allowed to rest throughout the shift.\n Reminded pt that she would not be able to walk independantly until\n healed.\n Response:\n Pt stating that she is able to walk with walker. Not remembering where\n she is but does remember nurses name easily. Mental status is clearing.\n Plan:\n Cont to reorient pt and remind her of limitations. Remind pt of the\n importance of turning in bed. Update son on any changes which occur. Pt\n is a potential call out to the floor.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun and creat are currently pending. u/o low but urine is yellow with\n some sediment. Pt has generalized edema. Cvp 13-16. pt is now taking in\n some po and drinking without difficulty.\n Action:\n Cont to monitor u/o and bun/creat. Pt has a fistula but renal team is\n trying to avoid hd so pt will regain enough kidney function on own.\n Response:\n Pt is drinking, acidosis is corrected.\n Plan:\n Cont to monitor kidney function and u/o. observe for increased edema.\n Encourage po intake.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 315813,
"text": "Altered mental status (not Delirium)\n Assessment:\n Pt cont moaning and only oriented to person. Does recognize son. Does\n follow simple commands. Unable to state where she is or explain how she\n feels. Cri, creat 3.9/bun 55. combative in ew. Cont grunting sounds\n when awake.\n Action:\n Pt is acidotic 7.13 and receiving sodium bicarb in d10 several meds\n have been held to correct cri. Pt has bed alarm on. Orient pt\n frequently. Pt received haldol in ew which helped with combativeness.\n Response:\n Pt still receiving d10 with bicarb and is resting. Less moaning and\ngrunting\n sounds. Vss.\n Plan:\n Cont with d10 and sodium bicarb. If pt becomes agitated, call son as\n he has a very calming effect on pt.\n Acidosis, Metabolic\n Assessment:\n Ph 7.13, confused.\n Action:\n D10 with sodium bicarb.\n Response:\n pending\n Plan:\n Cont with bicarb until ph is normal. Cont to reorient pt to place and\n time.\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 315798,
"text": "Chief Complaint: management of acidosis and acute mental status\n changes\n HPI:\n This is an 82 year-old female with history of CRI not on HD who was\n transferred to our ED for hyperkalemia and acidosis, transferred to the\n ICU for management of acidosis and acute mental status changes. She\n fell at her NH yesterday, and was discharged back to her NH after a\n reportedly negative work up at . Today her son saw her\n at the and felt that her MS .\n .\n At the OSH ED, labs showed K 6.7, Na 126, bicarb 7, and pH 7.11. They\n treated her hyperkalemia with Insulin/glucose, bicarbonate, and\n kayexelate. Ceftriaxone 1 g was given for a suspected UTI. She had a\n R TLC placed supraclavicularly, which had to be pulled back.\n .\n In the ED vitals were HR 89 BP 127/48 RR 15 SpO2 95% RA CVP 9. CT\n Head showed no bleed. Haldol 2.5 mg IV was given for agitation. Renal\n was called and suggested possible HD. She was admitted to the ICU for\n AMS and acidemia. Her TLC had oozing around the sutures site and a\n pressure dressing was placed.\n .\n Review of systems:\n On review of systems, the patient's son reports that she has increased\n facial swelling and leg edema over the last several days. +increased\n breathing x 1 day. +Poor energy; +poor appetite. In addition, she has\n been having episodes of muffled speech x 1 month, increasing in\n frequency. son does not feel that her speech is slurred but\n rather that her mouth is dry. She sometimes gets confused, but usually\n knows her son. She does c/o dyspnea, +thirsty.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Other medications:\n - Fluid restriction 1200ml\n - Levothyroxine 50 mcg PO DAILY\n - Guaifenesin 400mg PO TID\n - Hydralazine 50mg Q8H\n - Isosorbide Dinitrate 10 mg PO TID\n - Metoprolol Succinate 25mg QPM\n - Prilosec 20 mg PO daily\n - Calcium Carbonate 500 mg PO TID W/MEALS\n - Cholecalciferol (Vitamin D3) 800 unit PO DAILY\n - Multivitamin PO DAILY\n - Fentanyl 50 mcg/hr Patch 72HR -- placed \n - Senna 8.6 mg Tablet PO BID\n - Prednisone 5 mg PO daily\n - Trazodone 50 mg PO HS prn\n - Brimonidine Tartrate 0.2 % Drops \n - Epogen 4,000 units SubQ MF Every other week\n - Iron 325 daily\n - Potassium 20mEq daily\n - Nortryptiline 10mg QAM\n - Albuterol PRN\n - Macrobid 100mg PO BID x 10 days (Day 1 = )\n - Clonazepam 0.5mg QHS PRN\n - Renagel 800mg TID with meals\n - Combivent 2 puffs \n - Nystatin swish and swallow\n - Saline nasal spray five times a day\n - Paxil 30mg daily\n - Plavix 75mg daily\n - Singulair 10mg daily\n - Spironolactone 50mg daily\n - Lasix 100mg daily\n - Nasocort \n - Lactulose 15ml \n - Vitamin C 1000mg \n Past medical history:\n Family history:\n Social History:\n CKD Stage IV/V?? not on HD: Fistula placed right forearm in ,\n unknown baseline Cr; Nephrologist from \n CAD\n HTN\n GERD\n Pulmonary fibrosis\n RA - tx with MTX and prednisone\n h/o PCP PNA in \n ?PMR/TA\n hypothroidism\n depression and anxiety\n breast cancer s/p L mastectomy\n OA\n macular degeneration\n s/p B TKR\n chronic pain syndrome\n +breast CA in daughter. Had a son who died in his 50s of appendiceal\n carcinoid.\n Tobacco: Lifetime non-smoker.\n Alcohol: Rare ETOH.\n Other: Lives at a nursing home. Son involved in her care.\n Flowsheet Data as of 02:04 AM\n Vital Signs\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 108 (108 - 108) bpm\n BP: 161/122(136){161/122(136) - 161/122(136)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 16 mL\n PO:\n TF:\n IVF:\n 16 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 16 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs:\n OSH labs:\n Na 127, K 6.3\n Cl 108, CO2 7\n BUN 61, Cr 4.2\n Glucose 110\n Ca 9.2, Alb 3.8\n WBC 12.7\n Hct 31.1\n Plt 389\n .\n ABG: 7.11/21/97 on room air\n .\n UA: Cloudy with large leuks, neg nitrites, 3+ bact.\n Imaging:\n CT Head: No hemorrhage.\n .\n CXR:\n 1. No focal consolidation detected or evidence of pulmonary edema.\n However, the right lung base is limited given the overlying density.\n 2. Suggestion of biapical traction bronchiectasis.\n 3. Right humeral head deformity.\n 4. Clips in left axilla suggesting nodal dissection.\n ECG: OSH EKG: NSR, peaked T waves.\n .\n EKG at : NSR with LAD, a lot of artifact in the baseline, LVH by\n aVL criteria, poor R wave progression, ? inferior Q waves; peaked T\n waves resolved.\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Acute on Chronic Renal Failure, s/p fistula placement.\n ACIDOSIS, METABOLIC\n URINARY TRACT INFECTION (UTI)\n HYPERTENSION, BENIGN\n .H/O FALL(S)\n .H/O ARTHRITIS, RHEUMATOID (RA)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ANEMIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 315802,
"text": "Chief Complaint: management of acidosis and acute mental status\n changes\n HPI:\n This is an 82 year-old female with history of CRI not on HD who was\n transferred to our ED for hyperkalemia and acidosis, transferred to the\n ICU for management of acidosis and acute mental status changes. She\n fell at her NH yesterday, and was discharged back to her NH after a\n reportedly negative work up at . Today her son saw her\n at the and felt that her MS .\n .\n At the OSH ED, labs showed K 6.7, Na 126, bicarb 7, and pH 7.11. They\n treated her hyperkalemia with Insulin/glucose, bicarbonate, and\n kayexelate. Ceftriaxone 1 g was given for a suspected UTI. She had a\n R TLC placed supraclavicularly, which had to be pulled back.\n .\n In the ED vitals were HR 89 BP 127/48 RR 15 SpO2 95% RA CVP 9. CT\n Head showed no bleed. Haldol 2.5 mg IV was given for agitation. Renal\n was called and suggested possible HD. She was admitted to the ICU for\n AMS and acidemia. Her TLC had oozing around the sutures site and a\n pressure dressing was placed.\n .\n Review of systems:\n On review of systems, the patient's son reports that she has increased\n facial swelling and leg edema over the last several days. +increased\n breathing x 1 day. +Poor energy; +poor appetite. In addition, she has\n been having episodes of muffled speech x 1 month, increasing in\n frequency. son does not feel that her speech is slurred but\n rather that her mouth is dry. She sometimes gets confused, but usually\n knows her son. She does c/o dyspnea, +thirsty.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Other medications:\n - Fluid restriction 1200ml\n - Levothyroxine 50 mcg PO DAILY\n - Guaifenesin 400mg PO TID\n - Hydralazine 50mg Q8H\n - Isosorbide Dinitrate 10 mg PO TID\n - Metoprolol Succinate 25mg QPM\n - Prilosec 20 mg PO daily\n - Calcium Carbonate 500 mg PO TID W/MEALS\n - Cholecalciferol (Vitamin D3) 800 unit PO DAILY\n - Multivitamin PO DAILY\n - Fentanyl 50 mcg/hr Patch 72HR -- placed \n - Senna 8.6 mg Tablet PO BID\n - Prednisone 5 mg PO daily\n - Trazodone 50 mg PO HS prn\n - Brimonidine Tartrate 0.2 % Drops \n - Epogen 4,000 units SubQ MF Every other week\n - Iron 325 daily\n - Potassium 20mEq daily\n - Nortryptiline 10mg QAM\n - Albuterol PRN\n - Macrobid 100mg PO BID x 10 days (Day 1 = )\n - Clonazepam 0.5mg QHS PRN\n - Renagel 800mg TID with meals\n - Combivent 2 puffs \n - Nystatin swish and swallow\n - Saline nasal spray five times a day\n - Paxil 30mg daily\n - Plavix 75mg daily\n - Singulair 10mg daily\n - Spironolactone 50mg daily\n - Lasix 100mg daily\n - Nasocort \n - Lactulose 15ml \n - Vitamin C 1000mg \n Past medical history:\n Family history:\n Social History:\n CKD Stage IV/V?? not on HD: Fistula placed right forearm in ,\n unknown baseline Cr; Nephrologist from \n CAD\n HTN\n GERD\n Pulmonary fibrosis\n RA - tx with MTX and prednisone\n h/o PCP PNA in \n ?PMR/TA\n hypothroidism\n depression and anxiety\n breast cancer s/p L mastectomy\n OA\n macular degeneration\n s/p B TKR\n chronic pain syndrome\n +breast CA in daughter. Had a son who died in his 50s of appendiceal\n carcinoid.\n Tobacco: Lifetime non-smoker.\n Alcohol: Rare ETOH.\n Other: Lives at a nursing home. Son involved in her care.\n Flowsheet Data as of 02:04 AM\n Vital Signs\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 108 (108 - 108) bpm\n BP: 161/122(136){161/122(136) - 161/122(136)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 16 mL\n PO:\n TF:\n IVF:\n 16 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 16 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n General: Elderly woman, trembling and mumbling incoherently. Moaning\n in pain with any movement.\n HEENT: Mucous membranes dry, OP clear.\n Neck: Supple\n Chest: Moving air well b/l\n CV: S1, S2, RRR, +II/VI systolic murmur, no rub.\n Abd: Normoactive BS, NT, slightly distended. No masses or\n organomegaly.\n MS: Skin tear on left forearm; winces with pain with movement of left\n arm, no focal point tenderness. Also with extensive skin tear,\n bruising and soft tissue swelling of Right leg. No erythema, warmth,\n or fluid collection to indicate infection.\n Ext: +palpable thrill on Right forearm over AV fistula. No cyanosis,\n no clubbing, trace pedal edema with 2+ dorsalis pedis pulses\n bilaterally. Marked deviation of all toes on both feet.\n Neuro: Oriented to \"hospital.\" PERRL, follows commands but unable to\n maintain focus for conversation, closes eyes while talking and starts\n mumbling. +tremor of hands. Unable to test for asterixis b/c patient\n not cooperating. No clonus.\n Labs / Radiology\n 373\n 94\n 3.9\n 55\n 8\n 107\n 4.7\n 131\n 30.3\n 10.6\n [image002.jpg]\n Fluid analysis / Other labs:\n OSH labs:\n Na 127, K 6.3\n Cl 108, CO2 7\n BUN 61, Cr 4.2\n Glucose 110\n Ca 9.2, Alb 3.8\n WBC 12.7\n Hct 31.1\n Plt 389\n .\n ABG: 7.11/21/97 on room air\n .\n UA: Cloudy with large leuks, neg nitrites, 3+ bact.\n Imaging:\n CT Head: No hemorrhage.\n .\n CXR:\n 1. No focal consolidation detected or evidence of pulmonary edema.\n However, the right lung base is limited given the overlying density.\n 2. Suggestion of biapical traction bronchiectasis.\n 3. Right humeral head deformity.\n 4. Clips in left axilla suggesting nodal dissection.\n ECG: OSH EKG: NSR, peaked T waves.\n .\n EKG at : NSR with LAD, a lot of artifact in the baseline, LVH by\n aVL criteria, poor R wave progression, ? inferior Q waves; peaked T\n waves resolved.\n Assessment and Plan\n 82yo woman with h/o CRI not on HD admitted with altered mental status,\n hyperkalemia, and acidosis in the setting of elevated Cr.\n # Altered Mental Status:\n DDx includes uremia, electrolyte derangement, intracranial hemorrhage\n (unlikely in light of negative head CT), infection, hypothyroidism, B12\n deficiency, or NPH.\n - review of systems suggestive of uremic symptoms, appreciate renal\n input\n - address electrolytes as below\n - Head CT negative for bleed or hydrocephalus\n - infection may play a role; treat UTI\n - check TSH and B12\n - tox screen\n # Acute on Chronic Renal Failure: current Cr 4.2\n - obtain OSH records to determine baseline Cr (1.5 in )\n - unclear why patient has CRI (most likely hypertensive\n nephrosclerosis)\n - Acute worsening most likely due to volume depletion in the setting of\n high doses of diuretics and UTI\n - treat acidosis and hyperkalemia as discussed below\n - careful volume resuscitation with bicarb\n - hold diuretics\n - Foley to monitor I/Os\n - continue Epogen\n - appreciate renal recs; patient has AV fistula if she requires\n dialysis, but unclear if mature\n # Acidosis:\n - IVF with 3 amps NaHCO3 in D5 overnight\n - given injuries and maturing fistula, not possible to get radial\n artery access\n - follow VBG for the present\n .\n # Hyperkalemia:\n - improving, peaked T waves resolved\n - follow closely; would give Ca gluconate, insulin with dextrose, and\n kayexalate if K+ increases\n - AM EKG\n .\n # s/p fall: Most likely secondary to volume depletion/orthostasis but\n also possible that worsening mental status contributed.\n - wound care of skin tears\n - X-Rays of left arm and right leg given tenderness but incomplete\n history\n - no evidence of abuse on exam\n # Possible UTI:\n - UA dirty, though not positive for nitrites\n - f/u urine Cx\n - incompletely treated with macrobid; cipro for 7 day course (day 1 =\n )\n # Tachycardia:\n - most likely from volume depletion\n - careful volume repletion with IV fluids\n - note that patient has CKD with impaired ability to make urine, so\n monitor respiratory status closely with hydration\n - other possible causes for tachycardia include hyperthyroidism or pain\n # Macrocytic Anemia:\n - follow serial Hct, obtaining baseline from OSH\n - check B12 and Folate\n # CAD:\n - continue plavix and beta blocker as well as isosorbide\n - unclear why not on ASA or statin\n # HTN:\n - continue antihypertensives but hold diuretics\n # Rheumatoid Arthritis:\n - continue home meds, including low dose prednisone\n # Depression and Anxiety:\n - continue paxil, trazodone\n - clonazepam PRN\n # Hypothyroidism:\n - continue levothyroxine\n - check TSH\n # GERD:\n - continue PPI\n # FEN: renal, cardiac diet\n # PPx: PPI for GERD; heparin SubQ\n # Access: may need TLC pulled in AM as it was placed by OSH\n # FULL CODE but would not want sustained intubation\n # Comm: son (HCP) \n # Dispo: ICU\n"
},
{
"category": "Case Management ",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 315846,
"text": "Insurance information\n Primary insurance: MEDICARE A B (HOSP MED INS)\n Secondary insurance:\n Insurance reviewer::\n Free Care application: No\n Status:\n Medicaid application: No\n Pre-Hospitalization services: Mrs. is a resident at Center in .\n DME / Home O[2]:\n Functional Status / Home / Family Assessment:\n Mrs at baseline is oriented to person and place and uses a walker\n or a wheelchair for ambulation. She can make her needs known. Mrs.\n has a fistula in place for future dialyisis. It hasn't been\n initated.\n Primary Contact(s): (son)\n Health Proxy: .\n Dialysis: No\n Referrals Recommended:\n Current plan: Rehab\n To return to Center. She is on a 10 day bed hold.\n Patient (s) to Discharge: None\n Patient discussed with multidisciplinary team: No\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 315825,
"text": "Chief Complaint: Acidosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Moaning\n 24 Hour Events:\n MULTI LUMEN - START 12:00 AM\n pt came with site from osh\n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamides)\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 Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Respiratory: Dyspnea, Tachypnea\n Heme / Lymph: Anemia\n Pain: Moderate\n Pain location: diffuse\n Flowsheet Data as of 09:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.5\nC (99.5\n HR: 98 (98 - 108) bpm\n BP: 122/46(65){105/29(50) - 161/122(136)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 20 (5 - 20)mmHg\n Total In:\n 629 mL\n PO:\n TF:\n IVF:\n 629 mL\n Blood products:\n Total out:\n 0 mL\n 320 mL\n Urine:\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 309 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///10/\n Physical Examination\n General Appearance: frail\n Eyes / Conjunctiva: legally blind\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar)\n Abdominal: Soft\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, diffuse ecchymoses\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.2 g/dL\n 299 K/uL\n 160 mg/dL\n 4.0 mg/dL\n 10 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 110 mEq/L\n 134 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 12:38 AM\n 05:21 AM\n WBC\n 9.4\n Hct\n 26.2\n Plt\n 299\n Cr\n 3.9\n 4.0\n Glucose\n 94\n 160\n Other labs: PT / PTT / INR:14.1/37.8/1.2, Differential-Neuts:88.5 %,\n Lymph:6.5 %, Mono:4.5 %, Eos:0.2 %, Lactic Acid:1.3 mmol/L, Ca++:8.1\n mg/dL, Mg++:2.6 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Acute on Chronic Renal Failure, s/p fistula placement. Acute absence\n of history - Obviously has significant CRF as she has dialysis vascular\n access. Certainly acidosis is relatively recent but we desperately need\n baseline BUN/creat from her primary nephrologist. In meantime we are\n bolusing her with D5/NaHCO3. Will monitor her urine output and HR\n although tachycardia may also reflect her diffuse pain. Holding\n diuretics.\n ACIDOSIS, METABOLIC - primarily due to hyperchloremia and\n hyperphosphatemia. Hopefully will improve with volume but may need\n dialysis\n URINARY TRACT INFECTION (UTI)\n HYPERTENSION, BENIGN - normotensive now\n .H/O FALL(S) - checking X-Rays for fractures\n .H/O ARTHRITIS, RHEUMATOID (RA)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE) - unclear\n what history is - will obtain outside records\n ANEMIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 315828,
"text": "Chief Complaint: mental status change\n 24 Hour Events:\n MULTI LUMEN - START 12:00 AM\n pt came with site from osh\n Given 3amps of bicarbonate in D5W\n Subjective: +Constipation\n Allergies:\n Sulfa (Sulfonamides)\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 09:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.5\nC (99.5\n HR: 91 (91 - 108) bpm\n BP: 115/42(57){105/29(50) - 161/122(136)} mmHg\n RR: 12 (12 - 16) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 16 (5 - 20)mmHg\n Total In:\n 796 mL\n PO:\n TF:\n IVF:\n 796 mL\n Blood products:\n Total out:\n 0 mL\n 400 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 396 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///10/\n Physical Examination\n General Appearance: talking about needing to have a BM\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), no rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Musculoskeletal: pain with movement of left arm\n Skin: Not assessed, extensive bruising from injuries to left arm and\n right leg; palpable thrill over right arm fistula\n Neurologic: No(t) Oriented (to): place (\"hotel\") or time; no clonus;\n +tremulous, but unable to test asterixis b/c not cooperating\n Labs / Radiology\n 299 K/uL\n 8.2 g/dL\n 160 mg/dL\n 4.0 mg/dL\n 10 mEq/L\n 4.4 mEq/L\n 55 mg/dL\n 110 mEq/L\n 134 mEq/L\n 26.2 %\n 9.4 K/uL\n [image002.jpg]\n 12:38 AM\n 05:21 AM\n WBC\n 9.4\n Hct\n 26.2\n Plt\n 299\n Cr\n 3.9\n 4.0\n Glucose\n 94\n 160\n Other labs: PT / PTT / INR:14.1/37.8/1.2, Differential-Neuts:88.5 %,\n Lymph:6.5 %, Mono:4.5 %, Eos:0.2 %, Lactic Acid:1.3 mmol/L, Ca++:8.1\n mg/dL, Mg++:2.6 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n 82yo woman with h/o CKD not on hemodialysis admitted with altered\n mental status and acidosis.\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n - unclear if from uremia or has another underlying process,\n such as infection, B12 deficiency, etc as discussed in Admit H&P\n - hydrate with IV fluids and assess mental status during day\n - f/u tox screen, TSH, B12\n - head CT negative for bleed\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Acute on Chronic Renal Failure, s/p fistula placement. Most likely due\n to dehydration from excessive diuretics in setting of UTI.\n - trial of volume repletion with bicarbonate; monitor response\n of tachycardia and urine output to fluid challenge\n - monitor Q6H lytes to follow acidosis and K+; check VBGs as\n difficult to get ABGs in her\n - obtain OSH records to determine baseline Cr\n - continue renagel, epogen\n - follow I/O closely (Foley)\n - appreciate renal recs\n URINARY TRACT INFECTION (UTI)\n - treating with cipro x 7 days (day 1 = )\n - f/u UCx\n HYPERTENSION, BENIGN\n - holding diuretics, but will continue other antihypertensives\n .H/O FALL(S)\n - fall precautions\n - f/u X-Rays of left arm and right leg.\n - Appreciate wound care recs\n .H/O ARTHRITIS, RHEUMATOID (RA)\n - continue home meds, including prednisone 5mg daily\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n - unclear why pt not on ASA or statin\n - continue plavix, isosorbide, beta blocker\n ANEMIA, OTHER\n - check B12 and folate\n # Depression/Anxiety:\n - continue home meds but may need to hold sedating medications\n such as clonazepam and nortriptyline if mental status does not improve\n # Constipation: Bowel regimen\n ICU Care\n Nutrition:\n Comments: renal, cardiac diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n 18 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:ICU\n"
}
] |
30,987 | 180,501 | # UGI Bleed: EGD showed esophageal varices, one with ulcer on top, in the setting of cirrhosis, and he underwent banding. Patient was not transfused and Hct stablized over the course of 24 hrs. In AM of day 2 of ICU stay, patient had repeat hematemesis, but Hct was unchanged. He was continued on octreotide gtt and transitioned to IV PPI . After being called out to the floor, he was switched to oral PPI and Cipro. Octreotide was stopped after ~24 hours. His diet was advanced without incident, and his Hct remained stable with no further signs of significant bleeding. Nadolol was continued and carafate was started per hepatology. | .H/O esophageal varices Assessment: NBP 120s. .H/O esophageal varices Assessment: NBP 120s. .H/O esophageal varices Assessment: NBP 120s. .H/O esophageal varices Assessment: NBP 120s. Advanced diet to clear liquids from NPO. Advanced diet to clear liquids from NPO. Advanced diet to clear liquids from NPO. Advanced diet to clear liquids from NPO. Zofran x 1 given after hematemesis with good relief. Zofran x 1 given after hematemesis with good relief. Zofran x 1 given after hematemesis with good relief. Zofran x 1 given after hematemesis with good relief. Pt now s/p EGD c/ banding x 3. Assess for DTs using CIWA scale- reinforce need for abstaining from ETOH Assess for DTs using CIWA scale- reinforce need for abstaining from ETOH Assess for DTs using CIWA scale- reinforce need for abstaining from ETOH Assess for DTs using CIWA scale- reinforce need for abstaining from ETOH .H/O esophageal varices Assessment: Action: Response: Plan: .H/O esophageal varices Assessment: Action: Response: Plan: Pt currently on clear liquid c/ appropriate vitamin and mineral supplementation for ETOH. Pt at nutritional risk ETOH and hypermetabolism of cirrhosis. Action: Pt had an EGD done upon arrival to the floor. Pt stated that has had an etoh abuse problem. Admitted to MICU from ED for dark stools and ~ 1 cup of hematemesis- bright red. - still drinking - MELD 12 # ETOH: last drink was the day PTA, no h/o withdrawal sx/seizures - CIWA scale- pt has not yet scored >10 - SW c/s - continue thiamine, folate . - still drinking - MELD 12 # ETOH: last drink was the day PTA, no h/o withdrawal sx/seizures - CIWA scale- pt has not yet scored >10 - SW c/s - continue thiamine, folate . Will continue to get hct checks. Pt states his last drink was . Pt states his last drink was . Pt states his last drink was . Pt states his last drink was . CIWA scale q4hours. CIWA scale q4hours. CIWA scale q4hours. CIWA scale q4hours. He is followed outpt by Dr. . He is followed outpt by Dr. . Continue octreotide GTT. ------ Protected Section Addendum Entered By: , MD on: 14:12 ------ AM lab HCT 32.9 Plan: Monitor HCT. (-) CIWA denying HA, hallucinations, ( -) for tremors Action: Hemodynamic monitoring. (-) CIWA denying HA, hallucinations, ( -) for tremors Action: Hemodynamic monitoring. # PPx: pneumoboots, IV PPI . # PPx: pneumoboots, IV PPI . # PPx: pneumoboots, IV PPI . .H/O esophageal varices Assessment: NBP 120s. .H/O esophageal varices Assessment: NBP 120s. .H/O esophageal varices Assessment: NBP 120s. GI was consulted and he was started on Protonix IV and octreotide drip. GI was consulted and he was started on Protonix IV and octreotide drip. # Dispo: ICU for now . # Dispo: ICU for now . # Dispo: ICU for now . # FEN: NPO, IVF . # FEN: NPO, IVF . # FEN: NPO, IVF . CIWA scale q4hours. CIWA scale q4hours. CIWA scale q4hours. Pt states his last drink was . Pt states his last drink was . Pt states his last drink was . We are continuing octreatide and PPI. Patellar DTR +1. Patellar DTR +1. Continue octreotide GTT. Continue octreotide GTT. Re- canalized paraumbilical vein is seen. Re- canalized paraumbilical vein is seen. Allergies: NKDA . Allergies: NKDA . Zofran x 1 given after hematemesis with good relief. Zofran x 1 given after hematemesis with good relief. Zofran x 1 given after hematemesis with good relief. Advanced diet to clear liquids from NPO. Advanced diet to clear liquids from NPO. Advanced diet to clear liquids from NPO. Splenomegaly. Splenomegaly. - still drinking - DF 6 - MELD 12 # ETOH: last drink was yesterday, no h/o withdrawal sx/seizures - CIWA scale - SW c/s - continue thiamine, folate . - still drinking - DF 6 - MELD 12 # ETOH: last drink was yesterday, no h/o withdrawal sx/seizures - CIWA scale - SW c/s - continue thiamine, folate . - still drinking - DF 6 - MELD 12 # ETOH: last drink was yesterday, no h/o withdrawal sx/seizures - CIWA scale - SW c/s - continue thiamine, folate . Imaging: Liver u/s : 1. Imaging: Liver u/s : 1. In the ED, T 98.2 HR 68 BP 142/72 sat100% on RA. In the ED, T 98.2 HR 68 BP 142/72 sat100% on RA. Assess for DTs using CIWA scale- reinforce need for abstaining from ETOH. His last drink was on . His last drink was on . He is followed outpt by Dr. . He is followed outpt by Dr. . He is followed outpt by Dr. . | 22 | [
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 352461,
"text": "45 year old male admitted to MICU from ED with dark stools and\n hematemesis (bright red) due to ETOH cirrhosis and grade II esophageal\n varices. Prior to current MICU admission pt last banded in . Daily\n ETOH use includes 6 pack of Mikes Hard Lemonade pluse occasional\n tumbler of cognac. Pt states his last drink was .\n Upon arrival to MICU- EGD was performed with banding x3.\n .H/O esophageal varices\n Assessment:\n NBP 120\ns. NSR 60\ns. Skin is warm, strong pedal pulses. Sp02 94-98%\n 2 L NC, lungs clear. Abdomen soft, slightly distended (increased on\n left side), denies any abdominal pain, + bowel sounds, hematemesis x1\n ~200 cc bright red blood, c/o nausea just prior to hematemesis but\n expressed relief after episode, ~ 400 cc maroon liquid stool x1 in\n commode- Hct down 3 points to 29.9 from 0300 blood drawn to 0730 draw.\n Voiding without difficulty with urinal, urine amber and clear. BUN and\n CR WNL. Denies any dizziness or SOB. (-) CIWA denying HA,\n hallucinations, ( -) for tremors\n Action:\n Hemodynamic monitoring. Labs drawn. Zofran x 1 given after hematemesis\n with good relief. Advanced diet to clear liquids from NPO. Banana bag\n given. CIWA scale q4hours. Social work consulted- discussed with pt\n importance of abstaining from ETOH\n Response:\n Pt remains Hemodynamically stable with no drop in NBP with episodes of\n hematemesis and/or stooling. Hct stable at 29.9. Denies any nausea or\n abdominal pain- abdomen remains soft and distended. CIWA remains (-)\n Tolerated advance in diet.\n Plan:\n Hemodynamic monitoring. Assess and treat for s/s of continued bleeding\n and/or nausea (GI service believes bloody stool and vomit from earlier\n today is from old excess blood noted during EGD) Pt is cross-matched\n for 4 U PRBC. Follow up EGD and banding needed outpatient in 3 weeks.\n Continue to advance diet as tolerated. Assess for DT\ns using CIWA\n scale- reinforce need for abstaining from ETOH\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352462,
"text": "45 year old male admitted to MICU from ED with dark stools and\n hematemesis (bright red) due to ETOH cirrhosis and grade II esophageal\n varices. Prior to current MICU admission pt last banded in . Daily\n ETOH use includes 6 pack of Mikes Hard Lemonade pluse occasional\n tumbler of cognac. Pt states his last drink was .\n Upon arrival to MICU- EGD was performed with banding x3.\n .H/O esophageal varices\n Assessment:\n NBP 120\ns. NSR 60\ns. Skin is warm, strong pedal pulses. Sp02 94-98%\n 2 L NC, lungs clear. Abdomen soft, slightly distended (increased on\n left side), denies any abdominal pain, + bowel sounds, hematemesis x1\n ~200 cc bright red blood, c/o nausea just prior to hematemesis but\n expressed relief after episode, ~ 400 cc maroon liquid stool x1 in\n commode- Hct down 3 points to 29.9 from 0300 blood drawn to 0730 draw.\n Voiding without difficulty with urinal, urine amber and clear. BUN and\n CR WNL. Denies any dizziness or SOB. (-) CIWA denying HA,\n hallucinations, ( -) for tremors\n Action:\n Hemodynamic monitoring. Labs drawn. Zofran x 1 given after hematemesis\n with good relief. Advanced diet to clear liquids from NPO. Banana bag\n given. CIWA scale q4hours. Social work consulted- discussed with pt\n importance of abstaining from ETOH\n Response:\n Pt remains Hemodynamically stable with no drop in NBP with episodes of\n hematemesis and/or stooling. Hct stable at 29.9. Denies any nausea or\n abdominal pain- abdomen remains soft and distended. CIWA remains (-)\n Tolerated advance in diet.\n Plan:\n Hemodynamic monitoring. Assess and treat for s/s of continued bleeding\n and/or nausea (GI service believes bloody stool and vomit from earlier\n today is from old excess blood noted during EGD) Pt is cross-matched\n for 4 U PRBC. Follow up EGD and banding needed outpatient in 3 weeks.\n Continue to advance diet as tolerated. Assess for DT\ns using CIWA\n scale- reinforce need for abstaining from ETOH\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 352464,
"text": "45 year old male admitted to MICU from ED with dark stools and\n hematemesis (bright red) due to ETOH cirrhosis and grade II esophageal\n varices. Prior to current MICU admission pt last banded in . Daily\n ETOH use includes 6 pack of Mikes Hard Lemonade pluse occasional\n tumbler of cognac. ETOH abuse dates back 10 years, tobacco use of\n pack/day x 20 years as well. Pt states his last drink was .\n Upon arrival to MICU- EGD was performed with banding x3.\n .H/O esophageal varices\n Assessment:\n NBP 120\ns. NSR 60\ns. Skin is warm, strong pedal pulses. Sp02 94-98%\n 2 L NC, lungs clear. Abdomen soft, slightly distended (increased on\n left side), denies any abdominal pain, + bowel sounds, hematemesis x1\n ~200 cc bright red blood, c/o nausea just prior to hematemesis but\n expressed relief after episode, ~ 400 cc maroon liquid stool x1 in\n commode- Hct down 3 points to 29.9 from 0300 blood drawn to 0730 draw.\n Voiding without difficulty with urinal, urine amber and clear. BUN and\n CR WNL. Denies any dizziness or SOB. (-) CIWA denying HA,\n hallucinations, ( -) for tremors\n Action:\n Hemodynamic monitoring. Labs drawn. Zofran x 1 given after hematemesis\n with good relief. Advanced diet to clear liquids from NPO. Banana bag\n given. Ocreotide drip at 50 mcg/hr. CIWA scale q4hours. Social work\n consulted- discussed with pt importance of abstaining from ETOH\n Response:\n Pt remains Hemodynamically stable with no drop in NBP with episodes of\n hematemesis and/or stooling. Hct stable at 29.9. Denies any nausea or\n abdominal pain- abdomen remains soft and distended. CIWA remains (-)\n Tolerated advance in diet.\n Plan:\n Hemodynamic monitoring. Assess and treat for s/s of continued bleeding\n and/or nausea (GI service believes bloody stool and vomit from earlier\n today is from old excess blood noted during EGD) Pt is cross-matched\n for 4 U PRBC. Follow up EGD and banding needed outpatient in 3 weeks.\n Continue to advance diet as tolerated. Assess for DT\ns using CIWA\n scale- reinforce need for abstaining from ETOH\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352465,
"text": "45 year old male admitted to MICU from ED with dark stools and\n hematemesis (bright red) due to ETOH cirrhosis and grade II esophageal\n varices. Prior to current MICU admission pt last banded in . Daily\n ETOH use includes 6 pack of Mikes Hard Lemonade pluse occasional\n tumbler of cognac. ETOH abuse dates back 10 years, smoking history of\n pack/day x 20 years as well. Pt states his last drink was .\n Upon arrival to MICU- EGD was performed with banding x3.\n .H/O esophageal varices\n Assessment:\n NBP 120\ns. NSR 60\ns. Skin is warm, strong pedal pulses. Sp02 94-98%\n 2 L NC, lungs clear. Abdomen soft, slightly distended (increased on\n left side), denies any abdominal pain, + bowel sounds, hematemesis x1\n ~200 cc bright red blood, c/o nausea just prior to hematemesis but\n expressed relief after episode, ~ 400 cc maroon liquid stool x1 in\n commode- Hct down 3 points to 29.9 from 0300 blood drawn to 0730 draw.\n Voiding without difficulty with urinal, urine amber and clear. BUN and\n CR WNL. Denies any dizziness or SOB. (-) CIWA denying HA,\n hallucinations, ( -) for tremors\n Action:\n Hemodynamic monitoring. Labs drawn. Zofran x 1 given after hematemesis\n with good relief. Advanced diet to clear liquids from NPO. Banana bag\n given. Ocreotide drip at 50 mcg/hr running. CIWA scale q4hours. Social\n work consulted- discussed with pt importance of abstaining from ETOH\n Response:\n Pt remains Hemodynamically stable with no drop in NBP with episodes of\n hematemesis and/or stooling. Hct stable at 29.9. Denies any nausea or\n abdominal pain- abdomen remains soft and distended. CIWA remains (-)\n Tolerated advance in diet.\n Plan:\n Hemodynamic monitoring. Assess and treat for s/s of continued bleeding\n and/or nausea (GI service believes bloody stool and vomit from earlier\n today is from old excess blood noted during EGD) Pt is cross-matched\n for 4 U PRBC. Follow up EGD and banding needed outpatient in 3 weeks.\n Continue to advance diet as tolerated. Assess for DT\ns using CIWA\n scale- reinforce need for abstaining from ETOH\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing 1900-0700",
"row_id": 352388,
"text": "HPI: This is a 45 yo M with EtOH cirrhosis and grade II esophageal\n varices s/p banding in . Notes that yesterday and today he had dark\n stools. Then he noted at 3pm today he ate some lunch and felt nauseous\n and subsequently had ~ 1 cup of hematemesis- bright red. Denies having\n had any since.\n Pt states that he has a 6 pack of Mikes Hard Lemonade daily, plus\n occasional tumbler of cognac. His last drink was on .\n .H/O esophageal varices\n Assessment:\n Pt has had no vomiting since his admit to the ICU.\n Action:\n Pt had an EGD done upon arrival to the floor. Pt received a total of\n 125mcg of Fentanyl and 3mg of Versed. Pt had 3 banding done during\n procedure.\n Response:\n HCT post procedure was 34.5. Pt has c/o sore throat, however no other\n complaints of pain or discomfort. Pt has an octreotide GTT running at\n 50mcg/hr. Gag reflex intact, pt given a small cup of ice chips with no\n adverse reactions. AM lab HCT 32.9\n Plan:\n Monitor HCT. Continue octreotide GTT. Provide emotional support.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt has had no stool since admission. Liver enzymes with AM labs sent.\n Pt states that he has a 6 pack of Mikes Hard Lemonade daily, plus\n occasional tumbler of cognac\n Action:\n MD reminded pt the importance of him to stop drinking.\n Response:\n Pt stated,\nI know I have to stop but at least I am not drinking as\n much as I used to.\n AST = 62\n Plan:\n Continue providing emotional support to the pt in regards to drinking.\n Continue reinforcing the importance of him not drinkning.\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 352455,
"text": "Chief Complaint: UGIB\n 24 Hour Events:\n ENDOSCOPY - At 10:14 PM\n with banding x3.\n -Hct trending down from 37 to 34.5 to 32.9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:20 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 10:14 PM\n Fentanyl - 10:14 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 66 (64 - 75) bpm\n BP: 127/69(82) {125/63(77) - 156/75(91)} mmHg\n RR: 21 (18 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 144 mL\n 658 mL\n PO:\n TF:\n IVF:\n 144 mL\n 658 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 144 mL\n 658 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: 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 No(t) Crackles : , No(t) Wheezes : , 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 Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 92 K/uL\n 10.9 g/dL\n 121 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 107 mEq/L\n 138 mEq/L\n 32.9 %\n 7.8 K/uL\n [image002.jpg]\n 10:11 PM\n 03:31 AM\n WBC\n 7.8\n Hct\n 34.5\n 32.9\n Plt\n 92\n Cr\n 0.5\n Glucose\n 121\n Other labs: PT / PTT / INR:20.0/32.9/1.9, ALT / AST:28/62, Alk Phos / T\n Bili:63/4.2, Albumin:2.8 g/dL, LDH:124 IU/L\n Assessment and Plan\n .H/O ESOPHAGEAL VARICES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n Assessment: This is a 45-year-old man with ETOH cirrhosis and known\n grade II varices who p/w hematemesis.\n .\n Plan:\n .\n # UGI Bleed: likely due to varices in the setting of cirrhosis.\n Bleeding esophageal varix seen on EGD and banding performed x3.\n - continue octreotide gtt until 9p tonight (total of 24 hrs) , IV PPI\n - serial HCTs Q 6\n - Tx for HCT <25\n - Cipro IV the PO once tolerating PO x 5 days per GI recs\n .\n # Etoh Cirrhosis: Child B, complicated by esophageal varices. He is\n followed outpt by Dr. .\n - still drinking\n - MELD 12\n # ETOH: last drink was the day PTA, no h/o withdrawal sx/seizures\n - CIWA scale- pt has not yet scored >10\n - SW c/s\n - continue thiamine, folate\n .\n # Comm: girlfriend/HCP Phone: \n ICU Care\n Nutrition: Clear liquid diet started per GI recs\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 09:00 PM\n 16 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Consider transfer to the floor this afternoon\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n Variceal bleed, on therapy as outlined by Dr .\n Very well appearing, energetic on exam.\n Safe for transfer out to medical floor.\n Will continue to get hct checks.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:12 ------\n"
},
{
"category": "Social Work",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 352448,
"text": "Social Work\n SW consult received via POE to address etoh use.\n SW met w/pt at bedside. Pt was alert, cooperative, and welcomed the SW.\n Pt stated that is eager to go home. He lives w/his fianc\n of 5yrs and\n 17 y/o son. works full time.\n Pt stated that has had an etoh abuse problem. Since last admission to\n about 9 months ago he has decreased his etoh consumption. He said\n that cut down from a pint a day to 2 shots and a few wine coolers per\n day. He recognizes that his drinking is influencing his medical\n condition. He denied any problems at home or work. His fianc\n does not\n drink and son appears to not understand his etoh dependence. He said\n that is not able to stop drinking on his own. In the past he\ns been in\n detox program that was helpful. He denied any anxiety or\n depression and said that is not taking any psych meds. He also denied\n using any other drugs.\n Pt said that is planning to contact and may attend an AA\n meeting.\n Rohila, LCSW\n #\n"
},
{
"category": "Nutrition",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 352453,
"text": "Ht: 72\n Wt: 90.2 Kg\n IBW: 80.9 Kg\n %IBW: 111%\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 45 y/o male c/ ETOH cirrhosis p/w hematemesis variceal bleed. Pt\n now s/p EGD c/ banding x 3. Pt at nutritional risk ETOH and\n hypermetabolism of cirrhosis. Pt currently on clear liquid c/\n appropriate vitamin and mineral supplementation for ETOH. Will follow\n ability to advance diet and make recs prn. Please page c/ ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352456,
"text": ".H/O esophageal varices\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 352457,
"text": "This is a 45 yo M with EtOH cirrhosis and grade II esophageal varices\n s/p banding in . Admitted to MICU from ED for dark stools and ~ 1\n cup of hematemesis- bright red.\n Pt states that he has a 6 pack of Mikes Hard Lemonade daily, plus\n occasional tumbler of cognac. His last drink was on .\n .H/O esophageal varices\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 352446,
"text": "Chief Complaint: UGIB\n 24 Hour Events:\n ENDOSCOPY - At 10:14 PM\n with banding x3.\n -Hct trending down from 37 to 34.5 to 32.9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:20 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 10:14 PM\n Fentanyl - 10:14 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 66 (64 - 75) bpm\n BP: 127/69(82) {125/63(77) - 156/75(91)} mmHg\n RR: 21 (18 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 144 mL\n 658 mL\n PO:\n TF:\n IVF:\n 144 mL\n 658 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 144 mL\n 658 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: 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 No(t) Crackles : , No(t) Wheezes : , 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 Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 92 K/uL\n 10.9 g/dL\n 121 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 107 mEq/L\n 138 mEq/L\n 32.9 %\n 7.8 K/uL\n [image002.jpg]\n 10:11 PM\n 03:31 AM\n WBC\n 7.8\n Hct\n 34.5\n 32.9\n Plt\n 92\n Cr\n 0.5\n Glucose\n 121\n Other labs: PT / PTT / INR:20.0/32.9/1.9, ALT / AST:28/62, Alk Phos / T\n Bili:63/4.2, Albumin:2.8 g/dL, LDH:124 IU/L\n Assessment and Plan\n .H/O ESOPHAGEAL VARICES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n Assessment: This is a 45-year-old man with ETOH cirrhosis and known\n grade II varices who p/w hematemesis.\n .\n Plan:\n .\n # UGI Bleed: likely due to varices in the setting of cirrhosis.\n Bleeding esophageal varix seen on EGD and banding performed x3.\n - continue octreotide gtt until 9p tonight (total of 24 hrs) , IV PPI\n - serial HCTs Q 6\n - Tx for HCT <25\n - Cipro IV the PO once tolerating PO x 5 days per GI recs\n .\n # Etoh Cirrhosis: Child B, complicated by esophageal varices. He is\n followed outpt by Dr. .\n - still drinking\n - MELD 12\n # ETOH: last drink was the day PTA, no h/o withdrawal sx/seizures\n - CIWA scale- pt has not yet scored >10\n - SW c/s\n - continue thiamine, folate\n .\n # Comm: girlfriend/HCP Phone: \n ICU Care\n Nutrition: Clear liquid diet started per GI recs\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 09:00 PM\n 16 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Consider transfer to the floor this afternoon\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 352485,
"text": "45 year old male admitted to MICU from ED with dark stools and\n hematemesis (bright red) due to ETOH cirrhosis and grade II esophageal\n varices. Prior to current MICU admission pt last banded in . Daily\n ETOH use includes 6 pack of Mikes Hard Lemonade pluse occasional\n tumbler of cognac. ETOH abuse dates back 10 years, tobacco use of\n pack/day x 20 years as well. Pt states his last drink was .\n Upon arrival to MICU- EGD was performed with banding x3.\n .H/O esophageal varices\n Assessment:\n NBP 120\ns. NSR 60\ns. Skin is warm, strong pedal pulses. Sp02 94-98%\n 2 L NC, lungs clear. Abdomen soft, slightly distended (increased on\n left side), denies any abdominal pain, + bowel sounds, hematemesis x1\n ~200 cc bright red blood, c/o nausea just prior to hematemesis but\n expressed relief after episode, ~ 400 cc maroon liquid stool x1 in\n commode- Hct down 3 points to 29.9 from 0300 blood drawn to 0730 draw.\n Voiding without difficulty with urinal, urine amber and clear. BUN and\n CR WNL. Denies any dizziness or SOB. (-) CIWA denying HA,\n hallucinations, ( -) for tremors\n Action:\n Hemodynamic monitoring. Labs drawn. Zofran x 1 given after hematemesis\n with good relief. Advanced diet to clear liquids from NPO. Banana bag\n given. Ocreotide drip at 50 mcg/hr. CIWA scale q4hours. Social work\n consulted- discussed with pt importance of abstaining from ETOH\n Response:\n Pt remains Hemodynamically stable with no drop in NBP with episodes of\n hematemesis and/or stooling. Hct stable at 29. Denies any nausea or\n abdominal pain- abdomen remains soft and distended. CIWA remains (-)\n Tolerated advance in diet.\n Plan:\n Hemodynamic monitoring. Assess and treat for s/s of continued bleeding\n and/or nausea (GI service believes bloody stool and vomit from earlier\n today is from old excess blood noted during EGD) Pt is cross-matched\n for 4 U PRBC. Follow up EGD and banding needed outpatient in 3 weeks.\n Continue to advance diet as tolerated. Assess for DT\ns using CIWA\n scale- reinforce need for abstaining from ETOH\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352486,
"text": "45 year old male admitted to MICU from ED with dark stools and\n hematemesis (bright red) due to ETOH cirrhosis and grade II esophageal\n varices. Prior to current MICU admission pt last banded in . Daily\n ETOH use includes 6 pack of Mikes Hard Lemonade pluse occasional\n tumbler of cognac. ETOH abuse dates back 10 years, smoking history of\n pack/day x 20 years as well. Pt states his last drink was .\n Upon arrival to MICU- EGD was performed with banding x3.\n Pt called out and has bed.\n .H/O esophageal varices\n Assessment:\n NBP 120\ns. NSR 60\ns. Skin is warm, strong pedal pulses. Sp02 94-98%\n 2 L NC, lungs clear. Abdomen soft, slightly distended (increased on\n left side), denies any abdominal pain, + bowel sounds, hematemesis x1\n ~200 cc bright red blood, c/o nausea just prior to hematemesis but\n expressed relief after episode, ~ 400 cc maroon liquid stool x1 in\n commode- Hct down 3 points to 29.9 from 0300 blood drawn to 0730 draw.\n Voiding without difficulty with urinal, urine amber and clear. BUN and\n CR WNL. Denies any dizziness or SOB. (-) CIWA denying HA,\n hallucinations, ( -) for tremors\n Action:\n Hemodynamic monitoring. Labs drawn. Zofran x 1 given after hematemesis\n with good relief. Advanced diet to clear liquids from NPO. Banana bag\n given. Ocreotide drip at 50 mcg/hr running. CIWA scale q4hours. Social\n work consulted- discussed with pt importance of abstaining from ETOH\n Response:\n Pt remains Hemodynamically stable with no drop in NBP with episodes of\n hematemesis and/or stooling. Hct stable at 29. Denies any nausea or\n abdominal pain- abdomen remains soft and distended. CIWA remains (-)\n Tolerated advance in diet.\n Plan:\n Hemodynamic monitoring. Assess and treat for s/s of continued bleeding\n and/or nausea (GI service believes bloody stool and vomit from earlier\n today is from old excess blood noted during EGD) Pt is cross-matched\n for 4 U PRBC. Follow up EGD and banding needed outpatient in 3 weeks.\n Continue to advance diet as tolerated. Assess for DT\ns using CIWA\n scale- reinforce need for abstaining from ETOH.\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 352419,
"text": "Chief Complaint: UGIB\n 24 Hour Events:\n ENDOSCOPY - At 10:14 PM\n with banding x3.\n -Hct trending down from 37 to 34.5 to 32.9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:20 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 10:14 PM\n Fentanyl - 10:14 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.7\nC (98.1\n HR: 66 (64 - 75) bpm\n BP: 127/69(82) {125/63(77) - 156/75(91)} mmHg\n RR: 21 (18 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 74 Inch\n Total In:\n 144 mL\n 658 mL\n PO:\n TF:\n IVF:\n 144 mL\n 658 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 144 mL\n 658 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: 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 No(t) Crackles : , No(t) Wheezes : , 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 Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 92 K/uL\n 10.9 g/dL\n 121 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 107 mEq/L\n 138 mEq/L\n 32.9 %\n 7.8 K/uL\n [image002.jpg]\n 10:11 PM\n 03:31 AM\n WBC\n 7.8\n Hct\n 34.5\n 32.9\n Plt\n 92\n Cr\n 0.5\n Glucose\n 121\n Other labs: PT / PTT / INR:20.0/32.9/1.9, ALT / AST:28/62, Alk Phos / T\n Bili:63/4.2, Albumin:2.8 g/dL, LDH:124 IU/L\n Assessment and Plan\n .H/O ESOPHAGEAL VARICES\n .H/O CIRRHOSIS OF LIVER, ALCOHOLIC\n Assessment: This is a 45-year-old man with ETOH cirrhosis and known\n grade II varices who p/w hematemesis.\n .\n Plan:\n .\n # UGI Bleed: likely due to varices in the setting of cirrhosis.\n - plan for EGD per GI\n - continue octreotide, IV PPI\n - serial HCTs\n - Tx for HCT drop 2 points or greater\n - IVF bolus now\n - Cipro IV x 5 days per GI recs\n .\n # Etoh Cirrhosis: Child B, complicated by esophageal varices. He is\n followed outpt by Dr. .\n - still drinking\n - DF 6\n - MELD 12\n # ETOH: last drink was yesterday, no h/o withdrawal sx/seizures\n - CIWA scale\n - SW c/s\n - continue thiamine, folate\n .\n # FEN: NPO, IVF\n .\n # Access: PIVs\n .\n # PPx: pneumoboots, IV PPI\n .\n # Code: Full\n .\n # Dispo: ICU for now\n .\n # Comm: girlfriend/HCP Phone: \n ICU Care\n Nutrition: NPO until 1pm Hct stable\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 09:00 PM\n 16 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing 1900-0700",
"row_id": 352360,
"text": "HPI: This is a 45 yo M with EtOH cirrhosis and grade II esophageal\n varices s/p banding in . Notes that yesterday and today he had dark\n stools. Then he noted at 3pm today he ate some lunch and felt nauseous\n and subsequently had ~ 1 cup of hematemesis- bright red. Denies having\n had any since.\n Pt states that he has a 6 pack of Mikes Hard Lemonade daily, plus\n occasional tumbler of cognac. His last drink was on .\n .H/O esophageal varices\n Assessment:\n Pt has had no vomiting since his admit to the ICU.\n Action:\n Pt had an EGD done upon arrival to the floor. Pt received a total of\n 125mcg of Fentanyl and 3mg of Versed. Pt had 3 banding done during\n procedure.\n Response:\n HCT post procedure was 34.5. Pt has c/o sore throat, however no other\n complaints of pain or discomfort. Pt has an octreotide GTT running at\n 50mcg/hr. Gag reflex intact, pt given a small cup of ice chips with no\n adverse reactions.\n Plan:\n Monitor HCT. Continue octreotide GTT. Provide emotional support.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt has had no stool since admission. Liver enzymes with AM labs sent.\n Pt states that he has a 6 pack of Mikes Hard Lemonade daily, plus\n occasional tumbler of cognac\n Action:\n MD reminded pt the importance of him to stop drinking.\n Response:\n Pt stated,\nI know I have to stop but at least I am not drinking as\n much as I used to.\n Plan:\n Continue providing emotional support to the pt in regards to drinking.\n Continue reinforcing the importance of him not drinkning.\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-02 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 352354,
"text": " Resident Admission Note\n .\n Reason for MICU Admission: monitoring UGIB\n .\n Primary Care Physician: , MD\n .\n CC: .\n HPI: This is a 45 yo M with EtOH cirrhosis and grade II esophageal\n varices s/p banding in . Notes that yesterday and today he had dark\n stools. Then notes that ~3pm today he ate some lunch and then felt\n nauseous and subsequently had ~ 1 cup of hematemesis- bright red.\n Denies having had any since. Denies lightheadedness/chest pain\n associated. Notes that he has been drinking 6 pack of Mikes Hard\n Lemonade daily plus occassional tumbler of cognac, last drink was\n yesterday.\n .\n In the ED, T 98.2 HR 68 BP 142/72 sat100% on RA. GI was consulted and\n he was started on Protonix IV and octreotide drip. HCT was 37 and INR\n 1.8.\n .\n ROS: The patient denies any fevers, chills, abdominal pain, diarrhea,\n constipation, shortness of breath, orthopnea, PND, lower extremity\n edema, cough, weight change,urinary frequency, urgency, dysuria, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n .\n Past Medical History:\n grade II varices s/p banding \n Etoh cirrhosis\n .\n Medications:\n Nadolol 20mg daily\n Omeprazole 20mg daily\n Folic acid\n Multivitamin\n Thiamine\n .\n Allergies: NKDA\n .\n Social History: He had a history of 10 years of heavy drinking\n up to , drinking to 1 pint a day. He has been\n drinking 2 beers a day since . He has never gone\n through detox. He smokes a pack per day for the past 20\n years. He denies using IV drugs or smoking drugs. He lives in\n his apartment with his fiance and his 17-year-old son. \n works as an apartment building manager. He has had recent travel\n to .\n .\n Family Medical History: He denies any liver disease in his family. He\n has 9 sisters and 3 brothers. His mom died of pancreatic cancer\n at a young age. He denies any liver cancer in the family or GI\n cancer.\n .\n Physical Exam:\n Vitals: T: 99.2 BP: 156/75 HR: 69 RR: 21 O2Sat:98%RA\n GEN: Thin, Well-appearing, no acute distress\n HEENT: EOMI, PERRL, sclera icteric BL, no epistaxis or rhinorrhea, MMM,\n OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, no cervical\n lymphadenopathy, trachea midline\n COR: RRR, + flow murmur, G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: alert, oriented to person, place, and time. CN II\n XII grossly\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\n extremities. Patellar DTR +1. Plantar reflex downgoing. No asterixis\n noted\n SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.\n .\n Laboratories:\n HCT 37.0\n INR 1.8\n .\n ECG: Sinus rhythm at 65 bpm, no acute ST-T changes, no comparison.\n .\n Imaging:\n Liver u/s :\n 1. Reversal of flow is seen within the main portal vein as noted. Re-\n canalized paraumbilical vein is seen.\n 2. Splenomegaly.\n 3. Abnormally echogenic liver as noted above.\n .\n Assessment: This is a 45-year-old man with ETOH cirrhosis and known\n grade II varices who p/w hematemesis.\n .\n Plan:\n .\n # UGI Bleed: likely due to varices in the setting of cirrhosis.\n - plan for EGD per GI\n - continue octreotide, IV PPI\n - serial HCTs\n - Tx for HCT drop 2 points or greater\n - IVF bolus now\n - Cipro IV x 5 days per GI recs\n .\n # Etoh Cirrhosis: Child B, complicated by esophageal varices. He is\n followed outpt by Dr. .\n - still drinking\n - DF 6\n - MELD 12\n # ETOH: last drink was yesterday, no h/o withdrawal sx/seizures\n - CIWA scale\n - SW c/s\n - continue thiamine, folate\n .\n # FEN: NPO, IVF\n .\n # Access: PIVs\n .\n # PPx: pneumoboots, IV PPI\n .\n # Code: Full\n .\n # Dispo: ICU for now\n .\n # Comm: girlfriend/HCP Phone: \n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing 1900-0700",
"row_id": 352406,
"text": "HPI: This is a 45 yo M with EtOH cirrhosis and grade II esophageal\n varices s/p banding in . Notes that yesterday and today he had dark\n stools. Then he noted at 3pm today he ate some lunch and felt nauseous\n and subsequently had ~ 1 cup of hematemesis- bright red. Denies having\n had any since.\n Pt states that he has a 6 pack of Mikes Hard Lemonade daily, plus\n occasional tumbler of cognac. His last drink was on .\n .H/O esophageal varices\n Assessment:\n Pt has had no vomiting since his admit to the ICU.\n Action:\n Pt had an EGD done upon arrival to the floor. Pt received a total of\n 125mcg of Fentanyl and 3mg of Versed. Pt had 3 banding done during\n procedure.\n Response:\n HCT post procedure was 34.5. Pt has c/o sore throat, however no other\n complaints of pain or discomfort. Pt has an octreotide GTT running at\n 50mcg/hr. Gag reflex intact, pt given a small cup of ice chips with no\n adverse reactions. AM lab HCT 32.9\n Plan:\n Monitor HCT. Continue octreotide GTT. Provide emotional support.\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Pt has had no stool since admission. Liver enzymes with AM labs sent.\n Pt states that he has a 6 pack of Mikes Hard Lemonade daily, plus\n occasional tumbler of cognac.\n Action:\n MD reminded pt the importance of him to stop drinking.\n Response:\n Pt stated,\nI know I have to stop but at least I am not drinking as\n much as I used to.\n AST = 62\n Plan:\n Continue providing emotional support to the pt in regards to drinking.\n Continue reinforcing the importance of him not drinkning.\n"
},
{
"category": "Physician ",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 352357,
"text": " Resident Admission Note\n .\n Reason for MICU Admission: monitoring UGIB\n .\n Primary Care Physician: , MD\n .\n CC: .\n HPI: This is a 45 yo M with EtOH cirrhosis and grade II esophageal\n varices s/p banding in . Notes that yesterday and today he had dark\n stools. Then notes that ~3pm today he ate some lunch and then felt\n nauseous and subsequently had ~ 1 cup of hematemesis- bright red.\n Denies having had any since. Denies lightheadedness/chest pain\n associated. Notes that he has been drinking 6 pack of Mikes Hard\n Lemonade daily plus occassional tumbler of cognac, last drink was\n yesterday.\n .\n In the ED, T 98.2 HR 68 BP 142/72 sat100% on RA. GI was consulted and\n he was started on Protonix IV and octreotide drip. HCT was 37 and INR\n 1.8.\n .\n ROS: The patient denies any fevers, chills, abdominal pain, diarrhea,\n constipation, shortness of breath, orthopnea, PND, lower extremity\n edema, cough, weight change,urinary frequency, urgency, dysuria, gait\n unsteadiness, focal weakness, vision changes, headache, rash or skin\n changes.\n .\n Past Medical History:\n grade II varices s/p banding \n Etoh cirrhosis\n .\n Medications:\n Nadolol 20mg daily\n Omeprazole 20mg daily\n Folic acid\n Multivitamin\n Thiamine\n .\n Allergies: NKDA\n .\n Social History: He had a history of 10 years of heavy drinking\n up to , drinking to 1 pint a day. He has been\n drinking 2 beers a day since . He has never gone\n through detox. He smokes a pack per day for the past 20\n years. He denies using IV drugs or smoking drugs. He lives in\n his apartment with his fiance and his 17-year-old son. \n works as an apartment building manager. He has had recent travel\n to .\n .\n Family Medical History: He denies any liver disease in his family. He\n has 9 sisters and 3 brothers. His mom died of pancreatic cancer\n at a young age. He denies any liver cancer in the family or GI\n cancer.\n .\n Physical Exam:\n Vitals: T: 99.2 BP: 156/75 HR: 69 RR: 21 O2Sat:98%RA\n GEN: Thin, Well-appearing, no acute distress\n HEENT: EOMI, PERRL, sclera icteric BL, no epistaxis or rhinorrhea, MMM,\n OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, no cervical\n lymphadenopathy, trachea midline\n COR: RRR, + flow murmur, G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: alert, oriented to person, place, and time. CN II\n XII grossly\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\n extremities. Patellar DTR +1. Plantar reflex downgoing. No asterixis\n noted\n SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.\n .\n Laboratories:\n HCT 37.0\n INR 1.8\n .\n ECG: Sinus rhythm at 65 bpm, no acute ST-T changes, no comparison.\n .\n Imaging:\n Liver u/s :\n 1. Reversal of flow is seen within the main portal vein as noted. Re-\n canalized paraumbilical vein is seen.\n 2. Splenomegaly.\n 3. Abnormally echogenic liver as noted above.\n .\n Assessment: This is a 45-year-old man with ETOH cirrhosis and known\n grade II varices who p/w hematemesis.\n .\n Plan:\n .\n # UGI Bleed: likely due to varices in the setting of cirrhosis.\n - plan for EGD per GI\n - continue octreotide, IV PPI\n - serial HCTs\n - Tx for HCT drop 2 points or greater\n - IVF bolus now\n - Cipro IV x 5 days per GI recs\n .\n # Etoh Cirrhosis: Child B, complicated by esophageal varices. He is\n followed outpt by Dr. .\n - still drinking\n - DF 6\n - MELD 12\n # ETOH: last drink was yesterday, no h/o withdrawal sx/seizures\n - CIWA scale\n - SW c/s\n - continue thiamine, folate\n .\n # FEN: NPO, IVF\n .\n # Access: PIVs\n .\n # PPx: pneumoboots, IV PPI\n .\n # Code: Full\n .\n # Dispo: ICU for now\n .\n # Comm: girlfriend/HCP Phone: \n ------ Protected Section ------\n Critical Care\n Present for the key portions of history and exam. Agree with Dr. \n assessment and plan. Variceal bleed. He had significant blood loss but\n has now stabilized after EGD with banding. We are continuing octreatide\n and PPI. He needs further blood/ volume replacement but is\n hemodynamically stable. Will monitor urine output carefully.\n Time spent\n 35 min\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 01:19 ------\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing 1900-0700",
"row_id": 352358,
"text": "HPI: This is a 45 yo M with EtOH cirrhosis and grade II esophageal\n varices s/p banding in . Notes that yesterday and today he had dark\n stools. Then notes that ~3pm today he ate some lunch and then felt\n nauseous and subsequently had ~ 1 cup of hematemesis- bright red.\n Denies having had any since.\n .H/O esophageal varices\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-01-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 352490,
"text": "45 year old male admitted to MICU from ED with dark stools and\n hematemesis (bright red) due to ETOH cirrhosis and grade II esophageal\n varices. Prior to current MICU admission pt last banded in . Daily\n ETOH use includes 6 pack of Mikes Hard Lemonade pluse occasional\n tumbler of cognac. ETOH abuse dates back 10 years, tobacco use of\n pack/day x 20 years as well. Pt states his last drink was .\n Upon arrival to MICU- EGD was performed with banding x3.\n .H/O esophageal varices\n Assessment:\n NBP 120\ns. NSR 60\ns. Skin is warm, strong pedal pulses. Sp02 94-98%\n 2 L NC, lungs clear. Abdomen soft, slightly distended (increased on\n left side), denies any abdominal pain, + bowel sounds, hematemesis x1\n ~200 cc bright red blood, c/o nausea just prior to hematemesis but\n expressed relief after episode, ~ 400 cc maroon liquid stool x1 in\n commode- Hct down 3 points to 29.9 from 0300 blood drawn to 0730 draw.\n Voiding without difficulty with urinal, urine amber and clear. BUN and\n CR WNL. Denies any dizziness or SOB. (-) CIWA denying HA,\n hallucinations, ( -) for tremors\n Action:\n Hemodynamic monitoring. Labs drawn. Zofran x 1 given after hematemesis\n with good relief. Advanced diet to clear liquids from NPO. Banana bag\n given. Ocreotide drip at 50 mcg/hr. CIWA scale q4hours. Social work\n consulted- discussed with pt importance of abstaining from ETOH\n Response:\n Pt remains Hemodynamically stable with no drop in NBP with episodes of\n hematemesis and/or stooling. Hct stable at 29. Denies any nausea or\n abdominal pain- abdomen remains soft and distended. CIWA remains (-)\n Tolerated advance in diet.\n Plan:\n Hemodynamic monitoring. Assess and treat for s/s of continued bleeding\n and/or nausea (GI service believes bloody stool and vomit from earlier\n today is from old excess blood noted during EGD) Pt is cross-matched\n for 4 U PRBC. Follow up EGD and banding needed outpatient in 3 weeks.\n Continue to advance diet as tolerated. Assess for DT\ns using CIWA\n scale- reinforce need for abstaining from ETOH\n Demographics\n Attending MD:\n \n Admit diagnosis:\n UPPER GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n 74 Inch\n Admission weight:\n 90.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH\n CV-PMH:\n Additional history: Alcholic cirrhosis , esophageal varices\n Surgery / Procedure and date: Pt had varices banded last admit on\n \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:113\n D:70\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 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 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,999 mL\n 24h total out:\n 1,500 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 07:25 AM\n Potassium:\n 3.8 mEq/L\n 07:25 AM\n Chloride:\n 109 mEq/L\n 07:25 AM\n CO2:\n 22 mEq/L\n 03:31 AM\n BUN:\n 10 mg/dL\n 03:31 AM\n Creatinine:\n 0.5 mg/dL\n 03:31 AM\n Glucose:\n 121 mg/dL\n 03:31 AM\n Hematocrit:\n 29.0 %\n 05:29 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: 11R\n Date & time of Transfer: \n"
},
{
"category": "Radiology",
"chartdate": "2173-01-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1047494,
"text": " 5:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for intrathoracic trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hx varices, now with hemoptysis\n REASON FOR THIS EXAMINATION:\n eval for intrathoracic trauma\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old male with history of varices, now presenting with\n hemoptysis, to assess for a cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed. There\n is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n The left lower rib cage has not been included at this examination. Within\n these limitations, there is a calcified granuloma in the right mid zone.\n There is no focal pulmonary consolidation. The cardiomediastinal silhouette\n appears unremarkable.\n\n CONCLUSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2173-01-02 00:00:00.000",
"description": "Report",
"row_id": 214927,
"text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n"
}
] |
16,796 | 185,115 | # GI Bleeding: on admission, the pt had anemia in the setting of melena and guaiac positive stool that was likely GI bleed. All NSAIDs and aggrenox were held. She was admitted to the ICU, where she required transfusion of 4 units PRBCs to reach HCT of 37-38. She was evaluated with EGD that demonstrated gastritis and duodenitis, with no evidence of active bleeding. This was likely NSAID use, and explains the pt's abdominal pain. Treatment was started with protonix 40mg and carafate 1gm qid. She was transferred to the medical for ongoing care, where her HCT was observed to be stable and her abdominal pain improved. She will need to continue protonix and carafate for at least 6 weeks after discharge from the hospital, and perhaps longer depending on her symptom control. . # Orthostasis: on admission, she had orthostatic hypotension likely due to dehydration rather than acute bleeding. Pt reports very poor po intake over last several weeks. She was normotensive during her hospital stay, and was hydrated with normal saline until clinically euvolemic. At discharge, she is eating and drinking well and there is no evidence of dehydration. . # Renal: she has chronic renal insufficiency that remained at baseline during her admission. . # Dementia: she has dementia of the Alzheimer's type. She was conversational and attentive during her admission, with the exception of 2 episodes of delirium that resolved after treatment with haldol. At d/c, the pt is at baseline cognitive function, is attentive and conversational. . # Code status was DNR/DNI during this admission | Afebrile.GI: Pt. One episode of incontinence noted.Access: Pt. Denies nausea. Pt pleasantly demented. BP WNL. endoscopy ? Abd. Since the previous tracing of non-specific T waveabnormalities are seen. Vss. Continue to re-orient pt. Second unit of PRBCs given. Progress Note 7p-7aEvents: Pt. Sinus rhythm. + pulses. ? to be c/o to floor today. Transfuse as needed. Abdominal pain seems to have subsided.GU: Pt. Pleasantly demented. 2 iv's. No IVFs at this time.Plan: Pt. No pain issues at this time.Resp: Pt. Pt voiding adequate amts urine.Resp- Lungs clear with stable sats on ra.Id- Afebrile. soft. Breath sounds clear bilat. SR/SB throughout shift. Oriented to person/time. Abdomen soft with good bs. to place and time. Hemodynamically stable. No SOBCVS: Pt. Given one unit pc with post transfusion hct pending.Cardiac- Denies cp/sob Bp and hr stable. alert and oriented to self. BS + No evidence of bleeding noted. Crit drawn after transfusion came back 36.Neuro: Pt. No neuro deficits. No s/s active bleeding. voiding in bedpan. Pt is dnr/dni but wants full tx.Plan- Cont to follow hcts. Recieving ns at 75cc/hr. Confused at times. NPN 0700-1900Events/General: Endoscopy done > a single non bleeding ulcer seen, patchy erythema of the mucosa with no bleeding compatible with duodenitis, lots of air.Neuro: Alert, pleasantly confused; MAE's, turns side to side herself; became slightly agitated and more confused after EGD, has since improved.CV: NBP 152-171/47-71; HR 56-84, NSR no ectopy noted; transfused 1unit PRBC's, 2nd unit still transfusing so no repeat crit done yet > ordered for q 8hr crits; no s/sx of bleeding noted; peripheral pulses intact, no edema.Resp: resp regular, unlabored, no c/o SOB; O2 sat 98-100% on O2 2L; lung sounds are clear.GI: Abdomen softly distended, +tenderness upper and lower quads with some c/o cramping at end of shift > gi MD aware > probably gas or stool, denies nausea; pt NPO overnight.GU: Voiding 50-200cc at a time slightly concentrated but clear urine, incontinent large amt X1.Plan: Post transfusion crit then q 8hr crits; monitor stools color and guiac; monitor hemodynamic status; IVF while NPO. remains on clear liquid diet and tolerating well. call out to floor later today remains on room air with sats greater than 98%. Lives at with sister who is health care proxy. Trazadone 25mg given to help sleep with good effects. States she is in a hotel in . Admitted to smicu with gi bleed.See admission fhpa for details pmh/hpa.R.O.S.Gi- On admission pt c/o diffuse abdominal pain. slept throughout night. has 20g peripheral IV in each forearm patent. Smicu nsg progress note82yo nursing home resident with dementia who presented to ew with c/o worsening abd pain with n/v, myalgias and trace blood in stool. | 4 | [
{
"category": "ECG",
"chartdate": "2174-10-17 00:00:00.000",
"description": "Report",
"row_id": 259298,
"text": "Sinus rhythm. Since the previous tracing of non-specific T wave\nabnormalities are seen.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-10-18 00:00:00.000",
"description": "Report",
"row_id": 1482231,
"text": "Smicu nsg progress note\n82yo nursing home resident with dementia who presented to ew with c/o worsening abd pain with n/v, myalgias and trace blood in stool. While in ew pt passing black tarry stool with hct drop from 29.9 to 26.8 after 500cc fluid. Vss. Admitted to smicu with gi bleed.\nSee admission fhpa for details pmh/hpa.\nR.O.S.\nGi- On admission pt c/o diffuse abdominal pain. Abdomen soft with good bs. Denies nausea. No s/s active bleeding. Given one unit pc with post transfusion hct pending.\nCardiac- Denies cp/sob Bp and hr stable. Recieving ns at 75cc/hr. Pt voiding adequate amts urine.\nResp- Lungs clear with stable sats on ra.\nId- Afebrile.\n Pt pleasantly demented. Oriented to person/time. States she is in a hotel in . Lives at with sister who is health care proxy. Pt is dnr/dni but wants full tx.\nPlan- Cont to follow hcts. Transfuse as needed. 2 iv's. ? endoscopy ? call out to floor later today\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-10-18 00:00:00.000",
"description": "Report",
"row_id": 1482232,
"text": "NPN 0700-1900\n\nEvents/General: Endoscopy done > a single non bleeding ulcer seen, patchy erythema of the mucosa with no bleeding compatible with duodenitis, lots of air.\nNeuro: Alert, pleasantly confused; MAE's, turns side to side herself; became slightly agitated and more confused after EGD, has since improved.\nCV: NBP 152-171/47-71; HR 56-84, NSR no ectopy noted; transfused 1unit PRBC's, 2nd unit still transfusing so no repeat crit done yet > ordered for q 8hr crits; no s/sx of bleeding noted; peripheral pulses intact, no edema.\nResp: resp regular, unlabored, no c/o SOB; O2 sat 98-100% on O2 2L; lung sounds are clear.\nGI: Abdomen softly distended, +tenderness upper and lower quads with some c/o cramping at end of shift > gi MD aware > probably gas or stool, denies nausea; pt NPO overnight.\nGU: Voiding 50-200cc at a time slightly concentrated but clear urine, incontinent large amt X1.\nPlan: Post transfusion crit then q 8hr crits; monitor stools color and guiac; monitor hemodynamic status; IVF while NPO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-10-19 00:00:00.000",
"description": "Report",
"row_id": 1482233,
"text": "Progress Note 7p-7a\nEvents: Pt. slept throughout night. Second unit of PRBCs given. Crit drawn after transfusion came back 36.\n\nNeuro: Pt. alert and oriented to self. Pleasantly demented. Confused at times. Trazadone 25mg given to help sleep with good effects. No neuro deficits. No pain issues at this time.\n\nResp: Pt. remains on room air with sats greater than 98%. Breath sounds clear bilat. No SOB\n\nCVS: Pt. SR/SB throughout shift. BP WNL. Hemodynamically stable. + pulses. Afebrile.\n\nGI: Pt. remains on clear liquid diet and tolerating well. Abd. soft. BS + No evidence of bleeding noted. Abdominal pain seems to have subsided.\n\nGU: Pt. voiding in bedpan. One episode of incontinence noted.\n\nAccess: Pt. has 20g peripheral IV in each forearm patent. No IVFs at this time.\n\nPlan: Pt. to be c/o to floor today. Continue to re-orient pt. to place and time.\n"
}
] |
10,634 | 188,945 | 78 yo lady w/ recent urosepsis, recent right transmetatarsal ampuatation, adrenal insufficiency, temp, here w/ likely sepsis. 1. Sepsis/fever: patient was initially admitted to the MICU for sepsis protocol. She was started on empiric antibiotic therapy w/ vanco/levoflox/flagyl. She was pancultured and her PICC line was removed, central line placed. Her cultures (urine, blood, PICC line tip) are negative to date. She was given fluid resussitation w/ good response in her BP. She was on pressors for a short time in the intensive care unit as well but was quickly weaned. She was given stress dose steroids for her recent diagnosis of adrenal insufficiency. She stabalized, was afebrile after admission, and was transferred to the medical floor in stable condition. Her vancomycin and flagyl were stopped secondary to lack of culture data and stable, afebrile course. Levoflox was continued for 7 day course to tx for ?UTI. surgery service followed patient closely and felt her RLE warranted elective BKA but there was no active site of infection. Exam consistent w/ dry gangrene. ?RLE cellulits noted on admission H+P resolved quickly and was not thought to be source for sepsis. Upon d/c, she will be on no further antibiotic therapy. 2. Adrenal insufficiency/hemorrhage: patient had adrenal insufficiency during admission, was given stress dose steroids. Endocrine was consulted and requested dedicated ABD CT to adrenal glands. Bilateral adrenal hemorrhage was noted on the scan. She was at risk for this, given her recent surgery, coumadin use, hospitalization. Her hematocrits remained stable. Her steroids were rapidly weaned to prednisone 5 mg/day and fludricortisone was added on as well. An early morning cortisytropin stim test was done during admission (previous to her daily prednisone 5 mg dose given). This showed cortisol 1.3 w/ stim to 1.5 and 1.6 at 30 min and 60 min, respectively. This indicates that the patient remains adrenally insufficient and should continue on her prednisone. ACTH and aldosterone are pending at the time of this dictation and will be followed up as outpatient. Patient is scheduled for follow up with clinic. BP's remained stable after ICU course. 3. Hyperglycemia: not diabetic but kept on insulin scale while on high dose steroids. D/c'd this during her admission when steroids tapered down. 4. hypercoagulable state: has h/o of this-- is on coumadin. Details unclear. Goal INR . Coumadin transiently stopped during admit for line placement, etc. Restarted and will need dose adjustments after discharge. 5. PVD: s/p Right transmetatarsal amputation last month. followed patient during admission. On coumadin as above. Plans for right BKA discussed at length. Dr. from surgery wished to do this electively in 2 weeks, but not on this admission. Follow up scheduled. 6. thromocytopenia: stable and chronically low. No clear med-related decrease. Stable counts on admission. Peripheral smear w/o abnormality. 7. full code 8. dispo: daughter wanted to take patient home w/ services, but then decided pt best suited for rehab stay. | REMAINS ON CODE SEPSIS AT THIS TIME, BUT WILL BE RE ASSESS AGAIN THIS AM DUE TO A NORMAL LACTATE. Sinus rhythm.Anterior T wave changes are nonspecificSince previous tracing of the same date, the rate has decreased; anterior Twave changes newClinical correlation is suggested There is mild dilation of the extrahepatic biliary system, with dilation of the distal CBD, which could represent a choledochocele, but is unchanged since prior examination performed . Treated with vanco/levoflox/flagyl IV. The right sided PICC line terminates in the region of the superior SVC. THIS WAS CHANGED LAST HS, AND REMAINS D&I AT THIS TIME. Lactate level was normal and pt tranferred to MICU for further care.Allergies: NKAPMH: IDDM, Asthma, DVT/PE, PVD s/p recent right foot toes amputation. HAS BEEN STARTED ON A DIABETIC DIET WITH FAIR APETITE. FINDINGS: CT of the abdomen before and after the administration of IV contrast: The lung bases are clear, with mild dependent atelectasis bilaterally. Satisfactorily positioned right IJ line and right PICC without pneumothorax. BOWEL SOUNDS ARE NOTED AND PT. IMPRESSION: Patient is status post transmetatarsal amputation without acute evidence of osteomyelitis. In addition, after the administration of IV contrast, there is minimal enhancement. HAS REMAINED COARSE IN THE UPPER AIRWAYS BUT DIMINISHED IN BOTH BASES. Lungs are clear to coarse with deminished sounds at bases.ID: Temp 99.1 on admist to MICU. The visualized portions of the heart and pericardium are within normal limits. Given clinical history of recent onset adrenal insufficiency and bilateral renal masses, findings are consistent with chronic adrenal hemorrhage and less likely infection. DRESSING INTACT TO RIGHT LOWER LEG WHICH REMAINS D&I WITH NO DRAINAGE NOTED. MICU NPN Admit to MICU:78y.o. REASON FOR THIS EXAMINATION: Please assess bilateral adrenal masses No contraindications for IV contrast FINAL REPORT INDICATION: Bilateral adrenal masses, history of coagulopathy, with suspicion of adrenal insufficiency. O2 SATS REMAIN >98% WITH RESP RATE CONTROLLED.GU/GI; PT. Currently on .05mcg/kg/min with stable BP. IMPRESSION: Bilateral adrenal masses. B/P HAS BEEN STABLE, RESP STATUS IS BENIGN WITH SATS >98% PT. Bilateral effusions have decreased in the interim, though there is likely a left pleural effusion at the base layering posteriorly. There are bilateral adrenal masses. Technically difficult studySinus tachycardiaShort PR intervalInferior infarct - age undeterminedLeft ventricular hypertrophyNarrow inferiorQ wavesSince previous tracing of , low limb lead voltage less prominent HAS DRESSING TO RIGHT LOWER LEGS WHERE THE PT. IS NOTED TO MAE'S AND HAS BEEN AFEBRILE DURING THIS SHIFT.CV; PT. Currenly on 4u/hr. Will continue pt on vanco/levo/flagyl as ordered. Pt entered into sepsis protocol and had right IJ precept catheter inserted with CVP 8-11 while in EW. ARE EASILY AUDIBLE IN ALL QUADRANTS AND BLOOD SUGARS HAVE BEEN DECLINING SINCE PT. She had right PICC line at the rehab and her access was poor on admission to EW. Two boluses given so far with good effect. GOAL IS TO MAINTAIN THIS BETWEEN .RESP; PT. 1800 2 units Regular insulin given SC for BS 169.ID: Afebrile, 8AM lactate level= .7 now off sepsis protocol. Pt also getting stress dose steroids.GI: NPO for now except for meds. (Over) 1:30 PM CT ABD W&W/O C; CT 150CC NONIONIC CONTRAST Clip # Reason: Please assess bilateral adrenal masses Admitting Diagnosis: SEPSIS;TELEMETRY;FEVER,UNKNOWN ORIGIN Field of view: 44 Contrast: OPTIRAY Amt: FINAL REPORT (Cont) OLD BLEEDING NOTED AT THIS SITE, BUT THIS HAS STOPPED WITHOUT MAJOR INTERVENTION.DISPO; PT. HAS BEEN NSR-ST 80-105 WITH NO NOTED ECTOPY. Temp was 103.3, BP initially 116 dropped to 70's-80's shortly after getting there. Pt's deltoid muscles are hard with old hematomas noted. HAS BEEN NPO WITH SIPS WITH HER MEDS. SVO2 79-80. VERY PLEASANT AND COOPERATIVE.RESP; LUNGS CLEAR ON RA SATS 95-97% RR 18-22. B/P HAS BEEN SUPORTTED BY LEVOPHED AT LOW DOSE, BUT AFTER THREE ATTEMPTS THIS HAS BEEN WEANED OFF WITH GOALS MET OF MAP'S >65. REMAINS A/A/O AND A FULL CODE AT THIS TIME. HAS BEEN AFEBRILE, WITH NO NEURO DEFICITS NOTED DURING THIS SHIFT. Currently on SSI coverage. These are minimally enhancing. HAS HAD TWO SEMI FORMED STOOLS THAT GUAICED NEG. Comparison: Three views right foot dated . THREE VIEWS RIGHT FOOT: Patient is status post transmetatarsal amputation. NURSING NOTE: 7A-7P REVIEW OF SYSTEMS:NEURO: Awake alert and oriented X3. NO COUGH ENCOURAGED TO D/B AND COUGH.Q1 W A.CVS; TMAX 98 PO NSR 80-100 NO ECTOPY NOTED.BP 95-120/50-73.GU; MIN URINE VIA FOLEY 30 MLS FOR LAST 2 HRS. Goal CVP 8-12. Gets small doses IV hydromorphone PRN for foot pain.CV: Pt arrived on neo drip at 1.5mcg/kg/min. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. HAS BEEN A/A/O AND DENIED ANY OAIN OR DISCOMFORT A THIS TIME. CVP HAS BEEN DIFFICULT TO READ ON MONITOR, BUT WITH END EXPIRATION CVP IS NOTED AT 7-10. HAS RECENTLY UNDERWENT AMPUTATION OF RIGHT FOOT. Old left foot toes amputation, high cholesterolNeuro: Alert, oriented times three. Pt's remained alert and oriented times three in EW and mental status improved after fluids with improved BP. Levophed off since night shift, bolused X1 with 500cc .9NS.RESP: Lung sounds clear, O2 Sat ranging from 96-98% on RA.GI/GU: Abd obese and soft positive bowel sounds, no stools this shift. Surrounding soft tissues are thickened, but otherwise unremarkable. B.S. HAS A NON PRODUCTIVE COUGH AT THIS TIME. NEURO; PT. BLOOD SUGARS HAVE BEEN SLIGHTLY ELEVATED AND COVERED BY 2 UNITS OF REGULAR INSULIN. | 10 | [
{
"category": "Radiology",
"chartdate": "2169-05-04 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 859424,
"text": " 1:30 PM\n CT ABD W&W/O C; CT 150CC NONIONIC CONTRAST Clip # \n Reason: Please assess bilateral adrenal masses\n Admitting Diagnosis: SEPSIS;TELEMETRY;FEVER,UNKNOWN ORIGIN\n Field of view: 44 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with bilateral adrenal masses, h/o coagulopathy admitted\n with suspected adrenal insufficiency.\n REASON FOR THIS EXAMINATION:\n Please assess bilateral adrenal masses\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral adrenal masses, history of coagulopathy, with suspicion\n of adrenal insufficiency.\n\n TECHNIQUE: CT of the abdomen and pelvis were performed using adrenal\n protocol. Comparison is made to CT of the abdomen and pelvis performed\n .\n\n FINDINGS: CT of the abdomen before and after the administration of IV\n contrast:\n\n The lung bases are clear, with mild dependent atelectasis bilaterally. The\n visualized portions of the heart and pericardium are within normal limits.\n\n The liver, spleen, pancreas, and small bowel are unremarkable. There is mild\n dilation of the extrahepatic biliary system, with dilation of the distal CBD,\n which could represent a choledochocele, but is unchanged since prior\n examination performed . Gallbladder is not identified. Within both\n kidneys are small sub-centimeter low-density lesions which are well\n demarcated, probably representing small renal cysts, but indeterminately\n characterized on this examination. These are unchanged. There are bilateral\n adrenal masses. On the left, this measures up to 2.6 x 3.3 cm in size. On\n the right, this measures up to 1.8 x 2.9 cm in size. There is less fat\n stranding around the adrenal glands than on the prior examination. Precontrast\n Hounsfield unit measurement does not meet CT criteria for adrenal adenoma. In\n addition, after the administration of IV contrast, there is minimal\n enhancement.\n\n IMPRESSION: Bilateral adrenal masses. These are minimally enhancing. Given\n clinical history of recent onset adrenal insufficiency and bilateral renal\n masses, findings are consistent with chronic adrenal hemorrhage and less\n likely infection. However, MRI of the adrenal glands could confirm the\n presence of old hemorrhage within the adrenal masses if clinically indicated\n and could also be used for further evaluation of microscopic fat within these\n lesions.\n\n\n\n\n\n (Over)\n\n 1:30 PM\n CT ABD W&W/O C; CT 150CC NONIONIC CONTRAST Clip # \n Reason: Please assess bilateral adrenal masses\n Admitting Diagnosis: SEPSIS;TELEMETRY;FEVER,UNKNOWN ORIGIN\n Field of view: 44 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 859168,
"text": " 4:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EVAL FOR PNEUMONIA/ HX OF FEVER/ CENTRAL LINE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fever, hypotension.\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and hypotension. Evaluate for pneumonia.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The heart is enlarged, but stable in size. The aorta is\n tortuous. Bilateral effusions have decreased in the interim, though there is\n likely a left pleural effusion at the base layering posteriorly. No definite\n right effusion. There is increased opacity at the right lung base that may be\n related to the effusion, however, a consolidation at this locale cannot be\n excluded. When the patient is able, a lateral view will be more helpful in\n characterization. There is a right internal jugular central venous catheter\n with the tip overlying the caval-atrial junction. The right sided PICC line\n terminates in the region of the superior SVC. No pneumothorax is detected.\n\n IMPRESSION: Increased opacity at the left base likely relates to a persistent\n left pleural effusion. Satisfactorily positioned right IJ line and right PICC\n without pneumothorax.\n\n A lateral view will be more helpful for further evaluation once the patient\n becomes able.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-05-02 00:00:00.000",
"description": "RP FOOT AP,LAT & OBL RIGHT PORT",
"row_id": 859185,
"text": " 5:32 PM\n FOOT AP,LAT & OBL RIGHT PORT Clip # \n Reason: please eval for evidence of infection\n Admitting Diagnosis: SEPSIS;TELEMETRY;FEVER,UNKNOWN ORIGIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with chronic R TMA ischemia and sepsis\n REASON FOR THIS EXAMINATION:\n please eval for evidence of infection\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 78-year-old female with chronic right TMA ischemia and sepsis.\n Please evaluate for evidence of infection.\n\n Comparison: Three views right foot dated .\n\n THREE VIEWS RIGHT FOOT: Patient is status post transmetatarsal amputation.\n There is no evidence of subcutaneous emphysema, or significant soft tissue\n swelling. There is no periosteal reaction to indicate osteomyelitis. Bony\n mineralization is normal. There is no evidence of fracture or malalignment.\n Bony spurs are seen on the plantar and posterior aspects of the calcaneus.\n Joint spaces are preserved. Surrounding soft tissues are thickened, but\n otherwise unremarkable.\n\n IMPRESSION: Patient is status post transmetatarsal amputation without acute\n evidence of osteomyelitis. If clinical suspicion persists, bone scan or MRI\n is more sensitive.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-05-02 00:00:00.000",
"description": "Report",
"row_id": 106294,
"text": "Technically difficult study\nSinus tachycardia\nShort PR interval\nInferior infarct - age undetermined\nLeft ventricular hypertrophy\nNarrow inferiorQ waves\nSince previous tracing of , low limb lead voltage less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2169-05-02 00:00:00.000",
"description": "Report",
"row_id": 106295,
"text": "Sinus rhythm.\nAnterior T wave changes are nonspecific\nSince previous tracing of the same date, the rate has decreased; anterior T\nwave changes new\nClinical correlation is suggested\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-05-02 00:00:00.000",
"description": "Report",
"row_id": 1402715,
"text": "MICU NPN Admit to MICU:\n78y.o. spanish speaking female transferred from rehab today with fevers, hypotension, tachycardia and decreased mental status. She had recently been here at for UTI/cellulitis infection and just finished treatment with vanco/zosyn. She had right PICC line at the rehab and her access was poor on admission to EW. Temp was 103.3, BP initially 116 dropped to 70's-80's shortly after getting there. treated with total 5Liters IVF and started on neo drip. Pt entered into sepsis protocol and had right IJ precept catheter inserted with CVP 8-11 while in EW. Pt had two blood cultures sent(One from PICC and one peripheral) and urine cultures sent. Treated with vanco/levoflox/flagyl IV. Pt's remained alert and oriented times three in EW and mental status improved after fluids with improved BP. Lactate level was normal and pt tranferred to MICU for further care.\n\nAllergies: NKA\n\nPMH: IDDM, Asthma, DVT/PE, PVD s/p recent right foot toes amputation. Old left foot toes amputation, high cholesterol\n\nNeuro: Alert, oriented times three. MAE, follows commands. Denies pain. Gets small doses IV hydromorphone PRN for foot pain.\n\nCV: Pt arrived on neo drip at 1.5mcg/kg/min. Weaned drip down to .5mcg/kg/min but was unable to get it off. Team wrote for levophed drip to keep MAP>60 so drip was switched to levophed at . Currently on .05mcg/kg/min with stable BP. Goal CVP 8-12. Pt getting IVF boluses 500cc's PRN for CVP less than 8. Two boluses given so far with good effect. SVO2 79-80. Pt will have labs per sepsis protocol. Last chemistries/hematologies sent at 8PM.\n\nHeme: Pt is on coumadin at HS. Coags show INR 2.0 on admission.\n\nEndo: Pt's glucose elevated at 239 and pt started on insulin drip to get glucose under better control. Currenly on 4u/hr. Pt's deltoid muscles are hard with old hematomas noted. Team aware and I question how well she would absorb sc insulin given in thise areas.\n\nResp: O2 2L N/C with good sats. Lungs are clear to coarse with deminished sounds at bases.\n\nID: Temp 99.1 on admist to MICU. WBC 19.7 in EW labs. Will continue pt on vanco/levo/flagyl as ordered. Pt also getting stress dose steroids.\n\nGI: NPO for now except for meds. Took pills without difficulty. +BS\n\nGU: UO excellent via foley.\n\nSocial: Numerous family members visiting throughout the shift. Pt's daughter is her proxy and spokesperson and is aware of pt's condition and plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-05-03 00:00:00.000",
"description": "Report",
"row_id": 1402716,
"text": "NEURO; PT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT AT THIS TIME. PT. IS SPANISH SPEAKING ONLY. PT. IS NOTED TO MAE'S AND HAS BEEN AFEBRILE DURING THIS SHIFT.\n\nCV; PT. HAS BEEN NSR 70-90'S WITH NO NOTED ECTOPY AT THIS TIME. B/P HAS BEEN SUPORTTED BY LEVOPHED AT LOW DOSE, BUT AFTER THREE ATTEMPTS THIS HAS BEEN WEANED OFF WITH GOALS MET OF MAP'S >65. CVP HAS BEEN DIFFICULT TO READ ON MONITOR, BUT WITH END EXPIRATION CVP IS NOTED AT 7-10. GOAL IS TO MAINTAIN THIS BETWEEN .\n\nRESP; PT. HAS REMAINED COARSE IN THE UPPER AIRWAYS BUT DIMINISHED IN BOTH BASES. PT. HAS A NON PRODUCTIVE COUGH AT THIS TIME. O2 SATS REMAIN >98% WITH RESP RATE CONTROLLED.\n\nGU/GI; PT. HAS BEEN NPO WITH SIPS WITH HER MEDS. B.S. ARE EASILY AUDIBLE IN ALL QUADRANTS AND BLOOD SUGARS HAVE BEEN DECLINING SINCE PT. WAS PLACED ON INSULIN GTT, PRESENTLY 5UNITS/HR. NO STOOL NOTED DURING THIS SHIFT. ABD. IS OBESE AND SOFT AT THIS TIME. FOLEY IS IN PLACE AND CONTINUES TO DRAIN LARGE AMT'S OF PALE YELLOW URINE, 80-400CC/HR.\n\nSKIN; PT. HAS DRESSING TO RIGHT LOWER LEGS WHERE THE PT. HAS RECENTLY UNDERWENT AMPUTATION OF RIGHT FOOT. THIS WAS CHANGED LAST HS, AND REMAINS D&I AT THIS TIME. ALL LINES ARE INTACT AND FUNCTIONING WELL. OLD BLEEDING NOTED AT THIS SITE, BUT THIS HAS STOPPED WITHOUT MAJOR INTERVENTION.\n\nDISPO; PT. REMAINS A/A/O AND A FULL CODE AT THIS TIME. PT. REMAINS ON CODE SEPSIS AT THIS TIME, BUT WILL BE RE ASSESS AGAIN THIS AM DUE TO A NORMAL LACTATE. PT' NEXT LABS ARE DO AT 08:00 PER PROTOCOL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-05-03 00:00:00.000",
"description": "Report",
"row_id": 1402717,
"text": "NURSING NOTE: 7A-7P REVIEW OF SYSTEMS:\nNEURO: Awake alert and oriented X3. Spanish speaking limited english. PERL, MAEW to commands. Medicated X1 with Oxycodone 5mg for complaint of Right foot pain.\nC/V: NSR to ST rate 80's-low 100's. BP 90's-120's/ 40-50's. CVP 6-10 currently goal at 8-12. Levophed off since night shift, bolused X1 with 500cc .9NS.\nRESP: Lung sounds clear, O2 Sat ranging from 96-98% on RA.\nGI/GU: Abd obese and soft positive bowel sounds, no stools this shift. Specimens needed for lab when patient has BM. Taking diet in small amounts. Foley patent draining clear yellow urine 40-80cc/hr.\nENDO: Insulin drip at 6 units/hr at start of shift. Hourly glucose levels monitored and ranged from 64-169. Currently on SSI coverage. 1800 2 units Regular insulin given SC for BS 169.\nID: Afebrile, 8AM lactate level= .7 now off sepsis protocol. Continues on Levofloxacin, Vancomycin and Metronazole.\nSOCIAL: Daughters into visit most of day updated on patients POC.\nDISPO: Full Code, ready for transfer to floors when bed available, transfer note done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-05-04 00:00:00.000",
"description": "Report",
"row_id": 1402718,
"text": "PT. IS PRESENLTY A CALL OUT TO THE FLOOR, TRANSFER NOTE IS WRITTEN. PT. HAS BEEN A/A/O AND DENIED ANY OAIN OR DISCOMFORT A THIS TIME. PT. HAS BEEN RECEIVING OXYCONTIN PRN FOR PAIN AT SURGICAL SITE. PT. HAS BEEN AFEBRILE, WITH NO NEURO DEFICITS NOTED DURING THIS SHIFT. PT. HAS BEEN AWAKE FOR MOST OF THE SHIFT. PT. HAS BEEN NSR-ST 80-105 WITH NO NOTED ECTOPY. B/P HAS BEEN STABLE, RESP STATUS IS BENIGN WITH SATS >98% PT. HAS BEEN STARTED ON A DIABETIC DIET WITH FAIR APETITE. BLOOD SUGARS HAVE BEEN SLIGHTLY ELEVATED AND COVERED BY 2 UNITS OF REGULAR INSULIN. BOWEL SOUNDS ARE NOTED AND PT. HAS HAD TWO SEMI FORMED STOOLS THAT GUAICED NEG. FOLEY INTACT AND DRAINING SMALL, BUT AMPLE AMT'S OF CLEAR YELLOW-AMBER URINE. DRESSING INTACT TO RIGHT LOWER LEG WHICH REMAINS D&I WITH NO DRAINAGE NOTED. OTHERWISE RIGHT PRECEPT CATHETER REMAINS INTACT AND FUNCTIONING WELL. PT. REMAINS A FULL CODE AWAITING BED ON FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-05-04 00:00:00.000",
"description": "Report",
"row_id": 1402719,
"text": "npn 0700-1400;\nNEURO;78 YR OLD SPANISH SPEAKING LADY ABLE TO MAKE NEEDS KNOWN WITH GESTURES AND A LITTLE ENGLISH FAMILY AT BEDSIDE MOST OF DAY .PER FAMILY PT 3 MAE EQUALLY TO COMMAND.PERLA 3MM. VERY PLEASANT AND COOPERATIVE.\n\nRESP; LUNGS CLEAR ON RA SATS 95-97% RR 18-22. NO COUGH ENCOURAGED TO D/B AND COUGH.Q1 W A.\n\nCVS; TMAX 98 PO NSR 80-100 NO ECTOPY NOTED.BP 95-120/50-73.\n\nGU; MIN URINE VIA FOLEY 30 MLS FOR LAST 2 HRS. TEAM AWARE.\n\nGI; TAKING MOD AMOUNT PO, C/O OFNAUSEA RESPONDED TO DOLASETRON MESYLATEAND SOME TOAST,BELLY OBESE POS BS DENIES PAIN LAST BM LAST NIGHT GUIAC NEG.\n\nENDO; BS ON RISS\n\nPAIN ; USING TYLENOL OXYCODONE 5MGS WITH PAIN 6/10-0/10.\n\nSKIN; RT FOOT WITH DSSD BEING DONE BY VASCULAR LT TOES AMPUTATED.\nPOS WEAKLY PALP PULSES.\n\nSOC; FAMILY INTO VISIT AND UPDATED WITH PT CURRENT CONDITION AND TRANSFER TO FLOOR.\n\nID; CONTINUES ON ANTIBIOTIC REGIME.\n\nGIVEN 2 BOTTLES BARACAT INPREPARATION FOR CT TO EVALUATE ADRENAL TUMOURS.\n\nA/P STABLE CTSCAN AND TRANSFER TO FLOOR\nGU NEED FLUID BOLUS FOR LOW URINE OUTPUT ICU TEAM AND FLOOR TEAM AWARE.\n"
}
] |
13,080 | 181,323 | The patient was admitted to the hospital status post a left suboccipital craniotomy with resection of metastatic tumor on , without interoperative complication. The patient was monitored in the Surgical Intensive Care Unit postoperatively. Vital signs were stable. She was afebrile. Dressing was clean, dry and intact. She was intubated on admission to the Surgical Intensive Care Unit and extubated on postoperative day #1. Neurologically, she was awake, alert, oriented times three with no drift. EOMs were full. Smile symmetrical with no dysmetria. The patient was transferred to the regular floor on , where she remained stable. Vital signs remained stable. She was seen by the Department of Physical Therapy and Occupational Therapy and found to be safe for discharge to home. She was discharged to home on with followup with Dr. in the Brain Clinic on , at 4 p.m. She will be weaned to Decadron 2 mg p.o.b.i.d. over a week's time; Zantac 150 mg p.o.b.i.d.; Percocet one to two tablets p.o.q.4h.p.r.n. pain. Other medications at the time of discharge were the following: 1. Combivent MDI two puffs q.6h. 2. Flovent MDI two puffs b.i.d. 3. Albuterol MDI two puffs q.4h.p.r.n. 4. Lopressor 50 mg p.o.b.i.d. 5. Paxil 20 mg p.o.q.h.s. 6. Tums one to two tabs p.o.q.6h.p.r.n. 7. Diflucan 100 mg p.o.q.d. The patient was in stable condition at the time of discharge. The patient will followup with Dr. in the Brain Clinic on at 4 p.m. , M.D. Dictated By: MEDQUIST36 D: 12:04 T: 12:13 JOB#: | BS's exp wheezes, pt comfortable. PT REPORTS RESP STATUS AT BASELINE.GI-ABD SOFT, NT/ND. NO INCREASE NOTED.CV-AFEBRILE. SKIN W+D. hygeine. LS WITH WHEEZES. INITIALLY ON NIPRIDE AND LABETOLOL GTT, BOTH NOW OFF. +PP. PERRL. PERRLA. +bs, +flatus. +BS. no ectopy.Resp: Lung sounds w/exp. FOCUS: ADDMITING NOTE.ADMITED TO NSICU AND PLACED ON ECG- SATS- ALINE- AND RR MONITORING.NEURO: PARALIZED AND SEDATED ON ARRIVAL-- REVERSED IN N-SICU. Placed on vent briefly, then extubated without event. Inhalers q6hrs w/some effect. AT END OF SHIFT--ABLE TO FOLLOW COMMANDS, MAE, PERL, ALERT AND ORIENTED X 3. begin to wean Labetolol gtt, monitor resp. Staples intact to occipital area w/small amount old blood noted.CV: Remains on Labetolol gtt to keep SBP <140, turned off x2 hours secondary to SBP 100 or <. DENIES SOB. RESPIRATORY CARE:Pt admitted to NSICU, intubated #7.0 ETT. Oriented x 3. NEURO CHECKS. ABGs unchanged.GI: Abdomen soft, non-tender and non-distended. DENIES CARDIAC COMPLAINTS. HEAD DSG WITH SM AMT OLD DRIED STAIN. HR 80-90'S, NSR, NO ECTOPY. DOES NOT COMPLAIN OF PAIN OR HA.CV: TACHYCARDIC AND HYPERTENSIVE ON ARRIVAL, NIPRIDE GTT FOR SBP 120-140--CHANGED TO LABETALOL GTT TO WEAN NIPRIDE.RESP: INTUBATED ON ARRIVAL-- EXTUBATED COUPLE OF HOURS LATER. status closely, aggressive pulm. NSR 80s. PE AS FOLLOWS:NEURO-A+OX3. MAE. SBP MAINTAINED < 140. wheezing, diminished at bases. TRANSFER TO FLOOR WHEN BED AVAIL. TOL PO'S WITHOUT N/V.GU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.ACT-MAE. NORMAL EQUAL STRENGTH. Administering Combivent MDI with spacer. Smile symmetrical, no drift. PT HAS CONGESTED COUGH, ABLE TO CLEAR SECRETIONS ON OWN. See flowsheet for further pt data/rx's.Plan: RN's to follow with , pt has good technique. USING INHALERS WITH SOME EFFECT. Please call for further RT. No headache. WAS NOT RESPONSIVE TO PAINFUL STIMULI. Encouraged to cough and deep breathe. HER POST/OP ICU COURSE HAS BEEN UNEVENTFUL. no n/v. NO NEURO DEFICITS NOTED. no stool.GU: Foley patent adequate amounts clear yellow urine.ACT: pt. nsg progress/transfer noteSEE FLOWSHEET FOR SPECIFICS.PT IS A 62 Y/O FEMALE WITH NKDA. ASSESS PAIN. Sats 97-100% on 3L NC. MOVES I IN BED.COMFORT- X1 FOR C/O NECK SORENESS.PLAN-CON'T WITH CURRENT PLAN. moving in bed w/minimal assist, denies need for pain meds.Plan: cont. SHE WAS ADMITTED TO ON AND UNDERWENT A SUB OCCIPITAL CRANI ON THAT DATE. to monitor neuro signs, ? BOWEL SOUNDS PRESENT.SOCIAL: FAMILY VISIT.PLAN: CONTINUE TO ASSESS NEURO STATUS--CONTINUE TO ASSESS RESPIRATORY STATUS FOR FUTURE D/C Easily arousable to voice, following all commands. PBOOTS ON.RESP-O2 SAT 96-97% ON 1LNC. SHOVEL MASK PLACED SATS 98 T0 100. ABLE TO OPEN EYES AND FOLLOW COMMANDS INCONSISTENTLY COUPLE HOURS AFTER ARRIVAL. NC AT 5 L.--SATS 98-100.GI/GU: FOLEY PATENT DRAINING YELLOW CLEAR URINE. Tolerated a small amount of custard and ice chips. HER PMH IS SIGNIFICANT FOR: DYSPNEA, EMPHYSEMA, COPD, ASTHMA, LUNG CA (WITH BRAIN METS) TX'D WITH CHEMO, REFLUX, S/P TONSILLECTOMY, BACK , AND CARPAL TUNNEL . | 4 | [
{
"category": "Nursing/other",
"chartdate": "2109-02-06 00:00:00.000",
"description": "Report",
"row_id": 1433440,
"text": "nsg progress/transfer note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 62 Y/O FEMALE WITH NKDA. HER PMH IS SIGNIFICANT FOR: DYSPNEA, EMPHYSEMA, COPD, ASTHMA, LUNG CA (WITH BRAIN METS) TX'D WITH CHEMO, REFLUX, S/P TONSILLECTOMY, BACK , AND CARPAL TUNNEL . SHE WAS ADMITTED TO ON AND UNDERWENT A SUB OCCIPITAL CRANI ON THAT DATE. HER POST/OP ICU COURSE HAS BEEN UNEVENTFUL. PE AS FOLLOWS:\n\nNEURO-A+OX3. PERRL. MAE. NORMAL EQUAL STRENGTH. NO NEURO DEFICITS NOTED. HEAD DSG WITH SM AMT OLD DRIED STAIN. NO INCREASE NOTED.\n\nCV-AFEBRILE. INITIALLY ON NIPRIDE AND LABETOLOL GTT, BOTH NOW OFF. HR 80-90'S, NSR, NO ECTOPY. SBP MAINTAINED < 140. SKIN W+D. DENIES CARDIAC COMPLAINTS. +PP. PBOOTS ON.\n\nRESP-O2 SAT 96-97% ON 1LNC. LS WITH WHEEZES. USING INHALERS WITH SOME EFFECT. DENIES SOB. PT HAS CONGESTED COUGH, ABLE TO CLEAR SECRETIONS ON OWN. PT REPORTS RESP STATUS AT BASELINE.\n\nGI-ABD SOFT, NT/ND. +BS. TOL PO'S WITHOUT N/V.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-MAE. MOVES I IN BED.\n\nCOMFORT- X1 FOR C/O NECK SORENESS.\n\nPLAN-CON'T WITH CURRENT PLAN. NEURO CHECKS. ASSESS PAIN. TRANSFER TO FLOOR WHEN BED AVAIL.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-05 00:00:00.000",
"description": "Report",
"row_id": 1433437,
"text": "RESPIRATORY CARE:\n\nPt admitted to NSICU, intubated #7.0 ETT. Placed on vent briefly, then extubated without event. Administering Combivent MDI with spacer. BS's exp wheezes, pt comfortable. See flowsheet for further pt data/rx's.\nPlan: RN's to follow with , pt has good technique. Please call for further RT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-05 00:00:00.000",
"description": "Report",
"row_id": 1433438,
"text": "FOCUS: ADDMITING NOTE.\nADMITED TO NSICU AND PLACED ON ECG- SATS- ALINE- AND RR MONITORING.\n\nNEURO: PARALIZED AND SEDATED ON ARRIVAL-- REVERSED IN N-SICU. WAS NOT RESPONSIVE TO PAINFUL STIMULI. ABLE TO OPEN EYES AND FOLLOW COMMANDS INCONSISTENTLY COUPLE HOURS AFTER ARRIVAL. AT END OF SHIFT--ABLE TO FOLLOW COMMANDS, MAE, PERL, ALERT AND ORIENTED X 3. DOES NOT COMPLAIN OF PAIN OR HA.\n\nCV: TACHYCARDIC AND HYPERTENSIVE ON ARRIVAL, NIPRIDE GTT FOR SBP 120-140--CHANGED TO LABETALOL GTT TO WEAN NIPRIDE.\n\nRESP: INTUBATED ON ARRIVAL-- EXTUBATED COUPLE OF HOURS LATER. SHOVEL MASK PLACED SATS 98 T0 100. NC AT 5 L.--SATS 98-100.\n\nGI/GU: FOLEY PATENT DRAINING YELLOW CLEAR URINE. BOWEL SOUNDS PRESENT.\n\nSOCIAL: FAMILY VISIT.\n\nPLAN: CONTINUE TO ASSESS NEURO STATUS--CONTINUE TO ASSESS RESPIRATORY STATUS FOR FUTURE D/C\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-06 00:00:00.000",
"description": "Report",
"row_id": 1433439,
"text": "Nursing condition update:\nNeuro: Dozing intermittently through night. Easily arousable to voice, following all commands. PERRLA. Oriented x 3. Smile symmetrical, no drift. No headache. Staples intact to occipital area w/small amount old blood noted.\n\nCV: Remains on Labetolol gtt to keep SBP <140, turned off x2 hours secondary to SBP 100 or <. NSR 80s. no ectopy.\n\nResp: Lung sounds w/exp. wheezing, diminished at bases. Encouraged to cough and deep breathe. Sats 97-100% on 3L NC. Inhalers q6hrs w/some effect. ABGs unchanged.\n\nGI: Abdomen soft, non-tender and non-distended. Tolerated a small amount of custard and ice chips. no n/v. +bs, +flatus. no stool.\n\nGU: Foley patent adequate amounts clear yellow urine.\n\nACT: pt. moving in bed w/minimal assist, denies need for pain meds.\n\nPlan: cont. to monitor neuro signs, ? begin to wean Labetolol gtt, monitor resp. status closely, aggressive pulm. hygeine.\n"
}
] |
64,416 | 194,218 | IN SUMMARY This is a 62 yo male with ESLD recently admitted with R chest wall hematoma s/p two IR embolizations who presents with recurrent right groin sheath site. We managed his continuous oozing with manual pressure, topical anticoagulants and serial changes of pressure dressings. Ultimately, we achieved success with IV DDAVP and Amicar. We transitioned him to PO amicar and from to he had no oozing and actually formed a hard scar. He was transitioned from bedrest to OOB/In Chair with the goal of ambulation on . This goal was only achieved with PT clearance on and again on . He was discharged to complete a course of oral amicar and to follow up with his PCP. BY PROBLEM 1) Problem Coagulopathy: He came in bleeding from his arterial sheath site in hte right groin. At presentation his ultrasound was negative for pseudoaneurysm. He only ever had a minimal ooze that would sometimes accumulate into large collected clots. He was hypotensive and thus admitted to the MICU. In the MICU, his Hct was stable after 3 units of pRBC and thus he was transferred to the floor. Here, his HCT has waffled downards to a nadir of 20.3. He received 2 units of pRBCs with response. The second unit was given on , after he had one bloody BM with 2 FFP as well. Clot was evacuated from his groin and was not bleeding at 0545 on /9. This was his last bleed. On Rectal exam on , there was no blood, only a thrombosed external hemorrhoid. The Liver team was informed but not consulted, in the event that he opened up. Hematology was consulted and they ordered labs, suggested DDAVP and Systemic Amicar. The lab results revealed a global decrease in liver synthesized coagulation factors (2,7,10) as well as the Lupus Anticoagulant. By the time of discharge, he had not bleed for 96 hours. TO REVIEW: his coagulopathy is related to hepatic insufficiency and his PTT is chronically elevated secondary to the lupus coagulant. . 2) GI Bleed: Passed one bloody BM. Most likely LGIB (#1 = hemmorrhoid, avm, diverticolosis). Unlikely varices (none on last EGD), but possible. Also possible is ulcer disease, gastropathy, dieulafoy. The bleeding resolved spontaneously despite his coagulopathy. . 3) Right Chest/Back Hematoma: The thoracic arterial bleed that started his problems is quiescent. Pt reports that non-painfull fullness along R flank and scapula increased from discharge. The CT on admission ruled out hematoma expansion. . 4) Hypotension: Pt hypotensive to 70's on admission which has improved to 100's after 1 unit PRBC's. Likely this was hypovolemia in setting of groin bleed and possible R chest bleeding. Afebrile, w/out evidence of infection. Held diuretics but with stability was back on spironolactone and furosemide . 5) ARF: Likely hypovolemic leading to pre-renal physiology. Resolved with fluids and transfusion . 6) ESLD: Class C CPT. The laboratory evaluation of his coagulation factors revealed low levels of Factors 2, 7 and 10. This implies that his liver's synthetic function is actually very poor. Provided his sustains sobriety, he will certainly enter a transplant list with a high MELD given the INR and Bili. He must continue taking lactulose for encephalopathy . 7) LUPUS ANTICOAGULANT: The patient has a persistently elevated PTT. This test is absolutely useless in this patient and so long as he has ESLD, neither is PT/INR . TO BE RESOLVED OUTPATIENT 1) Groin care - careful bandage changes with protection from friction. 2) Physical therapy - patient is deconditioned 3) Malnutrition - patient is loosing muscle bulk and given his cirrhosis has increased nutritional requirements 4) Lupus Anticoagulant - PTT test is not useful for this patient 5) Amicar - patient is on oral amicar. 6) Hepatic Encephalopathy - pt is stable on lactulose, may want to add Rifaximin if his insurance will support it | Unchanged right, atelectasis and (Over) 4:34 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: please assess for interval change in R chest hematoma Admitting Diagnosis: ANEMIA FINAL REPORT (Cont) small perifissural right lower lobe nodule. - appreciate vascular recs -rec'd 3UPRBCs and 2UFFP yesterday, c minimal ooze until this am when had bleed of 150cc. - appreciate vascular recs -rec'd 3UPRBCs and 2UFFP yesterday, c minimal ooze until this am when had bleed of 150cc. - appreciate vascular recs -rec'd 3UPRBCs and 2UFFP yesterday, c minimal ooze until this am when had bleed of 150cc. In ED vitals on admission, T98.6 HR 73 BP 104/49 RR 14 O2Sat 100RA. In ED vitals on admission, T98.6 HR 73 BP 104/49 RR 14 O2Sat 100RA. On transfer to ICU vitals: T98.3 HR: 66 BP 97/53 RR 18 O2:100RA. On transfer to ICU vitals: T98.3 HR: 66 BP 97/53 RR 18 O2:100RA. Admitted to ICU with transient hypotension. Abdomen remains distended, +ascites. Abdomen remains distended, +ascites. Abdomen remains distended, +ascites. So, gave 1 addl unit and will recheck hct in the am -bleeding from groin site this am ~150cc Coagulopathy Assessment: Action: Response: Plan: So, gave 1 addl unit and will recheck hct in the am -bleeding from groin site this am ~150cc Coagulopathy Assessment: Action: Response: Plan: Coagulopathy Assessment: VS stable, SBP 95-115. Coagulopathy Assessment: VS stable, SBP 95-115. Coagulopathy Assessment: VS stable, SBP 95-115. Action: Additional unit PRBCs given, VS checked hourly, assessed for s/sx bleeding. Action: Additional unit PRBCs given, VS checked hourly, assessed for s/sx bleeding. Action: Additional unit PRBCs given, VS checked hourly, assessed for s/sx bleeding. - hold spironolactone and furosemide given unstable pressures - cont lactulose ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 10:07 AM 20 Gauge - 10:08 AM Prophylaxis: DVT: VDBs Stress ulcer: PPI VAP: Comments: Communication: HCP : Code status: FULL Disposition: ICU for now Response: SBP stable, resting comfortably overnight, no s/sx active bleeding until 0400 when R. groin w/significant area of oozing , unable to quantify amt. Renal U/S neg for pseudoaneurysm. Renal U/S neg for pseudoaneurysm. Renal U/S neg for pseudoaneurysm. Renal U/S neg for pseudoaneurysm. Renal U/S neg for pseudoaneurysm. # Hypotension: Blood pressure stable . # ARF: Likely hypovolemic leading to pre-renal physiology. # ARF: Likely hypovolemic leading to pre-renal physiology. # ARF: Likely hypovolemic leading to pre-renal physiology. # ARF: Likely hypovolemic leading to pre-renal physiology. # ARF: Likely hypovolemic leading to pre-renal physiology. Unchanged from Assessment and Plan This is a 62 yo male with ESLD recently admitted with R chest wall hematoma s/p two IR embolizations who presents with recurrent right sheath site. Unchanged from Assessment and Plan This is a 62 yo male with ESLD recently admitted with R chest wall hematoma s/p two IR embolizations who presents with recurrent right sheath site. HPI: Increased oozing from groin this AM - 150 cc 24 Hour Events: CT yesterday showed stable back hematoma Allergies: Codeine Rash; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: per ICU resident note Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Constitutional: No(t) Fever Cardiovascular: No(t) Chest pain Nutritional Support: No(t) NPO Respiratory: No(t) Dyspnea Gastrointestinal: No(t) Abdominal pain Genitourinary: No(t) Dysuria Pain: No pain / appears comfortable Flowsheet Data as of 08:46 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.3C (99.1 Tcurrent: 37.1C (98.7 HR: 69 (56 - 73) bpm BP: 102/53(64) {81/25(40) - 114/62(74)} mmHg RR: 20 (15 - 23) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 90 kg (admission): 87.3 kg Total In: 4,217 mL 1,068 mL PO: 760 mL 720 mL TF: IVF: 2,188 mL 348 mL Blood products: 1,269 mL Total out: 1,250 mL 1,300 mL Urine: 350 mL 400 mL NG: Stool: 900 mL 900 mL Drains: Balance: 2,967 mL -232 mL Respiratory support O2 Delivery Device: None SpO2: 99% ABG: ///20/ Physical Examination General Appearance: No acute distress Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Distended Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, pressure dressing on right groin Musculoskeletal: back hematoma unchanged Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 8.9 g/dL 104 K/uL 112 mg/dL 0.9 mg/dL 20 mEq/L 3.5 mEq/L 26 mg/dL 105 mEq/L 134 mEq/L 26.7 % 6.7 K/uL [image002.jpg] 11:43 AM 04:10 PM 07:45 PM 09:24 PM 02:21 AM 05:30 AM WBC 6.7 Hct 25.0 23.4 22.5 26.6 26.8 26.7 Plt 104 Cr 1.0 0.9 Glucose 93 112 Other labs: PT / PTT / INR:20.4/83.3/1.9, Ca++:8.7 mg/dL, Mg++:1.5 mg/dL, PO4:3.3 mg/dL Assessment and Plan Assessment and Plan This is a 62 yo male with ESLD recently admitted with R chest wall hematoma s/p two IR embolizations who presents with recurrent right groin sheath site. | 20 | [
{
"category": "Physician ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Physician Admission Note - MICU",
"row_id": 592799,
"text": "Chief Complaint: Right bleed\n HPI:\n Mr. is a 62 yo male with h/o ETOH cirrhosis, ESLD, Coagulopathy\n ESLD with recent prolonged hospitalization for right\n axillary hematoma requiring IR embolization x 2 and significant blood\n product recusitation (31 units PRBCs, 31 units FFP, 3 units cryo) who\n presents with recurrent bleeding from right , site of arterial\n sheath. Pt reports no bleeding from site since discharge on . He\n noticed R bleeding that began at 8pm last night.\n .\n In ED vitals on admission, T98.6 HR 73 BP 104/49 RR 14 O2Sat 100RA. Hct\n on admission 23 down from 29 on . Seen by vasc who cauterized\n with silver nitrate with effective hemostasis. No pseudoaneursym on\n femoral u/s. Notably, BP dropped to 70's/40-50's for 90 minutes. He\n received 1 unit PRBC's. Two large bore IVs in place. On transfer to ICU\n vitals: T98.3 HR: 66 BP 97/53 RR 18 O2:100RA.\n .\n In the ICU, patient has no complaints. Denies any R pain. Reports\n that he has been ambulating at home since discharge but denies any\n strenuous activity or lifting.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Codeine\n Rash;\n HOME MEDS:\n Furosemide 80 mg daily\n Thiamine 100 mg daily\n Folic Acid 1 mg daily\n Pantoprazole 40 mg daily\n Lactulose 30mL TID\n Spironolactone 100 mg daily\n Past medical history:\n Family history:\n Social History:\n -ETOH cirrhosis-ESLD, ascites, fibrosis by liver bx and\n steatohepatitis; negative hep serologies-has appt at for\n transplant eval.\n -Alcohol abuse (last drink )\n -Pancytopenia\n -Coagulopathy ESLD\n -HTN\n -GERD\n mother with arrhythmia and stroke, sister with HTN\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: last drink \n Other:\n Review of systems:\n (+) Per HPI.\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. Denied nausea, vomiting, constipation or abdominal pain.\n No recent change in bowel or bladder habits. No dysuria. Denied\n arthralgias or myalgias.\n Flowsheet Data as of 04:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.3\n HR: 61 (58 - 66) bpm\n BP: 87/25(41) {81/25(40) - 112/62(74)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,686 mL\n PO:\n 400 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 286 mL\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,486 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: +scleral icterus, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Back: Fullness from mid-right back up to scapula, overlying skin\n ecchymosis, non-tender to palpation\n Abdomen: soft, +moderately distended, +fluid shift,bowel sounds\n present, no rebound tenderness or guarding\n R : ~5mm everted granulation tissue that is\n slowly oozing bright red blood. Strong 2+ femoral pulse\n Ext: Warm, well perfused, 2+ pulses. 1+ pedal edema\n Neuro: A0x3, CN II-XII grossly intact, motor strength all 4 ext\n Labs / Radiology\n 95\n 7.7\n 129\n 1.4\n 35\n 22\n 101\n 3.8\n 134\n 23.6\n 6.4\n [image002.jpg]\n \n 2:33 A9/3/ 11:43 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Other labs: PT / PTT / INR:21/90/2, ALT / AST:15/37, Alk Phos / T\n Bili:70/13.5, Amylase / Lipase:/100\n Imaging: CT Chest :\n 1. No change in large chest wall hematoma from nine days ago.\n 2. Slight decrease in right pleural effusion.\n 3. Cirrhosis, with slight increase in ascites.\n 4. Unchanged right middle lobe pulmonary nodule\n .\n Femoral U/s: No pseudoaneurysm. Normal.\n ECG: sinus at 71 bpm, normal axis. Unchanged from \n Assessment and Plan\n This is a 62 yo male with ESLD recently admitted with R chest wall\n hematoma s/p two IR embolizations who presents with recurrent right\n sheath site.\n .\n .\n # Right Bleeding: Continues to have very slow ooze. Hct has\n remained stable around 24 which is down from 29 at DC on . Renal\n U/S neg for pseudoaneurysm.\n - silver nitrate and pressure drsg \n - serial hcts q3hrs\n - give 2 units FFP\n - appreciate vascular recs\n .\n # Right Chest/Back Hematoma: Pt reports that non-painfull fullness\n along R flank and scapula increased from discharge. Possible that he\n has begun re-bleeding into this space.\n - CT chest to assess for active bleeding\n - monitor serial Hct as per below\n - 2 units of FFP now\n .\n # Hypotension: Pt hypotensive to 70's on admission which has improved\n to 100's after 1 unit PRBC's. Likely this was hypovolemia in\n setting of bleed and possible R chest bleeding. Afebrile, w/out\n evidence of infection.\n - cont monitor Hct and transfuse with PRBC's as needed\n - IVF @ 125 cc/hr\n - holding diuretics: spironolactone and furosemide\n .\n # ARF: Likely hypovolemic leading to pre-renal physiology.\n - check urine lytes\n - IVF, blood products PRN\n - trend Cr\n .\n # ESLD: LFTs stable. Patient scheduled for transplant w/u at in\n few wks.\n - hold spironolactone and furosemide given unstable pressures\n - cont lactulose\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:07 AM\n 20 Gauge - 10:08 AM\n Prophylaxis:\n DVT: VDBs\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: HCP : \n Code status: FULL\n Disposition: ICU for now\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for the key portions of the services provided. I agree with\n the note above, including the assessment and plan. To that I would add\n the following:\n This is a 62 yo man with recent axillary hematoma who has persistent\n bleeding from R sheath site. Admitted to ICU with transient\n hypotension. CT chest now preliminarily with expansion of axillary\n hematoma. Will attempt to correct INR. Vascular surgery team involved\n in case.\n Pt is critically ill. Time spent 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:01 ------\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 592789,
"text": "Chief Complaint: Right bleed\n HPI:\n Mr. is a 62 yo male with h/o ETOH cirrhosis, ESLD, Coagulopathy\n ESLD with recent prolonged hospitalization for right\n axillary hematoma requiring IR embolization x 2 and significant blood\n product recusitation (31 units PRBCs, 31 units FFP, 3 units cryo) who\n presents with recurrent bleeding from right , site of arterial\n sheath. Pt reports no bleeding from site since discharge on . He\n noticed R bleeding that began at 8pm last night.\n .\n In ED vitals on admission, T98.6 HR 73 BP 104/49 RR 14 O2Sat 100RA. Hct\n on admission 23 down from 29 on . Seen by vasc who cauterized\n with silver nitrate with effective hemostasis. No pseudoaneursym on\n femoral u/s. Notably, BP dropped to 70's/40-50's for 90 minutes. He\n received 1 unit PRBC's. Two large bore IVs in place. On transfer to ICU\n vitals: T98.3 HR: 66 BP 97/53 RR 18 O2:100RA.\n .\n In the ICU, patient has no complaints. Denies any R pain. Reports\n that he has been ambulating at home since discharge but denies any\n strenuous activity or lifting.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Codeine\n Rash;\n HOME MEDS:\n Furosemide 80 mg daily\n Thiamine 100 mg daily\n Folic Acid 1 mg daily\n Pantoprazole 40 mg daily\n Lactulose 30mL TID\n Spironolactone 100 mg daily\n Past medical history:\n Family history:\n Social History:\n -ETOH cirrhosis-ESLD, ascites, fibrosis by liver bx and\n steatohepatitis; negative hep serologies-has appt at for\n transplant eval.\n -Alcohol abuse (last drink )\n -Pancytopenia\n -Coagulopathy ESLD\n -HTN\n -GERD\n mother with arrhythmia and stroke, sister with HTN\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: last drink \n Other:\n Review of systems:\n (+) Per HPI.\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. Denied nausea, vomiting, constipation or abdominal pain.\n No recent change in bowel or bladder habits. No dysuria. Denied\n arthralgias or myalgias.\n Flowsheet Data as of 04:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.3\n HR: 61 (58 - 66) bpm\n BP: 87/25(41) {81/25(40) - 112/62(74)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,686 mL\n PO:\n 400 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 286 mL\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,486 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: +scleral icterus, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Back: Fullness from mid-right back up to scapula, overlying skin\n ecchymosis, non-tender to palpation\n Abdomen: soft, +moderately distended, +fluid shift,bowel sounds\n present, no rebound tenderness or guarding\n R : ~5mm everted granulation tissue that is\n slowly oozing bright red blood. Strong 2+ femoral pulse\n Ext: Warm, well perfused, 2+ pulses. 1+ pedal edema\n Neuro: A0x3, CN II-XII grossly intact, motor strength all 4 ext\n Labs / Radiology\n 95\n 7.7\n 129\n 1.4\n 35\n 22\n 101\n 3.8\n 134\n 23.6\n 6.4\n [image002.jpg]\n \n 2:33 A9/3/ 11:43 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Other labs: PT / PTT / INR:21/90/2, ALT / AST:15/37, Alk Phos / T\n Bili:70/13.5, Amylase / Lipase:/100\n Imaging: CT Chest :\n 1. No change in large chest wall hematoma from nine days ago.\n 2. Slight decrease in right pleural effusion.\n 3. Cirrhosis, with slight increase in ascites.\n 4. Unchanged right middle lobe pulmonary nodule\n .\n Femoral U/s: No pseudoaneurysm. Normal.\n ECG: sinus at 71 bpm, normal axis. Unchanged from \n Assessment and Plan\n This is a 62 yo male with ESLD recently admitted with R chest wall\n hematoma s/p two IR embolizations who presents with recurrent right\n sheath site.\n .\n .\n # Right Bleeding: Continues to have very slow ooze. Hct has\n remained stable around 24 which is down from 29 at DC on . Renal\n U/S neg for pseudoaneurysm.\n - silver nitrate and pressure drsg \n - serial hcts q3hrs\n - give 2 units FFP\n - appreciate vascular recs\n .\n # Right Chest/Back Hematoma: Pt reports that non-painfull fullness\n along R flank and scapula increased from discharge. Possible that he\n has begun re-bleeding into this space.\n - CT chest to assess for active bleeding\n - monitor serial Hct as per below\n - 2 units of FFP now\n .\n # Hypotension: Pt hypotensive to 70's on admission which has improved\n to 100's after 1 unit PRBC's. Likely this was hypovolemia in\n setting of bleed and possible R chest bleeding. Afebrile, w/out\n evidence of infection.\n - cont monitor Hct and transfuse with PRBC's as needed\n - IVF @ 125 cc/hr\n - holding diuretics: spironolactone and furosemide\n .\n # ARF: Likely hypovolemic leading to pre-renal physiology.\n - check urine lytes\n - IVF, blood products PRN\n - trend Cr\n .\n # ESLD: LFTs stable. Patient scheduled for transplant w/u at in\n few wks.\n - hold spironolactone and furosemide given unstable pressures\n - cont lactulose\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:07 AM\n 20 Gauge - 10:08 AM\n Prophylaxis:\n DVT: VDBs\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: HCP : \n Code status: FULL\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 592758,
"text": "HPI: 62 M returns to the ED after a recent hospital stay in which\n he underwent 2 IR embolizations of right sided intercostal\n arteries (T7 & T9) s/p fall. He had sustained a large\n axillary/flank bleed that required 30 units RBC's and 18 FFP in\n total. This second IR procedure was complicated by\n bleeding/hematoma in the right groin that was treated with FFP\n and direct pressure. He was discharge on and had been doing\n well until today. VNA had been doing daily dressing changes,\n however he reports that a smaller dressing was placed over the\n site by his PCP . Around 7 PM he noticed bleeding. Denies\n any lightheadedness, dizziness, or pain.\n PMH: intercostal bleed s/p fall, ETOH cirrhosis, ETOH abuse\n (quiescent x 6 months per pt but recently resumed drinking), HTN,\n Anemia - EGD and colonoscopy at that showed a few polyps\n (benign), no active bleed or varices, ARF, GERD\n PSH: IR guided embolization of T7 and T9 intercostals on \n and ; right knee replacement '\n : Furosemide 80', thiamine, MVI, FA, protonix 40', lactulose\n TID, spironolactone 100', oxycodone prn\n .\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 592759,
"text": "HPI: 62 M returns to the ED after a recent hospital stay in which\n he underwent 2 IR embolizations of right sided intercostal\n arteries (T7 & T9) s/p fall. He had sustained a large\n axillary/flank bleed that required 30 units RBC's and 18 FFP in\n total. This second IR procedure was complicated by\n bleeding/hematoma in the right groin that was treated with FFP\n and direct pressure. He was discharge on and had been doing\n well until today. VNA had been doing daily dressing changes,\n however he reports that a smaller dressing was placed over the\n site by his PCP . Around 7 PM he noticed bleeding. Denies\n any lightheadedness, dizziness, or pain.\n PMH: intercostal bleed s/p fall, ETOH cirrhosis, ETOH abuse\n (quiescent x 6 months per pt but recently resumed drinking), HTN,\n Anemia - EGD and colonoscopy at that showed a few polyps\n (benign), no active bleed or varices, ARF, GERD\n PSH: IR guided embolization of T7 and T9 intercostals on \n and ; right knee replacement '\n : Furosemide 80', thiamine, MVI, FA, protonix 40', lactulose\n TID, spironolactone 100', oxycodone prn\n .\n Coagulopathy\n Assessment:\n There is dark ecchymotic skin color changes on his right\n lateral\n chest wall. There is a large area of fullness that extends from\n his mid back all the way up past his scapula.\n Right groin site oozing bright red blood\n Transfused with 1 unit PC in ED prior to transfer to\n SICU\n Action:\n Repeat hct 25\n Pressure dressing applied to right groin\n 2 units FFP infused\n Chest CT ordered\n Pt given 1 liter normal saline fluid bolus over 2 hrs\n Hct checked q3hrs\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 592833,
"text": "HPI: 62 M returns to the ED after a recent hospital stay in which\n he underwent 2 IR embolizations of right sided intercostal\n arteries (T7 & T9) s/p fall. He had sustained a large\n axillary/flank bleed that required 30 units RBC's and 18 FFP in\n total. This second IR procedure was complicated by\n bleeding/hematoma in the right groin that was treated with FFP\n and direct pressure. He was discharge on and had been doing\n well until today. VNA had been doing daily dressing changes,\n however he reports that a smaller dressing was placed over the\n site by his PCP . Around 7 PM he noticed bleeding. Denies\n any lightheadedness, dizziness, or pain.\n PMH: intercostal bleed s/p fall, ETOH cirrhosis, ETOH abuse\n (quiescent x 6 months per pt but recently resumed drinking), HTN,\n Anemia - EGD and colonoscopy at that showed a few polyps\n (benign), no active bleed or varices, ARF, GERD\n PSH: IR guided embolization of T7 and T9 intercostals on \n and ; right knee replacement '\n : Furosemide 80', thiamine, MVI, FA, protonix 40', lactulose\n TID, spironolactone 100', oxycodone prn\n .\n Coagulopathy\n Assessment:\n There is dark ecchymotic skin color changes on his right\n lateral\n chest wall. There is a large area of fullness that extends from\n his mid back all the way up past his scapula.\n Right groin site oozing bright red blood\n Transfused with 1 unit PC in ED prior to transfer to\n SICU\n Action:\n Repeat hct 25\n Pressure dressing applied to right groin\n 2 units FFP infused\n Chest CT ordered\n Pt given 1 liter normal saline fluid bolus over 2 hrs\n Hct checked q3hrs\n Chest CT with /without contrast done\n 1 unit PC infusing\n IVF with bicarb infusing at 125cc/hr after CT scan secondary\n to dye load\n Response:\n Continues to ooze from R groin site- pressure dressing\n changed at 1600 and presently clean and dry\n Hct 23.7\n Awaiting CT results\n Plan:\n Check HCT q3hrs as ordered\n Check groin site Q1hr for bleeding\n Maintain pressure dressing\n Await CT results\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 592899,
"text": "Coagulopathy\n Assessment:\n VS stable, SBP 95-115. No advancement of hematoma to R. scapula area\n noted. DSD to R. groin intact w/o oozing. Repeat hct @ 22.5 after\n 1 unit PRBCs given. Abdomen remains distended, +ascites. Pt. c/o\n feeling cold and using mult. Blankets but is normothermic.\n Action:\n Additional unit PRBCs given, VS checked hourly, assessed for s/sx\n bleeding.\n Response:\n SBP stable, resting comfortably overnight, no s/sx active bleeding\n until 0400 when R. groin w/significant area of oozing , unable to\n quantify amt. Dr. notified and hct to be repeated @ 0600.\n Pressure dressing replaced to R. groin.\n Plan:\n Cont. to follow hcts, assess groin and scapula area for continued\n bleeding, cont. current plan of care.\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 593074,
"text": "Mr. is a 62 yo male with h/o ETOH cirrhosis, ESLD, Coagulopathy\n ESLD with recent prolonged hospitalization for right\n axillary hematoma requiring IR embolization x 2 and significant blood\n product recusitation (31 units PRBCs, 31 units FFP, 3 units cryo) who\n presents with recurrent bleeding from right groin, site of arterial\n sheath. Pt reports no bleeding from site since discharge on . He\n noticed R groin bleeding that began at 8pm ..\n 24 Hour Events:\n -9p: pt received 1Uprbc in ED, 1Uprbc on floor, also rec'd 2uffp\n hcts remained stable, no sig bump.... So, gave 1 addl unit and will\n recheck hct in the am\n -bleeding from groin site this am ~150cc\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 593043,
"text": "Chief Complaint: Mr. is a 62 yo male with h/o ETOH cirrhosis,\n ESLD, Coagulopathy ESLD with recent prolonged hospitalization\n for right axillary hematoma requiring IR embolization x 2 and\n significant blood product recusitation (31 units PRBCs, 31 units FFP, 3\n units cryo) who presents with recurrent bleeding from right groin, site\n of arterial sheath. Pt reports no bleeding from site since discharge on\n . He noticed R groin bleeding that began at 8pm last night.\n 24 Hour Events:\n -9p: pt received 1Uprbc in ED, 1Uprbc on floor, also rec'd 2uffp\n hcts remained stable, no sig bump.... So, gave 1 addl unit and will\n recheck hct in the am\n -bleeding from groin site this am ~150cc\n Allergies:\n Codeine\n Rash;\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 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.8\nC (98.3\n HR: 73 (56 - 73) bpm\n BP: 114/58(72) {81/25(40) - 114/62(74)} mmHg\n RR: 18 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 87.3 kg\n Total In:\n 4,217 mL\n 811 mL\n PO:\n 760 mL\n 480 mL\n TF:\n IVF:\n 2,188 mL\n 331 mL\n Blood products:\n 1,269 mL\n Total out:\n 1,250 mL\n 1,300 mL\n Urine:\n 350 mL\n 400 mL\n NG:\n Stool:\n 900 mL\n 900 mL\n Drains:\n Balance:\n 2,967 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n Gen: calm, answers questions appropriately\n CV: RRR\n Resp: CTAB\n Abd: distended\n Groin: dressing c/d/I\n Back: swelling similar in size to yesterday\n Labs / Radiology\n 104 K/uL\n 8.9 g/dL\n 112 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 3.5 mEq/L\n 26 mg/dL\n 105 mEq/L\n 134 mEq/L\n 26.7 %\n 6.7 K/uL\n [image002.jpg]\n 11:43 AM\n 04:10 PM\n 07:45 PM\n 09:24 PM\n 02:21 AM\n 05:30 AM\n WBC\n 6.7\n Hct\n 25.0\n 23.4\n 22.5\n 26.6\n 26.8\n 26.7\n Plt\n 104\n Cr\n 1.0\n 0.9\n Glucose\n 93\n 112\n Other labs: PT / PTT / INR:20.4/83.3/1.9, Ca++:8.7 mg/dL, Mg++:1.5\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n COAGULOPATHY\n Assessment and Plan:\n This is a 62 yo male with ESLD recently admitted with R chest wall\n hematoma s/p two IR embolizations who presents with recurrent right\n groin sheath site.\n .\n .\n # Right Groin Bleeding: Continues to have very slow ooze. Hct has\n remained stable around 24 which is down from 29 at DC on . Renal\n U/S neg for pseudoaneurysm. Silver nitrate applied to groin site\n yesterday, however, surgery recommended do not do this again.\n - appreciate vascular recs\n -rec'd 3UPRBCs and 2UFFP yesterday, c minimal ooze until this am when\n had bleed of 150cc. recheck hct 26 from 26.\n -goal hct >26-28\n -aminocaproic acid topical\n -2 more units FFP today\n -HCT checks Q8 today\n .\n # Right Chest/Back Hematoma: Pt reports that non-painfull fullness\n along R flank and scapula increased from discharge. Possible that he\n has begun re-bleeding into this space.\n - CT chest showed no interval change\n .\n # Hypotension: Pt hypotensive to 70's on admission which has improved\n to 100's after 1 unit PRBC's. Likely this was hypovolemia in\n setting of groin bleed and possible R chest bleeding. Afebrile, w/out\n evidence of infection.\n - cont monitor Hct and transfuse with PRBC's as needed\n - holding diuretics: spironolactone and furosemide\n .\n # ARF: Likely hypovolemic leading to pre-renal physiology.\n - resolved am Cr 0.9\n .\n # ESLD: LFTs stable. Patient scheduled for transplant w/u at in\n few wks.\n - hold furosemide given unstable pressures, start spironolactone today\n at lower dose.\n - cont lactulose.\n .\n # FEN: IVF, replete electrolytes, HH diet\n .\n # Prophylaxis: boots\n .\n # Access: peripherals\n .\n # Code: FULL\n .\n # Communication: Patient\n .\n # Disposition: pending above - potentially to floor today if he\n remains stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:07 AM\n 20 Gauge - 10:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: full code\n Disposition: transfer to floor if stable\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 592877,
"text": "Coagulopathy\n Assessment:\n VS stable, SBP 95-115. No advancement of hematoma to R. scapula area\n noted. DSD to R. groin intact, no oozing. Repeat hct @ 22.5\n after 1 unit PRBCs given. Abdomen remains distended, +ascites. Pt.\n c/o feeling cold and using mult. Blankets but is normothermic.\n Action:\n Additional unit PRBCs given, VS checked hourly, assessed for s/sx\n bleeding.\n Response:\n SBP stable, resting comfortably overnight, no s/sx active bleeding.\n Plan:\n Cont. to follow hcts, assess groin and scapula area for bleeding, cont.\n current plan of care, ? to floor in am if stable.\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 593097,
"text": "Mr. is a 62 yo male with h/o ETOH cirrhosis, ESLD, Coagulopathy\n ESLD with recent prolonged hospitalization for right\n axillary hematoma requiring IR embolization x 2 and significant blood\n product recusitation (31 units PRBCs, 31 units FFP, 3 units cryo) who\n presents with recurrent bleeding from right groin, site of arterial\n sheath. Pt reports no bleeding from site since discharge on . He\n noticed R groin bleeding that began at 8pm ..\n Pt. received total of 3 units PRBC, 2 units FFP in SICU .\n Coagulopathy\n Assessment:\n Patient continues to have bleeding from groin site. DSD saturated x 3\n throughout day, site continuously oozes. HCT 26.7 after last unit of\n PRBC overnight. INR 1.9. Patient c/o dull mild pain in back 3 out of\n 10 where previous hematoma was, CT done did not show any bleeding\n in chest cavity per MICU team. Vitals stable SBP > 100 throughout day.\n Action:\n MICU team in to assess groin site after complete saturation of DSD,\n Given 2 units FFP,\n Pressure held on groin site after saturation of pad, aminocaprioc acid\n applied to site per hematology, figure eight pressure dressing applied\n to site.\n Response:\n HCT stable at 26.8,\n Not complaining of any pain.\n Plan:\n Continue to monitor, transfer to floor when bed available.\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 593153,
"text": "Mr. is a 62 yo male with h/o ETOH cirrhosis, ESLD, Coagulopathy\n ESLD with recent prolonged hospitalization for right\n axillary hematoma requiring IR embolization x 2 and significant blood\n product recusitation (31 units PRBCs, 31 units FFP, 3 units cryo) who\n presents with recurrent bleeding from right groin, site of arterial\n sheath. Pt reports no bleeding from site since discharge on . He\n noticed R groin bleeding that began at 8pm ..\n Pt. received total of 3 units PRBC, 2 units FFP in SICU .\n Coagulopathy\n Assessment:\n Patient continues to have bleeding from groin site. DSD saturated x 3\n throughout day, site continuously oozes. HCT 26.7 after last unit of\n PRBC overnight. INR 1.9. Patient c/o dull mild pain in back 3 out of\n 10 where previous hematoma was, CT done did not show any bleeding\n in chest cavity per MICU team. Vitals stable SBP > 100 throughout day.\n Action:\n MICU team in to assess groin site after complete saturation of DSD,\n Given 2 units FFP,\n Pressure held on groin site after saturation of pad, aminocaprioc acid\n applied to site per hematology, figure eight pressure dressing applied\n to site.\n Response:\n HCT stable at 26.8,\n Not complaining of any pain.\n Plan:\n Continue to monitor, transfer to floor when bed available.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ANEMIA\n Code status:\n Height:\n Admission weight:\n 87.3 kg\n Daily weight:\n 90 kg\n Allergies/Reactions:\n Codeine\n Rash;\n Precautions:\n PMH: Liver Failure\n CV-PMH: Hypertension\n Additional history: Hep C, ESLD, coagulopathic, etoh cirrhosis,\n ascites, ARF, GERD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:100\n D:42\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 68 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 2,816 mL\n 24h total out:\n 2,300 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 02:21 AM\n Potassium:\n 3.5 mEq/L\n 02:21 AM\n Chloride:\n 105 mEq/L\n 02:21 AM\n CO2:\n 20 mEq/L\n 02:21 AM\n BUN:\n 26 mg/dL\n 02:21 AM\n Creatinine:\n 0.9 mg/dL\n 02:21 AM\n Glucose:\n 112 mg/dL\n 02:21 AM\n Hematocrit:\n 26.8 %\n 11:21 AM\n Finger Stick Glucose:\n 107\n 04:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: watch on patient, cell phone and cell phone charger.\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 2\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 592867,
"text": "Coagulopathy\n Assessment:\n VS stable, SBP 95-115. No advancement of hematoma to R. scapula area\n noted. DSD to R. groin intact, no oozing. Repeat hct @ 22.5\n after 1 unit PRBCs given, rechecked and was 26. Abdomen remains\n distended, +ascites.\n Action:\n Additional unit PRBCs given, VS checked hourly, assessed for s/sx\n bleeding.\n Response:\n SBP stable, resting comfortably overnight, no s/sx active bleeding.\n Plan:\n Cont. to follow hcts, assess groin and scapula area for bleeding, cont.\n current plan of care, ? to floor in am if stable.\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 592962,
"text": "Chief Complaint: Mr. is a 62 yo male with h/o ETOH cirrhosis,\n ESLD, Coagulopathy ESLD with recent prolonged hospitalization\n for right axillary hematoma requiring IR embolization x 2 and\n significant blood product recusitation (31 units PRBCs, 31 units FFP, 3\n units cryo) who presents with recurrent bleeding from right groin, site\n of arterial sheath. Pt reports no bleeding from site since discharge on\n . He noticed R groin bleeding that began at 8pm last night.\n 24 Hour Events:\n -9p: pt received 1Uprbc in ED, 1Uprbc on floor, also rec'd 2uffp\n hcts remained stable, no sig bump.... So, gave 1 addl unit and will\n recheck hct in the am\n -bleeding from groin site this am ~150cc\n Allergies:\n Codeine\n Rash;\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 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.8\nC (98.3\n HR: 73 (56 - 73) bpm\n BP: 114/58(72) {81/25(40) - 114/62(74)} mmHg\n RR: 18 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 87.3 kg\n Total In:\n 4,217 mL\n 811 mL\n PO:\n 760 mL\n 480 mL\n TF:\n IVF:\n 2,188 mL\n 331 mL\n Blood products:\n 1,269 mL\n Total out:\n 1,250 mL\n 1,300 mL\n Urine:\n 350 mL\n 400 mL\n NG:\n Stool:\n 900 mL\n 900 mL\n Drains:\n Balance:\n 2,967 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\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 104 K/uL\n 8.9 g/dL\n 112 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 3.5 mEq/L\n 26 mg/dL\n 105 mEq/L\n 134 mEq/L\n 26.7 %\n 6.7 K/uL\n [image002.jpg]\n 11:43 AM\n 04:10 PM\n 07:45 PM\n 09:24 PM\n 02:21 AM\n 05:30 AM\n WBC\n 6.7\n Hct\n 25.0\n 23.4\n 22.5\n 26.6\n 26.8\n 26.7\n Plt\n 104\n Cr\n 1.0\n 0.9\n Glucose\n 93\n 112\n Other labs: PT / PTT / INR:20.4/83.3/1.9, Ca++:8.7 mg/dL, Mg++:1.5\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n COAGULOPATHY\n Assessment and Plan:\n This is a 62 yo male with ESLD recently admitted with R chest wall\n hematoma s/p two IR embolizations who presents with recurrent right\n groin sheath site.\n .\n .\n # Right Groin Bleeding: Continues to have very slow ooze. Hct has\n remained stable around 24 which is down from 29 at DC on . Renal\n U/S neg for pseudoaneurysm. Silver nitrate applied to groin site\n yesterday, however, surgery recommended do not do this again.\n - appreciate vascular recs\n -rec'd 3UPRBCs and 2UFFP yesterday, c minimal ooze until this am when\n had bleed of 150cc. recheck hct 26 from 26.\n -goal hct >26-28\n .\n # Right Chest/Back Hematoma: Pt reports that non-painfull fullness\n along R flank and scapula increased from discharge. Possible that he\n has begun re-bleeding into this space.\n - CT chest showed no interval change\n .\n # Hypotension: Pt hypotensive to 70's on admission which has improved\n to 100's after 1 unit PRBC's. Likely this was hypovolemia in\n setting of groin bleed and possible R chest bleeding. Afebrile, w/out\n evidence of infection.\n - cont monitor Hct and transfuse with PRBC's as needed\n - holding diuretics: spironolactone and furosemide\n .\n # ARF: Likely hypovolemic leading to pre-renal physiology.\n - resolved am Cr 0.9\n .\n # ESLD: LFTs stable. Patient scheduled for transplant w/u at in\n few wks.\n - hold spironolactone and furosemide given unstable pressures\n - cont lactulose\n .\n # FEN: IVF, replete electrolytes, HH diet\n .\n # Prophylaxis: boots\n .\n # Access: peripherals\n .\n # Code: FULL\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:07 AM\n 20 Gauge - 10:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 592987,
"text": "Chief Complaint: GGroin bleeding, Bck hematoma, blood loss anemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Increased oozing from groin this AM - 150 cc\n 24 Hour Events:\n CT yesterday showed stable back hematoma\n Allergies:\n Codeine\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: No(t) Dysuria\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.7\n HR: 69 (56 - 73) bpm\n BP: 102/53(64) {81/25(40) - 114/62(74)} mmHg\n RR: 20 (15 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 87.3 kg\n Total In:\n 4,217 mL\n 1,068 mL\n PO:\n 760 mL\n 720 mL\n TF:\n IVF:\n 2,188 mL\n 348 mL\n Blood products:\n 1,269 mL\n Total out:\n 1,250 mL\n 1,300 mL\n Urine:\n 350 mL\n 400 mL\n NG:\n Stool:\n 900 mL\n 900 mL\n Drains:\n Balance:\n 2,967 mL\n -232 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, pressure dressing on right groin\n Musculoskeletal: back hematoma unchanged\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 104 K/uL\n 112 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 3.5 mEq/L\n 26 mg/dL\n 105 mEq/L\n 134 mEq/L\n 26.7 %\n 6.7 K/uL\n [image002.jpg]\n 11:43 AM\n 04:10 PM\n 07:45 PM\n 09:24 PM\n 02:21 AM\n 05:30 AM\n WBC\n 6.7\n Hct\n 25.0\n 23.4\n 22.5\n 26.6\n 26.8\n 26.7\n Plt\n 104\n Cr\n 1.0\n 0.9\n Glucose\n 93\n 112\n Other labs: PT / PTT / INR:20.4/83.3/1.9, Ca++:8.7 mg/dL, Mg++:1.5\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n Assessment and Plan\n This is a 62 yo male with ESLD recently admitted with R chest wall\n hematoma s/p two IR embolizations who presents with recurrent right\n groin sheath site.\n # Right Groin Bleeding: Ongoing bleeding this AM. Will give more FFP.\n If bleeding more stable later in the day, may be able to send to the\n floor\n .\n # Right Chest/Back Hematoma: Stable by CT\n #Blood Loss Anemia: 3 total units pRBCs, 3 FFP total over last day\n .\n # Hypotension: Blood pressure stable\n .\n # ARF: Resolved\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:07 AM\n 20 Gauge - 10:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 593145,
"text": "Mr. is a 62 yo male with h/o ETOH cirrhosis, ESLD, Coagulopathy\n ESLD with recent prolonged hospitalization for right\n axillary hematoma requiring IR embolization x 2 and significant blood\n product recusitation (31 units PRBCs, 31 units FFP, 3 units cryo) who\n presents with recurrent bleeding from right groin, site of arterial\n sheath. Pt reports no bleeding from site since discharge on . He\n noticed R groin bleeding that began at 8pm ..\n Pt. received total of 3 units PRBC, 2 units FFP in SICU .\n Coagulopathy\n Assessment:\n Patient continues to have bleeding from groin site. DSD saturated x 3\n throughout day, site continuously oozes. HCT 26.7 after last unit of\n PRBC overnight. INR 1.9. Patient c/o dull mild pain in back 3 out of\n 10 where previous hematoma was, CT done did not show any bleeding\n in chest cavity per MICU team. Vitals stable SBP > 100 throughout day.\n Action:\n MICU team in to assess groin site after complete saturation of DSD,\n Given 2 units FFP,\n Pressure held on groin site after saturation of pad, aminocaprioc acid\n applied to site per hematology, figure eight pressure dressing applied\n to site.\n Response:\n HCT stable at 26.8,\n Not complaining of any pain.\n Plan:\n Continue to monitor, transfer to floor when bed available.\n"
},
{
"category": "Nursing",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 593081,
"text": "Mr. is a 62 yo male with h/o ETOH cirrhosis, ESLD, Coagulopathy\n ESLD with recent prolonged hospitalization for right\n axillary hematoma requiring IR embolization x 2 and significant blood\n product recusitation (31 units PRBCs, 31 units FFP, 3 units cryo) who\n presents with recurrent bleeding from right groin, site of arterial\n sheath. Pt reports no bleeding from site since discharge on . He\n noticed R groin bleeding that began at 8pm ..\n 24 Hour Events:\n -9p: pt received 1Uprbc in ED, 1Uprbc on floor, also rec'd 2uffp\n hcts remained stable, no sig bump.... So, gave 1 addl unit and will\n recheck hct in the am\n -bleeding from groin site this am ~150cc\n Coagulopathy\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2149-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 592988,
"text": "Chief Complaint: Mr. is a 62 yo male with h/o ETOH cirrhosis,\n ESLD, Coagulopathy ESLD with recent prolonged hospitalization\n for right axillary hematoma requiring IR embolization x 2 and\n significant blood product recusitation (31 units PRBCs, 31 units FFP, 3\n units cryo) who presents with recurrent bleeding from right groin, site\n of arterial sheath. Pt reports no bleeding from site since discharge on\n . He noticed R groin bleeding that began at 8pm last night.\n 24 Hour Events:\n -9p: pt received 1Uprbc in ED, 1Uprbc on floor, also rec'd 2uffp\n hcts remained stable, no sig bump.... So, gave 1 addl unit and will\n recheck hct in the am\n -bleeding from groin site this am ~150cc\n Allergies:\n Codeine\n Rash;\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 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.8\nC (98.3\n HR: 73 (56 - 73) bpm\n BP: 114/58(72) {81/25(40) - 114/62(74)} mmHg\n RR: 18 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90 kg (admission): 87.3 kg\n Total In:\n 4,217 mL\n 811 mL\n PO:\n 760 mL\n 480 mL\n TF:\n IVF:\n 2,188 mL\n 331 mL\n Blood products:\n 1,269 mL\n Total out:\n 1,250 mL\n 1,300 mL\n Urine:\n 350 mL\n 400 mL\n NG:\n Stool:\n 900 mL\n 900 mL\n Drains:\n Balance:\n 2,967 mL\n -489 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\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 104 K/uL\n 8.9 g/dL\n 112 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 3.5 mEq/L\n 26 mg/dL\n 105 mEq/L\n 134 mEq/L\n 26.7 %\n 6.7 K/uL\n [image002.jpg]\n 11:43 AM\n 04:10 PM\n 07:45 PM\n 09:24 PM\n 02:21 AM\n 05:30 AM\n WBC\n 6.7\n Hct\n 25.0\n 23.4\n 22.5\n 26.6\n 26.8\n 26.7\n Plt\n 104\n Cr\n 1.0\n 0.9\n Glucose\n 93\n 112\n Other labs: PT / PTT / INR:20.4/83.3/1.9, Ca++:8.7 mg/dL, Mg++:1.5\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n COAGULOPATHY\n Assessment and Plan:\n This is a 62 yo male with ESLD recently admitted with R chest wall\n hematoma s/p two IR embolizations who presents with recurrent right\n groin sheath site.\n .\n .\n # Right Groin Bleeding: Continues to have very slow ooze. Hct has\n remained stable around 24 which is down from 29 at DC on . Renal\n U/S neg for pseudoaneurysm. Silver nitrate applied to groin site\n yesterday, however, surgery recommended do not do this again.\n - appreciate vascular recs\n -rec'd 3UPRBCs and 2UFFP yesterday, c minimal ooze until this am when\n had bleed of 150cc. recheck hct 26 from 26.\n -goal hct >26-28\n -aminocaproic acid\n -2 more units FFP today\n -HCT checks Q8 today\n .\n # Right Chest/Back Hematoma: Pt reports that non-painfull fullness\n along R flank and scapula increased from discharge. Possible that he\n has begun re-bleeding into this space.\n - CT chest showed no interval change\n .\n # Hypotension: Pt hypotensive to 70's on admission which has improved\n to 100's after 1 unit PRBC's. Likely this was hypovolemia in\n setting of groin bleed and possible R chest bleeding. Afebrile, w/out\n evidence of infection.\n - cont monitor Hct and transfuse with PRBC's as needed\n - holding diuretics: spironolactone and furosemide\n .\n # ARF: Likely hypovolemic leading to pre-renal physiology.\n - resolved am Cr 0.9\n .\n # ESLD: LFTs stable. Patient scheduled for transplant w/u at in\n few wks.\n - hold furosemide given unstable pressures, start spironolactone today\n at lower dose.\n - cont lactulose.\n .\n # FEN: IVF, replete electrolytes, HH diet\n .\n # Prophylaxis: boots\n .\n # Access: peripherals\n .\n # Code: FULL\n .\n # Communication: Patient\n .\n # Disposition: pending above - potentially to floor today if he\n remains stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:07 AM\n 20 Gauge - 10:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: full code\n Disposition: transfer to floor if stable\n"
},
{
"category": "ECG",
"chartdate": "2149-09-11 00:00:00.000",
"description": "Report",
"row_id": 259666,
"text": "Sinus rhythm. Left atrial abnormality. Non-specific inferior ST-T wave change.\nCompared to the previous tracing of no diagnostic interim change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-09-11 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 1096208,
"text": " 2:16 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: ? PSEUDOANEURYSM, BLEEDING FROM CATH SITE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with recent vascular access in Right fem artery, wound with\n poor healing since. Tonight with bleeding from said wound, now stopped.\n Concern for underlying pseudoaneurysm, other malformation.\n REASON FOR THIS EXAMINATION:\n ?pseudoaneurysm\n ______________________________________________________________________________\n WET READ: 2:35 AM\n No pseudoaneurysm. Normal.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with recent vascular access in the right femoral\n artery, poor wound healing, earlier in the evening had bleed from wound.\n Concern for pseudoaneurysm.\n\n COMPARISON: None available in the PACS.\n\n RIGHT INGUINAL ULTRASOUND: The right common femoral vein and common femoral\n artery are identified with normal color-flow and Doppler waveforms. There is\n no evidence of pseudoaneurysm or large groin hematoma.\n\n IMPRESSION: No evidence of pseudoaneurysm.\n\n Findings posted to the ED dashboard.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-09-11 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1096351,
"text": " 4:34 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please assess for interval change in R chest hematoma\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with ESLD, severe coagulopathy recent admision for large right\n chest wall hematoma requiring embolization x 2. P/W right groin bleed but also\n reporting new fullness in right scapular region.\n REASON FOR THIS EXAMINATION:\n please assess for interval change in R chest hematoma\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n WET READ: 5:41 PM\n Large right chest wall hematoma appears to be little changed from . No\n active extravasation. Right pleural effusion stable. New small left sided\n pleural effusion. Large amount of ascites stable.\n ______________________________________________________________________________\n FINAL REPORT\n COMPUTED TOMOGRAPHY OF THE THORAX\n\n INDICATION: Severe coagulopathy, recent admission for large right chest wall\n hematoma requiring embolizations. Right groin bleed. New fullness in right\n scapular region. Assessment for interval changes.\n\n TECHNIQUE: CTPA protocol with Volumetric CT acquisitions in inspiration\n without contrast material and Volumetric CT acquisitions in shallow\n inspiration with contrast material. Multiplanar reconstructions.\n\n COMPARISON: .\n\n FINDINGS: Given that the examination was focused on the pulmonary arteries,\n the pre-existing large right chest wall hematoma is not entirely imaged on\n today's examination. The right-sided pleural effusion is stable. There is no\n evidence of active extravasation, as manifested by pathologic contrast\n accumulation. Newly occurred left-sided pleural effusion. Unchanged large\n size.\n\n Unchanged mild dilatation of the pulmonary arteries, unchanged coronary\n calcifications. In the lung parenchyma, there is unchanged evidence of a\n small right basilar atelectasis as a consequence of the right pleural\n effusion. A small right perifissural nodule (5, 41) is unchanged. Also\n unchanged is the moderate cardiomegaly.\n\n There is no evidence of newly appeared focal parenchymal opacities suggesting\n pneumonia. No signs indicative of overhydration\n 1. No evidence of active bleeding, the right chest wall hematoma is unchanged\n in size.\n\n 2. Two small newly occurred left-sided pleural effusion.\n\n 3. Unchanged right-sided pleural effusion. Unchanged right, atelectasis and\n (Over)\n\n 4:34 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please assess for interval change in R chest hematoma\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n small perifissural right lower lobe nodule.\n\n 4. No other relevant changes.\n\n\n"
}
] |
30,285 | 168,147 | Patient admitted from an outside hospital with 4 days now w/ LGIB. Has undergone tagged rbc scan, c-scope x 2 and got a total of 13U of blood over 4 days. He has per report been fairly hemodynamically stable throughout with lowest sbp in the 90s, mentating and not tachycardic. His bleeding has been intermittent, stopping, and therefore no bleeding ever seen on c-scope, just some old cauterized avms. tagged scan per report shows ? localiztion in right colon . . On he underwent a Subtotal colectomy with ileal rectal anastomosis. He tolerated the procedure well and went to the intensive care unit postoperatively. On he ruled in for a myocardial infarction with positive troponins. Cardiology was consulted and echo was done. . Studies: Echo (): Suboptimal image quality. LV systolic dysfunction c/w multivessel CAD (LVEF 50%). Mild-moderate AR. Mild MR. Moderate TR. He was transferred to the floor and slowly progressed to a soft diet. He was transfused one unit of packed cells per cardiology and restarted on asa as well as a beta blocker. He will be transferred to a rehab facility to help him regain his prior level of functioning with follow up with his primary care and his surgeon Dr. . | Chief complaint: LGIB PMHx: CAD, MIx2, CHF, CVA, prostate CA Current medications: 1. Chief complaint: LGIB PMHx: CAD, MIx2, CHF, CVA, prostate CA Current medications: 1. Edema, peripheral Assessment: X4 Ext pitting edema. ------ Protected Section ------ S/P colonectomy . AVMs were cauterized. AVMs were cauterized. Plan: Continue with morphine PCA. Plan: Continue with morphine PCA. Bleeding resumed and pt tx to . Bleeding resumed and pt tx to . Bleeding resumed and pt tx to . Bleeding resumed and pt tx to . This has been evaluated at with colonoscopy x2 (initial prep=poor) and TRBC scan. Action: Morphine ivp given and started PCA. Action: Morphine ivp given and started PCA. - continue atorvastatin, zetia - hold BB, lasix, isosorbide mononitrate - hold aspirin - transfuse to keep Hct > 30 given CAD and active bleed - check EKG . Hct at 1am down from 31 to 27.2, Action: Check with team re: transfusion Response: Pt hemodynamically stable Plan: Cont to follw hcts and assess output as ordered The AVMs were cauteraized. The AVMs were cauteraized. CC: GI Bleed Patient has had evolution if significant passage of hematochezia. Action: Pt s/p colonectomy. Action: Pt s/p colonectomy. .H/O coronary artery disease (CAD, ischemic heart disease) Assessment: Tropinin elvevated 1.07. .H/O coronary artery disease (CAD, ischemic heart disease) Assessment: Tropinin elvevated 1.07. Peripheral edema increasing, UOP reduced, usually takes Lasix. - tagged RBC scan negative here but localized to ascending colon at OSH. - tagged RBC scan negative here but localized to ascending colon at OSH. patient to be placed on standing dose of Lasix r/t hx. Holding aspirin and metoprolol given bleeding. Holding aspirin and metoprolol given bleeding. + tropinin on with new onset on ST depression second to decreased anemia and decreased BP ------ Protected Section Addendum Entered By: , RN on: 08:20 PM ------ ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 12:00 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Metoprolol Tartrate 7.5 mg IV Q4H hold for sbp<100, hr<60 Order date: @ 2145 4. PPx: pneumoboots. HPI: 85yM with CAD MIx2, CVA, prostate CA presented to OSH with painless rectal bleeding . Mild[1+] mitral regurgitation is seen. LINE PLACEMENT Clip # Reason: CHECK LINE PLACEMENT Admitting Diagnosis: LOWER GI BLEED FINAL REPORT CHEST, SINGLE VIEW. There is mildregional left ventricular systolic dysfunction with focal hypokinesis of themid inferolateral and distal inferior walls. Regional left ventricular systolicdysfunction c/w multivessel CAD. Anterolateral ST segment depressions suggest myocardial ischemia.Early transition. The AVMs were cauteraized. FINAL REPORT TYPE OF EXAMINATION: Chest PA and lateral. Comparison of the pulmonary vasculature suggests that a previously existing congestion previously described right internal jugular vein approach central venous line remains. Pt taken to OR for total colectomy, now extubated. Pt taken to OR for total colectomy, now extubated. Moderate [2+] tricuspid regurgitation isseen. Noresting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: midinferolateral - hypo; mid anterolateral - hypo; inferior apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mildly thickened aortic valve leaflets. Myocardial infarction.Height: (in) 70Weight (lb): 203BSA (m2): 2.10 m2BP (mm Hg): 120/61HR (bpm): 70Status: InpatientDate/Time: at 13:05Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Peripheral edema increasing, UOP reduced, usually takes Lasix. Bleeding resumed and pt tx to . There is mildsymmetric left ventricular hypertrophy with normal cavity size. If tolerated without hyperglycemia, adv to Day 2 standard TPN. If tolerated without hyperglycemia, adv to Day 2 standard TPN. Available for comparison is a preceding AP single view chest examination of . At least mild-moderate aortic regurgitation.Mild mitral regurgitation. At least mild to moderate (+) aorticregurgitation is seen. Sinus rhythm with borderline first degree A-V block. Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: VSS; HR 70s; BP 1-teens/70s; MAPs 80s. - continue atorvastatin, zetia - hold BB, lasix, isosorbide mononitrate - hold aspirin - transfuse to keep Hct > 30 given CAD and active bleed - check EKG . - continue atorvastatin, zetia - hold BB, lasix, isosorbide mononitrate - hold aspirin - transfuse to keep Hct > 30 given CAD and active bleed - check EKG . PPx: pneumoboots. PPx: pneumoboots. PPx: pneumoboots. ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: | 32 | [
{
"category": "General",
"chartdate": "2119-10-21 00:00:00.000",
"description": "ICU Event Note",
"row_id": 340294,
"text": "Clinician: Attending\n Patient transfer from .\n CC: GI Bleed\n Patient has had evolution if significant passage of hematochezia. This\n has been evaluated at with colonoscopy x2 (initial\n prep=poor) and TRBC scan. Suggestion was of possible source in right\n colon but with inability to perform angio patient now transfer to \n for further care.\n He, upon arrival-->\n Has complaint of thirst\n P=84, BP=116/69\n Patient comfortable, says \"they sent me here to fix this\"\n ABD: no tenderness, no rebound, hyperactive bowel sounds appreciated.\n Neck-_Right sided CVL in place.\n Mr. is an 85 yo male admit with GI Bleed with likely lower\n source. He had had 2 BM's since arrival suggesting significant ongoing\n bleeding. He does have background CAD and was on anti-platelet agents\n which may have been contributing but they have been D/C'd and DDAVP\n given.\n -Maintain CVL access--will need to change OSH line within 24 hours\n -Will repeat TRBC scan given ongoing bleeing and only documentation OSH\n on \n -Will consult GI and Surgery for aid in evaluation and decision making\n in light of testing results\n -HCT q 4 hours\n - need to consider angio as intervention if localization provided on\n TRBC scan and bleeding continued.\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340554,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning and groaning. Pt c/o cramping in abdominal area.\n Action:\n Morphine ivp given and started PCA.\n Response:\n Pt settled. Pt stated pain is decreased from 12 to 10. Pt appears more\n relaxed.\n Plan:\n Continue with morphine PCA.\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Tropinin elvevated 1.07. Increased CK 171. Pt denies chest pain or\n shortness of breath. EKG showing ST depression V3-5. MD aware.\n Action:\n EKG completed. Cardiology paged and made aware.\n Response:\n Pt chest pain free.\n Plan:\n Monitor tropinin and CK. Cardiology to follow up.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt passing bloody clots.\n Action:\n Pt s/p colonectomy. Monitor for further bleeding. HCT stable.\n Response:\n Pt remains hemodynamically stable. No further bleeding noted.\n Plan:\n Monitor HCT and stools.\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340557,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning and groaning. Pt c/o cramping in abdominal area.\n Action:\n Morphine ivp given and started PCA.\n Response:\n Pt settled. Pt stated pain is decreased from 12 to 10. Pt appears more\n relaxed.\n Plan:\n Continue with morphine PCA.\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Tropinin elvevated 1.07. Increased CK 171. Pt denies chest pain or\n shortness of breath. EKG showing ST depression V3-5. MD aware.\n Action:\n EKG completed. Cardiology paged and made aware.\n Response:\n Pt chest pain free.\n Plan:\n Monitor tropinin and CK. Cardiology to follow up.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt passing bloody clots.\n Action:\n Pt s/p colonectomy. Monitor for further bleeding. HCT stable.\n Response:\n Pt remains hemodynamically stable. No further bleeding noted.\n Plan:\n Monitor HCT and stools.\n ------ Protected Section ------\n S/P colonectomy . Pt originally admitted from presented with dark stools on . Pt on aspirin and\n aggrenox at home. Colonoscopy at showing lower\n gi bleed in ascending colon. Received total of 13 units of blood prior\n to BIMDC admission. + tropinin on with new onset on ST depression\n second to decreased anemia and decreased BP\n ------ Protected Section Addendum Entered By: , RN\n on: 08:20 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340563,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt sleeping unless stimulated, arouses easily to voice and reports that\n he is having pain in his belly when he is breathing, also c/o pain with\n turning yet dozes right back off to sleep when done moving. Pt had\n been having brief periods of apnea at the beginning of the shift yet no\n desaturation, has used PCA button once with prompting when pt being\n turned for total dose of 1mg morphine for the evening as he had been\n too somulent earlier after higher doses of morphine.\n Action:\n Pt moved very slowly with lots of encouragement and abdominal pad for\n splinting reserving morphine for larger activity\n Response:\n Pt less apnic as shift progresses, doing well with encouragement\n Plan:\n Con\nt to monitor pain and sedation levels closely, try non\n pharmalogical interventions first secondary to pt\ns age and sensitivity\n to narcotics, address decreasing PCA dose with team if somulence\n increased\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt denies chest pain, EKG unchanged from earlier, repeat troponin level\n pnd\n Action:\n Cardiology in to see pt secondary to troponin bump, had also been\n elevated on at OSH, recommend serial troponins and keeping Hct >\n 30, and increasing dose of lopressor\n Response:\n Pt con\nt asymptomatic, tolerating increased dose of IVP lopressor\n 7.5mg\n Plan:\n Con\nt to monitor closely, follow troponin levels, check with team re:\n transfusion if hct less than 30\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt incision with primary dsg yet dsg is stained w/ serosanguinous\n drainage, pt with 2 episodes of dark blood from rectum earlier this\n evening yet none since. Hct at 1am down from 31 to 27.2,\n Action:\n Check with team re: transfusion\n Response:\n Pt hemodynamically stable\n Plan:\n Con\nt to follw hcts and assess output as ordered\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340783,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain at abdomen incisional pain.\n Action:\n 50mcg Fentanyl Q 2. Patient taught splinting techniques to protect\n incision with mvt and coughing.\n Response:\n Pt reports adequate pain relief, able to cough and deep breathe, able\n to move/shift in bed.\n Plan:\n Cont current pain regime. Cont to enc pt to cough, deep breathe and\n move as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340320,
"text": "Chief Complaint: GI bleed\n HPI:\n Mr. is an 85 yo male with CAD s/p MI, CVA, h/o prostate cancer,\n congestive heart failure, admitted to on with rectal\n bleeding. He was found to be hypotensive to 70s systolic but improved\n with fluids and PRBCs and so was monitored in the ICU. Patient was on\n aspirin and aggrenox at home, so he was given DDAVP. He then got a\n tagged RBC scan which showed bleeding from right side of colon. He got\n two colonoscopies which revealed right sided AVMs but no active\n bleeding. The AVMs were cauteraized. His GI bleeding temporarily\n stopped but then resumed earlier today prior to trasnfer. His initial\n Hct was 31 on . He was transfused 9 units by when a repeat\n colonoscopy was performed which showed no bleeding from cauterized\n ulcers (from AVMs) and diverticula in the right colon. In total, he was\n transfused 13 units during his hospital stay.\n .\n On arrival to , patient reports ongoing BRBPR. He denies chest\n pain, shortness of breath, abdominal pain, fevers, chills, hematemasis,\n or any other concerning symptoms.\n Patient admitted from: Transfer from other hospital, \n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Aggrenox 25-5200 \n Atorvastatin 40 mg daily\n Progcrit 40,000 units SQ q 3 weeks\n Zetia 10 mg daily\n Flonase 2 puff daily\n Lasix 40 mg daily\n Zoladex\n Isosorbide mononitrate 30 mg daily\n Metoprolol Tartrate 50 mg daily\n Nitroglycerin PRN\n .\n Past medical history:\n Family history:\n Social History:\n Myocardial infarction\n CVA\n CAD\n prostate CA s/p prostatectomy and XRT)\n CHF\n Hyperlipidemia\n HTN\n noncontributory\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: Patient is married and lives at home with wife. denies\n tobacco or alcohol use.\n Review of systems:\n Constitutional: Fatigue, Fever, Weight loss\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis\n Cardiovascular: Chest pain, Palpitations\n Respiratory: Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis\n Genitourinary: Dysuria\n Neurologic: Numbness / tingling\n Flowsheet Data as of 03:22 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.3\n HR: 81 (81 - 89) bpm\n BP: 107/70(79) {98/64(74) - 125/78(87)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 170 mL\n Urine:\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -170 mL\n Respiratory\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal, No(t) Absent), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 106 K/uL\n 11.7 g/dL\n 128 mg/dL\n 0.9 mg/dL\n 13 mg/dL\n 23 mEq/L\n 115 mEq/L\n 3.9 mEq/L\n 142 mEq/L\n 31.9 %\n 9.4 K/uL\n [image002.jpg]\n \n 2:33 A9/6/ 12:24 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.4\n Hct\n 31.9\n Plt\n 106\n Cr\n 0.9\n Glucose\n 128\n Other labs: PT / PTT / INR:14.5/32.9/1.3, ALT / AST:17/39, Alk Phos / T\n Bili:37/1.2, Differential-Neuts:74.5 %, Lymph:17.9 %, Mono:5.7 %,\n Eos:1.6 %, Albumin:2.4 g/dL, LDH:270 IU/L, Ca++:7.6 mg/dL, Mg++:1.7\n mg/dL, PO4:2.8 mg/dL\n Imaging: Imaging:\n Colonoscopy .\n No active GI bleeding, but bleed could have been from AVMs vs.\n Diverticulosis. AVMs were suspected source due to location.\n .\n Tagged RBC scan. .\n Positive bleeding study with apparent origin of bleed in the ascending\n colon, near the hepatic flecture. Redunant transverse colon.\n .\n . Colonoscopy.\n No active bleeding seen. Possibly due to divericulsosis versus\n proximal to ileocecal valve.\n .\n Microbiology: None\n Assessment and Plan\n A/P: Mr. is an 85 yo male with CAD s/p MI, CVA, now with lower GI\n bleed for 4 days requiring 13 units of PRBCs.\n .\n 1. GI bleed. Patient admitted with ongoing lower GI bleed. Initial\n bleeding scan at OSH on revealed right sided bleeding, however\n colonoscopy x 2 failed to identify source of bleeding but there was\n concern for AVMs versus divertular bleed versus bleed proximal to the\n ileocecal valve. Currenly hemodynamically stable with ongoing\n bleeding. Will pursue tagged RBC today and then proceed to angiography\n versus surgery.\n - serial Hcts (q4 hours)\n - right IJ from OSH --> will need to replace in AM\n - type and cross 2 units\n - tagged RBCs today\n - Surgery consult given extent of bleed\n - GI consult\n - IV PPI , though less likely to be upper bleed\n .\n 2. CAD. Patient has history of CAD with EF of 45%. Cardiac cath in\n showed 3 vessel disease. No history of stents per patient. On\n Aspirin, lasix, atorvastatin, zetia, and metoprolol at home. However,\n given extensive bleed, will avoid antiplatelet therapy and\n antihypertesnives. Got DDAVP at OSH.\n - continue atorvastatin, zetia\n - hold BB, lasix, isosorbide mononitrate\n - hold aspirin\n - transfuse to keep Hct > 30 given CAD and active bleed\n - check EKG\n .\n 3. H/o stroke. Patient has history of CVA. However, given\n significant and prolonged bleed, will hold aggrenox.\n - hold agrenox\n .\n 4. FEN: IVF @ 150cc/hour, NPO for now.\n .\n 5. PPx: pneumoboots.\n .\n 6. FULL CODE, confirmed with patient.\n .\n Communication: patient\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340685,
"text": "SICU\n HPI:\n 85yM with CAD MIx2, CVA, prostate CA presented to OSH with painless\n rectal bleeding . Transfused 13 units PRBC at OSH, received 2\n c-scopes with evid of right sided AVMs but no active bleeding, tag scan\n showed right sided bleeding. Bleeding resumed and pt tx to . On\n MICU service but continued to bleed so taken to OR for total colectomy\n with ileorectal anastomosis.\n Chief complaint:\n LGIB\n PMHx:\n CAD, MIx2, CHF, CVA, prostate CA\n Current medications:\n 1. 1000 mL D5LR 2. 1000 mL NS 3. Calcium Gluconate 4. Fentanyl Citrate\n 5. Heparin 6. Insulin 7. Magnesium Sulfate\n 8. Metoprolol Tartrate 9. Ondansetron 10. Pantoprazole 11. Potassium\n Chloride\n 24 Hour Events:\n Transferred from SICU, s/p ileorectal anastomsis\n Post operative day:\n POD#1 - Colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:15 PM\n Pantoprazole (Protonix) - 08:14 AM\n Metoprolol - 10:00 AM\n Fentanyl - 10:00 AM\n Other medications:\n Flowsheet Data as of 11:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.2\nC (98.9\n HR: 83 (76 - 98) bpm\n BP: 125/66(87) {98/56(71) - 176/98(127)} mmHg\n RR: 17 (14 - 39) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 6 (3 - 8) mmHg\n Total In:\n 5,489 mL\n 3,147 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,811 mL\n 2,397 mL\n Blood products:\n 2,678 mL\n 750 mL\n Total out:\n 955 mL\n 489 mL\n Urine:\n 570 mL\n 439 mL\n NG:\n 50 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 4,534 mL\n 2,658 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: 7.34/34/162/19/-6\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Tender: appropriately\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands\n Labs / Radiology\n 118 K/uL\n 9.9 g/dL\n 133 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 14 mg/dL\n 116 mEq/L\n 141 mEq/L\n 32.9 %\n 13.3 K/uL\n [image002.jpg]\n 12:24 AM\n 05:51 AM\n 01:00 PM\n 02:04 PM\n 03:06 PM\n 04:46 PM\n 01:00 AM\n 07:40 AM\n WBC\n 9.4\n 8.2\n 8.4\n 13.3\n Hct\n 31.9\n 29.2\n 32\n 35\n 33\n 30.1\n 27.2\n 32.9\n Plt\n 106\n 112\n 125\n 118\n Creatinine\n 0.9\n 0.9\n 0.7\n 0.9\n Troponin T\n 1.02\n 1.18\n 0.64\n TCO2\n 23\n 20\n 19\n Glucose\n 128\n 115\n 109\n 143\n 125\n 160\n 133\n Other labs: PT / PTT / INR:13.8/29.9/1.2, CK / CK-MB / Troponin\n T:496/15/0.64, ALT / AST:17/39, Alk-Phos / T bili:37/1.2,\n Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %, Eos:1.2 %, Lactic\n Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:270 IU/L, Ca:7.7 mg/dL, Mg:2.4\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 85 year old male with LGIB s/p colectomy,\n complicated by NSTEMI perioperatively\n Neurologic: fentanyl prn pain\n Cardiovascular: , Pt with NSTEMI, cards consult\n appreciated, Goal HCT >30, Beta-blockade- Rate contol. Restart ASA.\n Pulmonary: Patient breathing spontaneously\n Gastrointestinal / Abdomen: s/p colectomy, NPO for now, NGT with\n minimal output, will flush output\n Nutrition: NPO\n Renal: Foley, Patient with boderline urine output, will check CVP, then\n given albumin if low\n Hematology: Serial Hct, follow CBC q6\n Endocrine: RISS\n Infectious Disease: no active ID issues\n Lines / Tubes / Drains: Foley, NGT\n Wounds: Dry dressings\n Imaging:\n Fluids: LR, change TO LR\n Consults: General surgery\n Billing Diagnosis: Acute MI / Ischemia\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent 30 minutes:\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340435,
"text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yo male admitted to on with BRBPR. Initial Hct there\n 31, transfused, hemodynamically stable. Got tagged RBC scan there\n which showed bleeding localized to ascending colon. Colonoscopy showed\n several R-sided AVMs and scattered diverticuli, no active bleeding.\n AVMs were cauterized. Bleeding appears to have stopped temporarily\n after that, but then he rebled. Got repeat colonoscopy which showed\n cauterized ulcers, not bleeding. Received 13U PRBCs total while there,\n transferred here for possible surgery.\n 24 Hour Events:\n MULTI LUMEN - START 12:00 AM\n NUCLEAR MEDICINE - At 06:31 AM\n Red Tag Study: negative\n Bled around 500 cc overnight. Hasn't bled since he returned from RBC\n scan. Hct 31->29.\n Evaluated by Surgery who felt that he may require surgery given amount\n of blood he required at OSH.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:34 AM\n Other medications:\n lipitor 40 daily, zetia 10 mg daily\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: BRBPR\n Flowsheet Data as of 09:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.2\n HR: 89 (70 - 89) bpm\n BP: 111/76(83) {98/64(74) - 139/112(118)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 900 mL\n PO:\n TF:\n IVF:\n 900 mL\n Blood products:\n Total out:\n 0 mL\n 340 mL\n Urine:\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 560 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 112 K/uL\n 115 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.2 %\n 8.2 K/uL\n [image002.jpg]\n 12:24 AM\n 05:51 AM\n WBC\n 9.4\n 8.2\n Hct\n 31.9\n 29.2\n Plt\n 106\n 112\n Cr\n 0.9\n 0.9\n Glucose\n 128\n 115\n Other labs: PT / PTT / INR:14.5/32.9/1.3, ALT / AST:17/39, Alk Phos / T\n Bili:37/1.2, Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %,\n Eos:1.2 %, Albumin:2.4 g/dL, LDH:270 IU/L, Ca++:7.4 mg/dL, Mg++:1.7\n mg/dL, PO4:2.9 mg/dL\n Imaging: CXR pending\n Assessment and Plan\n A/P: 85 y/o M w/MMP admitted with a lower GI bleed requiring 13 units\n of blood, with tagged RBC from OSH suggesting bleeding is from\n ascending colon. Currently just had another bloody BM so appears to be\n still bleeding.\n 1. GI bleed: Continuing to bleed despite cauterization of AVMs,\n suggesting that bleed is from another source, ? diverticuli.\n - transfuse 2 units PRBCs now, crossmatch additional 2 units\n - GI and Surgery following. Will discuss with Surgery whether they\n want to go to the OR versus angio vs continuing supportive care\n w/transfusions.\n - tagged RBC scan negative here but localized to ascending colon at\n OSH.\n - check Hct q4h\n - will change CVL\n 2. Hx CAD: had cath here with 3VD and EF 45%, underwent POBA. Has\n not had an intervention. Holding aspirin and metoprolol given\n bleeding.\n - No active chest pain\n - Cardiology consult for potential preoperative evaluation\n - cont statin & zetia\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340413,
"text": "Mr. is an 85 yo male with CAD s/p MI, CVA, h/o prostate cancer,\n congestive heart failure, admitted to on with rectal\n bleeding. He was found to be hypotensive to 70s systolic but improved\n with fluids and PRBCs and so was monitored in the ICU. Patient was on\n aspirin and aggrenox at home, so he was given DDAVP. He then got a\n tagged RBC scan which showed bleeding from right side of colon. He got\n two colonoscopies which revealed right sided AVMs but no active\n bleeding. The AVMs were cauteraized. His GI bleeding temporarily\n stopped but then resumed earlier today prior to trasnfer. His initial\n Hct was 31 on . He was transfused 9 units by when a repeat\n colonoscopy was performed which showed no bleeding from cauterized\n ulcers (from AVMs) and diverticula in the right colon. In total, he was\n transfused 13 units during his hospital stay.\n On arrival to , patient reports ongoing BRBPR. He denies chest\n pain, shortness of breath, abdominal pain, fevers, chills, hematemasis,\n or any other concerning symptoms.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n VSS; HR 70s; BP 1-teens/70s; MAPs 80s. BRBPR x 3..small to moderate\n (bedpan) with clots between admission (midnight) and 2am. Pt to\n Nuclear Med at 0300: Small BRBPR on pad\n Action:\n IVF &S sent; Two Hcts drawn\n Response:\n VSS; Last Hct 29.1 down from 30\n Plan:\n Serial Hcts; Possible Colonoscopy; Possible surgery.\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340493,
"text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yo male admitted to on with BRBPR. Initial Hct there\n 31, transfused, hemodynamically stable. Got tagged RBC scan there\n which showed bleeding localized to ascending colon. Colonoscopy showed\n several R-sided AVMs and scattered diverticuli, no active bleeding.\n AVMs were cauterized. Bleeding appears to have stopped temporarily\n after that, but then he rebled. Got repeat colonoscopy which showed\n cauterized ulcers, not bleeding. Received 13U PRBCs total while there,\n transferred here for possible surgery.\n 24 Hour Events:\n MULTI LUMEN - START 12:00 AM\n NUCLEAR MEDICINE - At 06:31 AM\n Red Tag Study: negative\n Bled around 500 cc overnight. Hasn't bled since he returned from RBC\n scan. Hct 31->29.\n Evaluated by Surgery who felt that he may require surgery given amount\n of blood he required at OSH.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:34 AM\n Other medications:\n lipitor 40 daily, zetia 10 mg daily\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: BRBPR\n Flowsheet Data as of 09:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.2\n HR: 89 (70 - 89) bpm\n BP: 111/76(83) {98/64(74) - 139/112(118)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 900 mL\n PO:\n TF:\n IVF:\n 900 mL\n Blood products:\n Total out:\n 0 mL\n 340 mL\n Urine:\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 560 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 112 K/uL\n 115 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.2 %\n 8.2 K/uL\n [image002.jpg]\n 12:24 AM\n 05:51 AM\n WBC\n 9.4\n 8.2\n Hct\n 31.9\n 29.2\n Plt\n 106\n 112\n Cr\n 0.9\n 0.9\n Glucose\n 128\n 115\n Other labs: PT / PTT / INR:14.5/32.9/1.3, ALT / AST:17/39, Alk Phos / T\n Bili:37/1.2, Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %,\n Eos:1.2 %, Albumin:2.4 g/dL, LDH:270 IU/L, Ca++:7.4 mg/dL, Mg++:1.7\n mg/dL, PO4:2.9 mg/dL\n Imaging: CXR pending\n Assessment and Plan\n A/P: 85 y/o M w/MMP admitted with a lower GI bleed requiring 13 units\n of blood, with tagged RBC from OSH suggesting bleeding is from\n ascending colon. Currently just had another bloody BM so appears to be\n still bleeding.\n 1. GI bleed: Continuing to bleed despite cauterization of AVMs,\n suggesting that bleed is from another source, ? diverticuli.\n - transfuse 2 units PRBCs now, crossmatch additional 2 units\n - GI and Surgery following. Will discuss with Surgery whether they\n want to go to the OR versus angio vs continuing supportive care\n w/transfusions.\n - tagged RBC scan negative here but localized to ascending colon at\n OSH.\n - check Hct q4h\n - will change CVL\n 2. Hx CAD: had cath here with 3VD and EF 45%, underwent POBA. Has\n not had an intervention. Holding aspirin and metoprolol given\n bleeding.\n - No active chest pain\n - Cardiology consult for potential preoperative evaluation\n - cont statin & zetia\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341101,
"text": "Edema, peripheral\n Assessment:\n X4 Ext pitting edema. Low urine output, <30cc/hr. Urine concentrated.\n Action:\n Alerted SICU Resident . Requested Lasix. Lasix 10mg IVP.\n Response:\n Urine output increased, urine yellow.\n Plan:\n ? patient to be placed on standing dose of Lasix r/t hx. of CHF and on\n Lasix at home.\n Hypokalemia (Low potassium, hypopotassemia)/ Multiple PVC\ns, Pacer Not\n Capturing, Pauses.\n Assessment:\n Per EKG, Labs.\n Action:\n Replete K+ as ordered via sliding scale. Reported to SICU resident\n PVCs, etc.\n Response:\n Plan:\n Continue to monitor and report to MDs.\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340890,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt stating he has incisional pain.\n Action:\n Fentanyl 50mcg/ iv given. Repositioned in bed.\n Response:\n Pain subsided. Pt sleeping.\n Plan:\n Continue to assess pain control and medicate prn\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340899,
"text": "SICU\n HPI:\n 85yM with CAD MIx2, CVA, prostate CA presented to OSH with painless\n rectal bleeding . Transfused 13 units PRBC at OSH, received 2\n c-scopes with evid of right sided AVMs but no active bleeding, tag scan\n showed right sided bleeding. Bleeding resumed and pt tx to . On\n MICU service but continued to bleed so taken to OR for total colectomy\n with ileorectal anastomosis\n Chief complaint:\n LGIB\n .\n PMHx:\n CAD, MIx2, CHF, CVA, prostate CA\n Current medications:\n 1000 mL D5LR\n Continuous at 75 ml/hr Order date: @ 1509 6. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 1617\n 2. Aspirin 325 mg PO DAILY Order date: @ 1509 7. Magnesium\n Sulfate 2 gm IV PRN Order date: @ 0053\n 3. Calcium Gluconate IV Sliding Scale Order date: @ 1617 8.\n Metoprolol Tartrate 7.5 mg IV Q4H\n hold for sbp<100, hr<60 Order date: @ 2145\n 4. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain Order date: @\n 0247 9. Pantoprazole 40 mg IV Q24H Order date: @ 1615\n 5. Heparin 5000 UNIT SC BID Start: In am Order date: @ 1849 10.\n Potassium Chloride IV Sliding Scale Order date: @ 1617\n 24 Hour Events:\n EKG - At 11:00 AM\n off vent/hemodynamically stable; no arrhythmias; troponin trending down\n Post operative day:\n POD#2 - Colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 04:00 AM\n Fentanyl - 07:02 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.1\nC (98.7\n HR: 74 (71 - 91) bpm\n BP: 126/69(91) {108/58(78) - 141/86(109)} mmHg\n RR: 26 (15 - 36) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 11 (5 - 11) mmHg\n Total In:\n 4,535 mL\n 740 mL\n PO:\n 50 mL\n Tube feeding:\n IV Fluid:\n 3,785 mL\n 690 mL\n Blood products:\n 750 mL\n Total out:\n 1,172 mL\n 530 mL\n Urine:\n 872 mL\n 430 mL\n NG:\n 300 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,363 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///22/\n Physical Examination\n Labs / Radiology\n 120 K/uL\n 10.3 g/dL\n 146 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 118 mEq/L\n 143 mEq/L\n 28.6 %\n 11.4 K/uL\n [image002.jpg]\n 12:24 AM\n 05:51 AM\n 01:00 PM\n 02:04 PM\n 03:06 PM\n 04:46 PM\n 01:00 AM\n 07:40 AM\n 10:47 PM\n 03:13 AM\n WBC\n 9.4\n 8.2\n 8.4\n 13.3\n 11.4\n Hct\n 31.9\n 29.2\n 32\n 35\n 33\n 30.1\n 27.2\n 32.9\n 28.4\n 28.6\n Plt\n 106\n 112\n 125\n 118\n 120\n Creatinine\n 0.9\n 0.9\n 0.7\n 0.9\n 0.8\n Troponin T\n 1.02\n 1.18\n 0.64\n TCO2\n 23\n 20\n 19\n Glucose\n 128\n 115\n 109\n 143\n 125\n 160\n 133\n 146\n Other labs: PT / PTT / INR:13.8/29.9/1.2, CK / CK-MB / Troponin\n T:496/15/0.64, ALT / AST:17/39, Alk-Phos / T bili:37/1.2,\n Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %, Eos:1.2 %, Lactic\n Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:270 IU/L, Ca:7.5 mg/dL, Mg:2.1\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic:\n Cardiovascular: restart aggrenox; improve beta blockade to pulse of 65,\n start heparin?\n Pulmonary: stable\n Gastrointestinal / Abdomen:\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging:\n Fluids: D5LR, 75 cc/hr\n Consults: General surgery\n Billing Diagnosis: Acute MI / Ischemia\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 min\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 341211,
"text": "HPI:\n 85yM with CAD MIx2, CVA, prostate CA presented to OSH with painless\n rectal bleeding . Transfused 13 units PRBC at OSH, received 2\n c-scopes with evidence of right sided AVMs but no active bleeding, tag\n scan showed right sided bleeding. Bleeding resumed and pt tx to .\n On MICU service but continued to bleed so taken to OR for total\n colectomy with ileorectal anastomosis.\n Chief complaint:\n LGIB\n PMHx:\n CAD, MIx2, CHF, CVA, prostate CA\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Post op day 3 of total colectomy and anastomosis, 1x episode of loose\n melena stool this shift, no evidence of active bleeding\n Action:\n Kept NPO to rest bowel\n Response:\n No further bleeding, Hct stable\n Plan:\n Monitor for further bleeding\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n NSR, paced, not always capturing so some ectopy at times. Peripheral\n edema increasing, UOP reduced, usually takes Lasix.\n Action:\n KCL repleated.\n Response:\n Pt in NSR\n Plan:\n Monitor and repleat lytes, ? start home Lasix dose\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 341163,
"text": "SICU\n HPI:\n 85yM with CAD MIx2, CVA, prostate CA presented to OSH with painless\n rectal bleeding . Transfused 13 units PRBC at OSH, received 2\n c-scopes with evid of right sided AVMs but no active bleeding, tag scan\n showed right sided bleeding. Bleeding resumed and pt tx to . On\n MICU service but continued to bleed so taken to OR for total colectomy\n with ileorectal anastomosis.\n Chief complaint:\n LGIB\n PMHx:\n CAD, MIx2, CHF, CVA, prostate CA\n Current medications:\n 1. 1000 mL D5LR 2. Aspirin 3. Calcium Gluconate 4. Dipyridamole-Aspirin\n 5. Fentanyl Citrate 6. Furosemide\n 7. Heparin 8. Insulin 9. Magnesium Sulfate 10. Metoprolol Tartrate 11.\n Pantoprazole 12. Potassium Chloride\n 24 Hour Events:\n no acute events\n Post operative day:\n POD#3 - Colectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 06:01 PM\n Furosemide (Lasix) - 12:00 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Fentanyl - 08:11 AM\n Other medications:\n Flowsheet Data as of 09:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.1\nC (98.7\n HR: 69 (62 - 81) bpm\n BP: 109/62(80) {99/51(69) - 130/70(94)} mmHg\n RR: 15 (15 - 31) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.1 kg (admission): 76.6 kg\n Height: 65 Inch\n CVP: 12 (2 - 12) mmHg\n Total In:\n 1,860 mL\n 747 mL\n PO:\n 50 mL\n Tube feeding:\n IV Fluid:\n 1,810 mL\n 747 mL\n Blood products:\n Total out:\n 952 mL\n 662 mL\n Urine:\n 852 mL\n 662 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 908 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 137 K/uL\n 9.2 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 116 mEq/L\n 143 mEq/L\n 26.0 %\n 9.3 K/uL\n [image002.jpg]\n 02:04 PM\n 03:06 PM\n 04:46 PM\n 01:00 AM\n 07:40 AM\n 10:47 PM\n 03:13 AM\n 09:17 AM\n 03:05 PM\n 03:25 AM\n WBC\n 8.4\n 13.3\n 11.4\n 9.3\n Hct\n 35\n 33\n 30.1\n 27.2\n 32.9\n 28.4\n 28.6\n 26.0\n Plt\n 125\n 118\n 120\n 137\n Creatinine\n 0.7\n 0.9\n 0.8\n 0.8\n Troponin T\n 1.02\n 1.18\n 0.64\n 0.69\n 0.70\n TCO2\n 20\n 19\n Glucose\n 143\n 125\n 160\n 133\n 146\n 130\n Other labs: PT / PTT / INR:13.8/29.9/1.2, CK / CK-MB / Troponin\n T:330/14/0.70, ALT / AST:17/39, Alk-Phos / T bili:37/1.2,\n Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %, Eos:1.2 %, Lactic\n Acid:1.1 mmol/L, Albumin:2.4 g/dL, LDH:270 IU/L, Ca:7.6 mg/dL, Mg:2.1\n mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n Assessment and Plan: 85 yo male s/p LGIB with colectomy, complicated by\n perioperative MI\n Neurologic: Stable, pain controlled\n Cardiovascular: Aspirin, Beta-blocker, perioperative MI, back on ASA\n and aggrenox, rate control with B blocker\n Pulmonary: doing well extubated\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: no fever\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: D5LR\n Consults: General surgery\n Billing Diagnosis: Other: LGIB, MI\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 12:00 AM\n Arterial Line - 04:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 341192,
"text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 341195,
"text": "HPI:\n 85yM with CAD MIx2, CVA, prostate CA presented to OSH with painless\n rectal bleeding . Transfused 13 units PRBC at OSH, received 2\n c-scopes with evidence of right sided AVMs but no active bleeding, tag\n scan showed right sided bleeding. Bleeding resumed and pt tx to .\n On MICU service but continued to bleed so taken to OR for total\n colectomy with ileorectal anastomosis.\n Chief complaint:\n LGIB\n PMHx:\n CAD, MIx2, CHF, CVA, prostate CA\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Post op day 3 of total colectomy and anastamosis, 1x episode of loose\n melena stool this shift, no evidence of active bleeding\n Action:\n Kept NPO to rest bowel\n Response:\n No further bleeding, Hct stable\n Plan:\n Monitor for further bleeding\n .H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n NSR, paced, not always capturing so some ectopy at times. Peripheral\n edema increasing, UOP reduced, usually takes Lasix.\n Action:\n KCL repleated.\n Response:\n Pt in NSR\n Plan:\n Monitor and repleat lytes, ? start home Lasix dose\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340992,
"text": ".H/O coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt ruled in for MI via lab work\n Action:\n Maintain bed rest, beta blockade\n Response:\n Slight raise in troponin and CK-MB.\n Plan:\n To transfer to floor if remains stable\n Pain control (acute pain, chronic pain)\n Assessment:\n Abdominal pain post colectomy for lower GI bleeding\n Action:\n Medicate with Fentanyl 25-100mcg Q2hrs\n Response:\n Pain free\n Plan:\n Monitor for pain frequently, splint abdomen when turning.\n"
},
{
"category": "Nutrition",
"chartdate": "2119-10-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 340982,
"text": "Subjective Pt reports good appetite PTA, however has lost ~7# over\n past few months. Pt eats meals/day.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 76.6 kg\n 81.9 kg ( 12:00 AM)\n 28\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.7 kg\n 117\n 72.2\n 106\n % Ideal body weight based on UBW\n Diagnosis: LGIB\n PMH : CAD, h/o MI, CVA x2, prostate Ca s/p prostatectomy via lower\n midline, chemo/XRT, pacemaker\n Pertinent medications: RISS, Protonix, Heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 146 mg/dL\n 03:13 AM\n Glucose Finger Stick\n 132\n 10:00 AM\n BUN\n 13 mg/dL\n 03:13 AM\n Creatinine\n 0.8 mg/dL\n 03:13 AM\n Sodium\n 143 mEq/L\n 03:13 AM\n Potassium\n 3.8 mEq/L\n 03:13 AM\n Chloride\n 118 mEq/L\n 03:13 AM\n Albumin\n 2.4 g/dL\n 12:24 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:13 AM\n Phosphorus\n 2.1 mg/dL\n 03:13 AM\n Ionized Calcium\n 1.10 mmol/L\n 03:06 PM\n Magnesium\n 2.1 mg/dL\n 03:13 AM\n Current diet order / nutrition support: NPO\n GI: NGT with 100cc o/p over past 12hrs\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Pt reported 7# (4%) weight loss over past few months\n Estimated Nutritional Needs\n Calories: 1800- (BEE x or / 25-28cal/kg UBW)\n Protein: 86-101 (1.2-1.4 g/kg UBW)\n Fluid:\n Estimation of previous intake: likely inadequate\n Estimation of current intake: inadequate (NPO)\n Specifics: 85 y.o. M adm from OSH with LGIB & BRBPR (pt received 13\n units of blood at OSH). Tagged RBC scan showed bleeding localized to\n ascending colon. Pt taken to OR for total colectomy, now extubated.\n Pt remains NPO with NGT to suction; minimal output over past 12 hrs.\n If pt unable to tolerate po\ns in the next 2 days, rec start nutrition\n support. If no s/s of GIB, rec TF over TPN. Noted Phos low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Adv pt\ns diet per team.\n 2) If pt unable to tolerate po\ns or if with continuing GIB, rec\n start TPN. Start with Day 1 std. If tolerated without hyperglycemia,\n adv to Day 2 standard TPN. Please check TG (if <400, ok to add lipid\n to TPN).\n 3) Goal TPN to be 70kg 3-in-1 = 1783kcals, 105g protein.\n 4) Will follow progress and plan re: nutrition.\n 5) Replete lytes as needed.\n"
},
{
"category": "Nutrition",
"chartdate": "2119-10-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 340983,
"text": "Subjective Pt reports good appetite PTA, however has lost ~7# over\n past few months. Pt eats meals/day.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 76.6 kg\n 81.9 kg ( 12:00 AM)\n 28\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.7 kg\n 117\n 72.2\n 106\n % Ideal body weight based on UBW\n Diagnosis: LGIB\n PMH : CAD, h/o MI, CVA x2, prostate Ca s/p prostatectomy via lower\n midline, chemo/XRT, pacemaker\n Pertinent medications: RISS, Protonix, Heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 146 mg/dL\n 03:13 AM\n Glucose Finger Stick\n 132\n 10:00 AM\n BUN\n 13 mg/dL\n 03:13 AM\n Creatinine\n 0.8 mg/dL\n 03:13 AM\n Sodium\n 143 mEq/L\n 03:13 AM\n Potassium\n 3.8 mEq/L\n 03:13 AM\n Chloride\n 118 mEq/L\n 03:13 AM\n Albumin\n 2.4 g/dL\n 12:24 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:13 AM\n Phosphorus\n 2.1 mg/dL\n 03:13 AM\n Ionized Calcium\n 1.10 mmol/L\n 03:06 PM\n Magnesium\n 2.1 mg/dL\n 03:13 AM\n Current diet order / nutrition support: NPO\n GI: NGT with 100cc o/p over past 12hrs\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Pt reported 7# (4%) weight loss over past few months\n Estimated Nutritional Needs\n Calories: 1800- (BEE x or / 25-28cal/kg UBW)\n Protein: 86-101 (1.2-1.4 g/kg UBW)\n Fluid:\n Estimation of previous intake: likely inadequate\n Estimation of current intake: inadequate (NPO)\n Specifics: 85 y.o. M adm from OSH with LGIB & BRBPR (pt received 13\n units of blood at OSH). Tagged RBC scan showed bleeding localized to\n ascending colon. Pt taken to OR for total colectomy, now extubated.\n Pt remains NPO with NGT to suction; minimal output over past 12 hrs.\n If pt unable to tolerate po\ns in the next 2 days, rec start nutrition\n support. If no s/s of GIB, rec TF over TPN. Noted Phos low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Adv pt\ns diet per team.\n 2) If pt unable to tolerate po\ns or if with continuing GIB, rec\n start TPN. Start with Day 1 std. If tolerated without hyperglycemia,\n adv to Day 2 standard TPN. Please check TG (if <400, ok to add lipid\n to TPN).\n 3) Goal TPN to be 70kg 3-in-1 = 1783kcals, 105g protein.\n 4) Will follow progress and plan re: nutrition.\n 5) Replete lytes as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340414,
"text": "Mr. is an 85 yo male with CAD s/p MI, CVA, h/o prostate cancer,\n congestive heart failure, admitted to on with rectal\n bleeding. He was found to be hypotensive to 70s systolic but improved\n with fluids and PRBCs and so was monitored in the ICU. Patient was on\n aspirin and aggrenox at home, so he was given DDAVP. He then got a\n tagged RBC scan which showed bleeding from right side of colon. He got\n two colonoscopies which revealed right sided AVMs but no active\n bleeding. The AVMs were cauteraized. His GI bleeding temporarily\n stopped but then resumed earlier today prior to trasnfer. His initial\n Hct was 31 on . He was transfused 9 units by when a repeat\n colonoscopy was performed which showed no bleeding from cauterized\n ulcers (from AVMs) and diverticula in the right colon. In total, he was\n transfused 13 units during his hospital stay.\n On arrival to , patient reports ongoing BRBPR. He denies chest\n pain, shortness of breath, abdominal pain, fevers, chills, hematemasis,\n or any other concerning symptoms.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n VSS; HR 70s; BP 1-teens/70s; MAPs 80s. BRBPR x 3..small to moderate\n (bedpan) with clots between admission (midnight) and 2am. Pt to\n Nuclear Med at 0300: Small BRBPR on pad\n Action:\n IVF &S sent; Two Hcts drawn\n Response:\n VSS; Last Hct 29.2 down from 31.9 (IVF at 125/hour).\n Plan:\n Serial Hcts; Possible Colonoscopy; Possible surgery.\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340425,
"text": "Chief Complaint: GI bleed\n 24 Hour Events:\n Tagged RBC scan negative for active bleed\n Surgery consulted\n GI consulted\n Patient had ongoing GI bleeding.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.3\n HR: 83 (70 - 89) bpm\n BP: 137/100(109) {98/64(74) - 139/112(118)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 814 mL\n PO:\n TF:\n IVF:\n 814 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 514 mL\n Respiratory support\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 112 K/uL\n 10.4 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.2 %\n 8.2 K/uL\n [image002.jpg]\n 12:24 AM\n 05:51 AM\n WBC\n 9.4\n 8.2\n Hct\n 31.9\n 29.2\n Plt\n 106\n 112\n Cr\n 0.9\n 0.9\n Glucose\n 128\n 115\n Other labs: PT / PTT / INR:14.5/32.9/1.3, ALT / AST:17/39, Alk Phos / T\n Bili:37/1.2, Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %,\n Eos:1.2 %, Albumin:2.4 g/dL, LDH:270 IU/L, Ca++:7.4 mg/dL, Mg++:1.7\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n A/P: Mr. is an 85 yo male with CAD s/p MI, CVA, now with lower GI\n bleed for 4 days requiring 13 units of PRBCs.\n .\n 1. GI bleed. Patient admitted with ongoing lower GI bleed. Initial\n bleeding scan at OSH on revealed right sided bleeding, however\n colonoscopy x 2 failed to identify source of bleeding but there was\n concern for AVMs versus divertular bleed versus bleed proximal to the\n ileocecal valve. Currenly hemodynamically stable with ongoing\n bleeding. Will pursue tagged RBC today and then proceed to angiography\n versus surgery.\n - serial Hcts (q4 hours)\n - right IJ from OSH --> will need to replace in AM\n - type and cross 2 units\n - tagged RBCs today\n - Surgery consult given extent of bleed\n - GI consult\n - IV PPI , though less likely to be upper bleed\n .\n 2. CAD. Patient has history of CAD with EF of 45%. Cardiac cath in\n showed 3 vessel disease. No history of stents per patient. On\n Aspirin, lasix, atorvastatin, zetia, and metoprolol at home. However,\n given extensive bleed, will avoid antiplatelet therapy and\n antihypertesnives. Got DDAVP at OSH.\n - continue atorvastatin, zetia\n - hold BB, lasix, isosorbide mononitrate\n - hold aspirin\n - transfuse to keep Hct > 30 given CAD and active bleed\n - check EKG\n .\n 3. H/o stroke. Patient has history of CVA. However, given\n significant and prolonged bleed, will hold aggrenox.\n - hold agrenox\n 4. FEN: IVF @ 150cc/hour, NPO for now.\n 5. PPx: pneumoboots.\n 6. FULL CODE, confirmed with patient.\n .\n Communication: patient\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340439,
"text": "Chief Complaint: GI bleed\n 24 Hour Events:\n Tagged RBC scan negative for active bleed\n Surgery consulted\n GI consulted\n Patient had ongoing GI bleeding.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:34 AM\n Other medications:\n Lipitor\n Zetia\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.3\n HR: 83 (70 - 89) bpm\n BP: 137/100(109) {98/64(74) - 139/112(118)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 814 mL\n PO:\n TF:\n IVF:\n 814 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 514 mL\n Respiratory support\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Gen: elderly African American male, NAD\n HEENT: right facial droop, EOMI, o/p clear\n CV: RRR, no m/r/g\n Pulm: CTA b/l\n Abd: soft, NT, ND, bowel sounds present\n Ext: peripheral edema note\n Labs / Radiology\n 112 K/uL\n 10.4 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.2 %\n 8.2 K/uL\n [image002.jpg]\n 12:24 AM\n 05:51 AM\n WBC\n 9.4\n 8.2\n Hct\n 31.9\n 29.2\n Plt\n 106\n 112\n Cr\n 0.9\n 0.9\n Glucose\n 128\n 115\n Other labs: PT / PTT / INR:14.5/32.9/1.3, ALT / AST:17/39, Alk Phos / T\n Bili:37/1.2, Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %,\n Eos:1.2 %, Albumin:2.4 g/dL, LDH:270 IU/L, Ca++:7.4 mg/dL, Mg++:1.7\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n A/P: Mr. is an 85 yo male with CAD s/p MI, CVA, now with lower GI\n bleed for 4 days requiring 13 units of PRBCs.\n 1. GI bleed. Patient admitted with ongoing lower GI bleed. Initial\n bleeding scan at OSH on revealed right sided bleeding, however\n colonoscopy x 2 failed to identify source of bleeding but there was\n concern for AVMs versus divertular bleed versus bleed proximal to the\n ileocecal valve. Currenly hemodynamically stable with ongoing\n bleeding. Will pursue tagged RBC today and then proceed to angiography\n versus surgery.\n - serial Hcts (q4 hours)\n - right IJ from OSH --> will need to replace in AM\n - type and cross 2 units\n - tagged RBCs today\n - Surgery consult given extent of bleed\n - GI consult\n - IV PPI , though less likely to be upper bleed\n .\n 2. CAD. Patient has history of CAD with EF of 45%. Cardiac cath in\n showed 3 vessel disease. No history of stents per patient. On\n Aspirin, lasix, atorvastatin, zetia, and metoprolol at home. However,\n given extensive bleed, will avoid antiplatelet therapy and\n antihypertesnives. Got DDAVP at OSH.\n - continue atorvastatin, zetia\n - hold BB, lasix, isosorbide mononitrate\n - hold aspirin\n - transfuse to keep Hct > 30 given CAD and active bleed\n - check EKG\n .\n 3. H/o stroke. Patient has history of CVA. However, given\n significant and prolonged bleed, will hold aggrenox.\n - hold agrenox\n 4. FEN: IVF @ 150cc/hour, NPO for now.\n 5. PPx: pneumoboots.\n 6. FULL CODE, confirmed with patient.\n .\n Communication: patient\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340444,
"text": "Chief Complaint: GI bleed\n 24 Hour Events:\n Tagged RBC scan negative for active bleed\n Surgery consulted and plans for surgery.\n GI consulted\n Patient had ongoing GI bleeding.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:34 AM\n Other medications:\n Lipitor\n Zetia\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.3\n HR: 83 (70 - 89) bpm\n BP: 137/100(109) {98/64(74) - 139/112(118)} mmHg\n RR: 14 (14 - 14) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 814 mL\n PO:\n TF:\n IVF:\n 814 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 514 mL\n Respiratory support\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Gen: elderly African American male, NAD\n HEENT: right facial droop, EOMI, o/p clear\n CV: RRR, no m/r/g\n Pulm: CTA b/l\n Abd: soft, NT, ND, bowel sounds present\n Ext: peripheral edema note\n Labs / Radiology\n 112 K/uL\n 10.4 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 115 mEq/L\n 142 mEq/L\n 29.2 %\n 8.2 K/uL\n [image002.jpg]\n 12:24 AM\n 05:51 AM\n WBC\n 9.4\n 8.2\n Hct\n 31.9\n 29.2\n Plt\n 106\n 112\n Cr\n 0.9\n 0.9\n Glucose\n 128\n 115\n Other labs: PT / PTT / INR:14.5/32.9/1.3, ALT / AST:17/39, Alk Phos / T\n Bili:37/1.2, Differential-Neuts:74.9 %, Lymph:18.7 %, Mono:5.0 %,\n Eos:1.2 %, Albumin:2.4 g/dL, LDH:270 IU/L, Ca++:7.4 mg/dL, Mg++:1.7\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Mr. is an 85 yo male with CAD s/p MI, CVA, now with lower GI bleed\n for 4 days requiring 13 units of PRBCs.\n 1. GI bleed. Patient admitted with ongoing lower GI bleed. Initial\n bleeding scan at OSH on revealed right sided bleeding, however\n colonoscopy x 2 failed to identify source of bleeding but there was\n concern for AVMs versus divertular bleed versus bleed proximal to the\n ileocecal valve. Currenly hemodynamically stable with ongoing\n bleeding. Tagged RBC scan negative but now bleeding again, so will go\n for total colectomy today.\n - serial Hcts (q4 hours)\n - right IJ from OSH --> will need to replace in AM\n - transfuse 2 units given ongoing brisk bleed\n - await surgical intervention\n - cards consult for clearance\n - IV PPI , though less likely to be upper bleed\n 2. CAD. Patient has history of CAD with EF of 45%. Cardiac cath in\n showed 3 vessel disease but unable to intervene by cath. No\n history of stents per patient. On Aspirin, lasix, atorvastatin, zetia,\n and metoprolol at home. However, given extensive bleed, will avoid\n antiplatelet therapy and antihypertesnives. Got DDAVP at OSH.\n - continue atorvastatin, zetia\n - hold BB, lasix, isosorbide mononitrate\n - hold aspirin\n - transfuse to keep Hct > 30 given CAD and active bleed\n - cards consult for clearance\n 3. H/o stroke. Patient has history of CVA. However, given\n significant and prolonged bleed, will hold aggrenox.\n - hold aggrenox\n 4. FEN: IVF @ 150cc/hour, NPO for now.\n 5. PPx: pneumoboots.\n 6. FULL CODE, confirmed with patient.\n Communication: patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:00 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: IV PPI\n VAP: not needed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to ICU today\n"
},
{
"category": "Echo",
"chartdate": "2119-10-23 00:00:00.000",
"description": "Report",
"row_id": 62521,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 203\nBSA (m2): 2.10 m2\nBP (mm Hg): 120/61\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 13:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Estimated cardiac index is normal (>=2.5L/min/m2). No\nresting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferolateral - hypo; mid anterolateral - hypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild to moderate\n(+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Moderate [2+] TR. Normal\nPA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size. There is mild\nregional left ventricular systolic dysfunction with focal hypokinesis of the\nmid inferolateral and distal inferior walls. The remaining segments contract\nwell and overall systolic function is mildly reduced (LVEF 50%). The estimated\ncardiac index is normal (>=2.5L/min/m2).Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets are mildly thickened.\nNo aortic stenosis is present. At least mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n[1+] mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is\nseen. The estimated pulmonary artery systolic pressure is high normal. There\nis no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Regional left ventricular systolic\ndysfunction c/w multivessel CAD. At least mild-moderate aortic regurgitation.\nMild mitral regurgitation. Moderate tricuspid 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": "Radiology",
"chartdate": "2119-10-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1032579,
"text": " 1:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CHECK LINE PLACEMENT\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW.\n\n HISTORY: Check line placement.\n\n FINDINGS: There is a new right IJ line with tip in SVC. Dual-lead pacemaker\n is again visualized. The NG tube is in the stomach. There are bilateral\n pleural effusions that are increased compared to the prior study from\n . An underlying infectious infiltrate cannot be excluded. There is\n no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-21 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 1032386,
"text": "GI BLEEDING STUDY Clip # \n Reason: CAD, MI, CVA, NOW BRISK BRBPR, EVAL FOR SOURCE\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 15.5 mCi Tc-m RBC ();\n HISTORY: 85 year old male with 500 cc BRBPR\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for minutes\n were obtained. A left lateral view of the pelvis was also obtained.\n\n Blood flow images show normal radiotracer distribution.\n\n Dynamic blood pool images show normal radiotracer distribution.\n\n No bleeding was identified.\n\n IMPRESSION: No bleeding was identified.\n\n\n\n , M.D.\n , M.D. Approved: TUE 3:51 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": "2119-10-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1032964,
"text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: many secretions\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with\n REASON FOR THIS EXAMINATION:\n many secretions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 2:24 PM\n ____pulmonary congestion, pleural effusions remain.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: Many secretions. Previous chest examination demonstrated\n bilateral pleural effusions.\n\n FINDINGS: Related to patient's general condition, AP and lateral chest views\n were obtained with patient in sitting upright position. Available for\n comparison is a preceding AP single view chest examination of . Previously described dual electrode permanent pacer system remains in\n unchanged position. The previously present NG tube has been removed.\n Bilateral pleural effusions obliterate the diaphragmatic contours and blunt\n the lateral pleural sinuses and obscure also major portion of the cardiac\n contours. Moderate cardiac enlargement with prominent left ventricular\n contour remains rather unchanged. Markedly unfolded thoracic aorta is again\n noted. The accessible lung fields do not demonstrate a significant pulmonary\n congestive pattern. On the bases, some linear densities in horizontal\n position and in supradiaphragmatic location are compatible with peripheral\n atelectases. No conclusive evidence for pulmonary infiltrate can be\n identified; however, the lung bases are obscured by the described pleural\n effusions. Comparison of the pulmonary vasculature suggests that a previously\n existing congestion previously described right internal jugular vein approach\n central venous line remains. No pneumothorax.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1032965,
"text": ", B. SICU-B 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: many secretions\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with\n REASON FOR THIS EXAMINATION:\n many secretions\n ______________________________________________________________________________\n PFI REPORT\n ____pulmonary congestion, pleural effusions remain.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-22 00:00:00.000",
"description": "Report",
"row_id": 120780,
"text": "Sinus rhythm. Low voltage. Compared to the previous tracing of \nST-T wave changes are similar.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Report",
"row_id": 120781,
"text": "Sinus rhythm. Low voltage. Anterior ST segment depressions are suggestive of\nischemia. Compared to the previous tracing of no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-21 00:00:00.000",
"description": "Report",
"row_id": 120782,
"text": "Sinus rhythm with borderline first degree A-V block. Consider left atrial\nabnormality. Anterolateral ST segment depressions suggest myocardial ischemia.\nEarly transition. Low QRS voltage in the limb leads. Compared to the previous\ntracing of the ventricular rate is slower. ST segment depression is\nmore pronounced.\n\n"
}
] |
22,810 | 123,890 | She was admitted status post a right occipital craniotomy. Preoperative diagnosis was metastatic lesion. At the time of surgery it was discovered that the patient had a dural arteriovenous malformation with large varices. Postoperatively, was monitored in the Recovery Room overnight. Her vital signs were stable. She was awake, alert and oriented times three. Extraocular movements were full. Her smile was symmetric. She had no drift. Her iliopsoas were . She did continue to have a left field cut that she had preoperatively; more left inferior quadrant than superior quadrant. Her vital signs remained stable, and she was transferred to the regular floor on postoperative day one. She was referred to Dr. for an arteriogram to assess for residual arteriovenous malformation or arteriovenous fistula. The patient was taken to the angiogram suite on where she underwent a diagnostic arteriogram which did not show evidence of remaining arteriovenous fistula but an aneurysm was detected that was not diagnosed prior to this arteriogram. The patient's right groin site was clean, dry, and intact status post procedure. She had strong pedal pulses with a warm foot. Her vital signs were stable. She was afebrile. She was alert, awake, and oriented times three with some intermittent periods of confusion; most likely related to sedation for angiogram and slight dehydration. The smile was full. No drift. Iliopsoas were . The patient was evaluated by Physical Therapy and Occupational Therapy and found to require rehabilitation prior to discharge to home. | IMPRESSION: Enhancing mass in the right parietal/occipital region with surrounding edema and adjacent leptomeningeal enhancement, not significantly changed since the prior study. It is consistent with a presence of a previous dilated right feeder to the right transverse sinus fistula. POSTOPERATIVE DIAGNOSIS: Dilated right posterior meningeal branch of the right vertebral artery with no rapid shunting but cannot rule out residual fistula consistent with a previous dural arteriovenous fistula status post at least partial if not complete resection and the presence of a 4 mm anterior communicating artery aneurysm. Injection of vertebral artery is within normal limits in the cervical region as well as intracranially. FINDINGS: Note is again made of enhancing mass in the right parietal region with surrounding edema, not significantly changed since the prior study. Injection of the right vertebral artery reveal it to be dilated in the cervical segment with no evidence of stenosis in the cervical region. Dr. at that point elected to resect the fistula. This was defined with three dimensional rotational angiography and appears to be at least amenable to endovascular therapy. ANESTHESIA: Conscious sedation. In addition, the basilar artery and vertebrobasilar junction appears to be free of atherosclerotic disease. PERRL.CV-NORMOTHERMIC. IMPRESSION: The presence of a dilated right posterior meningeal artery with currently no evidence of rapid shunting. Injection of the right external carotid artery reveals the presence of a slightly dilated right occipital artery with a muscular branch connection between the right occipital artery and the right vertebral artery which with forceful injection shows the previously described dilated right posterior meningeal branch of the right vertebral artery. In addition, injection of the right vertebral artery reveals a significantly dilated left posterior meningeal artery. It is recommended that the patient (Over) 9:39 AM CAROT/CEREB Clip # Reason: S/P RESECTION Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: OPTIRAY Amt: 180 FINAL REPORT (REVISED) (Cont) return for a supraselective evaluation of her right vertebral artery and right occipital artery to rule out the presence of any persistent dural fistula which at this present time cannot be visualized fully or completely ruled out. Injection of the left external carotid artery reveals a prominent supply to the dura which is diffuse and does not appear to constitute the fistula per se at the medial edge of the superior sagittal sinus. Next a diagnostic catheter was used to selectively catheterize the following vessels over a guidewire in succession: Innominate, right common carotid artery, right external carotid artery, right internal carotid artery, right subclavian artery, right vertebral artery, left (Over) 9:39 AM CAROT/CEREB Clip # Reason: S/P RESECTION Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: OPTIRAY Amt: 180 FINAL REPORT (REVISED) (Cont) subclavian artery, left vertebral artery, left common carotid artery, left external carotid artery, and left internal carotid artery. FINAL REPORT (REVISED) INDICATIONS: Right parietal and occipital preoperative brain tumor resection WAND study. Injection of the left subclavian artery is free of atherosclerotic disease. In addition, injection of the right internal carotid artery is within normal limits with no evidence of intracranial atherosclerosis or other arteriovenous malformation. The right groin area was prepped and draped in the usual sterile fashion. NURSING UPDATENEURO: NO NEURO DEFICITS THROUGHOUT NOC. C/O MODERATE HEADACHE X1, MSO4 2MG IVP WITH RELIEF.RESP: ABG'S WITHIN NORMAL PARAMETERS, O2 WEANED DOWN TO 2L N/PRONGS, CONTINUES TO SAT AT 98-99%. The dilatation of the right vertebral artery is consistent with a chronic high flow state. TECHNIQUE: Axial thin slice images of the brain with IV contrast were performed with a wand protocol. There is compression of the right lateral ventricular atrium . 9:39 AM CAROT/CEREB Clip # Reason: S/P RESECTION Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: OPTIRAY Amt: 180 ********************************* CPT Codes ******************************** * SEL CATH 3RD ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER * * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER * * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT * * EXT CAROTID BILAT VERT/CAROTID A-GRAM * * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * EXT BILAT A-GRAM -52 REDUCED SERVICES * **************************************************************************** FINAL REPORT (REVISED) PREOPERATIVE DIAGNOSIS: Rule out dural arteriovenous fistula. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2119-05-09 00:00:00.000",
"description": "Report",
"row_id": 1560208,
"text": "NURSING UPDATE\nNEURO:\n NO NEURO DEFICITS THROUGHOUT NOC. SLEPT WELL IN NAPS BUT EASILY ROUSED FOR CHECKS. ALERT AND ORIENTED X3. NO FACIAL DROOP, PUPILS EQUAL IN SIZE AND REACTIVITY. HAS REGAINED NORMAL STRENGTH IN ALL EXTREMITIES, NO DRIFT IN U/E'S. C/O MODERATE HEADACHE X1, MSO4 2MG IVP WITH RELIEF.\n\nRESP:\n ABG'S WITHIN NORMAL PARAMETERS, O2 WEANED DOWN TO 2L N/PRONGS, CONTINUES TO SAT AT 98-99%. BREATH SOUNDS CLEAR BILATERALLY, THOUGH DIMINISHED @ BASES. COUGH STRONG AND NON-PRODUCTIVE.\n\nCV:\n HYPOTENSIVE EARLY NOC, MAINTAINED ON NEO GTTS, NS 500CC BOLUS GIVEN X2, NEO WEANED DOWN SLOWLY, OFF @ 0400. BP REMAINS @ GOAL >110.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-05-09 00:00:00.000",
"description": "Report",
"row_id": 1560209,
"text": "D: Please see pt transfer note. Physical assessment unchanged, pt sitting up in bed visiting with family. VSS, 02sats 98% on RA. Good pain relief with mso4/tylenol. Pt taking good po intake, will be npo after breakfast tomorrow for angiogram. Brief verbal report given to on 5 with tranfer note sent by fax. Family aware of and agreeable to plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-05-08 00:00:00.000",
"description": "Report",
"row_id": 1560207,
"text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 78 Y/O FEMALE ADMITTED TO THE SICU FROM THE OR S/P CRANI FOR NEW OCCIPITAL MASS WHICH TURNED OUT TO BE AN AVM. PT ARRIVED TO THE UNIT IN NAD, AND EXTUBATED. PE AS FOLLOWS:\n\nNEURO-SLEEPY BUT EASILY AROUASBLE. ORIENTED X3. MAE SPONT. FOLLOWS COMMANDS. LIFTS AND HOLDS UPPER EXTREMITIES. LIFTS AND FALLS ON LOWER EXTREMITIES. PERRL.\n\nCV-NORMOTHERMIC. HRR, NSR. SBP DOWN TO 70'S SHORTLY AFTER ARRIVAL TO UNIT. NEO GTT STARTED, GOAL SBP 110-140. SKIN W+D. +PP. AWAITING ARRIVAL OF PBOOT MACHINE. CPK'S BEING CYCLED.\n\nRESP-02 SAT 99% ON 4L NC. LS CLEAR, DECREASED AT BASES. NARD NOTED. RR WNL.\n\nGI-ABD SOFT, NT/ND.\n\nGU-VOIDING VIA FOLEY CL YELLOW URINE.\n\nCOMFORT-DENIES PAIN.\n\nPLAN-NEURO CHECKS. KEEP SBP 110-140. FOLLOW LABS. ROUTINE POST OP CARE.\n"
},
{
"category": "Radiology",
"chartdate": "2119-05-08 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 791575,
"text": " 8:17 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: PRE-OP SCAN FOR PLACEMENT OF FIDUCIALS FOR WAND PROTOCOL. \n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Woman with right parietal occipital brain tumor.\n REASON FOR THIS EXAMINATION:\n PRE-OP SCAN FOR PLACEMENT OF FIDUCIALS FOR WAND PROTOCOL. SURGERY @ 11AM.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATIONS: Right parietal and occipital preoperative brain tumor\n resection WAND study.\n\n TECHNIQUE: Axial thin slice images of the brain with IV contrast were\n performed with a wand protocol. Preop localization only.\n\n COMPARISON: MR brain .\n\n FINDINGS: Note is again made of enhancing mass in the right parietal region\n with surrounding edema, not significantly changed since the prior study. There\n is compression of the right lateral ventricular atrium . adjacent\n cortical enhancement is noted , of uncertain significance, but certainly not\n typical of metastatic neoplasm.\n\n IMPRESSION: Enhancing mass in the right parietal/occipital region with\n surrounding edema and adjacent leptomeningeal enhancement, not significantly\n changed since the prior study. This is a limited study for preoperative\n localization only. The enhancement pattern is more in keeping with a primary\n brain malignancy, as opposed to a metastasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-05-10 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 791799,
"text": " 9:39 AM\n CAROT/CEREB Clip # \n Reason: S/P RESECTION\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: OPTIRAY Amt: 180\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Rule out dural arteriovenous fistula.\n\n POSTOPERATIVE DIAGNOSIS: Dilated right posterior meningeal branch of the\n right vertebral artery with no rapid shunting but cannot rule out residual\n fistula consistent with a previous dural arteriovenous fistula status post at\n least partial if not complete resection and the presence of a 4 mm anterior\n communicating artery aneurysm.\n\n ANESTHESIA: Conscious sedation.\n\n INDICATION: Ms. is a 78 year old woman with a history of metastatic\n tumor. She was seen to have an enhancing lesion on her right occipital lobe\n on the MRI. Accordingly, she was undergoing a craniotomy for resection of the\n lesion by Dr. at which point it was noted that the enhancing lesion\n was in fact a dilated draining vein. Dr. at that point elected to resect\n the fistula. This angiogram is being performed to determine the presence of\n persistent rapid shunting or cortical venous drainage. In addition, it is\n also perform to address the presence of other arteriovenous fistulas.\n\n CONSENT: The patient was given a full and complete explanation of the\n procedure. Specifically the indications, risks, benefits and alternatives to\n the procedure were explained in detail. In addition the possible\n complications such as the risk of bleeding, infection, stroke, neurological\n deficit or deterioration, groin hematoma, and other unforeseen complications\n including the risk of coma and even death were outlined. The patient\n understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the the endovascular suite\n and placed on the table in supine position. The right groin area was prepped\n and draped in the usual sterile fashion. A 19 gauge single wall needle was\n then used to puncture the right femoral artery and upon the return of brisk\n arterial blood, a 4 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Innominate, right common carotid artery, right external carotid artery, right\n internal carotid artery, right subclavian artery, right vertebral artery, left\n (Over)\n\n 9:39 AM\n CAROT/CEREB Clip # \n Reason: S/P RESECTION\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: OPTIRAY Amt: 180\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n subclavian artery, left vertebral artery, left common carotid artery, left\n external carotid artery, and left internal carotid artery.\n\n RESULTS: Injection of the innominate artery reveals the presence of a dilated\n right vertebral artery which harbors approximately 30% stenosis at its origin.\n The dilatation of the right vertebral artery is consistent with a chronic high\n flow state. There is no evidence of significant atherosclerosis at the\n innominate artery or the origin of the right common or right subclavian\n artery. Injection of the right vertebral artery reveal it to be dilated in\n the cervical segment with no evidence of stenosis in the cervical region. In\n addition, injection of the right vertebral artery reveals a significantly\n dilated left posterior meningeal artery. This left posterior meningeal artery\n has a currently slow flow but it is difficult without supraselective injection\n to determine whether there is any persistent dural fistula. It is consistent\n with a presence of a previous dilated right feeder to the right transverse\n sinus fistula. In addition, the basilar artery and vertebrobasilar junction\n appears to be free of atherosclerotic disease. There is also no other anomaly\n in the posterior circulation. Injection of the right common carotid artery\n reveals no evidence of stenosis or dissection in the cervical region.\n Injection of the right external carotid artery reveals the presence of a\n slightly dilated right occipital artery with a muscular branch connection\n between the right occipital artery and the right vertebral artery which with\n forceful injection shows the previously described dilated right posterior\n meningeal branch of the right vertebral artery. There is no other right\n external carotid artery fistula visualized. In addition, injection of the\n right internal carotid artery is within normal limits with no evidence of\n intracranial atherosclerosis or other arteriovenous malformation. Injection\n of the left subclavian artery is free of atherosclerotic disease. Injection\n of vertebral artery is within normal limits in the cervical region as well as\n intracranially. Injection of the left common carotid artery reveals the\n presence of approximately 30% smooth atherosclerotic stenosis at the origin of\n the left internal carotid artery. Injection of the left external carotid\n artery reveals a prominent supply to the dura which is diffuse and does not\n appear to constitute the fistula per se at the medial edge of the superior\n sagittal sinus. Injection of the left internal carotid artery shows the\n presence of a 4 mm aneurysm of the anterior communicating artery. This was\n defined with three dimensional rotational angiography and appears to be at\n least amenable to endovascular therapy.\n\n IMPRESSION: The presence of a dilated right posterior meningeal artery with\n currently no evidence of rapid shunting. It is difficult to rule out the\n presence of any persistent fistula without selective catheterization of this\n branch. This would necessitate heparinization and accordingly is not\n currently recommended post craniotomy. The presence of a 4 mm aneurysm at the\n anterior communicating artery junction. It is recommended that the patient\n (Over)\n\n 9:39 AM\n CAROT/CEREB Clip # \n Reason: S/P RESECTION\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: OPTIRAY Amt: 180\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n return for a supraselective evaluation of her right vertebral artery and right\n occipital artery to rule out the presence of any persistent dural fistula\n which at this present time cannot be visualized fully or completely ruled out.\n In addition, the options of treatment of the anterior communicating artery via\n endovascular route will also be discussed with the patient.\n\n\n\n\n"
}
] |
83,527 | 187,511 | 48 yo M with C4 tetraplegia s/p MVA, s/p trach/peg placement, recent DVT on coumadin with IVC filter who was admitted with UTI and PNA and transfered to the ICU for hypercarbic respiratory failure. Pt improved with IV cefepime/linezolid for HAP and was treated for yeast in urine Cx with IV fluconazole. He had another episode of respiratory decompensation on likely due LLL collapse on CXR. He improved with resp therapy, suctioning and increased o2. Pt had a CTA on with no PE but consolidation and collapse LLL. After this episode, he continued to improve from a respiratory standpoint. . # Pneumonia/Respiratory Failure: Pt was admitted with confusion and developed acute respiratory distress requiring MICU transfer. A bronch performed in the MICU revealed severe LLL and LUL mucous plugging that was difficult to clear with serial washes and he ultimately required placement on a ventilator via trach for hypercarbic respiratory failure. Infectious work up included a head CT that was negative and BAL cultures that were positive for yeast and MRSA. Pt was treated with linezolid, cefepime, and fluconazole for HAP. Pt was transferred to the on and had another episode of respiratory decompensation with bradycardia on that was felt likely due to mucus plugging. His status improved with suctioning, MIE and nebs. Pt underwent a CTA on which did not show any evidence of pulmonary embolism but there was left lower lobe volume loss, with low density plugging of the left lower lobe bronchus and nodular opacities noted in the right lower lobe, along with ground glass opacity seen in the left upper lobe. Given these persistent findings, pt was continued on IV antibiotics to complete a 14 day course of IV cefepime and linezolid. His respiratory status continued to improve with aggressive respiratory therapy support, suctionning and a new turing schedule with less time spent on his left side (1 hour on left side and 2 hours on right) to maximize ventilation on that side. . # UTI/Suprapubic cath: Patient has a suprapubic catheter and both MRSA and yeast on UCx. Urology was consulted and did not want to change out suprapubic catheter given that it was recently placed and the track is likely not epithelialized. He was treated with fluconazole, linezolid, and cefepime as above. Fluconazole finished and linezolid to finish . On suprapubic catheter was noted to be leaking and urology consult felt that could be due to bladder spasm vs UTI. By the time of discharge, the leak had improved significantly and pt will need to follow up with his urologist. . # Previous DVT on warfarin: Patient presented with an elevated INR at 4.1 in the setting of acute illness/infection. Warfarin was held until INR fell to ~3 and then restarted at lower dose. His INR was very labile in house likely due to medication interactions and LMWH was started at 1mg/kg . This can be stopped when INR is >2 for over 24 hours and will need to be reviewed at with daily INRs until it has stabilized. . # s/p C4 spinal injury: Neuro status at baseline. He requires an Aspen collar in place at all times with Q2H turns. He was continued on his home inhalers and PRN nebs. He is on oxycodone PRN for pain with a bowel regimen. Turns were changed to maximize ventilation 1hr left 2 hours on right. Pt was continued on high flow 50% via trache mask and this will need to be weaned at . . # LFTs: Patient was noted to have mildly elevated LFTs and on the ALT had risen to c200. This was felt likely Antibiotics/fluconazole. Fluconazole was stopped on as likely offending and completed course. LFTs will need to be trended at rehab to ensure resolution . # Poor po intake: Noted reduced po intake. PRN PEG feed. Improved on discharge. Will need nutrition support and calorie counting at rehab. . INACTIVE/CHRONIC ISSUES: . # Confusion: Likely secondary to infection/respiratory failure. CT-head was performed for anisocoria and was normal. Confusion resolved with resolution of infection. Anisocoria resolved . # Anemia/thrombocytosis: At baseline. | Unchanged angulation of the anterior fixation rods with indentation on the right sided oro- and hypo-pharynx. The thoracic aorta is normal in caliber. FINDINGS: There is relative lucency in the left lower hemithorax which suggests a pneumothorax but a subsequent erect radiograph excludes this. There is a stable calcified granuloma in the right lung apex (image 7 of series 6). There is partial opacification of bilateral mastoid air cells. The right lung is normal in appearance. FINDINGS: The pulmonary arteries opacify normally and taper distally without evidence of embolism. Unchanged inferior displacement of the intervertebral disc spacer. Retrocardiac density consistent with left lower lobe atelectasis is stable. A tracheostomy tube is unchanged in position since . Unchanged left lower lobe atelectasis. The right lung is essentially clear. Residual atelectasis and left effusion again seen. Normal sinus rhythm. Compared to the previous tracing of no major change.TRACING #1 Tracheostomy tube in standard placement. FINDINGS: In comparison with the study of , the elevation of the left hemidiaphragmatic contour is less prominent. Left lower lobe atelectasis is mild and appears to have improved since a radiograph from . The cardiac size is normal. Minimal mucosal thickening is noted within scattered ethmoid air cells. The ventricles and sulci are normal in size and configuration. Tracheostomy tube remains in place. Tracheostomy tube remains in place. Ventricles and sulci are normal in size and symmetric in configuration. IMPRESSION: No significant change compared to with 7.5 mm anterolisthesis of C3 on C4. Heart size normal. IMPRESSION: Lucency projected over the left hemidiaphragm is most likely within a loop of bowel rather than a pleural gas collection, this may either be subphrenic or within a diaphragmatic hernia, which could be ellucidated with CT, if clinically warranted. Compared to the previous tracing of no diagnosticinterval change. Pleural effusion on the left is minimal if any. A percutaneous gastrostomy tube and inferior vena cava filter are incidentally noted. Heart size is normal. The great vessels opacify normally. IMPRESSION: AP chest compared to and 20: Left lower lobe aeration has improved substantially, though there is some residual atelectasis and increasing small left pleural effusion. FINDINGS: Apparent lucency projected over the left hemidiaphragm on the prior radiograph lies within a loop of bowel. FINDINGS: A single portable semi-upright view of the chest was obtained. TECHNIQUE: Non-contrast MDCT axial images were acquired through the head. The upper lungs are grossly clear. hyperdensity at the right temporal pole is likely secondary to volume averaging and appears artefactual. The remainder of the visualized paranasal sinuses are clear. FINDINGS: Compared to , there is unchanged anterolisthesis of C3 on C4 measuring about 7.5 mm (grade 2). The remainder of the visualized paranasal sinuses is clear. Patient is status post laminectomy at C3/C4, unchanged kinking of the spinal cord at C3/C4. Normal tracing. Upper lungs clear. Limited exam due to motion artifact. Osseous structures are intact. Tracheostomy tube is in standard placement, but is relatively small given the size of the trachea and should be evaluated from a clinical standpoint. A small left pleural effusion has increased overnight. The heart is normal size. A few small bilateral hilar lymph nodes are identified. The cardiomediastinal silhouette is unremarkable allowing for patient position and technique. Nodular opacities noted in the right lower lobe, along with ground glass opacity seen in the left upper lobe. TECHNIQUE: Contiguous axial images were obtained through the head without the administration of IV contrast. An ill defined density in the right lower lung is present. IMPRESSION: PA and lateral chest compared to : Left lower lobe is collapsed, which may explain hypoxia. Left lower lobe volume loss, with low density plugging of the left lower lobe bronchus. The upper lungs are clear and there is no evidence of vascular congestion. Findings most likely represent (Over) 11:29 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ?PE Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) superimposed infectious process. No osseous abnormality is identified. Upper lungs are clear. There is no significant pleural or pericardial effusion. There is no shift from normally midline structures. Mucosal thickening is seen within scattered ethmoid air cells and there is partial opacification of mastoid air cells bilaterally. COMPARISON: CT of the head, . Included portions of the upper abdomen are unremarkable. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. IMPRESSION: Ill defined density in right lower lung, which may represent a small focus of aspiration or early developing pneumonia. Assess for interval change on head CT. -white matter differentiation is well preserved. No abnormal soft tissue masses are identified in the thorax. This is consistent with a left lower lobe collapse. There is increased lordosis at C2/C3, stable. A tracheostomy tube is noted. Sinus rhythm. Sinus rhythm. There is no pathologically enlarged mediastinal, hilar or axillary lymphadenopathy. Otherwise normal study. Incomplete right bundle-branch block. IMPRESSION: No acute intracranial process. There is left lower lobe collapse, with low density material within the left lower lobe bronchus. No evidence of pulmonary embolism as questioned. | 17 | [
{
"category": "Radiology",
"chartdate": "2156-10-22 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1163946,
"text": " 6:36 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with known c-spine fx\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe 8:45 PM\n No significant change from with stable 7 mm anterolisthesis of C3 on\n C4.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with known C-spine fracture. Please assess for\n interval change.\n\n TECHNIQUE: CT images of the cervical spine with sagittal and coronal\n reformats.\n\n FINDINGS:\n Compared to , there is unchanged anterolisthesis of C3 on C4\n measuring about 7.5 mm (grade 2). Unchanged angulation of the anterior\n fixation rods with indentation on the right sided oro- and hypo-pharynx.\n Unchanged inferior displacement of the intervertebral disc spacer. There is\n increased lordosis at C2/C3, stable. Patient is status post laminectomy at\n C3/C4, unchanged kinking of the spinal cord at C3/C4.\n\n IMPRESSION:\n No significant change compared to with 7.5 mm anterolisthesis\n of C3 on C4.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-24 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1164155,
"text": " 8:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with trach and shortness of breath\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy with shortness of breath.\n\n FINDINGS: In comparison with the earlier study of this date, there is some\n increasing opacification at the right base, most likely related to\n atelectasis. Residual atelectasis and left effusion again seen.\n\n The upper lungs are clear and there is no evidence of vascular congestion.\n Tracheostomy tube remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1164081,
"text": " 4:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: trach'd on vent\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man on vent\n REASON FOR THIS EXAMINATION:\n trach'd on vent\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:48 A.M. ON \n\n HISTORY: 48-year-old man on a ventilator with tracheostomy.\n\n IMPRESSION: AP chest compared to and 20:\n\n Left lower lobe aeration has improved substantially, though there is some\n residual atelectasis and increasing small left pleural effusion. Upper lungs\n clear. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-28 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1164828,
"text": " 11:29 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with respiratory distress and is subtherapeutic on coumadin\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old male with respiratory distress, subtherapeutic on\n Coumadin. Evaluate for pulmonary embolism.\n\n TECHNIQUE: CTA of the pulmonary arteries was performed following the\n administration of 100 cc of intravenous Optiray. Multiplanar reformatted\n images were also acquired.\n\n COMPARISON STUDY: CTA of the neck from .\n\n FINDINGS:\n\n The pulmonary arteries opacify normally and taper distally without evidence of\n embolism. The thoracic aorta is normal in caliber. The great vessels opacify\n normally. A tracheostomy tube is noted.\n\n There is left lower lobe collapse, with low density material within the left\n lower lobe bronchus. There is also some adjacent areas of ground glass opacity\n noted in the left upper lobe. There are patchy areas of nodular opacity seen\n in the right lower lobe, with a tree-in- appearance (image 66 of series 4).\n\n\n There is no significant pleural or pericardial effusion. There is a stable\n calcified granuloma in the right lung apex (image 7 of series 6). A few small\n bilateral hilar lymph nodes are identified. There is no pathologically\n enlarged mediastinal, hilar or axillary lymphadenopathy. No abnormal soft\n tissue masses are identified in the thorax.\n\n Included portions of the upper abdomen are unremarkable.\n\n OSSEOUS STRUCTURES:\n\n There is no lytic or blastic lesion identified.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism as questioned.\n 2. Left lower lobe volume loss, with low density plugging of the left lower\n lobe bronchus.\n 3. Nodular opacities noted in the right lower lobe, along with ground glass\n opacity seen in the left upper lobe. Findings most likely represent\n (Over)\n\n 11:29 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n superimposed infectious process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1164354,
"text": " 11:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: access for interval change on head CT\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with c4 tetraplegia now with left pupil greater in size than\n right\n REASON FOR THIS EXAMINATION:\n access for interval change on head CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 12:08 AM\n no definite actue intracranial pathology. hyperdensity at the right temporal\n pole is likely secondary to volume averaging and appears artefactual.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with C4 tetraplegia, now with left pupil greater\n in size than right. Assess for interval change on head CT.\n\n COMPARISON: CT of the head, .\n\n TECHNIQUE: Contiguous axial images were obtained through the head without the\n administration of IV contrast. Multiplanar reformats were generated and\n reviewed.\n\n FINDINGS: There is no evidence of hemorrhage, infarction, shift of normally\n midline structures, discrete masses, or brain edema. The ventricles and sulci\n are normal in size and configuration. Minimal mucosal thickening is noted\n within scattered ethmoid air cells. There is partial opacification of\n bilateral mastoid air cells. The remainder of the visualized paranasal sinuses\n is clear.\n\n Again demonstrated is dramatic subluxation of C3 on C4, better seen on the\n cervical spine CT of .\n\n IMPRESSION: Cervical spine subluxation. Otherwise normal study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1163978,
"text": " 3:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pneumothorax, other abnormalities\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with trach placement, recent DVT on coumadin with increasing O2\n requirement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumothorax, other abnormalities\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:38 A.M. ON \n\n HISTORY: Trach placement. Recent DVT, on Coumadin. Increasing hypoxia.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Left lower lobe is collapsed, which may explain hypoxia. A small region of\n consolidation could be pneumonia, but this has been abnormal since and\n may be in another region of atelectasis instead. The upper lungs are grossly\n clear. The heart is normal size. A small left pleural effusion has increased\n overnight. Tracheostomy tube is in standard placement, but is relatively\n small given the size of the trachea and should be evaluated from a clinical\n standpoint.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1164020,
"text": " 10:41 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: desatting on vent\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man\n REASON FOR THIS EXAMINATION:\n desatting on vent\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:56 A.M. \n\n HISTORY: 48-year-old man with desatting on a CT ventilator.\n\n IMPRESSION: AP chest compared to , 3:33 a.m.:\n\n Lung volumes are appreciably larger now than earlier today, with clearing of\n atelectasis in the right infrahilar lung, but the left lower lobe remains\n collapsed and may be the cause of hypoxia. Upper lungs are clear. Heart size\n is normal. Pleural effusion on the left is minimal if any. Tracheostomy tube\n in standard placement.\n\n Dr. was paged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1164174,
"text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with trach, vent, PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Quadriplegia, cervical spine fracture, evaluate for interval\n alteration in pneumonia. No recent thoracic or abdominal intervention.\n\n COMPARISON: Multiple radiographs dating back to and most recently\n .\n\n FINDINGS: There is relative lucency in the left lower hemithorax which\n suggests a pneumothorax but a subsequent erect radiograph excludes this.\n Retrocardiac density consistent with left lower lobe atelectasis is stable.\n The cardiac size is normal. The right lung is normal in appearance. A\n tracheostomy tube is unchanged in position since .\n\n IMPRESSION: No evidence of pneumonia. Unchanged left lower lobe atelectasis.\n\n\n Result communicated by telephone to clinical team member, Dr , at\n 15.30 hours .\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1163880,
"text": " 12:57 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich, cva\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with altered MS, on coumadin and fragmin\n REASON FOR THIS EXAMINATION:\n ich, cva\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MDAg 1:23 PM\n no acute intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Altered mental status, on Coumadin and Fragmin.\n\n COMPARISON: No relevant comparisons available.\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired through the head.\n Bone reconstructions were obtained for evaluation. The study is somewhat\n limited by motion artifact despite multiple acquisitions.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\n major vascular territorial infarct. Ventricles and sulci are normal in size\n and symmetric in configuration. There is no shift from normally midline\n structures. -white matter differentiation is well preserved. Mucosal\n thickening is seen within scattered ethmoid air cells and there is partial\n opacification of mastoid air cells bilaterally. The remainder of the\n visualized paranasal sinuses are clear. No osseous abnormality is identified.\n\n IMPRESSION: No acute intracranial process. Limited exam due to motion\n artifact.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1163877,
"text": " 12:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: cardiopulm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with quadraplegia, ? altered MS\n REASON FOR THIS EXAMINATION:\n cardiopulm\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Quadriplegia, altered mental status.\n\n COMPARISON: No relevant comparisons available.\n\n FINDINGS: A single portable semi-upright view of the chest was obtained. An\n ill defined density in the right lower lung is present. There is no effusion\n or pneumothorax. The cardiomediastinal silhouette is unremarkable allowing\n for patient position and technique. Osseous structures are intact.\n\n IMPRESSION: Ill defined density in right lower lung, which may represent a\n small focus of aspiration or early developing pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1164364,
"text": " 2:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change in lungs/PNA\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with trach and c4 tetraplegia\n REASON FOR THIS EXAMINATION:\n interval change in lungs/PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy.\n\n FINDINGS: In comparison with the study of , the elevation of the left\n hemidiaphragmatic contour is less prominent. Persistent opacification at the\n left base most likely represents atelectasis, though in the appropriate\n clinical setting the possibility of pneumonia would have to be considered.\n\n The right lung is essentially clear.\n\n Tracheostomy tube remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1164802,
"text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out acute process\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with PNA, trach'ed with increased work of breathing\n REASON FOR THIS EXAMINATION:\n rule out acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy with increased work of breathing.\n\n FINDINGS: In comparison with the study of , there is increased\n opacification in the retrocardiac region with silhouetting of the\n hemidiaphragm. This is consistent with a left lower lobe collapse. There is\n some shift of the mediastinum to the left, though some of this may merely\n reflect obliquity of the patient.\n\n No evidence of acute pneumonia or vascular congestion.\n\n This information has been telephoned to Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-25 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1164268,
"text": " 2:16 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: any obvious mucus plugging on the left\n Admitting Diagnosis: ALTERED MENTAL STATUS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with feeling of increased work of breathing\n REASON FOR THIS EXAMINATION:\n any obvious mucus plugging on the left\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheostomy tube in situ, pneumonia in background of cervical\n spine fracture and quadriplegia. Increased work of breathing. No recent chest\n or abdominal intervention.\n\n COMPARISON: Radiograph performed earlier today at 05:04 hours.\n\n FINDINGS: Apparent lucency projected over the left hemidiaphragm on the prior\n radiograph lies within a loop of bowel. Left lower lobe atelectasis is mild\n and appears to have improved since a radiograph from .\n\n A percutaneous gastrostomy tube and inferior vena cava filter are incidentally\n noted.\n\n IMPRESSION: Lucency projected over the left hemidiaphragm is most likely\n within a loop of bowel rather than a pleural gas collection, this may either\n be subphrenic or within a diaphragmatic hernia, which could be ellucidated\n with CT, if clinically warranted.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-10-28 00:00:00.000",
"description": "Report",
"row_id": 236127,
"text": "Sinus bradycardia. Compared to the previous tracing the rate is slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2156-10-28 00:00:00.000",
"description": "Report",
"row_id": 236128,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno major change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2156-10-23 00:00:00.000",
"description": "Report",
"row_id": 236129,
"text": "Normal sinus rhythm. RSR' pattern in leads V1-V2 with a QRS duration\nof 106 milliseconds. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-10-22 00:00:00.000",
"description": "Report",
"row_id": 236130,
"text": "Sinus rhythm. Incomplete right bundle-branch block. Compared to the previous\ntracing of the rate is increased.\n\n"
}
] |
28,211 | 185,631 | A/P: Pt is a 68 y.o male with HEP C cirrhosis, ETOH abuse, barrett's esophagitis, CVA, sz d/o who presents with encephalopathy and SBP. . #Shock -Likely that pt was somewhat hypotensive at baseline given liver dx. On Maps worsened to 50's on . Urine output decreased and IVF boluses were not helpful. Pt eventually was on three pressors levo/neo/vasopressin. Cause thought to be either sepsis as mixed venous 02 sat 85%, vs intravascular volume depletion (CVP low at times) vs hemorrhage (HCT dropped 6 points, then stabilized). PT given IVF to meet goal CVP of 10. Cultures demonstrated no growth, nonetheless, pt was covered broadly for infection with vanc/zosyn for SBP and aspiration pneumonia. Transaminases substantially dose thought to be element of shock liver, coags worsened, hypoglycemia persisted and pt eventually required D10gtt. PT continued to clinically decompensate, demonstrated shock liver, coagulopathy, hypoglycemia, a-fib with RVR to 180's. Pt's code status eventually changed to DNR. Pt eventually succumbed to his illness on . . #Respiratory Failure-hypoxic. Pt initially intubated for airway protection, but on increasing O2 requirement and PEEP requirement, thought to be due to worsening of aspiration. Pt eventually met criteria for ARDS net ventilation and continued to require this protocol. . #ARF-baseline Cr 0.8. up to 1.4 on admission ddx include prerenal and hepatorenal. Had many casts making ATN likely although no h/o hypotension anuric on , creatinine rising. PT not a candidate for HD, CVVH. . #cerebral edema-Pt monitored for cerebral edema. . #arrhythmia- Pt had episodes of A-fib with RVR, bigem/trigem/quadrigem. Pt on 3 pressors. Attempted to wean off levo/catechols. Pt given anti-nodal agents 2 days ago to attempt to slow rate. EKG showing afib/flutter. Cardiology called, suggested diltiazem. Electric cardioversion considered. . #Anemia-pt with anemia at baseline, admission hct 37 -likely hemoconcentrated, hct dropped form 26 to 20. Pt with gastroccult postive OGT output, BMs guaiac negative, history of varices. Tbili was rising, haptoglobin low. PT given folate and thiamine supplementation. . #Ileus-pt with hypoactive BS, increased output from OGT, pt stooling, diminished bowel sounds.KUB did not show obstruction and OGT was placed to suction. . #Encephalopathy/AMS: hepatic encephalopathy high on ddx. EEG ruled out status epilepticus, meningitis unlikely, other focus of infection and toxic metabolic derangements also likely and contributory.PT given lactulose PR as OGT with high residuals, unable to give adequate dosing of lactulose. SBP treated with vanco/zosyn. Tox screen negative. . #SBP: pt w/ e/o SBP on dx para. On vanco/zosyn. . #ASPiration PNA. Witnessed vomiting while trying to place NGT/OGT. Pt placed on vanc/zosyn. . #Cirrhosis: Hep C and etoh cirrhosis. Liver team followed pt. Given PR lactulose. Abd u/s with doppler did not show thrombosis of portal vein. . #H/o seizure disorder: EEG showed e/o encephalopathy. Pt had been on keppra for past 5 yrs. He was continued on this medication in the inpatient setting. . # Thrombocytopenia: within baseline range of 50 to 90. Platelet count trended, heparin products avoided. . # GERD/Barrett's esophagus: pt was continued on his home PPI. . PPX: PPI, pneumoboots, lactulose . #Access: , | Dopper pulses.GI: Abscent BS, OG tube to regular-changed to intermittent LWS. Vasopressin 2.4U, Neo ^^ 5mcg/k, levophed titrated as tolerated. Softsorb applied and scrotal sling utilized.ID - Pt slightly hypothermic with temp 96 po. Recieved pt hemodynamically unstable, hypotensive and minimal U/O. Pt fluid bolused. Replete lytes prn. Rx with zosyn. Hct stable, WBC^^, lactate 5.6. SVV 13-16.F/E - TFB + 11770ccs yest. BUN/Cr unchanged at 31/0.9 respectively. Lactate 5.6, WBC^^ 13.6. Rx with RISS. Goal to decrease PEEP by 1 as tolerated.ID: Temp 97.7 PO. Pt recieved on Fentanyl and Versed. Resp CarePt remains intubated vent settings weaend to PSV 15/10 abgs show metabolic acidosis rr 18-24 vt 450-550. Continues on lactulose PR.CV: NSR/atrial bigeminy. Fibrinogen 79.9. If low 60s and still in RAF--will cardiovert. RAFib to 160's, 3 separate events-lf amt ectopy/rythm changes,resolving on own/IV Lopressor/changing pressors. Remains on Fentanyl 75mcg/hr. ABG 4.40/38/86/24. ABGs acceptable at this time.SEE CAREVUE FLOWSHEET. Vanco held for level 21.8 - will send level this am.Endo - BS 178-243. Ionized ca 1.02 - treated with 2 gms cagluc iv, repeat IC 1.03 - receiving 4 gms cagluc iv. UOP 0-15cc/hr. Paracentensis done +SBP. Orally intubated on AC 400/28/12/80%. RESP CARE: Last ABG 7.41/40/135/26/0 FI02 decreased to .60. Continues on keppra. Continues on vasopressin 2.4units/hr, neosynephrine 4.5mcg/kg/min, and levophed 0.091mcg/kg/min (levophed titrated for MAP's >55 and urine output >30cc/hr). Vanco and zosyn for PNA and SBP. K 2.9 - repleted with 80 meq kcl iv, repeat K 4.6. bilious) fluid via ETT. Remains on 3 pressors - vasopressin infusing at 2.4 units/hr, neosyn at 4.50 mcgs/kg/min and levophed at .107mcg/kg/min. L pupil sluggish, R surgical. BP-titrate press Levo 0.12mcg/kg/hr. CVP 14-16.Resp: Vent AC 28/400/50%/PEEP 12. ABG's 7.26/32/94-down from 7.36, repete ABG 7.22/34/80 on AC 500/x22/60%/+10-inc Fio2 to 70%, RR 22 with rare overbreathing vent x 1 bpm. Continues on vanco (increased today) and zosyn.GI/GU: Abd-firm. HCT 33.3. Pt is at max dose of Vassopressin and Neo. Lactic acid trending down to 4.0. Lactate 9.2. FS amp D5W with approp responce. Labile FS w/ bicarb bolus/ D10 gtt, Q 1-2 hrs FS. CVP 5-12, inc post bolus approp. Transpulmonary Pressure on insp +2 and on expiration 11.7. Hold vanco dose for PM. PM vanco dose to be held.GI/GU: Abd-firm. Continues on vanco and zosyn. Continues on levophed, neosynephrine, and vasopressin. HR converted to ST, w/ occas PAC's. BP/UOP-titrate pressures as ordered/necessary3. Known aspirating while HOB flat. FBS now WNL.ID: Afebrile, Vanco held this morning secondary elevated level, now d/c'd. ABG 7.39/38/81/24. BS clr rt, vesicular on lt. RSBI 100. Continues on lactulose PR>Resp: Vent, AC 26/400/50%/PEEP 10. 0700-1600Pt recieved vented and DNR but full care warrented. BUN/CR 46/1.8 (44/1.2).FEN/ENDO: Accepted on D10 @ 75mc/hr, held during D5w Bicarb bolus, Fs 105-241. INR 7.00 and 2 units of FFP given...INR now 3.4. FiO2 weaned to .4. Access includes LIJ, L axillary a-line. Continues on Keppra. DNR/DNI.POC1. NPO- OG tube to intermittent LWS, /yellow aspirate, trace guiac pos. Pt/PTT/INR 51.5/>150/6.8. dilutional. Suctioned x 1 for scant amounts think, white secretions.GI: Absent BS, abdomen firm, OGT to LIWS, ~1L removed. HCT down however likely dilutional. Inc acidosis/ BP - treated w/ 3 amp bicarb in D5W 1 hr bolus. Pt had generalized +4 anasarca w/ weeping. Known aspiration while lying flat.CV: HR 96-116 SR/ST, inc in HR with inc in Levo, rare PAC, while turning went info atrial bigeminy low 100's. NBP 99-156/44-71. NPO w/ OG to LSW.ID: T max 98.4, on renally dosed IV Zosyn, Vanc QD trough drawn @ 0600. Resp CarePt remains intubated and currently vented per ARDS protocol with PEEP now decreased to 10cmh20 with goal to wean by 1 as tol. DNR/DNI-OK to escalate care.POC.1. Cont monitor resp status/wean as tolerated2. Monitor ABG/lytes. Does note tolerate activity (turning/positioning/suctioning)- drop BP/inc oral secretions/ sat/atrial disrythmias. Tolerates turning poorly- in BP. Last ABG WNL with adequate oxygenation on present settings. Bicarb given via RN. Continues none-minimal UOP despite inc in pressors w/ rising BUN/Cr. BS late AM coarse rhonchi on rt, vesicular left. BS at start of shift clear rt, vesicular left. There is a trivial/physiologic pericardial effusion. K 3.2 repleted 60meq IV KCL, repete 4.1. + ankle edema.GI - Abd soft. Hx thrombocyopenia. Rx with lactulose q 6hrs. In , pt underwent dx paracentesis which was + for SBP. Left atrialabnormality. Pt currently being given lactulose enema.GU: u/o 5-60cc/hr via foley. lactulose edema2. Resp CarePt with worsening abg. Cont monitor oupul OG tube ?ABD ct4. aspirated. Since the previous tracing of sinus bradycardia is now absent and atrial ectopy, low QRS voltage andST-T wave changes are now seen.TRACING #1 +bile aspirated and auscultated placement. 1 Unit RBC for HCt 20.1. UOP 7-38cc/hr. Hypotension. + aspiration precautions. Modest ST-T wave changes. IV kepra administered. Am lytes pend.GI - Abd firm. pcxr done this am~ multi focal pna and sm right pleural effusion. Given lactulose enema. per pcxr ogt tip facing upward toward the GE juncture, ogt pulled back. Bld and tox screens neg. Rx with ceftriaxone, albumin and lactulose. 7p to 7a Micu Progress NoteNeuro - Pt withdraws to nailbed pressure. Given thiamine and folate IV. Mixed venous 02 34. IV antibx for SBP/asp pna. LS crackles rt base and diminished left base. ceftaz and flagyl were addedperitoneal fluid c/s neg, bld cx pending, sputum c/s gram + rods so far culture pending. Pt oriented x 0. T max 97.2 PO. Monitor u/o and ARF. pt will require head CT if no improvement in MS.Resp - LS initially clear. Lactulose given. Decreased u/o over course of day; bolusing at present. Wean as tol. bilious gastric contents from ett. pt remains afebrile. Mg 2.0. L ALine placed, NBP and ABP correlating approp. FS 121-135-no coverage.ID: ON IV Vanco, IV Unasyn, started IV Ceftriaxone. RIJ TLCL placement confirmed. known SBP, PNA. Levo started @ .08mcg/kg/hr - titrated up, currenlt @ 1.2mcg/hr, attempting to wean drop MAP 53-58. MD attempted to place OGT. Right ventricular chamber size and free wall motion arenormal. | 41 | [
{
"category": "Nursing/other",
"chartdate": "2175-04-18 00:00:00.000",
"description": "Report",
"row_id": 1631101,
"text": "Resp Care\n\nPt remains intubated and currently vented on full support with esophageal balloon still in place for optimal ventilation/oxygenation monitoring. Measurements obtained this morning shows Transpulmonary end exp pressures at +4cmh2o and transpulmonary inspiratory pressure of 14 on 12cmh2o PEEP. Last ABG with adequate ventilation and acceptable pao2 in the 80s. Will wean PEEP by 1cmh20 to prevent derecruting. BS remains course sxing for thin bilious secretions via ETT. Will continue with vent support and adjust settings as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-19 00:00:00.000",
"description": "Report",
"row_id": 1631102,
"text": "MICU nursing progress note 7P-7A\nEvents - Pt converted from NSR->Aflutter 150s. NBP stable with RAF, fluid bolused 500cc x 2, trying to back off on levophed without success. Lactate 5.6, WBC^^ 13.6. Ca repleted, other lytes were WNL. low threshold for cardioversion --if NBP MAP decreases to low 60s, will CV.\n\nNeuro - Fentanyl 50 mcg/hr, pt is unresponsive to any stimuli, no overbreathing set RR on vent. No spontaneous movement, no gag/cough.\n\nResp - AC 400 x 28, +11, 60%. AM ABG 7.37/37/81/22, this was drawn immediately after pt in RAF. Sats 96-100%, RR 28. lungs coarse, diminished at bases. Sx small dark brown plug, spec sent to lab.\n\nCV - ABP dampened, 60-70 pts lower than NBP. NBP is accepted BP per team. NBP 135-168/48-59, MAPs 70-105. BP decreased to 89/60 during turn for bath, neo and levophed increased at that time. NSR 96-100, ->RAF 130s-150s, slight decrease in BP with RAF. Fluid bolused 500cc x 2. Vasopressin 2.4U, Neo ^^ 5mcg/k, levophed titrated as tolerated. Hct stable, WBC^^, lactate 5.6. Anasarca, weeping from all puncture site, scrotum.\n\nGI - Abd firm, no BS. Flexiseal with small amt liquid dark green stool. NPO, OGT-> LCS for yellow bilious dng.\n\nGU - UOP 7-30cc/hr amber urine.\n\nID - Afebrile. Vanco and zosyn for PNA and SBP. Many Cx pending.\n\nSocial - Wife called last night for update.\n\nPlan - Titrate levophed first if possible. Goal MAP >60 by NBP. If low 60s and still in RAF--will cardiovert. Follow lytes. Pt is full code, further discussion with wife re pts poor prognosis and plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 1631090,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details.Suctioned for mod amts thick yellow secretions.HR freq PVC'S.Sedated with fentanyl and midazolam.Getting levophed and pitressin.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 1631091,
"text": "Nurse Progress Note 1900-0700\n\nEvents: Total 4.5 L NC in bolus/IVF for low UOP/CVP/BP. RAFib to 160's, 3 separate events-lf amt ectopy/rythm changes,resolving on own/IV Lopressor/changing pressors. Atemmt to wean Levo to Neo failing in setting RAfib, Lactate rising, inc need O2 requirements, cont low BP/UOP. Vassopressin started, but needed to returned on Levo. currenlty Levo @ 1.0mcg/kr Neo 4.5 mcg/kg, 2.4 units/hr, fluid bulus and Bicarg gtt initiated for inc metabolic acidosis. Plan for meeting with wife in AM about care. See carevue for details.\n\nNeuro/Pain: Sedated on IV gtt 3mg/hr Versed, 75mcg/kg IV gtt Fent-no changed throughout shift, no bolusing required. R pupil irreg, nonreactive, L pupil 4mm with brisk reaction. Initially appearing aggitated with nursing care-mouthcare/turning, MAE in bed W/D to naibed stimuli, throughout shift in spont movement/movement with care-grimace with sternal rub. Abscent gag/cough.\n\nResp: Orally intubated for airway protection-now aspiration PNA, LS coarse throughout, sat 88-100% inc difficult to obtain, minimal change wih suctioning-minimal suction for thin tan secretions. ABG's 7.26/32/94-down from 7.36, repete ABG 7.22/34/80 on AC 500/x22/60%/+10-inc Fio2 to 70%, RR 22 with rare overbreathing vent x 1 bpm. Sputum growing gram neg cultures.\n\nCV: H Rythm SR/ST/SA to atrial bigeminy, trigeminy, run APC's, occ PVC's rapid afib 1140-170's. Spont into Rapid Afib x3, in/out rythm approx 10 min each time given 5mg IV Lopressor x2. BP 68-120's/30-50's- CVP goal >13, bolusing for T CVP (PEEP) 10 total 3.5 cc NS in 500cc bolus, approp temp inc in CVP/BP-overall trending down post boluses. CVP 5-13. Attempt to wean off Levo, stat Neo minimally successful MAP cont 50's Vassopressin started @ 2.4 units/hr, pt in RAF approx 0500 BP 68/30 Levo restarted and titrated-currently, Neo @ 4.5mcg/kg, @ 2.4 units/hr, Levo .10mch/kg Bp 90/40's- goal MAP >60. + pitting bilat lower extremitiy edema tapering up thigh, 3+ pitting bilar arm edema, mod dependent hip edema. Dopper pulses.\n\nGI: Abscent BS, OG tube to regular-changed to intermittent LWS. Thin bilious secretions. Flexiseal with minimal amt green liquid stool. IV Regalin.\n\nGU: Amber urine via foleu. UOP 0-15cc/hr. No change in UOP with in IVF. Pos 2400 past 24hrs, pos for LOS.\n\nFEN/ENDO: NS @ 125cc/hr-completed for low UOP. Repete K 3.4 repleted with 60 mcg IV KCL, Mg 2.0. Ionized calcium repleted 2 gm Calcium gluconate. Q6hrs labs. FS low 100's-no coverage.\n\nID: Tmax 97.2 t max 96.0. Vanco 32.8-no AM dose-needs QD dosing. PT/PTT/INR 38.8/61.5/INR 4.3- no intervention, known pancytopenia. Lactate inc 4-5.8.\n\nHeme: HCt stable 34.2\n\n\nSkin: Pt did not tolerate turning-no visible breakdown in skin integrity, oozing from previous IV access-no s/s infection.\n\nSocial: Wife called and by MS, will visit today, please call with any changes in care. Full Code\n\nPOC\n1. Cont monitor MS, lactulose edema, for ecepalopathy, keppra\n2. BP-titrate press\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 1631092,
"text": "(Continued)\nors\n3. Cont emotional support of pt and family\n4. COnt all routine ICU care\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 1631093,
"text": "Resp Care\n\nPt intubated and currently vented on full support via ARDS net protocol with multiple vent changes made to optimize ventilation/oxygenation status. Esophageal balloon also placed with transpulmonary pressures around 0 on PEEP 10cmh20. PEEP now at 12cmh2o. WIll obtain ABG on present settings and make changes accordingly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 1631094,
"text": "0700-1900 MICU PROGRESS NOTE\n\n\n68 yo male who was admitted on after being found by wife at home confused, combative and naked. Wife reported 2 days prior to admission. Pt has extensive PMH which includes Hep C and ETOH cirrhosis. Please see care-vue for detailed history. PT was very combative AND DIFFICULT TO CONTROL intially. Pt was intubated on and OGT placed w/ increased difficulty. Pt vomitted and abd was large and distended...KUB (-). Pt treated for aspiration pneumonia. Paracentensis done +SBP. Over the last 48 hr condition has deteriorated. Dr and team spoke with wife...remains FULL CODE.\n\n Recieved pt hemodynamically unstable, hypotensive and minimal U/O. PH at 7am => 7.22 and recieved a total of 13 amp BiCarb(mixed w/ IVF). pH 7.30 currently. Pt is at max dose of Vassopressin and Neo. Levo 0.12mcg/kg/hr. INR 4.3 this am and 6.8 this afternoon, vit K 10mg given. Versed stopped for decreasing mental status. Pt continues to aspirate gastric contents, suctioned for large amounts of green bile-like fluid via ETT.\n\n\n Pt recieved on Fentanyl and Versed. PT not resposive to painful or verbal stimuli. ? worsening encephalopathy vs acute process. Pt too unstable for CT scan, Versed stopped and neuo status monitored. Pt not blinking, eye care provided and natural tears ordered. Remains on Fentanyl 75mcg/hr. No Gag/ Cough reflex noted. Not moving extremities. No seizures noted, remains on Keppra.\n\n\nC/ Pt has sinus arrthymias this morning, ? bijemeny w/ frquent and multi PAC's. Pt also has episode of RAF this afternoon w/ rate increasing 120-140's. Pt fluid bolused. True calculated CVP 10-13(w/ goal ). Pt given total of >4L D5 w/ Bicarb. Pt had episode around noon B/P dropped tp the 70's, levo increased and was later titateddown. Pt was seen by cardio, who suggests Diltiazem for RAF w/ RVR. Pt third spacing edema throughout legs, scotum and sacral area. INR 6.8 this afternoon and Vit K given. ECHO completed today, see care-web for report. Vigeleo monitor placed on patient to measure SVV.\n\nRESP- CXR this am worsening, w/ B infiltrates and increasing \"white-out\". Pt placed on ARDS net protocol for ventillation. Suctioned frequently for what appears to be gastric contents, large amounts of greenish bile-like fluid. See care vue for ABG trending and vent changes. Ionized ca 1.05 at 4pm and replaced w/ 2gm calcium gluconate. SEE care vue for vent changes. Lungs coarse diminshed at bases.\n\n\nG/I- OGT to LWS draining > 800cc of light green fluid. ABd firm, slightly distended absent bowel sounds. Flexi-seal in place draining small amounts of liquid green stool.\n\nG/U - Urine minimal amounts, U/O 0-40cc/hr..urine dark brown cloudy\n\nSKIN- intact but jaundiced\n\n Wife , in today...spoke w/ Dr and team regarding plan and prognosis. Social work and clergy also in to provide support\n\n\n\nPlan-\nHead CT in am if more hemodynamically stable\nKeep CVP 12\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 1631095,
"text": "(Continued)\n-15\nBronch in am\nTitate pressors as tolerated\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-18 00:00:00.000",
"description": "Report",
"row_id": 1631096,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Remains unresponsive to stimuli. No gag/cough reflex. No movement of exts. R pupil surgical, L pupil 4mm, sluggish to react. Remains sedated with 75mcgs/hr fentanyl iv. No sz activity noted - rx with iv keppra. Plan is for head CT - pt still too unstable at this time.\n\nResp - No vent changes this shift. Orally intubated on AC 400/28/12/80%. RR 28. 02 sat 89-100%. LS coarse throughout. Sx for sm amts yellow (? bilious) fluid via ETT. Most recent ABG 7.32/49/66/26/-1.\n\nC-V - HR 62-78 NSR with occas PAC's, no runs of RAF. ABP 90-125/50's. SBP falls to 70s when pt placed flat for turns. aline dampened - ? will need to be replaced shortly. NBP ~ 10-15 pts higher than ABP. Remains on 3 pressors - vasopressin infusing at 2.4 units/hr, neosyn at 4.50 mcgs/kg/min and levophed at .107mcg/kg/min. Goal MAP > 60. MD, wean levophed prior to neo. Exts cool with pitting edema. + dopplerable pedal pulses. Vigileo monitor - CO 5.2-5.8. SVV 13-16.\n\nF/E - TFB + 11770ccs yest. Urine output 5-35ccs/hr via foley. Acidosis treated with 2 L 1/2 NS with 75 meq nabicarb. Ionized ca 1.02 - treated with 2 gms cagluc iv, repeat IC 1.03 - receiving 4 gms cagluc iv. K 2.9 - repleted with 80 meq kcl iv, repeat K 4.6. BUN/Cr unchanged at 31/0.9 respectively. CVP 10-12 ( goal 12).\n\nGI - Abd firm. Absent BS. No meds given via OGT. OGT to LWS draining ~100ccs yellow fluid. Flexiseal accidentally dislodged, replaced. Passed 200ccs greenish liquid stool.\n\nHeme - Hct stable at 30.9. PTT 107.2. INR 6.5( previously 6.8). No further vit K at this time MD. from IV access sites.\n\nSkin - Skin on back and coccyx intact. Pt oozing lg amts serous fluid from edematous scrotum and arms. Softsorb applied and scrotal sling utilized.\n\nID - Pt slightly hypothermic with temp 96 po. WBC 9.7. Lactic acid trending down to 4.0. Rx with zosyn. Vanco held for level 21.8 - will send level this am.\n\nEndo - BS 178-243. Rx with RISS. If BS remains elevated, pt may require insulin gtt.\n\nSocial - Wife called for update on pts condition.\n\nA+P - Attempt to wean fio2, ? increase peep. Plan is for bronchoscopy today. Ongoing neuro assessment. Wean pressors to maintain MAP > 60. Monitor f+e status. Replete lytes prn. Diligent skin care. Emotional support to wife.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-18 00:00:00.000",
"description": "Report",
"row_id": 1631097,
"text": "RESP CARE: Pt remains orally intubated with 7.5ETT/22 lip. on full vent support, no changes made overnight. ABGs acceptable at this time.SEE CAREVUE FLOWSHEET. Esophageal balloon still in place. No measurements this shift. Lungs crackles L>R. Sxd bile colored fluid. No RSBI due to FI02/PEEP level\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-18 00:00:00.000",
"description": "Report",
"row_id": 1631098,
"text": "RESP CARE: Last ABG 7.41/40/135/26/0 FI02 decreased to .60.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-18 00:00:00.000",
"description": "Report",
"row_id": 1631099,
"text": "Addendum - sats 100% - ABG sent - 7.40/41/135/0/26. Fio2 decreased to 60%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-18 00:00:00.000",
"description": "Report",
"row_id": 1631100,
"text": "MICU Nursing progress note 0700-1900\nNeuro: Fentanyl decreased to 50mcg. Not responding to painful stimuli. No movements of extremities. No seizure activity noted. Continues on keppra. Not following commands. L pupil sluggish, R surgical. Continues on lactulose PR.\n\nCV: NSR/atrial bigeminy. HR 70-104. NBP 104-141/41-63. SBP decreases to 70's when head put down. Continues on vasopressin 2.4units/hr, neosynephrine 4.5mcg/kg/min, and levophed 0.091mcg/kg/min (levophed titrated for MAP's >55 and urine output >30cc/hr). DP's dopplerable. Vigileo: CO 4.8-6.0 but a-line tracing dampened and accuracy of vigileo results questioned-team notified. A-line rewired but tracing continued to be dampened. No noted runs of a-fib. INR 6.5. HCT 33.3. Fibrinogen 79.9. ICa 1.10 (team aware). CVP 14-16.\n\nResp: Vent AC 28/400/50%/PEEP 12. ABG 4.40/38/86/24. O2 sats >97%. Suctioned small amts of yellow/thick secretions. Not breathing over vent. LS-coarse. Goal to decrease PEEP by 1 as tolerated.\n\nID: Temp 97.7 PO. WBC 9.7. Continues on vanco (increased today) and zosyn.\n\nGI/GU: Abd-firm. Absent BS. NPO. Flexiseal-trace amts of brown, liquid stool. OGT to LWS-yellow. Foley-amber/cloudy. Output 10-30cc/hr.\n\nSkin: Intact, jaundice. Anasarca throughout. Oozing from puncture sites/scrotum/upper extremities. Many bruises on skin.\n\nSocial: Full code. Wife visited, updated on POS.\n\nPlan: Wean PEEP by 1 as tolerated. ? A-line placement. Wean sedation as tolerated. Monitor lytes/HCT. Sputum culture. Wean pressors as tolerated-levophed first w/goal MAP>55 and urine output >30cc/hr. Continue skin care. Emotional support for patient/family. Routine ICU care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-20 00:00:00.000",
"description": "Report",
"row_id": 1631108,
"text": "Resp Care\nPt remains intubated vent settings weaend to PSV 15/10 abgs show metabolic acidosis rr 18-24 vt 450-550. BLBS course, lavaged and suctioned for scant thick yellow secretions. Plan to continue on PSV overnight a tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-20 00:00:00.000",
"description": "Report",
"row_id": 1631109,
"text": "MICU Nursing Progress Note 0700-1900\n\nCode: DNR/DNI\nAllergies: NKDA\n\nEvents: Axillary a-line placed, levophed titrated up to maintain MAP >50, started on D10 gtt for hypoglycemia, switched to CPAP+PS for dysynchrony with vent.\n\nNeuro: Pt unreposponsive, does not withdraw to noxious stimuli, no spontaneous movement noted to any extremity, L pupil sluggishly reactive, cough/gag absent. Fentanyl increased to for vent dysynchrony with some effect. Unable to assess pt's pain.\n\nCV: HR 90-120s SR/ST with no ectopy noted, BP 80-100 systolic, levophed increased in order to maintain MAPs >50 MD request. Other pressors remain unchanged. CVP 9-12. Received 1L fluid bolus this AM in order to get CVP >10. Axillary a-line placed under US by MD without incident, good waveform/correlation to NBP, radial a-line d/c'd. Received 2 units FFP and additional dose IV K prior to procedure for elevated coags with desired response. HCT down however likely dilutional. Lactate 9.2. Severe anasarca, weeping from multiple sites, drainage bag applied with excellent effect. Access includes LIJ, L axillary a-line. Extremities cool and mottled, team aware.\n\nResp: Pt on CPAP+PS for afternoon secondary to overbreathing/being discoordinate with vent, however switched back recently for increased WOB. Current vent settings AC 50%400*26/+10, STV 500s, MV , RR 20s with sats >90% with ABG of 7.28/33/60. Received 1.5 amps Bicarb for dropping level. Lungs clear to coarse, diminished on L side. Suctioned x 1 for scant amounts think, white secretions.\n\nGI: Absent BS, abdomen firm, OGT to LIWS, ~1L removed. All PO meds held. Flexiseal patent, draining small amounts green liquid stool.\n\nGU: Foley patent however pt anuric, made total 5cc urine this shift.\nAfternoon labs revealed worsening BUN/Cr.\n\nEndo: BS dropping this morning to 50s received amp D50 x 2 with temporary effect, eventually started on D10 gtt @ 50cc/hr. FBS now WNL.\n\nID: Afebrile, Vanco held this morning secondary elevated level, now d/c'd. On IV Zosyn for ASP PNA.\n\nSocial: Wife in this afternoon, updated by Dr. on pt's condition and plan of care. Brother updated by this RN over phone.\n\nPlan:\nwean pressors as tolerated\ngoal MAPs >50\nmonitor FBS\ncontinue to monitor lytes/HCT/lactate\nroutine ICU care and monitoring\nsupport to pt and family\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-21 00:00:00.000",
"description": "Report",
"row_id": 1631110,
"text": "Nurse Progress Note 1900-0700\n\nEvents: Levo titrated for goal MAP >50. Inc acidosis/ BP - treated w/ 3 amp bicarb in D5W 1 hr bolus. 25mg Albumin for low BP. Labile FS w/ bicarb bolus/ D10 gtt, Q 1-2 hrs FS. Inc Fent gtt for discoordination w/ vent with moderate effect. Does note tolerate activity (turning/positioning/suctioning)- drop BP/inc oral secretions/ sat/atrial disrythmias. Continues none-minimal UOP despite inc in pressors w/ rising BUN/Cr. See carevue for details.\n\nNeuro/Pain: Accepted on Fent gtt @ 55 mcg/hr, inc throughout night for discoordination with vent-currently Fent gtt @ 75mcg/hr with moderate improvment, in overbreathing. Unresponsive to any stimuli, no spont movment noted, no seisures noted. R pupil irreg, L pupil sluggish reaction. Abscent gag/cough.\n\nResp: Orally intubated for airway protection/asp PNA/ARDS AC 440/x26/50%/+10 ABG 7.28/32/76/16 sat 91%, post bicarb bolus/gtt 7.33/34/76/19. No vent changes overnight, AM ABG 7.33/35/64/19. Suctioned scant amt white/green thin secretions. LS bilat upper lobes clear/left coarse, bilat lower lobes deminished. Sa 93-98%. Known aspiration while lying flat.\n\nCV: HR 96-116 SR/ST, inc in HR with inc in Levo, rare PAC, while turning went info atrial bigeminy low 100's. Axillay Aline correlating approp w/ NBP, NBP MAP 41-55, ABP MAP 46-57, Vassopressin @ 2.4units/hr, Neo @ 5mcg/kg/min-no chanes overshift, titrating Levo for goal MAP >50, currently @ .137 mcg/kg/min. CVP 5-12, inc post bolus approp. Dopperable pulses, fingertips/toes cool and mottled, warm torso. Anasarca, for all previous IV access sites.\n\nGI: Absent BS, OGT to intermittent LWS, copious oral secretions while lying flat-appears bilious. Yellow to pink/brown aspirate with ? mucus, guiac +. Total 1 L out overnight. Lactulose enema given via flexiseal with poor return, minimal outpul overnight liquid green stool.\n\nGU: Brown urine via foley- UOP 0-6, total 8cc overnight. Approx 40cc pos past 24hrs, pos approx for LOS. BUN/CR 46/1.8 (44/1.2).\n\nFEN/ENDO: Accepted on D10 @ 75mc/hr, held during D5w Bicarb bolus, Fs 105-241. D10 currenly being held while FS drifting down. NPO w/ OG to LSW.\n\nID: T max 98.4, on renally dosed IV Zosyn, Vanc QD trough drawn @ 0600. Known SBP, asp PNA. Lactate 9.0(9.1)\n\nHeme: HCt 23.3(25.0), serial HCT-? dilutional. Given 25mg Albumin for in BP wit moderate effect.\n\nSkin: General edema, copious amt from scrotom, serosang drainage, chucks changed Q1hrs/PRN. R arm x2 site of drainage bag for cont oozing serosang from previous IV access. L wrist drainage bag for cont oozing sersang from previous ALine. Does not tolerate trydine turning, rolling in bed. Perianal area excoriated likely cont edema., cleaned and covered with barrier cream.\n\nSocial: Wife calling in evening and early morning, updated on pt condition, medications and POC. PT stated she will visit appron noon, her church priest will be in approx 2PM to renew wedding vows. Social\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-21 00:00:00.000",
"description": "Report",
"row_id": 1631111,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Vent settings Vt 440, A/C 26, Fio2 50% and Peep 10. PAP/Plateau 33/28. Auto peep 2. Pt. noted to be dysynchronous earlier this shift which was resolved with sedation. ETT rotated to L side and retaped at 22cm/lip. BS equal/clear bilaterally. Sx'd for minimal secretions. Repeat ABG revealed improved metabolic acidosis and PaO2. Bicarb given via RN. No further changes made. Hypotensive, pressors.\nPlan: Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-21 00:00:00.000",
"description": "Report",
"row_id": 1631112,
"text": "(Continued)\nfollowing. DNR/DNI-OK to escalate care.\n\nPOC.\n1. COnt neuro status/ IV fent for vent/pain, lactulose edmas for encepalopathy\n2. COnt titrate pressors goal MAP >50\n3. Con emotional support of pt and family\n4. Cont all skin care\n5. COnt all routine ICU care\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-21 00:00:00.000",
"description": "Report",
"row_id": 1631113,
"text": "ADD Nurse Progress not 1900-0700\n\n0630 while changing OG canister witnessed bright red blood output via OG tube, placed on cont suction with initial 100cc bright red blood, stat HCt drawn-results pending, ordered 2 untis FFP, type & sceeen drawn plan to crossmatch 4 units, MAP 49 Levo inc to .229 mcg/kg.min. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-21 00:00:00.000",
"description": "Report",
"row_id": 1631114,
"text": "0700-1600\n\nPt recieved vented and DNR but full care warrented. Pt has long PMH per care-vue. At 8m assessment pupils non-reactive, not moving extremities and non-responsive to painful stimuli. Pt had generalized +4 anasarca w/ weeping. At @8:30am pt turned, secondary to pads soaked. Tolerated turn poorly, B/P dropped and levophed maxed at 0.30mcg/kg/hr. Pt developed RAF w/ RVR..HR 170-200. Pt given Amioradone 150mg bolus. HR converted to ST, w/ occas PAC's. Ionized Ca continued to be low and pt was given total of 6gm of calcium Gluconate. INR 7.00 and 2 units of FFP given...INR now 3.4. Pt had no urinary output throughout day. Pt continued to have BPRB via OGT, team aware and HCT continued to drop 25(yester) to 20.6 this am. LFt continue to worsen. In regards to the worsening condition of the patient, team call wife to come in. Dr. spoke w/ wife at length at bedside regarding wosening condition. At that time wife was not ready to withdraw care, Fr called per family request and at bedside. Family's priest was also at bedside to provides blessing and last rites. Dr again spoke with wife, wife wants to speak with pt's brother before making any decisions. Brother called at about 3pm and spoke w/ Dr regarding current medical condition. Wife spoke w/ brother via phone and family all agrees to make comfort care only. Wife at bedside and spoke w/ Dr and descion to made to extubate and make CMO. Pt extbated and breathing ceased within about 5min. Resident at bedside to pronounce. Fr in per family request, and offered support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-19 00:00:00.000",
"description": "Report",
"row_id": 1631103,
"text": "RESP CARE: Pt remains orally intubated with 7.5ETT/22 lip. Lungs coarse/no vent changes overnight. ABGs acceptable. No RSBI due to PEEP/hemodynic instability.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-19 00:00:00.000",
"description": "Report",
"row_id": 1631104,
"text": "Resp Care\n\nPt remains intubated and currently vented per ARDS protocol with PEEP now decreased to 10cmh20 with goal to wean by 1 as tol. Esophageal balloon remains in place with measurements obtained this morning as follows: transpulmonary end exp pressure +3 on 11cmh20 PEEP. Peak pressures/plateau pressures 29/27 respectively. BS remains course sxing for small amts of thin yellow secretions. Last ABG WNL with adequate oxygenation on present settings. Will cont with vent support and make changes accordingly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-19 00:00:00.000",
"description": "Report",
"row_id": 1631105,
"text": "MICU Nursing progress note 0700-1900\nNeuro: Fentanyl decreased to 25mcg. Not responding to painful stimuli. No seizure activity noted. Continues on Keppra. No movements of extremities. Not following commands. Continues on lactulose PR>\n\nResp: Vent, AC 26/400/50%/PEEP 10. Occasionally breathing over vent by 1 or 2. ABG 7.39/38/81/24. O2 sats >96%. Suctioned small amts of yellow secretions x2. LS-coarse w/ dim bases.\n\nCV: A-flutter most of day. Self converted to NSR ~1700. HR 80's to 140's. NBP 99-156/44-71. Aline waveformed dampened and not used for BP. BP w/ activity. Continues on levophed, neosynephrine, and vasopressin. Levo titrated for NBP and urine output. DP's dopplerable. Extremities cool to touch. INR 5.0. Platelets 43. ICa 1.15.\n\nID: Afebrile. WBC 13.6. Continues on vanco and zosyn. Vanco trough 32.2 (not a true trough-ordered at wrong time), team aware. PM vanco dose to be held.\n\nGI/GU: Abd-firm. Absent BS. NPO including meds. Flexiseal-green/liquid. OGT to LWS-yellow secretions. Foley-amber/cloudy. Output-10-35cc/hr, s/p turning once output 220cc. ~34L + LOS.\n\nSkin: Intact, jaudice. Anasarca. Continues to drain from puncture sites and scrotum. Many bruises on extremities present. Changed to triadyne bed.\n\nSocial: DNR. Wife and nephew in to visit. Wife met w/ team and updated on patient's condition, decided to change code status to DNR. Brother from called and updated on POC. Wife stated ok to talk to patient's family about condintion and POC. Social work involved w/ wife.\n\nPlan: Wean levophed as tollerated. Monitor ABG/lytes. Wean PEEP as tolerated. Continue antibiotics. Goal MAP>55 and urine output>30. Continue skin care. Emotional support for family. Hold vanco dose for PM. Routine ICU care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-20 00:00:00.000",
"description": "Report",
"row_id": 1631106,
"text": "Nurse Progress Note 1900-0700\n\nEvents: Unable to wean from Levo, total 2L NS for low UOP/BP/CVP. Noted mild discoordination with vent-inc Fent 35mcg/kg, no purposful movement, rare spont movement head side/side. Tolerates turning poorly- in BP. FS amp D5W with approp responce. See carevue for details.\n\nNeuro/Pain: Accepted on 25mcg/kg IV Fentanyl, rare spont movment head side/side, 1x while ET suctioning sm movement left leg/head. No W/D to sternal rub. RR 26-28. RR up/discoordination with vent with in to 35mcg/kg IV Fent, rare bolusing. No s/s seizure/WD. No gag/1x impaired cough with ET suctioning.\n\nResp: Orally intubated for airway protection-now asp PNA/ARDS on AC 400/X26/50%/+10. Sat 93-100%-ABG while 93% 7.38/35/112/22. Sat varying throughout night with turning/RN care. LS coarse bilat upper lobes, coarse/deminished bilat lower lobes. Left pleual effusion. Rare suctioning green, thin secretions. Known aspirating while HOB flat. No vent changes overnight.\n\nCV: HR 91-109 SR/ST rare PAC, poor/varying correlation NBP/ABP, art line very positional, BP measured by NBP-cleared with team. BP 106-123/34-42 MAP 52-60, ABP MAP 41-56, T CVP 7-9 (10 PEEP). Total 1L NC in 500cc NS bolusing-approp inc in ABP, NBP and CVP with bolusing-trending down post bolus. Goal MAP >55, Vassopressin @ 2.4 units, hr, Neo @ 5mcg/kr, Levo currently @ .121mcg/kg-attempt to wean unsuccessfully-MAP 49-51. Anasarca, generalized large amts. Dopperable pulses, finger/toes cool and jaundiced.\n\nGI: Abscent BS, flexiseal in flace with minimal green liquid output. Firm abd-nondistended. US revealing mod ascities.\n\nGU: Amber urine with sedement via foley. UOP 0-30 cc/hr. Goal titrate meds/fluid bolus for UOP 30cc/hr. Pos approx 2060 past 24hrs, approx LOS. Foley irrigated-patent.\n\nFEN/ENDO: No cont IVF, NS fluid boluses. NPO- OG tube to intermittent LWS, /yellow aspirate, trace guiac pos. MD FS Amt D5W. K 4.2, Mg 2.1, Ionized Calcium 1.09-repleted 2mg IV Ca Gluconate. Q 12hr labs.\n\nID: Vanc/Zosyn for asp PNA/SBP. T max 98.4. Vanco trough drawn @ 6 AM. Sputum w/ budding yeast-all other cx pending. Known SBP. Lactate 5.\n\nHeme: HCt 29.4(31.5), giac all stool/gastric sectrtions. Pt/PTT/INR 51.5/>150/6.8. day #2 of daily IV Vit K.\n\nSkin: edema from all IV access. Bilat anticub , line from mult stick attempt-hemostat palced with good effect. LG from scrotum- DNG changed multiple times. Excoriated peri area likely from moiture from edema-barrier cream to site. Triadyne bed -tolerating 15 derees turning Q30min side/center/side for 2-3hrs,-not tolerating physical turning side to side.\n\nSocial: Wife calling in early evening update pt condition and POC. DNR/DNI.\n\nPOC\n1. Cont monitor resp status/wean as tolerated\n2. BP/UOP-titrate pressures as ordered/necessary\n3. Cont emotional support of pt and family ? discussion goals of care in AM\n4. Cont all routine ICU care\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-20 00:00:00.000",
"description": "Report",
"row_id": 1631107,
"text": "Respiratory Care:\n\nPatient intubated/sedated on mechanical support. Vent settings Vt 400, PRVC/AC 26, Fio2 50%, and Peep 10. PAP/Plateau 29/23. BS clear bilaterally. Sx'd for sm amount of thick yellow/green secretions. Auto peep . ETT rotated to R side and retaped at 22cm/lip. Repeat ABG revealed compensated metabolic acidosis with improved PaO2 112 from 81. Esophageal balloon in placed. Transpulmonary Pressure on insp +2 and on expiration 11.7. No further changes made.\nPlan: Continue with mechanical support and wean Peep by 1 every day.\nMonitor Transpulmonary pressures as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-15 00:00:00.000",
"description": "Report",
"row_id": 1631081,
"text": "Addendum - Pt increasingly unresponsive, sedation being weaned. Opens eyes to sternal rub but no movment of exts. Overbreathes vent by 2-5 breaths. RIBI 100. MD aware of mental status changes and INR 2.5. Lactulose to be increased. Albumin to be ordered. ? head CT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-15 00:00:00.000",
"description": "Report",
"row_id": 1631082,
"text": "Respiratory therapy\npt remains orally intubated on full ventilatory support. FiO2 weaned to .4. BS clr rt, vesicular on lt. RSBI 100. Continue ventilatory support, wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-15 00:00:00.000",
"description": "Report",
"row_id": 1631083,
"text": "Resp Care\n\nPt with multiple apparent aspiration. SPo2 trending to 90%. Peep to 10. Remains intubated on full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-15 00:00:00.000",
"description": "Report",
"row_id": 1631084,
"text": "MICU NPN 0700-1900\n\nEvents: Fentanyl weaned off and propofol started. Versed to be weaned down and off if pt tolerates. pt continues to have copious amounts of bile from OGT. Multiple witnessed aspirations from emesis noted today. Peep increased to 10 for decreasing saturation. Please see carevue for all objective data.\n\nneuro: Sedated on propofol gtt @ 35mcg/kg/min and versed at 1mg/hour. Goal is to wean versed off if pt tolerates. Pt does have h/o active drinking so will need to monitor for s/s withdrawal. Mental status remains minimal. Pt does open eyes to painful stimuli but does not track. He does not follow commands. He does withdraw to pain. All neuro checks have been done thus far with sedation on.\n\nResp: worsening PNA on CXR. LS crackles rt base and diminished left base. Current Vent settings ACx14/600/40/10. Sats 90-96%.\n\nCV: HR 90's-110's ST, with no ectopy noted. BP 84-119/43-41. Pt has received a total of 1 liter maintence fluids D5 .45 NS. He received a total of 1 liter NS fluid bolsues for low MAp and low u/o. Left IJ noted to bleed from exit site when turned on left side. CVP 11\n\nGI: OGT to LCS most of the day secondary to copious amount of bileous fluids Pt noted to have gastric emesis when laid flat and turned on 3 occasions. Pt noted to not absorb any po meds despite clamping OGT for 2+ hours after giving them. Team aware. KUB to be ordered. Pt currently being given lactulose enema.\n\nGU: u/o 5-60cc/hr via foley. Pt approx. 4 liters pos. today and overall pos. approx. 10 liters LOS.\n\nID: pt on vanco and ampacillin for PNA. Pt started on rifaximin for SBP.\n\nEndo: RISS\n\nSkin: intact\n\nSocial: wife in to visit with husband. Updated by Dr. .\n\nDispo: Remain in MICU. full code\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-16 00:00:00.000",
"description": "Report",
"row_id": 1631085,
"text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. BS at start of shift clear rt, vesicular left. Pt. fairly flat for arterial and central line placement. Cuff inflated W 5cc air for pressure 28cm H2O pressure. BS late AM coarse rhonchi on rt, vesicular left. Placed on heated humidified circuit. Sx sml to mod amts bileous secretions. Plan: suggest maintaining cuff pressure, keep HOB elevated. Wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-16 00:00:00.000",
"description": "Report",
"row_id": 1631086,
"text": "Nurse Progress Note 1900-0700\n\nEvents: Accepted on Propofol, Versed-all sedation off for neuro check-MAE, good strength, -no head CT, placed on Fent gtt, Versed gtt for sedation. Total 1500ml NS fluid bolus for UOP, CVP -mild inprovment UOP, CVP 11-15, MAP contsistantly 48-53 -Levophed started with goal MAP >55. Art line placed. Vent settings changed with change in sat, ABG. 1 Unit RBC for HCt 20.1. KUB for high residuals-OG to intermittent LWS-will need ABD CT. Noted to aspirate while lying flat. See carevue for details.\n\nNeuro/Pain: Accepted on 35mcg/kg Propofol, 1mg Versed-all sedation off for neuro check-MAE, good strength in arms/legs WD to painful stimuli. Grimace with oral care-impaired gag/cough. R pupil irreg, sluggish RXN, L pupil 3mm brisk reaction. Propofol D/C's-placed back on Fent/Versed-currently Fent @ 35mg/hr, Versed 1mg/hr -minimal bolusing with nursing care. Bilat wrist restraints for ETT protection. Cont IV Keppra-no seizures noted.\n\nResp: Orally intubated accepted on AC 600/x14/40%/+10 sat 89-90%- nothing to suction for ETT, placed on 70% with sat 100% ABG 7.33/40/127/-4. LS coarse throughout-RLL crackles. Placed back on 40% with sat drop 89-90% suctioned thin tan/green secretions ABG 7.34/38/44/-4-placed on 50% with sat trending up 95-97%. Sat drop to 84-85% with turing side to side. Witnessed aspiration when lying flat.\n\nCV: HR 87-110 SR/ST no ectopy noted. Inital NBP 85-90's/ MAP 48-51, CVP 11 (10 PEEP) given total 1500lm NC bolus CVP inc to 15 post bolus, blood. CVP goal >10. Levo started @ .08mcg/kg/hr - titrated up, currenlt @ 1.2mcg/hr, attempting to wean drop MAP 53-58. L ALine placed, NBP and ABP correlating approp. 2+ pitting pedal edema, mild-mod dependent hip and arm edema-elevated on pilows.\n\nGI: Hpoactive BS, OG to to low wall suction, flushing and aspirating thick bilious secretions. Guiac +, occ pink tingued. Firm, nondistended abd. KUB-no difinitive ileius-if stable ? ABD CT. No PO meds given. Liquid green stool via flexiseal.\n\nGU: Amber urine cia foley. UOP 7-38cc/hr. Pos 33cc past 24hrs, Pos LOS. a/p ARF BUN/Cr 28(29)/.7(.8)\n\nFEN/ENDO: NO cont IVD, IVF in 500cc NS bolus. K 3.2 repleted 60meq IV KCL, repete 4.1. Mg 2.0. FS 121-135-no coverage.\n\nID: ON IV Vanco, IV Unasyn, started IV Ceftriaxone. known SBP, PNA. T max 97.2 PO. Vanc trough due @ 0800, sputum culture sent\n\nHeme: HCt 20.1 transfused 1 unit pRBC, repete HCt 26. Pt/PTT/INR 29.2/60.2/3.0 fibrinogen 130. plt 36(25)\n\nSkin: No breakdown in skin integrity noted.\n\nAccess: R IJ-bleeding before shift with hemostat in place, oozing subsiding-DNG left in place.\n\nSocial: Wife calling in pt condition, medications, and POC. FUll Code.\n\nPOC\n1. COnt monitor MS, neuro checks, ? lactulose edema\n2. Cont monitor BP, CVP-goal MAP >55, goal CVP >11\n3. Cont monitor oupul OG tube ?ABD ct\n4. Cont all routine ICU care\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-16 00:00:00.000",
"description": "Report",
"row_id": 1631087,
"text": "Resp Care\n\nPt with worsening abg. MV increased as well as Fio2. BS are coarse and suctioning thick yellow bile.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-16 00:00:00.000",
"description": "Report",
"row_id": 1631088,
"text": "Resp Care\n\n\nPt remains intubated on full vent support. No changes in ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-16 00:00:00.000",
"description": "Report",
"row_id": 1631089,
"text": "Nursing progress notes\nReview of systems:\n\nNeuro: pt sedated on fentanyl 75mcq/hr and versed 3mg/hr. Sedation was increased this shift d/t increased restlessness and adaption to vent. pt MAE, does not follow commands no gag reflex noted\n\nResp: pt intubated abg this am at 0800 7.34/39/77. suctioning ? bilious gastric contents from ett. pt desated to 80s a few times this shift. abg redrawn at 1600 7.27/44/61/21 86% rr increased 22 from 14 fio2 increased from 50 to 60% abg at 1700 7.34/35/108 ls coarse to rhonchi upper lobes w/ diminished bases. pcxr done this am~ multi focal pna and sm right pleural effusion. pt aspirating gastric contents.\n\ncv: hrt rate 90-100s sbp 80s levo phed increased to .15mcq/kg/min. cvp low at 6 w/ low uop 3 500cc ns fluid boluses given w/ increase in cvp but no increase in uop. hrt sounds S1S2 left radial aline intact. hct at 1500 29 stable. venous sat drawn at 0800 85. venous sat drawn at 1500 76.\n\n\ngi: abd firm w/ absent bs. pt npo ogt to lcws w/ 500cc of bilious drainage removed. per pcxr ogt tip facing upward toward the GE juncture, ogt pulled back. lactalose enema given this afternoon pt held onto 650cc for 1/2 hr. flexiseal drained 150 of pt's own stool.\nliver team in this am and will cont to follow pt. reglan added qid.\n\n\ngu: urine output this shift 10-20cc/hr dispite fluid boluses. urine amber in color.\n\n\nendo: fingersticks qid\n\nid: pt random vanco 24.7 vanco held this afternoon. will recheck vanco trough tonight at 0100 and will dose qd. ceftaz and flagyl were added\nperitoneal fluid c/s neg, bld cx pending, sputum c/s gram + rods so far culture pending. pt remains afebrile. lactate 3.2/2.6/3.6\n\nsocial: pt only has his wife . his family is in and her family lives in .\n\nCode: pt full code as of now. micu md talked w/ regarding pt status and plan of care. emotional support given. would like to be called if there is any change in pt's status.\n\nPlan:\n\nvanco trough at 0100\nlabs in am\nfluid boluses prn for low cvp and low uop.\nlactalose enemas qd\ncont to give emotional support to wife and call w/ any change in status of pt.\nliver team to follow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-14 00:00:00.000",
"description": "Report",
"row_id": 1631079,
"text": "Nursing Note (0700-1900)\n\nEvents: Increased opacities on CXR with prob aspiration pna; pt intubated for airway management electively; IV antibx coverage for pna/SBP. Serial Hcts. IVF bolues.\n\nNeuro: Agitated, combative, confused in am;etomidate/succ for intubation; fent/versed for sedation, increased over course of afternoon. Presently mod sedated; withdrawing at times to nailbed pressure. +gag, weak. Wrist restraints removed as pt quite sedated. no sign seizure activity. Cont on iv antizeisure meds.\n\nCV: HR stable, SR. Hypotensive with line placement/intubation-- received multiple boluses over course of afternoon for total of 1.5L; presently receiving another 1L NS for decreased u/o and Bp in low 100's. CVP 10-11. Skin dry, min elasticity/tugor. RIJ TLCL placement confirmed. two piv's patent. unable to obtain aline. Serial hct's questionable for bleed vs hypovolemia. repeat hct for late this evening.\n\nResp: LS diminished with exp wheezing to RUL; some fine crackles to bases at times. Placed on ACV 14/600/70%/5, awaiting ABG. Begun on vanco/unasyn for asp pna.\n\nGi/GU: NGT placement initially placed and confirmed by aspiration by liver team; After line placement, found OGt to be coiled in mouth. Repositioned, and slightly coiled distally per CXR, advanced an additional 4cm per recommendation of resident. Lactulose given. +bile aspirated and auscultated placement. Abd sl firm, tender prior to intubation. Flexiseal in place for foul stool of sm amt; sm amt leakage around tube. Decreased u/o over course of day; bolusing at present. Urine amber. Urine lytes sent.\n\nEndo: Min need for SSI coverage.\n\nSocial: Brief visit by wife; updated by nursing and Dr. . Will need reinforcement of teachings/updates. Full code.\n\nPlan: Cont vent and hemodynamic support. Lactulose as ordered for hepatic encephalopathy. IV antibx for SBP/asp pna. Albumin. Monitor u/o and ARF. Monitor panocytopenia. Serial hcts. Emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-15 00:00:00.000",
"description": "Report",
"row_id": 1631080,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt withdraws to nailbed pressure. Opens eyes occasionally but does not visually track. No spont movement of exts noted - restraints remain off. + gag. Remains sedated with 55mcgs/hr fentanyl and 1 mg/hr versed. No sz activity observed - rx with keppra. Lactulose for encephelopathy.\n\nResp - Orally intubated, fio2 weaned down to 40%. Current vent settings AC 600/14/5/40%. Unable to obtain Aline or ABG. Mixed venous 02 34. RR 14-24. 02 sat > 96%. LS clear, diminished at bases with few LLL crackles. Sx for scant amts bilious and then blood-tinged secretions. copious amts bile removed from oral cavity with yankeur.\n\nC-V- HR 80-115 ST, no ectopy noted. NBP 100-120/40's. Weakly palp pedal pulses. Hct stable overnight, most recent hct 26.3. INR remains at 2.5 Plt 39.\n\nF/E - TFB + ~5500ccs yest. Pt with marginal urine output via foley ( 15-40ccs/hr). MD aware. Given one L NS fluid bolus with minimal effect. D 5 1/2 NS infusing at 125ccs/hr cont. CVP 9-12. Am lytes pend.\n\nGI - Abd firm. +BS. Draining ~100ccs liquid brown stool via flexiseal. Sm amt leakage around tube. Rx with lactulose q 6hrs. NPO . OGT to LIS draining copious amts bile.\n\nID - Max temp 100 po. WBC 2.7. PNA and SBP treated with vanco and unasyn iv.\n\nEndo - RISS\n\nSocial - Wife called last eve and states she will be in again today to visit.\n\nA+P - Continue to assess MS - may need to increase dosage and/or freq of lactulose. Monitor f+e status. + aspiration precautions. Emotional support to wife.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-14 00:00:00.000",
"description": "Report",
"row_id": 1631077,
"text": "Micu Acceptance Note and Review of Systems\n\n68 yo male with hx of hep C, etoh cirrhosis, seizure, hemicolectomy, Barretts esophagus and HTn presents wtih altered MS. Pt began vomiting 2 days prior to admission, MS reportedly off but pt able to understand and follow commands. Morning of wife woke up and found pt naked sitting on the bed not knowing where he was. He was agitated and vomited again. Wife called EMS. In , pt underwent dx paracentesis which was + for SBP. Rx with ceftriaxone, albumin and lactulose. Unable to pass NGT due to nasal bleeding. EEG performed that reportedly was consistant with encephelopathy. Bld and tox screens neg. Per wife, pt's last etoh intake was in .\n\n Pt oriented x 0. Very agitated, attempting to hit and kick staff. Bilateral wrist restraints and RLE restraint utilized. MAE. R hand slightly weaker ( hx CVA). Pt verbal - swearing and counting numbers. Eyes gaze upward, does not visually track. No sz activity noted. Pt has been taking kepra x 5 yrs for hx sz's. IV kepra administered. Encephelopathy treated with lactulose pr. ? pt will require head CT if no improvement in MS.\n\nResp - LS initially clear. Now with expiratory wheezing at bases after vomiting. RR 22-32. 02 sat > 94% on RA. + nonproductive cough.\n\nC-V - HR 100-120 ST, no ectopy noted. NBP 110-160/50-80. Rx with 5 mg lopressor iv with slight decrease in HR. Pt was taking metoprolol at home. + dopplerable pedal pulses. + ankle edema.\n\nGI - Abd soft. +BS. NPO. Not alert enough to take po's. MD attempted to place OGT. Pt began vomiting mod amt bilious fluid. ? aspirated. Given 75 mg albumin iv. Flexiseal placed. Given lactulose enema. Passing mod amt liquid brown stool via flexiseal but leaking copious amts around tube. Given thiamine and folate IV. Plan is for RUQ u/s.\n\nF/E - Voiding 40-100ccs/hr amber colored urine via foley. Pt with ARF - Creat up to 1.4 Rx with D5 1/2 NS at 125ccs/hr. ? renal u/s to be performed.\n\nHeme - Hct 37. Hx thrombocyopenia. Plt ct 75 on admit - am labs pend.\n\nID - Afeb. WBC 10.8. +SBP on parcentesis. Rx with ceftriaxone.\n\nSkin - + abd surgical scar. Dry mucous membranes. No areas of breakdown noted.\n\nAccess - arrived with on #20 angio R forearm. IV RN inserted second peripheral line into LAC ( #20). Pt very difficult to obtain blood from. ? will require further access.\n\nSocial - Spoke with wife on phone who was suprised that pt was still agitated and confused. States she has postponed her knee surgery to care for pt at home. She will be in today to visit pt.\n\nA+P - Continue to monitor neuro status closely- lactulose for encephelopathy, monitor for szs, safety precautions, ? head CT. + aspiration precautions - iv meds only until NG or OGT inserted. Monitor renal status - replete lytes prn. Emotional support to wife. Social service consult will be needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-04-14 00:00:00.000",
"description": "Report",
"row_id": 1631078,
"text": "pt intubated this shift due to probable aspiration and worsening CXR.sx'f for moderate amounts of secretions which appear like bile. plan to be revaluated in AM rounds.\n"
},
{
"category": "Echo",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 100769,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG./ arrhythmia. Left ventricular function. Hypotension. Evaluate for tamponade .\nHeight: (in) 68\nWeight (lb): 154\nBSA (m2): 1.83 m2\nBP (mm Hg): 115/53\nHR (bpm): 132\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. 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: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Regional left\nventricular wall motion is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. No masses or vegetations are\nseen on the aortic valve. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. No mass or vegetation is seen on the mitral\nvalve. There is a trivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2175-04-17 00:00:00.000",
"description": "Report",
"row_id": 293113,
"text": "Sinus rhythm with a four beat run of probable atrial tachycardia. Left atrial\nabnormality. Low QRS voltage. Modest ST-T wave changes. Findings are\nnon-specific but clinical correlation is suggested. Since the previous tracing\nof atrial ectopy appears less frequent and ST-T wave changes are\ndecreased.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2175-04-16 00:00:00.000",
"description": "Report",
"row_id": 293114,
"text": "Sinus rhythm. Atrial premature beats initially in a bigeminal pattern followed\nby a four beat run and a five beat run of probable atrial tachycardia. Low\nQRS voltage with diffuse ST-T wave changes. Findings are non-specific but\nclinical correlation is suggested. Since the previous tracing of \nsinus bradycardia is now absent and atrial ectopy, low QRS voltage and\nST-T wave changes are now seen.\nTRACING #1\n\n"
}
] |
25,673 | 197,957 | Brief Hospital Course, By problem: 56 y.o. woman with h/o breast CA, asthma, presenting with cough, dypnea and pleuritic chest pressure. On exam, pt had initial lowgrade fever which has now resolved. Labs/studies showed leukocytosis (improving) and b/l upper lobe infiltrates on CT. She was therefore treated with levaquin for CAP. Septic shock resolved quickly with fluid resuscitation only. Though there were nonspecific EKG changes, there is no evidence of ACS by enzymes. - 1) URI/Pneumonia: Defervesced and decreasing WBC indicate improvement. She received a 4 day course of levaquin. As she had more mostly URI symptoms with a prominent hoarseness of her throat, dry cough and rhinorrhea, and as she improved so quickly her symptoms were thought to be less likely related to a bacterial pulmonic process. - 2) Asthma: Exacerbated in setting of pneumonia. We continue inhaled steroids and standing albuterol. The later was tapered to prn by the day before discharge. She was requiring 2 puffs/day at discharge. She was also placed on a 7 day prednisone taper. Her symptoms improved significantly by the day of discharge with only minimal dyspnea with exertion - 3) CV: Though no ACS, EKG changes concerning given they were in contigous leads. A repeat EKG showed resolution of the changes. She may have had demand ischemia in setting of septic shock. She may need an outpt pharm stress test and echo if her dyspnea does not improve . 4) Sinus Tachycardia: Possible etiologies included persistent hypovolemia, frequent beta agonists. Her tachycardia improved with fluid resuscitation and tapering of her albuterol to prn. - 4) Diarrhea: She developed diarrhea on Day 3 of her hospital stay. A C. Dificile assay came back positive on the day of discharge and she was started on a ten day course of flagyl. 5) Psych: Outpatient regimen of effexor and seroquel. - 6) F/E/N: Cardiac diet - 7) Deconditioning: She was seen by Physical Therapy and thought to need services with home rehab. She was discharged with home physical therapy. | PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS.GI: ABD IS SOFT, OBESE, NON-TENDER TO PALPATION. Denies SOB, occasional nonproductive cough noted.CV: HR 90s-100s, SR to ST, no ectopy. The mediastinal and hilar contours are normal. DENIES ANY CHEST PAIN. Sinus rhythm Inferior/lateral ST-T changes are nonspecificEarly transitionSince previous tracing of , no significant change cv:nsr no ectopy. bp stable.afebrile. Remains on nebs and inhalers. Sinus rhythmEarly transitionNonspecific ST-T wave abnormalitiesSince previous tracing of , no significant change The chest x-ray is otherwise unchanged. PT HAS NO C/O DYPNEA OR DIFFICULTY BREATHING. Pulmonary vessels are normal. The cardiac silhouette is normal in size. The cardiac silhouette is normal in size. NO BM THIS SHIFT, PASSING FLATUS.GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. There are scattered, non-pathologically enlarged lymph nodes in the bilateral axilla and mediastinum. Surrounding soft tissue and osseous structures are normal. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. MAE X 4 WITHOUT DIFFICULTY. NO SEIZURE ACTIVITY NOTED.RR: BBS= ESSENTIALLY WHEEZY UPON INSPIRATION AND EXPIRATION- CLEAR TO COARSE LUNG SOUNDS AFTER RESPIRATORY TREATMENTS. CTA consistent with bilat. obese, nontender, soft, hypoactive BS. Remains on Colace . Both lungs are clear without infiltrates, effusions, or consolidations. Both lungs are clear without infiltrates, effusions, or consolidations. The remainder of the chest x-ray is unchanged from prior exam. LOW GRADE TEMP OF 99. CONTINOUS SVO2 MONITORING DC'D. ABLE TO TAKE PO MEDS WITHOUT DIFFICULTY. IMPRESSION: No acute cardiopulmonary process. Denies pain or discomfort. HYPOACTIVE BS X 4 QUADRANTS. NSR, HR 70-90'S WITH NO SIGNS OF ECTOPY NOTED. LACTATE DECREASED TO 1- PT NO LONGER ON SEPSIS PROTOCOL. The surrounding osseous structures show no suspicious lytic or blastic lesions, however, mild degenerative changes are noted in the thoracic spine. No pneumothorax. IMPRESSION: No evidence of pulmonary embolus. There is no pericardial effusion. States "feeling much better". CT PULMONARY ANGIOGRAM: No pulmonary embolus is identified. Sinus rhythm. NO C/O N/V/D. AP UPRIGHT PORTABLE CHEST X-RAY: Comparison is made with a prior AP supine portable chest x-ray dated . RT IJ PRESEPT CATHETER IS SECURE AND PATENT. CVP 4-11. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.INTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.SOCIAL: NO CONTACT.PLAN: ELECTROLYTE REPLETION- POSSIBLE CALL OUT. There is no pneumothorax. There is no pneumothorax. There is no pneumothorax. Good fluid intake. There are few areas of bilateral patchy airspace opacification within the upper lung lobes, distributed both centrally and peripherally. No BM. upper lobes patchy infiltrates. see careviewresp: room air..o2 sats 94-98%.breath sounds clear.gi: abd soft obese.positive bowel sounds.gu: foley draining clear yellow urine.neuro: alert and oriented calm and cooperative.stable overnight. LS diminished with occasional wheezes. slept well. 3L NC.CV: S1 AND S2 AS PER AUSCULTATION. Neuro: Pt. Cooperative with care. Left lower lung subsegmental atelectasis. BILATERAL CHEST EXPANSION NOTED. FOLLOWS COMMANDS WITHOUT DIFFICULTY, ABLE TO EXPRESS NEEDS WITHOUT DIFFICULTY. Continues on Levaquin PO. THANK YOU! The surrounding soft tissue and osseous structures are unremarkable. PLEASANT. There may be small bilateral pleural effusions, right greater than left. Compared to theprevious tracing anterolateral T wave inversion is new. No areas of airspace consolidation are seen in the lower lung lobes, however, the left lower lobe shows a small area of segmental atelectasis. BP 90s-110s/40s-50s. The visualized liver is unremarkable. The mediastinal and hilar contours are slightly enlarged, most likely related to patient's inspiratory effort. Anterolateral T wave inversion. The great vessels, heart, and pericardium are unremarkable. Evaluate. ALSO RECEIVED TOTAL OF 2L OF NS AND 1L LR BOLUSES. FINAL REPORT *ABNORMAL! Adequate UO.GI/GU: Tolerating heart healthy diet. Foley patent with clear yellow urine out.ID: Afebrile. The surrounding soft tissue structures show the patient is status post left mastectomy. No lymph nodes are identified within the hila. Abd. Transfer note initiated. PERRLA, 3 BRISK. Few areas of bilateral patchy airspace opacity in the upper lung lobes consistent with pneumonia. Clinical correlation is recommended. IMPRESSION: Right internal jugular central venous catheter with tip at the SVC/right atrial junction. IMPRESSION: Right internal jugular central venous catheter with the tip in the right atrium. Evaluate line placement. OOB to chair with 2 people assist, tolerated well.Resp: On 2L NC sats remain 97-99%, currently trialing on RA. Soar thorat persists per pt.Skin intact.Social: Friends visited today, updated on status and plan of care. PT HAD EPISODE OF HYPOTNESION WITH PATCHY PULMONARY PARENCHYMAL INFILTRATES. Optiray nonionic contrast was used secondary to the fast rate of bolus required for this examination. Early transition. SEPSIS PROTOCOL INITIATED AND TX TO MICU FOR OBSERVATION.NEURO: PT ALERT AND ORIENTED X 3. WBC 15.3. PT RECEIVED TOTAL OF 3GMS MAG IV. Strong pedal pulses. Subsegmental atelectasis in the left lower lobe. SP02 > OR = TO 95%. is A&Ox3. TECHNIQUE: Low-dose scan from the lung apices to the lung bases was performed followed by a CT pulmonary angiogram. 3:47 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: tachypnea, sob,r/o pe Contrast: OPTIRAY Amt: 100 MEDICAL CONDITION: 56 year old woman with REASON FOR THIS EXAMINATION: tachypnea, sob,r/o pe No contraindications for IV contrast WET READ: MJGe SAT 6:56 PM No PE. Bilateral patchy central and peripheral airspace opacities within the upper lung lobes, which is suggestive of pneumonia. AP UPRIGHT PORTABLE CHEST X-RAY: When compared with the prior AP upright portable chest x-ray obtained approximately half an hour earlier, there has been interval retraction of the right internal jugular central venous catheter with the tip currently residing in the lower superior vena cava/right atrium. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. Evaluate for infiltrate. RR 15-20. AP UPRIGHT PORTABLE CHEST X-RAY: When compared with the prior AP upright portable chest x-ray, obtained about 3 hours earlier, there has been interval placement of a right internal jugular central venous catheter with the tip in the right atrium. | 10 | [
{
"category": "Nursing/other",
"chartdate": "2180-05-28 00:00:00.000",
"description": "Report",
"row_id": 1596726,
"text": "NURSING PROGRESS NOTE 1900-0700\nTHIS IS A 56 Y/O FEMALE PT WITH A HX OF ASTHMA, BREAST CA AND DEPRESSION PRESENTING WITH C/O 2 DAY NON-PRODUCTIVE COUGH, PLEURITIC PAIN AND POSITIVE CHEST PRESSURE WITH COUGH AND DURING INSPIRATION AS WELL AS INCREASING DYSPNEA OVER THE PAST 24 HOURS. PT HAS BEEN INCREASING HER HOME USE OF ALBUTEROL FOR SYMPTOM RELIEF. PT HAD EPISODE OF HYPOTNESION WITH PATCHY PULMONARY PARENCHYMAL INFILTRATES. SEPSIS PROTOCOL INITIATED AND TX TO MICU FOR OBSERVATION.\n\nNEURO: PT ALERT AND ORIENTED X 3. PLEASANT. FOLLOWS COMMANDS WITHOUT DIFFICULTY, ABLE TO EXPRESS NEEDS WITHOUT DIFFICULTY. LOW GRADE TEMP OF 99. PERRLA, 3 BRISK. MAE X 4 WITHOUT DIFFICULTY. NO SEIZURE ACTIVITY NOTED.\n\nRR: BBS= ESSENTIALLY WHEEZY UPON INSPIRATION AND EXPIRATION- CLEAR TO COARSE LUNG SOUNDS AFTER RESPIRATORY TREATMENTS. BILATERAL CHEST EXPANSION NOTED. PT HAS NO C/O DYPNEA OR DIFFICULTY BREATHING. RR 15-20. SP02 > OR = TO 95%. 3L NC.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 70-90'S WITH NO SIGNS OF ECTOPY NOTED. DENIES ANY CHEST PAIN. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PT RECEIVED TOTAL OF 3GMS MAG IV. ALSO RECEIVED TOTAL OF 2L OF NS AND 1L LR BOLUSES. LACTATE DECREASED TO 1- PT NO LONGER ON SEPSIS PROTOCOL. CONTINOUS SVO2 MONITORING DC'D. RT IJ PRESEPT CATHETER IS SECURE AND PATENT. CVP 4-11. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS.\n\nGI: ABD IS SOFT, OBESE, NON-TENDER TO PALPATION. HYPOACTIVE BS X 4 QUADRANTS. NO C/O N/V/D. ABLE TO TAKE PO MEDS WITHOUT DIFFICULTY. NO BM THIS SHIFT, PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nSOCIAL: NO CONTACT.\n\nPLAN: ELECTROLYTE REPLETION- POSSIBLE CALL OUT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-05-28 00:00:00.000",
"description": "Report",
"row_id": 1596727,
"text": "Neuro: Pt. is A&Ox3. States \"feeling much better\". Denies pain or discomfort. Cooperative with care. OOB to chair with 2 people assist, tolerated well.\nResp: On 2L NC sats remain 97-99%, currently trialing on RA. LS diminished with occasional wheezes. Remains on nebs and inhalers. Denies SOB, occasional nonproductive cough noted.\nCV: HR 90s-100s, SR to ST, no ectopy. BP 90s-110s/40s-50s. Strong pedal pulses. Adequate UO.\nGI/GU: Tolerating heart healthy diet. Good fluid intake. Abd. obese, nontender, soft, hypoactive BS. No BM. Remains on Colace . Foley patent with clear yellow urine out.\nID: Afebrile. WBC 15.3. Continues on Levaquin PO. CTA consistent with bilat. upper lobes patchy infiltrates. Soar thorat persists per pt.\nSkin intact.\nSocial: Friends visited today, updated on status and plan of care. Pt's emergency contact is out of town.\nDispo: Called out to floor, awaiting for bed. Transfer note initiated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-05-29 00:00:00.000",
"description": "Report",
"row_id": 1596728,
"text": "cv:nsr no ectopy. bp stable.afebrile. see careview\n\nresp: room air..o2 sats 94-98%.breath sounds clear.\n\ngi: abd soft obese.positive bowel sounds.\n\ngu: foley draining clear yellow urine.\n\nneuro: alert and oriented calm and cooperative.\n\nstable overnight. slept well. pt is a call out awaiting a bed on the floor.\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 866298,
"text": " 4:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: confirm line placement after repositioned\n ______________________________________________________________________________\n MEDICAL CONDITION:\n cough, hypotension, code sepsis\n\n REASON FOR THIS EXAMINATION:\n confirm line placement after repositioned\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old female with cough and hypotension. Evaluate line\n placement.\n\n AP UPRIGHT PORTABLE CHEST X-RAY: When compared with the prior AP upright\n portable chest x-ray obtained approximately half an hour earlier, there has\n been interval retraction of the right internal jugular central venous catheter\n with the tip currently residing in the lower superior vena cava/right atrium.\n The remainder of the chest x-ray is unchanged from prior exam. There is no\n pneumothorax.\n\n IMPRESSION: Right internal jugular central venous catheter with tip at the\n SVC/right atrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 866295,
"text": " 4:19 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p R IJ placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n cough, hypotension, code sepsis\n REASON FOR THIS EXAMINATION:\n s/p R IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old female status post right internal jugular line\n placement. Evaluate.\n\n AP UPRIGHT PORTABLE CHEST X-RAY: When compared with the prior AP upright\n portable chest x-ray, obtained about 3 hours earlier, there has been interval\n placement of a right internal jugular central venous catheter with the tip in\n the right atrium. There is no pneumothorax. The chest x-ray is otherwise\n unchanged. The cardiac silhouette is normal in size. The mediastinal and\n hilar contours are slightly enlarged, most likely related to patient's\n inspiratory effort. Both lungs are clear without infiltrates, effusions, or\n consolidations. The surrounding soft tissue and osseous structures are\n unremarkable.\n\n IMPRESSION: Right internal jugular central venous catheter with the tip in\n the right atrium. No pneumothorax.\n\n These findings were called to Dr. at 5:45 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-27 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 866290,
"text": " 3:47 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: tachypnea, sob,r/o pe\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with\n REASON FOR THIS EXAMINATION:\n tachypnea, sob,r/o pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe SAT 6:56 PM\n No PE. Few areas of bilateral patchy airspace opacity in the upper lung lobes\n consistent with pneumonia. Subsegmental atelectasis in the left lower lobe.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: 56-year-old woman with tachypnea and shortness of breath.\n\n TECHNIQUE: Low-dose scan from the lung apices to the lung bases was performed\n followed by a CT pulmonary angiogram. Optiray nonionic contrast was used\n secondary to the fast rate of bolus required for this examination.\n\n CT PULMONARY ANGIOGRAM: No pulmonary embolus is identified. There are\n scattered, non-pathologically enlarged lymph nodes in the bilateral axilla and\n mediastinum. No lymph nodes are identified within the hila. The great\n vessels, heart, and pericardium are unremarkable. There is no pericardial\n effusion. There are few areas of bilateral patchy airspace opacification\n within the upper lung lobes, distributed both centrally and peripherally. No\n areas of airspace consolidation are seen in the lower lung lobes, however, the\n left lower lobe shows a small area of segmental atelectasis. There may be\n small bilateral pleural effusions, right greater than left. The visualized\n liver is unremarkable. The surrounding soft tissue structures show the\n patient is status post left mastectomy. The surrounding osseous structures\n show no suspicious lytic or blastic lesions, however, mild degenerative\n changes are noted in the thoracic spine.\n\n IMPRESSION: No evidence of pulmonary embolus. Bilateral patchy central and\n peripheral airspace opacities within the upper lung lobes, which is suggestive\n of pneumonia. Clinical correlation is recommended. Left lower lung\n subsegmental atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 866281,
"text": " 1:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fever and sob, eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n see above\n REASON FOR THIS EXAMINATION:\n fever and sob, eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and shortness of breath. Evaluate for infiltrate.\n\n AP UPRIGHT PORTABLE CHEST X-RAY: Comparison is made with a prior AP supine\n portable chest x-ray dated . The cardiac silhouette is\n normal in size. The mediastinal and hilar contours are normal. Pulmonary\n vessels are normal. There is no pneumothorax. Both lungs are clear without\n infiltrates, effusions, or consolidations. Surrounding soft tissue and\n osseous structures are normal.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-27 00:00:00.000",
"description": "Report",
"row_id": 163660,
"text": "Sinus rhythm. Early transition. Anterolateral T wave inversion. Compared to the\nprevious tracing anterolateral T wave inversion is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-30 00:00:00.000",
"description": "Report",
"row_id": 163658,
"text": "Sinus rhythm\n Inferior/lateral ST-T changes are nonspecific\nEarly transition\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-29 00:00:00.000",
"description": "Report",
"row_id": 163659,
"text": "Sinus rhythm\nEarly transition\nNonspecific ST-T wave abnormalities\nSince previous tracing of , no significant change\n\n"
}
] |
98,973 | 152,951 | HOSPITAL COURSE: Pleasant 87 yo female presenting with dizziness, hypotension concerning for sepsis initially requiring pressors in the ICU, who was then called out to the cardiology service with volume overload, AFIB and severe TR w/ RV dilation. Underwent DCCV but continued to be in afib and had to be transferred to the CCU for respiratory distress where she was diuresed and then transferred back to the cardiology floor. She was discharged to (LTAC). | Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen.The tricuspid valve leaflets fail to fully coapt. Mild (1+) mitral regurgitation is seen. FINDINGS: A right internal jugular central venous catheter has been retracted somewhat and terminates at the cavoatrial junction. Normal ascending aortadiameter. Severe [4+] TR.Given severity of TR, PASP may be underestimated due to elevated RA pressure.PULMONIC VALVE/PULMONARY ARTERY: Significant PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. There is at least moderate pulmonary artery systolichypertension. Allowing for differences in technique including lower lung volumes, the mediastinal and hilar contours appear likely unchanged including prominence of the aortopulmonary window suggesting perhaps enlargement of the main pulmonary artery. There is mild aortic valve stenosis (valvearea 1.2-1.9cm2). Simple atheroma in abdominalaorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. Overall normal LVEF(>55%).RIGHT VENTRICLE: RV not well seen.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Moderately thickened aortic valve leaflets.MITRAL VALVE: Mild (1+) MR.TRICUSPID VALVE: Tricuspid leaflets do not fully coapt. Findings suggesting mild vascular congestion including a suspected new small left-sided pleural effusion; no definite focal consolidation. There are simpleatheroma in the abdominal aorta. Compared to tracing #1 ventricularpaced beats are absent. Mild mitral regurgitation. The right ventricularcavity is mildly dilated with normal free wall contractility. Blunting and hazy opacity in the left lower hemithorax and costophrenic sulcus suggests a small pleural effusion. Scarring at each lung apex is probably unchanged. Moderate mitral regurgitation. An irregularly irregular rhythm is present consistent with atrial fibrillation.Non-specific ST-T wave changes are present which are unchanged compared witha prior study from earlier in the day.TRACING #1 There is mild symmetric left ventricularhypertrophy. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The aortic valve leaflets are moderatelythickened. Moderate (2+) mitral regurgitation is seen. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation.Height: (in) 67Weight (lb): 152BSA (m2): 1.80 m2BP (mm Hg): 124/78HR (bpm): 66Status: InpatientDate/Time: at 12:04Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.Depressed LAA emptying velocity (<0.2m/s)RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: RV not well seen.AORTA: Simple atheroma in descending aorta. Left ventricular function.BP (mm Hg): 100/60HR (bpm): 50Status: OutpatientDate/Time: at 07:17Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:On-call echo, limited study.LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal aortic arch diameter.AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. FINDINGS: A right internal jugular venous catheter terminates in the upper right atrium. There is still present pulmonary edema, with asymmetric appearance, mostly involving the upper perihilar areas. Valvular heart disease.Height: (in) 65Weight (lb): 152BSA (m2): 1.76 m2BP (mm Hg): 144/80HR (bpm): 110Status: InpatientDate/Time: at 09:58Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Underlying atrial rhythm appears to befibrillation. Compared to the previous tracing of the rhythm is now atrial paced with capture.TRACING #1 Underlying rhythm is probably atrial fibrillation. Underlying rhythm is probably atrial fibrillation. Inferior and lateral T waveinversions with Q-T interval prolongation. Aberrantly conducted ventricular beats. Nosignificant change compared with tracing #1.TRACING #2 Atrial paced ventricular sensed rhythm. Underlying rhythm is likely atrial fibrillation. Demand ventricular paced rhythm. Non-specific ST-T wave changes. MarkedST-T wave abnormalities. Compared to the previous tracing of ventricular pacedbeats are now present and the ventricular rate is slower.TRACING #1 Minor ST-T wave abnormalities. Atrial fibrillation. Atrial fibrillation. Atrial fibrillation. Atrial fibrillation. Compared to the previous tracingof ventricular pacing is new. ST segment elevation in theanteroseptal leads has resolved. Minor inferolateral ST-T wave abnormalities. T wave inversionsin the anterior precordial leads with Q-T interval prolongation. Ventricular sensing. ST-T wave changes,particularly in the inferior and anterolateral leads. Ventricularly paced rhythm.Marked T wave inversions in leads V2-V6. Minor diffuse ST-T wave abnormalities. Diffuse T wave inversions persist.TRACING #7 Extensive ST-T wave changes and Q-T intervalprolongation are new.TRACING #6 Prolonged Q-T interval. Compared to tracing #5 the rhythmis now atrial fibrillation. Atrial fibrillation with controlled ventricular response. Intraventricular conduction abnormality andrepolarization abnormality are new. When compared to the tracing of atrialfibrillation is not new. Diffuse non-specific ST-T wavechanges. Atrial fibrillation with a rapid ventricular response. Sequential demand pacingwith wide complex native ventricular beats. Atrial fibrillation with rapid ventricular response. Leftaxis deviation. A-V sequential pacemaker. Decreased QRS complex in the limb leads.Delayed R wave progression in the precordial leads. Compared to theprevious tracing of no significant change.TRACING #1 The underlying rhythm is atrial fibrillation with rapid ventricular response.Demand atrial pacing. Compared to tracing #4 extensive ST segment changes inthe anterior and inferior leads are new. Atrial paced rhythm. Compared to the previoustracing the Q-T interval is shorter and the pacemaker appears to be sensingappropriately.TRACING #2 Atrial paced rhythm with capture. Atrial paced rhythm with capture. ST segment elevation inleads V2 and V3 which may be related to ischemia. Normal Q-T interval. Normal Q-T interval. Because of baseline artifact, it is not clear whetherthere is atrial capture or whether the underlying atrial rhythm is atrialfibrillation. Compared to the previoustracing of the rate is faster and ST-T wave changes are less.Ventricular pacing is no longer present. Compared to theprevious tracing of there are several changes as outlined.TRACING #1 Compared totracing #1 no change.TRACING #2 Compared totracing #6 the ventricular response is controlled. Compared to tracing #2 no change.TRACING #3 Pacing spikes withoutcapture. Low voltage across the limb leads. Atrial pacingwith lack of capture. The force of ST segmentssuggesting possibility of drug toxicity or hyperkalemia. Compared to tracing #2 the intrinsic rate is faster.Otherwise, no diagnostic change.TRACING #3 Compared totracing #3 no change.TRACING #4 Consider metabolic derangement, hyperkalemia ormyocardial ischemia. No significant changecompared with tracing #2.TRACING #3 Artifact is present. Cannot exclude ischemia.TRACING #5 Compared to theprevious tracing of A-V pacemaker is new and there is no evidence ofintrinsic A-V conduction. | 36 | [
{
"category": "Radiology",
"chartdate": "2177-03-02 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1225816,
"text": " 11:56 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: r/o clot or intrinsic liver disease\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with shock liver, like to eval for other pathology.\n REASON FOR THIS EXAMINATION:\n r/o clot or intrinsic liver disease\n ______________________________________________________________________________\n WET READ: OXZa 9:08 PM\n Cholelithiasis without evidence of cholecystitis. Patent portal vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated liver function tests.\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n COMPARISON: Correlation with multiple prior CT examinations, the most recent\n dated .\n\n FINDINGS: The liver is normal in echogenicity and contour. No focal liver\n lesion is seen. Prominent hepatic veins are likely due to vascular\n congestion. The portal vein is patent with hepatopetal flow. No intra- or\n extra-hepatic biliary dilation is identified. The CBD measures up to 5 mm.\n There is cholelithiasis; however, the gallbladder is only minimally distended\n with no pericholecystic fluid or wall thickening. Son sign\n was negative. Views of the pancreas are unremarkable, though the distal tail\n is obscured by overlying bowel gas. There is suggestion of right renal\n fullness on partial views of the right kidney. No free fluid is seen.\n\n IMPRESSION:\n 1. Cholelithiasis without evidence of cholecystitis.\n 2. Patent portal vein. Prominent hepatic veins likely due to vascular\n congestion.\n 3. Possible right renal fullness seen on partial views of right kidney. If\n indicated, this could be evaluated with renal ultrasound.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1225951,
"text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with cardiogenic shock from TR\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiogenic shock.\n\n FINDINGS: In comparison with the study of , there are continued bilateral\n effusions with compressive atelectasis, though the possibility of supervening\n pneumonia at the bases can certainly not be excluded in the appropriate\n clinical setting. Continued enlargement of the cardiac silhouette with\n engorged mediastinal and peripheral vessels indicating elevated pulmonary\n venous pressure. Monitoring and support devices remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-02-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1225652,
"text": " 11:10 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? central line placement (had to be replaced )\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with central line removed and replaced\n REASON FOR THIS EXAMINATION:\n ? central line placement (had to be replaced )\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess new line.\n\n Right IJ catheter tip is at the cavoatrial junction. There is no\n pneumothorax. Worsening opacities in the left lower lobe compared to prior\n studies are consistent with atelectasis. There are no other interval changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1225677,
"text": " 4:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for worsening pulm edema\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with sob, admitted with sepsis\n REASON FOR THIS EXAMINATION:\n Please eval for worsening pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Sepsis SOB, evaluate for pulmonary edema.\n\n Comparison is made with prior study performed five hours earlier.\n\n Persistent low lung volume. Pulmonary edema has resolved. Pacer leads are in\n standard position. Right IJ catheter tip is in the upper right atrium. There\n is no evident pneumothorax. Bilateral pleural effusions are small. Bibasilar\n atelectases have improved on the left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-02-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1225642,
"text": " 8:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: TlC placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with TLC placement in right IJ\n REASON FOR THIS EXAMINATION:\n TlC placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Central line placement.\n\n COMPARISONS: Earlier on the same evening.\n\n TECHNIQUE: Chest, portable AP semi-upright.\n\n FINDINGS: A right internal jugular central venous catheter has been retracted\n somewhat and terminates at the cavoatrial junction. The cardiac, mediastinal\n and hilar contours appear unchanged. There is a mild interstitial prominence\n suggesting a slight congestion. Blunting of the costophrenic sulcus suggests\n a small pleural effusion potentially although less striking than on the recent\n prior examinations.\n\n IMPRESSION: Central venous catheter terminating at the cavoatrial junction.\n Findings suggesting mild pulmonary vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1226304,
"text": " 9:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Compare to prior, ? pulm edema\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with 4+TR, SOB worse with laying flat\n REASON FOR THIS EXAMINATION:\n Compare to prior, ? pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Triscuspid regurgitation, shortness of breath.\n\n Portable AP radiograph of the chest was compared to .\n\n Right internal jugular line tip is at the level of cavoatrial junction. There\n is still present pulmonary edema, with asymmetric appearance, mostly involving\n the upper perihilar areas. No interval development of pleural effusion is\n demonstrated. The radiograph is rotated that might explain left mediastinal\n shift. Pacemaker leads are unchanged in position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1225640,
"text": " 7:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Hypotension.\n\n COMPARISONS: .\n\n TECHNIQUE: Chest, semi-upright AP portable view.\n\n FINDINGS: A right internal jugular venous catheter terminates in the upper\n right atrium. A dual-lead pacemaker/ICD device appears unchanged. The heart\n is mild to moderately enlarged. Allowing for differences in technique\n including lower lung volumes, the mediastinal and hilar contours appear likely\n unchanged including prominence of the aortopulmonary window suggesting perhaps\n enlargement of the main pulmonary artery. The aorta is tortuous and\n calcified. Blunting and hazy opacity in the left lower hemithorax and\n costophrenic sulcus suggests a small pleural effusion. There is no definite\n pleural effusion on the right. There is a mild interstitial abnormality\n suggesting mild pulmonary congestion. Scarring at each lung apex is probably\n unchanged.\n\n IMPRESSION: Central venous catheter terminating in the right upper atrium.\n Findings suggesting mild vascular congestion including a suspected new small\n left-sided pleural effusion; no definite focal consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1225854,
"text": " 7:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary edema, interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 yo F w/ severe TR, in cardiac shock\n REASON FOR THIS EXAMINATION:\n ? pulmonary edema, interval change\n ______________________________________________________________________________\n WET READ: OXZa 8:35 PM\n persistent low lung volumes with slightly improved aeration at right base and\n stable to slightly increased atelectasis at left base. small effusions.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:52 P.M., \n\n HISTORY: Severe tricuspid regurgitation. Possible cardiac shock, evaluate\n pulmonary edema.\n\n IMPRESSION: AP chest compared to through 28:\n\n Small bilateral pleural effusions have increased. Greater opacification in\n both lung bases is most likely atelectasis or pneumonia, raising concern for\n aspiration, particularly since the stomach is moderately distended and there\n is no enteric drainage tube in place. Heart is moderately enlarged and\n mediastinal vasculature is engorged, but there is no pulmonary edema. Right\n internal jugular line ends in the upper right atrium. Transvenous right\n atrial and right ventricular pacer leads are unchanged in their respective\n positions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1226560,
"text": " 3:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: shortness of breath\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n shortness of breath\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Shortness of breath.\n\n Comparison is made with prior study, .\n\n Cardiomegaly is unchanged. Diffuse multifocal opacities have worsened,\n consistent with worsening pulmonary edema. Bilateral pleural effusions are\n small, larger on the right side. Right IJ catheter tip is in the upper right\n atrium. Left transvenous pacemaker leads are in standard position. There are\n low lung volumes. Widened mediastinum due to engorgement of the vessels is\n unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1227802,
"text": " 1:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusion, pulm edema\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with dyspnea, nausea, left sided dullness\n REASON FOR THIS EXAMINATION:\n eval for pleural effusion, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: radiograph.\n\n FINDINGS: Central venous catheter and permanent pacemaker remain unchanged in\n position allowing for positional differences of the patient. Cardiac\n silhouette is enlarged, accompanied by pulmonary vascular engorgement.\n Previously reported multifocal pulmonary opacities have partially cleared with\n residual opacities mostly in the perihilar regions. This likely reflects\n improving pulmonary edema. More confluent opacity in left retrocardiac region\n has only slightly improved and is likely due to a combination of atelectasis\n and effusion. Small right pleural effusion has decreased in size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-12 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1227150,
"text": " 12:21 PM\n RENAL U.S. Clip # \n Reason: PLEASE ULTRASOUND BLADDER AS WELL. Evidence of Clot in uret\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with hypertension, paroxysmal AF on coumadin, sick sinus\n syndrome s/p DDI PPM, remote breast CA s/p lumpectomy and XRT, now with new \n (Cr 1.1 to 1.8) in setting of gross hematuria.\n REASON FOR THIS EXAMINATION:\n PLEASE ULTRASOUND BLADDER AS WELL. Evidence of Clot in ureters? Renal mass?\n Bladder clot/mass?\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND.\n\n INDICATION: 87-year-old woman with history of hypertension and AFib on\n Coumadin with gross hematuria. Request to evaluate for hydronephrosis or\n bladder hematoma.\n\n COMPARISON: Comparison is made to a previous ultrasound of .\n\n TECHNIQUE: Grayscale and color Doppler used to evaluate both kidneys.\n\n FINDINGS:\n This is a limited examination given reduced acoustic penetration.\n The right kidney measures 10.7 cm in long axis. No evidence of hydronephrosis\n or focal mass lesion. The left kidney measures 10.8 cm in long axis and also\n outlines normally with no hydronephrosis, shadowing calculi, or mass lesions\n identified.\n The bladder is fully decompressed around a Foley catheter limiting\n visualisation.\n\n IMPRESSION:\n Somewhat limited study however both kidneys are within normal limits with good\n cortical thickness, no hydronephrosis or mass lesions identified.\n The bladder is fully decompressed around the Foley catheter.\n\n"
},
{
"category": "Echo",
"chartdate": "2177-03-07 00:00:00.000",
"description": "Report",
"row_id": 98436,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 67\nWeight (lb): 152\nBSA (m2): 1.80 m2\nBP (mm Hg): 124/78\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 12:04\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.\nDepressed LAA emptying velocity (<0.2m/s)\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Simple atheroma in descending aorta. Simple atheroma in abdominal\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was monitored by a nurse e throughout the procedure. The patient was monitored by a nurse e throughout the procedure. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). Local\nanesthesia was provided by benzocaine topical spray. The posterior pharynx was\nanesthetized with 2% viscous lidocaine. No glycopyrrolate was administered. No\nTEE related complications. The rhythm appears to be atrial fibrillation.\nResults were personally reviewed with the MD caring for the patient.\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium or left\natrial appendage. The left atrial appendage emptying velocity is depressed\n(<0.2m/s). Overall left ventricular systolic function is normal (LVEF>55%).\nThere are simple atheroma in the descending thoracic aorta. There are simple\natheroma in the abdominal aorta. The aortic valve leaflets are moderately\nthickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: No intracardiac thrombus seen. Moderate mitral regurgitation. Mild\naortic regurgitation.\n\nDr. was notified in person of the results immediately following\nthe procedure.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2177-03-04 00:00:00.000",
"description": "Report",
"row_id": 98437,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function. Valvular heart disease.\nHeight: (in) 65\nWeight (lb): 152\nBSA (m2): 1.76 m2\nBP (mm Hg): 144/80\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 09:58\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. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Severe [4+] TR.\nGiven severity of TR, PASP may be underestimated due to elevated RA pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). The right ventricular\ncavity is mildly dilated with normal free wall contractility. The aortic valve\nleaflets are moderately thickened. There is mild aortic valve stenosis (valve\narea 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened and there is severe tricuspid\nregurgitation. There is at least moderate pulmonary artery systolic\nhypertension. [In the setting of at least moderate to severe tricuspid\nregurgitation, the estimated pulmonary artery systolic pressure may be\nunderestimated due to a very high right atrial pressure.] Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , estimated\npulmonary artery systolic pressure is now higher.\n\nNOTE: Reported edited at 2:42 pm on to note that tricuspid\nregurgitation is severe.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2177-03-01 00:00:00.000",
"description": "Report",
"row_id": 98438,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Left ventricular function.\nBP (mm Hg): 100/60\nHR (bpm): 50\nStatus: Outpatient\nDate/Time: at 07:17\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nOn-call echo, limited study.\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Normal IVC diameter (>2.1cm)\nwith >50% decrease with sniff (estimated RA pressure (5-10 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets.\n\nMITRAL VALVE: Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid leaflets do not fully coapt. Severe [4+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent ventricular premature beats. If clinically\nindicated, a complete transthoracic examination with Doppler is recommended.\n\nConclusions:\nThe left atrium is elongated. The right atrium is markedly dilated. The\nestimated right atrial pressure is 5-10 mmHg. Left ventricular wall\nthicknesses and cavity size are normal. Overall left ventricular systolic\nfunction is probably normal (LVEF>55%). The aortic valve leaflets are\nmoderately thickened (unable to assess for aortic stenosis or aortic\nregurgitation due to limited study). Mild (1+) mitral regurgitation is seen.\nThe tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid\nregurgitation is seen (triangular/dagger shaped tricuspid regurgitation\ndoppler signal consistent with rapid equalization of pressures betwee the\nright ventricle and right atrium). There is borderline pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Limited transthoracic echocardiography. Unable to assess regional\nwall motion abnormalities due to limited study, but overall systolic function\nof the left ventricle is probably normal. Severe tricuspid regurgitation with\nfailure of tricuspid leaflet coaptation. Mild mitral regurgitation. Unable to\nfully assess aortic valve.\n\nCompared with the findings of the prior report (images unavailable for review)\nof , the tricuspid regurgitation is now severe. If clinically\nindicated, a complete transthoracic examination with Doppler is recommended.\n\nPreliminary findings were communicated to the referring physician by the\n cardiology fellow on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-03-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1227870,
"text": " 10:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pulm edema? cause for increased O2 requirement?\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pleasant 87 yo female presenting sepsis initially requiring pressors in the\n ICU, now called out to cardiology service with volume overload, AFIB and severe\n TR w/ RV dilation. S/p DCCV X 2 but still in afib.\n REASON FOR THIS EXAMINATION:\n pulm edema? cause for increased O2 requirement?\n ______________________________________________________________________________\n WET READ: JEKh MON 11:04 PM\n improved but persisting pulmonary edema compared to 14:06 ; similar-\n appearing L base opacity c/w pleural effusion/atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased oxygen requirement.\n\n Portable AP radiograph of the chest was reviewed in comparison to , 2:06 p.m.\n\n There is substantial interval improvement of pulmonary edema.\n Cardiomediastinal silhouette is unchanged including left retrocardiac\n atelectasis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-18 00:00:00.000",
"description": "Report",
"row_id": 277278,
"text": "The heart rate is 90 in atrial fibrillation. Non-specific ST-T wave changes\nremain throughout the anterior precordium which are again unchanged compared to\nprevious studies.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-17 00:00:00.000",
"description": "Report",
"row_id": 277279,
"text": "An irregularly irregular rhythm is present consistent with atrial fibrillation.\nNon-specific ST-T wave changes are present which are unchanged compared with\na prior study from earlier in the day.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-17 00:00:00.000",
"description": "Report",
"row_id": 277280,
"text": "Atrial fibrillation with controlled ventricular response. Intermittent pacer\nspikes which do not capture. Non-specific anterior and inferior ST-T wave\nchanges. Modest Q-T interval prolongation. Compared to tracing #1 ventricular\npaced beats are absent. Anterior ST-T wave changes are more pronounced.\nClinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-12 00:00:00.000",
"description": "Report",
"row_id": 277499,
"text": "Artifact is present. Atrial fibrillation with rapid ventricular response. Left\naxis deviation. Non-specific ST-T wave changes. Compared to the previous\ntracing of the rate is faster and ST-T wave changes are less.\nVentricular pacing is no longer present.\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-10 00:00:00.000",
"description": "Report",
"row_id": 277500,
"text": "Underlying rhythm is probably atrial fibrillation. Ventricularly paced rhythm.\nMarked T wave inversions in leads V2-V6. Compared to the previous tracing\nof ventricular pacing is new. Otherwise, there is no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-10 00:00:00.000",
"description": "Report",
"row_id": 277501,
"text": "Atrial fibrillation with controlled ventricular response. T wave inversions\nin the anterior precordial leads with Q-T interval prolongation. Compared to\ntracing #6 the ventricular response is controlled. ST segment elevation in the\nanteroseptal leads has resolved. Diffuse T wave inversions persist.\nTRACING #7\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-15 00:00:00.000",
"description": "Report",
"row_id": 277495,
"text": "Demand ventricular paced rhythm. Underlying atrial rhythm appears to be\nfibrillation. Compared to the previous tracing of ventricular paced\nbeats are now present and the ventricular rate is slower.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-14 00:00:00.000",
"description": "Report",
"row_id": 277496,
"text": "Atrial fibrillation. Minor ST-T wave abnormalities. No significant change\ncompared with tracing #2.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-13 00:00:00.000",
"description": "Report",
"row_id": 277497,
"text": "Atrial fibrillation. Minor inferolateral ST-T wave abnormalities. No\nsignificant change compared with tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-13 00:00:00.000",
"description": "Report",
"row_id": 277498,
"text": "Atrial fibrillation. Minor diffuse ST-T wave abnormalities. Compared to the\nprevious tracing of no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-08 00:00:00.000",
"description": "Report",
"row_id": 277502,
"text": "Atrial fibrillation with a rapid ventricular response. Pacing spikes without\ncapture. Aberrantly conducted ventricular beats. ST segment elevation in\nleads V2 and V3 which may be related to ischemia. Inferior and lateral T wave\ninversions with Q-T interval prolongation. Compared to tracing #5 the rhythm\nis now atrial fibrillation. Extensive ST-T wave changes and Q-T interval\nprolongation are new.\nTRACING #6\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-08 00:00:00.000",
"description": "Report",
"row_id": 277503,
"text": "Atrial paced rhythm. Compared to tracing #4 extensive ST segment changes in\nthe anterior and inferior leads are new. Cannot exclude ischemia.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-07 00:00:00.000",
"description": "Report",
"row_id": 277504,
"text": "Atrial paced rhythm with capture. Ventricular sensing. Compared to\ntracing #3 no change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-07 00:00:00.000",
"description": "Report",
"row_id": 277505,
"text": "Atrial paced rhythm with capture. Compared to tracing #2 no change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-07 00:00:00.000",
"description": "Report",
"row_id": 277506,
"text": "Atrial paced ventricular sensed rhythm. Normal Q-T interval. Compared to\ntracing #1 no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-07 00:00:00.000",
"description": "Report",
"row_id": 277507,
"text": "Atrial paced rhythm at 80 beats per minute. Diffuse non-specific ST-T wave\nchanges. Normal Q-T interval. Compared to the previous tracing of \nthe rhythm is now atrial paced with capture.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-06 00:00:00.000",
"description": "Report",
"row_id": 277508,
"text": "Atrial fibrillation. Low voltage across the limb leads. Atrial pacing\nwith lack of capture. When compared to the tracing of atrial\nfibrillation is not new.\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-03 00:00:00.000",
"description": "Report",
"row_id": 277509,
"text": "The underlying rhythm is atrial fibrillation with rapid ventricular response.\nDemand atrial pacing. Compared to tracing #2 the intrinsic rate is faster.\nOtherwise, no diagnostic change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-02 00:00:00.000",
"description": "Report",
"row_id": 277510,
"text": "Underlying rhythm is likely atrial fibrillation. Demand atrial paced rhythm at\na rate of 80-90 beats per minute. Decreased QRS complex in the limb leads.\nDelayed R wave progression in the precordial leads. ST-T wave changes,\nparticularly in the inferior and anterolateral leads. Compared to the previous\ntracing the Q-T interval is shorter and the pacemaker appears to be sensing\nappropriately.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-02-28 00:00:00.000",
"description": "Report",
"row_id": 273911,
"text": "A-V sequential pacemaker. Because of baseline artifact, it is not clear whether\nthere is atrial capture or whether the underlying atrial rhythm is atrial\nfibrillation. The QRS complex is markedly widened. The force of ST segments\nsuggesting possibility of drug toxicity or hyperkalemia. Compared to the\nprevious tracing of A-V pacemaker is new and there is no evidence of\nintrinsic A-V conduction. Intraventricular conduction abnormality and\nrepolarization abnormality are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2177-03-01 00:00:00.000",
"description": "Report",
"row_id": 273910,
"text": "Underlying rhythm is probably atrial fibrillation. Sequential demand pacing\nwith wide complex native ventricular beats. Prolonged Q-T interval. Marked\nST-T wave abnormalities. Consider metabolic derangement, hyperkalemia or\nmyocardial ischemia. Clinical correlation is suggested. Compared to the\nprevious tracing of there are several changes as outlined.\nTRACING #1\n\n"
}
] |
27,978 | 197,890 | Admitted and pre-op workup completed over the weekend. Underwent cabg x5 with Dr. on . Transferred to the CVICU in stable condition on phenylephrine and propofol drips. Extubated that evening and transferred to the floor on POD #2 to begin increasing his activity level. Chest tubes and pacing wires removed without incident. Pt works with pt / PT cleares for home with VNA. Foley DC'd without incident. | Normal ascending aortadiameter. LVwall motion appears imrproved to normal. Mild (1+) mitralregurgitation is seen. C/DB Q 1HR.GU: UOP ACCEPTABLE. Normal descending aorta diameter. Troponin from eve 0.59.Resp: Lungs clear to dim bases. Cough, non prod.GI: OGT dc'd with extubation. APPROPRIATE.ENDO: BS PER FLOW SHEET. ca+ repleted.Resp: ls clr-course, bases dim. Mild regionalLV systolic dysfunction. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Normal aortic arch diameter. FINDINGS: Cardiac silhouette is within normal limits. tolerates po lopressor. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. extrems w/d. There is minimal ST segment elevation with terminal T waveinversion in the inferior leads with non-diagnostic Q waves raisingconsideration for acute or evolving myocardial infarction. Evaluate Aortic Atheroma, Ventricular Function, Valve statusHeight: (in) 68Weight (lb): 262BSA (m2): 2.29 m2BP (mm Hg): 135/70HR (bpm): 70Status: InpatientDate/Time: at 09:28Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement. Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the aortic arch and the descending thoracicaorta. Wean o2 as tolerated. No AR.MITRAL VALVE: Normal mitral valve leaflets. The cardiomediastinal silhouette is unchanged including the moderate cardiomegaly. Mildly depressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -normal; anterior apex - hypo; apex - hypo; remaining LV segments contractnormally.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Normal sinus rhythm, rate 74. Hct 38.7. No TEE related complications.Suboptimal image quality - body habitus. Site is eccymotic but no hematoma.CV/resp vss. cv: hr 75-87 nsr no ectopy. Normal LV cavity size. BP LABILE, INITIALLY NEO OFF, RESTARTED FOR MARGINAL BP'S, CURRENTLY OFF AGAIN. Pt a&0x3. IMPRESSION: Small left-sided pleural effusion and left basilar atelectasis. +palp pp. There ismild regional left ventricular systolic dysfunction with distal and apicalanterior hypokinesis. Last bm . Left ventricular wallthicknesses are normal. Chest tubes with minimal output. Pt s/p cx4 from today, uneventful post op course, arrived apaced (for sb) on neo/prop. bp stable, 110s-130s. O2 SATS ADEQUATE. +pp. +bs. +bs. PROB: S/P CABGCV: SR NO VEA NOTED. Ct very dry.Resp: Initially orally intubated, weaned and extubated. c/o incisional pain tx w/percocet & toradol w/good effect. The left ventricular cavity size is normal. FINAL REPORT HISTORY: Effusion. Mediastinal and left-sided chest tubes are noted. The remaining left ventricular segments contractnormally. bp stable, no hypotention. Aortic contours intact. There is some slight left ventricular prominence. Retrocardiac opacity is noted likely represents atelectasis. CSRU npn 1500-190060 y/o male s/p IMI, S/P CATH AT HOSP.Pt a&o, independent w/ care. No thrombus in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. There is no pericardial effusion.Post bypass: Patient is av paced, then a paced on phenylepherine infusion. Probable acute inferior wall myocardialinfarction. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No CP, asymptomatic w/ low BP. tol regular diet well.misc. Pulses palp bilat. FINDINGS: The patient is status post CABG, sternotomy wires are noted. Patient is status post median sternotomy. MR isstill mild. Assessment is as follows:Neuro: Pain issues, minimal releif with morphine and toradol. No ASD or PFO by 2D, color Doppler or saline contrast withmaneuvers.LEFT VENTRICLE: Normal LV wall thickness. The aortic valve leaflets (3) appear structurally normal with goodleaflet excursion. 1710 PT TO FROM OTHER HOSP FOR POSSIBLE CABG/STENT PLACEMENT BRIEF PERIOD OF CP AND BOTH HAND TIGHTNESS NTG X 2 GIVEN GOOD EFFECT TRANSFERED TODAY POST CATH 3/VESSEL DIFFUSE LAD NEURO PT A/O RELAXED MAE WELL IN GOOD SPIRITS SLEPTS SHORT PERIODS HEART S1S2 NSR 66 TO 78 VSS NO PAIN NEG NVD NEG HJR PULSES POS 3 THRU OUT RIGHT GROIN SITE CLEAR ABD SOFT POS B/S VOIDING LG CLEAR URINE PO WELL NO N/V PLAN EVAL SUPPORTIVE CARE IMPRESSION: 1. BP dropped sbp to 78/54 w/o symptoms. PT USING COUGH PILLOW WITH SOME EFFECT.RESP: LUNGS CLEAR, DIM IN BASES. C/O rt groin pain (cath site) relieved with Percocet. Pt agreed.CV: SR 60's. pulm toilet. The osseous structures are unchanged. A&ox3, mae, perrlaCV: Now in own intrinsic sr 70's, bp low 100's titrating neo to maintain map>60. afebrile. Afebrile. PATIENT/TEST INFORMATION:Indication: Intraop CABG. Remains on heparin gtt at 1650units/hr; last PTT at 1030 51.8 with no rate change per Dr. .GI/GU: Abd soft/obese with +BS, taking cardiac diet s difficulty. Pt denies sob, cp. The patient appears to be in sinusrhythm.Conclusions:Pre bypass: The left atrium is moderately dilated. Normal RV function. uses I.S. neo weaned to .07 mics.kg/min goal map > 60. pa # 43-38/17-15. Remaining exam is unchanged. There is minimal blunting of the left costophrenic angle that could represent small pleural effusion. Cont to implement POC. On Hep gtt, last two ptts within range, MD no change made to gtt rate. Plan to visit in am.Plan: Cont assess cardio/resp status. Abd obese, soft. BP turned to 95/64. Monitor for ETOH withdrawal signs, pain med prn. Sinus bradycardia. An NG tube is noted with its side hole at the level of the GE junction. abd firm, obese, nt. The mitral valve leaflets are structurally normal. Pt is known for ETOH, no s/sx of withdrawal as of yet; valium 10mg po given earlier in shift MD order. ?switching bundles in beginning of shift- aware-ekg done. NO gag at present will cont to assessGU: UOP good, foley patent.ENdo: Insulin gtt started per protocol. Attempted to waken x1, extremely agiated, resedated and then rewoken, started on precedex. Clinicalcorrelation is suggested. NG tube with its sidehole at the level of the GE junction. pain managment. CVP varying , ? Able to wean and extubate without difficulty. Turns side to side independently. perrl.Cv: sr, hr 70s-80s, pacer off-wires sense but do not capture appropriately. COMPARISON: . resp rate teens. Next ptt w/ am labs.C/O pain at right groin sight, medicated w/ 2 percocet tabs w/ good effect. | 17 | [
{
"category": "Radiology",
"chartdate": "2121-08-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 980540,
"text": " 7:01 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o eff, inf\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o eff, inf\n ______________________________________________________________________________\n WET READ: DXAe FRI 9:53 PM\n Vascular prominence and small left effusion conistent with mild CHF.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Effusion.\n\n Three radiographs of the chest demonstrate a small left-sided pleural effusion\n and bibasilar atelectasis. Patient is status post median sternotomy.\n Cardiomediastinal contours are similar to that seen on . No\n consolidation is identified. No pneumothorax.\n\n IMPRESSION:\n\n Small left-sided pleural effusion and left basilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-08-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 979844,
"text": " 12:20 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with cad s/p CABG. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man status post CABG.\n\n COMPARISON: .\n\n FINDINGS: The patient is status post CABG, sternotomy wires are noted. Right-\n sided Swan-Ganz catheter with its tip projecting in the main pulmonary artery.\n An NG tube is noted with its side hole at the level of the GE junction.\n Advancement is recommended. Mediastinal and left-sided chest tubes are noted.\n There is no evidence of pneumothorax. Retrocardiac opacity is noted likely\n represents atelectasis. There is minimal blunting of the left costophrenic\n angle that could represent small pleural effusion. An endotracheal tube is\n seen with its tip projecting 4 cm above the carina.\n\n The osseous structures are unchanged.\n\n IMPRESSION:\n 1. Status post CABG with expected post surgical changes.\n\n 2. NG tube with its sidehole at the level of the GE junction. Advancement by\n 10 cm is recommended.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-08-22 00:00:00.000",
"description": "P CHEST (PRE-OP AP ONLY) PORT",
"row_id": 979554,
"text": " 5:49 PM\n CHEST (PRE-OP AP ONLY) PORT Clip # \n Reason: preop cabg\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with cad\n REASON FOR THIS EXAMINATION:\n preop cabg\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: 60-year-old man with coronary artery disease, anticipating cardiac\n surgery.\n\n FINDINGS: Cardiac silhouette is within normal limits. There is some slight\n left ventricular prominence. There is no focal consolidation, pleural\n effusions, or signs of overt pulmonary edema.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-26 00:00:00.000",
"description": "Report",
"row_id": 1628333,
"text": "PROB: S/P CABG\n\nCV: SR NO VEA NOTED. BP LABILE, INITIALLY NEO OFF, RESTARTED FOR MARGINAL BP'S, CURRENTLY OFF AGAIN. TORADOL AND PERCOCET FOR INCISIONAL PAIN WITH GOOD EFFECT, PT STILL C/O SOME PAIN WITH C/DB. PT USING COUGH PILLOW WITH SOME EFFECT.\n\nRESP: LUNGS CLEAR, DIM IN BASES. O2 SATS ADEQUATE. CONGESTED SOUNDING COUGH, UNABLE TO RAISE SPUTUM. C/DB Q 1HR.\n\nGU: UOP ACCEPTABLE. STARTED ON LASIX WITH GOOD EFFECT.\n\nGI: APPETITE GOOD. BOWEL SOUNDS PRESENT.\n\nNEURO: ALERT AND ORIENTED X3. MAE. APPROPRIATE.\n\nENDO: BS PER FLOW SHEET. INSULIN DRIP OFF THIS AM, GIEN 20 UNIT LANTIS AND TREATED PER S/S.\n\nASSESSMENT: TOLERATING NEO WEAN.\n\nPLAN: CONT.\nPAIN MED PRN.\nMONITOR BP, RESTART NEO PRN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-27 00:00:00.000",
"description": "Report",
"row_id": 1628334,
"text": "Neuro: a&ox3, follows commands, maes. slept well overnight, arouses easily to voice. c/o incisional pain tx w/percocet & toradol w/good effect. perrl.\n\nCv: sr, hr 70s-80s, pacer off-wires sense but do not capture appropriately. bp stable, 110s-130s. tolerates po lopressor. +pp. extrems w/d. afebrile. ca+ repleted.\n\nResp: ls clr-course, bases dim. o2sats 93-97% on 5l nc. resp rate teens. sats decrease rapidly to high 80s when o2 off or when mouth breathing, returns to baseline mid 90s rapidly. coughing & raising sm amts thk white sputum. uses I.S. to 750.\n\nGi/gu: tolerates h20 w/meds overnight, no c/o nausea. +bs. abd firm, obese, nt. huo adequate, initially appeared light pink, PA informed, catheter flushed-clr amber this AM. good response to lasix.\n\nEndo: rssi coverage required per ss.\n\nPlan: continue monitoring cardioresp status, labs, huo. pain managment. pulm toilet. increase activity & po intake as tolerated. transfer to 2.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979984,
"text": " 10:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assessment for pneumothorax s/p chest tubes removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with cad s/p CABG. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n Assessment for pneumothorax s/p chest tubes removal\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient after CABG.\n\n Portable AP chest radiograph compared to the .\n\n The patient was extubated in the meantime interval with removing of the NG\n tube, Swan-Ganz catheter and mediastinal drains. The cardiomediastinal\n silhouette is unchanged including the moderate cardiomegaly. There are\n bibasilar areas of atelectasis improved compared to the previous study. The\n upper lungs are grossly unremarkable. No sizeable pleural effusion is\n demonstrated. There is no pneumothorax.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-24 00:00:00.000",
"description": "Report",
"row_id": 1628329,
"text": "neuro: Alert and oriented x 3 pleasant and cooperative. Med x 1 with valium 10mg to aid in sleep with good effect. Med x 1 with percocet for groin pain at angio site when standing to void. Site is eccymotic but no hematoma.\n\nCV/resp vss. no ectopy. bp stable, no hypotention. o2 sat 95% on 2lnp. lungs are clear. no c/o chest pain.\n\ngi/gu no stools. voiding in urinal. tol regular diet well.\n\nmisc. Continues on heparin gtt.\n\nplan: pre-op for cabg..? Monday\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-24 00:00:00.000",
"description": "Report",
"row_id": 1628330,
"text": "Plan to transfer to 2 this am. Please see updated transfer note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-25 00:00:00.000",
"description": "Report",
"row_id": 1628331,
"text": "Pt s/p cx4 from today, uneventful post op course, arrived apaced (for sb) on neo/prop. Swan advanced in CSRU by anesth due to being in cvp. Chest tubes with minimal output. Poor oxygenation initially peep to 10, but weaned down. Attempted to waken x1, extremely agiated, resedated and then rewoken, started on precedex. Able to wean and extubate without difficulty. Pt a&0x3. Assessment is as follows:\nNeuro: Pain issues, minimal releif with morphine and toradol. A&ox3, mae, perrla\nCV: Now in own intrinsic sr 70's, bp low 100's titrating neo to maintain map>60. CI >3. CVP varying , ? validity. Pedal pulses initially palp , then became mottled, able to doppler PT, feet now warmer and can doppler all 4. Ct very dry.\nResp: Initially orally intubated, weaned and extubated. Currently on face tent fio2 80% post extubation abg wnl. Cough, non prod.\nGI: OGT dc'd with extubation. Abd obese, soft. No BS. NO gag at present will cont to assess\nGU: UOP good, foley patent.\nENdo: Insulin gtt started per protocol. see flowsheet, cont q1hr bs.\nSocial: Girlfriend called and updated on plan of care. Plan to visit in am.\nPlan: Cont assess cardio/resp status. Wean o2 as tolerated. Cont q1hr bs while on insulin gtt. increae po diet as gag returns. cont advance per post op course\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-26 00:00:00.000",
"description": "Report",
"row_id": 1628332,
"text": "cv: hr 75-87 nsr no ectopy. neo weaned to .07 mics.kg/min goal map > 60. pa # 43-38/17-15. cvp 14-8. temp 100.9 td to 99.9 td.\n\ngu: foley draining clear yellow urine. urine decreased to 10 cc/hr times one hour but then increased and pt is making 30 cc/hr.\n\ngi:pt tolerating water and meds. bowel sounds hypoactive.\n\nresp: coughing a lot and raising and swallowing. pt reports good responsse to pain med but continues to have pain with coughing. breath sounds clear upper and diminished bases.pt mouth breathing while asleep so open face tent .40 % on with sats 94-96 %\n\nendo: insulin drip at 0-3 units. titrate according to hourly blood sugars.\n\nPain: pt medicated with percocet 2 tabs at 2330 pt continues to experience painat ~ level 7 so morphine 2 mg iv times 2 and ketoralllc at 0300. pain is acceptable at ~ level 3 and does increase with coughing .\n\ndressings dry and intact.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-23 00:00:00.000",
"description": "Report",
"row_id": 1628326,
"text": "7p-7a\n\nPre-op for cabg Monday am.\n\nNeuro: Alert and oriented x3. C/O rt groin pain (cath site) relieved with Percocet. Turns side to side independently. Pt found oob using urinal at bedside. Reminded pt to call if he needs urinal -he is not to get oob. Pt agreed.\n\nCV: SR 60's. ?switching bundles in beginning of shift- aware-ekg done. SBP initially 140's, down to one teens to 120's after lopressor 25mg po. +palp pp. Hct 38.7. Heparin infusing at 1650cc/hr. PTT pending. Troponin from eve 0.59.\n\nResp: Lungs clear to dim bases. Sats 94-98% on 2L nc.\n\nGI/GU: Abdomen obese. +bs. Last bm . Appetite fair. Voiding yellow urine via urinal qs.\n\nSkin: Right groin cath site dry and intact, tissue soft.\n\nSocial: Girlfriend, , in to visit last eve.\n\nPlan: Cont to monitor hemodynamics and respiratory status closely. Monitor lab values closely, treat prn. Monitor for signs of etoh and nicotine withdrawal. NPO after midnight on Sunday for OR Monday, first case. Treat chest pain with nitro gtt, ?balloon, ?OR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-23 00:00:00.000",
"description": "Report",
"row_id": 1628327,
"text": "7a-3p NPN\n\nNEURO: Awake, A/O x3; percocet given for R groin pain (angio site) with good results. Pt is known for ETOH, no s/sx of withdrawal as of yet; valium 10mg po given earlier in shift MD order. Pt is calm/pleasant/cooperative. All procedures/POC explained to pt prior to initiation with verbalization of understanding.\n\nRESP: On 2L NC-sats WNL; lungs clear bilat with nonlabored resp.\n\nCV: NSR with HR in 60's, SBP 90-110's. No c/o CP this shift. Pulses palp bilat. Afebrile. Remains on heparin gtt at 1650units/hr; last PTT at 1030 51.8 with no rate change per Dr. .\n\nGI/GU: Abd soft/obese with +BS, taking cardiac diet s difficulty. Voiding clear dark yellow urine into urinal. No BM.\n\nSKIN: Intact, no breakdown noted; pt can reposition self.\n\nSOCIAL: Girlfriend called earlier-planning to visit this afternoon.\n\nPLAN: NPO p MN on Sun for CABG first case Monday am . Will cont to monitor for pain, hemodynamics; emotional support as needed. ? possible transfer out of unit prior to surgery-transfer note written. Cont to implement POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-23 00:00:00.000",
"description": "Report",
"row_id": 1628328,
"text": "CSRU npn 1500-1900\n60 y/o male s/p IMI, S/P CATH AT HOSP.\nPt a&o, independent w/ care. oob to commode and chair. Pt denies sob, cp. BP dropped sbp to 78/54 w/o symptoms. BP turned to 95/64. On Hep gtt, last two ptts within range, MD no change made to gtt rate. Next ptt w/ am labs.\nC/O pain at right groin sight, medicated w/ 2 percocet tabs w/ good effect. No Hematoma, only ecchymotic at site. + pedal pulses. No signs of ETOH withdrawal. Valium avail prn if needed.\na/p: pre-op for monday cabg on hep gtt. ? call out to floor. No CP, asymptomatic w/ low BP. Monitor for ETOH withdrawal signs, pain med prn.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-08-22 00:00:00.000",
"description": "Report",
"row_id": 1628325,
"text": " 1710\n PT TO FROM OTHER HOSP FOR POSSIBLE CABG/STENT PLACEMENT BRIEF PERIOD OF CP AND BOTH HAND TIGHTNESS NTG X 2 GIVEN GOOD EFFECT TRANSFERED TODAY POST CATH 3/VESSEL DIFFUSE LAD\n NEURO PT A/O RELAXED MAE WELL IN GOOD SPIRITS SLEPTS SHORT PERIODS\n HEART S1S2 NSR 66 TO 78 VSS NO PAIN NEG NVD NEG HJR PULSES POS 3 THRU OUT RIGHT GROIN SITE CLEAR\n ABD SOFT POS B/S VOIDING LG CLEAR URINE PO WELL NO N/V\n PLAN EVAL SUPPORTIVE CARE\n"
},
{
"category": "Echo",
"chartdate": "2121-08-25 00:00:00.000",
"description": "Report",
"row_id": 83641,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraop CABG. Evaluate Aortic Atheroma, Ventricular Function, Valve status\nHeight: (in) 68\nWeight (lb): 262\nBSA (m2): 2.29 m2\nBP (mm Hg): 135/70\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 09:28\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum. No ASD or PFO by 2D, color Doppler or saline contrast with\nmaneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\nLV systolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nnormal; anterior apex - hypo; apex - hypo; remaining LV segments contract\nnormally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No atheroma in ascending aorta. Normal aortic arch diameter. Complex\n(>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex\n(>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nSuboptimal image quality - body habitus. The patient appears to be in sinus\nrhythm.\n\nConclusions:\nPre bypass: The left atrium is moderately dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. There is\nmild regional left ventricular systolic dysfunction with distal and apical\nanterior hypokinesis. Overall left ventricular systolic function is mildly\ndepressed (LVEF= 45-50 %). The remaining left ventricular segments contract\nnormally. Right ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the aortic arch and the descending thoracic\naorta. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. There is no aortic valve stenosis. No aortic regurgitation\nis seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nPost bypass: Patient is av paced, then a paced on phenylepherine infusion. LV\nwall motion appears imrproved to normal. LVEF 55%. Normal RV function. MR is\nstill mild. Aortic contours intact. Remaining exam is unchanged. All findings\ndiscussed with surgeons at the time of the exam.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2121-08-22 00:00:00.000",
"description": "Report",
"row_id": 219933,
"text": "Normal sinus rhythm, rate 74. Probable acute inferior wall myocardial\ninfarction. Compared with tracing of inferior Q waves are more\npronounced and inferior ST segment elevation and T wave inversion is also more\npronounced.\n\n"
},
{
"category": "ECG",
"chartdate": "2121-08-25 00:00:00.000",
"description": "Report",
"row_id": 219934,
"text": "Sinus bradycardia. There is minimal ST segment elevation with terminal T wave\ninversion in the inferior leads with non-diagnostic Q waves raising\nconsideration for acute or evolving myocardial infarction. Clinical\ncorrelation is suggested. No previous tracing available for comparison.\n\n"
}
] |
9,782 | 151,652 | Assessment: 78 yo F w/ h/o paranoid schizophrenia, depression, CVA, hypoTH, spinal stenosis, and h/o recent sepsis attributed to PNA presented with nausea, hypotension found to be septic with LLL/RLL PNA requiring pressors x 24 hours. Transferred to floor after 3 day observation in the unit. . # Sepsis - Most likely source is PNA. Urine and Blood cx negative and no abd pain or other complaints. CT of the abdomen performed in ED was unimpressive. Patient was recently treated for MRSA PNA w/ vanc x 15 days, although there was only sparse MRSA in her sputum at that time. Therefore she was started on vancomycin, levoquin and flagyl. There was concern for aspiration as patient was vomiting 24 hours before presentation. She did do well on her speech and swallow exam. Patient was continued on vanc/levo and flagyl while in house. Because patient's cultures were negative, vancomycin is d/c upon discharge. She is to finish 2 week course of flagyl and levoquin. Patient is asymptomatic sating well on room air. Her WBC is trending down and is in normal range. She has been afebrile x 3days. Patient is to follow up with her PCP. note patient was also started on stress dose steroids while in the ICU. She is being d/c on her home dose of steroids for polymyositis. DFA was negative for flu. . ## Demand ischemia: Patient found with marginally elevated troponins most likely in light hypotension. There were no EKG changes appreciated. Patient also had elevated CK, but CKMB index was normal. Patient had an echo performed which showed significant valvular dz but otherwise normal wall motion and EF. Patient was never symptomatic and denied any anginal symptoms. Patient was started on aspirin. Her lipid profile was unremarkable with HDL of 65 and LDL of 75. Therefore no statins were started. Patient may also benefit from BB as outpatient once bp stable - outpatient stress test. . ## Hypoxia: Likely due to PNA. On nebs and ABX. EF compromised by valvular dz and likely has tendency for diastolic CHF but no overt CHF on CXR. Supplemental O2 prn. No h/o tobacco or emphysema so would aim for O2 > 95%. Patient was weaned off O2 as her PNA improved. . #. Chronic pain. Patient had b/l leg pain before admission. She has spinal stenosis and is being scheduled for evaluation by her outpatient doctor. She has been having deterioration in her functional status before being admitted. - Patient was continued on home regimen of Neurontin, Fentanyl patch, Lidoderm patch, and Percocet prn - Aggressive bowel regimen . ## ARF: Initial Cr rise to 1.3 from baseline that resolved w/ hydration. . ## Chronic pain: Continue home Neurontin, Fentanyl patch, Lidoderm patch, and Percocet prn. . ## Fe def anemia: HCT relatively stable since admission. Baseline 30-35. B12 and folate WNL . Hold iron while on po levofloxacin. - restart FeSO4 once off Levoquin; - patient will need hematology evaluation as outpatient for anemia of chronic disease as shown on labs (? due to polymyositis) . ## Hypothyroidism: Continue home Levothyroxine . ## Psychiatric issues: Continue home Geodon, Klonopin . ## FEN: cardiac diet of regular consistency w/ thin liquids (per speech/swallow) . ## Communications: Dtr - HCP w , , . #. FULL code . # Dispo: to for acute rehab | Moderate PA systolichypertension.PERICARDIUM: No pericardial effusion.Conclusions:1. CK X3 ELEVATED, MB POS, RI NEG, TROP 0.03-0.06. Again seen is a retrocardiac opacity consistent with consolidation as well as a stable appearing left-sided pleural effusion. IMPRESSION: AP chest compared to and : The previous region of consolidation in the superior segment of the right lower lobe has cleared, but the left lower lobe remains consolidated. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. Draining adequate amts.IV: right #16 antecub, right subclavian. Mild mitral annular calcification. AP CHEST RADIOGRAPH: Again seen is a right-sided subclavian central line in stable position. RSR' pattern in leads V1-V2 - probable normal variant.Compared to the previous tracing of no diagnostic interval change.TRACING #1 Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. TTE performed at the bedside...results are pending.RESP: Lungs with bibasilar rales. Mild (1+) aortic regurgitation is seen.4.The mitral valve leaflets are mildly thickened. ]RIGHT VENTRICLE: Normal RV wall thickness.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Normal regional LVsystolic function. Moderate (2+) mitral regurgitation is seen.5. LS= CLEAR/DIM. The rightatrium is moderately dilated.2.There is mild symmetric left ventricular hypertrophy. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 65Weight (lb): 167BSA (m2): 1.83 m2BP (mm Hg): 147/61HR (bpm): 82Status: InpatientDate/Time: at 12:09Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. sbp ranging 90-110's.neuro-> pt is lethargic but arousable and oriented x3. Hypoactive BS. PT APPEARS TO BE AUTO DIURESING AT THIS TIME. Low precordial voltage.RSR' pattern in leads V1-V2. Mild cardiomegaly persists. Initial lactate level 1.9. Occasional atrial premature beats. IV VANCO, FLAGYL, AND LEVAQUIN CONTINUE. A precept catheter was placed, SVO2 85-93. PT TOLERATING LOW NA/CARDIAC DIET. she denies sob and is maintaining sats >96% on 2 liters supplemental o2.cardiac-> hemodynamically stable. Normal LV cavity size. Moderate to severe [3+] tricuspid regurgitation is seen.6.There is moderate pulmonary artery systolic hypertension.7.There is no pericardial effusion. RSR' pattern in leads V1-V2. ?last bm. There is T wave inversion in lead II which is newcompared to tracing #2. CXR SHOWS LLL PNA AND LEFT PLEURAL EFFUSION W/ DEVELOPING PULMON EDEMA. CVP= . To ED, where BP was noted to be in the 80's and was hypoxic. No evidence of pneumothorax.ID: Received vanco, flagyl, and levo in EW. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. The left ventricularcavity size is normal. receiving abxs for pnx.endocrine-> pt receiving regular insulin per sliding scale parameters.access-> right sc tl precept catheter is patent and intact.dispo-> transfer to medicine when bed becomes availiable. REPLETED W/ IV MAG SULFATE 2GMS AND IV CALCIUM GLUCONATE 2GMS. Borderline left axisdeviation. PRESENT BS, SM BM X1. Received multiple IVABX while in the ED. Delayed R wave transition. B/P 110-140/syst. Abdomen soft and non tender with active BS throughout. Otherwise, no diagnostic interval change.TRACING #3 PT ALERT AND ORIENTED X3, MAE, PERLA. Moderate (2+) MR.TRICUSPID VALVE: Moderate to severe [3+] TR. Afebrile on arrival to MICU. Compared to the previoustracing of no diagnostic change.TRACING #2 CVP goal , which it has been. A code sepsis was initiated. NBP= 91-125/39-84. ]3.The aortic valve leaflets (3) are mildly thickened. MEDICATED W/ FENTANYL PATCH TO RIGHT SHOULDER AND LIDOCAINE PATCH TO RIGHT LOWER BACK, GOOD EFFECTS NOTED. AFEBRILE. 02 SAT 96-100% RA. The left atrium is mildly dilated. [Intrinsic LV systolic functionlikely depressed given the severity of valvular regurgitation. hr 50-90's, sb/sr with no noted ectopy. Respiratory is aware that cultures will need to be obtained.SVO2 since arrival 72-76. 3:05 PM CHEST PORT. PMH OF PARANOID SCHIZOPRENIA. While at the NH, on the morning of , pt was lethargic and febrile. Weaned quickly down to 4L NC. Treated successfully with lido patch, fentanyl patch, tylenol and neurontin.CVS: Heart rate ranges 50-80, NSR without VEA. PT DENIES SOB, NO RESP DISTRESS NOTED. 11:10 AM CHEST (PORTABLE AP) Clip # Reason: ? BP has been in the 90's while asleep and into the low 100's when awake. [Intrinsicleft ventricular systolic function is likely more depressed given the severityof valvular regurgitation. ABD SOFT/ OBESE. Regional left ventricular wall motion is normal.Overall left ventricular systolic function is normal (LVEF>55%). Compared to the previous tracing of the voltage in theprecordial leads has diminished. Imaging follow-up to resolution is recommended. (baseline). PT STABLE AND READY FOR TRANSFER TO FLOOR. tolerating a solid diet.gu-> uop tapering off over the last several hours to ~10cc/hr. Medications with water without difficulty. MICU WEST Nursing Progress NotePt. progression of PNA, eval CHF FINAL REPORT AP CHEST 11:09 A.M., HISTORY: Fever. Otherwise, no diagnostic change. Currently RR 12-16 non-labored with Sats of 98-99%. CXR revealed LLL pnx and left-side pleural effusion with devloping pulmonary edema. PT HAS BEEN PLEASANT AND COOPERATIVE W/ CARE, STRANG AFFECT NOTED. Daughter, , is the spokesperson..RN at . PT'S CONTACT PERSON IS DAUGHTER , CALLED THIS AM AND UPDTED ON CONDITION. Pulmonary edema has also resolved in the interim. RR in the mid 20's, no complaints of shortness of breath.GI: Passed swallowing study at the bedside. is alert and oriented, although quite lethargic...napping throughout the day. she is assiting w/adl's as she is able. Pt has a weak, non-productive cough. No stool this shift.RENAL: UOP >40cc/hr, clear, via foley catheter.SKIN: Intact.ID: Afebrile...continues on vanco, levo and flagyl for treatment of pneumonia.SOCIAL: Daughters a the bedside. MICU TEAM AWARE. COMPARISON: . | 11 | [
{
"category": "Echo",
"chartdate": "2120-01-29 00:00:00.000",
"description": "Report",
"row_id": 78842,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 167\nBSA (m2): 1.83 m2\nBP (mm Hg): 147/61\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 12:09\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: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Normal RV wall thickness.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild mitral annular calcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA systolic\nhypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated. The left atrium is elongated. The right\natrium is moderately dilated.\n2.There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). [Intrinsic\nleft ventricular systolic function is likely more depressed given the severity\nof valvular regurgitation.]\n3.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations\nare seen on the aortic valve. Mild (1+) aortic regurgitation is seen.\n4.The mitral valve leaflets are mildly thickened. No mass or vegetation is\nseen on the mitral valve. Moderate (2+) mitral regurgitation is seen.\n5. Moderate to severe [3+] tricuspid regurgitation is seen.\n6.There is moderate pulmonary artery systolic hypertension.\n7.There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2120-01-30 00:00:00.000",
"description": "Report",
"row_id": 210898,
"text": "Normal sinus rhythm. Occasional atrial premature beats. Low precordial voltage.\nRSR' pattern in leads V1-V2. Delayed R wave transition. Borderline left axis\ndeviation. Compared to the previous tracing of the voltage in the\nprecordial leads has diminished. Otherwise, no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2120-01-27 00:00:00.000",
"description": "Report",
"row_id": 210899,
"text": "Normal sinus rhythm. There is T wave inversion in lead II which is new\ncompared to tracing #2. Otherwise, no diagnostic interval change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2120-01-27 00:00:00.000",
"description": "Report",
"row_id": 210900,
"text": "Normal sinus rhythm. RSR' pattern in leads V1-V2. Compared to the previous\ntracing of no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2120-01-27 00:00:00.000",
"description": "Report",
"row_id": 210901,
"text": "Normal sinus rhythm. RSR' pattern in leads V1-V2 - probable normal variant.\nCompared to the previous tracing of no diagnostic interval change.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-01-29 00:00:00.000",
"description": "Report",
"row_id": 1391221,
"text": "pmicu npn 7p-7a\n\n\n 78yo woman admitted with sepis and currently being treated for pnx. the pt had an uneventful noc, sleeping for most of the shift. she is c/o to medicine and is currently awaiting a bed.\n\nreview of systems\n\nrespiratory-> lung sounds w/rales at the bases. she denies sob and is maintaining sats >96% on 2 liters supplemental o2.\n\ncardiac-> hemodynamically stable. hr 50-90's, sb/sr with no noted ectopy. sbp ranging 90-110's.\n\nneuro-> pt is lethargic but arousable and oriented x3. she is assiting w/adl's as she is able. sitting up in bed eating dinner earlier last evening.\n\ngi-> abd is soft, nontender w/+bs. ?last bm. tolerating a solid diet.\n\ngu-> uop tapering off over the last several hours to ~10cc/hr. the micu team is aware and would like to just continue following uop's for now. discussed lasix dosing with the team earlier in the shift but will hold off for now.\n\nid-> afebrile with a stable wbc. receiving abxs for pnx.\n\nendocrine-> pt receiving regular insulin per sliding scale parameters.\n\naccess-> right sc tl precept catheter is patent and intact.\n\ndispo-> transfer to medicine when bed becomes availiable. transfer note has been written.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-01-29 00:00:00.000",
"description": "Report",
"row_id": 1391222,
"text": "MICU WEST Nursing Progress Note\n\nPt. is awaiting transfer orders and will be transferred to the general medical unit.\n\nREVIEW OF SYSTEMS:\n\n\nCNS: Pt. is alert and oriented, although quite lethargic...napping throughout the day. Able to move all extremities.\n\nPAIN: Pt. c/o back/right breast pain and right leg pain with movement. (baseline). Treated successfully with lido patch, fentanyl patch, tylenol and neurontin.\n\nCVS: Heart rate ranges 50-80, NSR without VEA. B/P 110-140/syst. TTE performed at the bedside...results are pending.\n\nRESP: Lungs with bibasilar rales. Sats of 98% on 2lnc. RR in the mid 20's, no complaints of shortness of breath.\n\nGI: Passed swallowing study at the bedside. Taking thickened liquids, pureed foods a this time. Medications with water without difficulty. Will need to have her diet changed. Abdomen soft and non tender with active BS throughout. No stool this shift.\n\nRENAL: UOP >40cc/hr, clear, via foley catheter.\n\nSKIN: Intact.\n\nID: Afebrile...continues on vanco, levo and flagyl for treatment of pneumonia.\n\nSOCIAL: Daughters a the bedside. Daughter, , is the spokesperson..RN at .\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-01-28 00:00:00.000",
"description": "Report",
"row_id": 1391219,
"text": "MICU Nursing Admission Note 2200-0700\n Pt is a 78yo female, who was recently discharged from in , for tx of sepsis. While at the NH, on the morning of , pt was lethargic and febrile. To ED, where BP was noted to be in the 80's and was hypoxic. A code sepsis was initiated. Received multiple IVABX while in the ED. She was also place on 100% NRB with improvement of SATS. A precept catheter was placed, SVO2 85-93. She was given 4 liters IV fluid and started on a Levophed gtt. Transferred to MICU for further evaluation.\n\nPMH: CVA, GERD, Post herpetic neuralgia-Chronic pain began in , following episode of herpes zoster., polymyositis diagnosed in , hypothyroidism s/p thyroidectomy 12 yrs ago for goiter, stress fx of left thigh, spinal stenosis, basal cell carcinoma, recurrent falls, paranoid schizophrenia, depression, cholecystectomy pnx, urine incontinence.\n\n\nReview of Systems:\n\nResp: Arrived to MICU on 100% NRB with O2 sats of 100%. Weaned quickly down to 4L NC. Currently RR 12-16 non-labored with Sats of 98-99%. LS rales at bases, otherwise clear. Pt has a weak, non-productive cough. CXR revealed LLL pnx and left-side pleural effusion with devloping pulmonary edema. No evidence of pneumothorax.\n\nID: Received vanco, flagyl, and levo in EW. Initial lactate level 1.9. WBC 15. Afebrile on arrival to MICU. Placed on contact precautions for past h/p MRSA in sputum and droplet precautions for ?flu. Respiratory is aware that cultures will need to be obtained.\nSVO2 since arrival 72-76. CVP goal , which it has been. Has not required any IVF bolus' since arrival, however, did receive a total of 5l in ED.\n\nCV: Levophed weaned quickly to off on arrival. BP has been in the 90's while asleep and into the low 100's when awake. Cardiac enzymes being cycled to r/o MI. Received Ca+ and Phos replacements.\n\nNeuro: PMH of CVA and paranoid schizophrenia (last hospitalization 2 yrs ago). Pt is alert and oriented, pleasant and cooperative. She does need to be redirected at times. She has been restarted on her anti psychotic meds.\n\nSocial: Pt has 3 very supportive daughters and 2 sons. Pt's daughter is contact person, phone# in the chart. she is a nurse over at the .\n\nGI: NPO except meds at this moment. Hypoactive BS. Required disimpaction last night at NH prior to hospitalization.\n\nGU: u/o via foley. Draining adequate amts.\n\nIV: right #16 antecub, right subclavian.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-01-28 00:00:00.000",
"description": "Report",
"row_id": 1391220,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT CALLED OUT TO FLOOR, AWAIT BED PLACEMENT. DR PAGER# ON CALL FOR MICU TEAM TONIGHT. PT ALERT AND ORIENTED X3, MAE, PERLA. PMH OF PARANOID SCHIZOPRENIA. PT HAS BEEN PLEASANT AND COOPERATIVE W/ CARE, STRANG AFFECT NOTED. PT C/O CHRONIC BACK PAIN R/T HERPES NEURALGIA AND SPINAL STENOSIS. MEDICATED W/ FENTANYL PATCH TO RIGHT SHOULDER AND LIDOCAINE PATCH TO RIGHT LOWER BACK, GOOD EFFECTS NOTED. LS= CLEAR/DIM. 02 SAT 96-100% RA. PT DENIES SOB, NO RESP DISTRESS NOTED. CXR SHOWS LLL PNA AND LEFT PLEURAL EFFUSION W/ DEVELOPING PULMON EDEMA. IV VANCO, FLAGYL, AND LEVAQUIN CONTINUE. AM WBC= 13.3. AFEBRILE. CVP= . SB TO NSR @ 54-83. NBP= 91-125/39-84. REPLETED W/ IV MAG SULFATE 2GMS AND IV CALCIUM GLUCONATE 2GMS. CK X3 ELEVATED, MB POS, RI NEG, TROP 0.03-0.06. MICU TEAM AWARE. ABD SOFT/ OBESE. PRESENT BS, SM BM X1. PT TOLERATING LOW NA/CARDIAC DIET. FOLEY CATH D/S/P DRAINING CLEAR LIGHT YELLOW URINE 30-140CC/HR. PT APPEARS TO BE AUTO DIURESING AT THIS TIME. SKIN INTACT. FULL CODE. PT'S CONTACT PERSON IS DAUGHTER , CALLED THIS AM AND UPDTED ON CONDITION. PT STABLE AND READY FOR TRANSFER TO FLOOR. AWAIT TRANSFER ORDERS. NRSG WILL DISCONNECT SVO2 MONITOR WHEN BED AVAILABLE.\n"
},
{
"category": "Radiology",
"chartdate": "2120-01-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 900442,
"text": " 3:05 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fever s/p left subclavain line placed\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Status post left subclavian line placement.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH:\n\n Again seen is a right-sided subclavian central line in stable position. There\n is no evidence of a left-sided central line. No pneumothorax is seen. There\n appears to be an interval increase in vascular engorgement consistent with\n development of pulmonary edema. Again seen is a retrocardiac opacity\n consistent with consolidation as well as a stable appearing left-sided pleural\n effusion.\n\n IMPRESSION: Left lower lobe pneumonia and left-sided pleural effusion with\n developing pulmonary edema. No evidence of pneumothorax.\n\n ADDENDUM: Upon attending review, there is an area of increased opacity in the\n right lung concerning for pneumonia. Imaging follow-up to resolution is\n recommended. Changes discussed with Dr. via phone at\n 9:15PM on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900749,
"text": " 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? progression of PNA, eval CHF\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with fever and RML PNA, with LLL pna.\n REASON FOR THIS EXAMINATION:\n ? progression of PNA, eval CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:09 A.M., \n\n HISTORY: Fever. Right middle lobe and possible left lower lobe pneumonia.\n\n IMPRESSION: AP chest compared to and :\n\n The previous region of consolidation in the superior segment of the right\n lower lobe has cleared, but the left lower lobe remains consolidated.\n Pulmonary edema has also resolved in the interim. Mild cardiomegaly persists.\n Small left pleural effusion is larger. There is no appreciable right pleural\n effusion.\n\n\n"
}
] |
81,737 | 180,701 | Brief Summary: The patient was a 20 year old female with a ten year history of anorexia nervosa who presented voluntarily to the emergency department on for treatment of malnutrition. She was noted to have episodes of non-sustained ventricular tachycardia (NSVT) and hypotension in the setting of abnormal electrolytes. The patient refused to eat solid foods; thus, the eating disorder protocol was initiated, necessitating a nasogastric tube and tube feeds. Early in her hospital stay, the patient refused her tube feeds. The psychiatry service was consulted. Legal guardianship documents were filed. | TissueDoppler imaging suggests a normal left ventricular filling pressure(PCWP<12mmHg). Normalmitral valve supporting structures.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Small-to-moderate right pleural effusion remains. The mitral valve appears structurally normal with trivialmitral regurgitation. The cardiomediastinal contours are within normal limits. AnorexiaHeight: (in) 62Weight (lb): 80BSA (m2): 1.30 m2BP (mm Hg): 106/83Status: InpatientDate/Time: at 11:21Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Normaltricuspid valve supporting structures. The estimatedpulmonary artery systolic pressure is normal. Left ventricular function. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. Right PICC has been repositioned. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Normal sinus rhythm. Normal sinus rhythm. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. TECHNIQUE: Single AP radiograph of the abdomen and pelvis was obtained. Right lung hazy opacity likely represents combination of superimposition of soft tissues and atelectasis. Evaluate for ileus versus obstruction. Cardiomediastinal contours are normal. Sinus arrhythmia. TDI E/e' < 8, suggesting normal PCWP (<12mmHg).No resting LVOT gradient. Septal T waves are non-specific. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess right PICC after reposition. Sinus rhythm. Sinus rhythm. T wave abnormalities. There is no pericardialeffusion.IMPRESSION: normal study Clinical correlation issuggested. Right ventricularchamber size and free wall motion are normal. The Q-T interval has alsoshortened.TRACING #2 Considerhypokalemia.TRACING #2 There is normal bowel gas pattern without evidence for obstruction. Consider electrolyte abnormality.TRACING #1 FINDINGS: A Dobbhoff catheter was placed. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aorticregurgitation. IMPRESSION: Dilated air and stool-filled colon suggestive of ileus. FINDINGS: There are low lung volumes. Decreased caliber to the upper mediastinum probably reflects improved central venous pressure. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Since the previous tracing of the axis is less vertical.T waves may be improved.TRACING #1 repeat x-ray after repo. repeat x-ray after repo. The catheter shows normal course and correct position. REASON FOR THIS EXAMINATION: ileus/obstructive gas pattern? Baseline artifact. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF 60%). NG tube tip is out of view below the diaphragm. Sinus bradycardia, rate 48, with occasional ventricular premature beats.Q-T interval prolongation. IMPRESSION: No acute cardiopulmonary process. Compared to the previoustracing of the septal T waves have improved. IMPRESSION: Oro/nasogastric tube with tip in the stomach. FINDINGS: - or orogastric tube is seen with tip overlying the region of the stomach. Heart size is normal. Lungs are grossly clear. 3:27 PM PORTABLE ABDOMEN Clip # Reason: is dobhoff okay to use? 2:30 PM PORTABLE ABDOMEN Clip # Reason: ileus/obstructive gas pattern? Low voltage. Syncope. No evidence of complications, otherwise normal chest radiograph. Early precordial T waveinversions. PATIENT/TEST INFORMATION:Indication: Abnormal ECG. Compared to tracing #1 the Q-T interval has shortened andthe ST-T wave changes have decreased considerably. 11:48 AM CHEST PORT. FINDINGS: An oro- or nasogastric tube is seen with tip overlying the region of the stomach. The non-specificST-T wave changes noted on the prior tracings have continued to improved.TRACING #3 Right lung volume has improved. Few air-fluid levels are seen within the colon. TECHNIQUE: AP radiograph of the abdomen and pelvis with the patient in the supine position and left lateral decubitus radiograph of the abdomen and pelvis were obtained. IMPRESSION: AP chest compared to 2:59 a.m.: Feeding tube ends in the upper stomach. Right PICC is coiled in the proximal SVC around 4.5 cm. No PS.Physiologic PR. 8:09 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ? Apparent increased hazy opacity in the right mid to lower lung zone likely represents a combination of atelectasis and overlying soft tissues. Since the previous tracing T waveabormalities may be more marked. There is no ventricular septal defect. There is no mitral valve prolapse. No AS. No pleural effusion or pneumothorax. T wave inversion in leads aVL and V2-V4. The tip is at the cavoatrial junction. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: r dl picc coiled @ svc aera. Q-T interval is somewhat longer. The Q-T interval has shortened further. Valvular heart disease. The lungs are clear. COMPARISON: . Evaluate placement. No other interval change. RSR' pattern in lead V2 with QRS durationof 86 milliseconds. COMPARISON: None. There is no pneumothorax or pleural effusion. No previoustracing available for comparison. Stool is seen within the colon and rectum. This could be further evaluated with dedicated PA and lateral. No TS. If post-pyloric placement is desired, advancing the tube is recommended. The ascending, transverse and descending colon are dilated to a maximum diameter of 6.5 cm. Decubitus film demonstrates no evidence for free air. The osseous structures are grossly unremarkable. There is no free air or pneumatosis although this exam is not optimized for evaluation for ectopic air. | 14 | [
{
"category": "Radiology",
"chartdate": "2167-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154962,
"text": " 8:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? dobhoff tube placement\n Admitting Diagnosis: ANOREXIA NERVOSA;BMI 14.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with new dobhoff ng tube\n REASON FOR THIS EXAMINATION:\n ? dobhoff tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:27 P.M. ON \n\n HISTORY: 23-year-old woman with a new Dobbhoff nasogastric tube, question\n placement.\n\n IMPRESSION:\n AP chest compared to 2:59 a.m.:\n\n Feeding tube ends in the upper stomach. Right lung volume has improved.\n Small-to-moderate right pleural effusion remains. Decreased caliber to the\n upper mediastinum probably reflects improved central venous pressure. Heart\n size is normal. Lungs are grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1156328,
"text": " 10:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm placement\n Admitting Diagnosis: ANOREXIA NERVOSA;BMI 14.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with Dobhoff placed\n REASON FOR THIS EXAMINATION:\n Please confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Dobbhoff placement.\n\n COMPARISON: .\n\n FINDINGS: A Dobbhoff catheter was placed. The catheter shows normal course\n and correct position. No evidence of complications, otherwise normal chest\n radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1156631,
"text": " 3:27 PM\n PORTABLE ABDOMEN Clip # \n Reason: is dobhoff okay to use?\n Admitting Diagnosis: ANOREXIA NERVOSA;BMI 14.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with anorexia, new dobhoff placement\n REASON FOR THIS EXAMINATION:\n is dobhoff okay to use?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 20-year-old female with anorexia, status post Dobbhoff\n tube placement. Evaluate placement.\n\n COMPARISON: None.\n\n TECHNIQUE: Single AP radiograph of the abdomen and pelvis was obtained.\n\n FINDINGS: An oro- or nasogastric tube is seen with tip overlying the region\n of the stomach. There is normal bowel gas pattern without evidence for\n obstruction. There is no free air or pneumatosis although this exam is not\n optimized for evaluation for ectopic air.\n\n IMPRESSION: Oro/nasogastric tube with tip in the stomach. If post-pyloric\n placement is desired, advancing the tube is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1154810,
"text": " 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for abnormal cardiac morphology, signs of in\n Admitting Diagnosis: ANOREXIA NERVOSA;BMI 14.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with anorexia nervosa with NSVT\n REASON FOR THIS EXAMINATION:\n please evaluate for abnormal cardiac morphology, signs of infection\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMPARISON: None.\n\n HISTORY: Anorexia nervosa with NSVT, evaluate for abnormal cardiac morphology\n or signs of infection.\n\n FINDINGS:\n\n There are low lung volumes. The cardiomediastinal contours are within normal\n limits. Apparent increased hazy opacity in the right mid to lower lung zone\n likely represents a combination of atelectasis and overlying soft tissues.\n This could be further evaluated with dedicated PA and lateral. No pleural\n effusion or pneumothorax. The osseous structures are grossly unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process. Right lung hazy opacity likely\n represents combination of superimposition of soft tissues and atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-15 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1157103,
"text": " 2:30 PM\n PORTABLE ABDOMEN Clip # \n Reason: ileus/obstructive gas pattern?\n Admitting Diagnosis: ANOREXIA NERVOSA;BMI 14.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with anorexia nervosa, vomiting, no flatus, tympany on exam.\n REASON FOR THIS EXAMINATION:\n ileus/obstructive gas pattern?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 20-year-old female with anorexia, now with vomiting and\n no flatus. Evaluate for ileus versus obstruction.\n\n TECHNIQUE: AP radiograph of the abdomen and pelvis with the patient in the\n supine position and left lateral decubitus radiograph of the abdomen and\n pelvis were obtained.\n\n FINDINGS: - or orogastric tube is seen with tip overlying the region of\n the stomach. The ascending, transverse and descending colon are dilated to a\n maximum diameter of 6.5 cm. Stool is seen within the colon and rectum.\n Decubitus film demonstrates no evidence for free air. Few air-fluid levels\n are seen within the colon.\n\n IMPRESSION: Dilated air and stool-filled colon suggestive of ileus.\n\n These findings were communicated to Dr. at 2 p.m. by\n telephone on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1157396,
"text": " 11:48 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: r dl picc coiled @ svc aera. repeat x-ray after repo.\n Admitting Diagnosis: ANOREXIA NERVOSA;BMI 14.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl picc coiled @ svc aera. repeat x-ray after repo.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess right PICC after reposition.\n\n Comparison is made with prior study performed one hour earlier.\n\n Right PICC has been repositioned. The tip is at the cavoatrial junction. No\n other interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-10-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1157394,
"text": " 10:50 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl power picc 43cm, 2cm ex\n Admitting Diagnosis: ANOREXIA NERVOSA;BMI 14.7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl power picc 43cm, 2cm ex\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Right PICC is coiled in the proximal SVC around 4.5 cm. Findings were\n discussed with IV nurse. Cardiomediastinal contours are normal. The lungs\n are clear. There is no pneumothorax or pleural effusion. NG tube tip is out\n of view below the diaphragm.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Report",
"row_id": 90109,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Left ventricular function. Syncope. Valvular heart disease. Anorexia\nHeight: (in) 62\nWeight (lb): 80\nBSA (m2): 1.30 m2\nBP (mm Hg): 106/83\nStatus: Inpatient\nDate/Time: at 11:21\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg).\nNo resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF 60%). Tissue\nDoppler imaging suggests a normal left ventricular filling pressure\n(PCWP<12mmHg). There is no ventricular septal defect. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no mitral valve prolapse. The estimated\npulmonary artery systolic pressure is normal. There is no pericardial\neffusion.\n\nIMPRESSION: normal study\n\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-21 00:00:00.000",
"description": "Report",
"row_id": 237376,
"text": "Sinus arrhythmia. Septal T waves are non-specific. Compared to the previous\ntracing of the septal T waves have improved. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Report",
"row_id": 237612,
"text": "Normal sinus rhythm. The Q-T interval has shortened further. The non-specific\nST-T wave changes noted on the prior tracings have continued to improved.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Report",
"row_id": 237613,
"text": "Normal sinus rhythm. Compared to tracing #1 the Q-T interval has shortened and\nthe ST-T wave changes have decreased considerably. The Q-T interval has also\nshortened.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-02 00:00:00.000",
"description": "Report",
"row_id": 237609,
"text": "Sinus rhythm. T wave abnormalities. Since the previous tracing T wave\nabormalities may be more marked. Q-T interval is somewhat longer. Consider\nhypokalemia.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2167-10-01 00:00:00.000",
"description": "Report",
"row_id": 237610,
"text": "Baseline artifact. Sinus rhythm. Low voltage. Early precordial T wave\ninversions. Since the previous tracing of the axis is less vertical.\nT waves may be improved.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2167-09-30 00:00:00.000",
"description": "Report",
"row_id": 237611,
"text": "Sinus bradycardia, rate 48, with occasional ventricular premature beats.\nQ-T interval prolongation. RSR' pattern in lead V2 with QRS duration\nof 86 milliseconds. T wave inversion in leads aVL and V2-V4. No previous\ntracing available for comparison. Consider electrolyte abnormality.\nTRACING #1\n\n"
}
] |
7,190 | 191,465 | The patient was admitted to the hospital for pre-operative work-up prior to surgery. A carotid ultrasound was obtained, which showed less than 40% stenosis bilaterally. An echocardiogram was obtained, and showed moderate thickening of the aortic valve leaflets with severe aortic valve stenosis and mild (1+) aortic regurgitation. The mitral valve leaflets were also mildly thickened without evidence of regurgitation. The decision was made to take the patient to the operting room on , where a CABG x2 (SVG->OM, SVG->RCA) was performed, along with the placement of a 21 mm - pericardial tissue arotic valve. Please see operative note for full details. The patient tolerated this procedure well. Post-operatively, the patient was taken to the Cardiac Surgery Recovery Unit. There, the patient did well. He was extubated on post-op day #1. The PA catheter and chest tubes were removed on post-op day #2. One unit of red blood cells was transfused for a hematocrit of 25. The patient was transferred to the floor. On post-op day #3, the patient's pacing wires were removed, and the lopressor was increased. The patient was able to ambulate well, and was discharged home with services on post-op day #5 in stable condition. | CONT W/ ADEQUATE DIURESIS FROM AM LASIX. Glucoses now trending down-weaning gtt.Incisions: Sternum and CT DSD with old dng-Intact. leak noted via right CT.Bs: ess. F/C DD WITH ADEQUATE UOP. MILD MRSEEN.POST BYPASS BIVENTRICULAR SYSTOLIC FUNCTION IS PRESERVED. advanced to clear liqs. Midline drains, ET tube, and nasogastric tube are in standard placements. Secreations minimal.abgs:hyperoxygenated normal ph with mild hypercapnia.PlaN: cont. PATIENT/TEST INFORMATION:Indication: Pre CABG and AVRStatus: InpatientDate/Time: at 16:07Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The right ICA-CCA ratio is 1.0. Replete lytes prn. IMPRESSION: Postoperative appearance of the chest. AORTAINTACT POST DECANNULATION. Respiratory Care:Pt. Mild (1+)AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. PAD/CVP/SVO2 AND CO (BY CCO) GOOD DESPITE LARGE AMOUNT HOURLY MEDIASTINAL CT DRAINAGE.BREATHSOUNDS CLEAR BILATERALLY. Mild plaque is present near the origins of the right internal and external carotid arteries. Initially Hct dropping, volume resuscitated. REPEAT CXR DONE. HyperdynamicLVEF.RIGHT VENTRICLE: Normal RV wall thickness. MEDIASTINAL CT'S WITH SMALL AMT SEROSANG DRAINAGE. Normal RVsystolic function.AORTA: Normal aortic root diameter. LABILE BP REQUIRING NTG. Resp CarePt. HEMODYNAMICS WNL'S. Right ventricular systolicfunction is normal.4. A mitral valve replacement is seen. Normal regional LVsystolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated ascending aorta. Mild (1+) aorticregurgitation is seen.6.The mitral valve leaflets are mildly thickened. NEURO~INTUBATED & ON PROPOFOL. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Respiratory TherapyPt received from OR s/p CABG. Moderately thickened aortic valveleaflets. BIOPROSTHETIC VALVESEEN IN THE AORTIC POSITION APPEARS WELL SEATED. Chest tubes removed. MAINTAINING BG LEVELS WITH IN CSRU PROTOCOL.A/P~LABILE BP. There is moderate symmetric left ventricular hypertrophy. HYPOACTIVE BS.ENDO~CONT ON INS GTT. PA and lateral radiographs of the chest demonstrate a normal cardiomediastinal silhouette. The left ICA-CCA ratio was 1.7. Hct 28.3.Resp: Intubated on SIMV/40%/12/700/5PS/10PEEP with good ABG's. Wean milrinone. The pulmonary vascularity is probably within normal limits allowing for supine technique. MINIMAL DRAINAGE FROM CHEST TUBES.CARDIAC~SR/ST. PRBC, FFP, PLATELETS, DDAVP, PROTAMINE GIVEN (SEE FLOWSHEET/). Normal LV cavity size. Sinus rhythm. c & r scant tan.milrinone weaned to .125,plan to dc @ o400. Remains orally intubated on full mechanical support. OP DAY CABG X 2 AND BIOPROSTHETIC AVRNSR. Right ventricular chamber size is normal. Cont on milr .5 and NTG .5. Mild-to-moderate plaque is present at the origin of the left internal carotid artery. capoten & prn hydralazine added for htn,afterload reduction.adequate ci,svo2,filling pressures. remains hemodynamically stable, wean to extubate during day. 11P-7A SHIFT UPDATESEE CAREVIEW FOR COMPLETE ASSESSMENT.NEURO INTACT. Moderately dilated ascending aorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. Tip of the Swan-Ganz catheter can be traced as far as the right pulmonary artery, obscured by overlying appliances. ACE WRAP INTACT LLE.GI/GU: ABD SOFT WITH POSITIVE BS'S. LUNGS COARSE/CLEAR BILAT. The leftventricular cavity size is normal. Tip of the Swan-Ganz line is partially obscured at the level of the pulmonary outflow tract. diuresing w lasix. Min sang dng.GU: Foley to gd with UO>30cc/hr. Left ventricular systolic function ishyperdynamic (EF>75%).3. Ace wrap L leg with steris-C/D.Comfort: Sedated-MSO4 2mg IV given X2.Activity: Sedated. HISTORY: Status post AVR and CABG. CI>2.5 with SVO2 62-67. clear anteriorly. Left ventricular hypertrophy with ST-T wave changes.Compared to the previous tracing no significant change. RESPONDING APPROPRIATELY TO YES AND NO QUESTIONING. IMPRESSION: AP chest compared to , and : Postoperative enlargement of the cardiomediastinal silhouette is improving. TECHNIQUE: AP portable supine single view of the chest. There is an ET tube with the tip in good position. The ascending aorta is moderately dilated.5. Normal descending aorta diameter.Simple atheroma in descending aorta.AORTIC VALVE: Three aortic valve leaflets. RARE PVC'S NOTED. Clinicalcorrelation is suggested. Possible left anterior fascicular block. BP VIA CUFF. Sm. There is appropriate antegrade flow in the vertebral arteries bilaterally. The Doppler exam was inadequate to comment on valvularregurgitation/function.Conclusions:PREBYPASS LV AND RV FUNCTION WAS NORMAL. STERNAL DRESSING W/MINIMAL PINK-BLOODY STAINING.OGT DRAINING MINIMAL BILIOUS/CLEAR DRAINAGE. Aortic valve repair. ABG'S WNL. CI REMAINS > 2. Fio2 weaned otherwise no changes. a line removed & following cuff pressures for monitoring.oob->chair,tol. extubated to np's w/o incident. The left atrium is normal in size.2. IMPRESSION: AP chest compared to the earlier postoperative film from 7:05 p.m. and preoperative radiographs of : Mild interstitial pulmonary edema is new. Severe AS.MITRAL VALVE: Moderately thickened mitral valve leaflets. KCL REPLACEMENT AS NOTED.GLUCOSE ELEVATED. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Sinus bradycardia. Sinus bradycardia. CT DRAINAGE <100CC/HR AT THE TIME OF DR. Cr.8GI: Abd softly distended with no BS. There is moderate degree of left basal atelectasis increased slightly since following tracheal extubation. CONT ON NITRO CURRENTLY @ 3UCG/KG/MIN. FINDINGS: There is a right IJ Swan-Ganz catheter with the tip in the pulmonary artery trunk. POS PAL PEDAL PULSES BILAT.GI/GU~NPO. There is an NG tube with the tip in the stomach. goal is sbp < 140 w map's 70's. CUFF PRESSURES AND FEM ALINE CORRELATING. Lungs are otherwise grossly clear. Hemodynamically improved this morning. HISTORY: AVR and CABG. No PR.PERICARDIUM: No pericardial effusion.Conclusions:1. PLAN TO RECHECK COAGS AT 24/HR. The patient was under generalanesthesia throughout the procedure. K,Ca and Mag repleted. The aortic valve leaflets are moderately thickened. The patient appears to be in sinusrhythm. If pt. INSULIN RESUMED WITH CANCELLATION OF OR.PT HAS NOT AWOKEN. I certifyI was present in compliance with HCFA regulations. DUAL PM WIRES SECURE INTACT. Not wakened r/t bleeding. USING IS AS INSTRUCTED. provided w cough pillow,good resp, effort. No MR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Lateral ST-T wave abnormalities. NO RESP DISTRESS OVERNIGHT.CV: SWAN RIJ. PERRL.CV: 80-90's SR with occ MF RVC's and 12 beat run VT noted. IMPRESSION: AP chest compared to preoperative films on and postoperative on : Postoperative widening of the cardiomediastinal silhouette due in part to cardiomegaly, vascular engorgement and retained hematoma which increased between 7:05 p.m. and 9:30 p.m. on is stable subsequently. | 19 | [
{
"category": "Echo",
"chartdate": "2190-03-02 00:00:00.000",
"description": "Report",
"row_id": 80493,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pre CABG and AVR\nStatus: Inpatient\nDate/Time: at 16:07\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal regional LV\nsystolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated ascending aorta. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Severe AS.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. 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. The patient appears to be in sinus\nrhythm. Results were personally reviewed with the MD caring for the patient.\nEchocardiographic results were reviewed with the houseofficer caring for the\npatient. The Doppler exam was inadequate to comment on valvular\nregurgitation/function.\n\nConclusions:\nPREBYPASS LV AND RV FUNCTION WAS NORMAL. NO REGIONAL WALL MOTION ABNORMALITY\nSEEN. TRACE AORTIC REGURGITATION AND SEVERE AORTIC STENOSIS PRESENT. MILD MR\nSEEN.\n\n\nPOST BYPASS BIVENTRICULAR SYSTOLIC FUNCTION IS PRESERVED. BIOPROSTHETIC VALVE\nSEEN IN THE AORTIC POSITION APPEARS WELL SEATED. TRACE AI PRESENT. AORTA\nINTACT POST DECANNULATION.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2190-03-01 00:00:00.000",
"description": "Report",
"row_id": 80494,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment.\nHeight: (in) 66\nWeight (lb): 170\nBSA (m2): 1.87 m2\nBP (mm Hg): 111/72\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 09:13\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nduring the examination, the machine crashed making the calculation of the\ngradient impossible.\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Hyperdynamic\nLVEF.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS. Mild (1+)\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size.\n2. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4. The ascending aorta is moderately dilated.\n5. The aortic valve leaflets are moderately thickened. While a calculation of\nthe mean aortic valve gradient was not performed, given the velocity\nmeasurement across the aoritc valve, suspect that there is severe aortic\nstenosis. There is severe aortic valve stenosis. Mild (1+) aortic\nregurgitation is seen.\n6.The mitral valve leaflets are mildly thickened. No mitral regurgitation is\nseen.\n7.There is no pericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-02 00:00:00.000",
"description": "Report",
"row_id": 1358130,
"text": "Respiratory Therapy\n\nPt received from OR s/p CABG. Remains orally intubated on full mechanical support. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: wean to extubate per protocol...\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-03 00:00:00.000",
"description": "Report",
"row_id": 1358132,
"text": "Resp Care\nPt. remains intubated sedated overnight. Fio2 weaned otherwise no changes. Initially Hct dropping, volume resuscitated. Hemodynamically improved this morning. Sm. leak noted via right CT.\nBs: ess. clear anteriorly. Secreations minimal.\nabgs:hyperoxygenated normal ph with mild hypercapnia.\nPlaN: cont. to support. If pt. remains hemodynamically stable, wean to extubate during day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-02 00:00:00.000",
"description": "Report",
"row_id": 1358131,
"text": "OP DAY CABG X 2 AND BIOPROSTHETIC AVR\nNSR. LABILE BP REQUIRING NTG. MILRINONE @ .5MCG FROM THE OR. PAD/CVP/SVO2 AND CO (BY CCO) GOOD DESPITE LARGE AMOUNT HOURLY MEDIASTINAL CT DRAINAGE.\n\nBREATHSOUNDS CLEAR BILATERALLY. NO VENT WEANING PER DR. (TILL EVALUATION IN AM). MEDIASTINAL CT DRAINING AS MUCH AS 100CC Q/15 MINUTES. PRBC, FFP, PLATELETS, DDAVP, PROTAMINE GIVEN (SEE FLOWSHEET/). PEEP INCREASED TO 10. DR. CALLED BACK TO EXAMINE PATIENT. REPEAT CXR DONE. CT DRAINAGE <100CC/HR AT THE TIME OF DR. ARRIVAL. OR TEAM CANCELLED FOR RETURN TO OR. PLAN TO WATCH CT DRAINAGE CAREFULLY.\n\nALL LINE SITES DRY. STERNAL DRESSING W/MINIMAL PINK-BLOODY STAINING.\n\nOGT DRAINING MINIMAL BILIOUS/CLEAR DRAINAGE. ABD SOFT. ABSENT BOWEL SOUNDS.\n\nFOLEY DRAINING CLEAR YELLOW URINE AND AS MUCH AS 700CC EARLIER THIS SHIFT. KCL REPLACEMENT AS NOTED.\n\nGLUCOSE ELEVATED. CSRU GLUCOSE MANAGMENT PROTOCOL INITIATED. INSULIN GTT OFF FOR 1HR THIS EVENING IN PREPARATION FOR RETURN TO THE OR. INSULIN RESUMED WITH CANCELLATION OF OR.\n\nPT HAS NOT AWOKEN. NO ATTEMPT TO AWAKEN PATIENT WITH BLEEDING. PROPOFOL ON THROUGHOUT SHIFT. MORPHINE GIVEN PROPHYLACTICALLY.\n\nWIFE CALLED EARLIER BY SURGEON TO NOTIFY HER OF EXPECTED RETURN TO THE OR. DR. PHONED LATER THIS EVENING TO NOTIFY MRS. THAT PT DID NOT NEED TO GO TO THE OR.\n\nPLAN TO MONITOR FOR RETURN OF BLEEDING. PLAN TO WATCH FOR POTENTIAL SIGNS OF TAMPONADE. PLAN TO KEEP SEDATED AND INTUBATED OVERNIGHT. PLAN TO RECHECK COAGS AT 24/HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-04 00:00:00.000",
"description": "Report",
"row_id": 1358137,
"text": "11P-7A SHIFT UPDATE\nSEE CAREVIEW FOR COMPLETE ASSESSMENT.\n\nNEURO INTACT. MEDICATED X 2 FOR INCISIONAL PAIN WITH PO PERCOCETS.\n\nRESP: CRACKLES ON RIGHT. USING IS AS INSTRUCTED. STRONG PRODUCTIVE COUGH WHITE SPUTUM. NO RESP DISTRESS OVERNIGHT.\n\nCV: SWAN RIJ. HEMODYNAMICS WNL'S. BP VIA CUFF. MILRINONE D/C'D AT 0400 AS ORDERED. CI>2.3. DUAL PM WIRES SECURE INTACT. NO PACER ACTIVITY OVERNIGHT. MEDIASTINAL CT'S WITH SMALL AMT SEROSANG DRAINAGE. ACE WRAP INTACT LLE.\n\nGI/GU: ABD SOFT WITH POSITIVE BS'S. TAKING PO FLUIDS AND MEDS WITHOUT DIFFICULTY. F/C DD WITH ADEQUATE UOP. LASIX DUE AT 0600.\n\nSKIN: ALL DRSG'S C,D&I.\n\nLABS: AML'S PENDING. LABS OBTAINED FROM AFTER FLUSHED WITH 10 CC NS AND 6 CC WASTED. GLUCOSE FROM LINE ON ACCUCHECK= HIGH, FINGERSTICK=159. 6 UNITS REG SC GIVEN.\n\nPLAN: UP OOB TO CHAIR. D/C SWAN, CONTINUE TO ENCOURAGE IS, DB, COUGHING. ADVANCE DIET AS TOL, ?START COUMADIN TODAY. POSS TX TO 2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-03 00:00:00.000",
"description": "Report",
"row_id": 1358133,
"text": "NPN: S/P CABG X2/AVR\n\nNeuro: Sedated with propofol 50. Not wakened r/t bleeding. PERRL.\nCV: 80-90's SR with occ MF RVC's and 12 beat run VT noted. Cont on milr .5 and NTG .5. CI>2.5 with SVO2 62-67. Palp pedal pulses. Skin warm and dry. CVP 12-16 with PAD 22-26. K,Ca and Mag repleted. Hct 28.3.\nResp: Intubated on SIMV/40%/12/700/5PS/10PEEP with good ABG's. Sats>98%. Sxn X1 for thick pale yellow secretions. MT to sxn-no airleak. Min sang dng.\nGU: Foley to gd with UO>30cc/hr. Cr.8\nGI: Abd softly distended with no BS. NPO. OGT to LWS with small pink tinged dng.\nEndo: On insulin gtt per CTS protocol. Glucoses now trending down-weaning gtt.\nIncisions: Sternum and CT DSD with old dng-Intact. Ace wrap L leg with steris-C/D.\nComfort: Sedated-MSO4 2mg IV given X2.\nActivity: Sedated. Turned side to sdie q 2-3 hrs with max assist 2.\nA: Bleeding resolved.\nP: Awaiting assesment by team, then plan to awaken and consider weaning. Replete lytes prn. Wean milrinone.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-03 00:00:00.000",
"description": "Report",
"row_id": 1358134,
"text": "NEURO~INTUBATED & ON PROPOFOL. FC. MAE. RESPONDING APPROPRIATELY TO YES AND NO QUESTIONING. MORPHINE 2 MG FOR DISCOMFORT. EFFECTIVE. FAMILY CALLED AND NOTIFIED OF PT'S STATUS.\n\nRESP~CONT SIMV.ABLE TO WEAN PT TO CPAP PT READY FOR EXTUBATION BY 1100. ABG'S WNL. LUNGS COARSE/CLEAR BILAT. SX FOR SM AMTS OF THICK YELLOW SPUTUM. MAINTAINING SATS OF 97%. SVO2 68-70%. MINIMAL DRAINAGE FROM CHEST TUBES.\n\nCARDIAC~SR/ST. RARE PVC'S NOTED. MILNIRONE DECREASED FROM 5 UCG/KG/MIN TO .26 UCG/KG/MIN, @ 0830. CI REMAINS > 2. CONT ON NITRO CURRENTLY @ 3 UCG/KG/MIN. TO MAINTAIN MAP'S 60-90. CUFF PRESSURES AND FEM ALINE CORRELATING. RAD ALINE REMAINS 20-30 MMHG HIGHER. ELECTROLYTES REPLETED. POS PAL PEDAL PULSES BILAT.\n\nGI/GU~NPO. CONT W/ ADEQUATE DIURESIS FROM AM LASIX. HYPOACTIVE BS.\n\nENDO~CONT ON INS GTT. MAINTAINING BG LEVELS WITH IN CSRU PROTOCOL.\n\nA/P~LABILE BP. CONT ON NITRO CURRENTLY @ 3UCG/KG/MIN. TO BE GIVEN HYDRALAZINE 10 MG IV X1. NO FURTHER EPISODES OF ECTOPY OR VT THIS AM.\nPLAN TO EXTUBATE AND D/C FEM ALINE THIS AFTERNOON. TEAM TO RE EVAL\nNEEED FOR INOTROPE THIS AFTERNOON AND POSSIBLY FURTHER WEAN MILNIRONE TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-03 00:00:00.000",
"description": "Report",
"row_id": 1358135,
"text": "Respiratory Care:\nPt. extubated to a 50% cool neb. Seems to be doing well. PaO2 is @ aprox 80% on vent @ 40% Sat = 95%, HR = 88, BP = 153/65.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-03 00:00:00.000",
"description": "Report",
"row_id": 1358136,
"text": "extubated to np's w/o incident. provided w cough pillow,good resp, effort. performs spirometry with encouragement to 500-1000cc. c & r scant tan.milrinone weaned to .125,plan to dc @ o400. capoten & prn hydralazine added for htn,afterload reduction.adequate ci,svo2,filling pressures. diuresing w lasix. goal is sbp < 140 w map's 70's. radial a line increasingly damp & difficult to flush. great discrepancy between cuff(lower) & a line. a line removed & following cuff pressures for monitoring.oob->chair,tol. well. advanced to clear liqs. glucoses covered w ssri,see flow sheet.pain controlled w percocet.wife in,questions answered. see flow sheet.\n"
},
{
"category": "ECG",
"chartdate": "2190-03-02 00:00:00.000",
"description": "Report",
"row_id": 204844,
"text": "Sinus rhythm. Lateral ST-T wave abnormalities. Compared to the previous tracing\nof patient no longer meets criteria for left ventricular hypertrophy\nbut lateral ST-T wave abnormalities persist. These findings could be related to\nleft ventricular hypertrophy but cannot rule out myocardial ischemia. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-03-01 00:00:00.000",
"description": "Report",
"row_id": 204845,
"text": "Sinus bradycardia. Left ventricular hypertrophy with ST-T wave changes.\nCompared to the previous tracing no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-02-28 00:00:00.000",
"description": "Report",
"row_id": 204846,
"text": "Sinus bradycardia. Possible left anterior fascicular block. Non-diagnostic\nrepolarization abnormalities. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-03-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 899042,
"text": " 6:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: poostop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p AVR/cabg x2\n REASON FOR THIS EXAMINATION:\n poostop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male status post AVR and CABG.\n\n COMPARISONS: Comparison is made to preoperative chest x-ray from .\n\n TECHNIQUE: AP portable supine single view of the chest.\n\n FINDINGS: There is a right IJ Swan-Ganz catheter with the tip in the\n pulmonary artery trunk. There is an ET tube with the tip in good position.\n There is an NG tube with the tip in the stomach. There are two mediastinal\n tubes. There is no evidence of pneumothorax. There is cardiomegaly. The\n pulmonary vascularity is probably within normal limits allowing for supine\n technique. Skeletal structures demonstrate findings of median sternotomy. A\n mitral valve replacement is seen.\n\n IMPRESSION: Postoperative appearance of the chest. No evidence of\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-03-01 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 898844,
"text": " 9:22 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Please assess for carotid stenosis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with 3 vessel CAD and severe AS here for possible cardiac\n intervention\n REASON FOR THIS EXAMINATION:\n Please assess for carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old man with 3-vessel CAD and severe AS, here for possible\n cardiac intervention.\n\n No prior available for comparison.\n\n FINDINGS: The cervical portions of the carotid and vertebral arteries were\n examined with Duplex ultrasound bilaterally.\n\n Mild plaque is present near the origins of the right internal and external\n carotid arteries. The peak systolic velocities of the right internal, common,\n and external carotid arteries are 63, 58 and 50 cm/sec respectively. The\n right ICA-CCA ratio is 1.0.\n\n Mild-to-moderate plaque is present at the origin of the left internal carotid\n artery. Peak systolic velocities of the left internal, common, and external\n carotid arteries are 98, 56 and 59 cm/sec respectively. The left ICA-CCA\n ratio was 1.7.\n\n There is appropriate antegrade flow in the vertebral arteries bilaterally.\n\n IMPRESSION: Plaque is present in the internal carotid arteries bilaterally,\n more pronounced on the left than the right. The degree of stenosis is\n evaluated as less than 40% stenosis bilaterally.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 899077,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS FOR EFFUSIONS/INFILTRATES\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p AVR/cabg x2\n\n REASON FOR THIS EXAMINATION:\n ASSESS FOR EFFUSIONS/INFILTRATES\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:09 A.M. .\n\n HISTORY: Status post AVR and CABG.\n\n IMPRESSION: AP chest compared to preoperative films on and\n postoperative on :\n\n Postoperative widening of the cardiomediastinal silhouette due in part to\n cardiomegaly, vascular engorgement and retained hematoma which increased\n between 7:05 p.m. and 9:30 p.m. on is stable subsequently. Lung\n volumes have improved slightly and pulmonary edema has resolved since the\n laser study. Tip of the Swan-Ganz catheter can be traced as far as the right\n pulmonary artery, obscured by overlying appliances. Midline drains, ET tube,\n and nasogastric tube are in standard placements. There is no pneumothorax or\n appreciable pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 899054,
"text": " 9:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Bleeding\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p AVR/cabg x2\n\n REASON FOR THIS EXAMINATION:\n Bleeding\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:32 P.M., .\n\n HISTORY: AVR and CABG. Bleeding.\n\n IMPRESSION: AP chest compared to the earlier postoperative film from 7:05\n p.m. and preoperative radiographs of :\n\n Mild interstitial pulmonary edema is new. The accompanying increase in\n caliber of the cardiomediastinal silhouette at the level of the aortic arch\n and the superior vena cava could be due to volume retention and vascular\n engorgement, but a component of mediastinal hematoma may well be present.\n There is no pneumothorax or pleural effusion.\n\n Tip of the Swan-Ganz line is partially obscured at the level of the pulmonary\n outflow tract. Other lines and tubes are in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-02-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 898753,
"text": " 8:37 AM\n CHEST (PA & LAT) Clip # \n Reason: Preop\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with Aortic Stenosis\n REASON FOR THIS EXAMINATION:\n Preop\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aortic stenosis.\n\n PA and lateral radiographs of the chest demonstrate a normal cardiomediastinal\n silhouette. The aorta is calcified and tortuous. Lungs are clear. No\n effusion.\n\n IMPRESSION:\n\n No acute cardiopulmonary disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 899225,
"text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post-pull film. Evaluate for pneumothorax\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p CABG/aoric valve repair now s/p removal of chest tubes\n REASON FOR THIS EXAMINATION:\n post-pull film. Evaluate for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:35 A.M. \n\n HISTORY: CABG. Aortic valve repair. Chest tubes removed.\n\n IMPRESSION: AP chest compared to , and :\n\n Postoperative enlargement of the cardiomediastinal silhouette is improving.\n There is moderate degree of left basal atelectasis increased slightly since\n following tracheal extubation. Lungs are otherwise grossly clear.\n There is no pneumothorax or appreciable pleural fluid collection. Tip of the\n Swan-Ganz catheter projects over the proximal right pulmonary artery.\n\n\n"
}
] |
18,833 | 192,818 | 1. Respiratory. was initially on nasal cannula O2. With worsening respiratory effort, he was placed on continuous positive airway pressure. His work of breathing and respiratory effort improved and he was transitioned to room air on day of life number 2. He has remained in baseline room air for the rest of his neonatal intensive care unit admission. He had episodes of oxygen desaturation and developed stridor at 2 weeks of life. He was evaluated by the otorhinolaryngology service, attending Dr. . A bedside flexible laryngoscopic exam raised concern for laryngeomalacia. He underwent a rigid bronchoscopy under general anesthesia at , which was normal. It was felt at this time that his large tongue and small airway were the etiology for his stridor and episodes of oxygen desaturation. With the other facial findings a consultation with Dr. , plastic surgeon from , was obtained. It was Dr. opinion that had all the clinical features of Branchio-oculo-facial syndrome--a very rare genetic disorder characterized by the incomplete cleft of the lip and palate and the other craniofacial abnormalities. was successfully managed in the prone position without further episodes of serious desaturation. At the time of discharge, he is able to be in any position either prone or supine without episodes of desaturation. He passed a car seat test on . His baseline respiratory rate is 30 to 50 breaths per minute. He does develop stridor with feeds, which persist for a short time after the feeding. In between feedings his breath sounds are clear and equal and he does not have any evidence of respiratory distress. is slated to have surgical repair of his facial anomalies with Dr. in or . He is being discharged home with an oximeter for use while sleeping to ensure that he has no significant desaturations. 2. Cardiovascular. Due to the other abnormal clinical findings, had a screening electrocardiogram and echocardiogram. All results were within normal limits and the echocardiogram did not show any structural heart disease. Baseline heart rate is 100 to 160 beats per minute with a recent blood pressure of 93/66 with a mean of 74. 3. Fluids, electrolytes and nutrition. was initially NPO and maintained on intravenous fluids. Enteral feedings were started on day of life number 2 and gradually advanced. He had inconsistent success with po feedings even when different nipples and feeding devices were tried. His most consistent success was with a Habermann feeder. Due to the concern of ' inconsistent feeding ability, the decision was made to place a gastrostomy feeding tube. A surgically placed gastrostomy tube was placed at on by Dr. . The gastrostomy tube began leaking approximately 4 days postoperatively. He was diagnosed with a cellulitis at the site. He was made NPO and treated with a week of intravenous Kefzol. The enteral feeds were started again on and has been predominantly po feeding with some additional intake through the gastrostomy tube without any problem since that time. He is being discharged home on mother's breast milk fortified to 24 calories per ounce 4 calories/oz by Enfamil powder. Weight on the day of discharge is 3.92 kilograms with a corresponding head circumference of 36.5 cm and a length of 54 cm. Serum electrolytes were checked at numerous junctures and all were within normal limits. 4. Infectious disease. had a complete blood count and blood culture drawn on admission to the neonatal intensive care unit. The blood count was within normal limits. The blood culture was no growth at 48 hours. received 48 hours of Ampicillin and Gentamicin during the pending blood culture. As previously noted had a cellulitis at the gastrostomy tube insertion site and was treated with a week of Kefzol. Blood culture obtained at that time was also no growth. has had intermittent problems with eye drainage as part of his syndrome. He has a blocked tear duct on the right. In the past, with development of conjunctivitis, he has been treated with erythromycin, garamicin and polymixin. Currently the blocked duct is being treated with lacrimal massage and his mother has Ciprofloxacin by ointment to treat on an as needed basis, if he develops evidence of conjunctivitis. 5. Hematological. ' blood type A positive, Coombs negative, hematocrit at birth was 57.6%. He did not receive any transfusions of blood products. His most recent hematocrit was on at 28.9%. He is being discharged home on supplemental iron. 6. Gastrointestinal. required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life number 5, total 11.7/0.4 mg per deciliter direct. As noted he has a gastrostomy tube placed. 7. Genetics. As part of his workup for the abnormal physical findings, was evaluated by the genetic consult service at . He will be followed by Dr. at 4 months of age. Chromosomes were normal showing a normal karyotype. He also had a signature chip chromosome study sent with results that remain pending. There were extensive metabolic studies drawn with all results within normal limits. 8. Neurological. was also evaluated by the neurology service at . As time progressed, his tone improved. He will be followed in the neonatal neurology program at after discharge. Head ultrasound on was normal. An MRI performed on was also normal. Skull films were obtained as part of the workup and also were normal. 9. Sensory. Audiology hearing screening was performed with automated auditory responses. passed in the left ear and referred in the right ear. He was retested on and again referred in the right ear. He is being referred to for further audiological evaluation. Ophthalmology--As part of his work up for the abnormal physical findings, had an ophthalmological exam on . His eyes are structurally normal. He has intermittent problems with the blocked tear ducts and will be treated on an as needed basis with antibiotic opthalmic ointment. 10. Psycho/social. social work has been involved with this family. The contact person is and she can be reached at . | IVantibiotic D/C'd this am.# P: Cont to assess.#9 O: Remains on Cefazolin. g tube cellulitis resolved. Made NPO during day.Needing pacifier, swaddling or holding to settle.Hypertonic. Antibx as ordered. P: Cont to assess.#8 O: G-tube cleaned per protocol. Respiratory O: Pt. A: AGA, s/p g-tube placement. A: Stable NPO P: Monitor. A: Stable.P: Cont to assess. A: , concerndedparent P: Support and update. Someaudable stridor noted. A: Stable P:Monitor. noincreased wob noted. Monitor site.ID remains on IV Kefzol. Now stable in RA. Infusing well.Continues NPO per surgery. mild subcostal retractions. upper airway conjestion noted. LSclear/=. POST OP GT CARE O: GT securely in place. Labs noted and PN adjusted accordingly. A:Tolerating feeds & gaining wgt. A: s/p g-tube placement. G-tube site is C/D/I. Abd softwith active BS. Some upperairway congestion.Cont to monitor and support resp status.G/D with stable temps in OAC. Tolerating PN with good BS control. Support andeductae.G-tube with only single gauze under flange of G-Tube now.Monitor secretions. AccurateI/Os. A: Pt. A: Pt. A. NPO with IV hydration.P. GT site cleaned. Report anyredness. is tolerateing current nutritionalplan. P. Comfort measures as above.4. Support G/D.FenMade NPO during day. A: Stable on room air.Brady x2 P: Monitor and document.o3. abdexam benign. Apgars .Course in NICU remarkable for:1. Knowledgable. Sucrose per NICU protocol.4. small amount ofyellowish drainage noted on dressing. AGA with BOF synd.Fen on TF 120 cc/k/d. No resp distress at this time.G/D in OAC. AFOF sutures approximated. Remains oncefazolin. Updatesgiven. Sucrose given onpacifier. Mild SC retractionsnoted. Sm amt yel drainage noted. Ranitidine addedto PN. Temp. cleansed with1/4 str H2O2 and neosporin applied. LS clear andequal with occasional stridor audible. Continueantibiotic and monitor. Updated, asking appropriatequestions. Swaddled & sucrose pacifiergiven. On zantac. Resp O/A Rec'd inf in RA. ABX as ordered, NPO. P. Contiue to keepsidelying or supine. P.Cont. DS stable. Mild retractions. P: Continue with treatment. P: Cont to assess. Sitecleaned with 1/4 str H2O2, neosporin oint applied. Labs noted and PN adjusted accordingly. Asking appropriatequestions. Sitecleaned per protocol. G-tube: G-tube remains to gravity with sm-mod amounts ofclear mucousy drainage. Afebrile. Afebrile. A: AGA. Continuing IV cefazolin for now. LS clear. On kefzol.Eye drainage continues. P. Continue with care.9. F/N: NPO with PIV of PN (D10) and IL. PN is currently maximized and meeting recs for pro/vits and mins. Sitecleaned with 1/4 strength H2O2 and neosporin applied. NPO at present. LS CL=. Remains NPO. Sucrose prn with good effect. A. Sitehealing. Nodesats. A/A with cares. Inf remains in RA. A: Stable. A: Stable. A:Stable. A:Stable. P. Contiue NPO with IV hydration.5. Abd soft andflat. Remains in RA. REmains in RA. O: remains on TF's of 120cc/k/d. A. A. A:Calms with swaddling & pacifier. Remainson 120cc/k/d PN & IL. FEN O/A Inf in NPO. AFOF. P.Monitor.3. A: Stable in RA. See note above for . P.Support.4. Resp: Remains in RA, sats in mid90's-100%. Mildsc retractions. Noleakage noted A: GT intact P: GT care. Prone position.Cont to monitor.G+D: in OAC. Lungsclear with mild stridor upon auscultation. Smallamount of serosanguanous drng. Site cleansed w/-strength H202; Neosporin oint applied.G&D: CGA=43 wk. P: GT care. Temp 100.3, otherwise vital signs stable. in resp. Plan home with O2 sat monitor and g tube supplies.A: Stable. Voiding qs, stool x1 neg.Cont to monitor. IV heplocked. Gutbe in place, #12fr. RR 30-60s with mild SC retrx. Post-op Hct 29.5. Wake forfeeds. Lungs clearwith occasional inspitory stridor to auscultation. GT CARE O: GT secure to abdomen. A. Healing well. A. Lessirritable this shift. Monitor for s/s ofinfection. Sucrose given oncefor fussy period. Voiding and stooling normally. NPNResp: remains in RA. Area cleansedwith NS and sterile 2x2 applied. A. NPO, IVhydration. P. Comfort measures.4. BBS clearand equal with good aeration. BBS clearand equal with good aeration. BBS =/clear. Intermittent upper airwaycongestion audible. Mildsubcostal retractions. Wgt: 3.905k, down 10g A:Stable, tolerating feeds and meeting min. G-tube care and dsg change and PRN. Stable post op. FunctionO: Remains in RA with sats 98-100. P. Continue withappropriate developmental stim.4. Lungs coarse, well-aerated, mild intermittent retractions. RR 30-60s with mild SC retrx.Mild upper airway congestion noted. A: Stable on roomair and when bottle feeding P: Monitor for s/s respdistress esp. Abdpmenbenign, voiding and stooling qs. daily fluidrequirement. P.Monitor. A+A w/ cares. A: Appropriate P: Monitor. Tempremains stable. Mildsc retractions. F/Uappointments made. in resp. Baci oint applied. Stablein RA. Updates given. swaddled in OAC, temp. Continue with d/cteaching. Started on Fe and multivit. Received HIBand Prevnar this shift. NPNResp: remains in RA. Updated, asking appropriatequestions. Wt. Bacitracin oint ordered TID toarea. Wakes forfeedsing. Baci oint applied as ordered. Resp O/A Rec'd inf in RA. Resp O/A Rec'd inf in RA. Tol well. Tol well. Mildretractions. Pt. Pt. Pt. Pt. Onzantac. Area cleaned and dsg. Mild SC retractions. Teamaware. Temp and VS are stable and WNL. Inf remains in RA. Inf remains in RA. Remains in RA. Remains in RA. Mild retractions. Eyedrainage continues. A+A w/ cares. Mild subcostalretractions. LS clear. LS clear. Stable.3. AFF. Signed consent in chart. site O/A Site remains CDI, scant amt yeldrainage on dsg. Mild SCR noted. changed per NICU protocol. Will cont tomonitor.G-tube: G-tube still intact. G-tube site clear. Nospits. Small amt serous sang drainage noted, area slightlypink. Cleaned and new dsg applied. Lungs c/=. Temps stable. LS cl/-. Will cont to monitor.Dev: in OAC. () NPN DAYS2. NPN DAYS2. Pmonitor4. Final stages of discharge planning. PMonitor3. Continue G-tube care per NICU protocol. Abd. Abd. Plan to monitor resp.status.#3Dev. Continue with d/c teaching. Abd soft. stable. Monitor. P support8. P support8. GT intact. MAE. On BM 24. in proneposition. Belly soft, noloops. Monitor.3. Tmax 100.1 this am. In RA, RR 30-50s, continues with intermittentstridor. Area sl. DEV O/A remains swaddled in OAC with stabletemp. | 70 | [
{
"category": "Nursing/other",
"chartdate": "2107-11-11 00:00:00.000",
"description": "Report",
"row_id": 1940506,
"text": "NPN Nights 7pm-7am\n\n\n#2 O: remains in roomair with O2 sats mostly 99-100%.\n Lung sounds remain clear and equal wioth resprates 20-40s,\nmild retractions at times, \"hoarse\" sounding cry. Some\naudible upper airway congestion noted. A: maintaining adeq\nsats in roomair. P: COntinue to moniter.\n#3 O: Remains in open crib, temp stable. Alert and active\nwith cares. Did well bottling with tonight\n(10-20cc/k/day). Received tylenol X 2 for post-op\ndiscomfort. A: AGA, s/p g-tube placement. P: Continue to\nmoniter for milestones.\n#4 and #8 O: is now day 2 s/p g-tube placement.\nG-tube dressing was changed and area cleansed per NICU\ng-tube protocol (see info at bedside) - dressing noted to\nhave minimal amt serosanguinous drainage and skin area was\nwithout redness. remains on TF of 100cc/k/day. IVF\nof D10W with added lytes currently infusing at 80cc/k/day\nvia scalp IV. Feeds of BM 20 cals advanced from 10 to\n20cc/k/day - has taken all feeds (7-13cc) orally\nusing feeder. Abd remains soft, +bs, no loops.\n Voiding adeq amts and passed a biluous-green mucousy stool\nX 1 that was heme neg. A: s/p g-tube placement. P: Continue\nto encourage po intake as tolerated. Moniter g-tube site\nclosely and provide dressing changes as per protocol.\n#5 's mom called X 1 during the evening portion of the\nshift - updates given.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940556,
"text": "npn 1900-0700\neye drainage in Left eye\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940557,
"text": "Case Management Note\n will not require O2 sat monitoring at home per team so mom will bring the monitor back in today and I will return to Medical. Home Therapy () is following for feeds/supplies for home use. Family has had feed teach with this vendor already. I will be needing scripts for formula/supplies a day or so before anticipated d'c. This is needed in order to have supplies delivered to family home. Centrus Premier Home Care () had been called with referral many weeks ago and they will need to be called again with referral. EIP will be needed at d'c. I will cont to follow and assist w/any d'c plans along with team & family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940558,
"text": "Neonatology Attending\n\nDOL 70 PMA 41 3/7 weeks\n\nStable in RA.\n\nNo murmur. BP 68/34 mean 45\n\nOn 120 ml/kg/d with BM20 at 70 ml/kg and PN10/IL at 50 ml/kg. Advancing feeds 20 ml/kg . Takes partial pos with Habermann feeder otherwise feeds via g tube. DS 79. Wt 3875 grams (up 65).\n\nOn kefzol.\n\ng tube looks good. Being managed with single split gauze and flange snug to skin.\n\nLacrimal massage and warm soaks to eye.\n\nMother in and up to date.\n\nA: Stable. g tube cellulitis resolved. Advancing feeds.\n\nP: Monitor\n Advance feeds more quickly\n D/C PN\n D/C kefzol\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-16 00:00:00.000",
"description": "Report",
"row_id": 1940530,
"text": "Nursing Progress Note 0700-1500\n\n\n2. In room air with sats >95%, supine position. Lungs\nclear and equal with upper airway stridor. RR 20-30's.\na. Doing well in supine position. P. Continue with plan.\n3. Awake and alert, fussy at times, sucking vigorously on\npacifier. Sucrose given for agitation. Happy when mom\nholding. soothing sounds and music. A. Agitated due\nto NPO. P. Comfort measures as above.\n4. Fluids at 120cc/kg/d PIV in scalp. Infusing well.\nContinues NPO per surgery. No contact with surgery yet\ntoday. Voiding large amounts. Passing small amounts of\ngreen-black stools, heme neg. A. NPO with IV hydration.\nP. Continue with plan as per surgery.\n5. Mom in all afternoon, gave . Very\n. A.. mom. P. support.\n8. site appears slightly red with small to moderate\namts of green drainage. Care done with 1/4str H2O2,\nneosporin ointment applied, then sterile gauze. Flange at\n2.25cm mark. left open to gravity, draining small amt\nof thick saliva. A. site improving. P. Continue\nwith IV antibiotics and care as outlined above.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-17 00:00:00.000",
"description": "Report",
"row_id": 1940531,
"text": "1900-0730\n\n\n2. RESP O: Remains on room air with sats > 95%. BBS clear\nand eqial with good aeration. No stridor noted. RR 30-60s\nwith mold SC retrx noted. with occas. shallow\nrespirations. Had x2 brady with 1 observed apnea. No\ndesats with spells. Color pale. A: Stable on room air.\nBrady x2 P: Monitor and document.o\n3. G&D O: is active with cares. Resting\ncomfortably between cares. Sucks pacifier eagerly. Temp wnl\nin open crib. No s/s pain or discomfort. A: Stable P:\nMonitor. Comfort measures. Sucrose per NICU protocol.\n4. FEN O: Remains NPO. TF= 120cc/kg/day. \nreceiving D10 with lytes at 19.8cc/hr thru scalp PIV. Site\nfree of redness or edema. D/S 112. Abdomen soft and\nnontender with + BS x4 quads. Voiding with diaper changes.\nU/O= 2.8cc/kg/hr. A: Stable NPO P: Monitor. Accurate\nI/Os. Monitor lytes. IVF as ordered.\n5. PARENTING O: Mom called and updated. Assured mom that\n is resting comfortably. A: , concernded\nparent P: Support and update. Encourage to ask questions\nand voice concerns.\n8. POST OP GT CARE O: GT securely in place. Skin around\ninsertion site slightly reddened. No swelling noted. Sm.\namt pale yellow drainage noted on old gauze dressing. Area\ncleansed with 1/2 strength hydrogen peroxide. Neosporin\napplied around insertion site and covered with sterile 2x2.\nRemains on Cefazolin. Continues to be afebrile. A: GT\nintact. Wound improved as evidenced by decrease drainage\nand erythema P: Monitor. GT skin care as ordered.\nMonitor for s/s infection. Antibx as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-10 00:00:00.000",
"description": "Report",
"row_id": 1940504,
"text": "Neonatology Attending\n\n58 do former 34 week (PMA 42 5/7 weeks) male readmitted from s/p g tube placement, POD #1.\n\nPatient well known to our service from previous admission (birth to ).\n\n2880 gram 34 week male born to a 39 yo multip with negative PNS. Pregnancy c/b depression treated with welbutrin, zoloft and trazodone and SROM with preterm labor. Vaginal delivery. Apgars .\n\nCourse in NICU remarkable for:\n1. Transient respiratory distress treated with CPAP.\n\n2. Stridor evaluated by ORL () with bronchoscopy revealing moderate laryngomalacia, floppy airway with tongue causing intermittent upper airway obstruction. Evaluated by Dr. for potential tongue lip adhesion. Did not feel that tongue lip adhesion would be beneficial. Prone positioning recommended and helpful.\n\n3. -orbital-facial syndrome (cleft palate, small chin, broad nasal bridge with bifid nose, low set ears, question of neck thymic tissue) and hypotonia. Genetics and neurology consulted. Karyotype, organic and amino acids, lactate, pyruvate, LFTs, skull films, MRI, echocardiogram all normal. Signature chip pending. CMV negative.\n\n4. Unable to sustain full oral feedings (though he had some periods when he fed fully po, minimal volumes with ) therefore g tube placement by surgery requested. Laparoscopic assisted open G tube (12 Fr ) placed by Dr. on . Intubated fiberoptically by ORL, extubated POD 1. Developed stridor responsive to racemic epi. Now stable in RA. His g tube can now be used for feeds. Follow up with Dr. planned for 1 month post op and needs to be scheduled.\n\n5. Conjunctivitis (+staph species) treated with ilotycin-> garamycin-> polymyxin with improvmeent.\n\n6. Hearing screen referred on R. f/u needed.\n\n7. Ophthalmology exam normal.\n\nReturned for initiation and advancement of feeds then discharge home.\n\nExam Sedate male pink and comfortable in RA\nAF soft, flat, dysmorphic facies as previously noted, cleft palate, small amount of eye drainage, clear, equal bs, no murmur, soft abd, + bs, g tube in place, no hsm, normal male genitalia, circumcised, testes descended into scrotum, minimal spontaneous activity but responsive to exam.\n\nA: 34 week male (CGA 42 5/7 weeks) with brachio-oral-facial syndrome s/p g tube.\n\nP: Monitor\n Prone positioning\n Initiate feeds and advance to full volume feeds over next few days po and per g tube\n Tylenol for comfort\n Discharge teaching for mother re g tube\n Arrange equipment for discharge\n Repeat hearing screen\n Home once tolerating full feeds and discharge teaching done\n Pediatrician is \n Follow up with Dr. in 1 month\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-21 00:00:00.000",
"description": "Report",
"row_id": 1940554,
"text": "NPN 7a7p\n\n\nResp\n in RA with adeq sats. No spells. LSC. Some audable\nstridor noted when bottling. Some upperairway congestion.\nCont to monitor and support resp status.\nG/D\n with stable temps in OAC. MAEs. Hypertonic. FS&F. A/A\nwith cares. Settles well with swaddling and pacifier. AGA\n with BOF synd.\nFen\n on TF 120 cc/k/d. Has 70 cc/k/d of IV PND10 and IL\nand is on feeds of BM at 50 cc/k/d, increasing by 20 cc .\nUsing bottle. Remainder gavaged thru GT. Abd soft\nwith active BS. Voiding and small stools. Monitor tolerance\nto feeds. Monitor weight and exam.\nParenting\nMom and GM in for most of day. Participating independently\nwith cares. Invested and . Knowledgable. Support and\neductae.\nG-tube\n with only single gauze under flange of G-Tube now.\nMonitor secretions. wash with water only and neosporin dcd.\nArea under flange pink/red. Very small yellow serous\ndrainage. Cont IV abx. Monitor site.\nID\n remains on IV Kefzol. No additional S&S of infection.\nMonitor tmeps and GT site. L Eye with green drainage. Wrm\ncompresses x 2 everyday and lacrimil massages. Report any\nredness. Monitor.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940559,
"text": "Case Management Note\nCentrus Premier Home Care () has a home visit set up for Friday . I have confirmed this with in intake. Referral for will need to be faxed by WEDNESDAY afternoon due to holiday. Fax # is . Home Therapy () is aware that feed supplies need to be delivered to home. Scripts have been written & faxed today to vendor. EIP will need to be called with d'c date. All in agreement with plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940560,
"text": "Case Management Note\nAddendum: team now recommending sat monitor and I Medical. Mom has had teaching with monitor previously and had monitor at home already. No further script needed for monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940561,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~ 98-100%.\nRR ~30-50's, no increase work of breathing noted. LS\nclear/=. He has some transient upper airway congestion\nnoted. He has mild SC retractions. No A&B's noted this\nshift thus far. A: Pt. remains stable in RA. P: Continue\nto monitor respiratory status. Monitor for A&B's.\n\n#3. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. He is alert and active w/cares,\nsleeps well in between. Fontanelle soft/flat. He loves to\nuse his pacifier, brings hands to face. A: AGA P:\nContinue to provide environment approrpriate for growth and\ndevelopment.\n\n#4. FEN O: TF 120cc/kg/d. Enteral feeds of BM20 are\ncurrently @ 95cc/kg =61cc Q 4hrs. He is offerd a bottle Q\nfeed and takes ~20-47cc PO Q feed via the feeder,\nthe remainsder gavaged via his G-tube. IVF of D10PN +IL are\ninfuseing @25cc/kg without any difficulty. Abdomen is\nsoft, pink, +bs, no loops/spits noted. He is voiding well,\npassing stool. A: Pt. is tolerateing current nutritional\nplan. P: Continue to advance enteral feeds by 25cc/kg \n() as pt. tolerates. Once IVF are finished (IV+PO\n=120cc/kg OR the IV comes out) then advance TF to goal to\n150cc/kg/d. Continue to monitor for s/s of intolerance.\n\n#5. O: Mom in to visit throughout the shift, she\nwas updated at bedside on pt's current status and daily plan\nof care. are active and very independent in cares,\nasking appropriate questions. A: Family is and\ninvolved. P: Continue to udpate, support and edcuate.\nContinue w/ discharge teaching/planning.\n\n#8. GT site O: Pt's GT site is pink around stoma, small\namount of yellow crusty dry drainage removed on gauze pad.\nNo s/s of infection noted. Site cleaned with sterile water\n1x/day, split gauze placed and the flange is covered with 2\nstrips of tape to secure to abdomen. A: stable P:\nContinue w/ GT tube care as ordered per surgery. IV\nantibiotic D/C'd this am.\n\n#\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940562,
"text": "9 ID\n\nREVISIONS TO PATHWAY:\n\n 9 ID; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-22 00:00:00.000",
"description": "Report",
"row_id": 1940555,
"text": "npn 1900-0700\n\n\n2: resp\nremains in ra. no spells and no dsats. rr 30-50's. lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. upper airway conjestion noted. continue\ntomonitor for changes in resp status.\n\n3: dev\ntemps stable in an oac.alert and active with cares. sleeps\nwell inbetween. brings hands to face. sucks\nvigorously on pacifier. irritable at times but comforts with\npacifier. with green eye drainage to right eye. plan\nto continue with warm soaks and lacrimal massage. continue\nto monitor for developmental milestones.\n\n4: fen\ncurrent weight 3875gms up 65. total fluids remain at\n120cc/kilo/day. pn D1o with lipids is running at\n50cc/kilo/day via scalp iv. feeds of Bm 20cals are at\n70cc/kilo/day. attempting po feeds with remainder of\nvolume gavaged via g tub. increasing feeds by 20cc/kilo .\n tolerating increase of feeding this shift. abd\nexam benign. voiding and stooling. no spits. continuing to\nuse with each feeding. dstick 79. continue with\ncurrent feeding plan.\n\n5: parenting\nmom called x's 1. updated by this rn. very . asking\nappropriate questions. continue to support needs.\n\n\n8: g tube.\ng tube site intact. dark pink in color. small amount of\nyellowish drainage noted on dressing. g tube site\ncleaned with sterile water. one gauze with slit placed to\nprevent drainage. continue with current plan of care.\n\n9: id\n continues on Cefazolin q 8 hours. no signs and\nsymptoms of infection noted. continue with antibiotic\ntreatment as noted.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-21 00:00:00.000",
"description": "Report",
"row_id": 1940550,
"text": "Nursing progress note\n\n\n#2 O: Remains in room air with equal & clear breath sounds &\nmild SC retractions. O2 sats >98. A: Stable. P: Cont to\nassess.\n#3 O: temp stable in crib. Quietly alert with cares.\nSwaddled. Sucks on pacifier. Taking PO feed with \nfeeder. A: More comfortable since PO feeds started. P: Cont\nto assess.\n#4 O: Wgt up 55gns. Total fluids remain 120cc/k/d based on\ndry wgt of 3.9K. IV of PN & IL infusing thru scalp IV at\n90cc/k/d & PO feeds q4h are 30cc/k/d. Abd soft with active\nbowel sounds & no loops. Voiding & stooling. No spits. A:\nTolerating feeds & gaining wgt. No leaking noted at G-tube\nsite. P: Cont to assess.\n#8 O: G-tube cleaned per protocol. Site was sl red with\nsmall amt of pale green drg at 1AM & site was clean, dry &\nnot red at 5AM. No leaking noted.Seen by TCH surgeon. A:\nStable. P: Cont to assess.\n#9 O: Remains on Cefazolin. G-tube site is C/D/I. A: Stable.\nP: Cont to assess.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-21 00:00:00.000",
"description": "Report",
"row_id": 1940551,
"text": "Neonatology Attending\nExam AF soft, flat, comfortable being held by mother, clear bs, no murmur, g tube in place, no drainage, normal bs, no hsm, no , active and responsive\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-21 00:00:00.000",
"description": "Report",
"row_id": 1940552,
"text": "Neonatology Attending\n\nDOL 69 PMA 41 2/7 weeks\n\nStable in RA. Does not need oximetry monitoring at home.\n\nNo murmur. BP 82/51 mean 60\n\nStarted feeds at 30 ml/kg BM20 with , nothing via g tube. Otherwise on 90 ml/kg PN/IL. Voiding. Stooling. Wt 3810 grams (up 55).\n\nOn kefzol. Neosporin to g tube site.\n\nSeen by on Friday. Plan home without O2 sat, f/u appt with in , repair /.\n\nMother in and up to date.\n\nA: Stable. g tube cellulitis healing. Feeds restarted. Blocked tear duct without evidence of conjunctivitis.\n\nP: Monitor\n Advance feeds 20 ml/kg \n Kefzol to complete 1 week course\n Keep phlange of g tube snuggly opposed to skin\n Lacrimal massage\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-21 00:00:00.000",
"description": "Report",
"row_id": 1940553,
"text": "Clinical Nutrition\nO:\n~44 wk CGA BB on DOL 69.\nWT: 3810 g (+55)(~10th to 25th %Ile); birth wt: 2880 g. Wt is down ~170 g over past wk since GT placement.\nHC: 36.5 cm (~10th to 25th %Ile); last: 35.75 cm\nLN: 54 cm (~25th to 50th %Ile); ;last: 53 cm\nLabs noted\nNutrition: 120 cc/kg/day TF. Feeds currently @ 30 cc/kg/day BM 20 via , increasing 20 cc/kg/. Not currently using GT for feeds. Remaining fluids as PN via PIV; projected intake for next 24hrs from PN ~48 kcal/kg/day, ~1.8 g pro/kg/day and ~2 g fat/kg/day. From EN: ~33 kcal/kg/day, ~0.5 g pro/kg/day and ~1.9 g fat/kg/day. GIR from PN ~4.2 mg/kg/min.\nGI: Abdomen flat and soft, active bowel sounds. Passing g- stool\n\nA/Goals:\nTolerating feeds po without GI problems; advancing as per tolerance and ability to take po. GT site cellulitis healing; not using GT for feeds yet. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. CUrrent feeds + PN meeting recs for kcals/pro/fat/minerals and vits. Growth is meeting recs for HC and LN gain. WT gain is not meeting recs of ~20 to 35 g/day. Anticipate improvement in growth as feeds advance to full nutrition, when able to use GT for supplemental feeds. WIll continue to follow w/ team, optimize nutrition, and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-16 00:00:00.000",
"description": "Report",
"row_id": 1940527,
"text": "NPN 7p7a\n\n\nResp\n in RA with adeq sats. No spells or drifts. Some\naudable stridor noted. LSC. No resp distress at this time.\nG/D\n in OAC. Irritable and tense. Made NPO during day.\nNeeding pacifier, swaddling or holding to settle.\nHypertonic. Temps stable. Support G/D.\nFen\nMade NPO during day. on TF 120 cc/k/d of D10 with Na\nand K via PIV in scalp. DS 113. Abd flat with active BS.\nGreen stool. GT site cleaned. Very small secretions from\nsite and tube. Localized redness under flange. Surgery in to\nsee . Monitor weight and exam.\nParenting\nHave had no contact with this shift.\nGT\nMade NPO during day yesterday because of question of\ninfection. Began IV abx. Also site dsg changed tid/PRN with\ntrip abx ointment. Monitor for additional S&S of infection.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-16 00:00:00.000",
"description": "Report",
"row_id": 1940528,
"text": "Neonatology NP NOTE\nPLease refer to attending note for details of evaluation and plan.\n\nPE: growing preterm , now corrects to term , active and alert in open crib. Pale pink, skin warm and dry. AFOF sutures approximated. Left eye with conjunctivitis, right eye clear. Nares clear, soft cleft palte, MMMP\nChest is clear, equal bs, comfortbale resp pattern\nCV: RRR no murmur, pulses+2=\nAbd: soft, active bs site intact, skin appears pink with dry dsg in palce.\nGU: healed, testes descended.\nEXT: MAE, WWP\nNeuro: symmetric tone and reflexes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-16 00:00:00.000",
"description": "Report",
"row_id": 1940529,
"text": "Neonatology Attending\n\nDOL 64 PMA 43 4/7 weeks\n\nStable in RA in supine position. No desats.\n\nHR slightly irregular.\n\nNPO on D10W with lytes at 120 ml/kg/d. On zantac. Voiding. Stooling. DS 113. g tube to gravity drainage. Wt 3760 grams (down 200).\n\ng tube site looks better today. Neosporin being applied to site.\n\nCBC benign wbc 14 (38P/1B/53L), hct 28.9, plt 505. BC sent. On kefzol.\n\nEye drainage continues. Ophthalmology recommends applying pressure to duct 5x to aid in drainage, ciprofloxacin eye ointment when eye is red only. Surgery rarely is needed. Expect it to be better by 1 year of age.\n\nMother in and up to date.\n\nA: Stable. Arrhythmia without compromise. G tube cellulitis being treated. NPO to allow for g tube site healing with management per surgery. Blocked tear duct being treated.\n\nP: Monitor\n Check BP\n EKG\n Continue NPO with IV fluids\n Continue kefzol\n Continue topical treatment to g tube site\n Continue eye care\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-19 00:00:00.000",
"description": "Report",
"row_id": 1940542,
"text": "Nursing Progress Note\n\n\n#2. O: remains in RA with O2 sats >99%. RR 20's-40's.\nBreath sounds are clear and equal. Mild SC retractions\nnoted. Upper airway congestion noted. A: Stable in RA. P:\nContinue to monitor.\n\n#3. O: remains in open crib with stable temp. He is\nalert and active with cares. Otherwise sleeping well\novernight. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n#4. O: remains on TF's of 120cc/k/d. NPO. IVF's of\nD10PN and IL's infusing well via PIV. D/S 87. Abd soft and\nflat. Hypoactive bowel sounds. No loops. G-tube site\nslightly red with small amt of yellow drainage noted. Site\ncleaned with 1/4 strength H2O2 and neosporin applied. Wgt is\nup 35gms tonight to 3795gms. A: NPO P: Continue to monitor\nFEN status.\n\n#5. O: MOm called x1 for update. Asking appropriate\nquestions. A: Involved mother. P :Continue to inform and\nsupport.\n\n#9. O: Blood cultures remain negative to date. Remains on\ncefazolin. Old PIV site in scalp noted to be slightly red.\n aware and examined . Continue to watch closely. A:\nSepsis. P: Continue with treatment.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-20 00:00:00.000",
"description": "Report",
"row_id": 1940546,
"text": "Nursing progress note\n\n\n#2 O: Remains in room air with equal &clear breath sounds &\nmild SC retractions. A: Stable. P: Cont to assess.\n#3 O: Temp stable in crib. Swaddled. Irritable at start of\nshift but baby needed a new IV. Swaddled & sucrose pacifier\ngiven. Baby was quietly alert at 1AM & asleep at 5 AM. A:\nCalms with swaddling & pacifier. P: Cont to assess.\n#4 O: Wgt down 40gms. Remains NPO. New IV in scalp. Remains\non 120cc/k/d PN & IL. Abd soft. Hypoactive bowel sounds.\nBaby passed 2 stools. Voiding with diaper changes. A:\nStable. P: Cont to assess.\n#5 O: Mom phoned for update. A: family. P: Support.\n#8 O: G-tube site is clean, sl pink & has no drainage. Site\ncleaned per protocol. Seen by TCH surgeon. A: Stable. P:\nCont to assess.\n#9 O: Remains on Cefazolin for G-tube. Area is sl pink but\nhas no drainage. Left eye is draining green secretion.but is\nnot red. Eyes cleaned with sterile H2O & warm soaks done. A:\nStable. P: Cont to assess.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-20 00:00:00.000",
"description": "Report",
"row_id": 1940547,
"text": "Neonatology Attending\n\nDay 68 PMA 44 \n\nRemains in RA. Sats >98%. RR 20-40s. Clear breath sounds. Mild retractions. No murmur. Pale, pink. HR 80 - 110. Weight 3755 gms (-40). NPO. On PN 10 via peripheral IV. Benign abdomen. Surgical site much improved on cefazolin. Surgery suggests restarting feeds.\n\nDoing well from cardio-respiratory standpoint. Monitoring closely. Restarting feeds at 30 cc/kg/d. Further advance to be determined by team. Continuing IV cefazolin for now.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-20 00:00:00.000",
"description": "Report",
"row_id": 1940548,
"text": " Physical Exam\nPE: pale pink sleeping in a crib, scalp IV in place, no redness, breath sounds clear/equal with no stridor, no murmur, abd soft, GT site slightly red, minimal drainage.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-20 00:00:00.000",
"description": "Report",
"row_id": 1940549,
"text": "Nursing Progress Note\n\n\n2. In room air with sats .95, no desats in supine or\nsidelying position. Lungs clear, mild retractions. Some\nstridor heard on auscultation. A. Doing well. P.\nMonitor.\n3. Awake and alert, temp stable. A. Appropriate. P.\nSupport.\n4. Total fluids at 120cc/kg. IV TPN & IL at 90cc/kg.\nFeeds started at 30cc/kg po BM20cal, taken well by bottle\nwith feeder. Abdomen soft, good bowel sounds.\nVoiding well, one small black stool. A. Restarting feeds,\ndoing well so far. P. Continue feeds at 30cc/kg overnight,\nadvance per surgery.\n5. Mom in most of afternoon, doing all care. A. \nfamily. P. support.\n8. site pink with minimal yellow drainage. Site\ncleaned with 1/4 str H2O2, neosporin oint applied. A. Site\nhealing. P. Continue with care.\n9. See note above for . Antibiotics continued for 3\nmore days. Afebrile. A. Recovering from infection. P.\nCont. with plan per surgery.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-19 00:00:00.000",
"description": "Report",
"row_id": 1940543,
"text": "Neonatology\nDOing well. REmains in RA. NO spells. Comfortable apeparing.\n\nWt 3795 up 35. NPO at present. PN infusing.\n\nOn day of cefazolin for infection at g-tube site. Site reddened, but reported to be improved in appearance. Being fiollowed by surgical team.\n\nCOntinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-19 00:00:00.000",
"description": "Report",
"row_id": 1940544,
"text": "Nursing Progress Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. No\ndesats. LS CL=. Mild upper airway congestion noted. P\ncont to assess resp needs.\n3. DEV O/A remains swaddled in OAC with stable\ntemp. A/A with cares. Enjoys sitting in the swing or being\nheld. P cont to assess dev needs.\n4. FEN O/A Inf in NPO. TF=120cc/kg/day PND10 running at\n16.4cc/hr Lipids running at 2.4cc/hr via PIV now placed in\nleft hand. Voiding, trace stool, BS hypoactive. P cont to\nassess FEN needs.\n5. O/A Mom in for visit and cares. Updates\ngiven. Mom independent with ' care. P cont to\nsupport.\n8. O/A Site cleansed and dried, ABX ointment\napplied. Sl redness at site. Sm amt yel drainage noted. P\ncont to assess.\n9. Sepsis O/A Inf remains on Cefazolin as ordered, now\nday 4 of 5. P cont to assess.\nsee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-19 00:00:00.000",
"description": "Report",
"row_id": 1940545,
"text": " Physical Exam\nAwake and fussy. AFOF. Pale pink. Breath sounds clear and equal with very mild stridor. Minimal work of breathing. No murmur, normal pulses. Abdomen soft anf rounded with active bs, no HSM or masses. GTT site with mild redness above GTT, mush better than yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-15 00:00:00.000",
"description": "Report",
"row_id": 1940524,
"text": "Neonatology Attending\n\nDOL 63 PMA 43 3/7 weeks\n\nStable in RA. Sats >95%. No desats with supine or side lying.\n\nSoft intermittent murmur.\n\nOn 120 ml/kg/d BM20. G tube leaking significantly (everything in comes out) therefore made NPO this am. Minimal UO. Wt 3960 grams (down 20).\n\nG tube site leaking and with purulent discharge.\n\nAfebrile.\n\nMother in and up to date.\n\nA: Stable. No longer requiring prone positioning. G tube with leaking and question of wound infection. Surgery to evaluate.\n\nP: Monitor\n NPO for now. Consider IVF if unable to use g tube for prolonged period.\n Surgery to evaluate g tube\n Dr. to evaluate in f/u this week\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-15 00:00:00.000",
"description": "Report",
"row_id": 1940525,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\n made NPO at the suggestion of the Surgical Consult Fellow. This will allow his G-tube site time to heal without the gastric secretions leaking through. He will also be treated with Cefazolin IV. A CBC and blood culture were obtained.\n\nPediatric Ophthalmology consulted regarding concern for blocked tear duct. Instructions of how to massage the duct using firm pressure twice a day demonstrated and relayed to mother. Ciprofloxacin ophthalmic ointment can be used PRN for redness.\n\nPhysical Exam\nGeneral: in room air, open crib\nHEENT: facial features as previously noted, fontanel open, level\nChest; breath sounds clear/=; no stridor noted\nCV: RRR, no murmur appreciated; normal S1 S2; pulses +2\nABd; G-tube site red, odor present; abdomen soft; no masses; Non-tender\nGU: circumcised male; testes descended\nExt: moving all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-15 00:00:00.000",
"description": "Report",
"row_id": 1940526,
"text": "Nursing Progress Note\n\n\n2. Sats 95-100 in room air. placed on side or\nsupine in crib. No desats noted this shift. Lungs sound\nclear with upper airway congestion and stridor. RR 30-50's.\nA. Doing well in supine position. P. Contiue to keep\nsidelying or supine. Monitor.\n3. Awake and active, hungry today. Sucrose given on\npacifier. Temp. 100.3 this PM, came down to 99.2. A.\nUnhappy d/t NPO status. P. Comfort measures, pacifier and\nsucrose (dip pacifier only).\n4. NPO, fluids at 120cc/kg/d IV D10 c 2Na&1K/100cc\nrunning well through scalp IV. found in clothing\nsaturated with previous feeding which had oozed from \ninsertion site. Voidid small amount this shift, small\nstoolsx2. A. leaking all stoomach contents, NPO now.\n P. Contiue NPO with IV hydration.\n5. Mom in all afternoon, in briefly during lunch break.\n upset with new developments, mom supported by many\nvisiting friends. A. appropriately concerned. P.\nSupport.\n8. drenched with contents of stomach this AM. \nsite oozing large amounts of purulent drainage. Cleaned\nwith 1/4 strength H2O2 and dry dressing applied with\nneosporin ointment. New dry dressing changed frequently to\nkeep clean. Site appeared much cleaner and less red toward\nend of shift. CBC and blood cultures sent, pending. \nstarted on antibiotics. A. site infected. P. Check\nresults of CBC. ABX as ordered, NPO. to gravity\ndrainage.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-18 00:00:00.000",
"description": "Report",
"row_id": 1940538,
"text": "Clinical Nutrition\nO:\n34 wk gestational age BB, LGA, now on DOL 66, CGA 43 wk. s/p GT placement @ TCH on due to inability to take adequate volumes of po feeds.\nBirth wt: 2880 g (>90th %Ile); current wt: 3760 g (-200)(~90th %Ile).\nHC at birth: 34 cm (>90th %Ile); current HC: 35.75 cm (~75th to 90th %ile)\nLN at birth: 47 cm (~75th %Ile); current LN: 53 cm (~75th to 90th %Ile)\nLabs noted\nNutrition: 120 cc/kg/day TF. NPO since due to leaking GT. PN started on via PIV; projected intake for next 24hrs from PN ~78 kcal/kg/day, ~3 g pro/kg/day and ~3.1 g fat/kg/day. GIR from PN ~7.3 mg/kg/min\nGI: Abdomen benign. GT site reddened; draining to gravity w/ mucousy output.\n\nA/Goals:\nTolerating PN with good BS control. NPO until GT drainage stops per surgery. Labs noted and PN adjusted accordingly. PN is currently maximized and meeting recs for pro/vits and mins. Kcals are close to recs of ~80 kcal/kg/day. Expect to resume po/GT feeds soon; goal for feeds is ~165 cc/kg/day BM 20, providing ~110 kcal/kg/day and ~1.7 g pro/kg/day. will resume Fe and TVS supps when feeds resume. Growth goals are ~20 to 35 g/day for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain. Will follow w/team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-18 00:00:00.000",
"description": "Report",
"row_id": 1940539,
"text": "NPN DAYS\n\n\n2. Remains in RA. LS clear. RR 28-30's. Mild SC retractions.\nO2 sats>98%. No desats, no bradys. Stable in RA.\n\n3. Temp stable in open crib. Active and alert with cares.\nIrritable at times. Sucrose prn with good effect. Loves\npacifier.\n\n4&8 NPO. TF at 120cc/kg. PN an lipids infusing well. New PIV\nplaced. DS stable. Abd soft with hypoactive bowel sounds.\nVoiding, no stool. GT to gravity-draining clear gastic\nsecretions. GT dressing changed x2 thus far. cleansed with\n1/4 str H2O2 and neosporin applied. New dressing applied.\nSmall amt yellow drainage noted on old dressing. GT site sl\nreddened(less raw looking from monday). Continue to monitor\nclosely.\n\n5. Mother in this afternoon. Updated, asking appropriate\nquestions. Independent with cares. family.\n\nID: Continues on cefazolin as ordered. Afebrile. Continue\nantibiotic and monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-18 00:00:00.000",
"description": "Report",
"row_id": 1940540,
"text": "9 ID\n\nREVISIONS TO PATHWAY:\n\n 9 ID; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-18 00:00:00.000",
"description": "Report",
"row_id": 1940541,
"text": "Neonatology NP Note\nPlease refer to attending note for detials of evaluation and plan.\n\nPE: growing preterm , now term alert and responsive in open crib. AFOF sutures approximated, eyes clear, sm amt of clear drainage in left eye, no erythema, micrognathia unchaged,\nChest ius clear, eqaul bs\nCV: RRR, no murmur, pulses=2=\nAbd: soft, active bs, site with mild erthema around tube, minimal drainage\nGU healed, testes in scrotum\nEXT: MAE, WWP\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-18 00:00:00.000",
"description": "Report",
"row_id": 1940535,
"text": "NPN (1500-2300)\n\n\n2. Resp: Remains in RA, sats in mid90's-100%. LS clear and\nequal with occasional stridor audible. One brady at rest to\n60's with desat to 60's requiring BB02 and stim.\n\n3. Dev: Occasioanlly irritable but consolable with sucrose\nand or binky. Temp stable in crib. Care times and\ninterventions adjusted to allow to sleep when\npossible. Eye drainage continues to be thick and\nyellow-green from left eye...massaged by Mom. around\nleft eye noted to be slightly reddened and swollen, but the\nconjunctiva itself was not. Will monitor closely.\n\n4. F/N: NPO with PIV of PN (D10) and IL. Ranitidine added\nto PN. Abd soft, +BS, vdg well, passing small stools.\nLytes in am.\n\n5. Soc: Mom this evening, updated, independent with\ncare of .\n\n8. G-tube: G-tube remains to gravity with sm-mod amounts of\nclear mucousy drainage. Site is reddened with small amounts\nof greenish yellow drainage...cleansed with 1/2 strength\nH202 and neosporin ointment applied.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-18 00:00:00.000",
"description": "Report",
"row_id": 1940536,
"text": "NPN:\n\nRESP: Sats 100% in RA. RR=28-40. BBS =/clear. No A&Bs.\n\nCV: No murmur. HR=92-104. BP=84/39 (54). Color pale pink w/good perfusion. Hct=28.9.\n\nFEN: Wt=3760g (- 200g); wt checked x 2. NPO. TF=120cc/kg/d. PN(D-10) and IL via scalp vein. Elec: 140/ 3.9/ 100/ 15. Abd soft, flat, hypoactive bs. U/O=1.3cc/kg/h over past 8 h; no stool since yesterday. GT to gravity.\n\nID: Cefazolin (day 3). Small amt yellow-green drainage GT site; periphery reddened. Site cleansed w/-strength H202; Neosporin oint applied.\n\nG&D: CGA=43 wk. Small amt yellow eye drainage lt eye. Swaddled and resting well.\n\nSOCIAL: No contact w/.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-18 00:00:00.000",
"description": "Report",
"row_id": 1940537,
"text": "Neonatology Attending\n\nDOL 66 PMA 43 6/7 weeks\n\nStable in RA.\n\nNo murmur. BP 84/39 mean 54\n\nNPO on 120 ml/kg/d PN/IL. 140/3.9/108/21 DS 92 Voiding. No stool. Wt 3760 grams (down 200).\n\nG tube site improved. Small amount of drainage. G tube to gravity. Neosporin topically.\n\nKefzol being given. BC NGSF. Surgery would like to keep kefzol on for 5 days.\n\nMassage to eye.\n\nMother in and up to date.\n\nA: Stable. G tube needs to heal. Cellulitis being treated. Blocked tear duct being managed with massage.\n\nP: Monitor\n Continue kefzol for 5 days\n Reevaluate g tube site and consider feeds on Sunday\n Continue PN\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-17 00:00:00.000",
"description": "Report",
"row_id": 1940532,
"text": "Neonatology Attending\n\nDOL 65 PMA 43 5/7 weeks\n\nStable in RA.\n\nLow resting HR during sleep (70s-80s) but increases appropriately with activity. EKG done yesterday, final pending. No further arrhthymia noted.\n\nNPO on IV fluids D10+lytes at 120 ml/kg/d. g tube to gravity. Voiding. Stooling. Wt 3960 grams (up 175).\n\ng tube site with small amount of green drainage. Erythema around the site markedly improved. Culture growing GNR and gram positive bacteria. BC negative. Being treated with topical neosporin and IV kefzol. Surgeon recommends NPO until drainage resolves.\n\nUse ciprofloxacin eye ointment when redness is present.\n\nMother visiting and up to date.\n\nA: Stable. No resp issues. g tube site infection being treated.\n\nP: Monitor\n Check EKG results\n Start PN\n zantac in PN\n Check lytes\n Follow culture results\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-17 00:00:00.000",
"description": "Report",
"row_id": 1940533,
"text": "Nursing Progress Note 0700-1500\n\n\n2. In room air with sats >95 supine in crib. Lungs clear\nwith occasional inspitory stridor to auscultation. Mild\nsubcostal retractions. RR 30-50's. A. No distress. P.\nMonitor. Keep supine or sidelying R.\n3. Temp stable in open crib. Awake and alert, sucking on\npacifier. Not too irritable this shift. Sucrose given once\nfor fussy period. Up in car seat for awhile. A. Less\nirritable this shift. P. Comfort measures.\n4. Continues NPO per surgery. PIV in scalp D10 with\n2Na&1K/100cc running well, slightly red at insertion site\nthough redness has not increased this shift. No swelling\nnoted. Voiding large amounts. No stool this shift.\nAbdomen benign with good bowel sounds. A. NPO, IV\nhydration. P. Continue per surgical team.\n5. in at lunch break, held . Mom not in yet\ntoday. A. , invested family. P. Support.\n8. site red with moderate amt green drainage.\nChanged once this shift, cleaned with 1/2str H2O2, clean\ngauze and neosporin ointment applied. Flange at 2.25cm\nmark, tight to skin. Continues on IV antibiotics. A.\nStill draining some green drainage. P. Continue with plan\nper surgery.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-17 00:00:00.000",
"description": "Report",
"row_id": 1940534,
"text": "Neonatology NP note\nPE\nswaddled in open crib\nAFOF\nmild baseline subcostal retractions and nasal stuffiness, lungs bases clear/=\nRRR, no murmur, pale with pink mm, well perfused\nabdomen soft, nontender and nondistended, active bowel sounds, insertion site with moderate erythema and green drainage\ngreen eye drainage, no erythema\nactive with baseline tone\n\nMet with Mom at bedside, she is pleased that Dr. plans to do ' surgery in .\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-10 00:00:00.000",
"description": "Report",
"row_id": 1940505,
"text": "Nursing Admission Note\n is a 59 day old baby well known to us who was readmitted at 1403 following g-tube placement at yesterday. On admission pt. appeared pale, quiet but awake, well hydrated. Mom came in with maternal g-mother shortly after . Temp 100.3, otherwise vital signs stable. Gutbe in place, #12fr. . Secured at 2.5cm marking on tube. Dressing with small amount of serosanguinous drainage. Swaddled in open crib or in mom's arms. Lungs sound clear to auscultation with increased upper airway secretions, occasional congested cough. Sats 95-100 in room air, no desats. Prone when mom not holding. Fed po by mom with feeder, took 7cc, his 4hr volume at 10cc/kg/d. Voiding and stooling, abdomen soft with good bowel sounds. Post-op Hct 29.5. A. Stable post op. P. Feed breast milk po/pg at 10cc/kg/d tonight, increase 10/kg q 12hrs. Monitor gtube site. Dressing changes q shift: Clean site with sterile H20 and apply clean gauze. Mom scheduled for gtube teaching with home care company at 12noon Friday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-11 00:00:00.000",
"description": "Report",
"row_id": 1940507,
"text": "Neonatology Attending\n\nDOL 60 PMA 42 6/7 weeks\n\nStable in RA. Mild stridor with feeds. Prone positioning.\n\nSoft murmur heard overnight. BP 75/32 mean 47\n\nOn 100 ml/kg/d with 80 ml/kg D10+lytes and 20 ml/kg BM20 all po thus far. Plan to advance 10 ml/kg per surgery. Voiding. Stooling. Wt 4285 grams (up 310 from wt on ).\n\nL eye drainage present. On polymyxin eye ointment for 1 week.\n\nMother in and up to date. D/C teaching in progress.\n\nA: Stable. Refeeding after g tube placement.\n\nP: Monitor\n Advance feeds per plan, hopefully can speed up advance after a few days\n Tylenol for comfort\n Polymyxin through Sunday\n D/C teaching\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-11 00:00:00.000",
"description": "Report",
"row_id": 1940508,
"text": "Case Management Note\nChart has been reviewed and case known to me from previuos admission. D'c planning needs underway from last admit. For services, a referral had been called weeks ago to Centrus Premier Home Care () but they need to be called again with update on current care needs of as d'c date approaches. Would need to secure home visit and fax referral to them. Team previuosly wanted home on O2 sat monitor ,but no O2. Medical () has already done family teaching on monitor weeks ago. Monitor currently in 's room at hospital. Home Therapy () had been referred previuosly and they have completed feeeding teach with mom today. Mom has agreed she will teach about feeding pump after home d'c. Will need scripts for formula, pump, and supplies ready for early next week. EIP would need to be called at d'c. I will cont to follow and assist w/any d'c planning needs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-11 00:00:00.000",
"description": "Report",
"row_id": 1940509,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: sleeping in open crib, room air\nSkin: warm and dry; color pale/pink\nHEENT: facial features as previously described with low-set ears, small jaw, interrupted cleft lip; fontanels open\nChest: breath sounds clear/=; no stridor appreciated at time of exam\nCV: RRR, no murmur\nAbd: soft; no masses; G-Tube in place with intact dressing, no drainage\nGU: healed; testes descended\nExt: moving all\nNeuro: arousable; symmetric tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-12 00:00:00.000",
"description": "Report",
"row_id": 1940511,
"text": "NPN\n\n\nResp: remains in RA. Breathing 30-50s. LS cl/=. Mild\nsc retractions. Strior w/ feeds. No spells. Prone position.\nCont to monitor.\n\nG+D: in OAC. Temps stable. A+A w/ cares. Wake for\nfeeds. AGA, AFOF. Sucks on paci. Left eye drainage. Will\ncont to monitor.\n\nFEN: weight=4065+90g. TF 100cc/k. IVF@ 60/k of D10\n@Na1K=10.2cc/hr IW into scalp IV. Ent feeds of\nBM20=40cc/k=27cc q 4hrs. Tol well. Abd soft and pink. No\nloops. Voiding qs, stool x1 neg.Cont to monitor.\n\n: Mom called for update x1. and involved.\nAsking appropriate questions. Will cont to update and\nsupport as needed.\n\n: G-tube site has no redness. Dressing over site. Small\namount of serosanguanous drng. Cont to monitor and change\ndressings as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-12 00:00:00.000",
"description": "Report",
"row_id": 1940512,
"text": "Neonatology\nDOL #60, CGA 43 .\n\nPOD #3 from G-tube placement.\n\nCVR: Remains in RA, RR 30-60s. Lungs clear, mild intermittent retractions. No spells. Hemodynamically stable.\n\nFEN: Wt 4065 grams. TF 100 cc/kg/day, IV at 60 cc/kg/day, BM at 40 cc/kg/day, PO/GT. Voiding/stooling.\n\nDEV: In crib.\n\nIMP: Former 34 wk with \"BOFS\" syndrome, now s/p G-tube placement. Advancing back on enteral feeds.\n\nPLANS:\n- Continue advancing enteral feeds.\n- PO as able, rest PG.\n- Plan possible discharge early next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-12 00:00:00.000",
"description": "Report",
"row_id": 1940513,
"text": "Neonatology\nAddendum:\n\nExam: active , no distress. Dysmorphic facies, with some asymmetry of facial muscles, low-set ears, cleft palate, mildly small jaw. Fontanelles soft and flat. Lungs coarse, well-aerated, mild intermittent retractions. Cardiac RRR, no m/g. Abdomen soft, no HSM, active BS. G-tube site with mild erythema around incision, no drainage. Tone increased, activity appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-23 00:00:00.000",
"description": "Report",
"row_id": 1940563,
"text": "1900-0730\n\n\n2. RESP O: Remains on room air with sats > 95%. BBS clear\nand equal with good aeration. RR 30-60s with mild SC retrx.\nMild upper airway congestion noted. with very mild\ninspiratory stridor with bottle feeding. However, is\nvery comfortable with no resp. distress. A: Stable on room\nair and when bottle feeding P: Monitor for s/s resp\ndistress esp. with PO feedings.\n3. G&D O: is active and alert with cares.\nAwakens q4, quiet and looks around. Temp wnl in open crib.\nNo s/s pain or discomfort. Yellow secretions continue to\ndrain on lt. eye. Warm soaks rendered and lacrimal massage\ndone. A: Appropriate P: Monitor. Comfort measures. Eye\ncare.\n4. FEN O: Abdomen soft, assessment benign. Feeds advanced\nto 120cc/kg/day. D10 with lytes dc'd with PO increase. PIV\nin scalp remains patent to NS flush. nippled well\ntonight, taking 50-78cc. No emesis. Voiding with diaper\nchanges. Passed smear gr stool A: Tolerating feeds. Eager\nto PO feed tonight P: Monitor for feeding intolerance.\nEncourage PO feeds when awake and alert.\n5. PARENTING O: No contact thus far this shift P:\nSupport and update. Encourage to ask questions and voice\nconcerns.\n8. GT CARE O: GT secure to abdomen. Dressing in place.\nSkin around GT slightly reddened. No tenderness noted.\nSmall amt of yellow drainage noted on old 2x2. Area cleansed\nwith NS and sterile 2x2 applied. GT patent to feedings. No\nleakage noted A: GT intact P: GT care. Monitor for s/s of\ninfection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-23 00:00:00.000",
"description": "Report",
"row_id": 1940564,
"text": "Neonatology Attending\n\nDOL 71 PMA 41 4/7 weeks\n\nStable in RA.\n\nNo murmur. BP 87/60 mean 68\n\nOn 120 ml/kg/d BM20 all enteral. Bottles 50-80 ml, the remainder is via . IV heplocked. Wt 3915 grams (up 40).\n\ng tube site looks ok.\n\nEye sl puffy and red.\n\nHearing referred R side again.\n\nMother in and up to date. Plan home with O2 sat monitor and g tube supplies.\n\nA: Stable. Advance to full feeds today.\n\nP: Monitor\n Min 130 ml/kg 24 cal to optimize growth\n Restart iron and trivisol\n Anticipate discharge on Friday\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-23 00:00:00.000",
"description": "Report",
"row_id": 1940565,
"text": "Nursing Progres Note\n\n\n2. in room air with sats mostly 99-100. No desats.\nMaintained in supine or sidelying position in crib. Lungs\nclear with mild stridor upon auscultation. A. Doing well\nin RA. P. Monitor.\n3. Awake and alert, tracks faces. Temp stable in open\ncrib. Awake for long periods today, interacting with mom.\nA. well developentally. P. Continue with\nappropriate developmental stim.\n4. Calories increased to BM24cals this shift, put on ad lib\nschedule with 130cc/kg minimum. Bottled well this shift\nwith feeder taking 65,80,30, then 70cc. Abdpmen\nbenign, voiding and stooling qs. A. Feeding well po. P.\nContinue to offer po feed ad lib, if doesn't take minimum\nfor 24hrs gavage via g-tube.\n5. Mom in from 11am to 4pm feeding and playing with\n. Independent in all care. Happy to be going home\nFriday. today and will see on\nSaturday. Mom has pedi apt Monday. All other outpatient\nappointments will be scheduled by mom. equipment set\nup for delivery Friday am. will be in to take\n home after equip arrives.\n8. dry and intact with small amount of yellow\ndrainage. Pink , sl. red. Cleaned with H20 and dry sterile\ngauze applied. Flange tight to skin at 2cm mark, taped to\nabdomen. A. Healing well. P. Continue with care of \nas above.\n9. Left eye draining mod amts of yellow-green secretions.\nLacrimal duct pressure done by mom. Lid slightly red,\nsclera sl. red at outer corner. Mom has ointment at\nhome, will bring in tomorrow. All antibiotics d/c'd per\norder, g-tube site draining sm amt yellow secs as above.\nAP. Continue to monitor for infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-24 00:00:00.000",
"description": "Report",
"row_id": 1940566,
"text": "1900-0730\n\n\n2. RESP O: Remains on room air with sats > 96%. BBS clear\nand equal with good aeration. Intermittent upper airway\ncongestion audible. RR 30-60s with mild SC retrx. No\nspells. Occas mild inspiratory stridor noted with PO\nfeeding, but comfortable. A: Stable on room air P: Monitor\nand document.\n3. G&D O: Active and alert. Awakens for feeds, but calm\nand quiet. Looks around. No s/s pain or discomfort. Temp\nwnl in open crib. Will attempt to do car seat tonight.\nContinues to have green-yellowish drainage from lt. eye.\nArea cleansed with sterile H2O. Lacrimal massage rendered.\nA: Appropriate P: Monitor. Comfort measures.\n4. FEN O: Abdomen soft, assessment benign. No distention\nor tenderness noted. Ad lib feeds with min.\nTF=130cc/kg/day. Taking 80cc BM 24 q4. No emesis. Voiding\nand stooling with diaper changes. Wgt: 3.905k, down 10g A:\nStable, tolerating feeds and meeting min. daily fluid\nrequirement. P: Monitor for feeding intolerance.\n5. PARENTING O: No social contact thus far this shift P:\nSupport and update.\n8. GT CARE O: GT remains secure.. Mild redness and very\nsmall yellow drainage noted around tube. No swelling or\ntenderness. Area cleansed with sterile water. New 2x2\napplied and secured. A:GT intact. P: GT care. Monitor for\ns/s infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-13 00:00:00.000",
"description": "Report",
"row_id": 1940517,
"text": "Neonatology Attending\nDOL 61 / PMA 43-1/7\n\nRemains in room air with no apneas/bradycardias.\n\nMurmur noted. Well-perfused.\n\nWt 3985 (-80) on TFI 100 cc/kg/day with ad lib feeds in excess of this volume. Voiding and stooling normally. Abd benign.\n\nIncreased leakage around g-tube. Continues to flush easily.\n\nTemp stable in open crib. Received two-month immunizations over the past 24 hours.\n\nA&P\n34-3/7 week GA with brachio-orbital-facial syndrome, g-tube\n-Will discuss management of g-tube with surgery given leakage\n-No other changes in management\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-13 00:00:00.000",
"description": "Report",
"row_id": 1940518,
"text": "NPN 0700-1900\n\n#2 Alt. in resp. Function\nO: Remains in RA with sats 98-100. RR 30's-50's with baseline IC/SC retractions. Upper airway noise present, but breath sounds are clear and = bilat. No desats, bradycardia or apnea noted.\nA: Doing well in RA\nP: Continue close observation and monitoring for resp. function.\n\n#3 Alt. in Development\nO: Temps stable in opne crib, swaddled and positioned on side or supine. Very irritable today with difficulty settling after feeding. Sat in carseat for short periods w/o crying. Likes to be held with pacifier. G-tube leaking today, causing wet clothing and blankets and requiring frequent dsg. changes, ? adding to irritability. Tylenol given for discomfort post op G tube and post 60 day immunizations.\nA: Irritable today\nP: Continue comfort measures, positioning, frequent feedings etc. Continue Tylenol for discomfort as needed.\n\n#4 Alt. in Nutrition\nO: TF=min 120cc/kg=60cc BM Q 3 hrs. or 80cc Q 4 hrs. Abd. is full, soft with + BS, no loops. Voiding and passing stool. Feeding Q 2-3 hrs. Taking 40-90cc BM with feeder.\nA: ? meeting minimum\nP: Continue feeding on demand and assess TFI. If not meeting minimum in 24 hrs, suppiment feeds with G-tube feedings. Follow daily wt.\n\n#8 Post-op G-tube\nO: G-tube noted to be leaking copious amts fluid (clear fluid and also milk curds) around insertion site. Skin around tube noted to be reddened and irritated. Clothing, blankets and dsg. needing to be changed Q 1-2 hrs. Dr. notified and in to see . Surgery called and in to see tonight. G-tube adjusted, insertion site cleaned and balloon inflation checked by surgeon. New dsg. applied. Decrease in leaking noted since adjustment. Flushes easily.\nA: G-tube leaking, now improved\nP: Continue close observation and monitoring for leaking, irritation, s/s infection etc. G-tube care and dsg change and PRN. Flush When not in use.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-14 00:00:00.000",
"description": "Report",
"row_id": 1940519,
"text": "NPN 1900-0700\n\n\n#2Resp. In RA, RR 30-50s, continues with intermittent\nstridor. Sat 95 and above, no bradys. Plan to monitor resp.\nstatus.\n\n#3Dev. Pt. swaddled in OAC, temp. stable. Pt. initially\nfussy, but settled and did not wake for feeds overnight. Pt.\n\ngiven tylenol x1 for fussiness. Pt. has multiple scratches\non face. MAE. AFF. Plan to continue to support dev. needs,\ntylenol prn for pain.\n\n#4F/N.and #8Gtube. Wt. 3980gms, down 5 gms. On Minimum of\n120cc/k/day of Bm20. Pt. po fed x3, 35cc-75cc. Took\n102cc/k/day last 24 hrs. site has been leaking\novernight, increased leaking observed when breastmilk given\nthrough g tube. Redness around site, dressing changed\nfrequently. Abd. soft, pink, pt. voiding and stooling.\nZantac started.Plan surgery to see to evaluate .\n\n#5Parenting. Mom called x1, updated. Plan to support mom,\ncontinue discharge planning.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-14 00:00:00.000",
"description": "Report",
"row_id": 1940520,
"text": "Neonatology Attending Progress Note\n\nNow day of life 62, CA 2/7 weeks.\nPost-op day 5 from G-tube placement.\nIn RA with RR 30-50s.\nHR 140-150 BP 88/43 66\nNo episodes of apnea or desaturation.\n\nWt. 3980gm down 5gm on ad lib feedings of MM - feedings by .\nLeakage of gastric secretions and feedings around G-tube site noted frequently.\nSurgery to come to evaluate further.\n\nAssessment/plan:\nNow 2 months of age with leakage of G-tube.\nWill consult with Surgery for appropriate treatment.\nDischarge teaching/preparations in progress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-25 00:00:00.000",
"description": "Report",
"row_id": 1940573,
"text": "Nursing Progress and Discharge Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. No\ndesats, no drifts. No stridor noted during PO feeding. P\nMonitor\n3. DEV O/A remains swaddled in OAC with stable\ntemp. A/A with cares, sleeping well between cares. P\nmonitor\n4. FEN O/A TF=min of 130cc/kg. Inf waking q3hrs for\nfeeds taking 90-100cc. Tol well. No spits. Belly soft, no\nloops. Voiding, stooling. P cont to offer PO feeds.\n5. O/A Mom and in for visit and discharge.\nUpdates given. All questions answered at this time. F/U\nappointments made. comfortable and independent\ntaking home with complex needs. P support\n8. O/A Site pink, scant yel drainage, cleaned w/\nwater. P cont to monitor.\nSee flowsheet for further details.\nDischarge to home with as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-14 00:00:00.000",
"description": "Report",
"row_id": 1940521,
"text": "NPN DAYS\n\n\n2. Remains in RA. O2 sat>90%. LS clear. Mild SC retractions.\nRR 30-50's. No desats, no spells. Monitor. Prone positioning\nwhen not being held. Stable.\n\n3. Tmax 100.1 this am. F/U before tylenol: 98.5. Temp\nremains stable. Team aware. Irritable 1st half of shift d/t\nfluid leakage of GT site and very hungry and tired.\nAfter surgery came by and tighted disk of , \ncomfortable and feedings gavaged. Tylenol given x1 with good\neffect today. Remains in open crib.\n\n4&8. TF at min 120cc/kg of BM20. Waking q1-1.5 hrs this am\nwanting to eat. Unable to use GT at that time because of\nleakage. Less leakage noted when bottling. Using habermann\nnipple, taking 20-40cc with each feed(needing 80cc q4hr).\n hungry. Surgery into evaluate this afternoon and tube\ndisc adjusted. Less leakage noted. Per -small leakage is\nnormal and should stop in few days. Will monitor over noc,\nif continues to be an issue, will have surgery eval in am.\nGT site cleansed per p&p. Dressing changed frequently d/t\nleakage. Area sl. reddened. Bacitracin oint ordered TID to\narea. Voiding and stooling. Started on Fe and multivit. On\nzantac. Montitor closely.\n\n5. Mother in this afternoon, asking appropriate questions.\nConcerned appropriately about the leakage of GT site, met\nwith surgical MD. Happy with with improvement of site after\nsurgery tightened disc. Parnent information binder given to\nmother regarding info on GT care. Plan for d/c later this\nweek. Continue with d/c teaching.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-14 00:00:00.000",
"description": "Report",
"row_id": 1940522,
"text": "Neonatology NP note\nPE\nAFOF\ncomfortable respirations in room air except for mild nasal stuffiness,lungs clear/=\nRRR, no murmur appreciated, pale with pink mm, well perfused\nabdomen soft, nontender and nondistended, active bowel sounds, no drainage from g-tube at the time of my exam, erythema around insertion site\nage appropriate tone and reflexes\nupdated mother at bedside\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-15 00:00:00.000",
"description": "Report",
"row_id": 1940523,
"text": "NPN\n\n\nResp: remains in RA. Breathing 20-50s. LS cl/-. Mild\nsc retractions. O2 sat >96%. No desats. in prone\nposition. Will cont to monitor.\n\nDev: in OAC. Temps stable. A+A w/ cares. Wakes for\nfeedsing. Brings hands to face for comfort. Sucks on paci.\nPOssible d/c on Friday. Placed in prone/side position. Will\ncont to support and monitor G+D.\n\nFEN: Infants weight was 3960 -20g. TF min of 120cc/k of\nBM20=80cc q 4hrs. Took whole bottle @ 2200, po/pg rest of\nshift. Tol well. No spits. Abd soft and pink, no loops.\nG-tube site sl. red and dsg changed multiple times for\nwetness(team aware). Baci oint applied as ordered. On\nzantac, trivisol, and iron. Will cont to monitor closely.\n\nSocial: Mom called x1. Updated over the phone. Asking\nappropriate questions. and involved. Will cont to\nmonitor.\n\nG-tube: G-tube still intact. Area around tube sl. red.\nLeaking moderate amount of BM from area around tube. Team\naware. Dsg changed frequently. Baci oint applied. Will cont\nto monitor closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-12 00:00:00.000",
"description": "Report",
"row_id": 1940514,
"text": "NPN 0700-1900\n\n#2 Alt. in resp. Function\nO: In RA with sats 95-100. Breath sounds clear and = with some upper airway noise. Mild SC retractions. RR 20's-40's. No desats or spells, positioned prone.\nA: Doing well in RA with prone positioning\nP: Continue close observation and monitoring. Document any spells.\n\n#3 Alt. in Development\nO: Temp stable in open crib, swaddled and positioned prone for resp. issues. Waking for feeds and acting hungry. Feeding well with feeder, but not back to full volume yet. No spells. Long awake periods after feeding. Likes to be held. Settles with back patting, pacifier and music box. 60 day immunizations ordered.\nA: Appropriate for GA\nP: Continue to support developmental needs. Give immunizations when available from pharmacy.\n\n#4 Alt. in Nutrition\nO: TF=100cc/kg., currently with PIV D10W/ 2mEq NaCl and 1 mEq KCl at 45cc/kg (7.5cc/hr) and feeds at 55cc/kg=38cc BM Q 4 hrs. Increasing feeds by 15cc/kg . Abd. is full, soft with + BS, no loops. No spits. Voiding QS, no stools this shift. PO feeding well with .\nA: Tolerating advancing feeds well\nP: Continue with present feeding plan and assess for tolerance. Follow daily wts.\n\n#5 Alt.in Parenting\nO: Mom called X 2 for update. In to visit this afternoon. She is independent with cares and feeding.\nA: Involved mom\nP: informed and support. Continue D/C preparations.\n\n#8 Post-op G-Tube placement\nO: G-Tube site with small amt redness, minimal drainage, no swelling. Area cleaned and dsg. changed per NICU protocol. Temp and VS are stable and WNL. acting well.\nA: Doing well post-op, no s/s infection at G-tube insertion site\nP: Continue close observation and monitoring for and s/s infection. Continue G-tube care per NICU protocol. Begin to flush G-tube with next dsg. change. ()\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-13 00:00:00.000",
"description": "Report",
"row_id": 1940515,
"text": "NPN\n\n\n#2-O; in RA, sats >95, RR 30's-50's, mild sc retractions,\nsome upper airway cong noted, , no spells, no desats, clear\nand equal.\n\n#3-O; in crib, can be prone, but placed sidelying and supine\nto relieve pressure on g-tube site, tol well. AFOF,\nalert,active, awake and irritable at times. Received HIB\nand Prevnar this shift. .\n\n#4-O: currently on tf 100cc/k/d, IV out, po fed x 2 for\n65-75cc well w/ feeder, G-tube in place, flushed x\n1 as ordered. Dsg changed x 2, some leaking of clear fluid\nnoted at site, NP examined, cont to monitor. abd soft,\nactive sounds, voiding qs and stooled mod green x 1. wt\ndown todaoy 80gms to 3.985 kg.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-13 00:00:00.000",
"description": "Report",
"row_id": 1940516,
"text": "Neonatology Attending\nAddendum - Physical Examination\n\nwell-appearing \nHEENT \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; bs active; erythema approx 5-10 mm around g-tube insertion site with significant leakage of clear fluid and formula\nINTEG otherwise normal\nMSK normal insp/palp/ROM all ext\nCNS active, resp to stimn; tone normal and symm\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-11 00:00:00.000",
"description": "Report",
"row_id": 1940510,
"text": "NPN DAYS\n\n\n2. Remains in RA. O2 sats>94%. LS clear. Mild subcostal\nretractions. Mild stridor with feedings(improved since\nearlier in week). RR 30-40's. No spells. No desats. Stable\nin RA. Monitor.\n\n3. Temp stable in open crib. Active and alert with cares.\nTylenol given x1 as ordered for discomfort with good effect.\n\n\n4&8. TF remains at 100cc/kg. Feedings currently at 20cc/kg\nof BM20. bottling full amt with habermann=13cc. IVF\nD10 with lytes infusing well via PIV at 80cc/kg. Will\nincrease feeding as ordered this afternoon to 30cc/kg and\nadjust IVF rate accordingly. GT intact. Dressing changed per\nP&P. Small amt serous sang drainage noted, area slightly\npink. New dressing placed. Voiding and stool. No spits.\nContinue to advance feeds 10cc/kg and monitor.\n\n5. Mother in this afternoon. Updated, asking appropriate\nquestions. Independent with cares, fed . Home Care\nin with mother for GT pump teaching. Continue with d/c\nteaching.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-24 00:00:00.000",
"description": "Report",
"row_id": 1940567,
"text": "Neonatology Attending\n\nDay 72 PMA 44 \n\nRemains in RA. Clear breath sounds. Mild retractions. No bradycardia, desaturation. No murmur. HR 100-160s. BP mean 74. Weight 3905 gms (-10). On BM 24. Took 124 cc/kg yesterday po. No spits. G-tube site clear. Stable temperature in open crib. Passed car seat study.\n\nDoing well. Hope for discharge tomorrow. Will continue to monitor closely. Final stages of discharge planning.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-24 00:00:00.000",
"description": "Report",
"row_id": 1940568,
"text": "Neonatology Attending\n\nExam remarkable for term in no distress with pink color, no gfr, clear breath sounds, no murmur, clear g-tube site, flat soft n-t abdomen, nl perfusion, usual tone/activity.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-24 00:00:00.000",
"description": "Report",
"row_id": 1940569,
"text": "Nursing Progress Note\n\n\n2. Resp O/A Rec'd inf in RA. Inf remains in RA. No\ndesats, no drifts notd thus far. Mild SCR noted. Sl\nstridorous with PO feeds, much improved. P cont to assess\nresp needs.\n3. DEV O/A remains swaddled in OAC with stable\ntemp. A/A with cares, waking for feeds. Loves to be held.\nP cont to assess dev needs.\n4. FEN O/A TF=min of 130cc/kd/day of BM24. Inf PO\nfeeding 65-90cc q 3-4 hrs thus far. Tol feeds well. No\nspits. Belly soft, no loops. Voiding, stooling. P cont to\nassess FEN needs.\n5. O/A Mom in for visit and cares. Updates given.\n Mom independent with complex care of . Looking\nforward to D/C planned for tomorrow. P support\n8. site O/A Site remains CDI, scant amt yel\ndrainage on dsg. Cleansed with sterile water. P cont to\nmonitor.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-24 00:00:00.000",
"description": "Report",
"row_id": 1940570,
"text": "Nursing Progress Note\n given Synagis as ordered. Signed consent in chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-25 00:00:00.000",
"description": "Report",
"row_id": 1940571,
"text": "NPN NIGHTS\n\n\nResp: Remains on RA without desats or spells. Mild\nretractions. Lungs c/=. Occ stridor with feeds (markedly\nless for this infants history). Cont to monitor.\n\nDev: Wakes for feeds. Enjoys being swaddled and sucking\npacifier. Seems to have adapted to bottle feeding well. Eye\ndrainage continues. Cleaned with h2o.\n\nFEN: Gained 15g on min130cc/kg/d of BM24. So far took 90cc\nat 8pm and 1am. Tires by end of feeding. Voiding, no stool.\nNo spits. Abd soft. P: monitor intake and weight gain.\n\nParent: Mom called this evening for update. Excited about\ntaking him home this a.m. Support offered.\n\n: Dressing changed and noted to have small amt yellow\ndrainage. Site slightly pink at edges but does not appear\ninfected. Cleaned and new dsg applied.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-11-25 00:00:00.000",
"description": "Report",
"row_id": 1940572,
"text": "Neonatology Attending\n\nDOL 73 PMA 44 5/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 84/39 mean 56\n\nOn BM24. Took 106 ml/kg/d po yesterday. Voiding. Stooling. Wt 3920 grams (up 15).\n\ng tube site looks good.\n\nSynagis #2 given.\n\nMother in and up to date. g tube supplies have been delivered to home.\n\nA: Stable. Ready for discharge.\n\nP: Home today\n tomorrow\n Pediatrician ( ) on Monday\n\n"
}
] |
138 | 105,764 | Patient tolerated procedure well and was transferred to NSICU d/t cardiac history. Post-op course was unremarkable. Patient remained in NSICU for 2 days and was eventually transferred to 12Reisman. Pain was controlled with Dilaudid through hospitalization. On POD1, Chest tube was removed. On POD2, NGT was removed. On POD3, patient was transferred out of NSICU to 12R On POD4, patient began regular diet after onset of flatus. On POD5, patient was provided Toradol for pain. CT scan of thorax was performed to rule out any source for pain; scan revealed no hematoma/bleeding/fluid collection. On POD6, patient was deemed stable and suitable for discharge. On discharge patient remained therapeutic (INR 2.5-3.5) on Warfarin. | Left lower lobe consolidation/collapse is again noted, with unchanged appearance of the left-sided chest tube. IMPRESSION: 1) Right internal jugular catheter terminates in superior vena cava. npn 0700-1700.remains aoox3 cooperative with care after expaining that he could not ambulate by self.resp ; lungs clear diminished at bases. CHEST TUBE TO SUCTION WITH NO OUTPUT.RESP: LS CLEAR, DECREASED IN BASES. The right internal jugular central venous catheter, NG tube, and ICD are unchanged in position from the prior study. FINDINGS: A right internal jugular catheter is present, terminating in the superior vena cava and partially obscured by an overlying ICD device. IMPRESSION: Status post chest tube removal, without evidence of pneumothorax. TECHNIQUE: MDCT acquired images of the chest, abdomen and pelvis were obtained without IV contrast. dry vs. needing lasix dose. (Over) 12:22 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: We need CT without contrast. 12:22 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: We need CT without contrast. FINAL REPORT INDICATION: Status post nephrectomy. 1ST ABG OF AM ?ERRONEOUS RESULTS...PCO2 74, PH 7.19. CT OF THE CHEST WITHOUT IV CONTRAST: AP window node measuring 7 mm in short axis diameter is again identified, unchanged compared to the prior study. The right lung base has been excluded from the exam. There is a small amount of fluid in the left-sided nephrectomy bed. The patient is status post left nephrectomy and apparent left adrenalectomy. + HYPO BS, NO NAUSEA. A left subclavian intravenous pacemaker remains in place. 4) Stable cardiomegaly with slight decrease in interstitial edema since the prior exam. PRN Hydromorphone and tylenol given.A - Stable hemodynamics. O2 POST EXTUBATION ON NASAL CANNULA 98%.GI: NGT WITH MINIMAL OUTPUT. ABDOMEN SOFT WITH POSITIVE BOWEL SOUNDS, NO BM OVERNOC. PT HAS AICD WHICH WAS INTERIGATED BY EP AND IS FINE. HR NSR, TOLERATING LOPRESSOR WELL. Requires encouragement to C&DB.P - Continue to monitor resp and hemodynamic status. PT IS HIT +, AND CAN ONLY TAKE COUMADIN (NO GENERIC REPLACEMENTS). Peripheral pulses palpable, pedal edema.Resp - Weaned to 4L NC. EXTRA BOLUS OF DILAUDID 1MG IV WITH GOOD EFFECT ATTAINING ADEQUATE DRUG LEVEL, HAS MANAGED PAIN WELL THROUGHOUT NOC USING DILAUDID PCA ONLY.RESP: LEFT CHEST TUBE DRAINED TOTAL 160CC SEROSANG. COMPARISON: CT chest dated and CT torso dated . IMPRESSION: Multiple lines and tubes in place, unchanged in position. SURGICAL INCISION DRY AND INTACT.GI: NGT TO LOW WALL SUCTION DRAINING CLEAR TO SLIGHTLY PINK TINGED FLUID. There is left basilar atelectasis. Swan-Ganz catheter placed. NURSING UPDATECV: AFEBRILE. REASON FOR THIS EXAMINATION: We need CT without contrast. Previously described interstitial edema is slightly less prominent. BREATH SOUNDS COARSE, DIMINSHED @ BASES.RENAL/GU: HUO 35-70CC CLEAR YELLOW VIA FOLEY CATH. VENT WEANED AND PT . FINDINGS: UPRIGHT AP CHEST AT 20:15: The patient has been extubated. The lead is in the right ventricle. + EDEMA, GENERALIZED. ADMISSION NOTE/CONDITION UPDATE:PLEASE SEE ADMISSION FHP FOR PMH.D/A: PT ARRIVED FROM OR TO SICU ~ 1145 S/P RIGHT RADICAL NEPHRECTOMY SECONDARY TO RENAL CELL CA. The right adrenal gland has normal appearance. There is a small amount of intra-abdominal free air located anterior to the liver and in the surgical bed. An associated left pleural effusion cannot be excluded. C/O OF PAIN, DILAUDID PRN WITH POOR EFFECT THUS FAR. An endotracheal tube, ICD and nasogastric tube are in satisfactory position. CT OF THE PELVIS IV CONTRAST: The bladder, prostate, seminal vesicles, rectum, and sigmoid colon are unremarkable. Abdomen soft.GU - Urine output low - borderline. IMPRESSION: 1) Interval extubation of the patient. CLINICAL INDICATION: Swan-Ganz catheter placement. K+, BUN AND CREAT ALL WITHIN NORMAL PARAMETERS. Semi-upright AP chest at 13:20: The left chest tube has likely been removed since the prior study, though the lateral-most portion of left chest is not visualized on the view obtained. CVP continues .Pain - Pt continues to c/o pain. 500 cc NS bolus given x2 with minimal effect. Multiple tubes and catheters are unchanged from earlier today and the heart and lungs are also unchanged. Once again, the Swan-Ganz catheter is not identified. PLACEMENT CONFIRMED BY X-RAY. PCA ORDERED.CV: HR 70'S NSR. Repeat non-rotated examination is recommended if the exact position of these lines needs to be determined. There is increased left lower lobe atelectasis since the prior exam as evidenced by some obscuration of the left hemidiaphragm. CXR done. Chest tube removed by urology. The tip is in the superior vena cava. TLCL PLACED THROUGH CORDIS. There are small bilateral pleural effusions, left greater than right. BP NORMOTENSIVE. The right kidney is poorly evaluated on this noncontrast study. ?chest wall hematoma/?mass in a Admitting Diagnosis: RENAL CANCER/SDA Field of view: 47 FINAL REPORT (Cont) IMPRESSION: 1) Intra-abdominal free air and a small amount of fluid in the left nephrectomy bed with left retroperitoneal and left abdominal wall stranding, consistent with the patient's history of recent left nephrectomy. The left chest tube is again seen laterally. Bone windows reveal degenerative changes with no suspicious lytic or sclerotic foci. There is slightly increased left lower lobe atelectasis in the interim. CBC STABLE AND COAGS WITHIN PARAMETERS.PAIN: INCREASED PAIN @ CHEST TUBE SITE EARLY NOC. VSS, TEMP 96.7.NEURO: PROPOFOL GTT WEANED OFF, PT A+OX3 POST EXTUBATION, FOLLOWING ALL COMMANDS, MAE'S. | 12 | [
{
"category": "Radiology",
"chartdate": "2134-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 855015,
"text": " 8:42 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: We need CXR at 9AM.\n Admitting Diagnosis: RENAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p L nephrectomy with swan ganz catheter\n\n REASON FOR THIS EXAMINATION:\n We need CXR at 9AM.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post nephrectomy. Swan-Ganz catheter placed.\n\n COMPARISON: Earlier, same day.\n\n FINDINGS:\n\n The exam is underpenetrated. It is difficult to visualize the tip of the\n Swan-Ganz catheter and the tip of the NG tube. Left lower lobe\n consolidation/collapse is again noted, with unchanged appearance of the\n left-sided chest tube. The right lung base has been excluded from the exam.\n\n IMPRESSION:\n\n NG tube tip and Swan tip not well demonstrated. Repeat non-rotated\n examination is recommended if the exact position of these lines needs to be\n determined.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-06 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 855571,
"text": " 12:22 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: We need CT without contrast. ?chest wall hematoma/?mass in a\n Admitting Diagnosis: RENAL CANCER/SDA\n Field of view: 47\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p L nephrectomy with increased incisional and back pain.\n REASON FOR THIS EXAMINATION:\n We need CT without contrast. ?chest wall hematoma/?mass in abdomen/?fluid\n acculmulation/?subphrenic abscess\n CONTRAINDICATIONS for IV CONTRAST:\n s/p nephrectomy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left nephrectomy with increased incisional and back\n pain.\n\n COMPARISON: CT chest dated and CT torso dated .\n\n TECHNIQUE: MDCT acquired images of the chest, abdomen and pelvis were\n obtained without IV contrast.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: AP window node measuring 7 mm in short\n axis diameter is again identified, unchanged compared to the prior study.\n There are no pathologically enlarged axillary, mediastinal, or hilar lymph\n nodes. Sternotomy wires and pacing wires are again demonstrated. There are\n small bilateral pleural effusions, left greater than right. There is left\n basilar atelectasis. No focal pulmonary nodules are identified.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a peridiaphragmatic lymph node\n measuring 12 mm in short axis diameter that appears to be increased in size\n compared to the prior study. The patient is status post left nephrectomy and\n apparent left adrenalectomy. There is a small amount of intra-abdominal free\n air located anterior to the liver and in the surgical bed. The liver,\n gallbladder, pancreas, and spleen are unremarkable. The right adrenal gland\n has normal appearance. The right kidney is poorly evaluated on this\n noncontrast study. There is a small amount of fluid in the left-sided\n nephrectomy bed. Stranding is noted along the left psoas muscle and in the\n left abdominal wall. Skin staples at the left abdominal wall are identified.\n No pathologically enlarged retroperitoneal or mesenteric lymph nodes are\n identified. The stomach and intra-abdominal loops of small and large bowel\n are unremarkable.\n\n CT OF THE PELVIS IV CONTRAST: The bladder, prostate, seminal vesicles,\n rectum, and sigmoid colon are unremarkable. There is no pelvic free fluid.\n Stranding along the left iliopsoas muscle is demonstrated along with surgical\n clips along the left anterior margin of the iliopsoas muscle. There is no\n free pelvic fluid. There are no pathologically enlarged inguinal or pelvic\n lymph nodes. Bone windows reveal degenerative changes with no suspicious\n lytic or sclerotic foci.\n\n (Over)\n\n 12:22 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: We need CT without contrast. ?chest wall hematoma/?mass in a\n Admitting Diagnosis: RENAL CANCER/SDA\n Field of view: 47\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1) Intra-abdominal free air and a small amount of fluid in the left\n nephrectomy bed with left retroperitoneal and left abdominal wall stranding,\n consistent with the patient's history of recent left nephrectomy.\n\n 2) A 12-mm lymph node located anterior to the left lobe of the liver near the\n diaphragm that appears to have increased in size compared to prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 855052,
"text": " 12:56 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p CT removal\n Admitting Diagnosis: RENAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p L nephrectomy with swan ganz catheter\n\n REASON FOR THIS EXAMINATION:\n s/p CT removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post chest tube removal.\n\n COMPARISION: at 09:13.\n\n Semi-upright AP chest at 13:20: The left chest tube has likely been removed\n since the prior study, though the lateral-most portion of left chest is not\n visualized on the view obtained. There is no pneumothorax identified.\n Multiple tubes and catheters are unchanged from earlier today and the heart\n and lungs are also unchanged.\n\n IMPRESSION: Status post chest tube removal, without evidence of pneumothorax.\n The lateral-most left chest was not imaged and cannot be assessed, however.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854911,
"text": " 12:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SGC placement\n Admitting Diagnosis: RENAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p L nephrectomy with swan ganz catheter\n REASON FOR THIS EXAMINATION:\n SGC placement\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable supine chest of compared .\n\n CLINICAL INDICATION: Swan-Ganz catheter placement.\n\n FINDINGS:\n\n A right internal jugular catheter is present, terminating in the superior vena\n cava and partially obscured by an overlying ICD device. No indwelling\n Swan-Ganz catheter is identified within the right-sided cardiac or\n pulmonary vasculature. An endotracheal tube, ICD and nasogastric tube are in\n satisfactory position. There has been interval enlargement of the cardiac\n silhouette with increased pulmonary vascularity and development of a diffuse\n interstitial pattern. A left-sided chest tube has been placed, and there is\n no evidence of pneumothorax.\n\n IMPRESSION:\n\n 1) Right internal jugular catheter terminates in superior vena cava.\n\n 2) Interval development of interstitial pulmonary edema, which may be due to\n volume overload and/or CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854988,
"text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm edema\n Admitting Diagnosis: RENAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p L nephrectomy with swan ganz catheter\n\n REASON FOR THIS EXAMINATION:\n r/o pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 50-year-old status post nephrectomy, Swan-Ganz catheter placement.\n Evaluate for pulmonary edema.\n\n FINDINGS:\n\n Comparison is made to the prior examination of a day earlier. A left\n subclavian intravenous pacemaker remains in place. The lead is in the right\n ventricle. The right IJ line remains in place. The tip is in the superior\n vena cava. Also, there is continued application of the NG tube. Since the\n prior study, there has been further atelectasis of the left lower lobe with\n complete loss of the left hemidiaphragm. An associated left pleural effusion\n cannot be excluded. No other significant changes are noted.\n\n IMPRESSION:\n\n Multiple lines and tubes in place, unchanged in position.\n\n Worsening lower lobe partial atelectasis. No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854969,
"text": " 8:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval chest tube placement\n Admitting Diagnosis: RENAL CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p L nephrectomy with swan ganz catheter\n\n REASON FOR THIS EXAMINATION:\n eval chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left nephrectomy with Swan-Ganz. Evaluate chest tube\n placement.\n\n COMPARISON: at 12:54.\n\n FINDINGS:\n\n UPRIGHT AP CHEST AT 20:15: The patient has been extubated. The right\n internal jugular central venous catheter, NG tube, and ICD are unchanged in\n position from the prior study. Once again, the Swan-Ganz catheter is not\n identified. The left chest tube is again seen laterally. No evidence of a\n Pneumothorax. The cardiac silhouette is stable. Previously described\n interstitial edema is slightly less prominent. There is increased left lower\n lobe atelectasis since the prior exam as evidenced by some obscuration of the\n left hemidiaphragm.\n\n IMPRESSION:\n\n 1) Interval extubation of the patient.\n\n 2) Multiple lines and tubes as described.\n\n 3) No pneumothorax.\n\n 4) Stable cardiomegaly with slight decrease in interstitial edema since the\n prior exam. There is slightly increased left lower lobe atelectasis in the\n interim.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-01 00:00:00.000",
"description": "Report",
"row_id": 1261980,
"text": "ADMISSION NOTE/CONDITION UPDATE:\nPLEASE SEE ADMISSION FHP FOR PMH.\n\nD/A: PT ARRIVED FROM OR TO SICU ~ 1145 S/P RIGHT RADICAL NEPHRECTOMY SECONDARY TO RENAL CELL CA. VSS, TEMP 96.7.\n\nNEURO: PROPOFOL GTT WEANED OFF, PT A+OX3 POST EXTUBATION, FOLLOWING ALL COMMANDS, MAE'S. C/O OF PAIN, DILAUDID PRN WITH POOR EFFECT THUS FAR. PCA ORDERED.\n\nCV: HR 70'S NSR. PT HAS AICD WHICH WAS INTERIGATED BY EP AND IS FINE. ABP ~ 135/70. + PPP BILAT. + EDEMA, GENERALIZED. PA LINE ATTEMPTED TO BE PLACED, UNABLE TO PLACE. TLCL PLACED THROUGH CORDIS. PLACEMENT CONFIRMED BY X-RAY. FLUID BALANCE OR TO 1800: + 3458 CC'S. INR 2.2, GOAL > 2.5. PT IS HIT +, AND CAN ONLY TAKE COUMADIN (NO GENERIC REPLACEMENTS). COUMADIN ORDERED FOR TONIGHT. CHEST TUBE TO SUCTION WITH NO OUTPUT.\n\nRESP: LS CLEAR, DECREASED IN BASES. VENT WEANED AND PT . O2 POST EXTUBATION ON NASAL CANNULA 98%.\n\nGI: NGT WITH MINIMAL OUTPUT. + HYPO BS, NO NAUSEA. NPO.\n\nGU: FOLEY-BSD WITH CLOUDY YELLOW URINE, ADEQUATE AMOUNTS PER TEAM AS PT ONLY HAS OF ONE KIDNEY.\n\nSX: WIFE, SON AND OTHER FAMILY MEMBERS PRESENT.\n\nR: S/P RIGHT RADICAL NEPHRECTOMY WITH STABLE VS, , PAIN NOT YET UNDER CONTROL.\n\nP: CONTINUE TO CLOSELY MONITOR VS, S+S OF BLEEDING, LABS, FLUID STATUS AND URINE OUTPUT. CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT, PT AND FAMILY SUPPORT.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-02 00:00:00.000",
"description": "Report",
"row_id": 1261981,
"text": "NURSING UPDATE\nCV:\n AFEBRILE. HR NSR, TOLERATING LOPRESSOR WELL. NO ECTOPY. BP NORMOTENSIVE. CBC STABLE AND COAGS WITHIN PARAMETERS.\n\nPAIN:\n INCREASED PAIN @ CHEST TUBE SITE EARLY NOC. EXTRA BOLUS OF DILAUDID 1MG IV WITH GOOD EFFECT ATTAINING ADEQUATE DRUG LEVEL, HAS MANAGED PAIN WELL THROUGHOUT NOC USING DILAUDID PCA ONLY.\n\nRESP:\n LEFT CHEST TUBE DRAINED TOTAL 160CC SEROSANG. O2 SAT FLUCTUATING DOWN TO 90 ON NASAL PRONGS SO CHANGED TO FACE TENT WITH MIST WITH GOOD EFFECT. SATS 97-100% THRU NOC. 1ST ABG OF AM ?ERRONEOUS RESULTS...PCO2 74, PH 7.19. PT AWAKE AND APPROPRIATE AT THAT TIME. INCENTIVE SPIROMETRY AND DEEP BREATH AND COUGHING EXERCISES DONE X 20MIN, FOLLOW UP ABG WITHIN NORMAL PARAMETERS, PCO 41, PH 7.42. EXPECTORATING SCANT AMOUNTS THICK WHITE SECRETIONS. BREATH SOUNDS COARSE, DIMINSHED @ BASES.\n\nRENAL/GU:\n HUO 35-70CC CLEAR YELLOW VIA FOLEY CATH. K+, BUN AND CREAT ALL WITHIN NORMAL PARAMETERS. SURGICAL INCISION DRY AND INTACT.\n\nGI:\n NGT TO LOW WALL SUCTION DRAINING CLEAR TO SLIGHTLY PINK TINGED FLUID. ABDOMEN SOFT WITH POSITIVE BOWEL SOUNDS, NO BM OVERNOC. TAKING A FEW ICE CHIPS PO TO ASSIST WITH MOISTENING MOUTH AND CLEARING SECRETIONS.\n\n PT INITIALLY ANXIOUS EARLY NOC, BUT AFTER PAIN BROUGHT UNDER CONTROL HAS BEEN IN GOOD SPIRITS, AND COMPLIANT WITH ALL CARE AND INSTRUCTION.\n\nPLAN: RESP STATUS BEARS WATCHING AT THIS TIME. MAINTAIN COMFORT STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-02 00:00:00.000",
"description": "Report",
"row_id": 1261982,
"text": "SICU Nursing Progress Note\nNeuro - Pt x3, pleasant, conversationally appropriate. Moves all extremities with good strength.\n\nCV - SR 80s with occasional PVCs. SPB 100 - 120 by arterial line. CVP 1-2. Peripheral pulses palpable, pedal edema.\n\nResp - Weaned to 4L NC. O2 sat >96% when awake, low 90s when asleep. Chest tube removed by urology. CXR done. Imroving cough with much encouragement.\n\nGI - NGT to low wall suction draining clear fluid. + BS, no flatus, no BM. Abdomen soft.\n\nGU - Urine output low - borderline. 500 cc NS bolus given x2 with minimal effect. Pt uses lasix chronically at home. CVP continues .\n\nPain - Pt continues to c/o pain. Encouraged to use PCA more often. PRN Hydromorphone and tylenol given.\n\nA - Stable hemodynamics. ? dry vs. needing lasix dose. Requires encouragement to C&DB.\n\nP - Continue to monitor resp and hemodynamic status. Monitor UOP. Continue to medicate for pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-03 00:00:00.000",
"description": "Report",
"row_id": 1261983,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVIEW FOR SPECIFICS\nVERY ALERT AND COOPERATIVE, DANGELING OVER SIDE OF BED, COUGING AND DEEP BREATHING. USING DILAUDID PCA PUMP WITH FAIR RELIEF, RECEIVING PRN DIALAUDID TO CONTROL BREAKTHROUGH PAIN.\nURINE OUTPUT IMPROVING DURING NIGHT.\nSLEPT WELL.\n? TRANSFER TO FLOOR TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-03 00:00:00.000",
"description": "Report",
"row_id": 1261984,
"text": "npn 0700-1700.\n\nremains aoox3 cooperative with care after expaining that he could not ambulate by self.\nresp ; lungs clear diminished at bases. sats 92-95 % on ra occass drops when asleep to 89-93%.rr 14-18.\n\ncvs; tmax 98.7 po nsr 77-85.bp88-93/47 given fluid bolus 500 mlsx2 for low bp and low u/o with good response.\n\ngu 25-40 mls/hr after fluid boluses. goal greater than 30 mls/hr.\n\ngi;belly soft hypoactive bs in lower quads no stool no flatus,\ntaking small amount ice chips c/o of hunger.\n\npain; dilaudid pca increased to .25 mgs . with fair effect,\n pain free at rest \"excruciating\" with movement .\n\na/p continue to monitor u/o and increase activity and nutrition as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-03 00:00:00.000",
"description": "Report",
"row_id": 1261985,
"text": "addendum toabove note\n n/c with 3l fio2 added as pt dropping sats to 89-90% persistently when sleeping.\n"
}
] |
42,920 | 122,242 | In the OB/GYN triage, Ms. started passing large clots in toilet and then, while the OB/GYN resident was standing with her, she syncopized but didn't hit anything. Of note, her fingerstick was checked at this time and found to be 300, as she had turned off her pump on arrival to the hospital. She received 10 units of regular insulin. Given her acute blood loss and syncopal episode, she was taken back to the OR for urgent D+C. The D+C did not show retained products but she continued to have significant bleeding intra-operatively, such that an emergent hysterectomy was considered (approximately 2 Liters). At that point, a 30 CC Foley balloon was placed in uterus to tamponade. This was attached to a urimeter to monitor bleeding. She was transferred to the ICU with the intra-uterine Foley in place and on an insulin drip for close monitoring. Of note, her hematocrit on admission was noted to be 29. Intra-op, her hematocrit was 20 and she received 3 units of pRBC's. Her hematocrit at the end of the case was 28. Also, her INR was noted to be 1.3 and she received 1 unit of FFP. On HD#3/POD#2, her vital signs remained stable and her hematocrit stabilized at 22. She demonstrated minimal bleeding from the intra-uterine Foley catheter. Initially, the Foley catheter was partially deflated and her bleeding was observed during the morning. Her bleeding remained light and the catheter was removed completely that afternoon. Of note, Ms. blood sugar remained stable on the insulin drip and she was transitioned back onto her insulin pump. Ms. was called out of the unit on the evening of HD#3/POD#2. Her diet was advanced to regular and her vital signs remained stable overnight. On the morning of HD#4/POD#3, she continued to have minimal vaginal bleeding and was asymptomatic. She was tolerating a regular diet and her blood sugar was well-controlled on the insulin pump. She was discharged to home on HD#4/POD#3 in stable condition on Oral Iron. She will follow-up with Dr. in 2 weeks. | Hypotension (not Shock) Assessment: UOP down at 0500-0600. bp 83/60 . INR 1.3 - OB/GYN recommended one unit FFP to improve coags for now - Resent coags after FFP . MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Fully removed at 13:30 by ob and few small dark clots noted with removal. Fully removed at 13:30 by ob and few small dark clots noted with removal. Recovered bp and pulse upon sitting Action: Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced Response: Pt A&O x 3 and appropriate. Recovered bp and pulse upon sitting Action: Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced Response: Pt A&O x 3 and appropriate. Started with clindamycin iv q 8h. Started with clindamycin iv q 8h. Review of systems: Flowsheet Data as of 12:51 AM Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since AM Tmax: 36.1C (97 Tcurrent: 36.1C (96.9 HR: 73 (73 - 90) bpm BP: 86/42(61) {52/42(49) - 105/55(71)} mmHg RR: 14 (9 - 24) insp/min SpO2: 98% Height: 67 Inch Total In: 4,859 mL 259 mL PO: TF: IVF: 654 mL 104 mL Blood products: 155 mL 155 mL Total out: 400 mL 0 mL Urine: 100 mL NG: Stool: Drains: Balance: 4,459 mL 259 mL Respiratory O2 Delivery Device: None SpO2: 98% Physical Examination Vitals: T: afebrile BP: 105/50 P: 90 R: 14 18 O2: 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Labs / Radiology 25.3 % [image002.jpg] 2:33 A3/21/ 09:02 PM 10:20 P 1:20 P 11:50 P 1:20 A 7:20 P 1//11/006 1:23 P 1:20 P 11:20 P 4:20 P Hct 25.3 Assessment and Plan 34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p Bakri balloon placement now admitted to for closer monitoring. Hypotension (not Shock) Assessment: UOP down at 0500-0600. bp 83/60 . Hypotension (not Shock) Assessment: UOP down at 0500-0600. bp 83/60 . Hypotension (not Shock) Assessment: UOP down at 0500-0600. bp 83/60 . Hypotension (not Shock) Assessment: UOP down at 0500-0600. bp 83/60 . Hypotension (not Shock) Assessment: UOP down at 0500-0600. bp 83/60 . Hypotension (not Shock) Assessment: UOP down at 0500-0600. bp 83/60 . INR 1.3 - OB/GYN recommended one unit FFP to improve coags for now - Resent coags after FFP . MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. MINIMAL BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Fully removed at 13:30 by ob and few small dark clots noted with removal. Fully removed at 13:30 by ob and few small dark clots noted with removal. Fully removed at 13:30 by ob and few small dark clots noted with removal. Fully removed at 13:30 by ob and few small dark clots noted with removal. Fully removed at 13:30 by ob and few small dark clots noted with removal. Fully removed at 13:30 by ob and few small dark clots noted with removal. - HCT: 22.4 --> 22.4--> 21.3 (received 1L bolus): discussed transfusion with ob/gyn, they requested holding off - Following OB/GYN recs: pt is Rh negative, received Rhogam, Fetal Hgb pending. Started with clindamycin iv q 8h. Started with clindamycin iv q 8h. Also remains on Clindamycin (in place of Keflex given PCN allergy) for intrauterine foley. Recovered bp and pulse upon sitting Action: Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced Response: Pt A&O x 3 and appropriate. Recovered bp and pulse upon sitting Action: Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced Response: Pt A&O x 3 and appropriate. Recovered bp and pulse upon sitting Action: Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced Response: Pt A&O x 3 and appropriate. Recovered bp and pulse upon sitting Action: Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced Response: Pt A&O x 3 and appropriate. | 31 | [
{
"category": "Physician ",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 730822,
"text": "Chief Complaint: Anemia Secondary to Blood Loss\n Hypovolemia--secondary to blood loss\n Hyperglycemia--DM-_Type I--uncontrolled\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 07:48 PM\n started in or\n -Patient with no evidence of acute bleeding overnight.\n History obtained from Medical records\n Allergies:\n Keflex (Oral) (Cephalexin Monohydrate)\n Rash; sneezing\n Penicillins\n Hives; Fever/Ch\n Last dose of Antibiotics:\n Clindamycin - 07:45 AM\n Infusions:\n Insulin - Regular - 0.5 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Tachycardia\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 74 (64 - 92) bpm\n BP: 94/39(60) {52/35(49) - 105/55(71)} mmHg\n RR: 14 (9 - 24) insp/min\n SpO2: 99%\n Height: 67 Inch\n Total In:\n 4,870 mL\n 1,534 mL\n PO:\n TF:\n IVF:\n 665 mL\n 1,379 mL\n Blood products:\n 155 mL\n 155 mL\n Total out:\n 400 mL\n 1,310 mL\n Urine:\n 100 mL\n 1,310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,470 mL\n 224 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///26/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 178 K/uL\n 112 mg/dL\n 0.3 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 6 mg/dL\n 108 mEq/L\n 139 mEq/L\n 22.7 %\n 8.4 K/uL\n [image002.jpg]\n 09:02 PM\n 03:10 AM\n WBC\n 8.4\n Hct\n 25.3\n 22.7\n Plt\n 178\n Cr\n 0.3\n Glucose\n 112\n Other labs: PT / PTT / INR:13.5/23.6/1.2, Fibrinogen:220 mg/dL,\n Mg++:1.5 mg/dL\n Fluid analysis / Other labs: AG-5\n Assessment and Plan\n 34 yo female admitted with anemia secondary to blood loss from vaginal\n bleeding complicated by LOC and followed by D+C where 2 liters of blood\n loss was seen and now patient admitted to ICU with hypovolemic shock\n secondary to blood loss. She has had rapid intervention with D+C and\n now has had good stability of HCT with only modest decrease overnight.\n DIABETES MELLITUS (DM), TYPE I--Uncontrolled\n -Insulin gtt.\n -Will move to insulin pump at patients baseline dose\n UTERINE BLEEDING\n -Clindamycin\n -Foley in place and will leave balloon inflated until further notice\n -HCT q 4 hours\n -Will continue to follow\n -D+C completed\n -will follow for evidence of acute blood loss\n -FFP given and will follow coags and fibrinogen across time\nmay need to\n be replaced prior to balloon removal\n ICU Care\n Nutrition: PO intake\n Glycemic Control: Insulin gtt and will move to insulin infusion if we\n are able to return to po intake\n Lines:\n 18 Gauge - 07:46 PM\n Arterial Line - 07:48 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI to be given if prolonged npo status to be maintained.\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730645,
"text": "34 yr old pt type 1 diabetic. 9^th pregnancy, 6 live births. This\n latest miscarriage was late / ? .pt bleeding and having hcg\n levels checked to monitor discharge of fetus. Had increased bleeding\n last night and came to ob triage for eval at 15:00. at 15:30 went to\n toilet and bleed approx 2 liters into toilet and then fainted.\n Emergency anesthesia called and started iov\ns and took pt to or. Crit\n was 28 upon arrival to and 20 pre op. transfused 3 units prbcs in\n or and got 3000 cc ns. Output was 300 cc in or. D&C done but pt cont\n to bleed in recovery and returned to or for poss hysterectomy.\n Hysterectomy not done but lg foley placed in uterus with 30 cc balloon\n inflated to tamponade bleeding. Blood will pass via foley out to\n collection.\n type 1: gave 10 unit regular insulin iv at 17:55 in rec.\n for glu 275. after 1 hr at 1900 glu is 206. iv insulin started at 1\n unit /hr with q1hr FS. Pt had insulin pump but removed at 15:30 today\n Bleeding: crit out of or after 3 units blood ws 30. next crit due at\n 2100 for q4hr. watch output from foley in uterus for excessinve\n bleeding . if pain in abd becomes more like cramoing or contraction\n type this pain should be sign of bleeding andclots forming and OB\n should be called.\n Nausea: received zofran at 1735\n Pain: received .5 mg dilaudid iv at 1735 with good results. Pt having\n gas pain likely d/t free air used for to visualize uterus and\n repositioning helped this pain.access: a line, 2 # 18 PIV. Infusing LR\n 125cc/hr and insulin gtt at 1 unit /hr.\n Allergy: KEFLIX\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730686,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n Pt s/p D &C and Bakri ballon placement yesterday, no active bleeding\n noted sinces then ,minimal vaginal bleeding , VSS, foley to gravity\n ,urine output adequate,yellow clear. Small amount blood stained\n drainage through uterine ballon bag.\n Action:\n Crit 25.3 from PM labs, 1 unit FFP received during the shift,repeat\n coags and all the am labs sent at 3am. IVF LR @ 125cc/hr continued. No\n blood given after icu admission. Started with clindamycin iv q 8h.\n Response:\n Remained as stable now, no active bleeding noted. At alert and oriented\n x 3, comfortable, denies any pain/cramps.\n Plan:\n Continue to monitor for further bleeding,f/u with am labs and transfuse\n / replete as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730687,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n Pt s/p D &C and Bakri ballon placement yesterday, no active bleeding\n noted sinces then ,minimal vaginal bleeding , VSS, foley to gravity\n ,urine output adequate,yellow clear. Small amount blood stained\n drainage through uterine ballon bag.\n Action:\n Crit 25.3 from PM labs, 1 unit FFP received during the shift,repeat\n coags and all the am labs sent at 3am. IVF LR @ 125cc/hr continued. No\n blood given after icu admission. Started with clindamycin iv q 8h.\n Response:\n Remained as stable now, no active bleeding noted. At alert and oriented\n x 3, comfortable, denies any pain/cramps.\n Plan:\n Continue to monitor for further bleeding,f/u with am labs and transfuse\n / replete as needed.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730682,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730874,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOS and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of \n balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct conts to drop.\n Plan to remove Bakri balloon in AM by OB team.\n Diabetes Mellitus (DM), Type I\n Assessment:\n pt uses insulin pump at home, stopped for OR procedure and started on\n insulin gtt in MICU. BS stable in 100s through out shift. Remains NPO\n incase pt needs to return to OR.\n Action:\n Insulin gtt remains @0.5units/hr. cking BS q4hrs since BS have been\n stable in 100s.\n Response:\n BS remains stable.\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730871,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOS and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of \n balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct conts to drop.\n Plan to remove Bakri balloon in AM by OB team.\n Diabetes Mellitus (DM), Type I\n Assessment:\n pt uses insulin pump at home, stopped for OR procedure and started on\n insulin gtt in MICU. BS stable in 100s through out shift. Remains NPO\n incase pt needs to return to OR.\n Action:\n Insulin gtt remains @0.5units/hr. cking BS q4hrs since BS have been\n stable in 100s.\n Response:\n BS remains stable.\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730869,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOS and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of \n balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct conts to drop.\n Plan to remove Bakri balloon in AM by OB team.\n Diabetes Mellitus (DM), Type I\n Assessment:\n pt uses insulin pump at home, stopped for OR procedure and started on\n insulin gtt in MICU. BS stable in 100s through out shift. Remains NPO\n incase pt needs to return to OR.\n Action:\n Insulin gtt remains @0.5units/hr. cking BS q4hrs since BS have been\n stable in 100s.\n Response:\n BS remain stable.\n Plan:\n Transition pt to insulin pump when POs are started.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730860,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOS and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of \n balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct conts to drop.\n Plan to remove Bakri balloon in AM by OB team.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt type 1 diabetic for last 20years ,was on insulin pump for several\n years, dc\nd yesterday before the OR procedure, currently on insulin gtt\n . NPO now . pt checks her blood sugar 4 times daily at home.\n Action:\n Insulin gtt on, Finger stick blood sugar Q1H, titrated insulin as\n needed, gtt maintained 0.5- 3units/hr. IVF LR @125cc/hr.\n Response:\n Blood sugar maximum upto 200\ns. pt stable .\n Plan:\n Continue to monitor BS ,titrate insulin as needed, if need to restart\n with her own insulin pump,pt needs new insulin pump as the current one\n almost run out. ? check FS 4-6times/day\n"
},
{
"category": "Physician ",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 730661,
"text": "Chief Complaint: vaginal bleed\n HPI:\n 34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed\n with non-viable pregnancy in with bleeding off and on since\n then. Last week she went into her OB for a check up and was still\n having uterine bleeding with a positive HCG. Her OB said she needed a\n D+C but she wanted to wait until after passover to have this done and\n since she was having only minimal bleeding it was agreed that she could\n wait. However, overnight she had heavier bleeding including clots from\n her vagina. She tried to stay at home to manage it but this morning her\n husband convinced her to come to the OB/GYN.\n .\n In the OB/GYN triage unit she started passing large clots in toilet\n this am and then, while the OB/GYN resident was standing with her, she\n syncopized but didnt hit anything. Therefore she was taken back to the\n OR for urgent D+C. D+C didnt show retained products but continued to\n bleed afterward to the point that they were thinking of doing emergent\n hysterectomy (lost 2 liters). At that point she then got a foley\n balloon placed in uterus to tamponade (Bakri balloon). This was\n attached to a urimeter to monitor bleeding - will see it in bag or on\n her pad. Hct on admission was 29, intra op it was 20, received 3units\n pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen\n 190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping\n from uterus and LH after dilaudid but otherwise not symptomatic.\n .\n Also a type one diabetic but took it off when she got here but initial\n FSBS was 300 - received 10units reg insulin in OR and now written for a\n drip.\n .\n She was transferred to the for monitoring overnight.\n .\n On the floor, she was a little crampy but otherwise fine. She sat up\n without light-headedness.\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. Denied nausea, vomiting, diarrhea, constipation or\n abdominal pain. No recent change in bowel or bladder habits. No\n dysuria. Denied arthralgias or myalgias.\n Allergies:\n Keflex (Oral) (Cephalexin Monohydrate)\n Rash; sneezing\n Penicillins\n Hives; Fever/Ch\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Other medications:\n Medications at home:\n INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - as directed in\n pump pt is pregnant (increasing requirements)\n PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed\n by Other Provider) - Dosage uncertain\n .\n MEDS ON TRANSFER:\n Insulin gtt\n Past medical history:\n Family history:\n Social History:\n G8P6 with last pregnancy complicated by cerclage requirement, and then\n leaking, which led to a cesarean section after months of bed rest.\n Prior to that C-section, she had had VBAC before\n Type 1 diabetes - on insulin pump (last A1C 7)\n Iron deficiency anemia\n Vitamin D deficiency\n Recurrent Cystitis\n Maternal grandfather with insulin-dependent diabetes. Maternal\n grandmother with breast cancer in the mid 70s and a brother with\n diabetes.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She is happily married. They are monogamous.\n She has 6 children, the youngest is 19 months. She works at a\n school in .\n Review of systems:\n Flowsheet Data as of 12:51 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (96.9\n HR: 73 (73 - 90) bpm\n BP: 86/42(61) {52/42(49) - 105/55(71)} mmHg\n RR: 14 (9 - 24) insp/min\n SpO2: 98%\n Height: 67 Inch\n Total In:\n 4,859 mL\n 259 mL\n PO:\n TF:\n IVF:\n 654 mL\n 104 mL\n Blood products:\n 155 mL\n 155 mL\n Total out:\n 400 mL\n 0 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,459 mL\n 259 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n Vitals: T: afebrile BP: 105/50 P: 90 R: 14 18 O2: 97% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 25.3 %\n [image002.jpg]\n \n 2:33 A3/21/ 09:02 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 25.3\n Assessment and Plan\n 34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n .\n # Uterine Bleeding: Now s/p balloon insertion.\n - monitor Hct Q6H and transfuse for hct <21 if hemodynamically stable\n - monitor bleeding from catheter in uterus and on pads\n - Follow up OB/GYN recs\n - Active T+C\n - 2 PIVs in place\n .\n # Coagulopathy: PTT elevated. INR 1.3\n - OB/GYN recommended one unit FFP to improve coags for now\n - Resent coags after FFP\n .\n # Type 1 diabetes: Usually uses insulin pump but taken off in setting\n of bleeding today and going to OR.\n - Continue insulin gtt until sure no further need for OR\n - Monitor FSBS Q1H per insulin gtt protocol\n .\n FEN: IVF (Lr@75ml/hr while NPO), replete electrolytes, NPO in case\n going to OR in am\n .\n Prophylaxis: boots\n .\n Access: peripherals\n .\n Code: Full\n .\n Communication: Patient and husband\n .\n Disposition: pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 07:46 PM\n Arterial Line - 07:48 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ICU Attending Admit Note\n I saw and examined this pt, and was present with the ICU team for the\n key portions of services provided. I agree with Dr. \ns note,\n including assessment and plan, and would add:\n 34 yo G8P6 female, DM I dx'd with non viable pregnancy in -\n since then with intermittent bleeding. Last week in her OB-gyn's\n office, planned D&C to remove retained products. Originally scheduled\n for after Passover, however with heavier bleeding yesterday and she\n therefore presented to OB triage. She was overtly hemorraghing blood\n clots in the bathroom and had a syncopal episode, no head trauma. She\n underwent D&C in the OR today, no retained products. She continued to\n bleed in recovery and was taken back initially with considerations for\n hysterectomy, but they were able to insert a Bakry Balloon to tamponade\n the uterus. 2 liters EBL.\n Hct 29--> 20 (OR)-->28 after 3 units.\n Additionally, started on insulin gtt due to BG 300's and insulin pump\n getting turned off\n Transferred to afterwards for monitoring\n PMHx:\n G8P6, cerclage required during last pregnancy\n DM I on insulin pump\n BP 105/50, P90, 97% RA\n Urine output 50-100 cc/h\n Pale, sleeping but arousable, NAD\n Lungs: CTA\n CV: mildly tachy, RR\n Abd soft, +bs\n Bakry balloon with scant blood\n Ext: nontender, no peripheral edema\n Labs\n Hct 27.8-->25.3\n 7.37/40/283\n INR 1.3 (ffp given)\n Imp:\n Uterine bleed s/p spontaneous abortion; acute blood loss anemia- no\n retained products, but per Ob, likely a brisk bleed due to proximity of\n empty sac to uterine scar\n appears to have stopped with foley intrauterine balloon tamponade-\n serial hct's, 2 large bore IV\ns, transfusion if hct <21, sooner if\n hemodynamic instability/brisk bleeding. Ob following closely, if\n recurrent bleed develops despite tamponade they will take back to OR\n DM I: on insulin gtt, continue until able to resume pump\n Pt is critically ill. Total time spent: 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 01:09 ------\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 731052,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. No\n other signs of bleeding. Morning crit 21\n Action:\n Per Dr. no need for crit at midnight, just check with morning\n labs.\n Response:\n Pt A&O x 3 and appropriate. No s/s of bleeding noted. Hemodynamically\n stable.\n Plan:\n Cont to monitor for s/s bleeding. Plan to remove Bakri balloon in AM\n by OB team.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night.\n Action:\n Insulin gtt remains @0.5units/hr. Check blood sugars Q 2 hours and\n adjust gtt accordingly..\n Response:\n Ongoing. Blood sugars remain in 100\n Plan:\n Transition pt to insulin pump in AM.\n UOP down to 15ml/hr. Given 1000 ml NS bolus x 1.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730926,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of outpt\n from balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct drops. Plan to\n remove Bakri balloon in AM by OB team. Ck hct at 23/05\n Diabetes Mellitus (DM), Type I\n Assessment:\n pt uses insulin pump at home, stopped for OR procedure and started on\n insulin gtt in MICU. BS stable in 100s through out shift. Remains NPO\n incase pt needs to return to OR.\n Action:\n Insulin gtt remains @0.5units/hr. cking BS q4hrs since BS have been\n stable in 100s.\n Response:\n BS remains stable.\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 731228,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n Hypotension (not Shock)\n Assessment:\n UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .\n Action:\n 1000 cc ns bolus over 1 hr given\n Response:\n Bp 95-110 sys withmap > 60. hr 80\ns nsr. Slight tachy to 100 with\n exertion of OOB. Urine output this shift thus far is 1200 cc. minimal\n dizziness with standing. Improving crit\n Plan:\n Conts to monitor. Send to ob floor\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 731174,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n UOP down to 15ml/hr. Given 1000 ml NS bolus x 1.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730913,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOS and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of \n balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct conts to drop.\n Plan to remove Bakri balloon in AM by OB team. Ck hct at 23/05\n Diabetes Mellitus (DM), Type I\n Assessment:\n pt uses insulin pump at home, stopped for OR procedure and started on\n insulin gtt in MICU. BS stable in 100s through out shift. Remains NPO\n incase pt needs to return to OR.\n Action:\n Insulin gtt remains @0.5units/hr. cking BS q4hrs since BS have been\n stable in 100s.\n Response:\n BS remains stable.\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730984,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. No\n other signs of bleeding. Morning crit.\n Action:\n Per Dr. no need for crit at midnight, just check with morning\n labs.\n Response:\n Pt A&O x 3 and appropriate. No s/s of bleeding noted. Hemodynamically\n stable.\n Plan:\n Cont to monitor for s/s bleeding. Plan to remove Bakri balloon in AM\n by OB team.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night.\n Action:\n Insulin gtt remains @0.5units/hr. Check blood sugars Q 2 hours and\n adjust gtt accordingly..\n Response:\n Ongoing. Blood sugars remain in 100\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730844,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri ballon placement following LOS and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping.\n no active bleeding noted sinces then ,minimal vaginal bleeding , VSS,\n foley to gravity ,urine output adequate,yellow clear. Small amount\n blood stained drainage through uterine ballon bag.\n Action:\n Crit 25.3 from PM labs, 1 unit FFP received during the shift,repeat\n coags and all the am labs sent at 3am. IVF LR @ 125cc/hr continued. No\n blood given after icu admission. Started with clindamycin iv q 8h.\n Response:\n Remained as stable now, no active bleeding noted. At alert and oriented\n x 3, comfortable, denies any pain/cramps. Am labs crit 22.\n Plan:\n Continue to monitor for further bleeding,f/u with am labs and transfuse\n / replete as needed.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt type 1 diabetic for last 20years ,was on insulin pump for several\n years, dc\nd yesterday before the OR procedure, currently on insulin gtt\n . NPO now . pt checks her blood sugar 4 times daily at home.\n Action:\n Insulin gtt on, Finger stick blood sugar Q1H, titrated insulin as\n needed, gtt maintained 0.5- 3units/hr. IVF LR @125cc/hr.\n Response:\n Blood sugar maximum upto 200\ns. pt stable .\n Plan:\n Continue to monitor BS ,titrate insulin as needed, if need to restart\n with her own insulin pump,pt needs new insulin pump as the current one\n almost run out. ? check FS 4-6times/day\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 731230,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer\n monitoring.\n BRIEF HISTORY :\n 34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed\n with non-viable pregnancy in with bleeding off and on since\n then. Last week she went into her OB for a check up and was still\n having uterine bleeding with a positive HCG. Her OB said she needed a\n D+C but she wanted to wait until after passover to have this done and\n since she was having only minimal bleeding it was agreed that she could\n wait. However, overnight she had heavier bleeding including clots from\n her vagina. She tried to stay at home to manage it but this morning her\n husband convinced her to come to the OB/GYN.\n .\n In the OB/GYN triage unit she started passing large clots in toilet\n this am and then, while the OB/GYN resident was standing with her, she\n syncopized but didnt hit anything. Therefore she was taken back to the\n OR for urgent D+C. D+C didnt show retained products but continued to\n bleed afterward to the point that they were thinking of doing emergent\n hysterectomy (lost 2 liters). At that point she then got a foley\n balloon placed in uterus to tamponade (Bakri balloon). This was\n attached to a urimeter to monitor bleeding - will see it in bag or on\n her pad. Hct on admission was 29, intra op it was 20, received 3units\n pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen\n 190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping\n from uterus and LH after dilaudid but otherwise not symptomatic.\n .\n Also a type one diabetic but took it off when she got here but initial\n FSBS was 300 - received 10units reg insulin in OR and now written for a\n drip.\n .\n She was transferred to the for monitoring overnight.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n Hypotension (not Shock)\n Assessment:\n UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .\n Action:\n 1000 cc ns bolus over 1 hr given\n Response:\n Bp 95-110 sys withmap > 60. hr 80\ns nsr. Slight tachy to 100 with\n exertion of OOB. Urine output this shift thus far is 1200 cc. minimal\n dizziness with standing. Improving crit\n Plan:\n Conts to monitor. Send to ob floor\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 731231,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer\n monitoring.\n BRIEF HISTORY :\n 34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed\n with non-viable pregnancy in with bleeding off and on since\n then. Last week she went into her OB for a check up and was still\n having uterine bleeding with a positive HCG. Her OB said she needed a\n D+C but she wanted to wait until after passover to have this done and\n since she was having only minimal bleeding it was agreed that she could\n wait. However, overnight she had heavier bleeding including clots from\n her vagina. She tried to stay at home to manage it but this morning her\n husband convinced her to come to the OB/GYN.\n .\n In the OB/GYN triage unit she started passing large clots in toilet\n this am and then, while the OB/GYN resident was standing with her, she\n syncopized but didnt hit anything. Therefore she was taken back to the\n OR for urgent D+C. D+C didnt show retained products but continued to\n bleed afterward to the point that they were thinking of doing emergent\n hysterectomy (lost 2 liters). At that point she then got a foley\n balloon placed in uterus to tamponade (Bakri balloon). This was\n attached to a urimeter to monitor bleeding - will see it in bag or on\n her pad. Hct on admission was 29, intra op it was 20, received 3units\n pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen\n 190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping\n from uterus and LH after dilaudid but otherwise not symptomatic.\n .\n Also a type one diabetic but took it off when she got here but initial\n FSBS was 300 - received 10units reg insulin in OR and now written for a\n drip.\n .\n She was transferred to the for monitoring overnight.\n During ICU course she did received 1 unit FFP , no blood products, crit\n 22-25. insulin gtt off on by noon, on her own insulin pump\n now, FS to check 3-4 hrs time. OOB to chair today, started with PO\n diet , uterine balloon catheter dc\nd today.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n Hypotension (not Shock)\n Assessment:\n UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .\n Action:\n 1000 cc ns bolus over 1 hr given\n Response:\n Bp 95-110 sys withmap > 60. hr 80\ns nsr. Slight tachy to 100 with\n exertion of OOB. Urine output this shift thus far is 1200 cc. minimal\n dizziness with standing. Improving crit\n Plan:\n Conts to monitor. Send to ob floor\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 731232,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer\n monitoring.\n BRIEF HISTORY :\n 34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed\n with non-viable pregnancy in with bleeding off and on since\n then. Last week she went into her OB for a check up and was still\n having uterine bleeding with a positive HCG. Her OB said she needed a\n D+C but she wanted to wait until after passover to have this done and\n since she was having only minimal bleeding it was agreed that she could\n wait. However, overnight she had heavier bleeding including clots from\n her vagina. She tried to stay at home to manage it but this morning her\n husband convinced her to come to the OB/GYN.\n .\n In the OB/GYN triage unit she started passing large clots in toilet\n this am and then, while the OB/GYN resident was standing with her, she\n syncopized but didnt hit anything. Therefore she was taken back to the\n OR for urgent D+C. D+C didnt show retained products but continued to\n bleed afterward to the point that they were thinking of doing emergent\n hysterectomy (lost 2 liters). At that point she then got a foley\n balloon placed in uterus to tamponade (Bakri balloon). This was\n attached to a urimeter to monitor bleeding - will see it in bag or on\n her pad. Hct on admission was 29, intra op it was 20, received 3units\n pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen\n 190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping\n from uterus and LH after dilaudid but otherwise not symptomatic.\n .\n Also a type one diabetic but took it off when she got here but initial\n FSBS was 300 - received 10units reg insulin in OR and now written for a\n drip.\n .\n She was transferred to the for monitoring overnight.\n During ICU course she did received 1 unit FFP , no blood products, crit\n 22-25. insulin gtt off on by noon, on her own insulin pump\n now, FS to check 3-4 hrs time. OOB to chair today, started with PO\n diet , regular kosher diabetic diet, uterine balloon catheter dc\n today.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n Hypotension (not Shock)\n Assessment:\n UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .\n Action:\n 1000 cc ns bolus over 1 hr given\n Response:\n Bp 95-110 sys withmap > 60. hr 80\ns nsr. Slight tachy to 100 with\n exertion of OOB. Urine output this shift thus far is 1200 cc. minimal\n dizziness with standing. Improving crit\n Plan:\n Conts to monitor. Send to ob floor\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 731233,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer\n monitoring.\n BRIEF HISTORY :\n 34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed\n with non-viable pregnancy in with bleeding off and on since\n then. Last week she went into her OB for a check up and was still\n having uterine bleeding with a positive HCG. Her OB said she needed a\n D+C but she wanted to wait until after passover to have this done and\n since she was having only minimal bleeding it was agreed that she could\n wait. However, overnight she had heavier bleeding including clots from\n her vagina. She tried to stay at home to manage it but this morning her\n husband convinced her to come to the OB/GYN.\n .\n In the OB/GYN triage unit she started passing large clots in toilet\n this am and then, while the OB/GYN resident was standing with her, she\n syncopized but didnt hit anything. Therefore she was taken back to the\n OR for urgent D+C. D+C didnt show retained products but continued to\n bleed afterward to the point that they were thinking of doing emergent\n hysterectomy (lost 2 liters). At that point she then got a foley\n balloon placed in uterus to tamponade (Bakri balloon). This was\n attached to a urimeter to monitor bleeding - will see it in bag or on\n her pad. Hct on admission was 29, intra op it was 20, received 3units\n pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen\n 190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping\n from uterus and LH after dilaudid but otherwise not symptomatic.\n .\n Also a type one diabetic but took it off when she got here but initial\n FSBS was 300 - received 10units reg insulin in OR and now written for a\n drip.\n .\n She was transferred to the for monitoring overnight.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n crit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable. Checked pad q ihr and sm to mod amt old blood\n . bleeding did increase with standing but only small amt 5-10 cc on\n pad no clots, no large vol of bleeding.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n Hypotension (not Shock)\n Assessment:\n UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .oob to\n chair with bp standing 107/70 hr 127\n Action:\n 1000 cc ns bolus over 1 hr given at 0630. monitored and checked for\n orthostasis. Pt needs assist for trnasfers\n Response:\n Bp 95-110 sys with map > 60. hr 80\ns nsr. Slight tachy to 100 with\n exertion of OOB. Urine output this shift thus far is 1200 cc. minimal\n dizziness with standing. Improving crit\n Plan:\n Conts to monitor. Send to ob floor\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 731237,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer\n monitoring.\n BRIEF HISTORY :\n 34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed\n with non-viable pregnancy in with bleeding off and on since\n then. Last week she went into her OB for a check up and was still\n having uterine bleeding with a positive HCG. Her OB said she needed a\n D+C but she wanted to wait until after passover to have this done and\n since she was having only minimal bleeding it was agreed that she could\n wait. However, overnight she had heavier bleeding including clots from\n her vagina. She tried to stay at home to manage it but this morning her\n husband convinced her to come to the OB/GYN.\n .\n In the OB/GYN triage unit she started passing large clots in toilet\n this am and then, while the OB/GYN resident was standing with her, she\n syncopized but didnt hit anything. Therefore she was taken back to the\n OR for urgent D+C. D+C didnt show retained products but continued to\n bleed afterward to the point that they were thinking of doing emergent\n hysterectomy (lost 2 liters). At that point she then got a foley\n balloon placed in uterus to tamponade (Bakri balloon). This was\n attached to a urimeter to monitor bleeding - will see it in bag or on\n her pad. Hct on admission was 29, intra op it was 20, received 3units\n pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen\n 190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping\n from uterus and LH after dilaudid but otherwise not symptomatic.\n .\n Also a type one diabetic but took it off when she got here but initial\n FSBS was 300 - received 10units reg insulin in OR and now written for a\n drip.\n .\n She was transferred to the for monitoring overnight.\n During ICU course she did received 1 unit FFP , no blood products, crit\n 22-25. insulin gtt off on by noon, on her own insulin pump\n now, FS to check 3-4 hrs time. OOB to chair today, started with PO\n diet , regular kosher diabetic diet, uterine balloon catheter dc\n today.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n Hypotension (not Shock)\n Assessment:\n UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .\n Action:\n 1000 cc ns bolus over 1 hr given\n Response:\n Bp 95-110 sys withmap > 60. hr 80\ns nsr. Slight tachy to 100 with\n exertion of OOB. Urine output this shift thus far is 1200 cc. minimal\n dizziness with standing. Improving crit\n Plan:\n Conts to monitor. Send to ob floor\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n BLLEDING;D C\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 73.2 kg\n Daily weight:\n Allergies/Reactions:\n Keflex (Oral) (Cephalexin Monohydrate)\n Rash; sneezing\n Penicillins\n Hives; Fever/Ch\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date: Previous C sections x 2\n D&C on \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:102\n D:54\n Temperature:\n 97.5\n Arterial BP:\n S:78\n D:50\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,347 mL\n 24h total out:\n 1,785 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:36 AM\n Potassium:\n 3.7 mEq/L\n 04:36 AM\n Chloride:\n 110 mEq/L\n 04:36 AM\n CO2:\n 25 mEq/L\n 04:36 AM\n BUN:\n 6 mg/dL\n 04:36 AM\n Creatinine:\n 0.4 mg/dL\n 04:36 AM\n Glucose:\n 85 mg/dL\n 04:36 AM\n Hematocrit:\n 22.5 %\n 12:56 PM\n Finger Stick Glucose:\n 74\n 05:00 PM\n Valuables / Signature\n Patient valuables: cell phone with pt.\n Other valuables:\n Clothes: sent with pt to floor\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 MICU/SICU, 407\n Transferred to: 5 SOUTH\n Date & time of Transfer: 03/ 23/10 2030HRS\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730910,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOS and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of \n balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct conts to drop.\n Plan to remove Bakri balloon in AM by OB team. Ck hct at 23/05\n Diabetes Mellitus (DM), Type I\n Assessment:\n pt uses insulin pump at home, stopped for OR procedure and started on\n insulin gtt in MICU. BS stable in 100s through out shift. Remains NPO\n incase pt needs to return to OR.\n Action:\n Insulin gtt remains @0.5units/hr. cking BS q4hrs since BS have been\n stable in 100s.\n Response:\n BS remains stable.\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730985,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. No\n other signs of bleeding. Morning crit.\n Action:\n Per Dr. no need for crit at midnight, just check with morning\n labs.\n Response:\n Pt A&O x 3 and appropriate. No s/s of bleeding noted. Hemodynamically\n stable.\n Plan:\n Cont to monitor for s/s bleeding. Plan to remove Bakri balloon in AM\n by OB team.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night.\n Action:\n Insulin gtt remains @0.5units/hr. Check blood sugars Q 2 hours and\n adjust gtt accordingly..\n Response:\n Ongoing. Blood sugars remain in 100\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730920,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. No signs of bleeding, hct post 3units RBCs 25\n 23. VSS, BP\n 80-90s. adequate UO. No c/o pain or cramping. Small amount of outpt\n from balloon.\n Action:\n Monitor hct q6hrs. cont antibiotics and IVF.\n Response:\n Remains stable, no active bleeding noted. A&Ox3, no c/o pain. PM hct\n 22.4\n Plan:\n Cont to monitor for signs of bleeding, transfuse if hct drops. Plan to\n remove Bakri balloon in AM by OB team. Ck hct at 23/05\n Diabetes Mellitus (DM), Type I\n Assessment:\n pt uses insulin pump at home, stopped for OR procedure and started on\n insulin gtt in MICU. BS stable in 100s through out shift. Remains NPO\n incase pt needs to return to OR.\n Action:\n Insulin gtt remains @0.5units/hr. cking BS q4hrs since BS have been\n stable in 100s.\n Response:\n BS remains stable.\n Plan:\n Transition pt to insulin pump in AM.\n"
},
{
"category": "Physician ",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 731139,
"text": "Chief Complaint: Anemia--Secondary to blood loss\n Uterine Bleeding\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 24 Hour Events:\n -Patient without further evidence of brisk bleeding\n History obtained from Medical records\n Allergies:\n Keflex (Oral) (Cephalexin Monohydrate)\n Rash; sneezing\n Penicillins\n Hives; Fever/Ch\n Last dose of Antibiotics:\n Clindamycin - 09:25 AM\n Infusions:\n Insulin - Regular - 0.5 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.2\n HR: 83 (75 - 107) bpm\n BP: 91/43(55) {75/33(45) - 114/57(67)} mmHg\n RR: 20 (11 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,266 mL\n 1,106 mL\n PO:\n TF:\n IVF:\n 3,111 mL\n 1,106 mL\n Blood products:\n 155 mL\n Total out:\n 3,265 mL\n 505 mL\n Urine:\n 3,265 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 601 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.5 g/dL\n 188 K/uL\n 85 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 6 mg/dL\n 110 mEq/L\n 139 mEq/L\n 21.3 %\n 8.7 K/uL\n [image002.jpg]\n 09:02 PM\n 03:10 AM\n 11:47 AM\n 04:41 PM\n 04:36 AM\n WBC\n 8.4\n 8.7\n Hct\n 25.3\n 22.7\n 22.4\n 22.4\n 21.3\n Plt\n 178\n 188\n Cr\n 0.3\n 0.4\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:13.6/23.4/1.2, Fibrinogen:282 mg/dL,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Patient with admission with uterine bleeding noted and has had\n tamponade locally and with relief of tamponade patient has not had\n brisk bleeding return.\n 1)Anemia--Secondary to blood loss-\n -Follow for active bleeding\n -Transfuse for acute bleeding\n 2)Uterine Bleeding-\n -Clindamycin\n DIABETES MELLITUS (DM), TYPE I\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale, Insulin infusion\n Lines:\n 18 Gauge - 07:46 PM\n Arterial Line - 07:48 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730756,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n Pt s/p D &C and Bakri ballon placement yesterday, no active bleeding\n noted sinces then ,minimal vaginal bleeding , VSS, foley to gravity\n ,urine output adequate,yellow clear. Small amount blood stained\n drainage through uterine ballon bag.\n Action:\n Crit 25.3 from PM labs, 1 unit FFP received during the shift,repeat\n coags and all the am labs sent at 3am. IVF LR @ 125cc/hr continued. No\n blood given after icu admission. Started with clindamycin iv q 8h.\n Response:\n Remained as stable now, no active bleeding noted. At alert and oriented\n x 3, comfortable, denies any pain/cramps. Am labs crit 22.\n Plan:\n Continue to monitor for further bleeding,f/u with am labs and transfuse\n / replete as needed.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt type 1 diabetic for last 20years ,was on insulin pump for several\n years, dc\nd yesterday before the OR procedure, currently on insulin gtt\n . NPO now . pt checks her blood sugar 4 times daily at home.\n Action:\n Insulin gtt on, Finger stick blood sugar Q1H, titrated insulin as\n needed, gtt maintained 0.5- 3units/hr. IVF LR @125cc/hr.\n Response:\n Blood sugar maximum upto 200\ns. pt stable .\n Plan:\n Continue to monitor BS ,titrate insulin as needed, if need to restart\n with her own insulin pump,pt needs new insulin pump as the current one\n almost run out. ? check FS 4-6times/day\n"
},
{
"category": "Physician ",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 731084,
"text": "Chief Complaint:\n 24 Hour Events:\n - q6H HCT: 22.4 --> 22.4--> 21.3\n - insulin pump will restart in AM (patient did not have enough insulin\n with her)\n - discussed transfusion with ob/gyn, they requested holding off\n - boluses 1L for decrease in UOP\n -Pt is Rh negative, receive Rhogam, Fetal Hgb pending.\n Allergies:\n Keflex (Oral) (Cephalexin Monohydrate)\n Rash; sneezing\n Penicillins\n Hives; Fever/Ch\n Last dose of Antibiotics:\n Clindamycin - 12:12 AM\n Infusions:\n Insulin - Regular - 0.5 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 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 89 (69 - 107) bpm\n BP: 105/51(64) {89/44(55) - 114/67(75)} mmHg\n RR: 15 (11 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,266 mL\n 1,054 mL\n PO:\n TF:\n IVF:\n 3,111 mL\n 1,054 mL\n Blood products:\n 155 mL\n Total out:\n 3,265 mL\n 305 mL\n Urine:\n 3,265 mL\n 305 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 749 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 188 K/uL\n 7.5 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 6 mg/dL\n 110 mEq/L\n 139 mEq/L\n 21.3 %\n 8.7 K/uL\n [image002.jpg]\n 09:02 PM\n 03:10 AM\n 11:47 AM\n 04:41 PM\n 04:36 AM\n WBC\n 8.4\n 8.7\n Hct\n 25.3\n 22.7\n 22.4\n 22.4\n 21.3\n Plt\n 178\n 188\n Cr\n 0.3\n 0.4\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:13.6/23.4/1.2, Fibrinogen:282 mg/dL,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Imaging: None.\n Microbiology: None.\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:46 PM\n Arterial Line - 07:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 731175,
"text": "34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n Uterine bleeding\n Assessment:\n s/p D &C and Bakri balloon placement following LOC and 2L blood\n loss. Pt with small amt of output from balloon. Dark red in color. 15\n CC TODAY. No other signs of bleeding. Morning crit 21. MINIMAL\n BROWN/PINK DRAINAGE ON PERI PAD CHANGED Q4 HR. Bakri balloon defalted\n at 11:00 with no bleeding noted. Fully removed at 13:30 by ob and few\n small dark clots noted with removal. Pt oob to chair 30 min\n after balloon out with 1 3-4 cm brown/pink clot. 1 pad with pink brown\n serous drainage thus far noted. Minimal dizziness, bp 98/64.. hr up to\n 100 from 80\n2 with standing. Recovered bp and pulse upon sitting\n Action:\n Drit repeted at 13:30 and up to 22.4 oob to chair a line d/ced\n Response:\n Pt A&O x 3 and appropriate. No s/s of sever bleeding noted.\n Hemodynamically stable.\n Plan:\n Cont to monitor for s/s bleeding. Will start po intake if no bleeding\n 3-4 hr after balloon removed at 1700.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Received pt on insulin gtt at 0.5 units/hr. Blood sugars in the 100\n throughout night. Since 0700 glucone in 90-84 range.\n Action:\n Insulin gtt stopped at 13:30 and started on sub cutaneous humalog\n insulin pump per pt own device . dose is .45 units/hr SC. Blood\n glucose q 3-4 hr.\n Response:\n Ongoing. Good glucose control but pt is po. 2 PIV lines if needs\n glucose rescue.\n Plan:\n Plan to start feeding pt if no bleeding occurs and will not need \n transfer to OB floor and prob discharge in am if no further bleeding.\n Educate pt to diet intake for iron and volume for low crit.\n Hypotension (not Shock)\n Assessment:\n UOP down at 0500-0600. bp 83/60 . pt c/o slight dizziness .\n Action:\n 1000 cc ns bolus over 1 hr given\n Response:\n Bp 95-110 sys withmap > 60. hr 80\ns nsr. Slight tachy to 100 with\n exertion of OOB. Urine output this shift thus far is 1200 cc. minimal\n dizziness with standing. Improving crit\n Plan:\n Conts to monitor. Send to ob floor\n"
},
{
"category": "Physician ",
"chartdate": "2155-04-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 731090,
"text": "Chief Complaint:\n 24 Hour Events:\n - bolused 1L for decrease in UOP to 15 cc/hr.\n Allergies:\n Keflex (Oral) (Cephalexin Monohydrate)\n Rash; sneezing\n Penicillins\n Hives; Fever/Ch\n Last dose of Antibiotics:\n Clindamycin - 12:12 AM\n Infusions:\n Insulin - Regular - 0.5 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 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 89 (69 - 107) bpm\n BP: 105/51(64) {89/44(55) - 114/67(75)} mmHg\n RR: 15 (11 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,266 mL\n 1,054 mL\n PO:\n TF:\n IVF:\n 3,111 mL\n 1,054 mL\n Blood products:\n 155 mL\n Total out:\n 3,265 mL\n 305 mL\n Urine:\n 3,265 mL\n 305 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 749 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General: Pale, alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: foley in place\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 188 K/uL\n 7.5 g/dL\n 85 mg/dL\n 0.4 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 6 mg/dL\n 110 mEq/L\n 139 mEq/L\n 21.3 %\n 8.7 K/uL\n [image002.jpg]\n 09:02 PM\n 03:10 AM\n 11:47 AM\n 04:41 PM\n 04:36 AM\n WBC\n 8.4\n 8.7\n Hct\n 25.3\n 22.7\n 22.4\n 22.4\n 21.3\n Plt\n 178\n 188\n Cr\n 0.3\n 0.4\n Glucose\n 112\n 85\n Other labs: PT / PTT / INR:13.6/23.4/1.2, Fibrinogen:282 mg/dL,\n Ca++:8.2 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Imaging: None.\n Microbiology: None.\n Assessment and Plan\n 34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n .\n # Uterine Bleeding: Now s/p balloon insertion; deflated balloon 15ccs\n this AM and will observe x4hr and if min VB, will remove intrauterine\n foley. Bleeding and HCTs have been stable, pt has remained HD stable.\n - HCT: 22.4 --> 22.4--> 21.3 (received 1L bolus): discussed transfusion\n with ob/gyn, they requested holding off\n - Following OB/GYN recs: pt is Rh negative, received Rhogam, Fetal Hgb\n pending. Also remains on Clindamycin (in place of Keflex given PCN\n allergy) for intrauterine foley.\n - monitoring Hct Q6H and transfuse for hct <21\n - monitor bleeding from catheter in uterus and on pads\n - Active T+C\n - 2 PIVs in place\n .\n # Coagulopathy: PTT elevated. INR 1.3 given 1u FFP, now 1.2\n -Trend\n .\n # Type 1 diabetes: Usually uses insulin pump but taken off in setting\n of bleeding on admission, to restart today.\n - Continue insulin gtt until sure no further need for OR\n - Monitor FSBS Q1H per insulin gtt protocol\n .\n FEN: IVF (Lr@75ml/hr while NPO), replete electrolytes, NPO in case\n going to OR in am\n .\n ICU Care\n Nutrition: Still NPO.\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 07:46 PM\n Arterial Line - 07:48 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n Communication: Patient\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2155-04-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 730659,
"text": "Chief Complaint: vaginal bleed\n HPI:\n 34yo G8P6 admitted with vaginal bleeding. The patient was diagnosed\n with non-viable pregnancy in with bleeding off and on since\n then. Last week she went into her OB for a check up and was still\n having uterine bleeding with a positive HCG. Her OB said she needed a\n D+C but she wanted to wait until after passover to have this done and\n since she was having only minimal bleeding it was agreed that she could\n wait. However, overnight she had heavier bleeding including clots from\n her vagina. She tried to stay at home to manage it but this morning her\n husband convinced her to come to the OB/GYN.\n .\n In the OB/GYN triage unit she started passing large clots in toilet\n this am and then, while the OB/GYN resident was standing with her, she\n syncopized but didnt hit anything. Therefore she was taken back to the\n OR for urgent D+C. D+C didnt show retained products but continued to\n bleed afterward to the point that they were thinking of doing emergent\n hysterectomy (lost 2 liters). At that point she then got a foley\n balloon placed in uterus to tamponade (Bakri balloon). This was\n attached to a urimeter to monitor bleeding - will see it in bag or on\n her pad. Hct on admission was 29, intra op it was 20, received 3units\n pRBCs in OR and near end of case was 28. INR 1.3 intraop. Fibrinopgen\n 190. Has 2 pivs in place. Actiev T+S and aline. VSS currently. Cramping\n from uterus and LH after dilaudid but otherwise not symptomatic.\n .\n Also a type one diabetic but took it off when she got here but initial\n FSBS was 300 - received 10units reg insulin in OR and now written for a\n drip.\n .\n She was transferred to the for monitoring overnight.\n .\n On the floor, she was a little crampy but otherwise fine. She sat up\n without light-headedness.\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. Denied nausea, vomiting, diarrhea, constipation or\n abdominal pain. No recent change in bowel or bladder habits. No\n dysuria. Denied arthralgias or myalgias.\n Allergies:\n Keflex (Oral) (Cephalexin Monohydrate)\n Rash; sneezing\n Penicillins\n Hives; Fever/Ch\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Other medications:\n Medications at home:\n INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - as directed in\n pump pt is pregnant (increasing requirements)\n PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed\n by Other Provider) - Dosage uncertain\n .\n MEDS ON TRANSFER:\n Insulin gtt\n Past medical history:\n Family history:\n Social History:\n G8P6 with last pregnancy complicated by cerclage requirement, and then\n leaking, which led to a cesarean section after months of bed rest.\n Prior to that C-section, she had had VBAC before\n Type 1 diabetes - on insulin pump (last A1C 7)\n Iron deficiency anemia\n Vitamin D deficiency\n Recurrent Cystitis\n Maternal grandfather with insulin-dependent diabetes. Maternal\n grandmother with breast cancer in the mid 70s and a brother with\n diabetes.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She is happily married. They are monogamous.\n She has 6 children, the youngest is 19 months. She works at a\n school in .\n Review of systems:\n Flowsheet Data as of 12:51 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (96.9\n HR: 73 (73 - 90) bpm\n BP: 86/42(61) {52/42(49) - 105/55(71)} mmHg\n RR: 14 (9 - 24) insp/min\n SpO2: 98%\n Height: 67 Inch\n Total In:\n 4,859 mL\n 259 mL\n PO:\n TF:\n IVF:\n 654 mL\n 104 mL\n Blood products:\n 155 mL\n 155 mL\n Total out:\n 400 mL\n 0 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,459 mL\n 259 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n Vitals: T: afebrile BP: 105/50 P: 90 R: 14 18 O2: 97% RA\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 25.3 %\n [image002.jpg]\n \n 2:33 A3/21/ 09:02 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 25.3\n Assessment and Plan\n 34yo F G8P6 at 8weeks gestation admitted with uterine bleeding s/p\n Bakri balloon placement now admitted to for closer monitoring.\n .\n # Uterine Bleeding: Now s/p balloon insertion.\n - monitor Hct Q6H and transfuse for hct <21 if hemodynamically stable\n - monitor bleeding from catheter in uterus and on pads\n - Follow up OB/GYN recs\n - Active T+C\n - 2 PIVs in place\n .\n # Coagulopathy: PTT elevated. INR 1.3\n - OB/GYN recommended one unit FFP to improve coags for now\n - Resent coags after FFP\n .\n # Type 1 diabetes: Usually uses insulin pump but taken off in setting\n of bleeding today and going to OR.\n - Continue insulin gtt until sure no further need for OR\n - Monitor FSBS Q1H per insulin gtt protocol\n .\n FEN: IVF (Lr@75ml/hr while NPO), replete electrolytes, NPO in case\n going to OR in am\n .\n Prophylaxis: boots\n .\n Access: peripherals\n .\n Code: Full\n .\n Communication: Patient and husband\n .\n Disposition: pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 07:46 PM\n Arterial Line - 07:48 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
}
] |
14,947 | 186,122 | Briefly, this is a 63 year old with NASH who was transfered from OSH for UGIB and encephalopathy. He expired on in the setting of massive GI bleeding. The following is a brief hospital course by problem. . #Chronic Resp failure: The patient was extubated and reintubated three times for failure to clear secretions and poor cough reflex. He was presumed to have a tracheobronchitis with MRSA in sputum from , , and . He was maintained on primarily pressure support and MMV during times of apnea. He was treated with a 7 day course of ceftazadime and a 10 day course of vancomycin starting for tracheobronchitis/ventilator associated pneumonia. The patient's ABGs revealed a respiratory alkalosis with a PCO2 of 22-23. His resp alkalosis is likely partially as compensation for met acidosis and due to primary process. On the patient had increasing respiratory distress with hypoxemia, felt to be c/w mucus plugging on CXR. His CXR had improved by , as had his oxygenation. The pt was satting well on PS of % Fio2 on , but he had another GIB with suspected aspiration. Again, his PO2 dropped to 59 on the same vent settings, so he was placed back on AC. . #UGIB/Anemia: EGD revealed blood in the stomach with no active bleeding source. He has evidence of grade II esophagitis and gastritis. He had a recurrent bleed on with 400 cc of bloody return from his OGT, requiring reintubation. He received 2 units of PRBC on after his hct dropped from 44 to 30. He was maintained on an octreotide gtt for 2 days. His hematocrit wavered between 30 to 40 thereafter and seemed to be dependent on fluid shifts. CT of the abdomen on revealed no retroperitoneal bleed. He remained guaiac positive through his stay though to be due to the initial GI bleed. On the pts hct dropped from 35 to 25 with red clots noted in his stool. He was transfused 2 units of PRBC, 4 units of FFP, and 1 unit of plt. Octreotide gtt was again restarted. Repeat EGD on revealed massive amounts of blood in the stomach. There was so much bleeding that a source was not identified. He was continued on PPI, sucralfate, and rifaximine 400 tid. His nadolol was decreased from 40 mg/d to 20 mg/d due to low BP. On the pt made CMO due to uncontrollable bleeding. . # NASH with hepatic encephalopathy: The patient's encephalopathy resolved with lactulose, rifaximin, and pentoxyfilline. Diagnostic paracentesis on revealed no evidence of infection. The patient was continued on nadolol 20 mg/d. As per below, he developed hepatorenal syndrome and was maintained on daily midodrine/octreotide and albumin. . #ARF/Hepatorenal syndrome: The pts Cr on admission was 1.8. This slowly improved to 1.1, but on it slowly began to rise, and was up to 1.7 on despite albumin and fluid boluses. His UNa was less than 10 was UO of cc/hr, so his symptoms were felt to be c/w hepatorenal syndrome. The patient was started on daily midodrine/octreotide and albumin. As his creatinine increased to 2.4 by , his albumin was increased to 25 gm and midodrine was increased to 15 mg tid. . # Pancytopenia: The patient developed pancytopenia on with platelet dropping to the 30s, hematocrit dropping to 30, and WBC dropping from 24 to 4 in 24 hrs. His Vancomycin level was found to be in the 70s and thought to be the likely source. All cell lines gradually rose with cessation of further Vancomycin dosing. . #Chest Pain: The patient developed chest pain on the night of . EKG revealed poor R wave progression and loss of anterior forces. Cardiac enzymes revealed no elevation in CK, but Troponin elevated at 0.11 to 0.19 (likely due to renal failure). TTE on to eval for pericardial effusion was negative for effusion. . #UTI: The pt completed a 10 d course of Vanc for enterococcus growing in urine on . | The previously identified right lower lobe opacity has resolved, with minimal bibasilar atelectasis. The ET tube tip and the Dobbhoff tube in the right internal jugular line are in unchanged position. Diffuse low voltage.Prior inferior myocardial infarction. There is a new right- sided pleural effusion, probably subpulmonic, not apparent on recent chest radiographs. The right internal jugular line tip is in the lower SVC. Left pleural effusion. Ascites.Conclusions:The left atrium is mildly dilated. Transmitral Doppler and TVI c/w Grade I (mild) LVdiastolic dysfunction.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Distended stomach despite the NG tube placement. No TR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Sinus rhythmProbable left atrial abnormalityPrior inferior myocardial infarctionLow QRS voltage - clinical correlation is suggestedSince previous tracing of , atrial ectopy absent IMPRESSION: Slight interval worsening of left basilar atelectasis. SECREATIONS FROM BACK OF THROAT, THICK AND PALE IN COLOR.CV: HR 60'S NSR. lungs w/ decreased breath sounds, albuterol prn. ?ASPIRATE DUE TO ORAL AND ETT SECREATIONS. Right IJ line is in mid SVC. HYPO BS. The NG tube remains retroflexed in the upper stomach with its tip in the mid esophagus. Cont ceftazidime and vanco. LS CONT TO RHONCHEROUS. There is perinephric stranding, which is similar to the previous exam. PT CONT ON TID LACTULOSE. pt with periods of sleeping, resp rate drops, apnea alarms on vent.SKIN: coccxy with duoderm - intact. IMPRESSION: Probable infiltrate or atelectasis posterior segment right lower lobe. BUN/Creat this AM was 46/1.1. The Dobbhoff tube tip is in proximal esophagus. AM CHEST XRAY ORDERED. Small right pleural effusion likely evident. Bilateral small pleural effusions and associated compressive atelectasis. Lungs clear dim bases. Minimal right basilar atelectasis is seen. Please mark the spot for paracentesis. Bilateral small pleural effusions are identified. Similar appearance of right adrenal adenoma. Resp Care Note, Weaned FI02 for good ABG'S. DR TO PLACE NGT. CONT HCT CHECKS . cont l;actolose tid. REPEAT NEB GIVEN. pt dim at the r base s/p intubation. Albuterol given. CXR DONE. REPEAT CPT DONE AS BS ON RIGHT DIMINISHED. OGT DC'D WITH EXTUBATION. INITIAL ABG 7.40/37/96/24. focus; addendumRESP- CONT TO DESAT. pt reintubated w/o problem. BP 120-130's/50's.access: 2 piv, R radail aline, R sc tlc.gi/gu: Abdomen with ascites. MDI's given. MDI'S given. ngt up to wall suction for about the same. octreotide gtt to be restarted. NEB TX GIVEN. care note - Pt. REPLETED WITH 40MEQ KCL IV. Dr. in to lavage. DR NOTIFIED. ABG 7.40/37/57/24. Resp. Resp. titrate b blocker prn. Pt given 2 ALB nebs. Lungs coarse few I/E wheezes recieved MDI per resp, Dim BS @ bases. gi/liver to hold on scope at present, will scope in the am. peripheral pulses 3+DP/DT neg edema. CPT DONE. HE WAS VENTED AND ON A/C MODE OF VENT. Remains on levofloxacin.endo- ss q6hrs. K AT 1400 4.0.GI- ABD WITH ASICTES. now a dnr/dni. occastional leaking noted. Dispostion: Made DNI/DNRTodays events: Pt. CONT ON VANCO AND CEFTAZADIME. RSBI completed on PS 5=31. Endoscopy was ordered. ABD ascities, BS hypoactive. HAD FIB THIS AM. REPEAT SPUTUM SENT. BP WITHIN NORMAL LIMITS BY ALINE. resp. Resp. Resp. ngt in place. continued to have Hct drop. ABD GREATLY DISTENDED WITH ASCITES AND FIRM. K 3.4 TX WITH 40MEQ KCL IV TODAy.GI- ABD WITH ASICITES. and extubate. After pt. MIN RESIDUALS. Plan is wean as tol. REPEAT PLT COUNT PENDING. Received pt. NEXT HCT DUE AT . NPN Contiued:Pt. POS BS. POS BS. PLAN TO TRANSFUSE IF LESS THAN 28. FOCUS; ADDENDUMHEME- DR DECIDED TO TRANSFUSE 1U PRBC AND 1 MORE UNIT PLTS. LACTULOSE STARTED.REVEIW OF SYSTEMS-NEURO- OF NOTE PAITENT IS VERY HOH AND WEARS BILAT HEARING AIDES NORMALLY. follow BP and u/o follwos HCT, lytes, replete as needed. REPEAT U/A SENT. Albuterol MDI given. OCTREATIDE DRIP TO BE DC'D. GI: ab taut with ascites. Albuterol given. ON THIS SETTING ABG 7.38/26/208/16. Octreotide dc'd per team. abg: 7.42/22/120/15. cvp checked and is . Mdis given. CVP 4-9.GI- ABD WITH ASICTES. bp 90-120's this am via r radial abp.resp- as above. CONT ON CEFTAZADIME. abg: 7.40/22/92/14. lactate 2.1. R IJ TLC CVP 3-6, goal CVP =or>8, Peripheral pulses 3+ DP/DT, neg edema. Gi: ab with ascites, bs hypo. CXR to be repeated. will follow uo s/p fluid bolus and 2nd dose albumin. Suctioning thick tan secretions q 2-4hrs.Cv: HR 45-55 sb, a-line in place and wnl, right IJ infusing well, cvp8-10, sbp 100-130 nadalol hELD. Placed on AC due apnea spells. repeat ABG 7.36-27-237-16 FI02 to 60% AM ABG on 400-12 60% 10peep 7.38-24-137-15-8 Met acidosis resp compensation, peep to 5cm. recieved lactalose hepatic encephalopathyCV: HR 55-74 NSR-SB rare PAC, R radial aline inplace sharp wave form, SBP 90-104 maps >60 @ 0400 hypotensive SBP>90 CVP 3-5 recieved FB 1L with responding ^SBP. NPH fixed doses.Access/ID: RSC TLC, R radial A-line. CONT ON NADOLOL. Remains on prevacid and carafate. Receiving MDI's. CEFTAZ DC'D. became tachypneic x 1 while oob and mobilizing secretions. 4 U NPH GIVEN. CONT ON LACTULOSE AND RIFAXAMIN.RESP- REMAINS INTUBATED AND VENTED. ADMITTED WITH HEPATIC ENCEPHALOPATHY AND GIB. WRITIG NOTES. nadolol held this am. Continue TF, check residual, advance if tol. ADDENDUM TO NOTES ABOVEAT 0500 RESIDUAL 20CC, RESTART TF AT 20CC/HR,K=3.6, INR 1.8, DR AWARE. HYPOACTIVE BS. continue with mycostatin/aloe vesta to these areas. Resp. Resp. remains on lactulose. reattempt further weaning/breathing trial in am. gU: foley with uo 10-15cc's/hr. K 3.6 TX WITH 40MEQ KCL.GI- ABD WITH ASCITES. CarePt. CarePt. Abd very firm distended. ABD ascitis,BS hypoactive,TF hold d/t residual 100-150cc. IF FAILS THIS EXTUBATION MOVE TO TRACH AND PEG. Resident advanced feeding tube.. await cxr to see if post pyloric. respoiratory carept on the vent changes made tol well. remains on octreotide and midodrine for Hepato-renal syndrome. EXTUBATE IN NEXT DAY OR TWO ONCE SECRETIONS LESSENED . | 105 | [
{
"category": "Echo",
"chartdate": "2115-11-25 00:00:00.000",
"description": "Report",
"row_id": 81734,
"text": "PATIENT/TEST INFORMATION:\nIndication: ? Pericardial effusion. Low voltage on ECG.\nWeight (lb): 111\nBP (mm Hg): 124/55\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 14:47\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal LV wall\nthickness, cavity size, and systolic function (LVEF>55%). Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Overall\nnormal LVEF (>55%). Transmitral Doppler and TVI c/w Grade I (mild) LV\ndiastolic dysfunction.\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. No AS. No AR.\n\nMITRAL VALVE: Mitral valve not well seen. No MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. No TR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\nbradycardic (HR<60bpm). Ascites.\n\nConclusions:\nThe left atrium is mildly dilated. Transmitral Doppler and tissue velocity\nimaging are consistent with Grade I (mild) LV diastolic dysfunction. Left\nventricular cavity size is normal. Global systolic function is good.\nSuboptimal image quality precludes regional assessment. The right ventricular\ncavity size and free wall motion are normal. The aortic valve leaflets (?#)\nare mildly thickened. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve is not well seen. No mitral\nregurgitation is seen. There is a prominent anterior space in which most\nlikely represents an anterior fat pad.\n\nCompared to the previous study of , the findings are similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2115-11-24 00:00:00.000",
"description": "Report",
"row_id": 198293,
"text": "Normal sinus rhythm. Borderline A-V conduction delay. Diffuse low voltage.\nPrior inferior myocardial infarction. Compared to the previous tracing\nof no diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2115-11-14 00:00:00.000",
"description": "Report",
"row_id": 198294,
"text": "Sinus rhythm\nProbable left atrial abnormality\nPrior inferior myocardial infarction\nLow QRS voltage - clinical correlation is suggested\nSince previous tracing of , atrial ectopy absent\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-14 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 936140,
"text": " 8:46 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: Eval for ascites, mark for tap\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, NASH, presents with ascites and GIB,\n encephalopathy\n REASON FOR THIS EXAMINATION:\n Eval for ascites, mark for tap\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver and gallbladder ultrasound.\n\n CLINICAL HISTORY: 63-year-old man with cirrhosis, NASH, presenting with\n ascites and GI bleed, encephalopathy. Evaluate for ascites and mark for tap.\n\n Comparison made to prior study dated .\n\n FINDINGS: The liver demonstrates a markedly heterogeneous echotexture,\n consistent with known cirrhosis. No focal hepatic lesions are identified. No\n intrahepatic biliary ductal dilatation. Common bile duct is not dilated\n measuring 4 mm. The main portal vein is widely patent and demonstrates normal\n hepatopetal flow. The gallbladder is decompressed. The gallstones or well\n seen on the prior CT of the abdomen are not well seen on today's study.\n\n There is extensive ascites. A mark was reportedly previously placed.\n\n IMPRESSION:\n\n 1. Cirrhotic liver, without evidence of focal hepatic lesions.\n\n 2. Ascites.\n\n 3. Gallstones not well seen on this study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-14 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 936229,
"text": " 5:26 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess R IJ placement\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy\n\n REASON FOR THIS EXAMINATION:\n assess R IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with ascites and encephalopathy. Right IJ\n placement.\n\n COMPARISON: Comparison was made to prior chest radiograph dated .\n\n PORTABLE CHEST RADIOGRAPH: Right IJ line is terminating in mid SVC.\n Endotracheal tube is terminating 1.5 cm above the carina. NG tube is coursing\n down below the diaphragm, and the tip was not clearly identified. Note is\n made of tube-like opacity overlying the right mid lung field, probably outside\n of the patient. Again note is made of bibasilar effusion with opacities on\n the left, somewhat increased since prior study. Right costophrenic angle is\n not included in the present study. No pneumothorax is identified.\n\n IMPRESSION: Tubes and lines as described above. Bilateral pleural effusion\n with left lower lobe opacity, somewhat increased since prior study. The\n referring physician, . has been informed.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936718,
"text": " 10:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for CHF\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, recently extubated\n with onset of respiratory distress and hypoxia, now reintubated.\n REASON FOR THIS EXAMINATION:\n evaluate for CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 3 cm above the carina. The right internal jugular line tip\n is in the lower SVC. The heart size is normal. The mediastinal position,\n contour and width are unremarkable. The lung volumes are low. Bibasilar\n atelectasis and bilateral small pleural effusions.\n\n IMPRESSION: New small bilateral small pleural effusions. Adjacent basilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936392,
"text": " 6:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please confirm placement of ET tube\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, recently extubated with\n onset of respiratory distress and hypoxia, now reintubated.\n REASON FOR THIS EXAMINATION:\n Please confirm placement of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 63-year-old man with ascites and hepatic encephalopathy, with\n new respiratory distress and hypoxia, now reintubated.\n\n CHEST, SUPINE AP VIEW: Comparison is made to an earlier film of the same day.\n The patient has been intubated since the prior study. The endotracheal tube\n lies near the thoracic inlet, approximately 4.5 cm above the carina. There is\n a new nasogastric tube, terminating in the stomach. A right internal jugular\n central venous catheter is unchanged, projecting over the mid superior vena\n cava.\n\n Allowing for significant rotation, the cardiac and mediastinal contours\n are unchanged. There is a new right- sided pleural effusion, probably\n subpulmonic, not apparent on recent chest radiographs. Otherwise, the lungs\n are clear. There is no pneumothorax.\n\n IMPRESSION: Layering right-sided pleural effusion. Status post endotracheal\n intubation. Findings discussed with Dr. on the same evening.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936094,
"text": " 9:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for effusions, edema, other pathology\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy\n REASON FOR THIS EXAMINATION:\n Eval for effusions, edema, other pathology\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Encephalopathy.\n\n Portable AP chest radiograph compared to .\n\n The patient was intubated in the _____ interval with the ET tube tip\n projecting 3 cm above the carina. The NG tube tip is within the stomach but\n the stomach is still extended suggesting suboptimal NG tube drainage. The\n lungs are clear. The pleural surfaces are smooth. There is blunting of the\n left costophrenic sulcus suggesting small pleural effusion.\n\n IMPRESSION:\n 1. Left pleural effusion.\n 2. Distended stomach despite the NG tube placement.\n 3. Standard ET tube positioning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936922,
"text": " 1:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p NG tube pullback of 12 cm\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy s/p extubation and\n placement of NG tube\n REASON FOR THIS EXAMINATION:\n s/p NG tube pullback of 12 cm\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Ascites, NASH, encephalopathy, status post extubation and\n placement of NG tubes. NG tube pullback of 12 cm.\n\n FINDINGS: AP single view of the chest obtained with the patient in\n semi-upright position is analyzed in direct comparison with a similar\n preceding study obtained two hours earlier during the same date. As\n indicated, the NG tube has been withdrawn by 12 cm, however, the reversing\n portion ending in the upper esophagus approximately at the level of the aortic\n arch has not participated in this change. The loop formation of the NG tube\n within the stomach has decreased. High positioned diaphragms as before in\n this patient with history of ascites. No new pulmonary infiltrates have\n developed. Internal jugular vein catheter on the right side is in unchanged\n position.\n\n IMPRESSION: Withdrawal of NG tube by 12 cm has not changed position of the\n reversing portion directed upwards with its terminal portion in the upper\n esophagus. It is doubtful that correct position can be accomplished by simple\n withdrawal. Consider use of flexible guidewire or new NG tube placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 938066,
"text": " 5:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval changes\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, worsened oxygenation\n REASON FOR THIS EXAMINATION:\n assess interval changes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Worsening oxygenation.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is low, 2 cm above the carina. The right internal jugular\n line tip is in mid SVC. The Dobbhoff tube is coiled within the stomach but\n more distally than imaged on previous radiograph. The bilateral perihilar\n opacities are new, representing mild-to-moderate pulmonary edema. The left\n lower lobe retrocardiac atelectasis is unchanged. The bilateral pleural\n effusion is slightly increased. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Too low position of ET tube, should be pulled back for 2 cm.\n\n 2. New pulmonary edema and increased pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936426,
"text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate status of right globular infiltrate on scan prior t\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, recently extubated with\n onset of respiratory distress and hypoxia, now reintubated.\n REASON FOR THIS EXAMINATION:\n Evaluate status of right globular infiltrate on scan prior to last that\n disappeared with most recent scan (post extubation).\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: NASH, respiratory distress, hepatic encephalopathy,\n ascites.\n\n PORTABLE UPRIGHT VIEW OF THE CHEST\n\n The right internal jugular catheter and nasogastric tube are in stable\n position. The endotracheal tube is approximately 2.6 cm above the carina.\n Cardiomediastinal silhouette appears unremarkable. Lung volumes are\n diminished. The previously identified right lower lobe opacity has resolved,\n with minimal bibasilar atelectasis. No definite effusion is seen. There is\n no pneumothorax. Note is made of at least three right rib fractures, of the\n lateral eighth, ninth, and tenth ribs.\n\n IMPRESSION:\n\n 1. Improvement in pulmonary findings. Bibasilar atelectasis.\n 2. Fractures of the eighth, ninth, and tenth ribs, latterly. These findings\n are reported to Dr. at approximately 14:35 hours on .\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937313,
"text": " 10:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: atelectasis, collapse, edema, infiltrate\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, respiratory failure\n REASON FOR THIS EXAMINATION:\n atelectasis, collapse, edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with respiratory failure.\n\n Portable AP chest radiograph compared to .\n\n The heart size is mildly enlarged but unchanged. The lung volumes are again\n demonstrated low with no evidence of focal consolidations or sizable pleural\n effusions. The ET tube tip and the Dobbhoff tube in the right internal\n jugular line are in unchanged position.\n\n IMPRESSION: No significant change compared to previous chest radiograph. Low\n lung volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937141,
"text": " 8:01 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for proper NG tube placement\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy s/p placement of NG\n tube which is now advanced\n REASON FOR THIS EXAMINATION:\n please eval for proper NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate nasogastric tube placement.\n\n COMPARISON: Comparison is made to prior study of earlier the same date at\n 1617 hours.\n\n AP UPRIGHT CHEST: The cardiomediastinal silhouette is stable. The tip of a\n Dobbhoff feeding tube is seen within the body of the stomach. Right internal\n jugular central venous catheter and endotracheal tube are unchanged in\n standard positions. Bibasilar atelectasis is again demonstrated. Persistent\n small bilateral pleural effusions are unchanged. There is otherwise no\n significant change.\n\n IMPRESSION: No short-term interval change. Dobbhoff feeding tube located in\n a standard position within the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936842,
"text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change in infiltrates/consolida\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy s/p recent reintubation for\n respiratory failure\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change in infiltrates/consolidations\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure.\n\n COMPARISON: .\n\n CHEST AP: The tip of the right IJ line is in mid SVC. The tip of the\n endotracheal tube is about 2 cm above the carina. The tip of the feeding tube\n is in the stomach.\n\n There is a slight interval increase in the left basilar atelectasis. Small\n bilateral pleural effusions are stable. There is mild upper zone\n redistribution of pulmonary vasculature with mild pulmonary edema.\n\n IMPRESSION: Slight interval worsening of left basilar atelectasis. Stable\n bilateral effusions. Mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937891,
"text": " 5:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for NG tube to see if it is post pyloric\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, with NG tube\n REASON FOR THIS EXAMINATION:\n please eval for NG tube to see if it is post pyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 63-year-old man with ascites, NASH and nasogastric tube.\n Question NG tube placement.\n\n CHEST, FRONTAL VIEW: A weighted feeding tube terminates in the stomach. An\n endotracheal tube terminates beyond the thoracic inlet. A right internal\n jugular venous catheter terminates in the superior vena cava. The lung\n volumes are low. There is right basilar atelectasis, but otherwise the lungs\n are clear without effusions or pneumothorax.\n\n IMPRESSION: Nasogastric tube terminating in the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936898,
"text": " 11:02 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please evaluate for NG tube placement and post-extubation \n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy s/p extubation and\n placement of NG tube\n REASON FOR THIS EXAMINATION:\n Please evaluate for NG tube placement and post-extubation lung appearance\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:32 A.M., .\n\n HISTORY: Ascites. Status post extubation.\n\n IMPRESSION: AP chest compared to and 4:39 a.m. today:\n\n Nasogastric tube loops in the stomach and returns to the distal esophagus.\n Lung volumes remained low and small bilateral pleural effusions are unchanged.\n There is no pneumothorax. Upper lungs are clear. Heart size normal. Right\n internal jugular line tip projects over the upper SVC. Dr. was\n paged to report these findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937198,
"text": " 11:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, now with rising WBC\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 11:04 A.M.\n\n HISTORY: Ascites and NASH with encephalopathy and rising white blood cell\n count.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are low, likely secondary to tense ascites. There is\n no focal consolidation or superimposed edema. Support tubes and lines remain\n stable. Please note the enteric feeding tube terminates within the gastric\n fundus. This is inadequate position for enteric feeding. No pleural effusion\n or pneumothorax is evident.\n\n IMPRESSION: Stable radiograph with low lung volumes and no focal\n consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937418,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for daily change\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, respiratory\n failure\n REASON FOR THIS EXAMINATION:\n evaluate for daily change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Ascites, NASH, encephalopathy. Now in respiratory failure.\n\n CHEST: The position of the various lines and tubes is unchanged. The left\n lung remains clear with some atelectatic areas in the base. A right effusion\n is now seen more prominent than on the prior chest x-ray of .\n Because of rotation, the right lung is hard to evaluate\n\n IMPRESSION: Increasing right effusion. Right lung difficult to evaluate due\n to rotation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937115,
"text": " 4:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess NG tube\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy s/p placement of NG\n tube\n REASON FOR THIS EXAMINATION:\n assess NG tube\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of NG tube placement.\n\n Portable AP chest radiograph was compared to previous film done the same day\n at 13:14 p.m.\n\n The Dobbhoff tube tip is in proximal esophagus. No coiling of the NG tube is\n demonstrated in the upper esophagus.\n\n The bibasilar atelectasis are again demonstrated. The bilateral pleural\n effusion has been unchanged. These findings were discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-22 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 937327,
"text": " 11:38 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for RP and intraperitoneal bleed\n Admitting Diagnosis: VARICEAL BLEED\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis secondary to NASH admitted with ETOH\n withdrawal, fevers, UTI, UGIB with continued dropping HCT\n REASON FOR THIS EXAMINATION:\n please evaluate for RP and intraperitoneal bleed\n CONTRAINDICATIONS for IV CONTRAST:\n ARF, ESLD;ARF, ESLD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis secondary to NASH, now with upper GI bleed and\n continued drop in hematocrit.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the lung\n bases to the pubic symphysis without administration of IV or oral contrast.\n This study was compared to the most recent CT of .\n\n CT ABDOMEN WITHOUT IV CONTRAST: There are marked coronary vascular\n calcifications. Bilateral small pleural effusions are identified. Associated\n compressive atelectasis is seen. Multiple punctate calcifications in both\n lung bases probably reflect granulomas, and were identified on the previous\n exam. A Dobhoff feeding tube is seen with its tip in the stomach. The aorta\n is not dilated; there are aortic mural calcifications.\n\n A 14-mm right adrenal adenoma is again identified. The left adrenal is\n normal. The pancreas is small. The spleen is enlarged. The gallbladder has\n several radiopaque stones within it. The liver is small and nodular. Kidneys\n are within normal limits. There is perinephric stranding, which is similar to\n the previous exam. The abdomen is most notable for a large amount of ascites\n along both pericolic gutters, in the lesser sac, and down into the pelvis. The\n ascites measures simple fluid. Both psoas muscles are symmetric. There are\n no findings to suggest retroperitoneal hemorrhage. The aorta is normal in\n caliber, with mural calcifications.\n\n CT PELVIS: As noted above, there is a large amount of intraperitoneal free\n fluid. The bladder has a Foley within it; it is compressed by the large\n amount of ascites. The anteriormost aspect of it has nondependent air. There\n is no lymphadenopathy or free air. Vessels are heavily calcified.\n\n BONE WINDOWS: No suspicious sclerotic or lytic lesions are identified.\n\n IMPRESSION:\n 1. Large amount of ascites. No evidence of retroperitoneal hemorrhage.\n 2. Bilateral small pleural effusions and associated compressive atelectasis.\n 3. Radiopaque cholelithiasis in shrunken and nodular liver.\n 4. Similar appearance of right adrenal adenoma.\n\n\n (Over)\n\n 11:38 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for RP and intraperitoneal bleed\n Admitting Diagnosis: VARICEAL BLEED\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937498,
"text": " 6:32 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for effusion, infiltrate\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, respiratory\n failure with worsened oxygenation\n REASON FOR THIS EXAMINATION:\n please eval for effusion, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Encephalopathy, worsening O2 requirements.\n\n CHEST:\n\n Patient is considerably rotated. The endotracheal tube, nasogastric tube, and\n IJ line are unchanged in position. Atelectasis at the left base is seen. The\n right chest is difficult to evaluate due to rotation. There is probably an\n effusion present. Right effusion is again probably present.\n\n It is probable that there has been an increase in the size of the right\n effusion since the prior chest x-ray of seven hours previous.\n\n IMPRESSION: Probable increasing right effusion in chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-27 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 937959,
"text": " 11:12 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please advance NG tube to post pyloric\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, with NG tube\n REASON FOR THIS EXAMINATION:\n please advance NG tube to post pyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old with history of NASH and ascites requiring post-\n pyloric tube placement.\n\n PROCEDURE: Recent radiographs demonstrate a Dobhoff tube with its tip in the\n body of the stomach. The patient was placed supine on the fluoroscopic table.\n A guidewire was advanced through the indwelling Dobhoff catheter, however\n could not be advanced through the pylorus. The guidewire and the Dobbhoff\n were subsequently removed. The right naris was then anesthetized with jelly\n and Hurricaine Spray and - feeding tube was advanced through\n the right naris through the esophagus and into the stomach without difficulty.\n After injection of a small amount of air and contrast for guidance, the tube\n was positioned through the pylorus into the distal duodenum with its tip\n placed at the ligament of Treitz. A small amount of nonionic contrast was\n administered to confirm tube placement.\n\n IMPRESSION: Successful post-pyloric tube placement with its tip at the\n ligament of Treitz; tube is ready for use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937693,
"text": " 11:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for improved RLL\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, respiratory\n failure with mucus plugging\n REASON FOR THIS EXAMINATION:\n please eval for improved RLL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure with mucus plugging.\n\n COMPARISON: CXR .\n\n FINDINGS: Semi-upright portable radiograph of the chest. Endotracheal tube\n is approximately 3.2 cm from the carina. Right internal jugular line appears\n unchanged in position with its tip in the proximal to mid SVC. A Dobbhoff\n tube is unchanged in position with the tip within the gastric fundus.\n Calcification of the aortic knob is again seen. Low lung volumes are again\n noted. Minimal blunting of the right costophrenic angle appears stable. The\n left costophrenic angle is cut off on this film. Minimal right basilar\n atelectasis appears stable. No new consolidation is identified. No\n pneumothorax is seen.\n\n IMPRESSION: Stable appearance of lungs with low lung volumes and minimal\n right basilar atelectasis. Unchanged position of lines and tubes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936364,
"text": " 3:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, effusions, PNA\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, recently extubated with\n onset of respiratory distress and decreased BS on right.\n\n REASON FOR THIS EXAMINATION:\n PTX, effusions, PNA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Recent onset respiratory distress, decreased breath sounds\n on right.\n\n CHEST:\n\n Comparison is made with the prior chest x-ray of . The lung fields\n remain clear, and no effusions are present on either side.\n\n Since the prior chest x-ray, the endotracheal tube is being removed. The\n position of the right IJ catheter is unchanged.\n\n Some increased density is seen behind the right chest and atelectasis or\n infiltrate in the posterior segment of the right lower lobe could be present.\n\n IMPRESSION: Probable infiltrate or atelectasis posterior segment right lower\n lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-20 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 937075,
"text": " 1:08 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: evalute for ascites and please mark the spot\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, NASH, presents with ascites and GIB,\n encephalopathy\n REASON FOR THIS EXAMINATION:\n evalute for ascites and please mark the spot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old male with cirrhosis and ascites. Please mark the\n spot for paracentesis.\n\n COMPARISON: .\n\n Four quadrant ultrasound shows a large volume ascites throughout the abdomen.\n A suitable spot for bedside paracentesis by the referring team was marked in\n the left lower quadrant.\n\n IMPRESSION: Large volume of ascites. Suitable spot marked in the left lower\n quadrant.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936965,
"text": " 4:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval placement of ETT\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy s/p extubation and\n placement of NG tube\n REASON FOR THIS EXAMINATION:\n eval placement of ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube placement.\n\n COMPARISON: Three hours earlier.\n\n There has been interval placement of endotracheal tube with its tip about 3 to\n 4 cm above the carina. The NG tube remains retroflexed in the upper stomach\n with its tip in the mid esophagus. Right IJ line is in mid SVC. Mild\n bibasilar atelectasis and pleural effusions are unchanged.\n\n These findings were discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937574,
"text": " 10:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate right lung for effusion, collapse, infiltrate\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy, respiratory\n failure with worsened CXR, felt to be d/t mucous plug rather than effusion.\n REASON FOR THIS EXAMINATION:\n evaluate right lung for effusion, collapse, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 11:38 A.M.\n\n HISTORY: Extensive liver disease with history of collapse.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Low lung volumes are again evident, however, minimal improvement in\n aeration is noted. Minimal blunting of the right costophrenic angle is likely\n due to a small effusion. Minimal right basilar atelectasis is seen. There is\n no focal consolidation. Improved but minimal linear left lung atelectasis is\n also seen. The various support tubes and lines remain stable in position.\n Please note, the tip of the Dobbhoff tube remains in the gastric fundus in an\n inappropriate position for enteric feeds.\n\n IMPRESSION: Improved aeration with low lung volumes persisting as well as\n bibasilar atelectasis. Small right pleural effusion likely evident. Enteric\n feeding tube in an inappropriate position for feeds.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937071,
"text": " 12:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for new infiltrates, and NG tube\n Admitting Diagnosis: VARICEAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ascites, NASH, encephalopathy s/p extubation and\n placement of NG tube\n REASON FOR THIS EXAMINATION:\n evaluate for new infiltrates, and NG tube\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the NG tube placement.\n\n Portable AP chest radiograph compared to previous film from .\n\n The ET tube tip is 3.8 cm above the carina. The NG tube tip is still coiled\n in the esophagus. The right internal jugular line tip is in mid SVC. The\n lung volumes are low. The left lower lobe atelectasis is slightly worse but\n the bilateral pleural effusion is diminished. There is no congestive heart\n failure.\n\n IMPRESSION: NG tube still coiled within the esophagus. Worsening of the\n basal atelectasis. Decreased bilateral pleural effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-27 00:00:00.000",
"description": "Report",
"row_id": 1456887,
"text": "MICU 7 0700-1900 NPN\n\nNeuro: Pt. A/O x3. Found pt. to be very lethargic for most of shift. Pt is able to communicate needs very well via white board. Pt continues to receive eye drops for glaucoma. Moves upper extremities with purpose. Movement note on bed for lower extremities. Very weak gag and cough.\n\nCV: HR 45-55. A-line is in place and positional at times. SBP 60-120's. Gave 500cc fluid bolus for sbp of 60's, with good effect. SBP dropped again in the afternoon to 60's with MAP of 47. Stimulated pt. with pt. turn. sbp and map returned to 90's and 60's respectively. Team gave approval for another small bolus of 250cc, but held due to patient recovering on his own.\n\nResp: Continues to be intubated on CMV peep 5/ ps 5. Suctioned multiple times for yellow to white secretions. Pt. continues to drool from side of mouth at ET tube. Suctioned oral cavity several times for large amounts of thick bloody secretions. Provided oral care with minimal relief.\n\nGI/GU: Foley catheter intact and draining minimal urine. BUN/CR continue to increase 64 and 2.2 respectively. Bowel sounds are hypoactive and difficult to auscultate. Pt. had 2BM this shift. Dobhoff tube placed post pyloric by fluro today. Tube feeds currently running at 40cc per hour. Pt. continues to have very large ascites. No plans to tap abdomen at this time due to fear that it will worsen pt. renal function.\n\nEndo: FS q 6h requiring coverage at times.\n\nSkin: Duoderm on coccyx. Barrier cream applied to buttocks to protect skin from incontinence.\n\nPlan: Encourage team to talk to family regarding options. Encourage team to follow up with Transplant team regarding pt. options. Follow up on plan regarding his respiratory status, Trach or not to trach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-27 00:00:00.000",
"description": "Report",
"row_id": 1456888,
"text": "Respiratory Care: Pt remains on PS 5, P 5. Tolerating well. Suctioning frequently for ^amounts of thin secretions from ET and orally. Receiving MDI. LS slightly coarse. No current abg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-28 00:00:00.000",
"description": "Report",
"row_id": 1456889,
"text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT LETHARGIC, NOT ABLE TO WRITE NEEDS ON BOARD. PT WILL FOLLOW COMMANDS. WEAKLY MAE ON BED.\n\nRESP: PT RECEIVED ON PS 5/5 40% RR 25-35. ABG 7.33/29/134. DIFFICULT TO OBTAIN O2 SAT THROUGH OUT NIGHT. SUCTIONED FOR THIK YELLOW SECREATIONS. THIS AM SUCTIONED FOR THICK TAN, TF LIKE SECREATION, MODERATE ANMT. O2 SATS TRACING 88%. ABG OBTAINED, 7.20/38/56. TF HELD. AM CHEST XRAY ORDERED. PT PLACED ON AC. LS CONT TO RHONCHEROUS. ETT ROTATED. LESS ORAL SECREATIONS. SECREATIONS FROM BACK OF THROAT, THICK AND PALE IN COLOR.\n\nCV: HR 60'S NSR. SBP LIABLE, 70-100. AT TIMES PT SBP WOULD BREIFLY DIP AND COME BACK ON IT'S OWN. OITHER TIMES WOULD REMAIN IN 70'S. FB GIVEN FOR TOTAL 1.5L. DIFFICULT TO OBTAIN CVP, . PT AFEBRILE. GOAL IS TO KEEP MAP GREATER THAN 60. PT CONT ON ALBUMIN. AM HCT 27.5 FROM 34.3. WBC 11 FROM 6. AT THIS TIME TEAM WISHES TO REPEAT CBC PRIOR TO TREATING THE VALUES.\n\nGI/GU: ABD LG, +ASCITIES. HYPO BS. MUSHROOM CATH PLACED FOR LOOSE MAROON STOOL, GUIAC POS. BECOMING LIQUID AND BROWN THROUGH OUT NIGHT. 800CC OUT. PT CONT ON TID LACTULOSE. TF WERE AT 50CC/PEDI TUBE UNITL 0400. ?ASPIRATE DUE TO ORAL AND ETT SECREATIONS. TF ON HOLD. FOLEY INTACT DRAINING TOTAL 85CC/HR FOR SHIFT.\n\nDISPO: PLAN IS FOR REPEATE ABG, CBC AT 0600. TYPE AND CROSS TO BE SENT. FB FOR MAP LESS THAN 60. CONT OT MONITOR MS/PAIN MGT. PT IS A FULL CODE. NO CONTACT FROM FAMILY OVERNIGHT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-17 00:00:00.000",
"description": "Report",
"row_id": 1456839,
"text": "7A-7PM NPN\nRESP: pt remains intubated (ETT 8.0, taped at 20 cm), and vented on 40%, 5 peep, 5 pressures support, rr~ TV's~400 team decided to wait one more day,(extubation) for pt to wake up more. sx q 3 hrs for yellow to white secretions. lungs w/ decreased breath sounds, albuterol prn. ABG ~ 174/29/7.40\n\nCV/FLUIDS: bp stable 130/60 HR 45-56 SB, no vea noted. IVF done, just , UO~30 cc/hr\n\nGI: was NPO, back on tube feeds, FS Ultracal @ 65 cc/hr (goal), NPO after midnight for ?extubation in am. mushroom catheter in place, draining loose golden/brown stool. on Lansoprazole\nlactulose continues (1 liter stool every day)\n\nGU: foley intact, draining clear, yellow urine. (watch UO - may need fluid bolus)\n\nENDO: FS qid, FS @ 12pm 258 ~ pt received 6 units Humalog.\n\nNEURO: no sedation given, pt opens eyes spont, trying to mouth words to family, MAE to command. pt with periods of sleeping, resp rate drops, apnea alarms on vent.\n\nSKIN: coccxy with duoderm - intact. extremities with ecchymotic area, skin tears easily.\n\nSOCIAL: FULL CODE\n\nPLAN: liver team following, ?extubation in am, continue antibx, lactulose, follow BS's closely. NPO after midnight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-17 00:00:00.000",
"description": "Report",
"row_id": 1456840,
"text": "MICU 7 RN note 1900-2300\n\nNeuro: responsive to verbal stimulation, opens eyes, tracks surroundings, nods yes no, follws simple commands , equal hand grasps, moves Le on bed. denies pain. no tremors/siezures.\n\nCV/resp : HR 56-62 NSR-SB N ectopy. R radial aline inplace sharp wave BP 110-128/60-80 MAPS>65. R TLC inplace IV D5W 10cc/hr. may require fluid bolus for low urine output. Intubated #8.0 ETT pos 20 lip. Vent mode CPAP 5/5 40% TV >450 sats 100%, RR8-18 irreg pattern. Lungs clear dim bases. Suctioned via ETT for sm amt thick pale yellow, orally copious clear. Plan SBT am and ?extubation.\nID: Afebrile t 97.8, cont Abx Vanco, cefepine,rifaximine.\n\nGI: OGT started shift on TF 65cc/hr residual @ 160 TF held Plan to stop @ 12mn due to extubation cont gastric meds.\n\nGU: foley u/o 25-50cc/hr plan FB if u/o low\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-18 00:00:00.000",
"description": "Report",
"row_id": 1456841,
"text": "Resp Care Note, Pt placed on SBT this AM. RSBI done 35. Suctioned sml amts thick yellow secretions. MDI'S given. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-18 00:00:00.000",
"description": "Report",
"row_id": 1456842,
"text": "npn 23:00-07:00 (see carevue flownotes for objective data)\n\ndx: cirrhosis; on liver transplant list\n\npt afebrile, vss; a-line patent, good wave form;\nlungs remain clear, dim at bases;\nmade NPO at MN in preparation for extubation this morning;\ncontinues to receive abx as ordered;\nmushroom cath in place and in use for stool management, remains on RTC lactulose;\nmushroom cath leaks at times, peri-area cleaned, duodierm to coccyx intact;\nskin fragile;\non RISS for blood sugar control;\n\nno new issues;\n\nPLAN:\n1) hopeful extubation today\n2) check results a.m. labs\n3) skin care\n4) lactulose to assist LOC\n5) further plans per rounds\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-18 00:00:00.000",
"description": "Report",
"row_id": 1456843,
"text": "Nursing Progress Note 0700-1900\n*Full code\n\n*Allergies: Sulfa\n\n*Access: Rrad A-line, RIJ TLC\n\nNeuro: Pt very lethargic, though easy to arouse. Follows commands, answers questions w/ nodding. MAE on bed though weakly, does lift and hold upper extremeties w/ turning. No indication pain per vitals and non-verbal communication. Impaired cough and gag. PERRL 3mm/brisk.\n\nCardiac: SB w/o ectopy, HR 49-58, SBP 101-132. Hct stable @ 36.5, no signs of bleeding. INR 1.5. No lyte repleation needed following morning labs.\n\nResp: remains on Psup , 40%, ls clear upper and diminished lower, o2sat 100%, RR 7-14. Decreased resp rate at times causing low min.volume alarm on vent. Also a few times RR in high 20's/low 30's, sxn for mod/copious amts white/tan thick secretions and then RR corrects to teens. Plan today was for extubation, however team wanted clarification on the pt's wishes if he were to have difficulty again. ?trach vs no assistance. Fam discussed w/ pt and after several conversations, final plan is to have liver team visit w/ fam and if there is still a chance for him to have a transplant we may continue w/ aggressive care. If not, the choice will be put to the pt again.\n\nGI/GU: TF just restarted @ 10cc/hr to increase 10cc Q4H. TF OFF @ MN for possible extubation in AM. Hypoactive BS, abd soft, stool brown/liquid out mushroom cath. Cont lactulose for encephalopathy. Urine out foley in minimal amts, 10-40cc/hr, yellow/clear. BUN/Creat this AM was 46/1.1. FSBG Q6H, 150-193, covered per Humalog sliding scale.\n\nID: Afebrile, WBC 9.6. Cont ceftazidime and vanco. , pt currently being treated for VAP. Coccyx area covered w/ duoderm, IV sites wnl.\n\nPsychosocial: Fam in to visit, updated by MD's and had several conversations w/ pt and fam regarding his wished if extubation fails. It would be his second failed extubation and the next step would be a trach. At this point, fam waiting to discuss liver transplant possibility to help pt and fam determine final decision.\n\nDispo: cont to monitor resp status (sxn as needed), monitor neuro status (lethargy; cont lactulose), TF off @ MN for possible extubation in AM. cont med regimen and abx, cont fam support, still awaiting liver team rounds to discuss plan of care w/ fam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-18 00:00:00.000",
"description": "Report",
"row_id": 1456844,
"text": "Respiratory Care: Pt recieved on SBT this am, pt tolerated well Vt 400-450, RR 16-22, SpO2 98-100%. After approx 2 hours SBT suspended, pt then placed on PS5 and PEEP 5, Vt550-650, RR8-16, SpO2 99-100%. Pt's breath sounds coarse that clear with suctioning. Suctioned for moderate thick white secretions. MDIs given as ordered. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-16 00:00:00.000",
"description": "Report",
"row_id": 1456834,
"text": "Resp Care\nPt remains intubated and was switched from A/C to PS 5/5. Pt had periods of apnea on CPAP and had to be placed on MMV in order to keep MV consistant. Team plan was to extubate, but Pt did not appear ready and was not worth the risk of another reintubation. MDI's given. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-16 00:00:00.000",
"description": "Report",
"row_id": 1456835,
"text": "npn 0700-1900\nNo significant changes today.\n\nneuro: Pt is arousable to verbal stimuli. Was awake most of the morning while wife visited. Does not c/o pain or discomfort.\n\nresp: Trialed on this morning, but was having significant periods of apnea. Placed on MMV with a rate of 12, fiO2 of 40%. Sputum sent for culture this afternoon.\n\ncv: Sinus brady 48-60. (Not a new finding). BP 120-130's/50's.\n\naccess: 2 piv, R radail aline, R sc tlc.\n\ngi/gu: Abdomen with ascites. TF currently at 40cc/h with a goal of 65cc/h.Patent foley with ~ 3occ/h of urine.\n\nskin: Fragile skin. Arms are eccymotic around IV insertion sites. Back with bony prominences- is on an air bed. No areas of breakdown on back.\n\nsocial: Multiple visitors today. Brother became upset with nurse today because he felt RN was not putting the pt comfort as a priority. The situation resolved after he spoke with the resource nurse.\n\nendo: RISS.\n\ndispo: Full code.\n\nid: Afebrile today. Antibiotic coverage changed to vanco and ceftriaxone.\n\nPlan: wean vent as tolerated, careful attention to nutrition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-17 00:00:00.000",
"description": "Report",
"row_id": 1456836,
"text": "Resp Care Note,Rested on MMV most of the night. Pt placed on SBT this AM. RSBI done on 0 peep/5 ips 14. Suctioned for mod amts thick yellow secretions. MDI'S given. Awake at times.Plan to wean to extubate.Will cont to monitor resp status.? airway protection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-17 00:00:00.000",
"description": "Report",
"row_id": 1456837,
"text": "MICU 7 RN NOTE 1900-0700\n\nEVENTS: FB for low u/o. SBT RSBI 14\n\nNeuro: responsive to verbal stimulation opens eyes tracks surrounding, nods yes/no to verbal command. MUE random pt and found touching ETT soft wrist restraints applied for safety. moves LE on bed and to command. no tremor/siezures. Encephalopathy recieved Lactalose per routine.\n\nCV: HR 48=65 NSR-SB no ectopy. R radial aline in place sharp wave form BP 120-138/55-65. MAPS>65. RIJ TLC IV D5W 100cc/hr for 2.5L then pt is on liter #2. peripheral pulses 2+ DP/DT (-)edema.\nHeme: Hct 33.5 trending down (35.3)\n\nresp: intubated # 7.5 ETT. vent mode MMV 12/40% TV >300. Sats 98-100%. LS coarse Dim bases. Sucted via ETT for mod amt thick yellow and prally copious clear. . @ 0400 SBT 0/5 TV 200-400 RR 12-18 RSBI 14.\n\nGI: abd soft distended + BS mushroom cath inplace dra brown liq stool > 600 this shift. OGT inplace TF 40cc/hr nPO @ 0400 for ? extubation.\n\nGU: foley u/o 30-50cc/hr recieved FB 500cc x1 with responding ^u/o\n\nEndo: RFSBS coverager per protocol.\n\nDerm: Skin impaired multiple skin abrasions, pressure points, turned and positioned with skin care.\n\nSocial: Full code status. no familycontact this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-17 00:00:00.000",
"description": "Report",
"row_id": 1456838,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-19 00:00:00.000",
"description": "Report",
"row_id": 1456845,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient continues on Cpap/ps 5/5 and 40%. Spontaneous tidal volumes are around 600 with respiratory rates in the teens. RSBI today 20.8. breathsounds are coarse. Albuterol given. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-19 00:00:00.000",
"description": "Report",
"row_id": 1456846,
"text": "MICU7 RN Note 1900-0700\n\nEvents: marginal u/o team aware, NPO @ 0400 ? extubation.\n\nNeuro: responsive to verbal stimulation opens eyes spontaneously, tracks surroundings, follws simple commands, equal hand grasps, moves LE on bedand to command. no Tremors/siezures. cont on Lactalose (hepatic encephalopathy) denies pain although noted grimace with passive ROM.\n\nCV: HR 54-60 NSR-SB no ectopy, R radial aline inplace sharp wave form. BP 108-132/57-68 MAPS>65. peripheral pulses 3+DP/DT neg edema. labs pending. Access R IJ TLC NS 10cc/hr\n\nresp: Intubated #8.0 ETT pos 20 @lip, vent mode CPAP PSV 5/5 40%, Sats 100%, TV>350 varying MV trends down to 2 times. RR 12-16. Lungs coarse few I/E wheezes recieved MDI per resp, Dim BS @ bases. Suctioned via ETT for sm amts thicl pale yellow and orally mod clear.\nSBT RSBI 20. ABG 7.39-31-173-19\n\nID: Afebrile T-max 98.5, cult to date sputum GPC GNR, urine enterococci. cont abx ceftazidine,vanco,rafaximine.\n\nGI: Abd soft distended + BS, Mushroom cath inplaced changed for patency draining liq brown stool. OGT inplace low residuals TF adv to 30 then stopped @ 0400 pending extubation.\n\nGU: Foley u/o 20-50cc/hr Team made aware of low u/o.\n\nDerm: Impaired multiple skin abrassions, ecchymosis ans pressure points , pt on airbed, duoderm intact on coccyx. . frequent turns and position,\n\nSocial: Full code status, family visited @ start of shift. Plan decision to reintubate/trach if pt fails extubation. Family to meet with liver team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-19 00:00:00.000",
"description": "Report",
"row_id": 1456847,
"text": "micu npn 0700-1900\n~0330. Pt continued to ahve sats of 88-90% on 100%nrb. cpt again attempted. pt positioned on abck and nt suctioned for ~150cc of brb via ett. ngt up to wall suction for about the same. Dr. in to lavage. anaasthesia and liver team caleld. pt reintubated w/o problem. sm amts of yellow secretions from ett. pt dim at the r base s/p intubation. improving somewhat w/suctioning. cxr done, awaiting read. hct wnl. pt receiving 1 out of 2 units prbc's. octreotide gtt to be restarted. family (son and wife) at the bedside throughout this. family updated and questions answered. liver fellow plans to speak w/family.\nPlan to watch pt for now as bleeding has subsided. gi/liver to hold on scope at present, will scope in the am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-15 00:00:00.000",
"description": "Report",
"row_id": 1456827,
"text": "Resp. Care\nPt. remains on mech vent. Novent changes made during the shift. Pt. tube was pulled back 2cms to 22 and secured to left lip.Pt. has been sx for sm amts thick white with ess. clear b/s.No ABGs have drawn as of this note and his RSBI was 26.Plan is to wean as tol .\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-15 00:00:00.000",
"description": "Report",
"row_id": 1456828,
"text": "FOCUS: NURSING PROGRESS NOTE\n63 YEAR OLD MALE WITH NASH ADMITTED WITH GI BLEED AND ENCEPHALOPATHY.\nREVEIW OF SYSTEMS-\nNEURO- THIS AM ABLE TO FOLLOW COMMANDS CONSISTENTLY. MAE. PUPILS SURGICAL. GAG PRESENT WHEN MOUTH CAE DONE. COUGH PRESENT WITH SUCTIONING. LACTULOSE GIVEN Q 4 HOURS. SAFETY DEVICES WERE ON ARMS WHILE INTUBATED. DC'D AFTER EXTUBATION BUT HAVE BEEN REPLACED AS PAITENT FREQUENLY ATTEMPTING TO PULL OFF O2. POST EXTUBATION PATIENT ORIENTED TO PERSON AND TIME. THOUGHT HE WAS AT THE BENT .\nRESP- BS CLEAR DIMINISHED AT THE BASES. HE WAS VENTED AND ON A/C MODE OF VENT. WEANED TO PS OF 5 AND 5 PEEP. ON THIS HE HAD PERIODS WHERE HE WOULD DROP HIS RESP TO 9 AND TV TO 300. HE SET OFF LOW MINUTE VOLUME ALARM. RESP PLACED HIM ON MMV. ON ROUNDS DECISION MADE TO PLACE HIM ON PEEP 2 PS OF 5 AND FIO250%. ON THIS HIS RESP RATE WAS WITH TV FROM 300-1L. ABG WAS ACCEPTABLE, SEE CAREVUE AND DECISION WAS MADE TO EXTUBATE THE PATIENT. HE WAS EXTUBATED AND PLACED ON 50% FM. INITIAL ABG 7.40/37/96/24. HIS SAT WAS 98 % AT THE TIME. HE QUICKLY DESATED TO 85%. BACK OF HIS THROAT WAS SUCTIONED FOR THICK CLEAR SECRETIONS AND HIS SAT CAME BACK UP TO HIGH 90'S. HE DESATED AGAIN TO 85% AND SUCTIONING THE BACK OF HIS THROAT WAS NOT EFFECTIVE. 100% NRB PLACED. CPT DONE. NEB TX GIVEN. ABG 7.40/37/57/24. DR AT BEDSIDE. CXR DONE. REPEAT CPT DONE AS BS ON RIGHT DIMINISHED. SATS CAME BACK UP TO 100%. OXYGEN HAS AGAIN BEEN WEANED DOWN TO 50% HUMIDIFIED FM.\nCARDIAC- HR 80'S DOWN TO 50\"S SB WITH RARE PAC. NADOLOL DOSE INCREASED TO 40MG QD TODAY WHICH THE PAITENT RECEIVED. SBP 130-160. K 3.4 THIS AM. REPLETED WITH 40MEQ KCL IV. REPEAT 3.8. NEXT K TO BE CHECKED AT . NA 150 THIS AM. TX WITH D5W AT 60CC/HR X 1.5 L. REPEAT NA 153. D5W INCREASED TO 80CC/HR.\nGI- ABD WITH ASCITES. SOFT. WITH POS BS. OGT DC'D WITH EXTUBATION. DUE TO O2 ISSUES NEW TUBE TO BE PLACED BY DR FOR MEDS AND ? TF. PASSING STOOL TODAY GREEN BROWN GUAIC POS VIA MUSHROOM CATH. 500CC SO FAR THIS SHIFT. WILL CONT TO REQUIRE LACTULOSE. CONT ON SANDOSTATIN DRIP AT 50MCGS/HR AND PROTONIX AT 8MG/HR. CONT ON CARAFATE.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE AT 30-60CC/HR.\nRENAL- CREAT STABLE AT 1.7.\nENDO- SS INSULIN INCREASED TODAY AS BS HAD BEEN IN MID 200'S. BS AT NOON 2.2 TX WITH SS.\nHEME- HCT STABLE TODAY. LATEST HCT 34.4.\nSOCIAL- FAMILY IN TODAY AND UPDATED BY THIS NURSE AND DR .\nPLAN- PULM TOILET. DR TO PLACE NGT. CONT LACTULOSE. CONT HCT CHECKS .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-15 00:00:00.000",
"description": "Report",
"row_id": 1456829,
"text": "focus; addendum\nRESP- CONT TO DESAT. DR AND DR AT BEDSIDE. SATS DOWN TO 89% ON 100% HUMIDIFIED FM. NOT RESPONDING TO CPT. ENCOURAGING PATIENT TO COUGH AND DEEP BREATH. NASAL TRACHEAL SUCTIONING DONE BY RESP AFTER NASAL TRUMPET PLACED. SUCTIONED FOR SMALL AMOUNT THICK TAN SECRETIONS. REPEAT NEB GIVEN. WILL REATTMPT CPT.\nCARDIAC- SBP UP TO 170. DR NOTIFIED. 10MG IV HYDRALAZINE ORDERED. SBP DOWN TO 140'S WITHOUT DRUG. DR MADE AWARE THAT HYDRALAZINE WAS NOT GIVEN.\nPLAN- WILL REATTEMPT CPT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-15 00:00:00.000",
"description": "Report",
"row_id": 1456830,
"text": "Resp Care\nPt extubated amd remains on NRB due to declining Pao2. Possible reintubation pending, but team wants to give pt more time to see if he will turn around. Pt NTS for moderate amt of thick tan. Pt has NPA in left nare. No other changes noted. Pt given 2 ALB nebs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-15 00:00:00.000",
"description": "Report",
"row_id": 1456831,
"text": "focus; addendum\nresp- intubated at 1830 for low sats. Anesthesia here and intubated the patient. # 8 ett placed. Taped at 22cm at the lip. recieved 12 of etomidate and 50 of succ.\ncardiac- hr down to 47 after intubation. Sbp up to 190. Dr made aware. 10mg iv hydralazine given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-16 00:00:00.000",
"description": "Report",
"row_id": 1456832,
"text": "micu npn 1900-0700\nPlease see carevue flowsheet for all objective data\n\npt s/p variceal bleed/banding. hcts stable now x48 hrs. extubated and reintubated yesterday. remains on protonix and octreotide gtts.\n\nneuro- Patient responds to voice. nods head appropriately to y/n ?'s. mae. denies pain. (hx of cataract and glaucoma). waking up more this am, cont lactolose for encephalopathy.\n\ncv- hr emains in the 40-50's range, this am staring to hit 60 again. ?team this am if they want to keep same increased dose of nadolol. no ectopy. responding well to previous shift hydralizine dose given. abp 1teens-150/sys rest of night.\n\nresp- remains intubated, fio2 titrated down to 50-% o/n,. sats 99-100%. suctioned for thick yellow at times. pt having desat episode to 87-89%. no breath sounds heard to l chest. lavaged and suctioned for thick yellow/tan secretions. cpt done x2 overnighjt yielding good results\n\ngi/gu- tube feeds begun o/n ultracal to goal of 65cc/hr. currently tolerating 20cc/hr. sm amts of liquid golden/green stool via mushroom catheter. cont l;actolose tid. uop marginal at times, but usually ~30cc/hr.\n\nid- levofoloxacin conts. afebrile. on bair hugger overnight briefly. temp 96-97 po. pt does not seem to like it for very long.\n\ncont pulm toilet, lactolose for encephalopathy, follow wbc, hcts. titrate b blocker prn.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-16 00:00:00.000",
"description": "Report",
"row_id": 1456833,
"text": "Resp Care Note, Weaned FI02 for good ABG'S. See flow sheet for details.Suctioned for mod amts thick yellow secrtions.Started on albuterol prn.No RSBI done due to 10 of peep. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-29 00:00:00.000",
"description": "Report",
"row_id": 1456896,
"text": "npn 1900-0700 micu 7 west\nPt was received CMO on Morphine GTT 2mg/hr, intubated on vent setting AC .60%/TV400/Peep10/12RR, bleeding per mouth, sbp 58-60, and HR 60s, O2>93%.\n\nVent changed to .20%/5peep and then to CMV .20%/5peep/5ps breathing RR 20-31, TV 250, O2 88-91%. Sbp is now 45-50 and morphine gtt is at 6mg/hr. Pt appears to be breathing comfortably.\n\nPt is actively bleeding from mouth and nose, mushroom cath, foley, and right IJ are IN.\n\nFamily is present at bedside, emotional support provided.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-14 00:00:00.000",
"description": "Report",
"row_id": 1456823,
"text": "O. Neuro appears malnourished wt 51.8 kg, begining of shift pt not responding to even painful stimuli. Gaze to left and midline absent on right now opens eyes to command eyes moving both sides os>od, moves rt leg on his own, fc inconsistently. Given lactulose as ordered. Pupils surgical reactive to light sluggish.\nCVS HR 80-90 nsr without ectopy bp 120/-148/78 hct 27.5 received 2uprbc hct immediately post transfusion 34.4, skin cool and dry pp+ INR 1.5 received vit K 5mg sq x1\nResp cmv 50/500/14/5, abg 7.53/27/214/23/1 dropped him to 40/400 abg the same. Attempted PS 10 peep 5 then dropped PS 5 o2 sat dropped to 80% bp dropped quickly to 75/ placed back on vent 50/400/14/5, bp and sat recovered within 5 minutes. ABG pnding, EKG showed low voltage limb leads\ngi NPO receiving lactulose, abd ascites tapped 60cc removed sent for cx. Fecal bag in place black liq stool sm amt. Total bili 2.3\ngu u/o > 30cc qhr BUN 101 cr 1.8\nendo requiring ss insulin\naccess 3 20g periph, 1 22g, aline rt radial\nskin prominent spine kyphotic multiple pressure points, coccyx erythematous no breakdown, rt great toe amputated\na. ESLD encephalopathic, alt loc, intubated, gib unclear source, appears malnourished at risk for decubitus, DM, arf\np. serial hct, transfuse prn, if starts to bld obtain egd, protonix and ocreotide gtts, sucralfate, follow cr, bun, u/o, urine sent for lytes, ss insulin, ? nutrition consult ?TPN,lactulose as ordered monitor neuro signs, good skin care pt would benefit kcl bed, turn frequently, support pt and family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-14 00:00:00.000",
"description": "Report",
"row_id": 1456824,
"text": "Resp. Care\nPt. remains on mech. vent. See carevue for settings. At 0300 pt. was flipped from A/C to CPAP/PS 10/5 and 40%.Pt. became hypovolemic 70/40 and Sats dropped to the high 80s. Pt. was then puy back on original settings but with a Fio2 of 50.ABGs drawn showed a mod hypoxemia, and are awaiting the results of a later draw. RSBI not done because of events stated above. Plan is wean as tol. and extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-14 00:00:00.000",
"description": "Report",
"row_id": 1456825,
"text": "NURSING PROGRESS NOTE\n63 YEAR OLD ADMITTED TO MICU YESTERDAY WITH ENCEPHALOPATHY. HE HAD BEEN INTUBATED AT OSH FOR AIRWAY PROTECTION. HE WAS SCOPED FOR LOTS OF OLD BLOOD IN STOMACH. BANDED VARICES SEEN AND NOT BLEEDING. 23 U PRBC GIVEN FOR HCT OF 28. LACTULOSE STARTED.\nREVEIW OF SYSTEMS-\nNEURO- OF NOTE PAITENT IS VERY HOH AND WEARS BILAT HEARING AIDES NORMALLY. YOU NEED TO SPEAK RIGHT INTO HIS EARS. THIS AM HE WAS MINIMALLY RESPONSIVE. MIN SPONTANEOUS MOVEMENT. OF NOTE ALSO IS HE HAS BILAT LENS IMPLANTS. LEFT PUPIL NOT ROUND OR REACTIVE. LEFT IS 3MM AND APPEARS REACTIVE. HIS LACTULOSE WAS INCREASED TO Q 1 HOUR AND HE RECIEVED 1 PR LACTULOSE ENEMA. HE IS NOW MORE AWAKE. INCONSISTENTLY OBEYING COMMANDS. WILL CONT. LACTULOSE. HE PRESENTLY MAE. ALSO ON RIFAXAMIN.\nRESP- HE IS INTUBATED AND VENTED. ON 50% FIO2/ TV 400CC/ RATE OF 14 OVERBREATHING BY 1-7 BREATHS. BS COARSE TO CLEAR DIMINISHED AT THE BASES. SUCTIONED FOR SMALL TO MODERATE AMOUNTS OF THICK YELLOW TO TAN SECRETIONS.\nCARDIAC- HR IS 80-90'S NSR. THIS AM HAD RARE PAC. NO ECTOPI THIS AFTERNOON. SBP 1130-160. STARTED ON NADALOL TODAY. K 3.4 TX WITH 40MEQ KCL IV TODAy.\nGI- ABD WITH ASICITES. NOT TENSE. POS BS. HAS OGT THAT HAD OLD DARK MARROON BLOODY RETURNS THIS AM. DR WAS MADE AWARE. WAS OK TO GIVE PO MEDS PER HIM. THIS AFTERNOON RETURNS ARE DARK BROWN IN COLOR. IS NPO. HAD FIB THIS AM. CHANGED TO MUSHROOM CATH THIS AFTERNOON DUE TO LEAKAGE. PASSING DARK BROWN,BLACK, MARROON STOOL THAT IS GUIAC POS. HAD 1 1L LACTULOSE ENEMA.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE. UO 30-45CC/HR. UO DROPPED TO 20CC/HR FOR ONE HOUR. DR MADE AWARE. NO TX THAT HOUR. NEXT HOUR UO UP TO 30CC/HR.\nENDO- BS AT NOON 269. TX WITH SS INSULIN. ? NEED TO INCREASE SS.\n WILL SEE WHAT 1800 BS IS.\nHEME- HCTS CHECKED Q 4 HOURS TODAY. HCT HAVE BEEN 34.4-35.9-34.6-34.\nACCESS- HAS 3 # 20 AND 1 #22. CL TO BE PLACED DUE TO POOR ADDITIONAL ACCESS AND ? NEED FOR TPN IF UNABLE TO TAKE POS TOMMORROW.\n WIFE AND SON IN AND UPDATED BY THIS NURSE AND LIVER TRANSPLANT FELLOW.\nPLAN- MONITOR HCTS Q 4 HOURS. PLACE CL. CONT LACTULOSE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-15 00:00:00.000",
"description": "Report",
"row_id": 1456826,
"text": "micu npn 1900-0700\nPlease see carevue flowsheet for all objective data\n\nneuro- Patient slightly more awake and mobile in the bed overnight. Bilateral wrist restraints on for safety as he reaches for the ett. Mae, no defecits noted.\n\ncv/resp- hr 70-80's nsr, rare to occ pac noted this am. abp 140-150's systolic most of the night. RIJ tlc in good position per cxr. port saved for possible tpn. remains vented on ac 0.5 fio2 400x14 5-8 breaths above. per post line insertion cxr, ett needed to be pulled out 2cm. Ett now 22cm at the lip, retaped on l side as pt has sm amt of breakdown at l corner of lip. pt suctioned q4 hrs from ett for thick yellow/tan secretions.\n\ngi/gu- continues on q4hr lactolose as tolerated. Held 12am dose, as pt had put out 800cc of stool. mushroom catheter remains intact. occastional leaking noted. uop remains wnl, clear and yellow. ngt in place. npo except meds. sm amts of dark old blood return. HCT overnight 33.7, stable from yesterday. Will draw again w/am labs.\n\nid- afebrile 97.9-98.1 overnight. Remains on levofloxacin.\n\nendo- ss q6hrs. covered w/1u at midnight for bs of 179.\n\nPlan for liver to ?re-scope today. Cont to follow hcts. Lactolose as ordered/tolerated, follow mental status hopefully can start to wean to extubate as well.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-29 00:00:00.000",
"description": "Report",
"row_id": 1456897,
"text": "pmicu nursing 7a-11a\n\npt was CMO with morphine infusing at 6 mgs/hr-appeared comfortable. family surrounding patient. patient bathed, am care done, dressings changed, etc. patient with profuse bleeding from mouth, sx freq. on rounds decision made with family to extubate patient- this was done and patient shortly thereafter became bradycardic and then apneic, asystolic. family in attendance. patient pronounced by dr at 9:48 am. family discussing possibility of autopsy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-28 00:00:00.000",
"description": "Report",
"row_id": 1456890,
"text": "Respiratory Care:\nPatient switched from CPAP/PSV to A/C ventilatory support due to abg changes (hypoxemia and increased acidemia). FIO2increased from 40 to 60% and PEEP increased from 5 to 10 cm PEEP. SPO2 now at 97% (was at 87%). ABG's to be drawn on the newest settings.\n\nNo RSBI measured due to the high FIO2 and PEEP required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-28 00:00:00.000",
"description": "Report",
"row_id": 1456891,
"text": "Respiratory Care (addendum):\nRepeat abg results determined a partially compensated moderately sever metabolic acidemia with slightly improved hypoxemia on the current settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-28 00:00:00.000",
"description": "Report",
"row_id": 1456892,
"text": "MICU 7 0700-1900 NPN\n\nPt. Dispostion: Made DNI/DNR\n\nTodays events: Pt. continued to have Hct drop. Received pt. with a hct of 25. After pt. received 4 units of rbc hct continued to drop to 22. Endoscopy was ordered. Scope was started aproximately at 1400. Pt found to have to much blood in gut to find source of bleed. Erythromycin was then ordered to empty the gut and second scope planned for today at 1700. Post endoscopy pt sbp began to drop to low 80's and 500cc fluid bolus given. Up to this point pt. has received a total of 5 units or rbc (with one still pending administration), 2 units of fresh plasma, and a 500cc bolus.\n\nNeuro: A/O x2-3 at times. Continues to become more and more lethargic. During scope pt. received 50mcg of fentanyl and 0.5mg of versed with good effect.\n\nCV: SBP continued to stay in the mid 90's with slight increase with rbc and plasma infusions. HR SB/NSR with no ectopy noted this shift.\n\nPlease refer to following correction for remaining NPN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-28 00:00:00.000",
"description": "Report",
"row_id": 1456893,
"text": "NPN Contiued:\n\nPt. received second endoscopy at approximately 1700, with family at the bedside. At the start of procedure patients sbp began to drop into the 80's with map less than 60. Dr. ordered 250cc bolus. Pt. continued to drop his sbp 1000cc fluid bolus was start running wide open. Fluid bolus was ineffective. Team was unable to control the bleed and was ordered. At this point the family decided to hold any further care, and wanted to just make him comfortable. 1mg of morphine IV push was administered. Dr. placed order for morphine gtt which was started at 1800 at 2mg per hour. Currently all preventative drug therapy and fluids have been held wit the exception of morphine gtt. Family remains at bedside.\n\nAt this moment pt. remains intubated and on AC 60%fio2, 400TV, 12RR, 10peep. encourage family to decrease settings on vent. Pt. sbp is holding in the low 60's with map of 45.\n\nPlan: Continue to provide comfort care to patient and titrate morphine as needed. Provide emotional support to family. Establish plan for ventilator settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-28 00:00:00.000",
"description": "Report",
"row_id": 1456894,
"text": "resp. care\npt. remains intubated/vented/sedated. no vent\nchanges this shift. pt. scoped and revealed bleeding\nbut to much blood to determine site. now a dnr/dni.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-29 00:00:00.000",
"description": "Report",
"row_id": 1456895,
"text": "Respiratory Care:\nPatient titrated down to 21 % and switched to CPAP/PSV. Patient is CMO. No morning abg results at this time.\n\nRSBI = 20 on 0-PEEP and 5 cm PSV\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-20 00:00:00.000",
"description": "Report",
"row_id": 1456854,
"text": "RESP CARE\n\nPT RECEIVED ON PSV 5/5 TOL WELL WITH STABLE OXYGENATION AND VENTILATION BUT WAS SWITCHED BACK TO A/C TO REST UNTIL PNA RESOLVES. PT C/O OF DISCOMFORT AND PAIN IN BELLY DUE TO DYSYNCHRONY IN VENTILATOR WHEN PT TRIGGERS BREATH ON OWN AND WAS SUBSEQUENTLY PLACED BACK ON PSV 10/5 THIS EVENING IN WHICH HE APPEARS MORE COMFORTABLE. BS SLIGHTLY COURSE AT TIMES SXING FOR MOD AMTS OF THICK TAN SECRETIONS. WILL CONT WITH VENT SUPPORT AND ADJUST SETTINGS ACCORDINGLY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-21 00:00:00.000",
"description": "Report",
"row_id": 1456855,
"text": "1900-0700 rn notes micu\n\nneuro: pt intubated, alert at time and responds to voice, c/o of abd and teeth pain recived Morphine Iv 1mg with response. move upper extreimetes, minimal movement of low extremeitis.\n\nresp; recieved on CPAP/PS 10/peep 5, pt had several times episodes of apnea, vent changed to MMV 50%/400/RR 12/Ps 10/peep 5. ABG:7.46/23/223, LS coarse, sat 99-100%. suction moderate amount yellow/thick secretion, sputun cx sent. pt start on contact for MRSA in sputum.\n\ncv: HR 58-62\"s, NSR, no ectopy, received Albumin 12,5 mg and fluid bolus for SBP 83-88/40's with minimal response, SBP up to 93-96. HCT at 2200 34.1, morning labs pending..\n\ngi/gu: foley in place, u/o 7-10cc/hr, Dr aware, given fluid bolus Ns 250cc, with minimal response, u/o 15-25cc/hr, Md aware. received NPO, Doboff has been advace and confirm with Cxr, good to use, TF restart at 30c/hr, residual 40cc. ABD ascities, BS hypoactive. cont passing liquid stool via mushroom cath.\n\nid:contact precaution, afebrile, cont Vanco/ ceftazidime. blood cx sent.\n\nendo: NPO evening held, cover with sliding scale.\n\nsocial: full code, family visited, updated by Dr .\n\nplan: cont monitoring resp/cardio/neuro status.\n follow BP and u/o\n follwos HCT, lytes, replete as needed.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-21 00:00:00.000",
"description": "Report",
"row_id": 1456856,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on CPAP/PS settings. During the noc changed to MMV d/t periods of apnea >30 seconds. Tolerated well. ABG shows respiratory alkalosis. Will attempt to decrease PS. RSBI completed on PS 5=31. BLBS are coarse.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-21 00:00:00.000",
"description": "Report",
"row_id": 1456857,
"text": "FOCUS; NURSING PROGRESS NOTE\n63 YEAR OLD MALE WITH NASH ADMITTED WITH GIB AND ENCEPHOLOPATHY. WAS INTUBATED FOR AIRWAY PROTECTION AND FAILED EXTUBATION X2 DUE TO HYPOXIA. LAST ATTEMPT 2 DAYS AGO COMPLICATED BY 200CC BRB FROM MOUTH.\nREVEIW OF SYTEMS-\nNEURO- HE IS FOLLOWING COMMANDS CONSISTENTLY TODAY. WAS SLEEPY THIS AM BUT HAD A PERIOD TODAY WHERE HE WAS WIDE AWAKE WRITING NOTES. HE CONT ON LACTULOSE. MAE. PEARL. HAS HAD BILAT LENS IMPLANTS IN HIS EYES.\nRESP- IS INTUBATED AND VENTED. CONT WITH THICK TAN SECRETIONS. WAS ON MMV VEWNT THIS AM. CHANGED TO A/C TO REST HIM THEN AFTER ROUNDS DECISION WAS MADE TO PUT HIM ON MMV AGAIN. ON 40% FIO2 PEEP 5 AND PS OF 10 ABG 7.40/28/152/18. HE IS BREATHING IN THE TEENS WITH TV AROUND 500CC. BS COARSE DIMINISHED AT THE BASES.\nCARDIAC- HR 50-60'S NSR WITHOUT ECTOPI. SBP 104-122. NADOLOL DOSE DECREASED TODAY TO 20MG QD FROM 40MG. K WAS 3.4 THIS AM TX WITH 40 KCL PO AND ALSO RECEIVED K PHOS. K AT 1400 4.0.\nGI- ABD WITH ASICTES. DISTENDED BUT SOFT. POS BS. CONT ON TF VIA DOBOFF FT OF ULTRACAL AT 50CC/HR. MIN RESIDUALS. GOAL IS FOR 65CC/HR. PASSING BROWN GREEN LIQUID STOOL VIA MUSHROOM CATH THAT IS GUIAC POS. OCTREATIDE DRIP RESTARTED TODAY AT 50MCGS/HR DUE TO DECREASING HCTS.\nGU- FOLEY PATENT DRAINING DARK YELLOW URINE AT 28-35CC/HR.\nHEME- HCT TODAY TRENDING FROM 30.9 TO 28.7. PLAN TO TRANSFUSE IF LESS THAN 28. NEXT HCT DUE AT . PLTS DOWN TO 27 THIS AM. REPEAT 29. RECIEVED 1 UNIT APHERESIS PLTS WITHOUT SIGNS OR SYMPTOMS OF REACTION. REPEAT PLT COUNT PENDING. HEPARIN DEPENDENT ANTIBODY SENT. HEPARIN DC'D S CL FLUSHES. INR 1.8. SHE4 HAD RECEIVED PO VIT K FOR THIS AND 1 U FFP TRANSFUSED WITHOUT SIGNS OR SYMPTOMS OF REACTION.\nID- TEMP MAX 97.3. CONT ON VANCO AND CEFTAZADIME. REPEAT SPUTUM SENT. REPEAT U/A SENT.\n PATIENT WIFE AND SON IN TO VISIT. UPDATED BY THIS NURSE .\nDISPO- REMAINS IN MICU A FULL CODE.\nPLAN- CONT TO MONITOR HCTS Q 6 HOURS.\n CHECK RESULTS OF HEPAIN INDUCED ANTIBODIES.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-21 00:00:00.000",
"description": "Report",
"row_id": 1456858,
"text": "FOCUS; ADDENDUM\nHEME- DR DECIDED TO TRANSFUSE 1U PRBC AND 1 MORE UNIT PLTS. UNIT OF PRBC HUNG TO RUN OVER 3 HOURS. NO SIGNS AND SYMPTOMS OF REACTION . AFTER PLTS TRANSFUSE TO GET REPEAT PLT COUNT 1 HOUR AFTER TRANSFUSION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-21 00:00:00.000",
"description": "Report",
"row_id": 1456859,
"text": "Resp Care\n\nPt remains intubated and currently vented on MMV (400 x12) PSV 10/5 tol well with Vt around 400-500cc and RR in the mid to upper teens. BS slightly course sxing for small to mod amts of thick tan secretions. Will cont with vent support and reassess for further weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-25 00:00:00.000",
"description": "Report",
"row_id": 1456875,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT DOZING MOST OF THE NIGHT. ABLE TO COMMUNICATE BY WRITING ON BOARD. OPENING EYES SPONTANEOUSLY. EXTREMETIES VERY STIFF, ENCOURAGED PT DURING NIGHT TO STRAIGHTEN THEM OUT. PT IS ABLE TO DO THIS. PT WROTE ON BOARD IF HE WAS DYING.\n\nRESP: PT REMAINS ON VENT. NO VENT CHANGES MADE OVERNIGHT. REMAINS. ON 50% 12/+10. PT HAS BEEN SX'D FOR MOD AMT'S OF THICK YELLOW SECRETIONS. LUNG SOUNDS COARSE THROUGHOUT. O2 SAT'S IN THE MID TO HIGH 90'S WHEN ON BACK OR FACING TO THE LEFT. BUT WHEN LYING ON RIGHT PT DROPS TO 89-91%.\n\nCV: PT IN NSR 50'S-70'S. BP WITHIN NORMAL LIMITS BY ALINE. AFEBRILE. PT RECEIVING OCTREOTIDE SC.\n\nGI:PT RECEIVING AT 40/HR. GOAL IS 60. ABD GREATLY DISTENDED WITH ASCITES AND FIRM. NO PLANS FOR TAP AT THIS TIME. PT INC X 1 FOR MOD AMT OF SOFT LIGHT BROWN STOOL. PT RECEIVING SCHEDULED DOSES OF LACTULOSE.\n\nGU: FOLEY CATH DRAINING VERY SMALL AMT'S OF CLOUDY URINE.\n\nSKIN: PT'S SKIN ON COCCYX INTACT, SLIGHTLY REDENED. PT HAS SOME SKIN TEARS AND SCABBED OVER AREAS ON ARMS. PT WITH PNEUMO BOOTS.\n\nACCESS: ALINE AND RIJ TLC ALL WITHIN NORMAL LIMITS.\n\nENDO: FOLLOWING SLIDING SCALE AND FIXED DOSES OF INSULIN. FINGERSTICKS CHECKED Q 6HRS.\n\nSOCIAL: FAMILY LEFT A NOTE FOR THE PT ON BOARD. PT DID READ IT. NO CALLS OVERNIGHT. PT IS FULL CODE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-25 00:00:00.000",
"description": "Report",
"row_id": 1456876,
"text": "Resp. Care\nPt. remains on MMV 400x12. Pt sx for mod amts thick yellow with scat rhonchi. MDIs given with good effect. No vent changes made during the shift.No RSBI due to 10 of peep,ABGs pending. Pt. tends to drop his Sats when lying on his right side.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-25 00:00:00.000",
"description": "Report",
"row_id": 1456877,
"text": "Respiratory Care\nPt remains intubated via #8 ETT found 23cm at the lip. CXR confirms good placement. RN aware. BS reveal coarse rhonci bilat. Suctioned tan thick moderate amount of secretions. BS still remain coarse with a slight increase in aeratation bilat. MDI given as ordered. Tolerated treatment well. Most recent ABG from yesterday reveals Compenstated Metabolic Acidosis with hyperoxia. FIO2 weaned to 40% Spo2 100%. Pt awake and alert most of the morning. Pt was able to communicate with board. Family member in to visit. Pt is in no distress at this time. Continue to monitor pt on present settings. Contine to work toward goals.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-19 00:00:00.000",
"description": "Report",
"row_id": 1456848,
"text": "micu npn 0700-1900\nPlease see carevue flowsheet for all objective data\n\nPatient extubated this am after being received on . rsbi in the 20's this am. Extubated to 70% cool neb. Pt initially w/good cough effort, although unable to expectorate w/o nts. Now pt on 100% nrb vs. 100% cool neb solution. abg on 100% nrb showing ventillation o.k, but po2 in the 50's. Pt has been now maintaining sats 90-92% on 100% cool neb. will check another abg shortly to evaluate.\n\nneuro- post extubation, pt lethargic, but able to tell me who and where he was. More c/o being tired this afternoon, not able to get him to cough as much as earlier the day. conts to have a poor gag as well.\n\ncv- hr 50-60's this am. nadolol held. bp 90-120's this am via r radial abp.\n\nresp- as above. remains on 100% cool neb. sats 89-92%. cpt given x3. cont pulm toilet and try to avoid reintubation and trach placement.\n\ngi/gu- ngt put in prior to extubation for meds and anticipated feeding over the next several days if he does well extubated. abd remains distended, +bs. sm to mod amts of brown residuals. remains npo.\nuop low ~20cc/hr. team amde aware throughout the day, opting to watch for now as team is still debating fluids vs lasix. cvp checked and is . no s+s of bleeding gib resolved.\n\nsocial- family at the bedside through the day, attempting to encourage pt to bring up secretions. family have said pt agrees to be re-intubated and trached if he fails. They are hoping to speak with the liver team again today to talk about his future transplant options.\n\nCont agressive pulm toileting, ?mask ventillation if conts to desat vs/ re-intubation.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-19 00:00:00.000",
"description": "Report",
"row_id": 1456849,
"text": "Resp. Care Note\nPt initially intubated and vented on PSV 5 peep 5 and 40%. RSBI 35 this morning. Pt extubated about 13:00 but required reintubation about 3 hours later for worsening oxygenation, inability to clear secretions and bleeding from NGT. Pt reintubated with 8.0 ETT secured at 20cm lip. BS decreased at R base. + color change on EZ cap. Placed on vent with AC settings as charted on resp flowsheet. Albuterol MDI given. Follow ABG's adjust vent as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-20 00:00:00.000",
"description": "Report",
"row_id": 1456850,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. No vent changes made overnight. Continues on A/C 400*12 50% with peep 10. Breathsounds are coarse. Albuterol given. Suctioned for thick tan/brown secretions. Please see respiratory section for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-20 00:00:00.000",
"description": "Report",
"row_id": 1456851,
"text": "MICU 7 RN Note 1900-0700\n\nEvents: Hypoxic FIO2 ^, Hypotensive Low u/o, CVP 3-5 recieved FB.\n\nNeuro: responsive to verbal stimulation lethargic less interactive, opens eyes tracks surroundings Pupils 3mm equal react brisk. recieved Eye med per routine, L eye ^ redness. Moves UE minimally Equal weak hand grasps. Moves LE to command. No tremors/siezures. pt nods yes to pain indication abd discomfort with movement. recieved lactalose hepatic encephalopathy\n\nCV: HR 55-74 NSR-SB rare PAC, R radial aline inplace sharp wave form, SBP 90-104 maps >60 @ 0400 hypotensive SBP>90 CVP 3-5 recieved FB 1L with responding ^SBP. R IJ TLC CVP 3-6, goal CVP =or>8, Peripheral pulses 3+ DP/DT, neg edema. s/p transfusion Hct 44.4 this am lab pending. AM labs pending.\n\nResp: intubated # 7.5 ETT pos R lip. Started shift Vent mode CMV % 10peep ABG 3.36-28-57-16 FI02^70% pt then suctioned for lg amt thick tan/green secretion specimen sent to lab. repeat ABG 7.36-27-237-16 FI02 to 60% AM ABG on 400-12 60% 10peep 7.38-24-137-15-8 Met acidosis resp compensation, peep to 5cm. OBV 0-4BPM TV >300. Sats 100%, Lungs coarse, suctioned q3hrs thick tan secretions.\n\nID: Hypothermic Temp 95-96.3 Hugger all shift. lactate 1.8,^2.2, WBC trending ^ 18.2 (17.6), Abx Rifaximine, Ceftezidine, vanco awaiting ID approval not given this shift.\n\nGI/liver: Octreotide 50mcg/hr, Abd soft distended + BS NGT inplace Placement per CXR on Stomach coiled up to esophagus. NGT to Low sx dr bile/bl tinge no active bleed this shift clamped for meds. Mushroom cath in place dr green/brown stool.\n\nGU: foley u/o amber 10-30cc/hr BUN Creat 44/1.2\n\nDerm: Skin impaired mutiple abrasions, ecchymosis coccyx duoderm inplace. repos freq pt on airbed,\n\nSocial: full code status. Family visited @ start of shift.\n\nPLan: Wean vent as tol\n Maintain goal CVP\n Team to reposition NGT\n ? albumin\n Monitor for bleeding/seriel HCt\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-20 00:00:00.000",
"description": "Report",
"row_id": 1456852,
"text": "FOCUS: NURSING PROGRESS NOTE\n63 YEAR OLD MALE WITH ESLD ADMITTED FROM OSH INTUBATED WITH GIB AND ENCEPHALOPATHY. FAILED EXTUBATION X2 LAST BEING YESTERDAY WITH BRB FROM MOUTH.\nREVEIW OF SYSTEMS-\nNEURO- ABLE TO OBEY COMMANDS CONSISTENTLY. PEARL. OF NOTE HAS HAD LENS IMPLANTS IN BOTH EYES. MAE. DID ATTEMPT TO GRAB ETT SO SOFT WRIST SAFETY DEVICES PUT ON ARMS. CONT ON LACTULOSE.\nRESP- IS VENTED AND INTUBATED. ETT ROTATED AND RETAPED AT 20CM AT THE LIP ON RIGHT. SUCTIONED FOR THICK TAN SPUTUM. WAS ON CPAP OF THIS AM BUT CHANGED TO A/C 12 OVERBRETHING BY UP TO 10 BREATHS AND 60% FIO2 TV 400 AND 5 PEEP. THIS WAS TO TOTALLY REST THE PATIENT. ON THIS SETTING ABG 7.38/26/208/16. FIO2 DECREASED TO 50%. BS COARSE.\nCARDIAC- HR 70'S TO 60'S NSR. SBP 90-110. NADAOLOL HELD THIS AM DUE TO DECREASED BP. ON ROUNDS / AS TO WHETHER WE SHOULD GIVE HALF THE DOSE. SBP ABOVE 100 SO 20MG GIVEN WITH SBP DOWNT O 90'S THEN BQACK UP TO 100. CVP 4-9.\nGI- ABD WITH ASICTES. POS BS. HAD NG THAT WAS COILED IN ESOPHAGUS. THIS WAS PULLED BY LIVER TEAM. DOBOFF PLACED IN LEFT NARE BY DR . XRAY DONE. PENDING RESULTS BEFORE TUBE CAN BE USED. ? IF TF TO BE RESTARTED OR NOT. WILL CHECK WITH TEAM ONCE TUBE CONFIRMED. CONT ON OCTREATIDE AT 50MCGS/HR.\nGU- FOLEY PATENT. UO DOWN TO 8CC/HR THIS AM. LIVER TEAM WANTED HIM TO GET ALBUMIN. DR NOTIFIED AND 25GMS 25% ALBUMIN GIVEN. UP TO 25-30CC/HR. DR MADE AWARE.\nRENAL- CREAT STABLE AT 1.3.\nHEME- ON HCT CHECKS Q 6 HOURS. HCT THIS AM 44.6. 6 HOURS LATER 39.5 AFTER RECEIVING 1500CC FLUID. DR MADE AWARE. HCT AT 1500 35. DR MADE AWARE. GAOL IS TO KEEP IT ABOVE 28. STOOL IS BROWN GREEN GUIAC POS.\nID- TEMP 95.2 TO 98.1. BAIR HUGGER OFF NOW. VANCO ID APPROVED. RECEIVED 0800 DOSE AT 1500 WILL BE DUE AT FOR NEXT DOSE. CONT ON CEFTAZADIME. U/S OF ABD DONE TO MARK TAP SITE. TAPED FOR APPROXIMATELY 50CC OF CLEAR YELLOW FLUID THAT WAS SENT FOR SPEC.\nENDO- NPH INSULIN HELD AS NOT ON TF. ON SS INSULIN. BS AT NOON 180. WOULD HOLD PM NPH IF TF NOT RESTARTED.\nSOCIAL- MULT FAMILY MEMBERS IN AND UPDATED BY THIS NURSE.\nDISPO- REMAINS A FULL CODE.\nPLAN- FOLLOW HCTS Q 6 HOURS.\n MONITOR MS.\n MONITOR SPUTUM\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-20 00:00:00.000",
"description": "Report",
"row_id": 1456853,
"text": "FOCUS; ADDENDUM\nPAIN- C/O OF ABD PAIN THIS AFTERNOON. APPEARS TO BE RELATED TO BREATHING PATTERN ON A/C. WHEN HE TAKES BREATH AND IS AT THE SAME TIME GETTING A BREATH FROM THE VENT HIS BELLY POPS OUT CAUSING PAIN. DR MADE AWARE. WILL SWITCH TO PS VENT AT HIGHER PRESSURE SUPPRT THAN THIS AM AND SEE IF PATIENT MORE COMFORTABLE.\nGI- CHECKED WITH DR ABOUT FT PLACEMTN ON XRAY. SHE NEEDS TO ADVANCE THE TUBE MORE. OCTREATIDE DRIP TO BE DC'D. WILL DO NOW.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-24 00:00:00.000",
"description": "Report",
"row_id": 1456873,
"text": "pmicu nursing progress 7a-7p\nreview of systems\n\nCV-vs have been stable, but was bradycardic this am and corgard held due too hr of 49-55. no further chest pressure, cycling enzymes, which have been low.\n\nID-afebrile. wbc=9.3. vanco level was 42.1 and dose held.is on contact precautions\n\nGI-abd is tight with ascites and pt c/o pressure there, no acute abd pain.decision made on rounds not to tap belly.receiving lactulose and passing small amts liquid stool, ob-.is on ppi, carafate and h2 blocker.was started on octreatide sc q 8 hrs and mididrine po tid.minimal residuals via pedi feeding tube and tube feeds infusing at 40/hr. bladder pressure 12.\n\nNEURO-alert and oriented.has been lethargic but arousable, writing notes to all with many questions.accepted morphine at 4 pm-tx with 1 mg iv and did well, looked very cozy and was snoozing.\n\nF/E-has had continued low urinary output- 5-20/hr.team aware.received albumin usual qd dose.no further ivf boluses. urine osmolality sent.please see am labs.no periperal edema noted\n\nSKIN-reddened coccyx with aloe vesta cream applied, nystatin powder to perianal areas.elbows and knees also pink, is on kinair bed.\n\nRESP- a few adjustments were made to the vent to provide comfort to pt and wean fio2,is currently on 50% x 10 peep and 12 PS- sTVs are 500-600ccs and rr 15-24. o2 sats have been >95% and abg with po2 144, pco2 23 and pH 7.38. lungs sound coarse and pt has been sx several times for loose thick tan secretions.CXR done.\n\nIV ACCESS-has a triple lumen R neck IJ and an a-line R wrist.both sites look OK.\n\nSOCIAL-family in with many questions and suggestions, have left for the evening.\n\na-uneventful day, probably heading to hepatorenal failure\n\nP-will watch i's and o's, labs.extra albumin prn. continue to wean vent as we can.continue to assess daily need to tap belly for comfort.maintain communication with family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-24 00:00:00.000",
"description": "Report",
"row_id": 1456874,
"text": "Resp Care\n\nPt remains intubated and currently vented on MMV (400x12) PSV 12/10 tol well with Vt around 400-500cc and RR in the mid to upper teens. BS clear to slightly course sxing for small to mod amts of thick tan to yellow secretions. ETT secured/patent. ABG revealed compensated metabolic acidosis with excellent oxygenation on present vent settings. Bronchodilators given x2 with improved aeration. Will cont with vent support and reassess for further weanind if tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-24 00:00:00.000",
"description": "Report",
"row_id": 1456871,
"text": "NPN 7p-7a:\n Nuero: early in shift, pt reporting relief of ab discomfort and breathing discomfort s/p mso4 in evening. awakens to voice,\nA + O x 3, communicating needs via dry erase board. Reporting epigastric pressure/lower sternum pressure at 4am. ekg done and team into eval.. Per HO, pt with ? some anterior changes that do not appear new. cpk's sent, first cycle flat. pt fell to sleep after this without further intervention.\n RESP: pt apneic in evening s/p mso4.. placed on A/C 400 x 12/.60/peep 10. overbreathing to 18-20x/min total. abg: 7.40/22/92/14. team aware.. do not wish to make any further vent changes at this time. lactate 2.1. Sx for thick tan secretions q 3-4 hrs. evening cxr showed mucous plugging.\n CV: HR 70's nsr. bp 90's-100. cvp 10-12. ekg done, cpk's done as noted above. team does not feel origin of \"pressure\" is cardiac, as can reproduce by pressing epigastric area.\n GU: UO decreased to 5cc-10cc's/hr... received 12.5gm albumin x 2 o/n, as well as 250cc ns bolus x 2 without effect. bladder pressure 18. urine lytes sent.. per team, suspicious for developing Hepato-renal syndrome.\n Gi: ab with ascites, bs hypo. tf's restarted at 30cc's/hr, increased to 40cc's/hr d/t low residuals. mushroom cath clotted off with stool, so dc'd. no further stool o/n despite lactulose. Octreotide dc'd per team.\n Integ: mycostatin/aloe vesta to reddened scrotum and coccyx. multiple skin tears on arms/elbows. on kinair bed.\n FE: received 20meq iv kcl for am k+ 3.8. fsbs covered per ssi.\n Social: family in during evening and updated by team.\n A/p: pt with ? devoloping hepatorenal syndrome. UO worsening. will ROMI. will follow uo s/p fluid bolus and 2nd dose albumin. no vent changes at this time.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-24 00:00:00.000",
"description": "Report",
"row_id": 1456872,
"text": "Resp Care\nPt remains on vent. Intubated with # 8 ett @ 20. Patent and secure. Suctioned for mod amt of thick yellow secretions. Mdis given. Placed on AC due apnea spells. abg is copnsated metabolic acidosis. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-23 00:00:00.000",
"description": "Report",
"row_id": 1456867,
"text": "NPN 7p-7a:\n Nuero: Pt opens eyes spontaneously. follows commands. writes needs and questions on board. Mae. A+O x .. thought he was at . Reported ab cramping x 1.. lactulose held x 1 as pt with close to 1L stool out yesterday. cramping improved, no other pain.\n CV: HR 50's-60's SB, NSR and sbp 100-134. cvp 6.\n REsP: vented PSV 10/5/.40. tv's 360-400's, sats 99-100%. RR 20's. abg: 7.42/22/120/15. Sx for thick yellow secretions q 4 hrs.\n GI: ab taut with ascites. bs +. tf's advanced to 60cc's/hr.. goal is 65cc's/hr. mushroom catheter intact. 400cc's stool out this shift. on lactulose and rifaximin. CT showed no retroperitoneal bleed.\n GU: uo remains poor. team aware. total 1L fluid bolus given o/n. UO remains 15-20cc's/hr.\n ID: afebrile. On vanco.\n FE: fsbs per ssi.\n Integ: very poor. duoderm to coccyx. sores on elbows. tegaderms on arms. bruising to arms. pt on kinair bed.\n A/P: am labs pending. team to reevaluate ability to retrial extubation today. Has failed in past d/t hypoxemia. now also with metabolic acidosis as well. f/u results am labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-23 00:00:00.000",
"description": "Report",
"row_id": 1456868,
"text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-vs have been stable, MAP has been >60, all though corgard was held due to bp 90's/.no c/o CP or palps.\n\nID-has been afebrile. wbc=7.0 this am. vanco level 47.8 this am and so dose was held.is on contact precautions.\n\nGI-abd is large and ascitic, has hypoactive bowel sounds present.unable to withdraw residuals easily as feeding tube is a pedi tube.tube feeds infusing at 60/hr until pt c/o abd feeling too full-placed on hold.is on a ppi, carafate and h2 blocker.tx with lactulose-draing a small amt liquid yellow stool via mushroom catheter.octreatide infusing at 50/hr.no further apparent GI bleeding.\n\nNEURO-has been alert and writing appropriate questions, comments, c/o SOB and belly fullness.no sedatives given, patient refusing pain meds at this time.\n\nF/E- no further boluses given. ivf at . urine output has continued to be low,team aware.no peripheral edema noted. tx with daily albumin which did briefly improve u/o. please see labs in carevue, 5pm labs pnd.\n\nRESP-was looking comfortable on vent, snoozing and visiting, sx for small amt thick sputum.later this afternoon became SOB, tachypneic to 35 and increasingly hypoxic-o2 sat down to 89%, abg at this time with a p02 of 55, pco2 34 and pH 7.32. fio2 was increased to 60% and PS increased to 15. CXR from this am looked at again and noted was a R pleural effusion as well as pronounced ascites crowding lungs. patient requesting to have belly tapped-awaiting fellow to see patient.at this time o2 sats are 94% and rr 25, pt again c/o SOB.\n\nSKIN-elbows look pink and sore, duoderm on coccyx intact.was switched to a fresh kinair bed as the battery pack was broken on old one.\n\nENDO-receiving fixed dose of NPH and sliding scale of humalog.\n\nIV ACCESS-pt has an a-line R wrist and a triple lumen R IJ-all dressing changed and sites look good.\n\nSOCIAL-multiple family members in to visit, all with many questions and ideas on how to care for patient.updated by RN and resident.\n\na-pt now with worsening oxygenation and SOB, probably due to worsening ascites, pleural effusion.\n\nP-awaiting fellow for consult re: tapping belly. we are trying repositioning patient to make more comfortable.check 5 pm labs.keep patient, family updated as to all plans,procedures.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-23 00:00:00.000",
"description": "Report",
"row_id": 1456869,
"text": "Resp Care\n\nPt received on MMV (400x12) and was placed on PSV with no apneic periods noted this shift but required increase PS and fio2 to maintain adequate oxygenation and ventilation due to worsening pleural effusion on right side as noted per CXR. BS course sxing for small to mod amts of thick white to yellow secretions. ETT secured/patent. Will cont with vent support and make changes accordingly. ? tap effusion to better optimize oxygenation status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-23 00:00:00.000",
"description": "Report",
"row_id": 1456870,
"text": "pmicu nursing addendum:\n\n6pm- fellow and resident examined pt and looked at cxr, did a bedside US-decided against tapping belly. pt tx with 1 mg morphine (with his consent) and repositioned again for comfort.after repositioning was able to withdraw some residuals from pedi feeding tube-90ccs and so water bolus held and tube feeds continue to be held due to fullness in abdomen.of note, 5 pm wbc elevated to 12.8. CXR to be repeated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-13 00:00:00.000",
"description": "Report",
"row_id": 1456821,
"text": "resp. care\npt. intubated for airway protection at osh. scoped for gib.\n7.5 ett taped at 24 cm at the lip. bbs clear and equal. 63 yo\nliver failure on transplant list.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-13 00:00:00.000",
"description": "Report",
"row_id": 1456822,
"text": "1500-1900\npt admitted to @ 1500 from Hosp, intubated, unresponsive, sandostatin gtt @ 50 mcg/hr, 3 #20 g sl's, foley, responds to painful stimuli with facial grimacing, GI up & endoscopy done, no variceal bleeding noted, pt with moderate amt blood in stomach ? due to errosion, plan to continue sandostatin gtt & start protonix gtt, protonix gtt hung after endoscopy, to repeat endoscopy in days, admission labs sent, incont mod amt melana stool on admission, ho aware, FIB applied, family in & updated on pt's condition by nurse & medical team\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-27 00:00:00.000",
"description": "Report",
"row_id": 1456885,
"text": "NPN MICU-7 West 1900-0700\nAllergy: Sulfa\nFull Code\nContact Precautions\n\nDx: Nonalcoholic Liver Failure (hx Varices)\n\nNeuro: Pt is alert and oriented x 3, writes on wipe board clearly, pupils 2mm sluggish, glaucoma for which he received eye drops, hx of pink eye/style still receiving , appropriately for age, impaired gag and cough. Received Morphine 1 mg IV for abdominal pain.\n\nResp: Pt received on MMV (400 x 12) peep8 and Ps 10 weaned to CMV peep5/ps5 ABG wnl. Has had low C02 for some time and failed extubation x 3 due to inability to clear secretions. Risbi 31.\nLS rhonchi to clear, diminished at bases, RR 12-35. Suctioning thick tan secretions q 2-4hrs.\n\nCv: HR 45-55 sb, a-line in place and wnl, right IJ infusing well, cvp8-10, sbp 100-130 nadalol hELD. Pulses palpable in all four extremties.\n\nGu/Gi: Foley cath bloody around meatus outputing scant amounts of yellow/sediment urine per hour secondary to hepatorenal syndrome. BS distant, abd distended/+ascites, very small golden soft BM tonight.\nCachetic, TF HELD for Residual 400cc. TF still on HOLD awaiting advancement of Dobhoff to post-pyloric, will occurr in IR today.\n\nLabs: See carevue\n\nEndo: FSBS q ghrs requiring coverage\n\nId: afebrile\n\nSkin: KinAir bed, coccyx stage 1 ulcer improving barrier applied, old skin tears on hands. Microstatin applied to groin.\n\nSocial: Son visited last night\n\nPlan: Liver following patient, candidacy for transplant will depend on whether or not patient can tolerate extubation\n Extubate?\n Dobhoff advancement to post-pyloric in IR today\n No plan to tap ascites today re: Dr. \n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-27 00:00:00.000",
"description": "Report",
"row_id": 1456886,
"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": "2115-11-22 00:00:00.000",
"description": "Report",
"row_id": 1456863,
"text": "FOCUS; NURSING PROGRESS NOTE\n63 YEAR OLD WITH NASH. ADMITTED WITH HEPATIC ENCEPHALOPATHY AND GIB. FAILED EXTUBATION X2 DUE TO HYPOXEMIA. INTUBATED AND AWAKE AT PRESENT WITH ? VAP.\nREVIEW OF SYSTEMS\nNEURO-MUCH MORE AWAKE TODAY. WRITIG NOTES. MAE. FOLLOWS COMMANDS. CONT ON LACTULOSE AND RIFAXAMIN.\nRESP- REMAINS INTUBATED AND VENTED. ON40% FIO2 PEEP 5 AND 10PS WITH BACK UP MMV. TV HAVE BEEN 500-600CC WITH RESP . SATS 100%. ABG EARLY THIS AM ON THESE SETTINGS. BS COARSE DIMINISHED AT THE BASES. SUCTIONED FOR THICK TAN TO YELLOW SPUTUM WHICH IS THINNER AND LIGHTER IN COLOR THAN IT HAS BEEN. EXTUBATION BEING HELD DUE TO SECRETIONS AND PATIENT'S POOR COUGH EFFORT.\nCARDIAC- HR 50-70'S SB TO NSR WITHOUT ECTOPI. CONT ON NADOLOL. SBP 106-148. K 3.6 TX WITH 40MEQ KCL.\nGI- ABD WITH ASCITES. MUCH MORE INCREASED SINCE YESTERDAY. HYPOACTIVE BS. PASSING SMALL AMOUNTS GREEN BROWN STOOL VIA MUSHROOM CATH. CONT ON TF NOW UP TO 40CC/HR WITH MIN RESIDUALS. WILL CONT TO ADVANCE BY 10CC/HR Q 4 HOURS TO GOAL OF 65CC/HR.\nHEME- HCT THIS AM 32.1. REPEAT AT 0900 34.1. WILL RECEHCK AT 1700 ALONG WITH PLATS THAT WERE 35 THIS AM. HAD NONCONTRAST CT THIS AM TO LOOK FOR RETROPERITOEAL BLEED AS HE HAD A 10 PT HCT DROP OVER 24 HOURS. RESULTS PEND.\nENDO- DID NOT RECEIVE AM DOSE OF NPH THIS AM AS BS WITH AM LABS WAS 59. BS AT 1100 167. 4 U NPH GIVEN. BS AT NOON 175 TX WITH SS. WILL RECEIVE SUPPER NPH.\nID- TEMP MAX 100 TODAY DR MADE AWARE. CEFTAZ DC'D. WILL FOLLOW VANCO LEVELS TODAY.\nSOCIAL- FAMILY IN AND UPDATED BY THIS NURSE. IN AND UPDATED FAMILY AS WELL.\nDISPO- REMAINS IN MICU A FULL CODE.\nPLAN- CONT TO MONITOR HCT. CHECK RESULTS OF ABD CT. MONITOR SPUTUM. ? EXTUBATE IN NEXT DAY OR TWO ONCE SECRETIONS LESSENED . IF FAILS THIS EXTUBATION MOVE TO TRACH AND PEG.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-22 00:00:00.000",
"description": "Report",
"row_id": 1456864,
"text": "respiratory care\npt on the vent tol well no changes made. pt remains on MMV see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-22 00:00:00.000",
"description": "Report",
"row_id": 1456865,
"text": "focus; addendum\nheme- repeat hct stable at 33.5. plts stable at 35. preliminary report of abd ct neg for retroperitoneal bleed.\ngu- uo down to 25cc/hr then 20cc/hr . dr notified and 12.5 gms of 25% albumin ordered and given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-23 00:00:00.000",
"description": "Report",
"row_id": 1456866,
"text": "Respiratory Care Note:\n Patient continued through shift on MMV back up set of 4.8l. He appeared comfortable and breathed spontaneously on PSV of % with few periods of backup noted. Suctioned for pale yellow sputum, received albuterol MDIs Q4prn. See Carevue flowsheet for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-26 00:00:00.000",
"description": "Report",
"row_id": 1456880,
"text": "Resp. Care\nPt. remains on mech vent. No changes made during shift. Pt. sx for mod amts thick yellow with scat rhonchi clearing with sx. MDIs given with good effect.ABGs drawn,see carevue. RSBI not done due to peep of 10.Plan is to wean as tol,and to discuss with family about transplant.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-26 00:00:00.000",
"description": "Report",
"row_id": 1456881,
"text": "respoiratory care\npt on the vent changes made tol well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-26 00:00:00.000",
"description": "Report",
"row_id": 1456882,
"text": "Respiratory Care: Pt remains on current vent settings of MMV. Both peep and PS were decreased earlier today, and pt is tolerating changes well. Has a large amt secretions, which require frequent suctioning. Receiving MDI's. Occasionally has a ^RR and MV, but settles out.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-26 00:00:00.000",
"description": "Report",
"row_id": 1456883,
"text": "NPN 7a-7P:\n NUero: unchanged. Pt communicating via dry erase board. mae, normal strength upper, minimal strength lower extemeties. OOB to chair via lift x 2 hrs.\n rESP: remains on mmv vent mode, changed to 400 x 12/peep 8(10)/ps 10(12). sats remain high 90's-100, rr high teens to 20 most of shift. became tachypneic x 1 while oob and mobilizing secretions. sx for copious tan thick secretions while oob. LS bronchial bases. will send abg on current mode.\n CV: CVP 9-10. HR 50's-60's sb/nsr, sbp 100-130's. nadolol held this am.\n GI: tf's shut off d/t 400cc's residual. Resident advanced feeding tube.. await cxr to see if post pyloric. remains on lactulose. remains on octreotide and midodrine for Hepato-renal syndrome. Remains on prevacid and carafate. no s/s gib. moderate soft bm this am, brown, ob negative, sent for cdiff. ab tense with ascites.\n gU: foley with uo 10-15cc's/hr. urine yellow with sediment.\n Integ: groin and coccyx improved from this weekend. continue with mycostatin/aloe vesta to these areas. on kinair mattress, and therapeutic chair pad used when oob to chair.\n Social: plan is for team to speak with transplant surgery to discuss plan r/e could pt still be on transplant list with a trache.. if not, team to discuss this with family r/e other plans of care. Family intermittently in visiting throughout the day.\n A/p: pt not tolerating tf's, await to see if feeding tube is post pyloric. await word from transplant team r/e trache. in the meantime, will check abg on current settings, and ? reattempt further weaning/breathing trial in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-27 00:00:00.000",
"description": "Report",
"row_id": 1456884,
"text": "Resp. Care\nPt. remains on mech vent. At 2100 pt was flipped from MMV to CPAP/PS 5/5.Pt. tol change well continues too have a MV of rr14 and VT 400-500.Pt was given MDIs as ordered and tol well having good effect. Pt sx for large amts of thick tan secr.RSBI to be done later and plan is to wean as tol. to extubate today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-25 00:00:00.000",
"description": "Report",
"row_id": 1456878,
"text": "Nursing Progress Note 0700-1900\nS: Intubated, writing on dry erase board.\n\nO: Please see flowsheet for complete objective data.\n\nCV: SB/NSR, 50-60's. SBP 110-150's. CVP 15-17. Hct-33.6 (31.4) PM labs pending. C/o chest pressure last PM, r/o MI.\n\nRESP: Intubated on MMV, Tv-500, 40%, PEEP 10, PS 12. Sxn'd for thick whitish tan secretions. Sats remain @ 100, despite positional changes. Lungs coarse throughout. Mouth care done.\n\nGI: Liver cirrhosis caused by NASH, severe ascites. Abd very firm distended. TF via NGT @ 40cc/hr c goal of 60cc/hr. Residual 65.0cc, but TF not advanced. BS hypoactive, no stool, gave lactulose.\n\nGU: Foley draining amber/yellow sedimented urine. UO decreasing over LOS. Rec'ing albumin, attempting to reverse hepatorenal syndrome.\n\nEndo: FS Q6h, Humalog ss. NPH fixed doses.\n\nAccess/ID: RSC TLC, R radial A-line. Afebrile. WBC-7.6\n\nNeuro/Social: Dozing off and on. C/o being cold, stiffens arms and shakes. Settles with encouragement. Able to communicate by writing on dry erase board. Mentating. No c/o pain. Wife and son into visit today. Needs to have family meeting c Liver and MICU teams about POC.\n\nA: 63 yo male admitted for liver cirrhosis caused by NASH. c/b hepatorenal syndrome. s/p failed extubations r/t plugging and increased ascites.\n\nP: Continue to monitor hemodynamics and resp status. Continue TF, check residual, advance if tol. Monitor bladder pressure and UO. Follow up c PM labs. ?Family meeting re: transplant/trach, POC. Emotionally support pt and family. keep updated on plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-22 00:00:00.000",
"description": "Report",
"row_id": 1456860,
"text": "1900-0700 rn notes micu\n\nneuro: no changes in neuro status, alert/response to voice, able to write and nod for yes /no. lift and hold upper extremeties, moves low extremeties in bed, follows simple commands.\n\nresp: inrubated MMV mode 40%/400/RR 12/peep 5/PS 10, suction for small yellow secretion, LS coarse dim at bases.ABG: 7.45/24/142.\n\ncv: HR 53-60, SB no ectopy, ABP 110-115/50's, cont Octreodite, HCT at evening 30.6,PLT 35 after 1u PLT, MD aware.IMR 1.6.morning labs pending. no signs of bleeding.\n\nid: Tmax 98.5, cont ceftazidime, Vanco d/ced d/t level 67.8, that can cause leucopenia and rash. lactate 1.6.\n\ngi/gu: foley in place, uirne became cloudy, urine cx send, u/o 25-30cc/hr. ABD ascitis,BS hypoactive,TF hold d/t residual 100-150cc. cont passing liquid brown stool via mushroom cath.BS FS at morning 76.\n\nplan: cont moniotring neuro/resp/cardio status\n follow HCT,WBC level and signs of rash.\n follow u/o.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-22 00:00:00.000",
"description": "Report",
"row_id": 1456861,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Current vent settings MMV 400 x 12, PSV 10, Peep 5, Fio2 40%. Tolerating well. Spont vols 500's with RR low to mid teens. Very little support from MMV. Bs slightly coarse bilaterally. Sx'd for sm amounts of thick yellow secretions. RSBI 30 this am. CXR Low lung volumes due to tense ascites. Repeat ABG's reveals compensated metabolic acidosis. No further changes made.\nPlan: Continue with mechanical support and wean to PSV and decreased support as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-22 00:00:00.000",
"description": "Report",
"row_id": 1456862,
"text": "ADDENDUM TO NOTES ABOVE\n\nAT 0500 RESIDUAL 20CC, RESTART TF AT 20CC/HR,K=3.6, INR 1.8, DR AWARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-11-26 00:00:00.000",
"description": "Report",
"row_id": 1456879,
"text": "1900-0700 rn notes micu\n\nneuro: pt alert, comunicate by writting on white board and nodding head for yes/no, follows simple commands, moves upper extremeties, minimal movement of low extremeties. no c/o of pain.\n\nresp: intubated, MMV mode 40%/400/RR12, peep 10/PS12. sat 99-100%, suction for moderate tan thick secretion. LS coarse bilat., morning ABG 7.43/24/161.\n\ncv: HR 49-52, SB, no ectopy. ABP 112-130/50's. CVP 14-17. bladder pressure 12.HCT stable at 34.9 (33.6), no signs of bleeding. ocnt Octreotide SC.\n\ngi/gu: foley drainge yellow cloudy with sedemet urine 15-25cc/hr, MD aware. ABD firm/dist with ascitis, BS hypoactive, brown soft stool this shift. received TF at 40cc/hr, residual 60-80cc, decreased to 30cc/hr, residual 20cc. cont Lactalose.\n\nendo: cover by RISS and given NPH at everning.\n\nsocial: full code, family visited.\n\nplan: cont monitoring resp/cardio status\n follow u/o, residual advance TF as tollerates\n transplant surgion disscussion about further managment with micu team and family->?famuly meeting.\n\n\n\n\n"
}
] |
10,549 | 105,502 | The patient is an 84 year old male with a history of CAD s/p CABG (SVG->RCA, LAD), CHF EF 20%, HTN s/p AAA repair, significant tobacco history and HL, and chronic renal insufficiency (baseline Cr unknown) who presented on with NSTEMI with peak troponin of 9.18 now s/p cath with DES to LAD and LMCA The patient was continued on aspirin, plavix 75 mg x 9 months post PCI, Integrillin 18 hours post cath, and simvastatin 40 mg. His Atenolol 50 mg QD was changed to Lopressor 50 mg TID with good effect. The patient's BP remained well-controlled on Lopressor 50 mg TID. An ACE would be beneficial for cardiac remodeling, however, given his rising creatinine, an ACE was not initiated at this time. Patient has history of CHF with EF of 20%.The patient appeared overloaded on presentation. He is not on an ACE. We gave him another 40 mg IV lasix x 1 on transfer to the CCU, he received 40 mg IV lasix in the cath lab and was transferred from on Lasix 40 mg IV BID. He takes lasix 40 mg QD x 3 days (per patient) and HCTZ 50 mg x 4 days (per patient) at home for the past 2 weeks. He diuresed well to Lasix 80 mg IV and then stablized on lasix 40 mg QD. His baseline creatinine is unknown, it was 1.6 (1.5 at OSH)on presentation. It rose to 2.2 with aggressive diuresis. He was doing well post cardiac catheterization until the early morning of . He suddenly went into ventricular fibrillation. Code was called and was fully ran. He was defibrillated 10 times with no restoration of regular pulse. Patient was intubated. He also recieved epinephrine, atropine, magnesium and calcium when central access was established. Echocardiogram was performed at the bedside and no pericardial effusion was found. The code was ran for about 30 minutes. Family member and the attending were called. Family member denied post mortem. | NIBP 98-126/42-74. BUN/Cr 43/1.7. Ooze stabilized overnoc. Bicarb gtt dc'd d/t ^ volume status. VSS overnoc. Distal pulses +2/+1. Left A/C infiltrated. Dsg changed x1. +BS. Most recently admitted for NSTEMI and CHF exacerbation managed w/ diuresis at OSH. R>L. Will return this am. Pt is currently -618cc. H/O CRI but baseline unclear. Repeat labs this am K+ 3.7 following repletion. S/P stent placement x1 to LMCA and stent x3 to prox/mid LAD. Mg wnl. D/c Integrillin at 1015 am. IMPRESSION: Cardiomegaly and postoperative changes. There is elevation of the right hemidiaphragm. At 0200, pt awoke and self dc'd PIV. At 0200, pt self dc'd PIV. There is cardiomegaly and postoperative changes from prior sternotomy. F/C to gravity. Post op hydration cont 1/2 NS at 75cc x1L.ID: Tmax 98.2 PR. CR currently 1.7 following 390cc contrast load followed by Sodium bicarb gtt postprocedure. Transferred to for catheterization which revealed significant CAD. Cont gently diuresis as tolerated. Goal -1L. Goal -1L. 2nd PIV obtained in right arm. WBC this am 11.8.Access: Received pt w/ antecube IVs not working appropriately. RR 11-25. UO 100-200cc/hr. SB w/ rare PVC. PCWP post intervention 44. Pt received Plavix load last pm. An AP portable study of the chest was obtained. Received 6 units regular x1. HR 51-59. HCT stable at 34.6. Slightly diminished in bases. MAE. Cont FS qid and cover per RISS.Skin: No breakdown. PEARL. Right groin noted for small ooze. Ho will reevaluate need for additional diuresis following CXR. need central access if abx is needed or an emergent situation arises.Endo: BS 214-88. Faint bibasilar crackles auscultated initially. HO aware pt is only -600cc. Received Lasix 40 mg IV x1 at 2200. Integrellin renally dosed at 1 mcg/kg/min. Integrellin continues at renal dose of 1 mcg/kg/min. Irregular sinus bradycardiaQT interval prolonged for rateExtensive ST-T changes suggest myocardial injury/ischemia, metabolicabnormalitiesClinical correlation is suggested Replete electrolytes as needed. Pt reoriented quickly and answered questions appropriately.CV: VSS. MAPS>60. Brisk in response. O2 sats 99-100% via 3L NC. Pt refused dose in lab.Resp: LS cta. Pt denies pain when asked. 3mm in size. Repleted w/ 40 meq p0 KCL packets, 2 gm MGSO4. Venous access team/ RN unable to obtain additional access. No calls.A/P: 84 yo gentleman w/ significant cardiac hx. Cont to advance activity and diet as tolerated. Pt had episodes of apnea early in shift most likely d/t 175 mcg of Fentanyl received in cath lab.GI/GU: Abd soft. Sinus arrhythmiaExtensive ST-T changes suggest myocardial injury/ischemiaSince previous tracing, the heart rate has increased and QTc intervaldecreased, ST-T wave abnormalities less Marginal effect to 40 mg IV Lasix given last pm. No abx regimen. Spoke to HO regarding additional dose of Lasix but Ho will reevaluate need after CXR is obtained. Some infiltration and partial atelectasis involving the posterior segment of the left lower lobe is suspected. CCU Nursing Progress Note 1900-0700S: " I feel pretty good"O: Please see careview for complete VS/additional objective dataMS: AAOx3. No gross evidence of pleural effusion. Unable to judge fluid status given lack of PA line. Coccyx initially reddened from lack of repositioning. Keep family and pt aware of POC and support as needed. There are increased bronchovascular markings bilaterally which may indicate a mild degree of congestive heart failure. Increased bilateral bronchovascular markings, suggestive of Mild congestive heart failure? Pt denies SOB and is able to tolerate lying flat during repositioning. No evidence of pneumothoraces. There are no prior studies available for comparison. Barrier cream applied to area with improvement seen overnoc.Social: Number of family members into visit. All sheaths/ groin lines removed prior to arrival to CCU. Pleasant and cooperative. Pt tolerating po meds and sips of water without difficulty. No stool. | 4 | [
{
"category": "Radiology",
"chartdate": "2158-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857689,
"text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pulmonary edema\n Admitting Diagnosis: NON Q MI;CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with CHF\n REASON FOR THIS EXAMINATION:\n Please assess for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 84-year-old with CHF.\n\n An AP portable study of the chest was obtained. There are no prior studies\n available for comparison. There is cardiomegaly and postoperative changes\n from prior sternotomy. There is elevation of the right hemidiaphragm. There\n are increased bronchovascular markings bilaterally which may indicate a mild\n degree of congestive heart failure. No gross evidence of pleural effusion. No\n evidence of pneumothoraces. Some infiltration and partial atelectasis\n involving the posterior segment of the left lower lobe is suspected.\n\n IMPRESSION: Cardiomegaly and postoperative changes. Increased bilateral\n bronchovascular markings, suggestive of Mild congestive heart failure?\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Report",
"row_id": 180194,
"text": "Sinus arrhythmia\nExtensive ST-T changes suggest myocardial injury/ischemia\nSince previous tracing, the heart rate has increased and QTc interval\ndecreased, ST-T wave abnormalities less\n\n"
},
{
"category": "ECG",
"chartdate": "2158-02-15 00:00:00.000",
"description": "Report",
"row_id": 180195,
"text": "Irregular sinus bradycardia\nQT interval prolonged for rate\nExtensive ST-T changes suggest myocardial injury/ischemia, metabolic\nabnormalities\nClinical correlation is suggested\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-02-16 00:00:00.000",
"description": "Report",
"row_id": 1401694,
"text": "CCU Nursing Progress Note 1900-0700\nS: \" I feel pretty good\"\n\nO: Please see careview for complete VS/additional objective data\n\nMS: AAOx3. Pleasant and cooperative. Pt denies pain when asked. MAE. PEARL. 3mm in size. Brisk in response. At 0200, pt awoke and self dc'd PIV. Pt reoriented quickly and answered questions appropriately.\n\nCV: VSS. SB w/ rare PVC. HR 51-59. NIBP 98-126/42-74. MAPS>60. Integrellin continues at renal dose of 1 mcg/kg/min. All sheaths/ groin lines removed prior to arrival to CCU. Right groin noted for small ooze. Dsg changed x1. Ooze stabilized overnoc. Distal pulses +2/+1. R>L. HCT stable at 34.6. Repleted w/ 40 meq p0 KCL packets, 2 gm MGSO4. Repeat labs this am K+ 3.7 following repletion. Mg wnl. Pt received Plavix load last pm. Pt refused dose in lab.\n\nResp: LS cta. Slightly diminished in bases. Faint bibasilar crackles auscultated initially. Pt denies SOB and is able to tolerate lying flat during repositioning. RR 11-25. O2 sats 99-100% via 3L NC. Pt had episodes of apnea early in shift most likely d/t 175 mcg of Fentanyl received in cath lab.\n\nGI/GU: Abd soft. +BS. No stool. Pt tolerating po meds and sips of water without difficulty. F/C to gravity. UO 100-200cc/hr. Pt is currently -618cc. Goal -1L. Received Lasix 40 mg IV x1 at 2200. Spoke to HO regarding additional dose of Lasix but Ho will reevaluate need after CXR is obtained. Unable to judge fluid status given lack of PA line. BUN/Cr 43/1.7. Bicarb gtt dc'd d/t ^ volume status. Post op hydration cont 1/2 NS at 75cc x1L.\n\nID: Tmax 98.2 PR. No abx regimen. WBC this am 11.8.\n\nAccess: Received pt w/ antecube IVs not working appropriately. Left A/C infiltrated. 2nd PIV obtained in right arm. At 0200, pt self dc'd PIV. Venous access team/ RN unable to obtain additional access. need central access if abx is needed or an emergent situation arises.\n\nEndo: BS 214-88. Received 6 units regular x1. Cont FS qid and cover per RISS.\n\nSkin: No breakdown. Coccyx initially reddened from lack of repositioning. Barrier cream applied to area with improvement seen overnoc.\n\nSocial: Number of family members into visit. Will return this am. No calls.\n\nA/P: 84 yo gentleman w/ significant cardiac hx. Most recently admitted for NSTEMI and CHF exacerbation managed w/ diuresis at OSH. Transferred to for catheterization which revealed significant CAD. S/P stent placement x1 to LMCA and stent x3 to prox/mid LAD. VSS overnoc. Integrellin renally dosed at 1 mcg/kg/min. D/c Integrillin at 1015 am. H/O CRI but baseline unclear. CR currently 1.7 following 390cc contrast load followed by Sodium bicarb gtt postprocedure. PCWP post intervention 44. Cont gently diuresis as tolerated. Marginal effect to 40 mg IV Lasix given last pm. HO aware pt is only -600cc. Goal -1L. Ho will reevaluate need for additional diuresis following CXR. Replete electrolytes as needed. Keep family and pt aware of POC and support as needed. Cont to advance activity and diet as tolerated.\n"
}
] |
14,458 | 143,078 | This 64 year-old left handed female with a history of seizures presented with waxing and , change in mental status acutely, tonic eye deviation and twitch essentially appeared as an akinetic mute. It was doubtful that such lesion exists to cause a kinetic mutism, but left weakness may have been post ictal paralysis. It was thought that the patient was most likely in status epilepticus, although an ischemic lesion could not be ruled out. Her issues were as follows: 1. Neurological: Status post epilepticus was terminated with Ativan 1 mg q ten minutes and then she was transferred to the Intensive Care Unit for phenobarbital load 20 mg per kilogram. The phenobarbital load with the Ativan resulted in an immediate change in her mental status with more responsiveness and better control of motor activity. An electroencephalogram was performed that demonstrated electrical activity in the frontal lobes that could have been consistent with epileptiform activity, but showed no acute seizure activity while on the phenobarbital. Seizures were treated by titrating up her Lamictal. On her dose was increased to 25 mg b.i.d. and the patient will be discharged with instructions to continue titrating Lamictal in 25 mg increments every week to a goal of 300 mg b.i.d. as tolerated. An MRI/MRA of her brain to look for intracranial circulation defects and evidence of new ischemia was negative suggesting that the patient had not had a new acute infarct. 2. Cardiovascular: The patient has a history of hypertension, coronary artery disease and was admitted to the Intensive Care Unit and found to have an elevated troponin I of 9.3 with a negative CKMB. It was unclear whether this was secondary to cardiac ischemia, renal failure or congestive heart failure or a combination of above. Echocardiography was performed on demonstrating no new wall motion abnormalities and an EF of greater then 55% and an increase in mitral regurgitation compared to prior echocardiogram. After dialysis her troponin decreased down to 4.7. Because of the normal CK and no electrocardiogram changes with a normal echocardiogram, it was decided that she is not having an acute ischemic event and that her mitral regurgitation be treating increasing after load reduction. For this reason Diovan was increased from 160 mg per day to 240 mg per day. She was continued on beta blockers and will be discharged on her home dose of Atenolol 50 mg per day. She is continued on Zestril 2.5 mg per day for after load reduction as well as Lipitor and aspirin for coronary artery disease. The patient was placed on heparin for atrial fibrillation on admission and on discharge she will be recoumadinized with a goal INR of 2.3 and covered with Lovenox until the goal INR is reached. 3. Renal: The patient remained on hemodialysis during the hospital stay and there were no acute issues. 4. Infectious disease: The patient presented to an outside hospital with a fever of 102. She was given one dose of Gentamycin and Vancomycin during hemodialysis. Cultures remained negative. During her hospital stay on she again had a fever to 101.1. She was given a single dose of Vancomycin and Levofloxacin after cultures of urine and blood were taken. Chest x-ray showed no evidence of pneumonia or atelectasis. She was given no further antibiotics until blood culture results came back. 5. Endocrine: The patient has a history of insulin dependent diabetes mellitus with somewhat labile blood sugar by finger stick ranging from a low of 47 to a high of 500. For now she will continue on her NPH regimen until her diet is stabilized. 6. Fluids, electrolytes and nutrition: The patient had swallowing evaluation to ensure that the seizure activity had not left her with a diminished ability to swallow or increased risk for aspiration pneumonia. It was decided that she would need to be maintained on honey thick liquids and a soft pureed diet as she demonstrated some risk for aspiration with thin liquids. She will continue on her regimen of Renagel and Nephrocaps. The patient is being discharged to home with plans of Services. Her daughter has a home health care aid already in place and is able to care for the patient at home. | Moderate [2+]tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. tolerating lopressor, labetolol and diovan per NGT.resp: LS diminished bases. Mild (1+) aortic regurgitation is seen. WBC 5.9Await gent and vanco levels.ENDO: FS 160-185. Sinus bradycardia - premature ventricular contractionsLong QTc intervalLateral ST-T changes are nonspecificPossible left atrial abnormalityPoor R wave progressionLow frontal plain voltageSince previous tracing, sinus rate is slower & Ventricular premature complex isnew PHENOBARB SHUT OFF & HO CALLED. There is mildmitral annular calcification. Right ventricular systolic function isnormal. NPO except meds. PHENOBARB BOLUS OF 1GM PB GIVEN AS ORDERED. Left ventricular function.Height: (in) 63Weight (lb): 125BSA (m2): 1.59 m2BP (mm Hg): 135/82HR (bpm): 63Status: InpatientDate/Time: at 11:33Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy withnormal cavity size and systolic function (LVEF>55%). Neuro following closely.CV: NSR HR 60's no ectopy. meds via NGT. SHE WAS EVALUATED BY NEURO, & IT WAS FELT THAT SHE BE IN STATUS EPILEPTISUS. Adjust per hep ss. 3) Catheter terminates in proximal right atrium. Sinus rhythmPossible left atrial abnormalityLow frontal plan voltageST-T changes - Consider ischemiaSince previous tracing, ST changes more pronounced Moderate to severe (3+) mitral regurgitation isseen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild (1+)aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. IMPRESSION: Exam significantly limited by motion artifact. In particular, peak systolic velocities bilaterally are within normal limits as are the ICA to CCA ratios. waking to name and mild shaking. LEVELS SENT THIS AM. IMPRESSION: 1) Linear right upper lobe opacity, suggestive of atelectasis or scar. MRI/MRA. pt a/0 x3 ,interacting c family appropriately. FINDINGS: Duplex and color doppler demonstrate normal carotid systems bilaterally. The rightventricular free wall is hypertrophied. The linear right upper lobe opacity is new and consistent with discoid atelectasis. Pt resp rate appears even and unlabored. WITH GTT BUT SLOW INFUSION. Right ventricular systolic function isnormal.AORTA: The aortic root is normal in diameter. NGT in place to receive meds. Await MRI/MRA. BS+. There is a trivial/physiologic pericardialeffusion.Compared with the prior study of , the severity of mitral regurgitationhas increased. Quinton cath site WNL.ID: afebrile. DISTENDED. ALSO RECEIVED KCL 20MEQ VIA NGT X1 FOR K 3.O.GI: NPO. AT SOME POINT SHE WAS STARTED ON HEPARIN GTT. R stiffer than L.No seizure activity noted. The ascending aorta is mildly dilated. RR in the teens.GI: Abd soft NT +BS. BUN/ CREAT 35/4.5.ID: T 99.8(R)-> 97.9(PO). Moderate to severe (3+) mitral regurgitation isseen. BS DIMINISHED THROUGHOUT.CARDIAC: HR 64-85 SR. NO ECTOPY. troponin elevated secondary to ischemia vs RF per team. continue heparin for AFIB> ? NEURO: ON ADM. TO CCU, ALERT & CONVERSING. BUN 40 Creat 5.3. BC X1 SENT.ENDO: BS 178->114. There is severe pulmonary artery systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is a trivial/physiologic pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a moderate risk (prophylaxis recommended). AMT. HEAD CT WITHOUT CONTRAST: It should be noted that the majority of the sequences are severely degraded by motion artifact. TWOHEAD CT'S( & ) WERE WITHOUT ACUTE CHANGES. The heart is upper limits of normal in size. NGT FOR MEDS.GU: INC. SM. Sinus rhythmPossible left atrial abnormalityLeft ventricular hypertrophyPoor R wave progressionLow voltage in frontal leadsNondiagnostic ST-T abnormalitiesSince last ECG, no significant change Pupils 2mm with sluggish reactivity. PTT subtherapeutic.P: Follow neuro exam closley ? continue lamictal for siezure control. Wet to dry dsg appiled. AS OPPOSED TO 1HR. ON IV GENT/VANCO. PATIENT/TEST INFORMATION:Indication: Hypertension. Pt underwnet an EEG at the bedside revealing decreased amplitude in R hemisphere ? Mg repleted with 2g IV (Mg 1.9).PULM: LS diminished throughout. non productive cough, at times congested sounding.GU: anuricGI: tol. DECISION MADE TO CONT. Oruir radiograph of is available. vss . VSS. SL. ADMISSION NOTEMRS. on own and also on command. HER MENTAL STATUSWAXED & WANED, & AT TIMES SHE WAS MINIMALLY RESPONSIVE. stroke vs subdural with possibility of seizure activity. no sizuresP: follow neuro exam. pupils 2mm and sluggish.hands lightly restrained for safety with NGT.MRI not done tonight. BP 130-154/57-66. The ascending aorta is mildlydilated.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Support provided.A: Improved neuro status. Occasional non productive cough noted. K+2.9 pt rec'd 40meq KCL via NGT. SBP 106-140. Pt remains NPO. FS QID with reg insulin coverage. abd soft . There is one, somewhat bean-shaped area of high signal seen on diffusion weighted imaging in the right posterior frontal lobe which could be related to artifact; however, a true, focal area of restricted diffusion cannot be entirely excluded. A septal wall motion abnormality is not seen on the currentstudy (or review of the prior study), Pulmonary artery pressures are similar.Mild aortic regurgitation is seen (was trace on the prior study).Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). Buttocks intact.LINES: 2 PIV. repeat K+ 3.5. NO FURTHER DECREASE IN SATS. no stool.A: stable , more alert. IMPRESSION: normal study. URINE ON ADM TO CCU. ABD. The lungs reveal linear opacities in the right upper lobe which may reflect an area of scarring or atelectasis. Rightventricular chamber size is normal. Regional left ventricularwall motion is normal. opening eyes slowly and responding to name. The ventricles and sulci are prominent, which is age appropriate. Lower extremities with muscle atrophy. new ischemia vs. seizure from old ischemia REASON FOR THIS EXAMINATION: MRI and intracranial MRA for ischemia FINAL REPORT INDICATION: New left sided weakness and seizure. | 12 | [
{
"category": "Echo",
"chartdate": "2115-01-08 00:00:00.000",
"description": "Report",
"row_id": 65695,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function.\nHeight: (in) 63\nWeight (lb): 125\nBSA (m2): 1.59 m2\nBP (mm Hg): 135/82\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 11:33\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and systolic function (LVEF>55%). Regional left ventricular\nwall motion is normal. There is no resting left ventricular outflow tract\nobstruction.\n\nRIGHT VENTRICLE: The right ventricular free wall is hypertrophied. 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 mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Moderate to severe (3+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Moderate [2+]\ntricuspid regurgitation is seen. There is severe pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic function\n(LVEF>55%). Regional left ventricular wall motion is normal. The right\nventricular free wall is hypertrophied. Right ventricular systolic function is\nnormal. The ascending aorta is mildly dilated. The aortic valve leaflets (3)\nare mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is\nseen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nCompared with the prior study of , the severity of mitral regurgitation\nhas increased. A septal wall motion abnormality is not seen on the current\nstudy (or review of the prior study), Pulmonary artery pressures are similar.\nMild aortic regurgitation is seen (was trace on the prior study).\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": "2115-01-08 00:00:00.000",
"description": "Report",
"row_id": 140190,
"text": "Sinus bradycardia\n - premature ventricular contractions\nLong QTc interval\nLateral ST-T changes are nonspecific\nPossible left atrial abnormality\nPoor R wave progression\nLow frontal plain voltage\nSince previous tracing, sinus rate is slower & Ventricular premature complex is\nnew\n\n"
},
{
"category": "ECG",
"chartdate": "2115-01-07 00:00:00.000",
"description": "Report",
"row_id": 140191,
"text": "Sinus rhythm\nPossible left atrial abnormality\nLeft ventricular hypertrophy\nPoor R wave progression\nLow voltage in frontal leads\nNondiagnostic ST-T abnormalities\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2115-01-09 00:00:00.000",
"description": "Report",
"row_id": 140189,
"text": "Sinus rhythm\nPossible left atrial abnormality\nLow frontal plan voltage\nST-T changes - Consider ischemia\nSince previous tracing, ST changes more pronounced\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-01-10 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 747891,
"text": " 3:14 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with IDDM, ESRD on HD w/ low grade fevers.\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n\n SINGLE VIEW, CHEST:\n\n INDICATION: Low grade fever.\n\n A central venous catheter is present terminating in the right atrium. No\n pneumothorax is evident. The heart is upper limits of normal in size. The\n lungs reveal linear opacities in the right upper lobe which may reflect an\n area of scarring or atelectasis. No confluent areas of consolidation are\n identified. No pleural effusions are evident on this single view.\n\n IMPRESSION:\n 1) Linear right upper lobe opacity, suggestive of atelectasis or scar.\n\n 2) No evidence of pneumonia.\n\n 3) Catheter terminates in proximal right atrium.\n\n When prior radiographs of and become local on PACS, direct\n comparison can be made and an addendum can be issued to this report.\n\n\n Oruir radiograph of is available. The linear right upper lobe opacity\n is new and consistent with discoid atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-01-09 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 747793,
"text": " 1:58 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: LEFT SIDED WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with PMH CVA w/ new L sided weakness.\n REASON FOR THIS EXAMINATION:\n carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Prior stroke and left sided weakness.\n\n FINDINGS: Duplex and color doppler demonstrate normal carotid systems\n bilaterally. In particular, peak systolic velocities bilaterally are within\n normal limits as are the ICA to CCA ratios. There is normal antegrade flow in\n both vertebral arteries.\n\n IMPRESSION: normal study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-01-10 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 747872,
"text": " 12:18 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING\n Reason: MRI and intracranial MRA for ischemia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with PMH PAF, CVA, SZ disorder, w/ new L sided weakness. ?\n new ischemia vs. seizure from old ischemia\n REASON FOR THIS EXAMINATION:\n MRI and intracranial MRA for ischemia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New left sided weakness and seizure.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain including\n diffusion weighted images were obtained.\n\n HEAD CT WITHOUT CONTRAST: It should be noted that the majority of the\n sequences are severely degraded by motion artifact. There is one, somewhat\n bean-shaped area of high signal seen on diffusion weighted imaging in the\n right posterior frontal lobe which could be related to artifact; however, a\n true, focal area of restricted diffusion cannot be entirely excluded. There\n is no shift of normally midline structures. The ventricles and sulci are\n prominent, which is age appropriate. There are multiple areas of abnormal T2\n signal within the white matter of the corona radiata and centrum semiovale\n bilaterally, which is likely related to chronic microvascular ischemic\n disease. No areas of hemorrhagic residua are seen. Note is made of mucosal\n disease within the left maxillary sinus.\n\n BRAIN MRA:\n\n TECHNIQUE: 3D TOF images of the circle of were obtained and\n multiplanar reconstructed images were created.\n\n BRAIN MRA: Allowing for significant motion artifact, the major extracranial\n cerebral arteries are patent.\n\n IMPRESSION: Exam significantly limited by motion artifact. There is a small\n focal area of high signal seen on diffusion weighted images which may be\n related to artifact, rather than reflecting true area of restricted diffusion.\n No significant stenoses are seen involving the intracranial vasculature.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-01-07 00:00:00.000",
"description": "Report",
"row_id": 1450752,
"text": "ADMISSION NOTE\nMRS. IS A 64 YR. OLD WOMAN WHO WAS ADMITTED TO OUTSIDE HOSPITAL ON FOR ALTERED MENTAL STATUS & L. SIDED WEAKNESS. TWO\nHEAD CT'S( & ) WERE WITHOUT ACUTE CHANGES. HER MENTAL STATUS\nWAXED & WANED, & AT TIMES SHE WAS MINIMALLY RESPONSIVE. AT SOME POINT SHE WAS STARTED ON HEPARIN GTT. SHE ALSO HAD LOW-GRADE FEVERS, & WAS STARTED ON IV GENT & VANCO FOR ? INFECTION. SHE WAS ALSO DIALYZED ON . SHE WAS TRANSFERRED TO ~1800 AND ADMITTED TO F3.\nON F3, SHE WAS INITIALLY ABLE TO FOLLOW COMMANDS, BUT THEN LATER COULD NOT. SHE WAS ALSO NOTED TO HAVE MYOCLONIC TWITCHING OF R. ARM. SHE WAS EVALUATED BY NEURO, & IT WAS FELT THAT SHE BE IN STATUS EPILEPTISUS. INITIALLY SHE WAS TREATED WITH ATIVAN, BUT AFTER RECEIVING ATIVAN 1MG VP X2(2200 & 0100) NEURO DECIDED THAT SHE SHOULD BE LOADED WITH PHENOBARBITAL IV WHICH REQUIRES BEING MONITORED IN AN\nICU SETTING. SHE WAS STARTED ON A HEPARIN GTT AT 400U/HR AT 2300. MRS. WAS TRANSFERRED TO CCU 0200 FOR PHENOBARB INFUSION.\n\nALLERGIES: DILANTIN\n\nPMH: IDDM HX MRSA BACTEREMIA/KLEBSIELLA BACT.\n ESRD->HD 3X/WK HX CDIFF\n CAD->S/P MI HX BIPOLAR DISORDER\n HTN S/P TAH/BSO\n HX AF HX DVT\n S/P R. HIP FX->ORIF SEIZURE DISORDER\n S/P CVA HX NEUTOPENIA D/T DILANTIN\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-01-07 00:00:00.000",
"description": "Report",
"row_id": 1450753,
"text": "NEURO: ON ADM. TO CCU, ALERT & CONVERSING. WOULD NOT ANSWER QUESTIONS,\n BUT WOULD REPEAT WHAT WAS ASKED OF HER. FOLLOWING SIMPLE\n COMMANDS. PUPILS EQUAL BUT NOT REACTIVE. LEFT HAND GRASP VERY\n WEAK. PHENOBARB BOLUS OF 1GM PB GIVEN AS ORDERED. \n BARB PT ONLY RESPONDS TO PAINFUL STIMULI. HEPARIN GTT AT 400U\n /HR.\nRESP: ON ADM. TO CCU O2 SATS 97% ON RM. AIR. AFTER PHENOBARB GTT\n STARTED, STARTED HAVING APNEA & DROPPING SATS TO 60'S. PHENOBARB\n SHUT OFF & HO CALLED. DECISION MADE TO CONT. WITH GTT BUT SLOW\n INFUSION. TO INFUSE OVER 2HRS. AS OPPOSED TO 1HR. PLACED ON NP\n 2L WITH O2 SATS 100%. NO FURTHER DECREASE IN SATS. RR 17-19. BS\n DIMINISHED THROUGHOUT.\nCARDIAC: HR 64-85 SR. NO ECTOPY. BP 130-154/57-66. 1/2NS 40CC/HR\n CHANGED TO 1/2NS+20KCL 75CC/HR. ALSO RECEIVED KCL 20MEQ VIA\n NGT X1 FOR K 3.O.\nGI: NPO. ABD. SL. DISTENDED. BS+. NO STOOL. NGT FOR MEDS.\nGU: INC. SM. AMT. URINE ON ADM TO CCU. ON HD 3X/WK->DUE TODAY. BUN/\n CREAT 35/4.5.\nID: T 99.8(R)-> 97.9(PO). ON IV GENT/VANCO. LEVELS SENT THIS AM. BC X1\n SENT.\nENDO: BS 178->114. INSULIN PER SLIDING SCALE.\nCHEMISTRIES & DRUG LEVELS SENT. UNABLE TO GET ENOUGH BLOOD FOR CBC &\nCOAGS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-01-07 00:00:00.000",
"description": "Report",
"row_id": 1450754,
"text": "CCU Nursing Progress Note 7a-7p:\n\nNeuro: Pt only responsive to painful stimuli sternal rub, nail bed, blood draws and foley insertion until this afternoon. Pupils 2mm with sluggish reactivity. While daughter pt became more alert responding to her name attempting speak (per daughter asking for ice chips) and moving all extremities spontaneously. Lower extremities with muscle atrophy. R stiffer than L.\nNo seizure activity noted. No twitching noted. Pt underwnet an EEG at the bedside revealing decreased amplitude in R hemisphere ? stroke vs subdural with possibility of seizure activity. Await MRI/MRA. Neuro following closely.\n\nCV: NSR HR 60's no ectopy. SBP 106-140. Pt conts on current cardiac regimen for hx of CAD and MI. troponin elevated secondary to ischemia vs RF per team. Pt to undergo Echo .\nPt on hep gtt at 800u/hr for hx of afibb, check PTT at 10pm. Adjust per hep ss. K+2.9 pt rec'd 40meq KCL via NGT. Mg repleted with 2g IV (Mg 1.9).\n\nPULM: LS diminished throughout. sats 98% on 1l NC. Occasional non productive cough noted. Pt resp rate appears even and unlabored. RR in the teens.\n\nGI: Abd soft NT +BS. +flatus no stool. NGT in place to receive meds. Pt remains NPO. Per pt's daughter pt with excellant appetite. Nutrition consulted today.\n\nGU: Foley cath inserted draining cloudy yellow urine in small amts, urine sent for dipstick and culture. Pt to have dialysis at the bedside. BUN 40 Creat 5.3. Quinton cath site WNL.\n\nID: afebrile. WBC 5.9\nAwait gent and vanco levels.\n\nENDO: FS 160-185. Reg insulin ss for coverage and NPH 5u started tonight. Pt on d5 1/2 NS at 75cc/hr while NPO.\n\nSKIN: R heel with blister base red with scant amt of sang drainage. Wet to dry dsg appiled. Buttocks intact.\n\nLINES: 2 PIV. R subclavian Quinton cath.\n\nDISPO: Full Code\n\nSOCIAL: Pt lives with her daughter and has a caretaker. pt's daughter pt is wheelchair bound. Family visited throughout the day today. Support provided.\n\nA: Improved neuro status. No seizure activity noted.\n VSS. PTT subtherapeutic.\n\nP: Follow neuro exam closley ? MRI/MRA.\n Check PTT at 10 pm.\n NPO except meds.\n FS QID with reg insulin coverage.\n Follow labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-01-08 00:00:00.000",
"description": "Report",
"row_id": 1450755,
"text": "CCU NPN 1900-0700\nO:\npt. waking to name and mild shaking. opening eyes slowly and responding to name. able to state name and place \" \". speech very garbled and thick. also asking for ice. moving all extrem. on own and also on command. able to lift right arm off bed, others moving on bed. falls asleep when not stimulated. pupils 2mm and sluggish.\nhands lightly restrained for safety with NGT.\nMRI not done tonight. resident spoke with daughter on phone in eve and explained to her about wait for MRI.\n\nCV: HR 50's SB. no VEA. repeat K+ 3.5. BP 106-140/50-60. tolerating lopressor, labetolol and diovan per NGT.\n\nresp: LS diminished bases. 1lNC sats 99-100%. non productive cough, at times congested sounding.\n\nGU: anuric\nGI: tol. meds via NGT. abd soft . no stool.\n\nA: stable , more alert.\n no sizures\nP: follow neuro exam. continue lamictal for siezure control. continue heparin for AFIB> ? plan HD today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-01-08 00:00:00.000",
"description": "Report",
"row_id": 1450756,
"text": "no seizure activity noted . pt a/0 x3 ,interacting c family appropriately. vss . sat 99 on rm air . taking ice chips . to be dialized 12 noon .pt okd to be transferred .\n"
}
] |
47,884 | 124,207 | 48yo F with HTN who presented with headache and was found to have multiple strokes in the ACA/MCA territory, on admission thought likely embolic, also had cerebral edema and 11mm midline subfalcine shift likely secondary to ischemic stroke. | ATTENDING NOTE: Right uncal herniation not changed from MRI of . There is marked compression of the right lateral ventricle without evidence of entrapment of the left lateral ventricle. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 546/245, 436/135, 38/16, cm/sec. FINDINGS: There is a large confluent area of slow diffusion involving the right frontal lobe. Progressive hypoattenuation (evolution) of a large right frontal (MCA and ACA territory) infarction without hemorrhagic conversion or new infarcts. This minimal flow is identified as far distally as the right supraclinoid bifurcation. Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: MAGNEVIST Amt: 12 FINAL REPORT (Cont) extending into the right cavernous sinus. Minimal right lung base opacity, which is likely atelectasis, is unchanged. The intracranial MRA demonstrates reconstitution of flow in the right middle cerebral artery branches, which demonstrate diminished flow. The intracranial MRA demonstrates reconstitution of flow in the right middle cerebral artery branches, which demonstrate diminished flow. The ventricles are not enlarged with similar configuration with mass effect on the right lateral ventricle. IMPRESSION: Occlusion of right internal carotid artery bifurcation. IMPRESSION: Subacute right anterior and middle cerebral artery territory infarcts. No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 10:52 AM Occlusion of right internal carotid artery in the neck. Hypervascularity at the previously on MRI described mass at the right retroclival dura abutting the posterior cavernous sinus (likely meningioma), but no mass effect on the ICA. The right internal carotid intracranially appears to be reconstituted through collateral circulation from circle of . No MS. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Patient was unable to cooperate withmaneuvers.Conclusions:The left atrium is normal in size. An extra-axial mass originating from the right petroclival dura was better seen on prior MR. Interval stability of subacute right anterior and middle cerebral artery territory infarcts. Overall cardiac and mediastinal contours are likely within normal limits, given portable technique. FINDINGS: Right PICC line ends at lower SVC. FINDINGS: Again seen is hypodensity and edema within the right frontal lobe consistent with continued evolution of known prior infarction. No definite central herniation. No definite central herniation. No contraindications for IV contrast PFI REPORT 1. FINAL REPORT INDICATION: Known right-sided infarction with new headache. The mass effect from the infarct is largely unchanged, with subfalcine herniation, effacement of the frontal of the right lateral ventricle, and 13 mm leftward shift of midline structures, possibly MINIMALLY decreased from two days ago, when it measured 14 mm without significant change. There is somewhat diminished flow signal intensity seen within the right middle cerebral artery which appears to be secondary to collateral flow. Right subclavian PICC line with tip in the proximal right atrium/cavoatrial junction. TECHNIQUE: Fat-suppressed axial images of the neck were obtained. The gadolinium-enhanced MRA of the neck is somewhat limited by motion and by delays in the acquisition. The Sylvian fissures are effaced bilaterally. IMPRESSION: Interval evolution of infarction with mildly decreased but persistent edema and decreased leftward shift of midline structures. ?vascular occlusion. ?vascular occlusion. ?vascular occlusion. ?vascular occlusion. ?vascular occlusion. The left internal carotid and both vertebral arteries demonstrate normal flow signal although evaluation is slightly limited. Diminished flow signal in branches of the right middle cerebral artery are seen in the region of infarct. There is antegrade right vertebral artery flow. 3:23 PM MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # Reason: Right frontal stroke. No significant change in large right frontal lobe infarction. No contraindications for IV contrast PFI REPORT Occlusion of right internal carotid artery in the neck. TECHNIQUE: Sagittal T1 and axial T1, T2, FLAIR, gradient echo, and diffusion with ADC map images were obtained without contrast. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Findings: Duplex evaluation was performed of bilateral carotid arteries. PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIAWeight (lb): 130BP (mm Hg): 148/76HR (bpm): 66Status: InpatientDate/Time: at 10:52Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. FINDINGS: There is no appreciable change in size in the degree of cytotoxic edema centered within the right frontal lobe compared to MR . Almost 100%, likley atherosclerotic occlusion (Se 3, img 141) of the right ICA at the common carotid bifurcation with severely diminished flow ("string sign") in the distal ICA and some reconstiution at the cavernous ICA due to retrograde flow from the circle of . FINDINGS: NECK MRA: There is occlusion of the right internal carotid artery near the bifurcation. The flow signal is also diminished in both middle cerebral (Over) 3:23 PM MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # Reason: Right frontal stroke. | 14 | [
{
"category": "Radiology",
"chartdate": "2113-11-17 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 1218136,
"text": " 3:23 PM\n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n Reason: Right frontal stroke. ?vascular occlusion. ?dissection. Plea\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with right frontal stroke\n REASON FOR THIS EXAMINATION:\n Right frontal stroke. ?vascular occlusion. ?dissection. Please consider FATSAT\n neck. Thanks.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 10:52 AM\n Occlusion of right internal carotid artery in the neck. Fat-suppressed images\n demonstrate no intramural signal but in presence of occlusion, a dissection or\n primary occlusion from the neck at the bifurcation cannot be differentiated.\n However, given the occlusion starts at the carotid bifurcation at the level of\n the carotid bulb, dissection is less likely. The intracranial MRA\n demonstrates reconstitution of flow in the right middle cerebral artery\n branches, which demonstrate diminished flow.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRA of the neck and head.\n\n CLINICAL INFORMATION: Patient with right frontal infarct, for further\n evaluation of vascular structures.\n\n TECHNIQUE: Fat-suppressed axial images of the neck were obtained.\n Gadolinium-enhanced MRA of the neck and 3D time-of-flight MRA of the circle of\n acquired. The gadolinium-enhanced MRA of the neck is somewhat limited\n by motion and by delays in the acquisition.\n\n FINDINGS: NECK MRA:\n\n There is occlusion of the right internal carotid artery near the bifurcation.\n On fat-suppressed images, there is loss of signal but no evidence of blood\n clot identified adjacent to the vascular structure to suggest dissection. The\n findings are indicative of occlusion. The left internal carotid and both\n vertebral arteries demonstrate normal flow signal although evaluation is\n slightly limited.\n\n IMPRESSION: Occlusion of right internal carotid artery bifurcation. The\n right internal carotid intracranially appears to be reconstituted through\n collateral circulation from circle of .\n\n MRA HEAD:\n\n The head MRA demonstrates occlusion of the right intracranial internal carotid\n artery which is reconstituted in the supraclinoid region through collateral\n from the circle of . There is somewhat diminished flow signal intensity\n seen within the right middle cerebral artery which appears to be secondary to\n collateral flow. The flow signal is also diminished in both middle cerebral\n (Over)\n\n 3:23 PM\n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n Reason: Right frontal stroke. ?vascular occlusion. ?dissection. Plea\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artery by divisions. There are fewer sylvian branches visualized on the\n source images.\n\n IMPRESSION: Occlusion of the right internal carotid in the neck with\n reconstitution in the intracranial region. Diminished flow signal in branches\n of the right middle cerebral artery are seen in the region of infarct. The\n remaining arteries of the anterior and posterior circulation are normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-17 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 1218137,
"text": ", NMED SICU-B 3:23 PM\n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n Reason: Right frontal stroke. ?vascular occlusion. ?dissection. Plea\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with right frontal stroke\n REASON FOR THIS EXAMINATION:\n Right frontal stroke. ?vascular occlusion. ?dissection. Please consider FATSAT\n neck. Thanks.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Occlusion of right internal carotid artery in the neck. Fat-suppressed images\n demonstrate no intramural signal but in presence of occlusion, a dissection or\n primary occlusion from the neck at the bifurcation cannot be differentiated.\n However, given the occlusion starts at the carotid bifurcation at the level of\n the carotid bulb, dissection is less likely. The intracranial MRA\n demonstrates reconstitution of flow in the right middle cerebral artery\n branches, which demonstrate diminished flow.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1218344,
"text": " 3:02 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl power picc 46cm iv \n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl power picc 46cm iv \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM AT 15:04\n\n CLINICAL INDICATION: Status post right PICC, check line placement.\n\n No comparison studies.\n\n Portable AP upright chest film, at 15:04 is submitted.\n\n IMPRESSION:\n\n 1. Right subclavian PICC line with tip in the proximal right\n atrium/cavoatrial junction. Repositioning with pull back of approximately \n cm would be advised and was conveyed to the IV nurse, , by Dr.\n on at 3:23pm. Lungs are well inflated without evidence of\n focal airspace consolidation, pleural effusions or pneumothorax. No evidence\n of pulmonary edema. Overall cardiac and mediastinal contours are likely\n within normal limits, given portable technique.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-17 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1218018,
"text": " 1:33 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate for mass.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with new onset h/a yesterday, midline shift on CT.\n REASON FOR THIS EXAMINATION:\n Please evaluate for mass.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): HBcb FRI 8:13 PM\n 1. Territorial right frontal as well as multiple scattered right frontal and\n parietal ischemic infarcts which appear to be embolic in nature. Given\n associated T2 hyperintensity and significant mass effect with midline shift,\n the infarcts are likely subacute (days) in nature. There is no acute\n hydrocephalus, no evidence of herniation and no hemorrhagic transformation of\n the infarct.\n\n 2. Extra-axial mass originating from the right petroclival dura which is\n extending into the right cavernous sinus. While this lesion most likely\n represents a meningioma, differential diagnosis includes a dural-based\n metastasis, tuberculosis, or sarcoid.\n\n 3. The mass appears to encase the cavernous segment of the right ICA and\n causes severe stenosis. These findings should be further assessed by MRA of\n head and neck.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman with new onset of headache and midline shift\n seen on head CT. Assessment for mass.\n\n COMPARISON: Outside CT head dated .\n\n TECHNIQUE: Sagittal T1 and axial T1, T2, FLAIR, gradient echo, and diffusion\n with ADC map images were obtained without contrast. Following IV\n administration of gadolinium, sagittal MP-RAGE and axial T1 spin echo was\n obtained.\n\n FINDINGS: There is a large confluent area of slow diffusion involving the\n right frontal lobe. Multiple scattered small areas of slow diffusion are\n present elsewhere in the right frontal parietal lobes. The diffusion\n abnormalities are accompanied by FLAIR/T2 hyperintensity and significant mass\n effect with effacement of the intracerebral sulci in the right frontal area as\n well as midline shift and tightness around the basal cisterns. These infarcts\n are most likely embolic. There is no evidence of uncal or subfalcine\n herniation.\n Susceptibility-sensitive sequences do not demonstrate hemorrhagic\n transformation.\n\n A broad-based, homogeneously enhancing mass is arises from the right\n petroclival and tentorial dura, encroaching on the pontine cistern and\n (Over)\n\n 1:33 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate for mass.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n extending into the right cavernous sinus. Within the cavernous sinus, the\n mass encases the cavernous segment of the right ICA, which appears to be\n severely stenosed, but probably patent. This should be further evaluated with\n an MRA or CTA.\n\n No further extra-axial lesions are identified.\n The visualized paranasal sinuses and mastoid air cells are clear. The orbits\n and osseous structures are unremarkable.\n\n IMPRESSION:\n 1. The large right frontal infarction as well as multiple scattered smaller\n right frontal and parietal ischemic infarcts appear to be embolic in nature.\n Given associated T2 hyperintensity and significant mass effect with midline\n shift, the infarcts are likely subacute (days old). There is no hydrocephalus,\n no evidence of herniation and no hemorrhagic transformation of the infarct.\n\n 2. Extra-axial mass originating from the right petroclival dura which is\n extending into the right cavernous sinus. While this lesion most likely\n represents a meningioma, differential diagnosis includes a dural-based\n metastasis, tuberculosis, or sarcoid.\n\n 3. The mass appears to encase the cavernous segment of the right ICA and\n causes severe stenosis. These findings should be further assessed by MRA of\n head and neck.\n\n COMMENT: The findings were communicated by Dr. to Dr. via\n telephone at 1 pm on the day of the examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-17 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1218019,
"text": ", NSURG SICU-B 1:33 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate for mass.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with new onset h/a yesterday, midline shift on CT.\n REASON FOR THIS EXAMINATION:\n Please evaluate for mass.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Territorial right frontal as well as multiple scattered right frontal and\n parietal ischemic infarcts which appear to be embolic in nature. Given\n associated T2 hyperintensity and significant mass effect with midline shift,\n the infarcts are likely subacute (days) in nature. There is no acute\n hydrocephalus, no evidence of herniation and no hemorrhagic transformation of\n the infarct.\n\n 2. Extra-axial mass originating from the right petroclival dura which is\n extending into the right cavernous sinus. While this lesion most likely\n represents a meningioma, differential diagnosis includes a dural-based\n metastasis, tuberculosis, or sarcoid.\n\n 3. The mass appears to encase the cavernous segment of the right ICA and\n causes severe stenosis. These findings should be further assessed by MRA of\n head and neck.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1218551,
"text": " 4:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with R IC occulsion\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXPb TUE 11:21 AM\n No marked change in evolving infarct. No new infarct or hemorrhagic\n conversion. Similar extent of mass effect with possible 1 mm reduction in the\n shift of midline structures. - T. Pinar, reviewed with Dr. \n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for interval changes in subacute right anterior and\n middle cerebral artery territory infarcts due to high-grade stenosis of the\n origin of the right ICA.\n\n COMPARISONS: CTA head and neck dated , NECT head dated ,\n and MRA brain and neck dated .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered. Coronal and sagittal reformats provided and\n reviewed.\n\n FINDINGS:\n\n The large evolving subacute right frontal lobe infarct is stable from the\n prior study two days ago. There is no hemorrhagic conversion, nor new infarct\n in any other region identified. The mass effect from the infarct is largely\n unchanged, with subfalcine herniation, effacement of the frontal of the\n right lateral ventricle, and 13 mm leftward shift of midline structures,\n possibly MINIMALLY decreased from two days ago, when it measured 14 mm without\n significant change. The surrounding osseous and extracranial soft tissues do\n not reveal additional new abnormalities.\n\n IMPRESSION:\n 1. Interval stability of subacute right anterior and middle cerebral artery\n territory infarcts.\n 2. No evidence of hemorrhagic conversion or new infarct in other regions.\n 3. Similar degree of mass effect causing subfalcine herniation, effacement of\n the frontal , and 13-mm leftward shift of midline structures, possibly 1\n mm less than two days ago without significant change.\n (Over)\n\n 4:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1218213,
"text": " 7:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 48 year old woman with right mca stroke concern for hemorrha\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with right mca stroke concern for hemorrhagic conversion /\n extension of infarct\n REASON FOR THIS EXAMINATION:\n 48 year old woman with right mca stroke concern for hemorrhagic conversion /\n extension of infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SAT 9:58 AM\n No significant change in large right frontal lobe infarction. Additional\n smaller right frontal and parietal lobe infarcts were better seen on prior MR.\n hemorrhagic transformation. No significant change in leftward shift of\n normally midline structures. No definite central herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right MCA stroke, concerning for hemorrhagic conversion/extension\n of infarct.\n\n TECHNIQUE: Sequential axial images were acquired through the head without\n administration of intravenous contrast material.\n\n COMPARISON: MR head from .\n\n FINDINGS: There is no appreciable change in size in the degree of cytotoxic\n edema centered within the right frontal lobe compared to MR . Additional smaller right frontal and parietal infarcts were better seen\n on prior MR. There is no evidence of hemorrhagic conversion. Leftward shift\n of the normally midline structures by approximately 10 mm is unchanged. There\n is marked compression of the right lateral ventricle without evidence of\n entrapment of the left lateral ventricle. There is no definite central\n herniation. There is no new acute large vascular territorial infarction. An\n extra-axial mass originating from the right petroclival dura was better seen\n on prior MR. The visualized portions of the paranasal sinuses and mastoid air\n cells are well aerated. The orbits are grossly unremarkable.\n\n IMPRESSION:\n\n 1. No significant change in large right frontal lobe infarction. Additional\n smaller right frontal and parietal infarcts are better seen on prior MR.\n\n 2. No evidence of hemorrhagic transformation.\n\n 3. Persistent leftward shift of normally midline structures, not\n significantly changed. No definite central herniation.\n\n ATTENDING NOTE: Right uncal herniation not changed from MRI of .\n (Over)\n\n 7:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 48 year old woman with right mca stroke concern for hemorrha\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1218716,
"text": " 4:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with right ACA/MCA stroke w/ shift\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Single supine portable chest view was reviewed in comparison with\n prior radiograph from .\n\n FINDINGS:\n\n Right PICC line ends at lower SVC. Minimal right lung base opacity, which is\n likely atelectasis, is unchanged. There are no other lung opacities\n concerning for infection or pulmonary edema. Heart size is normal.\n Mediastinal and hilar contours are normal. There is no pleural abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1219312,
"text": " 9:15 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: any worsening edema?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with large MCA and ACA stroke, previously on mannitol, now\n off, but with new H/A and photophobia\n REASON FOR THIS EXAMINATION:\n any worsening edema?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa SUN 12:15 PM\n Interval evolution of infarction with decreased edema and decreased leftward\n shift of midline structures. No evidence of hemorrhagic conversion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known right-sided infarction with new headache. Evaluation for\n evidence of worsening edema.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast.\n\n COMPARISON: Multiple prior examinations, most recent CT dated .\n\n FINDINGS: Again seen is hypodensity and edema within the right frontal lobe\n consistent with continued evolution of known prior infarction. Sulcal\n effacement persists; however, the extent of edema has slightly improved on\n this examination. The degree of leftward shift of midline structures has also\n improved, now measuring approximately 7 mm, previously 13 mm. No evidence of\n acute hemorrhagic conversion is seen. The ventricles are not enlarged with\n similar configuration with mass effect on the right lateral ventricle. No\n concerning osseous lesion is seen. The visualized paranasal sinuses and\n mastoid air cells are clear.\n\n IMPRESSION: Interval evolution of infarction with mildly decreased but\n persistent edema and decreased leftward shift of midline structures. No\n evidence of hemorrhagic conversion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-19 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1218329,
"text": " 11:45 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: Evaluate for evolution\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OMNIPAQUE Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with Right MCA stroke with midline shift\n REASON FOR THIS EXAMINATION:\n Evaluate for evolution\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SUN 1:09 PM\n 1. Progressive hypoattenuation (evolution) of a large right frontal (MCA and\n ACA territory) infarction without hemorrhagic conversion or new infarcts.\n 2. Slightly worsened mass effect with slightly worsened cerebral edema. The\n suprasellar cisterns remain patent, but are effaced. The Sylvian fissures are\n effaced bilaterally. Midline shift to the left by about 12 mm, slightly\n progressed from previously 10 mm.\n 3. Almost 100%, likley atherosclerotic occlusion (Se 3, img 141) of the right\n ICA at the common carotid bifurcation with severely diminished flow (\"string\n sign\") in the distal ICA and some reconstiution at the cavernous ICA due to\n retrograde flow from the circle of .\n 4. Hypervascularity at the previously on MRI described mass at the right\n retroclival dura abutting the posterior cavernous sinus (likely meningioma),\n but no mass effect on the ICA.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAPHY OF THE NECK AND HEAD\n\n HISTORY: Right middle cerebral artery stroke with midline shift. Evaluate\n for evolution.\n\n TECHNIQUE: Non-contrast head CT scan followed by CT angiography of the neck\n and head.\n\n COMPARISON STUDY ON PACS ARCHIVE: MRI scan of the brain from as well\n as CT scan of the head from .\n\n FINDINGS: There is redemonstration of the large, subacute infarct involving\n both right anterior and middle cerebral artery divisions, with the middle\n cerebral artery component of the stroke consisting of involvement of the\n superior division of that vessel. There is continued evidence for\n considerable mass effect exerted upon the right frontal , with subfalcine\n herniation fairly similar to that seen on the previous day CT scan, and\n measuring 6.4 mm. There has been no hemorrhagic transformation. There were\n no other areas of infarction identified. There is no hydrocephalus. The\n surrounding osseous and extracranial soft tissues do not reveal additional new\n abnormalities.\n\n CT angiography of the neck and head reveals a high-grade (95% plus) stenosis\n (Over)\n\n 11:45 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: Evaluate for evolution\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OMNIPAQUE Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the origin of the right internal carotid artery, where there are also\n several punctate atherosclerotic calcifications. The CT angiogram does reveal\n a collapsed right internal carotid artery distal to the area of stenosis,\n representing the so-called \"string sign\". This minimal flow is identified as\n far distally as the right supraclinoid bifurcation. Based upon the limited\n scanner-generated reconstructions available at the time of this report, there\n were no other definite additional areas of hemodynamically significant\n stenosis identified, but there is clear diminished opacification of branches\n of the right anterior middle cerebral arteries that supply the area of the\n infarcts. The suspected clival meningioma is again seen, though more clearly\n on the previous MR study.\n\n IMPRESSION: Subacute right anterior and middle cerebral artery territory\n infarcts.\n High grade (>95%) stenosis of the origin of the right internal carotid artery,\n with \"string sign\" more distally. Other findings, noted above.\n\n COMMENT: I discussed these findings with Dr. , the radiology\n resident on duty at this time, who will be conveying the preliminary report to\n the physicians caring for the patient at this time. I also left my return\n telephone number in order that these physicians have access for immediate\n telephone consultation with me, if required.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-11-24 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1219062,
"text": " 8:37 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: please further eval both carotids for vascular surgery\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with 95% R ICA stenosis on CTA\n REASON FOR THIS EXAMINATION:\n please further eval both carotids for vascular surgery\n ______________________________________________________________________________\n FINAL REPORT\n\n Study: Carotid Series Complete\n\n Reason: .48 year old woman with carotid stenosis.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is very significant homogeneous, echolucent plaque seen in the\n ICA . On the left there is mild heterogeneous plaque seen in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 546/245, 436/135, 38/16, cm/sec. CCA peak systolic\n velocity is 44 cm/sec. ECA peak systolic velocity is 98 cm/sec. The ICA/CCA\n ratio is 12.4. These findings are consistent with 95% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 58/27, 75/34, 78/40, cm/sec. CCA peak systolic\n velocity is 69 cm/sec. ECA peak systolic velocity is 84 cm/sec. The ICA/CCA\n ratio is 1.1. 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 critical, 95%stenosis.\n Left ICA <40% stenosis.\n\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2113-11-17 00:00:00.000",
"description": "Report",
"row_id": 90117,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA\nWeight (lb): 130\nBP (mm Hg): 148/76\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 10:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Patient was unable to cooperate with\nmaneuvers.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast (rest injection only).\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF 70%). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic stenosis or aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2113-11-16 00:00:00.000",
"description": "Report",
"row_id": 238543,
"text": "Normal sinus rhythm. Within normal limits. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2113-11-17 00:00:00.000",
"description": "Report",
"row_id": 238542,
"text": "Normal sinus rhythm. Within normal limits. Compared to tracing #1 no\ndiagnostic interval change.\nTRACING #2\n\n"
}
] |
6,787 | 157,546 | Neuro-patient is in a persistent vegetative state and remained unresponsive and at his baseline throughout his hospital stay. Cardiovascular-patient was weaned off of pressor support shortly after admission, he was maintained on iv metoprolol with adequate control of his blood pressure. However, the pt. does not tolerate being turned on his right side - his pressures will decrease somewhat. If this occurs - place pt. back to supine position and blood pressure should correct. Respiratory-patient was intubated on admission. A series of discussions were had with the health care proxy, his daughter, regarding the need for tracheostomy. Both the primary general surgery team and the thoracic team were consulted regarding the need for tracheostomy. Eventually, a second opinion was requested by the daughter and obtained from general surgery. The daughter was told that the patient would likely benefit from tracheostomy and that extubation could very well lead to reintubation considering the patient's poor functional status. The daughter decided to attempt extubation, the pt. was extubated and has been doing very well for the past several days off of the vent. He has been maintaining O2 saturations in the high 90s with minimal oxygen from the face tent. GI-the patient was started on TPN for nutritional support. He was also given tube feedings. He is currently being maintained on tube feeds and no TPN. His albumin has been stable with this regimen and he should be continued on this: Nepro 45% strength for Osm of 280 at a goal rate of 70cc/hour. GU-Pt. has been getting Lasix throughout his stay for help w/diuresis. He was initially quite volume overloaded and need this to get fluid off so he could be extubated. He is no longer requiring lasix and is making adequate uring on his own. His renal function has also returned to . The pt. received a few transfusions of PRBCs during his and for the past week his hematocrit has been stable. We do not anticipate that he will need any further transfusions. Pt. was initially being treated for aspiration pneumonia and is requiring two more day of antibiotics to complete his course. His WBCs have been stable. Endo- stable | Foley patent drng adequate urine.Endo: RISSPlan: Cont with current plan of care. Pan cx for temp over . CHEST PT DONE PRN. PULM HYGIENE.SUPPORT. PT REMAINS ON ASSIST CONTROL, LUNG SOUNDS OCCASIONALLY COARSE. Respiratory Care: Pt remains on current vent settings, see carevue for details. Lungs coarse bilaterally, sux'd for mod. MDIs gven as ordered. FIB IN PLACE WITH LIQ BROWN STOOL.GU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.ENDO-SSRI.COMFORT-APPEARS COMFORTABLE.SKIN-DSG CHANGES AS ORDERED.A-STABLE.P-CON'T WITH CURRENT PLAN. Receiving MDI's. FOCUS: STATUS UPDATEDATA:NEUROLOGY STATUS UNCHANGED. Nursing Progress NotePlease see carvue for specifics:Neuro: UnchangedCV: Unchanged. NARD NOTED.GI-ABD REMAINS FIRM AND DISTENDED. Pt remained extubated overnight, NT sx for small to mod amts of bloody fluid. Pt in a-fib, with occassional PVC's, BP 95-120 systolic. vent weaned to and toleratingwell. Resp Care Note, Pt remains on current vent settings. Abdomen firmly distended w/ hypoactive BS. Allevyn tegaderm and sofsorb applied. WBC ^17.0 remains receiving Zosyn. Generalized edema noted. Pt w/ + generalized edema; pitting. Resp CarePt remains intubated and on CPAP/PSV with settings on . MDI'S given. Resp CarePt remains on simv-parameters noted. MDI'S GIVEN AS ODERED. RUA PICC line intact.GI/GU: Abd firmly distended, + BS. CONDITION UPDATEASSESSMENT: NEURO UNCHANGED. carept remains intubated/vented. J-G tube intact receiving Nepro @ goal and tolerating. MDIS GIVEN AS ORDERED. MDIS GIVEN AS ORDERED. ABDOMEN FIRM & DISTENDED, BUT TOLERATING TUBE FEEDS AND STOOLING REGULARLY. +PP P-boots on.GI: Abd firm distended. Oral ulcers noted. Will continue mech vent and wean as tol. Abdomen firmly distended w/ hypoactive BS. + pulses to lower ext. NARD NOTED AT THIS TIME.GI-ABD REMAINS FIRM AND DISTENDED. BS fine crackles RLL; no change with MDI's. BS fine crackles RLL; no change with MDI's. ABDOMEN FIRMLY DISTENDED, TPN FOR NUTRITION. No evidence of pain.GI/GU: Abd firmly distended, + BS, J-tube with Nepro @ goal, tolerating well. PULM HYGIENE. L TL Picc with one port clotted. W-D 1/2st Dakins solution. Lungs clear/diminished at the bases. LEFT HIP DSG CHANGED AS ORDERED. CV: Remains in afib, occational pvc's. BP slightly decreased systolic 80's, after lopressor, sicu team and team notified, maps wnl. GI: Abd firmly distended, bs absent. HCT SENT THIS PM AND PENDING RESULTS.ABD KUB DONE WITH GASTROGRAFFIN CONTRAST.PLAN:CONTINUE CURRENT PLAN OF CARE. Pt still being diuresed w/ 60mg lasix TID. Weak periph pulses, +genealized anasarca. +PP P boots on.GI: Abd firm distended. Hypoactive bs. Hypoactive BS. Pt tolerating well. MDI'd x1 given.Pt is being evaluated for trach. Pt suctioned for moderate amts thick secretions. Resp CarePt remains on PSV-parameters noted. BS coarse rhonchi bilaterally. Respiratory Care NotePt received on SIMV + PS as noted. HR 70-110 Afib with occasional PVC's. Resp CarePt remains intubated and on CPCP/PSV. Condition UpdatePlease see carevue for specifics.Pt continues to be non responsive. Remains on PS as per carevue. BS: wheezes on left, diminshed on right. RESPIRATORY CARE: PT W/ AN 8.0 ORAL ETT IN PLACE.AC MODE AS PER CV. MDI given a/o. Respiratory Care NotePt received on SIMV as noted. D:Pt stable overnight, metoprolol given and tolerated.Afeb, vss, TFs tolerated, 2 BMs fecal incontinence bag applied.A:StableContinue plan of care. ABDOMEN FIRM & SLIGHTLY DISTENDED (BASELINE), TOLERATING TUBE FEEDS @ GOAL RATE. TO BE DONE .VERY SLOW VENT WEAN BEING ATTEMPTED, ON CPAP 14/8, WITH RESP. BS coarse crackles LLL, otherwise CTAB; no change with MDI's. Pt afebrile, adequate peripheral pulses.Resp: Pt weaned to CPAP with 10 of PEEP, and 18 of Psupp, Weaned further to 16 of Psupp. CONDITIO UPDATEASSESSMENT: NEURO EXAM UNCHANGED. recieving tpn.integ left hip decub dsg changed as ordered. Pt tolerating well with VT 500-610, RR 18-22, MV 10.0-12.7. PERRL.CV: A-fib with occassional PVC's. Bs reveal bilateral aeration with diminished bases. RESPIRATORY CARE 1900-0700PT REMAINS ORALLY INTUBATED ON SIMV+PS. is firm and distended - discussed with Dr. , +bs. WBC 12.3.GI/GU: Abd firmly distended, hypoactive BS noted. Diueresing well.Endo: RISSPlan: supportive care, resp support. Pt had KUB this am, and recieved dulcolax suppository. Re-taped ETT. Resp Care Note, Pt remains on current vent settings. Remains receiving reglan. ETT retaped, rotated and secured. off as per orders.GU: foley draining adequate amts. cleansed around site with saline and tube re anchored. MDI'S given. TPN, Cycled TF's. upper extremities with stimulation - Dr. was notified and states that this is his baseline.CV: a-fib with no ectopy. Will continue mech vent at this time. Continue current POC. LOPRESSOR HELD. Pt ext contracted with generalized edema. left hip is draining serosanguinous. TID diuresis w/ lasix. Respiratory Care: Pt remains on current vent settings. KUB done and TF held Gastric tube to gravity drng minimal amts team is aware. + PITTING EDEMA TROUGHOUT. After access was obtained, a 0.018 guide wire was advanced under fluoroscopic guidance with its tip placed in the distal SVC. Nursing Progress NotePlease see carvue for specifics:Neuro: Pt is in a persistant vegatative state at baseline. Under fluoroscopic guidance, and 0.035 Bentson guidewire was advanced through the indwelling G- tube. MOUTH CARE DONE.GI-ABD FIRM, DISTENDED. Rectal exam by primary team neg. A stiff Amplatz wire was used to regain access, passed through the pylorus, obtained distal placement in the proximal jejunum. Will continue pulmunary hygiene and mech vent at this time. WEAN VENT AS TOL. EXTUBATE IF TOLERATES VENT SETTINGS VERSUS TRACH. SKIN CARE DONE FREQ.A-ALT IN SKIN INTEGRITY. Left-sided intra-abdominal catheter whose location is indeterminate. FINDINGS: Again note is made of predominantly gasless abdomen, with rectal tube. The most of the contrast injected has passed through the bowel, and was no longer identified in the abdomen. INDICATION: Paucity of bowel sounds. COMPARISON: Abdominal radiograph dated . COMPARISON: Abdominal radiograph dated . Reference is made to previous chest radiographs and plain films of the abdomen. FINDINGS: Note is made of predominantly gasless abdomen. Diffuse increasing opacity in the abdomen, which may represent ascites, however, the evaluation is limited on this plain film. FINDINGS: There is a relative paucity of bowel gas diffusely. As before, there is a paucity of gas within the abdomen. IMPRESSION: Faint contrast in the right upper and lower quadrants in bowel loops. | 156 | [
{
"category": "Nursing/other",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Report",
"row_id": 1351795,
"text": "Nursing Update\nsee careview flowsheet for specific info\n\nNeuro: Pt opens eyes to pain, does not track or follow commands. No spont. movement of extremities noted today.\n\nCV: triple lumen PICC in LUE. CVP transducer put on PICC line per Dr. , CVP in 20's. Pt in a-fib, with occassional PVC's, BP 95-120 systolic. a.m. lopressor held for SBP< 100, PM dose given.\n\nResp: Pt on AC 50% O2, 10 of PEEP, sats 95-100%. Lungs coarse bilaterally, sux'd for mod. amount of thick tan sputum.\n\nGI: Abdomen firmly distended, BS absent. Mushroom cath in place draining watery stool, pt had watery BM prior to mushroom cath being put in place. 3 KUB's taken today, one without gastrograph, and two after 60cc's instilled, no obstruction noted by primary team. 1/2 strength Nepro started today by Primary team at goal at 10cc/hr. TPN with lipids changed to TPN with Nephramine. G-tube to gravity this a.m., leaking around insertion site, SICU team notified, site dressed with aquacel and drain sponge.\n\nGU: Foley to gravity, UO 30-65cc/hr.\n\ninteg: pressure ulcer on left hip is to the bone, irrigated and packed with saline soaked gauze. pressure ulcers on right hip cleaned and covered with duoderm.\n\nSocial: No family mtg today. daughter in today, spoke with (social worker), and about plan of care.\n\nPlan: Cont. with tube feeds.\n Monitor cardiac and respiratory staus\n Monitor I&O\n SICU team aware of above, contact HO with changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Report",
"row_id": 1351796,
"text": "CONDITION UPDATE\nASSESSMENT:\n SEE FLOWSHEET FOR SPECIFICS, VITALS STABLE AND PHYSICAL EXAM UNCHANGED. PT REMAINS ON ASSIST CONTROL, LUNG SOUNDS OCCASIONALLY COARSE. ABDOMEN FIRM & DISTENDED, TPN INFUSING AND TUBE FEEDS @ 10 CC/HR. SMALL AMOUNTS LIQUID STOOL FROM MUSHROOM CATHETER. WEIGHT CONTINUES TO INCREASE AND PT EDEMATOUS.\nPLAN:\n REPEAT LABS THIS AM. CT SCAN IF CREAT COMING DONE. CONTINUE WITH WOUND/SKIN CARE. ? FAMILY MEETING TO DETERMINE PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-08 00:00:00.000",
"description": "Report",
"row_id": 1351821,
"text": "resp care\n\nMode of ventilation changed to Simv and rr increase to 18. Spo2 adequate in the high 90's. Suctioning large amts of thick yellow sputum and set to lab for culture\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-08 00:00:00.000",
"description": "Report",
"row_id": 1351822,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Unchanged\nCV: Unchanged. Pan cx for temp over . Given 60mg of lasix slow response this pm.\nResp: Vent changed to SIMV 600X18 . Pt respiratory pattern normal with a labored respiratory effort. ABG drawn on current settings. ABG's WNL. MD is aware and cont to monitor pt.\nSats 98-100%. Lungs coarse throughout Sxn for green thick sputum.\nGI/GU: TF off at 1800 for approx 50cc of emesis ? TF. MD made aware. TF on hold for approx 2hrs. Foley patent drng adequate urine.\nEndo: RISS\nPlan: Cont with current plan of care. Cont to diurese as tolerated.\nSoc: MD will be away untill Friday. All questions directed by daughter should be direct to MD . He wil address her concerns on his pt rounds . All question directed to nurses about meds or TPN ingredients or surgical procedures are to be redirected to MD 's team to be answered by MD or MD in Ficshers absence.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-02 00:00:00.000",
"description": "Report",
"row_id": 1351911,
"text": "Pt remained extubated overnight, NT sx for small to mod amts of bloody fluid. Pt given neb RX wth ALB/ATV but no change in diminished BS. Pt givn lasix for fluid\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-02 00:00:00.000",
"description": "Report",
"row_id": 1351912,
"text": "FOCUS: STATUS UPATE\nDATA;\nPT NOT FOLLOWING COMMANDS, RESPONDING VERY SLIGHTLY THIS AFTERNOON BY VERY WEAKLY COUGHING WHEN ASKED TO SEVERAL TIMES. WHOLE BODY VERY CONTRACTED AND DIFFICULT TO REPOSITION.\n\nLUNGS COARSE BILAT. CONTINUES TO SAT WELL IN THE MID 90'S WITH OPEN FM AT 50%. BACK OF THROAT SUCTIONED FOR THIN WHITE SECRETIONS. VERY POOR GAG. CPT DONE AND REPOSITION TO MAINTAIN RESP STATUS.\n\nCONTINUES TO TOL TUBE FEEDS WELL.\n\nPLAN:\nPULM TOILET FREQUENTLY, MONITOR RESP STATUS. REHAB SCREENING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-03 00:00:00.000",
"description": "Report",
"row_id": 1351913,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-AROUSES TO STIMULI. OPENS EYES SPONT. PERRL. NO SPEAKING NOTED. WEAK GAG. FLEX/WITHDRAWS ALL EXTREMITIES TO PAIN. DOES NOT FOLLOW COMMANDS.\n\nCV-REMAINS IN AFIB. RATE STABLE. SBP STABLE. SKIN W+D. +PP. PBOOTS ON.\n\nRESP-O2 SAT 97% ON 50% FACE TENT. LS COARSE, DECREASED AT BASES. CHEST PT DONE PRN. SXN X FEW FOR SM AMT THICK WHITE SPUTUM. WEAK COUGH/GAG. NARD NOTED.\n\nGI-ABD REMAINS FIRM AND DISTENDED. + BS. TOL TF AT GOAL VIA J-TUBE. G-TUBE TO GRAVITY WITH BILIOUS DRG. FIB IN PLACE WITH LIQ BROWN STOOL.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-SSRI.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nSKIN-DSG CHANGES AS ORDERED.\n\nA-STABLE.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHAGNES. PULM HYGIENE.SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-09 00:00:00.000",
"description": "Report",
"row_id": 1351826,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nPt had 5 beat run of vtach. Lytes sent. pt given Mag and K+. MD and MD of primary team aware. No other ectopy noted. Pt also 2 days with no BM pt will need enema tonight. Overall status unchanged. cont with plan of care. Daughter to receive updates from MD of primary team only. Cont to redirect daughter to MD if she attempts to ask nursing any questions in re: meds/TPN and POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 1351827,
"text": "Nursing note (1900-0700) 04:50\n\nSee careview for specific data.\nPt with unchanged status overnight, all VS stable, pt given fleets enema overnight, no descernible result so far, ? repeat later today.\nTF's being absorbed this shift, currently on hold, to restart at 0700, BS hypoactive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 1351828,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on SIMV settings. No vent changes made during the . RSBI completed on PS 5=47. BLBS are coarse rhonchi. Sxn for copious amounts yellow-green thick\nsecretions.\n\n , RRT\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-04 00:00:00.000",
"description": "Report",
"row_id": 1351915,
"text": "Condition Update\nPlease see carevue for specifics:\n\nPt vss with sbp 92-112 and hr 60-90 in afib with transient drops to 40's, returning on own. NSS and unchanged; pt does not follow commands has minimal cough, minimal gag, and only at times blinks to threat. MAE on bed to painful stimuli. LS coarse to diminished to clear- 02 sats 95-100% on 50% facemask with a resp rate of 18-30; chest PT q 2-4 hours and NT suctioning after chest PT returning small amounts of thick white/tan secretions. Abd firm and distended with +bs x4 and small amounts of loose stool PR into FIB; toelrating tubefeeds well and g-tube to gravity draining moderate amounts of bilious drainage. Foley draining adequate amounts of CYU; Pt running even for fluid status at mn. Pt on Lab holiday today per Dr. team. Cont surveillance of i/o's, vs, ns, and continue aggressive pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-17 00:00:00.000",
"description": "Report",
"row_id": 1351856,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results determined a compensated mild metabolic acidemia with good oxygenation on the current settings.\n\nRSBI = 86.8 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-17 00:00:00.000",
"description": "Report",
"row_id": 1351857,
"text": "respiratory care\npt on the vent on changes made this shift see respiratory page of care view for more information\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-17 00:00:00.000",
"description": "Report",
"row_id": 1351858,
"text": "FOCUS: STATUS UPDATE\nDATA:\nNEUROLOGY STATUS UNCHANGED. CONTINUES TO RESPOND TO STIMULI AND WITHDRAWING TO PAIN.\n\nLUNGS COARSE WITH EXPIRATORY WHEEZING AT TIMES ESPECIALLY AFTER EXERTION. CONTINUES ON SIMV/PS-NO VENT CHANGES TODAY. SATS STABLE 98-100%. MDI'S WITH EFFECT FROM RESP THERAPY. SUCTIONED FREQUENTLY FOR THICK TAN SPUTUM. AFEBRILE.\n\nABD SOFT AND DISTENDED WITH POSITIVE BOWEL SOUNDS. TOLERATING TUBE FEEDS WITHOUT RESIDUALS--6HRS ON CYCLED WITH 2HRS OFF. GT TO GRAVITY WITH BILIOUS OUTPUT. CONTINUES ON TPN.\n\nMUSHROOM CATHETER IN PLACE FOR LOOSE STOOL.\n\nPLAN:\nMONITOR RESPSTATUS CLOSELY. REPEAT HCT TONIGHT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-17 00:00:00.000",
"description": "Report",
"row_id": 1351859,
"text": " 2100\n NEURO SOME RANDOM MOTION TO STIMULI ONLY NO COMMANDS PLEASE SEE CAREVIEW FOR DETAILES STATUS\n RESP REMAINS ON SIMV ON 40 FIO2 TOL WELL THICK SPUTUM NOTED RHOCHI THRU OUT\n HEART AF VARIBLE RATE VSS NO TEMP NOTED POOR PULSES LG AMOUNT OF EDEMA NOTED WEAPING SKIN FLUID FILLED M HOLO\n GI POS B/S THRU OUT STOOLING BROWN TOL T/F WELL SOFT ABD NON TENDOR\n WOUND LEFT HIP DRESSING Q 12 SEE CAREVIEW FOR DETAILS SKIN CARE PER PROTOCOL\n PLAN SUPPORTIVE T/P CPT ROM MONITOR FLUID STATUS REPORT TO MD ANY CHANGE OF PT CONDITION FAMILY SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-17 00:00:00.000",
"description": "Report",
"row_id": 1351860,
"text": "Respiratory Care: Pt remains on current vent settings, see carevue for details. Receiving MDI's. No vent changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-18 00:00:00.000",
"description": "Report",
"row_id": 1351861,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 52.1 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-18 00:00:00.000",
"description": "Report",
"row_id": 1351862,
"text": "respiratory care\npt on the vent tol well no changes made, see respiratory page of care view for more information\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Report",
"row_id": 1351797,
"text": "Respiratory CAre 1900-0700\nPt remains orally intubated on vent support. No changes made to vent throughout the night. BS coarse bilat, sx for small to moderate of thick yellow secretions. MDIs gven as ordered. No ABG or RSBI this AM. See carevue for further questions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Report",
"row_id": 1351798,
"text": "resp care\npt remains intubated,converted to psv mode and ps level titrated to Vt 450-500. peep remains at 10, ?wean slightly more tonight. bs diffusely rhonchorous. sxning thick bld tinged to yellow sputum. bronchodilators given as needed. abg attempted, pt difficult stick due to edema. vbg with acceptable ventilation. need to confirm with team plans for tonight, if they want psv vs ac mode.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-21 00:00:00.000",
"description": "Report",
"row_id": 1351874,
"text": "RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON SIMV+PS. NO CAHANGES MADE TO VENT THROUGHOUT THE NIGHT. BS COARSE BILAT, SX FOR MODERATE AMT OF THICK YELLOW SECRETIONS. MDIS GIVEN AS ORDERED. RSBI THIS AM= 49.9. NO ABG DRAWN THIS AM.SEE CAREVUE FOR FURTHER QUESTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-21 00:00:00.000",
"description": "Report",
"row_id": 1351875,
"text": "Respiratory care: Patient remains on SIMV 500/18/5/15 40%. No ABG's were done, SpaO2 95% to 100% Pt stable.. Patient was tranfused today Hct 28.9 and Hb 9.6. A diagnostic bronchoscopy was performed. Pt was also evaluated for a tracheostomy, but no decision has been made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-21 00:00:00.000",
"description": "Report",
"row_id": 1351876,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Unchanged neuro exam. Pt opens eyes to voice; does not track. Grimaces at times, but appears comfortable after turned and repositioned. Withdraws all extremities when nailbed pinched. Afebrile. HR 70-90s (A.fib). NBP 90-110s/40-60s. Pt w/ + generalized edema; pitting. DP/PT pulses weakly palpable. Hct 26.7 this AM; transfused w/ 1unit PRBC (infused over 4hrs as ordered). Repeat Hct needed after transfusion finishes. Lungs clear, diminished at bases. SIMV: 40%, Vt 500x18, PEEP 5, PS 15. RR 20s. Pt w/ shallow breathing. Cough weak, nonproductive. O2 sat >/= 95%. Pt bronched today; sample sent for cultures by respiratory therapist. Dr. evaluated pt for trach today; , MD spoke w/ pt's daughter. Abdomen firmly distended w/ hypoactive BS. 40% str Nepro @ 70cc/hr via J-tube; no residuals. G-tube to gravity bag w/ 100cc green, bilious drainage. Mushroom cath in place; loose golden stool. BS 119-128; no insulin coverage per sliding scale. See CareVue for specifics on integumentary. Left hip decub w/ wet to dry dsg; packed w/ 2x2 gauze soaked in str Dakins solution. Outer part of decub measures 4cmx4cm; inner measures 2cmx2cm; depth: 2cm. Wound bed is pink; Dr. , Dr. , and , RN (wound care RN) notified of tunnelling noted around inside of wound; , RN tunnelling is not new. Wound w/ small amount serous drainage. Right hip w/ duoderm intact; no drainage noted. G/J tube site w/ DSD changed x1. Foley intact w/ clear, yellow urine. UO 30-80cc/hr. Pt's daughter visited most of day; updated on plan of care and on pt's condition.\n Plan: Monitor VS, I's and O's, labs, respiratory status. Monitor decub for s/s infection. Check Hct. Follow up cultures. Discuss plan of care w/ pt's daughter. Cont ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-22 00:00:00.000",
"description": "Report",
"row_id": 1351877,
"text": "RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON SIMV+PS. NO CHANGES MADE TO VENT THROUGHOUT THE NIGHT. BS COARSE BILAT, SX FOR MODERATE AMT OF FROTHY WHITE SECRETIONS. MDIS GIVEN AS ORDERED. RSBI THIS AM= 50. SEE CAREVUE FOR FURTHER DETAILS.\n\nPLAN: CONTINUE TO FOLLOW AND WEAN AS ABLE. ?TRACH\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-22 00:00:00.000",
"description": "Report",
"row_id": 1351878,
"text": "1900-0700\n\nNeuro: Pt neuro status remains unchanged. Pt has eye opening to verbal and tactile stimulation. Pt is contracted and does not move ext. Pt does not follow any commands. No seizure activity noted.\n\nResp: Pt orally intubated on mech ventilation. SIMV/PS, 40% 5/15. O2sat stable remains >95%. Lungs clear and diminished. Suctions for thick tan secretions.\n\nCV: Afib with hr 70-80s. SBP 95-115. afebrile, no evidence of pain. WBC ^17.0 remains receiving Zosyn. Generalized edema noted. See carevue for skin assessment. Hip decub dsg changed. Pt on Air mattress. Oral ulcers noted. RUA PICC line intact.\n\nGI/GU: Abd firmly distended, + BS. 2X large BM. Formed and golden in color. J-G tube intact receiving Nepro @ goal and tolerating. Foley to BSD draining clear yellow urine.\n\nEndo: RISS\n\nPlan: ? extubate vs tracheostomy. Supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-22 00:00:00.000",
"description": "Report",
"row_id": 1351879,
"text": "Events:\n\nPlan for ethics meeting to address plan of care with daughter per Dr. \n\nNeuro-spontaneously opens eyes, contracted extrem, no purposeful movements, does not follow commands, pupils unequal, apnea ventilation on CPAP trial\nCV-MP Afib SBP low 85/49 lasix held, + generalized pitting edema, RL extrem cool, SCDS on bilat\nResp-LS dim coarse upper lobes sx for thick yellow, attempt CPAP trial, pt with decreased TV, increase resp effort and periods of apnea, changed back to SIMV\nGI-abd firm distended hypo BS, Tf at 70cc/hr, liq stool out x2, glucose covered with SS insulin\nRenal-u/o >30cc/hr\nSkin-please see carvue\n\nPlan- cont TF, SIMV, ethics meeting,\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Report",
"row_id": 1351814,
"text": "NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\nNEURO: Unresponsive, does not follow commands, open eyes spontaneously.\nC/V: AFib 75-82, BP: 98-140/ 49-70's.\nRESP: Remains on AC settings of 500X 14X 40% with 5 PEEP, Suctioned X3 thick yellow secretions. Lung sounds rhonchi uper airways and diminished in bases.\nGI: Abd remains firm and distended, hypoactive bowel sounds noted, Tube feeding of str Nepro continues at 40cc/hr for five hours and off for three hours. Due to be restarted at 7PM at 40cc/hr.\nGU: Foley patent draining clear yellow, good diuresis from lasix 40mg given IVP.\nSOCIAL: Patients daughter into visit most of day, met with team as well as social service. Updated by Dr. on patents plan of care.\nSKIN: Left hip dsg done with 1/2 str dakins solutions wet to dry dressing.\nPLAN: ? surgical for possible trach placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Report",
"row_id": 1351815,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amtas thick tan secretions. MDI'S given. RSBI done on 9 peep/5 ips 30.7/ HR-A-Fib. Will cont to monitor resp status\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Report",
"row_id": 1351816,
"text": "cv: temp max 99.1 po. hr afib 75-90. short run of vea 8 beats. sbp 88-117/\n\ngu: foley draining cloudy yellow urine. lasix 60 mg iv given times one.. diuresed well.\n\ngi: tube feed nepro infusing as ordered at 40 cc/hr run for 5 hours and then off times 3 hours. residual at 8 pm and 11 pm = 0. pt turned onto his right side and vomited moderate amount tube feed ~ 40 cc. dr .. tube feed to be turned off times 3 hours and restarted at 40 cc/hr.abdomen is distended and firm . bowel sounds present and hypoactive. mushroojm catheter in place draining brown liquid stool.tub feed turned back on and currently resiiiiidual is 20 cc\n\nneuro: pt opens eyes to stimulus verbal and tactile.pupils equal and reactive.\n\nintegumentary: generalized body edena, r arm has a spot that is draining ascitiic fluid. coollection device applied and connected to draininge bag.left hip dressing changed decubitus is deep to the bone. 3 cm by 3 cm packed with the dakins solution and gauze,\n\npt is very contracted and pt tightens up with any care to patient\ngeneralized\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Report",
"row_id": 1351817,
"text": "Respiratory care\nPt remains on current ventilator settings with no changes. All questions directed by family to be answered by Dr about all aspects of this pt's care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-28 00:00:00.000",
"description": "Report",
"row_id": 1351905,
"text": "resp. care\npt remains intubated/vented. vent weaned to and tolerating\nwell. plan to extubate tomorrow. if pt needs reintubation will\ntrach asap.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-28 00:00:00.000",
"description": "Report",
"row_id": 1351906,
"text": "NURSING NOTE ADDM\n PATIENT TOLERATING CPAP 5/5, DR. AND ICU TEAM AWARE. PATIENT'S DAUGHTER SPOKE WITH DR. (ETHICAL COMMITTEE) REGARDING EXTUBATION. PATIENT'S DAUGHTER AWARE OF PLAN TO EXTUBATE WHEN PATIENT READY, POSSIBLY IF NO RESP ISSUES OVERNIGHT. PATIENT'S DAUGHTER ALSO DISCUSSED WITH DR. POTENTIAL FOR REINTUBATION IF PATIENT CANNOT MAINTAIN AIRWAY. IF THIS OCCURS, PATIENT WILL BE REINTUBATED BASED ON THE UNDERSTANDING THAT PATIENT WILL NEED TRACH. PT'S DAUGHTER AWARE OF THIS AND RECEIVED A COPY OF THE PLAN FROM DR. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-03 00:00:00.000",
"description": "Report",
"row_id": 1351914,
"text": "Nursing Note--A shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA and brisk. Occasionally opens eyes spontaneously. Does not blink to threat. Does not track. Does not follow commands. Extends to noxious stimuli. Moves all ext on bed minimally but not purposefully.\n\nRESP: LS coarse. Tol humidified shovel mask at 40%. Sat 97-100%. Non productive cough. NTS for small amts of thick white secretions.\n\nCARDIAC: Afebile. HR 70-80's SBP 90-110. +PP P-boots on.\n\nGI: Abd firm distended. +BS. Tol TF at goal thru J-tube. G-tube to gravity draining bilious liquid. FIB bag inact draining loose liquid light brown stool.\n\nGU: Foley intact draining qs clear yellow urine.\n\nINTEG: Left hip decub healing well with small area packed with dakin 2x2. Pink with small area of yellow exudate. Left hip duoderm intact. Eccymotic area on RUE elevated on pillows. Generalized edema. Small amount of serous ooze on LUE on the lower forearm. Allevyn tegaderm and sofsorb applied. T+R frequently. peg sites cdi.\n\nPSYCH/SOCIAL: Daughter visited in the late am and early afternoon.\n\nOTHER: Possible Screen from this afternoon. Mouthcare provided throughout shift.\n\nPLAN: Monitor MD of changes, Provide extra comfort and support and diligent skin care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-15 00:00:00.000",
"description": "Report",
"row_id": 1351848,
"text": "RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON CPAP+PS. NO CHANGES MADE TO VENT THROUGHOUT THE NIGHT. MDI'S GIVEN AS ODERED. BS COARSE BILAT, SX FOR MODERATE AMT OF THICK YELLOW SECRETIONS. RSBI THIS AM =65.9. SEE CAREVUE FOR FURTHER QUESTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-15 00:00:00.000",
"description": "Report",
"row_id": 1351849,
"text": "Resp Care\n\nPt remains intubated and on CPAP/PSV with settings on . Was placed on A/C for G/J tube procedure and transport was uneventful. Bs are coarse and suctioning large amts of thick yellow green sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-22 00:00:00.000",
"description": "Report",
"row_id": 1351880,
"text": "Resp Care\nPt remains on simv-parameters noted. Had brief period on CPAP/PS, but pt had apneic period. Coarse breath sounds bilat. Suction for thick yellow. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-23 00:00:00.000",
"description": "Report",
"row_id": 1351881,
"text": "CONDITION UPDATE\nASSESSMENT:\n SEE FLOWSHEET FOR ALL DETAILS. HEART RATE 60-80'S AFIB, OCCASIONALLY BRADYCARDIC TO 40'S BUT RESOLVES QUICKLY. BLOOD PRESSURE STABLE. NO VENT CHANGES MADE, SUCTIONED FOR THICK YELLOW SPUTUM. NEURO EXAM UNCHANGED. ABDOMEN FIRM & DISTENDED, BUT TOLERATING TUBE FEEDS AND STOOLING REGULARLY. PATIENT MAKING ADEQ URINE. SEE FLOWSHEET FOR SKIN CARE.\nPLAN:\n CONTINUE WITH NURSING CARE AND TREATMENT. ? DISCUSSION REGARDING TRACH TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-01 00:00:00.000",
"description": "Report",
"row_id": 1351907,
"text": "condition updated\npatient continues to tolerate cpap 5 but still has lots of secretions\nlasix given with good response\ncontinue current care\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-01 00:00:00.000",
"description": "Report",
"row_id": 1351908,
"text": "Respiratory Care\n\n Pt with +cuff leak extubated without incident. Placed on .50% hi/flow cool aerosol. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-01 00:00:00.000",
"description": "Report",
"row_id": 1351909,
"text": "CONDITION UPDATE\nASSESSMENT:\n NEURO UNCHANGED. PATIENT'S DAUGHTER SPOKE WITH DR. THIS AM REGARDING EXTUBATION. AGREEABLE TO EXTUBATION AND AWARE OF PLAN IF REINTUBATION NECESSARY (SEE CHART FOR DR. NOTE). PATIENT TOLERATING CPAP 5/5 WELL, RR ~ 24 AND PATIENT MAINTAINING ADEQUATE TIDAL VOLUMES. EXTUBATED ~ 10 AM AND PATIENT BREATHING COMFORTABLY. LUNG SOUNDS VERY DIMINISHED, PATIENT HAS MINIMAL COUGH. PATIENT REMAINS VERY EDEMATOUS AND WEIGHT STILL UP SEVERAL KGS, LASIX CONTINUES. SEE FLOWSHEET ALL DETAILS AND PHYSICAL ASSESSMENT.\nPLAN:\n PULMONARY HYGEINE. CONTINUE WITH CURRENT NURSING CARE AND TREATMENT. PROVIDE. SUPPORT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-03-02 00:00:00.000",
"description": "Report",
"row_id": 1351910,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT OPENS EYES SPONT. PERRL. MAE ON BED TO PAIN. NO SPONT MOVEMENT NOTED. DOES NOT FOLLOW COMMANDS. DOES NOT ATTEMPT TO SPEAK.\n\nCV-REMAINS IN AFIB WITH OCC PVC'S. SBP STABLE, BUT DOWN TO 80'S AT TIMES. SBP BACK UP WHEN STIMULATED. SKIN W+D. +PP. +EDEMA. PBOOTS ON. HCT STABLE.\n\nRESP-REMAINS ON 50% FACE TENT. O2 SAT 95-98%. LS COARSE, DECREASED AT BASES. NT SXN X 2 FOR THICK BLOODTINGED SPUTUM. YANKEAR X SEVERAL FOR THICK BLOOD TINGED SPUTUM. PT WITH WEAK COUGH/GAG. NARD NOTED AT THIS TIME.\n\nGI-ABD REMAINS FIRM AND DISTENDED. + BS. TOL TF VIA PEG. G-TUBE TO GRAVITY WITH BILIOUS DRG. FIB IN PLACE WITH LIQ GOLDEN STOOL.\n\nGU-REMAINS ON LASIX. VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nENDO-SSRI.\n\nSKIN-SEE FLOWSHEET. LEFT HIP DSG CHANGED AS ORDERED. WOUND WITH + GRANULATION TISSUE.\n\nSOCIAL-DAUGHTER HERE MOST OF NIGHT, REQUESTING TO SPEND NIGHT IN PT'S ROOM. DAUGHTER TOLD THAT VISITORS NOT ALLOWED TO SLEEP IN PT'S ROOM. DAUGHTER SPENT MOST OF , UNTIL 3AM, IN WAITING ROOM WITH OCC VISITS TO PT. DAUGHTER NOTED TO HAVE TAKEN PT'S O2 MASK OFF AND INSTRUCTED NOT TO DO THAT AGAIN. SHE AGREED AND THEN WENT HOME FOR THE REST OF THE .\n\nA-ALT IN RESP STATUS.\n\nP-CON'T WITH CURRENT PLAN. PULM HYGIENE. MONITOR FOR CHANGES. SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-15 00:00:00.000",
"description": "Report",
"row_id": 1351850,
"text": "SICU NN: See carevue for specifics, vitals, assessment. Patient opens eyes when suctioned and occasionally moves legs slightly. Otherwise patient lies supine in bed with eyes closed. Patient does not focus or track with eyes. Patient makes no attempts to communicate. ET to vent. Copious tenacious occasionally frothy secretions via et tube. Afib rate controlled on monitor. BP slightly decreased systolic 80's, after lopressor, sicu team and team notified, maps wnl. Patient to IR today to change G tube to G-J tube. Procedure explained to daughter and patient transported to and from procedure without incident. I stayed with patient throughout to monitor patient. Once returned to unit, G port to gravity and tube feeds to be started via J port once specific brand ordered is available from kitchen. No bm today. Foley intact and patent with adequate hourly urine outputs. Bilateral hip dressings done as ordered. Patient without any signs or symptoms of pain and does require sedation or restraints. Patients daughter present at bedside throughout shift and is very involved in patients care. Emotional support provided. Daughter spoke with physicians multiple times throughout day. Safety maintained.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-16 00:00:00.000",
"description": "Report",
"row_id": 1351851,
"text": "RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON VENTILATORY SUPPORT. PT CHANGED TO SIMV+PS THIS AM BECAUSE OF AN ACID-BASE IMBALANCE. BS RHONCHI BILAT, SX FOR COPIOUS AMTS OF THICK YELLOW SPUTUM. MDI'S GIVEN AS ORDERED. RSBI THIS AM =70. SEE CAREVUE FOR FURTHER DETAILS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-16 00:00:00.000",
"description": "Report",
"row_id": 1351852,
"text": "respiratory care\npt on the vent tol well no changes made see respiratory page of care veiw for more information\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-16 00:00:00.000",
"description": "Report",
"row_id": 1351853,
"text": "FOCUS; STATUS UPDATE\nDATA;\nPT WITHDRAWS TO STIMULI AND OPENS EYES WHEN STIMULATED. DOES NOT FOLLOW COMMANDS OR HAS PURPOSEFUL MOVEMENT.\n\nLUNGS COARSE BILAT WITH LARGE AMOUNTS OF THICK TAN SECRETIONS WHICH HAVE REQUIRED FREQUENT SUCTIONING. NO FURTHER VENT CHANGES. SATS 98-100. AFEBRILE.\n\nTOLERATING TUBE FEEDS. ABD FIRM AND DISTENDED-UNABLE TO HEAR BOWEL SOUNDS BUT HAS HAD FREQUENT GUAIAC POSITIVE STOOL-DR AWARE. HCT SENT THIS PM AND PENDING RESULTS.\n\nABD KUB DONE WITH GASTROGRAFFIN CONTRAST.\n\nPLAN:\nCONTINUE CURRENT PLAN OF CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-16 00:00:00.000",
"description": "Report",
"row_id": 1351854,
"text": "Respiratory Care: Pt remains on current vent settings, see carevue for details. No vent changes made this shift. Receiving MDI's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Report",
"row_id": 1351791,
"text": "NPN 0700-1900;\n\nNEURO; OPENS EYES TO NOXIOUS STIMULI,PERLA 3MM MIN MOVEMENT OF LIMBS.\n\nRESP LUNGS COARSE WITH INS/EXP WHEEZE TX WITH ALB INH,SUCTIONED QQ2-3 FOR MOD AMOUNTS THICK TAN SECRETIONS, PROFUSE ORAL SECRETTIONS SATS 95-97% NO VENT CHANGES MADE.\n\nCVS;TMAX 101 .1 TO 98.9 WIWTH TYLENOL BP 100-174/60 HR .AFIB 45-80 AFTER LOPRESSOR CURRENTLY BEING HELD.\n\nGU; MIN AMOUNTS SEDIMENTY URINE VIA FOLEY. TEAM AWARE NO LASIX GIVEN.\n\nGI; BELLY VERY FIRM AND DISTENDED TEAM AWARE,. RECTAL TUBE DRAINING LIQUID STOOL.HYPOACTIVE BS.\n\nENDO COVERED ON RISS.\n\nCONTINUES ON ALBUMEN DAUGHTER CONCERNED THAT PT IS NOT RECEIVING FREE WATER VIA G-TUBE NAD THAT PT HAS NOT HAD A PRE ALB. TO CALCULATE NUTRICION STATUS,\n\nSOC; DAUGHTER INTO VISIT ASKING LOTS OF QUESTIONS TAKING NUMBERS FROM VENT AND FROM COMPUTER, CONCERNED THAT PT IS STILL ON VANCO COMMUNNICATED CONCERNS TO DR TEAM. SPOKE AT LENGTH WITH LISW .AND CASEMANAGEMENT.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Report",
"row_id": 1351792,
"text": "CONDITION UPDATE\nASSESSMENT:\n PATIENT STABLE OVERNIGHT. BASELINE AFIB WITH OCCASIONAL PVCS, PT SLIGHTLY HYPERTENSIVE WITH SBP RANGING 130-150'S. AFEBRILE. PATIENT CONTINUES TO BE FLUID OVERLOADED, WEIGHT INCREASING. PATIENT MAKING APPROX 20-40 CC/HR OF CLOUDY URINE.\n NO VENT CHANGES MADE OVERNIGHT, PT CONTINUES TO HAVE THICK YELLOW/BROWN SECRETIONS. ABDOMEN FIRMLY DISTENDED, TPN FOR NUTRITION. MINIMAL GI OUTPUT FROM G-TUBE OR MUSHROOM CATHETER.\nPLAN:\n FAMILY MEETING TO BE HELD. CONTINUE WITH CURRENT ICU MONITORING AND TREATMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Report",
"row_id": 1351793,
"text": "Respiratory Care 1900-0700\nPt remains oraly intubated on vent support. No changes made to vent throughout the night, MDIs given as ordered. No ABG done this AM. Pt sx for moderate amt of thick yellow secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-01 00:00:00.000",
"description": "Report",
"row_id": 1351794,
"text": "BS fine crackles RLL; no change with MDI's. Sx'd for small amount thick yellow secretions. No vent changes or ABG's this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-20 00:00:00.000",
"description": "Report",
"row_id": 1351872,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n No change in neuro exam. Pt opens eyes to voice, but does not track. Does not follow commands. Withdraws extremities when nailbed pinched. Afebrile. HR 70s (A.fib). NBP 80-130s/30-80s. Metoprolol held d/t SBP <100. Dr. notified in afternoon when SBP was high 80s and MAP low 60s; per HO, no interventions. Pt w/ +3 generalized pitting edema. BUE elevated on pillows. DP/PT pulses weakly palpable. Hct this afternoon was 28.4. Cont Zosyn IV. Vancomycin 1gram IV x1. Right upper arm double-lumen PICC line placed in angio. Left PICC line d/c'd and tip sent for culture. Lungs clear, diminished at bases. No vent changes made. SIMV 40%, Vt 500x18, PEEP 5, PS 15. O2 sat >/= 97%. ETT moved to left side of mouth. Abdomen firmly distended w/ hypoactive BS. 40% strength Nepro increased to 70cc/hr via J-tube. No residuals; no emesis. G-tube to gravity bag w/ green, bilious output (75cc). Mushroom catheter intact; 300cc liquid, brown stool (guaiac negative; Dr. aware). BS 107-122; no insulin coverage per sliding scale. Foley intact w/ clear, yellow urine. Lasix 20mg IV x1. UO >/= 40cc/hr. Please see CareVue for integumentary section. Left hip w/ deep ulcer; packed w/ 2x2 gauze soaked in str Dakins solution; covered w/ DSD. Left lower arm w/ moderate amount serous drainage; covered w/ SofSorb and blue pad. T&R freq to maintain skin integrity. Pt on KinAir bed. Pt's daughter visited; updated on pt's condition, VS, plan of care.\n Plan: Monitor VS, I's and O's, labs. Dsg changes as ordered. Monitor resp/neuro status. Dr. will discuss ?trach w/ pt's daughter tomorrow. Update pt's daughter w/ plan of care. Cont ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-21 00:00:00.000",
"description": "Report",
"row_id": 1351873,
"text": "1900-0700\n\nNeuro: Pt unresponsive to stimuli. Spontaneous eye opening, not following commands and is contracted and suffers from years of dementia. Pt is nonverbal. Facial grimicing noted at times.\n\nResp: Pt remains orally intubated on mech ventilation, IMV/PS, 500, 40%, 18,5/15PS. Lungs clear/diminished at the bases. Suctions for small amounts of thick yellow secretions. O2sats remain stable. Resp shallow/cough is very weak.\n\nCV: Afib with HR 70s. SBP 90-100 lopressor held. afebrile. + pulses to lower ext. Skin warm/weeping and edematous. See carevue for further skin care issuses. HCT:26.7, WBC:12.2, K:3.7. No evidence of pain.\n\nGI/GU: Abd firmly distended, + BS, J-tube with Nepro @ goal, tolerating well. Foley to BSD draining clear yellow urine. Mushroomn catheter draining liquid brown stool, guiac negative.\n\nPlan; Supportive care, resp support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-14 00:00:00.000",
"description": "Report",
"row_id": 1351846,
"text": "Condition update\nAssessment:\nPlease see carvue for details\n\n Neuro: Pt unresponsive to stimuli, opens eyes spontaneously, does not track, pupils equal and reactive, does not follow commands, no spontaneous movement noted. very ridged and contracted. afebrile.\n\n CV: Remains in afib, occational pvc's. bp stable. recieving 80mg iv lasix tid x 2 days, with mod effect. Weak palp dp/pt bilat. +3 Edema, weapy through skin. L TL Picc with one port clotted.\n\n Resp: Remains on cpap 5/5, tol moderately. maintaining o2 sat >95%, but occationally labored breathing. Suctioned frequently for lg amounts of thin tan secretions, ? aspiration of tube feeds. Also lg amount of oral secretions that appeared to have gastric contents in them, ceased by end of shift. LS remain coarse bilat throughout.\n\n GI: Abd firmly distended, bs absent. Tube feeds d/c'd, g tube clamped. continuing with tpn.\n\n GU: small amounts of yellow urine with some sediment noted via foley cath. No leaking around foley noted. 24hr urine sent to lab for creat.\n\n Skin: L hip with decube to bone. Packed with ns wtd , yellow wound base, changed x1. R hip with Allevyn intact. No breakdown noted on coccyx or heels. Very moist due to weeping edema through skin. Frequent skin care to keep skin dry.\n\n Endo: blood sugars high to 233, covered with reg s/s insulin with pos effect.\n\n Social: Daughter into visit, spoke with Dr. x2. Was very inquisitive regarding father's care, was referred to Dr. . Social work and ethics involved.\n\nPlan: ?Trach vs. extubation (absolutely no reintubation if ectubated), G tube to be replaced with g/j tube, continue with tpn, ethics to meet with Dr. and Dr. regarding trach vs. extubation, family meeting needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-15 00:00:00.000",
"description": "Report",
"row_id": 1351847,
"text": "FULL CODE Contact Precautions \n\n\nNeuro: Awake, eyes open spont, but doesn't respond to verbal stim, doesn't focus or track. Withdraws arms when moved. No gag/cough. Pupils 2mm/sluggish.\n\nCV: HR=70-60s, afib, freq PVS. BP=90-110/30-40s. +periph pulses, extrems warm, +anasarca.\n\nResp: CPAP/PS 5/5 40% w/ 02sat 99-100%. 02sat down to 92%, and then suctioned for copious thick yellow/green secretions, altho during the nite, when sx, getting small to mod amt secretions. RR=20-24, Vt=400-450; resp always looked labored. White thick oral secretions.\n\nGI/GU: abd firm/distended, no BS, NPO. PEG clamped = ?G/JT placement today. Foley cath w/ clear yellow urine. Pt received last dose of Lasix 80mg IVP at 2am w/o great diruesis as w/ the previous dose.\n\nAccess: TLC PICC L brachial - ne port clotted. TPN and KVO fluids.\n\nID: afebrile, on Cipro\n\nSkin: L hip wet-to-dry dressing done - no change in wound. R hip allevyn dressing intact. Coccyx and heels OK - no redness or breakdown. Multi-podis boots on.\n\nSocial: Daughter, , called last evening for update.\n\nPlan: continue to monitor neuro/cardiac/resp status. ?G/JT placement today.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Report",
"row_id": 1351787,
"text": "FULL CODE Contact \n\n\nNeuro: Opens eyes to stim, does not focus, does not blink w/ threat. Moves LE to tactile stim, no movement noted in upper extrems. LE contracted. Pupils 3mm/brisk.\n\nCV: HR=70-80s, but had noted to go down to 50s and come right back up on his own and then up to 90s when on CPAP. Afib w/ occ PVCs. BP=120=140/40-50s. Weak periph pulses, extrems warm, +generalized edema.\n\nResp: Was on AC 600x12/ 50% and P=10. Attempted CPAP this afternoon, but pt pressures ^. Placed back on vent settings, currently at 500x20, 50% p=10. Suctioning very thick yellow secretions via ETT. Lungs coarse bilat.\n\nGI/GU: Abd very firm distended and seems to be more distended over the course of the day. Hypo BS earlier today, but none noted this afternoon. PEG to gravity w/ bilious drainage - 100cc for the shift. FIB in place w/ liquid brown stool - heme neg - 200cc. TPN, NPO, PPI. Foley cath 20cc/hr - Dr and teams aware. Amber urine.\n\nPain: Does not appear to be in any discomfort. Even when hip dressing was changed, he did not grimace.\n\nSkin: L hip dressing changed by wound care nurse - area inflamed, mod amt light yellow drainage noted. W-D 1/2st Dakins solution. Duoderms to R hip intact. Wound nurse to remove them tomorrow to assess.\n\nID: T=99.3. On Vanco, and meropenem.\n\nAccess\" L antecub TLC PICC.\n\nProcedures: abd U/S done at bedside.\n\nSocial: Daughter, , spoke w/ extensively about pt and about her 97-yr-old mother who is wheelchair bound and fell yesterday, fx her wrist.\n\nPlan: continue to monitor abd status. To recieve 1 unit RBCs for HCT 28.5. Monitor neuro/resp/cardiac status. Wound care as directed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Report",
"row_id": 1351788,
"text": "Respiratory Care Note:\n\nPt remain orally intubated on vent support. NO vent changes done. ALL alarms are functioning. BS are coarse bil. ETT tapes changed and rotated. ABG drawned from RT radial siet, no complications and results are acceptable. We are sxtn for small to mod amt of thick yel to tan secretions from ETT. Plan: Continue present ICU monitoring. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Report",
"row_id": 1351789,
"text": "CONDITION UPDATE\nASSESSMENT:\n PATIENT OPENS EYES WITH MOVEMENT/STIMULATION. APPEARS TO MOVE ALL EXTREMITIES MINIMALLY (NONPURPOSEFUL). PATIENT DOES NOT APPEAR TO BE IN PAIN, NO SEDATION OR PAIN MED REQUIRED.\n HEART RATE 90'S AFIB. PATIENT SLIGHTLY HYPERTENSIVE WITH SBP 140-150'S. PATIENT RECEIVED 1 UNIT PRBCS, AM HCT 32. HOURLY URINE 20-30 CC/HR, PATIENT APPROX 2 LITERS POSITIVE ON . CREAT SLOWLY RISING, 1.7 THIS AM.\n LUNG SOUNDS VERY COARSE, SUCTIONED OCCASIONALLY FOR THICK BROWN SPUTUM. NO VENT CHANGES MADE OVERNIGHT, PT ON ASSIST CONTROL. AFEBRILE.\n ABDOMEN FIRM & DISTENDED, NO BOWEL SOUNDS. G-TBUE TO DRAINAGE WITH GREEN/YELLOW OUTPUT. TPN INFUSING. SEE FLOWSHEET FOR SKIN CARE ISSUES.\nPLAN:\n CONTINUE WITH CURRENT ICU MONITORING AND CARE. ? FAMILY MEETING SOON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-31 00:00:00.000",
"description": "Report",
"row_id": 1351790,
"text": "BS fine crackles RLL; no change with MDI's. No vent changes or ABG's this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-19 00:00:00.000",
"description": "Report",
"row_id": 1351867,
"text": "respiratory care\npt on vent no changes made this shift. see resouratory page of care view for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-13 00:00:00.000",
"description": "Report",
"row_id": 1351841,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS.\\\nPATIENT WENED FROM SIMV TO CPAP, 5 PEEP AND 15 PRSSURE SUPPORT. LOOKED GOOD ON CPAP, WITH TIDAL VOLUMES AROUND 500 AND GOOD SATS AND RESP. RATE. PRESSURE SUPPORT GRADUALLY WEANED DOWN TO 5 THIS AFTERNOON, PATIENT TOLERATING CHANGES VERY WELL, CONTINUING TO MAINTAIN VOLUMES AND SATS. CONTINUES TO BE SUCTIONED FOR LARGE TO COPIOUS AMOUNTS OF THICK YELLOW SECRETIONS. CONTINUES TO BE DIURESED WITH LASIX (80 MG TID) AND ALDACTONE.\nDAUGHTER REMAINS AT BEDSIDE, AND CONTINUES TO RECEIVE INFORMATION FROM DR. /\nPLAN: CONTINUE ON CPAP WEAN AS TOLERATED, CAN INCREASE IPS DURING NIGHT IF NEEDED. SOCIAL WORKER VERY INVOLVED IN CASE, RECOGNIZES NEED FOR FAMILY MEETING, HOPEFULLY TOMORROW, AS PATIENT IS AS CLOSE TO EXTUBATION AS HE PROBABLY WILL BE. NEED TO DISCUSS WITH DAUGHTER PLAN RE: TRACH/NO REINTUBATION\nHO AWARE OF ABOVE, WILL CALL WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-13 00:00:00.000",
"description": "Report",
"row_id": 1351842,
"text": "Respiratory Care Note\nPt received on SIMV as noted. Pt weaned to PSV 15/5 and subsequently weaned to a PS of throughout shift with VT mid 500's and RR 18-21. Pt tolerating well. BS coarse bilaterally. Pt suctioned for moderate amt thick, green to yellow secretions. Plan to remain on PSV overnight. increase PS if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-14 00:00:00.000",
"description": "Report",
"row_id": 1351843,
"text": "FULL CODE Contact Precautions \n\n\nNeuro: Does not move extrems to tactile or painful stim - occ noted to be moving L leg on his own. When turned or sx, RR increases. Pupils 2mm/?non reactive/sluggish.\n\nCV: H=70-90s, afib w/ freq PVCs. BP=90-120/30-40. Weak periph pulses, +genealized anasarca. On lopressor, but has been held consistently for low BP.\n\nResp: CPAP/PS 5/5 40% increased PS to 10 during the night for labored/agonal breathing when VT <to 300 from 400-500. 02sat remains 100%. At 0600, PS back to 5, as pt's breathing is more relaxed and Vt at 450-500. Sx for mod to large amt tan, thick sx via mouth and secretins appear more green in color this am. Sx thick tan/lumpy secretions via mouth during the night - appears to be TF. Coarse BS bilat.\n\nGI/GU: Abd firm/distended, no BS. TF on hold at this time via PEG. Pt receiving lasix 80mg tid. Earlier in the shift, urine noted from around the cath - balloon checked - refilled. Then he received lasix and then found to still have leak - large amt urine. Foley cath changed to 16F, but still noted to be leaking around cath, but after checking ballon one more time, no more leaking. ? placement of cath - when new cath inserted, cath would curl and come right back out of the penis. After a few attempts, cath returned urine, but as noted, intermittent leaking.\n\nSkin: L hip dressing changed - tissue yellow w/ serous drainage - NS wet-to-dry dressing done. R hip dressing intact. No breakdown or redness on coccyx.\n\nAccess: L brachial TL PICC, but one port clotted. TPN/Lipids and KVO infusing.\n\nID: afebrile - on Cipro.\n\nSocial: Daughter, , called during the night for update - no change in pt's status to report. ?family meeting today w/ team and ethics.\n\nPlan: ? family meeting as noted. Monitor neuro/cardiac/resp status. Monitor I/o and foley cath. Continue to direct daughter's qeustions regarding pt's care to Dr .\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-20 00:00:00.000",
"description": "Report",
"row_id": 1351868,
"text": "Nursing Note--B Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: Rarely opens eyes spontaneously, does not track, does not blink to threat. Rarely has minimal movement of extremities. No purposeful movement. Does not follow commands. Does not respond to questions or voice. Abnormal flexion to noxious stimuli all 4 ext.\n\nRESP: LS coarse. Deep sxn for moderate to copious amts of thick yellow secretions. Tol vent settings.\n\nCARDIAC: Afebrile. 70-90's SR. SBP 95-114. +PP P boots on.\n\nGI: Abd firm distended. Hypoactive bs. G-tube to gravity draining bilious liquid. Tol TF thru J-tube at goal. Loose brown stool thru mushroom cath.\n\nGU: Foley intact draining qs clear amber urine.\n\nINTEG: Multiple skin issues please refer to CAREVUE. Skin very fragile and edematous.\n\nPLAN: Possible wean of vent on Tuesday, Monitor I&O's, Provide diligent skin care and extra comfort.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-20 00:00:00.000",
"description": "Report",
"row_id": 1351869,
"text": "RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON SIMV+PS. NO CHANGES MADE TO VENT THROUGHOUT THE NIGHT. BS COARSE BILAT, SX FOR MODERATE TO COPIOUS AMTS OF THICK YELLOW SPUTUM. MDI'S GIVEN AS ORDERED. NO AGB THIS AM, RSBI THIS AM = 64.5 ON CPAP-0 PS-5. SEE CAREVUE FOR FURTHER QUESTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-20 00:00:00.000",
"description": "Report",
"row_id": 1351870,
"text": "Respiratory Care: Pt with a 7.5 ETT. Remains on PS as per carevue. Spontaneous breathing trial was done for 4hrs, RSBI 48 at the beginning of trial in AM, RSBI started to increased after 4 hrs 75, so Pt was changed to PS 5/5. Pt suctioned for white thick secretions, breath sounds crackles, did not improve after suctioning. Pt now full code, extubation is on hold, pt to remain on PS of 5 over nite.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-20 00:00:00.000",
"description": "Report",
"row_id": 1351871,
"text": "Respiratory Care: Pt with a 8.0 oral ETT. Remains on SIMV as per carevue. Patient suctioned for white thick secretions. MDI'd x1 given.Pt is being evaluated for trach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-14 00:00:00.000",
"description": "Report",
"row_id": 1351844,
"text": "resp care\nPt inc to psv 10/peep5 and 40% for agonal/labored breathing that did not improve with suct and mdi. Pt fairly comfortable for the rest of the night on and 40%. This am psv back to 5 with volumes of 450-500cc.Mdi given as ordered. Will cont to follow and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-14 00:00:00.000",
"description": "Report",
"row_id": 1351845,
"text": "Resp Care\n\nPt remains intubated and on CPCP/PSV. MV being maintained at between 7-9L. BS are coarse and suctioning thick tan sputum. Spo2 98%. Receiving bronchodialtors.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-11 00:00:00.000",
"description": "Report",
"row_id": 1351834,
"text": "Respiratory Care Note\nPt received on SIMV + PS as noted. BS coarse, but decreased throughout. Pt suctioned for moderate amts thick secretions. MDI given a/o. Plan to remain on current settings at this time. Plan to transport pt to when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-12 00:00:00.000",
"description": "Report",
"row_id": 1351835,
"text": "Nursing note (1900-0700) 04:20\n\nPt with unchanged neuro status.\n\nVS stable, Lopressor held due to Lasix doses giving some hypotension.\n\nTF's cycled, TPN continues.\n\nWound to Left hip redressed, unchanged in appearance.\n\nPt with moderate amount of loose brown stool passed.\n\nAll Q's from Pt's daughter to be reffered to team. Pt refused admit to against daughters wishes.\n\nPlan.\nContinue current POC.\n?? Extubate or ?? for trache.\nWound care to dress wounds on Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-12 00:00:00.000",
"description": "Report",
"row_id": 1351836,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on SIMV settings. BLBS are coarse rhonchi. Sxn for thick yellow-tan secretions. RSBI completed on PS 5=50.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-12 00:00:00.000",
"description": "Report",
"row_id": 1351837,
"text": "Respiratory Care Note\nPt received on SIMV as noted. No vent changes this shift. BS coarse rhonchi bilaterally. Pt suctioned for thick, green to yellow secretions. Plan to remain on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-12 00:00:00.000",
"description": "Report",
"row_id": 1351838,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt continues to be non responsive. He moves extremities to painful stimuli. PERRL. TMAX 99.2 AFIB\n\nSxn'd several times for thick, yellow/green secretions. No vent changes made this shift. Pt continues on SIMV/40%/. Pt still being diuresed w/ 60mg lasix TID.\n\n str. Nepro infusing via peg tube and is being cycled on 5 hours/ off 3 hours and so on. TPN infusing.\n\nWounds unchanged.\n\nPt has a riss for bs coverage.\n\nPlan: continue with current plan of care per sicu/ MD team. TPN, Cycle TF, IV ABX, ? trach placement. Closely monitor electrolyte. PRN electrolyte repletion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-13 00:00:00.000",
"description": "Report",
"row_id": 1351839,
"text": "Nursing note. (1900-0700) 04:45.\n\nSee careview for details.\n\nPt with unchanged status overnight.\nTF's cycled as per plan.\nWound to Left hip redressed.\nNo stool overnight.\nNo vent changes made, pt with large amount of thick oral secretions also, Sx'd for thick yellow/green sputum Q 2-3 hrs.\n\nNo calls overnight.\n\nPlan.\n?? Dr to speak with Daughter today regarding ? trach or other options.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-13 00:00:00.000",
"description": "Report",
"row_id": 1351840,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on SIMV settings. BLBS are coarse. Sxn for thick green secretions.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Report",
"row_id": 1351784,
"text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA and brisk. Open eyes to noxious stimuli. Does not track. Does not follow commands. Does not track. Abnormal flexion to noxious stimuli. Moves UE's minimally but not purposefully. Does not blink to threat.\n\nRESP: LS coarse and diminished. Deep sxn for small to copious amts of thick tannish chunky secretions. Tol vent settings Sat 96-100%.\n\nCARDIAC: Tmax 100.4. HR 70-110 Afib with occasional PVC's. +PP difficult to palpate.\n\nGI: Abd large very firm. Hypoactive BS. Mushroom draining loose brown stool.\n\nGU: Foley intact draining yellow urine with sediment. 1x dose of 10mg of lasix with good effect.\n\nINTEG: Skin fragile erethematous and eccymotic. Please see carevue for specifics.\n\nPSYCH/SOCIAL: Daughter and wife into visit at . After family visiting at bedside-EKG leads were noted to be off and peg dressing ripped. Daughter called several times throughout shift overnight.\n\nPLAN: Attempt to wean vent, Monitor abdomen, I&O's, NEURO, Aggressive pulmonary toileting and skin care. Provide extra comfort to patient and firm boundaries for family members.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Report",
"row_id": 1351785,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Current settings: A/C 600*12 50% with 10 Peep. Breathsounds are coarse. Suctioned for copious amounts of thick tan secretions. ABG this am 7.45/36/114 26 and 1. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-30 00:00:00.000",
"description": "Report",
"row_id": 1351786,
"text": "RESPIRATORY CARE: PT W/ AN 8.0 ORAL ETT IN PLACE.\nAC MODE AS PER CV. WILL CHANGE TO PS TODAY. SX FOR\nTHICK YELLOW SPUTUM. WILL DECREASE PEEP TO 8 AND\nCHANGE TO PS AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Report",
"row_id": 1351805,
"text": "see focus data update\nsee careview for details\n\n\nNEURO: PT RESPONSIVE TO PAINFUL STIMULI ONLY, CONTRACTED, PERLA\n\nRESP: SX BOTH ORALLY AND ETT, VENT SETTING'S UNCHANGED, I/E WHEEZES NOTED B/L, VENT SETTING'S UNCHANGED\n\nCV: , PT FOUND TO HAVE B/P 70/30 DAUGHTER HAD PT SITTING IN HIGH POSITION, DAUGHTER NOT TO PT,\nMAP > 55, NO NEED FOR FLUID BOLUS NOW, EDMANOUS IN ALL EXT'S, RED AREA NOTED ON LEFT UPPER EXT, WARM TO TOUCH\n\nGI: ABD REMAIN DISTENDED, G-TUBE DSG BY SURGICAL TEAM, RESIDUALS < 100CC'S, MUSHROOM CATH IN PLACE, DRAING BROWN LIQ STOOL\n\nGU: ADEQUATE HOURLY U/O\n\nA/P: STABLE, DAUGHTER NEEDS REINFORCE,\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Report",
"row_id": 1351806,
"text": "Resp Care\nPt remains on PSV-parameters noted. No chg in vent settings at this time. Per team:increase PS if Increased WOB. BS: wheezes on left, diminshed on right. alb/atr MDI x 3. Suction for thick yellow. Plan is for possible trach on mon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Report",
"row_id": 1351807,
"text": "Resp: Pt rec'd on psv 16/8/50%. Ett retaped, rotated and secured. Alarms on and functioning/Ambu/ are coarse bilaterally. Suctioning for moderate amounts of thick tannish secretions. MDI's administered Q 4 Alb/Atr with no adverse reactions. Pt ordered for potassium iodide, after consulting pharmacy was advised not to administer down Ett, just PO. Pt placed on a/c 20/500/+8/50% to rest . AM ABG 7.47/30/182/22. Decreased rate to 14, fio2 to 40%, peep+5. Plan to wean back to psv today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Report",
"row_id": 1351808,
"text": " 7p-7a\nSee carevue flow sheets for specifics.\nNeuro:Pt responds to noxious stimuli by opening eyes, pt does not follow commands. Pt moves slightly lower extremites spontaneously. PERRLA.\nCV:One 4 beat run of nonsustained vtach noted. Dr notified. no treatment at this time. Metoprolol 2.5mg IVP given x 1 as ordered for rate control of a fib. Fluid balance pos 300ml by 12am. pt had minimal diuresis after spirolatone.\nResp:Pt appeared air hungry. O2sat 98% and RR 22 MV unchanged. Dr notified. No new resp orders at that time. Vent change later (0200) to CMV see resp note.\nGI:TFs tolerated as ordered 5 hours on and 3 hours off. pt also on TPN via PICC.\nGU:2 way foley to BSD drg cloudy yellow urine, u/o 30-100ml/hr.\nPlan:As per ICU team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-25 00:00:00.000",
"description": "Report",
"row_id": 1351892,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 46.6 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-25 00:00:00.000",
"description": "Report",
"row_id": 1351893,
"text": "BS coarse crackles LLL, otherwise CTAB; no change with MDI's. No ABG's or vent changes this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-18 00:00:00.000",
"description": "Report",
"row_id": 1351863,
"text": "7a-7p\nneuro: perl, opens eyes on own, no response to command, responds to painful stimuli with facial grimacing\n\ncv: hr a-fib(60-80), no ectopy, sbp 88-125, ho aware of low sbp, 12.5 gms 25% albumin x 1 with good effect, po lopressor held for sbp < 100\n\nresp: no vent changes, continues on 40% fio2, imv 18, 5 peep, 15 ps, sux lg amt loose thick yellow sputum, inhalers by R.T., sat 95-100, rr 21-34, no resp distress noted\n\ngi: tf via j-tube changed to 40% nepro @ 50 cc/hr, tf to run continuosly, g tube to gravity draining sm amt green bilious material, mushroom cath in, scant amt liquid green stool, po prevacid, colace & reglan\n\ngu: foley patent, low uo with hypotension today, ho aware, one time lasix dose dc'd due to hypotension, foley leaking this pm, 5 cc ns added to foley balloon, foley continues to leak & needs to be changed\n\nother: daughter in & updated on pt's condition, L hip dsg changed, wound healing per daughter, iv nurse not able to insert new PIC today, ho aware, blood cultures sent x 2, continues on TPN\n\nplan: continue with ventilatory support, antibiotics as ordered, ? pic line placement under fluoro on Monday, ? trach this week\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-19 00:00:00.000",
"description": "Report",
"row_id": 1351864,
"text": "RESPIRATORY CARE 1900-0700\nPT REMAINS ORALLY INTUBATED ON SIMV+PS. NO CHANGES MADE TO VENT THROUGHOUT THE NIGHT. BS COARSE BIALT, SX FOR MODERATE TO COPIOUS AMTS OF THICK YELLOW SPUTUM. MDI'S GIVEN AS ORDERED. RSBI THIS AM = 64.6, NO ABG THIS AM. SEE CAREVUE FOR FURTHER QUESTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-19 00:00:00.000",
"description": "Report",
"row_id": 1351865,
"text": "ASSESSMENT AS NOTED\n\nRES: THICK YELLOW SPUTUM IN ETT, ETT WAS REPOSITIONED, LS COARSE, RSBI WAS 65 IN AM, NO VENT CHANGED, NO ABG DRAWN\n\nCV: IN A/FIB, BP STABLE, GENERAL EDEMA, POOR WEAK PULSES, PICC LINE BENIGN ABLE TO DRAW BACK\n\nGU: GOT LASIX 20 LAST NIGHT , WENT FROM 200 DOWN TO 50/40 OVERNIGHT, TEAM AWARE\n\nID: NO FEVER, WBC , CONT ON VANCO-LEVELS WERE SENT\n\nGI: FIRM ABD, HYPO BS, G-TUBE DRAINED 200, CONT ON TUBE FEEDING 50/H\nUNABLE TO CHECK RESIDUL\n\nskin: SEE CAREVUE\n\nNEURO: DOES NOT FOLLOWS, LETHARGIC, W/D TO PAIN STIMULI\n\nSOCIAL: DAUGHTER WAS IN TO VISIT LAST NIGHT\n\nA: ASP PNEUMONIA, S/P STROKE ,\nP: SKIN CARE, FULL SUPPORT, NEEDS NEW PICC LINE, CARE AND COMFORT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-19 00:00:00.000",
"description": "Report",
"row_id": 1351866,
"text": "NURSING NOTE 7A-7P REVIEW OF SYSTEM:\nNEURO: Unresponsive, no movement of extremities noted, withdraws to pain, does not follow commands.\nC/V: Continues in AFib rate 70's with rare PVC's. BP 102-120's/ 50's-60's. Lopressor dose held this afternoon.\nRESP: Intubated vent settings unchanged, continues on SIMV, FiO2 at 40% 5PEEP and 15 of PS. Suctioned frequently thick yellow secretions both orally and via ET tube. Lung sounds coarse throughout.\nGI: Abd distended and firm hypoactive bowel sounds, G-Jtube in place, g-tube to gravity drainage with bile output. J-tube with feedings of Nepro 40% increased to 60cc/hr. TPN to be discontinued after current bag has infused. Mushroom cath intact draining liquid green in scant amounts. MOM given X1 dose.\nGU: Foley patent draining well 30-60cc/hr output.\nSOCIAL: Patients daughter into visit, questioned answered by nurse. Daughter updated on plan.\nID: Continues on Contact precautions, Vanco level drawn on Night shift please see carveue. Vancomycin one time dose of 1000mg given IV as ordered.\nENDO: FS at 10am= 151 treated with 2 units Regular insulin SC.\nPLAN: Awaiting second opinion for trach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-25 00:00:00.000",
"description": "Report",
"row_id": 1351894,
"text": "See carvue for specific\n\nEvents: Lasix with great diuresis, remains with gross edema, no change in neuro status, cont on TF and cont with ABX\n\nDaughter into see patient, only medical info to be provided by Dr. . Daughter stated \"my father was crying the other day\" I asked if she thought her father was in pain or suffering, she thought he was serene but maybe he was trying to tell her something.I asked the daughter what would her father be saying? replied he would say \"I want to die\" after a brief silence she smiled and stated thats whay you would want me to say. The medical care has been all negligence and thats why he is in this situation, I reassured her the excellenct care her father has been receiving. She said yes this hospital has been \"good\". I don't want the nurse to think I am chekcing up on them.\n\nI said we do need to know what her father would want with his care, and sometimes when you've been focused on the medical details and taking care of him you may loose site of his wishes. replied that she works with stroke victims that have made a great recovery, and at her house she watches her father and cares for him by a video camera when she is in the other room. The conversation then ended.\n\nPlan for daughter to meet with Dr. on Monday\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-26 00:00:00.000",
"description": "Report",
"row_id": 1351895,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 65.5 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-26 00:00:00.000",
"description": "Report",
"row_id": 1351896,
"text": "D:Pt stable overnight, metoprolol given and tolerated.\nAfeb, vss, TFs tolerated, 2 BMs fecal incontinence bag applied.\nA:Stable\nContinue plan of care. \n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-26 00:00:00.000",
"description": "Report",
"row_id": 1351897,
"text": "CONDITIO UPDATE\nASSESSMENT:\n NEURO EXAM UNCHANGED. HEART RATE 70-80'S AFIB, BLOOD PRESSURE STABLE. DIURESING WITH LASIX, CURRENT WEIGHT CLOSE TO ADMISSION WEIGHT. LUNG SOUNDS CLEAR, NO VENT CHANGES MADE. ABDOMEN FIRM & SLIGHTLY DISTENDED (BASELINE), TOLERATING TUBE FEEDS @ GOAL RATE. GLUCOSE NORMAL. SEE FLOWSHEET FOR WOUND/SKIN CARE.\nPLAN:\n CONTINUE WITH CURRENT NURSING CARE AND TREATMENT. SKIN CARE. PROVIDE SUPPORT TO FAMILY. ? EXTUBATION VERSUS TRACH THIS WEEK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-26 00:00:00.000",
"description": "Report",
"row_id": 1351898,
"text": "BS rhonchi LLL. Sx'd small amt pale yellow mucus. No change in BS with MDI's. No vent changes. Tolerates last night PSV wean when breathing spontaneously. Possible extubation .\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-27 00:00:00.000",
"description": "Report",
"row_id": 1351899,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on SIMV settings. No vent changes made. RSBI completed on PS 5=89.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-02 00:00:00.000",
"description": "Report",
"row_id": 1351799,
"text": "Nursing update\nSee careview for specific info.\n\nNeuro: Pt opens eyes to pain, but does not track, does not follow commands, moves LE's on bed, no movement of UE's noted. PERRL.\n\nCV: A-fib with occassional PVC's. Pt had acouple runs of V-tach today, SICU team notified, continuing to monitor. Lopressor held today for sys<100. Pt afebrile, adequate peripheral pulses.\n\nResp: Pt weaned to CPAP with 10 of PEEP, and 18 of Psupp, Weaned further to 16 of Psupp. ABG drawn by RRT. Lungs coarse bilaterally.\n\n\nGI: Abdomen firmly distended, BS absent. Continues to put out small amount of loose watery stool via mushroom cath. Diarrhesed with 10 of lasix at 1830. G-tube leaking around insertion site, plan is to change out to an 18g tomorrow per Dr. .\n\nGU: Foley to gravity, UO borderline.\n\nPlan: Diarrhese with lasix\n Change leaky g-tube tomorrow\n Monitor and replete lytes as needed.\n SICU team aware of above, contact HO with changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Report",
"row_id": 1351800,
"text": "resp cae note\n\nPt was sx Q2-4 hrs for mod to copious amts of thk tan secretions. He has remained on PSV 16 / +10 , 50% all night which matches Vt, MV while on AC vent. No ABG this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Report",
"row_id": 1351801,
"text": "Respiratory Care Note\nPt received on PSV 16/10 as noted. Peep weaned to 8 with sats of 100%. Pt tolerating well with VT 500-610, RR 18-22, MV 10.0-12.7. Pt suctioned for moderate to large amts thick, tan secretions. Plan to continue to wean peep and ps as tolerated. possibly rest overnight on AC if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-03 00:00:00.000",
"description": "Report",
"row_id": 1351802,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENT.\nPATIENT REMAINS NON RESPONSIVE EXCEPT FOR PAIN, DOES NOT FOLLOW COMMANDS, EXTREMLY CONTRACTED.\nSKIN CARE NURSE IN, LEFT HIP DRESSING CHANGED AND EXAMINED. QUARTER SIZE HOLE WITH AREAS OF TRACKING ALL AROUND. WOUND CLEANED WITH DAKINS AND PACKING WITH S NS W-DRY DRESSING. TO BE DONE .\nVERY SLOW VENT WEAN BEING ATTEMPTED, ON CPAP 14/8, WITH RESP. RATE AROUND 20, GOOD TIDAL VOLUMES AND SATS. CONTINUES TO BE SUCTIONED FOR MOD AMOUNTS OF THICK TAN SPUTUM.\nRECIEVED TWO DOSES OF LASIX, 10/20 MG WITH A FAIR DIURESIS.\nPLAN\" CONTINUE TO DIURESE/ WEAN AS TOLERATED MONITOR SKIN AND LEFT HIP DRESSING CALL HO WITH ANY CHANGES..\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Report",
"row_id": 1351803,
"text": "Resp: pt on psv 16/8/50%. Ett #8.0, 22 @ lip. Alarms on and functioning. Ambu/syringe @ hob. Bs reveal bilateral aeration with diminished bases. Suctioned small amount of thick yellow secretions. MDI's administered Alb/atr as ordered. 02 sats @ 100%. No abg's, no a-line. RSBI=64. Vent changes to decrease psv to 10, peep 5, fio2 40%. Pt is comfortable and tolerating changes with no distress. Will continue to wean appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-04 00:00:00.000",
"description": "Report",
"row_id": 1351804,
"text": "neuro: no changes. does not respond to stimuli. Does not follow commands.\ncv/resp bp stable afebrile. vent changes per resp but more distress noted. Call into Resp to assess. not tol vent wean this am.suctioned for thick white creamy secretions.\ngi/gu tol tube feeds well. minimal residuals. 6hours on 2hours off as ordered. abdomen distended w no bowel sounds and very minimal stool output. foley w good uop. recieving tpn.\ninteg left hip decub dsg changed as ordered. minimal drainage.\nturned in the bed q 2 hours tol well.\nPlan: Continue attempts to vent wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 1351829,
"text": "nursing note\nNeuro:Opens eyes with stimulation, grimaces wtih turns but otherwise no signs of pain.\nCV:Afib, rate controlled. lopressor held for hypotension, MD aware multiple times and lasix held.\nRESP:LS coarse, thick copious yellow secretions.\nGI:abd firm, distended, tol tube feed son 5 hours, off 3 hours. Loose BM x2.\nGU:Foley patent clear yellow urine.\nSKIN:hip changed a/o. duoderm intact, pouch to r arm intact.\nSOCIAL: Daughter receiving updates from MD only. In/out visiting throughout day.\n\nPLAN: cont pulm toilet, wound care, social support to daughter and route inquiries re:patient care to MD or MD .\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-10 00:00:00.000",
"description": "Report",
"row_id": 1351830,
"text": "Resp Care\nPt remains on mech vent-parameters noted. No wean this shift. Continue to suction thick yellow secretions. Alb/atro MDI x 3. Will continue mech vent at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-11 00:00:00.000",
"description": "Report",
"row_id": 1351831,
"text": "Nursing note (1900-0700) 04:30\n\nUnchanged exam overnight, see careview for details.\n\nCalled by supervisor at overnight for info on Pt, as they had recieved a call asking for them to take the pt, at the time I was unable to spend time on the call and asked for her to call back, as yet I have not heard back.\n\n\nPlan.\nContinue TF cycles of on for 5hrs, off for 3hrs.\ndress Left Hip Q shift.\nRefer Pt's daughter to for any updates/questions etc.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-11 00:00:00.000",
"description": "Report",
"row_id": 1351832,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and ventilated on SIMV settings. Re-taped ETT. BLBS are coarse rhonchi. Sxn for thick yellow-green secretions. RSBI completed on PS 5=53.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-11 00:00:00.000",
"description": "Report",
"row_id": 1351833,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt is alert. He is not following any commands. Pt not noted to move spontaneously. Lower extremities contracted.\nHe has been afebrile this shift. AFIB continues. HR 70's-80's.\nPt had to be sxn'd q 30 min- 1 hour for moderate to copious amts of thick, yellow sputum. Also sxn'd orally for thick, clear secretions. No vent changes made this shift. Pt continues on SIMV +PS 40%/. LS are coarse + rhonchi noted.\n\nTPN restarted this eve. str. nepro infusing via peg tube and is cycled. There has been no residuals this shift. Pt had a large, loose BM this afternoon. Foley is patent and draining patent amts of clear urine. Pt being diuresed w/ lasix TID.\n\nRISS for BS coverage.\n\nRight arm reddened. DSD placed over wound. Right hip w/ intact duoderm. Left hip w/ quarter sized opening that was packed w/ 2 2x2's. Wound base is pink and it drainied serosang fluid. Both arms w/ edema. Arms elevated on pillows. Pt's daughter expressing concern at seemingly increased amt of edema in pt's arms. MD notified and in to speak w/ pt.\n\nPlan: continue with current plan of care per sicu/ MD 's team. Pt denied admission to MD. . Continue to direct all inquiries from daughter to MD . dressing changes. Wound care RN to change AM dressings. TPN, Cycled TF's. TID diuresis w/ lasix. Closely monitor electrolytes. PRN electrolyte repletion. ?extubation on MOnday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-23 00:00:00.000",
"description": "Report",
"row_id": 1351882,
"text": "Resp Care\nPt remains on vent. Suctioned large amt of green to yellow secretions. Mdis given with good result: increased vts. Pt high peak pressures, changed i-time and slope to compensate. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-23 00:00:00.000",
"description": "Report",
"row_id": 1351883,
"text": "respiratory care\npt on the vent tol well no changes. see respitory page of care view for more information\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-23 00:00:00.000",
"description": "Report",
"row_id": 1351884,
"text": "Nursing note (0700-1900) 16:40\n\nExam unchanged from previous shift, occassional episodes of bradycardia, resolved spontaneously. Tollerating TF's well, loose stool x2 today, meds held.\nDaughter in for brief period today, did not speak with Dr or his team, no calls since either.\nWound redressed as per recs.\n\nPlan. Continue current POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-23 00:00:00.000",
"description": "Report",
"row_id": 1351885,
"text": "Respiratory Care: Pt remains on current vent settings. No changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-24 00:00:00.000",
"description": "Report",
"row_id": 1351886,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt moving legs in bed, posturing with left arm, and not moving right arm. Pupils unequal and left sluggish. Gag +, corneal +. Lungs coarse and diminished in bases. RISBI this mornign in 70s but low tidal volumes 200, continues all night on SIMV. Abdomen distended and hypoactive bowel sounds. Stooling liquid golden adn G-tube puttin gout greenish yellow bile. Tube feeds continue at goal via j-tube. Urine amber at times. Lasix 10 mg given with resulting sbp 85: Remaining 20 ordered lasix held at this time until adequate blood pressure obtained. Dressing to left hip applied. wife in last evening briefly. Please refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-24 00:00:00.000",
"description": "Report",
"row_id": 1351887,
"text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 76.9 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-24 00:00:00.000",
"description": "Report",
"row_id": 1351888,
"text": "respiratory care\npt on the vent tol well. see respiratory page of care view for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-24 00:00:00.000",
"description": "Report",
"row_id": 1351889,
"text": "CONDITION UPDATE\nASSESSMENT:\n NEURO EXAM UNCHANGED FROM BASELINE. PATIENT ATTEMPTED ON CPAP + PS THIS AM, HAVING PERIODS OF APNEA AND SIMV + PS RESUMED. LUNG SOUNDS OCCASIONALLY COARSE. HEART RATE RANGING 60'S-80'S AFIB, OCCASIONALLY DIPPING TO 40'S (HAS HAPPENED OVER THE LAST SEVERAL DAYS). LOPRESSOR HELD. BLOOD PRESSURE REMAINS STABLE, SBP > 90. PATIENT TOLERATING SMALL DOSES OF LASIX, FLUID BALANCE APPROX EVEN. TUBE FEEDS @ GOAL RATE AND PATIENT STOOLING REGULARLY.\nSEE FLOWSHEET FOR WOUND CARE.\nPLAN:\n EXTUBATION 3/14 PER DR. . CONTINUE WITH CURRENT NURSING CARE AND TREATMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-24 00:00:00.000",
"description": "Report",
"row_id": 1351890,
"text": "Respiratory Care: Pt remains on current vent settings, no changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-25 00:00:00.000",
"description": "Report",
"row_id": 1351891,
"text": "Update\nSee careview for details,,,\nNuero assessment unchanged, pt cont to be nonresponsive\n\nCV: Cont to have occas episodes of HR 40's, lopressor held, Afib, BP stable, + periph pulses, generalized edema with weeping in UE's\n\nResp: Vent settings unchanged, sats 99%, lungs clear and dimin at bases, SX thick tan secretions\n\nGI: tol TF's at 70/hr, Abd lrg and firm, +BS, no BM, sm bilious dng from j-tube drain\n\nGU: foley dng good amts clear yellow urine\n\nSkin: W to D dsg done to left hip decub, Duoderm intact to Right hip, turning pt q2hrs, skin weeping\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-07 00:00:00.000",
"description": "Report",
"row_id": 1351818,
"text": "condition update\nneuro: pt opens eyes to stimuli, does not follow commands, withdraws extremities to noxious stimuli. Pupils are equal and reactive. Pt appears comfortable, no grimacing. Occasional intermittant tremors noted in bilat. upper extremities with stimulation - Dr. was notified and states that this is his baseline.\nCV: a-fib with no ectopy. Pt became hypotensive this pm around 1645 - bp as low as 68/20's. Pt placed in t-, Dr. was notified, 250ns bolus was given. Pt improved with bolus and after being repositioned onto his right side, sbp up to 100's. Dr. and Dr. are aware.\nResp: no vent changes made today, suctioned for thick tan sputum, ls are coarse and diminished. 02 Sat 99-100%\nGI: abd. is firm and distended - discussed with Dr. , +bs. Pt had KUB this am, and recieved dulcolax suppository. Pt was incontinent of mod. sized loose bm this evening. Tf residual 0-25cc's. TF cycled 5hrs on and 3 hrs. off as per orders.\nGU: foley draining adequate amts. clear yellow urine.\nEndo: covered with ssri\nSkin: bilat. hip dsg's changed per wound care rn, see note.\nsocial: After meeting with daughter, social worker and Dr. , nursing as been instructed per Dr. that patient information is not to be discussed with patient's daughter - all questions should be deferred to DR. . Daughter called this evening with questions, and this plan was re-inforced.\nPlan: continue to monitor bp, skin care as ordered, cycle tube feeds as ordered, pulmonary toitleting\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-08 00:00:00.000",
"description": "Report",
"row_id": 1351819,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions. MDI'S given. RSBI done on 0 peep/5 ips 54. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-08 00:00:00.000",
"description": "Report",
"row_id": 1351820,
"text": "cv: hr continues in afib rate 70's to 90. sbp 92-110/ sbp decreased to 78 times one while pt sleeping on left side. pt repositioned and bp back up to 90's/\n\ngi: g tube continues same regimen. nepro strenght at 40 cc/hr kept on 5 hours and then off for 3 hours. residals 10 cc. g tube leaking around site times one large amount green bilious. cleansed around site with saline and tube re anchored. no further drainage noted. no vomiting. small amount of greenish stool.\n\ngu: foley draining adequate amounts clear yellow urine.\n\nneuro: pt opens eyes to voice and any stimulus, pupils equal and reactive.\n\nintegumentary:l axilla pink... will ask team for nilstatin powder order. l hip dressing changed. left hip is draining serosanguinous. skin around decub pink. duoderm placed around decub site ot protect skin from drainage. packed with dakins solution gauze and covered with a dsd. generalized body edema. r arm is draining a large amount of ascitic fluid. collection device to gravity drainage bag is intact. 240 cc drainage accounted for on I& o sheet.Legs ar severely contracted. pt tightens up even more when attmpts are made to clean pt under arms and between legs.\n\nresp: continue to suction pt for thick yellow and thick tan q 2 hours. breath sounds coarse bilateral.\n\nsocial: daughter in visiting at change of shift. daughter asking questions regarding her fathers care and writing in note book. daughter looks very closely at pumps and then jots things in her notebook. she looks closely at ventilator and then writes in her notebook. she asked wht her fathers temp was when i took it at 8 pm. She was informed of the temp and at this time daughter was reminded about agreement that all questions should be directed to dr .\ndaughter called from her phone a bit later in the evening. again she is asking questions about pt data. redirected daughter to agreement to discuss all matters with Dr . pt again called about 1/2 hour later and asking if pt iiis getting his \"ARICEPT' again this rn redirected pt to arrangement that all these questions should be directed to Dr . daughter stated that she would have her father transferred to another institution if .. and the line went silent. No further calls overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-09 00:00:00.000",
"description": "Report",
"row_id": 1351823,
"text": "1900-0700\n\nNeuro: Pt alert at times with spontaneous eye opening. Pt ext contracted with generalized edema. Pupils equala nd reactive. See carevue for skin care issues.\n\nResp: Pt orally intubated on mech ventilation. 40%, 18, IMV/PS. Tolerating well. Coarse BS bilaterally. Suctions for small to moderate amounts of thick tan/yellow secretions. Oral care rendered. O2sat stable through the night.\n\nCV: A fib with HR 80-90s. No vent ectopy noted. SBP 90-110. Afebrile. weak pulses to lower ext. TPN infusing via L arm PICC. Peg with feedings off at this time due to high residuals. WBC 12.3.\n\nGI/GU: Abd firmly distended, hypoactive BS noted. Remains receiving reglan. Foley to BSD draining clear yellow/gold urine. Received lasix in PM(scheduled dose). Diueresing well.\n\nEndo: RISS\n\nPlan: supportive care, resp support. WOund care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-09 00:00:00.000",
"description": "Report",
"row_id": 1351824,
"text": "Respiratory Care Note:\n patient remains on ventilatory support at this time. No changes have been made. For specifics please see carevue. SX'd for a small amount of yellowish tan secretions. Patient remained afebrile this shift. BS are coarse. MDI's administered as ordered. RSBI this am is 38.2 on 0peep/5 psv. ETT retaped, rotated and secured. Plan is to continue to provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-09 00:00:00.000",
"description": "Report",
"row_id": 1351825,
"text": "Resp Care\nPt remains on mech vent-parameters noted. PS decreased to 5. Breaths sounds are coarse bilat, diminshed in rt base. Suction for mod amt of thick greenish yellow secretions. Alb/atro MDI x 3. Will continue pulmunary hygiene and mech vent at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Report",
"row_id": 1351781,
"text": "0100-0700\nNursing Admit Note\n This is a yr old male transfered from Hosp. Patient's daughter requesting transfer of her father to be a patient of Dr. . Patient ia a resident of an acute rehab facility and was noted by staff to have tube feedings in back of mouth. ABG drawn noted to have a p02 of 35 ..with ^^ resp rate. Electively intubated at rehab and transfered to Hosp.\n\nPMHX\nAlzheimers\nPersistent Vegetative State\nAfib\nG-Tube placement\nPIC line ( triple lumen )\nMultiple Asp PNA\nMyoclonus\nLoer extremity contractures\nFull Code\n\nNKDA\n\nCV HR 90-100's afib ..SBP by NBP 90-100's/40's..LR at 100 cc/hr ...\n\nRESp ..FIO2 50%..rate in 18-22..tidal volumes 650's..5 peep..suctined q3 for moderate amounts thick yellow snxs..sputum sent ..lungs diminished at the bases ...\n\nGI Impact str begun at 0600 .. 20 cc/hr ..goal of 50 cc/hr .. vai G-Tube..Abd distended..hypoactive bowel sounds ..orders for TPN to be written... Given 30 cc MOM ..incont large amount of loose stool around rectal bag ..rectal tube inserted ..stool sent for c-diff\n\nGU minimal urine output ..despite hydration, albumin and one unit of PRBCS ..urine output 20-40 q2.. concentrated in appearnce\n\nID bld, urine, sputum and stool specs sent ..random vanco level pndg..wbc 16.9..imenpenum given ( requires ID approval for next dose)\n\nComfort ..no response to sternal rub. Lower extremities contracted ..myclonus movements noted to upper extremities during admission bath....\n\nSkin\nLeft hip with quarter size decub tracking down to bone ..grn drng ..ns wet > dry..\nright hip with large ( baseball size bruise ) potential breakdown ..duoderm applied to site ..skin nurse \n\nDaughter is proxy..arrived with patient to the SICU ..all questions answered by SICU resident ..Informed daughter of policy regarding no family members to stay overnite..She will return at noon\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Report",
"row_id": 1351782,
"text": "respiratory care\npt on the ventilator changes made tol well see respiratory page of care view for more information\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-01-29 00:00:00.000",
"description": "Report",
"row_id": 1351783,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt is in a persistant vegatative state at baseline. Pt currently opens eyes to to stimuli. No spontaneous or purposeful movements. Pt very contracted. Pt does not follow commands. Is not able to communicate.\nCV: BP stable. HR-afib. Pt currently afebrile. S/P 1unit PRBC for crit 25.6 and 10mg lasix for poor urine output\nResp: Pt currently on CMV 50% 600X14 with 10/peep. Pt was placed on CPAP trial this am lasted about one hour then needed to go back on CMV. Lungs remain clear to diminished at the bases. Sxn for thick secretions. Pt with ? aspiration pneumonia.\nGI/GU: Abd very firm and distended with hypo BS throughout. Rectal exam by primary team neg. Pt given MOM over per daughter. With some results. KUB done and TF held Gastric tube to gravity drng minimal amts team is aware. Foley patent\nID: On abx therapy for + sputum cx. Pt with history of Kliebsella in his decubitus ulcer.\nInteg: Pt with pressure ulcer on Lhip through to bone. Wet to dry drsg this shift. Wound bed pink some yellow areas noted. Wound bed drng green/yellow in color. Some odor noted. R hip with duoderm still intact.\nSoc: Pt's daughter is HCP. Daughter very involved. PT has been at multiple facilities in . Ethics c/s to be discussed with primary attending tomorrow ICU MD's today. This RN emailed this pm to make her aware of this pt and possible difficulties with daughter. n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-17 00:00:00.000",
"description": "Report",
"row_id": 1351855,
"text": "condition update\nsee carevue for specifics.\nneuro: pt opens eyes spontaneously or to stimuli, does not track in room, does not follow commands, withdraws to nailbed pressure. Pt appears comfortable.\ncv: afib - no ectopy, hr 81-94, sbp 90-127. +peripheral pulses. Pt recieved one unit prbc for hct of 26.1. will repeat hct this am.\nResp: vent settings unchanged, abg this am wnl. ls coarse bilaterally. suction for thick tan sputum.\nGI: abd firm distended, hypoactive bs, frequent liquid bm's, mushroom catheter placed, c. diff spec. sent. tF running at goal 40cc/hr (on for 5 hrs, off for 3 hrs.). G-tube to gravity draining bilious drainage.\nGu: foley draining adequate amts. clear/yellow urine, 24 hr urine collect in progress.\nendo:ssri\nplan: repeat hct., complete 24 hr. urine collect, pulmonary toileting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Report",
"row_id": 1351809,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT RESPONDS TO PAINFUL STIMULI. OPENS EYES. PERRL. MOVES LEGS SL ON BED SPONT. DOES NOT FOLLOWS ANY COMMANDS.\n\nCV-HR MOSTLY 80'S, AFIB. BP STABLE. MAP>60. SKIN W+D. + PITTING EDEMA TROUGHOUT. +PP. PBOOTS ON.\n\nRESP-NO VENT CHANGES MADE TODAY. O2 SAT 97%. LS CLEAR TO COARSE WITH OCC WHEEZES. ON INHALERS. SXN FOR SM AMT THICK TAN SPUTUM. MOUTH CARE DONE.\n\nGI-ABD FIRM, DISTENDED. TEAM AWARE. + BS. REMAINS ON TF AS ORDERED: ON 5 HRS/OFF 3 HRS. REMAINS ON TPN. HAS MUSHROOM CATH IN WITH SM AMT LOOSE BROWN STOOL.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nENDO-SSRI.\n\nSKIN-SEE FLOWSHEET. PT THROUGHOUT. HAS SM SKIN TEAR ON RIGHT ARM WITH SCANT SEROUS DRG. HAD DECUB TO BONE TO LEFT HIP. DSG CHAGNED AS ORDERED. HAS DUODERM ON RIGHT HIP C/D/I. ON AIR MATTRESS. MULTIPODUS BOOTS ON. SKIN CARE DONE FREQ.\n\nA-ALT IN SKIN INTEGRITY. SLOW VENT WEAN.\n\nP-CON'T WITH CURRENT PLAN. WEAN VENT AS TOL. TPN AND TF. SKIN CARE.\nASSESS PAIN. SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-05 00:00:00.000",
"description": "Report",
"row_id": 1351810,
"text": "Resp Care\nPt remains on mech vent-parameters noted. No wean this shift. Breath sounds coarse wheeze bilat. Suction for small amt of thick yellow. Alb/atro MDI x 3. Potassium iodide not administered per pharmacy's advice. Will continue mech vent at this time. Eval for trach on Mon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Report",
"row_id": 1351811,
"text": "Resp Care Note, Pt remain on current vent settings. See vent flowsheet for details.Suctioned for mod amts thick yellow secretions. MDI'S given. RSBI done on 0 peep/5 ips 55. Will cont to mom resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Report",
"row_id": 1351812,
"text": "D:PT STABLE SBP DECREASED 89 BUT ONCE PT STIMULATED SBP INCREASED TO HIGH 90'S. AFIB 80'S RATE CONTROLLED WITH LOPRESSOR.\nET TUBE RETAPPED X2 DUE TO INCREASED ORAL SECRETIONS. ET TUBE SECRETIONS HAVE DECREASED OVER PAST 24HRS, SEE RESP THERAPY NOTE ABOVE FOR SETTINGS.\nPEG TUBE IN PLACE WITH GREEN GASTRIC DRG AROUND TUBE, PRIMARY TEAM NOTIFIED AND PEG TUBE WAS ANCHORED AND TAPED AT INSERTION SITE.\nDECUB DSG LEFT HIP CHANGED, LESS PURULENT DRG THAN PREVIOUS .\nPTS DAUGHTER CALLED UNIT TO INQUIRE ABOUT HER FATHER'S CONDITION, SHE WAS UPDATED AND PT TOLD THAT HIS DAUGHTER CALLED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-06 00:00:00.000",
"description": "Report",
"row_id": 1351813,
"text": "Respiratory Care\nPt remains on current vent settings as noted on carevue MD order. To be evaluated for tracheostomy later today by thoracic.\nPt's daughter frequently at the bedside documenting staff names and all settings as well as questioning rational for specific settings. All speculation referred to physician .\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-27 00:00:00.000",
"description": "Report",
"row_id": 1351900,
"text": "D:Pt stable , lopressor tolerated slight drop in BP to 90s, diuresed well after lasix.\nA:stable\nP:CPAP trial today\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-27 00:00:00.000",
"description": "Report",
"row_id": 1351901,
"text": "NPN 0700-1500;\nNEURO UNCHANGED. CONTINUES TO TOLERATE CPAP WITH PS 5/5.SUCTIONED FOR MOD AMOUNTS THICK WHITE SECRETIONS.SATS 98%. VITAL SIGNS RUNNING LOWER THAN PREVIOUSLY 90-107/60.HR AFIB WITH BLOCKS TO 39 OCASSIONALLY.\nRESPONDING TO LAST DOSE OF LASIX CURRENTLY. TEAM AWARE.CONTINUES TO TOLERATE T/F AT GOAL BELLY FIRM DISTENDED. NO STOOL CONTINUES ON BOWEL REGIME,\nSOC; DAUGHTER HAS NOT VISITED TODAY SO FAR. CHAPLAIN TRYING TO CONTACT DAUGHTER PLAN FOR ETHICS DISCUSSION THIS AFTERNOON AT 5 PM WITH DR .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-27 00:00:00.000",
"description": "Report",
"row_id": 1351902,
"text": "Resp CARe\n\nPt's mode of ventilation was changed to CPAP/PSV with the pt maintaining a mv of approx 9-10L. Suctioning yellow sputum and Spo2 in the high 90's. Receiveing bronchodilators as ordered\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-27 00:00:00.000",
"description": "Report",
"row_id": 1351903,
"text": "SICU NPN RE FAMILY MEETING\nO: FAMILY MEETING AT BEDSIDE TODAY W/ PT' AND WIFE WHICH INCLUDED DR AND HIS TEAM, ETHICS MD TO ANSWER FAMILY'S QUESTIONS AND ADDRESS APPROPRIATE PLAN OF CARE. FAMILY CLERGY WAS ALSO PRESENT FOR DISCUSSION. PT' ASKED MANY QUESTIONS RE: WEANING, NUTRITION, CARE UP TO THIS POINT. DR. CORRECTED MANY OF THE MISCONCEPTIONS THAT PT'S DAUGHTER HAD RE HER INTERPRETATION OF MEDICAL INFORMATION AND WHAT HAS BEEN DONE SO FAR. OPTIONS PRESENTED TO FAMILY THAT IF LONGEVITY WAS THEIR GOAL FOR THE PATIENT THAT A TRACH IS NECESSARY TO SAFELY CONT TO WEAN THIS PT IN HOPES OF HIM SURVIVING OFF A VENTILATOR. THE SECOND OPTION WAS PRESENTED TO EXTUBATE THE PT AND IF HE FAILS TO MAKE HIM COMFORTABLE AND NOT REINTUBATE THE PT. CLARIFICATION OF INFORMATION WAS CONSISTENTLY PROVIDED BY ETHICS MD.\nDR. ALSO OFFERED TO STEP DOWN AND ALLOW FAMILY TO TRANSFER PT TO ANOTHER FACILITY IF SHE THOUGHT THIS WOULD BE BETTER FOR THE PT. A PLAN WAS THEN MADE FOR DR. TO CONTACT DR. TO COME AND DISCUSS THE RISKS AND BENEFITS OF THE TRACH AGAIN AND FOR THE ETHICS MD TO BE PRESENT FOR THE DISCUSSION TO PREVENT ANY MISCONCEPTIONS.\nA: SUCCESSFUL MEETING, PLAN OUTLINED BETWEEN DR AND FAMILY.\nP: CONT TO FOLLOW THROUGH W/ OUTLINED PLAN AND REEVALUATE AFTER DR. IS CONSULTED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-02-28 00:00:00.000",
"description": "Report",
"row_id": 1351904,
"text": "CONDITION UPDATE\nASSESSMENT:\n NEURO ASSESSMENT UNCHANGED. HEART RATE RANGING 60'S-80'S AFIB. PATIENT HYPOTENSIVE WITH SBP IN 80'S THIS AM. IMPROVING THROUGHOUT THE DAY, GIVEN 1 UNIT PRBCS. PATIENT + 1L IN AFTERNOON AND LASIX RESUMED, AWAITING EFFECT. LUNG SOUNDS COARSE, SUCTIONED APPROX EVERY 3 HOURS FOR FROTHY WHITE SPUTUM. VENT WEANED TO CPAP + PS 5/5, TOLERATING WELL. TUBE FEEDS @ GOAL RATE THRU J-TUBE, G-TUBE WITH BILIOUS DRAINAGE. STOOLING REGULARLY (LIQUID). SEE FLOWSHEET FOR WOUND/SKIN ISSUES.\nPLAN:\n ? EXTUBATE IF TOLERATES VENT SETTINGS VERSUS TRACH. CONTINUE WITH CURRENT NURSING CARE AND TREATMENT.\n"
},
{
"category": "ECG",
"chartdate": "2175-02-24 00:00:00.000",
"description": "Report",
"row_id": 108663,
"text": "Atrial fibrillation\nLeft axis deviation consistent with left anterior fascicular block\nRight bundle branch block\nLow QRS voltages in precordial leads\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2175-02-24 00:00:00.000",
"description": "Report",
"row_id": 108664,
"text": "Atrial fibrillation\nLead(s) unsuitable for analysis: V4\nMarked left axis deviation\nRBBB with left anterior fascicular block\nPoor R wave progression - probable normal variant\nLateral ST-T changes are nonspecific\nRepolarization changes may be partly due to rhythm\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-15 00:00:00.000",
"description": "REPOSITION GASTRIC TUBE INTO DUODENUM",
"row_id": 902623,
"text": " 7:48 AM\n PERC G/J TUBE CHECK Clip # \n Reason: please replace G tube with a GG-J tube of largest diameter a\n Admitting Diagnosis: FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 150\n ********************************* CPT Codes ********************************\n * REPOSITION GASTRIC TUBE INTO D PERC PLCMT ENTROCLYSIS TUBE *\n * CATH, TRANSLUM ANGIO NONLASER C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with recurrent aspiration\n REASON FOR THIS EXAMINATION:\n please replace G tube with a GG-J tube of largest diameter available\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recurrent aspiration pneumonia requiring conversion of G to GJ-\n tube.\n\n PROCEDURE: Procedure was performed by Dr. , Dr. , and Dr.\n , the Attending Radiologist, present and supervising the entire\n procedure. Full written informed consent was obtained. The patient was placed\n supine on the angiographic table and prepped and draped in the usual sterile\n fashion around the indwelling G- tube. Under fluoroscopic guidance, and 0.035\n Bentson guidewire was advanced through the indwelling G- tube. As the tip of\n the G tube was angled toward the fundus, it had to be repositioned so that its\n tip was aimed more towards the pylorus. A 0.035 Bentson guidewire was\n advanced under fluoroscopic guidance; however, despite several attempts, it\n was not able to be advanced past the pylorus. Approximately 5 cc of contrast\n was administered to aid in localizing the pylorus. After multiple unsuccessful\n attempts to feed the guidewire past the pylorus with the and Glidewire,\n a MIC wire was successfully advanced through the pylorus through the duodenum\n and into the proximal jejunum. Over an introducer sheath, a new 20-French MIC\n catheter was advanced under fluoroscopic guidance into the jejunum; however\n distal access with the guidewire was lost and the catheter was removed. A\n stiff Amplatz wire was used to regain access, passed through the pylorus,\n obtained distal placement in the proximal jejunum. After which, under\n fluoroscopic guidance, a 16-French - Coons- catheter was advanced\n with its distal tip placed in the proximal jejunum. The guidewire was\n removed. Under fluoroscopic guidance, the mushroom locking device was deployed\n in the stomach. Approximately 10 cc of additional contrast were used to\n confirm satisfactory placement of both the jejunal and gastric side ports.\n Both ports flushed well. The catheter was secured to the skin by 0 silk\n sutures as well Statlock device. There were no immediate postprocedure\n compications.\n\n IMPRESSION: Successful conversion of G tube to 16.5-French GJ-tube, the\n distal tip positioned within the proximal jejunum and proximal port in the\n stomach; the line is ready for use.\n\n (Over)\n\n 7:48 AM\n PERC G/J TUBE CHECK Clip # \n Reason: please replace G tube with a GG-J tube of largest diameter a\n Admitting Diagnosis: FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-20 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 903226,
"text": " 7:17 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place new PICC line and remove old PICC (please send\n Admitting Diagnosis: FAILURE TO THRIVE\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 year old man with + blood cultures and old IR placed PICC\n REASON FOR THIS EXAMINATION:\n please place new PICC line and remove old PICC (please send old PICC tip for\n culture)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bacteremia with question of PICC line infection. Please remove\n left-sided PICC line and place new right-sided PICC line.\n\n PROCEDURE: This procedure was performed by Dr. with Dr. , the\n Attending Radiologist, being present and supervising throughout. The patient\n was placed supine on the angiographic table and the right upper extremity was\n prepped and draped in the usual sterile fashion. As there is no suitable\n visible vein, ultrasound was used to identify an appropriate right cephalic\n vein, proximal to the area of the extremity edema. Under ultrasound guidance,\n a 21 gauge micropuncture needle was used to access the right basilic vein.\n Hard copy ultrasound images were printed before puncture and after catheter\n placement to document venous patency. After access was obtained, a 0.018\n guide wire was advanced under fluoroscopic guidance with its tip placed in the\n distal SVC. Over an introducer sheath, a double lumen PICC trimmed to 35 cm\n was advanced with its tip placed in the distal SVC. The catheter was flushed,\n Hep-locked, STAT- locked, and secured to the skin with sterile dressing. There\n are no immediate post-procedure complications. A final fluoroscopic spot\n image was taken to document placement. The left-sided PICC line was removed\n and its tip was sent for culture.\n\n IMPRESSION:\n 1) Successful placement of 35 cm double lumen PICC via the right cephalic vein\n with its tip in the distal SVC: Line is ready for use.\n 2) Left-sided PICC removed with its tip sent for culture.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-16 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 902784,
"text": " 5:37 AM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate for passage of contrast\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with increasingly protuberant abdomen\n\n REASON FOR THIS EXAMINATION:\n please evaluate for passage of contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old male with a protuberant abdomen.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP single view of the abdomen. There is a GJ tube overlying the\n abdomen. There is barium in the colon from prior contrast study. Study is\n limited due to technique. There is overall gasless appearance of the abdomen\n which may be secondary to technique. However, the appearance is nonspecific\n and obstruction cannot be excluded in this study.\n\n There are severe degenerative changes of the lumbar spine with a left convex\n scoliosis centered at level of L2/3. There is severe disc narrowing and\n osteophytes.\n\n IMPRESSION:\n 1. The contrast is within nondistended colon.\n 2. Relatively gasless small bowel which is a nonspecific finding.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-16 00:00:00.000",
"description": "G/GJ TUBE CHECK",
"row_id": 902867,
"text": " 1:50 PM\n G/GJ TUBE CHECK Clip # \n Reason: Tube study @ bedside. Please assess for transit of contrast.\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction, ascites now s/p 60cc gastrograffin injected\n via J-tube\n REASON FOR THIS EXAMINATION:\n Tube study @ bedside. Please assess for transit of contrast.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old male with question of obstruction post-injection of\n gastrografin via J-tube. Assess for transit of contrast.\n\n COMPARISON: , 0600 portable abdomen.\n\n Findings: Multiple nondistended contrast-filled loops of small bowel are\n seen. Residual contrast is seen within the large bowel. A well-circumscribed\n lytic area is noted in the region of the left greater trochanter in the\n proximal left femur which although it may represent projection would be better\n assessed with CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-30 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 900600,
"text": " 10:50 AM\n ABDOMEN U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: liver, portal vein patency, extent of ascites: PLEASE DO DUP\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ascites of unclear etiology\n REASON FOR THIS EXAMINATION:\n liver, portal vein patency, extent of ascites: PLEASE DO DUPLEX IMAGING OF\n PORTAL VEIN/LIVER VASCULATURE\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Doppler ultrasound of liver and ultrasound of abdomen.\n\n INDICATION: Patient with possible ascites. For evaluation.\n\n TECHNIQUE: Grayscale, color flow and pulse wave Doppler insonation of the\n liver and the liver vasculature was performed. Formal abdominal son was\n also performed.\n\n COMPARISON: No examination available for comparison. Reference is made to\n previous chest radiographs and plain films of the abdomen.\n\n REPORT:\n\n Examination was performed portably and this somewhat limits the quality of the\n examination.\n\n The left kidney measures 10.3 cm. The right kidney measures 10.8 cm. Both\n kidneys are normal size, shape, and echogenicity. The liver appears normal. A\n simple cyst is identified in the left lobe measuring 1.8 cm. Color flow and\n pulse wave Doppler insonation of the liver vasculature shows patent hepatic\n veins, portal veins and arteries, with normal hepatopetal flow identified in\n the portal vein and its branches, as well as a widely patent main hepatic\n artery. The gallbladder contains sludge, but is otherwise unremarkable\n without evidence of gallbladder wall thickening. No intra- or extra-hepatic\n biliary dilatation is identified. The midline pancreas and retroperitoneal\n organs appear normal. There is an intra-abdominal catheter or tube in situ on\n the left flank lying superior to the liver- probably a gastrostomy-It is\n difficult to determine whether this lies in an intraluminal location on the\n provided images.\n\n There is no evidence of ascites. A trace left-sided pleural effusion is seen.\n\n CONCLUSION:\n\n 1. No ascites seen.\n\n 2. Normal liver and Doppler liver ultrasound, duplex liver ultrasound.\n\n 3. Left-sided intra-abdominal catheter whose location is indeterminate.\n\n (Over)\n\n 10:50 AM\n ABDOMEN U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: liver, portal vein patency, extent of ascites: PLEASE DO DUP\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Trace left-sided pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900907,
"text": " 12:59 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: pls shoot higher abdomen- level of j tube. thanks.\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction, ascites. Injected 60cc gastrograffin\n into J-tube one hour ago.\n REASON FOR THIS EXAMINATION:\n pls shoot higher abdomen- level of j tube. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old male with obstruction, ascites.\n\n TECHNIQUE: Portable abdominal radiograph after injection of 60 cc of\n Gastrografin.\n\n COMPARISON: Abdominal radiograph taken earlier on the same day.\n\n FINDINGS: Note is made of G-tube overlying the right upper quadrant, with\n opacification of the stomach and duodenum and distal small bowel. No evidence\n of obstruction.\n\n IMPRESSION: Opacification of stomach, duodenum, and distal small bowel by\n Gastrografin.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-02 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900988,
"text": " 4:57 AM\n PORTABLE ABDOMEN Clip # \n Reason: progression of contrast\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction, ascites. Injected 60cc gastrograffin into\n J-tube\n REASON FOR THIS EXAMINATION:\n progression of contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old male with obstruction, ascites.\n\n TECHNIQUE: Portable abdominal radiograph after injection of 60 cc of\n gastrografin yesterday.\n\n COMPARISON: Multiple abdominal radiographs taken on .\n\n FINDINGS: Note is made of predominantly gasless abdomen. The most of the\n contrast injected has passed through the bowel, and was no longer identified\n in the abdomen. No evidence of obstruction.\n\n IMPRESSION: No evidence of obstruction. Most of the gastrografin injected\n yesterday passed through bowel, and was no longer identified on this film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-30 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900587,
"text": " 9:34 AM\n PORTABLE ABDOMEN Clip # \n Reason: ileus, stool\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction, ascites\n REASON FOR THIS EXAMINATION:\n ileus, stool\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old male with obstruction, ascites.\n\n PORTABLE ABDOMINAL RADIOGRAPH.\n\n COMPARISON: Abdominal radiograph dated .\n\n FINDINGS: The bowel gas pattern is unremarkable, with known dilated gas in\n the ascending colon, without evidence of obstruction. However, the abdomen is\n predominantly gasless. Note is made of diffuse increase in opacity of the\n abdomen, which may represent the presence of ascites, however, the evaluation\n is limited on this plain radiograph. The hepatic contour is somewhat\n prominent.\n\n IMPRESSION: Predominantly gasless abdomen, without evidence of obstruction.\n Diffuse increasing opacity in the abdomen, which may represent ascites,\n however, the evaluation is limited on this plain film. Please also refer to\n the official report of ultrasound which will be performed on the same day.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900487,
"text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ?asp pneumonia\n REASON FOR THIS EXAMINATION:\n PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 9:50\n\n INDICATION: Pneumonia - followup.\n\n COMPARISON: .\n\n FINDINGS: Since the prior study, a left CVL has been placed with its tip at\n the SVC, brachiocephalic junction, and no PTX. Tip of the ETT remains in\n place. Since the previous study, there is more extensive air space disease on\n the left and at the right base as well. Extension into the left upper lobe is\n seen, but the right upper lobe remains normal. Heart size and pulmonary\n vascular markings are prominent but stable.\n\n IMPRESSION:\n\n Progressive air space disease bilaterally but greater change seen on the left.\n Temporal changes will help distinguish between pneumonia's versus CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-29 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900485,
"text": " 9:32 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for ileus/obstruction\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction\n REASON FOR THIS EXAMINATION:\n Please evaluate for ileus/obstruction\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON AT 09:47.\n\n INDICATION: Paucity of bowel sounds.\n\n FINDINGS:\n There is a relative paucity of bowel gas diffusely. Scattered bits of air are\n seen without a definite obstructive pattern. In addition the right\n hemidiaphragm is partially cut off from view. No definite evidence for free\n air or pneumatosis.\n\n IMPRESSION:\n Limited film showed no definite features of obstruction or free air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900465,
"text": " 8:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement, pna, chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ?asp pneumonia\n REASON FOR THIS EXAMINATION:\n eval for ETT placement, pna, chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n INDICATION: Question aspiration pneumonia, status post intubation.\n\n No prior studies are available for comparison.\n\n FINDINGS: AP upright view of the chest was obtained. There is an\n endotracheal tube present, which terminates satisfactorily approximately 4 cm\n above the carina. The heart size is at the upper limits of normal. There are\n patchy perihilar increased densities, greater on the left side. There is also\n retrocardiac opacity with obscuration of the left hemidiaphragm. It is\n difficult to exclude the presence of small bilateral pleural effusions.\n Degenerative changes are noted in the visualized shoulders. There also\n appears to be a healed fracture of the left fifth rib.\n\n IMPRESSION:\n 1. Retrocardiac density, which could represent atelectasis or pneumonia.\n 2. Satisfactory placement of endotracheal tube.\n 3. Perihilar opacities, which could also represent aspiration pneumonia\n versus superimposed CHF. Followup to assess for temporal change would be most\n helpful.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-01-29 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900522,
"text": " 5:54 PM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval bowel gas pattern\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction\n\n REASON FOR THIS EXAMINATION:\n eval bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old man with obstruction. Bowel gas pattern.\n\n TECHNIQUE: Portable abdominal radiograph.\n\n COMPARISON: Abdominal radiograph dated .\n\n FINDINGS: The study is somewhat limited due to underpenetration, and does not\n include domes of the diaphragm and peripheral portion of right abdomen. The\n abdomen is predominantly gasless, and note is made of unremarkable bowel gas\n in the ascending colon. No evidence of significant obstruction. Rectal tube\n is noted.\n\n IMPRESSION: Limited study. Unremarkable bowel gas in ascending colon.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900925,
"text": " 2:50 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: progression of contrast--eval for obstruction\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction, ascites. Injected 60cc gastrograffin into\n J-tube one hour ago.\n REASON FOR THIS EXAMINATION:\n progression of contrast--eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old male with obstruction, ascites.\n\n TECHNIQUE: Portable abdominal radiograph after injection of 60 cc of\n Gastrografin into G-tube.\n\n COMPARISON: Abdominal radiograph taken earlier on the same day.\n\n FINDINGS: Note is made of somewhat diluted contrast in the stomach,\n duodenum, and small and large bowel, without evidence of obstruction.\n\n IMPRESSION: Further passage of contrast as described above, without\n evidence of obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900926,
"text": " 2:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ?asp pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE.\n\n INDICATION: -year-old man with aspiration pneumonia.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study of .\n\n The tip of the endotracheal tube is identified 5 cm above the carina. The\n left-sided PICC line remains in place. No pneumothorax is identified.\n\n There is gradual improvement of the bilateral multifocal opacities indicating\n gradually improving aspiration pneumonia. Please confirm resolution after\n treatment.\n\n There is continued mild congestive heart failure with cardiomegaly and small\n bilateral pleural effusion. There is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900898,
"text": " 12:01 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: PLease eval for transit, obstruction. His belly is very dist\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction, ascites. Injected 60cc gastrograffin into\n J-tube one hour ago.\n REASON FOR THIS EXAMINATION:\n PLease eval for transit, obstruction. His belly is very distended. Pls obtain\n in 1hr (an noon).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old male with obstruction, ascites.\n\n TECHNIQUE: Portable abdominal radiograph, after injection of 60 cc\n Gastrografin.\n\n COMPARISON: Abdominal radiograph taken earlier on the same day.\n\n FINDINGS: Again note is made of predominantly gasless abdomen, with rectal\n tube. Note is made of faint contrast within the bowel in the right upper and\n lower quadrants, however, the evaluation is limited due to underpenetration\n and body habitus.\n\n IMPRESSION: Faint contrast in the right upper and lower quadrants in bowel\n loops. Gasless abdomen. No evidence of obstruction. Please also refer to\n the official report of subsequent abdominal radiographs taken on the same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 900887,
"text": " 10:41 AM\n PORTABLE ABDOMEN Clip # \n Reason: baseline pls before study\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ? obstruction, ascites. Planning to inject gastrograffin,\n need baseline.\n REASON FOR THIS EXAMINATION:\n baseline pls before study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old man with obstruction, ascites.\n\n TECHNIQUE: Portable abdominal radiograph.\n\n COMPARISON: Abdominal radiograph dated , and abdominal\n ultrasound dated .\n\n FINDINGS: The bowel gas pattern is predominantly gasless, however, there is\n no definite obstruction or dilatation seen. The study is somewhat limited due\n to patient body habitus.\n\n IMPRESSION: Predominantly gasless abdomen, without definite evidence of\n obstruction or dilatation. Limited study due to body habitus.\n Please refer to the reports of subsequent post-contrast films for passage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 901361,
"text": " 9:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ?asp pneumonia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of possible aspiration.\n\n Chest is rotated to the right. Endotracheal tube is 4 cm above carina. There\n is cardiomegaly with persistent diffuse opacification of the left lung and\n patchy airspace opacities in the right lung consistent with pulmonary edema\n and probable associate pneumonia. There are probable bilateral pleural\n effusions. Left subclavian CV line overlies proximal SVC. No pneumothorax.\n\n IMPRESSION: No significant change since prior film of , with\n extensive bilateral pulmonary opacities as described, consistent with a\n combination of pulmonary edema and pulmonary consolidation. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 902483,
"text": " 8:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with ?asp pneumonia\n\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question aspiration pneumonia. Evaluate infiltrates.\n\n COMPARISON: .\n\n SUPINE RADIOGRAPH CHEST: Endotracheal tube still ends 4 cm above the carina.\n The tip of a left central venous catheter still projects over the upper SVC.\n The diffuse opacification in the left lung has improved substantially, less\n pronounced opacity in the right lung has improved minimally. Probably right\n pleural effusion is not large or changed.\n\n IMPRESSION: Improving bilateral pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-02-07 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 901601,
"text": " 8:58 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: gas pattern\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with increasingly protuberant abdomen\n REASON FOR THIS EXAMINATION:\n gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasingly protuberant abdomen.\n\n COMPARISON: Abdominal radiograph from .\n\n SUPINE AP VIEW OF THE ABDOMEN: Study is limited secondary to technique and\n patient positioning. As before, there is a paucity of gas within the abdomen.\n The left lateral aspect of the abdomen is excluded from the study. No\n definite free intraperitoneal air is seen. Degenerative changes are again\n noted within the thoracolumbar spine.\n\n IMPRESSION: Limited study without significant change in the interval.\n DFDdp\n\n"
}
] |
63,049 | 167,876 | Following the same day admission she went to the Operating Room where minimally invasive closure of the PFO was performed. Please see the operative note for details. She weaned from bypass on Propofol and neosynephrine in stable condition. She easily weaned from the ventilator and was extubated. Neosynephrine was off and on due to "soft" blood pressure for 24 hours. Her chest tubes were removed on the day after surgery and she was transferred to the floor. She was seen in consultation by the physical therapy service. By post-operative day 3 she was ready for discharge to home. Medications, activity limits and followup were discussed with her prior to discharge. Wounds were clean and healing well. there were no untoward effects of her right femoral cannulation. | Normalascending aorta diameter. PhysiologicMR (within normal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Problem Minimally invasive PFO closure Assessment: Pt received from OR at 1600 and received report from anesthesia. Normal aortic arch diameter. The mitralvalve appears structurally normal with trivial mitral regurgitation.Physiologic mitral regurgitation is seen (within normal limits). Minimally Invasive PFO Closure Assessment: AAO x 3. Minimally Invasive PFO Closure Assessment: AAO x 3. Placement checked and given ranitidine. Dressings CDI. Dressings CDI. Normal aortic diameter at the sinus level. LS-CTA/Dim. Hct 31. min dng from CT. neuro intact. WJMLEFT ATRIUM: Normal LA and RA cavity sizes. Now taking minimal po w/out issue. Nauseous x 2. Nauseous x 2. A left IJ central venous catheter tip terminates in the mid to upper SVC. Internal billing status corrected. IMPRESSION: Tiny right apical pneumothorax. Metoclopramide 19. R ptx. A right-sided pleural chest tube remains in place with tip terminating in the right apical region. HR down to 90s-100s once extubated and neo shut off with SBP 100s-110 K-2.9 and 60meq KCL IV given. A tiny right apical pneumothorax is seen. Right chest tube is in place. HR-NSR 80s-90s while sedated and SBP 80s to 100s and received on phenylephrine drip. K and Hct to be checked. SBP in high 80s, low 90s. SBP in high 80s, low 90s. Pt received sedated on propofol. Uop qs. The cardiomediastinal contours remain midline. Ranitidine 27. NG tube terminates in stomach, side port at GE junction. Furosemide 11. SBP low 90s. Morphine Sulfate 22. Pt given 1 liter of fluid. Aspirin EC 6. No TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Pain out of 10. lungs clear dim bases. Normal LV wall thickness and cavity size. I certify I was present in compliance with HCFAregulations. Left IJ line terminates in the upper portion of the SVC. Sinus rhythm. Wounds: Dry dressings Imaging: CXR today Fluids: Consults: P.T. Phenylephrine 25. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. . Bair hugger placed on pt for temp 95.7. Ketorolac 17. Milk of Magnesia 21. The left ventricularcavity size is normal. Reglan given IV as ordered with fair effect. Reglan given IV as ordered with fair effect. Normal descending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). Nutrition: Advance diet as tolerated Renal: Foley, Adequate UO Hematology: Mild anemia. Calcium Gluconate 7. NSR 80s. There is nopericardial effusion.Post byass: PFO/ASD now closed with some tissue bunching but no flow.Remaining exam is unchanged. Docusate Sodium 10. Afebrile. Afebrile. Problem - Description In Comments Assessment: Pod # 1 s/p min invasive PFO closure. Cont. MAE x 4 strongly. MAE x 4 strongly. Chest tube draining fair amount of serosanguinous drainage. Chest tube draining fair amount of serosanguinous drainage. Lungs clear with slightly diminished bases. Lungs clear with slightly diminished bases. Normal LV wall thickness.Normal LV cavity size. A patent foramenovale is present. CefazoLIN 8. Nitroglycerin 23. CVICU HPI: POD 1 35yoW s/p min inv PFO closure. CVICU HPI: HD2 POD 1 35yoW s/p min inv PFO closure. Left ventricular wall thicknesses and cavity size arenormal. COMPARISON: Chest radiographs of and . Metoprolol Tartrate 20. Left IJ line terminates in expected location of SVC. CTs d/c's without incident. Excellent hourly urine output. Excellent hourly urine output. FINDINGS: In comparison with the study of , there is now an endotracheal tube in place with the tip approximately 4.5 cm above the carina. present care. Left ventricular wall thicknesses are normal. Pt placed on CPAP at 1830 and pt with good ABG with base excess -4. Pulmonary toilet. Pt with blood sugars 70s-90 Action: Pt warmed, waked, and weaned. Began on dilaudid for pain and continues on ATC toradol. abd soft. The lungs appear grossly clear. Good (>20 cm/s) LAA ejectionvelocity. Right ventricular chamber size and free wall motion are normal.The ascending, transverse and descending thoracic aorta are normal in diameterand free of atherosclerotic plaque. No TEE relatedcomplications.post-CPB: Patient was weaned off bypass in sinus rhytm with 1 mcg/kg/min ofphenylephrine. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque. Soft with absent BS and draining bilious. Compared to the previous tracing of sinus tachycardia isno longer present. Magnesium Sulfate 18. doing well post op. HYDROmorphone (Dilaudid) 12. Neosynephrine used for maintain MAP >= 60. Neosynephrine used for maintain MAP >= 60. CVP- throughout shift. Had some hypotension which responded to volume. A TEE was performed in thelocation listed above. Remaining exam is unchanged. Abd. Ibuprofen 14. CVP ranging from 7 10. CVP ranging from 7 10. SB in 70s. MD aware and pt extubated with no complications. Pulses palpable. Pulses palpable. Monitor hemodynamics. to floor. Demographics Day of intubation: Day of mechanical ventilation: 1 Ideal body weight: 0 None Ideal tidal volume: 0 / 0 / 0 mL/kg Airway Airway Placement Data Known difficult intubation: Procedure location: Reason: Tube Type ETT: Position: 21 cm at teeth Route: Oral Type: Standard Size: 7mm Cuff Management: Vol/Press: Cuff pressure: cmH2O Cuff volume: mL / Airway problems: Comments: Lung sounds RLL Lung Sounds: Diminished RUL Lung Sounds: Clear LUL Lung Sounds: Clear LLL Lung Sounds: Diminished Comments: Secretions Sputum color / consistency: / Sputum source/amount: / Comments: Ventilation Assessment Level of breathing assistance: Continuous invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Assessment of breathing comfort: No response (sleeping / sedated) Invasive ventilation assessment: Trigger work assessment: Triggering synchronously Plan Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated; Comments: Wean on PSV when ready Reason for continuing current ventilatory support: Sedated / Paralyzed; Comments: post op patient Comments: Pt admitted from OR and is currently vented on SIMV with changes made to fio2 per ABG. | 12 | [
{
"category": "Nursing",
"chartdate": "2125-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683431,
"text": "Minimally Invasive PFO Closure\n Assessment:\n AAO x 3. Voice weak due to pain associated with prior ETT.\n Pain treated with Morphine IV and Toradol IM as ordered. Good\n relief achieved. Afebrile. MAE x 4 strongly. Turns with minimal\n assistance.\n SBP in high 80s, low 90s. SB in 70s. Neosynephrine used\n for maintain MAP >= 60. Pulses palpable.\n O2 sat 100% on 2LNC. Lungs clear with slightly diminished\n bases. No cough. Chest tube draining fair amount of serosanguinous\n drainage.\n Abdomen flat, soft, non-tender. Nauseous x 2. Reglan given\n IV as ordered with fair effect. Nausea sporadic and not clearly\n associated with oral intake (ice chips) or pain medications.\n Foley catheter draining light yellow/clear urine. Excellent\n hourly urine output. CVP ranging from 7\n 10. Received 1.5L LR upon\n onset of shift for base deficit -4.\n Skin intact. Neck and right groin incisions not assessed.\n Dressings CDI.\n Treated blood glucose according to CVICU sliding scale. See\n Metavision flowsheet for details.\n Plan:\n OOB to chair today. Continue pain control and administer PO meds as\n nausea subsides. Possible transfer to 6 today.\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-05-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 683376,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean on PSV when ready\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\n Comments: post op patient\n Comments: Pt admitted from OR and is currently vented on SIMV with\n changes made to fio2 per ABG. Will cont with vent support and wean when\n appropriate.\n"
},
{
"category": "Nursing",
"chartdate": "2125-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683415,
"text": "Minimally Invasive PFO Closure\n Assessment:\n AAO x 3. Voice weak due to pain associated with prior ETT.\n Pain treated with Morphine IV and Toradol IM as ordered. Good\n relief achieved. Afebrile. MAE x 4 strongly. Turns with minimal\n assistance.\n SBP in high 80s, low 90s. Neosynephrine used for maintain\n MAP >= 60. Pulses palpable.\n O2 sat 100% on 2LNC. Lungs clear with slightly diminished\n bases. No cough. Chest tube draining fair amount of serosanguinous\n drainage.\n Abdomen flat, soft, non-tender. Nauseous x 2. Reglan given\n IV as ordered with fair effect. Nausea sporadic and not clearly\n associated with oral intake (ice chips) or pain medications.\n Foley catheter draining light yellow/clear urine. Excellent\n hourly urine output. CVP ranging from 7\n 10. Received 1.5L LR upon\n onset of shift for base deficit -4.\n Skin intact. Neck and right groin incisions not assessed.\n Dressings CDI.\n Treated blood glucose according to CVICU sliding scale. See\n Metavision flowsheet for details.\n Plan:\n OOB to chair today. Continue pain control and administer PO meds as\n nausea subsides. Possible transfer to 6 today.\n"
},
{
"category": "Physician ",
"chartdate": "2125-05-31 00:00:00.000",
"description": "Intensivist Note",
"row_id": 683498,
"text": "CVICU\n HPI:\n HD2\n POD 1\n 35yoW s/p min inv PFO closure. \n EF 69% Cr 0.8 HgA1c 5.6 Wt 45.5K\n Antibx: Cefazolin\n PMH: TIA, PFO, Rt breast CA s/p rads/lumpectomy, Fibromyalgia,\n : ASA 325'\n Current medications:\n Acetaminophen 5. Aspirin EC 6. Calcium Gluconate 7. CefazoLIN 8.\n Dextrose 50%\n 9. Docusate Sodium 10. Furosemide 11. HYDROmorphone (Dilaudid) 12.\n HYDROmorphone (Dilaudid) 13. Ibuprofen\n 14. Insulin 15. Ketorolac 16. Ketorolac 17. Magnesium Sulfate 18.\n Metoclopramide 19. Metoprolol Tartrate\n 20. Milk of Magnesia 21. Morphine Sulfate 22. Nitroglycerin 23.\n Oxycodone-Acetaminophen 24. Phenylephrine\n 25. Potassium Chloride 26. Ranitidine 27. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INTUBATION - At 04:00 PM\n ARTERIAL LINE - START 04:00 PM\n INVASIVE VENTILATION - START 04:00 PM\n OR RECEIVED - At 04:10 PM\n MULTI LUMEN - START 04:15 PM\n EXTUBATION - At 07:30 PM\n INVASIVE VENTILATION - STOP 07:30 PM\n --Extubated overnight.\n Post operative day:\n POD#1 - invasive pfo closure\n Allergies:\n Succinylcholine\n no movement\n un\n Last dose of Antibiotics:\n Cefazolin - 03:30 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 05:51 AM\n Hydromorphone (Dilaudid) - 07:04 AM\n Ranitidine (Prophylaxis) - 08:05 AM\n Other medications:\n Flowsheet Data as of 10:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37\nC (98.6\n HR: 81 (78 - 121) bpm\n BP: 81/45(58) {80/45(58) - 120/77(95)} mmHg\n RR: 16 (11 - 33) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 51 kg (admission): 46 kg\n CVP: 5 (4 - 16) mmHg\n Total In:\n 4,674 mL\n 234 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,174 mL\n 234 mL\n Blood products:\n 500 mL\n Total out:\n 1,988 mL\n 876 mL\n Urine:\n 1,145 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,686 mL\n -642 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 524 (227 - 524) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 36\n PIP: 11 cmH2O\n Plateau: 14 cmH2O\n SPO2: 100%\n ABG: 7.38/41/183/23/0\n Ve: 7.1 L/min\n PaO2 / FiO2: 366\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : right base, Diminished: right base), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 154 K/uL\n 10.6 g/dL\n 135 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 107 mEq/L\n 136 mEq/L\n 31.5 %\n 13.3 K/uL\n [image002.jpg]\n 02:20 PM\n 03:14 PM\n 04:20 PM\n 04:30 PM\n 07:21 PM\n 09:36 PM\n 09:41 PM\n 01:55 AM\n WBC\n 12.6\n 13.3\n Hct\n 25\n 28\n 31.4\n 31.4\n 31.5\n Plt\n 166\n 154\n Creatinine\n 0.7\n 0.6\n TCO2\n 27\n 24\n 24\n 22\n 25\n Glucose\n 104\n 155\n 84\n 135\n Other labs: PT / PTT / INR:16.3/45.3/1.4, Lactic Acid:1.5 mmol/L\n Imaging: CXR - small apical pneumothorax on right.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan:\n Neurologic: Pain controlled, Percocet PRN and Toradol\n Cardiovascular: Aspirin, post-op hypotension --> wean neo gtt for MAP >\n 60.\n Pulmonary: Extubated overnight, doing well;\n Gastrointestinal / Abdomen: No issues.\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology: Mild anemia.\n Endocrine: RISS\n Infectious Disease: Periop Antibx.\n Lines / Tubes / Drains: Foley, Chest tube - mediastinal\n Wounds: Dry dressings\n Imaging: CXR today, Repeat CXR\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2125-05-31 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 683503,
"text": "CVICU\n HPI:\n POD 1\n 35yoW s/p min inv PFO closure. \n EF 69% Cr 0.8 HgA1c 5.6 Wt 45.5K\n Antibx: Cefazolin\n PMH: TIA, PFO, Rt breast CA s/p rads/lumpectomy, Fibromyalgia\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen , Aspirin EC ,Calcium Gluconate ,CefazoLIN , Dextrose\n 50%, Docusate Sodium , Furosemide, HYDROmorphone (Dilaudid) ,\n HYDROmorphone (Dilaudid) , Ibuprofen, Insulin , Ketorolac, Magnesium\n Sulfate, Metoclopramide , Metoprolol Tartrate , Milk of Magnesia ,\n Morphine Sulfate , Nitroglycerin , Oxycodone-Acetaminophen ,\n Phenylephrine, Potassium Chloride , Ranitidine , Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n INTUBATION - At 04:00 PM\n ARTERIAL LINE - START 04:00 PM\n INVASIVE VENTILATION - START 04:00 PM\n OR RECEIVED - At 04:10 PM\n MULTI LUMEN - START 04:15 PM\n EXTUBATION - At 07:30 PM\n INVASIVE VENTILATION - STOP 07:30 PM\n Post operative day:\n POD#1 - invasive pfo closure\n Allergies:\n Succinylcholine\n no movement\n un\n Last dose of Antibiotics:\n Cefazolin - 03:30 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:51 AM\n Hydromorphone (Dilaudid) - 07:04 AM\n Ranitidine (Prophylaxis) - 08:05 AM\n Other medications:\n Flowsheet Data as of 11:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37\nC (98.6\n HR: 99 (78 - 121) bpm\n BP: 91/52(61) {90/52(61) - 91/56(64)} mmHg\n RR: 26 (11 - 33) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 51 kg (admission): 46 kg\n CVP: 5 (4 - 16) mmHg\n Total In:\n 4,674 mL\n 233 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,174 mL\n 233 mL\n Blood products:\n 500 mL\n Total out:\n 1,988 mL\n 1,006 mL\n Urine:\n 1,145 mL\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,686 mL\n -773 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 524 (227 - 524) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 36\n PIP: 11 cmH2O\n Plateau: 14 cmH2O\n SPO2: 98%\n ABG: 7.38/41/183/23/0\n Ve: 7.1 L/min\n PaO2 / FiO2: 366\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 154 K/uL\n 10.6 g/dL\n 135 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 11 mg/dL\n 107 mEq/L\n 136 mEq/L\n 31.5 %\n 13.3 K/uL\n [image002.jpg]\n 02:20 PM\n 03:14 PM\n 04:20 PM\n 04:30 PM\n 07:21 PM\n 09:36 PM\n 09:41 PM\n 01:55 AM\n WBC\n 12.6\n 13.3\n Hct\n 25\n 28\n 31.4\n 31.4\n 31.5\n Plt\n 166\n 154\n Creatinine\n 0.7\n 0.6\n TCO2\n 27\n 24\n 24\n 22\n 25\n Glucose\n 104\n 155\n 84\n 135\n Other labs: PT / PTT / INR:16.3/45.3/1.4, Lactic Acid:1.5 mmol/L\n Imaging: CXR: sm. R ptx.\n Microbiology: all neg\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: Pt. doing well post op. Had some hypotension\n which responded to volume. CTs d/c's without incident. Tx. to floor.\n Cont. present care. Will recheck CXR this afternoon.\n Neurologic:\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: neg\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tubes\n d/c'd.\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2125-05-31 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 683517,
"text": " Problem - Description In Comments\n Assessment:\n Pod # 1 s/p min invasive PFO closure. NSR 80\ns. no ectopy noted. SBP\n low 90\ns. BP did drop to 60\ns w/ OOb to chair. Pt c/o\n going to pass\n out\n 500cc LR given w/ effect. BP return to 90\ns quickly. Hct 31. min\n dng from CT. neuro intact. Began on dilaudid for pain and continues on\n ATC toradol. Pain out of 10. lungs clear dim bases. O2 sats 100% on\n r/a. uses IS to 500cc. abd soft. Some low grade nausea overnoc. Now\n taking minimal po w/out issue. Uop qs. Husband at bedside much of am\n Action:\n No lasiix or betablockers yet r/t BP\n CT d/ by NP\n Analgesia\n Oob to ch\n Response:\n Bp drop w/ oob\n Plan:\n Cont to monitor\n Start Lasix & BB when BP allows.\n Increase activity and diet as able\n"
},
{
"category": "Nursing",
"chartdate": "2125-05-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683399,
"text": " Problem\n Minimally invasive PFO closure\n Assessment:\n Pt received from OR at 1600 and received report from anesthesia.\n Pt received sedated on propofol. HR-NSR 80\ns-90\ns while sedated and\n SBP 80\ns to 100\ns and received on phenylephrine drip. No ectopy\n noted. CVP- throughout shift.\n LS-CTA/Dim. at bases with good ABG on rate of 14.\n Abd. Soft with absent BS and draining bilious. Placement checked and\n given ranitidine.\n Pt with blood sugars 70\ns-90\n Action:\n Pt warmed, waked, and weaned. Bair hugger placed on pt for temp 95.7.\n Pt reversed and awake, restless, and following commands. Pt anxious\n when awake and HR 110\ns-130\ns and BP maintaining. Pt placed on CPAP\n at 1830 and pt with good ABG with base excess -4. Pt following\n commands and c/o no pain. MD aware and pt extubated with no\n complications. Pt given 1 liter of fluid. HR down to 90\ns-100\ns once\n extubated and neo shut off with SBP 100\ns-110\n K-2.9 and 60meq KCL IV given. K to be checked after 1900 this evening.\n Response:\n Pt resting in bed comfortably at this time with stable hemodynamics, on\n 3LO2, good UOP, and right pleural chest tube draining 5-20cc/hr. K and\n Hct to be checked.\n Plan:\n Monitor neuro status and assess pain level/administer pain meds prn.\n Pulmonary toilet.\n Monitor hemodynamics.\n ?transfer to floor tomorrow.\n"
},
{
"category": "Echo",
"chartdate": "2125-05-30 00:00:00.000",
"description": "Report",
"row_id": 84550,
"text": "PATIENT/TEST INFORMATION:\nIndication: asd/pfo s/p TIA\nHeight: (in) 64\nWeight (lb): 100\nBSA (m2): 1.46 m2\nBP (mm Hg): 110/60\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 15:20\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npre-CPB: 35 yr old female whose was found to have a PFO after a TIA. Her\ninta-operative echo revealed a preserved left ventricular function with an EF\nof >55% The PFO was interrogated by color doppler for confirmation of its\npresence. SVC and IVC cannulas were positioned with echocardiographic\nguidance.\n\n Internal billing status corrected. No changes made in findings. WJM\nLEFT ATRIUM: Normal LA and RA cavity sizes. Good (>20 cm/s) LAA ejection\nvelocity. All four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size. Normal LV wall thickness.\nNormal LV cavity size. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal aortic diameter at the sinus level. Normal\nascending aorta diameter. Normal aortic arch diameter. Normal descending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. . Physiologic\nMR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\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 under general anesthesia throughout the procedure.\nThe patient received antibiotic prophylaxis. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\npost-CPB: Patient was weaned off bypass in sinus rhytm with 1 mcg/kg/min of\nphenylephrine. Color doppler interrogation of the inter-atrial septum revealed\nno residual shunt which was confirmed in the presence of 2 attending\nanesthesiologists. Left ventricular function was similar to pre-bypss and\nthere was no sign of aortic dissection. Remaining exam is unchanged. All\nfindings discussed with surgeons at the time of the exam.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. A patent foramen\novale is present. Left ventricular wall thicknesses and cavity size are\nnormal. Left ventricular wall thicknesses are normal. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe ascending, transverse and descending thoracic aorta are normal in diameter\nand free of atherosclerotic plaque. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation.\nPhysiologic mitral regurgitation is seen (within normal limits). There is no\npericardial effusion.\n\nPost byass: PFO/ASD now closed with some tissue bunching but no flow.\nRemaining exam is unchanged. See Comments for remaining discussion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-05-31 00:00:00.000",
"description": "Report",
"row_id": 205913,
"text": "Sinus rhythm. Compared to the previous tracing of sinus tachycardia is\nno longer present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085556,
"text": " 9:18 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for left PTX\n Admitting Diagnosis: ATRIAL SEPTAL DEFECT\\REPAIR ATRIAL SEPTAL DEFECT LIMITED ACCESS /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with removal of left chest tube\n REASON FOR THIS EXAMINATION:\n eval for left PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left chest tube removal.\n\n FINDINGS: Following chest tube removal, there is no convincing evidence of\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085533,
"text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ct to water seal, r/o ptx\n Admitting Diagnosis: ATRIAL SEPTAL DEFECT\\REPAIR ATRIAL SEPTAL DEFECT LIMITED ACCESS /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman s/p MI ASD\n REASON FOR THIS EXAMINATION:\n ct to water seal, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old female with atrioseptal defect repair, now with chest\n tube to waterseal, here to assess for pneumothorax.\n\n COMPARISON: Chest radiographs of and .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: The patient has been extubated and the OG\n tube removed. A left IJ central venous catheter tip terminates in the mid to\n upper SVC. A right-sided pleural chest tube remains in place with tip\n terminating in the right apical region. A tiny right apical pneumothorax is\n seen. The cardiomediastinal contours remain midline. The lungs appear grossly\n clear.\n\n IMPRESSION: Tiny right apical pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-30 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1085477,
"text": " 4:50 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pneumothorax, pulmonary edema, tamponade.\n Admitting Diagnosis: ATRIAL SEPTAL DEFECT\\REPAIR ATRIAL SEPTAL DEFECT LIMITED ACCESS /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with PFO closure.\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pneumothorax, pulmonary edema, tamponade. \n with issues. Pt in OR 4 and will be in CSRU in 120 mins.\n ______________________________________________________________________________\n WET READ: JXRl WED 7:24 PM\n ETT approximately 4.5cm above carina. NG tube terminates in stomach, side\n port at GE junction. Left IJ line terminates in expected location of SVC. no\n pneumothorax, effusion or evidence of pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PFO closure.\n\n FINDINGS: In comparison with the study of , there is now an endotracheal\n tube in place with the tip approximately 4.5 cm above the carina. Nasogastric\n tube extends to the upper stomach, though the side port is at or above the\n esophagogastric junction. Left IJ line terminates in the upper portion of the\n SVC.\n\n No evidence of pneumonia, vascular congestion, pleural effusion, or\n pneumothorax.\n\n Right chest tube is in place.\n\n\n"
}
] |
65,481 | 152,194 | Action: Premedicated with Fomotidine and Benadryl as ordered. Action: Premedicated with Fomotidine and Benadryl as ordered. Action: Premedicated with Fomotidine and Benadryl as ordered. to infuse desensitization doses as per protocol. to infuse desensitization doses as per protocol. Administer caspofungin as per protocol. Patient admitted for Caspofungin desensitization. Premediation with benadryl and famotidine. Desensitization as per pharmacy protocol. Desensitization as per pharmacy protocol. Desensitization as per pharmacy protocol. ------ Protected Section Addendum Entered By: , RN on: 19:07 ------ PPX: -DVT: ambulatory -Bowel regimen: not needed . Assessment: Pt. Assessment: Pt. Assessment: Pt. + reflexes, equal BL. PERRLA/EOMI. ABDOMEN: NABS. Notes vaginal discharge, itching. Cough subsided and Infusion resumed. Plan: Cont. Plan: Cont. has branchospastic reaction to it) and Infusion of further doses restarted. has branchospastic reaction to it) and Infusion of further doses restarted. Will keep her NPO given potential for anaphyaxis and remote possibility that intubation be needed. EMERGENCY CONTACT: . CODE STATUS: Presumed full . MD aware of patient discharge. The same was treated with benadryl with good effect. Problem desensitization. Problem desensitization. Problem desensitization. Discharged with instructions to keep follow up appoint and report any signs or symptoms of a reaction. Cough subsided after Benadryl infusion completed. Cough subsided after Benadryl infusion completed. Seen in where vaginal swab sent off which grew . Response: VSS. Response: VSS. Response: VSS. Pt. Pt. ACCESS: PIV's . Normal S1, S2. LS clear no wheezing. LS clear no wheezing. MMM. Monitor for s/s of reaction. Monitor for s/s of reaction. Soft, NT, ND. Preserved sensation throughout. Plan: This was found to be sensitive to caspofungin per outside reference lab. OP clear. #. . . . DISPOSITION: -- ICU ICU Care Nutrition: Glycemic Control: Lines: Prophylaxis: DVT: (ambulatory) Stress ulcer: VAP: Comments: Communication: Family meeting held Comments: Code status: Full code Disposition: ICU Appropriate. LUNGS: CTAB, good air movement biaterally. Former NP in GI unit. started with frequent dry cough after Bag # 7. started with frequent dry cough after Bag # 7. Allegic reaction desensitization kit at bedskide, monitor in the ICU. On admissions she denies fevers, chills. Two peripheral IVs placed. Patient admitted from: Home History obtained from Patient Allergies: Penicillins Hives; Amoxicillin Unknown; Rash; E-Mycin (Oral) (Erythromycin Base) Unknown; Nausea Latex Hives; Ondansetron Rash; Vancomycin Hives; Levofloxacin Rash; Zofran (Intraven.) presented to MICU from home for an arranged desensitization for chronic vaginitis. presented to MICU from home for an arranged desensitization for chronic vaginitis. presented to MICU from home for an arranged desensitization for chronic vaginitis. (Ondansetron Hcl) Unknown; Phenergan (Injection) (Promethazine Hcl) Unknown; Dilaudid (Oral) (Hydromorphone Hcl) pruritis dysph Ceftriaxone Hives; Sulfamethoxazole/Trimethoprim (Oral) Nausea/Vomiting Voriconazole More allergies, please see POE for details Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: sucralfate Epi Pen Benadryl/viscous lidocaine mouth wash Past medical history: Family history: Social History: Chronic mouth ulcers Atonic colon Autonomic neuropathy Noncontributory Occupation: Nurse ugs: None Tobacco: None Alcohol: None Other: Married, 2 kids Review of systems: Pain: No pain / appears comfortable Flowsheet Data as of 04:23 PM Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since 12 AM Tmax: 36.9C (98.5 Tcurrent: 36.9C (98.5 HR: 96 (88 - 108) bpm BP: 125/73(86) {70/25(34) - 127/88(97)} mmHg RR: 21 (17 - 29) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Total In: 71 mL PO: TF: IVF: 71 mL Blood products: Total out: 0 mL 0 mL Urine: NG: Stool: Drains: Balance: 0 mL 71 mL Respiratory O2 Delivery Device: None SpO2: 100% ABG: //// Physical Examination General Appearance: Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, plantar portion right heel with small laceration, minimal surrounding erythema Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): x 3, Movement: Purposeful, Tone: Normal Labs / Radiology 277 41 0.7 11 27 101 4.3 137 4.0 [image002.jpg] Assessment and Plan 42 y.o. | 6 | [
{
"category": "Nursing",
"chartdate": "2100-11-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 605351,
"text": " Problem\n desensitization.\n Assessment:\n Pt. presented to MICU from home for an arranged \n desensitization for chronic vaginitis.\n Action:\n Premedicated with Fomotidine and Benadryl as ordered. Desensitization\n as per pharmacy protocol.\n Response:\n VSS. Pt. started with frequent dry cough after Bag # 7. Temp increased\n from 98.5 prior to starting to 100.0 at 1830. Medicated\n with Benadryl 25mg IV (which requires it to be infused over 30min as\n Pt. has branchospastic reaction to it) and Infusion of further doses\n restarted. Cough subsided after Benadryl infusion completed. LS clear\n no wheezing. O2 sat 96-98% on RA. Peek flow unchanged at 300. Team\n aware.\n Plan:\n Cont. to infuse desensitization doses as per protocol.\n Monitor for s/s of reaction.\n"
},
{
"category": "Nursing",
"chartdate": "2100-11-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 605380,
"text": "Patient admitted for Caspofungin desensitization. Infusion protocol\n completed at 2220 without any reaction during this shift, during the\n sixth dose she did have a low grade temperature and flushing. The same\n was treated with benadryl with good effect. No further reaction noted\n during the infusion of Caspofungin. Patient is alert oriented, moving\n all limbs well. No physiologic deficit noted. Discharged with\n instructions to keep follow up appoint and report any signs or symptoms\n of a reaction. Left after cab was called to take her home. MD aware of\n patient discharge. No new medications added.\n"
},
{
"category": "Physician ",
"chartdate": "2100-11-01 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 605305,
"text": "Chief Complaint: caspofungin desensitization\n HPI:\n 42yo female with extremely extensive allergy history and history of\n resistant yeast vaginitis treated with caspofungin a few years\n ago, to which she developed chest tightness during that course, who is\n now coming in for caspofungin desensitization in order to treat a\n recurrent resistant yest infection. Seen in where vaginal\n swab sent off which grew . This was found to be sensitive to\n caspofungin per outside reference lab. Given her history of allergic\n reaction to caspofungin, she is being admitted to the ICU for\n desensitization and monitoring.\n .\n Of note, she develops phlebitic reactions to catheters kept in beyonf\n the actual infusion (IVs, PICCs, etc). As a result, once desensitized,\n she will need daily outpatient IV's placed at the daycare infusion\n center in order to continue her caspofungin course.\n .\n Review of systems is positive for a small laceration on the bottom of\n her right foot. She cut her foot on a clean metal edgue after tripping\n while putting together a new bed; no rust or debris on the metal. No\n fevers, but small amount of erythema and discharge at the cut. Review\n of systems is otherwise negative.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Amoxicillin\n Unknown; Rash;\n E-Mycin (Oral) (Erythromycin Base)\n Unknown; Nausea\n Latex\n Hives;\n Ondansetron\n Rash;\n Vancomycin\n Hives;\n Levofloxacin\n Rash;\n Zofran (Intraven.) (Ondansetron Hcl)\n Unknown;\n Phenergan (Injection) (Promethazine Hcl)\n Unknown;\n Dilaudid (Oral) (Hydromorphone Hcl)\n pruritis\n dysph\n Ceftriaxone\n Hives;\n Sulfamethoxazole/Trimethoprim (Oral)\n Nausea/Vomiting\n Voriconazole\n More allergies, please see POE for details\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n MEDICATIONS per OMR:\n # Diphenhydramine 12.5 mg/5ml:Viscous Lidocaine 2%:Maalox swish and\n spit 5 ml up to five times daily as needed for prn mouth ulcers\n # Epinephrine [EpiPen] 0.3 mg/0.3 mL (1:1,000) Pen Injector prn\n # Estradiol [Estring] 7.5 mcg/24 hour Ring apply vaginally q3 months #\n Methylphenidate [Concerta] 18 mg Tab,Sust Rel Osmotic Push 24hr\n 2 Tab(s) by mouth once a day\n # Sucralfate 1 gram Tablet 1 Tablet(s) by mouth used topically four\n times a day compound and diluted to 4% into an ointment please make dye\n and fragrance free\n Past medical history:\n Family history:\n Social History:\n presumed autonomic neuropathy for which she receives IVIG\n bizarre phlebitic reactions to catheters kept in too long\n atonic colon s/p resection\n bronchospasm\n n/c\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: No tob, alcohol and illict drugs. Former NP in GI unit.\n Review of systems:\n Flowsheet Data as of 02:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n GENERAL: Pleasant, well appearing woman in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or .\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: small one cm superficial laceration on the bottom wof right foot\n with erythema, but no warmth, edema or purulent discharge\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Normal\n coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 95\n 0.7\n 11\n 27\n 101\n 4.3\n 137\n 41\n 4.0\n [image002.jpg]\n Assessment and Plan\n 42yo female with caspofungin allergy and resistant yeast\n vaginitis who presents for caspofungin desensitization.\n .\n #. Caspofungin desinsitization:\n - per protocol: premedication with benadryl and famotodine, epi at\n bedside\n - will get caspofunging per protocol\n - will get 62g \"loading dose\" today and then 50mg daily via daycare\n .\n # Foot laceration:\n - d/w PCP and ID, no tetanus shot today\n - keep clean and dry\n .\n FEN: regular diet\n .\n PPX:\n -DVT: ambulatory\n -Bowel regimen: not needed\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n .\n EMERGENCY CONTACT:\n .\n DISPOSITION:\n -- ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: (ambulatory)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2100-11-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 605361,
"text": " Problem\n desensitization.\n Assessment:\n Pt. presented to MICU from home for an arranged \n desensitization for chronic vaginitis.\n Action:\n Premedicated with Fomotidine and Benadryl as ordered. Desensitization\n as per pharmacy protocol.\n Response:\n VSS. Pt. started with frequent dry cough after Bag # 7. Temp increased\n from 98.5 prior to starting to 100.0 at 1830. Medicated\n with Benadryl 25mg IV (which requires it to be infused over 30min as\n Pt. has branchospastic reaction to it) and Infusion of further doses\n restarted. Cough subsided after Benadryl infusion completed. LS clear\n no wheezing. O2 sat 96-98% on RA. Peek flow unchanged at 300. Team\n aware.\n Plan:\n Cont. to infuse desensitization doses as per protocol.\n Monitor for s/s of reaction.\n ------ Protected Section ------\n Possible reaction, increasing cough, noted with infusion of Bag # 6\n and 7. Bag #8 held and benadryl 25mg IV given over 30min. Cough\n subsided and Infusion resumed.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:07 ------\n"
},
{
"category": "Nursing",
"chartdate": "2100-11-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 605327,
"text": " Problem\n desensitization.\n Assessment:\n Pt. presented to MICU from home for an arranged \n desensitization for chronic vaginitis.\n Action:\n Premedicated with Fomotidine and Benadryl as ordered. Desensitization\n as per pharmacy protocol.\n Response:\n VSS.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2100-11-01 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 605319,
"text": "Chief Complaint: Caspofungin desensitization\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 42 y.o. woman with resistant vaginal yeast infection and\n multiple drug allergies admitted for Caspfungen desensitization as she\n has prior hirtory of chest tightness when receiving the med in the\n past. On admissions she denies fevers, chills. She had lacerated her\n foot on metal recently. Notes vaginal discharge, itching.\n Patient admitted from: Home\n History obtained from Patient\n Allergies:\n Penicillins\n Hives;\n Amoxicillin\n Unknown; Rash;\n E-Mycin (Oral) (Erythromycin Base)\n Unknown; Nausea\n Latex\n Hives;\n Ondansetron\n Rash;\n Vancomycin\n Hives;\n Levofloxacin\n Rash;\n Zofran (Intraven.) (Ondansetron Hcl)\n Unknown;\n Phenergan (Injection) (Promethazine Hcl)\n Unknown;\n Dilaudid (Oral) (Hydromorphone Hcl)\n pruritis\n dysph\n Ceftriaxone\n Hives;\n Sulfamethoxazole/Trimethoprim (Oral)\n Nausea/Vomiting\n Voriconazole\n More allergies, please see POE for details\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n sucralfate\n Epi Pen\n Benadryl/viscous lidocaine mouth wash\n Past medical history:\n Family history:\n Social History:\n Chronic mouth ulcers\n Atonic colon\n Autonomic neuropathy\n Noncontributory\n Occupation: Nurse \nugs: None\n Tobacco: None\n Alcohol: None\n Other: Married, 2 kids\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 96 (88 - 108) bpm\n BP: 125/73(86) {70/25(34) - 127/88(97)} mmHg\n RR: 21 (17 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 71 mL\n PO:\n TF:\n IVF:\n 71 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 71 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, plantar portion right heel with small laceration,\n minimal surrounding erythema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x 3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 277\n 41\n 0.7\n 11\n 27\n 101\n 4.3\n 137\n 4.0\n [image002.jpg]\n Assessment and Plan\n 42 y.o. woman admitted from home with vaginal infection\n refractory to outpatient treatment, history of chest pain in setting of\n Caspofungin in the past so she is admitted for desensitization\n protocol. Two peripheral IVs placed. Allegic reaction desensitization\n kit at bedskide, monitor in the ICU. Premediation with benadryl and\n famotidine. Administer caspofungin as per protocol. Will keep her NPO\n given potential for anaphyaxis and remote possibility that intubation\n be needed.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 02:00 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
}
] |
|
30,117 | 177,272 | Patient entered with hypoglycemia and agonal breathing s/p intubation with shock, liver failure and renal failure. She became markedly hypotensive despite being on 2 pressors and being intubated. At this juncture, the family decided on providing comfort measures only at which point a decision was made to extubate the patient. She expired shortly thereafter. | Hep d/c'd for thrombocytopenia. Compared to tracing #1 atrial fibrillation has been replaced withsinus tachycardia.TRACING #2 In - ERCP planned, cleared by Cards, noted to be in afib at outset of procedure - aborted, tx'd with amiodarone and dilt and digoxin added. Vasopressin was added, but patient continud to be hypotensive. - RUQ U/S showed normal hepatic vein flow but sludging in the intrahepatic and portal vein, suggesting that their might be a partial thrombus. Small left effusion and retrocardiac atelectasis. Possible prior inferior myocardialinfarction. Small left pleural effusion, retrocardiac atelectasis. Prior cholecystectomy. There is marked hepatomegaly, with ascites. Underlying rightbundle-branch block and left anterior fascicular block with secondaryST-T wave abnormalities. FINDINGS: There are bilateral pleural effusions and adjacent atelectasis. REASON FOR THIS EXAMINATION: Please eval for hepatic or portal vein thrombosis with dopplers. REASON FOR THIS EXAMINATION: Please eval for hepatic or portal vein thrombosis with dopplers. There is prominence of the retrobulbar fat with proptosis bilaterally. Bactrim for l lower extrem skin tear last wk. CV: Distant heart sounds Pulm: Rhonchorous breathsounds bilaterally Abd: S/NT, +BS. Bilateral proptosis. Abd grossly distended with hepatomegaly. - RUQ U/S shows normal flow in the hepatic vein, but sludging in the intrahepatic and portal vein that cannot be ruled out as due to partial thrombus. Sinus tachycardia with right bundle-branch block. Sinus tachycardia with right bundle-branch block. There is mild prominence of the ventricles consistent with atrophy. Sluggish portal flow throughout the intrahepatic portal veins and main portal vein. - Monitor platelets TID - Monitor for signs of bleeding - DIC work-up as above # Elevated lipase: Ischemia versus drug induced, gallstones less likely - IVF - Continue to monitor # Diarrhea: Likely having loose stools in the setting of lactulose, but has been hospitalized on ABX and has elevated WBC - C.diff ordered # FEN: NPO, replete lytes, IVF # Code: Currently full code. Cannot exclude inferior myocardial infarction. Shock - on multiple pressors with persistent hypotension, minimal urine output despite > 12 liters positive 4.Hypoglycemia with Obtundation On D5, given D50 in ED 5.OSA not currently relevant on Vent 6. RUQ Echo - sludging in hepatic veins Allergies: Penicillins Unknown; Cephalosporins Unknown; Last dose of Antibiotics: Metronidazole - 01:00 AM Aztreonam - 02:00 AM Infusions: Vasopressin - 2.4 units/hour Other ICU medications: Other medications: norepinephrine, chlorhexidine, aztreonam, hydrocort Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 09:10 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38.2C (100.7 Tcurrent: 38.2C (100.7 HR: 124 (114 - 130) bpm BP: 100/55(65) {79/39(50) - 131/94(97)} mmHg RR: 23 (15 - 23) insp/min SpO2: 99% Heart rhythm: AF (Atrial Fibrillation), LBBB (Left Bundle Branch Block) CVP: 11 (-5 - 16)mmHg Total In: 11,268 mL 2,753 mL PO: TF: IVF: 4,708 mL 2,753 mL Blood products: Total out: 412 mL 118 mL Urine: 412 mL 118 mL NG: Stool: Drains: Balance: 10,856 mL 2,635 mL Respiratory support O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 550 (550 - 550) mL RR (Set): 24 RR (Spontaneous): 0 PEEP: 5 cmH2O FiO2: 50% RSBI Deferred: Hemodynamic Instability PIP: 19 cmH2O Plateau: 18 cmH2O SpO2: 99% ABG: 7.12/49/50/15/-13 - VBG Ve: 11.7 L/min PaO2 / FiO2: 100 Physical Examination General Appearance: Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Distant) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Rhonchorous: ) Abdominal: Distended, Tender: , Obese, hepatomegaly Extremities: Right: 1+, Left: 2+ Skin: Cool Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated, Tone: Not assessed Labs / Radiology 13.2 g/dL 76 K/uL 200 mg/dL 2.0 mg/dL 15 mEq/L 5.6 mEq/L 64 mg/dL 107 mEq/L 134 mEq/L 42.1 % 16.4 K/uL [image002.jpg] 04:30 PM 04:47 PM 07:22 PM 11:48 PM 12:34 AM 05:18 AM WBC 17.9 16.7 16.4 Hct 41.8 39.9 42.1 Plt 79 75 76 Cr 1.8 2.3 2.0 2.0 TropT 0.10 TCO2 17 Glucose 101 436 136 200 Other labs: PT / PTT / INR:29.9/83.6/3.1, CK / CKMB / Troponin-T:559/18/0.10, ALT / AST:, Alk Phos / T Bili:228/11.0, Amylase / Lipase:107/169, Differential-Neuts:90.0 %, Band:3.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:252 mg/dL, Lactic Acid:4.5 mmol/L, Albumin:1.8 g/dL, LDH:2630 IU/L, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL Imaging: CXR shows increasing vasc congestion Assessment and Plan 1.Respiratory Failure secondary to near arrest from low glucose Continue on CMV for the time being. She was hypotensive was briefly on peripheral dopamine and an emergent femoral line was placed and she was started on levophed. She became thrombocytopenic the day prior to transfer and heparin was d/c'd give concern for HIT. afib versus flutter with 2:1 block - check TSH, free T4 - continue digoxin after recheck level in AM - if unstable, consider cardioversion but at risk given she has been in afib for some time # AG metabolic acidosis and respiratory acidosis: Likely secondary to renal failure, lactic acidosis and respiratory failure in the setting of a hypoglycemia episode with compromised mental status - Check ABG if can obtain and try to place A line - If not, will monitor VBGs - Increase RR to correct acidemia, consider HCO3 of cannot get pH <7.2 - Monitor lactate # Coagulopathy: Likley related to liver failure and possibly DIC given elevated PT and PTT. Immediately intubated for resp failure, received 1 amp D50, 1 amp bicarb, femoral line placed then became hypotensive which was unresponsive to aggressive fluid resuscitation, started on levophed and broad spec abx . Immediately intubated for resp failure, received 1 amp D50, 1 amp bicarb, femoral line placed then became hypotensive which was unresponsive to aggressive fluid resuscitation, started on levophed and broad spec abx . Immediately intubated for resp failure, received 1 amp D50, 1 amp bicarb, femoral line placed then became hypotensive which was unresponsive to aggressive fluid resuscitation, started on levophed and broad spec abx . Immediately intubated for resp failure, received 1 amp D50, 1 amp bicarb, femoral line placed then became hypotensive which was unresponsive to aggressive fluid resuscitation, started on levophed and broad spec abx . In - ERCP planned, cleared by Cards, noted to be in afib at outset of procedure - aborted, tx'd with amiodarone and dilt and digoxin added. In - ERCP planned, cleared by Cards, noted to be in afib at outset of procedure - aborted, tx'd with amiodarone and dilt and digoxin added. In - ERCP planned, cleared by Cards, noted to be in afib at outset of procedure - aborted, tx'd with amiodarone and dilt and digoxin added. In - ERCP planned, cleared by Cards, noted to be in afib at outset of procedure - aborted, tx'd with amiodarone and dilt and digoxin added. Hep d/c'd for thrombocytopenia. Hep d/c'd for thrombocytopenia. Hep d/c'd for thrombocytopenia. Hep d/c'd for thrombocytopenia. Vasopressin was added, but patient continud to be hypotensive. | 30 | [
{
"category": "Physician ",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 329419,
"text": "Chief Complaint: 64 yr female DM, HBP, Fulminant Hepatic Failure,\n respiratory failure\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n afib with rvr, arrest upon arrival in ED with glucose 25\n 24 Hour Events:\n MULTI LUMEN - START 03:30 PM\n placed in EW emergently\n PICC LINE - START 04:00 PM\n Worsening liver failure with increasing bili, transaminases, requiring\n increasing doses of pressors (Levo/Vasopressin)\n Worsening coagulopathy.\n RUQ Echo - sludging in hepatic veins\n Allergies:\n Penicillins\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 01:00 AM\n Aztreonam - 02:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Other medications:\n norepinephrine, chlorhexidine, aztreonam, hydrocort\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 124 (114 - 130) bpm\n BP: 100/55(65) {79/39(50) - 131/94(97)} mmHg\n RR: 23 (15 - 23) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation), LBBB (Left Bundle Branch Block)\n CVP: 11 (-5 - 16)mmHg\n Total In:\n 11,268 mL\n 2,753 mL\n PO:\n TF:\n IVF:\n 4,708 mL\n 2,753 mL\n Blood products:\n Total out:\n 412 mL\n 118 mL\n Urine:\n 412 mL\n 118 mL\n NG:\n Stool:\n Drains:\n Balance:\n 10,856 mL\n 2,635 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 19 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.12/49/50/15/-13 - VBG\n Ve: 11.7 L/min\n PaO2 / FiO2: 100\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: Distended, Tender: , Obese, hepatomegaly\n Extremities: Right: 1+, Left: 2+\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 13.2 g/dL\n 76 K/uL\n 200 mg/dL\n 2.0 mg/dL\n 15 mEq/L\n 5.6 mEq/L\n 64 mg/dL\n 107 mEq/L\n 134 mEq/L\n 42.1 %\n 16.4 K/uL\n [image002.jpg]\n 04:30 PM\n 04:47 PM\n 07:22 PM\n 11:48 PM\n 12:34 AM\n 05:18 AM\n WBC\n 17.9\n 16.7\n 16.4\n Hct\n 41.8\n 39.9\n 42.1\n Plt\n 79\n 75\n 76\n Cr\n 1.8\n 2.3\n 2.0\n 2.0\n TropT\n 0.10\n TCO2\n 17\n Glucose\n 101\n 436\n 136\n 200\n Other labs: PT / PTT / INR:29.9/83.6/3.1, CK / CKMB /\n Troponin-T:559/18/0.10, ALT / AST:, Alk Phos / T Bili:228/11.0,\n Amylase / Lipase:107/169, Differential-Neuts:90.0 %, Band:3.0 %,\n Lymph:3.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:252 mg/dL, Lactic\n Acid:4.5 mmol/L, Albumin:1.8 g/dL, LDH:2630 IU/L, Ca++:7.0 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR shows increasing vasc congestion\n Assessment and Plan\n 1.Respiratory Failure\n secondary to near arrest from low glucose\n Continue on CMV for the time being. Worsening hepatic\n dysfunction makes prospects of weaning poor\n 2.Hepatic failure - ? Hepatic Vein Thrombosis, Acute Hepatitis, Drug\n Toxicity (On Bactim, Tylenol)\n Etiology still unclear, but worsening in fulminant manner\n Limited therapeutic options, will ask transplant to evaluate\n Very low albumin\n 3. Shock - on multiple pressors with persistent hypotension, minimal\n urine output despite > 12 liters positive\n 4.Hypoglycemia with Obtundation\n On D5, given D50 in ED\n 5.OSA\n not currently relevant on Vent\n 6. Afib with RVR\n on Amiodarone, digoxin with rate still elevated\n 7.? Thyroid dysfunction (on Amio)\n will send TFT\n 8. Coagulopathy - from hepatic failure, replacing factors\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:30 PM\n PICC Line - 04:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 329413,
"text": "Chief Complaint: Hypoglycemia and unresponsiveness\n 24 Hour Events:\n - Remains hypotensive, continued to receive fluid boluses and maxed out\n on levophed (although hands and feet are colder than on admission).\n Started vaso. Received 6L (ED) + 5 L (4 L NSS, 1 L NaHCO3). Added\n stress dose steroids and albumin.\n - RUQ U/S showed normal hepatic vein flow but sludging in the\n intrahepatic and portal vein, suggesting that their might be a partial\n thrombus. Transaminitis worsened overnight to ALT 1105 AST 1899, Tbili\n 13\n - CK elevated to 697 with MB 18 and trp of 0.10. Discussed with cards\n fellow, who thinks that she is in A flutter\n - Could not get art line last night. Will receive FFP tomorrow AM and\n get a new central line so that the femoral can be pulled\n - Oliguric at ~12cc/hour.\n - Family alerted of condition and plan to come in for discussion this\n AM.\n Allergies:\n Penicillins\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 01:00 AM\n Aztreonam - 02:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged from previous\n patient intubated and\n sedated\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.4\n HR: 114 (114 - 130) bpm\n BP: 89/45(55) {79/39(50) - 131/94(97)} mmHg\n RR: 21 (15 - 23) insp/min\n SpO2: 97%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n CVP: 11 (-5 - 16)mmHg\n Total In:\n 11,268 mL\n 2,661 mL\n PO:\n TF:\n IVF:\n 4,708 mL\n 2,661 mL\n Blood products:\n Total out:\n 412 mL\n 88 mL\n Urine:\n 412 mL\n 88 mL\n NG:\n Stool:\n Drains:\n Balance:\n 10,856 mL\n 2,573 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 22\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.12/49/50/15/-13\n Ve: 12.3 L/min\n PaO2 / FiO2: 100\n Physical Examination\n Gen: Sedated\n HEENT: Scleral icterus and edema. NCAT. ET in place.\n CV: Distant heart sounds\n Pulm: Rhonchorous breathsounds bilaterally\n Abd: S/NT, +BS. Abd grossly distended with hepatomegaly.\n Ext: 1+ edema BL, chronic venous stasis skin changes LE bilaterally,\n 3x4 ulceration on medial aspect of right leg.\n Skin: Jaundice\n Neuro: Sedated and unresponsive.\n Labs / Radiology\n 76 K/uL\n 13.2 g/dL\n 200 mg/dL\n 2.0 mg/dL\n 15 mEq/L\n 5.6 mEq/L\n 64 mg/dL\n 107 mEq/L\n 134 mEq/L\n 42.1 %\n 16.7 K/uL\n [image002.jpg]\n 04:30 PM\n 04:47 PM\n 07:22 PM\n 11:48 PM\n 12:34 AM\n 05:18 AM\n WBC\n 17.9\n 16.7\n Hct\n 41.8\n 39.9\n 42.1\n Plt\n 79\n 75\n 76\n Cr\n 1.8\n 2.3\n 2.0\n TropT\n 0.10\n TCO2\n 17\n Glucose\n 101\n 436\n 136\n 200\n Other labs: PT / PTT / INR:29.9/83.6/3.1, CK / CKMB /\n Troponin-T:559/18/0.10, ALT / AST:, Alk Phos / T Bili:228/11.0,\n Amylase / Lipase:107/169, Differential-Neuts:84.4 %, Band:0.0 %,\n Lymph:10.4 %, Mono:4.3 %, Eos:0.1 %, Fibrinogen:252 mg/dL, Lactic\n Acid:4.5 mmol/L, Albumin:1.8 g/dL, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n A/64 yo female transferred from OSH for evaluation of hepatitis who\n presents with hypoglycemia, shock, liver failure, coagulopathy, and\n renal failure.\n P/\n # Shock: Remained hypotensive overnight after receiving 12L fluid since\n admission. Vasopressin was added, but patient continud to be\n hypotensive. Stress dose steroids started this AM.\n - Continue with IVF boluses, including albumin\n - Has femoral line, but should be changed after correction of coags\n with FFP\n - Currently on levophed and vasopressin and hydrocortisone.\n - follow-up blood and urine cultures\n - Check echocardiogram to rule out new wall motion abnormality or right\n heart strain\n - CK 697, MB 18, trp 0.10 overnight likely due to demand and increased\n cardiac stress.\n # Hypoglycemia: Likely secondary to liver failure. Was receiving\n insulin at OSH and may be slow to clear given renal failure.\n - Hold insulin\n - Accuchecks in the 90s.\n - Q4 hour accuechkcs\n - If FS increased, add ISS.\n # Hepatitis/liver failure: Transaminases increased significantly,\n likely due to shocked liver. Possible etiologies of underlying\n transaminitis include liver failure secondary to bactrim toxicity,\n viral hepatitis, autoimmune hepatitis, portal vein thrombosis, or\n Budd-Chiari.\n - RUQ U/S shows normal flow in the hepatic vein, but sludging in the\n intrahepatic and portal vein that cannot be ruled out as due to partial\n thrombus.\n - Hep A,B,C serologies, , AMA, ceruloplasmin, iron studies to r/o\n hemochromatosis (unlikely), alpha-1 antitrypsin\n - continue lactulose\n - Monitor coags and for signs of bleeding\n - Have discussed with hepatology team, who will see in the AM\n - If stabilizes, consider liver biopsy\n # Acute renal failure and oliguria: Likely prerenal in the setting of\n shock versus hepatorenal\n - Albumin\n - Keep MAPS>60\n - UOP>50 cc/hr\n - Continue to monitor potassium\n # Hyperkalemia: potassium was 6.7 on admission likely in the setting of\n acidemia and renal failure\n - Last K was 5.5\n - Will continue to monitor K Q6H.\n - consider kayexalate if potassium >5.5 or if ECG changes\n # Afib: on digoxin with level of 2.0. Has rates in 110s-120s with ECG ?\n afib versus flutter with 2:1 block\n - TSH, free T4 pending\n - continue digoxin after recheck level in AM\n - Consider cardioversion if patient remains hemodynamically unstable\n # AG metabolic acidosis and respiratory acidosis: Likely secondary to\n renal failure, lactic acidosis and respiratory failure in the setting\n of a hypoglycemia episode with compromised mental status\n - Unable to get ABG\n - Last VBG shows persistent but closing AG metabolic acidosis\n - Maintain RR at 22 to blow of additional CO2.\n # Coagulopathy: Likley related to liver failure and possibly DIC given\n elevated PT and PTT. She was recently on heparin and had been on\n coumadin in the past, but not for sometime, so this is unlikely to have\n an effect. Other meds such as ciprofloxacin can contribute, but giving\n this clinical setting the etiology is most likley liver failure and/or\n DIC\n - Fibrinogen 252, Dimer >4000, cannot rule out DIC.\n - Vitamin K was given on ICU admission with no improvement in coags\n - monitor for signs of bleeding\n - FFP this AM prior to line placement\n # Thrombocytopenia: On admission to the hospital on platelets\n were 110 and now in 80s. Though there was concern for HIT at OSH, there\n was not a 50% drop in platelets after heparin exposure and there are\n numerous other more likely etiologies including hepatic failure,\n sepsis, medications, DIC.\n - Monitor platelets TID\n - Monitor for signs of bleeding\n - DIC work-up as above\n # Elevated lipase: Ischemia versus drug induced, gallstones less likely\n - IVF\n - Continue to monitor\n # Diarrhea: Likely having loose stools in the setting of lactulose, but\n has been hospitalized on ABX and has elevated WBC\n - C.diff ordered\n # FEN: NPO, replete lytes, IVF\n # Code: Currently full code. Family is coming in this morning for\n discussion on code status and treatment goals.\n # Contacts: daughter and sister-in-law\n # Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:30 PM\n PICC Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 329351,
"text": "Chief Complaint: 64 yr old woman with DM, HBP, DVT/PE with IVC Filter,\n Afib w/o anticoag, CAD, PVD now with Resp Failure obstundation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n admit to Hosp with anorexia, weakness x 2 days.\n Hyperglycemia for 10 d PTA with glucose 4-500. Bactrim for l lower\n extrem skin tear last wk. Bili increased to 4.4 with elevated\n transaminases compared to . CXR - cardiomegaly.\n ? Drug v gall stone hepatitis. Creat 2.1.\n In - ERCP planned, cleared by Cards, noted to be in afib at\n outset of procedure - aborted, tx'd with amiodarone and dilt and\n digoxin added. Started on Heparin, empiric Cipro. BUN rose to 52 in\n hospit in conjunction with rising creatinine.\n ALT, AST mildly elevated. Bili however up to 9.0. Transferred for\n further w/u. Profoundly hypoglycemic during transport. Near arrest in\n ED - intubated, emergent fem line, started on levophed.\n Hep d/c'd for thrombocytopenia. HIT antibody pending at OSH. Pulse now\n 110-120.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Insulin, digoxin, oscal, KCL, lactulose, Vancomycin, Aztreonam, tylenol\n prn\n Past medical history:\n Family history:\n Social History:\n Colonic polyps\n OSA\n Cardiac Echo - EF 75%.\n None available\n Occupation: None available\n Drugs: Unknown\n Tobacco: Unknown\n Alcohol: Unknown\n Other:\n Review of systems:\n Flowsheet Data as of 03:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n PEEP: 5 cmH2O\n PIP: 22 cmH2O\n ABG: 7.33/22/74 on RA at OSH\n Ve: 12 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, sceral icterus\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Heart\n normal s1, s2 no murmurs\n Abdominal: Bowel sounds present, Obese, massive heptomegaly, cannot\n feel spleen\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Unable to stand\n Skin: Not assessed, Rash: LE Chronic Stasis\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:4.6 mmol/L\n Fluid analysis / Other labs: Pending\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019558,
"text": " 6:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ET and NG placement.\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hepatitis, ARF, and shock.\n REASON FOR THIS EXAMINATION:\n ET and NG placement.\n ______________________________________________________________________________\n WET READ: 7:54 PM\n ETT 5.5 cm above carina and NG in stomach. Small left effusion and\n retrocardiac atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hepatitis with renal failure and shock, to evaluate for endotracheal\n and nasogastric tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, there is\n increasing prominence of the pulmonary vessels with perihilar haze, consistent\n with elevated pulmonary venous pressure. The reticular opacification is most\n prominent in the right upper lung zone, where it has a somewhat coalescent\n quality, raising the possibility of aspiration.\n\n Endotracheal tube remains well above the carina. Nasogastric tube extends at\n least to the lower body of the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-21 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1019462,
"text": " 11:21 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for acute pathology\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hx hepatitis, gallstones, presents hypotensive, apneic,\n lactate 6, creat > 2\n REASON FOR THIS EXAMINATION:\n eval for acute pathology\n CONTRAINDICATIONS for IV CONTRAST:\n creat\n ______________________________________________________________________________\n WET READ: 12:59 PM\n Limited study due to lack of oral/IV contrast. There is marked hepatomegaly,\n with ascites. Prior cholecystectomy. Diffuse stranding. Slightly thickened\n fluid filled small bowel, with mildly distended colon. No pneumatosis.\n Anasarca.\n bilat. pleural effusions. pericardial effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST:\n\n INDICATION: 64-year-old woman with history of hepatitis, gallstones who\n presents hypertensive and apneic with an elevated lactate and creatinine.\n\n TECHNIQUE: MDCT-acquired contiguous axial images of the abdomen and pelvis\n were obtained without IV contrast due to patient's acute renal failure and\n without oral contrast due to patient's critical clinical condition as\n discussed with Dr. . The patient arms were by her side during\n scanning, limiting evaluation.\n\n FINDINGS: There are bilateral pleural effusions and adjacent atelectasis.\n There are coronary artery calcifications. There is a small pericardial\n effusion. Evaluation of the solid organs is somewhat limited by the lack of IV\n contrast. There are no focal liver lesions. There are clips in the\n gallbladder fossa consistent with prior cholecystectomy. Limited view of the\n pancreas does not show any gross abnormality. The spleen, adrenals, and\n kidneys are normal. There is trace ascites. The NG tube is in the stomach.\n The small bowel is fluid- filled, but appears normal. The large bowel is\n mildly dilated, however, the wall appears thin. There is no mesenteric or\n retroperitoneal adenopathy. The mesentery is normal. There is no free air.\n The IVC filter is in standard position adjacent to the L1-2 vertebrae.\n\n CT PELVIS WITHOUT IV CONTRAST: The rectum and sigmoid colon appear normal.\n There are some calcifications within the uterus consistent with prior\n fibroids. There is a Foley catheter within the bladder. There is no free\n fluid in the pelvis. There is no inguinal or pelvic adenopathy. There is\n anasarca.\n\n MUSCULOSKELETAL: There is degenerative change in the spine.\n\n IMPRESSION:\n (Over)\n\n 11:21 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for acute pathology\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Hepatomegaly with ascites.\n 2. Bilateral pleural effusions. small pericardial effusion.\n 3. No gross abnormality in the bowel, although study is limited by the lack\n of contrast.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-21 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1019531,
"text": " 4:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please eval for hepatic or portal vein thrombosis with doppl\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hepatitis and PE with IVC filter placement now off\n anticoag.\n REASON FOR THIS EXAMINATION:\n Please eval for hepatic or portal vein thrombosis with dopplers.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:48 PM\n PFI: Sluggish portal flow diffusely without occlusive thrombus, though\n difficult to exclude partial thrombus. Normal hepatic vein flow and\n waveforms.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman with hepatitis and pulmonary embolism with IVC\n filter placement, off anticoagulation. Evaluate for hepatic or portal vein\n thrombosis.\n\n COMPARISON: CT abdomen and pelvis without contrast .\n\n FINDINGS: No focal or textural hepatic abnormality is identified. There is\n no intra- or extra-hepatic biliary ductal dilatation. No free fluid is\n identified in the right upper quadrant.\n\n Doppler interrogation of the main, left, and right hepatic veins demonstrates\n normal flow and waveforms. The main hepatic artery also demonstrates normal\n waveform with a peak systolic velocity of 63 cm/s. Although waveforms are\n demonstrable throughout the intrahepatic portal system and main portal vein,\n portal flow is quite sluggish. Evaluation of the midline structures and portal\n vasculature is limited due to difficult son penetration.\n\n IMPRESSION:\n 1. Sluggish portal flow throughout the intrahepatic portal veins and main\n portal vein. Difficult to exclude non-occlusive thrombus though there is no\n evidence for occlusive thrombus.\n 2. Normal hepatic vein flow and waveforms.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-21 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1019532,
"text": ", D. MED 4:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please eval for hepatic or portal vein thrombosis with doppl\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hepatitis and PE with IVC filter placement now off\n anticoag.\n REASON FOR THIS EXAMINATION:\n Please eval for hepatic or portal vein thrombosis with dopplers.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Sluggish portal flow diffusely without occlusive thrombus, though\n difficult to exclude partial thrombus. Normal hepatic vein flow and\n waveforms.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019450,
"text": " 10:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate? ett plaacement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with unresponsiveness hypotension\n REASON FOR THIS EXAMINATION:\n infiltrate? ett plaacement?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST:\n\n INDICATION: 64-year-old woman with unresponsiveness and hypertension,\n ?infiltrate and check ET tube placement.\n\n COMPARISON: None available.\n\n FINDINGS: The ET tube is 5.3 cm from the carina. The left-sided PICC line\n tip projects over the expected course of the mid SVC. Retrocardiac\n atelectasis without evidence of pneumonia or CHF. There is a small left\n pleural effusion. The cardiomediastinal silhouette is normal.\n\n IMPRESSION: Line and tube in appropriate position. Small left pleural\n effusion, retrocardiac atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-06-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1019474,
"text": " 12:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ich, mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with change in MS\n REASON FOR THIS EXAMINATION:\n eval for ich, mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:29 PM\n No ICH or infarct. MRI is more sensitive for evaluation of acute ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n INDICATION: 64-year-old woman with change in mental status, evaluate for\n intracranial hemorrhage or mass.\n\n TECHNIQUE: MDCT-acquired contiguous axial images of the head were obtained\n without IV contrast.\n\n COMPARISON: None available.\n\n FINDINGS: There is no acute intracranial hemorrhage, vascular territorial\n infarct, mass effect, or edema. Small vessel ischemic disease is identified.\n There is mild prominence of the ventricles consistent with atrophy. There are\n no fractures. There is mild mucosal thickening in the ethmoids. An NG tube\n and ET tube are noted. There is prominence of the retrobulbar fat with\n proptosis bilaterally.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage or infarct.\n 2. Bilateral proptosis.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Report",
"row_id": 221322,
"text": "Atrial fibrillation with rapid ventricular response. Right bundle-branch\nblock. Left anterior fascicular block. Possible prior inferior myocardial\ninfarction. Compared to tracing #3 atrial fibrillation is new.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Report",
"row_id": 221323,
"text": "Sinus tachycardia with right bundle-branch block. Left anterior fascicular\nblock. Cannot exclude inferior myocardial infarction. Compared to tracing #2\nno diagnostic interval change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Report",
"row_id": 221324,
"text": "Sinus tachycardia with right bundle-branch block. Left anterior fascicular\nblock. Compared to tracing #1 atrial fibrillation has been replaced with\nsinus tachycardia.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Report",
"row_id": 221325,
"text": "Atrial fibrillation with controlled ventricular response. Underlying right\nbundle-branch block and left anterior fascicular block with secondary\nST-T wave abnormalities. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Nutrition",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 329441,
"text": "Comments:\n Noted patient will be transitioned to CMO once the rest of the family\n arrive. Will sign off at this time.\n"
},
{
"category": "Social Work",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 329442,
"text": "Family Information\n Health Care Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record, (), the daughter who is HCP will\n bring in copy\n Family Spokesperson designated: ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: No\n Past psychiatric history: None known\n Past addictions history: None known\n Employment status: Retired\n Legal involvement: None known\n Mandated Reporting Information: No\n Additional Information:\n Patient / Family Assessment: This worker met with five of the pt's\n eight children (two will soon arrive for NY; there is a sis in MH who\n will not be coming at this time) in addition to Ms. \ns sister.\n The family is feeling numb because of the acute change in their mo's\n status--she had been doing well a week ago-- and the death of their fa\n , after having been ill with lung CA for a number of years. Pt\n having no appetite and having lost a few pounds, so she drove herself\n to . The family transferred pt yesterday\n because of their concern, and apparently her's as well, re the quality\n of her medical care. The issue of Ms. not having been given an\n IV until 24 hours after a family member had request one and a son not\n having seen a doctor during his four hour visit and it having taken a\n nurse 10 minutes to come to the pt's room. (This writer tried to\n educate them about the demands on healthcare providers and that unless\n there is a need, that doctors often AM.) The family is on\n agreement with their mo receiving CMO but do not want to make that\n decision until all family members have had an opportunity to talk\n further. The family have spoken to and made arrangements with an\n undertaker at Brown Funeral Home on St.,\n . It appears at this time that the family is coping as well\n as one might expect given the loss of their fa and the seriousness of\n their mo\ns illness.\n Clergy Contact: Name: Rev. , Phone: , Date\n contact: \n cation with Team:\n Primary Nurse: \n Plan / Follow up:\n 1. Family was informed of the availability of this worker should\n they want to talk further.\n 2. Meet with family tomorrow to assess their psychosocial\n functioining.\n"
},
{
"category": "Social Work",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 329444,
"text": "Family Information\n Health Care Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record. (), the daughter who is HCP will\n bring in copy.\n Family Spokesperson designated: ()\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: No\n Past psychiatric history: None known\n Past addictions history: None known\n Employment status: Retired\n Legal involvement: None known\n Mandated Reporting Information: No\n Additional Information:\n Patient / Family Assessment: This worker met with five of the pt's\n eight children (two will soon arrive from NY; there is a sis in MH who\n will not be coming at this time) in addition to Ms. \ns sister.\n The family is feeling numb because of the acute change in their mo's\n status--she had been doing well until a week ago--and the death of\n their fa after having been ill with lung CA for a number of\n years. Pt having no appetite and having lost a few pounds, drove\n herself to . The family transferred pt\n yesterday because of their concern, and apparently her's as well, re\n the quality of her medical care. The issues that precipitated the\n transfer was pt not having been given an IV until 24 hours after a\n family member had request one and a son not having seen a doctor during\n his four hour visit and it having taken a nurse 10 minutes to come to\n the pt's room. (This writer tried to educate them about the demands on\n healthcare providers and that unless there is a need, that doctors\n often AM. Their reaction was most likely in response to\n their anxiety re their mo\ns failing health.) The family is on agreement\n with their mo receiving CMO but do not want to make that decision until\n all family members have had an opportunity to talk further. The family\n have spoken to and made arrangements with an undertaker at Brown\n Funeral Home on St., . It appears at\n this time that the family is coping as well as one might expect given\n the loss of their fa and the seriousness of their mo\ns illness.\n Clergy Contact: Name: Rev. , Phone: , Date\n contact: \n cation with Team:\n Primary Nurse: \n Plan / Follow up:\n 1. Family was informed of the availability of this worker should\n they want to talk further.\n 2. Meet with family tomorrow to assess their psychosocial\n functioining.\n"
},
{
"category": "Physician ",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 329427,
"text": "Chief Complaint: Hypoglycemia and unresponsiveness\n 24 Hour Events:\n - Remains hypotensive, continued to receive fluid boluses and maxed out\n on levophed (although hands and feet are colder than on admission).\n Started vaso. Received 6L (ED) + 5 L (4 L NSS, 1 L NaHCO3). Added\n stress dose steroids and albumin.\n - RUQ U/S showed normal hepatic vein flow but sludging in the\n intrahepatic and portal vein, suggesting that their might be a partial\n thrombus. Transaminitis worsened overnight to ALT 1105 AST 1899, Tbili\n 13\n - CK elevated to 697 with MB 18 and trp of 0.10. Discussed with cards\n fellow, who thinks that she is in A flutter\n - Could not get art line last night. Will receive FFP tomorrow AM and\n get a new central line so that the femoral can be pulled\n - Oliguric at ~12cc/hour.\n - Family alerted of condition. After discussion with family this AM,\n patient was made DNR with plan to make CMO once remaining family\n members arrive later today.\n Allergies:\n Penicillins\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 01:00 AM\n Aztreonam - 02:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged from previous\n patient intubated and\n sedated\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.4\n HR: 114 (114 - 130) bpm\n BP: 89/45(55) {79/39(50) - 131/94(97)} mmHg\n RR: 21 (15 - 23) insp/min\n SpO2: 97%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n CVP: 11 (-5 - 16)mmHg\n Total In:\n 11,268 mL\n 2,661 mL\n PO:\n TF:\n IVF:\n 4,708 mL\n 2,661 mL\n Blood products:\n Total out:\n 412 mL\n 88 mL\n Urine:\n 412 mL\n 88 mL\n NG:\n Stool:\n Drains:\n Balance:\n 10,856 mL\n 2,573 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 22\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.12/49/50/15/-13\n Ve: 12.3 L/min\n PaO2 / FiO2: 100\n Physical Examination\n Gen: Sedated\n HEENT: Scleral icterus and conjunctival edema. NCAT. ET in place.\n CV: Distant heart sounds\n Pulm: Rhonchorous breathsounds bilaterally\n Abd: S/NT, +BS. Abd grossly distended with hepatomegaly.\n Ext: 1+ edema BL, chronic venous stasis skin changes LE bilaterally,\n 3x4 ulceration on medial aspect of right leg.\n Skin: Jaundice\n Neuro: Sedated and unresponsive.\n Labs / Radiology\n 76 K/uL\n 13.2 g/dL\n 200 mg/dL\n 2.0 mg/dL\n 15 mEq/L\n 5.6 mEq/L\n 64 mg/dL\n 107 mEq/L\n 134 mEq/L\n 42.1 %\n 16.7 K/uL\n [image002.jpg]\n 04:30 PM\n 04:47 PM\n 07:22 PM\n 11:48 PM\n 12:34 AM\n 05:18 AM\n WBC\n 17.9\n 16.7\n Hct\n 41.8\n 39.9\n 42.1\n Plt\n 79\n 75\n 76\n Cr\n 1.8\n 2.3\n 2.0\n TropT\n 0.10\n TCO2\n 17\n Glucose\n 101\n 436\n 136\n 200\n Other labs: PT / PTT / INR:29.9/83.6/3.1, CK / CKMB /\n Troponin-T:559/18/0.10, ALT / AST:, Alk Phos / T Bili:228/11.0,\n Amylase / Lipase:107/169, Differential-Neuts:84.4 %, Band:0.0 %,\n Lymph:10.4 %, Mono:4.3 %, Eos:0.1 %, Fibrinogen:252 mg/dL, Lactic\n Acid:4.5 mmol/L, Albumin:1.8 g/dL, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n A/64 yo female transferred from OSH for evaluation of hepatitis who\n presents with hypoglycemia, shock, liver failure, coagulopathy, and\n renal failure.\n P/\n # Shock: Remained hypotensive overnight after receiving 12L fluid since\n admission. Vasopressin was added, but patient continud to be\n hypotensive. Stress dose steroids started this AM.\n - Continue with IVF boluses, including albumin\n - Will hold off on FFP and line replacement give patient\ns code status.\n - Currently on levophed and vasopressin and hydrocortisone.\n - follow-up blood and urine cultures\n - Will hold off on echo given patient\ns code status.\n - CK 697, MB 18, trp 0.10 overnight likely due to demand and increased\n cardiac stress.\n # Hypoglycemia: Likely secondary to liver failure. Was receiving\n insulin at OSH and may be slow to clear given renal failure.\n - Hold insulin\n - Accuchecks in the 90s.\n - Q4 hour accuechkcs\n - If FS increased, add ISS.\n # Hepatitis/liver failure: Transaminases increased significantly,\n likely due to shocked liver. Possible etiologies of underlying\n transaminitis include liver failure secondary to bactrim toxicity,\n viral hepatitis, autoimmune hepatitis, portal vein thrombosis, or\n Budd-Chiari.\n - RUQ U/S shows normal flow in the hepatic vein, but sludging in the\n intrahepatic and portal vein that cannot be ruled out as due to partial\n thrombus.\n - Follow-up with hepatology recs.\n - Hep A,B,C serologies, , AMA, ceruloplasmin, iron studies to r/o\n hemochromatosis (unlikely), alpha-1 antitrypsin\n - continue lactulose\n - Monitor coags and for signs of bleeding\n - Have discussed with hepatology team, who will see in the AM\n - If stabilizes, consider liver biopsy\n # Acute renal failure and oliguria: Likely prerenal in the setting of\n shock versus hepatorenal\n - Keep MAPS>60\n - UOP>50 cc/hr\n - Continue to monitor potassium\n - Urine lytes pending, although this may be of little utility as most\n likely etiologies of ARF are pre-renal azotemia and hepatorenal\n syndrome, both of which would result in a FeNa of <1.\n # Hyperkalemia: potassium was 6.7 on admission likely in the setting of\n acidemia and renal failure\n - Last K was 5.5\n - Will continue to monitor K Q6H.\n - Kayexalate if potassium >5.5 or if ECG changes\n # Afib: on digoxin with level of 2.0. Has rates in 110s-120s with ECG ?\n afib versus flutter with 2:1 block\n - TSH, free T4 pending\n - Digoxin held pending AM level.\n - Consider cardioversion if patient remains hemodynamically unstable\n # AG metabolic acidosis and respiratory acidosis: Likely secondary to\n renal failure, lactic acidosis and respiratory failure in the setting\n of a hypoglycemia episode with compromised mental status\n - Unable to get ABG\n - Last VBG shows persistent AG metabolic acidosis\n - Increase RR to 24 to blow of CO2.\n - Recheck VBG this afternoon.\n # Coagulopathy: Given clinical picture, most likely DIC and/or liver\n failure.\n - Fibrinogen 252, Dimer >4000, cannot rule out DIC. Could also be due\n to liver failure.\n - Vitamin K was given on ICU admission with no improvement in coags\n - monitor for signs of bleeding\n # Elevated lipase: Ischemia versus drug induced, gallstones less likely\n - IVF\n - Continue to monitor\n # Diarrhea: Likely having loose stools in the setting of lactulose, but\n has been hospitalized on ABX and has elevated WBC\n - C.diff ordered\n # FEN: NPO, replete lytes, IVF\n # Code: After discussion with family, patient is currently DNR and will\n be made CMO following arrival of family members this afternoon..\n # Contacts: daughter and sister-in-law\n # Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:30 PM\n PICC Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 329448,
"text": "Comfort care (CMO, Comfort Measures)Met with family this morning, was\n awaiting more family to arrive this afternoon, again spoke with family\n at 330 pm and all were in aggrement that pt should be made cmo\n Assessment:\n Pressors to be stopped\n Action:\n Pressors stopped at 3: on morphin drip at 4 mg/hr, pt\n extubated\n Response:\n 420 pt passed away with family present\n Plan:\n Body to go to morgue\n"
},
{
"category": "Physician ",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 329409,
"text": "Chief Complaint: Hypoglycemia and unresponsiveness\n 24 Hour Events:\n - Remains hypotensive, continued to receive fluid boluses and maxed out\n on levophed (although hands and feet are colder than on admission).\n Started vaso. Received 6L (ED) + 5 L (4 L NSS, 1 L NaHCO3). Added\n stress dose steroids and albumin.\n - RUQ U/S showed normal hepatic vein flow but sludging in the\n intrahepatic and portal vein, suggesting that their might be a partial\n thrombus. Transaminitis worsened overnight to ALT 1105 AST 1899, Tbili\n 13\n - CK elevated to 697 with MB 18 and trp of 0.10. Discussed with cards\n fellow, who thinks that she is in A flutter\n - Could not get art line last night. Will receive FFP tomorrow AM and\n get a new central line so that the femoral can be pulled\n - Oliguric at ~12cc/hour.\n - Family alerted of condition and plan to come in for discussion this\n AM.\n Allergies:\n Penicillins\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 01:00 AM\n Aztreonam - 02:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 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 (99.4\n HR: 114 (114 - 130) bpm\n BP: 89/45(55) {79/39(50) - 131/94(97)} mmHg\n RR: 21 (15 - 23) insp/min\n SpO2: 97%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n CVP: 11 (-5 - 16)mmHg\n Total In:\n 11,268 mL\n 2,661 mL\n PO:\n TF:\n IVF:\n 4,708 mL\n 2,661 mL\n Blood products:\n Total out:\n 412 mL\n 88 mL\n Urine:\n 412 mL\n 88 mL\n NG:\n Stool:\n Drains:\n Balance:\n 10,856 mL\n 2,573 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 22\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.12/49/50/15/-13\n Ve: 12.3 L/min\n PaO2 / FiO2: 100\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 76 K/uL\n 13.2 g/dL\n 200 mg/dL\n 2.0 mg/dL\n 15 mEq/L\n 5.6 mEq/L\n 64 mg/dL\n 107 mEq/L\n 134 mEq/L\n 42.1 %\n 16.7 K/uL\n [image002.jpg]\n 04:30 PM\n 04:47 PM\n 07:22 PM\n 11:48 PM\n 12:34 AM\n 05:18 AM\n WBC\n 17.9\n 16.7\n Hct\n 41.8\n 39.9\n 42.1\n Plt\n 79\n 75\n 76\n Cr\n 1.8\n 2.3\n 2.0\n TropT\n 0.10\n TCO2\n 17\n Glucose\n 101\n 436\n 136\n 200\n Other labs: PT / PTT / INR:29.9/83.6/3.1, CK / CKMB /\n Troponin-T:559/18/0.10, ALT / AST:, Alk Phos / T Bili:228/11.0,\n Amylase / Lipase:107/169, Differential-Neuts:84.4 %, Band:0.0 %,\n Lymph:10.4 %, Mono:4.3 %, Eos:0.1 %, Fibrinogen:252 mg/dL, Lactic\n Acid:4.5 mmol/L, Albumin:1.8 g/dL, Ca++:7.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n A/64 yo female transferred from OSH for evaluation of hepatitis who\n presents with hypoglycemia, shock, liver failure, coagulopathy, and\n renal failure.\n P/\n # Shock: Remained hypotensive overnight after receiving 12L fluid since\n admission. Vasopressin was added, but patient continud to be\n hypotensive. Stress dose steroids started this AM.\n - Continue with IVF boluses, including albumin\n - Has femoral line, but should be changed after correction of coags\n with FFP\n - Currently on levophed and vasopressin and hydrocortisone.\n - follow-up blood and urine cultures\n - Check echocardiogram to rule out new wall motion abnormality or right\n heart strain\n - CK 697, MB 18, trp 0.10 overnight likely due to demand and increased\n cardiac stress.\n # Hypoglycemia: Likely secondary to liver failure. Was receiving\n insulin at OSH and may be slow to clear given renal failure.\n - Hold insulin\n - Accuchecks in the 90s.\n - Q4 hour accuechkcs\n - If FS increased, add ISS.\n # Hepatitis/liver failure: Transaminases increased significantly,\n likely due to shocked liver. Possible etiologies of underlying\n transaminitis include liver failure secondary to bactrim toxicity,\n viral hepatitis, autoimmune hepatitis, portal vein thrombosis, or\n Budd-Chiari.\n - RUQ U/S shows normal flow in the hepatic vein, but sludging in the\n intrahepatic and portal vein that cannot be ruled out as due to partial\n thrombus.\n - Hep A,B,C serologies, , AMA, ceruloplasmin, iron studies to r/o\n hemochromatosis (unlikely), alpha-1 antitrypsin\n - continue lactulose\n - Monitor coags and for signs of bleeding\n - Have discussed with hepatology team, who will see in the AM\n - If stabilizes, consider liver biopsy\n # Acute renal failure and oliguria: Likely prerenal in the setting of\n shock versus hepatorenal\n - Albumin\n - Keep MAPS>60\n - UOP>50 cc/hr\n - Continue to monitor potassium\n # Hyperkalemia: potassium was 6.7 on admission likely in the setting of\n acidemia and renal failure\n - Last K was 5.5\n - Will continue to monitor K Q6H.\n - consider kayexalate if potassium >5.5 or if ECG changes\n # Afib: on digoxin with level of 2.0. Has rates in 110s-120s with ECG ?\n afib versus flutter with 2:1 block\n - TSH, free T4 pending\n - continue digoxin after recheck level in AM\n - Consider cardioversion if patient remains hemodynamically unstable\n # AG metabolic acidosis and respiratory acidosis: Likely secondary to\n renal failure, lactic acidosis and respiratory failure in the setting\n of a hypoglycemia episode with compromised mental status\n - Unable to get ABG\n - Last VBG shows persistent but closing AG metabolic acidosis\n - Maintain RR at 22 to blow of additional CO2.\n # Coagulopathy: Likley related to liver failure and possibly DIC given\n elevated PT and PTT. She was recently on heparin and had been on\n coumadin in the past, but not for sometime, so this is unlikely to have\n an effect. Other meds such as ciprofloxacin can contribute, but giving\n this clinical setting the etiology is most likley liver failure and/or\n DIC\n - Fibrinogen 252, Dimer >4000, cannot rule out DIC.\n - Vitamin K was given on ICU admission with no improvement in coags\n - monitor for signs of bleeding\n - FFP this AM prior to line placement\n # Thrombocytopenia: On admission to the hospital on platelets\n were 110 and now in 80s. Though there was concern for HIT at OSH, there\n was not a 50% drop in platelets after heparin exposure and there are\n numerous other more likely etiologies including hepatic failure,\n sepsis, medications, DIC.\n - Monitor platelets TID\n - Monitor for signs of bleeding\n - DIC work-up as above\n # Elevated lipase: Ischemia versus drug induced, gallstones less likely\n - IVF\n - Continue to monitor\n # Diarrhea: Likely having loose stools in the setting of lactulose, but\n has been hospitalized on ABX and has elevated WBC\n - C.diff ordered\n # FEN: NPO, replete lytes, IVF\n # Code: Currently full code. Family is coming in this morning for\n discussion on code status and treatment goals.\n # Contacts: daughter and sister-in-law\n # Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:30 PM\n PICC Line - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 329400,
"text": "54 yo F with ho DM2, HTN, PVD, OSA, aortic stenosis (1.2 cm), h/o PE\n s/p IVC filter, admitted on to with anorexia\n and weakness x 2days. 2-3 weeks prior to admission was started on\n bactrim for possible LE cellulitis. Per her family she had anorexia and\n elevated blood sugars and presented to OSH, where she was admitted.\n She was found to have elvated LFTs which were thought to be \n bactrim. Abdominal US performed which found no evidence of ductal\n dilation or stones, but was started on cipro for possible cholecystitis\n then referred for ERCP for unclear reasons, but procedure aborted due\n to afib with RVR. She was started on heparin and continued on\n amiodarone ,diltiazem ,digoxin. Over the next few days became\n increasingly confused per family report. Transferred to for\n further workup of hepatitis however became unresponsive in the\n ambulance found to be profoundly hypoglycemic w/ a FS of 25.\n On arrival to the ED she was agonally breathing with a thready pulse.\n Immediately intubated for resp failure, received 1 amp D50, 1 amp\n bicarb, femoral line placed then became hypotensive which was\n unresponsive to aggressive fluid resuscitation, started on levophed and\n broad spec abx . CXR found no evidence of PNA. CT abdomen inidicative\n of hepatomegaly, ascites, bilateral pleural effusions, pericardial\n effusion, anasarca and no biliary dilitation. Head CT negative.\n Transferred to the M/SICU for further management.\n Overnight Events:\n - Multiple unsuccessful attempts made to obtain A line\n - PICC line transduced to obtain CVP (found to be approx 13 @ end\n expiration)\n - Received 3 L NS\n - 3 amps sodium bicarb\n - Levophed titrated up and eventually maxed out at .4mcg/kg\n - Vasopressin added\n - Cardiac, hepatic enzymes trended and continue to rise (last AST,ALT\n >1800 & 1100 respectively, up from 600\ns on admission)\n - Family meeting held @ 20:00 (pt remains full code @ this time)\n .H/O acidosis, Metabolic\n Assessment:\n Initially found to be profoundly acidotic VBG pH 7.12,\n Action:\n Received 3 amps Na bicarb, RR increased in attempt to blow of\n additional CO2\n Response:\n Most recent VBG pH7.25\n Plan:\n Cont to monitor, attempt to obtain ABG, consider additional bicarb\n .H/O hepatic failure, fulminant\n Assessment:\n Liver enzymes cont to trend up dramatically\n Action:\n Consult placed\n Response:\n Fulminant liver failure persists\n Plan:\n Liver consult to evaluate pt this AM.\n Family met with team @ 20:00 and expressed the desire for us to remain\n aggressive overnight. In the event hepatology feels no intervention is\n indicated, and pt would not likely return to previous state of health,\n family would opt for comfort measures. Plan for a family meeting\n today to discuss goals of care. HCP is the pts daughter \n (home and cell numbers on board).\n ------ Protected Section ------\n Family notified by resident @ 0600 that the pt has been doing\n progressively worse overnight, family will be coming in early this AM.\n Pt has now been made CPR not indicated.\n Additional 1 L NS bolus currently in progress\n Stress dose steroids/albumin have been ordered but awaiting\n confirmation from pharmacy\n ------ Protected Section Addendum Entered By: , RN\n on: 06:15 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 329388,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Tubular\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Remains intubated and ventilated on a/c mode with severe met.\n Acidosis,unstable hemodynamics\n"
},
{
"category": "Nursing",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 329389,
"text": "54 yo F with ho DM2, HTN, PVD, OSA, aortic stenosis (1.2 cm), h/o PE\n s/p IVC filter, admitted on to with anorexia\n and weakness x 2days. 2-3 weeks prior to admission was started on\n bactrim for possible LE cellulitis. Per her family she had anorexia and\n elevated blood sugars and presented to OSH, where she was admitted.\n She was found to have elvated LFTs which were thought to be \n bactrim. Abdominal US performed which found no evidence of ductal\n dilation or stones, but was started on cipro for possible cholecystitis\n then referred for ERCP for unclear reasons, but procedure aborted due\n to afib with RVR. She was started on heparin and continued on\n amiodarone ,diltiazem ,digoxin. Over the next few days became\n increasingly confused per family report. Transferred to for\n further workup of hepatitis however became unresponsive in the\n ambulance found to be profoundly hypoglycemic w/ a FS of 25.\n On arrival to the ED she was agonally breathing with a thready pulse.\n Immediately intubated for resp failure, received 1 amp D50, 1 amp\n bicarb, femoral line placed then became hypotensive which was\n unresponsive to aggressive fluid resuscitation, started on levophed and\n broad spec abx . CXR found no evidence of PNA. CT abdomen inidicative\n of hepatomegaly, ascites, bilateral pleural effusions, pericardial\n effusion, anasarca and no biliary dilitation. Head CT negative.\n Transferred to the M/SICU for further management.\n Overnight Events:\n - Multiple unsuccessful attempts made to obtain A line\n - Received 3 L NS\n - 3 amps sodium bicarb\n - Levophed titrated up and eventually maxed out at .4mcg/kg\n - Vasopressin added\n - Cardiac, hepatic enzymes trended and continue to rise (last AST,ALT\n >1800 & 1100 respectively, up from 600\ns on admission)\n - Family meeting held @ 20:00 (pt remains full code @ this time)\n .H/O acidosis, Metabolic\n Assessment:\n Initially found to be profoundly acidotic VBG pH 7.12,\n Action:\n Received 3 amps Na bicarb, RR increased in attempt to blow of\n additional CO2\n Response:\n Most recent VBG pH7.25\n Plan:\n Cont to monitor, attempt to obtain ABG, consider additional bicarb\n .H/O hepatic failure, fulminant\n Assessment:\n Liver enzymes cont to trend up dramatically\n Action:\n Consult placed\n Response:\n Fulminant liver failure persists\n Plan:\n Liver consult to evaluate pt this AM.\n Family met with team @ 20:00 and expressed the desire for us to remain\n aggressive overnight. In the event hepatology feels no intervention is\n indicated, and pt would not likely return to previous state of health,\n family would opt for comfort measures. Plan for a family meeting\n today to discuss goals of care. HCP is the pts daughter \n (home and cell numbers on board).\n"
},
{
"category": "Nursing",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 329390,
"text": "54 yo F with ho DM2, HTN, PVD, OSA, aortic stenosis (1.2 cm), h/o PE\n s/p IVC filter, admitted on to with anorexia\n and weakness x 2days. 2-3 weeks prior to admission was started on\n bactrim for possible LE cellulitis. Per her family she had anorexia and\n elevated blood sugars and presented to OSH, where she was admitted.\n She was found to have elvated LFTs which were thought to be \n bactrim. Abdominal US performed which found no evidence of ductal\n dilation or stones, but was started on cipro for possible cholecystitis\n then referred for ERCP for unclear reasons, but procedure aborted due\n to afib with RVR. She was started on heparin and continued on\n amiodarone ,diltiazem ,digoxin. Over the next few days became\n increasingly confused per family report. Transferred to for\n further workup of hepatitis however became unresponsive in the\n ambulance found to be profoundly hypoglycemic w/ a FS of 25.\n On arrival to the ED she was agonally breathing with a thready pulse.\n Immediately intubated for resp failure, received 1 amp D50, 1 amp\n bicarb, femoral line placed then became hypotensive which was\n unresponsive to aggressive fluid resuscitation, started on levophed and\n broad spec abx . CXR found no evidence of PNA. CT abdomen inidicative\n of hepatomegaly, ascites, bilateral pleural effusions, pericardial\n effusion, anasarca and no biliary dilitation. Head CT negative.\n Transferred to the M/SICU for further management.\n Overnight Events:\n - Multiple unsuccessful attempts made to obtain A line\n - PICC line transduced to obtain CVP (found to be approx 13 @ end\n expiration)\n - Received 3 L NS\n - 3 amps sodium bicarb\n - Levophed titrated up and eventually maxed out at .4mcg/kg\n - Vasopressin added\n - Cardiac, hepatic enzymes trended and continue to rise (last AST,ALT\n >1800 & 1100 respectively, up from 600\ns on admission)\n - Family meeting held @ 20:00 (pt remains full code @ this time)\n .H/O acidosis, Metabolic\n Assessment:\n Initially found to be profoundly acidotic VBG pH 7.12,\n Action:\n Received 3 amps Na bicarb, RR increased in attempt to blow of\n additional CO2\n Response:\n Most recent VBG pH7.25\n Plan:\n Cont to monitor, attempt to obtain ABG, consider additional bicarb\n .H/O hepatic failure, fulminant\n Assessment:\n Liver enzymes cont to trend up dramatically\n Action:\n Consult placed\n Response:\n Fulminant liver failure persists\n Plan:\n Liver consult to evaluate pt this AM.\n Family met with team @ 20:00 and expressed the desire for us to remain\n aggressive overnight. In the event hepatology feels no intervention is\n indicated, and pt would not likely return to previous state of health,\n family would opt for comfort measures. Plan for a family meeting\n today to discuss goals of care. HCP is the pts daughter \n (home and cell numbers on board).\n"
},
{
"category": "Nursing",
"chartdate": "2131-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 329391,
"text": "54 yo F with ho DM2, HTN, PVD, OSA, aortic stenosis (1.2 cm), h/o PE\n s/p IVC filter, admitted on to with anorexia\n and weakness x 2days. 2-3 weeks prior to admission was started on\n bactrim for possible LE cellulitis. Per her family she had anorexia and\n elevated blood sugars and presented to OSH, where she was admitted.\n She was found to have elvated LFTs which were thought to be \n bactrim. Abdominal US performed which found no evidence of ductal\n dilation or stones, but was started on cipro for possible cholecystitis\n then referred for ERCP for unclear reasons, but procedure aborted due\n to afib with RVR. She was started on heparin and continued on\n amiodarone ,diltiazem ,digoxin. Over the next few days became\n increasingly confused per family report. Transferred to for\n further workup of hepatitis however became unresponsive in the\n ambulance found to be profoundly hypoglycemic w/ a FS of 25.\n On arrival to the ED she was agonally breathing with a thready pulse.\n Immediately intubated for resp failure, received 1 amp D50, 1 amp\n bicarb, femoral line placed then became hypotensive which was\n unresponsive to aggressive fluid resuscitation, started on levophed and\n broad spec abx . CXR found no evidence of PNA. CT abdomen inidicative\n of hepatomegaly, ascites, bilateral pleural effusions, pericardial\n effusion, anasarca and no biliary dilitation. Head CT negative.\n Transferred to the M/SICU for further management.\n Overnight Events:\n - Multiple unsuccessful attempts made to obtain A line\n - PICC line transduced to obtain CVP (found to be approx 13 @ end\n expiration)\n - Received 3 L NS\n - 3 amps sodium bicarb\n - Levophed titrated up and eventually maxed out at .4mcg/kg\n - Vasopressin added\n - Cardiac, hepatic enzymes trended and continue to rise (last AST,ALT\n >1800 & 1100 respectively, up from 600\ns on admission)\n - Family meeting held @ 20:00 (pt remains full code @ this time)\n .H/O acidosis, Metabolic\n Assessment:\n Initially found to be profoundly acidotic VBG pH 7.12,\n Action:\n Received 3 amps Na bicarb, RR increased in attempt to blow of\n additional CO2\n Response:\n Most recent VBG pH7.25\n Plan:\n Cont to monitor, attempt to obtain ABG, consider additional bicarb\n .H/O hepatic failure, fulminant\n Assessment:\n Liver enzymes cont to trend up dramatically\n Action:\n Consult placed\n Response:\n Fulminant liver failure persists\n Plan:\n Liver consult to evaluate pt this AM.\n Family met with team @ 20:00 and expressed the desire for us to remain\n aggressive overnight. In the event hepatology feels no intervention is\n indicated, and pt would not likely return to previous state of health,\n family would opt for comfort measures. Plan for a family meeting\n today to discuss goals of care. HCP is the pts daughter \n (home and cell numbers on board).\n"
},
{
"category": "Nursing",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 329375,
"text": "64yo woman w/hx of afib, acute renal failure, DM, HTN, CAD< PVD was\n admitted to Hospital w/anorexia, weakness x 2 days.\n Hyperglycemia for 10 d PTA with glucose 4-500. Bactrim for left lower\n extrem skin tear the previous week. Bili increased to 4.4 with elevated\n transaminases compared to . CXR - cardiomegaly.\n ? Drug v gall stone hepatitis. Creat 2.1.\n In - ERCP planned, cleared by Cards, noted to be in afib at\n outset of procedure - aborted, tx'd with amiodarone and dilt and\n digoxin added. Started on Heparin, empiric Cipro. BUN rose to 52 in\n hospital in conjunction with rising creatinine.\n Transferred to for further w/u. Profoundly hypoglycemic during\n transport. Near arrest in ED - intubated, emergent left femoral line,\n started on dopamine for b/p support however, increasing tachycardia and\n switched to levophed.\n Hep d/c'd for thrombocytopenia. HIT antibody pending at OSH. Pulse now\n 110-120 AFib w/BBB and levophed @ .2mcg/kg/min. Receiving IVF boli to\n support b/p. Plan this evening is to place a-line and then have triple\n lumen placed in morning.\n Pt now having moderate amounts diarrhea w/small amt of blood PR. Spec\n to be sent for c-diff but suspect diarrhea from lactulose given for ^\n ammonia @ outside hospital.\n Dtr, and daughter in law, accompanied patient to\n hospital. describes self as HCP however, does not wish\n to be called for up dates on condition. Pt\ns husband died approx 2\n months ago.\n"
},
{
"category": "Physician ",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 329378,
"text": "Chief Complaint: Unresponsiveness, hypoglycemia\n HPI:\n 54 yo F with ho DM2, HTN, PVD, OSA, aortic stenosis (1.2 cm), RBBB/LAFB\n on EKG, PAF, h/o PE s/p IVC filter, adrenal mass, gastric & colonic\n polyps, s/p CCY, admitted on to with anorexia\n and weakness x 2days. In the 10 days prior to admission her FS had\n been in the 500s. Also, about 2-3 weeks prior to admission was started\n on bactrim for possible LE cellulitis. Per her family she had anorexia\n and elevated blood sugars and presented to OSH, where she was\n admitted. She was found to have elvated LFTs which were thought to be\n secondary to bactrim. She had an abdominal US with min ascites but no\n ductal dilation or stones, but was started on cipro for possible\n cholecystitis then referred for ERCP for unclear reasons, but procedure\n aborted due to afib with RVR to 140\ns. She was started on heparin and\n continued her on amiodarone and diltiazem and digoxin was added. She\n became increasingly confused per her family and was started on\n lactulose. In terms of her labs, WBC 14 AST 135, ALT 239, alkphos 154,\n bili 10.7 (trending up from 4.4 on admission), alb 1.7. Creatinine\n range 1.1 to low 2.0s and was trending up prior to transfer. AST and\n ALT remained stable but t bili increased to 10 and lipase 172. She\n became thrombocytopenic the day prior to transfer and heparin was d/c'd\n give concern for HIT. Her HRs 110s-120s. ABG 7.33/22/74 on RA. Was\n switched from cipro to aztreonam and vanco.\n Originally was transferred here for work-up of her hepatitis, then\n became unresponsive in the ambulance and FS found to be 25.\n On arrival to the ED she was agonally breathing with a thready pulse.\n She was given 1 amp of D50 and 1 amp HCO3 and was intubated. She was\n hypotensive was briefly on peripheral dopamine and an emergent femoral\n line was placed and she was started on levophed. An attempt at an\n a-line was made in both radial arteries as well as femoral, but was\n unsuccessful. Her VBG was 7.11/46/107 on AC with unclear settings and\n lactate 6.9. Her ECG showed a RBBB ? afib versus flutter with variable\n block. She was given 5 L NS, 1 liter LR, 2 amps D50, 2 amps HCO3,\n insulin, kayexalate, vancomycin, levofloxacin and flagyl. CXR revealed\n no PNA or CHF, CT abdomen with hepatomegaly, ascites, bilateral pleural\n effusions, pericardial effusion, anasarca and no biliary dilitation. CT\n head was negative. She was transferred to the ICU for further\n management.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Penicillins\n Unknown;\n Cephalosporins\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 07:20 PM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Medications on transfer\n NPH 18 \n Digoxin 125 mcg po qday\n Lacthytrim\n oscal 500 mg Po BID\n lactulose 30 ml Po QID\n vanco 1.5 g IV daily\n aztreonam 1 gram Q12H\n tylenol 650 q4h PRn (received 2 doses)\n Diltiazem ER 180 mg po qday\n Duoneb\n Past medical history:\n Family history:\n Social History:\n DM2\n OSA on CPAP\n aortic stenosis (1.2 cm)\n RBBB/LAFB on EKG\n PAF\n h/o PE s/p IVC filter\n adrenal mass\n gastric & colonic polyps\n s/p CCY\n LE cellulitis\n developed hepatitis while on Bactrim\n PVD\n Echo in with EF 75%\n Father with gastric cancer. No liver disease\n Occupation: retired\n Drugs: none\n Tobacco: quit 10 years ago\n Alcohol: none\n Other: Lives with daughter\n Review of systems:\n Eyes: scleral icterus\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Edema, Tachycardia\n Nutritional Support: NPO\n Gastrointestinal: Diarrhea\n Genitourinary: Foley\n Integumentary (skin): Jaundice\n Flowsheet Data as of 09:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 120 (115 - 124) bpm\n BP: 98/54(63) {79/47(53) - 113/94(97)} mmHg\n RR: 19 (15 - 23) insp/min\n SpO2: 97%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Total In:\n 9,945 mL\n PO:\n TF:\n IVF:\n 3,385 mL\n Blood products:\n Total out:\n 0 mL\n 377 mL\n Urine:\n 377 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 9,568 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 22\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n SpO2: 97%\n ABG: 7.12/49/50/16/-13\n Ve: 13 L/min\n PaO2 / FiO2: 100\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, scleral icterus\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: irregularly irregular\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n hepatomegaly with liver border 4 cm below costal margin\n Extremities: Right: 1+, Left: 1+, venous stasis changes, 3x4 ulceration\n on the medial aspect of right leg\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 79 K/uL\n 13.2 g/dL\n 101 mg/dL\n 59 mg/dL\n 16 mEq/L\n 108 mEq/L\n 5.2 mEq/L\n 137 mEq/L\n 41.8 %\n 17.9 K/uL\n [image002.jpg]\n \n 2:33 A6/26/ 04:30 PM\n \n 10:20 P6/26/ 04:47 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 17.9\n Hct\n 41.8\n Plt\n 79\n TC02\n 17\n Glucose\n 101\n Other labs: PT / PTT / INR:29.6/77.2/3.0, CK / CKMB / Troponin-T:CK:\n 307 MB: 11 MBI: 3.6 trop 0.06, Differential-Neuts:84.4 %, Band:0.0\n %, Lymph:10.4 %, Mono:4.3 %, Eos:0.1 %, Fibrinogen:252 mg/dL, Lactic\n Acid:4.5 mmol/L, Albumin:1.9 g/dL, Ca++:7.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:4.2 mg/dL\n Fluid analysis / Other labs: Color\n Amber Appear\n Hazy SpecGr\n 1.022 pH\n 6.5 Urobil\n 4 Bili\n Mod\n Leuk\n Neg Bld\n Neg Nitr\n Neg Prot\n Neg Glu\n Neg Ket\n Tr\n Imaging: CT abdomen: Limited study due to lack of oral/IV contrast.\n There is marked hepatomegaly, with ascites. Prior cholecystectomy.\n Diffuse stranding. Slightly thickened fluid filled small bowel, with\n mildly distended colon. No pneumatosis. Anasarca. bilat. pleural\n effusions. pericardial effusion.\n CT head: 1. No acute intracranial hemorrhage or infarct.\n 2. Bilateral proptosis\n CXR: Line and tube in appropriate position. Small left pleural\n effusion, retrocardiac atelectasis.\n Microbiology: Blood culturesx2: pending\n Urine culture: pending\n ECG: rhythm regular on some ECG and irregular on others rate 120s, no P\n waves present RBBB, left anteriorfasicular block, a fib versus a\n fluttter with 2:1 block\n Assessment and Plan\n 64 yo female transferred from OSH for evaluation of hepatitis who\n presents with hypoglycemia and agonal breathing s/p intubation with\n shock, liver failure and renal failure\n # Shock: Became hypotensive in the setting of hypoglycemia on down to\n the 60s. BPs in 90s at OSH with HRs in 110s-120s during most of her\n stay. She has had low grade temps at OSH and 99 PR in the ED. Given\n elevated WBC, hypotension, tachycardia would support septic shock. Also\n consider cardiogenic, but less likely. Unlikely MI given negative MD\n index, no ECG changes and troponin only 0.06 in the setting of renal\n failure. Possibly infectious sources include SBP, cholangitis,\n pulmonary (less likely given no CXR finding) or urinary.\n - Bolus with IVF to keep MAP>60 and UOP>50 cc/hr\n - Levophed for now, but try to wean and consider neo if problems with\n tachycardia\n - Has femoral line, but should be changed after correction of coags\n with FFP\n - Place A-line (5 attempts already made), if cannot get A-line or ABG,\n will follow VBG\n - follow-up blood and urine cultures\n - Check echocardiogram to rule out new wall motion abnormality or right\n heart strain\n - r/o MI\n - if stabilizes consider paracentesis\n # Hypoglycemia: Likely secondary to liver failure. Was receiving\n insulin at OSH and may be slow to clear given renal failure.\n - Hold insulin\n - Q1H fingersticks for now, and if stable can do Q3-4H\n - D10 if persistently hypoglycemic\n # Hepatitis/liver failure: ALT: 536 AP: 182 Tbili: 11.8 Alb: 1.9 AST:\n 773 Lip: 502. These are trending up and she is developing a worsening\n coagulopathy. Possible etiologies include bactrim toxicity resulting in\n hepatic failure, NASH with an acute insult from medications, viral\n hepatitis, autoimmune hepatitis, portal vein thrombosis, Budd-chiari,\n or some variation of chronic liver disease with an acute insult from\n bactrim toxicity.\n - RUQ U/S with dopplers to rule out portal vein thrombosis\n - Hep A,B,C serologies, , AMA, ceruloplasmin, iron studies to r/o\n hemochromatosis (unlikely), alpha-1 antitrypsin\n - continue lactulose\n - Monitor coags and for signs of bleeding\n - Liver team to see in AM\n - If stabilizes, consider liver biopsy\n # Acute renal failure: Likely prerenal in the setting of shock versus\n hepatorenal\n - fluid challenge consider albumin\n - Keep MAPS>60\n - UOP>50 cc/hr\n - monitor potassium\n # Hyperkalemia: potassium was 6.7 on admission likely in the setting of\n acidemia and renal failure\n - monitor Q6H potassium\n - continue IVF\n - consider kayexalate if potassium >5.5 or if ECG changes\n # Afib: on digoxin with level of 2.0. Has rates in 110s-120s with ECG ?\n afib versus flutter with 2:1 block\n - check TSH, free T4\n - continue digoxin after recheck level in AM\n - if unstable, consider cardioversion but at risk given she has been in\n afib for some time\n # AG metabolic acidosis and respiratory acidosis: Likely secondary to\n renal failure, lactic acidosis and respiratory failure in the setting\n of a hypoglycemia episode with compromised mental status\n - Check ABG if can obtain and try to place A line\n - If not, will monitor VBGs\n - Increase RR to correct acidemia, consider HCO3 of cannot get pH <7.2\n - Monitor lactate\n # Coagulopathy: Likley related to liver failure and possibly DIC given\n elevated PT and PTT. She was recently on heparin and had been on\n coumadin in the past, but not for sometime, so this is unlikely to have\n an effect. Other meds such as ciprofloxacin can contribute, but giving\n this clinical setting the etiology is most likley liver failure and/or\n DIC\n - check D-dimer, FDP split products, fibrinogen to evaluate for DIC\n - vitamin K to see if any benefit from correcting possible nutritional\n deficiencies\n - monitor for signs of bleeding\n # Thrombocytopenia: On admission to the hospital on platelets\n were 110 and now in 80s. Though there was concern for HIT at OSH, there\n was not a 50% drop in platelets after heparin exposure and there are\n numerous other more likely etiologies including hepatic failure,\n sepsis, medications, DIC.\n - Monitor platelets TID\n - Monitor for signs of bleeding\n - DIC work-up as above\n # Elevated lipase: Ischemia versus drug induced, gallstones less likely\n - IVF as above\n - Continue to monitor\n # Diarrhea: Likely having loose stools in the setting of lactulose, but\n has been hospitalized on ABX and has elevated WBC\n - check c.diff\n # FEN: NPO, replete lytes, IVF\n # Code: Full\n # Contacts: daughter and sister-in-law\n # Dispo: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 03:30 PM\n PICC Line - 04:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: Per family, they would like\n to be aggressive at this point, but if her liver continues to fail they\n would likely want to focus on comfort\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 329374,
"text": "64yo woman w/hx of afib, acute renal failure, DM, HTN, CAD< PVD was\n admitted to Hospital w/anorexia, weakness x 2 days.\n Hyperglycemia for 10 d PTA with glucose 4-500. Bactrim for left lower\n extrem skin tear the previous week. Bili increased to 4.4 with elevated\n transaminases compared to . CXR - cardiomegaly.\n ? Drug v gall stone hepatitis. Creat 2.1.\n In - ERCP planned, cleared by Cards, noted to be in afib at\n outset of procedure - aborted, tx'd with amiodarone and dilt and\n digoxin added. Started on Heparin, empiric Cipro. BUN rose to 52 in\n hospital in conjunction with rising creatinine.\n Transferred to for further w/u. Profoundly hypoglycemic during\n transport. Near arrest in ED - intubated, emergent left femoral line,\n started on dopamine for b/p support however, increasing tachycardia and\n switched to levophed.\n Hep d/c'd for thrombocytopenia. HIT antibody pending at OSH. Pulse now\n 110-120 AFib w/BBB and levophed @ .2mcg/kg/min. Receiving IVF boli to\n support b/p. Plan this evening is to place a-line and then have triple\n lumen placed in morning.\n Pt now having moderate amounts diarrhea w/small amt of blood PR. Spec\n to be sent for c-diff but suspect diarrhea from lactulose given for ^\n ammonia @ outside hospital.\n Dtr, and daughter in law, accompanied patient to\n hospital. describes self as HCP however, does not wish\n to be called for up dates on condition. Pt\ns husband died approx 2\n months ago.\n"
},
{
"category": "Physician ",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 329363,
"text": "Chief Complaint: 64 yr old woman with DM, HBP, DVT/PE with IVC Filter,\n Afib w/o anticoag, CAD, PVD now with Resp Failure obstundation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n admit to Hosp with anorexia, weakness x 2 days.\n Hyperglycemia for 10 d PTA with glucose 4-500. Bactrim for l lower\n extrem skin tear last wk. Bili increased to 4.4 with elevated\n transaminases compared to . CXR - cardiomegaly.\n ? Drug v gall stone hepatitis. Creat 2.1.\n In - ERCP planned, cleared by Cards, noted to be in afib at\n outset of procedure - aborted, tx'd with amiodarone and dilt and\n digoxin added. Started on Heparin, empiric Cipro. BUN rose to 52 in\n hospit in conjunction with rising creatinine.\n ALT, AST mildly elevated. Bili however up to 9.0. Transferred for\n further w/u. Profoundly hypoglycemic during transport. Near arrest in\n ED - intubated, emergent fem line, started on levophed.\n Hep d/c'd for thrombocytopenia. HIT antibody pending at OSH. Pulse now\n 110-120.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Insulin, digoxin, oscal, KCL, lactulose, Vancomycin, Aztreonam, tylenol\n prn\n Past medical history:\n Family history:\n Social History:\n Colonic polyps\n OSA\n Cardiac Echo - EF 75%.\n None available\n Occupation: None available\n Drugs: Unknown\n Tobacco: Unknown\n Alcohol: Unknown\n Other:\n Review of systems: unobtainable patient is comatose on vent\n Flowsheet Data as of 03:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n PEEP: 5 cmH2O\n PIP: 22 cmH2O\n ABG: 7.33/22/74 on RA at OSH\n Ve: 12 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, sceral icterus\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Heart\n normal s1, s2 no murmurs\n Abdominal: Bowel sounds present, Obese, massive heptomegaly, cannot\n feel spleen\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Unable to stand\n Skin: Not assessed, Rash: LE Chronic Stasis\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:4.6 mmol/L\n Fluid analysis / Other labs: Pending\n Assessment and Plan\n Respiratory Failure\n secondary to near arrest from low glucose\n Will likely be extubatable when she wakes from sedation and\n glucose better controlled.\n Continue on CMV for the time being.\n Hepatic failure - ? Hepatic Vein Thrombosis, Acute Hepatitis, Drug\n Toxicity (On Bactim, Tylenol)\n Hypoglycemia with Obtundation\n On D5, given D50 in ED\n OSA\n not currently relevant on Vent\n Afib with RVR\n on Amiodarone, diltiazem, digoxin with rate still\n elevated at 120\n ? Thyroid dysfunction (on Amio)\n will send TFT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n Also has been persistently hypotensive on low dose levophed\n will\n consider change to Neo because of tachycardia if her pressure is not\n volume responsive.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:28 ------\n"
},
{
"category": "Physician ",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 329353,
"text": "Chief Complaint: 64 yr old woman with DM, HBP, DVT/PE with IVC Filter,\n Afib w/o anticoag, CAD, PVD now with Resp Failure obstundation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n admit to Hosp with anorexia, weakness x 2 days.\n Hyperglycemia for 10 d PTA with glucose 4-500. Bactrim for l lower\n extrem skin tear last wk. Bili increased to 4.4 with elevated\n transaminases compared to . CXR - cardiomegaly.\n ? Drug v gall stone hepatitis. Creat 2.1.\n In - ERCP planned, cleared by Cards, noted to be in afib at\n outset of procedure - aborted, tx'd with amiodarone and dilt and\n digoxin added. Started on Heparin, empiric Cipro. BUN rose to 52 in\n hospit in conjunction with rising creatinine.\n ALT, AST mildly elevated. Bili however up to 9.0. Transferred for\n further w/u. Profoundly hypoglycemic during transport. Near arrest in\n ED - intubated, emergent fem line, started on levophed.\n Hep d/c'd for thrombocytopenia. HIT antibody pending at OSH. Pulse now\n 110-120.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Insulin, digoxin, oscal, KCL, lactulose, Vancomycin, Aztreonam, tylenol\n prn\n Past medical history:\n Family history:\n Social History:\n Colonic polyps\n OSA\n Cardiac Echo - EF 75%.\n None available\n Occupation: None available\n Drugs: Unknown\n Tobacco: Unknown\n Alcohol: Unknown\n Other:\n Review of systems: unobtainable patient is comatose on vent\n Flowsheet Data as of 03:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n PEEP: 5 cmH2O\n PIP: 22 cmH2O\n ABG: 7.33/22/74 on RA at OSH\n Ve: 12 L/min\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, sceral icterus\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Heart\n normal s1, s2 no murmurs\n Abdominal: Bowel sounds present, Obese, massive heptomegaly, cannot\n feel spleen\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Unable to stand\n Skin: Not assessed, Rash: LE Chronic Stasis\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:4.6 mmol/L\n Fluid analysis / Other labs: Pending\n Assessment and Plan\n Respiratory Failure\n secondary to near arrest from low glucose\n Will likely be extubatable when she wakes from sedation and\n glucose better controlled.\n Continue on CMV for the time being.\n Hepatic failure - ? Hepatic Vein Thrombosis, Acute Hepatitis, Drug\n Toxicity (On Bactim, Tylenol)\n Hypoglycemia with Obtundation\n On D5, given D50 in ED\n OSA\n not currently relevant on Vent\n Afib with RVR\n on Amiodarone, diltiazem, digoxin with rate still\n elevated at 120\n ? Thyroid dysfunction (on Amio)\n will send TFT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2131-06-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 329354,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt trans form the Ed to east intubated pt was placed on the vent tol\n well. See respiratory page of medivision for more information.\n"
}
] |
73,955 | 149,931 | In summary, Mrs is a 64 year old female with history of mixed cardiomyopathy, VF s/p ICD with ICD shocks, and inducible VT on transferred to the CCU following epicardial VT mapping and ablation procedure. . #. RHYTHM: The patient has a history of polymorphic, monomorphic VT as well as VF. She is now s/p epicardial mapping with ablation which appeared to be sucessful as she had no additional episodes of pacemaker firing while in the hospital. During the procedure she required pressor support and returned to the ICU on pressors, intubated and with pericardial drain in place given that a sternal approach was required for the procedure. After the procedure, the pericardial drain was removed and there was no evidence of further fluid accumulation. Additionally, she was started on propafenone, then transitioned to dronedarone, to help control her arrhythmia as she did have several runs of NSVT as well as afib while on tele in the unit. Afib responded to IV doses of metoprolol and she was in sinus rhythm for the majority of her hospitalization. Digoxin and PO metoprolol were also started for rate control and continued on discharge. Patient refused to take warfarin at discharge and given the stable nature of her condition and the recent pericardial drain placement, it was decided that she will meet with her cardiologist, Dr. , to discuss the use of warfarin in two weeks. . #. PUMP: The patient has a history of a mixed picture of cardiomyopathy with an EF documented at 40% in . TTE on discharge showed resolution of pericardial effusion that persisted after ablation procedure. . # CORONARIES: This admission coronary catheterization shows patency of RCA DES. No other occlusive coronary artery diease was present. She was continued on ASA and plavix, and also starting on a statin on discharge. . # Hypertension: Hx of hypertension prior to admission, however given her hypotension on admission, her home diovan was held. Could restart as an outpatient if needed for BP control. . # Respiratory: The patient was electively intubated for the procedure and general anesthesia however she was able to be extubated one day after the procedure and had no further respiratory issues while in the hospital. . # UTI: on the day of discharge, patient reported foul smelling urine and report that she usually contract UTI after foley placement. UA and Ucx showed evidence of UTI. She was given Bactrium DS and was send home on a 7 day course. Sensitivity were not back at the time of discharge and will require follow up as outpatient. . # Transgender operation: Premarin was held out of concern for increased risk of cardiac disease with high levels of estorgen use. . # Depression: Lexapro continued . # GERD: Zantac continued as an inpatient . # Chronic sinus problems: Flonase was restarted after extubation. | She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. ca corrected for albumin is wnl. ca corrected for albumin is wnl. ca corrected for albumin is wnl. ca corrected for albumin is wnl. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. Plan: Cont pericardial drain flushes q4hrs. - Continue ASA Plavix, statin . Propofol stopped and within 1 hr, SBT f/b extubation. To command and MAE on current dose of propofol. To command and MAE on current dose of propofol. To command and MAE on current dose of propofol. etio of diaphoresisno temp, ? She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. -Propofenone d/c'ed. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Currently euvolemic. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. See FHPA for PMH. : extubated and pressors dc/d Ventricular tachycardia, non-sustained (NSVT) Assessment: Action Recd pt in NSR 70-80 0750, HR noted 140-150s. - Continue ASA and plavix, statin . Routine ECG done. - Continue ASA and plavix - Continue statin . - Continue ASA and plavix - Continue statin . Neosynephrine was weaned to Response: Pericardial drain to gravity drainage for total of cc . etio of diaphoresisno temp, ? She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. She has undergone now endocardial and epicardial mapping with ablation. Recheck HCT. Recheck HCT. Transferred to CCU intubated, on propofol and neo turned to off on arrival. Routine ECG done. See FHPA for PMH. : extubated and pressors dc/d Ventricular tachycardia, non-sustained (NSVT) Assessment: Action Recd pt in NSR 70-80 0750, HR noted 140-150s. # GERD: Continue zantac . # GERD: Continue zantac . # GERD: Continue zantac . # GERD: Continue zantac . # GERD: Continue zantac . And digoxin. - Continue ASA and plavix - Continue statin . - Continue ASA and plavix - Continue statin . - Continue ASA and plavix - Continue statin . - Continue ASA and plavix - Continue statin . : extubated. : extubated. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There ismild (non-obstructive) focal hypertrophy of the basal septum. Mildthickening of mitral valve chordae.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:There is mild (non-obstructive) focal hypertrophy of the basal septum. The right ventricularcavity is mildly dilated with moderate global free wall hypokinesis. Myxomatous mitral valveleaflets.PERICARDIUM: Small pericardial effusion. There is a trivial/physiologic pericardialeffusion anterior to the right ventricle and no pericardial effusion posteriorto the left ventricle.IMPRESSION: Mildly depressed left ventricular systolic function. Thereis a trivial/physiologic pericardial effusion.IMPRESSION: Overall mildly depressed left ventricular systolic function. No echocardiographic signs oftamponade.Conclusions:The mitral valve leaflets are mildly thickened. There isa trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , the pericardialeffusion is smaller. Wide complex tachycardia which is irregular in nature suggesting atrialfibrillation with left bundle-branch block conduction. Mild (1+) mitral regurgitation is seen.Moderate [2+] tricuspid regurgitation is seen. No AR.MITRAL VALVE: Myxomatous mitral valve leaflets. Sinus bradycardia with ventricular premature beats. There is a small anterior pericardial effusion. F/U s/p tap.Height: (in) 66Weight (lb): 130BSA (m2): 1.67 m2BP (mm Hg): 110/64HR (bpm): 82Status: InpatientDate/Time: at 11:47Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:pt intubated on vent.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.MITRAL VALVE: Mildly thickened mitral valve leaflets. There ismoderate/severe mitral valve prolapse. Sinus rhythm with multiple ventricular premature beats and atrial prematurebeats. | 71 | [
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703516,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Pt in sinus rhythm with rare PVC. SBP mid 80\ns. Pericardial drain\n in place, draining sanguinous drainage (100cc in bag). Pt on\n 50%/500/12 PEEP 5, breathing in phase with vent. Lungs clear, sats\n 100%. On propofol gtt @ 70mcg/kg/min\n Action/Response:\n Neo gtt restarted @ 0.5 mcg/kg/min\n SBP ^ 110-120 without pulsus paradoxus.\n Pericardial drainage monitored , spoke with Dr. \n re: Pericardial flush, he prefers heparinized saline for flush\n Stat labs sent\n Hct 33.1 (32.5). Mg 1.6\n4 gm\n ABG obtained\n7.34/47/185/26/0\n Propafenone on hold for now until dose clarified as per CCU\n resident.\n Plan:\n Monitor pericardial drainage. Monitor for hypotension and pulsus. To\n remain intubated overnight as per Dr. . Assess rhythm and\n electrolytes.\n Impaired Skin Integrity\n Assessment:\n L mid back with pink rash in shape of defib pad.\n Action:\n Chart reviewed, this was present on admission to \n Site cleansed with foam cleanser, aloe vesta.\n Response:\n Plan:\n Continue to monitor site.\n Social: HCP is brother\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703517,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Pt in sinus rhythm with rare PVC. SBP mid 80\ns. Pericardial drain\n in place, draining sanguinous drainage (100cc in bag). Pt on\n 50%/500/12 PEEP 5, breathing in phase with vent. Lungs clear, sats\n 100%. On propofol gtt @ 70mcg/kg/min\n Action/Response:\n Neo gtt restarted @ 0.5 mcg/kg/min\n SBP ^ 110-120 without pulsus paradoxus.\n Pericardial drainage monitored , spoke with Dr. \n re: Pericardial flush, he prefers heparinized saline for flush\n Stat labs sent\n Hct 33.1 (32.5). Mg 1.6\n4 gm Ionized\n Calcium 0.95\n ABG obtained\n7.34/47/185/26/0, not over breathing vent.\n FiO2 decreased to 40% and ABG repeated when breathing breathes over\n vent: 7.35/39/140.\n Propafenone on hold for now until dose clarified as per CCU\n resident.\n Brother (HCP) updated by Dr. .\n Plan:\n Monitor pericardial drainage. Monitor for hypotension and pulsus. To\n remain intubated overnight as per Dr. . Assess rhythm,\n monitor electrolytes.\n Impaired Skin Integrity\n Assessment:\n L mid back with pink rash in shape of defib pad.\n Action:\n Chart reviewed, this was present on admission to \n Site cleansed with foam cleanser, aloe vesta.\n Response:\n Plan:\n Continue to monitor site.\n"
},
{
"category": "Respiratory ",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 703581,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 19cm at teeth\n Route: po\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt remains intubated, fully vent supported. No changes made\n overnight. RSBI=55 this am. See flowsheet for further pt data. Will\n follow.\n 06:30\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703687,
"text": "Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Electrophysiology Physician Note",
"row_id": 703782,
"text": "TITLE: EP Fellow Progress Note\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Housestaff and Dr. \n Events / History of present illness: No further drainage from\n pericardial drain\n Feels mildly \"shaky\", otherwise no complaints\n Occassional runs of VT, one sustianed episode at 160 bpm,\n self-terminated, tolerates hemodynamically\n Medications\n Unchanged\n Physical Exam\n General appearance: NAD, appears well\n BP: 101 / 57 mmHg\n HR: 89 bpm\n RR: 17 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.3 C\n T current F: 97.4 F\n O2 sat: 100 % on Supplemental oxygen:\n Previous day:\n Intake: 1,263 mL\n Output: 1,480 mL\n Fluid balance: -217 mL\n Today:\n Intake: 120 mL\n Output: 600 mL\n Fluid balance: -480 mL\n HEENT: (Oral mucosa: moist)\n Cardiovascular: (Auscultation: RRR, nml S1 and S2, no rubs)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: soft, NTND), (Auscultation: +BS)\n Neurological: (Orientation: Alert)\n Other: Pericardial drain in place\n Labs\n 191\n 8.9\n 117\n 0.9\n 27\n 4.0\n 9\n 105\n 136\n 25.6\n 8.3\n [image002.jpg]\n 02:21 PM\n 10:05 PM\n 04:34 AM\n 05:35 PM\n 08:31 PM\n 05:24 AM\n WBC\n 12.2\n 10.7\n 8.3\n Hgb\n 11.5\n 10.7\n 8.9\n Hct (Serum)\n 33.1\n 32.5\n 30.3\n 25.6\n Plt\n 238\n 221\n 191\n INR\n 1.0\n 1.0\n PTT\n 24.8\n 30.3\n Na+\n 142\n 141\n 138\n 136\n K + (Serum)\n 4.5\n 4.5\n 4.2\n 3.9\n 4.0\n Cl\n 111\n 108\n 106\n 105\n HCO3\n 24\n 25\n 24\n 27\n BUN\n 11\n 12\n 12\n 9\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.9\n Glucose\n 82\n 112\n 117\n ABG: / / / 27 / Values as of 05:24 AM\n Tests\n Telemetry: Runs of NSVT, one sustained this am MMVT at 160 bpm\n Assessment and Plan\n 64 year old feamle with infarct related myopathy, EF 40-45%, recurrent\n VT s/p recent epicardial and endocardial mapping with epicardial\n ablation c/b pericardial bleed s/p drainage, now improved with minimal\n drainage. Hct decreased from 30 to 25, but no clear active bleeding.\n Additionally, episodes of VT are becoming more frequent and more\n sustained, necessitating additional med therapy.\n 1. Hct drop:\n -Reassess brief TTE for effusion accumulation, although Hct likley\n reflective of prior bleed\n -Likely pull drain today if TTE stable\n -Recheck Hct later today and trend as needed\n 2. VT:\n -Increased episodes of MMVT\n -Continue Rhythmol for now, add metoprolol to aid in suppression\n -Will d/w Dr. re: further management of this\n D/W Housestaff.\n ------ Protected Section ------\n Pt seen, discussed and examined with Dr. ; agree with\n assessment and plan. Echo looks worse today than in past with EF ~30%.\n AF with with wide QRS and decreased BP. be propafenone excess.\n Will switch to dronedarone 400 Monday. Will stop propfenone now and\n add metoprolol and digoxin .25 now and .125 tonight ,. .125 daily Drain\n to be removed today.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:45 ------\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703786,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n INVASIVE VENTILATION - STOP 03:47 PM\n :\n -extubated\n -more frequent runs of NSVT (~6-10 beats) as evening went on.\n asymptomatic. mg repleted. evening lytes rechecked. repleted K, phos.\n ca corrected for albumin is wnl.\n -this AM, Hct down 5 points, but asymptomatic, vitals stable, drain not\n clogged, no new drainage, getting echo this am, so did not repeat Hct\n yet.\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 11:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.3\nC (97.4\n HR: 79 (74 - 113) bpm\n BP: 97/53(67) {87/49(64) - 145/72(98)} mmHg\n RR: 19 (11 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Height: 68 Inch\n Total In:\n 1,263 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 783 mL\n Blood products:\n Total out:\n 1,480 mL\n 600 mL\n Urine:\n 1,415 mL\n 600 mL\n NG:\n Stool:\n Drains:\n 65 mL\n Balance:\n -217 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (387 - 387) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n SpO2: 100%\n ABG: ///27/\n Ve: 11.2 L/min\n Physical Examination\n GENERAL: Alert, interactive, NAD\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n Labs / Radiology\n 191 K/uL\n 8.9 g/dL\n 117 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 105 mEq/L\n 136 mEq/L\n 25.6 %\n 8.3 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n 05:35 PM\n 05:24 AM\n WBC\n 12.2\n 10.7\n 8.3\n Hct\n 33.1\n 32.5\n 30.3\n 25.6\n Plt\n 238\n 221\n 191\n Cr\n 0.8\n 0.8\n 0.8\n 0.9\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n 117\n Other labs: PT / PTT / INR:11.9/30.3/1.0, Albumin:3.1 g/dL, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Imaging: TTE \n The mitral valve leaflets are mildly thickened. The mitral valve\n leaflets are myxomatous. There is a small anterior pericardial\n effusion. The effusion is echo dense, consistent with blood,\n inflammation or other cellular elements. There are no echocardiographic\n signs of tamponade. TR gradient 16mmHg.\n CXR pending\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n # s/p Pericardial Bleed: Drain in place with minimal drainage over\n the past 24 hours, but with 5 point Hct drop overnight, no clinical\n evidence of bleed on exam.\n - f/u repeat Hct, and check PM Hct\n - focused TTE this morning to monitor stability of pericardial bleed\n - If TTE stable, pull pericardial drain today\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place. Increasing frequency of slow VTs.\n - Continue Rhythmol (Propafenone) per EP recs\n - Initiate Metoprolol for suppression of slow VT\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue home flonase\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703787,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n INVASIVE VENTILATION - STOP 03:47 PM\n :\n -extubated\n -more frequent runs of NSVT (~6-10 beats) as evening went on.\n asymptomatic. mg repleted. evening lytes rechecked. repleted K, phos.\n ca corrected for albumin is wnl.\n -this AM, Hct down 5 points, but asymptomatic, vitals stable, drain not\n clogged, no new drainage, getting echo this am, so did not repeat Hct\n yet.\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 11:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.3\nC (97.4\n HR: 79 (74 - 113) bpm\n BP: 97/53(67) {87/49(64) - 145/72(98)} mmHg\n RR: 19 (11 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Height: 68 Inch\n Total In:\n 1,263 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 783 mL\n Blood products:\n Total out:\n 1,480 mL\n 600 mL\n Urine:\n 1,415 mL\n 600 mL\n NG:\n Stool:\n Drains:\n 65 mL\n Balance:\n -217 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (387 - 387) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n SpO2: 100%\n ABG: ///27/\n Ve: 11.2 L/min\n Physical Examination\n GENERAL: Alert, interactive, NAD\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n Labs / Radiology\n 191 K/uL\n 8.9 g/dL\n 117 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 105 mEq/L\n 136 mEq/L\n 25.6 %\n 8.3 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n 05:35 PM\n 05:24 AM\n WBC\n 12.2\n 10.7\n 8.3\n Hct\n 33.1\n 32.5\n 30.3\n 25.6\n Plt\n 238\n 221\n 191\n Cr\n 0.8\n 0.8\n 0.8\n 0.9\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n 117\n Other labs: PT / PTT / INR:11.9/30.3/1.0, Albumin:3.1 g/dL, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Imaging: TTE \n The mitral valve leaflets are mildly thickened. The mitral valve\n leaflets are myxomatous. There is a small anterior pericardial\n effusion. The effusion is echo dense, consistent with blood,\n inflammation or other cellular elements. There are no echocardiographic\n signs of tamponade. TR gradient 16mmHg.\n CXR pending\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n # s/p Pericardial Bleed: Drain in place with minimal drainage over\n the past 24 hours, but with 5 point Hct drop overnight, no clinical\n evidence of bleed on exam.\n - f/u repeat Hct, and check PM Hct\n - focused TTE this morning to monitor stability of pericardial bleed\n - If TTE stable, pull pericardial drain today\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place. Increasing frequency of slow VTs.\n - Continue Rhythmol (Propafenone) per EP recs\n - Initiate Metoprolol for suppression of slow VT\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue home flonase\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703792,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n INVASIVE VENTILATION - STOP 03:47 PM\n :\n -extubated\n -more frequent runs of NSVT (~6-10 beats) as evening went on.\n asymptomatic. mg repleted. evening lytes rechecked. repleted K, phos.\n ca corrected for albumin is wnl.\n -this AM, Hct down 5 points, but asymptomatic, vitals stable, drain not\n clogged, no new drainage, getting echo this am, so did not repeat Hct\n yet.\n -A fib with aberrancy/slow VT this morning, spontaneously converted to\n sinus twice, then required Metoprolol 5mg IV x1\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 11:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.3\nC (97.4\n HR: 79 (74 - 113) bpm\n BP: 97/53(67) {87/49(64) - 145/72(98)} mmHg\n RR: 19 (11 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Height: 68 Inch\n Total In:\n 1,263 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 783 mL\n Blood products:\n Total out:\n 1,480 mL\n 600 mL\n Urine:\n 1,415 mL\n 600 mL\n NG:\n Stool:\n Drains:\n 65 mL\n Balance:\n -217 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (387 - 387) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n SpO2: 100%\n ABG: ///27/\n Ve: 11.2 L/min\n Physical Examination\n GENERAL: Alert, interactive, NAD\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n Labs / Radiology\n 191 K/uL\n 8.9 g/dL\n 117 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 105 mEq/L\n 136 mEq/L\n 25.6 %\n 8.3 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n 05:35 PM\n 05:24 AM\n WBC\n 12.2\n 10.7\n 8.3\n Hct\n 33.1\n 32.5\n 30.3\n 25.6\n Plt\n 238\n 221\n 191\n Cr\n 0.8\n 0.8\n 0.8\n 0.9\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n 117\n Other labs: PT / PTT / INR:11.9/30.3/1.0, Albumin:3.1 g/dL, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Imaging: TTE \n The mitral valve leaflets are mildly thickened. The mitral valve\n leaflets are myxomatous. There is a small anterior pericardial\n effusion. The effusion is echo dense, consistent with blood,\n inflammation or other cellular elements. There are no echocardiographic\n signs of tamponade. TR gradient 16mmHg.\n CXR pending\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n # s/p Pericardial Bleed: Drain in place with minimal drainage over\n the past 24 hours, but with 5 point Hct drop overnight, no clinical\n evidence of bleed on exam.\n - f/u repeat Hct, and check PM Hct\n - focused TTE this morning to monitor stability of pericardial bleed\n - If TTE stable, pull pericardial drain today\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place. Increasing frequency of A fib with\n aberrancy/slow VTs.\n - Discontinue Rhythmol (Propafenone) per EP recs\n - Initiate Dronedarone 400mg Monday, following washout of\n Propafenone\n - Initiate Metoprolol 25mg po bid for suppression of A fib with\n aberrancy\n - Initiate Digoxin 0.25mg this morning, 0.125mg this PM, and 0.125mg\n daily starting tomorrow\n - ICD in place\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA Plavix, statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Extubated , currently stable.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy. Will discuss risks/benefits\n of starting Premarin prior to re-initiating given cardiac risks.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: home flonase now that pt is\n extubated.\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703570,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n HR 80-90\ns SR. occas. PVC. BP 87-1teens/50\n Pericardial drain was evaluated by RN and MD at 2200 and found to be\n kinked underneath the dressing. Catheter was straightened, area\n cleansed and redressed with clear tegaderm.\n Pt. wakes to name and to stimulation.\n Repeat HCT 32. team aware and will recheck with AM labs.\n Action:\n Able to flush pericardial drain easily. Unable to aspirate although it\n is draining to gravity.\n Attempted aspiration and flushed with heparinized saline per ICU\n protocol.\n Propofol weaned to 50mcq - pt. waking up , moving all extremeties and\n responding to commands, shaking head approp. To questions. Propofol\n currently at 60mcq for comfort and sedation.\n Response:\n Pericardial drain to gravity drainage for total of 50 cc serous fluid\n x12 hours.\n BP dropping to 85-88/50\ns (map 65) on neo 0.4mcq/k/min. titrated back\n up to 0.5mcq/k/min at 0430 with good effect.\n Pt. contin. To respond approp. To command and MAE on current dose of\n propofol.\n LS clear upper to course cleared with suctioning. Sats 100% on 40%\n FIO2.\n u/o 50-100cc/hr.\n OGT clamped. Tolerating po meds- bilious residuals.\n TM 99.6po. extremeties warm, forehead diaphoretic.\n Plan:\n Plan wean to extubate today. Wean neo as tolerated to keep SBP>90.\n follow temp.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703574,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n HR 80-90\ns SR. occas. PVC. BP 87-1teens/50\n Pericardial drain was evaluated by RN and MD at 2200 and found to be\n kinked underneath the dressing. Catheter was straightened, area\n cleansed and redressed with clear tegaderm.\n Pt. wakes to name and to stimulation.\n Repeat HCT 32. team aware and will recheck with AM labs. Pericardial\n site D/I.\n Action:\n Able to flush pericardial drain easily. Unable to aspirate although it\n is draining to gravity.\n Attempted aspiration and flushed with heparinized saline per ICU\n protocol.\n Propofol weaned to 50mcq - pt. waking up , moving all extremeties and\n responding to commands, shaking head approp. To questions. Propofol\n currently at 60mcq for comfort and sedation d/t pt. becoming more\n restless on decrease dose.\n Response:\n Pericardial drain to gravity drainage for total of 50 cc serous fluid\n x12 hours.\n BP dropping to 85-88/50\ns (map 65) on neo 0.4mcq/k/min. titrated back\n up to 0.5mcq/k/min at 0430 with good effect.\n No further episodes of hypertension noted through night.\n Pt. contin. To respond approp. To command and MAE on current dose of\n propofol.\n LS clear upper to course cleared with suctioning. Sats 100% on 40%\n FIO2.\n u/o 50-100cc/hr.\n OGT clamped. Tolerating po meds- bilious residuals.\n TM 99.6po. extremeties warm, forehead diaphoretic.\n Plan:\n Plan wean to extubate today. Wean neo as tolerated to keep SBP>90.\n follow temp.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703576,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n HR 80-90\ns SR. occas. PVC. BP 87-1teens/50\n Pericardial drain was evaluated by RN and MD at 2200 and found to be\n kinked underneath the dressing. Catheter was straightened, area\n cleansed and redressed with clear tegaderm.\n Pt. wakes to name and to stimulation.\n Repeat HCT 32. team aware and will recheck with AM labs. Pericardial\n site D/I.\n Action:\n Able to flush pericardial drain easily. Unable to aspirate although it\n is draining to gravity.\n Attempted aspiration and flushed with heparinized saline per ICU\n protocol.\n Propofol weaned to 50mcq - pt. waking up , moving all extremeties and\n responding to commands, shaking head approp. To questions. Propofol\n currently at 60mcq for comfort and sedation d/t pt. becoming more\n restless on decrease dose.\n Response:\n Pericardial drain to gravity drainage for total of 50 cc serous fluid\n x12 hours.\n BP dropping to 85-88/50\ns (map 65) on neo 0.4mcq/k/min. titrated back\n up to 0.5mcq/k/min at 0430 with good effect.\n No further episodes of hypertension noted through night.\n Pt. contin. To respond approp. To command and MAE on current dose of\n propofol.\n LS clear upper to course cleared with suctioning. Sats 100% on 40%\n FIO2.\n u/o 50-100cc/hr.\n OGT clamped. Tolerating po meds- bilious residuals.\n TM 99.6po. extremeties warm, forehead diaphoretic.\n Plan:\n Plan wean to extubate today. Wean neo as tolerated to keep SBP>90.\n follow temp.\n ? repeat echo to assess effusion and possibly d/c drain.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703932,
"text": "64 year old female with infarct related myopathy, EF 40-45% in past,\n although seems worse by focused views TTE, recurrent VT s/p recent\n epicardial and endocardial mapping with epicardial ablation c/b\n pericardial bleed s/p drainage, now improved with drain removed.\n Additionally, had AF with RVR, wide complex propafenone.\n Propafenone stopped, started on nodal agents with plan for dronedarone\n initiation tomorrow. PT HAS AICD IN 06 AFTER 2 VF ARRESTS\n Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy. Patient is comfortable\n holding Premarin for now.\n .\n # Depression: Continue lexapro. On chronic benzodiazapines,\n .\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- SB @ present w/ occ PVC\ns- HR 50\ns- Maps 58-87\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor and 2gm Mg IV\n given overnight for RAF w/ effect. Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats,BP IN THE 80S SYSTOLIC WHICH\n IS ACCEPTABLE ,PT OOB IN CHAIR,COMMODE\n Plan:\n -Plan dronederone initiation tomorrow at 400 mg to start in am\n Continue to rate control. Monitor VS as tolerated.\n TO BE STARTED ON COUMADIN TOMORROW\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703506,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Pt in sinus rhythm with rare PVC. SBP mid 80\ns. Pericardial drain\n in place, draining sanguinous drainage (100cc in bag). Pt on\n 50%/500/12 PEEP 5, breathing in phase with vent. Lungs clear, sats\n 100%. On propofol gtt @ 70mcg/kg/min\n Action/Response:\n Neo gtt restarted @ 0.5 mcg/kg/min\n SBP ^ 110-120 without pulsus paradoxus.\n Pericardial drainage monitored , spoke with Dr. \n re: Pericardial flush, he prefers heparinized saline for flush\n Stat labs sent\n Hct 33.1 (32.5). Mg 1.6\n ABG obtained\n7.34/47/185/26/0\n Propafenone on hold for now until dose clarified as per CCU\n resident.\n Plan:\n Monitor pericardial drainage. Monitor for hypotension and pulsus. To\n remain intubated overnight as per Dr. . Assess rhythm and\n electrolytes.\n Impaired Skin Integrity\n Assessment:\n L mid back with pink rash in shape of defib pad.\n Action:\n Chart reviewed, this was present on admission to \n Site cleansed with foam cleanser, aloe vesta.\n Response:\n Plan:\n Continue to monitor site.\n Social: HCP is brother\n"
},
{
"category": "Respiratory ",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 703507,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: no\n Procedure location: EP LAB\n Reason:\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was admitted via EP intubated placed on the vent tol well. See\n respiratory page of meta vision for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703677,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n HR 80\ns nsr w/ freq pvc\ns up to 10bruns.\n BP 90-110/50\ns on 0.4mcgs/kg/min Neo.\n Pericardial drain to serous drainage.\n Pt intubated on 40%/500/12/5. LS clear w/ sats 99-100%.\n Pt sedated on 60mcg/propofol\n R groin dsd di/. Pulses palpable.\n OGT clamped and utilized for meds.\n Action:\n Propafenone tid\n Drain flushed q4hs per protocol. Echo done.\n Propofol stopped and within 1 hr, SBT f/b extubation.\n 40% face tent f/b 2ln/p. Encouraged c/db.\n Response:\n Less ectopy post propafenone dose\n Expectorating mod amts sputum.\n Plan:\n Cont pericardial drain flushes q4hrs.\n Encourage c/db and expectoration of sputum.\n Possible removal of drain .\n Keep pt and brother informed of poc per multidisiciplinary rounds.\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Electrophysiology Physician Note",
"row_id": 703776,
"text": "TITLE: EP Fellow Progress Note\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Housestaff and Dr. \n Events / History of present illness: No further drainage from\n pericardial drain\n Feels mildly \"shaky\", otherwise no complaints\n Occassional runs of VT, one sustianed episode at 160 bpm,\n self-terminated, tolerates hemodynamically\n Medications\n Unchanged\n Physical Exam\n General appearance: NAD, appears well\n BP: 101 / 57 mmHg\n HR: 89 bpm\n RR: 17 insp/min\n Tmax C last 24 hours: 37.4 C\n Tmax F last 24 hours: 99.4 F\n T current C: 36.3 C\n T current F: 97.4 F\n O2 sat: 100 % on Supplemental oxygen:\n Previous day:\n Intake: 1,263 mL\n Output: 1,480 mL\n Fluid balance: -217 mL\n Today:\n Intake: 120 mL\n Output: 600 mL\n Fluid balance: -480 mL\n HEENT: (Oral mucosa: moist)\n Cardiovascular: (Auscultation: RRR, nml S1 and S2, no rubs)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: soft, NTND), (Auscultation: +BS)\n Neurological: (Orientation: Alert)\n Other: Pericardial drain in place\n Labs\n 191\n 8.9\n 117\n 0.9\n 27\n 4.0\n 9\n 105\n 136\n 25.6\n 8.3\n [image002.jpg]\n 02:21 PM\n 10:05 PM\n 04:34 AM\n 05:35 PM\n 08:31 PM\n 05:24 AM\n WBC\n 12.2\n 10.7\n 8.3\n Hgb\n 11.5\n 10.7\n 8.9\n Hct (Serum)\n 33.1\n 32.5\n 30.3\n 25.6\n Plt\n 238\n 221\n 191\n INR\n 1.0\n 1.0\n PTT\n 24.8\n 30.3\n Na+\n 142\n 141\n 138\n 136\n K + (Serum)\n 4.5\n 4.5\n 4.2\n 3.9\n 4.0\n Cl\n 111\n 108\n 106\n 105\n HCO3\n 24\n 25\n 24\n 27\n BUN\n 11\n 12\n 12\n 9\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.9\n Glucose\n 82\n 112\n 117\n ABG: / / / 27 / Values as of 05:24 AM\n Tests\n Telemetry: Runs of NSVT, one sustained this am MMVT at 160 bpm\n Assessment and Plan\n 64 year old feamle with infarct related myopathy, EF 40-45%, recurrent\n VT s/p recent epicardial and endocardial mapping with epicardial\n ablation c/b pericardial bleed s/p drainage, now improved with minimal\n drainage. Hct decreased from 30 to 25, but no clear active bleeding.\n Additionally, episodes of VT are becoming more frequent and more\n sustained, necessitating additional med therapy.\n 1. Hct drop:\n -Reassess brief TTE for effusion accumulation, although Hct likley\n reflective of prior bleed\n -Likely pull drain today if TTE stable\n -Recheck Hct later today and trend as needed\n 2. VT:\n -Increased episodes of MMVT\n -Continue Rhythmol for now, add metoprolol to aid in suppression\n -Will d/w Dr. re: further management of this\n D/W Housestaff.\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703772,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n INVASIVE VENTILATION - STOP 03:47 PM\n :\n -extubated\n -more frequent runs of NSVT (~6-10 beats) as evening went on.\n asymptomatic. mg repleted. evening lytes rechecked. repleted K, phos.\n ca corrected for albumin is wnl.\n -this AM, Hct down 5 points, but asymptomatic, vitals stable, drain not\n clogged, no new drainage, getting echo this am, so did not repeat Hct\n yet.\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 11:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.3\nC (97.4\n HR: 79 (74 - 113) bpm\n BP: 97/53(67) {87/49(64) - 145/72(98)} mmHg\n RR: 19 (11 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Height: 68 Inch\n Total In:\n 1,263 mL\n 120 mL\n PO:\n 240 mL\n 120 mL\n TF:\n IVF:\n 783 mL\n Blood products:\n Total out:\n 1,480 mL\n 600 mL\n Urine:\n 1,415 mL\n 600 mL\n NG:\n Stool:\n Drains:\n 65 mL\n Balance:\n -217 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (387 - 387) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 14 cmH2O\n SpO2: 100%\n ABG: ///27/\n Ve: 11.2 L/min\n Physical Examination\n GENERAL: Alert, interactive, NAD\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n Labs / Radiology\n 191 K/uL\n 8.9 g/dL\n 117 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 9 mg/dL\n 105 mEq/L\n 136 mEq/L\n 25.6 %\n 8.3 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n 05:35 PM\n 05:24 AM\n WBC\n 12.2\n 10.7\n 8.3\n Hct\n 33.1\n 32.5\n 30.3\n 25.6\n Plt\n 238\n 221\n 191\n Cr\n 0.8\n 0.8\n 0.8\n 0.9\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n 117\n Other labs: PT / PTT / INR:11.9/30.3/1.0, Albumin:3.1 g/dL, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Imaging: TTE \n The mitral valve leaflets are mildly thickened. The mitral valve\n leaflets are myxomatous. There is a small anterior pericardial\n effusion. The effusion is echo dense, consistent with blood,\n inflammation or other cellular elements. There are no echocardiographic\n signs of tamponade. TR gradient 16mmHg.\n CXR pending\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - TTE this AM, eval for resolution of effusion\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue home flonase\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703930,
"text": "64 year old female with infarct related myopathy, EF 40-45% in past,\n although seems worse by focused views TTE, recurrent VT s/p recent\n epicardial and endocardial mapping with epicardial ablation c/b\n pericardial bleed s/p drainage, now improved with drain removed.\n Additionally, had AF with RVR, wide complex propafenone.\n Propafenone stopped, started on nodal agents with plan for dronedarone\n initiation tomorrow. PT HAS AICD IN 06 AFTER 2 VF ARRESTS\n Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy. Patient is comfortable\n holding Premarin for now.\n .\n # Depression: Continue lexapro. On chronic benzodiazapines,\n .\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- SB @ present w/ occ PVC\ns- HR 50\ns- Maps 58-87\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor and 2gm Mg IV\n given overnight for RAF w/ effect. Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats,BP IN THE 80S SYSTOLIC WHICH\n IS ACCEPTABLE ,PT OOB IN CHAIR,COMMODE\n Plan:\n -Plan dronederone initiation tomorrow at 400 mg to start in am\n Continue to rate control. Monitor VS as tolerated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703565,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n HR 80-90\ns SR. occas. PVC. BP 87-1teens/50\n Pericardial drain was evaluated by RN and MD at 2200 and found to be\n kinked underneath the dressing. Catheter was straightened, area\n cleansed and redressed with clear tegaderm.\n Action:\n Able to flush pericardial drain easily. Unable to aspirate although it\n is draining to gravity.\n Neosynephrine was weaned to\n Response:\n Pericardial drain to gravity drainage for total of cc .\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703671,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n HR 80\ns nsr w/ freq pvc\ns up to 10bruns.\n BP 90-110/50\ns on 0.4mcgs/kg/min Neo.\n Pericardial drain to serous drainage.\n Pt intubated on 40%/500/12/5. LS clear w/ sats 99-100%.\n Pt sedated on 60mcg/propofol\n R groin dsd di/. Pulses palpable.\n OGT clamped and utilized for meds.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703929,
"text": "64 year old female with infarct related myopathy, EF 40-45% in past,\n although seems worse by focused views TTE, recurrent VT s/p recent\n epicardial and endocardial mapping with epicardial ablation c/b\n pericardial bleed s/p drainage, now improved with drain removed.\n Additionally, had AF with RVR, wide complex propafenone.\n Propafenone stopped, started on nodal agents with plan for dronedarone\n initiation tomorrow. PT HAS AICD IN 06 AFTER 2 VF ARRESTS\n Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy. Patient is comfortable\n holding Premarin for now.\n .\n # Depression: Continue lexapro. On chronic benzodiazapines,\n .\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- SB @ present w/ occ PVC\ns- HR 50\ns- Maps 58-87\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor and 2gm Mg IV\n given overnight for RAF w/ effect. Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats,BP IN THE 80S SYSTOLIC\n Plan:\n Continue to rate control. Monitor VS as tolerated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703837,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on Transferred to the\n CCU following epicardial VT mapping and VT ablation c/b\n pericardial effusion requiring drain, intubation and pressors.\n : extubated and pressors dc/d\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action\n Rec\nd pt in NSR 70-80\n 0750, HR noted 140-150\ns. BP down to 60\ns via aline. Tachy complexes\n are both wide and narrow.\n Pt rec\nd 5mg IVP lopressor, lyte replacement. Tachycardia resolved\n within 60min.\n Propafenone dc\nd in favor of dig 0.25 at noon and 0.125 at 1800.\n Lopressor started 25mg .\n Pericardial drain w/ no fluid removal. Removed by Card fellow.\n AM Hct 25.5\n OOB to chair this afternoon.\n All questions answered regarding med changes and POC.\n Response:\n Lytes adequately repleted (K+4.6, Mg 2.2)\n VEA continues.\n Repeat Hct 25.6\n Tolerated OOB to chair without difficulty.\n Good understanding of VT and meds.\n Plan:\n Close monitoring of lytes and Hct w/ aggressive repletion of lytes.\n Daily dose of dig . Dronedarone 400mg to start .\n Increase activity as tolerated.\n Keep pt informed of poc per multidisiciplinary rounds.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703927,
"text": "64 year old female with infarct related myopathy, EF 40-45% in past,\n although seems worse by focused views TTE, recurrent VT s/p recent\n epicardial and endocardial mapping with epicardial ablation c/b\n pericardial bleed s/p drainage, now improved with drain removed.\n Additionally, had AF with RVR, wide complex propafenone.\n Propafenone stopped, started on nodal agents with plan for dronedarone\n initiation tomorrow.\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- SB @ present w/ occ PVC\ns- HR 50\ns- Maps 58-87\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor and 2gm Mg IV\n given overnight for RAF w/ effect. Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats\n Plan:\n Continue to rate control. Monitor VS as tolerated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703906,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on Transferred to the\n CCU following epicardial VT mapping and VT ablation c/b\n pericardial effusion requiring drain, intubation and pressors.\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- SB @ present w/ occ PVC\ns- HR 50\ns- Maps 58-87\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor and 2gm Mg IV\n given overnight for RAF w/ effect. Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats\n Plan:\n Continue to rate control. Monitor VS as tolerated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703909,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 03:00 AM\n A fib with RVR . Pt asymptomatic. VSS.\n \n -In and out of what looked like slow VT, EP said a fib with aberrancy,\n given Metoprolol 5mg IV. Back in sinus.\n -focused TTE did not show recurrence of pericardial effusion.\n -Pericardial drain pulled. Scheduled for full TTE Mon to evaluate EF,\n as focused TTE seemed to show lower EF than most recent echo.\n -Pt ok with not taking Estrogen for a while in-house (skips weeks at a\n time at home)\n -Propofenone d/c'ed. Dronedarone 400mg to start Mon after\n Propofenone washes out.\n -Started on Metoprolol 25mg po bid (PM dose not given, as below)\n -Digoxin 'load' and initiated daily dose 0.125mg daily.\n -Back in a fib with RVR at 110's-130's, given Metoprolol 5mg IV x2, Mg\n 2mg IV, her evening Phos (not given when ordered), Metoprolol 12.5mg po\n (PM Metoprolol 25mg was not given for low BP and pt desire). Patient\n went back into sinus with HR 50s-60s and BP high 80's-90's.\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Metoprolol - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.1\nC (97\n HR: 56 (56 - 154) bpm\n BP: 96/53(67) {85/48(50) - 116/71(77)} mmHg\n RR: 14 (10 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 66.4 kg (admission): 65 kg\n Height: 68 Inch\n Total In:\n 1,070 mL\n 150 mL\n PO:\n 1,020 mL\n 100 mL\n TF:\n IVF:\n 50 mL\n 50 mL\n Blood products:\n Total out:\n 1,610 mL\n 0 mL\n Urine:\n 1,610 mL\n NG:\n Stool:\n Drains:\n Balance:\n -540 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n GENERAL: intubated, sedated, responsive\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n Labs / Radiology\n 214 K/uL\n 9.1 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 25.3 %\n 6.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n 05:35 PM\n 05:24 AM\n 04:18 PM\n 03:18 AM\n WBC\n 12.2\n 10.7\n 8.3\n 6.7\n Hct\n 33.1\n 32.5\n 30.3\n 25.6\n 25.5\n 25.3\n Plt\n 238\n 221\n 191\n 214\n Cr\n 0.8\n 0.8\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n 117\n 101\n Other labs: PT / PTT / INR:10.4/28.4/0.8, Albumin:3.1 g/dL, Ca++:8.0\n mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - TTE this AM, eval for resolution of effusion\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n 16 Gauge - 01:26 PM\n 20 Gauge - 08:00 AM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: Potentially call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703910,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 03:00 AM\n A fib with RVR . Pt asymptomatic. VSS.\n -In and out of what looked like slow VT, EP said rhythm is a fib with\n aberrancy, given Metoprolol 5mg IV with conversion to sinus.\n -Focused TTE did not show recurrence of pericardial effusion.\n Pericardial drain pulled. Scheduled for full TTE Mon to evaluate EF,\n as focused TTE seemed to show lower EF than most recent echo.\n -Propofenone d/c'ed. Dronedarone 400mg to start Mon after\n Propofenone washes out, per EP recs.\n -Digoxin 'load' and initiated daily dose 0.125mg daily.\n -Started on Metoprolol 25mg po bid (PM dose not given, as below)\n -Back in a fib with RVR at 110's-130's, given Metoprolol 5mg IV x2,\n Metoprolol 12.5mg po (PM Metoprolol 25mg was not given for low BP and\n pt refusal). Mg and Phos repleted. Patient went back into sinus with\n HR 50s-60s and BP high 80's-90's, continued to stay in sinus.\n -Pt ok with not taking Estrogen for a while in-house (skips weeks at a\n time at home)\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Metoprolol - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.1\nC (97\n HR: 56 (56 - 154) bpm\n BP: 96/53(67) {85/48(50) - 116/71(77)} mmHg\n RR: 14 (10 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 66.4 kg (admission): 65 kg\n Height: 68 Inch\n Total In:\n 1,070 mL\n 150 mL\n PO:\n 1,020 mL\n 100 mL\n TF:\n IVF:\n 50 mL\n 50 mL\n Blood products:\n Total out:\n 1,610 mL\n 0 mL\n Urine:\n 1,610 mL\n NG:\n Stool:\n Drains:\n Balance:\n -540 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n GENERAL: Alert, interactive, NAD\n CARDIAC: RRR, no MRG\n LUNGS: CTAB, poor air exchange b/l\n ABDOMEN: Soft, NTND.\n EXTREMITIES: No c/c/e.\n Labs / Radiology\n 214 K/uL\n 9.1 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 25.3 %\n 6.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n 05:35 PM\n 05:24 AM\n 04:18 PM\n 03:18 AM\n WBC\n 12.2\n 10.7\n 8.3\n 6.7\n Hct\n 33.1\n 32.5\n 30.3\n 25.6\n 25.5\n 25.3\n Plt\n 238\n 221\n 191\n 214\n Cr\n 0.8\n 0.8\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n 117\n 101\n Other labs: PT / PTT / INR:10.4/28.4/0.8, Albumin:3.1 g/dL, Ca++:8.0\n mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she had a\n pericardial drain which was pulled yesterday.\n - Propofenone discontinued\n - Dronedarone to be started Monday after Propofenone washes out\n - Continue Digoxin daily\n - TTE focused view yesterday, will evaluate with full TTE Monday or\n Tuesday\n - ICD in place\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Currently\n euvolemic.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery disease.\n - Continue ASA and plavix, statin\n .\n # Hypertension: Given borderline blood pressures, will hold home\n regimen of diovan.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy. Patient is comfortable\n holding Premarin for now.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n 16 Gauge - 01:26 PM\n 20 Gauge - 08:00 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: Potentially call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703601,
"text": "TITLE:\n Chief Complaint: ventricular arrhythmia\n 24 Hour Events:\n ARTERIAL LINE - START 01:24 PM\n Comfortable o/n, pt expressing desire to have tube pulled.\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 87 (57 - 87) bpm\n BP: 117/73(89) {85/52(62) - 148/78(98)} mmHg\n RR: 26 (7 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Total In:\n 4,228 mL\n 343 mL\n PO:\n TF:\n IVF:\n 4,168 mL\n 283 mL\n Blood products:\n Total out:\n 3,103 mL\n 345 mL\n Urine:\n 1,025 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 25 mL\n Balance:\n 1,125 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 17 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n ABG: 7.42/35/132/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 330\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 221 K/uL\n 10.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 12 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.3 %\n 10.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n WBC\n 12.2\n 10.7\n Hct\n 33.1\n 32.5\n 30.3\n Plt\n 238\n 221\n Cr\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n Other labs: PT / PTT / INR:12.2/24.8/1.0, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n VENTRICULAR TACHYCARDIA, NON-SUSTAINED (NSVT)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703603,
"text": "TITLE:\n Chief Complaint: ventricular arrhythmia\n 24 Hour Events:\n ARTERIAL LINE - START 01:24 PM\n Comfortable o/n, pt expressing desire to have tube pulled.\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 87 (57 - 87) bpm\n BP: 117/73(89) {85/52(62) - 148/78(98)} mmHg\n RR: 26 (7 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Total In:\n 4,228 mL\n 343 mL\n PO:\n TF:\n IVF:\n 4,168 mL\n 283 mL\n Blood products:\n Total out:\n 3,103 mL\n 345 mL\n Urine:\n 1,025 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 25 mL\n Balance:\n 1,125 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 17 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n ABG: 7.42/35/132/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 330\n Physical Examination\n GENERAL: intubated, sedated.\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 not elevated.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. pericardial\n drain in place draining sanginous fluid\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, coarse breath sounds\n bilaterally, no crackles, wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+\n Labs / Radiology\n 221 K/uL\n 10.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 12 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.3 %\n 10.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n WBC\n 12.2\n 10.7\n Hct\n 33.1\n 32.5\n 30.3\n Plt\n 238\n 221\n Cr\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n Other labs: PT / PTT / INR:12.2/24.8/1.0, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - Continue to monitor output of the pericardial drain. TTE in the AM\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure. Drain in place.\n - Continue to monitor drain output\n - will check for presence of persistence of pericardial effusion with\n repeat TTE in AM\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Unclear if had been taking a statin, will start one today\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and wean\n ventilator and sedation as tolerated.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n .\n FEN: NPO for now, will start heart healthy diet once extubated.\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC TID\n -Pain management with NSAIDS, morphine as needed\n -Bowel regimen with colace, senna\n .\n CODE: Presumed full\n .\n COMM: Brother and patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703606,
"text": "TITLE:\n Chief Complaint: ventricular arrhythmia\n 24 Hour Events:\n ARTERIAL LINE - START 01:24 PM\n Comfortable o/n, no pain, pt expressing desire to have tube pulled.\n -pericardial drain with 250 ccs thus far, 50 since 2AM\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 87 (57 - 87) bpm\n BP: 117/73(89) {85/52(62) - 148/78(98)} mmHg\n RR: 26 (7 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Total In:\n 4,228 mL\n 343 mL\n PO:\n TF:\n IVF:\n 4,168 mL\n 283 mL\n Blood products:\n Total out:\n 3,103 mL\n 345 mL\n Urine:\n 1,025 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 25 mL\n Balance:\n 1,125 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 17 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n ABG: 7.42/35/132/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 330\n Physical Examination\n GENERAL: intubated, sedated, responsive\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 221 K/uL\n 10.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 12 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.3 %\n 10.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n WBC\n 12.2\n 10.7\n Hct\n 33.1\n 32.5\n 30.3\n Plt\n 238\n 221\n Cr\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n Other labs: PT / PTT / INR:12.2/24.8/1.0, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - TTE this AM, eval for resolution of effusion\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n .\n FEN: NPO for now, will start heart healthy diet once extubated.\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC TID\n -Pain management with NSAIDS, morphine as needed\n -Bowel regimen with colace, senna\n .\n CODE: Presumed full\n .\n COMM: Brother and patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703945,
"text": "64 year old female with infarct related myopathy, EF 40-45% in past,\n although seems worse by focused views TTE, recurrent VT s/p recent\n epicardial and endocardial mapping with epicardial ablation c/b\n pericardial bleed s/p drainage, now improved with drain removed.\n Additionally, had AF with RVR, wide complex propafenone.\n Propafenone stopped, started on nodal agents with plan for dronedarone\n initiation tomorrow. PT HAS AICD IN 06 AFTER 2 VF ARRESTS\n Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy. Patient is comfortable\n holding Premarin for now.\n .\n # Depression: Continue lexapro. On chronic benzodiazapines,\n .\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- SB @ present w/ occ PVC\ns- HR 50\ns- Maps 58-87\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor and 2gm Mg IV\n given overnight for RAF w/ effect. Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats,BP IN THE 80S SYSTOLIC WHICH\n IS ACCEPTABLE ,PT OOB IN CHAIR,COMMODE\n Plan:\n -Plan dronederone initiation tomorrow at 400 mg to start in am\n Continue to rate control. Monitor VS as tolerated.\n TO BE STARTED ON COUMADIN TOMORROW\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VENTRICULAR TACHYCARDIA VENTRICULAR TACHYCARDIA ABLATION *\n Code status:\n Height:\n 68 Inch\n Admission weight:\n 65 kg\n Daily weight:\n 66.4 kg\n Allergies/Reactions:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, Hypertension, MI, Pacemaker\n Additional history: asthma, bronchitis, recent sinusitis, MI ' c/b\n VT, ICD placement. VRF arrest and generator change ', VVI pacer with\n lower rate 40, DES to RCA , EF 40 %, MR, transgendered ', GERD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:58\n Temperature:\n 97.2\n Arterial BP:\n S:102\n D:51\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 63 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 50% %\n 24h total in:\n 510 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:18 AM\n Potassium:\n 4.3 mEq/L\n 03:18 AM\n Chloride:\n 107 mEq/L\n 03:18 AM\n CO2:\n 24 mEq/L\n 03:18 AM\n BUN:\n 13 mg/dL\n 03:18 AM\n Creatinine:\n 0.8 mg/dL\n 03:18 AM\n Glucose:\n 101 mg/dL\n 03:18 AM\n Hematocrit:\n 25.3 %\n 03:18 AM\n Valuables / Signature\n Patient valuables: glasses,cellphone\n Other valuables:\n Clothes: Sent home with: with pt\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703498,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and 0.5 mcg/kg of neo.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703503,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Pt in sinus rhythm with rare PVC. SBP mid 80\ns. Pericardial drain\n in place, draining sanguinous drainage (100cc in bag). Pt on\n 50%/500/12 PEEP 5, breathing in phase with vent. Lungs clear, sats\n 100%. On propofol gtt @ 70mcg/kg/min\n Action/Response:\n Neo gtt restarted @ 0.5 mcg/kg/min\n SBP ^ 110-120 without pulsus paradoxus.\n Pericardial drainage monitored , spoke with Dr. \n re: Pericardial flush, he prefers heparinized saline for flush\n Stat labs sent\n ABG obtained\n Propafenone on hold for now until dose clarified as per CCU\n resident.\n Plan:\n Monitor pericardial drainage. Monitor for hypotension and pulsus. To\n remain intubated overnight as per Dr. . Assess rhythm and\n electrolytes.\n Social: HCP is brother\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703559,
"text": "Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703737,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n : extubated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n The patient has a history of polymorphic, monomorphic VT as well as\n VF. She has undergone now endocardial and epicardial mapping with\n ablation.\n Having freq. runs of VT, beats up to 10beats. Mg+ 1.8, K+ 3.9,\n Phos 3.4\n Pt. denies SOB, palps.\n Afeb.\n HR 90-113 ST in eve, BP 90\ns/50.\n Action:\n Mag , K and phos repleted.\n Response:\n VEA dramatically reduced after mag repletion. Only occas. PVC since\n 0300. HR down to 80\ns SR. BP stable.\n Pt. slept well . no pain. Warm extremeties.\n Asking about going home and overall plan.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703560,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n HR 80-90\ns SR. occas. PVC. BP 87-1teens/50\n Pericardial drain was evaluated by RN and MD at 2200 and found to be\n kinked underneath the dressing. Catheter was straightened, area\n cleansed and redressed with clear tegaderm.\n Action:\n Able to flush pericardial drain easily. Unable to aspirate although it\n is draining to gravity.\n Neosynephrine was weaned to\n Response:\n Pericardial drain to gravity drainage for total of cc .\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703535,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Pt in sinus rhythm with rare PVC. SBP mid 80\ns. Pericardial drain\n in place, draining sanguinous drainage (100cc in bag). Pt on\n 50%/500/12 PEEP 5, breathing in phase with vent. Lungs clear, sats\n 100%. On propofol gtt @ 70mcg/kg/min. Patient with intermittent\n diaphoresis, mostly of forehead. Not associated with change in VS,\n Oxygen saturation. Routine ECG done.\n Action/Response:\n Neo gtt restarted @ 0.5 mcg/kg/min\n SBP ^ 95-120 without pulsus paradoxus.\n Pericardial drainage monitored , spoke with Dr. \n re: Pericardial flush, he prefers heparinized saline for flush. One\n hour after heparinized saline flush, patient put out an additional 50\n cc of sanguinous drainage. CCU resident notified\n Stat labs sent\n Hct 33.1 (32.5). Mg 1.6\n4 gm Ionized\n Calcium 0.95\n2 Gm.\n ABG obtained\n7.34/47/185/26/0, not over breathing vent.\n FiO2 decreased to 40% and ABG repeated when breathing breathes over\n vent: 7.35/39/140.\n Propafenone initially held as per CCU resident. Spoke with\n Dr. , ok to give. .\n Brother (HCP) updated by Dr. .\n Discussed with CCU resident ? etio of diaphoresis\nno temp, ?\n hormone related (estrogens stopped), ? BZD\nreviewed with pharmacist,\n unlikely given dose of home oxazepam and presence of propofol\n Plan:\n Monitor pericardial drainage. Monitor for hypotension and pulsus. To\n remain intubated overnight as per Dr. . Assess rhythm,\n monitor electrolytes. Monitor diaphoresis, assess for etiology.\n Impaired Skin Integrity\n Assessment:\n L mid back with pink rash in shape of defib pad. R lower lip with 1 cm\n bruise, not located at ETT site.\n Action:\n Chart reviewed, this was present on admission to \n Site cleansed with foam cleanser, aloe vesta.\n Response:\n Plan:\n Continue to monitor skin on back and lip.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703538,
"text": "Pt is a 64 yo female with recent VT firing. See FHPA for PMH. ,\n underwent diagnositc cath to evaluate DES in RCA-->patent. Underwent\n EP mapping and returned to the EP lab today for an epicardial VT\n ablation under general anesthesia. Perciardial drain placed at\n beggining of case-->80cc. During course of case, drain--> a total of\n 800cc's of sanguinous drainage. Heparin turned off. CT consult\n obtained. Pt on dopamine, neo, received 2 U PRBC and Protamine. End\n of case TEE showed small amount of pericardial fluid. Transferred to\n CCU intubated, on propofol and neo turned to off on arrival.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Pt in sinus rhythm with rare PVC. SBP mid 80\ns. Pericardial drain\n in place, draining sanguinous drainage (100cc in bag). Pt on\n 50%/500/12 PEEP 5, breathing in phase with vent. Lungs clear, sats\n 100%. On propofol gtt @ 70mcg/kg/min. Patient with intermittent\n diaphoresis, mostly of forehead. Not associated with change in VS,\n Oxygen saturation. Routine ECG done.\n Action/Response:\n Neo gtt restarted @ 0.5 mcg/kg/min\n SBP ^ 95-120 without pulsus paradoxus.\n Pericardial drainage monitored , spoke with Dr. \n re: Pericardial flush, he prefers heparinized saline for flush. One\n hour after heparinized saline flush, patient put out an additional 50\n cc of sanguinous drainage. CCU resident notified\n Stat labs sent\n Hct 33.1 (32.5). Mg 1.6\n4 gm Ionized\n Calcium 0.95\n2 Gm.\n ABG obtained\n7.34/47/185/26/0, not over breathing vent.\n FiO2 decreased to 40% and ABG repeated when breathing breathes over\n vent: 7.35/39/140.\n Propafenone initially held as per CCU resident. Spoke with\n Dr. , ok to give. .\n Brother (HCP) updated by Dr. .\n Discussed with CCU resident ? etio of diaphoresis\nno temp, ?\n hormone related (estrogens stopped), ? BZD\nreviewed with pharmacist,\n unlikely given dose of home oxazepam and presence of propofol\n Plan:\n Monitor pericardial drainage. Monitor for hypotension and pulsus. To\n remain intubated overnight as per Dr. . Assess rhythm,\n monitor electrolytes. Monitor diaphoresis, assess for etiology.\n Impaired Skin Integrity\n Assessment:\n L mid back with pink rash in shape of defib pad. R lower lip with 1 cm\n bruise, not located at ETT site.\n Action:\n Chart reviewed, this was present on admission to \n Site cleansed with foam cleanser, aloe vesta.\n Response:\n Plan:\n Continue to monitor skin on back and lip.\n ------ Protected Section ------\n Pt demonstrating some variability in her HR/BP without any stimulation\n or change in IV gtts. Noted to have HR 70 sinus rhythm with SBP 102--\n one minute later, HR 58 SB, SBP 143. CCU resident notified.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:03 ------\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703545,
"text": "Npn: add s/p pericardial drain\n Pericardial drain flushed at 5pm. Intact. 50cc o/p after this w bag to\n gravity drainage. At 9pm attempted to flush w heparinized saline,\n unsuccessful. CCU resident and intern alerted. HR and BP remained\n stable. Cont on neo at .5. propofol at 60mcg. Pt responds to\n stimulation, follows commands.\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703654,
"text": "TITLE:\n Chief Complaint: ventricular arrhythmia\n 24 Hour Events:\n ARTERIAL LINE - START 01:24 PM\n Comfortable o/n, no pain, pt expressing desire to have tube pulled.\n -pericardial drain with 250 ccs thus far, 50 since 2AM\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 87 (57 - 87) bpm\n BP: 117/73(89) {85/52(62) - 148/78(98)} mmHg\n RR: 26 (7 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Total In:\n 4,228 mL\n 343 mL\n PO:\n TF:\n IVF:\n 4,168 mL\n 283 mL\n Blood products:\n Total out:\n 3,103 mL\n 345 mL\n Urine:\n 1,025 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 25 mL\n Balance:\n 1,125 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 17 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n ABG: 7.42/35/132/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 330\n Physical Examination\n GENERAL: intubated, sedated, responsive\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 221 K/uL\n 10.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 12 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.3 %\n 10.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n WBC\n 12.2\n 10.7\n Hct\n 33.1\n 32.5\n 30.3\n Plt\n 238\n 221\n Cr\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n Other labs: PT / PTT / INR:12.2/24.8/1.0, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - TTE this AM, eval for resolution of effusion\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n ------ Protected Section ------\n EPS Fellow addendum\n Pt seen and examined, agree with above.\n Pt had approx 150cc bloody drainage total since coming to ccu yesterday\n at 1:30 pm. Approx 50cc passive drainage 2am-10am. Passed her SBT\n today, getting echo.\n Short bursts of NSVT this morning but quiet since getting Rhythmol\n dose.\n VSS\n Opens eyes to voice, follows simple commands.\n RRR no rub\n Labs reviewed\n A/P\n 64 year old woman with VT and bleeding during attempt at epicardial\n ablation.\n 1. Pericardial drain: Still with some drainage. Will leave in\n overnight, repeat echo today\n 2. VT\n continue rhythmol\n 3. Respiratory: If effusion not enlarging, will wake patient up\n later today and likely extubate\n 4. Rest of plan per housestaff\n 5.\n 6. ------ Protected Section Addendum Entered By:\n , MD on: 11:44 ------\n 7.\n 8.\n 9. Electronically signed by , MD\n 11:44\n 10.\n 11. Pt seen discussed, examined with Dr. agree with\n assessment and plan to extubate tonite and hopefully remove drain in\n am. Minimal fuid anteriorly by echo. Short runs of nsvt., now quiet on\n rhythmol.\n 12. ------ Protected Section Addendum Entered By: , MD\n on: 04:58 PM ------\n 13.\n 14.\n 15. Electronically signed by , MD 04:58 PM\n 16.\n 17.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703732,
"text": "Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n The patient has a history of polymorphic, monomorphic VT as well as\n VF. She has undergone now endocardial and epicardial mapping with\n ablation.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703822,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on Transferred to the\n CCU following epicardial VT mapping and VT ablation c/b\n pericardial effusion requiring drain, intubation and pressors.\n : extubated and pressors dc/d\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action\n Rec\nd pt in NSR 70-80\n 0750, HR noted 140-150\ns. BP down to 60\ns via aline. Tachy complexes\n are both wide and narrow.\n Pt rec\nd 5mg IVP lopressor, lyte replacement. Tachycardia resolved\n within 60min.\n Propafenone dc\nd in favor of dig 0.25 at noon and 0.125 at 1800.\n Lopressor started 25mg .\n Pericardial drain w/ no fluid removal. Removed by Card fellow.\n AM Hct 25.5\n OOB to chair this afternoon.\n All questions answered regarding med changes and POC.\n Response:\n Lytes adequately repleted (K+4.6, Mg 2.2)\n VEA continues.\n Repeat Hct 25.6\n Tolerated OOB to chair without difficulty.\n Good understanding of VT and meds.\n Plan:\n Close monitoring of lytes and Hct w/ aggressive repletion of lytes.\n Daily dose of dig . Dronedarone 400mg to start .\n Increase activity as tolerated.\n Keep pt informed of poc per multidisiciplinary rounds.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703753,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n : extubated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n The patient has a history of polymorphic, monomorphic VT as well as\n VF. She has undergone now endocardial and epicardial mapping with\n ablation.\n Having freq. runs of VT, beats up to 10beats. Mg+ 1.8, K+ 3.9,\n Phos 3.4\n Pt. denies SOB, palps.\n Afeb.\n HR 90-113 ST in eve, BP 90\ns/50.\n Action:\n Mag , K and phos repleted. Contin. On antiarythmic propafenone HCL\n Pericardial drain unable to aspirate. Flushed with heparinized saline\n per ICU protocol. Flushes easily.\n Response:\n VEA dramatically reduced after mag repletion. Only occas. PVC since\n 0300. HR down to 80\ns SR. BP stable.\n Drain site D/I. fluid in tubing appears mostly serous.\n *** HCT in AM down 25.6 (30.3). HO aware. VSS and with no further\n fluid from drain- will monitor and recheck HCT with echo\n Pt. slept well . no pain. Warm extremeties.\n Asking about going home and overall plan.\n Plan:\n Echo in AM. Recheck HCT. Monitor lytes.\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Electrophysiology Physician Note",
"row_id": 703902,
"text": "TITLE: EP Fellow Progress Note\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: -No new events\n -Propafenone stopped\n -AF with narrow complex response at 3 am at rate 120's, tolerated well\n -Started digoxin and metoprolol\n -Pericardial drain removed yesterday\n Medications\n Changed\n Digoxin 0.125 mg daily\n Metoprolol 5 mg IV x 2, 12.5 po x 1\n Physical Exam\n General appearance: NAD, appears well\n BP: 130 / 70 mmHg\n HR: 60 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 37.6 C\n Tmax F last 24 hours: 99.6 F\n T current C: 36.1 C\n T current F: F\n O2 sat: 100 % on Supplemental oxygen:\n Previous day:\n Intake: 1,070 mL\n Output: 1,610 mL\n Fluid balance: -540 mL\n Today:\n Intake: 150 mL\n Output: 0 mL\n Fluid balance: 150 mL\n HEENT: (Oral mucosa: Moist)\n Cardiovascular: (Auscultation: RRR, Nml S1 and S2)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: Soft, NTND)\n Neurological: (Orientation: alert, appropriate)\n Extremities:\n Right: (Edema: None)\n Left: (Edema: None)\n Labs\n 214\n 9.1\n 101\n 0.8\n 24\n 4.3\n 13\n 107\n 142\n 25.3\n 6.7\n [image002.jpg]\n 02:21 PM\n 10:05 PM\n 04:34 AM\n 05:35 PM\n 08:31 PM\n 05:24 AM\n 04:18 PM\n 03:18 AM\n WBC\n 12.2\n 10.7\n 8.3\n 6.7\n Hgb\n 11.5\n 10.7\n 8.9\n 9.1\n Hct (Serum)\n 33.1\n 32.5\n 30.3\n 25.6\n 25.5\n 25.3\n Plt\n 238\n 221\n 191\n 214\n INR\n 1.0\n 1.0\n 0.8\n PTT\n 24.8\n 30.3\n 28.4\n Na+\n 142\n 141\n 138\n 136\n 142\n K + (Serum)\n 4.5\n 4.5\n 4.2\n 3.9\n 4.0\n 4.6\n 4.3\n Cl\n 111\n 108\n 106\n 105\n 107\n HCO3\n 24\n 25\n 24\n 27\n 24\n BUN\n 11\n 12\n 12\n 9\n 13\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.9\n 0.8\n 0.8\n Glucose\n 82\n 112\n 117\n 101\n ABG: / / / 24 / Values as of 03:18 AM\n Tests\n ECG: (Date: ), AF at 125 bpm with QRS at 120 ms; nml QTc\n Assessment and Plan\n 64 year old female with infarct related myopathy, EF 40-45% in past,\n although seems worse by focused views TTE, recurrent VT s/p recent\n epicardial and endocardial mapping with epicardial ablation c/b\n pericardial bleed s/p drainage, now improved with drain removed.\n Additionally, had AF with RVR, wide complex propafenone.\n Propafenone stopped, started on nodal agents with plan for dronedarone\n initiation tomorrow.\n 1. AF:\n -Brief episodes last night as refused higher dose of BB (only received\n 1 dose po)\n -Continue digoxin 0.125 daily\n -Please initiate metoprolol 25 mg (or at least 12.5 mg )\n -Plan dronederone initiation tomorrow at 400 mg to start in am\n 2. VT:\n - No increased episodes\n -Start dronederone tomorrow as noted above\n 3. Heart Failure:\n -Obtain TTE tomorrow\n -Continue BB\n D/W Housestaff and Dr. . Rest of plan per housestaff.\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703903,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on Transferred to the\n CCU following epicardial VT mapping and VT ablation c/b\n pericardial effusion requiring drain, intubation and pressors.\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- HR now\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor. 2gm Mg IV.\n Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats\n Plan:\n Continue to rate control. Monitor VS as tolerated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703904,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on Transferred to the\n CCU following epicardial VT mapping and VT ablation c/b\n pericardial effusion requiring drain, intubation and pressors.\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF overnight- SB @ present w/ occ PVC\ns- HR 50\ns- Maps 58-87\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor. 2gm Mg IV.\n Lopressor 25mg given this am.\n Response:\n NSR/SB with with frequent ectopic beats\n Plan:\n Continue to rate control. Monitor VS as tolerated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight. Occ to freq PVC\n today.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Electrophysiology Physician Note",
"row_id": 703905,
"text": "TITLE: EP Fellow Progress Note\n History of Present Illness\n Date: \n Subsequent care\n Seen and examined with: Dr. and housestaff\n Events / History of present illness: -No new events\n -Propafenone stopped\n -AF with narrow complex response at 3 am at rate 120's, tolerated well\n -Started digoxin and metoprolol\n -Pericardial drain removed yesterday\n Medications\n Changed\n Digoxin 0.125 mg daily\n Metoprolol 5 mg IV x 2, 12.5 po x 1\n Physical Exam\n General appearance: NAD, appears well\n BP: 130 / 70 mmHg\n HR: 60 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 37.6 C\n Tmax F last 24 hours: 99.6 F\n T current C: 36.1 C\n T current F: F\n O2 sat: 100 % on Supplemental oxygen:\n Previous day:\n Intake: 1,070 mL\n Output: 1,610 mL\n Fluid balance: -540 mL\n Today:\n Intake: 150 mL\n Output: 0 mL\n Fluid balance: 150 mL\n HEENT: (Oral mucosa: Moist)\n Cardiovascular: (Auscultation: RRR, Nml S1 and S2)\n Respiratory: (Auscultation: CTA B/L)\n Abdomen: (Palpation: Soft, NTND)\n Neurological: (Orientation: alert, appropriate)\n Extremities:\n Right: (Edema: None)\n Left: (Edema: None)\n Labs\n 214\n 9.1\n 101\n 0.8\n 24\n 4.3\n 13\n 107\n 142\n 25.3\n 6.7\n [image002.jpg]\n 02:21 PM\n 10:05 PM\n 04:34 AM\n 05:35 PM\n 08:31 PM\n 05:24 AM\n 04:18 PM\n 03:18 AM\n WBC\n 12.2\n 10.7\n 8.3\n 6.7\n Hgb\n 11.5\n 10.7\n 8.9\n 9.1\n Hct (Serum)\n 33.1\n 32.5\n 30.3\n 25.6\n 25.5\n 25.3\n Plt\n 238\n 221\n 191\n 214\n INR\n 1.0\n 1.0\n 0.8\n PTT\n 24.8\n 30.3\n 28.4\n Na+\n 142\n 141\n 138\n 136\n 142\n K + (Serum)\n 4.5\n 4.5\n 4.2\n 3.9\n 4.0\n 4.6\n 4.3\n Cl\n 111\n 108\n 106\n 105\n 107\n HCO3\n 24\n 25\n 24\n 27\n 24\n BUN\n 11\n 12\n 12\n 9\n 13\n Creatinine\n 0.8\n 0.8\n 0.8\n 0.9\n 0.8\n 0.8\n Glucose\n 82\n 112\n 117\n 101\n ABG: / / / 24 / Values as of 03:18 AM\n Tests\n ECG: (Date: ), AF at 125 bpm with QRS at 120 ms; nml QTc\n Assessment and Plan\n 64 year old female with infarct related myopathy, EF 40-45% in past,\n although seems worse by focused views TTE, recurrent VT s/p recent\n epicardial and endocardial mapping with epicardial ablation c/b\n pericardial bleed s/p drainage, now improved with drain removed.\n Additionally, had AF with RVR, wide complex propafenone.\n Propafenone stopped, started on nodal agents with plan for dronedarone\n initiation tomorrow.\n 1. AF:\n -Brief episodes last night as refused higher dose of BB (only received\n 1 dose po)\n -Continue digoxin 0.125 daily\n -Please initiate metoprolol 25 mg (or at least 12.5 mg )\n -Plan dronederone initiation tomorrow at 400 mg to start in am\n 2. VT:\n - No increased episodes\n -Start dronederone tomorrow as noted above\n 3. Heart Failure:\n -Obtain TTE tomorrow\n -Continue BB\n D/W Housestaff and Dr. . Rest of plan per housestaff.\n ------ Protected Section ------\n Pt seen, examined, discussed with Dr , agree with assessment and\n plan to give BB and dronederone. And digoxin. Off propafenone QRS\n narrower. Also had some NS-VT. If she has recurrent AF on dronederone,\n I would consider an AF ablation. Repeat echo in am and start coumadin\n tomorrow. Needs anemia w/u (she was 29% on admission). To .\n ------ Protected Section Addendum Entered By: , MD\n on: 09:04 ------\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703634,
"text": "TITLE:\n Chief Complaint: ventricular arrhythmia\n 24 Hour Events:\n ARTERIAL LINE - START 01:24 PM\n Comfortable o/n, no pain, pt expressing desire to have tube pulled.\n -pericardial drain with 250 ccs thus far, 50 since 2AM\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 87 (57 - 87) bpm\n BP: 117/73(89) {85/52(62) - 148/78(98)} mmHg\n RR: 26 (7 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Total In:\n 4,228 mL\n 343 mL\n PO:\n TF:\n IVF:\n 4,168 mL\n 283 mL\n Blood products:\n Total out:\n 3,103 mL\n 345 mL\n Urine:\n 1,025 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 25 mL\n Balance:\n 1,125 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 17 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n ABG: 7.42/35/132/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 330\n Physical Examination\n GENERAL: intubated, sedated, responsive\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 221 K/uL\n 10.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 12 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.3 %\n 10.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n WBC\n 12.2\n 10.7\n Hct\n 33.1\n 32.5\n 30.3\n Plt\n 238\n 221\n Cr\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n Other labs: PT / PTT / INR:12.2/24.8/1.0, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - TTE this AM, eval for resolution of effusion\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n ------ Protected Section ------\n EPS Fellow addendum\n Pt seen and examined, agree with above.\n Pt had approx 150cc bloody drainage total since coming to ccu yesterday\n at 1:30 pm. Approx 50cc passive drainage 2am-10am. Passed her SBT\n today, getting echo.\n Short bursts of NSVT this morning but quiet since getting Rhythmol\n dose.\n VSS\n Opens eyes to voice, follows simple commands.\n RRR no rub\n Labs reviewed\n A/P\n 64 year old woman with VT and bleeding during attempt at epicardial\n ablation.\n 1. Pericardial drain: Still with some drainage. Will leave in\n overnight, repeat echo today\n 2. VT\n continue rhythmol\n 3. Respiratory: If effusion not enlarging, will wake patient up\n later today and likely extubate\n 4. Rest of plan per housestaff\n 5.\n 6. ------ Protected Section Addendum Entered By:\n , MD on: 11:44 ------\n 7.\n 8.\n 9. Electronically signed by , MD\n 11:44\n 10.\n 11.\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 703527,
"text": "Chief Complaint:\n HPI:\n 64 yo female with a history of a mixed dilated cardiomyopathy, EF 40%,\n s/p VF arrest and ICD placement in (with a coronary cath without\n obstructive CAD) who was admitted on for her ICD firing. In\n the past, pt had ICD shocks and underwent cath with 70-80% RCA\n lesion that was stented with DES, with no other coronary disease\n noted. On , she had a repeat coronary angiography which was\n negative for new obstructive disease. She also underwent an EPS for VT\n with VT mapping. Polymorphic VT and VF were induced, as well as a\n superiorly directed monomorphic VT that did not\n appear to originate from the endocardial region of scar by\n voltage mapping (basal scar identified). As pt is also known to\n have akinesis of mid anterior wall, as well as basal aneurysm,\n this was thought to be a possible focus of her VT, thus was planned for\n epicardial VT mapping. No ablation was attempted on the first EP\n study.\n .\n Today, the patient underwent epicardial as well left sided VT mapping\n and ablation under general anesthesia. Two types of VT were induced\n during the procedure. During the procedure she required dopamine\n infusion (up to 10mcg/kg/min) for hypotension, which was changed to\n norepinephrine prior to transfer to the CCU. She had a pericardial\n drain placed for the epicardial procedure which continues to drain\n fluid, draining a total of 800ccs of blood. After this was noted the\n patient was given protamine (total of 40mg) to reverse the heparin\n given in the procedure. She was also transfused two units of PRBCs\n although her Hct did not decrease dramatically.\n .\n Unable to obtain review of symptoms given the patient is intubated and\n sedated\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Propofol - 70 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Rhythmol 325mg \n Lexapro 10mg daily\n Diovan 40mg daily\n Oxazepam 15mg qhs prn\n Premarin 1.25mg daily\n Plavix 75mg daily\n Crestor 5mg daily\n Aspirin 325mg daily\n Zantac 150mg PRN\n Flonase 2 sprays each nostril PRN\n Ntg 0.4 SL PRN\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: (+)Hypertension\n 2. CARDIAC HISTORY: Cardiomyopathy with EF 40%, mixed etiology\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS: CAD s/p RCA DES \n -PACING/ICD: VF arrest s/p AICD implant , generator change \n .\n 3. OTHER PAST MEDICAL HISTORY:\n Transgender operation approx -male to female\n Asthma\n Bronchitis\n Recent URI-treated with Cipro\n Acid Reflux\n Face lift \n Recent sinus infections\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: socially\n Other: The patient lives alone and works as a quality technician and\n cashier at stop and shop.\n Review of systems:\n Flowsheet Data as of 06:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (97\n HR: 68 (66 - 84) bpm\n BP: 106/61(76) {85/52(62) - 127/73(90)} mmHg\n RR: 15 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Total In:\n 251 mL\n PO:\n TF:\n IVF:\n 251 mL\n Blood products:\n Total out:\n 0 mL\n 2,588 mL\n Urine:\n 585 mL\n NG:\n Stool:\n Drains:\n 103 mL\n Balance:\n 0 mL\n -2,337 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n ABG: 7.35/39/140/24/-3\n Ve: 10.9 L/min\n PaO2 / FiO2: 350\n Physical Examination\n GENERAL: intubated, sedated.\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 not elevated.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. pericardial\n drain in place draining sanginous fluid\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, coarse breath sounds\n bilaterally, no crackles, wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+\n Labs / Radiology\n 238 K/uL\n 11.5 g/dL\n 82 mg/dL\n 0.8 mg/dL\n 11 mg/dL\n 24 mEq/L\n 111 mEq/L\n 4.5 mEq/L\n 142 mEq/L\n 33.1 %\n 12.2 K/uL\n [image002.jpg]\n \n 2:33 A10/22/ 02:21 PM\n \n 10:20 P10/22/ 02:25 PM\n \n 1:20 P10/22/ 05:07 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 12.2\n Hct\n 33.1\n Plt\n 238\n Cr\n 0.8\n TC02\n 26\n 22\n Glucose\n 82\n Other labs: PT / PTT / INR:12.2/24.8/1.0, Ca++:7.2 mg/dL, Mg++:1.6\n mg/dL, PO4:5.0 mg/dL\n EKG: Sinus rhythm at a rate of 70bpm, interventricular conduction\n delay, with a left- axis.\n .\n TELEMETRY: normal sinus rhythm\n .\n 2D-ECHOCARDIOGRAM: - not in our system - EF 40% LV mildly\n dilated, mild hypokinesis of the basal segment and anteroseptal\n segment, impaired relaxation of the LV, moderate MVP, moderate to\n severe, 3+MR, moderate to severe TR.\n .\n ETT: none\n .\n CARDIAC CATH: \n 1- Selective coronary angiography of this right dominant system showed\n patent ostial RCA stent, mild luminal irregularities to the LMCA and\n LAD system with 20% tubular stenosis in the proximal LCX (small\n vessel).\n 2- Diffisulty engaging the RCA ostium due to the stent \"sticking out\"\n into the aorta. A LIMA catheter eventually engeged (after several\n attempts and failure of JR4 and AR-1 catheters).\n 3- Normal systemnic arterial blood pressure.\n 4- An attempt to close the R groin with Perclose device was aborted as\n the EP service requested preservation of arterial access. The 5 French\n sheath was exchanged for a new 8 French sheath.\n FINAL DIAGNOSIS:\n 1. Patent RCA stent and no occlusive CAD in the rest of the coronary\n arteries.\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - Continue to monitor output of the pericardial drain. TTE in the AM\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure. Drain in place.\n - Continue to monitor drain output\n - will check for presence of persistence of pericardial effusion with\n repeat TTE in AM\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Unclear if had been taking a statin, will start one today\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and wean\n ventilator and sedation as tolerated.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n .\n FEN: NPO for now, will start heart healthy diet once extubated.\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC TID\n -Pain management with NSAIDS, morphine as needed\n -Bowel regimen with colace, senna\n .\n CODE: Presumed full\n .\n COMM: Brother and patient\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703876,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 03:00 AM\n New rhythmn on telemetry. Pt asymptomatic. VSS.\n \n -In and out of what looked like slow VT, EP said a fib with aberrancy,\n given Metoprolol 5mg IV. Back in sinus.\n -focused TTE did not show recurrence of pericardial effusion.\n -Pericardial drain pulled. Scheduled for full TTE Mon to evaluate EF,\n as focused TTE seemed to show lower EF than most recent echo.\n -Pt ok with not taking Estrogen for a while in-house (skips weeks at a\n time at home)\n -Propofenone d/c'ed. Dronedarone 400mg to start Mon after\n Propofenone washes out.\n -Started on Metoprolol 25mg po bid (PM dose not given, as below)\n -Digoxin 'load' and initiated daily dose 0.125mg daily.\n -Back in a fib with RVR at 110's-130's, given Metoprolol 5mg IV x2, Mg\n 2mg IV, her evening Phos (not given when ordered), Metoprolol 12.5mg po\n (PM Metoprolol 25mg was not given for low BP and pt desire). Patient\n went back into sinus with HR 50s-60s and BP high 80's-90's.\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Metoprolol - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.1\nC (97\n HR: 56 (56 - 154) bpm\n BP: 96/53(67) {85/48(50) - 116/71(77)} mmHg\n RR: 14 (10 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 66.4 kg (admission): 65 kg\n Height: 68 Inch\n Total In:\n 1,070 mL\n 150 mL\n PO:\n 1,020 mL\n 100 mL\n TF:\n IVF:\n 50 mL\n 50 mL\n Blood products:\n Total out:\n 1,610 mL\n 0 mL\n Urine:\n 1,610 mL\n NG:\n Stool:\n Drains:\n Balance:\n -540 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n GENERAL: intubated, sedated, responsive\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n Labs / Radiology\n 214 K/uL\n 9.1 g/dL\n 101 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 107 mEq/L\n 142 mEq/L\n 25.3 %\n 6.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n 05:35 PM\n 05:24 AM\n 04:18 PM\n 03:18 AM\n WBC\n 12.2\n 10.7\n 8.3\n 6.7\n Hct\n 33.1\n 32.5\n 30.3\n 25.6\n 25.5\n 25.3\n Plt\n 238\n 221\n 191\n 214\n Cr\n 0.8\n 0.8\n 0.8\n 0.9\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n 117\n 101\n Other labs: PT / PTT / INR:10.4/28.4/0.8, Albumin:3.1 g/dL, Ca++:8.0\n mg/dL, Mg++:2.0 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - TTE this AM, eval for resolution of effusion\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:24 PM\n 16 Gauge - 01:26 PM\n 20 Gauge - 08:00 AM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: Potentially call out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703881,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on Transferred to the\n CCU following epicardial VT mapping and VT ablation c/b\n pericardial effusion requiring drain, intubation and pressors.\n : extubated and pressors dc/d\n 24hr Significant Event\n RAF 110-140s. VSS. Asymptomatic.\n Foley discontinued\n Atrial fibrillation (Afib)\n Assessment:\n RAF\n Action:\n Lopressor 5mg IV x 2 followed by 12.5mg of PO Lopressor. 2gm Mg IV\n Response:\n NSR/SB with with frequent ectopic beats\n Plan:\n Continue to rate control. Monitor VS as tolerated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Occasional VEA, self-limiting runs x 2 overnight.\n Action:\n Continue Digoxin load. Plans to start Dronedarone on .\n Response:\n VEA decreasing\n Plan:\n Continue to monitor telemetry, antiarrythmics as needed, follow lytes\n and replete as neccesary\n"
},
{
"category": "Physician ",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703607,
"text": "TITLE:\n Chief Complaint: ventricular arrhythmia\n 24 Hour Events:\n ARTERIAL LINE - START 01:24 PM\n Comfortable o/n, no pain, pt expressing desire to have tube pulled.\n -pericardial drain with 250 ccs thus far, 50 since 2AM\n Allergies:\n Penicillins\n asthma attack i\n Amiodarone\n Unknown;\n Quinidine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 87 (57 - 87) bpm\n BP: 117/73(89) {85/52(62) - 148/78(98)} mmHg\n RR: 26 (7 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.4 kg (admission): 65 kg\n Total In:\n 4,228 mL\n 343 mL\n PO:\n TF:\n IVF:\n 4,168 mL\n 283 mL\n Blood products:\n Total out:\n 3,103 mL\n 345 mL\n Urine:\n 1,025 mL\n 320 mL\n NG:\n Stool:\n Drains:\n 178 mL\n 25 mL\n Balance:\n 1,125 mL\n -2 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 17 cmH2O\n Plateau: 11 cmH2O\n SpO2: 100%\n ABG: 7.42/35/132/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 330\n Physical Examination\n GENERAL: intubated, sedated, responsive\n HEENT: MMM\n CARDIAC: RRR, no MRG pericardial drain in place draining sanginous\n fluid\n LUNGS: CTAB, course BS\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Left groin site has no\n hematoma, bruit or oozing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 221 K/uL\n 10.7 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 12 mg/dL\n 108 mEq/L\n 141 mEq/L\n 30.3 %\n 10.7 K/uL\n [image002.jpg]\n 02:21 PM\n 02:25 PM\n 05:07 PM\n 10:05 PM\n 04:34 AM\n 05:27 AM\n WBC\n 12.2\n 10.7\n Hct\n 33.1\n 32.5\n 30.3\n Plt\n 238\n 221\n Cr\n 0.8\n 0.8\n TCO2\n 26\n 22\n 23\n Glucose\n 82\n 112\n Other labs: PT / PTT / INR:12.2/24.8/1.0, Ca++:8.0 mg/dL, Mg++:2.2\n mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on transferred to the\n CCU following epicardial VT mapping.\n .\n #. RHYTHM: The patient has a history of polymorphic, monomorphic VT\n as well as VF. She has undergone now endocardial and epicardial\n mapping with ablation. Given the epicardial approach, she has a\n pericardial drain in place.\n - TTE this AM, eval for resolution of effusion\n - Continue propafenone, CR not on formulary, will require TID dosing\n - ICD in place\n - Monitor on telemetry\n .\n #. PUMP: The patient has a history of a mixed picture of\n cardiomyopathy with an EF documented at 40% in . Should repeat\n TTE while inpatient to document level of pericardial fluid following\n procedure, however no evidence of tamponade physiology o/n. Drain in\n place.\n - Continue to monitor drain output, will dc if fluid output continues\n to decline and there is no evidence of effusion on ECHO.\n - Monitor I/0s and daily weights\n .\n # CORONARIES: This admission coronary catheterization shows patency of\n RCA DES. No other occlusive coronary artery diease.\n - Continue ASA and plavix\n - Continue statin\n .\n # Hypertension: Monitor blood pressures closely given risk of\n tamponade. Given borderline blood pressures, will hold home regimen of\n diovan.\n .\n # Respiratory: The patient was electively intubated for the procedure\n and general anesthesia. Will montior respiratory status and plan for\n extubation after TTE today.\n .\n # Transgender operation: Hold premarin used for hormone replacement\n while the patient is in the CCU given increased risk of coronary artery\n disease with hormone replacement therapy.\n .\n # Depression: Continue lexapro. On chronic , use\n propofol for sedation and restart oxazepam when off sedation.\n .\n # GERD: Continue zantac\n .\n # Chronic sinus problems: Continue flonase when extubated.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: n/a\n Lines:\n Arterial Line - 01:24 PM\n 22 Gauge - 01:25 PM\n 20 Gauge - 01:25 PM\n 16 Gauge - 01:26 PM\n Prophylaxis:\n DVT: heparin subcu\n Stress ulcer: ranitidine\n VAP: elevate HOB\n Comments:\n Communication: Comments: with pt and brother, who is HCP\n status: full\n Disposition: CCU while drain in place\n"
},
{
"category": "Nutrition",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 703628,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Ht: 68in\n Wt: 65kg\n IBW: 63.5kg\n %IBW: 102%\n BMI: 21.7\n Diet order: NPO\n PMHx:\nNon-ischemic cardiomyopathy\nVF arrest and \nCAD s/p Xience DES to RCA \nAsthma\nBronchitis\nGERD\nRecent URI treated with Cipro\nRecent Sinus infection\ns/p AICD \nTransgender opeation approx - male to female\ns/p Face lift \n Comments:\n ABDOMEN: Soft, NTND. No HSM or tenderness.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n 64 year old female transferred to the CCU following VT mapping.\n Patient was electively intubated for the procedure and general\n anesthesia. Per chart, plan for extubation after TTE today. Will\n follow up regarding diet advancement. \n"
},
{
"category": "Nursing",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703814,
"text": "64 year old female with history of mixed cardiomyopathy, VF s/p ICD\n with ICD shocks, no new CAD, and inducible VT on Transferred to the\n CCU following epicardial VT mapping and VT ablation c/b\n pericardial effusion requiring drain, intubation and pressors.\n : extubated.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action\n Rec\nd pt in NSR 70-80\n 0750, HR noted 140-150\ns. BP down to 60\ns via aline. Tachy complexes\n are both wide and narrow.\n Pt rec\nd 5mg IVP lopressor, lyte replacement. Tachycardia resolved\n within 60min.\n Propafenone\n Action:\n Mag , K and phos repleted. Contin. On antiarythmic propafenone HCL\n Pericardial drain unable to aspirate. Flushed with heparinized saline\n per ICU protocol. Flushes easily.\n Response:\n VEA dramatically reduced after mag repletion. Only occas. PVC since\n 0300. HR down to 80\ns SR. BP stable.\n Drain site D/I. fluid in tubing appears mostly serous.\n *** HCT in AM down 25.6 (30.3). HO aware. VSS and with no further\n fluid from drain- will monitor and recheck HCT with echo\n Pt. slept well . no pain. Warm extremeties.\n Asking about going home and overall plan.\n Plan:\n Echo in AM. Recheck HCT. Monitor lytes.\n Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703624,
"text": "Ventricular tachycardia, non-sustained (NSVT)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Echo",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Report",
"row_id": 95128,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/p emergent tap for tamponade during EP procedure.\nAssess for residual effusion.\nHeight: (in) 66\nWeight (lb): 132\nBSA (m2): 1.68 m2\nBP (mm Hg): 102/63\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 12:00\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum.\nMildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe MVP. Mild\nthickening of mitral valve chordae.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThere is mild (non-obstructive) focal hypertrophy of the basal septum. Overall\nleft ventricular systolic function is mildly depressed (LVEF= 45 %). Right\nventricular chamber size and free wall motion are normal. The mitral valve\nleaflets are myxomatous. There is moderate/severe mitral valve prolapse. There\nis a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Overall mildly depressed left ventricular systolic function. No\nsignficant pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2123-11-15 00:00:00.000",
"description": "Report",
"row_id": 95608,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 66\nWeight (lb): 136\nBSA (m2): 1.70 m2\nBP (mm Hg): 105/62\nHR (bpm): 58\nStatus: Inpatient\nDate/Time: at 08:43\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\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Normal IVC diameter (<2.1cm) with >55% decrease\nduring respiration (estimated RA pressure (0-5mmHg).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous mitral valve\nleaflets. Mild MVP.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe estimated right atrial pressure is 0-5 mmHg. The mitral valve leaflets are\nmildly thickened/myxomatous with bileaflet systolic prolapse. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Report",
"row_id": 95060,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate pericardial effusion.\nHeight: (in) 66\nWeight (lb): 136\nBSA (m2): 1.70 m2\nBP (mm Hg): 95/53\nHR (bpm): 122\nStatus: Inpatient\nDate/Time: at 11:08\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nOverall left ventricular systolic function is severely depressed (LVEF= 20-30\n%) although difficult to assess given rapid heart rate. The right ventricular\ncavity is mildly dilated with moderate global free wall hypokinesis. There is\na trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is smaller.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Report",
"row_id": 95061,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Right ventricular function.\nHeight: (in) 66\nWeight (lb): 132\nBSA (m2): 1.68 m2\nBP (mm Hg): 98/62\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 13:04\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum.\nMildly depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: No atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe MVP. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\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 monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Emergency study.\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium. There is\nmild (non-obstructive) focal hypertrophy of the basal septum. Overall left\nventricular systolic function is mildly depressed (LVEF= 40 %). Right\nventricular chamber size and free wall motion are normal. Multiple wires are\npresent the RA/RV. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are myxomatous. There is\nmoderate/severe mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery\nsystolic pressure is normal. There is a trivial/physiologic pericardial\neffusion anterior to the right ventricle and no pericardial effusion posterior\nto the left ventricle.\n\nIMPRESSION: Mildly depressed left ventricular systolic function. Trivial\npericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Report",
"row_id": 95127,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. F/U s/p tap.\nHeight: (in) 66\nWeight (lb): 130\nBSA (m2): 1.67 m2\nBP (mm Hg): 110/64\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 11:47\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npt intubated on vent.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous mitral valve\nleaflets.\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe mitral valve leaflets are mildly thickened. The mitral valve leaflets are\nmyxomatous. There is a small anterior pericardial effusion. The effusion is\necho dense, consistent with blood, inflammation or other cellular elements.\nThere are no echocardiographic signs of tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Report",
"row_id": 252829,
"text": "Sinus rhythm with short bursts of wide complex tachycardia which is likely\natrial fibrillation with rapid ventricular response, although short bursts of\nventricular tachycardia is also a possibility. Conducted complexes are\nconducted with intraventricular conduction delay. The other complexes have a\nfull left bundle-branch block pattern. Compared to tracing #1 the rate is\ndecreased. Sinus rhythm is seen on the current tracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Report",
"row_id": 252830,
"text": "Wide complex tachycardia which is irregular in nature suggesting atrial\nfibrillation with left bundle-branch block conduction. However, ventricular\ntachycardia is not excluded. Compared to the previous tracing of the\nrhythm is now irregular, the rate has increased substantially and the\nQRS complexes appear substantially wider. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-15 00:00:00.000",
"description": "Report",
"row_id": 252826,
"text": "Sinus bradycardia with ventricular premature beats. Diffuse non-specific\nST-T wave abnormalities. Compared to the previous tracing of rapid\natrial fibrillation has resolved. Clinical correlation and repeat tracing are\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-14 00:00:00.000",
"description": "Report",
"row_id": 252827,
"text": "Atrial fibrillation with rapid ventricular response. Intraventricular\nconduction delay. Compared to tracing #3 the rate has increased again. The\nrhythm appears to be atrial fibrillation. Of note, the complexes\nappear to be narrower in spite of the increased rate.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-13 00:00:00.000",
"description": "Report",
"row_id": 252828,
"text": "Sinus rhythm with multiple ventricular premature beats and atrial premature\nbeats. Intraventricular conduction delay of left bundle-branch block type.\nCompared to tracing #2 the rate is further decreased and there are no bursts of\nwide complex tachycardia seen on the current tracing.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-11 00:00:00.000",
"description": "Report",
"row_id": 253055,
"text": "Baseline artifact. Probable sinus rhythm. Intraventricular conduction delay.\nLeftward axis. T wave abnormalities. Since the previous tracing of \nlateral precordial T wave abnormalities are more prominent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-10 00:00:00.000",
"description": "Report",
"row_id": 253056,
"text": "Normal sinus rhythm. Intraventricular conduction delay. Compared to\ntracing #1 no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-09 00:00:00.000",
"description": "Report",
"row_id": 253057,
"text": "Sinus bradycardia. Intraventricular conduction delay. Compared to the previous\ntracing of no diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2123-11-12 00:00:00.000",
"description": "Report",
"row_id": 253054,
"text": "Sinus rhythm with a wide complex premature beat which may be supraventricular\ntachycardia with aberration or ventricular in origin. Conducted complexes\nhave an intraventricular conduction delay pattern. ST-T wave abnormalities.\nSince the previous tracing wide complex beats are new. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104243,
"text": " 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for consolidation or edema\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA\\VENTRICULAR TACHYCARDIA ABLATION **REMOTE WEST**/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for consolidation or edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph was compared to .\n\n The patient was extubated in the meantime interval. Heart size is mildly\n enlarged, stable. Mediastinal position, contour and width are stable as well.\n Distention of the azygos vein is noted but there is no evidence of pulmonary\n vasculature engorgement or edema.\n\n The two pacemaker defibrillator leads terminate in right ventricle with one of\n them looping most likely within the right atrium. The NG tube has been\n removed in the interim. There is a line projecting over the left upper\n abdomen, its purpose is unclear and should be correlated with clinical\n history. The lungs are clear. There is no pleural effusion or pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103940,
"text": " 3:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval OG placement\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA\\VENTRICULAR TACHYCARDIA ABLATION **REMOTE WEST**/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 yo female with a history of a mixed dilated cardiomyopathy, EF 40%, s/p VF\n arrest and ICD placement in (with a coronary cath without obstructive CAD)\n who was admitted on for her ICD firing.\n REASON FOR THIS EXAMINATION:\n Please eval OG placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 5:07 PM\n OG tube reaching well below the diaphragm.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: A 64-year-old female patient with history of mixed dilated\n cardiomyopathy, ejection fraction 40%, status post ventricular fibrillation\n arrest and ICD placement in . Admitted now on , for her ICD\n firing. Evaluate orogastric tube placement.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. The patient is intubated. The ETT terminates in the trachea\n some 5 cm above the level of the carina. A left-sided permanent pacer is\n identified, seen to be connected to two intracavitary ICD wires, none of which\n has been forming a small loop in the right atrial area. Both wires terminate\n in positions compatible with apical portion of the right ventricle. An NG\n tube has been placed seen to reach well below the diaphragm including the side\n port. There are other tortuous tubes overlying the upper abdominal area, but\n they may be external.\n\n The chest view does not include the entire left lateral portion.\n\n The accessible lung fields do not disclose any pulmonary vascular congestion\n or any acute infiltrates.\n\n IMPRESSION: Orogastric tube placed successfully to reach below the diaphragm\n in intubated patient with evidence of ICD device. No previous chest\n examination available for direct comparison.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103941,
"text": ", 3:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval OG placement\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA\\VENTRICULAR TACHYCARDIA ABLATION **REMOTE WEST**/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 yo female with a history of a mixed dilated cardiomyopathy, EF 40%, s/p VF\n arrest and ICD placement in (with a coronary cath without obstructive CAD)\n who was admitted on for her ICD firing.\n REASON FOR THIS EXAMINATION:\n Please eval OG placement\n ______________________________________________________________________________\n PFI REPORT\n OG tube reaching well below the diaphragm.\n\n\n"
}
] |
73,371 | 152,991 | Patient is a year-old woman with HTN, HLD, s/p multiple surgeries and history of SOB requiring ExLap who was transferd from Hospital with partial SBO and marked leucocytosis. . #. Small bowel obstruction: Patient has had mulitple admissions for SBO, most recently in requiring exploratory laparotomy with adhesionolysis now admitted with abdoinal pain, with n/v/d and leucocytosis. Blood cultures showed no growth at and were no growth (from )here at the time of discharge. She had diffuse TTP with rebound and guarding on admission exam. Patient was started on levaquin and flagyl at OSH and was continued on these medications. She was seen by the surgical service who recommended that she undergo surgery for complete small bowel obstruction. Both the patient and her family declined surgery and her goals of care were transitioned to focus on comfort while in the ICU. She was called out of the ICU on and her clinical status including exam, laboratory data, improved from . After discussion with her family and the patient, the decision was made to transition to conservative management for her SBO and IV antibiotics were restarted. She was changed from Cipro/Flagyl to Ceftriaxone/Flagyl due to itching and rash which developed up her arm with Cipro. NGT pulled night of since it had been displaced. She started having BMs on to the point of diarrhea with some formed stools. C. diff was negative and diarrhea improved by the morning of . Her diet was advanced which she tolerated well. Antibiotics were discontinued prior to discharge. . # Hypertension: Home lisinopril was initially stopped and then restarted. . Non-active issues: # hypothyroidism: continued home synthroid . # HLD: held home simvastatin and asa until better able to tolerate full diet. These medications were restarted on discharge. . # dementia: restarted home donezepil, holding namenda for now as non-formulary. This medication was restarted on discharge. . # Code: DNR/DNI (confirmed with patient). Discussed what she would want if SBO were to recur and plan would be to come to the hospital to get confortable with likely transition to comfort care (possible home hospice) . # Communication: Patient, daughter cell; home: ; son: . TRANSITIONAL ISSUES - blood cultures were pending at the time of discharge | FINDINGS: Orogastric tube tip terminates approximately at the level of the clavicles. Mild atherosclerotic calcification is present in the aortic arch. Mild tortuosity of the thoracic aorta. Mild elevation of the left hemidiaphragm. FINDINGS: Status post cholecystectomy. SBO FINAL REPORT PORTABLE ABDOMEN INDICATION: Abdominal pain and leukocytosis, shortness of breath. Nasogastric tube with normal course, the tip of the tube is not included on the image and can be appreciated on the plain abdomen film that was performed today. Normal distribution of intestinal gas. Mild cardiomegaly without evidence of pulmonary edema. pulmonary process FINAL REPORT CHEST RADIOGRAPH INDICATION: Abdominal pain and leukocytosis, questionable pulmonary process. REASON FOR THIS EXAMINATION: please evaluate for correct positioning of NG tube FINAL REPORT CHEST RADIOGRAPH TECHNIQUE: Portable AP semi-erect chest view was read in comparison with prior chest radiograph from . Heart size, mediastinal and hilar contours are normal. FINDINGS: The lung volumes are normal. Consider repositioning the orogastric tube. According clips in situ. Nasogastric tube with side port approximately 4-5 cm distal to the gastroesophageal junction. The tip projects over the middle parts of the stomach. 12:30 AM PORTABLE ABDOMEN Clip # Reason: ? 12:30 AM CHEST (PORTABLE AP) Clip # Reason: ? Whether this is positioned within the esophagus or is within the airway is difficult to determine based on the single view. 9:11 PM CHEST (PORTABLE AP) Clip # Reason: please evaluate for correct positioning of NG tube Admitting Diagnosis: PARTIAL SMALL BOWEL OBSTRUCTION MEDICAL CONDITION: year old woman with HTN, HLD, s/p multiple surgeries, SBO, now CMO with likely bowel strangulation, discomfort with NGtube suctioning. No intestinal distention. COMPARISON: . COMPARISON: . There are no lung opacities concerning for pneumonia. pulmonary process Admitting Diagnosis: PARTIAL SMALL BOWEL OBSTRUCTION MEDICAL CONDITION: year old woman with abdominal pain and leucocytosis REASON FOR THIS EXAMINATION: ? Extensive degenerative spine disease. SBO Admitting Diagnosis: PARTIAL SMALL BOWEL OBSTRUCTION MEDICAL CONDITION: year old woman with abdominal pain and leucocytosis REASON FOR THIS EXAMINATION: ? Findings related to the orogastric tube was discussed by with on at 10:27 p.m. No free air, no pathological calcifications. | 3 | [
{
"category": "Radiology",
"chartdate": "2109-02-10 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1221206,
"text": " 12:30 AM\n PORTABLE ABDOMEN Clip # \n Reason: ? SBO\n Admitting Diagnosis: PARTIAL SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abdominal pain and leucocytosis\n REASON FOR THIS EXAMINATION:\n ? SBO\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n INDICATION: Abdominal pain and leukocytosis, shortness of breath.\n\n COMPARISON: .\n\n FINDINGS: Status post cholecystectomy. According clips in situ. No free\n air, no pathological calcifications. Nasogastric tube with side port\n approximately 4-5 cm distal to the gastroesophageal junction. The tip\n projects over the middle parts of the stomach. Normal distribution of\n intestinal gas. No intestinal distention. No evidence of wall thickening, no\n air-fluid levels.\n\n Extensive degenerative spine disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1221207,
"text": " 12:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary process\n Admitting Diagnosis: PARTIAL SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abdominal pain and leucocytosis\n REASON FOR THIS EXAMINATION:\n ? pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Abdominal pain and leukocytosis, questionable pulmonary process.\n\n COMPARISON: .\n\n FINDINGS: The lung volumes are normal. Mild cardiomegaly without evidence of\n pulmonary edema. Nasogastric tube with normal course, the tip of the tube is\n not included on the image and can be appreciated on the plain abdomen film\n that was performed today. Mild elevation of the left hemidiaphragm. Mild\n tortuosity of the thoracic aorta.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1221333,
"text": " 9:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for correct positioning of NG tube\n Admitting Diagnosis: PARTIAL SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with HTN, HLD, s/p multiple surgeries, SBO, now CMO with\n likely bowel strangulation, discomfort with NG_tube suctioning.\n REASON FOR THIS EXAMINATION:\n please evaluate for correct positioning of NG tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Portable AP semi-erect chest view was read in comparison with\n prior chest radiograph from .\n\n FINDINGS: Orogastric tube tip terminates approximately at the level of the\n clavicles. Whether this is positioned within the esophagus or is within the\n airway is difficult to determine based on the single view. Consider\n repositioning the orogastric tube. There are no lung opacities concerning for\n pneumonia. Heart size, mediastinal and hilar contours are normal. Mild\n atherosclerotic calcification is present in the aortic arch. Findings related\n to the orogastric tube was discussed by with on \n at 10:27 p.m.\n\n"
}
] |
28,149 | 129,436 | The patient was admitted to the cardiology floor and placed on telemetry. EKG showed sinus bradycardia that over the course of several hours trended to HR in 60s with 2 brief episodes of bradycardia to 30s-40s with bowel movements, resolved before intervention made. He initially had a SBP in low 100s, and was given 1L IVFs over several hours. On the morning after admission, the patient had a decrease in BP from SBPs in 90s, 100s to 60s-70s. Despite IVFs, he continued to be hypotensive, requiring transfer to the ICU. His family and friends were called and given severe lung disease and poor response to resuscitation it was decided to pursue comfort measures and he died on . | In the right mid zone, there is a unilateral consolidation which could be acute or chronic in nature. FINAL REPORT INDICATION: Bronchiectasis, now with hypoxia and hypotension and respiratory difficulty. R wave progression is slower withpossible underlying anterior myocardial infarction. Sinus rhythm with possible subtle atrial ectopy. Left ventricularhypertrophy. Inferolateral ST segmentsagging is more pronounced raising question of ischemia, digitalis, etc.Exclude hyperkalemia, if clinically indicated. Left atrial abnormality. In addition, there is an unilateral opacity seen in the right mid zone along with more opacification seen at the right lower zone, worrisome for an acute on chronic lung disease. Sinus rhythm with borderline 1st degree A-V blockLeft ventricular hypertrophySince previous tracing of , heart rate faster, T wave amplitude lessprominent Intraventricular conduction delay. MildP-R interval prolongation. Vertical QRS axis in thiscontext raises consideration of biventricular overload. LS diminished upper and crackles lower. Clinical correlation issuggested.TRACING #1 FINAL REPORT PROCEDURE: Chest portable AP on . start morphine gtt), ? PNA and/or flu. Compared to the previous exam, there is new consolidation in the right lower lung zone and left lower lung zone. Droplet precautions for ? IMPRESSION: Radiographic evidence of fibrotic lung disease associated with traction bronchiectasis, bibasilar honeycombing and pleural fibrosis, right more than left. The extensive pleural thickening, bronchiectasis, and severe volume loss in the upper lobes is unchanged. In addition, there is more opacification at the right lung base, suspicious for an acute process. CXR done this AM, results pending.GI/GU: NPO, +BS, no stool this shift, abd soft/non-tender. CMO today as pt's resp status is not improving. Sinus rhythm. flu. 9:55 AM CHEST (PORTABLE AP) Clip # Reason: infiltrate, mass, edema? Compared to the previous tracing of multipleabnormalities are as previously reported. Clinical correlation issuggested.TRACING #2 3:25 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate, effusion. CHEST, ONE VIEW: Comparison with . Awaiting AM labs.Resp: CXR showed significant fibrotic lung disease in both lungs (worse on R side) w/ pleural fibrosis as well, and acute on chronic lung opacifications. FINDINGS: There is significant fibrotic lung disease seen in both lungs, right worse than left, with traction bronchiectasis in the right upper lobe, pleural thickening in both lungs, bibasal honeycombing. IMPRESSION: New bilateral lower lobe opacities may represent developing consolidations. Repleted Mg in evening w/ 2grams IV. bilat soft wrist restraints to keep o2 on and for line/tube safety, as pt is confused.Cardiac: NSR w/ occasional PVC's, several episodes brady to 40's but returns soon after, x1 episode asystolic for about 5seconds w/ oral care, recovered on own, MD was present. HR 66-85, SBP 70-121, remains on Dopamine @ 10mcg/kg/min. Treating w/ Vancomycin and piperacillin for ? REASON FOR THIS EXAMINATION: assess for infiltrate, effusion. Cardiac contour is difficult to assess due to overlying lung parenchyma, however, mediastinal, and hilar contours are probably similar. Caregiver updated by MD overnight.Dispo: cont to monitor BP, cont meds and abx, monitor pt for discomfort (? The lungs are over-inflated. Compared to theprevious tracing of no diagnostic change. Baseline artifact. No nasal aspirate d/t risk of brady and/or asystole. Hct stable @ 41.6. COMPARISON: None similar. Admitting Diagnosis: BRADYCADIA MEDICAL CONDITION: 87 year old man with bronchiectasis with cad with hypoxemia and hypotension. DL WBC 0.9 from 1.3 this AM. skin feels warm and pt states he is comfortable and does not feel cool. ab pt now on 100% NR and 6L NC w/ o2sat trending down this shift, now < 80%; desat to 50's when o2 removed. Skin w/d/i.Psychosocial: pt has sister that is yo w/ baseline dementia, has a caregiver are communicating w/, also a minister to contact as well. FSBG 100, no coverage per RISS.ID: unable to get temp oral, axillary, and rectal. Admitting Diagnosis: BRADYCADIA MEDICAL CONDITION: 87 year old man with tachypnea, hypoxia and cough productive of white mucus REASON FOR THIS EXAMINATION: infiltrate, mass, edema? Urine out foley yellow/clear, 20-190cc/hr w/ larger amts following 20mg IV lasix given in order to attempt to improve o2sat, treatment had no effect on o2sat. This shift o2sat 91-75%, rr 14-29. HISTORY: 87-year-old man with tachypnea, hypoxia and cough production of white mucus, evaluate for mass, edema. Osseous structures are unchanged. No cough noted. These findings necessitate further evaluation by a chest CT, preferably a high-resolution chest CT scan examination if the patient can tolerate the procedure, or if not, then a standard chest CT scan examination. Nursing Progress Note 1900-0700*DNR/DNI (confirmed w/ pt when he was alert and fully oriented)*Access: 18g PIV and 20g PIV*NKDA** Please see admit note/FHP for admit info and hx.Neuro: pt increasingly confused through shift, now A&Ox1, difficult to understand, confused, awaking and shouting thinking he is @ home and has to turn off the stove or put things in the fridge. The heart is not enlarged. Very restless in the bed. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2182-03-07 00:00:00.000",
"description": "Report",
"row_id": 1630060,
"text": "Nursing Progress Note 1900-0700\n*DNR/DNI (confirmed w/ pt when he was alert and fully oriented)\n\n*Access: 18g PIV and 20g PIV\n\n*NKDA\n\n** Please see admit note/FHP for admit info and hx.\n\nNeuro: pt increasingly confused through shift, now A&Ox1, difficult to understand, confused, awaking and shouting thinking he is @ home and has to turn off the stove or put things in the fridge. Very restless in the bed. However continues to state that he has no pain, is not uncomfortable and is having no difficulty breathing. bilat soft wrist restraints to keep o2 on and for line/tube safety, as pt is confused.\n\nCardiac: NSR w/ occasional PVC's, several episodes brady to 40's but returns soon after, x1 episode asystolic for about 5seconds w/ oral care, recovered on own, MD was present. HR 66-85, SBP 70-121, remains on Dopamine @ 10mcg/kg/min. Repleted Mg in evening w/ 2grams IV. Hct stable @ 41.6. Awaiting AM labs.\n\nResp: CXR showed significant fibrotic lung disease in both lungs (worse on R side) w/ pleural fibrosis as well, and acute on chronic lung opacifications. pt now on 100% NR and 6L NC w/ o2sat trending down this shift, now < 80%; desat to 50's when o2 removed. LS diminished upper and crackles lower. This shift o2sat 91-75%, rr 14-29. No cough noted. CXR done this AM, results pending.\n\nGI/GU: NPO, +BS, no stool this shift, abd soft/non-tender. Urine out foley yellow/clear, 20-190cc/hr w/ larger amts following 20mg IV lasix given in order to attempt to improve o2sat, treatment had no effect on o2sat. FSBG 100, no coverage per RISS.\n\nID: unable to get temp oral, axillary, and rectal. skin feels warm and pt states he is comfortable and does not feel cool. WBC 0.9 from 1.3 this AM. Treating w/ Vancomycin and piperacillin for ? PNA and/or flu. Droplet precautions for ? flu. No nasal aspirate d/t risk of brady and/or asystole. Skin w/d/i.\n\nPsychosocial: pt has sister that is yo w/ baseline dementia, has a caregiver are communicating w/, also a minister to contact as well. Caregiver updated by MD overnight.\n\nDispo: cont to monitor BP, cont meds and abx, monitor pt for discomfort (? start morphine gtt), ? CMO today as pt's resp status is not improving.\n"
},
{
"category": "Radiology",
"chartdate": "2182-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000923,
"text": " 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate, mass, edema?\n Admitting Diagnosis: BRADYCADIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with tachypnea, hypoxia and cough productive of white mucus\n REASON FOR THIS EXAMINATION:\n infiltrate, mass, edema?\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: None similar.\n\n HISTORY: 87-year-old man with tachypnea, hypoxia and cough production of\n white mucus, evaluate for mass, edema.\n\n FINDINGS: There is significant fibrotic lung disease seen in both lungs,\n right worse than left, with traction bronchiectasis in the right upper lobe,\n pleural thickening in both lungs, bibasal honeycombing. In the right mid\n zone, there is a unilateral consolidation which could be acute or chronic in\n nature. In addition, there is more opacification at the right lung base,\n suspicious for an acute process. The lungs are over-inflated. The heart is\n not enlarged.\n\n IMPRESSION:\n\n Radiographic evidence of fibrotic lung disease associated with traction\n bronchiectasis, bibasilar honeycombing and pleural fibrosis, right more than\n left. In addition, there is an unilateral opacity seen in the right mid zone\n along with more opacification seen at the right lower zone, worrisome for an\n acute on chronic lung disease. These findings necessitate further evaluation\n by a chest CT, preferably a high-resolution chest CT scan examination if the\n patient can tolerate the procedure, or if not, then a standard chest CT scan\n examination.\n\n\n\n DL\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1001050,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusion.\n Admitting Diagnosis: BRADYCADIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with bronchiectasis with cad with hypoxemia and hypotension.\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bronchiectasis, now with hypoxia and hypotension and respiratory\n difficulty.\n\n CHEST, ONE VIEW: Comparison with . Compared to the previous\n exam, there is new consolidation in the right lower lung zone and left lower\n lung zone. The extensive pleural thickening, bronchiectasis, and severe\n volume loss in the upper lobes is unchanged. Cardiac contour is difficult to\n assess due to overlying lung parenchyma, however, mediastinal, and hilar\n contours are probably similar. Osseous structures are unchanged.\n\n IMPRESSION: New bilateral lower lobe opacities may represent developing\n consolidations.\n\n ab\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-07 00:00:00.000",
"description": "Report",
"row_id": 196704,
"text": "Sinus rhythm. Compared to the previous tracing of multiple\nabnormalities are as previously reported. R wave progression is slower with\npossible underlying anterior myocardial infarction. Inferolateral ST segment\nsagging is more pronounced raising question of ischemia, digitalis, etc.\nExclude hyperkalemia, if clinically indicated. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-06 00:00:00.000",
"description": "Report",
"row_id": 196705,
"text": "Baseline artifact. Sinus rhythm with possible subtle atrial ectopy. Mild\nP-R interval prolongation. Left atrial abnormality. Left ventricular\nhypertrophy. Intraventricular conduction delay. Vertical QRS axis in this\ncontext raises consideration of biventricular overload. Compared to the\nprevious tracing of no diagnostic change. Clinical correlation is\nsuggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2182-03-06 00:00:00.000",
"description": "Report",
"row_id": 196706,
"text": "Sinus rhythm with borderline 1st degree A-V block\nLeft ventricular hypertrophy\nSince previous tracing of , heart rate faster, T wave amplitude less\nprominent\n\n"
}
] |
8,231 | 152,678 | Hospital course was significant for the following issues: | IS A DNR/DNI.DISPO - COLONOSCOPY TODAY. OVER/NOC -SM. HAS TAKEN GO-LYTELY PREP. PERIPHERAL PULSES PALPABLE.ID - AFEBRILE. PT IS DNR/DNI. PT NOW DOWN TO ONE ON THE RIGHT.PT IS MRSA POSITIVE. OVER/NOC EVENTS.NEURO - PT. UPPER EXTREM OKAY.ACCESS: PT ARRIVED WITH 2 18GUAGE PERIPH IV'S. START ON LEVOQUIN YEST. MAE ad lib. U/O qs q2h via foley.ID/Endo/Integ: Tmax=99.0. C/o rt. AMTS. STATUS AND CONT. INDWELLING FOLEY IN PLACE; PATENT W/ADEQUATE U/O OVER/NOC - CLEAR - YELLOW, URINE.ACCESS - NEWLY PLACED - MULTI-LUMEN RIJ FROM YEST. 1100-1345 NPNSee carevue for subjective/objective data. Pt. Pt. PT. PT. MUSH CATH. REMAINS NPO FOR COLONOSCOPY TODAY. W/POST HCT LAST . Neuro: Pt. COOPERATIVE WITH CARE.RESP- ON 2L NC WITH RESP 23-28. RECEIVED FIRST DOSE OVER/NOC.ENDO - ON QID RISS AND STANDING DOSE 70/30 - FSBG STABLE OVER/NOC 146-147 - REQUIRING NO COVERAGE PER SS.GI/GU - TOL SIPS CLEARS. Pt is DNR/DNI per her request. BP WITHIN NORMAL LIMITS. MONITOR HCT. IF PT. AXOXO3. SBP 146-152.GI- ABD SOFT OBESE WITH POS BS. BS CLEAR WITH CRACKLES AT THE BASES.CARDIAC- HR 60'S NSR WITHOUT ECTOPI. NBP 140'S-160'S/30'S-60'S. Cataracts both eyes.CV/Pulm: MP=AFib, no VEA noted. VSS. Rt. LOWER EXTREMETIES ARE EDEMATOUS. OBESE, SOFT, NT W/+BS. There is associated right bundle-branch block. AS ABOVE TOOK ENTIRE GO-LYTELY PREP. LS CLEAR UPPER W/FINE BIBASILAR CRACKLES. Neuro: A+Ox3. Last Hct at 0400 31.8. BS clear upper lobes with bibasilar crackles. PT IS ALERT AND ORIENTED X 3. ABD. 30.3. Adequate UO 100-200 cc/hr.GI/GU: Abd. Skin intact.Psychosocial/Plan: Emotional support given to pt. TX. PLAN OF CARE. ON Q6/HR INHALERS.C/V - HR 60'S-70'S, A-FIB, W/NO ECTOPY NOTED. soft, nontender, +BS. X1 NEAR CHANGE OF SHIFT W/ X1 10MG IV HYDRALAZINE FOR SBP 160'S. LEFT SITE INFILT. The left brachial vein was patent and compressible. denies nausea or abd. Compared to the previous tracing of theventricular response rate is marginally more irregular suggesting atrialfibrillation with intrinsic A-V nodal disease as the basic underlyingmechanism. PICC line was advanced over a 4-French introducer sheath under fluoroscopic guidance into the superior vena cava. The sheath was removed. IN PLACE - NO NEW MELENA - OLD LIQUID STOOL IN BAG. Thedifferential lies between sinus rhythm, rate 70, with marked sinus arrhythmia,atrial fibrillation with some regularization of the ventricular rate, andatrial fibrillation with accelerated (but somewhat variable) junctionalpacemaker. IF HEMODYNAMICALLY UNSTABLE WILL PLAN RBC SCAN. CVP 8-20. DENIES SOB. IMPRESSION: Successful placement of 43-cm long left PICC line with tip in the superior vena cava. Denies SOB, no wheezing.CV: HR 60s-80s, AF, no ectopy, BP 110s-160s/60s-80s. PT IS OBESE WITH SOFT DISTENDED ABD AND NONTENDER. received unit of PRBC in AM due to infiltrated IV. Initially on np at 2l however sats high 90's on room air, O2 removed. The left upper arm was prepped and draped in the usual sterile fashion. Dr. reviewed this case. Abd soft, non-tender, bowel sounds present. No change in abx. Mushroom catheter in place-->brown liquid at this time. A final fluoroscopic spot view of the chest demonstrated the tip of the catheter to be in the superior vena cava. PT 2 UNITS PACKED CELLS, POST HCT 26. MICU-B NPN 1900-0700PLEASE SEE FHP AND ADMIT NOTE FOR ADMIT DETAILS AND PMHX.PT. DAY/SHIFT. 74 Y/O S/P GIB - HAS RECEIVED TOTAL OF 4U PRBCS SINCE ADMIT - 2 YEST. The frontal planeaxis is indeterminate. O2SATS 97-100% ON 2L NC. Speech clear. Contact precautions DC'd per ID as pt has hx of MRSA in past however pt screened negative for MRSA. DENIES ANY PAIN. Sliding scale insulin coverage. The catheter was trimmed to length. Based on markers on the catheter, it was determined that a length of 46 cm would be suitable. is A&Ox3, pleasant, cooperative. RED-TAG SCAN IF MASSIVE GIB. Plan colonoscopy in AM.1500 HCT 28.6, up from 24 this AM. BEGINS TO HAVE MASSIVE BLEED WILL NEED TO HAVE RED-TAG SCAN.NO SIGNIF. +MAE - MOVING W/ASSIST IN BED.RESP - STABLE. SATS 96-98% ON 2L NC. The catheter was flushed. PROCEDURE/FINDINGS: This procedure was performed by Drs. The line is ready for use. The line is ready for use. DENIES ANY CP. ABLE TO MOVE ALL EXTREMETIES WITH SOME DIFFICULTY DUE TO OSTEOARTHRITIS. NO C/O PAIN.RESP: PT HAS HX OF ASTHMA AND TAKES INHALERS, LUNG SOUNDS CLEAR AND O2 SAT'S IN HIGH 90'S ON 2LNC.CV: PT IS IN AFIB WITH RATES IN THE 60'S TO 80'S. FIB APPLIED THIS AM AS PT DOES NOT KNOW WHEN SHE IS PASSING MELENA.GU: PT HAS FOLEY CATH WHICH IS PATENT AND DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.HEME: PT'S HCT ON ADM PRIOR TO PACKED CELLS 22. RECHECKING AT 0400.ENDO: PT IS IDDM BLOOD SUGAR AT 2400 79, NO INSULIN GIVEN.SKIN: PT HAS NO SKIN BREAKDOWN. FOLEY PTENT DRAINING CLEAR YELLOW URINE AT 80-95CC/HR.ID- AFEBRILE. shoulder arthritic pain, medicated with Tylenol x1 with some relief.Resp: 2L NC weaned to RA with Sats high 90s, LS clear, nonproductive cough noted, started on inhalers per orders. FOCUS; NURSING PROGRESS NOTE74 YEAR OLD WITH LOWER GI BLEED GOING FOR COLONOSCOPY TODAY.REVIEW OF SYSTEMS-NEURO- ALERT AND ORIENTED X3. A StatLock was applied and the line was flushed with saline. ON CONTACT PRECAUTIONS FOR A HX OF MRSA ENDOCARDITIIS.HEME- NO FURTHER HCT CHCEKS THIS AM.DISPO- REMAINS IN THE MICU A DNR/DNI.SOCIAL- DAUGHTER CALLED AND WAS UPDATED BY THIS NURSE.PLAN- FOR COLONOSCOPY TODAY. Plan is to trans to 709; pt to have colonoscopy this afternoon. pain. RR TEENS>20'S. PT HAS BEEN INCONTINENT OF 3 LOOSE MAROON STOOLS. The underlying rhythm is uncertain. PORTUGESE WOMEN - BUT SPEAKS GOOD ENGLISH. AFEBRILE, RESP RATE IN THE TEENS TO LOW 20'S.GI: PT IS NPO EXCEPT FOR MEDS AND ICE CHIPS. Foley patent, yellow urine with strong odor noted, culture sent. PT ALSO HAS EXTENSIVE PMH, SEE FHP. GoLytely PO (~3L in), liquid maroon stool out via mushroom catheter (~1500cc). 3 lumen IJ placed at noon, CXR confirmed placement per team, another unit of RBC started at 1500, well. | 7 | [
{
"category": "Radiology",
"chartdate": "2118-02-02 00:00:00.000",
"description": "FLUOR GUID PLCT/REPLCT/REMOVE",
"row_id": 851144,
"text": " 4:32 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: L PICC line placement for iv antibiotics\n Admitting Diagnosis: BRIGHT RED BLOOD PER RECTUM\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with UTI, antibiotic allergies who needs iv antibiotics\n REASON FOR THIS EXAMINATION:\n L PICC line placement for iv antibiotics\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Urinary tract infection, heparin-induced thrombocytopenia, requires\n IV antibiotics.\n\n PROCEDURE/FINDINGS: This procedure was performed by Drs. and ,\n with Dr. , the Attending Radiologist, present and supervising throughout.\n Dr. reviewed this case.\n\n The left upper arm was prepped and draped in the usual sterile fashion.\n Because no suitable superficial veins were visible, ultrasound was used to\n find a suitable vein. The left brachial vein was patent and compressible.\n After local anesthesia with 3 cc of 1% lidocaine, the brachial vein was\n entered under ultrasonographic guidance with a 21-gauge needle. \n PICC line was advanced over a 4-French introducer sheath under fluoroscopic\n guidance into the superior vena cava. Based on markers on the catheter, it\n was determined that a length of 46 cm would be suitable. The catheter was\n trimmed to length. The sheath was removed. The catheter was flushed. A\n final fluoroscopic spot view of the chest demonstrated the tip of the catheter\n to be in the superior vena cava. The line is ready for use. A StatLock was\n applied and the line was flushed with saline.\n\n IMPRESSION: Successful placement of 43-cm long left PICC line with\n tip in the superior vena cava. The line is ready for use.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-02-01 00:00:00.000",
"description": "Report",
"row_id": 1371656,
"text": "FOCUS; NURSING PROGRESS NOTE\n74 YEAR OLD WITH LOWER GI BLEED GOING FOR COLONOSCOPY TODAY.\nREVIEW OF SYSTEMS-\nNEURO- ALERT AND ORIENTED X3. COOPERATIVE WITH CARE.\nRESP- ON 2L NC WITH RESP 23-28. SATS 96-98% ON 2L NC. BS CLEAR WITH CRACKLES AT THE BASES.\nCARDIAC- HR 60'S NSR WITHOUT ECTOPI. SBP 146-152.\nGI- ABD SOFT OBESE WITH POS BS. REMAINS NPO FOR COLONOSCOPY TODAY. HAS MUSHROOM CATH WITH MIN AMOUNTS LIQUID BROWN MAAROON GUIAC POS STOOL.\nSKIN- INTACT.\n FOLEY PTENT DRAINING CLEAR YELLOW URINE AT 80-95CC/HR.\nID- AFEBRILE. ON CONTACT PRECAUTIONS FOR A HX OF MRSA ENDOCARDITIIS.\nHEME- NO FURTHER HCT CHCEKS THIS AM.\nDISPO- REMAINS IN THE MICU A DNR/DNI.\nSOCIAL- DAUGHTER CALLED AND WAS UPDATED BY THIS NURSE.\nPLAN- FOR COLONOSCOPY TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-02-01 00:00:00.000",
"description": "Report",
"row_id": 1371657,
"text": "1100-1345 NPN\nSee carevue for subjective/objective data. Neuro: A+Ox3. Speech clear. MAE ad lib. Cataracts both eyes.\n\nCV/Pulm: MP=AFib, no VEA noted. VSS. Initially on np at 2l however sats high 90's on room air, O2 removed. BS clear upper lobes with bibasilar crackles. No SOB or DOE noted.\n\nGI/GU: No active bleeding at this time. Last Hct at 0400 31.8. Mushroom catheter in place-->brown liquid at this time. Abd soft, non-tender, bowel sounds present. U/O qs q2h via foley.\n\nID/Endo/Integ: Tmax=99.0. No change in abx. Contact precautions DC'd per ID as pt has hx of MRSA in past however pt screened negative for MRSA. Sliding scale insulin coverage. Skin intact.\n\nPsychosocial/Plan: Emotional support given to pt. Plan is to trans to 709; pt to have colonoscopy this afternoon. Pt is DNR/DNI per her request.\n"
},
{
"category": "ECG",
"chartdate": "2118-01-30 00:00:00.000",
"description": "Report",
"row_id": 284917,
"text": "The underlying rhythm is uncertain. It is difficult to identify P waves. The\ndifferential lies between sinus rhythm, rate 70, with marked sinus arrhythmia,\natrial fibrillation with some regularization of the ventricular rate, and\natrial fibrillation with accelerated (but somewhat variable) junctional\npacemaker. There is associated right bundle-branch block. The frontal plane\naxis is indeterminate. Compared to the previous tracing of the\nventricular response rate is marginally more irregular suggesting atrial\nfibrillation with intrinsic A-V nodal disease as the basic underlying\nmechanism.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-31 00:00:00.000",
"description": "Report",
"row_id": 1371654,
"text": "Neuro: Pt. is A&Ox3, pleasant, cooperative. C/o rt. shoulder arthritic pain, medicated with Tylenol x1 with some relief.\nResp: 2L NC weaned to RA with Sats high 90s, LS clear, nonproductive cough noted, started on inhalers per orders. Denies SOB, no wheezing.\nCV: HR 60s-80s, AF, no ectopy, BP 110s-160s/60s-80s. CVP 8-20. Adequate UO 100-200 cc/hr.\nGI/GU: Abd. soft, nontender, +BS. GoLytely PO (~3L in), liquid maroon stool out via mushroom catheter (~1500cc). Pt. denies nausea or abd. pain. Foley patent, yellow urine with strong odor noted, culture sent. Plan colonoscopy in AM.\n1500 HCT 28.6, up from 24 this AM. Pt. received unit of PRBC in AM due to infiltrated IV. Rt. 3 lumen IJ placed at noon, CXR confirmed placement per team, another unit of RBC started at 1500, well. Recheck Hct at 2100 per orders.\nSocial: Family visited, updated on plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-02-01 00:00:00.000",
"description": "Report",
"row_id": 1371655,
"text": "MICU-B NPN 1900-0700\nPLEASE SEE FHP AND ADMIT NOTE FOR ADMIT DETAILS AND PMHX.\n\nPT. 74 Y/O S/P GIB - HAS RECEIVED TOTAL OF 4U PRBCS SINCE ADMIT - 2 YEST. W/POST HCT LAST . 30.3. NO EVIDENCE ACTIVE BLEEDING OVER/NOC. EGD ON ADMIT WITH NO EVIDENCE UGIB +GASTRITIS IN STOMACH- PLANNED COLONOSCOPY TODAY - PT. HAS TAKEN GO-LYTELY PREP. IF PT. BEGINS TO HAVE MASSIVE BLEED WILL NEED TO HAVE RED-TAG SCAN.\n\nNO SIGNIF. OVER/NOC EVENTS.\n\nNEURO - PT. AXOXO3. PORTUGESE WOMEN - BUT SPEAKS GOOD ENGLISH. DENIES ANY PAIN. +MAE - MOVING W/ASSIST IN BED.\n\nRESP - STABLE. RR TEENS>20'S. O2SATS 97-100% ON 2L NC. LS CLEAR UPPER W/FINE BIBASILAR CRACKLES. DENIES SOB. ON Q6/HR INHALERS.\n\nC/V - HR 60'S-70'S, A-FIB, W/NO ECTOPY NOTED. NBP 140'S-160'S/30'S-60'S. TX. X1 NEAR CHANGE OF SHIFT W/ X1 10MG IV HYDRALAZINE FOR SBP 160'S. PT. DENIES ANY CP. PERIPHERAL PULSES PALPABLE.\n\nID - AFEBRILE. START ON LEVOQUIN YEST. RECEIVED FIRST DOSE OVER/NOC.\n\nENDO - ON QID RISS AND STANDING DOSE 70/30 - FSBG STABLE OVER/NOC 146-147 - REQUIRING NO COVERAGE PER SS.\n\nGI/GU - TOL SIPS CLEARS. OVER/NOC -SM. AMTS. AS ABOVE TOOK ENTIRE GO-LYTELY PREP. ABD. OBESE, SOFT, NT W/+BS. MUSH CATH. IN PLACE - NO NEW MELENA - OLD LIQUID STOOL IN BAG. INDWELLING FOLEY IN PLACE; PATENT W/ADEQUATE U/O OVER/NOC - CLEAR - YELLOW, URINE.\n\nACCESS - NEWLY PLACED - MULTI-LUMEN RIJ FROM YEST. DAY/SHIFT. SITE W/OLD DRIED BLOOD - PATENT, +DRAW.\n\nSOCIAL - NUMEROUS FAMILY MEMBERS IN AT CHANGE OF SHIFT - UPDATED ON PT. STATUS AND CONT. PLAN OF CARE. PT. IS A DNR/DNI.\n\nDISPO - COLONOSCOPY TODAY. RED-TAG SCAN IF MASSIVE GIB. MONITOR HCT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-31 00:00:00.000",
"description": "Report",
"row_id": 1371653,
"text": "NURSING PROGRESS NOTE:\nPT 74 Y/O FEMALE WITH HX OF MULTIPLE GI BLEEDS DUE TO MULTIPLE AVM'S IN AND SM INTESTINE. PT BROUGHT TO ED FROM HOME AND HAD ENDOSCOPY FROM ABOVE BUT UNABLE TO VISUALIZE SOURCE. PT ALSO HAS EXTENSIVE PMH, SEE FHP. LAST ADM .\n\nNEURO: PT IS SPANISH SPEAKING WOMAN BUT ALSO SPEAKS BROKEN ENGLISH QUITE WELL. PT IS ALERT AND ORIENTED X 3. ABLE TO MOVE ALL EXTREMETIES WITH SOME DIFFICULTY DUE TO OSTEOARTHRITIS. NO C/O PAIN.\n\nRESP: PT HAS HX OF ASTHMA AND TAKES INHALERS, LUNG SOUNDS CLEAR AND O2 SAT'S IN HIGH 90'S ON 2LNC.\n\nCV: PT IS IN AFIB WITH RATES IN THE 60'S TO 80'S. BP WITHIN NORMAL LIMITS. AFEBRILE, RESP RATE IN THE TEENS TO LOW 20'S.\n\nGI: PT IS NPO EXCEPT FOR MEDS AND ICE CHIPS. PT IS OBESE WITH SOFT DISTENDED ABD AND NONTENDER. PT HAS BEEN INCONTINENT OF 3 LOOSE MAROON STOOLS. FIB APPLIED THIS AM AS PT DOES NOT KNOW WHEN SHE IS PASSING MELENA.\n\nGU: PT HAS FOLEY CATH WHICH IS PATENT AND DRAINING ADEQUATE AMT'S OF CLEAR YELLOW URINE.\n\nHEME: PT'S HCT ON ADM PRIOR TO PACKED CELLS 22. PT 2 UNITS PACKED CELLS, POST HCT 26. RECHECKING AT 0400.\n\nENDO: PT IS IDDM BLOOD SUGAR AT 2400 79, NO INSULIN GIVEN.\n\nSKIN: PT HAS NO SKIN BREAKDOWN. LOWER EXTREMETIES ARE EDEMATOUS. UPPER EXTREM OKAY.\n\nACCESS: PT ARRIVED WITH 2 18GUAGE PERIPH IV'S. LEFT SITE INFILT. PT NOW DOWN TO ONE ON THE RIGHT.\n\nPT IS MRSA POSITIVE. PT IS DNR/DNI. PT LIVES ALONE BUT HAS 8 CHILDREN WHO LOOK IN ON HER.\n\nPLAN: FOR FOR COLONOSCOPY ON TUES WITH INTUBATION. IF HEMODYNAMICALLY UNSTABLE WILL PLAN RBC SCAN.\n"
}
] |
11,399 | 176,171 | Respiratory - The patient was maintained on CPAP approximately 48 hours following which time the patient was weaned to room air. Since day of life #2 the patient has been stable, breathing comfortably in room air without need for supplemental oxygen or notable respiratory distress. Cardiovascular - The patient has been hemodynamically stable throughout admission without the need for blood pressure support. No evidence of patent ductus arteriosus developed. Fluids, electrolytes and nutrition - The patient was is maintained on intravenous fluids with stable blood sugars. Enteral feeds were begun on day of life #2 and were taken orally from the start. The volumes of feedings were gradually advanced to full feeds. Subsequently the calories were increased to 26 cal/oz and supplemental iron was added. At the time of discharge, the patient has been taking Neosure 26 cal/oz formula orally with adequate volumes and as demonstrated appropriate weight gain. Weight on , two days prior to discharge is 1770 gm, increasing steadily over the past several days. On it was 1840. HC was 30.5 cm. Lth was 41.5 cm. Infectious disease - Initial complete blood count revealed a white count of 22 with a benign differential, hematocrit of 52% and platelets of 247. Blood culture was sent and subsequently has been negative. Ampicillin and gentamicin were given 48 hours pending negative cultures and benign clinical course. Gastrointestinal - The patient exhibited mild hyperbilirubinemia of prematurity and received phototherapy for several days. Neurological - The patient was noted to be somewhat jittery for the first several days of life. Urine toxicology screen on the infant revealed barbiturates which are consistent with maternal medication use. Absence scores were followed and in the first several days of life ranged between 3 and 8. On day of life #4 onwards the absence scores were basically 0 and the infant exhibited no further signs of withdrawal. Of note, no medications were administered for the early symptoms of mild withdrawal. Social - Social work was involved, given the maternal history in addition to the positive toxicology screens. DSS was involved and a 51A was filed. Social work and DSS worked actively with the family and at the time of discharge the DSS case is still open but the family maintains custody. Substantial supports have been arranged for the mother and the family. Sensory - Hearing screen was performed with automated auditory brain stem responses and passed bilaterally. | rebound bili to bechecked later today.Dev: Temps remain stable in a covered isolette. O: Temp.stable swaddled in off isolette.Pt.alert with cares, settles between cares. Girth's stable.Voiding and stooling. Comfortable Temp stable.Still below birthwight. Abd exam benign. A: Stable resp. Abd exam benign.girth's stable. effort,clear and equalbreath sounds, rep40-60's,no spells thus far this shift.A;Stable in R. air. Alert and active with care, tremors +,temp-99.3,isolette turned off. IVF of D10 with 2 and 1heplocked. Lungs cl=, rr50-70.mild IC retractions.A/P; Cont to monitor,#3 FEN:O: wt 1.655(-25 gms) On min. Lung soundsclear and equal. Remains on R. air, easy resp. Neonatology Attending Progress NoteNow day of life 5.Cardiorespiratory status stable in RA.Wt. NPN#2 RDS:O: Remains in RA with sats 100. P:Continue to monitor.#3FEN O: Wt. Rebound bili 5/0.3/4.7A/P: Consider repeat rebound in a few days.#6 dev:O: Temps stable in off isolette. IMPRESSION: Findings consistent with mild RDS. possible discharge in days if weight gain remains adequate and supports are in place G&DPREPARING FOR DISCHARGE. Rebound bili collected. PMD to be . continue with 26 cals formula, vigilence for adequate intake3. Neonatology AttendingNow day of life 4.Cardiorespiratory status stable in RA.No apnea and bradycardia.Wt. Voiding in good amts. Alert/ active waking forcares. Duscussed bili andphototherapy. A: ^bili levels today -phootherapy started. Updated on baby'sprogress and plan for discharge. A/P: sepsis resolvedfor now. A-Bili needs wnl thisshift.#6O/A-Nas scores of this shift with mild tremorsdisturbed. Infant continues on Ampi and Gent. P: Recheck bilirubin level intomorrow. 24 hr bili 5.0 0.3 4.7 plan to recheck bili in am.Infant is ruddy and slightly jaundice. ThisRN stated that babies,in general usually get irratablearound fdgs. Will monitor.P: OT to follow recommend the following:1. A/P: Cont to cluster care. Abd exam soft with active bowelsounds. P-Cont to enc callsand visits.#5O/A-Rem on single photo with bili masks in place.Masksremoved with cares. P-Contto assess g&d needs. A-Parenting needs wnl this shift. P: Cont to monitor wt and pointake.4. O: Mom in at . A: Taking adequate amts. A: appr for GA, irritable attimes.. P: Continue to moniter for milestones, moniteractivity characteristics. }Mom assisted with cares. Baby is voiding, nostool as of this progress note.+ Bowel sounds. Changed to isolette. temp elevated with tempprobe loose. Plans for am bili. Nursing Progress Note1. Rest of fluids are PN/IL by IV.Bili 5.1 down on phototherapy.Social - meeting with yesterday - they are aware of 51A and DSS evaluation.Assessment/Plan:Stable course continues.NAS scores low at this point - will follow.Will continue with encouragement of po feedings.Possible transfer to for further care. D10W with lytesinfusing per order. O: Received infant on NPCPAp. Updated oninfant's status. TF@ a min. Vdg & stooling q.s.Lytes sent. RN updated Mom. A:Tolerating feeds P: Plans for d/c on wed/thurs.4. givento Mom. NPN 1900-07001.O: Infant remains on ampi & gent per order. +b.s. Completed discharge teaching with Momtoday. Momrequested for NICU with information. A- WNL for gestational age. Statedmom was on Mag. BS ess clear with mod retractions. RR60-70's with mild retractions noted. w/ maternal history will send u.tox.plan:- Monitor resp status. P- Continue tosupport G/D. NPCPAP d/c at 0300.Presently, infant remains in room air. CBG 7.37/47. + bowelsounds. Wakesfor feeds, bottled well. d/s 93/108. PE24, PO. Continue per plan. A: Involved family P:Continue to update,educate and support.5.O: Bili sent.P: Results pending.6.O: remains hypertonic. Co Worker Note3 FEN: O-TF MIN.- 120cc/k/d. Brought back to the NICU and started on NP CPAP for GFR. and active withcares. to inform, family meeting w/ momwhen able. P: Continue to assess.3. spoke with R.N.Updated on baby's status and plan. +bs. BP's wnl.A/P: Mild RDS, tachypneic but comfortable, low 02requirement, adjust as tolerated, improving CBG's.Wean off cpap as tolerated.3.FEN: IV TF at 60cc/kg/d of d10w, Wy=1.775, down 5gr.UOP+2.3cc/kg/hr, abd full/soft on cpap, stooled mec x1.Dstix wnlA/P: Check 24hr lytes today, cont. Amp and Gent given asordered. Temp stable. Mommade formula independ. PKU done. contto monitor temp. EI faxed. A: Toleratesfeeds. P: Cont tomonitor wt, and po intake.4. A/P: Cont to cluster care. V/S. administration onSaturday. Mom EI in prep. O: mom in at . Plan is to d/c home over the w/e, on Neosure26. Pt. Abd benign. met goal wt. NPN3.Min. Abd benign, BS active. D-sticks 96 and107. WIC form given tomom as well. Temps stable swaddled in off isolette. for d/c. Mod. Bottles well. Cont.to as tolerated.4. NAS scores today. Respiratory Care NotePt. in to visit and held. wakes for feeds. DS 50/71. Pttook 169cc/kg yest. Discussed plans forfeeding. Sucking onpacifier when offered. Sucking onpacifier when offered. LS CTA bilaterally. AFOF. with supervision. Nospits. Abd. Abd. Abd. sx'd for mod. NICU NPN/DISCAHRGE NOTE 0700-1900Infant in RA. spit x1. Takign adequate feeds. above note written by MD. D/T tachypnea and FIO2 requirement CBGobtained 7.24/38/69/17/-10 and 18cc NS bolus given over 10min. P: Continue with plan and monitor.4. Min 120cc/kg of Neosure 26 po. and activewith cares. Ls clear. Waking for feeds. Waking for feeds. A: Taking adequate pos. Will continue to monitor resp status closley, Started infant on D10w at 60cc/kg/d. Goodcoordination noted. Tolerating pofeeds of pe24 well. independent with cares, asking appropriatequestions. D/c teqaching initiated. abd benign. Update given. Residing inoff-isolette. girthstable. Abd exam benign, +BS. NAS D/C'edtoday. d'cteaching reinforced. A: aga P: Continue to supportdevelopment. A:stable. Abd exam benign, +BS.Voiding and stooling (heme -). Started on Fe.Gaining wgt. P: Continue to supportdevelopment. On Fe.DVLP: Moved to crib--tolerating this well.NEURO: Will d/c abstinence --has been below threshold. Temps stable. DEV: O: is active/alert with cares. Abdomen is benign, pos BS. A: Tolerating feeds. Abdominal exam benign. A: aga. A: AGA. : Hearing screen done. +bs. Relatively independentwith baby. DSS evaluation in process.A&PSGA infant with recently established thermoregulation. Weight stable. DEV: O: Received in off isolette, moved to opencrib this am. P: Continue to keepinformed, d/c teaching.#6 DEV O: Temps are stable, swaddled in crib. examneuro: alert, not hypersensitivelungs: clr, equal BSheart: no murmurabd: soft, NDwell perfused Waking for feeds , bottling well. A: Involved,loving . Passed hearing screen. no spits.4 Socialmom called and was updated by rn.6 G&Dtemp remains stable in off isolette. P: Cont to monitor.4. Neonatology- Physical ExamInfant remains stable in RA. Mod spit x1. P: Continue to keep informed.#6 DEV O: temps are stable, swaddled in crib. | 84 | [
{
"category": "Radiology",
"chartdate": "2182-03-09 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 757424,
"text": " 2:49 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: 34 week infant with respiratory distress (mild); assess for\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n above.\n REASON FOR THIS EXAMINATION:\n 34 week infant with respiratory distress (mild); assess for lung\n disease/pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 34-week , mild.\n\n The heart is normal in size. Mild hazy opacification is seen in both lungs\n and mild RDS cannot be excluded. No focal consolidation is identified.\n\n IMPRESSION: Findings consistent with mild RDS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 1838594,
"text": "Neonatology\nRemains in RA. No spells. Comfortable Temp stable.\n\nStill below birthwight. Took in good amount yesterday. Mother dc teaching re meds and formula preparation. Receiving 26 cal. Abdomen benign.\n\nPlan to continue to monitor grwoth over course of weekend. be ready for dc home sunday. DSS involved. EI arranged. PMD to be .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 1838595,
"text": "NICU Fellow Exam Note\nPhysical Exam:\nSmall premature infant, well developed in no distress.\nActive and .\nFontanelles soft and flat.\nChest clear.\nCardiac regular without murmur.\nAbdomen soft without hepatomegaly.\nFemoral pulses 2+.\nExtremities warm.\nSkin clear.\nAppropriate tone and activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-20 00:00:00.000",
"description": "Report",
"row_id": 1838587,
"text": "NICU nursing progress note\n\n\nFEN\nO: received on an ad lib schedule with TF of\nmin120cc/kg/day, of Neosure 26, made with corn oil. Bottling\n30-50cc and doing well though takes up to 30 minutes to feed\nher. She begins vigorously and slows down after approx.\n30cc. No spits. Abd. soft, round, pink, no loops, active bs.\nVoiding and Stooling. A: Tolerating current feeding plan,\ngaining weight. P: Cont to support optimal nutrtion.\nG and D\nO: Temp stable in open crib. Vigorously sucks pacifier. MAE.\nBrings hands to midline. Follows with eyes. Awakes for feeds\napprox. q 4 hours. Active with cares and sleeps well in\nbetween. A: AGA P: Cont to support dev. milestones.\nSocial\nO: called and update given, verbalizes understanding.\nFamily meeting scheduled for 1600 tomorrow. Social services\nto meet with team prior to family meeting at 1530. Possible\nd/c to in 2 days pending. Mom and plan to take\nCPR at 1900 on Thurs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-14 00:00:00.000",
"description": "Report",
"row_id": 1838552,
"text": "Nicu Nursing Note 1900-0700\n\n\n#2RDS. O: In room air, RR 40-60s,sat 98 and above,\nnospells.Breath soundsclear and equal,ITC and SC retractions\ncontinue. A: Stable resp. status. P:Continue to monitor.\n\n#3FEN O: Wt. 1655gms(-25gms).On TF of 100cc/kg/day of pe20,\nall po feeds. Pt.took 99cc/kg/day last 24 hour period.No\n spits, abd.soft with active bowel sounds, stable girth.D\nstick61 tonight. Voiding in good amts. One small heme neg.\nyellow stool tonight.A: Tolerating po feeds.P:Continue to\nassess for tolerance of feeds.\n\n#4Social. O: Mom called x1 tonight, asking appropriate\nquestion,updated. A:Involved .P:Provide support to\n.\n\n#6Development. O: Temp.stable swaddled in off isolette.\nPt.alert with cares, settles between cares. Taking pacifier,\nputting thumb in mouth. NASscore 3 tonight,jittery with\ncares and resp. rate over 60 with retractions.A:AGA. P:\nContinue to monitor NAS, Support development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-14 00:00:00.000",
"description": "Report",
"row_id": 1838553,
"text": "Social Work\nMet w/ DSS wkr, Ms. , this morning as part of her investigation. At this time, she does not any issues w/ baby going home w/ mother from NICU. She is assessing whether dss will be involved re this family given mental health and substance abuse issues. I will f/u w/ her next wk re their decision. Ms. also met w/ at their hotel, which she reports is a clean and appropriate environment. Couple have chosen to remain at the hotel until the end of term in , and will look for more stable living conditions at this time. Financially, according to couple and DSS, they can afford to remain in hotel. Pls page me when family arrives today and i will see them during their visit.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-14 00:00:00.000",
"description": "Report",
"row_id": 1838554,
"text": "Neonatology Attending Progress Note\n\nNow day of life 5.\nCardiorespiratory status stable in RA.\n\nWt. 1655gm down 25gm on 100cc/kg/d of PE20.\nFeedings all po - well tolerated.\nDS 50-70.\n\nBili 4.7\n\nNAS scores \n\nSocial - DSS evalulation in progress.\n\nAssessment/Plan:\nBaby continues to make steady progress.\nWill continue with advancement of feedings to PE22 and 120cc/kg/d.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-14 00:00:00.000",
"description": "Report",
"row_id": 1838555,
"text": "Clinical Nutrition:\nO:\nFormer 34 weeker, now on DOL #5\nBirth wt: 1785g (25th%ile)\nCurrent wt: 1655g (-25g); down ~7% from birth wt.\nBirth LN: 41cm (10-25th%ile)\nBirth HC: 30.5cm (25-50th%ile)\nLabs: lytes noted\nDsticks: 48-71 over the last 24 hrs\nTF: 120 cc/kg/day\nNutrition: PE22 @ 120 cc/kg/day\nGI: benign\n\nA/goals:\nTolerating feeding advancement. Currently feeds are all PO. Lytes wnl, Dsticks borderline low; should improve w/ feeding advancement today.\nGoal growth: ~15 g/kg/day, ~0.5-1.0 cm/wk for HC & ~1.0 cm/wk for LN. Suggest: add iron once @ 24 Kcals & check nutrition labs (if needed) in ~1week. Will cont. to follow w/team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-21 00:00:00.000",
"description": "Report",
"row_id": 1838588,
"text": "NURSING PROGRESS NOTE\n\n\n3. F/N\nTONIGHT'S WEIGHT UP 20 GRAMS TO 1.74KG. FEEDING WELL, WAKING\nPRIOR TO FEEDINGS.\n4. SOCIAL\n CALLED FOR UPDATE, STATED THAT MOM WAS REARRANGING THE\nHOUSE FOR BABY'S HOMECOMING. WILL BE IN FOR FAMILY MEETING\nTODAY.\n6. G&D\nPREPARING FOR DISCHARGE. TENTATIVE DATE .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-21 00:00:00.000",
"description": "Report",
"row_id": 1838589,
"text": "Social Work\nSpoke to DSS wker, Ms. , this morning to further discuss discharge planning re . DSS asked mo for a urine screen today, given info re slurred speech by NICU staff. They will continue to do periodic urine screening as they feel necessary.\n\nDSS agree taht there should be other agencies involved in the d'c, such as EIP and updating the pedi. Pedi is out of medical center. Mo is trying to find a counselor, and DSS are aware of this, and the inmportance of having appts set up upon d'c. I am currently awaiting results of DSS's urine screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-21 00:00:00.000",
"description": "Report",
"row_id": 1838590,
"text": "NICU Fellow Note\nDay 12 of life. No major events.\n\nInfant continues to do well. Remains cardiovascularly stable, on room air without desaturations. Feeding Neosure 26 on an ad lib basis, taking more than 120 cc/kg/day. Normal urine and stool output. Weight 1740, up 20 gm.\n\nPasses hearing test and car seat test.\n\nPhysical exam reveals well appearing infant, small, in no acute distress. Fontanelles are soft and flat. Oropharynx is clear. Chest is clear and well aerated. Cardiac is regular without murmur. Abdomen is soft without hepatomegaly. Extremities are warm and well perfused. Tone and activity are appropriate.\n\nFamily meeting held today with , RN, and social worker. Infant's progress discussed, including likely suitability for discharge over next several days if feedings continue to go well and infant continues to demonstrate weight gain. DSS involvement and need for arrangment of further supports, including early intervention and visiting nurse, discussed.\n\nImpression: 12 day old former 34 week infant, now 1740 gm, doing well on room air.\n\nPlans:\n1. continue to monitor respiratory status\n2. continue with 26 cals formula, vigilence for adequate intake\n3. monitor weight gain\n4. discharge planning, arrange VNA, early intervention, PMD\n5. possible discharge in days if weight gain remains adequate and supports are in place\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-13 00:00:00.000",
"description": "Report",
"row_id": 1838550,
"text": "NPNOte:\n\n\n#2. Remains on R. air, easy resp. effort,clear and equal\nbreath sounds, rep40-60's,no spells thus far this shift.A;\nStable in R. air. p; continue to monitor.\n\n#3. TF= minimum 100cc/kg/day,PE 20, PO feeds sucked well,\nspit x1,medium, following 8am feed, rest feed tolerated.BS+,\nno loops, voided and stooled watery x1. D'stix 63.Hep. lock\nin situ left hand. A; Feeds tolerated, other than spit x1.\nP; continue po feds.\n\n#4. Mom called for a update, will not be in today, sibling\nhas doctor's appointment and planning to visit in am.\n\n#5. Rebound bili collected. at 12pm.Still looks mildly\njaundiced.\n\n#6. Alert and active with care, tremors +,temp-99.3,\nisolette turned off. P; continue to monitor.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-13 00:00:00.000",
"description": "Report",
"row_id": 1838551,
"text": "NPN\n\n\n#2 RDS:\nO: Remains in RA with sats 100. No spells. Lungs cl=, rr\n50-70.mild IC retractions.\nA/P; Cont to monitor,\n\n#3 FEN:\nO: wt 1.655(-25 gms) On min. 100cc/k/d PE20, bottling\n30-40cc. No spits. Voiding and passed sm. formed stool\nA/P: Cont to feed on demand.Minitor wt's.\n\n\n#4 Social:\nO: and sister in to visit. unable to make it\nfor feeding time and just held her. Mom handling infant well\nbut still timid about placing infant back into isolette. Mom\nupset that \"jitters\" that infant is having possibly could be\nrelated to drugs she was qiven for her migraines. Mom\n-eyed and I explained to her that symptoms are not\nsevere enough to warrent withdrawal meds. Mom and held\ninfant and talking to infant. plan to visit tomorrow\nat 4pm. excited that infant is doing well enough to\nbe taking all bottles and wean from isolette\nA: Involved family with social service issues.\nP: Cont to support and inform.Followup on 51A.\n\n#5 Bili:\nO: Off phototherapy. Rebound bili 5/0.3/4.7\nA/P: Consider repeat rebound in a few days.\n\n#6 dev:\nO: Temps stable in off isolette. Alert/ active waking for\ncares. Jittery with mild tremors. NAS scores . settling\nwell between cares. MAE. Nested in sheepskin with rolls for\ncontainment.\nA; Mild symptoms of withdrawal.\nP: Cont to monitor.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-13 00:00:00.000",
"description": "Report",
"row_id": 1838547,
"text": "npn 1900-0700\n\n\n\n2. RDS:\n\nsats remain > 95 % on Ra Resp Rate 40-60's. Lung sounds\nclear and equal. No retractons and no excess work of\nbreathing. No spells this shift\n\n3. FEN:\nWeight is currently at 1.680 gms down 20gms. Total fluids\nare at 100cc/kilo/day min. Feeds are of PE 20 with a min of\n30cc. Meeting minimum requirements. IVF of D10 with 2 and 1\nheplocked. Dsticks stable at 67 and 58. Abd exam benign.\ngirth's stable. no spits. Voiding and stooling.\n\n4: Social:\n\n called at 9pm and updated on infant. No contact with\nmom. NO visit from .\n\n5: Bili:\nSingle phototherapy dc'd at midnight. rebound bili to be\nchecked later today.\n\nDev: Temps remain stable in a covered isolette. Isolette\nchanged from servo to air. Temps remain stable. alert and\nactive with cares. At times irritable during cares. Infant\nsucks vigourously on pacifier. Brings hands to hace.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-13 00:00:00.000",
"description": "Report",
"row_id": 1838548,
"text": "Neonatology Attending\n\nNow day of life 4.\n\nCardiorespiratory status stable in RA.\nNo apnea and bradycardia.\n\nWt. 1680gm down 20gm on 100cc/kg/d of PE20\nFeedings well tolerated all by bottle.\nDS 56\n\nBili - pending\n\nNAS scores - \n\nAssessment/Plan:\nDoing well.\nWill continue with feeding advancement as tolerated.\nAwaiting word from DSS on status of 51A.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-12 00:00:00.000",
"description": "Report",
"row_id": 1838542,
"text": "npn 2300-0700\n\n\n2: RDS:\n\nSats> 95 % on ra. REsp rate 40-70's. Mild intercostal\nretractions with no excess work of breathing. lungs clear\nand equal.\n\n3. FEN:\n\nweight currently 1.700 gms down 35gms. Total fluids remain\nar 80cc/kilo/day. Feeds are at 30cc/kilo of pe 20. tol all\nbottle feeds. Remains on ivf of D10 with 2 meq NA and 1 Meq\nkcl at 50cc/kilo/day. Abd exam benign. Girth's stable.\nVoiding and stooling. No spits.\n\n4. Social:\nNoc contact with thus far this shift.\n\n5: Bili:\n\nRemains under single phototherapy. Protective shileds in\nplace. Temps remain stable. Bili to be sent later this\nmorning.\n\n6. Dev:\n\nTemps remain stable in a servo isolette. Active and alert\nwith cares also irritable with cares. sleeps well inbetween\ncares. sucks on pacifier and brings hands to face:\n\n^:\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-12 00:00:00.000",
"description": "Report",
"row_id": 1838543,
"text": "exam\nneuro: sleeping, easily awakened, not hypersensitive\nheent: af soft\nlungs: clear b/l and equal\nheart: no murmur\nabd: soft, ND\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-12 00:00:00.000",
"description": "Report",
"row_id": 1838544,
"text": "Social Work:\nFamily meeting held yesterday with , Dr. , , RN and this writer, (covering for , LICSW who is not in on Mondays and Tuesdays). Ms. note from yesterday nicely summarizes the meeting. Please see her note for details.\n\n , continue to follow the family while baby is in NICU. She returns tomorrow. Ms. planned to file the 51 A with DSS. aware. Please call with any questions in the interim.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-12 00:00:00.000",
"description": "Report",
"row_id": 1838545,
"text": "Neonatology Attending Progress Note\n\nNow day of life 3 for this 34 week gestation infant.\n\nCardiorespiratory status stable in RA.\n\nWt. 1700gm donw 35gm on 80cc/kg/d - feedings up to 30cc/kg/d of PE all po. Rest of fluids are PN/IL by IV.\n\nBili 5.1 down on phototherapy.\n\nSocial - meeting with yesterday - they are aware of 51A and DSS evaluation.\n\nAssessment/Plan:\nStable course continues.\nNAS scores low at this point - will follow.\n\nWill continue with encouragement of po feedings.\nPossible transfer to for further care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-12 00:00:00.000",
"description": "Report",
"row_id": 1838546,
"text": "Nrsg Progress Note-0700-1900\n\n\n#2O/A-Rr 30-50's maintaining 02 sats >96% with no desats.\nColor pink-sl jaundice. A-Resp status stable. P-Cont to\nassess resp needs.\n#3O/A-Tf remain 80 cc's with advance to ad lib for pe 20\nall po's . Po fed 20cc's (60 cc's/kg) with d10w with 2 meq\nnacl and 1meq kcl/100 cc's.Abd soft with no loops,spits,or\nasps. Ag 21-22 cms. A-Fen needs wnl this shift. P-Cont to\nassess fen needs.\n#4O/A-Mom phoned with complete update given with Mom asking\nabout fdg tolerance and expressing infant has a temper. This\nRN stated that babies,in general usually get irratable\naround fdgs. Mom may not be able to visit tonight but will\ncall. A-Parenting needs wnl this shift. P-Cont to enc calls\nand visits.\n#5O/A-Rem on single photo with bili masks in place.Masks\nremoved with cares. Plans for am bili. A-Bili needs wnl this\nshift.\n#6O/A-Nas scores of this shift with mild tremors\ndisturbed. Rem in heated isol on servo at 36.0 . Sucking\nvigorously on pacifier. A-G&d needs wnl this shift. P-Cont\nto assess g&d needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-13 00:00:00.000",
"description": "Report",
"row_id": 1838549,
"text": "Social Work\nThis social worker met w/ mother and husband once during mo's induction last Friday. Pls refer to my omr note for relevant details re mo's hx of chronic pain, polysubstance use, and depression. Briefly, mo has suffered and struggled for many yrs w/ chronic migraines, and has been on multiple medications/pain management w/ various providers, including medical dctrs and psychiatrists. She has been seeing psychiatrist from Advocates in , Dr. # , for past 4 yrs since having inpt psych stay in following fetal demise of 20wkr when she had a bout of severe depression.\n\nThere was some confusion re this couple re prior positive tox screen and DSS involvement, as their prenatal care was transferred from and there was no record of the screen in mo\ns medical record. did file a 51a on behalf of the 9 yo dtr based on positive tox screen for cocaine, amphet, barbit, and opiates. Following mo's upset over the screen, a 2nd was done that day w/ same results. Metrow also had some concerns over mo's difficulty in focusing/tangental presentation, and w/ couple's living environment. I also filed a 51a re dtr and , and was open w/ about my mandated responsibilities.\n\nI was told by DSS that they have been investigating this family since the first filing on , and they complete their 10 day process this Friday. I have been unable to connect w/ the DSS investigator and have been therefore unsucessful in gaining any additional information re DSS status.\n\nIt will be helpful for me to meet w/ couple tomorrow at some point during their visit. Please feel free to page me when they arrive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-19 00:00:00.000",
"description": "Report",
"row_id": 1838583,
"text": "Nursing Note\nI agree with above note written Co-worker. in to visit today. Mom brought in corn oil and recipe card made for her. Mom shown how to make Neosure 26 cal. Mom also shown discharge checklist and some items completed. Mom is able to take temp, do cord care and change diaper. Mom also aware that carseat too big for infant and she plans to get a different one (more appropriate for small baby). Mom did return to NICU at 1900 with new carseat. Mom holding infant and doing bottle feed with minimal assistance. Social service involved with family and aware of potential discharge this week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-20 00:00:00.000",
"description": "Report",
"row_id": 1838584,
"text": "NPN 1900-0700\n\n\n3. O: Wt 1720 gms, up 15. Min 102cc/kg of Neosure 26 po.\nTook 166cc/kg for last 24 hrs. No spits. +bs. Voiding. No\nstool. A: Taking adequate amts. P: Cont to monitor wt and po\nintake.\n\n4. O: Mom in at . asking mult d/c questions. Mom also\ncalled X1. Asking appropriate questions. Rn updated Mom.\nA/P: Cont to educate and support family.\n\n6. O: Waking for feeds. and active with care. Temp\nstable swaddled in open crib. Passed car seat test with\nGraco carseat. A/P: Cont to cluster care. Cont to monitor\ntemp.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-20 00:00:00.000",
"description": "Report",
"row_id": 1838585,
"text": "Neonatology\nDoing well. RA. No spells. Comfortable appearing.\n\nWt 1720 up 15. Abdomen Benign. Taking ad lib feeds well ad lib\n\nNAS scores low.\n\nWill consider transfer to NN while awaiting clarification of social situation and plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-20 00:00:00.000",
"description": "Report",
"row_id": 1838586,
"text": "Social Work\nSw continues to follow, and to collaborate w/ DSS. DSs have decided to open the case post their investigation and have assigned a worker, # , on allegations of neglect re 9 yo and infant. Have spoken briefly to Ms. . She is aware of mo's presentation on re slurred speech. I highlighted to DSS the need for their continued monitoring re this mo, her ongoing presentation, and polysubstance use. It will be important for the NICU staff to be concrete w/ regards to this family in the ways we communicate w/ them, and our expectations/what is needed upon discharge. A solid plan needs to be in place for re EIP, collaboration w/ pedi, DSS, mo's psychiatrist, and finding counselor for mo for f/u re psych issues along w/ her medication mngt.\n\nFamily mtng planned for tomorrow. I will meet w/ staff prior at 3:30pm, and mtng @ 4pm Thurs. I\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-11 00:00:00.000",
"description": "Report",
"row_id": 1838537,
"text": "Respiratory Care Note\nPt. began shift on 6cmH2O of NPCPAP nad weaned to 21%. BS clear. Pt. looked comfortable(although tachypneic). Pt. d/c'd at 0300. Pt. doing well off CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-11 00:00:00.000",
"description": "Report",
"row_id": 1838538,
"text": "Neonatology Attending Progress Note\nNow day 2 of life.\nCardiorespiratory status stable off CPAP and in RA with RR 60-70s.\nNo apnea and bradycardia noted.\n\nWt. 1735gm down 40gm on IV fluids 60cc/kg/d.\nNPO\nNormal urine and meconium output noted.\n\nNeuro - baby noted to be irritable when on CPAP but less so now.\nUrine tox screen is positive for barbiturates - maternal medication for her headaches.\n\nSocial - with history of maternal cocaine use, 51-A to be filed.\n\nAssessment/Plan:\nGood progress with respiratory status.\nWill initiate feedings slowly today.\nFamily meeting planned for later today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-11 00:00:00.000",
"description": "Report",
"row_id": 1838539,
"text": "NPN Days 7am-3pm\n\n\n#1 O: Infant is active and alert with cares. Temp stable on\nopen warmer. Blood cultures negative this afternoon for 48+\nhrs therefore antibiotics were d/c'd. A/P: sepsis resolved\nfor now. P: Continue to moniter for s/s potential sepsis.\n#2 O: Infant remains in roomair with O2 sats 96-100%. Resp\nrates mostly 40s-60s, occasionally to the 70s, with mild\nretractions. No episodes of desats. A: breathing\ncomforatbly in roomair, with occasional tachypnea. P:\nContinue to moniter.\n#3 O: TF increased to 80cc/k/day. Started feeds this\nafternoon at 30cc/k/day of Pe 20 cals - infant bottled the\nneeded 9cc well. Abd remains soft, +bs, no loops. Remainder\nof fluids are D10W with added lytes, infusing peripherally.\nD-stick 55. Voiding adeq amts. A: started feeds. P:\nMoniter tolerance of feeds.\n#4 O: Infant's mother up to visit this afternoon. She sat\nat the bedside, talked to and touched infant appr. She asked\nasked appr questions and made many comparisons between her\ncurrent infant's care what happened to her now 9 yo when\nshe was prematurly. A: invested mother visiting at\nbedside. P: Continue to support. Family meeting planned\nfor later this afternoon when infant's father arrives.\n#5 O: Single phototherapy started this morning for bili\nresults of 6.6/.4/6.2. Skin ruddy. A: ^bili levels today -\nphootherapy started. P: Recheck bilirubin level in\ntomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-11 00:00:00.000",
"description": "Report",
"row_id": 1838540,
"text": "NPN Days continued\n\n\n#6 O: Infant active with cares, irritable when initially\ndisturbed and \"jittery\" at times, but settles with sucking\non pacifier and with containment. Temp stable on servo\ncontrol warmer. SLeeping well between cares, will awake\noccasionally and cry. Sucks vigorously on her pacifer and\nbottled her first feeding. A: appr for GA, irritable at\ntimes.. P: Continue to moniter for milestones, moniter\nactivity characteristics.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-11 00:00:00.000",
"description": "Report",
"row_id": 1838541,
"text": "NPN\n\n\n#1 Sepsis:\nO; BC neg at 48 hrs. Abx d/c'ed.\n\n#2 RDS:\nO: remains in RA with sats 100. RR 60-70, mild iC\nretractions. occasionally 80 with agitation. infant\nruddy/pink well perfused. no murmur\nA: resolving RDS\np; Cont to monitor\n\n#3 FEN:o: On TF 80cc/k/d . Feeds PE20 at 30cc/k/d Bottled\nboth feeds well. AG 20. no loops. no spits. voiding\n2.3cc/k/h, passed lg mec.\nIVF infusing at 50cc/k/d.\nA: Tol feeds\np: cont to offer po, gavage when unable to feed volume.,\n\n#4 Social:\no; Family mtg held with myself, , Neo\nFellow. Parents both verbal and talking about their past\nexperience with having a preemie 9 yrs ago. Mom has been\nseen at pain clinic for migraines and was open about\nprescription meds she was on. stating he wanted to\n\"clear the air\" about the pos tox sceens on mom on the 15th\nat . he sated that they were positive for cocaine,\nbarbituates because of the treatments she recieved for her\nmigraines at pain clinic. They both stated they\nunderstood the process of filing the 51A and do not want the\nbaby taken away from them for this. Parents seemed very\nloving and committed to each other. stated he did not\nwant mom to be staying long hours at the hospital like she\ndid when their other child was because she wore herself\nout.Parents in and handled baby briefly before mom was\ndischarged home. Parents declined transfer to for\nnow and plan to visit daily.\nA: Involved loving parents in need of social services\nsupport , Mom with hx depression and Migraines.\nP: Cont to involve social services.\n\n#5 Bili:\no: Under single phototx with eyepatches in place.Color ruddy\nA/P Cont with light. Bili in am.\n\n#6 dev:\no; Infant alert, active with cares Jittery and difficult to\nconsole at times, Infant sucking on pacifier and bottle.\nBottled well. Changed to isolette. temp elevated with temp\nprobe loose. Nested in sheepskin with rolls.\nA; AGA with possible symptoms of withdrawal.\np: Cont to support dev. monitor for withdrawal.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-19 00:00:00.000",
"description": "Report",
"row_id": 1838581,
"text": "Co Worker Note\n\n\nFEN: O/A- TF min 120cc/k/d of NeoSure 26 cal. ad lib. Please\nsee flowsheet for examination of this shift. Belly is soft\nand full. No loops. No spits noted. Baby is voiding, no\nstool as of this progress note.+ Bowel sounds. Desitin\napplied to bottom. Baby is tolerating feeds. P: Continue to\nassess FEN status.\n\nSOCIAL: O/ Mom in this afternoon. Updated on baby's\nprogress and plan for discharge. {Spoke with R.N.}\nMom assisted with cares. Continue to support and educate\n.\n\nDEVELOPMENT: O/A- Baby is in RA, open crib. Temp. remains\nstable. Wakes for feeds, sleeps well in between. A bit\nirritable during cares. and active. Loves her binkie.\nWNL for gestational age. P- Continue to support G/D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-19 00:00:00.000",
"description": "Report",
"row_id": 1838582,
"text": "Rehab/OT\n\nAsked to see a former 34 week infant on to a 37 yo G5 P1 mother. c/b HTN, oligo, + tox screen for cocaine, amphetamines, and barbituates. NAS screening now stopped secondary to low scores. Infant observed during cares. Status as follows:\n\nState transition: smoothe transition from sleep to wake. Able to achieve state 4. Escalates quickly to state 6 without pacifier.\n\nResting posture: fisted hands, flexed elbows, flexed/abducted LE's.\n\nMovement/Tone: hypertonic througout. Able to move through full ROM. Prefers flexor pattern. Scissoring of bilateral lower extremities secondary to increased tone. Mild tremors in disturbed state.\n\nSkin: no excoriation noted. Coworker reporting scratching her face.\n\nA; Former 34 week infant with possible withdrawal from maternal substance abuse. Appears comfortable with appropriate state transition with environmental modifications (decreased light/ pacifier). Tone is hypertonic yet not affecting full ROM. Prefers flexor pattern yet easily extends when placed in antigravity position (sidelying). Does have some tremors in states. Tremors and hypertonicity mildly impairing quality of movement. Will monitor.\n\nP: OT to follow recommend the following:\n\n1. Side to side to increase extension (antigravity position).\n\n2. Swaddle with hands to face. Monitor for scratching of her face.\n\n3. Decreased lighting.\n\n4. Boundaries to maximize comfort.\n\nOT to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838533,
"text": "Nursing Progress Note\n\n\n1. Infant continues on Ampi and Gent. BC neg to date.\nTemps stable. Infant active. Will continue to monitor.\n\n2. Continues on NP CPAP 6cm, FIO2 mostly 26-38%. Breath\nsounds clear and equal. RR moslty 60-80's with mild\ninter/subcostal retractions. Sxn for mod white secretions.\nWill continue to monitor.\n\n3. TF 60cc/kg/d D10w. Abd exam soft with active bowel\nsounds. Voiding QS, mec stools. 24 hr lytes 135/4.1/100/24\n- reported to . Infant to start on D10 with\n2NaCl and 1 KCL when availabe from pharmacy. D-stick 60.\nVoiding QS meconium stools.\n\n4. 24 hr bili 5.0 0.3 4.7 plan to recheck bili in am.\nInfant is ruddy and slightly jaundice. Will continue to\nmonitor and assess for need for phototherapy. Infant is\nvoiding and stooling.\n\n5. Infant has has bruizing on Rt hand, movement normal.\nInfant jittery at times and irritable/difficult to console\nat times. Also infant arching with cares. Infant sucking\non pacifier vigorously at times. Sent urine for tox\npositive for barbit only -reported to . Will\ncontinue to monitor.\n\n6. Family in visiting throughout day, updated at bedside.\nDiscussed care times 9-1-5. Duscussed bili and\nphototherapy. Discussed CPAP. Parents appropiate-dad \neyed. Will continue to monitor and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838534,
"text": "4 Social\n5 Bili\n\nREVISIONS TO PATHWAY:\n\n 4 Social; added\n Start date: \n 5 Bili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838535,
"text": "Respiratory Care Note\nBaby Girl - continues on +6NP cpap and 21-26%. Slight grunting noted. Plan to leave on cpap today, RR 70-80. BS ess clear with mod retractions. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-11 00:00:00.000",
"description": "Report",
"row_id": 1838536,
"text": "NPN 1900-0700\n\n\n1.O: Infant remains on ampi & gent per order. A:R/O sepsis\nP: Await blood culture results.\n\n2. O: Received infant on NPCPAp. NPCPAP d/c at 0300.\nPresently, infant remains in room air. O2 sats >95%. RR\n60-70's with mild retractions noted. LS clear bilaterally.\nA: Infant in room air. P: Continue to assess.\n\n3. O: Wt.-40g 1735g. NPO. TF=60cc/kg/d. D10W with lytes\ninfusing per order. Abdomen soft. +b.s. Vdg & stooling q.s.\nLytes sent. A: NPO P: ? begin feeds today.\n\n4.O: Mom,,Grandma & 9 year old sister in for a visit.\nParents asking appropriate questions. Sister held swaddled\ninfant per parents request. Grandma held infant briefly.\nEntire family kissed good night. Mom up for another\nvisit at 0200. Provided hand containment for infant. Mom\nrequested for NICU with information. given\nto Mom. Informed Mom that family meeting will be held prior\nto d/c. Mom is eager for the meeting. A: Involved family P:\nContinue to update,educate and support.\n\n5.O: Bili sent.P: Results pending.\n\n6.O: remains hypertonic. Sleeps between cares. Calms\nwith pacifier which she sucks on vigorously. Irritable about\n15\" prior to cares. Easily consoled with pacifier,diaper\nchange and position change. Maintaining temperature on\nservo-controlled warmer. Nested. MAE. Left hand remains\nbruised. AGA P:Continue to support development.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-18 00:00:00.000",
"description": "Report",
"row_id": 1838575,
"text": "Co Worker Note\n\n\n3 FEN: O-TF MIN.- 120cc/k/d. PE24, PO. Baby has become AD\nLIB. Please see flowsheet for examination of this shift.\nBaby is voiding, no stool as of this progress note. + bowel\nsounds. Tummy is soft and round. A- Baby is tolerating\nfeeds. P- Continue to monitor for any changes in regime.\n\n4 SOCIAL: O-Mom in this morning. spoke with R.N.\nUpdated on baby's status and plan. Mom active with baby's\ncares. P- Continue to support and educate.\n\n6 G/D: O- Baby is in open crib. Temps have been stable. She\nis waking for feeds. sleeps well in between. Active and\n with cares. A- WNL for gestational age. P- Continue to\nsupport G/D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-18 00:00:00.000",
"description": "Report",
"row_id": 1838576,
"text": "NPN\n\n\n3. TF@ a min. of 120/kg/d of now neosure 24 cals/oz with mct\noil to = 26cals/oz. Ad lib feeds q 2.5-4 hrs., taking\n15-50cc's. Voiding qs, desitin to groin area, reddened. A:\nTolerating feeds P: Plans for d/c on wed/thurs.\n4. Mom in and fed. Handles baby with\ndiapering, temp taking. DSS involved. A: Involved P:\nDischarge teaching.\n6. In open crib with stable temp, and active. Waking\nfor feeds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-19 00:00:00.000",
"description": "Report",
"row_id": 1838577,
"text": "progress note 1900-0700\n\n\n3 FEN\nwt is 1705 grams (+25). remains on an adlib schedule of a\nmin of 120cc/kilo/day of neosure 26. taking 35-45cc every\nfour hours. abd benign. +bs. voiding and stooling. pt\ntook in 132cc/kilo in the past 24 hours. no spits thus far\nthis shift\n\n4 Social\nmom called and was updated by rn.\n\n6 DEV\ntemp remains stable in open crib. and active with\ncares. wakes for feeds, sleeps well in between. roots\naround. sucks vigorously on pacifier. + grasp. no s/s of\nwithdrawl. pt is very wide-eyed and .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-19 00:00:00.000",
"description": "Report",
"row_id": 1838578,
"text": "NPN 1900-0700\nAgree with above Co-worker note. Mom called X1 at 0200. Asking appropriate questions while slurring words and repeating herself. RN updated Mom. stated she would be in in the am after older sib went to school. Cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-19 00:00:00.000",
"description": "Report",
"row_id": 1838579,
"text": "Addendum\nRn attempted to place pt in own car seat. Unable to fasten car seat in a safe manner with or withoout rolls. Car seat not completed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-19 00:00:00.000",
"description": "Report",
"row_id": 1838580,
"text": "Neonatology Attending Progress Note\n\nNow day of life 10.\nCardiorespiratory status stable in RA with no apnea and bradycardia.\n\nWt. 1705 up 25gm taking ad lib Neosure 26kcal/oz\nTransition to Neosure tolerated well.\n\nSocial - mother called in last night and was reported to have slurred speech. Will discuss with Social Work, .\n\nAssessment/Plan:\nBaby is doing well.\nWill discuss discharge disposition with Social Work, will contact DSS with concerns.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838529,
"text": "NPN\n\n\n1.Sepsis: Temp WNL on warmer, on antibiotics , awaiting\nblood culture results.\nA/P: No signs and symptoms of sepsis-ruling out-cont.\nantbx-check gent levels as ordered.\n\n2.RDS: Remains on NPT(2.5) CPAP of 6, in 21-35%- mostly in\n25-30% overnight. RR=60-90's BBS clear w/ mild IC/SC\nretractions. Sats 92-99 in prone position, sxn for mod-lg\nthick yellow secretions via ETTx1. CBG's with adequate\nventilation and correcting metabolic acidosis. BP's wnl.\nA/P: Mild RDS, tachypneic but comfortable, low 02\nrequirement, adjust as tolerated, improving CBG's.\nWean off cpap as tolerated.\n\n3.FEN: IV TF at 60cc/kg/d of d10w, Wy=1.775, down 5gr.\nUOP+2.3cc/kg/hr, abd full/soft on cpap, stooled mec x1.\nDstix wnl\nA/P: Check 24hr lytes today, cont. to monitor Dstix as\nordered.\n\n4.Social: Father and sibling in--very excited and\nloving towards baby. Father asking appropriate qs. Stated\nmom was on Mag. and would not come to see baby\nA/P: Updated father, cont. to inform, family meeting w/ mom\nwhen able.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838530,
"text": "NNP Physical Exam\n\nPE: ruddy pink, jaundiced, AFOF, NPCPAP in place, breath sounds clear/equal with mild subcostal retracting, no murmur, normal pulses, abd soft, non distended, bowel sounds present, mild generalized edema with puffy eyes lids, active with age appropriate tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838531,
"text": "Neonatology Attending Note\nDay 1\n\nPrematurity\nTTN vs mild RDS\nr/o sepsis\npotential maternal substance exposure\n\nNow in CPAP +6, 21-26%. CBG 7.37/47. RR70-80s. No murmur. HR 130-150s. Pink.ruddy. Mean BP 55. Wt down 5 to 1775. TF at 60 w D10w. NPO. d/s 93/108. Nl voiding. Passed mec stools. Under radiant warmer. On amp/gent.\n\nNeuro: appears irritable, jittery, unconsolable, arches. w/ maternal history will send u.tox.\n\nplan:\n- Monitor resp status. Maintain CPAP for now\n- Keep NPO for now\n- Check 24 h lytes, bili\n- Con't abx pending labs, clinical course\n- Check u.tox.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838532,
"text": "Nursing Progress Note\nInfant continues to be jittery-D-stick now 80. Ionized Calcium 1.12. Will continue to monitor. Infant continues to be irritable and hypertonic with exagurated response to stimuli and hyperactive morrow. Team aware of above. Will continue to monitor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-23 00:00:00.000",
"description": "Report",
"row_id": 1838601,
"text": "NICU NPN 0700-1900\n\n\nFEN: Tf=min 120cc/k/d. Infant has bottled 51-54cc of Neosure\n26 q 3-4 hours this shift. No spits. Abdominal exam benign.\nVoiding, no stool this shift. On Fe - today's dose drawn up\nand administered by Mom (dose adjusted to 0.2cc for\ndischarge). Continue per plan.\n\n: Mom in from 0930 until end of shift. Updated on\ninfant's status. Completed discharge teaching with Mom\ntoday. Mom drew up and administered Fe (aware of new dose).\nMom gave infant a bath. Mom also made infant's formula using\nrecipe card without difficulty. Needs carseat instruction\nprior to discharge. Updated at bedside on infant's status.\nMom plans to call tonight and again tomorrow morning around\n0900/1000 to find out if discharge is still planned for\ntomorrow. Continue to support and update .\n\nDEV: Infant is swaddled in an open crib, stable temps this\nshift. and active with cares, sleeping well b/w. Wakes\nfor feeds, bottled well. Brings hands to face, loves\npacifier. Continue to support growth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-09 00:00:00.000",
"description": "Report",
"row_id": 1838523,
"text": "Neonatology Attending Admit Note:\n\nx-34 week infant admitted for issues of prematurity.\n\nInfant born to a 37 year old G5P1 mother blood type A positive, negative, RPR NR, RI, antibody negative. EDC (9week US)\n\nPrenatal course significant for:\n1) decreased interval growth ; received betamethasone x 2 at that time--maybe due to possible induction (not documented)\n2) hypertension probably due to combination of chronic hypertension and pre-eclampsia. labs: normal LFTs, uric acid, plt, small amount protein in urine on most recent UA.\n3) admitted with headache, blurry vision and photophobia; history of migraines; due to severity of HA and associated symptoms, MRI/MRA done and results within normal\n4) development of oligo approximately 2 weeks ago\n5) plan for induction due to oligohydramnios (decreased from AFI=5 on to AFI=2 on ) and increased BP--145/98; mother receiving Mag\n6) urine test at significant for cocaine and amphetamines; repeat utox at on negative for cocaine and negative for amphetamines, positive for barbiturates\n7) amnio with 46 XX\n\nOB Hx:\n--( Hospital) 30 week premature infant, induction for PIH, infant with grade III IVH, no shunt required, mild cerebral palsy\n\nPMH: c/o migraines, fibromyalgia with meds: fuorinal, tylenol, zantac, pain service following due to migraines and receiving lidocaine injections\n\nSocial Hx: prevous admission to in for suicide attempt and followed closely by psych; lives in with husband (not father of baby) and 9 year old\n\nPrenatal Care: \n\nDelivery Room: asked by Dr. to attend delivery due to prematurity. unknown GBS, no maternal fever, ROM x 13 hours prior to delivery, maternal antibiotics x 16 hours prior to delivery; Infant born by vaginal delivery on at 12:51pm with APGARS of 8 (min) and 9 (5min). infant emerged with good respiratory effort, HR always over 100; brought to warmer, dried, bulb suctionned and given BB oxygen for central cyanosis; good response and brought to NICU for further evaluation; of note--left hand and distal arm noted to be edematous with significant bruising of hand\n\nUpon arrival to NICU, noted to have significant desaturation, received BB oxygen with some improvement in saturation yet due to persistent oxygen requirement and mild respiratory distress, placed on CPAP.\n\nPE--wt=1785g (10-25%), HC=30.5cm (25-50%), L=41cm (10-25%), HR=160's, RR=60, T=98.4 BP=61/31 (mean=45); active, AFOF, bilateral RR present. normalS1S2, no murmur, breath sounds slightly coarse bilaterally, mild ic/sc retx. abdomen soft, nontender, nondistended, ext warm, well perfused, tone aga. hips stable. no dimple noted. left hand swollen and bruised; some swelling of distal left arm; no other swelling noted.\n\nLabs: CBC--WBC-22 (uncorrected, diff pending), crit=52%, plt=247, dstx=96\nblood culture pending\n\nImp/Plan: x-34 week female infant with mild respiratory distress probably due to mild HMD vs TT\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-09 00:00:00.000",
"description": "Report",
"row_id": 1838524,
"text": "(Continued)\nN (clinical course may assist with differentiating diagnosis), possible sepsis and in utero cocaine exposure.\n--continue CPAP, check CXR to confirm without pneumothorax and assess degree of lung disease, wean oxygen as tolerated\n--due to respiratory distress and prematurity, will start amp and gent with length to be determined by clinical course and blood culture results.\n--continue to monitor dstx and BP\n--will speak with family and then send u tox\n--will involve social worker on \n--monitor for jaundice over next few days\n--will place on IVF D10 W for now, lytes at 24 hours if remains NPO\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-09 00:00:00.000",
"description": "Report",
"row_id": 1838525,
"text": "1 Infant with Potential Sepsis\n2 RDS\n3 FEN\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 RDS; added\n Start date: \n 3 FEN; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-09 00:00:00.000",
"description": "Report",
"row_id": 1838526,
"text": "Respiratory Therapy\n34 weeker born this afternoon. Brought back to the NICU and started on NP CPAP for GFR. Currently on NP CPAP of 6, 0.21-0.40. Tachypneic to 100. Will continue with CPAP and increase support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-09 00:00:00.000",
"description": "Report",
"row_id": 1838527,
"text": "Nursing Admission Note\n\n\n 34 week baby girl to a 37 yo G5 P1-2 mother. \nabove note written by MD.\n D/T FIO2 requirement and retractions placed NP CPAP 6cm\nFIO2 on CPAP 32-40%. CXR obtained and looked at by team.\nRR mostly 60-70's. D/T tachypnea and FIO2 requirement CBG\nobtained 7.24/38/69/17/-10 and 18cc NS bolus given over 10\nmin. Breath sounds coarse, Sxn ETT for small white\nsecretions and orally for mod amts of old blood tinged\nsecretions. Will continue to monitor resp status closley,\n Started infant on D10w at 60cc/kg/d. D-sticks 96 and\n107. Void X1 2cc, no stools. Abdomen soft/flat active\nbowel sounds.\nInfant placed on servo warmer. Temp stable. Infant is\nalert and active with irritability with cares.\n CBC and blood cultures done. Amp and Gent given as\nordered. Will monitor for s/s sepsis.\n**Plan to check 24 hr lytes and bili tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-10 00:00:00.000",
"description": "Report",
"row_id": 1838528,
"text": "Respiratory Care Note\nPt. continues on 6cmH2O of NPCPAP nas 25-30% most of shift. BS are clear, Pt. sx'd for mod. thick yellow secretions. Pt. at times tachypneic--however appears comfortable. Cap gas 7.29/49. plan is to obtain another gas prior to end of shift. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-24 00:00:00.000",
"description": "Report",
"row_id": 1838602,
"text": "Patient Care CoWorker Notes/Nights\n\n\n3. O: Total fluids Ad-lib demand minimum 140cc/kg Neoshore\n26. Voiding and stooling. Abd benign. No spits. A: Tolerates\nfeeds. Bottles well. P: Continue with plan and monitor.\n\n4. No contact from this shift.\n\n6. O: Infant in RA in open crib swaddled w/hat. Temps remain\nstable. and active with cares. Wakes for feeds.\nSucking on pacifier. Eyes open and looking around. A: AGA.\nP: Continue to support developmental needs and monitor.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-24 00:00:00.000",
"description": "Report",
"row_id": 1838603,
"text": "NPN 1900-0700\nAgree with above Co-worker note. Ls clear. Pink. HR 140-170's. Wt 1840, up 25gms. Po ad lib min of 120cc/kg of Neosure 26. Took 45 +70cc. Voiding and stooling. WAking for feeds Q3-4 hrs. No contact from family thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-24 00:00:00.000",
"description": "Report",
"row_id": 1838604,
"text": "NICU Attending Discharge Note\n\nDOL # 15 = 36 1/7 weeks CGA ready for discharge to home.\n\nPlease see PEx form for details of discharge PEx: Unremarkable in detail.\n\nCVR/RESP: RA, RR 30-40, no A/B, no murmur, HR 140-160.\n\nFEN: Weight today 1840 (up 25 gm), on minimum of 120 cc/kg/d, took 174 cc/kg in last 24 hours, on neosure 26, tolerated well. Also on supplemental Fe.\n\nENV'T: Stable temp in opne crib.\n\nDISPO: Passed hearings screen and car seat test. Too small for HepB vaccine. Will discharge to home today, VNA to visit tomorrow and Thursday. PMD is Dr. , appt Tuesday.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-24 00:00:00.000",
"description": "Report",
"row_id": 1838605,
"text": "NICU NPN/DISCAHRGE NOTE 0700-1900\n\nInfant in RA. RR 40-60's. LS CTA bilaterally. HR 150-160's. No murmur. Pink, well perfused. Bottling Neosure 26, 30-60cc q 1.5-4 hours this shift. Abdominal exam benign. Voiding, stooling. On Fe - given by Mom prior to discharge. In open crib with stable temps. and active, wakes for feeds. Brings hands to face, likes pacifier.\n\n in at 1300. Independent with cares. Mom administered Fe to infant and bottled infant. placed infant in carseat without assistance. Reviwed discahrge sheet with , all questions answered. Pedi appt made for Tuesday. VNA to visit tomorrow. EI faxed. PKU done. Discharge order present in chart. ID bands checked with Mom.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 1838596,
"text": "Clinical Nutrition:\nO:\n35 wks CGA, BG now on DOL #13\nWt: 1770g (+30g)-(10-25th%ile); gained an average of 9 g/kg/day over the last week.\nLN: 41cm (<10th%ile)\nHC: 30.5cm (10-25th%ile)\nLabs: none recent\nMeds: Iron\nNutrition: Neosure 26 (min. 120 cc/kg/day)\nGoal feeds of 150 cc/kg/d= ~130 Kcals/kg & ~3.2 g/kg of protein\nGI: medium spit today\n\nA/goals:\nTolerating feeds all PO. Plan is to d/c home over the w/e, on Neosure26. met goal wt. gain over the last 2days (20-35g/day) on Neosure26 w/ a minimum of 120 cc/kg/day. Continues on Iron. Mom has been instructed on mixing the Neosure26, provided coupons for Neosure & will be available if questions arise post d/c.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 1838597,
"text": "NPN/0700-1900\n\n\n#3 FEN: TF=min120cc/k/d of Neosure26. Bottling 45-55cc\nQ3-4hrs. Mod. spit x1. Abd. benign. Voiding; no stools.\nRemains on Fe QD.\n\n#4 SOCIAL: Spoke with mom this afternoon; updated. Mom\nstill planning on coming to NICU for good part of tomorrow\nday and doing all of infant's cares and feedings in prep.\nfor d/c on Sunday. No further contact this shift.\n\n#6 DEVELOPMENT: Infant swaddled in open crib; temps stable.\nActive and with cares. Waking for feeds. Sucking on\npacifier when offered. AFOF.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-23 00:00:00.000",
"description": "Report",
"row_id": 1838598,
"text": "NPN 1900-0700\n\n\n3. O: Wt 1815 gms, up 45. Min 120cc/kg of Neosure 26 po. Pt\ntook 169cc/kg yest. No spits. waking q 3 hrs for feeds.\nVoiding and stooling G-. A: Taking adequate pos. P: Cont to\nmonitor wt, and po intake.\n\n4. O: mom in at . Mom independent with cares and feeding\npt. Asking appropriate questions. A/P: Mom to be in in am.\nCont to educate and support Mom.\n\n6. O: Temp sawddled in open crib. and active\nwith cares. wakes for feeds. A/P: Cont to cluster care. cont\nto monitor temp.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-23 00:00:00.000",
"description": "Report",
"row_id": 1838599,
"text": "Neonatology Attending\n\nAddendum - PE\nBaby pink breathing comfortably in RA.\nAF soft and flat.\nLungs clear and equal.\nCVS - S1 S2 normal intensity, no murmur\nAbd - soft with normal bowel sounds\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-23 00:00:00.000",
"description": "Report",
"row_id": 1838600,
"text": "Neonatology Attending\nNow 2 weeks of age.\n\nCardiorespiratory status stable in RA.\nHR 130-170s\n\nWt. 1815gm up 45gm - took in 170cc/kg/d of Neosure 26\nFeedings going very well by bottle.\n\nSocial - discharge arrangements set - will go home tomorrow with close follow-up with Pediatrician and DSS.\n\nWill continue with current management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-21 00:00:00.000",
"description": "Report",
"row_id": 1838591,
"text": "Neonatology\nAs above, working with , DSS and community services to raedy services. Takign adequate feeds. Will meet with family and plan time for mother to provide all of a days feedings to assure comfort and adequacy of feeding.\n\nDischarge teaching and assessment continues.\n\nFamily meeting held today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-21 00:00:00.000",
"description": "Report",
"row_id": 1838592,
"text": "NPN/0700-1900\n\n\n#3 FEN: TF=min120cc/k/d of Neosure26 cals. Bottling\nQ2-4hrs, and taking between 45-60cc with each feed. No\nspits. Abd. benign. V/S. Remains on Fe.\n\n#6 DEVELOPMENT: Infant swaddled in open crib; temps stable.\nActive and with cares. Waking for feeds. Sucking on\npacifier when offered. +rooting; sucking on hands. AFOF.\n\n#4 SOCIAL: Mom, , and older sibling visiting at 1600 for\nFTM. Social work, Drs. and present. Meeting\ncentered around infant's potential d/c on Sunday. \ntalking at length about their readiness to take infant home.\nInfant's pedi appt has been made for , as well as mom's\nown psych appt. Mom EI in prep. for d/c. Mom\nplanning to come in on Saturday to spend the day and care\nfor infant. Both asking many appropriate questions;\nmom taking lots of notes in notebook. Both seem\nvery appropriate with infant and eager to have infant home.\nAfter meeting, d/c teaching continued with . Mom\nmade formula independ. with supervision. WIC form given to\nmom as well. Plan to have mom review med. administration on\nSaturday. Both and sibling will be taking CPR this\nevening. have not provided care for infant thus far\nthis shift (infant had just eaten prior to their arrival for\nmeeting).\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-22 00:00:00.000",
"description": "Report",
"row_id": 1838593,
"text": "NPN\n\n\nNPN#3 WT UP 30GMS TO 1770 STILL BELOW BW OF 1785, MIN TF AT\n120CC/KG/D OF NEOSURE 26CALS..WAKING ABOUT EVERY\n4HRS..BOTTLING WELL FOR 58-60CC QFEEDING, TOL WELL, NO\nSPITS, ABD EXAM SOFTLY ROUNED & BENIGN, VOIDING, NO STOOL\nOVERNIGHT A= TOL FEEDS/ GAINING WT P= CONT PER PLAN, FOLLOW\nWT GAIN\n\nNPN#4 O= & SIBLING IN TO VISIT..TOOK CPR CLASS, MOM\nINDEPENDENT WITH CARES..BOTH HELD BABY..STATES WILL BE IN\nTOMORROW AND PLANS TO STAY MOST OF DAY SATURDAY A= \nANXIOUSLY AWAITING FOR DISCHARGE/ TEACHING IN PROGRESS P=\nCONT TO UPDATE & SUPPORT, CONT WITH DISCHARGE TEACHING AS\nNEEDED\n\nNPN#6 O= TEMP STABLE IN OPEN CRIB SWADDLED , AF SOFT 7 FLAT\n, WAKING FOR FEEDS, ACTIVE 7 WITH CARES, GOOD TONE/\nHANDS TO FACE A= AGA P= CONT TO ASSESS & SUPPORT DEV NEEDS\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-14 00:00:00.000",
"description": "Report",
"row_id": 1838556,
"text": "Nursing Note 0700-1900\n\n\nFEN: TF increased from 100 to 120cc/k/day of PE22 (increased\nfrom PE20 at 1600). All bottles, taking 28-36cc w/ yellow\nnipple. Abd benign, BS active. No spits. DS 50/71. voiding\nqs, no stool this shift. Tolerating feeds well, con't to\nencourage POs.\n\nSocial: were expected in at 1300, no contact so far\nthis shift. DSS came in this am to check on baby and get\nupdated. Social worker also met w/ DSS and then came\nto check on baby. Please page social worker \nwhen come to visit. Con't to support and update as\nneeded.\n\nG&D: Alert and active w/ cares, wakes for feeds rooting,\nsleeping well. Slightly jittery when disturbed. NAS scores\n today. Sucks on pacifier and bottles w/ good\ncoordination. Temps stable swaddled in off isolette. AGA,\ncon't to support dev needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-15 00:00:00.000",
"description": "Report",
"row_id": 1838557,
"text": "NPN\n\n\n3.Min. of 120/kg/d of PE 22, ad lib, all po feeds,\ntaking35-40 cc's q 4hrs. Abd. benign,soft,ag stable, voiding\nand stooling qs. A: All PO feeds so far P:Continue to\nobserve for signs of tiring. Cont.to as tolerated.\n4. in to visit and held. Discussed plans for\nfeeding. P:Continueto encourage to ask questions.\n6. Alert and active with cares , no signs of withdrawals,\nNAS score 0-1. Sleeps comfortably b/w cares. A: No\nevidence of withdrawals.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-15 00:00:00.000",
"description": "Report",
"row_id": 1838558,
"text": "Neonatology Attending Progress Note\nNow day of life 6.\n\nRespiratory status remains stable in RA.\nRR 30-40s.\nNo apnea and bradycardia.\n\nWt. 1655gm - no change\nFeedings ad lib PE22 - took in 126cc/kg/d - feedings are well tolerated.\n\nNAS scores 0-1\n\nAssessment/Plan:\nBaby continues to do well.\nWill advance to PE24.\nResults of 51-A pending.\nWill no longer require NAS .\nFe therapy to be initiated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-15 00:00:00.000",
"description": "Report",
"row_id": 1838559,
"text": "exam\nneuro: alert, not hypersensitive\nlungs: clr, equal BS\nheart: no murmur\nabd: soft, ND\nwell perfused\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-15 00:00:00.000",
"description": "Report",
"row_id": 1838560,
"text": "Progress Note 0700-1900\n\n\n3. FEN: O: TF min 120cc/kg/d PE24 ad lib. Bottling\n36-40cc/feed q4h. Abd exam benign, +BS. No spits. Voiding\nand stooling (heme -). Weight stable. A: Tolerating feeds.\nP: Cont to monitor.\n\n4. SOCIAL: O: Mother w/ hx of drug abuse during pregnancy.\nVoluntarily offered to me that she \"doesn't remember doing\nit\" (cocaine, etc). Mom in to visit today. Very emotional\nand expressive about present situation (51A pending). Spoke\na great deal about older daughter (9yo) and expressed much\nlove for her children and family. Relatively independent\nwith baby. Asking appropriate questions. Very loving with\n. A: Loving family. P: Cont to follow situation\nclosely and support Mom's needs.\n\n6. DEV: O: is active/alert with cares. Residing in\noff-isolette. Temps stable. Waking q4h to feed. NAS D/C'ed\ntoday. No evidence of tremors or withdrawal sx's. Sleeping\nwell b/w. Roots and sucks on pacifier. A: AGA. P: Cont to\nsupport 's dev needs.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-15 00:00:00.000",
"description": "Report",
"row_id": 1838561,
"text": "NPNote:\nI agree with Co-workers above note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-16 00:00:00.000",
"description": "Report",
"row_id": 1838562,
"text": "progress note 1900-0700\n\n\n3 FEN\nwt is 1660 grams (+5). remains on an adlib schedule of a\nmin of 120cc/kilo/day of PE 24. wakes evry four hours for\nfeeding. tolerates them well. abd benign. +bs. girth\nstable. voiding. no stool thus far. no spits.\n\n4 Social\nmom called and was updated by rn.\n\n6 G&D\ntemp remains stable in off isolette. alert and active with\ncares. occ hyperactive. roots around vigorously. brings\nhands to face. wakes for feeding, sleeps well in between.\nno s/s of withdrawl.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-16 00:00:00.000",
"description": "Report",
"row_id": 1838563,
"text": "NEONATOLOGY ATTENDING\n\nDay 7 for .\n\nRESP: No apneas, on RA, comfortable.\n\nCV: Pink, perfused, no murmur.\n\nFEN: 1660 +5g. 120/kg. On 24 cal PE. All PO, voiding, stooling. On Fe.\n\nDVLP: Moved to crib--tolerating this well.\n\nNEURO: Will d/c abstinence --has been below threshold.\n\n: Hearing screen done. She is just 35 weeks, and very tiny. Need to defer HepB. Will need car seat test.\n\n: Will be in today. Social issues will be an important determinant of discharge timing.\n\nSee exam note below.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-16 00:00:00.000",
"description": "Report",
"row_id": 1838564,
"text": "Progress Note 0700-1900\n\n\n3. FEN: O: TF min 120cc/kg/d PE24. All feeds po. Bottling\n35-42cc/feed with yellow nipple. Abd exam benign, +BS.\nVoiding and stooling (heme -). Mod spit x1. Started on Fe.\nGaining wgt. A: Tolerating feeds. P: Cont to monitor.\n\n4. SOCIAL: O: called for update this am, spoke with RN.\nReported that he or Mom may be in later today. Have not come\nin so far this shift. A: Loving family. P: Cont to support\nand educate family, prepare for D/C home.\n\n6. DEV: O: Received in off isolette, moved to open\ncrib this am. Temps stable swaddled in crib. Appears\nsleepier today but still waking q4h for feeds. Sucks\nvigorously on pacifier. No tremors or other s/s withdrawal.\nA: AGA. P: Cont to support 's dev needs.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-16 00:00:00.000",
"description": "Report",
"row_id": 1838565,
"text": "NPN 7a-7p\n Agree with note and asessment as written above by coworker.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-16 00:00:00.000",
"description": "Report",
"row_id": 1838566,
"text": "Neonatology- Physical Exam\n\nInfant remains stable in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone, slghtly hypertonic. BBS clear and equal with good air entry. No murmur, pulses +2, pink, CRT < 3 secs. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note above for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-17 00:00:00.000",
"description": "Report",
"row_id": 1838567,
"text": "NICU NPN 1900-0700\n\n\n#3 FEN O: Tf remain at a min of 120cc/k/d. Took in 136cc/k\nyesterday. Waking for feeds , bottling well. Weight 1665g,\nup 5g. Abdominal exam benign. Voiding and stooling. A:\nstable. P: Continue feeding plan.\n\n#4 Social O: in to visit. D/c teqaching initiated.\n independent with cares, asking appropriate\nquestions. A: involved . P: Continue to keep\ninformed, d/c teaching.\n\n#6 DEV O: Temps are stable, swaddled in crib. Baby is \nand active with cares, sleeps well in between. Fontanells\nare soft and flat. A: aga P: Continue to support\ndevelopment.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-17 00:00:00.000",
"description": "Report",
"row_id": 1838568,
"text": "Neonatology Attending\nAddendum - Physical Examination\nHEENT AFSF\nCHEST no retractions; good bs bilat; no crackles\nCVS well perfused; RRR; PPP; S1S2 normal; no murmur\nABD soft, non-distended; bs active\nCNS active, , resp to stim; tone slightly increased; mild jittery movements of extremities with stim; suck/root/gag/grasp/Moro normal\nINTEG normal\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-17 00:00:00.000",
"description": "Report",
"row_id": 1838569,
"text": "Neonatology Attending\nDOL 8\n\nRemains in room air with no cardiorespriatory events. Wt 1665 (+5) on minimum TFI 120 cc/kg/day, with intake 136 cc/kg/day PE24. Temperature stable in open crib. Mild jitteriness, but no other unusual behaviors. DSS evaluation in process.\n\nA&P\nSGA infant with recently established thermoregulation. Continue to monitor temperature for another 24 hours prior to consideration of transfer to regular nursery.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-17 00:00:00.000",
"description": "Report",
"row_id": 1838570,
"text": "Nursing Progress Note\n\n\nFEN O/A: BW 1780g, Current Wt= 1665g TF @ minimum of\n120cc/k/d of PE20. Infant should receive ~36cc q4h. \nhas bottled 40-45cc w/ the yellow nipple today. Good\ncoordination noted. Abdomen is benign, pos BS. No spits P:\nCont to encourage po intake & monitor feeding tolerance.\n\nSOC O/A: No contact from thus far today.\n\nG&D O/A: Temps stable in an open crib. sleeps well\nbetween feedings and is & active with cares. Infant is\nslightly jittery & very wide eyed as well. Sucks on fingers\nor pacifier for comfort P: Will cont to support\ndevelopmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-17 00:00:00.000",
"description": "Report",
"row_id": 1838571,
"text": "NPN 7a-7p\n Agree with ( coworker) note and asessment as written above. Passed hearing screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-17 00:00:00.000",
"description": "Report",
"row_id": 1838572,
"text": "NPN addendum\n Mom came in to visit at 6:30pm beteen care times. Mom held infant briefly. Update given. mom to try to stay for 9pm cares.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-18 00:00:00.000",
"description": "Report",
"row_id": 1838573,
"text": "NICU NPN 1900-0700\n\n\n#3 FEN O: Tf remain at a min of 120cc/k/d. Tolerating po\nfeeds of pe24 well. Voiding and stooling, abdominal exam\nbenign, baby is waking for feeds. Weight 1680g, up 15g. A:\nFeeding well, gaining weight. P: Continue to monitor weight\ngain.\n\n#4 Parenting O: Mom in for 9pm cares, independent, asking\nappropriate questions. Very loving towards baby. d'c\nteaching reinforced. called x1 for update. A: Involved,\nloving . P: Continue to keep informed.\n\n#6 DEV O: temps are stable, swaddled in crib. Baby is \nand active with cares, sleeps well in between cares,\nfontanells are soft and flat. A: aga. P: Continue to support\ndevelopment.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-18 00:00:00.000",
"description": "Report",
"row_id": 1838574,
"text": "Neonatology Attending Progress Note\n\nNow day of life 9.\n\nCardiorespiratory status stable in RA.\nNo apnea and bradycardia.\nRR 40-60s\nHR 120-150s\n\nWt. 1680 up 15gm on PE24 - took in 148cc/kg/d over past 24 hours.\nFeedings well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nBaby continues to do well.\nTaking full volume now by mouth.\nWill switch to Neosure 24 with Corn oil to 26kcal/oz in anticipation of discharge to home in the next week.\nStill awaiting final word from DSS/Social Work on discharge disposition/ plans for follow-up.\n\n"
}
] |
9,043 | 145,837 | The patient was admitted to the Coronary Care Unit for further management. The patient underwent stat dialysis to reverse his hyperkalemia. Further amiodarone was held. As noted above, the patient was intubated and was transferred to the Coronary Care Unit. 1. Cardiovascular: A. Coronary artery disease: Following the patient's dialysis, he went for cardiac catheterization. Coronary angiography revealed severe two vessel coronary artery disease. The LMCA had no significant stenosis. The left anterior descending had a focal 80% stenosis in the proximal vessel and luminal irregularities throughout the remainder of the vessel. The left anterior descending supplied a moderate-sized bifurcating D1 that had an 80% stenosis in the lower pole. The left circumflex had diffuse luminal irregularities and supplied a large trifurcating obtuse marginal I and a small obtuse marginal II before terminating in the AV groove. The obtuse marginal branches were free of significant disease. The right coronary artery had serial 99% lesions in the proximal and mid-vessel, with evidence of low flow in the distal vessel. The posterior descending artery and PLV were small and filled faintly. Limited resting hemodynamics revealed normal left ventricular filling pressures with an left ventricular end diastolic pressure of 15 mm Hg in the setting of normal systemic arterial blood pressure, no gradient across the aortic valve was seen. Left ventriculography demonstrated inferior and posterobasal hypokinesis with a calculated left ventricular ejection fraction of 45%, mild 1+ mitral regurgitation was seen. Rotational atherectomy/PTCA/stenting of the right coronary artery was performed using three stents. There was 10% residual stenosis, normal flow, and no apparent dissection. Successful percutaneous transluminal coronary angioplasty/stenting of the proximal left anterior descending was performed as well. There was no residual stenosis, normal flow, and no apparent dissection. The patient was maintained on aspirin and statin, and was started on Plavix, which he will require for 12 months. As the patient's blood pressure tolerated, he was started on a beta blocker and ACE inhibitor. | Overall leftventricular systolic function cannot be reliably assessed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Small right intramuscular hematoma. There ismild regional left ventricular systolic dysfunction.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: Moderate (2+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There has been interval adjustment of a right-sided chest tube which is kinked over upon itself and is located overlying the right hemithorax. The mitral regurgitation jet is eccentric.TRICUSPID VALVE: Mild to moderate [+] tricuspid regurgitation is seen.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: The patient is tachycardic (HR>100bpm).Conclusions:The left atrium is mildly dilated. Also - RIJ quentin catheter placed - not owrking; concern its not in right place. Rule out pneumothorax, check hematoma. There is left ventricular enlargement. PORTABLE UPRIGHT CHEST: The right-sided chest tube has been removed. FINDINGS: CT ABDOMEN WITHOUT CONTRAST: Bibasilar atelectasis is present. Right sided chest tube, without interval change compared with 2 days earlier, and some surrounding opacity, presumably atelectasis and hematoma. There is mild regional left ventricular systolic dysfunction withsevere hypokinesis of the inferior wall and inferior septum. ?tamponade/perforation.Height: (in) 69Weight (lb): 160BSA (m2): 1.88 m2BP (mm Hg): 140/37Status: InpatientDate/Time: at 16:22Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity size is normal. S/P VF arrest.Height: (in) 69Weight (lb): 160BSA (m2): 1.88 m2BP (mm Hg): 127/69HR (bpm): 115Status: InpatientDate/Time: at 12:13Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. IMPRESSION: 1) Right-sided chest tube kinked upon itself. Sinus arrhythmiaLead(s) unsuitable for analysis: V2Short PR intervalInferior infarct - age undetermined Lateral ST-T changes offer additional evidence of ischemiaSince last ECG, no significant change HD dependent.IV's: right IJ quinton cath **INFILTRATED**. + Bld R pleural/ mediastinal space d/t quinton cath displacement. repro on and d/c'd d/t high act. Compared to the previoustracing of arrhythmia has appeared.TRACING #1 CCU NSG PROGRESS NOTE.O:NEURO=ARNGY. DC RIJ HD CATH W OR BACKUP. WO LEAK/ CREPITUS. Anterior ischemia.TRACING #3 s/p arrest, cath/stents/rotoblationccu npn- see transfer sheet alsoo- id- afebrile. required atropine x1. ST segment depressions are now horizontal in leads V4-V6.Ischemia is likely.TRACING #2 CT with contrast after HD today. on return sheaths r groin with scant ooze, pulses 1+/dopp bilat dp/pt. Sinus rhythmAberrantly conducted supraventricular extrasystolesPremature ventricular contractionsSupraventricular extrasystolesShort PR intervalOld inferior infarct Lateral ST changes are nonspecificSince last ECG, more ventricular premature complexes, atrial prematurecomplexes CT dsg CDI. Sinus rhythmPremature atrial contractionsPrior inferior infarct, age indeterminate - may be old clinical correlation issuggestedSince previous tracing of : atrial ectopic activity appears to havedecreased CO R-SIDED DISCOMFORT---MED W FENT/MSO4 PRN W EFFECT. Upper airways clr/ diminished bases. SL OOZE @ CT INSERTION SITE-DSG REINFORCED. Echo negative for pericardial effusion. ID=AFEBRILE. HEME=TX W U-PLAT BEFORE CT INSERTION. Atrial fibrillation. Atrial fibrillation. CT PLACED WO DIFFICULTY.P: PT/FAMILY. Ventricular ectopypersists. RENAL=HD DONE ON AM'S. ESRD-> Pt remains anuric. HOH- Left hearing aid in use.CV: Afib-NSR. Compared to the previous tracing atrial fibrillation hasreplaced sinus rhythm. hyperkalemic vs ischemic event. New Quinton cath placed today right femoral. Right femoral Quinton cath. Hypoactive BS, no BM.GU: Anuric. HCT rechecked @ 0530.Resp: Pt remains on 2L O2 NC accompanied w/ face mask. (Pt was found pulling @ CT). Possibly reposition right CT? Possible old inferior myocardial infarction.TRACING #1 T waves are now deeply inverted in leads I and V2-V6. Pt denies SOB> RR 17-24. T- PLACED CT R-ANTERIOR TO UNDER WATER SEAL W SX. Stable-> transferred to floor. Compared to the previous tracing ventricular ectopy hasappeared.TRACING #2 ST segmentdepression is present in lead aVL and ST segment elevations are present inleads III and aVF. reoriented freq, past events explained mult. resolved with heparin adjustment.neuro: pt. CAPTOPRIL & DILTIAZEM. R. CT DSG D&I. LYTES PND. addendumO: AM ABG 7.56/29/129. Right posterior CT now to H20 seal. propofol weaned to 11mcq and pt. Anuric at baseline.Neuro: Pt. Repeat PTT 39.0. TRANSFUSED 1U PRBC. QUINTON CATH PLACED IN RIGHT IJ. MB 7/3/9/9 trop 5.1. HCT stable 32.5. LEFT A/C AREA WITH POS PULSES AND DSD. well.LS scatt. Eye drop to L eye a/o.CV: NSR HR 74-80 with occasional PVC's. anticipate titrate lopressor. NPO AFTER MIDNOC FOR OR TODAY REVISION L. AVF. Follow HCT and Ck's. PLAT CT 207(171).GI: ADB. PO MEDS HELD FOR NOW. follow CK's, lytes. BP 92-119/34-38 after HD. Pt requiring encouragment and reassurance. 2+ distal pulses.A: s/p VF arrest, stable hemodynamics. FOLLOW FOR ARRYTHMIAS. memory lossP: NPO for cath. rate down to 10-> ABG 7.51/35/157. POST-TRANSFUSION HCT 30.4 (27.2). dose adjusted.P: wean to extubate today. Plan to start ace .PULM: Pt extubated w/o incidence. PTT 150: HEp off x1hour and restarted at 550u/rh.small amt. Captopril dc'd prior to start of it, in setting of low Hct with unknown etiology. Await cardiac cath . DEFIB PADS REMOVED. plan d/c propofol. CCU and Renal agree to DC Quinton. to CT to r/o retroperitonal bleed, neg. Respositioning, heating pad to right shoulder and MS04 given. Yank sxning with effect. PLAN IS TO TURN VENT DOWN IN EARLY AM AND TURN OFF PROPOFOL.ID: AFEB.GI: OGT IN PROPER PLACE. CHECK LEFT ARM AS ABOVE Q1H. OOB AND FEED IN AM. Cont current medical mgmt, titrate Ace and BB as tolerated. right pupil 2mm, left pupil 4mm, both reactive.CV: SBP remains 120-140 range, pronounced systolic murmur. lopressor 12.5mg tol. Follow HCT q 6hrs until stable. occas. BP follwing extubation 128/41. Pt. pt. Pt. Sitter ordered for pt. HCT post procedure 25.9-26.9, Pt. Abd soft NT +BS. Monitor temp, f/u with sputum culture. | 49 | [
{
"category": "Radiology",
"chartdate": "2171-03-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 785000,
"text": " 12:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 78 yo M , s/p cardiac arrest, now s/p resuscitation w/ asymm\n ______________________________________________________________________________\n FINAL ADDENDUM\n CT does not provide optimum vascular detail nor the greatest sensitivity for\n early infarction. For these purposes, MR weighted scanning as\n well as MR angiography is a preferable diagnostic imaging procedure.\n\n\n 12:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 78 yo M , s/p cardiac arrest, now s/p resuscitation w/ asymm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n 78 yo M , s/p cardiac arrest, now s/p resuscitation w/ asymmetric pupils\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT SCAN:\n\n HISTORY: S/P cardiac arrest with asymmetric pupils.\n\n TECHNIQUE: Noncontrast head CT scan was obtained.\n\n FINDINGS: There are streak artifacts arising from an object external to the\n head. These artifacts degrade several scans.\n\n The present study does not show definable intracranial hemorrhage or signs of\n an ongoing infarct. However, in this regard MRI scanning with \n weighted imaging would be more sensitive. There are probable chronic lacunar\n infarcts within the left lentiform nucleus. There is mild global brain\n atrophy seen. There is calcification, likely atherosclerotic, within the\n proximal portion of the basilar artery.\n\n CONCLUSION: No intracranial hemorrhage. Other findings as noted above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 784996,
"text": " 11:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: code\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with mi\n REASON FOR THIS EXAMINATION:\n code\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 79-year-old man with MI.\n\n CHEST X-RAY, PORTABLE AP: Comparison . The film is limited\n with incomplete visualization of the left hemithorax. The patient is also on\n a trauma board which also partially limits visualization. An endotracheal\n tube is seen with the tip 4.4 cm from the carina. Pacing paddles are\n appreciated. The cardiomediastinal silhouette is grossly unremarkable. The\n right lung demonstrates no focal opacities, consolidations, or pleural\n effusions. The visualized upper portion of the left lung also appears clear,\n without infiltrate or consolidation. There is no pneumothorax. The osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1. Study limited secondary to incomplete visualization of the left\n hemithorax. Would recommend follow up study when clinically stable.\n 2. No acute infiltrate.\n 3. Endotracheal tube in good position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786392,
"text": " 5:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt c/o CP/cough\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p adjustment of chest tube\n\n REASON FOR THIS EXAMINATION:\n Pt c/o CP/cough\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post adjustment of chest tube. Chest pain and cough.\n\n COMPARISON: .\n PORTABLE UPRIGHT CHEST: The right-sided chest tube has been removed. There\n is persistent opacity in the lateral portion right chest, likely fluid,\n adjacent to where the chest tube used to reside. There is no pneumothorax,\n however, there is persistent apical pleural thickening and blunting at the CP\n angle on the right. There is increased retrocardiac opacity on the left. The\n left CP angle is excluded. The cardiac and mediastinal contours are unchanged\n allowing for differences in technique.\n\n IMPRESSION: Interval development of segmental left lower lobe collapse and/ or\n consolidation. Right effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785699,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval hemothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ESRD on HD with clotted graft, s/p cardiac arrest\n\n REASON FOR THIS EXAMINATION:\n eval hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemothorax.\n\n PORTABLE CHEST: Right sided chest tube is coiled once in the chest. Prominence\n of the right superior mediastinum and right lung apex are consistent with\n known hemothorax. There is no interval change compared to exam one day\n previously. The heart is enlarged. There is bilateral patchy basilar\n atelectasis. There is no pneumothorax.\n\n IMPRESSION: No interval change in loculated right hemothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-15 00:00:00.000",
"description": "L UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT",
"row_id": 785879,
"text": " 7:01 PM\n UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT Clip # \n Reason: REVASCULARIZATION\n ______________________________________________________________________________\n FINAL REPORT\n An upper extremity fluoro was performed without a Radiologist present. 3\n minutes and 45 seconds fluoro time was used. No films are submitted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785918,
"text": " 12:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Check CT/rule out pneumothorax/check hematoma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p adjustment of chest tube\n\n REASON FOR THIS EXAMINATION:\n Check CT/rule out pneumothorax/check hematoma\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post adjustment of chest tube. Rule out pneumothorax, check\n hematoma.\n\n CHEST, SINGLE AP VIEW: Compared with 2 days earlier, the right chest tube is\n again seen, overall similar in appearance, with side port projecting over\n right upper line and hair pin type curve distal to the side port. There is\n patchy opacity about the tube, slightly different in configuration, but\n overall unchanged compared with 2 days earlier. Again seen is right apical\n thickening and a prominent cardiomediastinal silhouette. No pneumothorax is\n identified. The cardiomediastinal silhouette is unchanged compared with\n . No CHF. Subsegmental atelectasis left base. No left sided\n effusion.\n\n IMPRESSION: Prominent cardiomediastinal silhouette, unchanged, with right\n apical thickening. Right sided chest tube, without interval change\n compared with 2 days earlier, and some surrounding opacity, presumably\n atelectasis and hematoma. No significant right sided effusion and no\n pneumothorax identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785029,
"text": " 4:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate quinton catheter placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ESRD on HD with clotted graft, s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n evaluate quinton catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease on hemodialysis with clotted graft.\n Status post cardiac arrest. Check position of Quinton catheter.\n\n FINDINGS: The Quinton catheter is well positioned with its tip in the mid\n SVC. The endotracheal tube and the NG tube are also satisfactory positioned.\n The heart shows moderate left ventricular enlargement and the aorta is\n unfolded. There is no evidence of cardiac failure. Some minor linear\n atelectasis is noted at the left base, but the lungs otherwise clear. No\n effusions are detected.\n\n IMPRESSION: Satisfactory placement of Quinton catheter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-12 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 785516,
"text": " 10:11 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: STAT PORTABLE US OF RUE, CHECK QUENTIN PLACEMENT, HCT DROPPING, CHECK FOR BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p placement of right quentin catheter. Now drop in Hct from\n 37->22; Patient with c/o back pain and catheter not working. Concern that\n quentin cath not in right place. Request STAT portable US to evaluate placemnt\n of catheter.\n REASON FOR THIS EXAMINATION:\n Request STAT portable US of R UE quentin placement; Patient is being\n transported right now from three to CCU (CC674)\n ______________________________________________________________________________\n FINAL REPORT\n UPPER EXTREMITY ULTRASOUND\n\n INDICATION: Large hematocrit drop after placement of internal jugular venous\n catheter. Please evaluate.\n\n UPPER EXTREMITY ULTRASOUND: scale, color Doppler son evaluation\n was performed of the right internal jugular vein and the site of insertion of\n the central venous catheter. The catheter site does not demonstrate a large\n fluid collection or hematoma. The jugular vein is patent. The catheter is\n seen in an intraluminal location.\n\n IMPRESSION: No evidence for hematoma at the site of puncture of the internal\n jugular vein. The internal jugular vein is patent and the catheter is\n intraluminal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785554,
"text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval mediastinal bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ESRD on HD with clotted graft, s/p cardiac arrest\n\n REASON FOR THIS EXAMINATION:\n eval mediastinal bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease on hemodialysis, cardiac arrest, evaluate\n mediastinal bleed.\n\n Single frontal chest radiograph dated is compared with prior\n chest radiograph dated .\n\n There is interval removal of the ET tube and NG tube. Right IJ catheter is\n projected over the right superior mediastinum. There is significant interval\n widening of the mediastinum, worrisome for mediastinal hematoma. There is also\n increased opacity of the right hemithorax and left lower lung zone, consistent\n with pleural effusions. There is left ventricular enlargement.\n\n IMPRESSION: Widened mediastinum, worrisome for mediastinal hematoma. Bilateral\n pleural effusions, right greater than left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-07 00:00:00.000",
"description": "ART DUP EXT LO UNI;F/U",
"row_id": 785120,
"text": " 3:22 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: new left groin hematoma s/p pulling A-line from fem. Heparin\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with V FIB arrest\n REASON FOR THIS EXAMINATION:\n new left groin hematoma s/p pulling A-line from fem. Heparin stopped 1-2 hours\n prior to pull.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left groin hematoma after cardiac catheterization.\n\n FINDINGS: Pulse and color Doppler demonstrate no evidence of a hematoma or\n pseudoaneurysm within the left inguinal region.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-12 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 785544,
"text": " 1:48 PM\n CT PELVIS W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for retroperitoneal bleed and placement of RIJ quen\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with drop in Hct 37 -> 22; Severe back pain. Had several groin\n lines. Also - RIJ quentin catheter placed - not owrking; concern its not in\n right place. Evaluate for retroperitoneal bleed and placement of RIJ catheter.\n with questions;\n REASON FOR THIS EXAMINATION:\n evaluate for retroperitoneal bleed and placement of RIJ quentin catheter;\n REQUEST CHEST AND ABDOMEN CT scan\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Malfunctioning right IJ Quinton catheter. Evaluate position.\n Also patient has a new Quinton placed in the right groin with a hematocrit\n drop. Evaluate for retroperitoneal hematoma.\n\n TECHNIQUE: Axial images were performed from the lung apices through the pubic\n symphysis without the administration of oral or intravenous contrast. Please\n note, the abdomen was scanned incidentally and the patient should not be\n billed for this.\n\n CT OF THE CHEST WITHOUT CONTRAST: A catheter is seen on the most superior\n image in the right internal jugular vein which then courses out and its tip is\n located freely within the right paratracheal mediastinum. There is soft-\n tissue density surrounding the catheter, as well as expected air. There are\n moderate bilateral freely layering pleural effusions, right greater than left.\n The aorta is tortuous and calcified. There are coronary artery calcifications\n and calcifications of the aortic leaflets. On lung windows, there are linear\n opacities in both lung bases as well as compressive atelectasis. There is\n crowding of structures in the hila likely related to volume loss from the\n large pericardial effusions. Additionally, within the mid lung zones, there\n are nonspecific ground glass opacities.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: Non-contrast images of the liver, spleen,\n pancreas, and adrenals are grossly unremarkable. There is high-density\n material within the gallbladder which either represents layering sludge or\n vicarious excretion of intravenous contrast administered for a prior study.\n Both kidneys appear atrophic and contain numerous low-density lesions. Each\n of these measures approximately 25 Hounsfield Units. The bowel loops are\n unremarkable.\n\n CT OF THE PELVIS WITHOUT CONTRAST: There is no pelvic free fluid. The\n urinary bladder is not distended. The prostate and seminal vesicles are\n unremarkable.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are seen.\n\n IMPRESSION:\n (Over)\n\n 1:48 PM\n CT PELVIS W/O CONTRAST; CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for retroperitoneal bleed and placement of RIJ quen\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1) Malpositioned right internal jugular central venous catheter with the tip\n lying freely within the soft tissues of the mediastinum.\n\n 2) Soft-tissue density in the mediastinum likely a component of fluid and\n hematoma.\n\n 3) Bilateral moderate-sized freely-layering pleural fluid.\n\n 4) Nonspecific opacities within the lungs likely due to a combination of\n atelectasis and fluid overload.\n\n 5) Multiple low-density lesions within each kidney. These cannot be fully\n evaluated without contrast.\n 6) Femoral Line in appropriate position, no associated heamtoma.\n\n The findings were discussed with Dr. at the time of the exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785587,
"text": " 10:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ESRD on HD with clotted graft, s/p cardiac arrest\n\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease with clotted graft. Status post cardiac\n arrest. Rule out pneumothorax.\n\n FINDINGS: A single AP semiupright view. Comparison study dated 8 hours\n earlier. There is persistent widening of the right superior mediastinum,\n presumably related to the right IJ central line placement. This could\n represent a hematoma of the mediastinum. The heart again shows fairly marked\n left ventricular enlargement. The aorta is dilated and unfolded. The\n pulmonary vessels do not indicate cardiac failure. However, there is evidence\n of some patchy infiltrate in the right mid and lower zones and some\n atelectasis is also present in the basal segments of the left lower lobe\n behind the heart.\n\n IMPRESSION: Persistent widening of the superior mediastinum, consistent with\n a mediastinal hematoma. CT evaluation would clarify this.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785673,
"text": " 6:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check position of chest tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p adjustment of chest tube\n REASON FOR THIS EXAMINATION:\n check position of chest tube\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP bedside chest radiograph.\n\n INDICATION: 78 year old male with recent chest tube placement. Evaluate\n position of chest tube.\n\n FINDINGS: Comparison is made to a prior radiograph performed on the same day.\n There has been interval adjustment of a right-sided chest tube which is\n kinked over upon itself and is located overlying the right hemithorax. There\n is an unchanged appearance of widening of the mediastinum when compared to the\n prior exam. The heart size is enlarged and stable when compared to the prior\n exam. The previously-described opacification within the right mid lung zone\n is improved when compared to the prior exam. There is no evidence of\n pneumothorax.\n\n IMPRESSION:\n\n 1) Right-sided chest tube kinked upon itself.\n\n 2) Unchanged widening of the mediastinum and cardiomegaly.\n\n 3) Improved area of focal opacification within the right mid lung zone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-03-08 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 785245,
"text": " 11:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o retroperitoneal bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p cardiac catheterization - dropping Hct; r/o retroperitoneal\n bleed; with questions\n REASON FOR THIS EXAMINATION:\n r/o retroperitoneal bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P cardiac cath dropping hematocrit, evaluate for retroperitoneal\n bleed.\n\n COMPARISON: No prior abdominal CT scans available for comparison.\n\n TECHNIQUE: Axial images of the abdomen and pelvis were acquired helically from\n the lung bases to the pubic symphysis without IV contrasts. No contrast was\n used secondary to patient's elevated creatinine.\n\n FINDINGS:\n\n CT ABDOMEN WITHOUT CONTRAST: Bibasilar atelectasis is present. There is\n extensive coronary arterial calcification. Evaluation of solid abdominal\n organs is limited without the use of IV contrast. There is a focal area of\n decreased attenuation within segment 4 of the liver, which likely represents a\n simple cyst, but is not fully evaluated without IV contrast. The spleen,\n pancreas, gallbladder, adrenal glands, stomach, and intraabdominal loops of\n small and large bowel are unremarkable. Numerous likely simple renal cysts\n are present bilaterally. No stones are seen. Residual contrast is seen within\n renal collecting systems from prior coronary artery catheterization. The\n abdominal aorta is heavily calcified. Retroperitoneal structures are similar\n without evidence of hematoma. No intraabdominal fluid collections are\n present.\n\n CT PELVIS WITH IV CONTRAST: There is no evidence of retroperitoneal bleed\n within the pelvis. The iliac and femoral vessels are heavily calcified. There\n is relative asymmetry in the adductor compartment, with the left adductor\n muscles being slightly more prominent and demonstrating increased attenuation.\n This may represent a small amount of intramuscular hematoma. The amount is not\n likely to account for the patient's dropping hematocrit. The bladder, sigmoid\n colon, and rectum are unremarkable. There is no free fluid in the pelvis.\n\n Diffuse degenerative changes are seen in the hip joints and in the spine. No\n suspicious lytic or sclerotic osseous lesions are present.\n\n IMPRESSION: No significant retroperitoneal bleed is seen. Small right\n intramuscular hematoma.\n (Over)\n\n 11:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o retroperitoneal bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Echo",
"chartdate": "2171-03-12 00:00:00.000",
"description": "Report",
"row_id": 64325,
"text": "PATIENT/TEST INFORMATION:\nIndication: Mediastinal Bleed.Echo requested to attempt to see dialysis catheter tip location. ?tamponade/perforation.\nHeight: (in) 69\nWeight (lb): 160\nBSA (m2): 1.88 m2\nBP (mm Hg): 140/37\nStatus: Inpatient\nDate/Time: at 16:22\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\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: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function cannot be reliably assessed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function cannot be reliably assessed. 2. The aortic valve leaflets\nare mildly thickened.\n3. The mitral valve leaflets are mildly thickened.\n4. No catheter is seen in the right atrium or ventricle.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2171-03-06 00:00:00.000",
"description": "Report",
"row_id": 64326,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P VF arrest.\nHeight: (in) 69\nWeight (lb): 160\nBSA (m2): 1.88 m2\nBP (mm Hg): 127/69\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 12:13\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. There is\nmild regional left ventricular systolic dysfunction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: Moderate (2+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Moderate to severe (3+) mitral regurgitation is\nseen. The mitral regurgitation jet is eccentric.\n\nTRICUSPID VALVE: Mild to moderate [+] tricuspid regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: The patient is tachycardic (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. There is mild regional left ventricular systolic dysfunction with\nsevere hypokinesis of the inferior wall and inferior septum. Right ventricular\nchamber size and free wall motion are normal. There is at least moderate (2+)\naortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate\nto severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is\neccentric. There is no pericardial effusion.\n\nCompared with the prior study of , left ventricular systolic function\nlooks less vigorous but no new wall motion abnormalities\n\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-08 00:00:00.000",
"description": "Report",
"row_id": 132353,
"text": "Sinus arrhythmia\nLead(s) unsuitable for analysis: V2\nShort PR interval\nInferior infarct - age undetermined\n Lateral ST-T changes offer additional evidence of ischemia\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-06 00:00:00.000",
"description": "Report",
"row_id": 132354,
"text": "Normal sinus rhythm. Transmujral inferior myocardial infarction. Resolution of\nST-T wave abnormalities.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-06 00:00:00.000",
"description": "Report",
"row_id": 132358,
"text": "Atrial fibrillation with a rapid ventricular response. Wide QRS complexes.\nSeptal Q waves in leads II, III and aVF. Deep S waves in lead V3. ST segment\ndepressions in leads V4-V6. INT: Atrial fibrillation. Intraventricular\nconduction disturbance. Possible inferior myocardial infarction or prominent\nseptal forces. Non-specific ST segment depressions. Compared to the previous\ntracing of arrhythmia has appeared.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-06 00:00:00.000",
"description": "Report",
"row_id": 132355,
"text": "Return to atrial fibrillation with a rapid rate. Otherwise,no important\nchange.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-06 00:00:00.000",
"description": "Report",
"row_id": 132356,
"text": "Atrial fibrillation with normal ventricular response. Ventricular ectopy\npersists. T waves are now deeply inverted in leads I and V2-V6. ST segment\ndepression is present in lead aVL and ST segment elevations are present in\nleads III and aVF. INT: Inferior injury. Anterior ischemia.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-06 00:00:00.000",
"description": "Report",
"row_id": 132357,
"text": "Atrial fibrillation. ST segment depressions are now horizontal in leads V4-V6.\nIschemia is likely.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-21 00:00:00.000",
"description": "Report",
"row_id": 132303,
"text": "Sinus rhythm, rate 73. Non-diagnostic inferior Q waves. Non-specific\nmid-precordial QRS notching. Possible old inferior myocardial infarction.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-14 00:00:00.000",
"description": "Report",
"row_id": 132304,
"text": "Atrial fibrillation. Compared to the previous tracing atrial fibrillation has\nreplaced sinus rhythm. Rare ventricular premature beat has newly appeared.\nThere is a rapid ventricular response.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-15 00:00:00.000",
"description": "Report",
"row_id": 132305,
"text": "Sinus rhythm. Compared to the previous tracing of no significant change\nin QRTS complexes. Atrial ectopy is no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-12 00:00:00.000",
"description": "Report",
"row_id": 132306,
"text": "Sinus rhythm\nPremature atrial contractions\nPrior inferior infarct, age indeterminate - may be old clinical correlation is\nsuggested\nSince previous tracing of : atrial ectopic activity appears to have\ndecreased\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-09 00:00:00.000",
"description": "Report",
"row_id": 132307,
"text": "Sinus rhythm\nAberrantly conducted supraventricular extrasystoles\nPremature ventricular contractions\nSupraventricular extrasystoles\nShort PR interval\nOld inferior infarct\n Lateral ST changes are nonspecific\nSince last ECG, more ventricular premature complexes, atrial premature\ncomplexes\n\n\n"
},
{
"category": "ECG",
"chartdate": "2171-03-21 00:00:00.000",
"description": "Report",
"row_id": 132302,
"text": "Sinus rhythm. Compared to the previous tracing ventricular ectopy has\nappeared.\nTRACING #2\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-12 00:00:00.000",
"description": "Report",
"row_id": 1382031,
"text": "Nursing note\nPt received from 3 in bed, siderails up x 2. Pt connected to monitor, and moved to CCU bed. Pt in extreme pain when moved to new bed.\n\nGeneral: pt's HCT drops from 32-> 22 in a 24hour period. Transferred to CCU for further mngmt. Pt taken to CT for thoracic/abdominal view to evaluate bleeding. Found tip of Right IJ quinton displaced into right pleural space, with blood in right pleural and mediastinal space.\n\nNeuro: Pt alert and oriented, occasionally confused, but easily reoriented. C/O upper back/right scapula/right shoulder pain. Given fentanyl and Mso4 to manage pain.MAE. Follow commands, strong cough.\n\nCV: NSR with occasional PAC's upon arrival, now more frequent PAC's, possible Afib? SBP remains 130-140 range. Good pulses on all 4 extrem. Afebrile, good cap refills. Pt Type and crossed for 4 units PRBC's.\n\nResp: 3L NC. Lungs clear in upper fields, diminished in lower lung fields. Denies SOB. Sats remain>96%.\n\nGI: NPO except for meds. Hypoactive BS, no BM.\n\nGU: Anuric. HD dependent.\n\nIV's: right IJ quinton cath **INFILTRATED**. #20g right FA, #14g right AC. New Quinton cath placed today right femoral. Left arm with AV shunt with thrombosis. **DO NOT USE LEFT ARM FOR BP OR BLOOD DRAWS**\n\nSkin: Large areas of ecchymosis bilateral femoral.\n\nPlan: Goal to increase HCT to > right pleural CT, and remove right IJ Quinton. CT with contrast after HD today. Pt given 1 U PRBC's before dialysis. Received 3 U during dialysis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-12 00:00:00.000",
"description": "Report",
"row_id": 1382032,
"text": "Update:\nPt won't go for CTwith contrast. Plan to place right pleural CT tonight after 6 pack of plts. given.\nPlan for tomorrow: Revisionof AF shunt on left arm. NPO tonight.\nFuture Plan: AICD. When??\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-13 00:00:00.000",
"description": "Report",
"row_id": 1382033,
"text": "CCU NSG PROGRESS NOTE.\nO:NEURO=ARNGY. WANTING TO GET EVERYTHING OUT. TIRED. UPSET W BEING RESTRAINED! FAMILY STATES \"HE WILL PULL THINGS OUT IF HE GETS UPSET ENOUGH!\" CO R-SIDED DISCOMFORT---MED W FENT/MSO4 PRN W EFFECT.\n PULM=O2-NC @ 2L & SHOVEL MASK W FIO2 100% (MOUTH BREATHER). BREATH SOUNDS=CLEAR R-SIDE DEMINISHED. SATS MID TO UPPER 90'S. T- PLACED CT R-ANTERIOR TO UNDER WATER SEAL W SX. DRAINAGE-BLOODY. WO LEAK/ CREPITUS. SL OOZE @ CT INSERTION SITE-DSG REINFORCED. MED W FENT/MSO4 FOR DISCOMFORT W EFFECT.\n CV=INITIALLY RAPID AF W RATE TO 120'S-RELATED TO AGITATION/ RESTLESSNESS. PRESENTLY AF W RATE IN 90'S. BP STABLE.\n GI=NPO.\n HEME=TX W U-PLAT BEFORE CT INSERTION. PLAT BEFORE TX 170 @ 2300 182. TX W TOTAL 4U RBC BEFORE CT INSERTION-- HCT 24.3 TO 35 AFTERWARDS @ 2300 30.7 (2 URBC SETUP IN BB).\n RENAL=HD DONE ON AM'S.\n ID=AFEBRILE.\n LABS=AM TO BE SENT.\n MISC=RIJ HD CATH CLAMPED-TO REMAIN INPLACE TILL AM . R5-FEM HD CATH-SL OOZE NOTED.\n\nA:EASILY AGITATED/RESTLESS-TIRED OF EVERYTHING THATS GONE ON-WANTS TO GO HOME. CT PLACED WO DIFFICULTY.\n\nP: PT/FAMILY. MED PRN FOR DISCOMFORT/AGITATION. DC RIJ HD CATH W OR BACKUP. CONTIN PRESNENT MANAGEMENT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-13 00:00:00.000",
"description": "Report",
"row_id": 1382034,
"text": "Nursing NOte 7am-7pm\n\nPt received in bed, side rails up x 2. Monitor checked. Alarms set, Assessment complete.\n\nGeneral: This is a pt who had a vfib arrest in parking lot of en route to have his AV shunt revised. Pt was intubated and had several lines in bilateral groins at that time. Pt was dialyzed using right IJ quinton during hospital stay. Large bilateral groin hematomas developed, pt extubated and sent to floor. Pt readmitted to CCU secondary to drop in HCT (34->22). CT showed right IJ cath tip migrated from jugular into plerual space, with large hema-thorax of the right lung, as well as minimal fluid in the pericardium. Right IJ DC'd today after platelet infusion today. No hematoma noted.\n\nNeuro: Pt becomes more alert and oriented as shift progresses. Initially pt restrained bilat. arms, but unrestrained quickly. Pt MAE. Right leg in knee immobilizer, pt follow commands, HOH with hearing aid in left ear. Pt does become slightly agitated with Mso4, but easily reoriented.\n\nCV: Afib in 80-90's. SBP remains 130-150. Oral HTN meds started today. Pulses palpable on all 4 extrem. Tmax 98.9 oral. No edema noted. Rare PVC noted.\n\nResp: 2L NC, with humidified blow by O2 (pt refuses to wear mask). Sats remain >93%. Lungs clear in upper lung fields, coarseness in bilateral bases, which clears greatly with coughing (thick yellow copious secretions with strong coughs!!). Right lower field diminished. CT to right posterior chest wall, 20cm h20 suction, sanguinous drainage. No leak or crepitus.\n\nGI: Clear liquids today, tolerates well. BS present, no BM today. NPO after midnight tonight for AV fistula revision surgery in AM.\n\nGU: Anuric, HD dependent.\n\nSkin: Bilateral groin ecchymosis. Right IJ dressing, no hematoma, from Quinton removal today. Right groin Quinton with continuous oozing. Dressing changed twice, pressure held, but site continues to ooze.\n\nAccess: Right 14g AC. Right femoral Quinton cath. Left AV fistula with thrombosis, no bruit detected.\n\nPlan: AV fistual revision in AM. Hemodialysis tomorrow using right femoral quinton cath, then DC Quinton?? Possibly reposition right CT? Long term plan: AICD placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-14 00:00:00.000",
"description": "Report",
"row_id": 1382035,
"text": "CCU Nursing Progress Note 7p-7a\nS: \" I want to get up\"\n\nO: Please see careview for complete VS/ Objective data\n\nNeuro: Pt A&O to person and place. Disoriented to time (stated it was and the year was ). Pt ^ confused . Easily reoriented. ? degree of ICU psychosis. Pt remained pleasant. MAE and following commands. Early in shift C/O pain associated with position changes and treated w/ Ativan with good effect. At 00 pt ^ HR, hypertensive and frequently coughing. Treated for pain w/ MSO4 2mgx2. Minimal effect observed until tx w/ second dose. Soft restraints applied transiently for protection of invasive line and chest tube. (Pt was found pulling @ CT). Restraints removed and remained off remainder of evening. HOH- Left hearing aid in use.\n\nCV: Afib-NSR. Minimal ectopy noted. HR 84-94 (^113 x 1 episode of agitation) NBP 141-182/39-57 (^ w/ coughing episodes, otherwise NBP 140-150s) Tolerated Captopril and Lopressor po doses. At 0200 given additional dose of Captopril 12.5mg for SBP 150s. Am doses cardiac meds ^ to Captopril 12.5mg and Lopressor 25mg. HCT @ 2100-> 27.8(28). Earlier CT scan revealed previous RIJ Quinton displaced R pleural space w/ bleeding in R pleural and mediastinal spaces + hemothorax-> CT placed. Pt transfused 1 UPRBCs infusion was completed @ 0300. AV fistula hematoma marked and bilateral groin hematomas marked and resolution continues. Groin sites remain ecchymotic. Distal pulses intact. Echo negative for pericardial effusion. HCT rechecked @ 0530.\n\nResp: Pt remains on 2L O2 NC accompanied w/ face mask. Upper airways clr/ diminished bases. Pt denies SOB> RR 17-24. O2 sats 93-100%. Mouth breather-> desats to 80s once face mask is removed. CT dsg CDI. CT 20cm/ H20. - air leak/ - crepitus. Approximately 250cc Sanguinous drainage from CT. + COUGH\n\nGI/GU: Fluids/ Popsicles. NPO after midnight except meds for AV fistula revision scheduled for today. Tolerating po meds without difficulty. Abd soft. BS present. No BM. ESRD-> Pt remains anuric. HD patient. Dialysis scheduled for today. +290cc/ LOS\n\nID: Tmax 100.3 po. Resolved without tylenol.\n\nAccess: AV fistula located in left arm-> no bld draws or BP in that arm. #14 R antecub. #20 gauge inserted to R lower arm prior to bld transfusion. Quinton cath located in R femoral artery oozing despite multiple dsg changes. Applied pressure dsg w/ good effect. No longer oozing at site.\n\nMisc: Eye gtts x3 to Left eye s/p cataract surgery.\n\nSocial: No calls or visitors .\n\nA/P: 78 yo male w/ESRD, NSTEMI , scheduled for HD collapsed in parking lot-> s/p Vfib arrest ? hyperkalemic vs ischemic event. <10 min downtime. Head ct/ cxray clear. cath revealed 2VCAD successful rota/stent RCA and stent LAD. Stable-> transferred to floor. Returned to CCU following HCt 32->22. Transfused 4U PRBcs and FFP. + Bld R pleural/ mediastinal space d/t quinton cath displacement. + Hemothorax-> CT placed 650cc removed. Pulled out CT slightly to remove additional pocket of fluid. HD scheduled for today, followed by AV fi\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-08 00:00:00.000",
"description": "Report",
"row_id": 1382028,
"text": "s/p arrest, cath/stents/rotoblation\nccu npn- see transfer sheet also\no- id- afebrile. cv- hr 70-80s sr with freq pacs, pvcs, up to 90-120 during dialysis this pm. labs k-4.8, creat 8.9, hct 30.2, plts 154. ck 540-7. repeat hct post cath 26.7, plts 135. to receive 1 unit prbcs. to cath lab this am and had stent to lad and rotoblation/stents to rca. required atropine x1. repro on and d/c'd d/t high act. on return sheaths r groin with scant ooze, pulses 1+/dopp bilat dp/pt. act 224 on return, plan check act after dialysis and pull sheaths- ok with c. fellow. no cpain or cv c/o.\nresp- on face tent to 3l n/c, sats 95-100, difficult to register at times, on forehead/fingers. l/s dim, cxs bases.\nrenal- dialysis begun at 1600 for 3hrs. no fluid being removed d/t increased atrial ect/higher hr on dialysis.\ngi- npo am, taking sips/meds ok this pm. resume diet after sheaths pulled. no bm.\nskin- intact, groin as above. log rolled with skin care. on back for dialysis this pm.\nms- oriented to self only. confused/anxious with poor short term memory. reoriented freq, past events explained mult. times. all procedures, pt status, outcomes explained to pt/fx.\nsocial- dtr/wife in this pm, supportive to pt. dentures/h. aide lost in arrest acc. to fx. ew did not find acc. to fx. they are checking with social service office, may need to out forms to replace.\nplan- monitor, transfer to floor tomorrow when ready, per team. ?eps/aicd monday or next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-09 00:00:00.000",
"description": "Report",
"row_id": 1382029,
"text": "CCU NPN 7P-7A\nS;\"I need to blow my nose and when can I get up?\"\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable but HR with increased tachycardia, remained in ST with frequent APCs, occ. PVC.EKG checked and assessed by CCU team. K+ 3.9 after dialysis. Given increased dose of 25mg po Lopressor at and additional 25mg po Lopressor at 0030, HR trended down to 80's-90 NSR s/p Lopressor and PRBCs. BP stable 120-140/40-70's. Captopril dc'd prior to start of it, in setting of low Hct with unknown etiology. HCT post procedure 25.9-26.9, Pt. had received one unit PRBCs with dialysis previous shift, given second unit PRBCs 2220-0100, tolerated well. 0400 Hct 31.8. Right groin with art./. sheaths in place post procedure dc'd at 2215 without incident. (serial ACTs as per flow.) Right groin D/I with pressure dressing without palp. hematoma, left groin with site markings from old hematoma resolving. Distal pulses intact. Pt. to CT to r/o retroperitonal bleed, neg. for bleed. PLT 145 this am. CPKS trending down. Pt. denies CP, SOB, admits to chest soreness with position changes s/p CPR, shock.\n\nResp: Sats 95-98% on 3l n/c. Lungs coarse with diminished bases dependently L>R. Strong productive cough for thick, yellow sputum. sample sent for culture and gram stain. small amount of blood from left nare after blowing nose.\n\nID: Tmax 100.4 rectally, down to 99.8 without treatment. AM WBC 7.7.\n\nGI:GU: Taking po's, no N/V. Abdomen soft with active bowel sounds, no stool this shift. Anuric at baseline.\n\nNeuro: Pt. alert and cooperative. A/A/O to person and place, disoriented to time telling me it was . Unaware of events leading to hospitalization. Reoriented to procedures performed , cath lab, sheaths etc. Very poor short term memory, needs frequent repetition of information. Close observation for safety. Bedrest maintained.\n\nAccess: 2 peripheral IVs, patent and intact. RIJ dialysis line in place.\n\nA: Tachycardia in setting of low Hct, responded to PRBCs and increased Lopressor.\n\nP: Cont to monitor hemodynamics, assess for CP, ischemia. Increased Lopressor as ordered. Monitor Hcts q 6 hours, may need dialysis in setting of volume. Follow up with am labs. Monitor temp, f/u with sputum culture. Cont. to assess neuro status, safety precautions. Comfort and emotional support to Pt. and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-09 00:00:00.000",
"description": "Report",
"row_id": 1382030,
"text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SR with freq PAC's- HR 71 when sleeping to 97- R groin ecchymotic- L groin hematoma resolving- 1 (+) pulses of lower extremities- feet = warm- Hct this am 31.8- K 4.5- CPK 339 MB 11\ntolerating lopressor- to start on captopril this afternoon.\n\nresp- In O2 3l via NC- lung sounds with bibasilar crackles- SaO2 94-99%.\n\nneuro- oriented to person- confused but cooperative- moving all extremities- follows command.\n\ngi- abd soft with (+) bowel sounds- taking PO without difficulty.\n\ngu- L arm fistula not functioning- R IJ dialysis cath capped- dialyzed yesterday- BUN 34 CREA 6.6\n\nA- S/P cardiac cath - hemodynamically stable today.\n\nP- Monitor vs, lung sounds, I&O, & labs- follow neuro status- offer emotional support to Pt & family- keep them updated on plan of care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-07 00:00:00.000",
"description": "Report",
"row_id": 1382026,
"text": "CCU Nursing Progress Note 7a-7p:\n\ns/p Extubation\n\nNeuro: Propofol d/c'd pt awoke alert and oriented x2. Following commands and moving all extremities spontaneously. Pt forgetful regarding cardiac events . Pt requiring encouragment and reassurance. Pt c/o over all discomfort rec'd tylenol 650mg po with fair effect. Eye drop to L eye a/o.\n\nCV: NSR HR 74-80 with occasional PVC's. HR ST to 115 with pvc's and couplets during HD. Hep gtt d/c'd during HD at 9:30am. Repeat PTT 39.0. BP 92-119/34-38 after HD. Pt to start on lopressor 12.5 mg po tonight. BP follwing extubation 128/41. Pt denies CP. K+ 4.1. CK's 110/140/388/555. MB 7/3/9/9 trop 5.1. Small R groin hematoma at trauma line site. Pt with L groin hematoma s/p pulling of L fem a-line. Pressure held. US preformed at bedside revealing stable hematoma. HCT stable 32.5. Cardiac cath placed on hold plan to cath to determine extent of CAD and possible contribution to Vfib. Echo revealed EF 40% with no new motion abnormalities. Plan to start ace .\n\nPULM: Pt extubated w/o incidence. LS clear. Pt with strong productive congested cough raising thick yellow blood tinged secretions. Yank sxning with effect. Cool neb .35% Sats 100%. RR 18-22. Pt denies SOB. Nasal packing in place at this time.\n\nGI: Pt initially with coffee grounds from OGT. Abd soft NT +BS. No stool. Taking sips of water.\n\nGU: HD removed 1300cc. Foley in place pt making 5cc of urine.\n\nID: low grade temp 99.8.\n\nSKIN: intact.\n\nLINES: 2 PIV flushing w/o incidence.\n\nDISPO: Full Code/CCU.\n\nSOCIAL: Wife and children visiting today, updated on pt's condition.\n\nA/P: s/p extubation. Hemodynamically stable. Await cardiac cath . Start cardiac meds. Encourage pulm toileting. Follow HCT and Ck's. Provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-08 00:00:00.000",
"description": "Report",
"row_id": 1382027,
"text": "CCU NPN 1900-0700\nS: \" I don't remember anything \"\nO: pt. with memory loss surrounding recent events. also does not remember wife and children visiting yesterday. Ox2 for most part. did not know where he was once. asking questions about what happened. slept through night. wakes easily.\n\nHR 70's sr. occas. PVC. BP 105-120/50's. lopressor 12.5mg tol. well.\nLS scatt. course. sats 99-100% on 35% face tent. denies SOB. occas. prod. cough thick yellow blood tinged sputum.\npacking taken out of left nare. pt. blowing nose gently for blood tinged secretions. off heparin since .\nHCT stable at 30.\n\nright groin with stable soft hematoma. 2+ distal pulses.\n\nA: s/p VF arrest, stable hemodynamics.\n memory loss\nP: NPO for cath. monitor for any further nose bleed post cath and heparin. orient as needed. safety precautions for memory loss. anticipate titrate lopressor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-16 00:00:00.000",
"description": "Report",
"row_id": 1382043,
"text": "Update 4:30pm\n\nTransplant surgeon at bedside. Confirms that AV fistula has thrill/+bruit, and will be okay to use for HD whenever next needed. CCU and Renal agree to DC Quinton. Coags WNL and current HCT 34.\nRight femoral Quinton cath removed by CCU Resident. Pressure held x 15 min and pressure dressing applied.\nPt continues to c/o back pain. Respositioning, heating pad to right shoulder and MS04 given. Sitter ordered for pt. upon arrival to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-16 00:00:00.000",
"description": "Report",
"row_id": 1382041,
"text": "S/P ARREST\nSTENT TO LAD/RCA\nDE-CLOTTING OF LEFT AVF\nS \" I'M AWAKE ...HELP ME \"\nO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HR 80'S..CONVERTING TO AFIB AT 0600...RATE OF 100'S...AFIB ...SBP 130-160'S/70'S....\nRESP ..LUNGS COARSE ...CONGESTED COUGH..02 SAT 97% ON 3L NP\nGI TOLERATING ICE CHIPS\nGU ANURIC\nAVF ..LEFT AVF WITH POS BRUIT AND THRILL...POS LEFT RADIAL PULSE ...HAND WARM\nCOMPLAINED OF GENERALIZED PAIN..THROUGHOUT BODY...UNABLE TO TURN PT WITHOUT SCREAMING IN PAIN..GIVEN A TOTAL OF 2 MG OF IV MS04....UNABLE TO FOLLOW SIMPLE INSTRUCTIONS ...GRABBING QUINTON CATH ...CHEST TUBE ..REQUIRING WRIST RESTRAINTS ..ESCALATING DELIRIUM...REQUIRING SEVERAL DOSES OF HALDOL......\nMINIMAL CT OUTPUT\nA RECURRENT AFIB\nP DILTIAZEM FOR RATE CONTROL...? D/C CHEST TUBE ..CALL OUT WITH SITTER\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-16 00:00:00.000",
"description": "Report",
"row_id": 1382042,
"text": "Nursing Note 7am -transfer\n\nPt received in bed, siderails up x 2. monitor checked and alarms set. Assessment complete.\n\nGeneral: pt had surgery yesterday late afternoon to remove clot from left arm AV fistula.\n\nNeuro: Pt lethargic at start of shift, but oriented x 3. MAE. Periodically c/o back/right shoulder pain, helped with repostioning. Swallow, cough and gag intact. Left eye s/p eye surgery (when?) right pupil 2mm, left pupil 4mm, both reactive.\n\nCV: SBP remains 120-140 range, pronounced systolic murmur. This AM in afib, given 20mg by MD, now in NSR with rare PAC and PVC. Afebrile, strong palpable pulses all 4 extrem. Good cap refills.\n\nResp: 4L NC. also with blow by o2 with humidification. Lungs clear in upper airways, coarse in bilateral lower lobes with significant clearing with cough. Productive cough with thick yellow secretions. Right posterior CT now to H20 seal. Minimal sero-sang drainage.\n\nGI: Clear Liquid this AM, pt tolerates well. Diet advanced to renal, pt not very hungry, has only a small amt. of food. Good BS, no BM.\n\nGU: Anuric, HD dependent.\n\nIV's: 2 PIV's right arm both 20g. Right femoral Quinton cath, dressing changed at 10am. Left arm AV fistula with good thrill and + bruit.\n\nSkin: Hematoma left arm with borders defined with marker. Bilateral groin bruising, resolving.\n\nPlan: C/O to . Future plan: AICD placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-14 00:00:00.000",
"description": "Report",
"row_id": 1382036,
"text": "CCU Nursing Progress Note 7p-7a\n(Continued)\nstula revision d/t left arm AV shunt w/ thrombosis. Cont current medical mgmt, titrate Ace and BB as tolerated. Future consult this admission for AICD placement. Continue to provide emotional support to pt as indicated. Follow HCT q 6hrs until stable. Transfuse if necessary.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-14 00:00:00.000",
"description": "Report",
"row_id": 1382037,
"text": "CCU NPN\nPlease see carevue for all objective data\n\ncv: hr ^ 130's, st w/ very freq apc's during dialysis and continuing after treatment completed. Received total 15mg lopressor iv, and additional po dose w/ little effect. then given dilt total 35mg iv and started on po 30mg q6hr. hr now down to 107. bp 115-140/50-60.\nresp: sats 92-98% on 3lnp.lung sounds diminished. ct draining ~300cc bloody drainage past 12 hr. Pt c/o sharp pain under r arm (near ct) lasting few minutes, given additional dose mso4 w/ some relief.\ngi: had been npo most of day for graft revision, but now will not be done until . no stool\ngu: aneuric, dialysis today w/ no fluid removal.\nid: afebrile\npain/comfort: pt complaining of general discomfort all day, frequently calling out but unable to quantify discomfort, w/ exception of pain under r arm.\nlines: 2 PIV in r arm. Quinton cath in r fem, oozing sm amts.\nA: tachycardia under poor control, generalized discomfort, CT w/ ~ 300cc bloody drainage.\nP: monitor HR, CT drainage. graft revision \n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-15 00:00:00.000",
"description": "Report",
"row_id": 1382038,
"text": "PRE-OP NOTE 2300-0700\nNEURO: ORIENTED TO PERSON & PLACE. DISORIENTED TO DATE & TIME. MAE.\n CONSTANTLY YELLING OUT & PICKING AT THINGS.\nRESP: 02->3L NP. RR 15-23. O2 SATS 94-97%. BS CLEAR BUT DIMINISHED AT\n BASES. R. CT DSG D&I. CT DRAINED 90CC BLOODY DRAINAGE X8HRS.\n C&R THICK YELLOW SPUTUM.\nCARDIAC: HR 72-76 SR, NO ECTOPY. BP 113-137/26-45. TOL. CAPTOPRIL &\n DILTIAZEM. TRANSFUSED 1U PRBC. POST-TRANSFUSION HCT 30.4\n (27.2). PLAT CT 207(171).\nGI: ADB. SL. DISTENDED. BS+. NO STOOL. NPO AFTER MIDNOC FOR OR TODAY\n REVISION L. AVF. OR PHONE CONSENT OBTAINED FROM WIFE.\nGU: ANURIC D/T CRF.\nID: T99->99.2(PO).\nLABS: WBC 9.3, HCT 29.4, PLAT CT 200K, CHEMISTRIES & COAGS PENDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-15 00:00:00.000",
"description": "Report",
"row_id": 1382039,
"text": "CCU NPN\nneuro: alert/oriented x3, cooperative\ncv: hr sr 70-80's w/ occ apc, bp 130-140/50-60.\nresp: sats 92-95% on 3lnp, luns diminished at bases. CT draining sanguinous fluid ~ 100 pst 9 hrs.\ngi: npo for graft revision, no stool\ngu: anuric, dialysis today w. 650cc fluid removal, tolerated well.\nheme: hct this am 29, transfused w/ 1uprbc and f/u hct 33.4.\npt to or at 1600 for graft revision.\nA: sr rate 70's, no af. decreased CT drainage\nP: monitor rhythm, follow hct, amt CT drainage.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-15 00:00:00.000",
"description": "Report",
"row_id": 1382040,
"text": "CCU NPN 2100-2300\nS/O: PT RETURNED FROM SURGERY AT 2100. LEFT A/C AREA WITH POS PULSES AND DSD. LEFT BRACHIAL AREA WITH POS THRILL AND 2 CM SPOT ON DSD. SURGERY IN TO CHECK AND STATED TO CHECK LEFT A/C FOR PULSES AND BRACHIAL AREA FOR THRILL ALONG WITH DRSG Q1H OVERNIGHT. PT PROPOFOL IN OR, AWAKE BUT CONFUSED, TRYING TO GET OOB AND PULLING OFF O2. PT NOT RESTRAINED WHEN FAMILY IN ROOM BUT WRIST RESTRAINTS PLACED WHEN ALONE. PT SLEEPING AT PRESENT. PO MEDS HELD FOR NOW. LABS TO BE SENT AT 2300. POS PRODUCTIVE COUGH. SATS VARIABLE FROM 90-96%.\n\nA/P: STABLE POST FISTULA REVISION. CHECK LEFT ARM AS ABOVE Q1H. RESTRAIN AS NECESSARY FOR SAFETY. FOLLOW HCT AND PTT OVERNIGHT. ENCOURAGE COUGH AND DEEP BREATHS. OOB AND FEED IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-06 00:00:00.000",
"description": "Report",
"row_id": 1382023,
"text": "CCU NPN 1400-2300\nS/O:\n\nCV: OCC PVC'S, COUPLETS. NSR. LYTES PND. SBP STABLE EXCEPT SLIGHT HYPOTENSION DURING DIALYSIS. DEFIB PADS REMOVED. CARDIAC MEDS HELD. TRAUMA LINE REMOVED FROM RIGHT GROIN, ? PLACED IN ARTERY. PRESSURE HELD FOR 25 MIN AND GROIN SITE WITHOUT HEMATOMA OR OOZE. ALINE IN LEFT GROIN D/I. SECOND PERIPHERAL LINE PLACED. QUINTON CATH PLACED IN RIGHT IJ. PLAN IS FOR CATH IN AM.\n\nRESP: CONT ON 40% 700 X14 WITH 5PS/5PEEP. PT OVERBREATHING AT TIMES, POS GAG AND COUGH. SUCTIONED FOR SMALL THICK WHITE SPUTUM. LUNGS WITH OCC RHONCHI, NO RALES. PLAN IS TO TURN VENT DOWN IN EARLY AM AND TURN OFF PROPOFOL.\n\nID: AFEB.\n\nGI: OGT IN PROPER PLACE. NO MEDS GIVEN. POS BS, ABD SOFT.\n\nGU: FOLEY IN PLACE, URINE CLOUDY AND SCANT. URINE SENT FOR CS BUT NOT SUFFICIENT QUANTITY FOR U/A. DIALYSIS DONE FOR 2H TODAY, 800CC TAKEN OFF. LYTES PND.\n\nMS: PROPOFOL STARTED IV FOR QUENTIN PLACEMENT. PT TITRATED TO 44 MCG WITH GOOD SEDATION. PT WITH SOME PURPOSEFUL MOVEMENT LATE TONIGHT, OTHERWISE NO SIGNS OF ORIENTATION. SEE CAREVUE FOR NEURO SIGNS.\n\nSOCIAL: WIFE AND CHILDREN IN TODAY, UPDATED ON CONDITION BY NURSING AND MEDICAL STAFF. FAMILY IS APPROPRIATE AND UNDERSTANDS PT'S CONDITION.\n\nA/P: PLAN IS TO EXTUBATE AND POSSIBLY CATH IN AM. FOLLOW AND CORRECT LYTES. FOLLOW FOR ARRYTHMIAS. UPDATE FAMILY AS NECESSARY.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-07 00:00:00.000",
"description": "Report",
"row_id": 1382024,
"text": "CCU NPN 1900-0700\nTM 98.9po.\nHR 64-71 SR no VEA. BP 110-130/40's. PTT 150: HEp off x1hour and restarted at 550u/rh.\nsmall amt. of bleeding from left nare and also from mouth. resolved with heparin adjustment.\n\nneuro: pt. initially on propofol 45mcq. very sedated, responding to painful stim. only. propofol weaned to 11mcq and pt. waking, opening eyes spont. nodding head appop. to questions and moving all extrem.\n\n(+) gag and cough. suctioned for thick yellow sputum. course BS.\n\nremains on 700x14/.40/5/5 overnight. RR 14-18. plan to change to PSV 10/5 at 0600 with goal for extubation today.\n\nno u/o\nno stool.\nAM labs pnd 0530.\n\nA/P: responding with decrease propofol\n VSS\n mild nose/mouth bleeding with heparin. dose adjusted.\nP: wean to extubate today. plan d/c propofol. follow CK's, lytes. monitor neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-03-07 00:00:00.000",
"description": "Report",
"row_id": 1382025,
"text": "addendum\nO: AM ABG 7.56/29/129. rate down to 10-> ABG 7.51/35/157. Tv decreased to 550 at 0645. pt. also re sedated on propofol. titrated up to 18mcq with good effect. currently on IMV 550x10/.40/5/5.\nMrs called at 0700 and updated.\n"
}
] |
10,564 | 155,262 | The patient went to the Cardiac Catheterization laboratory upon admission where he was found to have an ejection fraction of 46% with a 90% stenosis of his distal left main and 90% ostial stenosis of his left anterior descending and 100% mid stenosis of his right coronary artery and his left circumflex was okay. Upon arrival to the floor following cardiac catheterization, the patient was noted to have "chest discomfort" which was relieved with sublingual Nitroglycerin. There was some discussion as to whether the patient should receive intra-aortic balloon pump versus going right to the Operating Room and the decision was made for him to undergo urgent coronary artery bypass grafting times four with a left internal mammary artery to left anterior descending artery and a saphenous vein graft to the ramus, to the obtuse marginal and to the PDA. The surgery was performed by Dr. with Dr. as assistant. The surgery was performed under general endotracheal anesthesia with a cardiopulmonary bypass time of 61 minutes and a cross clamp time of 52 minutes. The patient tolerated the procedure well and was transferred to the Surgical Intensive Care Unit in critical but stable condition, A-paced and on neo-synephrine and Propofol drips. The patient did well on the postoperative night; he did require an insulin drip throughout the night and a Neo-Synephrine drip was continued. He was extubated on the postoperative night without difficulty. He did remain in the Cardiac Surgery Recovery Unit for an additional day while he was weaned off the Neo-Synephrine drip. By postoperative day number two, he was able to be transferred to the Surgical Floor. His chest tubes were discontinued on this day without incident and he was started on beta blocker. He also began a gentle diuresis with intravenous Lasix on this day. He began working with Physical Therapy and continued cardiac rehabilitation. On postoperative day number three, his pacing wires were discontinued without incident and he continued to work with Physical Therapy. He was noted on this day to have a hematocrit of 21 and he was therefore transfused two units of packed red blood cells. His hematocrit on the day following transfusion was 26. He continued to progress well and on postoperative day number five, it was felt that he was ready to be discharged to home. His discharge examination shows his vital signs to be stable. He has been afebrile with a heart rate of 72. His blood pressure was 143/88; respiratory rate 20; oxygen saturation 98% on room air. He has been diuresing well and was back to almost his preoperative weight. His lungs were clear to auscultation bilaterally. His heart was regular rate and rhythm. His abdomen was positive bowel sounds, soft, nontender, nondistended. His extremities do show one plus pitting edema in the left lower extremity around his saphenectomy site. His incisions are otherwise clean, dry and intact and the sternum had clips in place and intact. His discharge laboratory studies showed a hematocrit of 30.3, with a potassium of 3.8, which was repleted, BUN of 12, and a creatinine of 0.8. He has been noted to have blood sugars ranging from 120 to 170s postoperatively with the goal of keeping blood sugar less than 120. He should have this followed up on as an outpatient as he did receive sliding scale coverage. This could resolve spontaneously when at home. His discharge chest x-ray shows no signs of infiltrate or effusion and no sign of pneumothorax. Mr. will be discharged home with and will be discharged to home on the following medications. | UOP QS VIA FOLEY.ASSESS; STABLE PM, DECREASED HCT TO 22.5, ASSYMPTOMATIC.PLAN: MAKE TEAM AWARE OF HCT. CT REMAIN IN D/T AMOUNT SANGUINOUS DRAINAGE. SBP STABLE OFF NEOSYNEPHRINE. DRY HEAVES WITH 1ST OOB. K REPLACED WITH RARE PVC NOW NOTED. HCT 22.5 THIS AM.RESP; LUNGS CLEAR BILAT. Changed to 2 L NP this AM w/ good sats.CV: See flowsheet. Lytes repleted.GI: Bowel sounds present this AM. Propofol dc'd. IMPRESSION: Small bilateral pneumothoraces. COMPARISON: CHEST PA AND LATERAL: The patient is S/P CABG. There is moderate left ventricular enlargement. HR NSR w/ rare PVC's. Currently at 2 u/hr.Pain: Medicated w/ sc MSO4 x 3 and percocets x 1. Small left lower lobe atelectasis is seen. IMPRESSION: Mild bilateral pleural effusions. There is interval development of mild pleural effusions bilaterally. MGSO4 2 GM GIVEN W/ SOME EFFECT. The left chest tube and mediastinal drain have been removed. BSP. Precidex off shortly after extubation. The patient is s/p CABG and median sternotomy. RECIEPT LEFT IN CHART.PLAN TO MONITOR BS, FOLLOW SSRI, MINIMIZE PAIN. Small biapical pneumothoraces are seen. CSRU UPDATENEURO: INTACT. CSRU Update:Neuro: Intact. L LEG ACE WRAP REMOVED AND REAPPLIED AFTER DSG CHANGE. WEANED OFF INSULIN GTT. PERCOCET 2 TABS FOR PAIN W/ GOOD EFFECT.CV: VSS, REFER TO FLOWSHEET. BS ELEVATED. SC INSULIN STARTED. Precidex started and titrated for effect. C+DB done. SOME DRY HEAVES WITH GETTING OOB. Neo titrated for SBP > 100. Postop changes. TO BEGIN LOPRESSOR THIS AM. NSR W/ PVC,COUPLING NOTED. Patchy atelectasis in the left lung base. No flatus.GU: Good uop all noc.Endo: BS's elevated - insulin gtt on throughout noc. Sinus rhythmInferior infarct - age undetermined TRANSFER TO 2 AS ABLE. Sinus rhythmIntraventricular conduction defectInferior infarct - age undeterminedNo change from previous The tip of the nasogastric tube is seen in the proximal stomach. Median sternotomy sutures and cardiovascular clips are also visualized. Patchy atelectasis is seen in the left lung base. Better pain control w/ percocets - though pain relif lasted ~ 2 hrs. Appropriate.Pulm: Extubated at 2400. SC INSULIN GIVEN @ 12 & 17.URINE OUTPUT ADEQUATE VIA FOLEY. GOOD C+DB. CT W/ MIN SEROSANG DNG, NO AIR LEAK.GI/GU: ABD SOFT. NSR. L LEG STERI-STRIPS INTACT. CS clr, decreased at bases. SMALL AMOUNT BLOODY DRAINAGE FROM L GROIN OPENING IN SKIN.C/O #4 STERNAL AREA DISCOMFORT THIS AM. APPROXIMATELY 250CC BLOODY DRAINAGE THIS SHIFT.BOWEL SOUNDS PRESENT. Incisions w/ dsgs, staining on sternal dsg. There is widening of the mediastinum consistent with postop changes. There is probably a tiny left apical pneumothorax (less than 5%). DB AND COUGHING ENCOURAGED. A mediastinal drain is also visualized. NO DIURETICS THUS FAR POST-OP.ORIGINAL STERNAL AND MEDISTINAL DSG INTACT. SEE TRANSFER NOTE. O2 SATS DRIFTING TO 93% WHEN ASLEEP. DSG's intact. PLAN TO TRANSFER TO 2 WHEN BED AVAILABLE. PT STATES THAT HE HAS BEEN ADVISED BY HIS MD THAT HIS BS BE RUNNING HIGH. The ETT and NG tube has been also removed. IMPRESSION: Tiny left apical pneumothorax, less than 5%. ONLY TAKING SIPS W/ MEDS. IS INSTRUCTION GIVEN. PERCOCET GIVEN @ 08. MAE. PT DOING 1000CC IS Q1-2HR. Currently on .5 mcg/kg/min. GREEN OVERNIGHT BAG AND PLASTIC HOSPITAL BAG OF BELONGINGS NOTED. COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with the previous study of . Woke easily. PLAN TO START BETABLOCKER LATER TODAY.BS DIMINISHED AT BASES EARLIER TODAY. The lungs are clear otherwise. K+ ALSO REPLETED. Initially agitated with waking. PT DENIED NEED FOR ADDITIONAL PERCOCET LATER IN THE DAY.OOB TO CHAIR X 2. IS TO 1000CC. CHEST, PORTABLE AP: The tip of the endotracheal tube is seen about 5 cm above the carina. 2ND OOB PT MORE COMFORTABLE.CHILDREN IN TO VISIT. PT WILL DIABETIC EDUCATION IF HE IS TO FOLLOW A DIABETIC DIET. 10:54 AM CHEST (PA & LAT) Clip # Reason: s/p CABG w/decreased breath sounds-r/o effusion/ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH MEDICAL CONDITION: 61 year old man with as above REASON FOR THIS EXAMINATION: s/p CABG w/decreased breath sounds-r/o effusion/ptx FINAL REPORT INDICATION: Decreased breath sounds rule out pleural effusion/pneumothorax. Pacer demand rate dropped to 50 d/t competition. TAKING FLUIDS/DIET JELLO ONLY. SENSITIVE TO BETADINE NPRESP LUNGS CLEAR SATS 100% 50% O2 REMAINS ON IMV 10 WILL WEAN WHEN AWAKE CHEST TUBES WITH MOD SANG INCREASE AMTS VIA TUBES WITH AGITATION AND THRASHING IN BEDGU/GI LARGE URINE OUT 2000CC FIRST 2 HOURS POST OP 1900 IN OR ABD SOFT NEGATIVE BOWEL SOUNDS OG UNABLE TO VALIDATE PLACEMENT CXR SHOWS HIGH POSITION ADVANCED WITH PLACMENT HEARD IN STOMACH DRAINING BILIOUS DRAINAGEPLAN START PRECEDEX WEAN PROPOFOL AND EXTUBATE TONOC Good ABG's on 50% open face tent. The lung fields are clear. FAMILY HISTORY OF DIABETES. NEURO ARRIVED FROM OR PROPOFOL 40MCGS SEDATED BUT INCREASED B/P AND HR WITH STIMULATION PROPOFOL INCREASE TO 50 WITH SOME IMPROVEMENT CONTINUES TO BE EASILY AGITATED REVERSED AND PROPOFOL WEANED 530 WITH PT WAKING MOVING ALL EXTREMETIES AGITATED THRASHING IN BED BITING ETT TUBE THRASHING HEAD DOES NOT FOLLOW COMMANDS OR RESPOND TO VOICE PROPOFOL INCREASE TO SEDATE MS TO WAKE WITH SAME AGITATION THRASHING IN BED BITING ETT PROPOFOL INCREASE TO SEDATE MD AWARE TO START PRECEDEX BEFORE WEANING PROPOFOL PUPILS REACTIVE TO LIGHTC/V NSR TO ST WITH AGITATION OR STIMULATION OCC PVC TX K 3.8 B/P DECREASE TO 70S WITH AGITATION BRONCHOSPASTIC WITH EPISODES OF HYPERTENSION TX WITH FLUID REPLACEMENT PER DR DUE TO LARGE URINE OUT CVP 7-12 CURRENT B/P 105/57 EPI WIRES INTACT ARRIVED APACED 80 UNDERLYING 70S NSR PACER SET TO BACKUP OF 60 AWIRES SENSE AND PACE APPROPRIATLY V WIRES SENSE CAPTURE NOT ASSESSED GOOD PEDAL PULSES PALP FEET WARM R LEG RED AREAS ON UPPER THIGH NOTED ? | 9 | [
{
"category": "Radiology",
"chartdate": "2133-11-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 808281,
"text": " 3:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p emergency cabg x4\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 1 VIEW PORTABLE:\n\n INDICATION: 61 y/o man s/p CABG, chest tube removal.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study of .\n\n The patient is s/p CABG and median sternotomy. The left chest tube and\n mediastinal drain have been removed. There is probably a tiny left apical\n pneumothorax (less than 5%). Patchy atelectasis is seen in the left lung base.\n The lungs are clear otherwise. The ETT and NG tube has been also removed.\n\n IMPRESSION: Tiny left apical pneumothorax, less than 5%. Patchy atelectasis in\n the left lung base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 808498,
"text": " 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG w/decreased breath sounds-r/o effusion/ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/decreased breath sounds-r/o effusion/ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreased breath sounds rule out pleural effusion/pneumothorax.\n\n COMPARISON: \n\n CHEST PA AND LATERAL: The patient is S/P CABG. There is moderate left\n ventricular enlargement. No pneumothoraces are identified. There is interval\n development of mild pleural effusions bilaterally.\n\n IMPRESSION: Mild bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 808124,
"text": " 3:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p emergency cabg x4\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop film for emergency CABG x 4.\n\n CHEST, PORTABLE AP: The tip of the endotracheal tube is seen about 5 cm above\n the carina. The tip of the nasogastric tube is seen in the proximal stomach.\n A mediastinal drain is also visualized. Small biapical pneumothoraces are\n seen. Median sternotomy sutures and cardiovascular clips are also visualized.\n Small left lower lobe atelectasis is seen. There is widening of the\n mediastinum consistent with postop changes. The lung fields are clear. No\n pleural effusions are seen.\n\n IMPRESSION: Small bilateral pneumothoraces. Postop changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2133-11-27 00:00:00.000",
"description": "Report",
"row_id": 158969,
"text": "Sinus rhythm\nIntraventricular conduction defect\nInferior infarct - age undetermined\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2133-11-27 00:00:00.000",
"description": "Report",
"row_id": 158970,
"text": "Sinus rhythm\nInferior infarct - age undetermined\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-11-27 00:00:00.000",
"description": "Report",
"row_id": 1402001,
"text": "NEURO ARRIVED FROM OR PROPOFOL 40MCGS SEDATED BUT INCREASED B/P AND HR WITH STIMULATION PROPOFOL INCREASE TO 50 WITH SOME IMPROVEMENT CONTINUES TO BE EASILY AGITATED REVERSED AND PROPOFOL WEANED 530 WITH PT WAKING MOVING ALL EXTREMETIES AGITATED THRASHING IN BED BITING ETT TUBE THRASHING HEAD DOES NOT FOLLOW COMMANDS OR RESPOND TO VOICE PROPOFOL INCREASE TO SEDATE MS TO WAKE WITH SAME AGITATION THRASHING IN BED BITING ETT PROPOFOL INCREASE TO SEDATE MD AWARE TO START PRECEDEX BEFORE WEANING PROPOFOL PUPILS REACTIVE TO LIGHT\n\nC/V NSR TO ST WITH AGITATION OR STIMULATION OCC PVC TX K 3.8 B/P DECREASE TO 70S WITH AGITATION BRONCHOSPASTIC WITH EPISODES OF HYPERTENSION TX WITH FLUID REPLACEMENT PER DR DUE TO LARGE URINE OUT CVP 7-12 CURRENT B/P 105/57 EPI WIRES INTACT ARRIVED APACED 80 UNDERLYING 70S NSR PACER SET TO BACKUP OF 60 AWIRES SENSE AND PACE APPROPRIATLY V WIRES SENSE CAPTURE NOT ASSESSED GOOD PEDAL PULSES PALP FEET WARM R LEG RED AREAS ON UPPER THIGH NOTED ? SENSITIVE TO BETADINE NP\n\nRESP LUNGS CLEAR SATS 100% 50% O2 REMAINS ON IMV 10 WILL WEAN WHEN AWAKE CHEST TUBES WITH MOD SANG INCREASE AMTS VIA TUBES WITH AGITATION AND THRASHING IN BED\n\nGU/GI LARGE URINE OUT 2000CC FIRST 2 HOURS POST OP 1900 IN OR ABD SOFT NEGATIVE BOWEL SOUNDS OG UNABLE TO VALIDATE PLACEMENT CXR SHOWS HIGH POSITION ADVANCED WITH PLACMENT HEARD IN STOMACH DRAINING BILIOUS DRAINAGE\n\nPLAN START PRECEDEX WEAN PROPOFOL AND EXTUBATE TONOC\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-11-29 00:00:00.000",
"description": "Report",
"row_id": 1402004,
"text": "CSRU UPDATE\nNEURO: INTACT. PERCOCET 2 TABS FOR PAIN W/ GOOD EFFECT.\n\nCV: VSS, REFER TO FLOWSHEET. NSR W/ PVC,COUPLING NOTED. MGSO4 2 GM GIVEN W/ SOME EFFECT. K+ ALSO REPLETED. TO BEGIN LOPRESSOR THIS AM. HCT 22.5 THIS AM.\n\nRESP; LUNGS CLEAR BILAT. IS TO 1000CC. GOOD C+DB. NO SECRETIONS RAISED. O2 SATS DRIFTING TO 93% WHEN ASLEEP. CT W/ MIN SEROSANG DNG, NO AIR LEAK.\n\nGI/GU: ABD SOFT. BSP. ONLY TAKING SIPS W/ MEDS. UOP QS VIA FOLEY.\n\nASSESS; STABLE PM, DECREASED HCT TO 22.5, ASSYMPTOMATIC.\n\nPLAN: MAKE TEAM AWARE OF HCT. TRANSFER TO 2 AS ABLE. INCREASE ACTIVITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-11-28 00:00:00.000",
"description": "Report",
"row_id": 1402002,
"text": "CSRU Update:\nNeuro: Intact. Initially agitated with waking. Precidex started and titrated for effect. Propofol dc'd. Woke easily. Precidex off shortly after extubation. MAE. Appropriate.\n\nPulm: Extubated at 2400. Good ABG's on 50% open face tent. CS clr, decreased at bases. C+DB done. Changed to 2 L NP this AM w/ good sats.\n\nCV: See flowsheet. Neo titrated for SBP > 100. Currently on .5 mcg/kg/min. HR NSR w/ rare PVC's. Pacer demand rate dropped to 50 d/t competition. Incisions w/ dsgs, staining on sternal dsg. DSG's intact. Lytes repleted.\n\nGI: Bowel sounds present this AM. No flatus.\n\nGU: Good uop all noc.\n\nEndo: BS's elevated - insulin gtt on throughout noc. Currently at 2 u/hr.\n\nPain: Medicated w/ sc MSO4 x 3 and percocets x 1. Better pain control w/ percocets - though pain relif lasted ~ 2 hrs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-11-28 00:00:00.000",
"description": "Report",
"row_id": 1402003,
"text": "POD #1 CABG\nHIGH SCHOOL BIOLOGY TEACHER TRANSFER TO 2. NSR. K REPLACED WITH RARE PVC NOW NOTED. SBP STABLE OFF NEOSYNEPHRINE. PLAN TO START BETABLOCKER LATER TODAY.\n\nBS DIMINISHED AT BASES EARLIER TODAY. DB AND COUGHING ENCOURAGED. IS INSTRUCTION GIVEN. PT DOING 1000CC IS Q1-2HR. CT REMAIN IN D/T AMOUNT SANGUINOUS DRAINAGE. APPROXIMATELY 250CC BLOODY DRAINAGE THIS SHIFT.\n\nBOWEL SOUNDS PRESENT. TAKING FLUIDS/DIET JELLO ONLY. SOME DRY HEAVES WITH GETTING OOB. BS ELEVATED. WEANED OFF INSULIN GTT. SC INSULIN STARTED. PT STATES THAT HE HAS BEEN ADVISED BY HIS MD THAT HIS BS BE RUNNING HIGH. FAMILY HISTORY OF DIABETES. SC INSULIN GIVEN @ 12 & 17.\n\nURINE OUTPUT ADEQUATE VIA FOLEY. NO DIURETICS THUS FAR POST-OP.\n\nORIGINAL STERNAL AND MEDISTINAL DSG INTACT. L LEG ACE WRAP REMOVED AND REAPPLIED AFTER DSG CHANGE. L LEG STERI-STRIPS INTACT. NO LEG DRAINAGE NOTED. SMALL AMOUNT BLOODY DRAINAGE FROM L GROIN OPENING IN SKIN.\n\nC/O #4 STERNAL AREA DISCOMFORT THIS AM. PERCOCET GIVEN @ 08. PT DENIED NEED FOR ADDITIONAL PERCOCET LATER IN THE DAY.\n\nOOB TO CHAIR X 2. DRY HEAVES WITH 1ST OOB. 2ND OOB PT MORE COMFORTABLE.\n\nCHILDREN IN TO VISIT. GREEN OVERNIGHT BAG AND PLASTIC HOSPITAL BAG OF BELONGINGS NOTED. WALLET SECURED IN THE SAFE. RECIEPT LEFT IN CHART.\nPLAN TO MONITOR BS, FOLLOW SSRI, MINIMIZE PAIN. PLAN TO TRANSFER TO 2 WHEN BED AVAILABLE. SEE TRANSFER NOTE. PT WILL DIABETIC EDUCATION IF HE IS TO FOLLOW A DIABETIC DIET.\n"
}
] |
79,539 | 186,192 | Rightward axis is non-specificbut raises the consideration of possible biventricular hypertrophy. IMPRESSION: Nonspecific bowel gas pattern. No definite acute intrathoracic abnormality. IMPRESSION: Patent bilateral greater saphenous veins with somewhat diminutive features as described above. Noprevious tracing available for comparison. ModestST-T wave changes are non-specific. Sinus bradycardia. No large amounts of free air are noted. Left ventricular hypertrophy. No evidence for ileus. It is diminutive knee to the ankle. Right greater saphenous vein is patent with diameters of 0.22 to 0.38. Heart and mediastinum are normal. COMPARISON: None. There are no dilated loops of bowel. It is diminutive from lower thigh to the ankle. On the left, the diameters range from 0.23 to 0.31. IMPRESSION: Enlargement of the right hilum. There is no pneumothorax or pleural effusion. Please faciliate exam to provide care. REASON FOR THIS EXAMINATION: lower extremity vein mapping FINAL REPORT VENOUS DUPLEX LOWER EXTREMITY FINDINGS: Duplex evaluation was performed of both lower extremity venous systems. If continued clinical concern dedicated abdominal series are suggested. AP AND LATERAL VIEWS OF THE CHEST: Lungs are clear with no pneumonia or congestive heart failure. PORTABLE ABDOMEN: Air is identified in small and large bowel with fecal matter in the ascending and transverse colon. The right hilum is enlarged. Clinical correlation is suggested. Pt may "refuse" but he is not mentally capacitated to know what is "going on." Thank you. 10:42 PM PORTABLE ABDOMEN Clip # Reason: please eval for bowel distension (ileus) Admitting Diagnosis: ULCER LEFT LEG MEDICAL CONDITION: 77 year old man with abdominal distension REASON FOR THIS EXAMINATION: please eval for bowel distension (ileus) WET READ: SHfd WED 12:15 AM no definite bowel obstruction or free air on this supine film. FINAL REPORT PORTABLE ABDOMEN INDICATION: 77-year-old man with abdominal distention, please evaluate for ileus. 9:28 PM CHEST (PRE-OP PA & LAT) Clip # Reason: ULCER LEFT LEG Admitting Diagnosis: ULCER LEFT LEG MEDICAL CONDITION: 77 year old man with need for angio REASON FOR THIS EXAMINATION: pre-op FINAL REPORT REASON FOR EXAM: Preop radiograph. | 4 | [
{
"category": "Radiology",
"chartdate": "2107-05-15 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1136119,
"text": " 9:28 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ULCER LEFT LEG\n Admitting Diagnosis: ULCER LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with need for angio\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Preop radiograph.\n\n COMPARISON: None.\n\n AP AND LATERAL VIEWS OF THE CHEST: Lungs are clear with no pneumonia or\n congestive heart failure. There is no pneumothorax or pleural effusion. The\n right hilum is enlarged. Heart and mediastinum are normal.\n\n IMPRESSION: Enlargement of the right hilum. No definite acute intrathoracic\n abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-05-17 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1136474,
"text": " 10:42 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for bowel distension (ileus)\n Admitting Diagnosis: ULCER LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with abdominal distension\n REASON FOR THIS EXAMINATION:\n please eval for bowel distension (ileus)\n ______________________________________________________________________________\n WET READ: SHfd WED 12:15 AM\n no definite bowel obstruction or free air on this supine film. If continued\n clinical concern dedicated abdominal series are suggested. \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n INDICATION: 77-year-old man with abdominal distention, please evaluate for\n ileus.\n\n PORTABLE ABDOMEN: Air is identified in small and large bowel with fecal matter\n in the ascending and transverse colon. There are no dilated loops of bowel.\n No large amounts of free air are noted.\n\n IMPRESSION: Nonspecific bowel gas pattern. No evidence for ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-05-19 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 1136734,
"text": " 1:53 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: \\\n Admitting Diagnosis: ULCER LEFT LEG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with Dementia for likely bipass Friday. Pt may \"refuse\" but he\n is not mentally capacitated to know what is \"going on.\" Please faciliate exam\n to provide care. Thank you.\n REASON FOR THIS EXAMINATION:\n lower extremity vein mapping\n ______________________________________________________________________________\n FINAL REPORT\n VENOUS DUPLEX LOWER EXTREMITY\n\n FINDINGS: Duplex evaluation was performed of both lower extremity venous\n systems. Right greater saphenous vein is patent with diameters of 0.22 to\n 0.38. It is diminutive knee to the ankle. On the left, the diameters range\n from 0.23 to 0.31. It is diminutive from lower thigh to the ankle.\n\n IMPRESSION: Patent bilateral greater saphenous veins with somewhat diminutive\n features as described above.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-05-16 00:00:00.000",
"description": "Report",
"row_id": 231290,
"text": "Sinus bradycardia. Left ventricular hypertrophy. Rightward axis is non-specific\nbut raises the consideration of possible biventricular hypertrophy. Modest\nST-T wave changes are non-specific. Clinical correlation is suggested. No\nprevious tracing available for comparison.\n\n"
}
] |
|
10,973 | 125,313 | 1. Gastrointestinal bleed: Mr. presented to this facility with an INR of 15.4 and reporting melena since his stenting and bright red blood per rectum for the past few days prior to admission. He denied hematemesis. He was thought to be coagulopathic due to his unmonitored use of plavix, aspirin, and coumadin for his left ventricular wall motion abnormalities. His INR improved with administration of vitamin K and 4 units of fresh frozen plasma. He also received 4 units of packed red blood cells for his hematocrit of 21. An EGD revealed gastritis but no acute bleed. His coumadin, aspirin, plavix, beta blocker, and ACE inhibitor were discontinued. Placed on a twice daily PPI, he stabilized quickly and once his coagulopathy resolved, he required only one additional transfusion of packed red blood cells. He was found to be negative for h. pylori. His plavix and aspirin were restarted once his hematocrit had been stable for 2 days. 2. Coronary artery disease: Mr. is status post anterior ST elevation myocardial infarction with stenting x 2 in of following a motor vehicle accident. He had been doing well until a few days ago when he noticed the onset of intermittent chest pain, mostly at rest. At times it was accompanied by dyspnea and might last up to 30 minutes. He also had some paroxysmal nocturnal dyspnea in the last few days. The night before admission he experienced chest pain that woke him from sleep and was accompanied by dyspnea and light headedness. He denied nausea, emesis, diaphoresis, or dizzyness. These symptoms resolved within 30 minutes. The morning of admission, he called his primary care physician who advised him to come to the Emergency Department for evaluation. At admission, he was on aspirin, plavix, an ACE inhibitor, and a beta blocker. With the exception of the ACE inhibitor, these were continued in their short acting forms during this admission. The ACE inhibitor was held until his kidney function normalized. It was restarted on the day of discharge and the patient's blood pressures have tolerated it well. He will be continued on his current medication. If his renal function deteriorates, consider discontinuing ACE inhibitor. 2. Congestive heart failure: Mr. has a history of CHF with EF of 20% with RV apical akinesis and an apical left ventricular aneurysm. For this reason, he had been placed on coumadin during his previous hospitalization. In addition to aggressive diuresis to avoid volume overload, he received at least 8 units of blood products for his GIB and to prevent further myocardial ischemia. Although his ins and outs were negative, Mr. soon developed respiratory failure. On the evening of admission, he suddenly became dyspneic, tachypneic, and diaphoretic. He was emergently intubated for flash pulmonary edema and upon introducing the endotracheal tube, large quantities of foamy red secretions emerged. The patient was restarted on coumadin, however, given his past medical history, he may not be a candidate for coumadin therapy. Dr. will discuss with Dr. , the patient's psychiatrist, whether the patient is reliable to remain on Coumadin. Please verify with Dr. whether to send the patient home on Coumadin prior to discharge form rehabilitation hospital. 3. Cardiogenic Shock: Shortly after his intubation, Mr. ' systolic blood pressures fell to the 70s. A pulmonary artery catheter was placed and norepinephrine, dopamine, and dobutamine drips were started. These pressors were titrated to maintain a mean arterial pressure greater than 65. His pulmonary artery catheter revealed pressures consistent with volume overload and cardiogenic shock (CVP 18, RA 15, RV 58/20, PA 58/27/40, PCWP 24). The patient's cardiac markers were cycled and were consistent with new ischemia, although a later transthoracic echo was unchanged. He was transfused intermittently to maintain a hematocrit greater than 30. 4. Atrial fibrillation/SVT: One day after placement of the PA catheter, the patient developed hypotension with a narrow complex tachycardia, which did not break with carotid massage. The dobutamine, dopamine, and norepinephrine were turned off. Neosynephrine was started and a liter of normal saline was bolused with improvement in the BP to the 90's and 100's. When adenosine did not break the rhythm, which appeared to be atrial fibrillation, amiodarone was loaded. Concomittently, electrical cardioversion with 100 then 200 joules was initiated, whereupon sinus rhythm was recovered. In the following days, the neosynephrine was weaned, the amiodarone was continued, and the patient remained in sinus rhythm with a brief episode of atrioventricular node reentrent tachycardia. Once off pressors, beta blockade was initiated to rate control the patient. It was thought that these arrhythmias occured in the setting of cardiogenic shock and the irritating effect of the catheter on the myocardium. Given these considerations, no AV node ablation or long term amiodarone was indicated. 5. Respiratory Failure: Mr. developed flash pulmonary edema in the setting of receiving several units of blood and fresh frozen plasma. He was emergently intubated and sedated. He remained on the ventilator until his cardiogenic shock was resolved and then was weaned. He did well until he became febrile and developed the onset of increasing secretions and oxygen desaturations. His endotracheal secretions grew out serratia and he responded well to piperacillin/ tazobactam. Once the patient produced fewere secretions and his ventilator requirements decreased, he was successfully extubated. 6. Acute Renal Failure: Mr. ' baseline creatinine is 1.5 but when he presented, it was 3.1. His failure was though to be secondary to prerenal hypoperfusion due to the GI bleed, the myocardial ischemia, and the CHF. His ACE inhibitor had been started during his previous hospitalization in and likely contributed to the increase in the creatinine. Both his ACE inhibitor and the lithium were held until his renal failure resolved. Once his cardiogenic shock resolved and perfusion to his kidneys improved, Mr. ' creatinine trended down. In the interim, he developed hypercalcemia which was though to represent the action of lithium usually blunting the calcium sensing receptors on the parathyroid gland. It was believed that this would resolve once his lithium was restarted. He also briefly became hypernatremic, which was thought to be due to increased insensible losses during his febrile state (ventilatory associated pneumonia) vs RTA and resolved with free water boluses and administration of IV D5W. The patient's sodium has been stable in the last few days prior to discharge. 7. Bipolar disorder: Mr. has a history of bipolar disorder and has been followed at this facility by Dr. . According to the patient and his brother, he had been stable on lithium for about 4 years. In the interest of preserving his renal function, his lithium was discontinued and other medications were initiated. However, he developed severe depression and was placed back on lithium. When he presented to this facility, his lithium level was 2, much higher than his usual tight control of 0.5 - 1.0. This increase was thought to be secondary to his acute renal failure. Dr. was contact and the decision was made to restart lithium with close monitoring. The patient will need close monitoring for his lithium level and follow up with Dr. . Dr. will be notified of the rehabilitation facility. 8. Thrombocytosis - the patients platelet count has been trending up. The etiology of this is not entirely clear. The patient does not look actively infected to explain acute phase reactant effect. Please monitor platelet counts closely. | There is atrivial/physiologic pericardial effusion.Compared with the prior study (tape reviewed) of , moderate pulmonaryartery systolic hypertension is now identified. Trace aortic regurgitation is seen. Based upon review of prior studies, the appearance favors asymmetrical edema. Persistent left retrocardiac opacity is again seen. Stable examination with asymmetric pulmonary opacity in the perihilar regions (left greater than right). Interval development of a mild degree of right lower lobe partial atelectasis. There is an apical left ventricularaneurysm. Anterolateral myocardial injury/ischemia pattern persist. This finding could represent asymmetric pulmonary edema. Compared tothe previous tracing of the patient is now in sinus rhythm. Moderate (2+) mitral regurgitation is seen.TRICUSPID VALVE: There is moderate pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is a trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. In addition, peribronchovascular blunting, consistent with some left ventricular failure. Partial atelectasis involving the right lower lobe. Nomasses or thrombi are seen in the left ventricle.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: mid anterior - akinetic; mid anteroseptal - akinetic;mid inferoseptal - akinetic; basal inferior - akinetic; basal inferolateral -hypokinetic; anterior apex - hypokinetic; septal apex- akinetic; lateral apex- hypokinetic; apex - akinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Left ventricular wall thicknesses arenormal. There is moderate pulmonary artery systolic hypertension. .50/600/22/10 weaned to .40/600/22/10 peep w/o complication. Dopa/dobut d/c, neo started. ABG good.po2>120 pH 7.35. Compared to the previous tracingof anterolateral ST-T wave changes persist.TRACING #1 (With rate 22, ABG97/28/7.38). MN->0500 balance -59ml with LOS + 3.7liters.ID: Afebrile. sig for Low BP req dopa and dobutamine> afib @130, cardioversion 100 and 200 w/o change. At 0400 ABG 7.33/36/115, lactic acid 1.9.CV: Amiodarone and Neo-synephrine have remained @ 0.5mg/min and 1mcg/kg/min respectively. His RR was , B/P 162/66, HR 92. Fluid balance @ MN -1207ml, and MN->0500 -839ml. Probable A-V nodal re-entranttachycardia. Amiod bolus and gtt> NSR. By 12n he started to C/O SOB, ABG showed pH 7.38, CO2 33. BP 108/47-149/69.GI: TF of Nepro cont @ goal of 45ml/hr via OGT. 4.74(5.62) and SVR 1181(954). VS then stabilized @ baseline. Cr declining 2.7 (3.0 ). 1300 HR90-110 SR/ST w/ freq PAC's and bts. Doing well except for BP 85-90/Neuro-Awakens to voice, FC, MAE. Amiodarone qtts D/C'd @ 2100, and pt rec'd scheduled po doses Amio, Lopressor and Hydralazine. Bowel snds hypoactive. Compared to theprevious tracing of there are persistent Q waves with mild ST segmentelevations in the anterior leads suggestive of myocardial injury/ischemia whichis recent. Compared to the previous tracing of narow complexsupraventricular tachycardia persist. Amiod restarted, gtt to finish 2100, give po dose @ . Compared to the previous tracing of there are slightST segment elevation in leads V2-V3 with pseudonormalization of T waves inleads V3-V4 suggestive of anterior myocardial injury/ischemia. ABG post intubation 7.27-40-80-19. Presently rec'ing #1 of 2 units FFP.GI: NPO, abd obese/soft with hypoactive bowel snds. MICU A NSG 7A-7PMRESP--PT EXTUBATED AT ~930 AND TOL WELL. Pt transfused with 2 u prbc and 1 u plts today. Abd softly distended with + BS. Abd softly distended with + BS. ABG post-intubation on 100% 7.27/40/80. r/t temp. FiO2 weaned appropriatly. Of note, pt appears to be ruling in for MI with CPK/MB 419/49. Placed back on A/C w/ gd effect. At 0530, transfusion of 1uFFP started.Review of Systems:Neuro: Pt presently lightly sedated with Versed @ 3mg/hr, Fentanyl @ 75mcg/hr. BP tenuous per carevue, and pt rec'd several NS fluid boluses for total ~2liters. Changed to PSV w/ gd effect. HR/BP stable per carevue. Tylenol if tspike. Pt tollerating turing well. BP 53/15->102/46. c-diff. Resp Care,Pt. ABG revealed compensated metabolic alkalosis w/ normoxia, however, Pt c/o SOB. As SBP>100, Versed and Fentanyl qtts started for sedation. ETT placement confirmed by CXR. Eventually Dopamine and Levophed cont IV started with BP slowly stabilizing. Progress NoteMICU A 0700-1900Neuro: Pt A/O x3, PERRLA, cooperative and follows commandsCV: Hemodynamically stable. Fluid balance @ MN -491ml.ID: Tmax overnight 100.6po @ . Has increased to the low 100's following fliud resucitation. at 2130 short bursts of SVT rate 130's lopressor due at 2200 given early 2.5mg IVB.with effect pt remain in sr with occassional PAC's. mushroom cath placed.Gu: foley to c/d . Occas ectopy. RIJ PA cath patent wave form good documented .Lungs: initially BS coarse to decreased very thick tan blood tinged sputum suction . BP stabilized and pt converted to NSR withoug further cardioversion. Free water boluses D/C'd and then resumed Q6hrs. Hct 29.8, Tx 1 UPRBC. Suctionned ETT secretions thick/bloody.Review of systems:Neuro: Sedation unchanged from Fentanyl @ 75mcg/hr, Versed @ 1mg/hr. GI: Abd soft but distended this am--decompressed with CWS during morning. Hct trending down, team aware.GI: TF of Nepro/Promod cont @ goal of 65ml/hr with small residuals. Plt ct 209.GI: Abd soft/obese with + bowel snds. (1st liter now hanging. CPK/MB 433/37(419/49).Hct 28.5 @ MN, so pt transfused 2u PRBC's. Pulm: Pt placed back on AC during instablity this am. ABG @ 0400 7.33/40/131. AC->PS, tol well. Neo gtt started at max dose with NS fluids wide open. Lung sounds course throughout, occas crackle @ R base, and noted to have diminished sounds @ L base @ 0200. ABG pndg. Presently, Dopamine @ 11mcg/kg/min, Dobutamine @ 5mcg/kg/min, Levophed @ 0.06mcg/kg/min with MAP 65. Pt rec'd Lasix 20mg X 1.ID: Temp 100.6po. SRR 8-19 and regular. Peep 'd to 8, and following ABG 7.36/25/125. Pt rec'd neb tx X 1 -> sat inc to 99% and RR 23.CV: HR 60-71SR without ectopy, BP 113/46-124/62. Pt rec'ing D5W @ 75ml/hr X 2liters. Suctioned for mod amt yellow/thick secretions ~Q2hrs. Cont to follow troponin/CPK-MB. Coags normalized with INR = 1.6. Pt returned to previous settings with peep 5. CV: Low grade temps of 99. Lytes from 1730 pndg.GI: TF changed to Nepro 1/2 strength + Promod 70gm/day, beginning @ 70ml/hr. | 69 | [
{
"category": "Radiology",
"chartdate": "2146-09-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837994,
"text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated and with new a fib\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB, GIB, CHF, now with hemoptysis.\n\n REASON FOR THIS EXAMINATION:\n intubated and with new a fib\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, chest pain, shortness of breath, GI\n bleed, congestive heart failure, now with hemoptysis.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of . An endotracheal tube is present with tip ----- There is a nasogastric\n tube, which passes into the stomach below the level of the film. A right\n internal jugular SG catheter is present with tip in the distal right main\n pulonary artery. The heart size has decreased in the interval. There is\n improvement in the bilateral perihilar opacities. Mild bibasilar atelectasis\n is present.\n\n IMPRESSION:\n\n 1. Endotracheal tube positioned with tip at the thoracic inlet.\n 2. Improved pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838587,
"text": " 10:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from previous\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CAD s/p MI, CHF, now intubated w/ fevers, increased sputum\n production\n REASON FOR THIS EXAMINATION:\n change from previous\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 y/o male, coronary artery disease, status post myocardial\n infarction, CHF, now intubated and with fevers.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with the previous chest radiograph dated .\n\n The locations of the right IJ line, endotracheal tube, and the nasogastric\n tube are not changed compared to the previous study.\n\n The patient has mild cardiomegaly. There is increased pulmonary vasculature\n in bilateral upper lung zones, indicating mild CHF.\n\n There is continued infiltration of the left lower lobe, as well as faint\n patchy opacity in left upper lobe, which can represent aspiration vs.\n pneumonia. Please correlate clinically.\n\n IMPRESSION:\n\n Continued Mild CHF. Infiltration in left lower lobe and left upper lobe,\n which can represent aspiration vs. pneumonia. Please correlate clinically.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838214,
"text": " 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB, CHF, s/p new RIJ\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia with coronary artery disease status post new right IJ line\n placement.\n\n FINDINGS: The study is compared to the previous study of the day earlier.\n The tip of the right IJ line is higher at this time and is in the distal\n superior vena cava. Mild pulmonary vascular congestion is again noted\n unchanged. ET tube remains in place as well as NG tube.\n\n IMPRESSION: The tip of the right IJ line is higher. No evidence of\n pneumothorax.\n\n Bilateral pulmonary vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838698,
"text": " 6:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from previous\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CAD s/p MI, CHF, now intubated w/ fevers, increased sputum\n production\n REASON FOR THIS EXAMINATION:\n change from previous\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: patient with coronary artery disease post myocardial infarction.\n\n PORTABLE AP CHEST: Comparison is made to the prior study from .\n\n TECHNIQUE: Supine, AP radiographs were obtained.\n\n FINDINGS: Multiple supportive hardware is in situ. The tip of the ET tube is\n identified 5 cm above the carina.\n\n A right sided IJ line is seen in good position. There is an ET tube , the tip\n at the thoracic inlet.NGT with its tip in the stomach.\n There is prominence of the central pulmonary artery bilaterally. In addition,\n peribronchovascular blunting, consistent with some left ventricular failure.\n There is no representative atelectasis or consolidation. No definite pleural\n effusions are seen. There is little interval change from the radiograph dated\n .\n\n IMPRESSION: Little interval change. Evidence of cardiac failure.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838238,
"text": " 6:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from previous\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB, GIB, CHF, on admission with hemoptysis, now with\n AMI, cardiogenic failure, episodes afib/svt.\n REASON FOR THIS EXAMINATION:\n change from previous\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 71-year-old man with shortness of breath, CHF, admission with acute\n myocardial infarction and cardiogenic failure.\n\n COMPARISON: Comparison is made to the prior study of a day earlier.\n\n CHEST, PORTABLE AP VIEW: The jugular, CVP line, the ETT Tube and NG tube\n remain in place. Partial atelectasis involving the right lower lobe.\n Bilateral pulmonary vascular congestion is noted which is more pronounced in\n the left lung. The right lower lobe partial atelectasis is new. There are no\n significant changes in the appearance of bilateral pulmonary vascular\n congestion. Cardiomegaly is suspected.\n\n IMPRESSION\n\n 1. Bilateral pulmonary edema, unchanged.\n\n 2. Interval development of a mild degree of right lower lobe partial\n atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837878,
"text": " 1:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF, infiltrate.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB, GIB, CHF, now with hemoptysis.\n REASON FOR THIS EXAMINATION:\n CHF, infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate CHF and infiltrate.\n\n PORTABLE AP CHEST: Comparison made to study from . ET tube and NG tube\n are again seen and unchanged in position. The tip of the NG tube is not\n visualized as it extends beyond the inferior margin of the image field. A\n right- sided Swan- Ganz catheter is seen with the tip positioned in the distal\n right pulmonary artery. There is prominence of the pulmonary vasculature and\n bilateral patchy opacities in the hilar areas, representing pulmonary edema\n which appears to have improved since the previous exam. Left retrocardiac\n opacity is again seen and is relatively unchanged. Pleural effusions are\n seen. No pneumothorax is seen. The mediastinal and hilar contours are\n unchanged.\n\n IMPRESSION:\n\n 1. Prominence of the pulmonary vasculature with hilar opacities again seen,\n representing pulmonary edema which is improved compared to the recent exam.\n\n 2. Persistent left retrocardiac opacity is again seen.\n\n 3. Right-sided Swan-Ganz catheter is seen with the tip positioned in the\n right pulmonary artery.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837769,
"text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm et tube placement, assess for pulmonary edema\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB s/p blood transfusion\n\n REASON FOR THIS EXAMINATION:\n confirm et tube placement, assess for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease with chest pain and shortness of breath.\n Status post blood transfusion. Check tube placement and assess for pulmonary\n edema.\n\n FINDINGS: A single AP supine image. Comparison study dated .\n The endotracheal tube is well positioned with its tip approximately 7 cm above\n the carina. The heart again shows moderatly left ventricular enlargement.\n There are increasing perihilar infiltrate bilaterally, consistent with\n worsening pulmonary edema. No definite pleural effusion is demonstrated but\n small posterior layering effusions cannot be excluded.\n\n IMPRESSION: Worsening pulmonary edema associated with left heart failure.\n Satisfactory placement of the endotracheal tube. Surgical clips noted in the\n right upper quadrant of the abdomen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837730,
"text": " 4:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: change from previous, effusion, edema\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB s/p blood transfusion\n\n REASON FOR THIS EXAMINATION:\n change from previous, effusion, edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 71-year-old male with chest pain and shortness of breath after\n blood transfusion.\n\n FINDINGS: Comparison is made to a prior chest radiograph performed earlier\n the same day. The heart is enlarged but stable in size. There is evidence of\n increased opacity in the perihilar regions (left greater than right). There\n is no evidence of pleural effusion or pneumothorax. The osseous structures\n are unremarkable.\n\n IMPRESSION:\n 1. Stable examination with asymmetric pulmonary opacity in the perihilar\n regions (left greater than right). This finding could represent asymmetric\n pulmonary edema. Multifocal pneumonia or aspiration event are also diagnostic\n considerations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837813,
"text": " 12:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess swan placement, ptx\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB, GIB, now s/p R IJ cordis and swan placement.\n REASON FOR THIS EXAMINATION:\n assess swan placement, ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CAD with chest pain and shortness of breath, status post right\n internal jugular Cordis and Swan placement.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of nine hours\n earlier. There is an endotracheal tube probably positioned at the thoracic\n inlet. A right internal jugular Cordis and SG catheter are present. The tip\n of the SG catheter is in the right main pulmonary artery. There is no\n pneumothorax. A nasogastric tube is present, which passes into the stomach\n out of sight below the level of the film. Surgical clips are present in the\n right upper quadrant. The heart is at the upper limits of normal in size.\n There are bilateral perihilar alveolar opacities, which have decreased since\n the prior study. There has been interval decreased distension of the\n stomach.\n\n IMPRESSION:\n\n 1. Right internal jugular Cordis and SG catheter with tip of the catheter in\n the right pulmonary artery. No pneumothorax.\n\n 2. Improved pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837923,
"text": " 11:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx, assess tube placement\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB, GIB, CHF, now with hemoptysis.\n\n REASON FOR THIS EXAMINATION:\n r/o ptx, assess tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year old male with CAD, shortness of breath, CHF, and\n hemoptysis.\n\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the\n previous chest radiograph taken earlier on the same day, .\n\n FINDINGS: The right IJ line is removed. There is a new venous line from IVC,\n at the level of seventh thoracic vertebra. The tip of the Swan-Ganz catheter\n is in right main pulmonary artery. Left-sided chest tube is noted.\n Nasogastric tube is coursing down below the hemidiaphragm.\n\n Previously noted bilateral parenchymal edema has decreased on the right,\n slightly increased on the left. There are continued small pleural effusions.\n No pneumothorax.\n\n IMPRESSION: Tubes and lines as described above. Bilateral parenchymal edema,\n decreased on the right, increased on the left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837689,
"text": " 11:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CP/SOB\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain and shortness of breath.\n\n PORTABLE AP CHEST: Images from prior studies are not available for comparison.\n Reference is made to the report. There is mild cardiomegaly. There are areas\n of increased opacity in the perihilar areas, as well as asymmetrically\n increased opacity in the left upper lung zone and left lower lobe. The\n findings are likely due to asymmetrical pulmonary edema, but evaluation is\n limited without comparison studies. An acute multifocal pneumonia or\n aspiration cannot be excluded. There are surgical clips in the right upper\n abdomen.\n\n IMPRESSION: Likely asymmetrical pulmonary edema, but evaluation limited\n without prior comparison studies. Should these become available, an addendum\n will be issued to this report. Multifocal pneumonia or aspiration cannot be\n excluded.\n\n ADDENDUM: Comparison CXR of and have become available. The\n appearance on the current CXR is worse than on . Based upon review of\n prior studies, the appearance favors asymmetrical edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 838434,
"text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M CAD with CAD s/p MI, CHF, now intubated w/ fevers, increased sputum\n production\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and increased sputum production.\n\n FINDINGS: Single supine portable AP view of the chest shows bibasilar\n collapse/consolidation, left greater than right. An underlying pneumonic\n process cannot be ruled out. The endotracheal tube and right internal jugular\n catheter are in good position. There is no evidence of significant cardiac\n failure.\n\n IMPRESSION: Bibasilar consolidation, left greater than right.\n\n"
},
{
"category": "Echo",
"chartdate": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 67254,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 220\nBSA (m2): 2.22 m2\nBP (mm Hg): 110/64\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 16:10\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: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. There is an apical left ventricular\naneurysm. There is severe regional left ventricular systolic dysfunction. No\nmasses or thrombi are seen in the left ventricle.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: mid anterior - akinetic; mid anteroseptal - akinetic;\nmid inferoseptal - akinetic; basal inferior - akinetic; basal inferolateral -\nhypokinetic; anterior apex - hypokinetic; septal apex- akinetic; lateral apex\n- hypokinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Moderate (2+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: There is moderate pulmonary artery systolic hypertension.\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 - 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 mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated with severe regional\ndysfunction - with severe hypokinesis of the basal inferolateral and basal\ninferior walls, and near akinesis of the distal half of the septum, distal\nhalf of the anterior wall, and distal inferior wall. The apex is mildly\naneurysmal and akinetic. No masses or thrombi are seen in the left ventricle.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets are mildly thickened. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\nis seen. There is moderate pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the prior study (tape reviewed) of , moderate pulmonary\nartery systolic hypertension is now identified. Overall and regional left\nventricular systolic function is similar.\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": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 145805,
"text": "Sinus rhythm. Loss of R waves in leads V1-V4 suggestive of old anteroseptal\nmyocardial infarction. Non-specific inferior ST-T wave changes. Anterolateral\nST-T wave changes - cannot rule out myocardial ischemia. Compared to the\nprevious tracing of anterolateral and inferior ST-T wave changes\npersist. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-13 00:00:00.000",
"description": "Report",
"row_id": 145806,
"text": "Sinus rhythm. Insignificant Q waves in leads III and aVF, absence of septal\nQ waves in leads I and aVL. T wave inversion in leads I, aVL and V4-V6.\nPoor R wave progression in leads VI-V3 with ST segment elevations in\nleads V2-V3 and terminal T wave inversions. INT: Anterior injury. Rule out\nnon-Q wave infarction. Compared to the previous tracing of anteromedial\nST segment elevations were previously present, new T wave inversions have\nappeared in leads I, aVL and V2-V3 and have deepened in leads V4-V6.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-19 00:00:00.000",
"description": "Report",
"row_id": 145751,
"text": "Sinus rhythm. Compared to the previous tracing of there is no\nsignificant diagnostic change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-18 00:00:00.000",
"description": "Report",
"row_id": 145752,
"text": "Sinus tachycardia. Probable old anteroseptal myocardial infarction. Compared to\nthe previous tracing of the patient is now in sinus rhythm. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-16 00:00:00.000",
"description": "Report",
"row_id": 145756,
"text": "Sinus bradycardia. Compared to the previous tracing of atrial ectopies\nare absent. Anterolateral myocardial injury/ischemia pattern persist. However,\nT waves are more biphasic in leads V2-V4 suggestive of more evolving pattern.\nST segments are significantly improved. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-15 00:00:00.000",
"description": "Report",
"row_id": 145757,
"text": "Sinus tachycardia with frequent atrial premature beats. Compared to the\nprevious tracing of there are persistent Q waves with mild ST segment\nelevations in the anterior leads suggestive of myocardial injury/ischemia which\nis recent. Lateral ST-T wave changes suggestive of myocardial ischemia.\nClinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-15 00:00:00.000",
"description": "Report",
"row_id": 145802,
"text": "Sinus tachycardia. Compared to the previous tracing of there are slight\nST segment elevation in leads V2-V3 with pseudonormalization of T waves in\nleads V3-V4 suggestive of anterior myocardial injury/ischemia. Possible\npersistent lateral ST-T wave changes. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 145803,
"text": "Sinus rhythm. Poor R wave progression. ST-T wave abnormalities in the\nanterolateral leads. These findings are suggestive of old anteroseptal\nmyocardial infarction and possible anterolateral myocardial ischemia. Low\nQRS voltages in the precordial leads. Compared to the previous tracing\nof anterolateral ST-T wave changes persist.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 145804,
"text": "Sinus rhythm. Compared to tracing #1, lateral ST-T wave changes have improved.\nClinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-17 00:00:00.000",
"description": "Report",
"row_id": 145753,
"text": "Narrow complex supraventricular tachycardia. Probable A-V nodal re-entrant\ntachycardia. There are probable P waves present following the QRS complex.\nIntraventricular conduction defect. Non-specific inferolateral ST-T wave\nchanges. Compared to the previous tracing of narow complex\nsupraventricular tachycardia persist. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-16 00:00:00.000",
"description": "Report",
"row_id": 145754,
"text": "Sinus tachycardia\nFrequent premature ventricular contractions\nConsider anteroseptal infarct - age undetermined\nInferior/lateral ST-T changes suggest possible myocardial ischemia/digitalis\neffect\nLow QRS voltages in precordial leads\nT wave abnormalities in leads V4-V6, less pronounced than previous - consider\nresolving ischemia\n\n"
},
{
"category": "ECG",
"chartdate": "2146-09-17 00:00:00.000",
"description": "Report",
"row_id": 145755,
"text": "Wide complex tachycardia.\nProbably supraventricular tachycardia with aberrancy but cannot rule out the\npossiblity that these are not ventricular tachycardia\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-18 00:00:00.000",
"description": "Report",
"row_id": 1406477,
"text": "Nursing Addendum 0645\nPt noted by resp therapist to have increased work of breathing, using accessory muscles, @ 0615. HR increased to 130ST, RR mid-30's per carevue. Pt admitted to SOB but denied pain. RR setting on vent raised to match pt's rate. BP/HR slowly decreasing spont. However, SBP then in 80's and pt less responsive. Fluid bolus started and after 25ml NS infused, SBP again 130-140. VS then stabilized @ baseline. EKG done, and CXR done immed prior to event. ABG post event pndg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-18 00:00:00.000",
"description": "Report",
"row_id": 1406478,
"text": "Respiratory Addendum\nShortly after 0600 pt became dyspneic, increased WOB with retractions and use of accessory muscles.Heart rate and BP increased with resp.rate of 33. Peep increased to 10 and set rate to 33. Suctioned for copious amounts creamy yellow tan secretions with plugs. See Careview for parameters. By 0645 pt. settled,appears comfortable set respiratory decreased to 22.Regular respiratory rate and rhythm. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-18 00:00:00.000",
"description": "Report",
"row_id": 1406479,
"text": "Resp. Care:\n Pt. remains intubated and on vent.support. Sx'ng foul smelling sputum in mod. amt.'s. Without resp. changes made today. Please see flow sheet for information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-18 00:00:00.000",
"description": "Report",
"row_id": 1406480,
"text": "Neuro sedated 50 mcg fentanyl, 1mg iv versed pupils equal and reactive mae fc\ncardiac hr 85-110 nsr-st without ectopy remains on lopressor 2.5mg iv q 6, amirodarone, bp 94/-123/57 on hydralazine 10mg q 6, Na 150 started on 350cc free h20 bolus q 6, skin w+diaph at time pp+3\nresp cmv 50%/600/22/10 lungs cta sx for min amt of white secretions\ngu u/o 45-180 neg 768 since mn, urine sent for osmolarity\ngi nephro fs 45cc q hr min residuals, started on free h20 bolus 350cc q 6, abd soft distended bs+ mushroom cath in place stool brown liq ob + very odorous sample sent for cdiff\nendo ss insulin covered\naccess lt radial aline mult RIJ\nID wbc 17.4 temp max 101.2 pan cx\na. s/p arrythmias, s/p mi, chf ef 20%, s/p gi bld high inr, cri cr 2.2 hypernatrium\nnew fever\np. ep consulted will evaluate monday, on lopressor and amirodarone, keep hct > 30 asa, plavix, lopressor monitor s+s of failure, give free h20 bolus q 6 monitor Na, cr, check osmolarity of urine, monitor wbc temp await cx result. Attempt to wean from vent\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-19 00:00:00.000",
"description": "Report",
"row_id": 1406481,
"text": "Respiratory Care\nPt remains orally intubated on full support. BS slightly diminished.\nSuctioned for copious amount dark tan secretions with plugs.Will continue to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-17 00:00:00.000",
"description": "Report",
"row_id": 1406474,
"text": "Micu Nursing Progress Notes\nEvents: Swan D/C'ed, Failed attempt at PSV -continues to have a metabolic acidosis, introducer changed over a wire to a triple lumen. He had one episode of SVT lasting 3 sec, given aniodarone 400mg PO early, no further epidodes.\n\nResp: Vent settings AC 600 x 22/Peep5, FiO2 50%. He was trialed on PSV 8/Peep5 at 11am. His RR was very irregular with periods of apnea followed by breath with tidal volumes of .3L. His RR was , B/P 162/66, HR 92. By 12n he started to C/O SOB, ABG showed pH 7.38, CO2 33. He was changed back to A/C. He was suctioned q3-4h for thick yellow/reddish secretions. Specimen sent for culture.\n\nCardiac: Maintained on amiodarone at 0.5mg/min. HR 72-88. At 1530 he had one episode of SVT lasting about 3 sec. He was given 400 mg PO amiodarone early, IV due to be D/C'ed at . B/P 110-150's/60's. Swan catheter was D/C'ed and the introducer was changed over a wire to a triple lumen.\n\nGI: Tube feedings restarted via OGT at 9am, initially at 30cc/hr for 2hour. At 11am he had 5cc residual so the Nepro was increased to his goal rate of 45cc/hr. He continues to have low residuals. His mushroom catheter is draining liquid brown stool.\n\nEndo: BS at 12n 146 and at 1800 154, He was given 2u regular insulin.\n\nGU: Foley draining clear yellow urine, U/O has been 100-125 cc/hr.\n\nNeuro: He has been alert and responding appropriately to questions. He remains on fentanyl at 50mcg/hr, decreased to 25 at 11am with the start of PSV. The versed is infused at 0.5mg/hr.\n\nID: temp has been 98.6-99.1.\n\nSocial: brother and several other family members in to visit. They stayed for about 1/2h then left.\n\nPlan: D/C IV amiodarone at , continue to monitor cardiac rhythm, Monitor I&O, hct drawn at 1800 and monitor if HCT stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-18 00:00:00.000",
"description": "Report",
"row_id": 1406475,
"text": "Respiratory Care\nPt remains on mechanical ventilation via ETT, on A/C,Vt 600 rate-22 FiO2 50%. Suctioned for moderate thick tan greenish secretions. BS coarse. Plan: wean as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-18 00:00:00.000",
"description": "Report",
"row_id": 1406476,
"text": "Nursing progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt remains lightly sedated with Fentanyl @ 75mcg/hr, Versed 1mg/hr. Both meds increased overnight for agitation, increased RR/HR. Pt opens eyes to voice and mouths words (\"I want to go home.\") Moves all extremeties on bed, occas raises and briefly holds arms up. Follows commands consistantly. Pt denies pain.\n\nResp: Pt remains on AC vent with settings presently 16 X 600/5 peep/50%. Sating 97-100%. (With rate 22, ABG97/28/7.38). Suctionned for mod->copious amts thick,yellow secretions ~ q3hrs. Lungs coarse throughout.\n\nCV: HR increasing over shift from 78->109SR without ectopy. Amiodarone qtts D/C'd @ 2100, and pt rec'd scheduled po doses Amio, Lopressor and Hydralazine. BP 108/47-149/69.\n\nGI: TF of Nepro cont @ goal of 45ml/hr via OGT. Residuals scant. Bowel snds present. Musroom cath draining mod amt foul smelling brown liquid stool.\n\nGU: Urine output 120-400ml/hr yellow/clear. Fluid balance @ MN -1207ml, and MN->0500 -839ml. LOS balance @ 0500 +1829ml.\n\nID: Temp 99.7po.\n\nAccess: Art line site bldg, dsg changed without resolution. Waveform not dampened and line not positional.\n\nPlan: Await results of sputum spec. Cont aggressive pulm toilet. ? c-diff in stool. AM labs pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-16 00:00:00.000",
"description": "Report",
"row_id": 1406467,
"text": "Nursing Progress Note 1900-0700\nEvents: Amiodarone, Phenylephrine qtt rates without change overnight. MAP remained > 65, but HR occas dropping to 46-50SB/no ectopy. Troponin level again increasing, and ST changes noted on Q8hr EKG's. C.O. decreasing. Hct stable.\n\nReview of Systems:\n\nNeuro: Sedation without changes overnight from Fentanyl @ 75mcg/hr, Versed @ 1mg/hr. Pt remains easily woken for brief periods, during which he responds approp to questions. No spont movement of extremeties noted except to commands.\n\nResp: Vent settings unchanged from AC 50% 22 X 600/peep 10. No spont resp. Sat 98-100%. Lungs snds coarse. Not requiring suctioning. At 0400 ABG 7.33/36/115, lactic acid 1.9.\n\nCV: Amiodarone and Neo-synephrine have remained @ 0.5mg/min and 1mcg/kg/min respectively. Attempted to titrate Neo down, but MAP dropping below 65 so returned to 1mcg. HR 46-66SR without ectopy. At 0400, C.O. 4.74(5.62) and SVR 1181(954). CVP 16. Troponin @ 1.17(0.98).\n\nGI: TF of Nepro increased to 20ml/hr (goal 45ml/hr) with residuals 5-10ml. Bowel snds hypoactive. Abd soft/obese. No stool this shift. Hct stable @ 33.2. Plt ct 224(202).\n\nGU: Urine output avg 100ml/hr, with MN balance +1481. MN->0500 balance -59ml with LOS + 3.7liters.\n\nID: Afebrile. AM WBC 18.2(17.5).\n\nSocial: Brother, , spoke with nurse X 1 re pt's status.\n\nPlan: Cont to cycle enzymes Q 8hrs, hct Q6hrs. Attempt to titrate Neo to off. Amiodarone cont for total of 18hrs @ present rate (until 2100 today). Cont to increase TF Q8hrs as tol to goal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-16 00:00:00.000",
"description": "Report",
"row_id": 1406468,
"text": "RESP CARE\nPt remained on a/c 600x22 50% and 10 peep all night with acceptable abg.peak/plat 28/25. BS coarse bil. Pao2 greater than 100 all night. Will cont to follow and attempt weaning peep and fio2 when able.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-16 00:00:00.000",
"description": "Report",
"row_id": 1406469,
"text": "MICU Nursing Progress Note 7a-7p\n71 y/o male s/p AMI w/ occlusions to LAD, stent x2, placed on plavix and ASA. Admitted p 4d dark tarry stools. Present to ED w/ Hct 22, INR 15. Probable hypovol ischemia, flash pul edema requiring intubation, then cardiogenic shock. Blood products given.\n sig for Low BP req dopa and dobutamine> afib @130, cardioversion 100 and 200 w/o change. Dopa/dobut d/c, neo started. Amiod bolus and gtt> NSR. Overnight stable. Today wean and d/c neo, tried to change amiod- unable see below. Doing well except for BP 85-90/\n\nNeuro-\nAwakens to voice, FC, MAE. Sedation on Versed 1.0>.5mg/hr, Fentanyl 75>50 mcg/hr. No aggitation, completely compliant, not restrained.\n\nCV-Probable R/I for small MI this admit from low volume.CPK decreasing\nNSR56-60 on Amiod .5mg/min gtt. Decision to change d/c amiod early and try digoxin as + inotrop and pload reduction @12noon. 1300 HR90-110 SR/ST w/ freq PAC's and bts. BP 90-130/50-70. Cardioology called as consult. Amiod restarted, gtt to finish 2100, give po dose @ . No C/o SOB, CP, palp.\nSince episode BP 85-95/, HR 80's SR. Lopressor 2.5 mg IV q6h held @1600 for BP 88/50. Goal BP MAP 60-65, HR 80's.\nPA LINE- CO improved over day from 5.5-7.29, PA 40-30/28-19; PCWP- ( trace variable/inconsistant);CVP 12-10. UNable to obtain Fick CO, unable to obtain MV blood gas from PA port.\nREsp-\nDoing well. .50/600/22/10 weaned to .40/600/22/10 peep w/o complication. ABG good.po2>120 pH 7.35. Pt ro remain on settings, ? attempt to wean tomorrow- . BS clear upper, diminished lower. Sx q3 for thick tan secretions. No c/o SOB.\nREnal-\nRenal consulting. Probable 'stunned kidney syndrome' w/ GIBld event. Cr declining 2.7 (3.0 ). u/o 30-100/hr. I-1100(iv), 500(nepro); O-1415. +150 for day. Lytes wnl> renal advised monitor Na daily as pt may develop free h20 deficit.\n\nBrother and sister in law visited briefly. Pt very happy to see them.\nA/P\nNeuro- intact cont sedation as needed. have decreased smallamt now to help BP.\nCV-Goal BP 90 or MAP 60-65, HR 80's. Monitor BP/HR closely, approp rx prn. Cont amiod gtt until 2100 then d/c p po dose .\nREsp- Weaned peep and Fi02 today, try to wean to extubate tomorrow as approp if pt ready clinically.\nREnal-Monitor u/o, lytes, I/O.\nKeep pt and family informed as to pt status and plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-16 00:00:00.000",
"description": "Report",
"row_id": 1406470,
"text": "Patient remains on mechanical ventilation has copoius amount of bloody sputum. Abg acceptable,plan to try to extubate in AM post weaning trial.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-17 00:00:00.000",
"description": "Report",
"row_id": 1406471,
"text": "Respiratory Care\nPt remains orally intubated on full ventilatory support. BS coarse, diminished RML and RLL. Suctioned for copious amounts of thick bloody to greenish blood tinged secretions. Plan: wean to extubate as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-17 00:00:00.000",
"description": "Report",
"row_id": 1406472,
"text": "D pt easily aroused. alert and responding appropriately to commands and question. mouth words and shaking head to communicate fairly effectively. pt very calm . tolerates vent and turns well on versed .5mg and fentanyl 50mcg. MAE demonstrates strength and sensorium.\nCV: initially pt in SR with PACs . at amniodarone 400mg given down NG. @ 2100 drip stopped. at 2130 short bursts of SVT rate 130's lopressor due at 2200 given early 2.5mg IVB.with effect pt remain in sr with occassional PAC's. at 0005 pt HR was 151 SBP remain > 100; PAS/PAD unchanged. SAT remained> 94. see care view. HO and resident called . Lopressor 5mg given hr down to 139 repeated Hr down to 132 repeated down to 127. SBP still > 100.pt denies chest pain or any other discomfort. HO discussed tx with cardiology and ICU on call attending. amniodarone bolus 150mg and .5 mg drip was stared. pt hr down to 80 after bolus given. pt had frequent PAC's and PVC's after converted. no VEA noted prior to this. pt had periods of ventricular bigemini that were not initially well tolerated. SBP dropped to 80's. ectopi has decreased no tx was given. currently rare PVC's and frequent PAC's. Palp D/P and P/T. RIJ PA cath patent wave form good documented .\nLungs: initially BS coarse to decreased very thick tan blood tinged sputum suction . currently upper lobes clear and bases are coarse. Fio2 dropped to 70% but SVO2 is 74 . pt on the vent 40/600/22 Fio2 increased to 50%.\nGI: ABD soft and distended. TF nepro at 45cc goal stopped at 0030. Will restart TF if pt remains stable .\nSkin: skin intact anus and buttock slightly red skin prep applied. pt passing liquid brown quiac positive stool. mushroom cath placed.\nGu: foley to c/d . urine clear with > 30 cc out and hour.\nA unstable. unclear what caused SVT or drop in pao2.\nP continue amniodarone drip at .5mg as ordered.resume TF in am if pt stable. monitor PAS/PAD and Cco/CI. awaiting results of FIck. held 4 am lopressor. monitor pt very closely. tx as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-17 00:00:00.000",
"description": "Report",
"row_id": 1406473,
"text": "Resp care: Pt remains intubated via #8 ETT secured 24cm at lip. BS clear bilat. Sx'd reg for copious amts thick tan sputum. Pip/Plat=23/16. placed on PSV. Pt having irreg breathing pattern and ^'d PAC's. ABG revealed compensated metabolic alkalosis w/ normoxia, however, Pt c/o SOB. Placed back on A/C w/ gd effect. Team aware. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-19 00:00:00.000",
"description": "Report",
"row_id": 1406482,
"text": "Nursing Progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt remains sedated on Fentanyl @ 50mcg/hr, Versed 1mg/hr. Opens eyes to voice, nods head approp, follows commands consistantly.\n\nResp: Vent settings unchanged from AC 50%/22 X 600/+10, no over-breathing. Sating at 98-99%. Lungs sound clear. Strong productive cough. Suctionned freq for copious amts thick, tan secretions with plugs. AM ABG 7.35/37/112.\n\nCV: HR 82-105SR without ectopy. BP 111/54-125/59. Hydralazine held @ MN because of low BP. AM labs include Hct 32.3(34.1), plt ct 191(201) Na 147(148).\n\nGI: TF of Nepro cont @ goal of 45ml/hr with scant residuals. Pt also rec'ing free water boluses of 350 ml Q6hrs for elevated Na. Abd distended/soft/obese with positive bowel snds. Mushroom cath draining small amt foul-smelling brown, liquid stool.\n\nGU: Urine output yellow/amber @ 35-100ml/hr out. Fluid balance @ MN -491ml.\n\nID: Tmax overnight 100.6po @ . AM WBC 15.7(17.4).\n\nPlan: Cont aggressive pulm toilet. Await results of ? c-diff. Follow Hct closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-19 00:00:00.000",
"description": "Report",
"row_id": 1406483,
"text": "MICU NPN 0700-:\n Events: Pt started on vanco/zosyn for presumed vent aquired pneumonia (GPC and GNR in sputum). Pt febrile with tmax 102.3--tylenol administered X 2 today and pan cultures sent this am. Also of note, BC from growing out GPC (site was aline)--? contaminant, but team may change TLC tonight.\n\n Neuro: Pt much more lethargic today, ? r/t temp. Sedatives weaned to 0.5 mg/hr versed and 25 mcg/hr fentanyl--on these doses, pt wakes to voice and follows commands consistantly. Pt moving all extremities, denies pain.\n\n CV: Pt in NSR rate 80-110. Occas ectopy. BP stable with MAP consistantly > 65. BP tollerating hydralazine and lopressor doses. Sodium to be rechecked at 6pm--pt continues on q 6 hour FW boluses (350 cc) for hypernatremia.\n\n Pulm: Pt continues on AC settings with prob new VAP. Pt suctioned numerous times (q 15 minutes this am to q 2 hours this afternoon) for huge amts thick, tenacious tan sputum. Specimen sent to micro. ETT retaped and rotated.\n\n GI: TF changed to 1/3 str nepro with promod--new goal is 60 cc/hr. Current rate is 45 cc/hr--titrate up q 4-6 hours as pt tollerates. Abd softly distended with + BS. No stool drainage in mushroom catheter. Restart bowel regimen tommorrow if no diarrhea overnight.\n\n GU: FOley to GD. UOP excellent 80-120 cc/hr. Yellow/clear.\n\n Skin: Intact. Buttocks reddened but intact. Pt tollerating turing well.\n\n Family: Pts brother, , called X 2 today--updated on POC, new VAP, etc.\n\n Plan: 1. Continue current vent settings while pt with new pneumonia.\n 2. Monitor sodium , continue FW boluses\n 3. Follow up on line change with team.\n 4. Tylenol if tspike. Next cultures due in am if pt febrile.\n 5. Titrate up TF to goal of 60 cc/hr if pt tollerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-13 00:00:00.000",
"description": "Report",
"row_id": 1406458,
"text": "Progress Note\nMICU A 0700-1900\n\n\nNeuro: Pt A/O x3, PERRLA, cooperative and follows commands\n\nCV: Hemodynamically stable. BP's originally in 70's systolically in E.D. Has increased to the low 100's following fliud resucitation. K 5.9 on admission, decreased to 5.4 after fluids/blood products. Hct 21 after 1st unit. Pt receiving 2nd unit of prbc's and has already gotten 2 units of FFP with two more to follow this evening. After FFP, INR down to 2.6 from > 15. Pt in NSR with a rate in high 60's. 2nd set of cardiac enzymes/troponin sent at 1830.\n\nResp: Following transfusion of 1st unti blood, pt experienced increased resp distress RR 30's, use of accessory muscles noted, o2 sats 93-98% on 2l o2 via NC. Given 10mg followed by additional 20 mg of lasix. Results were 2L of fluid diuresed and 2nd unit of prbc's hung. Pt felt much better after diuresis with RR in 20's, o2 sat 99%.\n\nGI: no stool this shift BS positive but hypo. Npo except for ice chips. Gastric lavage in ER with BRB, cleared with lavage. NGT d/c'd in ER.\n\nGU: Pt refused foley and condom cath. Pt voiding well- light yellow, clear urine. out this shift. UA C&S to lab\n\nSocial: family consists of brother and sister in law, niece, nephew who are pt's main support system\n\nPlan: continue with transfusions with hopes of increasing hct > 30 so that pt. may have endoscopy in AM. FFP to further decrease INR. Pt needs orders for further transfusions after current unit of blood completes. Next hct due at 2100.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 1406459,
"text": "Respiratory Care\nPt presented in acute respiratory distress. Increased work of breathing with retractions and use of accessory muscles. Could not speak more than 2 words at a time. Placed on non-rebreather mask with no improvement proccede to non invasive ventilation of CPAP 10/5. Within 30 min. pt was intubated on CMV. Please see careview for settings. ABG post intubation 7.27-40-80-19. Continue full ventilatory support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 1406460,
"text": "Nursing Progress Note 1900-0700\nEvents:Pt rec'd on 2l NC, sat unreliable but intermit mid-90's. HR/BP stable per carevue. Pt transfused 2uFFP slowly. At MN transfusion of 1uPRBC's started, infusing over 4hrs. At 0130, pt flat in bed for bedpan and suddenly SOB with audible crackles. MD notified, blood transfusion stopped, and pt given Lasix 30mg + 60mg and MSO4 1mg X 2. Foley cath inserted and drained 400ml shortly after Lasix. Pt placed on non-rebreather mask and then bi-pap without improvement in resp status. At 0150, pt was given Etomidate 18mg per anesthesia and intubated without difficulty. ETT placement confirmed by CXR. Pt suctionned for mod amt bloody secretions. Pt given Versed 2mg, Fentanyl 50mcg X 1. BP tenuous per carevue, and pt rec'd several NS fluid boluses for total ~2liters. Pt also rec'd rest of unit PRBC's plus 2nd unit PRBC's. Eventually Dopamine and Levophed cont IV started with BP slowly stabilizing. Triple lumen line inserted in L groin, site bleeding. Multiple attempts @ art-line insertion unsuccessful. As SBP>100, Versed and Fentanyl qtts started for sedation. At 0530, transfusion of 1uFFP started.\n\nReview of Systems:\nNeuro: Pt presently lightly sedated with Versed @ 3mg/hr, Fentanyl @ 75mcg/hr. Pt remains with eyes half open and moving arms which are restrained with soft wrist restraints bilat.\n\nResp: On vent with settings AC 100% 24 X 600/peep 10, sating 99%. ABG post-intubation on 100% 7.27/40/80. Noted to be occas dyssynchronous with vent. Lungs coarse throughout.\n\nCV: Dopamine @ 15mcg/kg/min, Levophed @ 0.12mcg/kg/min with HR 90-111SR without ectopy. BP 53/15->102/46. Hct 25.4/25.9. INR 1.9 @0325 after 2uFFP. Presently rec'ing #1 of 2 units FFP.\n\nGI: NPO, abd obese/soft with hypoactive bowel snds. Large amt liquid stool X1, brown/heme pos.\n\nGU: Initially voiding ~450ml/hr. After rec'ing Lasix 90mg, 400ml light yellow urine out via foley. Since that time, output very low per carevue.\n\nSocial: MD updated friend, , and brother, , about change in pt's status.\n\nPlan: Cont to balance supporting BP with pt's need for sedation. AM labs @ 0800.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 1406461,
"text": "Resp care: Pt remains intubated via #8 ETT secured 24cm at lip. BS bilat rales. Not req freq sx'ing by RT. Pt having periods of dissynchrony with vent. Changed to PSV w/ gd effect. Failed PEEP wean. ABG reveals Metabolic acidosis w/ hyperoxia. FiO2 weaned appropriatly. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-14 00:00:00.000",
"description": "Report",
"row_id": 1406462,
"text": "MICU NPN 0700-:\n\n Pt had eventful day. Swanganz catheter placed showing mixed picture but probable cardiogenic shock. EGD done--only mild gastritis seen, no s/sx of active bleeding. Cardiac echo done that showed massive hypokinesis of anterior wall and EF of approx 25%.\n\n Sedation: Pt well sedated on fentanyl/versed. Pt becoming more heavily sedated during am, so fentanyl and versed decreased to 75 mcg/hr and 1 mg/hr respectively. On these settings, pt will open eyes to voice, RN and intermittantly follow commands. Pupils 2-3 mm and reactive. Bilateral soft wrist restraints maintained for pt safety while intubated.\n\n Hypotension: Pt recieved on 10 mcg/kg/min dopamine and 0.12 mcg/kg/min levophed. Through course of day, dopamine weaned to 7 mcg/kg/min. Swan placed by team with opening wedge of 30, CO 6.22, CI 2.9, SVR 797. The swan wedged at 60 cm. With low CI, it is felt pt in cardiac shock (also in setting of CXR that show's classic pattern of cardiac related pulmonary edema). Decision made by team (with cardiology consult) to start dobutamine in hopes of weaning levophed. Dobutamine started at 1700--pt appears to be tollerating therapy well without increase in ectopy or hypotension. Of note, pt appears to be ruling in for MI with CPK/MB 419/49.\n\n GIB: No s/sx of active bleeding with EGD. OGT placed and position confirmed. Pt transfused with 2 u prbc and 1 u plts today. Last hct up to 28 and INR 1.4 Pt premedicated with tylenol/benedryl for plts and pt had no s/sx reaction. F/U hct to be drawn at 1800. Abd softly distended with + BS. No melana. Gastric contents bilious. New R IJ cordis with swan in place for access--old L groin TLC d/ MD. Mild bruising from insertion (bilateral groin), but no hematoma.\n\n CHF/Resp failure: Pt changed to PSV 12/15. On these settings, pt much less paradoxical and appears comfortable on the vent. Lungs with bibasilar crackles. Fi02 weaned to 50% with excellent ABG. Attempts to wean PEEP unsuccessful as pt dropped sat to 90%. Hope is for 2 L diuresis with dobutamine, but pt + 3.8 liters since midnight. UOP (prior to dobutamine 100-250 cc/hr).\n\nPlan:\n 1. Titrate up dobutamine and titrate down levophed as BP allows.\n 2. q 6 hour hct with transfusions for INR > 1.5, hct < 30. If pt starts actively bleeding again, consider plt transfusion as pt suspected to have plt dysfunction related to uremia/plavix/asa. Premedicate with tylenol/benedryl for trnasfusions.\n 3. Next set cardiac enzymes due at .\n 4. Wean PEEP/fio2 as able.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-15 00:00:00.000",
"description": "Report",
"row_id": 1406463,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for lrg amts thick bldy secretions.BP labile increased Dopa, on dobutamine,levo,sedated with fentanyl and midaz.No RSBI done due to increased amts of peep. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-22 00:00:00.000",
"description": "Report",
"row_id": 1406495,
"text": "Resp Care,\nPt. remains intubated on IPS . IPS decreased to 8 from 12 due to VT >1L. RSBI 38 this am. Placed on SBT 545 am. VT 600's, RR 20's. Suctioned x1 for copious amount thick yellow sputum. Possible extubation in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-22 00:00:00.000",
"description": "Report",
"row_id": 1406496,
"text": "Shift Update 1900-0700\n\n Pt awakens easily to voice/touch and follows all commands with MOEx4. Pt calm and cooperative-all sedation has been off for a minimum of 12 hrs.\n\n Pt.on CPAP through night, tolerated well. Possible extubation this am\n\nCardio- HR 70-100, SBP 85-140. Sinus rhythm without ectopy, hemodynamically stable through night. Na decreased to 146 this am\n\nGI- Nepro 1/2 strength +promod 70g/day tube feeds to new goal of 90cc/hr. Minimal residuals noted. Pt. had two large, liquid brown stools which tested guiaic +.\n\n Pt.diureses well on own. Clear, yellow urine.\n\nSkin- Overall intact. One area noted on the tip of the pts penis. Pink/red in color, tender and has occasional sanguinous drainage. No skin breakdown noted on back/buttox.\n\n Pt. denies any pain or discomfort, fent gtt off overnight.\n\nSocial- No contact with family overnight. Possible extubation this am\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-22 00:00:00.000",
"description": "Report",
"row_id": 1406497,
"text": "MICU A NSG 7A-7PM\nRESP--PT EXTUBATED AT ~930 AND TOL WELL. PLACED ON FACE TENT AND FIO2 WEANED TO 35%. SATS >95% RR 20'S OFF VENT. PT EXPECTORATING AND SWALLOWING SECRETIONS, LUNGS SOUNDS REMAIN COARSE.\n\nCV--CONTS IN SR 60-80 NO ECTOPY NOTED, REMAINS ON PO AMIODARONE. BP STABLE 100-140'S/. CONTS IN IV LOPRESSOR AND HYDRALIZINE. TRACE EDEMA NOTED IN EXTREMITES. RECEIVED LASIX 20MG IV THIS AM. NA REMAINS ELEVATED, WILL HAVE PM LYTES CHECKED.\n\nNEURO--PT ALERT AND ORIENTED X2-3. MOVES ALL EXTREITES WELL. OOB TO CHAIR X4 HOURS. ABLE TO STAND AND TAKE STEPS WITH ASSIST.\n\nGI--OGT REMOVED WITH EXTUBATION. TOL PO'S, CLEAR LIQUIDS WITH S/S ASPIRATION. PASSING LG AMOUNTS OF FLATUS AND INC STOOL X2.\n\nGU--BRISK RESPONSE TO LASIX, U/O 50-300CC/HR. CONTS TO BE FOLLOWED BY RENAL FOR ELEVATED CREAT.\n\nSOCIAL--BROTHER CALLED AND WAS UPDATED ON PT'S CONDITION, PT ALSO HAD VISIT FROM FRIEND.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-22 00:00:00.000",
"description": "Report",
"row_id": 1406498,
"text": "Respiratory Care Note\nPt. Extubated this am. tolerated well weaned to 35% face tent. Abg-\n734/36/147/20/- on 70%. B.S. coarse Pt. coughing secrections and swallowing them.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-23 00:00:00.000",
"description": "Report",
"row_id": 1406499,
"text": "Respiratory care:\nPatient checked for Bronchodilator therapy. Breathsounds are essentially clear. Patient with a strong tight sounding cough. Please see respiratory section of carevue for treatment times and data.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-21 00:00:00.000",
"description": "Report",
"row_id": 1406490,
"text": "Shift Update\n\n Pt.awakens easily to voice/touch and follows commands with x4. Nods head appropriately to yes/no questions. Fentanyl and versed gtts continue running.\n\n Pt.remains on vent with O2@ 50%. Lungs with bil course crackles. Copius amts of oral and ett secretions noted. Thick yellow secretions changed to pink this am, possibly from frequent suctioning.\n\nCardio- HR 80-100, SBP 90-115 with sinus rhythm without ectopy.\n\nGI- Tube feeds running at goal of 60cc/hr. Minimal residuals noted.\n\nGU- Foley draining clear, yellow urine. Pt.diuresing well on own, one dose of lasix was given around and pt diuresed > one Liter after\nthat.\n\n Pt.spiked temp overnight, pan cx sent.\n\nPain- Fent gtt running, pt.denies any pain at this time.\n\nSkin- Skin intact, no breakdown noted on back/buttox. Some redness noted this am on R hip. Will continue to monitor.\n\nNo contact with family overnight\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-21 00:00:00.000",
"description": "Report",
"row_id": 1406491,
"text": "Resp Care,\nPt. remains intubated on A/C . Suctioned for copious amount thick yellow sputum. Spec sent. ABG WNL. RSBI 70 this am. Maintain current vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-21 00:00:00.000",
"description": "Report",
"row_id": 1406492,
"text": "Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS coarse bilat. Sx'd for small to mod amts thick yellow sputum. OOB to chair. Changed to PSV. Tol well. Plan per rounds is to wean IPS as tol and rest on ^'d IPS to noc. And place on SBT in AM. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-21 00:00:00.000",
"description": "Report",
"row_id": 1406493,
"text": "Nursing Progress Note 0700-1900\nEvents: Pt OOB to chair X 4hrs, returned to bed by standing with assist of PT. AC->PS, tol well. Requiring less freq suctionning. Afebrile. Fent/Versed off @ 1600.\n\nReview of Systems:\n\nNeuro: Pt rec'd on Fent 25mcg/hr, Versed 0.5mg/hr. At 1600 both qtts D/C'd and pt has not had C/O discomfort since. He has been generally more alert today, following commands consistantly with good muscle strength in all extrememties. OOB to chair via lift @ 1100, returned to bed @ 1630 by standing with assist of PT with belt.\n\nPulm: Rec'd on vent settings AC 22 X 600/+5/50%. At 1000, changed to PS 14/peep 5/50% with SRR 14-23 and regular. Sating 97-99%. Lungs coarse with rare I/E wheezes. Strong cough. Suctioned for mod amt yellow/thick secretions ~Q2hrs. ABG @ 1700 7.34/34/160. PS decreased to 12 @ 1745.\n\nCV: HR 68-84SR without ectopy, BP 92/42-117/54. Lopressor held @ 1000 and Hydralazine held @ 1200 because of SBP < 100. Lytes from 1730 pndg.\n\nGI: TF changed to Nepro 1/2 strength + Promod 70gm/day, beginning @ 70ml/hr. Goal 90ml/hr. Pt with brown, liquid stool X 2 since change in TF. Pt cont to receive free water boluses of 350ml Q6hrs for elevated Na.\n\nGU: Urine yellow/clear @ 80-180ml/hr. Fluid balance MN->1700 +508ml, with LOS balance +4.2liters. Pt rec'ing D5W @ 75ml/hr X 2liters. (1st liter now hanging.)\n\nID: Afebrile. No change in antibiotic tx.\n\nSocial: Brother, , called X 1 re pt's condition, and close friend visited briefly.\n\nPlan: Cont to wean vent as tol, with ? extubation tomorrow. Haldol for restlessness per psych. If pt cont freq stooling, nutrition consult re TF.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-22 00:00:00.000",
"description": "Report",
"row_id": 1406494,
"text": "Guiaic + stool (no frank blood seen), Dr. notified.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-19 00:00:00.000",
"description": "Report",
"row_id": 1406484,
"text": "Resp\nPt remains on mech vent-parameters noted. Breath sounds are rhonchial bilat. Suction for lg amt of tan secretions. Tubing changed due to contamination with secretions. No wean today. Will continue mech vent and bronchial hygiene.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-20 00:00:00.000",
"description": "Report",
"row_id": 1406485,
"text": "Respiratory Care\n Pt remains orally intubated on full mechanical ventilation. No changes overnight. Suctioned frequently for moderate amount of thick tan secretions with red flecks.BS coarse, clear after suctioning. See careview for specifics. Plan: wean as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-20 00:00:00.000",
"description": "Report",
"row_id": 1406486,
"text": "Shift Update -0700\n\n Pt.opens eyes easily to voice/touch and follows commands with MOEx4. Nods head appropriately (yes/no) to simple questions. Pt has been calm/cooperative throughout the night.\n\n Pt.remains intubated on ventilator at 50%O2. Sats run 95-100%.\n\nCardiac- HR 75-90, SBP 95-120 SR throughout night without ectopy\n\nGI- TF's running at 60cc hr (goal). Minimal residuals noted. Mushroom catheter removed d/t no drainage in 3 days.\n\nGU- Foley cath intact draining clear, yellow urine.\n\nSkin- Intact. No breakdown on back/buttox noted\n\n Pt.denied pain throughout the night,fentanyl gtt running.\n\nNo contact with family through the night. Will continue to monitor\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-20 00:00:00.000",
"description": "Report",
"row_id": 1406487,
"text": "Resp Care\nPt remains on A/C-parameters noted. Peep weaned to 5. Pt had SBT with a RSBI in 50s. Trialed on PS:5, PEEP: 5, but pt became tachypneic and had incr WOB. Rhonchial breath sounds bilat. Suctioned for a large amt of thick yellow secretions. Will continue mech vent at this time and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-20 00:00:00.000",
"description": "Report",
"row_id": 1406488,
"text": "Nursing Progress Note 1100-1900\nReview of Systems:\n\nNeuro: Pt remains lightly sedated with Fentanyl 25mcg/Versed 0.5mg. Pt opens eyes to voice, nods approp to questions, follows commands consistantly. MAEE, esp wiggling both feet.\n\nPulm: Pt rec'd on vent settings CMV 50% 22 X 600/+10 with rare over-breathing. Peep 'd to 8, and following ABG 7.36/25/125. Attempted trial of CPAP/PS, but after 30min, pt RR 30 and pt C/O SOB. Pt returned to previous settings with peep 5. ABG pndg. Sating 95-99%. Lungs coarse throughout, with occas rhonchi in RUL. Suctionned freq for mod->copious amts thick, yellow secretions.\n\nCV: HR 79-94SR without ectopy. BP 92/46-119/57 with rare to SBP high 80's. Na 145. Free water boluses D/C'd and then resumed Q6hrs. Hct trending down, team aware.\n\nGI: TF of Nepro/Promod cont @ goal of 65ml/hr with small residuals. Bowel snds present, abd obese/soft. No stool this shift.\n\nGU: Urine yellow/clear, out @ 55-150ml/hr. Pt rec'd Lasix 20mg X 1.\n\nID: Temp 100.6po. Vanco D/C'd.\n\nSocial: Brother, , spoke with nsg X 1.\n\nPlan: Cont gentle diuresis to maintain even fluid balance. Labs @ 1800. Quaiac stool when available. Cont slow vent wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-21 00:00:00.000",
"description": "Report",
"row_id": 1406489,
"text": "Pts temp increasing, Dr. paged and notified-pan cx drawn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-15 00:00:00.000",
"description": "Report",
"row_id": 1406464,
"text": "Nursing Progress Note 1900-0700\nEvents: Attempts unsuccessful to titrate Levophed to off while increasing Dobutamine/Dopamine to maintain MAP> 65. Also unable to make progress in taking off fluid and reach a negative balance. Transfused 2u PRBC's for Hct< 30. Suctionned ETT secretions thick/bloody.\n\nReview of systems:\n\nNeuro: Sedation unchanged from Fentanyl @ 75mcg/hr, Versed @ 1mg/hr. Pt appearing well sedated, but rouses easily to voice and then appears alert/responds approp to conversation for brief periods. Moving arms/legs on bed when woken. No grimacing or indications of discomfort.\n\nResp: Vent settings unchanged from PS 10/peep 15 on 50% O2. SRR 8-19 and regular. ABG @ 0400 7.33/40/131. Suctionned ~ q4hrs for mod-> lg amts thick, bloody secretions. Lung sounds course throughout, occas crackle @ R base, and noted to have diminished sounds @ L base @ 0200. CXR showed improvement in upper lobes, density in bases.\n\nCV: Pressors adjusted overnight per above and carevue. Presently, Dopamine @ 11mcg/kg/min, Dobutamine @ 5mcg/kg/min, Levophed @ 0.06mcg/kg/min with MAP 65. HR 80-103SR without ectopy. SBP 83-107. At MN, C.O.9.13(8.76), C.I. 4.31, SVR 394(502). CPK/MB 433/37(419/49).Hct 28.5 @ MN, so pt transfused 2u PRBC's. Pt rec'd Lasix 40mg btwn units. Plt ct 209.\n\nGI: Abd soft/obese with + bowel snds. Passing flatus, no stool this shift. OGT has remained clamped, with secretions bilious.\n\nGU: Pt given Lasix 20mg + 40mg with fair results. Urine light yellow/clear. Net fluid balance @ MN +3.3liters, LOS balance +2.2liters.\n\nID: Pt cont to have low grade temp of 37.4core. WBC trending down 18.5->14.8.\n\nPlan: Cont to titrate Levophed to off, while increasing Dopamine if neccessary. Repeat Hct after 2nd unit PRBC's infused. Cont to follow troponin/CPK-MB.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-15 00:00:00.000",
"description": "Report",
"row_id": 1406465,
"text": "MICU NPN 0700-:\n Events: Pt noted to have increased atrial ectopy/atrial bigemeny this am. BP initially stable, then decreased transiently to 70's with turning. Around 11am, pt went into SVT with rate 170-180. Carotid sinus massage decreased rate transiently, but BP dropped to 50's. Pt cardioverted X 2 at 100J, then 200J. Pt sedated with 50 mcg fentanyl and 2 mg versed bolus for cardioversion and gtt rates increased. Dobutamine/dopamine and levophed off. Neo gtt started at max dose with NS fluids wide open. 150 mg amiodarone IV bolus administered, followed by 1 mg/min IV gtt. BP stabilized and pt converted to NSR withoug further cardioversion. Neo gtt weaned down throughout day to current dose of 1 mcg/kg/min and amio gtt decreased to 0.5 mg/min after pt became bradycardic to 50's. UOP good and plan is to continue current management overnight.\n\n Neuro: Sedation decreased back to origional doses of 75 mcg/hr of fentanyl and 1 mg/hr versed. On these doses, pt very well sedated--waking easily and following commands, but sleeping soundly unless stimulated.\n\n CV: Low grade temps of 99. Pt currently in NSR with rates in 70's. BP stable with MAP > 65 on neo gtt. Hct stable after transfusions overnight at 31--next hct due at 2200 ( q 6 hours). No s/sx of active bleeding. Coags normalized with INR = 1.6. Please refer to flow sheet for swan numbers. Of note, at 1600 thermodilution CO correlated with FICK cardiac output at 5.6.\n\n Pulm: Pt placed back on AC during instablity this am. Currently pt on AC 22/600/50%/10 with excellent ABG. Pt appears comfortable on vent. Pt suctioned for large amts thick blood tinged (old) pluggy secretions. Per report, CXR failure much improved from yesterday.\n\n GI: Abd soft but distended this am--decompressed with CWS during morning. Pt then started on TF late this afternoon with nepro at 10 cc/hr. Plan to titrate up to goal as pt tollerates. Consider adding reglan if residuals increase (pt on significant dose of fentanyl).\n\n GU: FOley to gravity. UOP brisk averaging 120 cc/hr. Renal questioning diuresis r/t lithium level. Urine is light yellow/clear.\n\n Skin: Intact.\n\n Family: Brother updated by dr this afternoon about events of am.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-15 00:00:00.000",
"description": "Report",
"row_id": 1406466,
"text": "Patient remains on mechanical ventilation went into SVT treated with meds,defibrillated and changed from PSV to AC. Doing a lot better now with decent ABG,BS ,suctioned PRN will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-23 00:00:00.000",
"description": "Report",
"row_id": 1406500,
"text": "Nursing Progress Note 1900-0700\nReview of systems:\n\nNeuro: Pt X3, calm/cooperative, follows commands consist. MAEE with good strength. Dozing intermit overnight.\n\nPulm: Pt remained on humidified FT @ 35%, sating 96-99% with RR 18-30 and regular. Attempted RA, sats dropped to 95% and RR increased to low 30's, ABG 7.43/27/83. Pt denied SOB. Pt initially with prod cough of mod amt, but as noc progressed, cough unproductive and rare inspir wheeze @ R base. Lungs otherwise clear/coarse. Pt rec'd neb tx X 1 -> sat inc to 99% and RR 23.\n\nCV: HR 60-71SR without ectopy, BP 113/46-124/62. AM labs include Na 146, BUN/creat trending down to 62/2.2, Hct 29.8, WBC 11.3.\n\nGI: Pt taking clear liqs, swallowing pills well. Bowel snds hyperactive and pt incont of mod-lg amt brown, loose stool X 3.\n\nGU: Urine yellow/clear @ 80-140ml/hr out. Fluid balance +715ml @ MN. MN->0500 +224, with LOS balance +5.6liters.\n\nAccess: Art line bldg @ site, dsg changed. Tracing remains sharp with good blood return. No bldg from RIJ site. Two periph IV's WNL.\n\nPlan: Cont to encourage C&DB. Neb tx as needed. Advance diet. Monitor Hct with ? transfusion. ? transfer to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-09-23 00:00:00.000",
"description": "Report",
"row_id": 1406501,
"text": "MICU nursing progress note\nNeuro - A&O x 3, Pt transferred bed to chair with CG x 2, did very well. MAE, assists with turns.\n\nResp - Pt on RA this AM, ABG showed PO2 68, Sats 95%. NC 2 L placed, Sats 97-98%. RR 20s-31. lungs clear, crackles at bases. Pt denies SOB.\n\nCV - SR 60s, cont on lopressor and ammiodarone. Hct 29.8, Tx 1 UPRBC. Lasix 20 mg post Tx given. BP normotensive,see careview.\n\nGI - Tol low Na diet, appetite good. Taking po fluids well, IVF d/c'd. Inc loose brown stool x 1. Using commode x 1 later. OB (+).\n\nGU - Good , pt diuresing from lasix now.\n\nSocial - Brother called for update and aware of Tx to floor.\n\nPlan - Called out to floor. Monitor for CHF s/p Tx.\n"
}
] |
52,307 | 194,810 | Summary: 74yoF with history of wegener's granulomatosis with recent admission for post-obstructive pneumonia, who was re-admitted from rehab for asymptomatic hyperkalemia and EKG changes . # Hyperkalemia: Felt to be most likely related to exogenous potassium supplementation in the setting of acute kidney failure (baseline 0.5-0.7, 1.1 on admission). Her potassium normalized after medications including insulin, kayexelate and Ca gluconate. She was initially transferred to the MICU for EKG changes (peaked T waves). These changes remained stable and present after her potassium had normalized for 24 hours, and she was transferred to the floor, where she was subsequently discharged to rehab without incident. . # Acute renal failure: Baseline Cr 0.5-0.7, admitted with Cr 1.1, improved with IV hydration. Possibly related to decreased PO intake in setting of chronic loose stool. . # Transaminitis: Improved, likely related to voriconazole therapy. U/s did raise possibility of parenchymal disease, so this may warrant further outpatient work-up. . # Recent PNA and Aspergillous infection/COPD: Diagnosed with presumed post-obstruction pneumonia recently on on vanco/zosyn/vori. Slated to finish Vanc/zosyn on and voriconazole on , and this course was continued this admission . # Wegener's Granulomatosis: Last ANCA in house was negative. Her prednisone dose during last admission was 20mg per rheumatology. She came in on 30mg daily, and this was decreased back to 20mg daily this admission . # Osteoporosis: We continued calcium/vitamin D . # Hypothyroidism: We continued home levothyroxine . # Depression/Anxiety: We continued home citalopram and ativan ===== Transitional issues: #) hyperkalemia: if potassium needs to be repleted, would do so very judiciously given her hyperkalemia that required MICU transfer. . #) EKG: Her EKGs have persistently peaked T waves, and these T waves were present on multiple EKGs well after potassium had been corrected . #) Antibiotics: Should complete the course previously set on the last admission. Vanc/zosyn to finish , and voriconazole on . . #) Liver ultrasound: Suggested the possibility of parenchymal disease, which may suggest the need to be investigated further as an outpatient. . | Right atrial abnormality. Right atrial abnormality. Biatrial abnormality. Sinus rhythm. Left axis deviation. Left axis deviation. Delayed R wave transition. Prominent P waves in the inferior leads suggestive ofright atrial enlargement. Compared totracing #1 the T waves in the precordial leads are less prominent.TRACING #2 Prior inferior myocardial infarction.Compared to the previous tracing findings are similar. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. Nodiagnostic change from tracing #2.TRACING #3 Compared to the previous tracing of the prominent T wavesin the precordial leads are new.TRACING #1 | 4 | [
{
"category": "ECG",
"chartdate": "2174-11-26 00:00:00.000",
"description": "Report",
"row_id": 268335,
"text": "Sinus rhythm. Biatrial abnormality. Prior inferior myocardial infarction.\nCompared to the previous tracing findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-11-25 00:00:00.000",
"description": "Report",
"row_id": 268336,
"text": "Normal sinus rhythm. Right atrial abnormality. Left axis deviation. No\ndiagnostic change from tracing #2.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2174-11-25 00:00:00.000",
"description": "Report",
"row_id": 268337,
"text": "Normal sinus rhythm. Right atrial abnormality. Left axis deviation. Compared to\ntracing #1 the T waves in the precordial leads are less prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2174-11-25 00:00:00.000",
"description": "Report",
"row_id": 268338,
"text": "Normal sinus rhythm. Prominent P waves in the inferior leads suggestive of\nright atrial enlargement. Delayed R wave transition. There are also prominent\nT waves in the precordial leads suggestive of myocardial ischemia and/or\nhyperkalemia. Compared to the previous tracing of the prominent T waves\nin the precordial leads are new.\nTRACING #1\n\n"
}
] |
9,144 | 178,473 | 70 year old man with a complicated history including CAD s/p CABG, PAD, systolic CHF (EF 45-50% in ) w/ diastolic dysfunction, severe COPD, severe AS (0.8cm2) & AI and a severe ventral hernia who presents as a transfer from for respiratory failure. After rapid stabilization of his respiratory status, he went for a cath with PCI with DESx2 to the RCA on . He had intermittent abdominal pain that progressed to an SBO on . Patient made progressively less urine and was transferred to MICU through . He was sent to the cardiology service on and the SBO subsequently resolved. # Small bowel obstruction Patient has history of severe ventral hernia s/p laparotomy for colon resection and intermittent abdominal pain, last on . He received a CT ABD with contrast that was negative for SBO at that time. On he complained of abdominal pain that passed with ativan and simethicone. On he had constipation, he had obstipation, bilious emesis and acute renal failure. A NGT was placed. Surgery was consulted. All PO only medications were held except for Plavix which was given down the NGT. Surgery followed and his NGT drainage decreased and he started to have BMs on . On the NGT was pulled. Mr. then had intermittent nausea without vomiting which resolved with Ranitidine. He continue to have BMs and flatus. # ARF: On he developed ARF in the setting of SBO. Patient made very little urine and was therefore transfered to a MICU for management of fluid status given ARF and Aortic stenosis. IVF were started and a foley catheter was placed which was subsequently removed with voiding prior to discharge. His creatinine at d/c was 1.2, at his baseline. # Respiratory failure/ COPD Patient with known history of COPD, Asthma, and OSA as well as an extensive smoking history. He is on 2L of continuous O2 as well as Albuterol, Advair, and Tiotropium at home and over the past 3 months has required multiple intubations for respiratory distress despite repeated courses of Prednisone & antibiotics, most recently approximately 2 weeks PTA. He was intubated on at for an ABG of 7.12/91/62/32 and was extubated on AM to CPAP prior to transfer after improved respiratory status. Etiology likely obstructive lung disease with systolic CHF as patient did not demonstrate e/o infection. In the CCU, the patient was placed on BIPAP and eventually weaned to 2L of NC over approximately 24 hours. He received 40 mg of Prednisone daily and a course of levaquin. By , he was on 2 litres, saturating at 97%. He was able to tolerate room air with good saturations on day of discharge. He was discharged with a slow steroid taper. # Systolic Heart Failure Diasolic Heart Failure Aortic Stenosis, Severe Aortic Insufficiency Patient with known systolic heart failure, last EF in demonstrated EF 45-50% with severe AS (mean gradient 47 mm Hg and area 0.8cm^2) and + AR. His EF is unchanged from echocardiograms, but as his AR has progressed significantly since his last echo one month prior, his true forward flow is likely more compromised than his EF would suggest. CXR's from OSH have not demonstrated e/o congestion or effusions and clinical exam does not support fluid overload, but pBNP was elevated at 3969. Patient possibly a candidate for percucanteous valve replacement vs valvuloplasty however this decision will be deferred to the outpatient setting. | He was treated with solu-medrol and eventually extubated, although was found to have continued dypnea and continuous elevated cardiac enzymes CK 51->229, Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? He was treated with solu-medrol and eventually extubated, although was found to have continued dypnea and continuous elevated cardiac enzymes CK 51->229, Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? .H/O myocardial infarction Assessment: Patient has hx of NSTEMI 2 stents to RCA during this admission HR NSR 70s-80s frequent PAC SBP 100s-130 On 2 L NC sating 94-98% lungs clear but diminished at bases. .H/O myocardial infarction Assessment: Patient has hx of NSTEMI 2 stents to RCA during this admission HR NSR 70s-80s frequent PAC SBP 100s-130 On 2 L NC sating 94-98% lungs clear but diminished at bases. - Continue NG tube to suction - IV Ativan or PR Phenergan (avoid IM dosing out of concern for CV side effects) PRN - Repeat KUB today - Serial abdominal exams # Chest Pain Second anginal episode s/p cath. 1)Small Bowel Obstruction- cont bilious NGT output -Cont NPO, careful fluid managment given SBO 2)Respiratory Distress- -Improved 3)Renal Failure- -Cr improving 4)Chest Pain: -Repeat EKG this AM. - IV NS @ 150cc/hour x1L - Check lytes -avoid nephrotoxins -renally dose meds # Leukocytosis Trending down now. - Unable to give po Celexa given NPO - Continue Lorazepam 1-2mg q4H:PRN anxiety # Peripheral vascular disease: Patient with known PAD s/p LLE Fem- bypass (unclear when). Likely prerenal in the setting of inadequate fluid rescusitation. Likely prerenal in the setting of inadequate fluid rescusitation. Would hold on PPI given patient now on plavix. Would hold on PPI given patient now on plavix. Cath showed mid RCA stenosis. Cath showed mid RCA stenosis. Plan for acute renal failure: Caution with fluid resuscitation given critical AS. Plan for acute renal failure: Caution with fluid resuscitation given critical AS. In the OSH ICU, EKG's demonstrated sinus tachycardia with left anterior fascicular block and ST depressions in II, V3, V4. In the OSH ICU, EKG's demonstrated sinus tachycardia with left anterior fascicular block and ST depressions in II, V3, V4. Action: NG kept to wall suction, NPO, Given IVF 150 cc/hr Po meds changed to IV. Action: NG kept to wall suction, NPO, Given IVF 150 cc/hr Po meds changed to IV. He was initially treated for presumed systolic CHF exacerbation and COPD with CPAP, IV Solumedrol, nebulizers, Lasix, and Nitrates. He was initially treated for presumed systolic CHF exacerbation and COPD with CPAP, IV Solumedrol, nebulizers, Lasix, and Nitrates. .H/O myocardial infarction Assessment: Patient has hx of NSTEMI 2 stents to RCA during this admission HR NSR 70s-80s frequent PAC SBP 100s-130 On 2 L NC sating 94-98% lungs clear but diminished at bases. .H/O myocardial infarction Assessment: Patient has hx of NSTEMI 2 stents to RCA during this admission HR NSR 70s-80s frequent PAC SBP 100s-130 On 2 L NC sating 94-98% lungs clear but diminished at bases. Plan for small bowel obstruction: IVF, maintain NPO staus, continue NG tube to suction per surgery recommendations. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Received pt A+Ox3, coop w/ care. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Received pt A+Ox3, coop w/ care. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Received pt A+Ox3, coop w/ care. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Pt A+Ox3, coop w/ care. He was treated with solu-medrol and eventually extubated, although was found to have continued dypnea and continuous elevated cardiac enzymes CK 51->229, Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? He was treated with solu-medrol and eventually extubated, although was found to have continued dypnea and continuous elevated cardiac enzymes CK 51->229, Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? He was treated with solu-medrol and eventually extubated, although was found to have continued dypnea and continuous elevated cardiac enzymes CK 51->229, Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? He was treated with solu-medrol and eventually extubated, although was found to have continued dypnea and continuous elevated cardiac enzymes CK 51->229, Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? -PERCUTANEOUS CORONARY INTERVENTIONS: last cath in demonstrated occlusions of all SVG's -PACING/ICD: none 3. .H/O myocardial infarction Assessment: Patient has hx of NSTEMI 2 stents to RCA during this admission HR NSR 70s-80s frequent PAC SBP 100s-130 On 2 L NC sating 94-98% lungs clear but diminished at bases. .H/O myocardial infarction Assessment: Patient has hx of NSTEMI 2 stents to RCA during this admission HR NSR 70s-80s frequent PAC SBP 100s-130 On 2 L NC sating 94-98% lungs clear but diminished at bases. | 60 | [
{
"category": "Echo",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Report",
"row_id": 101711,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Chronic lung disease. Congestive heart failure. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 195\nBSA (m2): 2.07 m2\nBP (mm Hg): 149/66\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the 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. Mild-moderate\nglobal left ventricular hypokinesis. No LV mass/thrombus. Trabeculated LV\napex. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(area 0.8-1.0cm2). Mild (1+) AR. Eccentric AR jet.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild to moderate global left\nventricular hypokinesis (LVEF = 35%), with basal segments contracting better\nthan distal segments, suggesting a coronary etiology. No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level and the ascending aorta is moderately\ndilated. The aortic valve leaflets are severely thickened/deformed. There is\nsevere aortic valve stenosis (valve area 0.8-1.0cm2). An eccentric jet of mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with mild to moderate\nsystolic dysfunction, suggestive of CAD. Severe calcific aortic stenosis. Mild\naortic and mitral regurgitation. Moderate pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , LV function may\nhave decreased slightly. The other findings are similar.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399086,
"text": "Pt is a 70yo man with PMH severe AS ( 0.8) CABG/CAD, recent cath\n with 3VD & TO of SVGs and patent LIMA-LAD. COPD on home O2, ETOH\n abuse with history of DTs. Presented to w/ acute hypercarbic\n respiratory distress, s/p BIPAP trial-> intubation. He was treated\n with solu-medrol and eventually extubated, although was found to have\n continued dypnea and continuous elevated cardiac enzymes CK 51->229,\n Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? plavix\n load. Tnsf to for possible cath and further management. Received\n on BIPAP, heparin gtt at 800 units/hr. Noted lg skin tear (? from tape)\n on L medial forearm, applied adaptic/ dsd cover.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n NPO, Restarted on Heparin gtt at 800 units/hr. Conts on BIPAP\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 399162,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n Heparin gtt infusing at 550units/hr. NPO\n Action:\n CKs cycled\n Heparin gtt stopped, diet resumed.\n Maintance fluid conts for lower UOP and Cr 1.3\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n NPO p mn. Cardiac cath tomorrow to assess AS\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 1L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/ distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted. Slight hand tremors pt states he\n experiences occas. Of note: pt does state he has anxiety at baseline.\n Anxious r/ missing MD appt today being hospitalized\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix\n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n Less bleeding noted from skin tear. Pt able to turn x1 assist in bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n Code status:\n Full code\n Height:\n 28 Inch\n Admission weight:\n 83.5 kg\n Daily weight:\n 83.9 kg\n Allergies/Reactions:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Precautions: Contact\n PMH: Anemia, COPD, ETOH, Renal Failure, Smoker\n CV-PMH: Angina, CAD, CHF, Hypertension, MI, PVD\n Additional history: Carotid stenosis L, AS, colon ca s/p collectomy, lg\n Imbilical hernia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:56\n Temperature:\n 98.1\n Arterial BP:\n S:121\n D:113\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 Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 30% %\n 24h total in:\n 988 mL\n 24h total out:\n 705 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 06:41 AM\n Potassium:\n 3.7 mEq/L\n 06:41 AM\n Chloride:\n 101 mEq/L\n 06:41 AM\n CO2:\n 28 mEq/L\n 06:41 AM\n BUN:\n 25 mg/dL\n 06:41 AM\n Creatinine:\n 1.1 mg/dL\n 06:41 AM\n Glucose:\n 111 mg/dL\n 06:41 AM\n Hematocrit:\n 32.8 %\n 06:41 AM\n Finger Stick Glucose:\n 195\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: 3\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399082,
"text": "Pt is a 70yo man with PMH severe AS ( 0.8) CABG/CAD, recent cath\n with 3VD & TO of SVGs and patent LIMA-LAD. COPD on home O2, ETOH\n abuse with history of DTs. Presented to w/ acute hypercarbic\n respiratory distress, s/p BIPAP trial-> intubation. He was treated\n with solu-medrol and eventually extubated, although was found to have\n continued dypnea and continuous elevated cardiac enzymes CK 51->229,\n Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? plavix\n load. Tnsf to for possible cath and further management. Received\n on BIPAP, heparin gtt at 800 units/hr. Noted lg skin tear (? from tape)\n on L medial forearm, applied adaptic/ dsd cover.\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 399160,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n Heparin gtt infusing at 550units/hr. NPO\n Action:\n CKs cycled\n Heparin gtt stopped, diet resumed.\n Maintance fluid conts for lower UOP and Cr 1.3\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n NPO p mn. Cardiac cath tomorrow to assess AS\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 1L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/ distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted. Slight hand tremors pt states he\n experiences occas. Of note: pt does state he has anxiety at baseline.\n Anxious r/ missing MD appt today being hospitalized\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix\n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n Less bleeding noted from skin tear. Pt able to turn x1 assist in bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n"
},
{
"category": "Physician ",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399460,
"text": "Chief Complaint: Transferred to MICU service from (under CCU care)\n with small bowel obstruction and acute on chronic renal failure.\n 24 Hour Events:\n EKG - At 06:08 AM\n - On a.m. of had chest discomfort , like past angina, starting\n after waking at about 5:30 a.m. Pressure like, non-radiating. Likely\n did not receive full effect of meds given NGT suction yesterday\n (included , , Imdur). Gave PR, EKG w/ TWI in II, III, AVR\n and ST depression in II. Did not give BB given distribution of changes\n and did not give nitrates given AS. Gave morphine 1 IV and continued nc\n O2. Pain resolved. Serial EKGs and enzymes sent.\n - NGT output 750 mL; OUP 30-100 cc/hr\n - Receiving NS at 150 cc/hr\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 PM\n Metoprolol - 02:00 AM\n Morphine Sulfate - 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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 81 (70 - 94) bpm\n BP: 115/77(86) {95/41(56) - 150/83(91)} mmHg\n RR: 18 (15 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.3 kg (admission): 83 kg\n Height: 28 Inch\n Total In:\n 1,008 mL\n 1,195 mL\n PO:\n TF:\n IVF:\n 1,008 mL\n 1,195 mL\n Blood products:\n Total out:\n 340 mL\n 880 mL\n Urine:\n 240 mL\n 430 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 668 mL\n 315 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///27/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. NG tube in place.\n Neck: supple, JVP not elevated, no LAD\n Lungs: Mild wheezing L>R. No crackles.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Large ventral hernia present, partly reducible but\n uncomfortable (limits attempt), bowel loops in hernia without visible\n peristalsis on percussion.. Mild tenderness to palpation over hernia\n only. Non-distended. No rebound or guarding.\n GU: Foley present\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 134 K/uL\n 11.3 g/dL\n 112 mg/dL\n 1.8 mg/dL\n 27 mEq/L\n 4.5 mEq/L\n 47 mg/dL\n 104 mEq/L\n 140 mEq/L\n 32.5 %\n 9.8 K/uL\n [image002.jpg]\n 03:55 PM\n 08:01 PM\n 11:26 PM\n 11:39 PM\n 06:41 AM\n 06:51 AM\n 02:54 AM\n 06:44 AM\n WBC\n 9.0\n 15.6\n 10.4\n 9.8\n Hct\n 31.8\n 32.8\n 32.7\n 32.5\n Plt\n 142\n 147\n 135\n 134\n Cr\n 1.3\n 1.1\n 1.8\n TropT\n 0.26\n 0.21\n 0.17\n TCO2\n 29\n 30\n 31\n Glucose\n 171\n 111\n 112\n Other labs: PT / PTT / INR:12.4/28.5/1.0, CK / CKMB /\n Troponin-T:50/16/0.17, ALT / AST:27/17, Alk Phos / T Bili:46/0.5,\n Differential-Neuts:88.7 %, Lymph:6.4 %, Mono:4.7 %, Eos:0.1 %, Lactic\n Acid:1.0 mmol/L, LDH:213 IU/L, Ca++:8.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.4\n mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR this a.m.: Clear\n cardiac border not enlarged, no edema,\n infiltrate.\n Microbiology: Urine culture pending only.\n Assessment and Plan\n 70 year old man with a history of CAD s/p CABG, PAD, systolic CHF (EF\n 35%), severe COPD, severe AS (0.8cm2) & AI who was admitted to after\n NSTEMI and respiratory failure, now admitted to the MICU for SBO,\n requiring further fluid rescusitation.\n # SBO\n Seen on CT scan. History of cholecystectomy and colon cancer, with\n prior sigmoid resection, and subsequent large ventral hernia. Hernia\n was reducible and not incarcerated yesterday, but no movement of bowel\n with percussion. Given size of defect still unlikely incarcerated. Exam\n still not concerning for surgical abdomen.\n - f/u surgery recs: medical management for now\n - NPO\n - IV fluids: NS @ 150cc/hour\n keep track of NGT and urinary output.\n - Continue NG tube to suction\n - IV Ativan or PR Phenergan (avoid IM dosing out of concern for CV side\n effects) PRN\n - Repeat KUB today\n - Serial abdominal exams\n # Chest Pain\n Second anginal episode s/p cath. Concerning that Imdur held\n but need\n to be cautious given AS. EKG changes relatively minor and may be partly\n related to cath.\n - Repeat EKG\n - Trend enzymes\n - Follow clinically\n # Acute renal failure\n FeUrea is 35% - borderline. Fluid status now improved, but pre-renal\n prior. Cr was 2.6, now 1.8 and baseline 1.1-1.2. Likely prerenal in\n the setting of inadequate fluid rescusitation. However patient also\n received C. cath on . So there may be a component of ATN\n contributing. Patient has critical AS with valve area of 0.8. However,\n currently requiring no Oxygen. Would favor further fluid rescusitation\n with close monitoring of respiratory status.\n - IV NS @ 150cc/hour x1L\n - Check lytes \n -avoid nephrotoxins\n -renally dose meds\n # Leukocytosis\n Trending down now. No other focal signs of infection. CXR clear. CT\n Abdomen without concern for abscess or diverticulitis.\n - Await urine culture\n - Obtain blood cultures if spikes a fever\n # COPD exacerbation\n Clinically improved. Leading to respiratory failure and intubating at\n OSH. He is on 2L of continuous O2 as well as Albuterol, Advair, and\n Tiotropium at home. Completed a 5 day course of Levofloxacin.\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Steroids: On chronic prednisone, however given that patient is NPO,\n he was switched back to Methylprednisolone today.\n - Taper steroids back to home dose\n - Switch back to MDI\n - Continue IV bactrim for PCP prophylaxis given chronic steroid use\n # Chronic systolic Congestive Heart Failure\n EF 35% on most recent echo, also with severe AS. S/p cardiac\n catheterization, but not a candidate for aortoplasty. Currently dry on\n exam from emesis and SBO.\n - Careful IVF's @ 150cc/hr given AS to avoid pulmonary edema\n - Hold Imdur 60mg daily for now\n - Change metoprolol to 5mg IV q6h\n change back to PO when no longer\n obstipated and NGT output decreased\n - Change enalapril to 0.625mg IV q6h - change back to PO as above\n # CAD s/p NSTEMI\n Stents (2 x DES) on . Needs to be on /integrilin. Patient s/p\n CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA graft ').\n Patient s/p RCA stent x2. Peak CK 229. Patient currently on ,\n statin, beta-blocker. He did not receive as he has a history of\n GI bleed and thrombocytopenia while on . Given h/o AS, patient\n likely pre-load dependent.\n - Continue 325mg PR daily\n - Unable to give Simvastatin 80mg qHS given NPO\n - Metoprolol 5mg IV q6h\n - Enalapril 0.625mg IV q6h\n - Unable to give Imdur 60mg given that NPO\n - Avoid SL Nitro for CP/angina\n - Start integrilin ? (d/w Cardiology)\n # Alcohol abuse\n Stable. Out of window for withdrawal. Patient with extensive EtOH\n history and an episode of DT in requiring intubation. His EtOH\n screen on at was negative and his wife reports that his last\n drink was on . No sx of withdrawl as an inpatient.\n # Anxiety\n Stable at present. Patient with h/o anxiety, on Celexa 80mg daily,\n Lorazepam 1mg TID:PRN.\n - Unable to give po Celexa given NPO\n - Continue Lorazepam 1-2mg q4H:PRN anxiety\n # Peripheral vascular disease\n Patient with known PAD s/p LLE Fem- bypass (unclear when). He also\n has a known ascending aortic aneurysm last measured at 4.2cm x 4.2cm in\n 5/. Pulses on left LE < RLE. Stable.\n - 325mg PR daily\n - Hold Simvastatin 80mg qHS\n - Hold Pentoxyfylline SR 400mg TID given NPO\n # Normocytic Anemia\n Iron studies normal. Patient takes Vitamin B-12 for h/o deficiency.\n - Hold Vit B12 given NPO\n # GERD\n Patient takes Omeprazole 20mg daily at home. Would hold on PPI given\n patient now on . Will monitor for symptoms.\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:20 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: H2 IV\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code (confirmed)\n Disposition:\n"
},
{
"category": "Case Management ",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 399137,
"text": "Insurance information\n Primary insurance: BLUE CARE 65\n Secondary insurance: SELF PAY\n Insurance reviewer::\n Free Care application:\n Status:\n Medicaid application:\n Pre-Hospitalization services:\n DME / Home O[2]:\n Functional Status / Home / Family Assessment:\n PTA\n Primary Contact(s): wife\n Health Proxy: Yes - But NO copy of signed proxy form in medical\n record.\n Dialysis: No\n Referrals Recommended: Addictions\n Current plan: Home\n Patient (s) to Discharge:\n Patient discussed with multidisciplinary team: Yes\n rn,ccm\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399140,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n - weaned from supplemental O2 overnight, breathing comfortably on room\n air\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Levofloxacin - 09:30 PM\n Infusions:\n Heparin Sodium - 550 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 84 (73 - 89) bpm\n BP: 140/62(91) {123/50(77) - 147/63(94)} mmHg\n RR: 22 (8 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 28 Inch\n Total In:\n 222 mL\n 317 mL\n PO:\n TF:\n IVF:\n 92 mL\n 317 mL\n Blood products:\n Total out:\n 455 mL\n 350 mL\n Urine:\n 455 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -233 mL\n -33 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: None\n Vt (Spontaneous): 522 (522 - 665) mL\n PS : 0 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 30%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.50/38/69/31\n Ve: 4.7 L/min\n PaO2 / FiO2: 443\n Physical Examination\n General: Elderly man , lying in bed sleeping, NAD\n HEENT: NC/AT, clear oropharynx\n Cardio: Regular rate & rhythm, no audible murmurs\n Respiratory: Clear to auscultation anteriorly, no wheezes or rhonchi,\n but significantly increased expiratory phase\n Abdominal: soft, ventral hernia appreciated, NT/ND, + bowel sounds\n Peripheral Vascular: (Right radial pulse: present), (Left radial pulse:\n present), (Right DP pulse: present), (Left DP pulse: present)\n Skin: skin tear in left antecubital fossa\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 147 K/uL\n 11.3 g/dL\n 111 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 3.7\n 25 mg/dL\n 101 mEq/L\n 138 mEq/L\n 32.8 %\n 15.6 K/uL\n [image002.jpg]\n 03:55 PM\n 08:01 PM\n 11:26 PM\n 11:39 PM\n WBC\n 9.0\n Hct\n 31.8\n Plt\n 142\n Cr\n 1.3\n TropT\n 0.26\n 0.21\n TCO2\n 29\n 30\n Glucose\n 171\n Other labs: PT / PTT / INR:11.6/36.2/1.0, CK / CKMB /\n Troponin-T:81/16/0.21, ALT / AST:46/45, Alk Phos / T Bili:48/0.4,\n Differential-Neuts:90.0 %, Lymph:7.1 %, Mono:2.2 %, Eos:0.6 %, Lactic\n Acid:1.0 mmol/L, LDH:262 IU/L, Ca++:9.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n 70 year old man with a complicated history including CAD s/p CABG, PAD,\n systolic CHF (EF 45-50% in ) w/ diastolic dysfunction, severe\n COPD, severe AS (0.8cm2) & AI who presents as a transfer from for respiratory failure.\n # Respiratory failure: Patient with known history of COPD, Asthma, and\n OSA as well as an extensive smoking history here with likely\n exacerbation of obstructive lung disease with component of acute\n systolic CHF given respiratory acidosis and no e/o infection on CXR. He\n has required multiple intubations for respiratory distress over the\n past 3 months despite repeated courses of Prednisone & antibiotics,\n most recently on at . He was extubated on AM and since\n then has weaned his oxygen requirement completely. His ABG this AM\n demonstrates a metabolic alkalosis, likely unable to compensate from a\n respiratory standpoint. CXR remains clear.\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Prednisone PO 40mg daily, day 2\n would favor slow taper given\n history\n - Levofloxacin 750mg daily, day \n - Regular ABG's\n - BIPAP PRN\n - Consider Bactrim prophylaxis as outpatient given chronic steroid use\n # PUMP: Patient with known systolic heart failure, last EF in \n demonstrated EF 45-50% with severe AS (mean gradient 47 mm Hg and area\n 0.8cm^2) and + AR. Prior catheterization in supports mild\n pulmonary hypertension with mean PA pressure 20mm Hg. His EF is\n unchanged from echocardiograms, but as his AR has progressed\n significantly since his last echo one month prior, his true forward\n flow is likely more compromised than his EF would suggest. CXR's have\n not demonstrated e/o congestion or effusions and clinical exam does not\n support fluid overload, but pBNP was elevated at 3969. While patient\n has known 3VD, may benefit from cardiac catheterization for aortic\n valvuloplasty as he is a poor surgical candidate.\n - Restart home Imdur given clinical improvement\n - Continue Metoprolol 25mg \n - Start Lisinopril 2.5mg daily\n - Repeat TTE this AM\n - Discuss aortic valvuloplasty vs. possible percutaneous valve\n replacement with Dr. today\n # CORONARIES: Patient s/p CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA;\n stent to RCA graft '). His last cardiac catheterization in \n demonstrated three vessel coronary disease with a patent LIMA, but\n occlusion of all vein grafts. Patient with possible old inferior MI\n based on micro-Q waves in II, III, AvF, but EKG on admission does not\n demonstrate new ST changes. CE's trending down from OSH levels (peak CK\n 229) and patient CP free. Patient currently on Heparin gtt, ASA,\n statin, beta-blocker. He did not receive Plavix at OSH as he has a\n history of GI bleed and thrombocytopenia while on Plavix.\n - Discontinue Heparin gtt as presentation unlikely to be ACS\n - Continue ASA 325mg daily\n - Simvastatin 80mg qHS\n - Metoprolol 25mg \n # RHYTHM: Patient without known history of arrythmia, but micro-Q waves\n in II, III, and AvF suggest prior inferior infarct not seen on ECG from\n 11/. Currently not an active issue, but will continue to monitor\n closely.\n - On continuous telemetry\n # Hypertension: Patient takes Imdur SR 60 mg daily & Metoprolol\n Tartrate 25mg at home. Blood pressures at OSH and in CCU have been\n well-controlled. Given h/o AS, patient likely pre-load dependent.\n - Can restart home Imdur as long-standing medication and in context of\n clinical improvement\n - Continue Metoprolol 25mg with holding parameters\n # Hyperlipidemia: Patient takes Simvastatin 20mg qHS at home. Given\n question of ACS, high dose statin warranted.\n - Simvastatin 80mg qHS\n - Fish Oil 1,000mg daily\n # Alcohol abuse: Patient with extensive EtOH history and an episode of\n DT in requiring intubation. His EtOH screen on at was\n negative and his wife reports that his last drink was on .\n - CIWA scale\n - If CIWA > 10, Lorazepam 1-2mg q4H:PRN\n # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam\n 1mg TID:PRN, and Seroquel 12.5mg at home. Per OMR records, patient\n prefers not to take Seroquel out of concern for side effects, so it is\n unlikely to be an active medication.\n - Continue Celexa 80mg daily\n - Continue Lorazepam 1-2mg q4H:PRN anxiety/withdrawal\n # Peripheral vascular disease: Patient with known PAD s/p LLE Fem-\n bypass (unclear when). He also has a known ascending aortic aneurysm\n last measured at 4.2cm x 4.2cm in 5/.\n - ASA 325mg daily\n - Simvastatin 80mg qHS\n - Pentoxyfylline SR 400mg TID\n # Chronic Renal insufficiency: Baseline Cr 1.2-1.3. Cr on admission\n 1.3. Etiology unknown, but not currently an active issue.\n - Daily Cr\n - Avoid nephrotoxic agents\n # Anemia: Patient with known Vitamin B-12 deficiency anemia for which\n he receives daily supplementation. He has an Anti-E antibody\n transfusion reaction making him prone to hemolytic anemia from\n transfusions. His last iron studies were assessed in and he has\n had iron deficiency in the past.\n - Active T&S\n - Daily CBC\n - Continue B-12 1,000 mcg daily\n - F/U iron studies\n # GERD: Patient takes Omeprazole 20mg daily at home.\n - Continue Omeprazole PO 20mg daily\n # H/o recurrent C. difficile colitis: Patient has failed multiple\n Flagyl regimens in the past in the context of EtOH use, successfully\n treated with extended course Vancomycin.\n - Send C.diff if patient develops diarrhea\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia. Patient uses belt for hernia control, but this\n has exacerbated SOB in the past, so no plan for hernia belt.\n # Active smoking habit: Patient smokes ~ 1ppd with >150 pack year\n history.\n - Nicotine TD\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control: none\n Lines:\n 22 Gauge - 03:50 PM\n 20 Gauge - 03:51 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: Omeprazole 20mg daily\n VAP: none\n Communication: Patient & patient\ns wife\n status: Full code\n Disposition: pending clinical improvement\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399143,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n - weaned from supplemental O2 overnight, breathing comfortably on room\n air\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Levofloxacin - 09:30 PM\n Infusions:\n Heparin Sodium - 550 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 84 (73 - 89) bpm\n BP: 140/62(91) {123/50(77) - 147/63(94)} mmHg\n RR: 22 (8 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 28 Inch\n Total In:\n 222 mL\n 317 mL\n PO:\n TF:\n IVF:\n 92 mL\n 317 mL\n Blood products:\n Total out:\n 455 mL\n 350 mL\n Urine:\n 455 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -233 mL\n -33 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: None\n Vt (Spontaneous): 522 (522 - 665) mL\n PS : 0 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 30%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.50/38/69/31\n Ve: 4.7 L/min\n PaO2 / FiO2: 443\n Physical Examination\n General: Elderly man , lying in bed sleeping, NAD\n HEENT: NC/AT, clear oropharynx\n Cardio: Regular rate & rhythm, no audible murmurs\n Respiratory: Clear to auscultation anteriorly, no wheezes or rhonchi,\n but significantly increased expiratory phase\n Abdominal: soft, ventral hernia appreciated, NT/ND, + bowel sounds\n Peripheral Vascular: (Right radial pulse: present), (Left radial pulse:\n present), (Right DP pulse: present), (Left DP pulse: present)\n Skin: skin tear in left antecubital fossa\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 147 K/uL\n 11.3 g/dL\n 111 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 3.7\n 25 mg/dL\n 101 mEq/L\n 138 mEq/L\n 32.8 %\n 15.6 K/uL\n [image002.jpg]\n 03:55 PM\n 08:01 PM\n 11:26 PM\n 11:39 PM\n WBC\n 9.0\n Hct\n 31.8\n Plt\n 142\n Cr\n 1.3\n TropT\n 0.26\n 0.21\n TCO2\n 29\n 30\n Glucose\n 171\n Other labs: PT / PTT / INR:11.6/36.2/1.0, CK / CKMB /\n Troponin-T:81/16/0.21, ALT / AST:46/45, Alk Phos / T Bili:48/0.4,\n Differential-Neuts:90.0 %, Lymph:7.1 %, Mono:2.2 %, Eos:0.6 %, Lactic\n Acid:1.0 mmol/L, LDH:262 IU/L, Ca++:9.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n 70 year old man with a complicated history including CAD s/p CABG, PAD,\n systolic CHF (EF 45-50% in ) w/ diastolic dysfunction, severe\n COPD, severe AS (0.8cm2) & AI who presents as a transfer from for respiratory failure.\n # Respiratory failure: Patient with known history of COPD, Asthma, and\n OSA as well as an extensive smoking history here with likely\n exacerbation of obstructive lung disease with component of acute\n systolic CHF given respiratory acidosis and no e/o infection on CXR. He\n has required multiple intubations for respiratory distress over the\n past 3 months despite repeated courses of Prednisone & antibiotics,\n most recently on at . He was extubated on AM and since\n then has weaned his oxygen requirement completely. His ABG this AM\n demonstrates a metabolic alkalosis, likely unable to compensate from a\n respiratory standpoint. CXR remains clear.\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Prednisone PO 40mg daily, day 2\n would favor slow taper given\n history\n - Levofloxacin 750mg daily, day \n - Regular ABG's\n - BIPAP PRN\n - Consider Bactrim prophylaxis as outpatient given chronic steroid use\n # PUMP: Patient with known systolic heart failure, last EF in \n demonstrated EF 45-50% with severe AS (mean gradient 47 mm Hg and area\n 0.8cm^2) and + AR. Prior catheterization in supports mild\n pulmonary hypertension with mean PA pressure 20mm Hg. His EF is\n unchanged from echocardiograms, but as his AR has progressed\n significantly since his last echo one month prior, his true forward\n flow is likely more compromised than his EF would suggest. CXR's have\n not demonstrated e/o congestion or effusions and clinical exam does not\n support fluid overload, but pBNP was elevated at 3969. While patient\n has known 3VD, may benefit from cardiac catheterization for aortic\n valvuloplasty as he is a poor surgical candidate.\n - Restart home Imdur given clinical improvement\n - Continue Metoprolol 25mg \n - Start Lisinopril 2.5mg daily\n - Repeat TTE this AM\n - Discuss aortic valvuloplasty vs. possible percutaneous valve\n replacement with Dr. today\n # CORONARIES: Patient s/p CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA;\n stent to RCA graft '). His last cardiac catheterization in \n demonstrated three vessel coronary disease with a patent LIMA, but\n occlusion of all vein grafts. Patient with possible old inferior MI\n based on micro-Q waves in II, III, AvF, but EKG on admission does not\n demonstrate new ST changes. CE's trending down from OSH levels (peak CK\n 229) and patient CP free. Patient currently on Heparin gtt, ASA,\n statin, beta-blocker. He did not receive Plavix at OSH as he has a\n history of GI bleed and thrombocytopenia while on Plavix.\n - Discontinue Heparin gtt as presentation unlikely to be ACS\n - Continue ASA 325mg daily\n - Simvastatin 80mg qHS\n - Metoprolol 25mg \n # RHYTHM: Patient without known history of arrythmia, but micro-Q waves\n in II, III, and AvF suggest prior inferior infarct not seen on ECG from\n 11/. Currently not an active issue, but will continue to monitor\n closely.\n - On continuous telemetry\n # Hypertension: Patient takes Imdur SR 60 mg daily & Metoprolol\n Tartrate 25mg at home. Blood pressures at OSH and in CCU have been\n well-controlled. Given h/o AS, patient likely pre-load dependent.\n - Can restart home Imdur as long-standing medication and in context of\n clinical improvement\n - Continue Metoprolol 25mg with holding parameters\n # Hyperlipidemia: Patient takes Simvastatin 20mg qHS at home. Given\n question of ACS, high dose statin warranted.\n - Simvastatin 80mg qHS\n - Fish Oil 1,000mg daily\n # Alcohol abuse: Patient with extensive EtOH history and an episode of\n DT in requiring intubation. His EtOH screen on at was\n negative and his wife reports that his last drink was on .\n - CIWA scale\n - If CIWA > 10, Lorazepam 1-2mg q4H:PRN\n # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam\n 1mg TID:PRN, and Seroquel 12.5mg at home. Per OMR records, patient\n prefers not to take Seroquel out of concern for side effects, so it is\n unlikely to be an active medication.\n - Continue Celexa 80mg daily\n - Continue Lorazepam 1-2mg q4H:PRN anxiety/withdrawal\n # Peripheral vascular disease: Patient with known PAD s/p LLE Fem-\n bypass (unclear when). He also has a known ascending aortic aneurysm\n last measured at 4.2cm x 4.2cm in 5/.\n - ASA 325mg daily\n - Simvastatin 80mg qHS\n - Pentoxyfylline SR 400mg TID\n # Chronic Renal insufficiency: Baseline Cr 1.2-1.3. Cr on admission\n 1.3. Etiology unknown, but not currently an active issue.\n - Daily Cr\n - Avoid nephrotoxic agents\n # Anemia: Patient with known Vitamin B-12 deficiency anemia for which\n he receives daily supplementation. He has an Anti-E antibody\n transfusion reaction making him prone to hemolytic anemia from\n transfusions. His last iron studies were assessed in and he has\n had iron deficiency in the past.\n - Active T&S\n - Daily CBC\n - Continue B-12 1,000 mcg daily\n - F/U iron studies\n # GERD: Patient takes Omeprazole 20mg daily at home.\n - Continue Omeprazole PO 20mg daily\n # H/o recurrent C. difficile colitis: Patient has failed multiple\n Flagyl regimens in the past in the context of EtOH use, successfully\n treated with extended course Vancomycin.\n - Send C.diff if patient develops diarrhea\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia. Patient uses belt for hernia control, but this\n has exacerbated SOB in the past, so no plan for hernia belt.\n # Active smoking habit: Patient smokes ~ 1ppd with >150 pack year\n history.\n - Nicotine TD\n ICU Care\n Nutrition: cardiac diet\n Glycemic Control: none\n Lines:\n 22 Gauge - 03:50 PM\n 20 Gauge - 03:51 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: Omeprazole 20mg daily\n VAP: none\n Communication: Patient & patient\ns wife\n status: Full code\n Disposition: pending clinical improvement\n ------ Protected Section ------\n Attending\ns Note.08.30hrs\n Reviewed data.examined Pt and agree with Dr.\ns note\n \n Spent 45mins on case\n ------ Protected Section Addendum Entered By: \n on: 10:15 ------\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-27 00:00:00.000",
"description": "CCU Fellow Addendum",
"row_id": 399062,
"text": "TITLE: CCU Fellow Addendum\n Patient seen and plan discussed with CCU housestaff. For details, see\n CCU resident H&P. Briefly, the patient is a 70 year old man with PMH\n severe AS ( 0.8), CABG/CAD with most recent cath with 3VD and\n TO SVGs and patent LIMA-LAD, COPD on home O2, alcohol abuse with\n history of DTs, who presented to with acute\n hypercarbic respiratory distress, s/p intubation. He was treated with\n solu-medrol and eventually extubated, although he was found to have\n continued dypnea and was found to have elevated cardiac biomarkers. He\n was started on heparin, as well as plavix and aspirin, and transferred\n here for possible cath and further management. He had hematuria en\n route, and his heparin gtt was decreased. On exam, he is mildly\n dyspneic with AS murmur and skin lesions c/w tape trauma. ECG from \n initially showed ST depressions in anterior precordial leads, which\n resolved on follow-up, although he had new TW flattening inferiorly of\n uncertain significance. Plan for tonight will be close monitoring of\n respiratory status, cycle cardiac enzymes, and monitor clinically.\n Will continue heparin, follow Hct and hematuria. NPO for possible cath\n in AM, but will monitor overnight.\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399124,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n - weaned from supplemental O2 overnight, breathing comfortably on room\n air\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Levofloxacin - 09:30 PM\n Infusions:\n Heparin Sodium - 550 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 84 (73 - 89) bpm\n BP: 140/62(91) {123/50(77) - 147/63(94)} mmHg\n RR: 22 (8 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 28 Inch\n Total In:\n 222 mL\n 317 mL\n PO:\n TF:\n IVF:\n 92 mL\n 317 mL\n Blood products:\n Total out:\n 455 mL\n 350 mL\n Urine:\n 455 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -233 mL\n -33 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: None\n Vt (Spontaneous): 522 (522 - 665) mL\n PS : 0 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 30%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.50/38/69/31\n Ve: 4.7 L/min\n PaO2 / FiO2: 443\n Physical Examination\n General: Elderly man , lying in bed sleeping, NAD\n HEENT: NC/AT, clear oropharynx\n Cardio: Regular rate & rhythm, no audible murmurs\n Respiratory: Clear to auscultation anteriorly, no wheezes or rhonchi\n Abdominal: soft, ventral hernia appreciated, NT/ND, + bowel sounds\n Peripheral Vascular: (Right radial pulse: present), (Left radial pulse:\n present), (Right DP pulse: present), (Left DP pulse: present)\n Skin: skin tear in left antecubital fossa\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 142 K/uL\n 11.0 g/dL\n 171 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 25 mg/dL\n 99 mEq/L\n 137 mEq/L\n 31.8 %\n 9.0 K/uL\n [image002.jpg]\n 03:55 PM\n 08:01 PM\n 11:26 PM\n 11:39 PM\n WBC\n 9.0\n Hct\n 31.8\n Plt\n 142\n Cr\n 1.3\n TropT\n 0.26\n 0.21\n TCO2\n 29\n 30\n Glucose\n 171\n Other labs: PT / PTT / INR:11.6/36.2/1.0, CK / CKMB /\n Troponin-T:81/16/0.21, ALT / AST:46/45, Alk Phos / T Bili:48/0.4,\n Differential-Neuts:90.0 %, Lymph:7.1 %, Mono:2.2 %, Eos:0.6 %, Lactic\n Acid:1.0 mmol/L, LDH:262 IU/L, Ca++:9.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: none\n Lines:\n 22 Gauge - 03:50 PM\n 20 Gauge - 03:51 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: Omeprazole 20mg daily\n VAP: none\n Communication: Patient & patient\ns wife\n status: Full code\n Disposition: pending clinical improvement\n"
},
{
"category": "Physician ",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 399458,
"text": "Chief Complaint: Renal failure, aortic stenosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Chest pain overnight - 1mg morphine, pain resolved.\n Cr down to 1.6\n 24 Hour Events:\n EKG - At 06:08 AM\n History obtained from Medical records, icu team\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:45 AM\n Metoprolol - 08:34 AM\n Heparin Sodium (Prophylaxis) - 08:35 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.6\nC (97.9\n HR: 81 (70 - 94) bpm\n BP: 113/65(76) {95/41(56) - 150/83(91)} mmHg\n RR: 16 (15 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.3 kg (admission): 83 kg\n Height: 28 Inch\n Total In:\n 1,008 mL\n 1,568 mL\n PO:\n TF:\n IVF:\n 1,008 mL\n 1,568 mL\n Blood products:\n Total out:\n 340 mL\n 1,330 mL\n Urine:\n 240 mL\n 530 mL\n NG:\n 800 mL\n Stool:\n Drains:\n Balance:\n 668 mL\n 238 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended, large ventral hernia,\n non-tender, minimal but present bowel sounds\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, pleasant,\n coversive\n Labs / Radiology\n 11.3 g/dL\n 134 K/uL\n 93 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 45 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.5 %\n 9.8 K/uL\n [image002.jpg]\n 03:55 PM\n 08:01 PM\n 11:26 PM\n 11:39 PM\n 06:41 AM\n 06:51 AM\n 02:54 AM\n 06:44 AM\n WBC\n 9.0\n 15.6\n 10.4\n 9.8\n Hct\n 31.8\n 32.8\n 32.7\n 32.5\n Plt\n 142\n 147\n 135\n 134\n Cr\n 1.3\n 1.1\n 1.8\n 1.6\n TropT\n 0.26\n 0.21\n 0.17\n 0.35\n TCO2\n 29\n 30\n 31\n Glucose\n 171\n 111\n 112\n 93\n Other labs: PT / PTT / INR:12.4/28.5/1.0, CK / CKMB /\n Troponin-T:18/16/0.35, ALT / AST:27/17, Alk Phos / T Bili:46/0.5,\n Differential-Neuts:88.7 %, Lymph:6.4 %, Mono:4.7 %, Eos:0.1 %, Lactic\n Acid:1.0 mmol/L, LDH:213 IU/L, Ca++:8.5 mg/dL, Mg++:2.3 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n SMALL BOWEL OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING\n INTUSSUSCEPTION, ADHESIONS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n IMPAIRED SKIN INTEGRITY\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n .H/O MYOCARDIAL INFARCTION\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n In summary patient is 70 yo male with history of colon cancer and now\n with recurrent SBO presenting with significant pain and distention.\n Certainly bowel ischemia is of concern given significant vascular\n disease or referred pain from true cardiac source. The level of\n obstruction is of concern for being related to hernia but this is\n easily reducible on exam.\n 1)Small Bowel Obstruction- cont bilious NGT output\n -Cont NPO, careful fluid managment given SBO\n 2)Respiratory Distress-\n -Improved\n 3)Renal Failure-\n -Cr improving\n 4)Chest Pain:\n -Repeat EKG this AM. No further CP. Cycling cardiac enzymes\n Additional Issues to be addressed as defined in the housestaff note of\n this date.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399130,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n - weaned from supplemental O2 overnight, breathing comfortably on room\n air\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Levofloxacin - 09:30 PM\n Infusions:\n Heparin Sodium - 550 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 84 (73 - 89) bpm\n BP: 140/62(91) {123/50(77) - 147/63(94)} mmHg\n RR: 22 (8 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 28 Inch\n Total In:\n 222 mL\n 317 mL\n PO:\n TF:\n IVF:\n 92 mL\n 317 mL\n Blood products:\n Total out:\n 455 mL\n 350 mL\n Urine:\n 455 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -233 mL\n -33 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: None\n Vt (Spontaneous): 522 (522 - 665) mL\n PS : 0 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 30%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.50/38/69/31\n Ve: 4.7 L/min\n PaO2 / FiO2: 443\n Physical Examination\n General: Elderly man , lying in bed sleeping, NAD\n HEENT: NC/AT, clear oropharynx\n Cardio: Regular rate & rhythm, no audible murmurs\n Respiratory: Clear to auscultation anteriorly, no wheezes or rhonchi\n Abdominal: soft, ventral hernia appreciated, NT/ND, + bowel sounds\n Peripheral Vascular: (Right radial pulse: present), (Left radial pulse:\n present), (Right DP pulse: present), (Left DP pulse: present)\n Skin: skin tear in left antecubital fossa\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 147 K/uL\n 11.3 g/dL\n mg/dL\n mg/dL\n mEq/L\n mEq/L\n mg/dL\n mEq/L\n mEq/L\n 32.8 %\n 15.6 K/uL\n [image002.jpg]\n 03:55 PM\n 08:01 PM\n 11:26 PM\n 11:39 PM\n WBC\n 9.0\n Hct\n 31.8\n Plt\n 142\n Cr\n 1.3\n TropT\n 0.26\n 0.21\n TCO2\n 29\n 30\n Glucose\n 171\n Other labs: PT / PTT / INR:11.6/36.2/1.0, CK / CKMB /\n Troponin-T:81/16/0.21, ALT / AST:46/45, Alk Phos / T Bili:48/0.4,\n Differential-Neuts:90.0 %, Lymph:7.1 %, Mono:2.2 %, Eos:0.6 %, Lactic\n Acid:1.0 mmol/L, LDH:262 IU/L, Ca++:9.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n 70 year old man with a complicated history including CAD s/p CABG, PAD,\n systolic CHF (EF 45-50% in ) w/ diastolic dysfunction, severe\n COPD, severe AS (0.8cm2) & AI who presents as a transfer from for respiratory failure.\n # Respiratory failure: Patient with known history of COPD, Asthma, and\n OSA as well as an extensive smoking history here with likely\n exacerbation of obstructive lung disease with component of acute\n systolic CHF given respiratory acidosis and no e/o infection on CXR. He\n has required multiple intubations for respiratory distress over the\n past 3 months despite repeated courses of Prednisone & antibiotics,\n most recently on at . He was extubated on AM and since\n then has weaned his oxygen requirement completely. His ABG this AM\n demonstrates a metabolic alkalosis, likely unable to compensate from a\n respiratory standpoint. CXR remains clear.\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Prednisone PO 40mg daily, day 2\n would favor slow taper given\n history\n - Levofloxacin 750mg daily, day \n - Regular ABG's\n - BIPAP PRN\n - Consider Bactrim prophylaxis as outpatient given chronic steroid use\n # PUMP: Patient with known systolic heart failure, last EF in \n demonstrated EF 45-50% with severe AS (mean gradient 47 mm Hg and area\n 0.8cm^2) and + AR. Prior catheterization in supports mild\n pulmonary hypertension with mean PA pressure 20mm Hg. His EF is\n unchanged from echocardiograms, but as his AR has progressed\n significantly since his last echo one month prior, his true forward\n flow is likely more compromised than his EF would suggest. CXR's have\n not demonstrated e/o congestion or effusions and clinical exam does not\n support fluid overload, but pBNP was elevated at 3969. While patient\n has known 3VD, may benefit from cardiac catheterization for aortic\n valvuloplasty.\n - Hold home Imdur for now\n - Continue Metoprolol 25mg \n - Start Lisinopril 2.5mg daily\n - Patient NPO for now pending possible catheterization for aortic\n valvuloplasty & possible percutaneous valve replacement\n - Patient unlikely to be surgical candidate given recent functional\n status, but can consider Csurg eval if patient improves\n # CORONARIES: Patient s/p CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA;\n stent to RCA graft '). His last cardiac catheterization in \n demonstrated three vessel coronary disease with a patent LIMA, but\n occlusion of all vein grafts. Patient with possible old inferior MI\n based on micro-Q waves in II, III, AvF, but EKG on admission does not\n demonstrate new ST changes. CE's trending down from OSH levels (peak CK\n 229) and patient CP free. Patient currently on Heparin gtt, ASA,\n statin, beta-blocker. He did not receive Plavix at OSH as he has a\n history of GI bleed and thrombocytopenia while on Plavix.\n - Discontinue Heparin gtt as presentation unlikely to be ACS\n - Continue ASA 325mg daily\n - Simvastatin 80mg qHS\n - Metoprolol 25mg \n # RHYTHM: Patient without known history of arrythmia, but micro-Q waves\n in II, III, and AvF suggest prior inferior infarct not seen on ECG from\n 11/. Currently not an active issue, but will continue to monitor\n closely.\n - On continuous telemetry\n # Hypertension: Patient takes Imdur SR 60 mg daily & Metoprolol\n Tartrate 25mg at home. Blood pressures at OSH and in CCU have been\n well-controlled. Given h/o AS, patient likely pre-load dependent.\n - Hold Imdur for now\n - Continue Metoprolol 25mg with holding parameters\n # Hyperlipidemia: Patient takes Simvastatin 20mg qHS at home. Given\n question of ACS, high dose statin warranted.\n - Simvastatin 80mg qHS\n - Fish Oil 1,000mg daily\n # Alcohol abuse: Patient with extensive EtOH history and an episode of\n DT in requiring intubation. His EtOH screen on at was\n negative and his wife reports that his last drink was on .\n - CIWA scale\n - If CIWA > 10, Lorazepam 1-2mg q4H:PRN\n # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam\n 1mg TID:PRN, and Seroquel 12.5mg at home. Per OMR records, patient\n prefers not to take Seroquel out of concern for side effects, so it is\n unlikely to be an active medication.\n - Continue Celexa 80mg daily\n - Continue Lorazepam 1-2mg q4H:PRN anxiety/withdrawal\n # Peripheral vascular disease: Patient with known PAD s/p LLE Fem-\n bypass (unclear when). He also has a known ascending aortic aneurysm\n last measured at 4.2cm x 4.2cm in 5/.\n - ASA 325mg daily\n - Simvastatin 80mg qHS\n - Pentoxyfylline SR 400mg TID\n # Chronic Renal insufficiency: Baseline Cr 1.2-1.3. Cr on admission\n 1.3. Etiology unknown, but not currently an active issue.\n - Daily Cr\n - Avoid nephrotoxic agents\n # Anemia: Patient with known Vitamin B-12 deficiency anemia for which\n he receives daily supplementation. He has an Anti-E antibody\n transfusion reaction making him prone to hemolytic anemia from\n transfusions. His last iron studies were assessed in and he has\n had iron deficiency in the past.\n - Active T&S\n - Daily CBC\n - Continue B-12 1,000 mcg daily\n - F/U iron studies\n # GERD: Patient takes Omeprazole 20mg daily at home.\n - Continue Omeprazole PO 20mg daily\n # H/o recurrent C. difficile colitis: Patient has failed multiple\n Flagyl regimens in the past in the context of EtOH use, successfully\n treated with extended course Vancomycin.\n - Send C.diff if patient develops diarrhea\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia. Patient uses belt for hernia control, but this\n has exacerbated SOB in the past, so no plan for hernia belt.\n # Active smoking habit: Patient smokes ~ 1ppd with >150 pack year\n history.\n - Nicotine TD\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: none\n Lines:\n 22 Gauge - 03:50 PM\n 20 Gauge - 03:51 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: Omeprazole 20mg daily\n VAP: none\n Communication: Patient & patient\ns wife\n status: Full code\n Disposition: pending clinical improvement\n"
},
{
"category": "Physician ",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 399447,
"text": "Chief Complaint: Transferred to MICU service from (under CCU care)\n with small bowel obstruction and acute on chronic renal failure.\n 24 Hour Events:\n EKG - At 06:08 AM\n - On a.m. of had chest discomfort , like past angina, starting\n after waking at about 5:30 a.m. Pressure like, non-radiating. Likely\n did not receive full effect of meds given NGT suction yesterday\n (included , , Imdur). Gave PR, EKG w/ TWI in II, III, AVR\n and ST depression in II. Did not give BB given distribution of changes\n and did not give nitrates given AS. Gave morphine 1 IV and continued nc\n O2. Pain resolved. Serial EKGs and enzymes sent.\n - NGT output 750 mL; OUP 30-100 cc/hr\n - Receiving NS at 150 cc/hr\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 PM\n Metoprolol - 02:00 AM\n Morphine Sulfate - 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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 81 (70 - 94) bpm\n BP: 115/77(86) {95/41(56) - 150/83(91)} mmHg\n RR: 18 (15 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.3 kg (admission): 83 kg\n Height: 28 Inch\n Total In:\n 1,008 mL\n 1,195 mL\n PO:\n TF:\n IVF:\n 1,008 mL\n 1,195 mL\n Blood products:\n Total out:\n 340 mL\n 880 mL\n Urine:\n 240 mL\n 430 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 668 mL\n 315 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 134 K/uL\n 11.3 g/dL\n 112 mg/dL\n 1.8 mg/dL\n 27 mEq/L\n 4.5 mEq/L\n 47 mg/dL\n 104 mEq/L\n 140 mEq/L\n 32.5 %\n 9.8 K/uL\n [image002.jpg]\n 03:55 PM\n 08:01 PM\n 11:26 PM\n 11:39 PM\n 06:41 AM\n 06:51 AM\n 02:54 AM\n 06:44 AM\n WBC\n 9.0\n 15.6\n 10.4\n 9.8\n Hct\n 31.8\n 32.8\n 32.7\n 32.5\n Plt\n 142\n 147\n 135\n 134\n Cr\n 1.3\n 1.1\n 1.8\n TropT\n 0.26\n 0.21\n 0.17\n TCO2\n 29\n 30\n 31\n Glucose\n 171\n 111\n 112\n Other labs: PT / PTT / INR:12.4/28.5/1.0, CK / CKMB /\n Troponin-T:50/16/0.17, ALT / AST:27/17, Alk Phos / T Bili:46/0.5,\n Differential-Neuts:88.7 %, Lymph:6.4 %, Mono:4.7 %, Eos:0.1 %, Lactic\n Acid:1.0 mmol/L, LDH:213 IU/L, Ca++:8.4 mg/dL, Mg++:2.3 mg/dL, PO4:4.4\n mg/dL\n Fluid analysis / Other labs: None.\n Imaging: CXR this a.m.:\n Microbiology: Urine culture pending only.\n Assessment and Plan\n SMALL BOWEL OBSTRUCTION (INTESTINAL OBSTRUCTION, SBO, INCLUDING\n INTUSSUSCEPTION, ADHESIONS)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n IMPAIRED SKIN INTEGRITY\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n .H/O MYOCARDIAL INFARCTION\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n 70 year old man with a history of CAD s/p CABG, PAD, systolic CHF (EF\n 35%), severe COPD, severe AS (0.8cm2) & AI who was admitted to after\n NSTEMI and respiratory failure, now admitted to the MICU for SBO,\n requiring further fluid rescusitation.\n # SBO: Seen on CT scan today. Patient has history of cholecystectomy\n and colon cancer, with prior sigmoid resection, and subsequent large\n ventral hernia. Hernia is reducable and not incarcerated. Exam not\n concerning for surgical abdomen.\n - f/ recs: medical management for now\n - NPO\n - IV fluids: NS @ 150cc/hour -will closely monitor respiratory status\n - continue NG tube to suction\n - IV Ativan or PR Phenergan (avoid IM dosing out of concern for CV side\n effects) PRN\n # Acute renal failure: Cr 2.6. Baseline 1.1. Likely prerenal in the\n setting of inadequate fluid rescusitation. However patient also\n received C. cath on . So there may be a component of ATN\n contributing. Patient has critical AS with valve area of 0.8. However,\n currently requiring no Oxygen. Would favor further fluid rescusitation\n with close monitoring of respiratory status.\n -IV NS @ 150cc/hour x1L\n -recheck lytes in the AM\n -avoid nephrotoxins\n -renally dose meds\n # Leukocytosis: WBC 13.7. Likely SBO. No other focal signs of\n infection. CXR clear. CT Abdomen without concern for abscess or\n diverticulitis.\n -obtain UA, UCx\n -obtain blood cultures if spikes a fever\n # COPD exacerbation: Leading to respiratory failure and intubating at\n OSH. He is on 2L of continuous O2 as well as Albuterol, Advair, and\n Tiotropium at home. Completed a 5 day course of Levofloxacin.\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Steroids: On chronic prednisone, however given that patient is NPO,\n he was switched back to Methylprednisolone today.\n - continue methylpred 32mg IV q24h\n - continue IV bactrim for PCP prophylaxis given chronic steroid use\n # Chronic systolic Congestive Heart Failure: EF 35% on most recent\n echo, also with severe AS. S/p cardiac catheterization, but not a\n candidate for aortoplasty. Currently dry on exam from emesis and SBO.\n - Careful IVF's @ 150cc/hr given AS to avoid pulmonary edema\n - Hold Imdur 60mg daily for now\n - Change metoprolol to 5mg IV q6h\n - Change enalapril to 0.625mg IV q6h\n # CAD s/p NSTEMI: Patient s/p CABG ' (LIMA -> LAD, SVG -> D2, OM2,\n RCA; stent to RCA graft '). Patient s/p RCA stent x2. Peak CK 229.\n Patient currently on , statin, beta-blocker. He did not receive\n as he has a history of GI bleed and thrombocytopenia while on\n . Given h/o AS, patient likely pre-load dependent.\n - Continue 325mg PR daily\n - Unable to give Simvastatin 80mg qHS given NPO\n - Metoprolol 5mg IV q6h\n - Enalapril 0.625mg IV q6h\n - Unable to give Imdur 60mg given that NPO\n - Avoid SL Nitro for CP/angina\n # Alcohol abuse: Patient with extensive EtOH history and an episode of\n DT in requiring intubation. His EtOH screen on at was\n negative and his wife reports that his last drink was on . No sx of\n withdrawl as an inpatient.\n - continue to monitor\n # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam\n 1mg TID:PRN.\n - Unable to give po Celexa given NPO\n - Continue Lorazepam 1-2mg q4H:PRN anxiety\n # Peripheral vascular disease: Patient with known PAD s/p LLE Fem-\n bypass (unclear when). He also has a known ascending aortic aneurysm\n last measured at 4.2cm x 4.2cm in 5/. Pulses on left LE < RLE.\n Stable.\n - 325mg PR daily\n - Hold Simvastatin 80mg qHS\n - Hold Pentoxyfylline SR 400mg TID given NPO\n # Normocytic Anemia: Iron studies normal. Patient takes Vitamin B-12\n for h/o deficiency.\n - continue to monitor\n - Hold Vit B12 given NPO\n # GERD: Patient takes Omeprazole 20mg daily at home. Would hold on PPI\n given patient now on . Will monitor for symptoms.\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399439,
"text": "70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV. , no po meds overnight per MICU team\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 450 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n On 2 L NC sating 94-98% lungs clear but diminished at bases.\n 0600 patient started c/o chest discomfort and slight SOB,\n c/o 2 out of 10 chest pain\n Action:\n *MD from MICU in to assess,\n *EKG done (showed some inferior wall changes)\n Given PR ASA,\n 1 mg morphine given\n CKMB, troponin and lytes drawn.\n Response:\n Patient continues to have chest discomfort, MD aware.\n Plan:\n Consult with MICU about restarting po meds, repeat EKG at 0730.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr throughout night\n Response:\n u/o now 30-70 cc/hr,\n SBP 100\ns-130\n Creat. down to 1.8, BUN 47.\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399431,
"text": "70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV. , no po meds overnight per MICU team\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 450 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n On 2 L NC sating 94-98% lungs clear but diminished at bases.\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr throughout night\n Response:\n u/o now 30-70 cc/hr,\n SBP 100\ns-130\n Creat. down to 1.8, BUN 47.\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "ECG",
"chartdate": "2142-01-05 00:00:00.000",
"description": "Report",
"row_id": 296634,
"text": "Sinus tachycardia, rate 108. Frequent atrial premature beats. Marked leftward\naxis at minus 57 degrees. Poor R wave progression in leads V1-V4. Compared to\nthe previous tracing of no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2142-01-05 00:00:00.000",
"description": "Report",
"row_id": 296635,
"text": "Normal sinus rhythm, rate 82. Left axis deviation. Medium frequency atrial\npremature beats. Non-specific inferolateral repolarization changes. Compared\nto the previous tracing of inferolateral repolarization changes are\nless striking and atrial ectopy is new. There may be left atrial abnormality\nin both tracings.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Report",
"row_id": 296849,
"text": "Sinus arrhythmia. Left atrial abnormality. ST segment depression and biphasic\nT waves in leads II, III and aVF. ST segment depression in leads V5-V6 with\nslowing of the rate as compared with . The axis remains leftward but\nless so as compared with prior recording. Clinical correlation is suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2141-12-31 00:00:00.000",
"description": "Report",
"row_id": 296850,
"text": "Sinus tachycardia. Left anterior fascicular block. Compared to the previous\ntracing the rate has increased.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2141-12-30 00:00:00.000",
"description": "Report",
"row_id": 296851,
"text": "Sinus rhythm with occasional atrial premature beats. Left anterior fascicular\nblock. Compared to the previous tracing atrial ectopy has recurred.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2141-12-29 00:00:00.000",
"description": "Report",
"row_id": 296852,
"text": "Sinus rhythm. Left anterior fascicular block. Compared to the previous tracing\natrial ectopy has resolved.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2141-12-29 00:00:00.000",
"description": "Report",
"row_id": 296853,
"text": "Sinus rhythm. Occasional atrial premature beats. Left anterior fascicular\nblock. Compared to the previous tracing of there is no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Report",
"row_id": 296854,
"text": "Sinus rhythm with atrial premature beats. Left axis deviation may be due to\nleft anterior fascicular block. QTc interval may be prolonged but it is\ndifficult to measure. ST-T wave changes are non-specific. Baseline artifact\nin the precordial leads makes assessment difficult. Since the previous tracing\nof no significant change in the limb leads but baseline artifact in\nthe precordial leads makes comparison of those leads difficult.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Report",
"row_id": 296855,
"text": "Sinus rhythm with atrial premature beats. Left axis deviation may be due to\nleft anterior fascicular block, although it is non-diagnostic. Prolonged\nQTc interval. ST-T wave abnormalities. Findings are non-specific. Clinical\ncorrelation is suggested. Since the previous tracing of QTc interval\nappears longer. Otherwise, there may be no significant change.\nTRACING #1\n\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-31 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 399400,
"text": "Chief Complaint: Chief Complaint: respiratory failure\n Reason for MICU transfer: SBO, hypovolemia\n HPI:\n Mr. is a 70 year old man with a history of CAD s/p CABG in\n , systolic CHF (EF 45-50% in ), severe COPD, severe AS\n (0.8cm2) & AI, colon ca s/p sigmoid colectomy with a residual large\n ventral hernia who was admitted to on after being\n transferred from OSH for respiratory failure.\n .\n One day prior to admission his breathing and chest pain symptoms\n worsened. He was taken to OSH by ambulance and found to be non-verbal\n in the ED. He was initially treated for presumed systolic CHF\n exacerbation and COPD with CPAP, IV Solumedrol, nebulizers, Lasix, and\n Nitrates. He was also given a dose of IV Levaquin out of concern for\n infection but his respiratory rate declined and his ABG's demonstrated\n severe respiratory acidosis so he was intubated in the OSH ED. In the\n OSH ICU, EKG's demonstrated sinus tachycardia with left anterior\n fascicular block and ST depressions in II, V3, V4. CE's rose with CK's\n peaking at 229 and Troponin levels peaking at 0.45. He was placed on a\n Heparin gtt, ASA, beta-blocker, and a statin. The following morning, he\n was extubated and transferred to CCU on BIPAP per family\n request.\n .\n Cath showed mid RCA stenosis. DESx2 were placed. During his entire\n hospital stay he has been complaining of abdominal pain. KUB on \n showed distended bowel loops, no free air. Patient had worsening nausea\n and vomiting, abdominal pain, and no flatus. CT abdomen revealed SBO.\n On KUB showed air fluid levels. Surgery was consulted and\n recommended medical management. NG tube was placed. He received about\n 2L IV fluids over the past day. The primary team was hesitant to give\n more fluids in the setting of critical AS. He was transferred to the\n medical ICU for close monitoring for respiratory failure in the setting\n of IV fluids.\n .\n .\n On the floor, the patient is comfortable. He has some mild abdominal\n discomfort with palpation. Breathing comfortably, denies CP.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n cough, shortness of breath, or wheezing. Denies chest pain, chest\n pressure, palpitations, or weakness. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications on transfer:\n MethylPREDNISolone Sodium Succ 32 mg IV Q24H\n Lorazepam 1 mg IV Q6H:PRN nausea, anxiety\n Promethazine 25 mg PR Q6H:PRN nausea\n Lorazepam 1 mg IV ONCE:PRN nausea\n traZODONE 25 mg PO/NG HS:PRN insomnia\n Prochlorperazine 5-10 mg IV Q6H:PRN nausea\n Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY\n Clopidogrel 75 mg PO DAILY\n Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG QID:PRN gas pain\n Heparin 5000 UNIT SC TID\n Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY\n Omeprazole 20 mg PO DAILY\n Simvastatin 80 mg PO/NG HS\n Nicotine Patch 14 mg TD DAILY\n Acetaminophen 325-650 mg PO/PR Q8H:PRN pain, fever\n Lisinopril 2.5 mg PO/NG DAILY\n Docusate Sodium 100 mg PO BID\n Fish Oil (Omega 3) 1000 mg PO DAILY\n Cyanocobalamin 1000 mcg PO/NG DAILY\n Aspirin 325 mg PO/NG DAILY\n Pentoxifylline 400 mg PO TID\n Hydrocodone-Acetaminophen TAB PO BID:PRN pain\n Citalopram Hydrobromide 80 mg PO/NG DAILY\n Metoprolol Tartrate 25 mg PO/NG \n Albuterol 0.083% Neb Soln NEB IH Q4H:PRN shortness of breath\n Ipratropium Bromide Neb 2 NEB IH Q6H\n Past medical history:\n Family history:\n Social History:\n - GERD\n - h/o GI bleed and thrombocytopenia on Plavix\n - h/o recurrent C. difficile colitis\n - Colon cancer s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy\n - h/o cholecystitis s/p percutaneous cholecystostomy tube placement,\n \n -CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA\n graft '). Has three vessel coronary disease.\n - severe AORTIC STENOSIS (mean gradient 47 mmHg) 0.8cm^2\n - + AR (per OSH echo )\n - h/o (unclear when)\n - Hyperlipidemia\n - HTN\n - Obstructive sleep apnea\n - PVD\n - B12 deficiency anemia\n - Ascending aortic aneurysm (4.2x4.2 in )\n - Anterior wall abdominal hernia\n - COPD on 2L O2 at home, required intubation x 3 in the last 3 months\n - Asthma\n - Alcohol abuse/DT's with withdrawal requiring intubation \n - Anxiety\n - Anti-E antibody transfusion reaction\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Tobacco: 150 pk-year smoker (currently smokes 1ppd and more in\n the past), still smoking.\n EtOH: Greater than 50 years of significant EtOH (previously reported 4\n tumblers of vodka/day, recently reporting 2-4 beers per day).\n Illicits: None\n Used to work in security and at a mattress factory, has not worked for\n several years.\n Walks without assistance at baseline\n Review of systems:\n Flowsheet Data as of 07:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 94 (91 - 94) bpm\n BP: 121/55(72) {106/43(56) - 121/62(74)} mmHg\n RR: 23 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83 kg (admission): 83 kg\n Height: 28 Inch\n Total In:\n 305 mL\n PO:\n TF:\n IVF:\n 305 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 205 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. NG tube in place.\n Neck: supple, JVP not elevated, no LAD\n Lungs: Mild wheezing L>R. No crackles.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Large ventral hernia present, reducible. Mild tenderness to\n palpation over hernia only. Non distended. No rebound or guarding.\n GU: Foley present\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 147 K/uL\n 11.3 g/dL\n 111 mg/dL\n 1.1 mg/dL\n 25 mg/dL\n 28 mEq/L\n 101 mEq/L\n 3.7 mEq/L\n 138 mEq/L\n 32.8 %\n 15.6 K/uL\n [image002.jpg]\n \n 2:33 A1/20/ 03:55 PM\n \n 10:20 P1/20/ 08:01 PM\n \n 1:20 P1/20/ 11:26 PM\n \n 11:50 P1/20/ 11:39 PM\n \n 1:20 A1/21/ 06:41 AM\n \n 7:20 P1/21/ 06:51 AM\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 9.0\n 15.6\n Hct\n 31.8\n 32.8\n Plt\n 142\n 147\n Cr\n 1.3\n 1.1\n TropT\n 0.26\n 0.21\n 0.17\n TC02\n 29\n 30\n 31\n Glucose\n 171\n 111\n Other labs: PT / PTT / INR:11.6/34.7/1.0, CK / CKMB /\n Troponin-T:50/16/0.17, ALT / AST:40/32, Alk Phos / T Bili:44/0.3,\n Differential-Neuts:88.7 %, Lymph:6.4 %, Mono:4.7 %, Eos:0.1 %, Lactic\n Acid:1.0 mmol/L, LDH:255 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.2\n mg/dL\n Fluid analysis / Other labs: Lactate 1.7\n Cr 2.6\n WBC 13.7\n Imaging: CT Abdomen \n Small bowel obstruction situated at the mouth of the large ventral\n hernia, with proximal small bowel dilated to 4 cm, and marked distal\n decompression.\n Residual oral contrast in large bowel from prior study (either \n or at OSH) suggests this could be early high grade obstruction.\n No extraluminal fluid or air.\n .\n CXR (my read): No infiltrates or effusions.\n Microbiology: Urine culture pending\n ECG: EKG: Sinus tachycardia @ 102bpm. LAD. Normal intervals. No ST\n segment changes.\n Assessment and Plan\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n IMPAIRED SKIN INTEGRITY\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n 70 year old man with a history of CAD s/p CABG, PAD, systolic CHF (EF\n 35%), severe COPD, severe AS (0.8cm2) & AI who was admitted to after\n NSTEMI and respiratory failure, now admitted to the MICU for SBO,\n requiring further fluid rescusitation.\n .\n # SBO: Seen on CT scan today. Patient has history of cholecystectomy\n and colon cancer, with prior sigmoid resection, and subsequent large\n ventral hernia. Hernia is reducable and not incarcerated. Exam not\n concerning for surgical abdomen.\n - f/ recs: medical management for now\n - NPO\n - IV fluids: NS @ 150cc/hour -will closely monitor respiratory status\n - continue NG tube to suction\n - IV Ativan or PR Phenergan (avoid IM dosing out of concern for CV side\n effects) PRN\n .\n # Acute renal failure: Cr 2.6. Baseline 1.1. Likely prerenal in the\n setting of inadequate fluid rescusitation. However patient also\n received C. cath on . So there may be a component of ATN\n contributing. Patient has critical AS with valve area of 0.8. However,\n currently requiring no Oxygen. Would favor further fluid rescusitation\n with close monitoring of respiratory status.\n -IV NS @ 150cc/hour x1L\n -recheck lytes in the AM\n -avoid nephrotoxins\n -renally dose meds\n .\n # Leukocytosis: WBC 13.7. Likely SBO. No other focal signs of\n infection. CXR clear. CT Abdomen without concern for abscess or\n diverticulitis.\n -obtain UA, UCx\n -obtain blood cultures if spikes a fever\n .\n # COPD exacerbation: Leading to respiratory failure and intubating at\n OSH. He is on 2L of continuous O2 as well as Albuterol, Advair, and\n Tiotropium at home. Completed a 5 day course of Levofloxacin.\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Steroids: On chronic prednisone, however given that patient is NPO,\n he was switched back to Methylprednisolone today.\n - continue methylpred 32mg IV q24h\n - continue IV bactrim for PCP prophylaxis given chronic steroid use\n .\n # Chronic systolic Congestive Heart Failure: EF 35% on most recent\n echo, also with severe AS. S/p cardiac catheterization, but not a\n candidate for aortoplasty. Currently dry on exam from emesis and SBO.\n - Careful IVF's @ 150cc/hr given AS to avoid pulmonary edema\n - Hold Imdur 60mg daily for now\n - Change metoprolol to 5mg IV q6h\n - Change enalapril to 0.625mg IV q6h\n .\n # CAD s/p NSTEMI: Patient s/p CABG ' (LIMA -> LAD, SVG -> D2, OM2,\n RCA; stent to RCA graft '). Patient s/p RCA stent x2. Peak CK 229.\n Patient currently on ASA, statin, beta-blocker. He did not receive\n Plavix as he has a history of GI bleed and thrombocytopenia while on\n Plavix. Given h/o AS, patient likely pre-load dependent.\n - Continue ASA 325mg PR daily\n - Unable to give Simvastatin 80mg qHS given NPO\n - Metoprolol 5mg IV q6h\n - Enalapril 0.625mg IV q6h\n - Unable to give Imdur 60mg given that NPO\n - Avoid SL Nitro for CP/angina\n .\n # Alcohol abuse: Patient with extensive EtOH history and an episode of\n DT in requiring intubation. His EtOH screen on at was\n negative and his wife reports that his last drink was on . No sx of\n withdrawl as an inpatient.\n - continue to monitor\n .\n # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam\n 1mg TID:PRN.\n - Unable to give po Celexa given NPO\n - Continue Lorazepam 1-2mg q4H:PRN anxiety\n .\n # Peripheral vascular disease: Patient with known PAD s/p Fem-\n bypass (unclear when). He also has a known ascending aortic aneurysm\n last measured at 4.2cm x 4.2cm in 5/. Pulses on left LE < RLE.\n Stable.\n - ASA 325mg PR daily\n - Hold Simvastatin 80mg qHS\n - Hold Pentoxyfylline SR 400mg TID given NPO\n .\n .\n # Normocytic Anemia: Iron studies normal. Patient takes Vitamin B-12\n for h/o deficiency.\n - continue to monitor\n - Hold Vit B12 given NPO\n .\n # GERD: Patient takes Omeprazole 20mg daily at home. Would hold on PPI\n given patient now on plavix. Will monitor for symptoms.\n .\n .\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia.\n .\n .\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399401,
"text": "Brief Nursing Admit Note:\n Received patient at 1700 from F3.\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399402,
"text": "Brief Nursing Admit Note:\n 70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399403,
"text": "Brief Nursing Admit Note 1700-1900:\n 70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Arrived CCU hemodynamically stable in no acute distress, complaining of\n mild () abdominal comfort. NGT to mid-level intermittent suction (\n surgical MD) draining light green colored bile. Infusing NS at 150\n ml/hr for 1 liter as ordered. Lung exam clear, slightly diminished\n bases, sats > 96% on 2 liters NC. Arrived SR, rate 90\ns with frequent\n PAC\ns noted, NIBP stable. Notable abdominal hernia, slight abdominal\n pain as above. Foley in place with minimal output. Skin with tear from\n tape placed at OSH on left arm. Patient sleeping comfortably shortly\n after admission. Wife updated by CCU team (transferring team on\n admission).\n General plan: NSTEMI management with medications s/p stents, has been\n CP free and working with PT. Supportive skin care, paper tape given\n fragile skin and skin tear present to left arm. Known history of ETOH\n withdrawal- monitor. On bactrim for infection prophylaxis. On\n solumedrol for COPD management. Close management of respiratory status\n with fluid administration.\n Plan for small bowel obstruction: IVF, maintain NPO staus, continue NG\n tube to suction per surgery recommendations. Has available IV and PR\n medications for nausea. MICU service to switch medications to IV as\n appropriate.\n Plan for acute renal failure: Caution with fluid resuscitation given\n critical AS. NS at 150 ml/hr for 1 liter. Follow lytes and renal labs\n per orders.\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399404,
"text": "Brief Nursing Admit Note 1700-1900:\n 70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Arrived CCU hemodynamically stable in no acute distress, complaining of\n mild () abdominal comfort. NGT to mid-level intermittent suction (\n surgical MD) draining light green colored bile. Infusing NS at 150\n ml/hr for 1 liter as ordered. Lung exam clear, slightly diminished\n bases, sats > 96% on 2 liters NC. Arrived SR, rate 90\ns with frequent\n PAC\ns noted, NIBP stable. Notable abdominal hernia, slight abdominal\n pain as above. Foley in place with minimal output. Skin with tear from\n tape placed at OSH on left arm. Patient sleeping comfortably shortly\n after admission. Wife updated by CCU team (transferring team on\n admission).\n General plan: NSTEMI management with medications s/p stents, has been\n CP free and working with PT. Supportive skin care, paper tape given\n fragile skin and skin tear present to left arm. Known history of ETOH\n withdrawal- monitor. On bactrim for PCP prophylaxis given that patient\n is on solumedrol for COPD management. Close management of respiratory\n status with fluid administration.\n Plan for small bowel obstruction: IVF, maintain NPO staus, continue NG\n tube to suction per surgery recommendations. Has available IV and PR\n medications for nausea. MICU service to switch medications to IV as\n appropriate.\n Plan for acute renal failure: Caution with fluid resuscitation given\n critical AS. NS at 150 ml/hr for 1 liter. Follow lytes and renal labs\n per orders.\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-31 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 399407,
"text": "Chief Complaint: Chief Complaint: respiratory failure\n Reason for MICU transfer: SBO, hypovolemia\n HPI:\n Mr. is a 70 year old man with a history of CAD s/p CABG in\n , systolic CHF (EF 45-50% in ), severe COPD, severe AS\n (0.8cm2) & AI, colon ca s/p sigmoid colectomy with a residual large\n ventral hernia who was admitted to on after being\n transferred from OSH for respiratory failure.\n .\n One day prior to admission his breathing and chest pain symptoms\n worsened. He was taken to OSH by ambulance and found to be non-verbal\n in the ED. He was initially treated for presumed systolic CHF\n exacerbation and COPD with CPAP, IV Solumedrol, nebulizers, Lasix, and\n Nitrates. He was also given a dose of IV Levaquin out of concern for\n infection but his respiratory rate declined and his ABG's demonstrated\n severe respiratory acidosis so he was intubated in the OSH ED. In the\n OSH ICU, EKG's demonstrated sinus tachycardia with left anterior\n fascicular block and ST depressions in II, V3, V4. CE's rose with CK's\n peaking at 229 and Troponin levels peaking at 0.45. He was placed on a\n Heparin gtt, ASA, beta-blocker, and a statin. The following morning, he\n was extubated and transferred to CCU on BIPAP per family\n request.\n .\n Cath showed mid RCA stenosis. DESx2 were placed. During his entire\n hospital stay he has been complaining of abdominal pain. KUB on \n showed distended bowel loops, no free air. Patient had worsening nausea\n and vomiting, abdominal pain, and no flatus. CT abdomen revealed SBO.\n On KUB showed air fluid levels. Surgery was consulted and\n recommended medical management. NG tube was placed. He received about\n 2L IV fluids over the past day. The primary team was hesitant to give\n more fluids in the setting of critical AS. He was transferred to the\n medical ICU for close monitoring for respiratory failure in the setting\n of IV fluids.\n .\n .\n On the floor, the patient is comfortable. He has some mild abdominal\n discomfort with palpation. Breathing comfortably, denies CP.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n cough, shortness of breath, or wheezing. Denies chest pain, chest\n pressure, palpitations, or weakness. Denies dysuria, frequency, or\n urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications on transfer:\n MethylPREDNISolone Sodium Succ 32 mg IV Q24H\n Lorazepam 1 mg IV Q6H:PRN nausea, anxiety\n Promethazine 25 mg PR Q6H:PRN nausea\n Lorazepam 1 mg IV ONCE:PRN nausea\n traZODONE 25 mg PO/NG HS:PRN insomnia\n Prochlorperazine 5-10 mg IV Q6H:PRN nausea\n Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY\n Clopidogrel 75 mg PO DAILY\n Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG QID:PRN gas pain\n Heparin 5000 UNIT SC TID\n Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY\n Omeprazole 20 mg PO DAILY\n Simvastatin 80 mg PO/NG HS\n Nicotine Patch 14 mg TD DAILY\n Acetaminophen 325-650 mg PO/PR Q8H:PRN pain, fever\n Lisinopril 2.5 mg PO/NG DAILY\n Docusate Sodium 100 mg PO BID\n Fish Oil (Omega 3) 1000 mg PO DAILY\n Cyanocobalamin 1000 mcg PO/NG DAILY\n Aspirin 325 mg PO/NG DAILY\n Pentoxifylline 400 mg PO TID\n Hydrocodone-Acetaminophen TAB PO BID:PRN pain\n Citalopram Hydrobromide 80 mg PO/NG DAILY\n Metoprolol Tartrate 25 mg PO/NG \n Albuterol 0.083% Neb Soln NEB IH Q4H:PRN shortness of breath\n Ipratropium Bromide Neb 2 NEB IH Q6H\n Past medical history:\n Family history:\n Social History:\n - GERD\n - h/o GI bleed and thrombocytopenia on Plavix\n - h/o recurrent C. difficile colitis\n - Colon cancer s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy\n - h/o cholecystitis s/p percutaneous cholecystostomy tube placement,\n \n -CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA\n graft '). Has three vessel coronary disease.\n - severe AORTIC STENOSIS (mean gradient 47 mmHg) 0.8cm^2\n - + AR (per OSH echo )\n - h/o (unclear when)\n - Hyperlipidemia\n - HTN\n - Obstructive sleep apnea\n - PVD\n - B12 deficiency anemia\n - Ascending aortic aneurysm (4.2x4.2 in )\n - Anterior wall abdominal hernia\n - COPD on 2L O2 at home, required intubation x 3 in the last 3 months\n - Asthma\n - Alcohol abuse/DT's with withdrawal requiring intubation \n - Anxiety\n - Anti-E antibody transfusion reaction\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Tobacco: 150 pk-year smoker (currently smokes 1ppd and more in\n the past), still smoking.\n EtOH: Greater than 50 years of significant EtOH (previously reported 4\n tumblers of vodka/day, recently reporting 2-4 beers per day).\n Illicits: None\n Used to work in security and at a mattress factory, has not worked for\n several years.\n Walks without assistance at baseline\n Review of systems:\n Flowsheet Data as of 07:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 94 (91 - 94) bpm\n BP: 121/55(72) {106/43(56) - 121/62(74)} mmHg\n RR: 23 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83 kg (admission): 83 kg\n Height: 28 Inch\n Total In:\n 305 mL\n PO:\n TF:\n IVF:\n 305 mL\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 205 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear. NG tube in place.\n Neck: supple, JVP not elevated, no LAD\n Lungs: Mild wheezing L>R. No crackles.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Large ventral hernia present, reducible. Mild tenderness to\n palpation over hernia only. Non distended. No rebound or guarding.\n GU: Foley present\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 147 K/uL\n 11.3 g/dL\n 111 mg/dL\n 1.1 mg/dL\n 25 mg/dL\n 28 mEq/L\n 101 mEq/L\n 3.7 mEq/L\n 138 mEq/L\n 32.8 %\n 15.6 K/uL\n [image002.jpg]\n \n 2:33 A1/20/ 03:55 PM\n \n 10:20 P1/20/ 08:01 PM\n \n 1:20 P1/20/ 11:26 PM\n \n 11:50 P1/20/ 11:39 PM\n \n 1:20 A1/21/ 06:41 AM\n \n 7:20 P1/21/ 06:51 AM\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 9.0\n 15.6\n Hct\n 31.8\n 32.8\n Plt\n 142\n 147\n Cr\n 1.3\n 1.1\n TropT\n 0.26\n 0.21\n 0.17\n TC02\n 29\n 30\n 31\n Glucose\n 171\n 111\n Other labs: PT / PTT / INR:11.6/34.7/1.0, CK / CKMB /\n Troponin-T:50/16/0.17, ALT / AST:40/32, Alk Phos / T Bili:44/0.3,\n Differential-Neuts:88.7 %, Lymph:6.4 %, Mono:4.7 %, Eos:0.1 %, Lactic\n Acid:1.0 mmol/L, LDH:255 IU/L, Ca++:8.8 mg/dL, Mg++:2.1 mg/dL, PO4:3.2\n mg/dL\n Fluid analysis / Other labs: Lactate 1.7\n Cr 2.6\n WBC 13.7\n Imaging: CT Abdomen \n Small bowel obstruction situated at the mouth of the large ventral\n hernia, with proximal small bowel dilated to 4 cm, and marked distal\n decompression.\n Residual oral contrast in large bowel from prior study (either \n or at OSH) suggests this could be early high grade obstruction.\n No extraluminal fluid or air.\n .\n CXR (my read): No infiltrates or effusions.\n Microbiology: Urine culture pending\n ECG: EKG: Sinus tachycardia @ 102bpm. LAD. Normal intervals. No ST\n segment changes.\n Assessment and Plan\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n IMPAIRED SKIN INTEGRITY\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n 70 year old man with a history of CAD s/p CABG, PAD, systolic CHF (EF\n 35%), severe COPD, severe AS (0.8cm2) & AI who was admitted to after\n NSTEMI and respiratory failure, now admitted to the MICU for SBO,\n requiring further fluid rescusitation.\n .\n # SBO: Seen on CT scan today. Patient has history of cholecystectomy\n and colon cancer, with prior sigmoid resection, and subsequent large\n ventral hernia. Hernia is reducable and not incarcerated. Exam not\n concerning for surgical abdomen.\n - f/ recs: medical management for now\n - NPO\n - IV fluids: NS @ 150cc/hour -will closely monitor respiratory status\n - continue NG tube to suction\n - IV Ativan or PR Phenergan (avoid IM dosing out of concern for CV side\n effects) PRN\n .\n # Acute renal failure: Cr 2.6. Baseline 1.1. Likely prerenal in the\n setting of inadequate fluid rescusitation. However patient also\n received C. cath on . So there may be a component of ATN\n contributing. Patient has critical AS with valve area of 0.8. However,\n currently requiring no Oxygen. Would favor further fluid rescusitation\n with close monitoring of respiratory status.\n -IV NS @ 150cc/hour x1L\n -recheck lytes in the AM\n -avoid nephrotoxins\n -renally dose meds\n .\n # Leukocytosis: WBC 13.7. Likely SBO. No other focal signs of\n infection. CXR clear. CT Abdomen without concern for abscess or\n diverticulitis.\n -obtain UA, UCx\n -obtain blood cultures if spikes a fever\n .\n # COPD exacerbation: Leading to respiratory failure and intubating at\n OSH. He is on 2L of continuous O2 as well as Albuterol, Advair, and\n Tiotropium at home. Completed a 5 day course of Levofloxacin.\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Steroids: On chronic prednisone, however given that patient is NPO,\n he was switched back to Methylprednisolone today.\n - continue methylpred 32mg IV q24h\n - continue IV bactrim for PCP prophylaxis given chronic steroid use\n .\n # Chronic systolic Congestive Heart Failure: EF 35% on most recent\n echo, also with severe AS. S/p cardiac catheterization, but not a\n candidate for aortoplasty. Currently dry on exam from emesis and SBO.\n - Careful IVF's @ 150cc/hr given AS to avoid pulmonary edema\n - Hold Imdur 60mg daily for now\n - Change metoprolol to 5mg IV q6h\n - Change enalapril to 0.625mg IV q6h\n .\n # CAD s/p NSTEMI: Patient s/p CABG ' (LIMA -> LAD, SVG -> D2, OM2,\n RCA; stent to RCA graft '). Patient s/p RCA stent x2. Peak CK 229.\n Patient currently on ASA, statin, beta-blocker. He did not receive\n Plavix as he has a history of GI bleed and thrombocytopenia while on\n Plavix. Given h/o AS, patient likely pre-load dependent.\n - Continue ASA 325mg PR daily\n - Unable to give Simvastatin 80mg qHS given NPO\n - Metoprolol 5mg IV q6h\n - Enalapril 0.625mg IV q6h\n - Unable to give Imdur 60mg given that NPO\n - Avoid SL Nitro for CP/angina\n .\n # Alcohol abuse: Patient with extensive EtOH history and an episode of\n DT in requiring intubation. His EtOH screen on at was\n negative and his wife reports that his last drink was on . No sx of\n withdrawl as an inpatient.\n - continue to monitor\n .\n # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam\n 1mg TID:PRN.\n - Unable to give po Celexa given NPO\n - Continue Lorazepam 1-2mg q4H:PRN anxiety\n .\n # Peripheral vascular disease: Patient with known PAD s/p Fem-\n bypass (unclear when). He also has a known ascending aortic aneurysm\n last measured at 4.2cm x 4.2cm in 5/. Pulses on left LE < RLE.\n Stable.\n - ASA 325mg PR daily\n - Hold Simvastatin 80mg qHS\n - Hold Pentoxyfylline SR 400mg TID given NPO\n .\n .\n # Normocytic Anemia: Iron studies normal. Patient takes Vitamin B-12\n for h/o deficiency.\n - continue to monitor\n - Hold Vit B12 given NPO\n .\n # GERD: Patient takes Omeprazole 20mg daily at home. Would hold on PPI\n given patient now on plavix. Will monitor for symptoms.\n .\n .\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia.\n .\n .\n .\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n I was physically present with the resident team for discussion of the\n above findings in regards to history, physical data and assessment and\n plan with which I agree on this date. I would add the following\n comments.\n 70 yo male with severe AS, COPD and SBO with recent resection. He now\n has admission initially with hypercarbic respiratory failure and NSTEMI\n at OSH and then was admitted to CCU here at . Following admission\n patient has two stents placed to RCA after being successfully\n extubated.\n Now patient with nausea, vomiting and abdominal pain with imaging\n consistent with SBO recurrent and with surgery evaluation patient now\n undergoing medical management given relative considerations with recent\n cardiac events and hopes for resolution with bowl decompression.\n EXAM-\n -Patient on 2 lpm O2\n -Patient with mild abdominal pain with palpation, significantly\n decreased bowel sounds\n KUB-Patient with dilated bowel loops consistent with obstruction.\n CT-High grade small bowel obstruction at the level of ventral hernia\n In summary patient is 70 yo male with history of colon cancer and now\n with recurrent SBO presenting with significant pain and distention.\n Certainly bowel ischemia is of concern given significant vascular\n disease or referred pain from true cardiac source. The level of\n obstruction is of concern for being related to hernia but this is\n easily reducible on exam.\n 1)Small Bowel Obstruction-\n -NPO\n -NGT to suction\n -Follow abdominal exam\n -Daily KUB reasonable until improvement seen\n -Will have to be conservative with fluids in the setting of substantial\n aortic stenosis\n 2)Respiratory Distress-Presenting as primarily tachypnea rather than\n hypoxemia\n -Will continue with steroid taper\n -Maintain saturations >90% with supplemental O2\n -Continue MDI\n 3)Renal Failure-_Chronic\n -Hydration as needed based upon obstruction\n -Will follow urine output\n Additional Issues to be addressed as defined in the housestaff note of\n this date.\n Critical Care Time-35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 22:47 ------\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 399479,
"text": "70 year old man initially transferred to BICMC from OSH with\n respiratory hypercarbic failure and NSTEMI. While here, had 2 stents\n (DES) placed in RCA and was extubated. Patient was TX from CCU to \n 3 when patient developed nausea, vomiting; now SBO by CT scan. Patient\n transferred back to CCU on for medical management of SBO in\n setting of rising creatinine, severe AS, and recent cardiac\n intervention.\n PMH: CAD s/p CABG , systolic CHR (EF 45-50% ) severe COPD,\n severe AS and AI, colon CA s/p sigmoid colectomy with a residual large\n ventral hernia.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n + hypo active bowel sounds\n NGT with 950cc\ns bilious output MN\n 12pm\n No nausea\n No flatus or stool\n Action:\n NGT to LCWS\n NPO\n Pepcid IV\n NS @ 150 cc\ns / hr\n Response:\n No abdominal pain\n No nausea\n NGT output has decreased to just 200 cc\ns in the last 4\n hours\n Plan:\n Continue medical management\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n patient\ns creatinine 2.6\n minimal urine output\n Action:\n IVF resuscitation\n Response:\n Today ~ 0600 labs, creatinine 1.6\n Urine output ~ 40-60 cc\ns an hour\n Clear yellow urine\n Fluid balance MN -16 pm including NGT output +1000 cc\n Plan:\n Follow up on urine culture that is pending\n Continue fluid resuscitation\n Possibly decrease IVF rate as patient is now one liter\n positive.\n .H/O myocardial infarction\n Assessment:\n C/O chest pain / tightness on previous shift with EKG\n showing some ST changes treated with Morphine and rectal aspirin.\n LS clear, no SOB\n Action:\n Repeat EKG done one hour later ~ 0730 am showing no changes\n from previous EKG per cardiology and MICU team.\n Plavix given via NGT clamped x 1 hour\n CK and Troponin levels rechecked @ 1400, results pending\n Oxygen @ 2 l/m\n Response:\n Troponin .35, MICU team aware, 1400 pending\n No further chest pain\n IV lopressor and Vasotec given as ordered\n Plan:\n Continue to monitor for S+S of chest pain\n MICU team to discuss with Interventional Cardiology\n To transfer to 3 step down unit when bed available\n Patients wife was updated by MICU team at her request\n Demographics\n Attending MD:\n \n Admit diagnosis:\n MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n Code status:\n Full code\n Height:\n 28 Inch\n Admission weight:\n 83 kg\n Daily weight:\n 82.3 kg\n Allergies/Reactions:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Precautions: Contact\n PMH: Anemia, COPD, ETOH, Renal Failure, Smoker\n CV-PMH: Angina, CAD, CHF, Hypertension, MI, PVD\n Additional history: Carotid stenosis L, AS, colon ca s/p collectomy, lg\n Imbilical hernia\n Surgery / Procedure and date: S/P 2 stents placed RCA\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:123\n D:57\n Temperature:\n 99.3\n Arterial BP:\n S:128\n D:54\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 83 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 30% %\n 24h total in:\n 2,935 mL\n 24h total out:\n 1,960 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 06:44 AM\n Potassium:\n 4.2 mEq/L\n 06:44 AM\n Chloride:\n 105 mEq/L\n 06:44 AM\n CO2:\n 26 mEq/L\n 06:44 AM\n BUN:\n 45 mg/dL\n 06:44 AM\n Creatinine:\n 1.6 mg/dL\n 06:44 AM\n Glucose:\n 93 mg/dL\n 06:44 AM\n Hematocrit:\n 32.5 %\n 06:44 AM\n Finger Stick Glucose:\n 122\n 05:00 PM\n Additional pertinent labs:\n 1430 troponin still pending\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: patient wearing glasses\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: \n Transferred to: \n Date & time of Transfer: 17:00\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 399469,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n + hypo active bowel sounds\n NGT with 950cc\ns bilious output MN\n 12pm\n No nausea\n No flatus or stool\n Action:\n NGT to LCWS\n NPO\n Pepcid IV\n NS @ 150 cc\ns / hr\n Response:\n No abdominal pain\n No nausea\n Plan:\n Continue medical management\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n patient\ns creatinine 2.6\n minimal urine output\n Action:\n IVF resuscitation\n Response:\n Today ~ 0600 labs, creatinine 1.6\n Urine output ~ 40-60 cc\ns an hour\n Clear yellow urine\n Fluid balance MN -12pm including NGT output + 600 cc\n Plan:\n Follow up on urine culture that is pending\n Continue fluid rescucitation\n .H/O myocardial infarction\n Assessment:\n C/O chest pain / tightness on previous shift with EKG\n showing some ST changes treated with Morphine and rectal aspirin.\n Action:\n Repeat EKG done one hour later ~ 0730 am showing no changes\n from previous EKG per cardiology and MICU team.\n Plavix given via NGT clamped x 1 hour\n Response:\n Troponin .35, MICU team aware\n Plan:\n To recheck Troponin @ 1400\n Continue to monitor for S+S of chest pain\n MICU team to discuss with Interventional Cardiology\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 399470,
"text": "70 year old man initially transferred to BICMC from OSH with\n respiratory hypercarbic failure and NSTEMI. While here, had 2 stents\n (DES) placed in RCA and was extubated. Patient was TX from CCU to \n 3 when patient developed nausea, vomiting; now SBO by CT scan. Patient\n transferred back to CCU on for medical management of SBO in\n setting of rising creatinine, severe AS, and recent cardiac\n intervention.\n PMH: CAD s/p CABG , systolic CHR (EF 45-50% ) severe COPD,\n severe AS and AI, colon CA s/p sigmoid colectomy with a residual large\n ventral hernia.\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n + hypo active bowel sounds\n NGT with 950cc\ns bilious output MN\n 12pm\n No nausea\n No flatus or stool\n Action:\n NGT to LCWS\n NPO\n Pepcid IV\n NS @ 150 cc\ns / hr\n Response:\n No abdominal pain\n No nausea\n Plan:\n Continue medical management\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n patient\ns creatinine 2.6\n minimal urine output\n Action:\n IVF resuscitation\n Response:\n Today ~ 0600 labs, creatinine 1.6\n Urine output ~ 40-60 cc\ns an hour\n Clear yellow urine\n Fluid balance MN -12pm including NGT output + 600 cc\n Plan:\n Follow up on urine culture that is pending\n Continue fluid resuscitation\n .H/O myocardial infarction\n Assessment:\n C/O chest pain / tightness on previous shift with EKG\n showing some ST changes treated with Morphine and rectal aspirin.\n Action:\n Repeat EKG done one hour later ~ 0730 am showing no changes\n from previous EKG per cardiology and MICU team.\n Plavix given via NGT clamped x 1 hour\n Response:\n Troponin .35, MICU team aware\n Plan:\n To recheck Troponin @ 1400\n Continue to monitor for S+S of chest pain\n MICU team to discuss with Interventional Cardiology\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399112,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n PTT at 23:30 subtherapeutic- 36.2 on 450units/hr heparin. NPO\n Action:\n CKs cycled\n Heparin gtt ^d per SS order\n Maintance fluid started for lower UOP and Cr 1.3\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n F/u w/ PTT at 06:30\n ? cardiac cath today to assess AS\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 2L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted. Slight hand tremors pt states he\n experiences occas. Of note: pt does state he has anxiety at baseline.\n Anxious r/ missing MD appt today being hospitalized\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix\n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n Less bleeding noted from skin tear. Pt able to turn x1 assist in bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399110,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n PTT at 23:30 subtherapeutic- 36.2 on 450units/hr heparin. NPO\n Action:\n CKs cycled\n Heparin gtt ^d per SS order\n Maintance fluid started for lower UOP and Cr 1.3\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n F/u w/ PTT at 06:30\n ? cardiac cath today to assess AS\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 2L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n ? DC NGT today as pt alert and able to swallow pills\n H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix at 20:45 \n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n No further bleeding noted from skin tear. Pt able to turn x1 assist in\n bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399104,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n PTT subtherapeutic 36.2 on 450units/hr heparin.\n Action:\n NPO for possible cath today to assess AS\n CKs cycled\n Maintance fluid started\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n F/u w/ PTT at 06:30\n .H/O chronic obstructive pulmonary disease (COPD,\n Bronchitis, Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 2L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n ? DC NGT today as pt alert and able to swallow pills\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix at 20:45 \n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n No further bleeding noted from skin tear. Pt able to turn x1 assist in\n bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399105,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n PTT at 23:30 subtherapeutic- 36.2 on 450units/hr heparin. NPO\n Action:\n CKs cycled\n Maintance fluid started for lower UOP and Cr 1.3\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n F/u w/ PTT at 06:30\n ? cardiac cath today to assess AS\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 2L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n ? DC NGT today as pt alert and able to swallow pills\n H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix at 20:45 \n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n No further bleeding noted from skin tear. Pt able to turn x1 assist in\n bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399425,
"text": "70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV. , no po meds overnight per MICU team\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 300 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n On 2 L NC sating 94-98% lungs clear but diminished at bases.\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr\n Response:\n u/o now 30-70 cc/hr,\n SBP 100\ns-130\n Creat. Down to 1.8, BUN 47.\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399426,
"text": "70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV. , no po meds overnight per MICU team\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 300 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n On 2 L NC sating 94-98% lungs clear but diminished at bases.\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr throughout night\n Response:\n u/o now 30-70 cc/hr,\n SBP 100\ns-130\n Creat. down to 1.8, BUN 47.\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399103,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n PTT subtherapeutic 36.2 on 450units/hr heparin.\n Action:\n NPO for possible cath today to assess AS\n CKs cycled\n Maintance fluid started\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n F/u w/ PTT at 06:30\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 2L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n ? DC NGT today as pt alert and able to swallow pills\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix at 20:45 \n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n No further bleeding noted from skin tear. Pt able to turn x1 assist in\n bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399092,
"text": "Pt is a 70yo man with PMH severe AS ( 0.8) CABG/CAD, recent cath\n with 3VD & TO of SVGs and patent LIMA-LAD. COPD on home O2, ETOH\n abuse with history of DTs. Presented to w/ acute hypercarbic\n respiratory distress, s/p BIPAP trial-> intubation. He was treated\n with solu-medrol and eventually extubated, although was found to have\n continued dypnea and continuous elevated cardiac enzymes CK 51->229,\n Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? plavix\n load. Tnsf to for possible cath and further management. Received\n on BIPAP, heparin gtt at 800 units/hr. Noted lg skin tear (? from tape)\n on L arm.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received pt A+Ox3, coop w/ care. No c/o chest pain/ sob, no s/s of etoh\n withdrawl. On Heparin gtt @ 800 units/hr. On BIPAP mask 30% 8/5, RR\n 20s, sats >95%. Lg skin tear on L medial arm covered w/ dsd.\n Action:\n Made NPO, resumed Heparin gtt at 800 units/hr. Cont\nd on BIPAP 30% 8/5.\n Placed on CIWA scale, prn ativan order. L arm dsg changed, wound 6cm x\n 6cm, oozing blood. Redressed w/ adaptic gauze & kerlex.\n Response:\n PTT 116, heparin reduced to 450 units/hr. PTT due at 1130. Sleeping w/o\n s/s of withdrawls.\n Plan:\n Possible cath intervention tomorrow, intern to place A-line. Monitor\n CIWA.\n"
},
{
"category": "Physician ",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 399099,
"text": "Chief Complaint: shortness of breath\n HPI:\n Mr. is a 70 year old man with a complicated history including\n CAD s/p CABG in , PVD, systolic CHF (EF 45-50% in ) w/\n diastolic dysfunction, severe COPD, severe AS (0.8cm2) & AI who\n presents as a transfer from for respiratory\n failure. Mr. has been hospitalized multiple times in the last\n several months for respiratory failure and has been intubated 3 times\n over the past 3 months most recently in early at . Following\n his most recent discharge, he was seen by his PCP, . on \n for persistent upper respiratory symptoms and placed on a Z-pack. His\n symptoms improved, but the patient's wife called the patient's PCP 3\n days prior to this admission stating that the patient had developed\n worsening cough productive of thick yellow-green sputum and worsening\n shortness of breath on his home 2L O2, as well as chest tightness that\n resolved after SL NTG x 2. At that time, his wife reported that he had\n no chest pain, nausea, sweating, fever, chills, vomiting or dizziness\n and he was directed to for further evaluation.\n For unclear reasons, he did not seek care until the day prior to\n admission when his breathing and chest pain symptoms worsened. He was\n taken to by ambulance and found to be non-verbal\n in the ED. CXR was negative and pBNP was 3969. He was initially treated\n for presumed systolic CHF exacerbation and COPD with CPAP, IV\n Solumedrol, nebulizers, Lasix, and Nitrates. He was also given a dose\n of IV Levaquin out of concern for infection but his respiratory rate\n declined and his ABG's demonstrated severe respiratory acidosis so he\n was intubated in the ED. In the ICU, EKG's demonstrated\n sinus tachycardia with left anterior fascicular block and ST\n depressions in II, V3, V4. CE's rose with CK's peaking at 229 and\n Troponin levels peaking at 0.45. He was placed on a Heparin gtt, ASA,\n beta-blocker, and a statin. The following morning, his respiratory\n status improved and he was extubated and placed on BIPAP before being\n transferred to the at family request.\n On arrival to the CCU, the patient was noted to be on BIPAP, but not in\n respiratory distress. He was able to speak with the health care team,\n but demonstrated a visible left hand tremor and was relative immobile.\n acknowledges some mild shortness of breath, but otherwise had not\n complaints.\n On review of systems, he denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, myalgias, joint pains, cough,\n hemoptysis, black stools or red stools. He denies recent fevers, chills\n or rigors, chest pain, ankle edema, palpitations, syncope or\n presyncope.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 450 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:50 PM\n Other medications:\n ALBUTEROL SULFATE 90 mcg HFA Inhaler 1-2 puffs q4-6H:PRN\n AMITRIPTYLINE 50 mg qHS\n CITALOPRAM 80mg daily\n FLUTICASONE-SALMETEROL 500 mcg-50 mcg \n HYDROCODONE-ACETAMINOPHEN 5 mg-500 mg :PRN\n IPRATROPIUM-ALBUTEROL 2.5-0.5 mg/3 mL NEB QID\n ISOSORBIDE MONONITRATE SR 60 mg daily\n LORAZEPAM 1 mg TID:PRN anxiety\n METOPROLOL TARTRATE 25mg \n NITROGLYCERIN 0.4 mg SL PRN:chest pain\n OMEPRAZOLE EC 20 mg daily\n PENTOXIFYLLINE SR 400 mg TID\n PREDNISONE taper (taper unknown)\n QUETIAPINE 12.5 mg Tablet \n SIMVASTATIN 20 mg qHS\n TIOTROPIUM BROMIDE 18 mcg, 1 puff daily\n ASPIRIN 81 mg Tablet \n CYANOCOBALAMIN 1,000 mcg daily\n OMEGA-3 FATTY ACIDS 1,000 mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG:CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA\n graft '). Has three vessel coronary disease.\n -PERCUTANEOUS CORONARY INTERVENTIONS: last cath in demonstrated\n occlusions of all SVG's\n -PACING/ICD: none\n 3. OTHER PMH:\n - severe AORTIC STENOSIS (mean gradient 47 mmHg) 0.8cm^2\n - + AR (per OSH echo )\n - h/o (unclear when)\n - Hyperlipidemia\n - HTN\n - Obstructive sleep apnea\n - GERD\n - h/o GI bleed and thrombocytopenia on Plavix\n - h/o recurrent C. difficile colitis\n - Colon cancer s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy\n - h/o cholecystitis s/p percutaneous cholecystostomy tube placement,\n \n - PVD\n - B12 deficiency anemia\n - Ascending aortic aneurysm (4.2x4.2 in )\n - Anterior wall abdominal hernia\n - COPD on 2L O2 at home, required intubation x 3 in the last 3 months\n - Asthma\n - Alcohol abuse/DT's with withdrawal requiring intubation \n - Anxiety\n - Anti-E antibody transfusion reaction\n Father died of MI at 57. One brother with emphysema, one brother with a\n brain tumor.\n Occupation: unemployed, Used to work in security and at a mattress\n factory, has not worked for several years.\n Drugs: None\n Tobacco: 150 pk-year smoker, currently smokes 1 ppd\n Alcohol: Greater than 50 years of significant EtOH (previously reported\n 4 tumblers of vodka/day, recently reporting 2-4 beers per day). Last\n drink two days prior to admission.\n Other: Walks without assistance at baseline\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Rash\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.1\nC (97\n HR: 86 (80 - 89) bpm\n BP: 147/62(94) {135/55(85) - 147/63(94)} mmHg\n RR: 14 (8 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 28 Inch\n Total In:\n 150 mL\n PO:\n TF:\n IVF:\n 80 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -210 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 665 (665 - 665) mL\n PS : 8 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.46/40/129/30/5\n Ve: 6.1 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: Well nourished man, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 142 K/uL\n 11.0 g/dL\n 171 mg/dL\n 1.3 mg/dL\n 25 mg/dL\n 30 mEq/L\n 99 mEq/L\n 3.8 mEq/L\n 137 mEq/L\n 31.8 %\n 9.0 K/uL\n [image002.jpg]\n \n 2:33 A1/20/ 03:55 PM\n \n 10:20 P1/20/ 08:01 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.0\n Hct\n 31.8\n Plt\n 142\n Cr\n 1.3\n TropT\n 0.26\n TC02\n 29\n Glucose\n 171\n Other labs: PT / PTT / INR:12.0/116.0/1.0, CK / CKMB /\n Troponin-T:124/16/0.26, ALT / AST:46/45, Alk Phos / T Bili:48/0.4,\n Differential-Neuts:90.0 %, Lymph:7.1 %, Mono:2.2 %, Eos:0.6 %, Lactic\n Acid:1.0 mmol/L, LDH:262 IU/L, Ca++:9.1 mg/dL, Mg++:1.6 mg/dL, PO4:3.4\n mg/dL\n Assessment and Plan\n 70 year old man with a complicated history including CAD s/p CABG, PAD,\n systolic CHF (EF 45-50% in ) w/ diastolic dysfunction, severe\n COPD, severe AS (0.8cm2) & AI who presents as a transfer from for respiratory failure.\n # Respiratory failure: Patient with known history of COPD, Asthma, and\n OSA as well as an extensive smoking history. He is on 2L of continuous\n O2 as well as Albuterol, Advair, and Tiotropium at home and over the\n past 3 months has required multiple intubations for respiratory\n distress despite repeated courses of Prednisone & antibiotics, most\n recently approximately 2 weeks ago. He was intubated on at for\n an ABG of 7.12/91/62/32 and was extubated on AM to CPAP prior to\n transfer after improved respiratory status. Etiology likely\n exacerbation of obstructive lung disease with component of acute\n systolic CHF as patient does not demonstrate e/o infection.\n - Repeat CXR\n - BIPAP PRN\n - Albuterol & Ipratropium nebs q6H:PRN SOB, wheezing\n - Levofloxacin 750mg daily, day \n - A-line with regular ABG's\n - Prednisone PO 40mg daily\n # PUMP: Patient with known systolic heart failure, last EF in \n demonstrated EF 45-50% with severe AS (mean gradient 47 mm Hg and area\n 0.8cm^2) and + AR. Prior catheterization in supports mild\n pulmonary hypertension with mean PA pressure 20mm Hg. His EF is\n unchanged from echocardiograms, but as his AR has progressed\n significantly since his last echo one month prior, his true forward\n flow is likely more compromised than his EF would suggest. CXR's from\n OSH have not demonstrated e/o congestion or effusions and clinical exam\n does not support fluid overload, but pBNP was elevated at 3969. While\n patient has known 3VD, may benefit from cardiac catheterization for\n aortic valvuloplasty.\n - Hold home Imdur for now\n - Continue Metoprolol 25mg \n - Start Lisinopril 2.5mg daily\n - Patient NPO for now pending possible catheterization for aortic\n valvuloplasty & possible percutaneous valve replacement\n - Patient unlikely to be surgical candidate given recent functional\n status, but can consider Csurg eval if patient improves\n # CORONARIES: Patient s/p CABG ' (LIMA -> LAD, SVG -> D2, OM2, RCA;\n stent to RCA graft '). His last cardiac catheterization in \n demonstrated three vessel coronary disease with a patent LIMA, but\n occlusion of all vein grafts. Patient with possible old inferior MI\n based on micro-Q waves in II, III, AvF, but EKG on admission does not\n demonstrate new ST changes. CE's trending down from OSH levels (peak CK\n 229) and patient CP free. Patient currently on Heparin gtt, ASA,\n statin, beta-blocker. He did not receive Plavix at OSH as he has a\n history of GI bleed and thrombocytopenia while on Plavix.\n - Trend CE's\n - Continue Heparin gtt for 48 hours from initiation (started PM)\n - Continue ASA 325mg daily\n - Simvastatin 80mg qHS\n - Metoprolol 25mg \n # RHYTHM: Patient without known history of arrythmia, but micro-Q waves\n in II, III, and AvF suggest prior inferior infarct not seen on ECG from\n 11/. Currently not an active issue, but will continue to monitor\n closely.\n - On continuous telemetry\n # Hypertension: Patient takes Imdur SR 60 mg daily & Metoprolol\n Tartrate 25mg at home. Blood pressures at OSH and in CCU have been\n well-controlled. Given h/o AS, patient likely pre-load dependent.\n - Hold Imdur for now\n - Continue Metoprolol 25mg with holding parameters\n # Hyperlipidemia: Patient takes Simvastatin 20mg qHS at home. Given\n question of ACS, high dose statin warranted.\n - Simvastatin 80mg qHS\n - Fish Oil 1,000mg daily\n # Alcohol abuse: Patient with extensive EtOH history and an episode of\n DT in requiring intubation. His EtOH screen on at was\n negative and his wife reports that his last drink was on .\n - CIWA scale\n - If CIWA > 10, Lorazepam 1-2mg q4H:PRN\n # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam\n 1mg TID:PRN, and Seroquel 12.5mg at home. Per OMR records, patient\n prefers not to take Seroquel out of concern for side effects, so it is\n unlikely to be an active medication.\n - Continue Celexa 80mg daily\n - Continue Lorazepam 1-2mg q4H:PRN anxiety/withdrawal\n # Peripheral vascular disease: Patient with known PAD s/p Fem-\n bypass (unclear when). He also has a known ascending aortic aneurysm\n last measured at 4.2cm x 4.2cm in 5/.\n - ASA 325mg daily\n - Simvastatin 80mg qHS\n - Pentoxyfylline SR 400mg TID\n # Chronic Renal insufficiency: Baseline Cr 1.2-1.3. Cr on admission\n 1.3. Etiology unknown, but not currently an active issue.\n - Daily Cr\n - Avoid nephrotoxic agents\n # Anemia: Patient with known Vitamin B-12 deficiency anemia for which\n he receives daily supplementation. He has an Anti-E antibody\n transfusion reaction making him prone to hemolytic anemia from\n transfusions. His last iron studies were assessed in and he has\n had iron deficiency in the past.\n - Active T&S\n - CBC\n - Continue B-12 1,000 mcg daily\n - F/U iron studies\n # GERD: Patient takes Omeprazole 20mg daily at home.\n - Continue Omeprazole PO 20mg daily\n # H/o recurrent C. difficile colitis: Patient has failed multiple\n Flagyl regimens in the past in the context of EtOH use, successfully\n treated with extended course Vancomycin.\n - Send C.diff if patient develops diarrhea\n # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis\n ' and adjuvant Xeloda therapy with resulting post-surgical anterior\n wall abdominal hernia. Patient uses belt for hernia control, but this\n has exacerbated SOB in the past, so no plan for hernia belt.\n # Active smoking habit: Patient smokes ~ 1ppd with >150 pack year\n history.\n - Nicotine TD\n ICU Care\n Nutrition: NPO after MN\n Glycemic Control: none\n Lines:\n 22 Gauge - 03:50 PM\n 20 Gauge - 03:51 PM\n A-line\n \n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: none\n Communication: Patient & patient\ns wife (\n Code status: Full code (confirmed with patient & patient\ns wife)\n Disposition: pending clinical improvement\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399418,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV.\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 200 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n On 2 L NC sating 94-98% lungs clear but diminished at bases.\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr\n Response:\n u/o now 30-60 cc/hr,\n SBP 100\ns-130\n Creat.\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399419,
"text": "70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV. , no po meds overnight per MICU team\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 200 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n On 2 L NC sating 94-98% lungs clear but diminished at bases.\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr\n Response:\n u/o now 30-70 cc/hr,\n SBP 100\ns-130\n Creat. This am\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399420,
"text": "70 year old man with a history of CAD s/p CABG in , systolic CHF\n (EF 45-50% in ), severe COPD, severe AS (0.8cm2) & AI, colon ca\n s/p sigmoid colectomy with a residual large ventral hernia who was\n admitted to on after being transferred from OSH for\n respiratory failure. Transferred to per family request, admitted\n CCU service . Ruled-in for an NSTEMI, taken to cardiac cath where 2\n DES were placed to his RCA. Transferred to 3 on where he\n continued to complain of abdominal pain. : KUB showed distended\n bowel loops, no free air. Patient had worsening nausea and vomiting,\n abdominal pain, and no flatus. : CT abdomen revealed small bowel\n obstruction, surgery was consulted and recommended medical management.\n NG tube was placed. He received about 2L IV fluids over the past day.\n He is now transferred to the MICU service (CCU border) for close\n monitoring of fluid administration given critical AS in combination\n with his acute renal failure (now 2.6 rising from admission level of\n 1.2).\n Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV. , no po meds overnight per MICU team\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 300 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n On 2 L NC sating 94-98% lungs clear but diminished at bases.\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr\n Response:\n u/o now 30-70 cc/hr,\n SBP 100\ns-130\n Creat. This am\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399089,
"text": "Pt is a 70yo man with PMH severe AS ( 0.8) CABG/CAD, recent cath\n with 3VD & TO of SVGs and patent LIMA-LAD. COPD on home O2, ETOH\n abuse with history of DTs. Presented to w/ acute hypercarbic\n respiratory distress, s/p BIPAP trial-> intubation. He was treated\n with solu-medrol and eventually extubated, although was found to have\n continued dypnea and continuous elevated cardiac enzymes CK 51->229,\n Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? plavix\n load. Tnsf to for possible cath and further management. Received\n on BIPAP, heparin gtt at 800 units/hr. Noted lg skin tear (? from tape)\n on L medial forearm, applied adaptic/ dsd cover.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received pt A+Ox3, coop w/ care. No c/o chest pain/ sob, no s/s of etoh\n withdrawl. On Heparin gtt @ 800 units/hr. On BIPAP mask\n Action:\n NPO, Restarted on Heparin gtt at 800 units/hr. Conts on BIPAP\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 399184,
"text": "Myocardial infarction, acute (NSTEMI)/ Aortic stenosis/ CHF\n Assessment:\n Heparin gtt infusing at 550units/hr. NPO\n Action:\n CKs cycled\n Heparin gtt stopped, diet resumed.\n Maintance fluid conts for lower UOP and Cr 1.3\n Response:\n No pain, cardiac enzymes trending down. No further hematuria\n Plan:\n NPO p mn. Cardiac cath tomorrow to assess AS\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n NIMV sats 98-100%. ABG 7.46/40/129\n Action:\n Placed on 1L NC w/o drop in sats, ABG 7.46/41/133\n SMOKING CESSATION packet given\n Levofloxacin ordered for 4 doses\n Response:\n Comfortable, no SOB/ distress\n Plan:\n Wean 02 as tol (pt has been on 2L NC at home)\n Continue nebs/steroids/abx\ncheck FS QID while on prednisone\n Re-inforce smoking cessation\n H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks ~1 beer/day per pt. Unsure last drink\n Action:\n CIWA Q4hrs\n Response:\n No evidence of ETOH withdrawal noted. Slight hand tremors pt states he\n experiences occas. Of note: pt does state he has anxiety at baseline.\n Anxious r/ missing MD appt today being hospitalized\n Plan:\n Continue to monitor, Valium PRN\n Impaired Skin Integrity\n Assessment:\n Lg skin tear L arm-bleeding. Mult ecchymotic area on arms.\n Red/blanching heels and elbows\n Action:\n SKIN TEAR: Dsg changed\n adaptic f/b aquacel, gauze & wrapped\n in kerlix\n Heels and elbows well lubricated w/ aloe vesta and placed\n off bed suspended on pillows\n Response:\n Less bleeding noted from skin tear. Pt able to turn x1 assist in bed\n Plan:\n Moisturize pressure points, prevent breakdown. Change L arm\n skin tear dsg PRN\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n Code status:\n Full code\n Height:\n 28 Inch\n Admission weight:\n 83.5 kg\n Daily weight:\n 83.9 kg\n Allergies/Reactions:\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Ciprofloxacin\n Diarrhea; h/o C\n Precautions: Contact\n PMH: Anemia, COPD, ETOH, Renal Failure, Smoker\n CV-PMH: Angina, CAD, CHF, Hypertension, MI, PVD\n Additional history: Carotid stenosis L, AS, colon ca s/p collectomy, lg\n Imbilical hernia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:143\n D:56\n Temperature:\n 98.1\n Arterial BP:\n S:121\n D:113\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 Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 30% %\n 24h total in:\n 988 mL\n 24h total out:\n 705 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 06:41 AM\n Potassium:\n 3.7 mEq/L\n 06:41 AM\n Chloride:\n 101 mEq/L\n 06:41 AM\n CO2:\n 28 mEq/L\n 06:41 AM\n BUN:\n 25 mg/dL\n 06:41 AM\n Creatinine:\n 1.1 mg/dL\n 06:41 AM\n Glucose:\n 111 mg/dL\n 06:41 AM\n Hematocrit:\n 32.8 %\n 06:41 AM\n Finger Stick Glucose:\n 195\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: 3\n Date & time of Transfer: , 1849\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399090,
"text": "Pt is a 70yo man with PMH severe AS ( 0.8) CABG/CAD, recent cath\n with 3VD & TO of SVGs and patent LIMA-LAD. COPD on home O2, ETOH\n abuse with history of DTs. Presented to w/ acute hypercarbic\n respiratory distress, s/p BIPAP trial-> intubation. He was treated\n with solu-medrol and eventually extubated, although was found to have\n continued dypnea and continuous elevated cardiac enzymes CK 51->229,\n Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? plavix\n load. Tnsf to for possible cath and further management. Received\n on BIPAP, heparin gtt at 800 units/hr. Noted lg skin tear (? from tape)\n on L medial forearm, applied adaptic/ dsd cover.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received pt A+Ox3, coop w/ care. No c/o chest pain/ sob, no s/s of etoh\n withdrawl. On Heparin gtt @ 800 units/hr. On BIPAP mask 30% 8/5, RR\n 20s, sats >95%\n Action:\n Made NPO, resumed Heparin gtt at 800 units/hr. Cont\nd on BIPAP 30% 8/5.\n ABG\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399088,
"text": "Pt is a 70yo man with PMH severe AS ( 0.8) CABG/CAD, recent cath\n with 3VD & TO of SVGs and patent LIMA-LAD. COPD on home O2, ETOH\n abuse with history of DTs. Presented to w/ acute hypercarbic\n respiratory distress, s/p BIPAP trial-> intubation. He was treated\n with solu-medrol and eventually extubated, although was found to have\n continued dypnea and continuous elevated cardiac enzymes CK 51->229,\n Trop .20-> .45 Started on heparin gtt, given aspirin/ BB, ? plavix\n load. Tnsf to for possible cath and further management. Received\n on BIPAP, heparin gtt at 800 units/hr. Noted lg skin tear (? from tape)\n on L medial forearm, applied adaptic/ dsd cover.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt A+Ox3, coop w/ care. No c/o chest pain/sob on Heparin gtt\n Action:\n NPO, Restarted on Heparin gtt at 800 units/hr. Conts on BIPAP\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399408,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV.\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 200 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n"
},
{
"category": "Nursing",
"chartdate": "2142-01-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 399409,
"text": "Small bowel obstruction (Intestinal obstruction, SBO, including\n intussusception, adhesions)\n Assessment:\n Patient admitted to CCU under MICU service for SBO confirmed by CT\n scan. Abdomen soft and distended, known hernia present. Bowel sounds\n present.\n NG to moderate intermittent suction with billeous output.\n Patient denies abd. Pain or nausea.\n Action:\n NG kept to wall suction,\n NPO,\n Given IVF 150 cc/hr\n Po meds changed to IV.\n Response:\n Abdomen continues to be soft and distended,\n Denies nausea/pain\n 200 cc billeous output for shift.\n Plan:\n Continue to monitor.\n .H/O myocardial infarction\n Assessment:\n Patient has hx of NSTEMI 2 stents to RCA during this admission\n HR NSR 70\ns-80\ns frequent PAC\n SBP 100\ns-130\n Action:\n Continue on post MI meds\n Response:\n No change, VSS\n Plan:\n Consult with MICU about resuming po meds in morning.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient admitted from floor for increasing fluid requirements, SBO,\n creat increase to 2.6.\n Patient had low u/o on floor\n Action:\n Given IVF 150 cc/hr\n Response:\n u/o now 30-60 cc/hr,\n SBP 100\ns-130\n Creat.\n Plan:\n Continue to monitor, continue with fluid resusitaiton.\n"
},
{
"category": "Radiology",
"chartdate": "2141-12-31 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1117902,
"text": " 8:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction vs. cholecystitis\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with CAD s/p cardiac cath now with bilious emesis and\n epigastric pain\n REASON FOR THIS EXAMINATION:\n ? obstruction vs. cholecystitis\n CONTRAINDICATIONS for IV CONTRAST:\n chronic renal insufficiency;chronic renal insufficiency\n ______________________________________________________________________________\n WET READ: CXWc 11:50 AM\n Small bowel obstruction situated at the mouth of the large ventral hernia,\n with proximal small bowel dilated to 4 cm, and marked distal decompression.\n Residual oral contrast in large bowel from prior study (either or\n at OSH) suggests this could be early high grade obstruction. No extraluminal\n fluid or air.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man with bilious emesis and epigastric pain following\n cardiac catheterization.\n\n COMPARISON: CT abdomen and pelvis of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis. No IV contrast was administered secondary to chronic renal\n insufficiency. No oral contrast was administered. Multiplanar reformatted\n images were generated.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Lung bases are clear without consolidation or\n pleural effusion. The heart size is normal without pericardial effusion.\n Dense calcification of the coronary arteries is noted.\n\n In the abdomen, assessment of solid organs is limited in the absence of IV\n contrast. However, the liver is grossly unremarkable. A focal hypodensity\n anteriorly is unchanged and likely represents focal fatty infiltration. A\n small gallstone is present in a decompressed gallbladder. The pancreas,\n spleen, adrenal glands and kidneys are grossly unremarkable. There is no\n hydronephrosis in either kidney. Perinephric stranding size is unchanged.\n\n The stomach and duodenum are distended with fluid and small amount of ingested\n material. The esophagus also contains fluid.\n\n There is no free air or free fluid in the abdomen. The abdominal aorta\n demonstrates atherosclerotic calcification, but is normal in caliber. There\n is no mesenteric or retroperitoneal lymphadenopathy by size criteria.\n\n CT PELVIS WITHOUT IV CONTRAST: Large bowel demonstrates residual oral\n contrast material, possibly from the CT of or from an outside\n hospital study. Loops of small bowel are distended, extending to the distal\n small bowel. Both small and large bowel extends into a large, wide-based\n (Over)\n\n 8:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction vs. cholecystitis\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ventral hernia. A transition in small bowel caliber is noted just adjacent to\n the ventral hernia, with a small segment of fecalization of contents of the\n dilated small bowel, measuring up to 4 cm. Distally, there is marked\n decompression of the distal and terminal ileum. The colon is relatively\n decompressed, although still retained a small amount of stool and contrast\n material. There is no extraluminal fluid or air. The sigmoid colon\n demonstrates scattered diverticulosis without diverticulitis. There is no\n free fluid layering dependently in the pelvis. The urinary bladder contains\n excrete contrast material. There is no pelvic or inguinal lymphadenopathy by\n size criteria. A fem-fem bypass graft is in place. The patient has undergone\n prior low anterior resection and surgical material is present at the\n rectosigmoid junction.\n\n OSSEOUS STRUCTURES: Degenerative changes are present throughout the lower\n spine, with no interval change. There is no new fracture.\n\n IMPRESSION:\n\n 1. High-grade small-bowel obstruction, with dilatation of proximal loops up\n to 4 cm, and complete decompression of the distal and terminal ileum.\n Obstruction may be early, as there is residual oral contrast and stool within\n the colon, which is minimally decompressed. No evidence of perforation.\n Obstruction occurs adjacent to the mouth of the large ventral hernia.\n However, both dilated and decompressed loops pass into and out of the hernia\n sac. Obstruction may be related to adhesions.\n\n 2. Cholelithiasis without cholecystitis.\n\n 3. Diverticulosis without diverticulitis.\n\n 4. No evidence of obstruction at the rectosigmoid anastomosis.\n\n 5. Atherosclerotic disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-12-30 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1117829,
"text": " 1:30 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: obstruction\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with ventral hernia, has abdominal pain\n REASON FOR THIS EXAMINATION:\n obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, TWO VIEWS, .\n\n CLINICAL INFORMATION: Ventral hernia.\n\n FINDINGS:\n\n Two views of the abdomen are obtained including left lateral decubitus. There\n are scattered air-fluid levels seen on the decubitus view. The supine view is\n somewhat underpenetrated secondary to the density into the soft tissues. No\n large distended bowel is identified. No free air identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1118334,
"text": " 7:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with hx of AS and recent SBO received liters of IVF. No new\n oxygen requirement but dyspneic.\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70 year-old man with history of aortic stenosis and recent\n small-bowel obstruction complaining of dyspnea.\n\n COMPARISON: radiograph.\n\n AP UPRIGHT CHEST RADIOGRAPH: The cardiomediastinal silhouette is\n unremarkable. Flattening of the hemidiaphragms bilaterally reflects lung\n overinflation from underlying emphysema. The lungs are clear without effusion,\n consolidation, or pneumothorax. There is minimal bibasilar atelectasis.\n There are seven intact median sternotomy wires.\n\n IMPRESSION: No evidence of pneumonia or CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-12-31 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1117918,
"text": " 11:28 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm NGT placement\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with ngt\n REASON FOR THIS EXAMINATION:\n confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Portable line placement.\n\n FINDINGS:\n\n AP view of the chest is compared to the prior study from . Left\n costophrenic angle is omitted from the study. Nasogastric tube is present and\n it just barely enters the stomach. Side port is not well seen. It should be\n advanced into the stomach. Heart and mediastinum within normal limits. The\n lungs are otherwise grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-12-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1117469,
"text": " 9:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for acute process\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with COPD, CHF, presenting with respiratory distress\n REASON FOR THIS EXAMINATION:\n Evaluate for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, chronic heart failure, respiratory distress.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the sternal wires are\n unchanged. Unchanged course of the nasogastric tube. Unchanged signs of\n moderate overinflation. No evidence of pneumonia, no pulmonary edema. Normal\n size of the cardiac silhouette, minimal tortuosity of the thoracic aorta.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-01-01 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1118020,
"text": " 11:00 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: Eval SBO\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with SBO\n REASON FOR THIS EXAMINATION:\n Eval SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man with small bowel obstruction.\n\n COMPARISON: CT abdomen and pelvis, .\n\n Single supine portable abdomen radiograph was obtained. The radiograph\n demonstrates focal mild dilatation of small bowel loops in the epigastric\n region measuring 3.2 cm, consistent with the small bowel loops seen within the\n ventral hernia on the prior CT scan. Air is seen within the descending colon\n and the rectum. The relative lack of air in the distal small bowel suggests\n likely partial or early small bowel obstruction. There is no intraperitoneal\n free air.\n\n The NG tube terminates at the gastroesophageal junction, and the sideholes\n likely are at the distal esophagus. Recommended advancement of the NG tube.\n\n IMPRESSION:\n 1. Findings suggestive of early/partial small bowel obstruction.\n 2. Recommended further advancement of the NG tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-01-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1117986,
"text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid overload\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with CHF\n REASON FOR THIS EXAMINATION:\n eval for fluid overload\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe MON 10:40 AM\n No evidence of pneumonia or acute interstitial edema. Known underlying upper\n lobe predominant emphysema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive heart failure, evaluate for change in interstitial edema.\n\n\n UPRIGHT PORTABLE CHEST: Comparison is made to multiple prior radiographs,\n most recently . Exam is somewhat limited due to patient's\n rotation. Given these limitations no pneumonia, edema, or pneumothorax is\n present. No large right effusion is seen with the left costophrenic sulcus\n not included on the current film. A nasogastric tube projects below the\n diaphragm although its tip is not included on the current film. Configuration\n of the median sternotomy wires is stable as is the flattening of\n hemidiaphragms and increased lucency projecting over the upper lobes\n consistent with the known underlying emphysema.\n\n IMPRESSION:\n\n No evidence of pneumonia or acute interstitial edema. Known underlying upper\n lobe predominant emphysema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-01-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1117987,
"text": ", B. 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid overload\n Admitting Diagnosis: MYOCARDIAL INFARCTION;SEVERE AORTIC STENOSIS;ALCOHOL ABUSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with CHF\n REASON FOR THIS EXAMINATION:\n eval for fluid overload\n ______________________________________________________________________________\n PFI REPORT\n No evidence of pneumonia or acute interstitial edema. Known underlying upper\n lobe predominant emphysema.\n\n\n"
}
] |
48,697 | 112,253 | Admitted and underwent coronary artery bypass surgery with Dr. . Please see operative note for further details. Transferred to the CVICU in stable condition on titrated propofol and phenylephrine drips. Extubated later that day. Transferred to the floor on POD #1 to begin increasin his activity level. Gently diuresed toward his preop weight. Chest tubes and pacing wires were discontinued without complication. On POD 3 the patient was noted to have significant abdominal distention. KUB revealed evidence of colonic ileus, including air-fluid levels. Nasogastric tube was placed in an effort to decompress the GI tract. GI and general surgery services were consulted. C-diff toxin was sent and returned negative. The patient remained afebrile with a normal white blood cell count. Rectal tube was placed, and eventually ileus resolved. Additionally, the patient went into atrial fibrillation, briefly, on POD 4. He received a fluid bolus, amiodarone, and his beta blocker was increased. He returned to sinus rhythm shortly thereafter, and would remain in sinus rhythm throughout the hospital course. The physical therapy service was consulted for assistance with strength and mobility. The patient made excellent progress and was discharged home on POD 6. | Hydralazine ordered PRN. Hydralazine ordered PRN. Hydralazine ordered PRN. Action: Given 1 percocet for pain and pt repositioned. Action: Given 1 percocet for pain and pt repositioned. Action: Given 1 percocet for pain and pt repositioned. Action: Given 1 percocet for pain and pt repositioned. Metoprolol Tartrate 17. CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. Action: Bowel Regimen: Bisacodyl/ colace/ Reglan. Hypertension, benign Assessment: Pts SBP in 140s and 150s at onset of am shift. Phenylephrine 22. HD2 POD 1 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) EF 65 cre0.7 Wt93 PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar radiculopathy, basal cell CA s/p resection on forehead and back, BPH, s/p B inguinal herniorrhaphies Hypertension, benign Assessment: Pts SBP in 140s and 150s at onset of am shift. HD2 POD 1 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) EF 65 cre0.7 Wt93 PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar radiculopathy, basal cell CA s/p resection on forehead and back, BPH, s/p B inguinal herniorrhaphies Hypertension, benign Assessment: Pts SBP in 140s and 150s at onset of am shift. Electrolyte & fluid disorder, other Assessment: Pt with K-3.9 and pt with occas. Electrolyte & fluid disorder, other Assessment: Pt with K-3.9 and pt with occas. Electrolyte & fluid disorder, other Assessment: Pt with K-3.9 and pt with occas. Electrolyte & fluid disorder, other Assessment: Pt with K-3.9 and pt with occas. Incrase b-blocker dose and resume home dose lisinopril. Diurese 1-2 L today Hematology: Serial Hct, Stable anemia. Metoclopramide 18. Pt status discussed with RN Intervention: Other: Diagnosis: 1. Received on neo & prop. Received on neo & prop. Received on neo & prop. Received on neo & prop. Aspirin EC 5. Morphine given Response: SBP <130, BS monitored Q1h, inadequate pain relief with Morphine ->changed to Dilaudid IV. Transfers, Impaired Clinical impression / Prognosis: 61 yo m s/p CABG x 4 presents with above impairments c/w CV pump dysfunction. CVICU HPI: HD2 POD 1 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) EF 65 cre0.7 Wt93 PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar radiculopathy, basal cell CA s/p resection on forehead and back, BPH, s/p B inguinal herniorrhaphies :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80, isorsorbide 60, finasteride 5, ASA 81, loratadine 10 HD2 POD 1 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) EF 65 cre0.7 Wt93 PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar radiculopathy, basal cell CA s/p resection on forehead and back, BPH, s/p B inguinal herniorrhaphies :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80, isorsorbide 60, finasteride 5, ASA 81, loratadine 10 HD2 POD 1 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) EF 65 cre0.7 Wt93 PMHx: PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar radiculopathy, basal cell CA s/p resection on forehead and back, BPH, s/p B inguinal herniorrhaphies :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80, isorsorbide 60, finasteride 5, ASA 81, loratadine 10 Current medications: HD2 POD 1 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) EF 65 cre0.7 Wt93 PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar radiculopathy, basal cell CA s/p resection on forehead and back, BPH, s/p B inguinal herniorrhaphies :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80, isorsorbide 60, finasteride 5, ASA 81, loratadine 10 Active Medications , J 1. Normalascending aorta diameter. Renal: Adequate UO, dc foley. Consistent with colonic ileus. Consistent with colonic ileus. Consistent with colonic ileus. Normal aortic arch diameter. Normal aortic diameter at the sinus level. Hematology: Serial Hct, stable anemia. IMPRESSION: Findings consistent with colonic ileus. gentle diuresis Hematology: stable, Cont. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Status: InpatientDate/Time: at 10:48Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque. IMPRESSION: Findings most consistent with colonic ileus not significantly changed. No AR.MITRAL VALVE: Normal mitral valve leaflets.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. distension,LFTs/KUB done. Less bowel dilatation. Less bowel dilatation. Less bowel dilatation. Rule out pneumothorax. dilaudid DC'd. Small bilateral pleural effusion persists. Small bilateral pleural effusion persists. The ascending, transverse and descending thoracic aorta are normalin diameter and free of atherosclerotic plaque to 22 cm from the incisors. Inferolateral T wave inversions suggest myocardial ischemia.Non-specific slight ST segment elevation in leads V2-V3. FINDINGS: As compared to the previous radiograph, there is status post sternotomy and CABG. KUB= dilated Bowel. The aorta is tortuous but stable in appearance and the hilar and mediastinal contours are unchanged in appearance. Pulmonary: IS, CXR post Ct removal. Small bilateral pleural effusions. Small bilateral pleural effusions. Small bilateral pleural effusions. Dilatation of bowel loops suggests ileus. Small bilateral pleural effusions persist. In the visualized lung bases, there are small pleural effusions bilaterally. The endotracheal tube is located in the right main bronchus. Air-filled mildly dilated small bowel is again demonstrated. -plavix restarted for cartid stent. Normal descending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). RSR' pattern is present in lead V1. Right ventricular chamber size and free wall motionare normal. Atrial fibrillation with controlled ventricular response. Nonspecific air-fluid levels are seen within the colon on the upright views. RSR' patternin lead V1. OOB PT eval. Patient is status post median sternotomy and CABG. Compared to the previous tracing of bradycardia isabsent. Sinus rhythm. gentle diuresis. There are colonic air-fluid levels on the upright view. The mitral valve leaflets arestructurally normal. FINDINGS: There is stable cardiomegaly. There are small bilateral pleural effusions. Sternotomy cerclage wires are stable in appearance. +BM after supp. There is a moderate amount of gas in the colon, which is mildly, if at all, dilated. | 32 | [
{
"category": "Nursing",
"chartdate": "2173-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542363,
"text": " CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. CPB 74mins, XCL\n 56mins; 1 units platelets given (pre-op plavix). Ez intub, epicardial\n 2As/2Vs. EF 50%. Received on neo & prop. Extubated without incident.\n Coronary artery bypass graft (CABG)\n Assessment:\n Tachy ^ 120, SBP 150s, CI>2, PADs 16-20s, CVP 10-18, mod CT drainage\n throughout shift. BS 138. Pt c/o pain , unable to take deep breath.\n Extremities cool to touch, palpable pulses. 6 hour post Hct 29.5.\n Action:\n ~ 2.5L NS given, Nitro gtt started, insulin gtt started per CVICU\n protocol. Morphine given for pain management.\n Response:\n SBP <130, BS monitored Q1h, inadequate pain relief with Morphine\n ->changed to Dilaudid IV.\n Plan:\n Monitor Hemodynamics, wean nitro keep SBP 100-120, wean insulin gtt per\n CVICU protocol, aggressive pulm toileting, pain management, Monitor CT\n drainage.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt has OSA, but does not wear CPAP machine at home. Pt desats when he\n sleeps to 90-92%. While pt awake, sats >96%. LS clear, dim in bases.\n Dependent lobes diminished when turned.\n Action:\n Added NC.\n Response:\n No change in O2 sat while pt sleeping, pt mouth breather/snores; NC\n turned off.\n Plan:\n Cont to monitor O2 sat, ^ FiO2 If needed.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542364,
"text": " CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. CPB 74mins, XCL\n 56mins; 1 units platelets given (pre-op plavix). Ez intub, epicardial\n 2As/2Vs. EF 50%. Received on neo & prop. Extubated without incident.\n Coronary artery bypass graft (CABG)\n Assessment:\n Tachy ^ 120, SBP 150s, CI>2, PADs 16-20s, CVP 10-18, mod CT drainage\n throughout shift. BS 138. Pt c/o pain , unable to take deep breath.\n Extremities cool to touch, palpable pulses. 6 hour post Hct 29.5.\n Action:\n ~ 2.5L NS given, Nitro gtt started, insulin gtt started per CVICU\n protocol. Morphine given for pain management. 5mg IV lopressor.\n Response:\n SBP <130, BS monitored Q1h, inadequate pain relief with Morphine\n ->changed to Dilaudid IV. HR >100.\n Plan:\n Monitor Hemodynamics, wean nitro keep SBP 100-120, wean insulin gtt per\n CVICU protocol, aggressive pulm toileting, pain management, Monitor CT\n drainage. ? need for PO lopressor.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt has OSA, but does not wear CPAP machine at home. Pt desats when he\n sleeps to 90-92%. While pt awake, sats >96%. LS clear, dim in bases.\n Dependent lobes diminished when turned.\n Action:\n Added NC.\n Response:\n No change in O2 sat while pt sleeping, pt mouth breather/snores; NC\n turned off.\n Plan:\n Cont to monitor O2 sat, ^ FiO2 If needed.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542361,
"text": " CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. CPB 74mins, XCL\n 56mins; 1 units platelets given (pre-op plavix). Ez intub, epicardial\n 2As/2Vs. EF 50%. Received on neo & prop. Extubated without incident.\n Coronary artery bypass graft (CABG)\n Assessment:\n Tachy ^ 115, SBP 130s, CI>2, PADs 16-20s, CVP 10-18, mod CT drainage\n throughout shift. BS 138. Pt c/o pain , unable to take deep breath.\n Extremeties cool to touch, palpable pulses.\n Action:\n ~ 2.5L NS given, Nitro gtt started, insulin gtt started per CVICU\n protocol. Morphine given\n Response:\n SBP <130, BS monitored Q1h, inadequate pain relief with Morphine\n ->changed to Dilaudid IV.\n Plan:\n Monitor Hemodynamics, keep SBP 100-120, wean insulin gtt per CVICU\n protocol, aggressive pulm toileting, pain management, Monitor CT\n drainage.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542362,
"text": " CABG x 4 LIMA->LAD, SVG->DIAG, SVG->OM, SVG->PDA. CPB 74mins, XCL\n 56mins; 1 units platelets given (pre-op plavix). Ez intub, epicardial\n 2As/2Vs. EF 50%. Received on neo & prop. Extubated without incident.\n Coronary artery bypass graft (CABG)\n Assessment:\n Tachy ^ 120, SBP 150s, CI>2, PADs 16-20s, CVP 10-18, mod CT drainage\n throughout shift. BS 138. Pt c/o pain , unable to take deep breath.\n Extremities cool to touch, palpable pulses. 6 hour post Hct 29.5.\n Action:\n ~ 2.5L NS given, Nitro gtt started, insulin gtt started per CVICU\n protocol. Morphine given for pain management.\n Response:\n SBP <130, BS monitored Q1h, inadequate pain relief with Morphine\n ->changed to Dilaudid IV.\n Plan:\n Monitor Hemodynamics, wean nitro keep SBP 100-120, wean insulin gtt per\n CVICU protocol, aggressive pulm toileting, pain management, Monitor CT\n drainage.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt has OSA, but does not wear CPAP machine at home. Pt desats when he\n sleeps to 90-92%. While pt awake, sats >96%. LS clear, dim in bases.\n Dependent lobes diminished when turned.\n Action:\n Added NC.\n Response:\n No change in O2 sat while pt sleeping, pt mouth breather/snores; NC\n turned off.\n Plan:\n Cont to monitor O2 sat, ^ FiO2 If needed.\n"
},
{
"category": "Physician ",
"chartdate": "2173-12-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 542414,
"text": "CVICU\n HPI:\n 61M POD 1 from CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to\n PDA), EF 65. Extubated. Hypertensive post op, tachycardic\n Chief complaint:\n PMHx:\n HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar\n radiculopathy, basal cell CA s/p resection on forehead and back, BPH,\n s/p B inguinal herniorrhaphies.\n Current medications:\n 24 Hour Events:\n OR RECEIVED - At 01:12 PM\n INVASIVE VENTILATION - START 01:15 PM\n ARTERIAL LINE - START 01:15 PM\n PA CATHETER - START 01:15 PM\n CORDIS/INTRODUCER - START 01:16 PM\n EKG - At 02:31 PM\n NASAL SWAB - At 04:08 PM\n EXTUBATION - At 05:30 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:15 PM\n Metoprolol - 10:20 PM\n Hydromorphone (Dilaudid) - 04:17 AM\n Insulin - Regular - 06:23 AM\n Ranitidine (Prophylaxis) - 08:41 AM\n Other medications:\n Flowsheet Data as of 10:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.6\nC (99.7\n HR: 99 (76 - 111) bpm\n BP: 119/64(79) {96/45(61) - 133/66(88)} mmHg\n RR: 18 (9 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.4 kg (admission): 93.8 kg\n Height: 69 Inch\n CVP: 6 (6 - 19) mmHg\n PAP: (29 mmHg) / (16 mmHg)\n CO/CI (Thermodilution): (7.39 L/min) / (3.5 L/min/m2)\n SVR: 779 dynes*sec/cm5\n SV: 70 mL\n SVI: 33 mL/m2\n Total In:\n 7,771 mL\n 795 mL\n PO:\n 30 mL\n 440 mL\n Tube feeding:\n IV Fluid:\n 6,744 mL\n 355 mL\n Blood products:\n 997 mL\n Total out:\n 2,755 mL\n 1,320 mL\n Urine:\n 1,325 mL\n 990 mL\n NG:\n 350 mL\n Stool:\n Drains:\n 30 mL\n 20 mL\n Balance:\n 5,016 mL\n -525 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 413 (264 - 413) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 3%\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 98%\n ABG: 7.35/46/105/23/0\n Ve: 7.6 L/min\n PaO2 / FiO2: 3,500\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese\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 Moves all extremities\n Labs / Radiology\n 200 K/uL\n 10.7 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 110 mEq/L\n 139 mEq/L\n 30.5 %\n 7.8 K/uL\n [image002.jpg]\n 11:02 AM\n 11:45 AM\n 12:28 PM\n 12:51 PM\n 01:57 PM\n 02:08 PM\n 05:21 PM\n 08:20 PM\n 03:03 AM\n WBC\n 11.5\n 10.0\n 7.8\n Hct\n 28\n 28\n 27.5\n 30\n 30.6\n 29.5\n 30.5\n Plt\n \n Creatinine\n 0.8\n 0.7\n TCO2\n 29\n 28\n 27\n 28\n 26\n Glucose\n 100\n 192\n 145\n 96\n 138\n 135\n Other labs: PT / PTT / INR:14.3/31.8/1.2, Fibrinogen:230 mg/dL, Lactic\n Acid:1.7 mmol/L, Mg:1.9 mg/dL\n Assessment and Plan\n HYPERGLYCEMIA, ELECTROLYTE & FLUID DISORDER, OTHER, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN, OBSTRUCTIVE SLEEP APNEA\n (OSA), CORONARY ARTERY BYPASS GRAFT (CABG), .H/O PROSTATIC HYPERTROPHY,\n BENIGN (BPH), .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITHOUT CRITICAL\n LIMB ISCHEMIA\n Assessment and Plan: 61M POD 1 from CABGx4 (LIMA to LAD, SVG to Diag,\n SVG to OM, SVG to PDA), EF 65. Extubated. Stable hemodynamically after\n hypertension overnight.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Percocet and\n hydromorphone with adequate pain control.\n Cardiovascular: Aspirin, Hypotension followed by hypertension. Off NTG\n but still hypertensive. Incrase b-blocker dose and resume home dose\n lisinopril. Plavix\n Pulmonary: IS, Stable OOB --> chair. Chest PT\n Gastrointestinal / Abdomen: No issues. Bowel regimen\n Nutrition: NPO, Start regular diet today\n Renal: Foley, Adequate UO, No issues. Diurese 1-2 L today\n Hematology: Serial Hct, Stable anemia. Monitor\n Endocrine: RISS, Glucose well controlled. Keep < 150\n Infectious Disease: No evidence of infection. Periop cefazolin\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypotension, Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:15 PM\n PA Catheter - 01:15 PM\n Cordis/Introducer - 01:16 PM\n 16 Gauge - 01:16 PM\n Prophylaxis:\n DVT: (Not indicated)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 25 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2173-12-16 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 542415,
"text": "CVICU\n HPI:\n HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80,\n isorsorbide 60, finasteride 5, ASA 81, loratadine 10\n HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80,\n isorsorbide 60, finasteride 5, ASA 81, loratadine 10\n HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMHx:\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80,\n isorsorbide 60, finasteride 5, ASA 81, loratadine 10\n Current medications:\n HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80,\n isorsorbide 60, finasteride 5, ASA 81, loratadine 10\n Active Medications , J\n 1. 2. 250 mL D5W 3. Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6.\n CefazoLIN 7. Clopidogrel\n 8. Dextrose 50% 9. Docusate Sodium 10. Furosemide 11. HYDROmorphone\n (Dilaudid) 12. Influenza Virus Vaccine\n 13. Insulin 14. Magnesium Sulfate 15. Metoprolol Tartrate 16.\n Metoprolol Tartrate 17. Metoclopramide\n 18. Milk of Magnesia 19. Nitroglycerin 20. Oxycodone-Acetaminophen 21.\n Phenylephrine 22. Potassium Chloride\n 23. Ranitidine\n 24 Hour Events:\n OR RECEIVED - At 01:12 PM\n INVASIVE VENTILATION - START 01:15 PM\n ARTERIAL LINE - START 01:15 PM\n PA CATHETER - START 01:15 PM\n CORDIS/INTRODUCER - START 01:16 PM\n EKG - At 02:31 PM\n NASAL SWAB - At 04:08 PM\n EXTUBATION - At 05:30 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n Post operative day:\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n 24hour events: Extubated, started Bblockers and diuretics\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:15 PM\n Metoprolol - 10:20 PM\n Hydromorphone (Dilaudid) - 04:17 AM\n Insulin - Regular - 06:23 AM\n Ranitidine (Prophylaxis) - 08:41 AM\n Other medications:\n Flowsheet Data as of 10:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.6\nC (99.7\n HR: 99 (76 - 111) bpm\n BP: 119/64(79) {96/45(61) - 133/66(88)} mmHg\n RR: 18 (9 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 99.4 kg (admission): 93.8 kg\n Height: 69 Inch\n CVP: 6 (6 - 19) mmHg\n PAP: (29 mmHg) / (16 mmHg)\n CO/CI (Thermodilution): (7.39 L/min) / (3.5 L/min/m2)\n SVR: -11 dynes*sec/cm5\n SV: 72 mL\n SVI: 34 mL/m2\n Total In:\n 7,771 mL\n 795 mL\n PO:\n 30 mL\n 440 mL\n Tube feeding:\n IV Fluid:\n 6,744 mL\n 355 mL\n Blood products:\n 997 mL\n Total out:\n 2,755 mL\n 1,320 mL\n Urine:\n 1,325 mL\n 990 mL\n NG:\n 350 mL\n Stool:\n Drains:\n 30 mL\n 20 mL\n Balance:\n 5,016 mL\n -525 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 413 (264 - 413) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 3%\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 98%\n ABG: 7.35/46/105/23/0\n Ve: 7.6 L/min\n PaO2 / FiO2: 3,500\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 200 K/uL\n 10.7 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 110 mEq/L\n 139 mEq/L\n 30.5 %\n 7.8 K/uL\n [image002.jpg]\n 11:02 AM\n 11:45 AM\n 12:28 PM\n 12:51 PM\n 01:57 PM\n 02:08 PM\n 05:21 PM\n 08:20 PM\n 03:03 AM\n WBC\n 11.5\n 10.0\n 7.8\n Hct\n 28\n 28\n 27.5\n 30\n 30.6\n 29.5\n 30.5\n Plt\n \n Creatinine\n 0.8\n 0.7\n TCO2\n 29\n 28\n 27\n 28\n 26\n Glucose\n 100\n 192\n 145\n 96\n 138\n 135\n Other labs: PT / PTT / INR:14.3/31.8/1.2, Fibrinogen:230 mg/dL, Lactic\n Acid:1.7 mmol/L, Mg:1.9 mg/dL\n Assessment and Plan\n HYPERGLYCEMIA, ELECTROLYTE & FLUID DISORDER, OTHER, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN, OBSTRUCTIVE SLEEP APNEA\n (OSA), CORONARY ARTERY BYPASS GRAFT (CABG), .H/O PROSTATIC HYPERTROPHY,\n BENIGN (BPH), .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITHOUT CRITICAL\n LIMB ISCHEMIA\n Assessment and Plan: 61yoM s/p CABG doing well POD1\n Neurologic: resume Plavix, s/p carotid stent\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n resume ACE.\n Pulmonary: extubated\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, start diuretic today. resume bph meds\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest\n tube - pleural , Chest tube - mediastinal, Pacing wires, d/c JP drain\n Wounds: Dry dressings\n Fluids: KVO\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:15 PM\n PA Catheter - 01:15 PM\n Cordis/Introducer - 01:16 PM\n 16 Gauge - 01:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor if able to wean off NTG gtt\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542482,
"text": "HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o Incisional pain with C&DB.\n Action:\n Given 1 percocet for pain and pt repositioned.\n Response:\n Pt c/o of no pain at this time.\n Plan:\n Continue to assess pain and administer pain meds prn.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with K-3.9 and pt with occas. PVC\ns. Magnesium-2.1\n Action:\n Pt given 20meq KCL and 2g of mag.\n Response:\n Pt with no ectopy at this present time.\n Plan:\n Will continue to monitor for ectopy and recheck electrolytes.\n Nausea / vomiting\n Assessment:\n Pt c/o nausea at 0200. Abd. soft and distended with +BS.\n Action:\n Pt given 10mg reglan IV.\n Response:\n Pt c/o no nausea at this present time.\n Plan:\n Continue to assess for nausea and continue to assess how pt tolerates\n diet.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542478,
"text": "HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o Incisional pain with C&DB.\n Action:\n Given 1 percocet for pain and pt repositioned.\n Response:\n Pt c/o of no pain at this time.\n Plan:\n Continue to assess pain and administer pain meds prn.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with K-3.9 and pt with occas. PVC\ns. Magnesium-2.1\n Action:\n Pt given 20meq KCL and 2g of mag.\n Response:\n Pt with no ectopy at this present time.\n Plan:\n Will continue to monitor for ectopy and recheck electrolytes.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542479,
"text": "HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o Incisional pain with C&DB.\n Action:\n Given 1 percocet for pain and pt repositioned.\n Response:\n Pt c/o of no pain at this time.\n Plan:\n Continue to assess pain and administer pain meds prn.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with K-3.9 and pt with occas. PVC\ns. Magnesium-2.1\n Action:\n Pt given 20meq KCL and 2g of mag.\n Response:\n Pt with no ectopy at this present time.\n Plan:\n Will continue to monitor for ectopy and recheck electrolytes.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542480,
"text": "HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o Incisional pain with C&DB.\n Action:\n Given 1 percocet for pain and pt repositioned.\n Response:\n Pt c/o of no pain at this time.\n Plan:\n Continue to assess pain and administer pain meds prn.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with K-3.9 and pt with occas. PVC\ns. Magnesium-2.1\n Action:\n Pt given 20meq KCL and 2g of mag.\n Response:\n Pt with no ectopy at this present time.\n Plan:\n Will continue to monitor for ectopy and recheck electrolytes.\n Nausea / vomiting\n Assessment:\n Pt c/o nausea at 0200. Abd. soft and distended with +BS.\n Action:\n Pt given 10mg reglan IV.\n Response:\n Pt c/o no nausea at this present time.\n Plan:\n Continue to assess for nausea and continue to assess how pt tolerates\n diet.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542388,
"text": "Hyperglycemia\n Assessment:\n Elevated blood sugars\n Action:\n Switched from insulin gtt to riss. Sugar at 6am 121, given 2 units\n regular insulin sc.\n Response:\n Blood sugar under control\n Plan:\n Continue to monitor sugars per protocol\n Electrolyte & fluid disorder, other\n Assessment:\n Calcium and mag low with am labs\n Action:\n 2gm ca and 2gm mag given iv\n Response:\n TBD with lab draw\n Plan:\n Monitor labs as needed\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o incisional pain\n Action:\n Treated with 1mg Dilaudid iv throughout night. Given 2 percocet at\n 6am.\n Response:\n Pain well controlled with narcotics\n Plan:\n Asses pain and treat as needed\n Hypertension, benign\n Assessment:\n Tachycardic all night 90\ns-110\ns. SBP into 150\ns around 6am\n Action:\n aware of HR, no orders. Nitro gtt on at 0.4mcg/kg/min\n Response:\n SBP decreased to keep below 130\n Plan:\n Start PO lopressor and home cardiac meds this am pending rounds\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542458,
"text": "HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n Hypertension, benign\n Assessment:\n Pt\ns SBP in 140s and 150s at onset of am shift.\n Action:\n Administered 50mg Lopressor PO. Good effect observed. Later\n administered 10mg Lisinopril and 20mg Lasix.\n Response:\n BP maintained <= 120s.\n Plan:\n Continue to monitor BP and administer antihypertensives as ordered.\n Hydralazine ordered PRN.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with pain to sternal incision.\n Action:\n Administered Percocet (2 tabs) and 30mg Toradol IM.\n Response:\n Pt in no acute pain. Feels comfortable. Pt stated,\nI can breath\n better now\n Plan:\n Continue to monitor pain as needed. Medicate accordingly.\n Note: atrial wires unable to pace properly. Ventricular backup of 60\n set.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 542531,
"text": "Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 93.8 kg\n Daily weight:\n 99.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CAD, CVA, Hypertension, PVD\n Additional history: Hyperlipidemia, BPH, stent LCA, b/l inguinal\n herniorraphies, lumbar radiculopathy, basal cell cancer s/p resection.\n OSA\n Father - CAD, MI @ 80 y/o\n Surgery / Procedure and date: CABG x 4 LIMA->LAD, SVG->DIAG,\n SVG->OM, SVG->PDA. CPB 74mins, XCL 56mins; 1 units platelets given\n (pre-op plavix). Ez intub, epicardial 2As/2Vs. EF 50%. CI>2. Out on neo\n & prop. 350 CT drainage for 6 hours. Transient Nitro. Insulin gtt\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:62\n Temperature:\n 98.7\n Arterial BP:\n S:123\n D:66\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 3% %\n 24h total in:\n 580 mL\n 24h total out:\n 770 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Pacer Turned Off\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 01:52 AM\n Potassium:\n 4.0 mEq/L\n 01:52 AM\n Chloride:\n 105 mEq/L\n 01:52 AM\n CO2:\n 26 mEq/L\n 01:52 AM\n BUN:\n 21 mg/dL\n 01:52 AM\n Creatinine:\n 0.8 mg/dL\n 01:52 AM\n Glucose:\n 130 mg/dL\n 01:52 AM\n Hematocrit:\n 26.3 %\n 01:52 AM\n Finger Stick Glucose:\n 143\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: Daughter\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: 1215hr\n Hyperglycemia\n Assessment:\n FSBS >120mgdL\n Action:\n Monitor Glycemia ACHS; Follow SS\n Response:\n FSBS 120-130 . PO intake decreased due to abdominal discomfort\n Plan:\n Continue to monitor FSBS and cover using SS\n Tachycardia, Other\n Assessment:\n HR 90-100\n Action:\n Lopressor PO\n Response:\n Remains Tachy HR 90\n Plan:\n Reassess this evening. Pt may require increase on Metoprolol dose\n Pain control (acute pain, chronic pain)\n Assessment:\n C/O Mild Chest pain. Pericardial rub auscultated\n Action:\n Percocet PO and Toradol IV\n Response:\n Good analgesia provided with med intervention.\n Plan:\n Continue to monitor pain and for med intervention. Document accordingly\n Abdominal pain (including abdominal tenderness)\n Assessment:\n C/O abdominal pain.\n Action:\n Bowel Regimen: Bisacodyl/ colace/ Reglan. ABD XRAY And KUB this am\n showing Ileus\n Response:\n BM Large and Large amounts of gas passed\n Plan:\n Continue Bowel regimen and PO intake\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542446,
"text": "Hypertension, benign\n Assessment:\n Pt\ns SBP in 140s and 150s at onset of am shift.\n Action:\n Administered 50mg Lopressor PO. Good effect observed. Later\n administered 10mg Lisinopril and 20mg Lasix.\n Response:\n BP maintained <= 120s.\n Plan:\n Continue to monitor BP and administer antihypertensives as ordered.\n Hydralazine ordered PRN.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with pain to sternal incision.\n Action:\n Administered Percocet (2 tabs) and 30mg Toradol IM.\n Response:\n Pt in no acute pain. Feels comfortable. Pt stated,\nI can breath\n better now\n Plan:\n Continue to monitor pain as needed. Medicate accordingly.\n Note: atrial wires unable to pace properly. Ventricular backup of 60\n set.\n"
},
{
"category": "Nursing",
"chartdate": "2173-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542447,
"text": "HD2\n POD 1\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n Hypertension, benign\n Assessment:\n Pt\ns SBP in 140s and 150s at onset of am shift.\n Action:\n Administered 50mg Lopressor PO. Good effect observed. Later\n administered 10mg Lisinopril and 20mg Lasix.\n Response:\n BP maintained <= 120s.\n Plan:\n Continue to monitor BP and administer antihypertensives as ordered.\n Hydralazine ordered PRN.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt with pain to sternal incision.\n Action:\n Administered Percocet (2 tabs) and 30mg Toradol IM.\n Response:\n Pt in no acute pain. Feels comfortable. Pt stated,\nI can breath\n better now\n Plan:\n Continue to monitor pain as needed. Medicate accordingly.\n Note: atrial wires unable to pace properly. Ventricular backup of 60\n set.\n"
},
{
"category": "Rehab Services",
"chartdate": "2173-12-17 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 542521,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: CAD / 414.00\n Reason of referral: EVal and tx\n History of Present Illness / Subjective Complaint: 61 yo m c + stress\n and cath showing 3 VD, s/p carotid stenting underwent CABG x 4\n , LIMA > LAD, SVG > DIAG, SVG > OM, SVG > PDA, CPB 74 XCL 56.\n Past Medical / Surgical History: CAD, CVA, lumbar radiculopathy, basal\n cell CA, BPH, HTN\n Medications: Dilaudid, Atorvastatin, Metoclopramide, Tamsulosin,\n Ketorolac, Lisinopril\n Radiology: CXR pending\n Labs:\n 26.3\n 9.4\n 164\n 7.8\n [image002.jpg]\n Other labs:\n Activity Orders: Per cardiac guidelines\n Social / Occupational History: Lives alone, has 2 grown children who\n live in the area\n Living Environment: Private home FOS to bedroom\n Prior Functional Status / Activity Level: PTA worked occasionally in\n construction, I with ADLs\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O x 3\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 94\n 99/54\n 96% 2L\n Sit\n /\n Activity\n 95\n 116/54\n 90% RA\n Stand\n /\n Recovery\n 92\n 112/54\n 96% 2L\n Total distance walked: 10\n Minutes:\n Pulmonary Status: Diminished LS, weak dry nonproductive cough\n Integumentary / Vascular: Pacing wires, sternal dressing c/d/i, foley,\n L LE with ace wrap intact. RRR\n Sensory Integrity: No reports of paresthesia\n Pain / Limiting Symptoms: Pt reports no incisional pain, only abdominal\n discomfort\n Posture:\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n B UE and LE > \n Motor Function: No abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt amb 10' c HHA\n Decreased cadence and decreased B step length\n Distance limited leaving floor for xray\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\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\n T\n\n\n Stairs:\n\n\n\n\n\n Balance: No LOB with ambulation required min A lines\n Education / Communication: Pt educated on role of PT. Pt status\n discussed with RN\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Respiration / Gas Exchange, Impaired\n 4.\n Transfers, Impaired\n Clinical impression / Prognosis: 61 yo m s/p CABG x 4 presents with\n above impairments c/w CV pump dysfunction. Pt is currently functioning\n below baseline, anticipate with increased activity pt will progress to\n safe level of I for d/c home with increase in family support for IADLS.\n Pt will benefit from f/u in outpt cardiac rehab as appropriate.\n Goals\n Time frame: 1wk\n 1.\n I mobility\n 2.\n I amb > 500'\n 3.\n I ascend/descend FOS\n 4.\n Demonstrate return knowledge of cardiac activity guidelines and sternal\n precautions.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1 wk\n f.u progress activity, and continue pt edu and 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": "2173-12-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 542525,
"text": "CVICU\n HPI:\n 61M pod2, s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to\n PDA). EF 65% doing well, kept in the icu due to lack of open bed\n on the floor.\n Chief complaint:\n PMHx:\n HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago, lumbar\n radiculopathy, basal cell CA s/p resection on forehead and back, BPH,\n s/p B inguinal herniorrhaphies\n Current medications:\n 24 Hour Events:\n PA CATHETER - STOP 10:30 AM\n ARTERIAL LINE - STOP 10:30 AM\n CALLED OUT\n Post operative day:\n 24hr events:\n -tachycardia, resolved w/ lopressor.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:03 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:45 AM\n Other medications:\n Flowsheet Data as of 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.1\nC (98.7\n HR: 95 (91 - 112) bpm\n BP: 99/65(73) {89/40(52) - 131/77(82)} mmHg\n RR: 20 (14 - 25) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.4 kg (admission): 93.8 kg\n Height: 69 Inch\n Total In:\n 1,610 mL\n 580 mL\n PO:\n 1,040 mL\n 480 mL\n Tube feeding:\n IV Fluid:\n 570 mL\n 100 mL\n Blood products:\n Total out:\n 4,085 mL\n 570 mL\n Urine:\n 3,595 mL\n 490 mL\n NG:\n Stool:\n Drains:\n 20 mL\n Balance:\n -2,475 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Distended, Obese, +flatus,\n +BM\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 164 K/uL\n 9.4 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 105 mEq/L\n 136 mEq/L\n 26.3 %\n 7.8 K/uL\n [image002.jpg]\n 12:28 PM\n 12:51 PM\n 01:57 PM\n 02:08 PM\n 05:21 PM\n 08:20 PM\n 03:03 AM\n 03:52 PM\n 10:12 PM\n 01:52 AM\n WBC\n 11.5\n 10.0\n 7.8\n 7.8\n Hct\n 27.5\n 30\n 30.6\n 29.5\n 30.5\n 26.3\n Plt\n 64\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 27\n 28\n 26\n Glucose\n 145\n 96\n 138\n 135\n 131\n 129\n 130\n Other labs: PT / PTT / INR:14.3/31.8/1.2, ALT / AST:23/26, Alk-Phos / T\n bili:77/0.6, Amylase / Lipase:30/20, Fibrinogen:230 mg/dL, Lactic\n Acid:1.7 mmol/L, Albumin:3.2 g/dL, LDH:259 IU/L, Ca:8.5 mg/dL, Mg:2.1\n mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, KNOWLEDGE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, NAUSEA /\n VOMITING, HYPERGLYCEMIA, ELECTROLYTE & FLUID DISORDER, OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN, OBSTRUCTIVE\n SLEEP APNEA (OSA), CORONARY ARTERY BYPASS GRAFT (CABG), .H/O PROSTATIC\n HYPERTROPHY, BENIGN (BPH), .H/O PERIPHERAL VASCULAR DISEASE (PVD)\n WITHOUT CRITICAL LIMB ISCHEMIA\n Assessment and Plan: 61M pod2, s/p CABGx4 (LIMA to LAD, SVG to Diag,\n SVG to OM, SVG to PDA). EF 65% doing well, kept in the icu due to\n lack of open bed on the floor.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, pain controlled w/\n percocets PO. dilaudid DC'd. OOB PT eval.\n Cardiovascular: Aspirin, Beta-blocker, Statins, -acei.\n -pacing wires in.\n -plavix restarted for cartid stent.\n Pulmonary: IS, CXR post Ct removal.\n Gastrointestinal / Abdomen: ileus/ dilated bowel by kub. BM today.\n Nutrition: Advance diet as tolerated , full liquids today.\n Renal: Adequate UO, dc foley. gentle diuresis.\n Hematology: Serial Hct, stable anemia.\n Endocrine: RISS, euglycemia on riss.\n Infectious Disease: no e/o infection\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: KUB today\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Arrhythmia\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 01:16 PM\n 20 Gauge - 11:30 AM\n Prophylaxis:\n DVT: (plavix)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2173-12-17 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 542526,
"text": "CVICU\n HPI:\n POD 2\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n EF 65 cre0.7 Wt93\n PMH:HTN, carotid stenosis s/p stent , CAD, s/p CVA 5 yrs ago,\n lumbar radiculopathy, basal cell CA s/p resection on forehead and back,\n BPH, s/p B inguinal herniorrhaphies\n :lisinopril 10, flomax 0.4, plavix 75, atenolol 50, lipitor 80,\n isorsorbide 60, finasteride 5, ASA 81, loratadine 10\n Current medications:\n Acetaminophen Aspirin EC. Atorvastatin Bisacodyl Calcium Gluconate\n Clopidogrel Docusate Sodium Finasteride . Furosemide . HYDROmorphone\n (Dilaudid) . HydrALAzine Insulin Ketorolac Lisinopril . Magnesium\n Sulfate metoprolol Tartrate. Metoclopramide Milk of Magnesia .\n Oxycodone-Acetaminophen. Potassium Chloride Ranitidine 30. Tamsulosin\n 24 Hour Events:\n PA CATHETER - STOP 10:30 AM\n ARTERIAL LINE - STOP 10:30 AM\n CALLED OUT\n Post operative day:\n POD 2\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n 24H Events: Abd. distension,LFTs/KUB done. +BM this AM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:03 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:45 AM\n Other medications:\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.1\nC (98.7\n HR: 95 (91 - 112) bpm\n BP: 99/65(73) {89/40(52) - 131/77(82)} mmHg\n RR: 20 (14 - 25) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.4 kg (admission): 93.8 kg\n Height: 69 Inch\n Total In:\n 1,610 mL\n 580 mL\n PO:\n 1,040 mL\n 480 mL\n Tube feeding:\n IV Fluid:\n 570 mL\n 100 mL\n Blood products:\n Total out:\n 4,085 mL\n 570 mL\n Urine:\n 3,595 mL\n 490 mL\n NG:\n Stool:\n Drains:\n 20 mL\n Balance:\n -2,475 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: 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 164 K/uL\n 9.4 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 105 mEq/L\n 136 mEq/L\n 26.3 %\n 7.8 K/uL\n [image002.jpg]\n 12:28 PM\n 12:51 PM\n 01:57 PM\n 02:08 PM\n 05:21 PM\n 08:20 PM\n 03:03 AM\n 03:52 PM\n 10:12 PM\n 01:52 AM\n WBC\n 11.5\n 10.0\n 7.8\n 7.8\n Hct\n 27.5\n 30\n 30.6\n 29.5\n 30.5\n 26.3\n Plt\n 64\n Creatinine\n 0.8\n 0.7\n 0.8\n TCO2\n 27\n 28\n 26\n Glucose\n 145\n 96\n 138\n 135\n 131\n 129\n 130\n Other labs: PT / PTT / INR:14.3/31.8/1.2, Fibrinogen:230 mg/dL, Lactic\n Acid:1.7 mmol/L, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, KNOWLEDGE, IMPAIRED,\n RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS, IMPAIRED, NAUSEA /\n VOMITING, HYPERGLYCEMIA, ELECTROLYTE & FLUID DISORDER, OTHER, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), HYPERTENSION, BENIGN, OBSTRUCTIVE\n SLEEP APNEA (OSA), CORONARY ARTERY BYPASS GRAFT (CABG), .H/O PROSTATIC\n HYPERTROPHY, BENIGN (BPH), .H/O PERIPHERAL VASCULAR DISEASE (PVD)\n WITHOUT CRITICAL LIMB ISCHEMIA\n Assessment and Plan: POD 2\n 61M s/p CABGx4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)\n Neurologic: Neuro checks Q: 4 hr, Pain meds prn/OOB/PT eval\n Cardiovascular: Aspirin, Beta-blocker, Statins, PWs in/ ACE-I\n Pulmonary: IS, Encourage DB &C, CXR after CTs dc'd: No PTX\n Gastrointestinal / Abdomen: Post-op ileus, LFTs NL. KUB= dilated Bowel.\n +BM after supp. Add Reglan x24H/ Liquiud diet only\n Nutrition: Full liquids, Advance diet as tolerated\n Renal: Foley, DC now. Cont. gentle diuresis\n Hematology: stable, Cont. Plavix\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, Pacing wires, DC PWs on #3/ DC foley now\n Wounds: Dry dressings\n Imaging: CXR today, Post pull no PTX, KUB + dilated Bowel\n Consults: P.T.\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 01:16 PM\n 20 Gauge - 11:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Echo",
"chartdate": "2173-12-15 00:00:00.000",
"description": "Report",
"row_id": 87824,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nStatus: Inpatient\nDate/Time: at 10:48\nTest: Portable TEE (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 and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal aortic diameter at the sinus level. Normal\nascending aorta diameter. Normal aortic arch diameter. Normal descending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\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.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Right ventricular chamber size and free wall motion\nare normal. The ascending, transverse and descending thoracic aorta are normal\nin diameter and free of atherosclerotic plaque to 22 cm from the incisors. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. There is no pericardial effusion.\nPost Bypass\nPreserved LV function with EF of 55%\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-18 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1044719,
"text": " 11:28 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: f/u ileus\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n f/u ileus\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN.\n\n HISTORY: CABG, followup ileus.\n\n Five views. Comparison with the previous study done . Air-filled\n mildly dilated small bowel is again demonstrated. There are colonic air-fluid\n levels on the upright view. Soft tissues and bony structures are\n unremarkable. There is no significant change.\n\n IMPRESSION: Findings consistent with colonic ileus. No definite change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-20 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1044947,
"text": " 8:38 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: f/u colonic ileus\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n f/u colonic ileus\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 5:38 PM\n PFI: Persistent colonic ileus, slightly improved compared to prior study.\n Small bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male, status post CABG. Follow up colonic ileus for\n interval change.\n\n FINDINGS: Three views of the abdomen in comparison to . There\n is a moderate amount of gas in the colon, which is mildly, if at all, dilated.\n Nonspecific air-fluid levels are seen within the colon on the upright views.\n There are no dilated loops of small bowel or small bowel air-fluid levels. The\n overall appearance is improved compared to yesterday's study. There is no\n intraperitoneal free air or pneumatosis. No soft tissue calcifications. The\n osseous structures are unremarkable. In the visualized lung bases, there are\n small pleural effusions bilaterally.\n\n IMPRESSION: Findings consistent with colonic ileus, slightly improved\n compared to prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-17 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1044481,
"text": " 10:01 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ileus\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n ileus\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 4:01 PM\n PFI: Multiple dilated loops of large bowel. Consistent with colonic ileus.\n No free air, bowel wall thickening, pneumatosis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male status post AVR. Evaluate for ileus\n\n FINDINGS: Three views of the abdomen reviewed without prior comparison. There\n are multiple loops of dilated air-filled large bowel. There is also air\n within a single loop of nondilated small bowel. There is no intraperitoneal\n free air. No bowel thickening or pneumatosis. No soft tissue calcifications.\n Osseous structures are unremarkable. Overlying defibrillator pads are noted.\n\n IMPRESSION: Air-filled, dilated large bowel. Consistent with colonic ileus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1044101,
"text": " 1:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p CABG - with results @ \n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Post-surgical followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is status post\n sternotomy and CABG. The chest tubes and mediastinal drains, the Swan-Ganz\n catheter is in regular position. The endotracheal tube is located in the\n right main bronchus. The referring physician was paged at the time\n of dictation. No pneumothorax. No focal parenchymal opacities suggestive of\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-19 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1044821,
"text": " 9:12 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o colonic obstruction\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n r/o colonic obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN.\n\n HISTORY: CABG, ileus, evaluate for obstruction.\n\n Two views. The diaphragm is not included on supine or upright views.\n Comparison with the previous study done . There is now a large amount\n of gas in mildly dilated colon. There are nonspecific air-fluid levels on the\n upright view. The bowel gas pattern is otherwise unremarkable. Compared with\n the previous study, there is little interval change.\n\n IMPRESSION: Findings most consistent with colonic ileus not significantly\n changed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1044950,
"text": ", R. CSURG FA6A 8:39 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u atx, effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n f/u atx, effusion\n ______________________________________________________________________________\n PFI REPORT\n Small bilateral pleural effusions. Improving bilateral basilar atelectasis.\n Less bowel dilatation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1044484,
"text": ", R. CSURG CSRU 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: PTX- **please dp at 10A w/ KUB-thx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG x4\n REASON FOR THIS EXAMINATION:\n PTX- **please dp at 10A w/ KUB-thx\n ______________________________________________________________________________\n PFI REPORT\n Bibasilar atelectasis increased. Small bilateral pleural effusion persists.\n No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-20 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1044948,
"text": ", R. CSURG FA6A 8:38 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: f/u colonic ileus\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n f/u colonic ileus\n ______________________________________________________________________________\n PFI REPORT\n PFI: Persistent colonic ileus, slightly improved compared to prior study.\n Small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-17 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1044482,
"text": ", R. CSURG CSRU 10:01 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ileus\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n ileus\n ______________________________________________________________________________\n PFI REPORT\n PFI: Multiple dilated loops of large bowel. Consistent with colonic ileus.\n No free air, bowel wall thickening, pneumatosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1044483,
"text": " 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: PTX- **please dp at 10A w/ KUB-thx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG x4\n REASON FOR THIS EXAMINATION:\n PTX- **please dp at 10A w/ KUB-thx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 11:44 AM\n Bibasilar atelectasis increased. Small bilateral pleural effusion persists.\n No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL:\n\n REASON FOR EXAM: Status post CABG x 4. Rule out pneumothorax.\n\n Since , all tubes and catheters were removed except the right\n internal jugular sheath.\n\n Left lower lobe and right basal atelectasis increased. Small bilateral\n pleural effusions persist. There is no volume overload. Dilatation of bowel\n loops suggests ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-12-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1044949,
"text": " 8:39 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u atx, effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n f/u atx, effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 10:48 AM\n Small bilateral pleural effusions. Improving bilateral basilar atelectasis.\n Less bowel dilatation.\n ______________________________________________________________________________\n FINAL REPORT\n PA LATERAL CHEST RADIOGRAPH\n\n HISTORY: 61-year-old man status post CABG. Evaluate for pneumothorax or\n effusion.\n\n COMPARISON: Chest radiograph from , and\n .\n\n FINDINGS: There is stable cardiomegaly. The aorta is tortuous but stable in\n appearance and the hilar and mediastinal contours are unchanged in appearance.\n Patient is status post median sternotomy and CABG. Sternotomy cerclage wires\n are stable in appearance. There are small bilateral pleural effusions. There\n is improved bilateral basilar atelectasis. There is less bowel dilatation\n compared to . There is no pneumothorax.\n\n IMPRESSION:\n 1. Small bilateral pleural effusions. Improving bilateral basilar\n atelectasis.\n 2. No pneumothorax.\n 3. Less bowel dilatation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2173-12-19 00:00:00.000",
"description": "Report",
"row_id": 221941,
"text": "Atrial fibrillation with controlled ventricular response. Compared to the\nprevious tracing of the rhythm has changed.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-12-15 00:00:00.000",
"description": "Report",
"row_id": 221942,
"text": "Sinus rhythm. Inferolateral T wave inversions suggest myocardial ischemia.\nNon-specific slight ST segment elevation in leads V2-V3. RSR' pattern\nin lead V1. Compared to the previous tracing of bradycardia is\nabsent. RSR' pattern is present in lead V1.\n\n"
}
] |
11,605 | 120,175 | 66 year-old M with mantle cell lymphoma with pancytopenia, cryptogenic cirrhosis, and DM who presents s/p failed TIPS procedure admitted for monitoring. Hospital course by problem below: # Cryptogenic Cirrhosis with failed TIPS: Doppler US showed patent vasculature. IR repeated TIPS via percutaneous approach on and failed. His diuretics and nadolol were initially held, but were restarted on . Patient had a therapeutic paracentesis on day of discharge performed by attd after marked with ultrasound. Two bags of platelets were administered prior to tap. | Maintained on D10 gtt until 1700 then d/ tem test done r/o adrenal insuficiencyGI/ hepato: abd firm distended acites. Lungs clear dim @ bases.ID: Afebrile T-max 98.2, neutopenic WBC 1.0. abx levofloxcin and acyclovir.Endo: BS labile FSBS q1-2hrs, 58-147. Returned IR intubated anestitized (vecuronium) and sedated Propofol 60mcg/kg/min wean to 30mcg/kg/min. updated on status and plan of care.Plan: Seriel Hcts/labs transfuse for falling Hct. (Over) 7:37 AM TIPS Clip # Reason: please assess the portal pressures and perform a TIPS if the Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\TIPS ** REMOTE WEST ** INR STE/SDA Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) FULL CODE.NEURO: RECEIVED PT INTUBATED ON PROPOFOL GTT, WEANED TO EXTUBATION. To IR for TIPS procedure @ 0930, Paracentesis in IR removed 1910cc fluid (+ blood). Hyponatremia N+ 133/135, K+ 3.7... IV access d/c 2 LE PIV Porta-cath access, R wrist #16 PIV. HCT dropped to 20, receieved 2unit PC, post transfusion HCT 28 and PLT 60, goal PLT >50.full codeneuro: pt A/Ox3, follows commands, MAE, no c/o abd pain, per abd US pt has left lobe hematoma of liver.c/o pain in foley, lidocin urojet apllied with good effect.resp: NC 3L, sat 96-97%, on RA desat to 87-88%, overnight pt had wheezing, Cxray shown fluids, given lasix 20mg x2 with some effect.cv: HR 70-80's, NSR, no ectopym, ocass HR up to 120's, ST,back to 80's w/o , MD aware. MICU7 RN Note 0700-1900Events: Pre and post procedure Platelets, s/p FFP/PRBC, Hypoglycemic. FINAL REPORT HISTORY: Cirrhosis with TIPS now extubated patient with wheezing. BP SYS 85-105/60, MAPS>60, RR- 18/MIN, PP DOPPLER+. side of parecentesis leaking, pressure dressing apllied.id: tmax 99.2, cont Acyclovir IV and Levoflaxacin PO.endo: cont d10% currently at 100cc/hr d/t BS 68.plan: NPO for tips in the morning given PLT and recheck PLt after infusion. The largest pocket at the left lower quadrant was marked for subsequent paracentesis. 12:02 AM CHEST (PORTABLE AP) Clip # Reason: Pls eval for fluid. UNILATERAL UPPER EXTREMITY ULTRASOUND: Grayscale and color Doppler son was performed of the left internal jugular, axillary, brachial, cephalic, and basilic veins. ECHYMOTIC SITE.HEME: HCT DONE 26.6. 12:31 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: eval for clot. L arm edema>R, ? Limited ultrasound revealing extensive ascites. Doppler evaluation demonstrates patent hepatopetal flow within the main portal vein. MICU7 RN NOTE 0700-1900EVENTS: HYPOGLYCEMIA, ABD USNEURO: RECEIVED PT AWAKE AND ORIENTED, MAE EQUAL STRENGHT, PUPILS 4MM EQUAL REACT BRISKCV: HR 65-80 NSR NO ECTOPY. A 0.035- wire was advanced through the micropuncture sheath up to the level of the IVC under fluoroscopic guidance. require straight cath if no void.ID: Afebrile 98.4 po. Neutropenic precautions.Plan: Pt. The anterior right portal vein is patent with a velocity of 9.3 cm/sec. TIs procedure unsuccessful returned to MICU @ 1300.GU: foley autodiuresis 50-300cc/hr.Derm:skin impaired dry, eccymosis, jaudiceSocial: Full code status. ABD dist ascites, pt start on liquid diet, advanced as tollerate.id: neutropenic precaution, Tmax 99, cont levoflaxacin po and acyclovir iv.endo: yesterday hypoglycemia BS 80-90's, was on D10%. To MICU after hypotensive episode to 70's, brady to 40's; Neo and atropine. IR for TIPS and Paracentesis, returned Intubated sedated/aline, hypotensive levophed, post anesthesia recovery. In the left lobe of the liver, there is a new ill-defined hyperechoic region with central low signal intensity compatible with hematoma from patient's recent prior TIPS attempt placement. PT IS SCHEDULED FOR DUPLEX DOPPLER OF ABDOMEN/PELVIS AND US OF LIVER/GALLBLADDER TODAY. Please mark a spot for paracentesis. R rad arterial line removed today @ 1000, pressure held x10minutes due to throbocytopenia, pressure dressing intact. PALPABLE RADIALS, DP PULSES AUDIBLE WITH DOPPLER. Abdomen distended with ascites. sedation to off by 1545 Extubated. Returned s/p procedure Intubated #7.5 awaken from anesthesis/sedation and extubated @1600. placed on FT 50% wean to NC 3L/min sats 95-100%. PT HAS SINCE BEEN WEANED TO ROOM AIR WITH RR 15-20 AND SPO2 93-97%, DENIES SOB AND NO INCREASED WOB NOTED. PORTABLE CHEST RADIOGRAPH: There has been interval extubation. R radial aline sharp wave form SBP85-126/43-70 Maps >60 s/p procedure hypotensive SBP 80 starteed Levophed titrated to maintian Maps>60 SBP>90. Neutopenic precautions. Note: An ultrasound on demonstrated a patent portal vein. ABD US DONE REVEALS PATENT PORTAL VEIN AND HEMATOMA IN THE LEFT LOBE OF LIVER, MILD SEROUS FLUID FROM PARACENTHSIS SITE. Hypoactive BS present. Peripheral pulses 3+ DP/DT neg edeme. PT TO RECEIVE IV ALBUMIN IF HE HAS ANOTHER HYPOTENSIVE EPISODE OF SUSTAINED SBP <85. FINDINGS: The liver is echogenic with a shrunken and nodular morphology. LUNGS CLEAR BILATERAL UPPER LOBES, DIMINISHED AT THE BASES.GI/GU: ABDOMEN FIRM AND DISTENDED WITH ASCITES, DENIES ABDOMINAL PAIN. 1900-0700 rn notes micuneuro: A.Ox3, and cooperative.c/o pain in foley, apllied lidocain urojet with some effect.resp: RA, sat 96%, LS clear. | 16 | [
{
"category": "Radiology",
"chartdate": "2179-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961427,
"text": " 10:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with cirrhosis s/p TIPS now intubated.\n REASON FOR THIS EXAMINATION:\n eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n\n REASON FOR EXAMINATION: Intubation of the patient with known cirrhosis after\n tip placement.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip terminates 7.8 cm above the carina, too high than expected\n above the level of the clavicles. The left subclavian line tip terminates at\n the level of cavoatrial junction. The left lower lobe retrocardiac\n atelectasis is demonstrated as well as right lower and right middle lobe\n partial atelectasis _____ due to low lung volumes and high position of the\n diaphragm. The left costophrenic angle was not included in the field of view,\n thus the appreciation of pleural effusion cannot be assessed. Small right\n pleural effusion cannot be excluded. These findings were discussed with Dr.\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 961878,
"text": " 10:26 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for infiltrate or effusion\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with mantle cell lymphoma, liver disease with cirrhosis,\n hypoxia, neutropenia\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate or effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, , AT 10:29 A.M.\n\n HISTORY: Mantle cell lymphoma, liver disease with cirrhosis, hypoxia, and\n neutropenia.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The Port-A-Cath is stable in course and position. The distal tip\n is not clearly visualized in the region of the cavoatrial junction. Lung\n volumes remain markedly low with subsegmental atelectasis radiating from the\n left hilum and involving the entire right middle lobe and portions of the\n right lower lobe. There are bilateral effusions, right much greater than\n left. Within differences of technique, however, these effusions are similar\n in size.\n\n IMPRESSION: Within differences of technique, no significant interval change.\n There is bibasilar atelectasis, worse on the right secondary to a large\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-23 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 961617,
"text": " 7:37 AM\n TIPS Clip # \n Reason: please assess the portal pressures and perform a TIPS if the\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n Contrast: OPTIRAY Amt: 70\n ********************************* CPT Codes ********************************\n * PERC PORTAL VEIN CATH -52 REDUCED SERVICES *\n * PARACENTESIS INITAL PROC -51 MULTI-PROCEDURE SAME DAY *\n * US GUID FOR NEEDLE PLACEMENT -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with diuretic resistant ascites with cirrhosis.\n\n REASON FOR THIS EXAMINATION:\n please assess the portal pressures and perform a TIPS if there is a significant\n gradient\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 66-year-old man with intractable ascites and\n liver cirrhosis.\n\n RADIOLOGISTS: The procedure was performed by Drs. , Dr. and Dr.\n , attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiographic table and the abdomen and the neck were prepped and\n draped in standard sterile fashion. General anesthesia was administered\n throughout the procedure. Using ultrasonographic guidance and micropuncture\n system, paracentesis was performed prior to the initiation of the procedure\n and 3,000 mL were drained during the procedure. Using an intercostal approach\n and a 22-gauge needle, access was gained into the liver parenchyma in order to\n access a portal vein branch. Multiple passes were performed with unsuccessful\n access to the portal vein. Then, using ultrasonographic guidance, 2 attempts\n were made in order to cannulate the portal vein with a 20-gauge needle. Since\n all attempts were unsuccessful and due to the coagulation parameters of the\n patient, the procedure was discontinued and re-attempt will be performed in 1\n week after coags improve. The patient was transfused with 2 units of\n platelets before the procedure and will have 2 more units afterwards, as well\n as 1 unit of FFP. The patient was transferred to the ICU in good condition.\n\n IMPRESSION: Unsuccessful percutaneous transhepatic portogram. We will re-\n attempt in 1 week when coagulation factors will be corrected.\n\n\n\n\n\n\n\n (Over)\n\n 7:37 AM\n TIPS Clip # \n Reason: please assess the portal pressures and perform a TIPS if the\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-22 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 961473,
"text": " 9:25 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: assess for portal vein thrombosis\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with cirrhosis, failed tips\n REASON FOR THIS EXAMINATION:\n assess for portal vein thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old man with cirrhosis, failed TIPS placement yesterday,\n please evaluate for venous anatomy.\n\n TECHNIQUE: Multiple son and Doppler images of the liver are submitted\n for interpretation. Findings are compared with prior ultrasound dated\n .\n\n FINDINGS: The liver is echogenic with a shrunken and nodular morphology.\n There is a large amount of ascites within the abdomen. In the left lobe of\n the liver, there is a new ill-defined hyperechoic region with central low\n signal intensity compatible with hematoma from patient's recent prior TIPS\n attempt placement. The gallbladder is contracted and contains shadowing\n gallstones. The gallbladder lumen is not distended.\n\n Doppler evaluation demonstrates patent hepatopetal flow within the main portal\n vein. Velocity of the MPV is 17.0 cm/sec. The hepatic artery demonstrates a\n normal resistive index of 0.65. The anterior right portal vein is patent with\n a velocity of 9.3 cm/sec. The posterior right hepatic vein is also widely\n patent. The left portal vein demonstrates appropriate flow. The hepatic\n veins are all widely patent. -scale images of the portal vein\n demonstrates no evidence for intraluminal thrombus. The spleen measures 17.1\n cm. There is appropriate hepatofugal flow within the splenic vein.\n\n IMPRESSION: Interval development of a hematoma within the left lobe of the\n liver. No evidence for portal venous thrombosis. Appropriate Doppler\n waveforms visualized within the liver.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-24 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 961789,
"text": " 12:31 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: eval for clot.\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new LUE swelling, eval for clot.\n REASON FOR THIS EXAMINATION:\n eval for clot.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with new left upper extremity swelling. Evaluate\n for clot.\n\n COMPARISON: None.\n\n UNILATERAL UPPER EXTREMITY ULTRASOUND: Grayscale and color Doppler son\n was performed of the left internal jugular, axillary, brachial, cephalic, and\n basilic veins. There is thrombus identified with loss of flow in the\n superficial left cephalic vein. Normal flow, waveforms, augmentation, and\n compressibility are demonstrated in all the remaining veins. No other areas\n of intraluminal thrombus is identified.\n\n IMPRESSION: No DVT. Thrombus is identified within the superficial left\n cephalic vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-21 00:00:00.000",
"description": "INSERT HEPATIC HUNT TIPS",
"row_id": 961291,
"text": " 7:29 AM\n TIPS Clip # \n Reason: please assess the portal pressures and perform a TIPS if the\n ********************************* CPT Codes ********************************\n * INSERT HEPATIC HUNT TIPS -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with diuretic resistant ascites with cirrhosis.\n REASON FOR THIS EXAMINATION:\n please assess the portal pressures and perform a TIPS if there is a significant\n gradient\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION FOR EXAM: This is a 66-year-old man with cirrhosis and diuretic-\n resistant ascites.\n\n RADIOLOGIST: The procedure was performed by Dr. and , the\n attending radiologist, who was present supervising throughout the procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiographic table, and general anesthesia was administered\n throughout the procedure. The right neck and the abdomen were prepped and\n draped in standard sterile fashion. Paracentesis was performed with drainage\n of 300 cc of ascites before the procedure was initiated. Using the\n micropuncture system, access was gained into the right internal jugular vein\n under ultrasonographic guidance. A 0.035- wire was advanced through the\n micropuncture sheath up to the level of the IVC under fluoroscopic guidance.\n The micropuncture sheath was exchanged for 10 French vascular sheath, which\n was connected to a continous side arm flush. Using a 5 French head \n catheter and a 0.035- wire, access was gained into the middle hepatic\n vein, and the sheath was advanced to the tip within the hepatic vein. The\n head catheter was removed and exchanged for a balloon occlusion\n catheter, which was used to perform a CO2 hepatic venogram. The CO2 hepatic\n venogram didn't demonstrate the right and left portal veins, neither the main\n portal vein. CO2 venogram was then performed on a lateral projection, and no\n opacification of the portal vein was achieved. Using - access\n set, four passes were performed in order to puncture the portal vein, which\n were unsuccessful.\n At that point, it was decided to terminate the procedure. The patient was\n transferred to the PACU in good condition. The vascular sheath was removed,\n and manual compression was held for 10 minutes until hemostasis was achieved.\n\n IMPRESSION: Unsuccessful TIPSS.\n Note: An ultrasound on demonstrated a patent portal vein. We will\n reccommend a redo with a wire in the protal vein as a target.\n\n\n\n (Over)\n\n 7:29 AM\n TIPS Clip # \n Reason: please assess the portal pressures and perform a TIPS if the\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961729,
"text": " 12:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls eval for fluid.\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with cirrhosis s/p TIPS extubated. Pt with wheezing.\n\n REASON FOR THIS EXAMINATION:\n Pls eval for fluid.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis with TIPS now extubated patient with wheezing.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: There has been interval extubation. There are low\n lung volumes, with volume loss on the right with a small-to-moderate right\n pleural effusion. There is ascites.\n\n IMPRESSION: Low lung volumes with right basilar atelectasis. Left subclavian\n line tip projects over the upper SVC.\n\n"
},
{
"category": "ECG",
"chartdate": "2179-04-22 00:00:00.000",
"description": "Report",
"row_id": 194107,
"text": "Sinus rhythm\nLow precordial lead QRS voltages - is nonspecific\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2179-04-20 00:00:00.000",
"description": "Report",
"row_id": 194108,
"text": "Normal sinus rhythm. Left axis deviation. Probable left anterior fascicular\nblock. Compared to the previous tracing of the axis has shifted\nleftward. Otherwise, no change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-04-23 00:00:00.000",
"description": "Report",
"row_id": 1414228,
"text": "1900-0700 rn notes micu\n\nneuro: A.Ox3, and cooperative.c/o pain in foley, apllied lidocain urojet with some effect.\n\nresp: RA, sat 96%, LS clear. pt posible has sleep apnea durine sleeping sat dropped to 87-88%.\n\ncv: HR 80's, NSR, SBP 90-102/50 with MAP>60, received on D10% 50cc/hr, BS checked q2hr, last BS 68, put D10% to 100cc/hr , Dr aware. midnight HCT stable at 26, morning labs pending. plan to give plt in the morning.\n\ngu/gi: foley in place drainged yellow/clear 80-200cc/hr. pt NPO after midnight for procedure. ABD dist ascites. side of parecentesis leaking, pressure dressing apllied.\n\nid: tmax 99.2, cont Acyclovir IV and Levoflaxacin PO.\n\nendo: cont d10% currently at 100cc/hr d/t BS 68.\n\nplan: NPO for tips in the morning\n given PLT and recheck PLt after infusion.\n cont monitoring BS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-04-23 00:00:00.000",
"description": "Report",
"row_id": 1414229,
"text": "MICU7 RN Note 0700-1900\n\nEvents: Pre and post procedure Platelets, s/p FFP/PRBC, Hypoglycemic. IR for TIPS and Paracentesis, returned Intubated sedated/aline, hypotensive levophed, post anesthesia recovery. Extubated. Falling Hct transfusion. stem test.\n\nNeuro: Baseline awake alert oriented x3 MAE random equal strength. Pupils 3mm equal react . No c/o pain. Returned IR intubated anestitized (vecuronium) and sedated Propofol 60mcg/kg/min wean to 30mcg/kg/min. post anesthesia recovery wakeup by 1400 increased responsiveness and agitation from ETT. sedation to off by 1545 Extubated. Currently awake alert oriented x3 drowsy, Pupils 3mm react , random equal strength/baseline. No c/o of pain just positional discomfort.\n\nCV: HR 70-122 NSR-ST occass PAC. R radial aline sharp wave form SBP85-126/43-70 Maps >60 s/p procedure hypotensive SBP 80 starteed Levophed titrated to maintian Maps>60 SBP>90. Levo off @ 1630, hemodynamically stable. Peripheral pulses 3+ DP/DT neg edeme. Hyponatremia N+ 133/135, K+ 3.7... IV access d/c 2 LE PIV Porta-cath access, R wrist #16 PIV. IV NS 10cc/hr D10 gtt off @ 1700.\n\nHeme: @ start of shift recieved Plts 46 s/p 1 U Plts recieve 2nd unit. post procedure s/p 2U plts level 73. recieved 2U FFP and @units PRBC s/p HCT 20.\n\nResp: Started shift RA sats 100%, RR 18. Returned s/p procedure Intubated #7.5 awaken from anesthesis/sedation and extubated @1600. placed on FT 50% wean to NC 3L/min sats 95-100%. Lungs clear dim @ bases.\n\nID: Afebrile T-max 98.2, neutopenic WBC 1.0. Neutopenic precautions. abx levofloxcin and acyclovir.\n\nEndo: BS labile FSBS q1-2hrs, 58-147. Maintained on D10 gtt until 1700 then d/ tem test done r/o adrenal insuficiency\n\nGI/ hepato: abd firm distended acites. Partacentesis site s, serous drainagae. hypoactive BS no stool this shift. NPO. To IR for TIPS procedure @ 0930, Paracentesis in IR removed 1910cc fluid (+ blood). TIs procedure unsuccessful returned to MICU @ 1300.\n\nGU: foley autodiuresis 50-300cc/hr.\n\nDerm:skin impaired dry, eccymosis, jaudice\n\nSocial: Full code status. Wife and family visited met with team and consultants. updated on status and plan of care.\n\n\nPlan: Seriel Hcts/labs\n transfuse for falling Hct. Goal plts >50\n Monitor for abd pain\n Stabalize BS\n ? TIPS procedured in 1 week.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-04-24 00:00:00.000",
"description": "Report",
"row_id": 1414230,
"text": "1900-0700 rn notes micu\n66y.o male with h/o mantel cell lymphoma, cryptogenic cirrhosis, CRI, pancytopania, ascites admitted for tips placement that was failed, pt became hypotension likely d/t sedation/intubation.\n\n went to IR for parasentesis 1950cc bloody and TIPS placement, that failed. HCT dropped to 20, receieved 2unit PC, post transfusion HCT 28 and PLT 60, goal PLT >50.\n\nfull code\n\nneuro: pt A/Ox3, follows commands, MAE, no c/o abd pain, per abd US pt has left lobe hematoma of liver.c/o pain in foley, lidocin urojet apllied with good effect.\n\nresp: NC 3L, sat 96-97%, on RA desat to 87-88%, overnight pt had wheezing, Cxray shown fluids, given lasix 20mg x2 with some effect.\n\ncv: HR 70-80's, NSR, no ectopym, ocass HR up to 120's, ST,back to 80's w/o , MD aware. ABP stable at 116-122/60's. morning labs pending.\n\ngu/gi: foley in place drainge yellow urine 80-200cc/hr, after lasix 300-500cc/hr. ABD dist ascites, pt start on liquid diet, advanced as tollerate.\n\nid: neutropenic precaution, Tmax 99, cont levoflaxacin po and acyclovir iv.\n\nendo: yesterday hypoglycemia BS 80-90's, was on D10%. overnight BS 349, start sliding scale.\n\nplan: cont monitoring resp/cardio status\n HCT q6hr, monitoring PLT\n ?TIPS next week.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-04-24 00:00:00.000",
"description": "Report",
"row_id": 1414231,
"text": "66 y.o. male admitted for scheduled TIPS procedure . Unsuccessful x2 attempts , . To MICU after hypotensive episode to 70's, brady to 40's; Neo and atropine. Rec'd total of 2 units plt, 4 units PRBC. Has L liver lobe hematoma.\n\nFULL CODE/Neutropenic precautions/Allergy: Benadryl.\n\nPMH: Type 2 DM, cryptogenic cirrhosis, portal vein HTN, Stage 4 mantle cell carcinoma dx , CRI, ascites, colitis, Chron's dx., L kidney cysts, thrombocytopenia.\n\nAccess: port-a-cath, #16 RFA.\n\nNeuro: A&Ox3, OOB to recliner x2hrs. PERL. Able to bear weight well, slightly unsteady due to deconditioning. Intact cough/gag. Denies pain.\n\nCV: NSR rate 70-90's, occais ST 100's for brief periods. Occaisional PVC's. R rad arterial line removed today @ 1000, pressure held x10minutes due to throbocytopenia, pressure dressing intact. SBP 110-120's via art, running 90's-100 via cuff. Nadolol 20mg PO daily begun @ 1000, tolerated well. HCT=27.3 with AM labs, 28 @ 1000. plt=43. WBC=1.2. L arm edema>R, ? infiltrated IV was D/C'd overnight. To Ultrasound today for US of L arm to r/o DVT. Awaiting read.\n\nResp: weaning O2 NC from 3L to 1L, SAT 96-99%. Lung sounds clear upper lobes, exp wheezes to bilt bases this AM, cleared this evening. Strong cough, expectorated thick pale yellow sputum x1 this shift.\n\nGI: Diet advanced to , tolerating well. Lrg BM x1 this shift. Hypoactive BS present. Endo: oral diabetic agents on hold due to hypoglycemic episodes. Coverage with SSI regular insulin. 0600=. Abdomen distended with ascites. Aldosterone, Lasix PO BID re-started @ 1400.\n\nGU: Foley cath draining clear dark yellow urine 30-80cc/hr. Foley D/C'd @1100. Patient has attempted to urinate x1 unsuccessfully. require straight cath if no void.\n\nID: Afebrile 98.4 po. Acyclovir, Levofloxacin PO. Neutropenic precautions.\n\nPlan: Pt. has been called out, awaiting private room for precautions. Will be followed by liver team. ? possible 3rd attempt at TIPS procedure next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-04-22 00:00:00.000",
"description": "Report",
"row_id": 1414226,
"text": "NURSING ADMISSION NOTE 2230-0700\nPT IS A 66 Y/O MALE WHO WAS SCHEDULED FOR ELECTIVE TIPS PROCEDURE FOR DIURETIC RESISTANT ASCITES AND HYPONATREMIA. TIPS FAILED INABILITY TO CANNULATE THE PORTAL VEIN. SHEATH WAS REMOVED AND THE PT REMAINED INTUBATED DUE TO CONCERN FOR HEMATOMA FORMATION WITH EXTUBATION. TRANSFERRED TO MICU FOR FURTHER MANAGEMENT. RECEIVED PT FROM AT APPROX 2230, TRANSFERRED TO BED WITHOUT INCIDENT. FULL CODE.\n\nNEURO: RECEIVED PT INTUBATED ON PROPOFOL GTT, WEANED TO EXTUBATION. ALERT AND ORIENTED X3, CALM AND COOPERATIVE WITH CARE. MAE X4, DENIES DISCOMFORT. PERRL 3MM/BRISK BILATERALLY. AFEBRILE.\n\nCV: HR 60'S-80'S NSR WITHOUT ECTOPY NOTED. SBP UPON ARRIVAL 70'S, RECEIVED 250ML FLUID BOLUS X1 WITH FAIR EFFECT. SBP HAS REMAINED STABLE MID 80'S TO MID 90'S, MAPS 60' PT STATES HIS BASELINE SBP IS MID 80'S - DR. AWARE. PT TO RECEIVE IV ALBUMIN IF HE HAS ANOTHER HYPOTENSIVE EPISODE OF SUSTAINED SBP <85. PALPABLE RADIALS, DP PULSES AUDIBLE WITH DOPPLER. DENIES CP. LEFT SC PORTA-CATH NOT ACCESSED. LEFT ARM HAS 2 #18 PIV'S - SECURE AND PATENT.\n\nRESP: RECEIVED PT INTUBATED ON CPAP/50%/10PS/5PEEP WITH TV'S 500-600. PROPOFOL GTT WEANED DOWN - THOUGHT TO BE AFFECTING SBP - AND PT NOTED TO BECOME INCREASINGLY AGITATED. EXTUBATED AT APPROX 0100, PLACED ON FACE TENT 40% FIO2 WITH SPO2 100%. PT HAS SINCE BEEN WEANED TO ROOM AIR WITH RR 15-20 AND SPO2 93-97%, DENIES SOB AND NO INCREASED WOB NOTED. LUNGS CLEAR BILATERAL UPPER LOBES, DIMINISHED AT THE BASES.\n\nGI/GU: ABDOMEN FIRM AND DISTENDED WITH ASCITES, DENIES ABDOMINAL PAIN. BOWEL SOUNDS HYPOACTIVE. CLEAR DIET, NO STOOL THIS SHIFT. INDWELLING FOLEY CATHETER SECURE AND PATENT WITH APPROX 25-100ML CLEAR AMBER URINE/HOUR.\n\nENDO: FSBS LABILE RANGING 30'S-150'S. PT HAS REQUIRED D50 X3. REMAINS ASYMPTOMATIC AND ALERT & ORIENTED DESPITE BS IN 30'S.\n\nINTEG: NO SIGNS OF BREAKDOWN TO BACK. BUTTOCKS NOTED TO BE PINK UPON ARRIVAL, APPLIED ALOE VESTA CREAM LIBERALLY. SMALL ABRASION ON RIGHT LIP AND RIGHT WRIST, OPEN TO AIR.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT. WIFE IS HCP.\n\nPLAN: CONTINUE ICU SUPPORTIVE CARE. MONITOR SBP, IF < 85 NOTIFY MD TO DETERMINE WHETHER ALBUMIN TO BE GIVEN PER ORDER. SERIAL HEMATOCRITS EVERY 4 HOURS, NEXT DUE AT 1000 - NOTIFY MD IF < CONSIDER TRANSFUSING PRBC'S. MONITOR FSBS EVERY HOUR UNTIL STABLE, THEN EVERY 4 HOURS AS ORDERED. PT IS SCHEDULED FOR DUPLEX DOPPLER OF ABDOMEN/PELVIS AND US OF LIVER/GALLBLADDER TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-04-22 00:00:00.000",
"description": "Report",
"row_id": 1414227,
"text": "MICU7 RN NOTE 0700-1900\n\nEVENTS: HYPOGLYCEMIA, ABD US\n\nNEURO: RECEIVED PT AWAKE AND ORIENTED, MAE EQUAL STRENGHT, PUPILS 4MM EQUAL REACT BRISK\n\n\nCV: HR 65-80 NSR NO ECTOPY. BP SYS 85-105/60, MAPS>60, RR- 18/MIN, PP DOPPLER+. IV ACCESS W/ NS CHANGED TO D10% 75 ML/HR DECREASED TO 50 ML/HOUR, AC LINE W/ 5%DEX KVO. ECHYMOTIC SITE.\n\nHEME: HCT DONE 26.6. INR 1.5, PLATELETS 38. PLATELETS TO BE INFUSED IN THE MORNING BEFORE TIPS. GOAL TO MAITAIN PLATLETS >50.\n\nRESP: SPO2 92-98% RA. LS DIMINISHED AND CLEAR, R 20/MIN\n\nENDO: DIABETIC ON ORAL HYPOGLYCEMIC HAS NOT TAKEN FOR 2DAYS, FSBS Q1HR HYPOGYCENMIC MOST OF SHIFT 50-80 RECIEVED AMP D50 AND STARTED IV 10% DEXTROSE. FSBS @ 1700 127 10%DEX GTT REDUCED TO 50 ML/HR.\n\nGU: FOLEY URINE YELLOW AND CLEAR OUTPUT ADEQUATE.\n\nGI: ABD FIRM AND DISTENDED, DIET RENAL LOW NA. ABD US DONE REVEALS PATENT PORTAL VEIN AND HEMATOMA IN THE LEFT LOBE OF LIVER, MILD SEROUS FLUID FROM PARACENTHSIS SITE. PLAN NPO AFTER 12 MIDNIGHT FOR TIPS .\n\nID: T-MAX 98.7 ON ACYCLOVIR AND LEVOFLOXIN.\n\nSKIN: PALE SL JAUNDICE SKIN INTACT. SMALL ECHYMOTIC AREA NOTED IN IHE RIGHT WRIST. COCCYX PINK.\n\nSOCIAL: FULL CODE STATUS, WIFE VISITED AND MET W/TEAM UPDATED ONM PLAN OF CARE\n\nPLAN: NPO AFTER MN\n PLATLETS TO BE GIVEN IN AM WITH GOAL PLTS>50\n TIPS PROCEDURE\n SERIEL HCTS/PLTS\n CONT Q1HR FSBS\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-04-27 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 962169,
"text": " 2:34 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ASCITES, PLEASE MARK A SPOT FOR PARACENTESUIS\n Admitting Diagnosis: DIARETIC RESISTANT ASCITES W/ CIRRHOSIS\\TIPS ** REMOTE WEST ** INR STE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with cirrhosis, failed TIPS and symptomatic ascites.\n REASON FOR THIS EXAMINATION:\n Please mark a spot for paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n LIMITED ABDOMINAL ULTRASOUND\n\n CLINICAL HISTORY: 66-year-old man with cirrhosis, failed TIPS, and\n symptomatic ascites. Please mark a spot for paracentesis.\n\n Comparison made to prior studies, including duplex Doppler ultrasound of\n abdomen and pelvis dated .\n\n FINDINGS: Limited ultrasound of the abdomen was performed. There is\n extensive ascites. Moderate- to large-sized pockets of ascites were\n identified at the right lower quadrant and left lower quadrant. The largest\n pocket at the left lower quadrant was marked for subsequent paracentesis. Note\n is made of small bilateral pleural effusions.\n\n IMPRESSION:\n 1. Limited ultrasound revealing extensive ascites. Mark made at left lower\n quadrant for subsequent paracentesis.\n 2. Bilateral pleural effusions.\n\n"
}
] |
4,724 | 162,007 | Respiratory - had mild respiratory distress which resolved within a matter of hours. He remained in room air and well saturated. He had a normal respiratory pattern and he did not require any xanthines; had only minimal apnea of prematurity which resolved well before discharge. Cardiovascular - The infant remained cardiovascularly stable and had normal pulse and blood pressures throughout his hospital course. Fluids, electrolytes and nutrition - Initially was NPO. He had an initial blood glucose of 41 for which he received a bolus of intravenous fluids of D10/W and was placed on a running intravenous line of the same. He started enteral feeds on day of life #1 with premature Enfamil 20 calorie or breastmilk. Initially he was fed by oral gavage. He transitioned to oral feedings with breastfeeding being initiated at 33 weeks corrected gestational age. He had some spitting which resolved with increased feeding time. He gradually became able to p.o. feed exclusively and has breastfed well with p.o. supplements for the last three days prior to discharge. Mother has had consultations with the lactation service to assist in their breastfeeding. supplemental feedings consist of mother's milk 24 calories prepared with Enfamil powder. His weight on the day of discharge is 2.685 kg at 35 4/7 weeks corrected gestational age. Length is 49 cm (19.3 in). Head circumference is 33.5 cm. Gastrointestinal - The baby has had a normal stooling pattern. He was treated for physiologic hyperbilirubinemia with a peak bilirubin on day of life #3 of 12.0. He continued on phototherapy until day of life #6 and had a rebound of bilirubin of 6.9 on day of life #7. Hematologic - He did initially have a white blood cell count of 11 with a normal differential and hematocrit of 52% and 261,000 platelets. did not receive any blood products throughout his hospitalization. He was started on iron on day of life #19 and at discharge is on Iron and Tri-Vi- for anemia of prematurity. Infectious disease - Due to preterm premature rupture of membranes, had a complete blood count and blood culture drawn upon admission and received 48 hours of ampicillin and gentamicin which were discontinued on day of life #2. He has remained clinically well since. Neurology - has demonstrated appropriate tone and activity for his gestational age. Sensory - Audiology, had a hearing screening which was done on ; he passed in both ears. Psychosocial - parents were followed by the social work team at during hospitalization; Social Work can be reached at . | Independent with temp &diaper change. P-Continue withcurrent regimen as ordered.G/D: o/A-Temp stable in OAC. soft, bs+, voiding/stooling qsheme. Wakes calmly for feeds.MAE. stable, a/a withcares, settles well inbetween, fonts soft/flat. NPN 0700-This RN assessed infant and agrees with the above note by Tran; PCA. Minimal aspirates, nospits.G&D O/A: Temps stable in an OAC. Infantis voiding, trace stool x2 thus far. PCA Note:FEN: O: Wt. Neonatology-NNP Physical ExamInfant remains in RA. Abd benign. Updated by thisPCA and RN . Calms withpacifier. AGREE WITH PCA NOTE. Neonatology - NNP Progress Note is active with good tone. Requires moderate stim, no O2. NPN DAYS ADDENDUMAGREE WITH ABOVE ASSESSMENT AND PLAN. to support nutritional needs.5infant remains swaddled in OAC, temp. AF-Flat.Sucking intermit. NO SPELLSA:STABLEP:CONTINUE TO MONITOR PCA Note9 A's & B'sFEN: TF min 130cc/k/d of BM24 with enf. P: Continue tosupport infant's nutritional needs.DEV: O: Infant is swaddled in an OAC, maintaining stabletemps. Continue to encourage PO's and BF.DEV: Infant swaddled in OAC. Min 130cc/kg BM24 w/ enfamilpowder. Clinda and erythro continued d/. P-Continue with current regimen asordered.G&D: O/A-Temp stable in OAC. Both veryaffectionate to pt. Bld cxpending. Updates given. Ampi & gent started. neg.P:cont. Start infusion of D10W. Gavaged remainder. Abdomen soft, +BS, AG stable, sm spitX1, soft loops noted X1, NNP Buck notified and examinedinfant. Hem neg. Hem neg. Updated by the RN. Voiding and stooling (heme-) with cares.BS+ bilaterally. A: AGA. A: AGA. Will cont. NPN 0700-This RN assessed infant and agrees with the above note by ; PCA. Pt. Pt. Attempt to PO as tolerated. AGA. Oriented both to unitguidelines. MAE's approp. P: continue to monitor CV.#4FEN: BW 2100grams. Actingappropriate. Active Bowelsounds. Neonatology - NNP Progress Note is active with good tone. Abd is roundand soft with active bs.2. Maxaspirate 2. P-Continue with current regimen asordered.G/D: O/A-Temp stable, slightly warm in OAC. Occ variable decels. Abdomen isunremarkable. Active bowel sounds. BP 58/31(38).Pt. A: Loving. MAE.AFSF. askedappropriate questions. to offer PO's as tolerated. Voiding and stooling,heme neg.G&D: Temps stable, swaddled in 'off' isolette. abd soft, bs+, noloops, max asp. A/A WITHCARES. Bld cx NGTD. Abd exam stable. RR/HR stable. Placed pt. TFCONT. Hem neg. UPdates given. Abd benign. BS+. in servoisolette. BP stable. Will D/Cproblem.4. Abd soft, +BS. Abd soft, +BS. WT. Did have mild brady this am, QSR. Mild sc rtxns. AGA. P:cont. Cl and =. NPN 1900-07001. : Pt remains on Ampi and Gent. Rebound bili 6.7/0.2 this AM. NPN 7a-7pAssessed infant and agree with above note by PCA . A/G stable.D/S stable. Continue abx as ordered.2. Temp stable in servo isolette. NPN 0700-4. MAE's approp. TO SUPPORT G/D.6. Lungs CTA, =. Lungs CTA, =. Temps now stable in servo. P-Continue to encourage PO feeds.G/D: O/A-Temp stable in OAC. Continue to promote gorwth anddevelopment.6. Awake & alert forcares. F&N: TF remain at 80cc/k/d. Belly soft, +BS, no loops, nospits, min aspirates. DEV: Pt received on radiant servo warmer. TOSUPPORT AND EDUCATE . to support nutritionalneeds.5infant remains swaddled in off isolette, temp stable, a/awith cares, settles well in between, fonts soft/flat.P:cont. Abd benign.Voiding and stooling. Voiding andstooling well.A: Taking in adequate amts. Min aspirates. Bottled x1 took amt. P-Continue with current regimen asordered.G&D: O/A-In RA. P-Continue with current regimen.G/D: O/A-Temp stable in OAC. Willcontinue with current plan of care.Alt in G&D: Temp stable in servo isolette, nested onsheepskin. Hem neg. Abdomen benign, bowel sounds active. Abd soft, bowel snds active. Updated on status andimmediate plan by R.N. Settles well in between cares. Suckingon pacifier. to supportnutritional needs.5infant remains swaddled in OAC, temp. P:cont. P:cont. P: Cont. P: Cont. P: Cont. Temps wnl.A: AGAP: Cont dev. NPN ADDENDUMThis R.N. neg. G/D: Temps stable in servo-isolette. Rootingaround. A: AGA. PG thisshift. Updated himon day. AGA. AGA. AGA. One smallspit noted. LAst spell w/ feedSat-. NPN I have examined this infant and am in agreement w/aboveassessment and note by PCA . Voiding qs and stoolingheme neg. Nospits. Mild sc rtxns. for eventual d/c. Neonatology-NNP Physical ExamInfant remains in RA. Cl and =. Neonatology aTtendingAddendum: PEAsleep with appropriate tone/activity; pink; AFOF. Correction: Baby is in servo isolette. supports.#6 : here this AM and mother here thisafternoon. to support nutritionalneeds.5infant remains in cerve isolette, temp. tosupport nutritional needs.5infant remains in OAC, temp. Tolerating gavage whenneeded. Infantawake and alert w/ cares. Abd soft, bowel snds active.Voiding and stooling.A: Learning to br. soft, bs+, infant had soft loops at1300 care, ag stable 24cm, max asp. NPN DAYSI have examined this baby and agree with above note by , PCA. Nsg NoteAgree with above note by PCA. active and alert with cares, temp stable nested in heatedisolette with boundaries, on servo control, sucks onpacifier, sleeps best on tummy A: AGA P: continue to supportneeds for growth and development6. Willcontinue to encourage PO feeds.G/D: In OAC. NPN NOCSI have examined infant and agree with note written by , PCA. feed/bottle feed.P: cont to encourage br. Temp stable. Neonatology - NNP progress noteInfant is active with good tone. to update oninfant's progress.9no A's and B's thus far this shift. Updated by thisPCA and RN . Continue toencourage PO's.DEV: Temps stable in OAC. Updated on eachoccasion by R.N. Placed back in isolette. Temp nowstable. A: Tol feedswell. G+D Swaddled in air isolette. A: AGA P: Contto support dev needs. AFOF, ng in place. BILI Bili lvl this am 11.7/0.3/12.0. Nospits.A. in and fed with support.Tol all po at this time. A: AGA. Cont to instruct on preenie stresscues.6. Abdbenign. Repeat bili level was 10.2/0.3. Nursing Progress Note#1. NPN 0700-This RN assessed infant and agrees with the above note by Tran; PCA. COnsentsigned. P-Continue to follow current regimen as ordered.G/D: O/A-Temp stable in OAC. AGA. P: Continue with current regimen as tolerated.DEV: Temp stable in servo controlled isolette. A: Jaundice, P:Will cont with light and monitor. TF min 130 cc/k/d.PO. O: Infant remains on TF's of 80cc/k/d of PE20. Continue to monitorclosely. PCA NoteFEN: TF min 130cc/k/d of BM24 with enf. Pt changed to air mode isolette. Pt changed to air mode isolette. | 116 | [
{
"category": "Nursing/other",
"chartdate": "2197-04-27 00:00:00.000",
"description": "Report",
"row_id": 1742098,
"text": "PCA 0700-1900\n\n\n4\ninfant remains on TF 150cc/kg/d of BM26 with promod=56cc q4h\ngavaged over 60 minutes. infant PO'd for the first time\ntoday, bottling 9cc with no desats and no bradys, remainder\nof feed was gavaged. adb. soft, bs+, voiding/stooling qs\nheme. neg. infant had small spits X2, ag stable 25-25.5cm,\nmax asp. 4.2cc of partially digested BM refed to infant.\nP:cont. to support nutritional needs.\n\n5\ninfant remains swaddled in OAC, temp. stable, a/a with\ncares, settles well inbetween, fonts soft/flat. infant\nbrings hands to mouth for comfort, likes pacifier. P:cont.\nto support growth and developement.\n\n6\n in to visit at 1300, took temp., changed diaper and\nbottled infant. was very excited about giving infant\nfirst bottle. held infant while gavage feed was going.\nP:cont. to update on infant's progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-27 00:00:00.000",
"description": "Report",
"row_id": 1742099,
"text": "NPN DAYS ADDENDUM\nAGREE WITH ABOVE ASSESSMENT AND PLAN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-28 00:00:00.000",
"description": "Report",
"row_id": 1742100,
"text": "1900-0700 NPN\n\n\n#4F/E/N\nO:TF AT 150CC/KG BM26 W/PROMOD 56CC Q4HR GAVAGE OVER ONE\nHOUR 20\". ABDOMEN SOFT, FULL WITH GOOD BS. 0-2CC ASPIRATES,\nNO LOOPS. MOD SPIT X1. AG 25-26CM. VOIDING WELL; SMALL\nYELLOW STOOL X1.\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, MONITOR SPITS\n\n#5G&D\nO:IN OAC WITH STABLE TEMPERATURE. ACTIVE/MAE WITH CARES;\nSLEEPING WELL BETWEEN. FONTANEL SOFT AND FLAT; SUTURES\nSMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#6PARENTING\nO:NO CONTACT\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, MONITOR AND KEEP UP TO DATE\n\nRESPIRATORY\nO:REMAINS IN RA WIHT SATS >92%. BS CLEAR. RESP RATE 30-58\nWITHOUT DISTRESS. NO SPELLS\nA:STABLE\nP:CONTINUE TO MONITOR\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-28 00:00:00.000",
"description": "Report",
"row_id": 1742101,
"text": "Neonatology NP Exam Note\nPLease refer to attending note for details of evaluation and plan.\n\nPE: small infant asleep in open crib, transitions easily to quiet alert state.\nAFOF, sutures approximated. Eyes clear, ng in place, MMMP\nChest is clear, with equal BS, comfortable resp pattern.\nCV: RRR, no murmur, pulses+2=\nAbd: soft with active BS NTND, no HSM\nGU: normal external male genitalia testes palpable in scrotum\nExt: MAE, WWP\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-28 00:00:00.000",
"description": "Report",
"row_id": 1742102,
"text": "Neonatology Attending\n is 13do, 34 wks corrected\nRA, open crib\nOne a/b in past 24hrs\nWt 2270g up 50 on TF150 MM26 with Promod pg>>po -- nurses well\n\nImp/ age-appropriate cvr, feeding immaturity\nPlan/ continue to monitor cvr status, growth/development.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-28 00:00:00.000",
"description": "Report",
"row_id": 1742103,
"text": "Nursing Progress Note\n\n\nFEN O/A: TF @ 150cc/k/d; BM26 w/ Promod. Infant recieves\n~57cc q4h pg. Tolerating feeds gavaged over 90 minutes. Put\nto breast for ~10 minutes today; passive/no latch. Abdomen\nsoft/active BS. Voiding/stooling. Minimal aspirates, no\nspits.\n\nG&D O/A: Temps stable in an OAC. Sleeps well b/t feeds, A/A\nwith cares. Likes pacifier. Brings hands to face, MAE, AGA\nP: Cont to support developmental needs.\n\nPAR O/A: in for 1300 cares. Independent with temp &\ndiaper change. Very affectionate with infant. Mon sceduled\nfor lactation consult tomorrow. P: Cont to support NICU\n.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-19 00:00:00.000",
"description": "Report",
"row_id": 1742062,
"text": "Neonatology Attending\nDOL 4\n\nRemains in room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 66/37 (52).\n\nUnder single phototherapy with bilirubin 10.2/0.3 this morning ( from yesterday).\n\nWt 2045 (-15) on TFI 120 cc/kg/day PE20 by gavage, tolerating well. Abd benign. Voiding and stooling normally.\n\nTemperature stable in servo isolette.\n\nA&P\n32-1/7 week GA infant with hyperbilirubinemia, feeding immaturity\n-Continue to await maturation of oral feeding skills\n-Continue phototherapy and repeat bilirubin in 48 hours\n-Increase TFI to 140 cc/kg/day\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-06 00:00:00.000",
"description": "Report",
"row_id": 1742143,
"text": "PCA Note\n\n9 A's & B's\n\nFEN: TF min 130cc/k/d of BM24 with enf. powder = 57cc Q4.\nAll PO's. Infant bottling 70cc and then 10cc after BF for\n20 min. Infant is tolerating feeds well; no spits thus far.\nAbd. benign - soft, round, +BS, no loops. is voiding\nand stooling; heme neg. Continue to encourage PO's and BF.\n\nDEV: Infant swaddled in OAC. Alert and active with cares;\nsleeping very soundly in between. Wakes calmly for feeds.\nMAE. Enjoys sucking on pacifier. OB in to assess for\ncircumcision this afternoon. Will not be d/c'd tomorrow as\nplanned d/t brady with feed. Continue to support\ndevelopmental needs.\n\n: Mom and in this afternoon. Updated by this\nPCA and RN . Very loving and independent with cares.\nAware that will not be d/c'd tomorrow. Some teaching\ndone by RN. Asking appropriate questions. Very loving and\ninvested. Continue to support and update.\n\nA's & B's: Infant had one brady with feed this shift.\nInfant choked on formula. Mom sat him up and gave him pats\non the back. Infant will not be d/c'd home tomorrow.\nContinue to monitor closely.\n\nREVISIONS TO PATHWAY:\n\n 9 A's & B's; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-06 00:00:00.000",
"description": "Report",
"row_id": 1742144,
"text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by Tran; PCA. Some D/C teaching done; see NICU D/C instruction form in chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-06 00:00:00.000",
"description": "Report",
"row_id": 1742145,
"text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\nrespirations unlabored,lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\ngood tone.\nMet with mother at bedside, updated on progress and plan to restart countdown\nDiscussed breastfeeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-07 00:00:00.000",
"description": "Report",
"row_id": 1742146,
"text": "PCA Note:\n\n\nFEN: O: Wt. = 2.695kg (^50g). Min 130cc/kg BM24 w/ enfamil\npowder. All feeds PO, q3-4hrs. Infant lacking coordination\nat times, resulting in choking with apnea. No spits.\nInfant's abdomen is soft, nontender, +BS, no loops. Infant\nis voiding, trace stool x2 thus far. Circ site red, tender\nw/ scant blood; treated with vaseline and sterile gauze. A:\nInfant tolerating feeds fairly well. Eager to bottle, strong\nsuck yet, extremely uncoordinated at times. P: Continue to\nsupport infant's nutritional needs.\n\nDEV: O: Infant is swaddled in an OAC, maintaining stable\ntemps. Infant sleeps well between cares. Wakes for feeds and\nremains alert and active throughout cares. Calms with\npacifier. A: Developmentally appropriate. P: Continue to\nsupport infant's developmental needs.\n\n: O: Mom called x1, was updated by RN. P: Continue to\nsupport and teach.\n\nA's & B's: O: Infant chokes while bottling and becomes\nsignificantly apnic. Requires moderate stim, no O2. No\nassociated brady's. P: Continue to monitor closely.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-07 00:00:00.000",
"description": "Report",
"row_id": 1742147,
"text": "NPN Addendum\nI have examined infant and agree with above note from , PCA.\nInfant rec'd Tylenol x2 o/n (s/p circ) with excellent effect. Circ site is red with scant amount of bld on 2x2.\nInfant with some choking at beginning of feeds. No bradys. Coordination does improve with bottling.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-26 00:00:00.000",
"description": "Report",
"row_id": 1742091,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. 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": "2197-04-26 00:00:00.000",
"description": "Report",
"row_id": 1742092,
"text": "Neonatology Attending\n is 11do, 33 wks corrected\nRA, no a/b\nIn open crib now!\nWt 2170 up 45 on TF150 MM26 with Promod pg plus nursing practice\n\nImp/ age-appropriate feeding immaturity; making good progress\nPlan/ continue to monitor cvr status, growth/development.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-26 00:00:00.000",
"description": "Report",
"row_id": 1742093,
"text": "NPN 0700-\n\n\n4. TF 150cc/kg/day, BM 26 with promod; 54cc gavaged over 1\nhour. Belly soft, +BS, no loops. Min aspirates, no spits.\nVoiding, stooling. Mom put to breast at 1pm care- infant\nsuckling, attempting to latch. Continue to monitor\ntolerance to feeds.\n\n5. Temp stable in open crib. Alert and active with cares,\nresting well between cares. Occasionally waking before\nfeeds. Continue to promote growth and development.\n\n6. here for 1pm care, updated on progress and plan\nof care. loving and attentive, asking appropriate\nquestions. given some names of pediatrician's in\nthe area, will research and settle on pedi. Continue\nto update, educate and support .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-27 00:00:00.000",
"description": "Report",
"row_id": 1742094,
"text": "CO WORKER NOTE\n\n\nFEN: O/A-Current weight 2.020, ^50gm. TF 150cc/k/d of BM 26\nwith promod. PG/1 hour. is voiding and stooling. Hem\nneg. Active bowel sounds. Abdomen is unremarkable. Minimal\nresiduals. No spits. Tolerating feeds. P-Continue with\ncurrent regimen as ordered.\n\nG/D: o/A-Temp stable in OAC. Waking slowly for feeds. Alert\nand active with cares. Sleeps peacefully. MAE. AF-Flat.\nSucking intermit. on pacifier. Mild disposition. AGA.\nP-Continue to monitor for developmental milestones.\n\n: No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-27 00:00:00.000",
"description": "Report",
"row_id": 1742095,
"text": "1900-0700 NPN\nBABY EXAMINED AND ASSESSED BY THIS RN. AGREE WITH PCA NOTE. NO CONTACT WITH FAMILY OVERNIGHT\nBABY REMAINS ON OXIMETER WITH SATS >95% AND NO DISTRESS\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-27 00:00:00.000",
"description": "Report",
"row_id": 1742096,
"text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating full volume po/pg feeds. Abd soft, active bowel sounds, no loops, Voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-27 00:00:00.000",
"description": "Report",
"row_id": 1742097,
"text": "Neonatology Attending\n is 12do, 33 wks corrected\nRA, open crib\nNo a/b\nWt 2220 up 50 on TF150 MM26 with Promod pg; working on learning to nurse\n\nimp/ age-appropriate immaturity of feeding. doing well.\nplan/ continue to monitor cvr status, growth/development\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-04 00:00:00.000",
"description": "Report",
"row_id": 1742133,
"text": "Neonatology Attending\n is 19do, 34 6/7wks corrected\nRA, open crib\nNo a/b\nWt 2530 up 30 on TF150 MM24 pg>po; dyscoordinated bottling; nursing well when mom here\n\nImp/ age appropriate feeding immaturity\nPlan/ continue to monitor cvr status, growth/development. starting Fe today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-04 00:00:00.000",
"description": "Report",
"row_id": 1742134,
"text": "NPN 0700-1900\n\n\n#4: O: Total fluid minimum 150cc/kg/day of breastmilk 24,\n63cc q4 hours. Alternating PO/PG feeds. Infant breastfed\nwell at the afternoon feed and half volume of feed was\ngavaged after. Abdomen is benign, voiding and stooling.\nStools heme negative. Minimal aspirates and no spits. A:\nInfant tolerating feeds. P: Continue with current feeding\nplan.\n\n#5: O: Temperature stable in OAC. Infant wakes for some\nfeeds, alert and active with cares. Brings hands to face for\ncomfort, calms with pacifier. Infant remains swaddled in\ncrib. A: AGA. P: Continue to support growth and development.\n\n#6: O: Mom and in today for afternoon feed. A: Loving\n. P: Continue to support in the care of their\ninfant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-04 00:00:00.000",
"description": "Report",
"row_id": 1742135,
"text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by ; PCA. Infant was able to take whole bottle at 1700 very well. Will cont. to offer PO's as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-05 00:00:00.000",
"description": "Report",
"row_id": 1742136,
"text": "PCA NOTE\n\n\nFEN: O/A-Current weight 2.565, ^35gm. TF 150cc/k/d. Taking\nfull volume PO thus far this shift. is voiding and\nstooling. Hem neg. Active bowel sounds. Abdomen is\nunremarkable. Minimal residuals. Small spits noted.\nTolerating feeds. P-Continue with current regimen as\nordered.\n\nG&D: O/A-Temp stable in OAC. Waking for feeds. Alert and\nactive with cares. Sleeps well. MAE. AF-flat. Rooting. Sweet\ndisposition. AGA. P-Continue to monitor for developmental\nmilestones.\n\n: No contact thus far this shift.\n\n *****See flowsheet for further information*****\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-05 00:00:00.000",
"description": "Report",
"row_id": 1742137,
"text": "NPN 1900-0730\nI HAVE ASSESSED INFANT AND READ NOTE WRITTEN BY PCA AND AGREE WITH HER ASSESSMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-05 00:00:00.000",
"description": "Report",
"row_id": 1742138,
"text": "Neonatology Attending\n is 20do, 35wks corrected\nRA, open crib\nNo a/b in at least a week.\nWt 2565 up 35 on TF150 MM24 - all po for almost 24hrs!\n\nMeds Fe\n\nimp/ age-appropriate feeding maturity, approaching readiness for d/c\n\nPlan/ continue to monitor cvr status, growth/. Will decrease TF to min130 today, change HMF to Enfamil powder. Still needs hearing screen, car seat test. Need to check with re: circ plans and primary pediatrician decision. Tentative d/c home as early as tomorrow contingent upon continued evidence of maturity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-05 00:00:00.000",
"description": "Report",
"row_id": 1742139,
"text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. BS clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Normal phallus, testes down bilaterally. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-25 00:00:00.000",
"description": "Report",
"row_id": 1742084,
"text": "NPN 1900-0700\n\n\nFEN: wt=2125g (up 10g). TF=150cc/kg/d of BM/PE26. All PG,\ngavaged over 60min. Abdomen soft, +BS, AG stable, sm spit\nX1, soft loops noted X1, NNP Buck notified and examined\ninfant. Infant also had asps of .4cc, which were benign,\nrefed slowly and subtracted from feed. Voiding and stooling,\nheme neg.\n\nG&D: Temps stable, swaddled in 'off' isolette. Alert and\nactive with cares. Sleeps well between.\n\n: No contact thus far overnight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-25 00:00:00.000",
"description": "Report",
"row_id": 1742085,
"text": "Neonatology Attending\n is 10 do, 33 wks corrected\nRA, isolette\nOne bradycardic episode/24 hrs (? if apnea or desat associated)\nWt 2125 up 10g on TF150 MM/PE26 pg plus nursing x1 yesterday (Bwt 2150)\n\nImp/ age appropriate immaturity of cvr, feeding, thermoregulation\nPlan/ continue to monitor cvr status, growth/development. Will add Promod to feeds today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-25 00:00:00.000",
"description": "Report",
"row_id": 1742086,
"text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating full volume po/pg feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-15 00:00:00.000",
"description": "Report",
"row_id": 1742044,
"text": "Newborn Med Attending\n\n2100g, 32 week male infant born by vaginal delivery to a 32 yo G2 P0. Pregnancy complicated by P3ROM. Mother presented to L&D on with ROM and PTL. Mother rx with MgSo4, BMZ, erythro and clinda. Magnesium d/c'd upon completion of BMZ rx. Today increased contractions and labor augmented due to ROM. Occ variable decels. Clinda and erythro continued d/. No materanl fever or fetal tach. Infant emerged with good cry. Given BBO2 only. Apgars .\n\nPNS: B+/Ab-/RPRNR/HBSAg-/nl fetal survey/GBS unknown\n\nExam: see newborn exam sheet, but no abnormalities.\n\nA: Preterm male infant presents with several sepsis risk factors, but no clinical evidence of infection at this time. No signs of resp distress at this time.\n\nP: Monitor resp staus by exam and pulse oximetry. Will obtain CBC and blood cx and rx with IV amp and gent pending 48h cx results and clinical course. Monitor DS. Start infusion of D10W. Will start feeds in next few hours if normal respiratory pattern continues. Keep family informed of plans and progress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-25 00:00:00.000",
"description": "Report",
"row_id": 1742087,
"text": "PCA 0700-1900\n\n\n4\ninfant remain on TF 150cc/kg/d, is now onBM/PE26 with\npromod, promod added today, infant receives 54cc q4h gavaged\nover 60 minutes. abd soft, bs+, no loops, ag stable 26cm,\nmax asp. 2.2cc, no spits, voiding/stooling qs, heme. neg.\nP:cont. to support nutritional needs.\n\n5\ninfant is now in OAC, moved from off isolette at 0900 care,\ntemp stable, a/a with cares, settles well in between, fonts\nsoft/flat. infant brings hands to mouth for comfort.\nP:cont. to support dev. needs.\n\n6\n in for 1300 care, took temp and changed diaper. \nwas a little nervous about holding infant, but held him and\nread him a story while his feed was gavaged. asked\nappropriate questions. mom and plan on visiting\ntommorrow. P:cont to updtae on infant's progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-25 00:00:00.000",
"description": "Report",
"row_id": 1742088,
"text": "NPN 0700-\nI have examined the infant and agree with the above note written by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-26 00:00:00.000",
"description": "Report",
"row_id": 1742089,
"text": "CO WORKER NOTE\n\n\nFEN: O/A-Current weight 2.170, +45gm. TF 150cc/k/d. PG/60\nmins. is voiding and stooling. Hem neg. Active Bowel\nsounds. Girth is stable. Abdomen in unremarkable. Max\naspirate 2. No spits. P-Continue with current regimen as\nordered.\n\nG/D: O/A-Temp stable, slightly warm in OAC. Slowly waking\nfor feeds. Semi alert and active. Sleeping peacefully. MAE.\nAFSF. Mild mannered. P-Continue to monitor for developmental\nmilestones.\n\n: No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-26 00:00:00.000",
"description": "Report",
"row_id": 1742090,
"text": "I have examined infant and agree with above note by by .\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-15 00:00:00.000",
"description": "Report",
"row_id": 1742045,
"text": "Nursing admit note\n\n1 Infant with Potential Sepsis\n2 Alt in Resp\n3 Alt in CV\n4 Alt in FEN\n5 Alt in G&D\n6 Alt in parenting\n\nPt. is a 32 wk male admitted from L&D this am. Pt. emerged\nw/ good spont effort & received only BBO2 initially. Apgars\n8&8. Pt. transferred to NICU from L& MD note for\ncomplete hx.\n#2Resp: Pt. remains on RA. RR 30-50's w/ mild SC\nretractions. Lungs clear bilaterally. No spells or desats\nso far this shift. P: continue to monitor resp status.\n\n#1Pot for sepsis: Bld cx & CBC drawn on arrival. Bld cx\npending. CBC results in chart. Ampi & gent started. P:\ncontinue on abx & monitor for s/s of infection.\n\n#3CV: Hemodynamics stable. HR 130-160's. BP 58/31(38).\nPt. ruddy, well-perfused. Palpable pulses, brisk cap\nrefill. P: continue to monitor CV.\n\n#4FEN: BW 2100grams. TF @ 80cc/kg/day of D10W infusing\nthrough PIV. Inital D/S on arrival was 41. 2cc/kg bolus of\nD10W given. Following D/S 77 & 107. Abd soft & round, +BS,\nno loops. AG 23.5cm. Voiding. No stool so far this shift.\nP: continue to monitor FEN & start enteral feeds tonight.\n\n#5G&D: Temps stable nested in servo warmer. Awake & alert\nfor cares. MAE's approp. Appears content & comfortable\nprone. Fontanelles soft & flat. P: continue to support\ndev needs.\n\n#6Parenting: Parents in today. Oriented both to unit\nguidelines. Both asking approp questions. Both very\naffectionate to pt. Updates given. P: continue to support\n& update.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Alt in Resp; added\n Start date: \n 3 Alt in CV; added\n Start date: \n 4 Alt in FEN; added\n Start date: \n 5 Alt in G&D; added\n Start date: \n 6 Alt in parenting; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-02 00:00:00.000",
"description": "Report",
"row_id": 1742117,
"text": "NPN 1900-0700\n\n\n1. FEN: WT=2425gms (up 20gms). TF=150cc/k/day BM26.\nBottled 25cc at 0100. Stayed awake during feeding, but had\nuncoordinated suck/swallow/breathe pattern. Needed frequent\nrest periods during bottling. Gavaged remainder. Min\nasp/no spits. V&S with each diaper change. Abd is round\nand soft with active bs.\n\n2. G&D: Infant woke for feedings, but had difficulty\nbottling. Alert and active with cares. Sleeps well between\ncares. Uses pacifier to comfort self during gavage\nfeedings. Temps stable swaddled in open crib. AFSF. AGA.\n\n3. : Mom called x1 for update. Asked appropriate\nquestions about infant's feedings.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-02 00:00:00.000",
"description": "Report",
"row_id": 1742118,
"text": "Neonatology Attending\naddendum: PE\n\nActive, alert, appropriate, pink. AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-02 00:00:00.000",
"description": "Report",
"row_id": 1742119,
"text": "Neonatology Attending\naddendum: PE\n\nActive, alert, appropriate, pink. AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-02 00:00:00.000",
"description": "Report",
"row_id": 1742120,
"text": "Neonatology Attending\n is 17do, 34 wks corrected\nRA, open crib\nNo a/b\nWt 2425 up 20g on TF150 MM26 pg>po; beginning to wake for feeds\n\nImp/ age appropriate feeding immaturity, demonstrating gradual maturation.\nPlan/ continue to monitor cvr status, growth/development. D/c planning in progress contingent upon further evidence of maturity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-02 00:00:00.000",
"description": "Report",
"row_id": 1742121,
"text": "PCA 0700-1900\n\n\nFEN\n#4 O: Total fluids = 150cc/k/day of BM26; 61cc q4 hours\ngavaged over 45 min. Attempt to PO as tolerated. Infant\nbottled 26cc at 0900 and 20cc at 1300. Abdomen is round,\nsoft and benign; no loops noted. Small spit X1 as of now.\nMinimal aspirates. Voiding and stooling (heme-) with cares.\nBS+ bilaterally. A: Infant is tolerating feeds well. P:\nContinue to encourage PO feeds, and ensure that all\nnutritional requirements are met.\n\nG&D\n#5 O: Infant is swaddled in an OAC, maintaining stable\ntemps. Wakes for most cares and is alert and active; sleeps\nwell in between. AFSF. Brings hands to face/mouth for\ncomfort. A: AGA. P: Continue to monitor infants growth and\nsupport developmental needs.\n\n\n#6 O: was in at 1300 to assist with cares. Bottled the\ninfant and held him while he was being gavaged. Acting\nappropriate. Updated by the RN. A: are loving and\ninvolved. P: Continue to support the family and update them\nwith the infants progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-02 00:00:00.000",
"description": "Report",
"row_id": 1742122,
"text": "Nursing note\n\n\nI agree with the note written above by PCA . In\naddition, Dr. has spoken with re circumcision and\nconsent form has been signed. Circ will be scheduled closer\nto d/c.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-03 00:00:00.000",
"description": "Report",
"row_id": 1742123,
"text": "PCA NOTE\n\n\nFEN: O/A-Current weight 2.500, ^75gm. TF 150cc/k/d. BM 26.\nOffering PO x2 this shift. See flowsheet for specifics.\n is voiding and stooling. Hem neg. Active bowel sounds.\nAbdomen is unremarkable. Minimal residuals. No spits.\nTolerating feeds. P-Continue to encourage PO feeds.\n\nG/D: O/A-Temp stable in OAC. Slowly waking for feeds. Alert\nand active. Sleeping peacefully. AFSF. MAE. Uncoordinated\nwith PO feeds. AGA. P-Continue to monitor for developmental\nmilestones.\n\n: No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-23 00:00:00.000",
"description": "Report",
"row_id": 1742079,
"text": "NPN 0700-\n\n\n4. TF 150cc/kg/day, PE/BM 24, all gavage feeds. Belly\nsoft, +BS, no loops. Small spit this AM, min aspirates.\nVoiding, stooling, heme negative. Continue to monitor\ntolerance to feeds.\n\n5. Recieved infant in servo controlled isolette. Infant\nswaddled and isolette set to air mode, weaning as tolerated,\ntemp stable. Alert and active with cares, rests well\nbetween cares. Sucks well on pacifier. Continue to promote\ngrowth and development.\n\n6. here for 1pm care, updated on progress and plan of\ncare. independent with diaper change, temp taking,\nsigned consent for hep B- will administer this afternoon.\nMom feeling well, but resting at home- will visit 2x per\nweek. Spoke with regarding possibility of starting\nbreastfeeding with moms next visit. Continue to update,\neducate and support .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-24 00:00:00.000",
"description": "Report",
"row_id": 1742080,
"text": "NPN 1900-0730\n\n\n4. WT. THIS SHIFT 2.115GMS. DOWN 15GMS FROM YESTERDAY. TF\nCONT. AT 150CC/K/D OF BM24 OR 54CC Q 4HRS, GAVAGED OVER 1HR.\nTOLERATING WELL. NO SPITS OR ASP. ABD SOFT, NO LOOPS. +BS.\nVOIDING, STOOLING GUIAC- STOOL. GIRTH 23-24CM. PLAN; CONT.\nTO ASSESS WT. GAIN ON CURRENT FLUIDS.\n\n5. REMAINS IN OFF ISOLETTE WITH TEMPS STABLE. A/A WITH\nCARES. HEP B VACCINE GIVEN. MOVING ALL EXTREMETIES. REMAINS\nGAVAGE FEEDINGS. PLAN; CONT. TO SUPPORT G/D.\n\n6. NO CONTACT FROM SO FAR THIS SHIFT. PLAN; CONT. TO\nSUPPORT AND EDUCATE .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-24 00:00:00.000",
"description": "Report",
"row_id": 1742081,
"text": "Neonatology Attending\n is 9do, 33 wks\nRA, sats >95% with occ drifts to low 90s, no a/b\nWt 2115g down 15 on TF150 MM/PE24 pg (Bwt 2100)\n\"off\" isolette with stable temps\nGot HBV\n\nPE active, appropriate, pink AFOF. Lungs CTA, heart rrr s murmur, abd soft, extr well perfused\n\nImp/ age apporpriate immaturity of cvr, feeding, thermoregulation.\nPlan/ will increase to 26 cal/oz feeds today, continue to monitor cvr status, growth/development\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-24 00:00:00.000",
"description": "Report",
"row_id": 1742082,
"text": "PCA 0700-1900\n\n\n4\ninfant remains on TF 150cc/kg/d, calories were increased\nfrom PE24 to PE26, q4h 54cc is gavaged over 60 minutes.\ninfant attempted to BF today for the first time, latched on\nand sucked occ. for almost 5 minutes. abd soft, bs+, no\nloops, max asp. 2.0cc, ag stable 24-25cm, no spits, voiding\nqs, no stool thus far. P:cont. to support nutritional\nneeds.\n\n5\ninfant remains swaddled in off isolette, temp stable, a/a\nwith cares, settles well in between, fonts soft/flat.\nP:cont. to support dev. needs.\n\n6\nmom and in for 1300 care, worked together taking\ntemp. and changing diaper, ind. with cares, mom put infant\nto breast for the first time was very excited. would like\nto have a lactation appt. mom also kangarooed infant.\nP:cont. to update on infant's progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-24 00:00:00.000",
"description": "Report",
"row_id": 1742083,
"text": "NPN 7a-7p\nAssessed infant and agree with above note by PCA .\n\n remains in RA, breathing comfortably. RR/HR stable. No murmur noted. Did have mild brady this am, QSR. Abd exam stable. Tol'ing feeds gavaged over 1hr. ^'ed to 26cals as ordered. Voiding/stooling. Did attempt to breastfeed for 1st time, did well. in this afternoon, update given. Both eagerly participating in care. Mom held infant.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-22 00:00:00.000",
"description": "Report",
"row_id": 1742073,
"text": "NPN\n\n\n#4-O: On 150cc/k/d BM22/PE22 = 54cc q 4 hrs PG over 1 hr.,\ntol well , no aspirates, no spits, abd soft, benign, BS\nactive. Voiding, no stool, wt. up 10 gms to 2.080kg.\n\n#5-O: temps stable in servo isolette, alert and active with\ncares, no spells, AFOF, acts approp. for age.\n\n#6-O; mom called x 2, appropriately concerned, updated,\nwill visit today.\n\n#7-O; off phototherapy, sl jaundiced, rebound bili drawn\nthis am , pending.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-22 00:00:00.000",
"description": "Report",
"row_id": 1742074,
"text": "NICU Attending Note\n\nDOL # 7 = 33 1/7 weeks CGA with issues of growth and nutrition, resolving hyperbili.\n\nPlease see full NNP Zacagnini\n\nCVR/RESP: RRR without murmur, skin pink and well perfused. BS clear/=, RA, no A/B/desats, no caffeine. will continue to monitor.\n\nFEN: Abd benign, active BS, AG stable, weight today 2080, up 10 gm (BW 2150), on 150 cc/kg/ PE/MM 22 all PG. Tolerated well. Will increase to 24 cal/oz.\n\nGI: Bili yesterday 7.0/0.3, phototx d/c'ed, rebound this am 6.7/0.2. Will monitor bili clinically.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-22 00:00:00.000",
"description": "Report",
"row_id": 1742075,
"text": "NPN 0700-\n\n7 Hyperbili\n\n4. TF 150cc/kg/day, BM/PE 24, calories increased today.\n54cc gavaged over 1 hour. Belly soft, +BS, no loops, no\nspits, min aspirates. Voiding, stooling, heme negative.\nContinue to monitor tolerance to feeds.\n\n5. Temp stable in servo isolette. Alert and active with\ncares, rests well between cares. Sucks well on pacifier.\nMAE, brings hands to face. Continue to promote gorwth and\ndevelopment.\n\n6. here for 1pm care, updated on progress and plan of\ncare. kangarooed for approx 1 hour, 15 minutes, infant\ntolerated well. Continue to update, educate and support\n.\n\n7. Rebound bili 6.7/0.2 this AM. Continue to monitor for\ns/s of hyperbili.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbili; d/c'd\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-15 00:00:00.000",
"description": "Report",
"row_id": 1742046,
"text": "Physical Exam\nGen well appearing active\nAnt font open flat suture approximated\nlung shallow but good breath sounds bilaterally\nCV regular rate and rhythm no murmur femoral pulses 2+ bilaterlly\nAbd soft with active bowel sounds no masses or distention\nExt warm well perfused with brisk cap refill\nNormal tone good suck normal cry\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1742047,
"text": "NPN 1900-0700\n\n\n1. : Pt remains on Ampi and Gent. Blood cultures\nnegative so far. Continue abx as ordered.\n\n2. RESP: Pt remaisnin RA with RR 30-50's. Sats >95%.\nLung sounds are clear. No spells or sat drifts noted. Will\nD/C problem.\n\n3. C/V: No murmur heard. HR 130-150. Pt is pink and\nwell-perfused. BP stable. Mild gen edema noted. Will D/C\nproblem.\n\n4. F&N: TF remain at 80cc/k/d. Feeds started at 30cc/k/d\nat and were advanced to 50cc/k/d of BM/PE20. Feeds\ngavaged in over 20 minutes. Abd benign. BS+. A/G stable.\nD/S stable. 24 hour lytes and bili pending. U/O 2.9cc/k/h\nthis shift. No stool noted. gain 35 grams.\n\n5. DEV: Pt received on radiant servo warmer. Pt swaddled\nand placed into open crib. Temp stable so far this shift.\nHe is active and alert during his cares. Sleeps well\nbetween cares after being swaddled.\n\n6. PAR: Parents in for a quick visit to see infant. They\nwill plan their visits around his cares times today so that\nMom can hold infant. They asked appropriate questions and\nspoke lovingly to infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1742048,
"text": "Neonatology Attending Note\nExam:\nResting comfortably in isolette. AFSF. Lungs CTA, =. CV RRR, no murmur, 2+FP. Abd soft, +BS. Ext pink, well perfused, full ROM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1742049,
"text": "Neonatology Attending Note\nExam:\nResting comfortably in isolette. AFSF. Lungs CTA, =. CV RRR, no murmur, 2+FP. Abd soft, +BS. Ext pink, well perfused, full ROM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1742050,
"text": "Neonatology Attending Note\nDay 1\nCGA 32 2\n\nRA. RR30-50s. No A&Bs. Cl and =. Mild sc rtxns. No murmur. HR 130-150s. Pink/ruddy. Mean BP 47.\n\nBili 6.4.\n\nWt 2135, up 35 gms. TF 80 = 50 cc/k/enteral feedings PE20 + D10w.\n133/6.3/100/24. Tol feedings. Nl voiding at 2.9. No stool yet.\n\nOn amp/gent.\n\nIn isolette.\n\nA/P:\n- Monitor for AOP\n- Cont feeding advance\n- Complete sepsis evaluation, probable 48 hr eval w/ abx\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1742051,
"text": "NPN 0700-1900\n\n\n#1Pot.for sepsis: Pt. on day #2 of ampi & gent for 48 hr\nr/o. Bld cx NGTD. P: Continue to monitor for s/s of\ninfection.\n\n#4FEN: Tf @ 80cc/kg/day of IVF & enteral feeds. D10W @\n10cc/kg infusing through PIV & PE 20cal/oz @ 70cc/kg NG Q\n4hrs. Increasing feeds 10cc/kg Q feed. Abd soft & round,\n+BS, no loops. AG 23cm. Voiding. No stool so far this\nshift. Min asp, no spits. P: Continue to increase feeds\nuntil @ 80cc/kg. Continue to monitor FEN.\n\n#5G&D: Temp 97.5 in open crib this am. Placed pt. in servo\nisolette. Temps now stable in servo. Awake & alert for\ncares. MAE's approp. Likes pacifier. Kangaroo'd today for\nfirst time for 1hr & tolerated well. P: continue to\nsupport dev needs.\n\n#6Parenting: Parents in @ care times today. Demonstrated\nto mom how to take temp & change diaper. Parents asking\napprop questions. UPdates given. Mom so happy to be able\nto hold her baby. very supportive of mom & taking\npictures. Both very affectionate towards pt. P: continue\nto support & update.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-03 00:00:00.000",
"description": "Report",
"row_id": 1742124,
"text": "NPN Addendum\nI have examined infant and agree with above note from , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-03 00:00:00.000",
"description": "Report",
"row_id": 1742125,
"text": "Neonatology Attending\naddendum: PE\n\nActive sleep; appropriate tone/activity; pink; AFOF; lungs cta; heart rrr s murmur; abd soft; extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-03 00:00:00.000",
"description": "Report",
"row_id": 1742126,
"text": "Neonatology Attending\n is 18do, 34 wks corrected\nRA, open crib\nNo a/b\nWt 2500 up75 on TF150 MM26 po/pg, fairly well coordinated feeding skills, occasionally waking for feeds\n\nImp/ age appropriate feeding immaturity, making progress; growing well\nPlan/ continue to monitor cvr status, growth/development. Will decrease to 24cal/oz feeds today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-03 00:00:00.000",
"description": "Report",
"row_id": 1742127,
"text": "Neonatology Attending\naddendum: PE\n\nActive sleep; appropriate tone/activity; pink; AFOF; lungs cta; heart rrr s murmur; abd soft; extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-03 00:00:00.000",
"description": "Report",
"row_id": 1742128,
"text": "PCA 0700-1900\n\n\n4\ninfant remains on TF 150cc/kg/d, calories decreased from\nBM26 to BM24, 63cc q4h alt PO/PG feeds. infant fed\nwell at 1300 care for 15 minutes and half of feed was\ngavaged. abd. soft, bs+, no loops, small spit X1, min.\nasp., voiding/stooling qs heme. neg. P:cont. to support\nnutritional needs.\n\n5\ninfant remains swaddled in OAC, temp. stable, a/a with\ncares, settles well in between, fonts soft/flat, infant\nbrings hands to mouth, likes pacifier. P:cont to support\ngrowth and development.\n\n6\nmom and in for 1300 care, independant with cares, mom\nnursed infant while read a story, mom was very excited\nabout how well was breast feeding. very loving\n. P:cont. to update on infant's progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-03 00:00:00.000",
"description": "Report",
"row_id": 1742129,
"text": "NPN \n\n\n\n I have examined this infant and am in agreement w/above\nassessment and note by PCA .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-04 00:00:00.000",
"description": "Report",
"row_id": 1742130,
"text": "PCA NOTE\n\n\nFEN: O/A-Current weight 2.530, ^ 30gm. TF 150cc/k/d of BM/PE\n24. Alternating PO/PG. Remains uncoordinated with bottling.\n is voiding and stooling. Hem neg. Active bowel sounds.\nAbdomen is unremarkable. Minimal residuals. Small spit\nnoted. Tolerating feeds. P-Continue with current regimen.\n\nG/D: O/A-Temp stable in OAC. Waking for feeds. Alert and\nactive with cares. Sleeps peacefully. MAE. AFSF. Rooting\naround. Enjoys pacifier. Curious natured. AGA. P-Continue to\nmonitor for developmental milestones.\n\n: Mom called x1. Updated by nurse, K.\n\n ****See flowsheet for specifics****\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-04 00:00:00.000",
"description": "Report",
"row_id": 1742131,
"text": "NPN Addendum\nI have examined infant and agree with above note from , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-04 00:00:00.000",
"description": "Report",
"row_id": 1742132,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. 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 atteding progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-22 00:00:00.000",
"description": "Report",
"row_id": 1742076,
"text": "Neonatology-NNP PRogress Note\n\nPE: remains in his isolette, in room air, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, afso, active with care\n\nSee attending note forp plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-23 00:00:00.000",
"description": "Report",
"row_id": 1742077,
"text": "NPN 0700-1900\n\n\n1. FEN: Weight is 2130 gms up 50 gms. TF remain at 150\ncc/kg/day of PE/BM24. Tolerating NGT feedings well; abd\nexam benign, no spits, min asp. Voiding qs and stooling\nheme neg. P: Cont. to support nutritional needs.\n\n2. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Infant is alert/active\nwith cares. Settles well in between cares. Appropriately\nbrings hands to face and sucks on pacifier to comfort self.\nAFSF. AGA. P: Cont. to support developmental needs.\n\n3. : No contact thus far. Unable to assess at this\ntime. P: Cont. to support and update .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-23 00:00:00.000",
"description": "Report",
"row_id": 1742078,
"text": "Newborn Med Attending\n\nDOL#8. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2130 up 50, on 150 cc/kg/d PE24 PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-09 00:00:00.000",
"description": "Report",
"row_id": 1742159,
"text": "NURSING DISCHARGE NOTE\n\n\nF&N: Infant waking q 4hrs for feeds, taking 70-75cc of BM24.\n Recipe and frequency of giving added cal formula reviewed\nw/ . Infant bottled w/good coordination. One small\nspit noted. Abd is benign. He has voided and stooled\ntoday.\n\nG&D: Circ site continues to heal well. Vaseline applied\nliberally. Waking for feeds. Temp is stable in open crib.\nTone is wnl. Infant passed hearing and car seat test.\n\nA/B's: No spont bradys since . LAst spell w/ feed\nSat-.\n\n:Mom and in at 1500. Mom is independent w/ basic\ninfant care. She bottled today but was very\ntentative, as she had not bottle fed him before. is\nmore confident w/ feedings, but with some cues, Mom handled\ninfant very well during this feeding. Reviewed infant\npositioning in car seat and car seat safety as well as when\nto call the doctor. Mom was very nervous to take infant\nhome but also excited. Tags were matched w/ Mom's bands.\n placed infant in car seat and infant was discharged\nat 1530.\n Pedi appt scheduled for - at 11am. VNA ( \nVNA) to see infant tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-30 00:00:00.000",
"description": "Report",
"row_id": 1742110,
"text": "Neonatology Attending\n\nDOL 15 CGA 34 2/7 weeks\n\nStable in RA. No A/B.\n\nOn 150 cc/kg/d BM 26 with promod pg. Took a full po today. Voiding. Stooling. Wt 2345 grams (up 25).\n\nMRSA precautions secondary to roommate MRSA positive.\n\n visiting and up to date.\n\nA: Stable. On countdown D1. Needs to learn to feed.\n\nP: Monitor\n Encourage pos\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-30 00:00:00.000",
"description": "Report",
"row_id": 1742111,
"text": "Neonatology - NNP PRogress note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating po/pg feeds. Abd soft, active bowel sounds, no loops, voidng and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-30 00:00:00.000",
"description": "Report",
"row_id": 1742112,
"text": "NPN 1600\n\n\n#4 F/N: Total fluids at 150cc/kg/d br. milk 26 + Promod,\n58cc q 4 hrs. Infant bottled full bottles X2 today, tol\nwell. No spits. Abd soft, bowel snds active. Voiding and\nstooling well.\nA: Taking in adequate amts. need pg feed at 5pm d/t\nsleepy infant.\nP: Assess readiness to bottle however encourage br. feeding\nwhen mother here.\n#5 G/D: is alert and active w/ cares. Swaddled w/i\nboundaries in the open crib. Temps wnl.\nA: AGA\nP: Cont dev. supports.\n#6 : Mom stayed home today d/t not feeling well. \nin to visit at 1pm. Took the baby's temp and changed the\ndiaper. Asking appropriate questions.\nA: Invested family learning to care for premature infant.\nP: Cont parent teaching, prep. for eventual d/c.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-01 00:00:00.000",
"description": "Report",
"row_id": 1742113,
"text": "NPN NOCS\n\n\n4. Wt up 60gms. TF at 150cc/kg of BM26 with PM. Gavaged over\n50min. Bottled x1 took amt. No spits. Abd benign.\nVoiding and stooling. Working on po feeds.\n\n5. Alert and active with cares. Temp stable in open crib.\nAGA.\n\n6. No contact from thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-01 00:00:00.000",
"description": "Report",
"row_id": 1742114,
"text": "Neonatology Attending Note\nDay 16\nCGA 34 3\n\nRA. RR30-60s. Cl and =. Mild sc rtxns. No caffiene. No A&Bs. HR 150-160s. Pink, ruddy. BP 70/44, 60.\n\nWt 2405, up 60 gms. TF 150 cc/k/day BM26. PG over 45 minutes, plus po attempts.\n\nNl voiding and stooling. Min aspirates. No spits.\n\nIn open crib.\n\nA/P: Growing preterm infant learning how to po feed. Improving growth, will d/c promod today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-01 00:00:00.000",
"description": "Report",
"row_id": 1742115,
"text": "NPN 0700-1900\n\n\n#4: O: Total fluid minimum 150cc/kg/day of breastmilk 26\nwith promod, 60cc q4 hours gavaged over 50 min. Infant is PO\nfed once a shift or when awake. Bottled 17cc this shift for\n. Abdomen benign, bowel sounds active. No spits, minimal\naspirates. Voiding and stooling, stools heme negative. A:\nInfant tolerating feeds. P: Continue with current feeding\nplan.\n\n#5: O: Temperature stable in OAC. Infant does not wake for\nfeeds, alert and active with cares. Brings hands to face for\ncomfort and calms with pacifier. Infant remains swaddled in\ncrib. A: AGA. P: Continue to support growth and development.\n\n#6: O: Mom in in for afternoon feed. A: Loving .\nP: Continue to support in the care of their infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-01 00:00:00.000",
"description": "Report",
"row_id": 1742116,
"text": "Nursing note\n\n\nI agree with the above note provided by PCA ; in\naddition plan to po feed infant every other feed or when\nshowing oral feeding cues.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-29 00:00:00.000",
"description": "Report",
"row_id": 1742104,
"text": "PCA NOTE\n\n\nFEN: O/A-Current weight 2.320 ^ 50gm. TF 150cc/k/d. PG this\nshift. is voiding and stooling, hem neg. Active bowel\nsounds. Abdomen is unremarkable. Minimal residuals. No\nspits. Tolerating feeds. P-Continue with current regimen as\nordered.\n\nG&D: O/A-In RA. Temp stable in OAC. Slowly waking for feeds.\nAlert and active. Sleeping peacefully. MAE. AF-flat. Sucking\non pacifier. AGA. P-Continue to monitor for developmental\nmilestones.\n\n: Mom called x1. Updated on status and\nimmediate plan by R.N.\n\n *****See flowsheet for further information*****\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-29 00:00:00.000",
"description": "Report",
"row_id": 1742105,
"text": "NPN ADDENDUM\n\nThis R.N. has examined Baby bay and agrees with assessment and note by pca.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-20 00:00:00.000",
"description": "Report",
"row_id": 1742067,
"text": "NPN DAYS\n\n\nAlt in FEN: TF increased to 150cc/kg/day PE20/BM20, gavaging\nfeeds over 1 hour. No spits. Minimal aspirates. Belly\nbenign. Voiding and stooling with every diaper change. Will\ncontinue with current plan of care.\n\nAlt in G&D: Temp stable in servo isolette, nested on\nsheepskin. Awake and alert with cares. Passively sucking on\npacifier. Kangaroo'd with x1 hour and did great. Hep B\nordered, need consent before giving.\n\nAlt in Parenting: in to visit and kangaroo'd for the\nfirst time. He also changed the diaper and checked baby's\ntemp with assist. Asking appropriate questions. Updated him\non day. Will continue to provide updates and\nsupport.\n\nHyperbili: Remains under single phototherapy. Will check\nbili in the morning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-29 00:00:00.000",
"description": "Report",
"row_id": 1742106,
"text": "Neonatology Attending Progress Note:\n\nDOL #14\n32 week infant\nremains in RA, RR=40-50's, one brady yesterday\nHR=150-160's, wt up 50g, on TF 150cc/kg/d BM 26 with Promod, po x 1 feed\nvoiding, stooling (heme negative)\n\nPE: well appearing, AFOF, normal S1S2, no murmur, breath sounds clear abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: premie doing well, AOP, F and G\n--encourage po feeds, monitor weight\n--monitor for spells\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-29 00:00:00.000",
"description": "Report",
"row_id": 1742107,
"text": "NPN 1740\n\n\n#4 F/N: Infant remains on total fluids of 150cc/kg/d br.\nmilk26 + Promod, 58cc q 4 hrs. Tolerating gavage when\nneeded. Offered bottle this am, infant took 35cc fairly\nwell. Br. fed very well at 1pm w/ mom using a nipple shield\nprovided by LC . Abd soft, bowel snds active.\nVoiding and stooling.\nA: Learning to br. feed/bottle feed.\nP: cont to encourage br. feeding when mother here.\n#5 G/D: Infant remains in an open crib w/ temps wnl. Infant\nawake and alert w/ cares. Swaddled w/ boundaries in place.\nPlan to refer infant to Early Intervention Program, due to\nprematurity, mother aware.\nA: Infant AGA\nP: cont dev. supports.\n#6 : here this AM and mother here this\nafternoon. Invested and involved in care of son. Gaining\nconfidence in caring for him. Bath given to mother this\nafternoon.\nA: Invested loving learning baby cares.\nP: Cont parent support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-30 00:00:00.000",
"description": "Report",
"row_id": 1742108,
"text": "PCA NOTE\n\n\nFEN: Current weight 2.345, ^25gm. TF 150cc/k/d of BM 26 with\npromod.. PG/PO. Offered po x1 this shift, took 30cc' \nis voiding and stooling. Active bowel sounds. Abdomen is\nunremarkable. Minimal residuals. Small spit noted. Will\ncontinue to encourage PO feeds.\n\nG/D: In OAC. Temp stable. Waking for feeds. Alert and\nactive. Sleeps peacefully. MAE. AFSF. Rooting.\n\n: Mom in earlier part of evening. Called x1, updated\nby . Loving and involved.\n\n *****See flowsheet for further information*****\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-30 00:00:00.000",
"description": "Report",
"row_id": 1742109,
"text": "NPN NOCS\nI have examined infant and agree with note written by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-21 00:00:00.000",
"description": "Report",
"row_id": 1742068,
"text": "NPN\n\n\nNPN#4 O= WT up 25gms to 2070, TF at 150cc/kg/d of BM/PE20\nq4hrs feeds gavaged over 60min..tol well, no spits, min asp,\nabd exam softly rounded & benign, +active BS, no loops, AG\nstable at 22.0-23.0cm, voiding & stooling A= tol feeds P=\ncont per plan, follow daily wts\n\nNPN#5 O= remains in heated isolette on servo under\nphotoherapy..temp stable when skin probe intact, AF soft &\nflat, active & alert with cares..occ fiesty but settles with\ncontainment & pacifer, good tone, nested in sheepskin with\nboundaries in place A= behaviors appropriate for GA P= cont\nto assess & support dev needs\n\nNPN#6 O= no contact thus far from this\nshift..A/P=cont to teach/ update & support\n\nNPN#7 O= remains sl jaundiced under single phototherapy with\nprotective eye patches in place..bili level drawn..results\npnd A= hyperbili P= cont to max skin exposure to lights,\nfollow bili level\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-21 00:00:00.000",
"description": "Report",
"row_id": 1742069,
"text": "Neonatology aTtending\n is 6do, 33 wks corrected\nRA, isolette\nSats 95-98%; no a/b/desats\nRemains under single phototherapy; bili this am 7.0/0.3\nWt 2070 up 25 on TF150 PE/MM20 pg\n\nImp/ age-appropriate feeding & thermoregulatory immaturity; resolving hyperbilirubinemia\nPlan/ continue to monitor cvr stastu, growth/development. Will d/c phototherapy today, repeat bili in am. Increase to 22 cal/oz feeds as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-21 00:00:00.000",
"description": "Report",
"row_id": 1742070,
"text": "Neonatology aTtending\nAddendum: PE\nAsleep with appropriate tone/activity; pink; AFOF. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-21 00:00:00.000",
"description": "Report",
"row_id": 1742071,
"text": "PCA 0700-1500\n\n\n4\ninfant remains on TF 150cc/kg/d of BM/PE20=54cc q4h gavaged\nover 60 minutes. abd. soft, bs+, infant had soft loops at\n1300 care, ag stable 24cm, max asp. 1.8cc, no spits, voiding\nqs, no stool thus far. P:cont. to support nutritional\nneeds.\n\n5\ninfant remains in cerve isolette, temp. stable, a/a with\ncares, settles well in between, fonts soft/flat, infant\ntolerated kangarooing well. P:cont. to support dev. needs.\n\n6\nmom and in for 1300 care, mom kangarooed infant while\n read a story, asked appropriate questions, very caring.\nP:cont. to update.\n\n7\ninfant was under single photo therapy lights, d/c'd at 1300.\nP: recheck bili levels in the am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-21 00:00:00.000",
"description": "Report",
"row_id": 1742072,
"text": "NPN DAYS\nI have examined this baby and agree with above note by , PCA. Correction: Baby is in servo isolette.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-08 00:00:00.000",
"description": "Report",
"row_id": 1742153,
"text": "Nsg Note\n\nAgree with above note by PCA. Baby cont to bottle all feeds. Taking 60-70cc BM24 with Enfamil powder q3-4 hours. Circ site clean and dry. No bleeding. Vaseline gauze applied. Breast milk prep with Enf powder reviewed with Mom. Medication administration revied with Mom.\n needs car seat test.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-08 00:00:00.000",
"description": "Report",
"row_id": 1742154,
"text": "Neonatology aTtending\n is 23do, 35 wks\nRA, open crib\nNo a/b\nWt 2685 down 10 on ad lib minTF130 MM24 po plus nursing\nDay 2 s/p dyscoord feeding/choking episode\n\nMeds fe/vits\n\nImp/ approaching readiness for d/c\nPlan/ continue to monitor cvr status, growth/development. D/c home tomorrow if maintains stable cvr status wtih po feeds. Has appt with pedi tomorrow afternoon (?)\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-19 00:00:00.000",
"description": "Report",
"row_id": 1742063,
"text": "4. TF increased to 140cc/k/d BM/PE20 pg over 70 min, abd\nsoft, girth stable, no loops, active bowel sounds, no spits,\nminimal aspirates, voiding and passing transitional stool A:\ntolerating feedings P: continue present care, monitor/assess\nfor intolerance.\n5. active and alert with cares, temp stable nested in heated\nisolette with boundaries, on servo control, sucks on\npacifier, sleeps best on tummy A: AGA P: continue to support\nneeds for growth and development\n6. here for 1300 cares, took temp and\nchanged diaper, Mom kangarooing while reads to baby, \nbrought in breast milk A: very loving and involved \nP: continue to update and offer support.\n7. remains under single phototherapy with eyes\ncovered, color sl jaundice, voiding and passing stool, am\nbili 10.2/0.3 A: tx for hyperbil P: continue phototherapy,\ncheck bili friday am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-19 00:00:00.000",
"description": "Report",
"row_id": 1742064,
"text": "Neonatology NP Note\nPe\nnested in isolette under phototherapy\nAFOF, sutures opposed\nrespirations unlabored,lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft\ngood tone\nface and trunk jaundice\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-08 00:00:00.000",
"description": "Report",
"row_id": 1742155,
"text": "PCA 0700-1900\n\n\n4\ninfant remains on TF 130cc/kg/d of BM24 with promod=58cc\nq4h, infant is feeding on an adlib schedule, waking q4-4.5h\nbottling 57-67cc with no drifts in HR or O2 SATs. abd soft,\nbs+, no loops, small spit X2, voiding/stooling qs heme neg.,\ndesitin being applied with each diaper change. P:cont. to\nsupport nutritional needs.\n\n5\ninfant remains in OAC, temp. stable, wakes for feeds, a/a\nwith cares, settles well in between, fonts soft/flat, brings\nhands to mouth for comfort, likes pacifier. P:cont. to\nsupport growth and development.\n\n6\nmom called and was updated by RN, P:cont. to update on\ninfant's progress.\n\n9\nno A's and B's thus far this shift.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-08 00:00:00.000",
"description": "Report",
"row_id": 1742156,
"text": "Nursing NICU Note\n\n\nI have read the above note written by PCA and\nagree with the information as stated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-09 00:00:00.000",
"description": "Report",
"row_id": 1742157,
"text": "4 F/N\n Abdomen soft, + bowel sounds, 0 loops, 0 distention,\nbottled well all shift taking at least 100cc per\nfeed.Feeding about every 4 to 5 hours, voiding, stooling.\nWt. up 35gms to 2.720. Continue present plans.\n6 \n Mom called X1 so far tonight, anxious to have home,\ngiven updates. Plan to keep family informed.\n9 A/Bs\n No A/Bs so far tonight, continue to monitor and record any\nchanges.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-09 00:00:00.000",
"description": "Report",
"row_id": 1742158,
"text": "Neonatology Attending\n is 24do,35 wks corrected\nRA, open crib\nNo a/b x5days\nWt up 35g to 2720 on ad lib Mm24 minTF130 po plus nursing well\n\nMeds Fe\n\nImp/ ready for d/c home with today!\nPlan/ d/c home on Fe, nursing plus 24cal/oz bottles a few times a day till weight gain well-established. Has pediatric appt . Full details in dictated summary - >30min spent on d/c process.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-20 00:00:00.000",
"description": "Report",
"row_id": 1742065,
"text": "NPN\n\n\nNPN#4 O= WT 2045gms..remains unchanged, TF at 140cc/kg/d of\nPE/BM20 q4hrs gavaged over 60min,..tol well, no spits, min\nasp, Abd exam softly rounded & benign, + active BS, no\nloops, AG 22-23.0,voiding & stooling..mod trans. stool G-,\nA= tol feeds well/ no wt gain P=cont to monitor tol of feeds\n\nNPN#5 O= remains in heated isolette on servo under\nphototherapy with Tmax 99.2 ( skin probe off found off\ninfant ) otherwise temp stable, AF soft & flat, active &\nalert with cares, nested in sheepskin with boundaries in\nplace, loves pacifer, good tone A= behaviors appropriate for\nGA P= cont to assess & support dev needs\n\nNPN#6 O= Mom called x1 for update..asking appropriate\nquestions A= involved P= cont to teach/ update &\nsupport\n\nNPN#7 O= remains under single phototherapy with protective\neye patches in place,color pink/ jaundiced..tol feeds &\nstooling A= hyperbili P= cont to monitor bili levels..due to\nbe drawn on , skin exposure to lights\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-20 00:00:00.000",
"description": "Report",
"row_id": 1742066,
"text": "Neonatology Attending\n is 5do, 32 wks corrected.\nRA, isolette\nNo a/b\nWt 2045 unchanged (Bwt 2100) on TF140 MM/PE20 pg\nUnder single phototherapy (bili 10.2/0.3 yesterday)\n\nPE sleeping quietly; appropriate activity/tone. AFOF. Pink. No distress. Lungs cta, heart rrr s murmur, abd soft, extr well perfused.\n\nImp/ age-appropriate immaturity of feeding, thermoregulation, bilirubin metabolism. Doing well.\n\nPlan/ Will increase TF to 150cc/kg/day today; continue to monitor cvr status, feeding tolerance, growth/development. Give HBV if/when parental consent obtained. Repeat bili level planned for tomorrow am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-07 00:00:00.000",
"description": "Report",
"row_id": 1742148,
"text": "Neonatology Attending\nDOL 22 / CGA 35-2/7 week GA\n\nRemains in room air with bradycardia yesterday with feed. No further bradycardia, but he does have some ongoing feeding discoordination.\n\nBP 65/31 (41).\n\nWt 2695 (+50) on min TFI 130 cc/kg/day with intake 76 cc/kg/day in addition to breastfeeding. Abd benign. Voiding and stooling normally. On trivisol and iron.\n\nA&P\n32-1/7 week GA infant with feeding incoordination\n-Will monitor for 5-day asymptomatic period prior to discharge home\n-No evidence of a pathological process underlying the discoordination; it is likely that this is simply immaturity with some element of fatigue\n-Monitor fluid intake\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-07 00:00:00.000",
"description": "Report",
"row_id": 1742149,
"text": "Neonatology - NNP progress note\n\nInfant is active with good tone. AFOf. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is having coordination issues with feeds having desats to 60's. Abd soft, active bowel sounds, no loops, Voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1742052,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains on ampicillin and gentamicin for r/o\nsepsis. Blood cultures negative thus far. A: Sepsis. P:\nContinue to monitor for S&S of sepsis. Check blood culture\nat 48hrs.\n\n#4. O: Infant remains on TF's of 80cc/k/d of PE20. No spits.\nMinimal aspirates. AG stable. Abd soft and round with active\nbowel sounds. No loops. Voiding qs. Mec x1. D/S 70. Wgt is\ndown 30gms tonight to 2105gms. A: Tolerating feeds P:\nContinue to monitor feeding tolerance.\n\n#5. O: Infant remains in servo isolette with stable temp. HE\nis alert and active with cares. MAEW. Sucking on pacifier\nduring pg feeds. A: AGA. P: Continue to assess and support\ndevelomental needs.\n\n#6. No contact thus far from parents.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1742053,
"text": "Neonatology Attending\nDOL 2\n\nRemains in room air with no distress. One bradycardia in 24 hours.\n\nNo murmur. BP 66/39 (45).\n\nBilirubin at 24 hours 6.4.\n\nWt 2105 (-30) on TFI 80 cc/kg/day PE20/BM20, tolerating well. Voiding and stooling normally. D-stick 70.\n\nOn ampicillin and gentamicin with negative cultures.\n\nActive. Temperature stable.\n\nA&P\n32-1/7 week GA infant with sepsis risk, respiratory and feeding immaturity\n-Monitor adequacy of respiratory drive\n-Discontinue antibiotics today\n-Advance TFI to 100 cc/kg/day.\n-Family meeting will be arranged for today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1742054,
"text": "NPN: 0700-\n\n1 Infant with Potential Sepsis\n\nFEN: Infant's TF's increased today from 80cc to 100cc/kg/d\nof PE/BM20= 35cc q 4hrs gavaged over 40mins. Infant\ntolerating feeds well, no spits, minimal aspirates. Abd\nbenign, soft, no loops, +bs, abd girth stable at 23cm.\nInfant voiding, no stool thus far passed last meconium stool\non . P: Continue with current regimen as tolerated.\n\nDEV: Temp stable in servo controlled isolette. Infant alert\nand active with cares. Sucks vigorously on pacificer during\npg feeds and when offered. Appropriately brings hands to\nface to console himself. Settles easily and sleep well in\nbetween cares. AFSF. MAE. AGA. P: Continue to monitor and\nsupport developmental needs.\n\nPAR: Parents in this afternoon, updated by RN at bedside.\nInvolved and loving parents. P: Continue to update and\nsupport parents throughout infant's NICU stay.\n\n**Please refer to flowsheet for any additional information**\n\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1742055,
"text": "NPN: 0700-\nI agree with the above coworkers note. Pt changed to air mode isolette. swaddled with hat on. Parents visiting. family meeting scheduled for 3pm. Ampi and gent dc'd, IV dc'd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1742056,
"text": "NPN: 0700-\nI agree with the above coworkers note. Pt changed to air mode isolette. swaddled with hat on. Parents visiting. family meeting scheduled for 3pm. Ampi and gent dc'd, IV dc'd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1742057,
"text": "Neonatology Np Exam Note\nPt examined, care discussed with team. PLease refer to Dr note for details of evaluation and plan.\n\nPE: small infant kangarooing with mother. Placed back in isolette. Pink, warm and well perfused in RA. AFOF, ng in place. MMMP\nChest is clear, =.\nCV: RRR, no murmur. pulses +2=\nAbd: soft, active BS\nGU immature male genitalia\nEXT: MAE, WWP\nNeuro: appropriate for GA\nMeeting with parents this afternoon for update.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-18 00:00:00.000",
"description": "Report",
"row_id": 1742058,
"text": "NPN 1900-0700\n\n\n4. FEN Current wt 2.060 (-45). TF remain @ 100cc/k/d,\nBM/PE20. Gavaged over 50 min. Belly round/soft, ag 23.5cm,\nno spits, min asps. Voiding each change, lg mec. x2. D/S\n63.\nPlan to continue to monitor feeding tolerance.\n\n5. G+D Swaddled in air isolette. Increased air temp for\ntemp 97.7 (ax), and applied hat and extra blanket. Temp now\nstable. Alert/active, using pacifier.\nPlan to continue to monitor temp and support needs.\n\n6. PARENTS Mom visited overnight, asking approp questions.\nParticipating in cares. Held infant during gavage feed.\nPlan to continue to support and update parents regularly.\n\n7. BILI Bili lvl this am 11.7/0.3/12.0. Infant ruddy.\nPlan to notify NNP of current bili lvl, anticipate phototx\nto start.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-18 00:00:00.000",
"description": "Report",
"row_id": 1742059,
"text": "7 Hyperbili\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-18 00:00:00.000",
"description": "Report",
"row_id": 1742060,
"text": "SOCIAL WORK\nMet briefly with mother today during her visit to the NICU. Provided reduced parking paperwork and let mum know that I available to her. Understand a family meeting was held yesterday. Parents adjusting well to NICU environment. Will follow. Thank-you.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-19 00:00:00.000",
"description": "Report",
"row_id": 1742061,
"text": "NPN 7pm-7am\n\n\nFEN: Infants current weight 2045gms down 15gms. Infant on TF\n120cc/kg/day of PG feeds, PE20. 42cc's gavaged over 1hr tol\nwell. Abd soft, girth stable, no loops noted, +bs. Voiding\nand stooling heme neg. No spits and no asp. A: Tol feeds\nwell. P: Will cont to monitor weight and exam.\n\nG/D: Infant is in servo isolette, nested on sheepskin. Temp\nstable. Alert and active with cares. Sleeps well between.\nSucks on pacifier. MAE. Font soft and flat. A: AGA P: Cont\nto support dev needs.\n\n: No contact from at this time in shift.\n\nBILI: Infant under single photothearpy with eyes covered.\nJaundice and ruddy. Infant tol feeds well. Voiding and\nstooling. Repeat bili level was 10.2/0.3. A: Jaundice, P:\nWill cont with light and monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-07 00:00:00.000",
"description": "Report",
"row_id": 1742150,
"text": "PCA Note\n\n\nFEN: TF min 130cc/k/d of BM24 with enf. powder = 58cc Q4 or\n44cc Q3. Infant is bottling 57-70cc this shift with BFx1\nthus far. Abd. benign - soft, round, good BS, no loops.\nSmall spit x1. Infant is voiding and stooling; trace\npositive (possibly from circumcision). Continue to\nencourage PO's.\n\nDEV: Temps stable in OAC. Alert and active with cares.\nWaking Q3h for feeds. Stirring occassionally in between\ncares but falling back to sleep. Infant has good suck when\nbottling, however is still occassionally choking.\nQuickly resolves with nipple removal. Nurses well. Circ\nsite is healing well with minimal to no bleeding and remains\nslightly red; 2x2 with vaseline applied with each diaper\nchange. Continue to support developmental needs.\n\n: Mom and in this afternoon. Updated by this\nPCA and RN . Independent with cares. Asking\nappropriate questions and very invested. Mom nursed for\nabout 10-15min. Brought in car seat. Continue to support\nand update.\n\nA's & B's: Infant had no bradys or desats this shift thus\nfar. Placed back on O2sat monitor. Continue to monitor\nclosely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-07 00:00:00.000",
"description": "Report",
"row_id": 1742151,
"text": "NPN 0700-\nThis RN assessed infant and agrees with the above note by Tran; PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-08 00:00:00.000",
"description": "Report",
"row_id": 1742152,
"text": "PCA NOTE\n\n\nFEN: O/A-Current weight 2.685, -10 gm. TF min 130 cc/k/d.\nPO. Took 150 cc/k in last 24 hours. is voiding, trace\nstool. Active bowel sounds. Abdomen is unremarkable. No\nspits. P-Continue to follow current regimen as ordered.\n\nG/D: O/A-Temp stable in OAC. Waking for feeds. Alert and\nactive with cares. Sleeping peacefully. MAE. Sweet natured.\nP-Continue to monitor for developmental milestones.\n\n: Mom in earlier in shift. Called x1. Updated on each\noccasion by R.N. See nurse addendum for further informatiom.\n\nA/B: O/A- No spells or desats noted. No drifts. stable.\nP-Continue to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-05 00:00:00.000",
"description": "Report",
"row_id": 1742140,
"text": "NPN\n\n\n4. TF min 130cc/kg/day. Taking 55-65cc po MBM24. NGT remains\nout at this time. All pox24 hours. Voiding qs. Stool x1. Abd\nbenign. in and fed with support.\nTol all po at this time. Coordinated suck/swallow.\nCont po feeds as tol.\n5. In open crib maintaining temp. Sucks on pacifier.\nSwaddled with boundries. Settles between feeds.\nAble to handle stressors appropriately with stress\nprecautions. Cont to instruct on preenie stress\ncues.\n6. in for 1300 feeding. Took temp and changed diaper\nindependently. Asking appropriate questions. Discussed\npossiblity of discharge over weekend or beginning of next\nweek if infant cont with po feeds. Instructed to\npurchase carseat and bring in ASAP for testing. Also\ninstructed him to contact OB for circ arrangements. COnsent\nsigned. DIscussed supplies needed for discharge and gave \na list of basic necessities ie. bottles, diapers. nipples\netc. Discussed choosing a pedi and making an appointment for\nearly next week after discharge. verbalized\nunderstanding of all details needed to complete for\ndischarge.\nInvolved parent trying to prepare for infant discharge.\nCont to support and review discharge planning.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-06 00:00:00.000",
"description": "Report",
"row_id": 1742141,
"text": "#4FEN\nWt 2.645 up 80g. Baby cont to bottle all feeds taking 60cc\nBM24 q4h. Awakening for most feeds. Void and stooling. No\nspits.\nA. Cont to po all feed\nP. Cont to monitor weight gain and po feed skills.\n#5Dev\nTemp stable in an open crib. Awakening for most feeds.\nActive and alert with cares.\n#6Parent\nMom called for an update. Pleased that baby is taking feed\nby bottle. Voicing concern that milk supply has decreased\nsomewhat. Increase pumping and fluids recommended. Mom\nreminded that baby could be discharged soon. Encouraged Mom\nto visit tomorrow so teaching could be done. Mom told to\nbring in car seat. still need to choose a\npediatricin.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-05-06 00:00:00.000",
"description": "Report",
"row_id": 1742142,
"text": "Neonatology Attending\n\nNow day of life 21, CA 1/7 weeks.\nIn RA with RR 30-60s and sats 96-99%.\nNo apnea and bradycardia.\nHR 140-160s BP 70/36 49\n\nWt. 2645gm up 80gm on ad lib feedings of MM with 4kcal of Enfamil powder.\nFeedings going very well po - took in 160cc/kg/d/\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nDischarge teaching in progress.\nWill start Trivisol.\nNeeds discharge screening - carseat test and hearing screening today.\nPediatrician still being identified.\n\n\n"
}
] |
3,771 | 101,197 | The patient was admitted to the medical service, and a preoperative workup was performed including a geriatric service consultation who deemed her to be at high risk for the OR given her moderate aortic stenosis. Discussion with the family yielded a request for full code and for addressing the fracture surgically in order to facilitate mobilization. The patient was stabilized overnight, transfused, rehydrated and was able to undergo surgical repair of her femoral fracture with plate on the 17th. The surgical repair went uneventfully, and the patient was taken to the post anesthesia care unit. However, she had difficulty after extubation requiring her to be reintubated. She also had difficulty sustaining her blood pressure requiring pressors. She was admitted to the medical ICU on the 18th. She required an additional transfusion. On her first medical ICU day, she failed a second attempt at weaning her off the ventilator. She was able to be extubated on . At that point, some evidence of acute renal failure was also resolving; and she improved to the point where she was ready to be transferred back to the regular floor for further nursing and postoperative care. She was transferred to the floor on . On the evening of a trigger event was called because the patient was noted to be hypotensive with a systolic pressure of 86. Initial floor management consisted of normal saline infusion without improvement requiring transfer to the intensive care unit at that time. The patient went in the ICU where she was found to have persistent hypotension. There was no evidence of septic or distributive shock. Her hematocrit was 32. Her ABGs showed a pH of 7.26; a lactate of 0.8; and she responded to a liter of normal saline. The patient remained extubated and breathing spontaneously. By , the patient remained in the ICU. Her hypotension had stabilized. She had evidence of poor peripheral vasoconstriction. She remained extubated and breathing spontaneously, but with some worsening shortness of breath. This had responded initially to diuresis, but at this point diuresis was held secondary to peripheral vasoconstriction. The patient remained full code at this point. Due to a rising creatinine, a renal consult was obtained for management of renal failure. Diuresis was recommended with an increase of the Lasix dosage. The patient's respiratory status, however, decompensated on the evening of requiring an urgent intubation. She also became hypotensive and required using pressors as well in the form of Levophed. On the early morning of , the son was by the medical service who expressed the patient's desires not to be persistently intubated. The patient subsequently was made comfort care measures only and expired on . , MD Dictated By: MEDQUIST36 D: 08:59:36 T: 11:17:00 Job#: | Moderate AS.No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. MONITER RESPIRATORY STATUS. There is moderate pulmonaryartery systolic hypertension. Normal interatrialseptum. Moderate [2+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Dilated main PA.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. The rightatrium is moderately dilated. /Resp distressHeight: (in) 64Weight (lb): 145BSA (m2): 1.71 m2BP (mm Hg): 93/38HR (bpm): 73Status: InpatientDate/Time: at 15:40Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Dilated coronary sinus 1.7 cm.This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement. The tricuspid valve leaflets are mildly thickened.Moderate [2+] tricuspid regurgitation is seen. Resp Care,Pt. Mild to moderate (+)MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The ascending aortais mildly dilated. See data, MD notes/orders.Neuro: HOH, oriented x3, sleepy, follows commands, voices no painCV: Ongoing hypotension being tx'd with gentle hydration via fluid boluses with varrying response. BS clear, but diminished bilaterally. pt intubated via anesthesia with #8 ETT/19@ lip. Mild to moderate (+) mitralregurgitation is seen. Chronic afib with rate in 90's-100's, burst to 130's during last fluid bolus, self limiting. Pt neuro status unchanged-see carevue. DR NOTIFIED. Dilated coronary sinus.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Generalized weeping edema remains. LUNGS WITH INCREASED RALES, STILL BILATERALLY. Respiratory Care NotePt received from PACU intubated and mechanically ventilated. Metoprolol has been held for hypotension.Pulm: Lungs clear, decreased at bases, 02 sats 99%.GU: Uo 0-25cc/hr clear amber.GI: Abd obese, bs+, taking full liquid diet without dyspagia and with fair appetite.Act: CPM machine initiated and tolerated well.Soc: Involved family, updated by phone, dispo: FUll code.P: Ongoing assessment/tx of hypotension and low uo with caution given pts afib and aortic stenosis with concern for pulmonary edema. NURSING VSS OVERNIGHT,AFEBRILE.SBP 100-110. Mildly dilated ascending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. 0630AM: Pt transfered from CC703 for hypotension-BP on floor noted at 72 over palp. L knee remains in ace wrap in an immobilizer. Positive cuff leak. Pt placed on full ventilator support and ETT securred. MEDICATE FOR PAIN PRN. TAKING PO FLUIDS WITH THICKET WITH NO DIFFICULTIES SWALLOWING.CONTINUE TO MONITER PAIN LEVELS AND MEDICATE PRN. Bilateral breath sounds noted with CO2 indicator response. Left ventricular wall thickness, cavity size, and systolic functionare normal (LVEF>55%). pt comfortable and with RN at time of death. CONTINUE TO MONITER HEMODYNAMICS, FOLLOW LYTES CLOSELY WITH LASIX . No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Themitral valve leaflets are mildly thickened. GIVEN Q 4/HRS. Pt placed on SBT with RSBI of 79. CONT DIURESIS Please refer to respiratory therapist's note above. LUNGS WITH RALES BILATERALLY NOTED AT 2100. AT 0400 FINGERTIPS NOTED TO BE BLUE TINGED AND COOL. Foley intact with 10cc cloudy urine. CONTINUES WITH BLOOD PRESSURES IN THE 86-100 RANGE, WHICH FOR HER IS BASELINE. Left ventricular function. RESPIRATORY CARE:Pt for CMO and placed on 2 liters nasal cannula. PT ABLE TO SWALLOW PILLSSKIN: L. UPPER LEG INCISION OOZING MOD AMNT-DSD WAS APPLIED, DUODERM ON COCCYX, L KNEE IS CONTRUCTED/FLEXED, BOTH ARMS EDEMATOUS AND RUGHT IS LEAKING OFF SMALL SKIN TEARNEURO: A+O X 3, GROSSLY INTACT, GENERAL WEAKNESSENDO: BS WERE UP IN 200S AND RI GTT WAS INITIATED BY MED TEAM, UP TO 5U/HPLAN: OT+PT , MONITOR RES, ENDO, ? Stable cardiomegaly, bilateral small effusions, and left lower lobe atelectasis. FINDINGS: A right subclavian line ends in the right atrium. This endotracheal tube is slightly distended. Moderate cardiac enlargement, with particular left basal dilatation is unchanged. Unchanged bibasilar atelectasis and effusions. ORAL MEMBRANES DRY.CARDIAC--SBP >90/40. Moderate cardiomegaly and mild failure are unchanged compared to . Bilateral effusions and bibasilar atelectasis are unchanged. IMPRESSION: Unchanged cardiomegaly with continued mild failure compared to . Hypotension issues persisted t/o noc. FINDINGS: A pacemaking device overlying the left chest with pacer lead overlying the region of the right atrium and right ventricle is unchanged. A right subclavian line ends just below the SVC/right atrial junction. There are bilateral small pleural effusions with probable bibasilar atelectasis. The interstitial edema is less pronounced since the previous examination of . Markedly tortuous calcified thoracic aorta is seen. An endotracheal tube is in place with a slightly overdistended cuff. Bilateral effusions and bibasilar atelectasis are also unchanged. URINE IS CLOUDY.ENDO--COVERED WITH SSRI X2.SKIN--BUTTOCKS WITH DUODERM INTACT. Moderate cardiomegaly is present. IMPRESSION: Right pleural effusion. A central line ends in the upper right atrium. There is a right pleural effusion. Bibasilar atelectasis with bilateral pleural effusions. Atelectasis is present at both lung bases with pleural effusions that are decreased compared to . Atrial fibrillation. Moderate CHF is unchanged. Atrial fibrillationLeft bundle branch block with left axis deviationSince previous tracing of , no significant change Transvenous right atrial and right ventricular pacer leads follow the expected courses. Moderate cardiomegaly is unchanged. IMPRESSION: Improved mild CHF. There is a right subclavian central venous catheter with the tip in distal SVC. The endotracheal tube has been removed since the previous exam. There is an endotracheal tube with its tip approximately 2.8 cm proximal to carina. IMPRESSION: Slightly worsening CHF compared to . PER PT, SHE STATES HER WT IS APPROX. CHF is slightly worsening compared to . HR 80'S SR WITH OCCASIONAL PVC'S.RESP--ON 2L NC WITH SPONT RESP 24-44. Mild cardiomegaly is unchanged. Note is made of left basilar atelectasis. AFEBRILE.PAIN--NO C/O PAIN .A--SBP ABOVE 100. +BS.GU--FOLEY CATH CHANGED TODAY. Left lower lobe opacity representing atelectasis is stable. FINAL REPORT HISTORY: Renal failure. Mild CHF is improved. The pacemaker leads and right subclavian IV catheter remain in place. The patient is status post ORIF with dynamic hip screw for a impacted intertrochanteric fracture, with partially backed out dynamic screw which appears unchanged from . O2 sat and RR WNL on 2lncGI: Abd soft, nontender, +BSx4. ORAL MEMBRANES DRY. Respiratory failure. Bilateral effusions are stable. DR. DR. DR. FINDINGS: There are bilateral small kidneys, the right measuring 8.9 cm, and the left measuring 8.8 cm. Again, note is made of dual-chamber pacemaker with the leads in right atrium and ventricle. Treated with gentle IV hydration with some improvement.Resp: LS clear, but dim at bases. Unchanged failure. HISTORY: Status post hip surgery. 11:51 AM FEMUR (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # Reason: ORIF LT DISTAL FEMUR Admitting Diagnosis: ANEMIA;TELEMETRY FINAL REPORT EXAM ORDER: Left femur. | 30 | [
{
"category": "Echo",
"chartdate": "2190-12-13 00:00:00.000",
"description": "Report",
"row_id": 64101,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function. /Resp distress\nHeight: (in) 64\nWeight (lb): 145\nBSA (m2): 1.71 m2\nBP (mm Hg): 93/38\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 15:40\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nDilated coronary sinus 1.7 cm.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement. Dilated coronary sinus.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). TVI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Moderate AS.\nNo AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Dilated main PA.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The coronary sinus is dilated. The right\natrium is moderately dilated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Tissue velocity imaging E/e' is elevated (>15)\nsuggesting increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets are severely thickened/deformed.\nThere is moderate aortic valve stenosis. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Mild to moderate (+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. The main pulmonary artery is dilated. There is\nno pericardial effusion.\n\nCompared with the prior study (tape reviewed) of , no diagnostic\nchange.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-12 00:00:00.000",
"description": "Report",
"row_id": 1310787,
"text": "Respiratory Care Note\nPt received from PACU intubated and mechanically ventilated. BS clear, but diminished bilaterally. Pt weaned to PSV 5/5 - pt tolerated well. Pt placed on SBT with RSBI of 79. Positive cuff leak. Pt extubated to cool aerosol w/o incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-12 00:00:00.000",
"description": "Report",
"row_id": 1310788,
"text": "MSicu nursing progress note\nPlease refer to admission note and flowsheet for specific information and detailed history. Patient extubated to face tent after being transfered in from PACU. Please refer to respiratory therapist's note above. Continues to do well with sat's 98-100%. Afib with rate of 78-88. Pleasant and alert following commands consistently. Denies any pain at present. Appears comfortable and without distress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-12 00:00:00.000",
"description": "Report",
"row_id": 1310789,
"text": "NURSING\n VSS. AFEBRILE. CONTINUES WITH BLOOD PRESSURES IN THE 86-100 RANGE, WHICH FOR HER IS BASELINE. CVP AT 3-5. MD BY TO EVALUATE LOW URINE OUTPUT, WILL TRY TO KEEP >30 ML/HR. JUST FINISHED 500 CC BOLUS FOR LOW URINE OUTPUT, LAST HOUR 29 ML. IVF OF D5 WITH 20 KCL STARTED. WILL CONTINUE TO MONITER U/O, VS/ CVP'S.\n C/O PAIN IN LEFT SIDE OF LEG, REPOSITIONED WITH GOOD EFFECT. TAKING PO FLUIDS WITH THICKET WITH NO DIFFICULTIES SWALLOWING.CONTINUE TO MONITER PAIN LEVELS AND MEDICATE PRN. SEE CARE VUE FOR COMPLETE SPECIFICS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-13 00:00:00.000",
"description": "Report",
"row_id": 1310790,
"text": "Resp Care,\nPt. ordered on mask ventilation , on hold at this time per MICU team until consult with cardiology. Sat 97% on 35% cool mist, BS clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-17 00:00:00.000",
"description": "Report",
"row_id": 1310800,
"text": "see for details\n\nNEURO: PT LETHARGIC EARLY AM, DECREASED LOC NOTED @ 1030 AM, BS 57, INSULIN GTT TURNED OFF REPEAT FS 30, PT GREEN TEAM NOTIFIED\n\nRESP: CO2 MID 70'S, PT INTUBATED BY ICU ATTENDING WITHOUT INCIDENT, REPEAT GASES MONITORED, FENTANYLN AND VERSED GTT STARTED FOR COMFORT,\nVENOUS GASES DRAWN\n\nCV: PT HYPOTENSIVE, NS OPEN, LEVO GTT TITRATED, A-LINE INSERTED RIGHT RADIAL, IV DECADRON GIVEN, LABS MONITORED, HEPERIN GTT STARTED,\n\nGI: OGT INSERTED, PLACEMENT CHECKED\n\nGU: RENAL INTO SEE PT, BUN/CRT UN CHANGED FOLEY PATENT\n\nA/P: DR. PT'S, UPDATED FAMILY ON CONDITION, PT STATUS CHANGED TO CMO, MORPHINE GTT STARTED, VERSED CONTINUED, PT \n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-17 00:00:00.000",
"description": "Report",
"row_id": 1310801,
"text": "RESPIRATORY CARE:\nPt for CMO and placed on 2 liters nasal cannula.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-17 00:00:00.000",
"description": "Report",
"row_id": 1310802,
"text": "conditiopn update\nplease see carevue:\n\n\nPt on morphine nad versed for comfort- pt sb p droppe dot 30's at and time of death called by MICU resident at 2057, he was d at 2055. Family called nad made aware- coroner called. pt comfortable and with RN at time of death.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-16 00:00:00.000",
"description": "Report",
"row_id": 1310796,
"text": "NURSING\n VSS OVERNIGHT,AFEBRILE.SBP 100-110. UNABLE TO OBTAIN GOOD RESPIRATORY TRACING. LUNGS WITH RALES BILATERALLY NOTED AT 2100. DR NOTIFIED. ADDITIONAL 40 MG LASIX IV ORDERED AND GIVEN. GOOD RESPONSE TO LASIX. CVP 15-18 OVERNIGHT.\n AT 0400 FINGERTIPS NOTED TO BE BLUE TINGED AND COOL. LOWER AND UPPER EXTREMITIES ALSO NOTED TO BE MUCH MORE EDEMATOUS THAN THEY WERE AT THE BEGINNING OF THE EVENING. DR. NOTIFIED AND PT WAS EXAMINED BY HIM. LUNGS WITH INCREASED RALES, STILL BILATERALLY. SBP HOVERING AT AROUND 100. DUE TO LOW BLOOD PRESSURE NO FURTHER LASIX GIVEN AT THIS TIME. SWITCHED FROM NASAL CANNULA TI FACE MASK AT 35%. NO OTHER TREATMENTS ORDERED PRESENTLY.\n C/O PAIN IN LEFT HIP AND LEG, MEDICATED WITH ONE PERCOCET AND TYLENOL WITH GOOD EFFECT. GIVEN Q 4/HRS. PILLS TAKEN IN UPRIGHT POSITION WITH APPLESAUCE OR JELLO. THICKENED LIQUIDS ONLY TO BE GIVEN.\n CONTINUE TO MONITER HEMODYNAMICS, FOLLOW LYTES CLOSELY WITH LASIX . MONITER RESPIRATORY STATUS. MEDICATE FOR PAIN PRN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-16 00:00:00.000",
"description": "Report",
"row_id": 1310797,
"text": "see for details\n\n\nneuro: a/o x2, medicated with percocet and morphine for pain control\nbedrest today, evaluated by PT, csm + lle,\n\nresp: sob upon excertion desaturating with movement, fio2 increased to 50% humidified face mask, improved sats,b/l bs coarsed and diminished @ bases\n\ncv: afebrile, gross third spacing noted in all ext's, medicated with ivp lasix, po lopressor held early am r/t b/p, given this pm without incident, hr 90-100 a-fib with occassional pvc's, pm labs pending\n\ngi: tol full liqs, fs glucose rx'd with ssi, no bm, bs active\n\ngu:increased bun and creat, renal consult done, renal team will follow pt\n\na/p: family contact re pt's condition, both educational and emmotional support given to both pt and family, full code status remains at present time\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-17 00:00:00.000",
"description": "Report",
"row_id": 1310798,
"text": "ASSESSMENT AS NOTED\n\nRES: ON COOLMIST 40 %, MAINTAINS SO2.>98, +PRODUCTIVE COUGH, LS COARSE/DIM\n\nCV: SBP 90S, IN A.FIB, WAS DIURESED TWICE LAST NIGHT 40/80 LASIX WITH FAIR RESPONSE. + GENERAL EDEMA, + WEAK PULSES,\n\nGI: TOL THICK LIQUIDS MEDICAL TEAM WAS IN TRYING TO INSERT FEEDING TUBE AND DID NOT SUCCEED. +HYPO BS, NO BM. PT ABLE TO SWALLOW PILLS\n\nSKIN: L. UPPER LEG INCISION OOZING MOD AMNT-DSD WAS APPLIED, DUODERM ON COCCYX, L KNEE IS CONTRUCTED/FLEXED, BOTH ARMS EDEMATOUS AND RUGHT IS LEAKING OFF SMALL SKIN TEAR\n\nNEURO: A+O X 3, GROSSLY INTACT, GENERAL WEAKNESS\n\nENDO: BS WERE UP IN 200S AND RI GTT WAS INITIATED BY MED TEAM, UP TO 5U/H\n\nPLAN: OT+PT , MONITOR RES, ENDO, ? CONT DIURESIS\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-17 00:00:00.000",
"description": "Report",
"row_id": 1310799,
"text": "RESPIRATORY CARE:\nPt intubated today for airway protection/resp failure. pt intubated via anesthesia with #8 ETT/19@ lip. Bilateral breath sounds noted with CO2 indicator response. Pt placed on full ventilator support and ETT securred. Will continue to monitor as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-13 00:00:00.000",
"description": "Report",
"row_id": 1310791,
"text": "SICU NN: See carevue for all patient specifics. See transfer note for today's nurses note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-14 00:00:00.000",
"description": "Report",
"row_id": 1310792,
"text": "0630AM: Pt transfered from CC703 for hypotension-BP on floor noted at 72 over palp. Pt received 1250cc NSS as bolus. Urine output remains diminished and worsened on floor.\n Pt SBP >90 upon arrival to SICU. Pt neuro status unchanged-see carevue. Resp easy and regular without difficulty. Crackles remain at the bases. Generalized weeping edema remains. Foley intact with 10cc cloudy urine. L knee remains in ace wrap in an immobilizer. Pt resting comfortably and pain free at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-14 00:00:00.000",
"description": "Report",
"row_id": 1310793,
"text": "See data, MD notes/orders.\n\nNeuro: HOH, oriented x3, sleepy, follows commands, voices no pain\n\nCV: Ongoing hypotension being tx'd with gentle hydration via fluid boluses with varrying response. CVP 10-15, BP 100-80's/40's. Chronic afib with rate in 90's-100's, burst to 130's during last fluid bolus, self limiting. Metoprolol has been held for hypotension.\n\nPulm: Lungs clear, decreased at bases, 02 sats 99%.\n\nGU: Uo 0-25cc/hr clear amber.\n\nGI: Abd obese, bs+, taking full liquid diet without dyspagia and with fair appetite.\n\nAct: CPM machine initiated and tolerated well.\n\nSoc: Involved family, updated by phone, dispo: FUll code.\n\nP: Ongoing assessment/tx of hypotension and low uo with caution given pts afib and aortic stenosis with concern for pulmonary edema.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-15 00:00:00.000",
"description": "Report",
"row_id": 1310794,
"text": "See ICU flow sheet for detailed VS and assessment\nNeuro: Pt. A&Ox3, follows commands. Able to make needs known.\nCV. Remains in AFib. Hypotension issues persisted t/o noc. Treated with gentle IV hydration with some improvement.\nResp: LS clear, but dim at bases. O2 sat and RR WNL on 2lnc\nGI: Abd soft, nontender, +BSx4. No BM. Taking pills w/ thickened water without any problems.\nGU: UO despite fluid boluses, clear yellow urine.\nSkin: Pt. + edema to all extremeties. BUE red and slightly warm. Elevated on pillows. Afebrile. No complaints of pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-15 00:00:00.000",
"description": "Report",
"row_id": 1310795,
"text": "SICU NURSING PROGRESS NOTE 0700-1900\nNEURO--ALERT AND ORIENTED X2. MAE ON BED EXCEPT FOR L LEG. CAN WIGGLE TOES. SPEECH CL. ORAL MEMBRANES DRY.\n\nCARDIAC--SBP >90/40. HR 80'S SR WITH OCCASIONAL PVC'S.\n\nRESP--ON 2L NC WITH SPONT RESP 24-44. RALES HEARD EARLIER BUT HAVE SUBSIDED. WEAK PRODUCTIVE COUGH. SAO2 >95%.\n\nGI--TOL. PUREED FOODS. NO STOOL. +BS.\n\nGU--FOLEY CATH CHANGED TODAY. UO POOR ~15 CC HR. GIVEN 20 MG IV LASIX WITHOUT RESPONSE. GIVEN 40 MG IV LASIX WITH 150CC. URINE IS CLOUDY.\n\nENDO--COVERED WITH SSRI X2.\n\nSKIN--BUTTOCKS WITH DUODERM INTACT. ANASARCA THROUGHOUT BODY. FINGERS ARE BECOMING MORE CYANOTIC. ORAL MEMBRANES DRY. PER PT, SHE STATES HER WT IS APPROX. 135 LBS. USING CPM MACHINE TO 65 DEGREE ANGLE WITHOUT PAIN.\n\nCOPING--SON AND DAUGHTER HAVE PHONED AND HAVE BEEN UPDATED REGARDING POSSIBLE TX TO FLOOR.\n\nID--ON ABX. AFEBRILE.\n\nPAIN--NO C/O PAIN .\n\nA--SBP ABOVE 100. FINGERS ARE MORE CYANOTIC. ? TX TO FLOOR.\n\nP--HAVE TEAM MAKE DECISION OF TX TO FLOOR. OBTAIN LABS IN AM. OFFER SUPPORT TO PT AND FAMILY. HAVE FAMILY MEETING TO DISCUSS PLAN OF CARE AND DIRECTIVES.\n"
},
{
"category": "ECG",
"chartdate": "2190-12-13 00:00:00.000",
"description": "Report",
"row_id": 125824,
"text": "Atrial fibrillation\nLeft bundle branch block with left axis deviation\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2190-12-10 00:00:00.000",
"description": "Report",
"row_id": 125825,
"text": "Atrial fibrillation. Left bundle-branch block. Left axis deviation. Since the\nprevious tracing of the rate has slowed and pacing is not seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894176,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening CHF/EFFUSIONS\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with severe aortic stenosis s/p hip surgery, with hypercarbia\n respiratory failure in unit\n REASON FOR THIS EXAMINATION:\n ? worsening CHF/EFFUSIONS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic stenosis and hip surgery. Respiratory failure.\n\n FINDINGS: A right subclavian line ends in the right atrium. A pacemaking\n device overlying the left chest is in unchanged position with pacing\n electrodes in the expected location of the right atrium and right ventricle.\n Mild cardiomegaly is unchanged. Bilateral effusions and bibasilar atelectasis\n are unchanged. CHF is slightly worsening compared to . No\n pneumothorax or osseous abnormalities seen.\n\n IMPRESSION: Slightly worsening CHF compared to . Unchanged\n bibasilar atelectasis and effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893592,
"text": " 6:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change in pulmonary edema s/p volume r\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with severe aortic stenosis s/p hip surgery, s/p central\n line placement now s/p extubation and volume resusitation\n REASON FOR THIS EXAMINATION:\n evaluate for interval change in pulmonary edema s/p volume repletion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n HISTORY: Severe aortic stenosis following surgery. Central line placement.\n\n IMPRESSION: AP chest compared to :\n\n Moderate-sized bilateral pleural effusion, right greater than left, has\n increased since accompanied by mild pulmonary edema that has\n recurred. Moderate cardiac enlargement, with particular left basal dilatation\n is unchanged. Transvenous right atrial and right ventricular pacer leads\n follow the expected courses. Tip of the right subclavian line projects over\n the superior cavoatrial junction. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893855,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with severe aortic stenosis s/p hip surgery, with\n hypercarbia\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE:\n\n INDICATION: -year-old woman with severe aortic stenosis, status post hip\n surgery.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n There is increased mild congestive heart failure with cardiomegaly with\n increased small bilateral pleural effusion. There is also increasing\n bibasilar patchy atelectasis.\n\n There is continued marked tortuosity of the thoracic aorta with calcification.\n\n The pacemaker leads and right subclavian IV catheter remain in place. No\n pneumothorax is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 893511,
"text": " 12:42 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm line placement, eval for CHF\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p hip surgery, s/p central line placement\n REASON FOR THIS EXAMINATION:\n confirm line placement, eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Status post central line placement, hip surgery.\n\n Chest: A single supine AP view at 00:50 hours is compared to previous\n examination of . There are bilateral pleural effusions likely\n layering on the right. The interstitial edema is less pronounced since the\n previous examination of . Note is made of left basilar\n atelectasis.\n\n There is an endotracheal tube with its tip approximately 2.8 cm proximal to\n carina. There is also right subclavian central venous catheter with the tip in\n distal SVC. There is a dual chamber pacemaker with the leads overlying the\n right atrium and right ventricle.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2190-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893698,
"text": " 5:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for worsening CHF\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with severe aortic stenosis s/p hip surgery, with\n hypercarbia\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Heart disease.\n\n FINDINGS: A pacemaking device is in place with electrodes overlying the\n region of the right atrium and right ventricle. A right subclavian line ends\n just below the SVC/right atrial junction. Moderate cardiomegaly is unchanged.\n Mild CHF is improved. Bilateral effusions are stable. Left lower lobe\n opacity representing atelectasis is stable.\n\n IMPRESSION: Improved mild CHF. Stable cardiomegaly, bilateral small\n effusions, and left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-11 00:00:00.000",
"description": "L FEMUR (AP & LAT) LEFT",
"row_id": 893456,
"text": " 11:51 AM\n FEMUR (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: ORIF LT DISTAL FEMUR\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Left femur.\n\n HISTORY: ORIF distal femur.\n\n Left femur, six intraoperative fluoroscopic spot images were obtained during\n the open reduction and internal fixation of supra/intercondylar distal left\n femoral fracture. The final films are not available.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2190-12-10 00:00:00.000",
"description": "L FEMUR (AP & LAT) LEFT",
"row_id": 893325,
"text": " 8:24 AM\n FEMUR (AP & LAT) LEFT Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L hip femur and knee, ext rotation s/p fall, s/p\n orif left hip fx recently but now with recurrent injury\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recurrent injury of left hip, status post ORIF.\n\n The study consists of two exams including left hip with five views as well as\n a left knee with two views. There is a new Y intercondylar fracture of the\n left femur, with lateral displacement of the distal fracture segment with\n respect to the shaft. The patient is status post ORIF with dynamic hip screw\n for a impacted intertrochanteric fracture, with partially backed out dynamic\n screw which appears unchanged from . There has been a new\n heterotopic bone formation about the left hip. There is compression fracture\n in lower lumbar spine.\n\n IMPRESSION: New intercondylar fracture of the distal left femur.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-10 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 893324,
"text": " 8:23 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: likely to OR- pls eval edema, infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L hip pain, ext rotation s/p fall, s/p orif left\n hip fx recently but now with recurrent injury\n REASON FOR THIS EXAMINATION:\n likely to OR- pls eval edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n Left hip pain. Awaiting surgery.\n\n FINDINGS: A pacemaking device overlying the left chest with pacer lead\n overlying the region of the right atrium and right ventricle is unchanged.\n Moderate cardiomegaly and mild failure are unchanged compared to .\n Markedly tortuous calcified thoracic aorta is seen. Atelectasis is present at\n both lung bases with pleural effusions that are decreased compared to .\n No pneumothorax or pulmonary parenchymal consolidation is seen. No osseous\n abnormalities identified.\n\n IMPRESSION: Unchanged cardiomegaly with continued mild failure compared to\n . No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894225,
"text": " 12:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett position\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with severe aortic stenosis s/p hip surgery, with\n hypercarbia respiratory failure in unit s/p intubation.\n REASON FOR THIS EXAMINATION:\n ett position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic stenosis, hip surgery.\n\n FINDINGS: An endotracheal tube ends 3 cm above the carina. This endotracheal\n tube is slightly distended. Moderate cardiomegaly is present. A central\n line ends in the upper right atrium. A pacemaking device overlies the left\n chest with electrodes overlying the expected location of the right atrium and\n right ventricle. Moderate CHF is unchanged. Bilateral effusions and bibasilar\n atelectasis are also unchanged. No pneumothorax is seen. No osseous\n abnormalities are identified.\n\n IMPRESSION:\n\n 1. An endotracheal tube is in place with a slightly overdistended cuff.\n\n 2. Unchanged failure. Bibasilar atelectasis with bilateral pleural\n effusions.\n\n Findings were discussed with Dr. at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893558,
"text": " 2:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval change\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with severe aortic stenosis s/p hip surgery, s/p central\n line placement now s/p extubation\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Status post hip surgery.\n\n A single AP upright view at 3 p.m. is compared to a previous examination\n earlier from the same day. The endotracheal tube has been removed since the\n previous exam. There are bilateral small pleural effusions with probable\n bibasilar atelectasis. There is mild engorgement of the pulmonary vasculature\n without evidence of overt edema. Cardiomegaly.\n There is a right subclavian central venous catheter with the tip in distal\n SVC. Again, note is made of dual-chamber pacemaker with the leads in right\n atrium and ventricle.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2190-12-15 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 893924,
"text": " 12:41 PM\n RENAL U.S. PORT Clip # \n Reason: please do DOPPLERS to evaluate renal artery perfusion and u/\n Admitting Diagnosis: ANEMIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with h/o AS, TR, pulm HTN, s/p ORIF now with acute renal\n failure.\n REASON FOR THIS EXAMINATION:\n please do DOPPLERS to evaluate renal artery perfusion and u/s of kidneys for\n hydronephrosis and evidence of chronic kidney disease.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal failure.\n\n RENAL ULTRASOUND: This study is limited due to it being performed as a\n portable ultrasound at the request of the referring clinician.\n\n FINDINGS: There are bilateral small kidneys, the right measuring 8.9 cm, and\n the left measuring 8.8 cm. There is no hydronephrosis, renal mass, or stone.\n There is limited Doppler flow to both kidneys, but this could be technical.\n There is a right pleural effusion.\n\n IMPRESSION: Right pleural effusion. Very limited exam due to\n requested portable technique. The visualized lack of renal flow could be\n technical.\n\n"
}
] |
8,363 | 101,614 | The patient was taken to the operating room on where he underwent an aortic valve replacement with a limited access incision by Dr. . He had a 25-mm CarboMedics mechanical valve placed. Postoperatively he was transported from the operating room to the cardiac surgery recovery unit in good condition. He was weaned from the mechanical ventilator and extubated later on the day of surgery. On postoperative day one the patient was noted to have some atrial fibrillation which was treated with IV diltiazem through the course of the day. He had been out of bed and was beginning to ambulate. On postoperative day two the patient had since converted back to normal sinus rhythm on the diltiazem. This was transitioned to Lopressor and the diltiazem was ultimately discontinued. He was started on Coumadin on postoperative day two, and transferred out of the intensive care unit to the telemetry floor. The patient began to progress with cardiac rehabilitation, increasing ambulation and pulmonary toilet, and had tolerated that advancement in his activity level well. The patient had a subsequent episode of atrial fibrillation with a ventricular response in the 120s the following day on , which was treated with IV Lopressor, and he has since converted back to normal sinus rhythm. He had been started on a heparin drip at that point due to his atrial fibrillation as well as having a mechanical aortic valve placed. He had been maintained on the telemetry floor over the next few days on an IV heparin drip, with a PTT in the 50-70 range while increasing his daily Coumadin dosing to get him to a therapeutic level for his mechanical aortic valve. He has remained in sinus rhythm with good hemodynamics, and he is now ambulating independently, has not had any other difficulties during his postoperative course, and is ready to be discharged today, . | REPETE PRN. ROS: Neuro: A+O. CT DCD THIS AM. KCL REPLETED PRN. Dilt. on amiodarone and then d/c dilt. CT MIN OUTPUT. HYPOACTIVE BS. Anticoag . Pt. PT. PT. PT. PT. PT. MANAGEMENT FOR AFIB.OOB WHEN STABLE. START ANTICOAG. ID: Afebrile, on vanco. Transfer pt. EFFECTIVE.RESP~ON 2 L NP. AMBULATED AROUND UNIT W/ WC S/ DIFFICULTY.PLAN: DELINE. BS TX SSR THIS AM PER PROTOCOL.ACT: PT OOB W/ MIN ASSIST X1. DISTAL PULSES PALP. HR AND SUBSIDES WHEN HR NORMAL.DIURESING WELL WITH LASIX. + PULSES. ST-T wave configurationsuggests, in part, early repolarization pasttern. PROGRESS ACTIVITIES AS TOL. NEURO: A&OX3-MAE. P.O. ADMINISTRATION.PT. TRANSIENT EPISODE SVT. Sinus rhythm. SELF LIMITING.CV: BP 98-130/50. Atrial fibrillation. Clinical correlation issuggested. ck's to be drawn q8'. DIURESING WELL.A/P~FOLLOWING NORMAL POST OP COURSE. DR. . PRESENT FOR EPISODE AND MED. Keep on lopressor. KEEP ELECTROLYTES WNL. RESOLVED ON OWN. NML COLOR/SENSATION. ? Ventricular premature beat. converted to nsr.Electrolytes wnl. GI: On ranitidine, taking cl liqs. FOLLOWS COMMANDS. Resp: Extubated easily. wires dc'd @ 1630.RESP: On RA, sats. CONT TO MONITOR ELETROLYTES. Clinicalcorrelation is suggested. LUNGS CLEAR UPPER DIMINISHED IN BASES. Atrial fibrillation with a moderate ventricular response. Rehab: OOB with minimal assistance.A: STABLEP: Cont to progress. to floor. Since the previous tracing of atrialfibrillation is absent.TRACING #3 TX F2 AND BEGIN D/C TEACHING. POST CXR DONE.GI/GU~TOL PO FOOD AND FLUIDS. and started on PO, low grade temp. Since the previous tracing of sinus rhythmis absent. Modest non-specificlow amplitude T wave changes. First dose @ 0400. FOR PAIN WITH PERCOCET. Modest non-specific lateral ST-T wave changes. 1250 on IS. CARDIAC~EPISODE OF SVT @ 1555. Since the previous tracing earlier this date the ventricular rate isslower.TRACING #2 RELIEVED THIS MORNING WHEN HR REGULATED.PLAN~ MONITOR FOR TACHYARRYTHMIAS. URINE OUTPUT MARG. Heme: Hct 37, CT drg minimal. OOB TO CHAIR AND AMB X1. CONVERTED WITHIN MINUTES TO NSR ~ 64. 100 @ 1600, epi. HR 60-80'S NSR NO ECTOPY. MED W/ PERC 2 TABS X2 FOR C/O INCISIONAL DISCOMFORT. CONTINUE FAST TRACK. 2A 2V WIRES ON AD 60.RESP: O2 WEANED TO OFF SATS>93% ABG WNL. >94%, lungs clear and diminished at bases, encourage use of IS, need to remind to cough.GI: Abd. Renal: Brisk uo, now 40/hr. IS TO 1500.GI/GU: TOL CLEAR DIET. had repeated episode of afib/svt @ 2300. TAKING GOOD PO'S. LUNGS CLEAR TO BASES. PICKING UP SLIGHTLY THIS AM >30CC/HRPAIN: MED W/ PERCOCET TABS/ TORADOL FOR PAIN W/ GOOD RELIEF.ENDO: INSULING GTT WEANED TO OFF. Drip cut back to 10mg.Pt. BACK TO BED.ELECTROLYTES REPLENISHED. Sinus bradycardiaEarly R wave progressionSince last ECG, no significant change MAINTAINING SATS 100%. Atrial fibrillation with a rapid ventricular response. GIVEN MSO4 2 MG AND MIDAZOLAM 1 MG FOR DISCOMFORT AND ANXIETY.NEURO~COMPLETELY INTACT. No previous tracingavailable for comparison.TRACING #1 Endo: Insulin drip per flow sheet. ALERT WHEN AWAKE BUT ANXIOUS ABOUT EPISODE OF SVT/AFIB. Med with percocet for pain. was increased to 60mg po q6. RATE 90'S UP TO 145 DURING BURSTS. CSRU AdmissionS/O: 49 yo male s/p AVR (mech). Skin: Intact. OTHER LABS WNL.MED. CV: Stable, no drips. NO FURTHER EPISODES NOTED. NO FURTHER EPISODES NOTED. Last draw @ 1500.Team discussed starting pt. PT IN CHAIR AT THE TIME AND FELT HOT AND A TIGHTNESS IN HIS THROAT. HAS "INDIGESTION" FEELING IN HIS THROAT WITH ACCEL. Sinus rhythmSince previous tracing, the heart rate is faster MAINTAINED AFIB/ATRIAL FLUTTER WITH BURSTS OF PSVT THROUGH THE NIGHT. LOPRESSOR 5MG IVP GIVEN AT 0455 FOLLOWED BY INCREASED PO DOSE LOPRESSOR 25MG. CARDIOLOGY CONSULT TO HELP WITH PROPER MED. NEURO: A/O X3, anxious this a.m. secondary to events last night and lack of sleep, follows all commands, MAE.CV: NSR with no ectopy, weaned off Diltiazem gtt. Treated with 20 mg total of Diltiazem iv and a drip was resumed at 15mg/hr. C/O "PINS AND NEEDLES" LEFT LEG IN BED. GIVEN EXTRA DOSE OF LASIX 20 MG IV THIS EVENING. SLEPT LIGHTLY THROUGHTOUT THE NIGHT; EASILY AROUSABLE. I SPOKE WITH WIFE 3X ON PHONE. ALSO C/O SHARP STABBING PAIN IN LOWER CHEST (OLD CT SITE). sft, BS +, tolerating meals wellGU: Foley intact, clear yellow urine, diuresing well with lasixACTIVITY: OOB to CH for all meals, ambulated with PT, tolerated well, wife at bedside all day.PAIN: Medicated X 1 for incisional pain.PLAN: Encourage pulmonary toilet, monitor for ectopy, monitor pain and temp. DID NOT WANT HER TO COME IN.SVT/AFLUTTER RATE 150 TREATED WITH 20 MG TOTAL IV LOPRESSOR AND DILTIAZEM DRIP THAT WAS TITRATED TO 15MG/HR AFTER RECEIVING 20MG OVER 2 MINUTES. slept most of the night. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2121-06-28 00:00:00.000",
"description": "Report",
"row_id": 1372769,
"text": "CARDIAC~EPISODE OF SVT @ 1555. RESOLVED ON OWN. PT IN CHAIR AT THE TIME AND FELT HOT AND A TIGHTNESS IN HIS THROAT. ALSO C/O SHARP STABBING PAIN IN LOWER CHEST (OLD CT SITE). BACK TO BED.\nELECTROLYTES REPLENISHED. NO FURTHER EPISODES NOTED. GIVEN MSO4 2 MG AND MIDAZOLAM 1 MG FOR DISCOMFORT AND ANXIETY.\n\nNEURO~COMPLETELY INTACT. OOB TO CHAIR AND AMB X1. MED W/ PERC 2 TABS X2 FOR C/O INCISIONAL DISCOMFORT. EFFECTIVE.\n\nRESP~ON 2 L NP. MAINTAINING SATS 100%. LUNGS CLEAR UPPER DIMINISHED IN BASES. CT DCD THIS AM. POST CXR DONE.\n\nGI/GU~TOL PO FOOD AND FLUIDS. GIVEN EXTRA DOSE OF LASIX 20 MG IV THIS EVENING. DIURESING WELL.\n\nA/P~FOLLOWING NORMAL POST OP COURSE. TRANSIENT EPISODE SVT. NO FURTHER EPISODES NOTED. CONT TO MONITOR ELETROLYTES. REPETE PRN.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-29 00:00:00.000",
"description": "Report",
"row_id": 1372770,
"text": "PT. ALERT WHEN AWAKE BUT ANXIOUS ABOUT EPISODE OF SVT/AFIB. PT. REASSURED THAT HE WAS STABLE BUT HE DID NOT WANT TO FALL ASLEEP FOR FEAR THAT HE WOULDN'T WAKE UP. I SPOKE WITH WIFE 3X ON PHONE. PT. DID NOT WANT HER TO COME IN.\n\nSVT/AFLUTTER RATE 150 TREATED WITH 20 MG TOTAL IV LOPRESSOR AND DILTIAZEM DRIP THAT WAS TITRATED TO 15MG/HR AFTER RECEIVING 20MG OVER 2 MINUTES. DR. PRESENT FOR EPISODE AND MED. ADMINISTRATION.PT. MAINTAINED AFIB/ATRIAL FLUTTER WITH BURSTS OF PSVT THROUGH THE NIGHT. RATE 90'S UP TO 145 DURING BURSTS. . LOPRESSOR 5MG IVP GIVEN AT 0455 FOLLOWED BY INCREASED PO DOSE LOPRESSOR 25MG. PT. CONVERTED WITHIN MINUTES TO NSR ~ 64. PT. HAS \"INDIGESTION\" FEELING IN HIS THROAT WITH ACCEL. HR AND SUBSIDES WHEN HR NORMAL.\n\nDIURESING WELL WITH LASIX. KCL REPLETED PRN. OTHER LABS WNL.\n\nMED. FOR PAIN WITH PERCOCET. SLEPT LIGHTLY THROUGHTOUT THE NIGHT; EASILY AROUSABLE. RELIEVED THIS MORNING WHEN HR REGULATED.\n\nPLAN~ MONITOR FOR TACHYARRYTHMIAS. ? CARDIOLOGY CONSULT TO HELP WITH PROPER MED. MANAGEMENT FOR AFIB.\nOOB WHEN STABLE. PROGRESS ACTIVITIES AS TOL. KEEP ELECTROLYTES WNL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-29 00:00:00.000",
"description": "Report",
"row_id": 1372771,
"text": "NEURO: A/O X3, anxious this a.m. secondary to events last night and lack of sleep, follows all commands, MAE.\n\nCV: NSR with no ectopy, weaned off Diltiazem gtt. and started on PO, low grade temp. 100 @ 1600, epi. wires dc'd @ 1630.\n\nRESP: On RA, sats. >94%, lungs clear and diminished at bases, encourage use of IS, need to remind to cough.\n\nGI: Abd. sft, BS +, tolerating meals well\n\nGU: Foley intact, clear yellow urine, diuresing well with lasix\n\nACTIVITY: OOB to CH for all meals, ambulated with PT, tolerated well, wife at bedside all day.\n\nPAIN: Medicated X 1 for incisional pain.\n\nPLAN: Encourage pulmonary toilet, monitor for ectopy, monitor pain and temp.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-30 00:00:00.000",
"description": "Report",
"row_id": 1372772,
"text": "Pt. had repeated episode of afib/svt @ 2300. Treated with 20 mg total of Diltiazem iv and a drip was resumed at 15mg/hr. P.O. Dilt. was increased to 60mg po q6. First dose @ 0400. Drip cut back to 10mg.Pt. slept most of the night. converted to nsr.\n\nElectrolytes wnl. ck's to be drawn q8'. Last draw @ 1500.\n\nTeam discussed starting pt. on amiodarone and then d/c dilt. Keep on lopressor. Transfer pt. to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-27 00:00:00.000",
"description": "Report",
"row_id": 1372767,
"text": "CSRU Admission\nS/O: 49 yo male s/p AVR (mech).\n ROS: Neuro: A+O. Med with percocet for pain.\n CV: Stable, no drips.\n Resp: Extubated easily. 1250 on IS.\n Renal: Brisk uo, now 40/hr.\n Heme: Hct 37, CT drg minimal.\n ID: Afebrile, on vanco.\n GI: On ranitidine, taking cl liqs.\n Endo: Insulin drip per flow sheet.\n Skin: Intact.\n Rehab: OOB with minimal assistance.\nA: STABLE\nP: Cont to progress. Anticoag .\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-28 00:00:00.000",
"description": "Report",
"row_id": 1372768,
"text": "NEURO: A&OX3-MAE. FOLLOWS COMMANDS. C/O \"PINS AND NEEDLES\" LEFT LEG IN BED. NML COLOR/SENSATION. + PULSES. SELF LIMITING.\nCV: BP 98-130/50. HR 60-80'S NSR NO ECTOPY. DISTAL PULSES PALP. CT MIN OUTPUT. 2A 2V WIRES ON AD 60.\nRESP: O2 WEANED TO OFF SATS>93% ABG WNL. LUNGS CLEAR TO BASES. IS TO 1500.\nGI/GU: TOL CLEAR DIET. TAKING GOOD PO'S. HYPOACTIVE BS. URINE OUTPUT MARG. PICKING UP SLIGHTLY THIS AM >30CC/HR\nPAIN: MED W/ PERCOCET TABS/ TORADOL FOR PAIN W/ GOOD RELIEF.\nENDO: INSULING GTT WEANED TO OFF. BS TX SSR THIS AM PER PROTOCOL.\nACT: PT OOB W/ MIN ASSIST X1. AMBULATED AROUND UNIT W/ WC S/ DIFFICULTY.\nPLAN: DELINE. CONTINUE FAST TRACK. START ANTICOAG. TX F2 AND BEGIN D/C TEACHING.\n"
},
{
"category": "ECG",
"chartdate": "2121-07-02 00:00:00.000",
"description": "Report",
"row_id": 181593,
"text": "Atrial fibrillation with a moderate ventricular response. Modest non-specific\nlow amplitude T wave changes. Since the previous tracing of sinus rhythm\nis absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-26 00:00:00.000",
"description": "Report",
"row_id": 181594,
"text": "Sinus bradycardia\nEarly R wave progression\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-27 00:00:00.000",
"description": "Report",
"row_id": 177958,
"text": "Sinus rhythm\nSince previous tracing, the heart rate is faster\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-26 00:00:00.000",
"description": "Report",
"row_id": 177959,
"text": "Sinus rhythm. Modest non-specific lateral ST-T wave changes. Clinical\ncorrelation is suggested. Since the previous tracing of atrial\nfibrillation is absent.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-25 00:00:00.000",
"description": "Report",
"row_id": 177960,
"text": "Atrial fibrillation. Ventricular premature beat. ST-T wave configuration\nsuggests, in part, early repolarization pasttern. Clinical correlation is\nsuggested. Since the previous tracing earlier this date the ventricular rate is\nslower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-25 00:00:00.000",
"description": "Report",
"row_id": 177961,
"text": "Atrial fibrillation with a rapid ventricular response. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
}
] |
50,895 | 136,047 | During the preoperative workup, an abdominal MRI was performed to evaluate the abdominal aorta for plaque/calcifications, and evaluate renal arteries for plaques/calcifications. Based on the MRI results, a future MRCP was recommended by Radiology. The MRI results per Radiology are as follows: | There are simpleatheroma in the ascending aorta. Simple atheroma in aortic arch. Mild (1+) aorticregurgitation is seen. Simple atheroma in ascendingaorta. Mildly dilated aortic arch. There is mild symmetric left ventricular hypertrophy. Minimal calcification in the ascending aorta. FINDINGS: Calcification is minimal in the ascending aorta above the level of the ostia of the coronary arteries and mild in the aortic arch. Mild (1+) AR.MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Mild vascular congestion is present as well as bibasal retrocardiac atelectasis and small pleural effusions, left greater than right. IMPRESSION: Bibasilar atelectasis and small-to-moderate pleural effusions. Persistent bibasilar retrocardiac atelectasis and small effusions. There is mild functional mitral stenosis (mean gradient4 mmHg) due to mitral annular calcification. Bibasilar discoid atelectasis and bilateral small-to-moderate pleural effusions are present. Shortness of breath.BP (mm Hg): 115/67HR (bpm): 76Status: InpatientDate/Time: at 09:10Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate to severe spontaneous echo contrast in the body of theLA. Normal RV systolicfunction.AORTA: Normal ascending aorta diameter. Theaortic arch is mildly dilated. There iscritical aortic valve stenosis (valve area <0.8cm2). On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 61/11, 51/12, 62/12 cm/sec. There isST segment flattening and slight depression in leads I, II, aVL, aVF and V3-V6.The ST segments are downsloping in leads V4-V6. Decrease in width of cardiomediastinal contours and resolution of mild edema. Right ventricular function. Severe PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mild (1+) mitral regurgitation isseen. Mild atherosclerotic disease is noted. FINDINGS: Interval median sternotomy and aortic valve replacement. There are simple atheroma in the aortic arch.There are complex (>4mm) atheroma in the descending thoracic aorta.Post BypassThe patient is a neosynephrine dripThere is now a bioprosthetic valve with apporpriate gradients for size andcardiac outputLV Function is similar to prebypasThere is no dissection seen in the ascending aorta The right ventricular free wall is hypertrophied. A right internal jugular catheter has been inserted and terminates at the level of the cavoatrial junction. Enlargement of the cardiac silhouette persists with little change in the degree of pneumopericardium or anterior basal left pneumothorax. The tricuspid valve leaflets are mildlythickened. Mild symmetric LVH.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -hypo;AORTA: Normal aortic diameter at the sinus level. Left ventricular hypertrophy withST-T wave abnormalities. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Congestive heart failureHeight: (in) 64Weight (lb): 165BSA (m2): 1.80 m2BP (mm Hg): 148/87HR (bpm): 78Status: InpatientDate/Time: at 09:22Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No VSD.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- akinetic; mid anterior - akinetic; basal inferior - hypo; mid inferior -hypo; basal inferolateral - hypo; mid inferolateral - akinetic; basalanterolateral - akinetic; mid anterolateral - akinetic; anterior apex - hypo;inferior apex - hypo; lateral apex - hypo;RIGHT VENTRICLE: RV hypertrophy. Cannot rule out myocardial ischemia.Clinical correlation and repeat tracing are suggested. Persistent left basilar atelectasis and adjacent pleural effusion, but slight worsening of right basilar atelectasis and decrease in small right pleural effusion. Left atrial abnormality. Left atrial abnormality. A nasogastric tube and Swan-Ganz catheter have been withdrawn. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 28/5, 74/18, 58/14 cm/sec. There is a right pleural effusion. There is antegrade left vertebral artery flow. Mild thickening of mitral valve chordae.Calcified tips of papillary muscles. Interval decrease in focal curvilinear gas collection adjacent to left ventricular apex, likely due to resolving pneumopericardium. Complex (>4mm) atheroma in thedescending thoracic aorta.GENERAL COMMENTS: A TEE was performed in the location listed above. The patient is status post median sternotomy, as before. IMPRESSION: Interval improvement in pleural fluid and bibasilar atelectasis. Of note, there is an independent origin of the left gastric artery off of the aorta. There is interval improvement in bibasilar atelectasis and small pleural effusions. Diffuse intralobular septal thickening is smooth throughout the lungs and worst in the lung bases and more dependent positions of the lungs and a small right pleural effusion is non-hemorrhagic. Left ventricular function. Pancreatic duct is of normal caliber. No TEE relatedcomplications.Conclusions:Moderate to severe spontaneous echo contrast is seen in the body of the leftatrium. There is nopericardial effusion. ]TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. There are focal calcifications in the aorticarch. However,concomitant inferolateral myocardial ischemia cannot be excluded. CHEST, PA AND LATERAL: A right internal jugular central venous catheter is stable in position. While this most likely represents a hemorrhagic cyst, hemorrhage into an underlying lesion is not definitely excluded. These findings may representthe repolarization abnormality of left ventricular hypertrophy. Degenerative changes are moderately severe in the thoracic spine with DISH. One within the left lateral interpolar region is not definitively a hemorrhagic cyst and may represent hemorrhage into an underlying lesion. No MVP.Severe mitral annular calcification. Of note, there is a big left atrium and left ventricular hypertrophy. Moderate enlargement of the cardiac size is unchanged. Within the pancreas innumerable T2 hyperintense lesions are noted, consistent with simple cysts. Tip of endotracheal tube is about 1.6 cm above carina and could be withdrawn a few centimeters for standard positioning and the side port of the nasogastric tube is near the GE junction and could be advanced a few centimeters for standard positioning. Mild (1+)MR. [Due to acoustic shadowing, the severity of MR may be significantlyUNDERestimated. There is antegrade right vertebral artery flow. TECHNIQUE: MDCT chest was performed without IV contrast. | 16 | [
{
"category": "Radiology",
"chartdate": "2106-06-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1132610,
"text": " 10:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p AVR w/worsening hypoxia r/o PTX/eval ETT position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR w/worsening hypoxia r/o PTX/eval ETT position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post aortic valve replacement with worsening hypoxia, to\n evaluate for pneumothorax and ET tube position.\n\n FINDINGS: In comparison with the study of , the tip of the endotracheal\n tube lies approximately 2.5 cm above the carina. No evidence of pneumothorax.\n Swan-Ganz catheter, mediastinal drains, and nasogastric tube remain in place.\n Enlargement of the cardiac silhouette persists with little change in the\n degree of pneumopericardium or anterior basal left pneumothorax. The degree\n of vascular congestion appears to have increased somewhat. Bibasilar\n atelectasis and small pleural effusions are again seen, somewhat more\n prominent on the left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1133232,
"text": " 8:49 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male status post CABG, here for evaluation of\n effusions.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: A right internal jugular central venous catheter is\n stable in position. Median sternotomy wires are intact. Moderate enlargement\n of the cardiac size is unchanged. The mediastinal and hilar contours are\n within normal limits. Bibasilar discoid atelectasis and bilateral\n small-to-moderate pleural effusions are present. Upper lungs are clear,\n without pulmonary vascular congestion or pneumothorax.\n\n IMPRESSION: Bibasilar atelectasis and small-to-moderate pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1132992,
"text": " 12:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for pneumothorax s/p line change over a wire\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 yr old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p line change over a wire\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: AVR. Pneumothorax.\n\n One portable view. Comparison with . There is interval improvement in\n bibasilar atelectasis and small pleural effusions. The patient is status post\n median sternotomy, as before. A nasogastric tube and Swan-Ganz catheter have\n been withdrawn. A right internal jugular catheter has been inserted and\n terminates at the level of the cavoatrial junction. There is no other\n significant change.\n\n IMPRESSION: Interval improvement in pleural fluid and bibasilar atelectasis.\n Line placement as described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-08 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1132152,
"text": " 10:11 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for aortic plaque, calcifications\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with aortic stenosis, due for AVR\n REASON FOR THIS EXAMINATION:\n evaluate for aortic plaque, calcifications\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure, prior history of cholesterol embolus\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast.\n\n REASON FOR EXAM: Evaluate for aortic plaque or calcifications, pre-operative\n AVR.\n\n TECHNIQUE: MDCT chest was performed without IV contrast. 5-mm and 1.25-mm\n axial slices were acquired with coronal and sagittal reformats.\n\n No previous CT was available for comparison.\n\n FINDINGS: Calcification is minimal in the ascending aorta above the level of\n the ostia of the coronary arteries and mild in the aortic arch. The pulmonary\n artery is enlarged at 32 mm in the main trunk and 33 mm in the right main\n pulmonary artery with peripheral tapering of the segmental arteries consistent\n with pulmonary arterial hypertension. Multiple pathologically enlarged lymph\n nodes of the mediastinum are largest in the subcarinal region at 11 mm and 10\n mm in the right hilum. Central airways are widely patent.\n\n There is cardiomegaly with diffuse calcification in the mitral annulus, aortic\n annulus and throughout the coronary arteries. No pericardial effusion.\n\n Diffuse intralobular septal thickening is smooth throughout the lungs and\n worst in the lung bases and more dependent positions of the lungs and a small\n right pleural effusion is non-hemorrhagic. No lung nodules concerning for\n malignancy. Atelectasis in the middle lobe is linear and mild.\n\n This examination was not designed for subdiaphragmatic evaluation except to\n note a small hiatal hernia and atherosclerotic calcifications throughout the\n abdominal aorta. Degenerative changes are moderately severe in the thoracic\n spine with DISH. No destructive or sclerotic bone lesions worrisome for\n malignancy.\n\n IMPRESSION:\n\n 1. Minimal calcification in the ascending aorta. Diffuse mitral annular,\n aortic annular and coronary artery calcification.\n\n 2. Enlargement of the pulmonary artery and peripheral tapering consistent\n with pulmonary arterial hypertension.\n\n (Over)\n\n 10:11 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for aortic plaque, calcifications\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Diffuse intralobular septal thickening with a small right pleural effusion\n is most likely due to mild pulmonary edema which is probably the cause of the\n enlarged mediastinal lymph nodes and bronchial wall thickening.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1132637,
"text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AVR w/worsening oxygenation r/o effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR w/worsening oxygenation r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Status post AVR. Worsening oxygenation.\n\n FINDINGS: Indwelling devices are in standard position. Interval decrease in\n focal curvilinear gas collection adjacent to left ventricular apex, likely due\n to resolving pneumopericardium. Decrease in width of cardiomediastinal\n contours and resolution of mild edema. Persistent bibasilar retrocardiac\n atelectasis and small effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-08 00:00:00.000",
"description": "MRA ABDOMEN W/O CONTRAST",
"row_id": 1132230,
"text": " 3:25 PM\n MRA ABDOMEN W/O CONTRAST Clip # \n Reason: please evaluate abdominal aorta for plaque/calcifications, a\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with severe AS, pre-op for aortic valve replacement\n REASON FOR THIS EXAMINATION:\n please evaluate abdominal aorta for plaque/calcifications, and evaluate renal\n arteries for plaques/calcifications (NO CONTRAST)\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure, prior history of emboli secondary to contrast\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI abdomen without contrast obtained .\n\n HISTORY: An 82-year-old male with severe aortic stenosis, preoperative for\n aortic valve replacement, rule out AAA or renal artery abnormality.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet. Dynamic 3D images were not obtained as the clinician did not\n want it.\n\n Multiplanar 2D and 3D reformations were generated on an independent\n workstation.\n\n FINDINGS: The liver is homogeneous in signal intensity without definite\n abnormality identified. There is no intrahepatic biliary ductal dilatation.\n Gallbladder, spleen, and adrenal glands are unremarkable in appearance in\n their visualized portions.\n\n Within the pancreas innumerable T2 hyperintense lesions are noted, consistent\n with simple cysts. Two dominant cysts are noted, one in the proximal body\n measuring 1.4 x 1.3 cm in size and the second within the head measuring 2.9 cm\n in size. These do not definitely connect with the main pancreatic duct,\n although limited visualization on these images. No evidence of septations\n within these cysts. Pancreatic duct is of normal caliber.\n\n Innumerable cysts are noted within the kidneys bilaterally, some of which are\n hemorrhagic. One within the left lateral interpolar kidney, which\n demonstrates T2 hypointense signal, also has Hemosiderin ring on the T1\n in-phase images, but is not completely evaluated. While this most likely\n represents a hemorrhagic cyst, hemorrhage into an underlying lesion is not\n definitely excluded. This measures 2.0 x 1.9 cm in size.\n\n There is a right pleural effusion. For lung/thorax findings, please refer to\n CT from the same day obtained at 10:24 hours. Of note, there is a\n big left atrium and left ventricular hypertrophy.\n\n The abdominal aorta has a normal course and caliber without aneurysmal\n dilatation. Mild atherosclerotic disease is noted. The renal arteries are\n (Over)\n\n 3:25 PM\n MRA ABDOMEN W/O CONTRAST Clip # \n Reason: please evaluate abdominal aorta for plaque/calcifications, a\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n patent with no evidence of narrowing or irregularity. Of note, there is an\n independent origin of the left gastric artery off of the aorta.\n\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\n dynamic series.\n\n IMPRESSION:\n 1. No evidence of AAA.\n\n 2. Main renal arteries are normal.\n\n 3. Innumerable pancreatic cysts, which are not fully evaluated on this study.\n A six-month MRCP is recommended with contrast for further evaluation.\n Diagnostic considerations include multiple side branch IPMNs versus sequela of\n pancreatitis.\n\n 4. Multiple hemorrhagic cysts within the kidneys. One within the left\n lateral interpolar region is not definitively a hemorrhagic cyst and may\n represent hemorrhage into an underlying lesion. Therefore, this should be\n evaluated at the time of patient's MRCP with contrast.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-08 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1132122,
"text": " 7:59 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: eval carotids for plaques\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with severe aortic stenosis, getting AVR\n REASON FOR THIS EXAMINATION:\n eval carotids for plaques\n ______________________________________________________________________________\n FINAL REPORT\n \n Radiology Department\n Vascular Laboratory:\n\n Study: Carotid Series Complete\n\n Reason: 83 yr old man with severe aortic stenosis, getting AVR\n\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is calcified plaque in the ICA. On the left there is\n heterogeneous plaque in the ICA .\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 61/11, 51/12, 62/12 cm/sec. CCA peak systolic velocity\n is 71 cm/sec. ECA peak systolic velocity is 66 cm/sec. The ICA/CCA ratio is\n 0.87. 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 28/5, 74/18, 58/14 cm/sec. CCA peak systolic velocity\n is 78 cm/sec. ECA peak systolic velocity is 61 cm/sec. The ICA/CCA ratio is\n 0.94. 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"
},
{
"category": "Radiology",
"chartdate": "2106-06-09 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1132405,
"text": " 5:04 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with aortic stenosis, shortness of breath\n REASON FOR THIS EXAMINATION:\n preop for AVR replacement\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 83-year-old male with history of aortic stenosis,\n shortness of breath, pre-op chest radiograph for aortic valve replacement.\n\n COMPARISON: Reference made to chest CT from .\n\n FINDINGS: Frontal and lateral views of the chest were obtained.\n Indistinctness of the central vasculature likely reflects a component of\n edema/pulmonary vascular congestion. Haziness at the right lung base may be\n due to layering of pleural effusion seen one day prior with overlying\n atelectasis. The cardiac and mediastinal silhouettes remain enlarged,\n unchanged since the scout view from . Degenerative changes are\n again seen along the thoracic spine, including DISH.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1132701,
"text": " 1:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST :\n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Chest tube removal.\n\n FINDINGS: Midline drain has been removed, with no evidence of pneumothorax.\n Localized pneumopericardium is not appreciably changed. Indwelling devices\n remain in standard position. Persistent left basilar atelectasis and adjacent\n pleural effusion, but slight worsening of right basilar atelectasis and\n decrease in small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-06-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1132531,
"text": " 1:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with AVR\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post AVR.\n\n FINDINGS: Interval median sternotomy and aortic valve replacement. Tip of\n endotracheal tube is about 1.6 cm above carina and could be withdrawn a few\n centimeters for standard positioning and the side port of the nasogastric tube\n is near the GE junction and could be advanced a few centimeters for standard\n positioning. Swan-Ganz catheter and mediastinal drains are in standard\n position. Cardiac silhouette is enlarged, and a lucency paralleling the left\n heart border could either reflect a localized pneumopericardium or an anterior\n medial left pneumothorax. Mild vascular congestion is present as well as\n bibasal retrocardiac atelectasis and small pleural effusions, left greater\n than right.\n\n"
},
{
"category": "Echo",
"chartdate": "2106-06-10 00:00:00.000",
"description": "Report",
"row_id": 90710,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Pulmonary hypertension. Right ventricular function. Shortness of breath.\nBP (mm Hg): 115/67\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 09:10\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate to severe spontaneous echo contrast in the body of the\nLA. No mass/thrombus in the LAA.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nAORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending\naorta. Simple atheroma in aortic arch. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\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.\n\nConclusions:\nModerate to severe spontaneous echo contrast is seen in the body of the left\natrium. No mass/thrombus is seen in the left atrium or left atrial appendage.\nThere is mild symmetric left ventricular hypertrophy. There are simple\natheroma in the ascending aorta. There are simple atheroma in the aortic arch.\nThere are complex (>4mm) atheroma in the descending thoracic aorta.\nPost Bypass\nThe patient is a neosynephrine drip\nThere is now a bioprosthetic valve with apporpriate gradients for size and\ncardiac output\nLV Function is similar to prebypas\nThere is no dissection seen in the ascending aorta\n\n\n"
},
{
"category": "Echo",
"chartdate": "2106-06-08 00:00:00.000",
"description": "Report",
"row_id": 90712,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Shortness of breath. Left ventricular function. Congestive heart failure\nHeight: (in) 64\nWeight (lb): 165\nBSA (m2): 1.80 m2\nBP (mm Hg): 148/87\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 09:22\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with 35-50% decrease during respiration (estimated RA pressure\n(0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mildly depressed\nLVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - akinetic; basal inferior - hypo; mid inferior -\nhypo; basal inferolateral - hypo; mid inferolateral - akinetic; basal\nanterolateral - akinetic; mid anterolateral - akinetic; anterior apex - hypo;\ninferior apex - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Normal RV systolic\nfunction.\n\nAORTA: Normal ascending aorta diameter. Focal calcifications in ascending\naorta. Mildly dilated aortic arch. Focal calcifications in aortic arch.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. No MVP.\nSevere mitral annular calcification. Mild thickening of mitral valve chordae.\nCalcified tips of papillary muscles. Mild functional MS due to MAC. Mild (1+)\nMR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Severe PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The estimated right atrial pressure is\n0-10mmHg. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed (LVEF= 45 %). Tissue Doppler imaging suggests an increased\nleft ventricular filling pressure (PCWP>18mmHg). There is no ventricular\nseptal defect. The right ventricular free wall is hypertrophied. Right\nventricular chamber size is normal. with normal free wall contractility. The\naortic arch is mildly dilated. There are focal calcifications in the aortic\narch. The aortic valve leaflets are severely thickened/deformed. There is\ncritical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are severely\nthickened/deformed. There is no mitral valve prolapse. There is severe mitral\nannular calcification. There is mild functional mitral stenosis (mean gradient\n4 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. There is severe pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2106-06-07 00:00:00.000",
"description": "Report",
"row_id": 232023,
"text": "Sinus rhythm. Left ventricular hypertrophy with ST-T wave change. There is\nST segment flattening and slight depression in leads I, II, aVL, aVF and V3-V6.\nThe ST segments are downsloping in leads V4-V6. These findings may represent\nthe repolarization abnormality of left ventricular hypertrophy. However,\nconcomitant inferolateral myocardial ischemia cannot be excluded. Followup and\nclinical correlation are suggested. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-06-12 00:00:00.000",
"description": "Report",
"row_id": 232020,
"text": "Normal sinus rhythm. Diffuse ST-T wave abnormalities, which are more\nmarked compared to the prior tracing of , are most notable in\nleads I, II, aVF and V3-V6. Cannot rule out myocardial ischemia.\nClinical correlation and repeat tracing are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-06-10 00:00:00.000",
"description": "Report",
"row_id": 232021,
"text": "Sinus rhythm. Left atrial abnormality. Diffuse ST-T wave abnormalities with\nprolonged QTc interval may be due to drug/electrolyte/metabolic effect or\npossible myocardial ischemia. Clinical correlation is suggested. Since the\nprevious tracing of QRS voltage is less prominent, the QTc interval\nappears longer and further ST-T wave changes are seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-06-08 00:00:00.000",
"description": "Report",
"row_id": 232022,
"text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with\nST-T wave abnormalities. Early preocordial QRS transition is non-specific.\nThe ST-T wave abnormalities are diffuse and clinical correlation is suggested.\nSince the previous tracing of early precordial QRS transition is more\nprominent but there is probably no significant change.\n\n"
}
] |
1,855 | 150,580 | 68 yo male w/ HTN, DM, s/p recent NSTEMI who presented to OSH after developing chest pain and SOB, intubated at OSH for increasing hypoxia and concern for pulmonary edema. Cardiac cath revealed severe 3VD with decreased EF, elevated pulmonary pressures, and thrombocytopenia. He was not a CT surgical candidate, so he underwent repeat cardiac catheterization with atherectomy and placement of BMS to the LAD. . # Cardiogenic shock/CHF - The patient presented in shock, most likely due to LV dysfunction secondary to underlying ischemia. This resulted in systemic hypoperfusion, hypoxemia and lactic acidosis. He had elevated cardiac enzymes and severe 3 vessel CAD at cath, felt not ammenable for stenting initially. He was evaluated but deemed not a CT surgical candidate, so was taken for cath to undergo high risk intervention. He received rotational atherectomy with stent placement x2 (BMS). Initially he had increased R and L sided pressures, w/ extremely elevated PCWP of 65; this improved after diuresis and placement of IABP. He was started on CVVH for volume removal. Initail echo showed EF 25%, but repeat TEE showed improvemed EF of 35-40%, with evidence of ant/lat wall hypokinesis, and MR. His IABP and pressers were weaned slowly and the patient extubated. He was continued on statin, Aspirin, and Plavix. His blood pressure remained stable and he was started on low dose b-blocker and ACEi. He was transfered to the floor and monitored. He will be discharged to rehab and scheduled for follow up with his cardiologist at , Dr. , in 1 month. . # Ischemia - The patient had a documented NSTEMI and severe 3VD by c.cath, but was not a surgical candidate due to his poor overall functioning. He underwent repeat cardiac cath for high risk intervention, and had rotational atherectomy and placement of 2 bare metal stents, to the LAD and diagonal branch. He was continued on aspirin, plavix, and statin. B-blocker and ACEi were begun once the patient was stabilized. He will f/u with Dr. , his cardiologist at . . # Rhythm - The patient had bigeminy initially causing technical difficulty with balloon pump. He was then in sinus rhythm for the remainder of his hospitalization. . # Respiratory failure - The patient was intubated on arrival at for increasing shortness of breath and dropping O2 sats. This was likely due to acute cardiogenic pulmonary edema in setting of impaired cardiac function/shock. He developed ventilator-associated pneumonia, initially with enterobacter in the sputum, then with MSSA. He received > two weeks of IV antibiotics (cefepime/cipro, then switched to vancomycin, then to nafcillin). . # Hyperbilirubinemia: The patient was noted to have elevated bilirubin, (direct primarily) along with mild elevation in LFTs. His exam was benign and RUQ was negative. DIC labs were checked and were normal. . # Thrmobocytopenia: Platelets dropped significantly during the hospitalization. HIT and DIC labs were negative. The likely etiology was acute inflammation. The patient's platelets normalized and remained stable. . # Renal failure - The patient had a baseline Cr 3.0- 4.0, but had not yet started Dialysis. He was placed on CVVH for volume removal, and followed by the Renal Service. After extubation, a tunnelled catheter (R IJ) was placed and he began hemodialysis M,W,F, which will be continued after discharge. His Hepatitis B serologies are as follows: Surface antigen negative, Surface antibody positive, Core antibody negative. . # Anemia - Normocytic, likely anemia related to chronic kidney disease. Iron studies revealed mixed AOCD with iron deficiency (iron 32, TIBC 191, ferritin 215, transferrin 147). Folate was >20, and vitamin B12 was 795. He had no obvious source of blood loss. Epogen was started three times a week with hemodialysis. . # HTN - He was initially on pressers and had a balloon pump. After these were weaned, low dose b-blocker (metoprolol 12.5 ) and ace-inhibitor (captopril 6.25 tid) were begun. . # DM - His Diabetes is longstanding with nephropathy and blindness. HgA1C was 6.4 upon admission. He was on NPH and regular insulin at home; while on CVVH and TPH, he was given an insulin drip. This was changed to a sliding scale. NPH was not re-started during the hospitalization as pt's intake was moderate and sugars were controlled with the sliding scale. . # Hyperlipidemia - The patient was continued on lipitor. . # FEN - He was placed on TPN while intubated, but restarted on a renal/cardiac diet after extubation. He tolerated his diet w/o difficulty. . # Prophylaxis - The patient was on a heparin drip while on the IABP. After removal of the balloon pump, he was placed on SC heparin. He was kept on a PPI. . FULL CODE | COMPARISON: Supine portable chest x-ray dated . Bibasilar atelectasis is noted with interval slight worsening, and there remains elevation of the right hemidiaphragm. Internal jugular vascular catheter is unchanged in position but a left subclavian catheter has been slightly withdrawn with tip now terminating in the left brachiocephalic vein proximal to the confluence with the superior vena cava. COMPARISON: AP supine portable chest x-ray dated . The radiopaque marker is stable overlying the descending aorta at a site approximately 2.9 cm from the inferior edge of the aortic knob. IMPRESSION: Patent bilateral cephalic and basilic veins with diameters as noted above. Endotracheal tube is in standard position with tip terminating 4.5 cm above the carina, and nasogastric tube remains in standard position. Again seen is mild biapical pleural thickening. FINDINGS: Duplex evaluation was performed of bilateral upper extremity veins. Simple atheroma in ascendingaorta. IMPRESSION: Subclavian line with tip at the junction of the brachiocephalic vessels, slightly withdrawn compared to prior study. There is a trivial/physiologic pericardial effusion. Bibasilar atelectasis and right pleural effusion, unchanged. Mild to moderate (+)MR.TRICUSPID VALVE: Mild [1+] TR.GENERAL COMMENTS: A TEE was performed in the location listed above. Moderately depressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- akinetic; mid anterior - akinetic; mid inferolateral - hypo; basalanterolateral - hypo; mid anterolateral - hypo; anterior apex - akinetic;lateral apex - hypo; apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: No atheroma in aortic arch.AORTIC VALVE: Normal aortic valve leaflets (3). Left subclavian vein catheter tip is in the mid SVC, unchanged. Second catheter is seen overlying the mediastinum which is unchanged in position. FINDINGS: Single frontal radiograph of the chest labeled semi-upright again demonstrates an endotracheal tube with distal tip at the level of the clavicles, unchanged in position. Slow atrial flutter with 2:1 A-V block. He was restarted on argatroban at lower dose of .1mic/kilo with first PTT 6 hrs later 66.9. HX OF GERD IDDM, HTN AND ^CHOLES. IABP 1:1 W/ GOOD AUGMENTATION. Non-specific T wave inversions in leads I, II, aVL, V5-V6.Compared to the previous tracing of ventricular bigeminy is no longerpresent. Sinus rhythm with borderlineP-R interval prolongation. Since the previous tracingof the rhythm is clearly atrial flutter. Compared to the previous tracing of ventricularbigeminy has appeared. There are non-diagnsotic Q waves in leads I, aVL and V6.TRACING #1 Compared to the previous tracing of multipleabnormalities are as previously reported with ventricular premature beats notseen. BS VERY HYPOACTIVE. Lateral ST-T waveabnormalities persist. SUCT FOR THICK YEL MOD AMT.ID:AFEBRILE W/ NL WBCS, ON CIPRO AND CEFAPINE FOR 4+GNR IN SPUTUMENDO REMAINS ON INS GTT W/ CONKTROLED GLUC.GI:TF SHUT OFF D/T RESIDUALS >100 X3. cv=hemody stable on iabp 1:1. levo weaned & dced. Albuterol/Atrovent MDI's given Q4hr. maint adeq sedation. tolerating fio2 wean w gd abg/sats. Weaned fio2 and peep based abgs. ?add tf w gradual dc tpn. ci 2.65-3.27. access-iabp l fem (central lumen clotted-capped off-team aware), paline lsc, & aline r radial. pulm=intubated/vented. K and Ca gtts titrated per sliding scale.id: afebrile. r/l fem sites-old ooze--presently c&d. id=hypotermic-bair hugger added. ccu nsg progressn ote. ccu nsg progress note.o:neuro=lightly sedated w propofol gtt. contin freq (q1hr) bs. following ica & k q6hrs-rxing w contin calcium & k gtts. contin ooze from r fem site. VAP bundle follow within limits of pt tolerance.RENAL: Pt conts on CVVUF. Sedated w/ fentanyl/versed. care note - Pt. care note - Pt. resp CarePt returned from or. iabp 1:1 chged to 1:2 x4hrs w stable maps/pad/co-ci/svr--placed back on 1:1 to rest. cv=continues on iabp 1:1 w maps 60-70 & pads 16-19. contin on dopa gtt-weaned from 10-6mcg & levophed gtt @ 0.032mcg. "O- see flowsheet for all objective data.cv- Tele: SR-ST with rare PVC noted- HR 91-105- ABP 95-127/47-58 MAPs 58-76 on dopamine gtt- weaned down to 4mcq/kg/min- PAS 31-36 PAD 15-18CVP 6-8- last CO 5.5 CI 2.35 SVR 945- Hct trending down- last 26.3- T&C sent- transfuse 1u PRBC's when available- PTT 50.5- heparin 300u/hr infusing via CVVHD- K 4.4 KCL gtt @ 20cc/hr- ionized Ca 1.21 Ca gtt @ 25cc/hr.resp- In O2 4L via NC- last ABG 7.43-36-%-lung sounds coarse, diminished @ bases- SpO2 98-100%- last mixed venous 57%.neuro- feeling a better today & verbalizing wish to go home- A&O X2- moving all extremities- pleasant & cooperative- follows command.gi- abd soft (+) bowel sounds- taking small amts Po without incident-1 mod loose grn/brn colored stool- quiac (+)- con't on insulin gtt @ 1u/hr- glucose range 108-121.gu- foley draining scant amt conc amber brown colored urine- con't on CVVHD- CCU team in this am & decision made to wean Pt off dopamine gtt rather than take off 50cc/hr- running Pt even- able to wean Pt to 4mcq/kg/min- If Pt able to be off pressors, CVVHD will be D/ Pt will go to IR for tunneled line placement for dialysis access.Id- T Max 98.2 Core- WBC 12.9- nafacillin D/C'd.skin- duoderm on coccyx intact- skin care given PRN- on air mattress.A- tolerating weaning pressor.P- transfuse 1u PRBC's tonight- wean off dopamine gtt if able- ? He conts on nafcillin QID.CV: Pt remains dopa dependent. maintained on 20mcq dopa and 0 PFR until ~ 0200 when tolerated slow wean of dopa.currently at 16mcq/k/min with MAP 65-70. good augmentation and syst/diast. still with episodes of hypotension - contin. starting to get neg fl balance.p:contin present managment. required echmo post cath and returned to CCU post cath on dopa/IABP. vanco level-7.3---recieved dose 0200. contin on ceftriaxone. sputum with MSSA(+). HR- 80-90 ST, REMAINS WITH FREQ PVC/BIGEMINY IN SPITE OF NML ELECTROLYTES- K- 4.1, CA- 1.20, MG- 2.0. on reglan and colace.neuro: fent. pulses doppler DP/absent PT. PT WAS RESTARTED ON REGLAN. CCU NSG NOTE: ALT IN CV/RESP/RENAL(Continued)th ultrafiltration. BS are decreased with some course sound heard in middle lobes.RENAL: Pt conts on CVVH. hypoactive BS. started on epogen per renal recs.A/: tolerating very slow dopa wean. ccu nsg progressn ote.o:neuro=sedated w fent/versed gtts w effect. left SC CL placed in EW at OSH- and other lines- given dose vanco and started on ceftriax q24hr.CV: IABP 1:1. abg: 7.30/38/89/19/-6sxn'd for thin bldy secretions.gi: npo. Respiratory therapy Pt presents on n/c in NAD, BS clear bilaterally W diminished bases. AM EKG/CXR. pulm=remains intubated/vented w unchg vent settings. labs=am sent.a:tolerating hd. dopa/neo for hypotension. HCT 28.5, recieving HD tx w/ goal fluid removal only -1L. pressors weaned off, trans on nipride and ntg, then dopa req to be resumed. electively intubated in OSH, on pressors, transferred to for cath.cath showing severe 3VD, mild AI, mod MR. 60- down to 30 after IABP placed. titrate fent/versed for comfort.renal following for recs. MAINTAINING BP- 104/44- 123/49 VIA RT RADIAL ALINE. fem sites-c&d. held x1 hr and decreased per protocol at 0530CPK 911-884.K+ 5.6. ionized Ca 1.06 on Cagluonate gtt per CRRT protocol.Resp: AC 550x24/10peep/100%. | 139 | [
{
"category": "Radiology",
"chartdate": "2124-03-16 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 951904,
"text": " 9:44 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: VEIN MAPPING FOR AVF\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: BILATERAL UPPER EXTREMITY VENOUS DUPLEX.\n\n REASON: Preop for arteriovenous fistula.\n\n FINDINGS: Duplex evaluation was performed of bilateral upper extremity veins.\n The subclavian veins are patent with phasic flow bilaterally. The brachial\n arteries are patent with triphasic Doppler waveforms bilaterally.\n\n The cephalic and basilic veins are patent bilaterally. In the right upper\n extremity cephalic vein diameters range from 0.19-0.23 cm. The right basilic\n vein diameters range from 0.30-0.34 cm. In the left upper extremity cephalic\n vein diameters range from 0.14-0.36 cm. The left basilic diameters range from\n 0.20-0.38 cm.\n\n IMPRESSION: Patent bilateral cephalic and basilic veins with diameters as\n noted above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 948941,
"text": " 7:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess tube postition\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n please assess tube postition\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Assess different lines position. Patient with CAD, IABP.\n\n Comparison is made with prior study performed the day before.\n\n FINDINGS: The tip of the intra-aortic balloon pump is located 4.7 cm above\n the superior edge of the left main bronchus. ET tube is in standard position.\n NG tube tip is out of view below the diaphragm. Small right pleural effusion\n increased in size. Increased right lower opacity is consistent with increased\n atelectasis. Left lower lobe atelectasis is increasing.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 950285,
"text": " 10:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CAD, IABP, ET tube, question interval change.\n\n CHEST, SINGLE AP SUPINE VIEW.\n\n There are low inspiratory volumes. An ET tube is present, tip approximately\n 3.9 cm above the carina. A left subclavian Swan-Ganz catheter is present, tip\n overlying pulmonary outflow tract. An intra-aortic balloon pump is present.\n The radiopaque marker is stable overlying the descending aorta at a site\n approximately 2.9 cm from the inferior edge of the aortic knob. Again seen is\n mild biapical pleural thickening. There is bibasilar atelectasis. Compared\n with , I doubt significant interval change in the parenchymal findings.\n No gross CHF or effusion.\n\n IMPRESSION:\n 1. Low inspiratory volumes with bibasilar atelectasis.\n 2. IABP overlying the descending aorta, at a level approximately 2.9 cm below\n the inferior margin of the aortic knob. Clinical correlation is requested as\n this lies somewhat low.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-27 00:00:00.000",
"description": "P US ABD LIMIT, SINGLE ORGAN PORT",
"row_id": 949244,
"text": " 3:17 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: ? acalculus cholecystitis\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with rising direct bilirubinemia, sedated and intubated\n REASON FOR THIS EXAMINATION:\n ? acalculus cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male with rising direct bilirubinemia. Assess for\n acalculous cholecystitis.\n\n Comparison is made to prior ultrasound dated .\n\n LIMITED RIGHT UPPER QUADRANT ABDOMINAL ULTRASOUND\n\n Please note overall examination is limited due to patient immobility and\n intubated status. No focal liver masses are identified, and the liver\n parenchyma appears to be of normal echotexture. No intrahepatic biliary\n dilatation is noted and the common bile duct measures approximately 3 mm. The\n portal vein is patent with normal hepatopedal flow. The gallbladder is\n slightly distended but without evidence of wall edema or cholelithiasis. There\n is perhaps a mild amount of dependent sludge identified within the lumen. The\n right kidney measures approximately 11.3 cm and does not display any evidence\n of renal calculi or hydronephrosis. Pancreas was unable to be fully evaluated\n due to a large amount of intra-abdominal air.\n\n IMPRESSION:\n\n 1. Limited study due to patient immobility and intubated status. However, no\n son evidence of cholecystitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949414,
"text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tubes/lines\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n tubes/lines\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:09 A.M. \n\n HISTORY: IABP. ET tube. Coronary artery disease.\n\n IMPRESSION: AP chest compared to through 19:\n\n Tip of the intra-aortic balloon pump is at the apex of the aortic knob at\n least 5 cm above the upper margin of the left main bronchus, the standard\n position for these pumps. Tip of the ascending Swan-Ganz catheter projects\n over the pulmonary outflow tract. ET tube is in standard placement.\n Nasogastric tube passes beyond the mid stomach and out of view. Mild\n bibasilar atelectasis and small left pleural effusion unchanged. Heart size\n normal. ET tube and left subclavian lines in standard placements\n respectively.\n\n Dr. and I discussed these findings by telephone at the time of\n dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-10 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 951183,
"text": " 3:46 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: tunnelled cath placement for HD\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with ESRD.\n REASON FOR THIS EXAMINATION:\n tunnelled cath placement for HD\n ______________________________________________________________________________\n FINAL REPORT\n THIS IS TUNNELED DIALYSIS CATHETER\n\n INDICATION: End-stage renal disease, needs catheter for hemodialysis.\n\n Details of the procedure and possible complications were explained to the\n patient and his family and informed consent was obtained.\n\n RADIOLOGIST: Dr. was performing the procedure.\n\n TECHNIQUE: Using sterile technique, local anesthesia and conscious sedation,\n the right internal jugular vein was localized with ultrasound and punctured\n under direct ultrasound guidance. A micropuncture set was used to gain an\n access. Hard copies of ultrasound images were obtained before and immediately\n after obtaining intravenous access. A subcutaneous tunnel was created in the\n right anterior chest wall. The catheter was introduced through the tunnel.\n The tract into the vein was dilated with serial dilators and a peel-away\n sheath was then placed over the wire. The catheter was then advanced through\n the peel-away sheath and its tip positioned in the right atrium under\n fluoroscopic guidance. The peel-away sheath was removed. Position of the\n catheter was confirmed by chest x-ray in one view. Incision on the neck was\n closed with Dermabond. The catheter was secured to the skin and a sterile\n dressing was applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided tunneled\n hemodialysis catheter placement via the right internal jugular venous approach\n with the tip positioned in the right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949624,
"text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls assess for interval change in pulmonary edema\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n REASON FOR THIS EXAMINATION:\n Pls assess for interval change in pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with coronary artery disease. Evaluate for\n change in pulmonary edema.\n\n COMPARISON: AP supine portable chest x-ray dated .\n\n AP SUPINE PORTABLE CHEST X-RAY: An endotracheal tube terminates 4.8 cm above\n the carina. A femoral Swan-Ganz catheter terminates in the pulmonary artery\n outflow tract. A femoral intra-aortic balloon pump abuts the aortic arch. A\n nasogastric tube descends below the diaphragm with the tip not visualized.\n\n The appearance of the chest is not significantly changed since prior exam. The\n pulmonary vasculature is not significantly engorged, and bilateral small\n pleural effusions, left greater than right are stable in size. Bibasilar\n patchy atelectasis, more prominent in the retrocardiac space is also stable.\n\n IMPRESSION: IABP abutting the right aortic arch. Otherwise, no change.\n\n Called ot Dr. at 10am on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 950553,
"text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett, volume\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD, cardiogenic shock, intubated\n\n REASON FOR THIS EXAMINATION:\n ett, volume\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest 7:55 A.M .\n\n HISTORY: Coronary artery disease, cardiogenic shock.\n\n IMPRESSION: AP chest compared to through 27:\n\n Upper mediastinal widening is probably due to vascular engorgement,\n exaggerated by supine positioning. Right hemidiaphragm is elevated, as\n before. No pleural effusion or pneumothorax. Lungs clear. Overall heart\n size is normal. ET tube in standard placement and nasogastric tube passes\n below the diaphragm and out of view. Tip of the Swan-Ganz catheter projects\n over the main pulmonary artery. The tip of the intra-aortic balloon pump is\n partially obscured by the overlying Swan-Ganz line, but may have migrated\n distally at the level of the eighth posterior interspace, previously at the\n seventh.\n\n Findings were discussed by telephone with Dr. at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949948,
"text": " 4:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess tube positions\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n please assess tube positions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:23 A.M. \n\n HISTORY: Intraaortic balloon pump. ET tube. CHF.\n\n IMPRESSION: AP chest compared to through 22:\n\n As before, the tip of the intraaortic balloon pump is at the apex of the\n aortic knob. Clinical service has been notified several times of\n displacement. ET tube, left subclavian line, and nasogastric tube are in\n standard placements. An ascending Swan-Ganz catheter tip projects over the\n pulmonary outflow tract. Atelectasis persists at the right lung base. Lungs\n otherwise clear. Heart size is normal. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949802,
"text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tubes/lines\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n tubes/lines\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with coronary artery disease and intraaortic\n balloon pump in place. Evaluate positioning.\n\n COMPARISON: Supine portable chest x-ray dated .\n\n AP SUPINE PORTABLE CHEST X-RAY: A femoral intraaortic balloon pump remains\n positioned with the tip abutting the aortic arch. A femoral Swan-Ganz\n catheter is in unchanged position in the pulmonary artery outflow tract.\n Endotracheal tube 5.4 cm above the carina. Nasogastric tube below the\n diaphragms. A left subclavian central venous catheter terminates in the\n distal left brachiocephalic vein. Bibasilar consolidations appears slightly\n worse than one day earlier, and pneumonia is not excluded. A small left\n pleural effusion is unchanged.\n\n IMPRESSION:\n 1. Intraaortic balloon pump tip is at level of aortic arch and could be\n withdrawn approximately 2.5 cm for standard positioning.\n 2. Increased bibasilar opacities, which may be due to atelectasis and/or\n pneumonia.\n Findings discussed with Dr. at 1:40 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949293,
"text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lines, tubes, ASD\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n assess lines, tubes, ASD\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess lines and tubes, ASD.\n\n chest, 1 vw\n\n An ET tube is present, in satisfactory position, 6.3 cm above the carina. An\n NG tube is present, tip beneath diaphragm off film. A left subclavian central\n line is present, tip over proximal SVC. An additional catheter is present\n from a right inferior approach and overlies the main pulmonary artery. Its\n exact position is not well delineated by these views. The patient's aortic\n balloon pump is visualized, but obscured by an overlying EKG clip. It\n overlies the aortic knob.\n\n There are low inspiratory volumes on this supine film. Again seen is patchy\n opacity in the left infrahilar region and increased retrocardiac density,\n essentially unchanged compared with one day earlier. No CHF or gross effusion\n is identified.\n\n IMPRESSION:\n\n 1. Lines and tubes as described. The balloon pump overlies the aortic knob\n and clinical correlation regarding positioning is requested as this may be\n slightly high. Clinical correlation is also requested regarding the inferior\n approach line, which is grossly stable in position.\n\n 2. Left lower lobe collapse and/or consolidation and perihilar atelectasis.\n In the appropriate clinical setting, a pneumonic infiltrate would be difficult\n to exclude. No change compared with one day earlier.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 951089,
"text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett, volume\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year-old man with CAD, cardiogenic shock, intubated.\n\n REASON FOR THIS EXAMINATION:\n ett, volume\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:46 A.M., \n\n HISTORY: Coronary artery disease and cardiogenic shock.\n\n IMPRESSION: AP chest compared to through at 6:47 a.m.:\n\n Right hemidiaphragm is chronically elevated. Lungs are clear aside from mild\n right perihilar atelectasis. Tip of the central venous line through the left\n subclavian introducer is obscured by cardiac motion. Left lung is clear. No\n pneumothorax or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949209,
"text": " 8:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess tubes/pump/lines, enterobacter pna\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n assess tubes/pump/lines, enterobacter pna\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 68-year-old man with coronary artery disease status post thoracic\n surgery and placement of intraaortic balloon pump.\n\n FINDINGS: Comparison is made to previous study from .\n\n The tip of the endotracheal tube is 5.8 cm above the carina. The nasogastric\n tube, intraaortic balloon pump, left sided central venous catheter, and\n multiple drains are unchanged in position. A cardiac silhouette is within\n normal limits. There is a persistent left retrocardiac opacity, which is\n unchanged. There is elevation of the right hemidiaphragm.\n\n IMPRESSION:\n\n No interval change since the previous study. Persistent left retrocardiac\n opacity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949542,
"text": " 4:42 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Pls assess new position of IABP\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT; s/p adjustment of IABP\n position\n REASON FOR THIS EXAMINATION:\n Pls assess new position of IABP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with CAD/three-vessel disease, intraaortic\n balloon pump, ETT. Assess adjustment of IABP.\n\n AP CHEST: Comparison is made to 8:09 a.m. today. The tip of the intraaortic\n balloon pump appears to have been retracted minimally. The tip still projects\n over the left posterior 5th rib. Endotracheal tube terminates 4.5 cm above the\n carina. The Swan-Ganz catheter via inferior axis again projects over the\n pulmonary outflow tract. Left subclavian line is unchamged. The NG tube\n courses across the stomach and out of view. Bilateral basilar atelectasis is\n again noted. The left lateral chest is not included in the study. No right-\n sided pleural effusion is seen.\n\n IMPRESSION: Minimal interval retraction of the IABP. Further retraction of \n cm may be considered for optimal placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 950156,
"text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls assess pulmonary edema\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n Pls assess pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Coronary artery disease. Assess pulmonary edema.\n\n Single portable radiograph of the chest demonstrates no change in the\n cardiomediastinal contour when compared with . Lung volumes are low,\n but the lungs are clear. Support lines are unchanged. There is persistent\n left-sided effusion. No pneumothorax.\n\n IMPRESSION:\n\n Small left-sided pleural effusion. Support lines in place. No pulmonary\n edema detected.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 950734,
"text": " 7:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess fluid status, lines, infection.\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year-old man with CAD, cardiogenic shock, intubated.\n\n REASON FOR THIS EXAMINATION:\n Assess fluid status, lines, infection.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:19 A.M., .\n\n HISTORY: Coronary artery disease and cardiogenic shock. Assess fluid status.\n\n IMPRESSION: AP chest compared to through 27:\n\n Elevation of the right hemidiaphragm is longstanding. Lungs are grossly\n clear. Cardiomediastinal silhouette is stable and unremarkable. ET tube is\n in standard placement, nasogastric tube passes below the diaphragm and out of\n view, tip of the Swan-Ganz catheter projects over the main pulmonary artery,\n and I no longer see an intraaortic balloon pump. There is no pleural effusion\n or pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 951480,
"text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year-old man with CAD, cardiogenic shock.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Cardiogenic shock.\n\n Internal jugular vascular catheter is unchanged in position but a left\n subclavian catheter has been slightly withdrawn with tip now terminating in\n the left brachiocephalic vein proximal to the confluence with the superior\n vena cava. Cardiac and mediastinal contours are stable. Minor atelectatic\n changes are again demonstrated in the right perihilar and left basilar\n regions. There is no evidence of pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 950398,
"text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for acute process, ETT placement\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD, cardiogenic shock, intubated\n REASON FOR THIS EXAMINATION:\n assess for acute process, ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY: \n\n COMPARISON: .\n\n INDICATION: Endotracheal tube assessment.\n\n Intraaortic balloon pump is again identified with radiodense tip in a\n relatively low position now about 9 cm below the superior aspect of the aortic\n arch. Endotracheal tube is in standard position with tip terminating 4.5 cm\n above the carina, and nasogastric tube remains in standard position. Cardiac\n and mediastinal contours are stable. Bibasilar atelectasis is noted with\n interval slight worsening, and there remains elevation of the right\n hemidiaphragm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 951256,
"text": " 6:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cardiopulmonary or line-related causes of chest pain.\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year-old man with CAD, cardiogenic shock now with chest pain. \n \n REASON FOR THIS EXAMINATION:\n cardiopulmonary or line-related causes of chest pain.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Coronary artery disease, cardiogenic shock, now with chest\n pain.\n\n The position of the tubes and lines is unchanged, and both appear to be in\n satisfactory position. There is poor lung expansion, but no evidence of\n failure or infiltrate is seen.\n\n IMPRESSION: No change since prior chest. Position of lines remain\n satisfactory.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 951084,
"text": " 6:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year-old man with CAD, cardiogenic shock s/p NGT.\n\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:47 A.M., \n\n HISTORY: Coronary artery disease and cardiogenic shock. Check NG tube.\n\n IMPRESSION: AP chest compared to through :\n\n Moderate degree of right perihilar atelectasis, continues to improve. Heart\n size is normal. Right hemidiaphragm is chronically elevated. Left lung is\n clear. No pneumothorax or pleural effusion. Tip of the Swan-Ganz catheter\n passes at least as far as the main pulmonary artery, but the tip is obscured\n by cardiac motion. No pneumothorax or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 950119,
"text": " 11:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Pls assess position of new IABP\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT, s/p IABP removal and re-placement\n\n REASON FOR THIS EXAMINATION:\n Pls assess position of new IABP\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST.\n\n DATE: .\n\n HISTORY: Replacement of the intraaortic balloon pump.\n\n FINDINGS: Comparison is made with the prior examination performed earlier the\n same day. There has been interval slight retraction of the intraaortic\n balloon pump, which now resides in the mid descending thoracic aorta.\n Replacement of the Swan-Ganz catheter has also been performed via the left\n subclavian vein. Endotracheal tube and NG tube appear in proper position.\n There has been no interval change in the appearance of the lungs.\n\n IMPRESSION: Interval retraction of the intraaortic balloon pump, tip of which\n now resides in the mid descending thoracic aorta.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 951230,
"text": " 11:03 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement, bleeding\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year-old man with CAD, cardiogenic shock s/p left subclavian line change.\n \n REASON FOR THIS EXAMINATION:\n line placement, bleeding\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cardiogenic shock, left subclavian line placed, check\n position.\n\n The tip of the left subclavian line lies at the junction of the left\n innominate and SVC. No pneumothorax is present. Elevation of the right\n hemidiaphragm and some atelectasis is again noted in the right side.\n\n IMPRESSION: No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949067,
"text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluated for acute process\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place, ETT\n\n REASON FOR THIS EXAMINATION:\n evaluated for acute process\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: One-view chest .\n\n COMPARISON: One-view chest dated .\n\n INDICATION: 68-year-old male with CAD/three VD, IABP in place, ET tube,\n evaluate for acute process.\n\n FINDINGS: Single frontal radiograph of the chest labeled semi-upright again\n demonstrates an endotracheal tube with distal tip at the level of the\n clavicles, unchanged in position. A nasogastric tube is seen. Distal tip\n excluded by collimation; however, the side port is visualized overlying the\n body of the stomach. There is a left subclavian central line in place,\n unchanged. There is an intra-aortic balloon pump seen overlying the aorta\n with distal metallic tip approximately 1.5 cm from the aortic arch and 4.5 cm\n above the left mainstem bronchus. Second catheter is seen overlying the\n mediastinum which is unchanged in position. Again seen is opacity at both\n lung bases, not significantly changed, the findings most likely reflect right\n pleural effusion which is stable as well as right lower lobe atelectasis.\n There is retrocardiac airspace disease, likely atelectasis. There is no\n evidence of pneumothorax.\n\n IMPRESSION:\n 1. Bibasilar atelectasis and right pleural effusion, unchanged. Stable left\n lower lobe atelectasis.\n 2. Mild chf.\n 3. Radio-opaque tip of balloon pump overlies the aortic knob -- clinical\n correlation regarding positioning is requested.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 950890,
"text": " 7:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year-old man with CAD, cardiogenic shock, intubated.\n\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE SINGLE VIEW\n\n INDICATION: Coronary artery disease, cardiogenic shock, and intubated.\n Evaluate for interval change.\n\n FINDINGS: AP single view of the chest obtained with patient in supine\n position is analyzed in direct comparison with a similar preceding study of\n . During the interval, the patient has been extubated, and\n the NG tube has been removed. The left subclavian approach Swan-Ganz catheter\n remains and still terminates in the proximal portion of the main pulmonary\n artery. There is no evidence of significant pulmonary vascular congestion,\n and no acute parenchymal infiltrates are identified. No pneumothorax is seen.\n\n Review of multiple previous chest examinations indicate that there was no\n conclusive evidence for pulmonary edema persisting after the initial episode\n on .\n\n IMPRESSION: Stable followup examination. No evidence of acute infiltrates or\n significant CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-23 00:00:00.000",
"description": "P CAROTID SERIES COMPLETE PORT",
"row_id": 948671,
"text": " 2:01 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: assess for carotid artery stenosis\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CAD/3VD, intubated\n REASON FOR THIS EXAMINATION:\n assess for carotid artery stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY\n\n HISTORY: Coronary artery disease and three-vessel disease.\n\n FINDINGS: Mild calcific plaque involving the origin of both internal carotid\n arteries. However, the peak systolic velocities bilaterally are normal as are\n the ICA/CCA ratios. There is also normal antegrade flow involving both\n vertebral arteries.\n\n IMPRESSION: Minimal bilateral ICA calcific plaque, no appreciable associated\n stenosis, however (graded as less than 40% bilaterally).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-24 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 948874,
"text": " 4:16 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: please assess for sbo, ileus\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with acute MI, intubated on paralytics, no bowel sounds but\n soft abdomen\n REASON FOR THIS EXAMINATION:\n please assess for sbo, ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with acute MI, intubated on paralytics, no\n gallstones but soft abdomen.\n\n COMPARISONS: None.\n\n FINDINGS: Two frontal views of the abdomen demonstrate a nasogastric tube\n with its tip in the body of the stomach. A right femoral Swan-Ganz catheter\n and intra-aortic balloon pump project over the mid abdomen above the level of\n the diaphragm and out of view. A central venous catheter projects over the\n left groin. There is a relative paucity of bowel gas within the abdomen. A\n small amount of air is seen within the ascending and descending colon. No\n definite free intraperitoneal air is present. Calcifications are present\n within the vas deferens. Visualized osseous structures are unremarkable.\n\n IMPRESSION:\n 1. Nonspecific bowel gas pattern with paucity of air within the small bowel.\n Findings may represent fluid-filled loops of bowel. Correlate clinically and\n with followup radiographs at an appropriate clinical interval.\n 2. Vas deferens calcifications consistent with underlying diabetes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 948607,
"text": " 7:50 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for worsening edema\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, intubated, increasingly hypoxic\n REASON FOR THIS EXAMINATION:\n please eval for worsening edema\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OFHTE CHEST:\n\n REASON FOR EXAM: Evaluate for interval changes. Patient with three vessel\n disease CAD.\n\n Comparison is made with prior study performed five hours before.\n\n Compared to prior study, there has been mild improvement in mild pulmonary\n edema. Improved left lower lobe atelectasis. Right mid-lung atelectasis is\n almost resolved. Small right pleural effusion is unchanged. Otherwise the\n support devices are in unchanged position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-23 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 948622,
"text": " 9:33 AM\n RENAL U.S. PORT Clip # \n Reason: please eval for for evidence of obstruction\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with hx of DM, HTN, hx of chronic renal insufficiency, now w/\n MI and cardiogenic shock, acute oliguric renal failure\n REASON FOR THIS EXAMINATION:\n please eval for for evidence of obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with past medical history of diabetes,\n hypertension, chronic renal failure, presenting with myocardial infarction,\n cardiogenic shock, acute oliguric renal failure. Rule out obstruction.\n\n COMPARISON: Not available.\n\n FINDINGS: Bedside study, markedly limited by patient's body habitus and\n inability to cooperate. Kidneys are relatively small in size, right measuring\n 9 cm and the left measuring 9.1 cm. There is no gross hydronephrosis. Cannot\n assess parenchymal details on this limited study.\n\n IMPRESSION: No evidence of obstruction on this limited portable study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 948776,
"text": " 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please check position of IABP, also please assess air space\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, IABP in place\n REASON FOR THIS EXAMINATION:\n please check position of IABP, also please assess air space\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please check position of IABP. Assess airspace.\n\n COMPARISON: .\n\n PORTABLE CHEST:\n\n Intraaortic balloon pump seen with tip approximately 3 cm below the aortic\n arch. Swan-Ganz catheter seen, left-sided subclavian line, NG tube, and\n endotracheal tube. Relatively stable position. Cardiac and mediastinal\n contours appear stable. No new focal consolidations are seen within the\n lungs. Again noted is relative elevation of the right hemidiaphragm. No\n significant change from prior studies.\n\n IMPRESSION: Intraaortic balloon pump with tip approximately 3 cm below the\n aortic arch. Otherwise, little change from prior.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 948702,
"text": " 4:10 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pls assess central line position\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, s/p L subclavian line replacement\n REASON FOR THIS EXAMINATION:\n Pls assess central line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left subclavian line placement.\n\n COMPARISON: Comparison is made to study performed eight hours earlier.\n\n PORTABLE CHEST:\n\n Left-sided subclavian line seen with tip at the junction of the\n brachiocephalic vessels. This appears slightly withdrawn compared to prior\n study. Nasogastric tube, endotracheal tube, Swan-Ganz catheter, and intra-\n aortic balloon pump appear in relatively stable position. Cardiac and\n mediastinal contours appear stable. No new focal consolidations seen within\n the lungs. No definite evidence of pneumothorax identified.\n\n IMPRESSION: Subclavian line with tip at the junction of the brachiocephalic\n vessels, slightly withdrawn compared to prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 948588,
"text": " 3:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for acute cardiopulmonary process\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, intubated, respiratory stataus acutely worse with drop\n in SBP to 70s\n REASON FOR THIS EXAMINATION:\n please eval for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Assess for interval changes. Patient with CAD, three-vessel\n disease with drop in SBP.\n\n Comparison is made with prior study performed 9 hours before.\n\n FINDINGS\n ET tube tip is in standard position. Left subclavian vein catheter tip is in\n the mid SVC, unchanged. Cardiac size is top normal. Intraaortic balloon pump\n is in unchanged position. Swan-Ganz catheter tip is in the main pulmonary\n artery trunk. NG tube tip is out view below the diaphragm. There is no\n pneumothorax or pleural effusion. Persistent left lower lobe atelectasis,\n unchanged mid-right discoid atelectasis. Lower lung volumes. Unchanged\n moderate pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-02-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 948540,
"text": " 5:41 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm placement of L subclavian, Swann, balloon pump\n Admitting Diagnosis: CARDIOGENIC SHOCK\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 YO man with CAD/3VD, intubated with new line placements\n REASON FOR THIS EXAMINATION:\n confirm placement of L subclavian, Swann, balloon pump\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male with coronary disease. Referred for assessment of\n position of various tubes and lines.\n\n COMPARISON: No prior study available.\n\n FINDINGS: Single supine AP portable chest radiograph demonstrates top normal\n heart size. The mediastinal contours are within normal limits. The patient\n is intubated with tip of the ET tube in appropriate position 4.5 cm above the\n carina. Left subclavian central catheter tip is in the SVC. Intraaortic\n balloon pump is in appropriate position with termination in the descending\n aorta below the level of the left subclavian artery. Inferior approach Swan-\n Ganz catheter tip is in the main pulmonary artery trunk. Nasogastric tube tip\n is in the stomach, but the side hole is above the GE junction. There is plate-\n like atelectasis of the right middle lung zone. The pulmonary vasculature is\n engorged and there is bilateral perihilar haziness consistent with pulmonary\n edema. Focal left retrocardiac opacity is noted and may represent pneumonia\n or aspiration. There is no pneumothorax or pleural effusion.\n\n IMPRESSION:\n 1. Support devices as described. Sidehole of nasogastric tube above the GE\n junction and advancement suggested.\n 2. Pulmonary edema.\n 3. Discoid atelectasis of the right mid lung.\n 4. Retrocardiac opacity could represent pneumonia or aspiration and clinical\n correlation is suggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2124-02-22 00:00:00.000",
"description": "Report",
"row_id": 84028,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Patient on IABP\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 106/81\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Severe regional LV systolic dysfunction. Severely depressed\nLVEF.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild thickening\nof mitral valve chordae. Moderate to severe (3+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThere is severe regional left ventricular systolic dysfunction with severe\nhypokinesis of the anterior wall, apex, lateral wall and basal to mid inferior\nwalls. The distal inferior and basal anteroseptal walls contract best. Overall\nleft ventricular systolic function is severely depressed (EF 20-25%) The\naortic valve leaflets are mildly thickened. Trace aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. An eccentric jet of moderate to severe (3+) mitral regurgitation is\nseen. There is a trivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2124-03-03 00:00:00.000",
"description": "Report",
"row_id": 84666,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for ECMO cannula placement and PCI\nHeight: (in) 71\nWeight (lb): 224\nBSA (m2): 2.22 m2\nBP (mm Hg): 104/49\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 16:42\nTest: TEE (Complete)\nDoppler: Limited Doppler and color 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\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Moderate-severe regional left ventricular systolic\ndysfunction. Moderately depressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid inferior -\nhypo; basal inferolateral - hypo; mid inferolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending\naorta. Normal descending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: 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. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\n\n1.No atrial septal defect is seen by 2D or color Doppler.\n\n2.There is moderate to severe regional left ventricular systolic dysfunction\nwith hypokinesia of the apex, mid and apical portions of the inferolateral,\nlateral and inferior walls. Overall left ventricular systolic function is\nmoderately depressed.\n\n3.Right ventricular function is mildly depressed.\n\n4.There are simple atheroma in the ascending aorta.\n\n5.The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n\n6.The mitral valve leaflets are mildly thickened. Mild to moderate (+)\nmitral regurgitation is seen.\n\n7. Tip of the intraortic balloon pump in good position.\n\n8. Post percutaneous intervention ejection fraction is slightly improved.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2124-02-22 00:00:00.000",
"description": "Report",
"row_id": 84667,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Cardiogenic shock. Valvular heart disease.\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 86/64\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 17:02\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient was intubated and sedated in the cardiac catheterization laboratory\nprior to TEE, with monitoring by catheterization lab nursing. An intraaortic\nballoon pump had also been inserted prior to TEE.\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Moderate-severe regional left ventricular systolic\ndysfunction. Moderately depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - akinetic; mid inferolateral - hypo; basal\nanterolateral - hypo; mid anterolateral - hypo; anterior apex - akinetic;\nlateral apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: No atheroma in aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). No TEE related complications. The patient was under general\nanesthesia throughout the procedure. Emergency study.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. There is\nmoderate to severe regional left ventricular systolic dysfunction with\nanterior and lateral hypokinesis to akinesis and mild inferior wall\nhypokinesis. Overall left ventricular systolic function is moderately\ndepressed. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild to moderate (+) mitral regurgitation was present\nwhen the patient is on 1:1 intraortic balloon pump counterpulsation, and\nmoderate mitral regurgitation was seen upon withholding of intraortic balloon\npump. The ascending and descending aorta could not be easily visualized due to\npresence of IABP. The pulmonic valve leaflets are thickened. There is no\npericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-15 00:00:00.000",
"description": "Report",
"row_id": 205434,
"text": "Sinus rhythm\nMarked right axis deviation\nRight bundle branch block\nInferior/lateral ST-T changes are nonspecific\nGeneralized low QRS voltages\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-14 00:00:00.000",
"description": "Report",
"row_id": 205435,
"text": "Sinus arrhythmia\nRight axis deviation\nRight bundle branch block\nInferior/lateral ST-T changes are nonspecific\nGeneralized low QRS voltages in limb leads\nSince previous tracing of , irregular rhythm seen\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-13 00:00:00.000",
"description": "Report",
"row_id": 205436,
"text": "Sinus rhythm\nRight axis deviation\nRight bundle branch block\nST-T changes are nonspecific\nGeneralized low QRS voltages\nSince previous tracing of , lower QRS voltages noted\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-11 00:00:00.000",
"description": "Report",
"row_id": 205437,
"text": "Sinus rhythm\nRight axis deviation\nRight bundle branch block\nT wave changes are nonspecific\nSince previous tracing of , anterior T waves more upright\n\n"
},
{
"category": "ECG",
"chartdate": "2124-02-29 00:00:00.000",
"description": "Report",
"row_id": 205676,
"text": "Sinus rhythm with baseline artifact. P-R interval 0.16. Left axis deviation\nwith possible left anterior fascicular block. Probable left atrial abnormality.\nPossible prior inferior wall myocardial infarction. Slow R wave progression.\nRelatively low limb and lateral precordial voltage. Non-specific ST-T wave\nchanges. Compared to the previous tracing of no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2124-02-27 00:00:00.000",
"description": "Report",
"row_id": 205677,
"text": "Sinus rhythm\nConsider prior inferior myocardial infarction although is nondiagnostic\nNonspecific ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2124-02-26 00:00:00.000",
"description": "Report",
"row_id": 205678,
"text": "Sinus rhythm\nConsider prior inferior myocardial infarction although is nondiagnostic\nNonspecific ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-10 00:00:00.000",
"description": "Report",
"row_id": 205666,
"text": "Sinus rhythm. Diffuse low voltage. Right bundle-branch block. Compared to the\nprevious tracing of the anterolateral ST segment depression has improved\nraising the question of ischemic ST segment changes superimposed on the\nrepolarization abnormality of right bundle-branch block. Followup and clinical\ncorrelation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-09 00:00:00.000",
"description": "Report",
"row_id": 205667,
"text": "Sinus tachycardia. Right bundle-branch block. Diffuse low voltage. Compared to\nthe previous tracing of the inferior ST-T wave abnormalities have\nimproved. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-08 00:00:00.000",
"description": "Report",
"row_id": 205668,
"text": "Atrial flutter\nRight bundle branch block\nRightward axis\nGeneralized low voltage\nThese findings are nonspecific but clinical correlation is suggested for\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-07 00:00:00.000",
"description": "Report",
"row_id": 205669,
"text": "Atrial flutter with a mean ventricular response, rate 111. Right bundle-branch\nblock pattern. Compared to the previous tracing of multiple\nabnormalities persist without major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-06 00:00:00.000",
"description": "Report",
"row_id": 205670,
"text": "Slow atrial flutter with 2:1 A-V block. Since the previous tracing\nof the rhythm is clearly atrial flutter. No other changes have\noccurred.\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-05 00:00:00.000",
"description": "Report",
"row_id": 205671,
"text": "Sinus tachycardia. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-04 00:00:00.000",
"description": "Report",
"row_id": 205672,
"text": "Compared to the previous tracing sinus tachycardia at rate 106 has supervened.\nThere is new right bundle-branch block. There are non-specific inferior\nrepolarization changes. The frontal plane axis has shifted from leftward to\nindeterminate. There are non-diagnsotic Q waves in leads I, aVL and V6.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-03 00:00:00.000",
"description": "Report",
"row_id": 205673,
"text": "Baseline artifact precludes definite assessment. Sinus rhythm with borderline\nP-R interval prolongation. Compared to the previous tracing of multiple\nabnormalities are as previously reported with ventricular premature beats not\nseen. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-02 00:00:00.000",
"description": "Report",
"row_id": 205674,
"text": "Sinus rhythm\nVentricular premature complexes\nProbable left atrial abnormality\nLow limb lead QRS voltages\nConsider prior inferior myocardial infarction\nLate precordial QRS transition\nST-T wave abnormalities\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , ventricular ectopy present\n\n"
},
{
"category": "ECG",
"chartdate": "2124-03-01 00:00:00.000",
"description": "Report",
"row_id": 205675,
"text": "Sinus rhythm\nProbable left atrial abnormality\nLow limb lead QRS voltages\nConsider prior inferior myocardial infarction\nLate precordial QRS transition\nST-T wave abnormalities\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2124-02-25 00:00:00.000",
"description": "Report",
"row_id": 225192,
"text": "Sinus rhythm. QS deflections in lead III. Low voltage in the limb and\nprecordial leads. Non-specific T wave inversions in leads I, II, aVL, V5-V6.\nCompared to the previous tracing of ventricular bigeminy is no longer\npresent.\n\n"
},
{
"category": "ECG",
"chartdate": "2124-02-23 00:00:00.000",
"description": "Report",
"row_id": 225193,
"text": "Sinus rhythm and ventricular bigeminy. Diffuse low voltage. Lateral ST-T wave\nabnormalities persist. Compared to the previous tracing of ventricular\nbigeminy has appeared. Clinical correlation is suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2124-02-23 00:00:00.000",
"description": "Report",
"row_id": 225194,
"text": "Sinus rhythm. Prior inferior myocardial infarction. Diffuse low voltage. T wave\ninversions in leads I, aVL and V5-V6 raising the question of lateral ischemic\nprocess. Delayed precordial R wave progression. No previous tracing available\nfor comparison. Followup and clinical correlation are suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-27 00:00:00.000",
"description": "Report",
"row_id": 1285803,
"text": "CCU NURSING PROGRESS NOTE\nS:INTUBATED X 6DAYS\nO:PT IS A 68YOM W/ PMH OF NON STEMI 2WKS AGO, MEDICALLY MGT'D D/T CRI. HIS BASE LINE RUNS . HX OF GERD IDDM, HTN AND ^CHOLES. PT WAS FROM AND BROUGHT TO CATH LAB. PT WAS FOUND TO HAVE 3VD, AND WAS IN CARDIOGENIC SHOCK. IAPB INSERTED AND PRESSORS STARTED.\n\nNEURO; REMAINS SEDATED WITH FENTANYL AND VERSED, WILL ATTEMPT TO LIGHTEN BY END OF SHIFT. PT HAS MADE MINIMAL MOVEMENTS OF UE.\n\nCV: 70-90'SR, NO SUSTAINED EPISODES OF BIGEMINY. IABP 1:1 W/ GOOD AUGMENTATION. SYS UNLOADING 12-20MMHG AND DIASTOLIC UNLOADING . REMAINS DOPA DEPENDANT, CURRENTLY AT 14MCG/KG/MIN. LEVOPHED HAS BEEN TITRATED TO A MAP >60, CURRENTLY AT 0.011MCG/KG/MIN. BLUE SWAN-PAD 24-28 VIA R FEM SHEATH. CI 2.3/SVR 730. DP PULSES AUDIBLE W/ , L PT VERY WEAK. LEFT RADIAL PALP. CAP REFILL SEC. +2EDEMA IN ALL EXTREMITIES.\n\nRESP: AM ABG 7.45/39/108/28/98% . VENT:AC/500/16/PEEP8. FIO2 DECREASED TO 40%. LS COARSE, AND DIM AT BASES. SUCT FOR THICK YEL MOD AMT.\n\nID:AFEBRILE W/ NL WBCS, ON CIPRO AND CEFAPINE FOR 4+GNR IN SPUTUM\n\nENDO REMAINS ON INS GTT W/ CONKTROLED GLUC.\n\nGI:TF SHUT OFF D/T RESIDUALS >100 X3. BS VERY HYPOACTIVE. NO STOOL.\nPT CURRENTLY ON REGLAN.\n\nRENAL;CVVH, PULLING 50-60CC/HR, PT BECOMES HYPOTENSIVE W/ HIGHER FLUID REMOVAL.\n\nGU:OLIGURIC AMBER URINE.\n\nSKIN:RED RASH OVER BUTTOCK. ANTIFUNGAL CREAM APPLIED.\n\nA/P:CADIOGENIC SHOCK, IABP, AND PRESSOR DEPENDENT. FOR POSS HIGH RISK ANGIOPLASTY TUES. REVIEW LABS W/ RENAL, PT BECOMING HYPONATREMIC. WILL CHANGED GTTS TO NS. PT NOT TF FOR NUTRITION SUPPORT, CONSIDER OTHER OBTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-27 00:00:00.000",
"description": "Report",
"row_id": 1285804,
"text": "resp care\nPt remained on a/c 500x16 40% 8peep with peak/plat 20/17.BS coarse bil. Suct for sml amts of thick yellow sput. Alb/atro mdi given as ordered.RSBI held due to hemodynamic instability. fio2 wean with sats remaining at 98%. Will cont to follow and adjust vent as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-27 00:00:00.000",
"description": "Report",
"row_id": 1285805,
"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 = 20/18. SpO2 90s. MDIs given as ordered. ETT secure/patent. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-27 00:00:00.000",
"description": "Report",
"row_id": 1285806,
"text": "CCU NSG NOTE: ALT IN CV/RESP/RENAL\nO: For complete VS see CCU flow sheet.\nThis 68y old male with PMH of HTN, CRI, IDDM, GERD and MI 2 weeks ago that was medically managed went to OSH with SOB, was intubated and to cath lab where he was found to be in cardiogenic shock, with 3VS and 4+ MR. was started on pressurs and IABP was placed and he was to CCU for further care. Once here he was started on CVVHD.\nID: T-max 99 r, until 1600 when temp down to 96.5. he is back on barehugger. WBCs 8. He conts on cipro and cefepine.\nCV: With some weaning of sedation pt was able to tolerate slow wean of pressurs. Levo, which had been increased to .02mic/kilo at 8a is down to .01 mic/kilo. Dopamine is down to 10mic/kilo. He is still very pressure dependent and will drop his bp quickly if drips stop. He remains on IABP 1:1 with good augmentation and unloading. AS:83-113/ AD 105-130/ BAEDP 39-44 and maps 80-90. PAP has ranged 50s/27 down to low 20s by late afternoon. CVP 8-11. Last CO was 5.2/2.3/ 723. HR has been in 70s NSR with occasional PVCs. No runs bigeminy seen. He was restarted on argatroban at lower dose of .1mic/kilo with first PTT 6 hrs later 66.9. Pharmacy helped with modified sliding scale as he was so supratheraputic when he was on it before. Both groin sites are dry with no ooze or hematoma. All pulses dopplerable. Feet are warm and pink. He was started on plavix today, but it is unclear if he is absorbing anything.\nRESP: Pt remains intubated on AC 500 X 16 with no overbreathing, 40% and 8 peep. No attempt to wean today. He is suctioned for thick yellow sputum in small to mod amts. Last gas was 7.41/ 37/ 87/24. He conts on VAP bundle.\nRENAL: Ultrafiltration conts with goal of 1.5 to 2 liters off today. He is presently 1.1 liters neg for the day and 5200cc LOS. Lytes are being repleted per protocol. Phos low today at 1.5 and he is being repleted with K-phos 15mm X 2. BUN/Creat stable at baseline 23/2.3. He put 600cc of consentrated urine today.\nGI: Pt continues to have lg amts light green watery asp in stomach that is g-. As his bili was elevated he had ultrasound that was neg for calculi. No attempts at feeding. No bowel sounds heard.\nENDO: Pt stable on insulin gtt at .5u/hr.\nSKIN: Area around buttocks continues reddened. Aloevesta antifungal and moisture barrier applied.\nNEURO/SEDATION: Fentanyl has been weaned to 75mic/hr and versed to 3mg hr. Pt not moving when left alone, breathing in synch with vent and appear comfortable. But for the first time was seen to move both upper extremities during suctioning. Lower extremity movement not seen. He grimaces more with mouth care. He followed no commands for me, but his wife said he squeezed her hand.\nA: Tolerating wean of dopamine and sedation\nP: Labs due 2100. Follow modified ss for titrating argantraban. Continue to wean pressures and sedation as tolerated. Hang second K+phos when first bag finishes. Keep careful I & O. Take of 100-150cc/hr as tolerated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-28 00:00:00.000",
"description": "Report",
"row_id": 1285807,
"text": "resp care\nPt remained on a/c 500x18 40% 8peep with peak/plat 19/16. BS coarse with rare insp wheeze. ALB/Atro given as ordered.Suct for sml amt of thick tannish sput. RSBI held due to hemodynamic instability.ABG acceptable.Will cont to follow and make adjustments as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-06 00:00:00.000",
"description": "Report",
"row_id": 1285843,
"text": "GOAL TODAY TO WEAN IABP,TRY CPAQP,PULL 500 TO 1000CC OFF VIA .BP CRASHED HOWEVER. ALSO DISCUSSED CODE STATUS AND NEED FOR TRACH AND PEG C WIFE,NO DECISION TODAY.\n\nSR 90S C NO ECTOPY. IABP 1TO 3 C CI 2.4,SVR 887.DOPAMINE INCREASED TO 10MIC TO ALLOW INCREASE IN PFR AND BALLOON WEAN .MAPS > 60 .WHEN BALLOON SHUT OFF FOR DC BP CRASHED TO 60S .DOP0MINE INCREASED TO 20 MIC,IABP TO 1 TO1 .PFR TO 0 .50 CC NS BOLLUS GIVEN.BP STABLIZED .PRESENTLY WEANING DOPAMINE,INCREASING PFR.HEPARIN RESTARTED 400U AT 5PM.TO ATTEMPT MILRINONE LATER .PT OOZING FROM ECMO SITE R GROIN,STITCHED BY VASCULR RESIDENT,NO VISIBLE BLEED OR HEMATOMA .HCT PENDING .NO . CVP 5 .DP BY DOP,NO PT\n\nABGS 7.44/37/109/26/98 ON CPAP 40%/PEEP 5,PS 10,RR 15,TV 500.BACK ON CMV WHEN BP CRASHED.\n\nBILIOUS DRAIN FROM OG TUBE ,NO BS.\n\n,PFR UP TO 240 FOR NEG BALANCE BUT PRESENTLY BALANCE EVEN DUE TO BP .WILL TRY TO TITRATE PFR TO 200 FOR NEG 50CC/HR .K,CA REPLACEMENT PER PROTOCOL .\n\nPT OPENS EYES TO WIFE,SQUEEZES HAND TO COMMAND AT TIMES .FENTANYL,VERSED DECREASED DURING VENT WEAN .\n\nTEMP FLAT ,VANCO DC ,ON NAFCILLIN.\n\nDUODERM TO COCCYX\n\nCARDIGENIC SHOCK,IABP DEPENDENT\n\nWEAN DOPAMINE,START MILRINONE\nMONITOR FOR BLEEDING R FEM SITE\nCHECK C HO CONCERNING FLUID GOALS FOR \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-25 00:00:00.000",
"description": "Report",
"row_id": 1285799,
"text": "CCU NPN\n\n0700-2200\n\nneuro: paralyzed w/ cisatracurium until 2100 when d/c. Sedated w/ fentanyl/versed. train oof four 4 twitches at 40ma.\ncv: remains on iabp 1:1 w/ maps 58-76. fair unloading. Continues on dopamine at 9 mcg/kg/min. PAD 24-27. Argatroban held since 0930 d/t ptt 106, f/u 97.2, current ptt pnd. Awaiting results of HIT antibody. here to evaluate, felt not to be a surgical candidtate at this time.\nresp: pls see carevue for all vent settings and abg. sx q 3-4 hr for sm amts thick tan secretions.\ngi: NPO at this time, 500cc bilious drainage via LIS. No stool\ngu: foley draining sm amts dk yellow urine. Continues on CRRT. Continueing slow fluid removal, Tolerating well. See carevue for details. ~ 1500cc neg since mn. K and Ca gtts titrated per sliding scale.\nid: afebrile. Cont on abx.\nend: continues on insulin gtt, bs 97-136, currently on 2 units/hr.\nskin: intact, coccyx red, barrier cream applied, pt turned side to side.\nsocial: wife in, updated on .\nA: Unable to wean pressors further, tolerating slow fluid removal, good BS control on insulin gtt. Paralytics d/c,\nP: Continue current , wean fio2 as possible, wean pressors as possible. Emotional support to wife.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-26 00:00:00.000",
"description": "Report",
"row_id": 1285800,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Paralytics taken off. PaO2 improving and Peep weaned to 8. Repeat Abg's WNL with PaO2 81. Currrent vent settings Vt 500, A/c 18, Fio2 50% and Peep 8. BS clear and decreased bilaterally. Albuterol/Atrovent MDI's given Q4hr. Sx'd for sm amount of thick tan and blood tinged secretions. No further changes made. See Carevue for further details.\nPlan: Continue with mechanical support and wean peep as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-04 00:00:00.000",
"description": "Report",
"row_id": 1285834,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-04 00:00:00.000",
"description": "Report",
"row_id": 1285835,
"text": "CCU NSG 0700-1900 CARDIOGENIC SHOCK, S/P ^RISK STENT\nS. REMAINS INTUBATED/SEDATED\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nNEURO: PROPOFOL WEANED FROM 25 - 8 MCGS/KG - PT TO STIMULATION, INTERMITTENTLY FOLLOWS COMMANDS - WIGGLES TOES, CLOSES EYES TIGHTLY TO COMMAND, OTHERWISE NOT MOVING EXTREMITIES SPONTANEOUSLY, WEAK GAG, + COUGH W/SUX\n\nCV: IABP AT 1:1 55-99/77-112/40-52 MAPS 54-81, PRESSURE DOWN W/MAPS BELOW 60 OFF/ON - VERY SENSITIVE TO CHANGES IN DOPMINE; MAPS INCREASE WITH LESS PROPOFOL, SYST UNLOADING , DIAST 0-10; EXCELLENT TRACING, W/O PROBLEMS W/IABP - BALLOONING OFF RADIAL A-LINE AS CENTRAL LUMEN CLOTTED OFF; HR 90'S-100'S ST RARE PVC, PAD 38-48/21-32 CVP 17 DOWN TO 9, UNABLE TO ; REMAINS ON DOPAMINE GTT 5.5-7 MCGS PRESENTLY AT 6.0MCGS/KG W/CO / CI 2.9-3.4 SVR 500-600'S; TROPNIN LEVELS ON RISE LAST 1.97 AT 1300 CPK'S FLAT AT 70\n\nHEME: HCT 25 IN AM - RECEIVED 1 UNIT PRBC'S - REPEAT 28; R GROIN SITE S/P ECMO W/ BLOODY DSG IN PLACE, NO FURTHER BLEEDING NOTED, LATER IN DAY SURGERY BY - TOOK DSG OFF - REBLED UNDER SITE; SITE HELD - MODIFIED PRESSURE DSG APPLIED - NO FURTHER OOZE FROM UNDER DSG AT PRESENT TIME; HEPARIN HAS BEEN HELD SINCE 1430 AFTER PTT 150 ON 800U/HR >150, REPEAT AT 1645 140, REPEAT AT 1745 PENDING; PLT 119\n\nRESP: REMAINS VENTED ON AC .40/500X14, 8 EEP LAST ABG 7.42.42.97.24.0\nLUNGS DIMINIDSHED THROUGHOUT, SUX Q 3-4HR FOR THICK TAN SPUTUM IN MODERATE AMT-LG AMTS\n\nRENAL: CVVH CONTINUES W/1500CC REPLACEMENT SOLUTION 120ML/HR FLOW RATE - SETTINGS ESSENTIALLY UNCHANGED, RECEIVING K+ AND CA+ REPLACEMENT CONTINUOUSLY PER SLIDING SCALE; TAKING OFF GOAL -100CC/HR; -1200CC THUS FAR TODAY; DIFFICULT TO PULL MORE AT TIMES DUE TO LOW MAPS, BUN/CR 32/2.2 - STABLE\n\nENDO: INSULIN SLIDING SCALE HAS BEEN AT 10 DOWN TO 7 UNITS PER HOUR MOST OF DAY W/BS 90-110\n\nGI: TPN CONTINUES, OGT IN PLACE W/LG AMTS BILEOUS TO CLEAR SECRETIONS SUX OUT INTERMITTENTLY - TOTAL 500CC TODAY; GUIAC POSITIVE BUT NO FRANF BLOOD, REGLAN CONTINUES Q 6HR - TO RESTART TUBE FEEDS AT LOW DOSE AND ASSESS TOLERTION, ABDOMEN SOFT, OBESE W/HYPOACTIVE BS, NO STOOL, RECEIVING COLACE\n\nGU: FOLEY IN PLACE - DRAINING AMBER URINE IN SM AMTS\n\nSOCIAL: FAMILY IN TO VISIT TODAY UPDATED BY MDS/RN REGARDING PT'S CONDITION AND PLAN OF CARE AS DISCUSSED IN MULTIDISCIPLINARY ROUNDS\n\nA: S/P HIGH RISK STENTS PLACED TO LAD/LCX, REMAINS ON IABP//DOPAMINE/VENT W/EPISODES HYPOTENSION ESP W/^PROPOFOL; CO/CI STABLE, ABG'S STABLE\n\nP: FOLLOW HEMODYNAMICS, CONT AS ORDERED, FOLLOW LYTES AND REPLACE PER SLIDING SCALE, CONT VENT SUPPORT FOR NOW, WEAN AS TOLERATED, FOLLOW NEURO STATUS, CONSIDER IABP WEAN TO 1:2 AND ASSESS TOLERATION; CONT SUPPORTIVE CARE, KEEP FAMILY INFORMED OF PROGRESS/PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-05 00:00:00.000",
"description": "Report",
"row_id": 1285836,
"text": "Resp Care\nPt remains on vent. Weaned fio2 and peep based abgs. Suctioned mod amt of tan secretions. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-26 00:00:00.000",
"description": "Report",
"row_id": 1285801,
"text": "CCU NURSING PROGRESS NOTE\nS:INTUBATEDD\nO:PT S/P NON STEMI TO WKS AGO, FROM OSH IN CARDIOGENIC SHOCK. PT WAS FOUND TO HAVE 3VD IN CATH LAB AND NOT A CANDIDATE AT THIS TIME. MOST RESENT ECHO, EF 25%.\n\nNEURO:PT OFF PARALYTICS. SEDATED W/ VERSED AND FENTANYL PT IS BLIND, L PUPIL DOES NOT REACT. PT HAS MOVED UE ON BED.\n\nCV: PT W/ BREIF EPISODE OF BRADYCARDIA DOWN TO 56 SB ASSCOCIATED W/ HYPOTENTION MAP 40, DOPAMINE INCREASED TO 20MCG/KG/MIN, BRIEFLY. LEVOPHED ON BRIEFLY. PAD 27-30. DR IN TO SEE PT. NO FLUID REMOVAL THE PAST HOUR ON CVVH. R FEM IABP 1:1, W/ GOOD AUGMENTATION 10 TO 20POINTS. R FEM IABP SITE CL AND DRY. NO BLEEDING, NO HEMATIOMA. DP PULSES AUDIBLE W/ . TOES AND PLANTER FOOT SLT DUSKY, W/ CAP REFILL 4-5SEC. ALL EXTREMITIES COOL TO TOUCH BUT DRY. PT DEVELOPED CONTINUOUS BIGEMINY, ADDITIONAL POTASSIUM GIVEN, LAST POTASSIUM 3.7. CALCIUM GLUC OFF D/T I-CALCIUM >1.3. OFF PTT REMAINS >80.\n\nRESP:AC/50/500/16/PEEP WAS 10, NOW 8. ABG 7.41/40/81/26/95. COARSE BS BILAT, SUCTIONED FOR TAN SECRETIONS.\n\nENDO:INSULIN OFF AT THIS TIME AS PER GUIDELINES,\n\nGI:VERY HYPOACTIVE BS IN ALL 4 QUADS, OGT DRG LARGE AMTS OF BILIOUS GASTRIC CONTENT. NO STOOL.\n\nGU:OLIGURIC, AMBER W/ SEDIMENT.\n\nSKIN:EDEMA AND SLT REDNESS OF HEEL, BUT . MPB APPLIED TO LE.\n\nA/P:CARDIOGENIC SHOCK, ACUTE RENAL FAILURE REQUIRING CVVH. CONTINUE ULTRAFILTRATION 25-50CC. CONTINUE TO SUPPORT W/ IABP AND INOTROPIC THERAPY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-26 00:00:00.000",
"description": "Report",
"row_id": 1285802,
"text": "CCU NSG NOTE: ALT IN CV/RENAL\nO: For complete VS see CCU flow sheet.\nTHis 68y old male with PMH of IDDM, gerd, MI 2 week ago, CRI came to OSH with acute sob requiring intubation. Came to where cath showed severe 3VS and 4+MR. intervention done, IABP placed, CT contsult done.He has required pressures, is on IABP, CVVHD, ABX. CT will not operate. High risk angioplasty planned for Tues.\nID: Pt remains hypothermic with flat WBCs. He is on cipro and cephapine from + sputum.\nCV: Pt slightly less labile today. He initially had episode of vent bigeminy-but PVCs were electrical only, there was no perfusion. No episodes since 2pm. HR in 70s NSR. He remains on IABP 1:1 with good augmentation and unloading 14-24p. AD 92-132/ AS 55-104/ BAEDP 32-40, with maps 52-93. He remained on dopamine at 14mic/kilo all day with stable BP until ~1600 when maps began to drop to 50s. He was restarted on levofed at first .03mic/kilo then decreased to .01mic/kilo with maps now in 70s. PAP has ranged 48-58/ 24-28 and CVP 10-12. LAst CO/CI was 7.1/ 3.1/ 654. Argantroban remains off due to elevated PTT. His R groin is dry with no ooze or hematoma and all pulses are dopplerable. His feet are warm and CSM nl.\nRESP: Pt remains intubated on AC 500 X 16 with no overbreathing, 50% and 8 PEEP. His last gas on that setting was 7.41/43/81/28. He has very decreased breath sounds. His is being suctioned for small amts thick bloody sputum. VAP bundle follow within limits of pt tolerance.\nRENAL: Pt conts on CVVUF. Goal is to take of 100cc/hr, dropping amt with decreased BP. He has tolerated goal most of day. He is 1 liter neg for the day. Lytes are being replaced per Renal protocol.BUN and Creat remains baseline at 24/2.1. Dialysis catheter site is dry and in tact. No clots seen in filter.\nGI: Pt cont to have bilious drainage. Reglan was started. Tube feeding of probalance at 10cc/hr was begun at 1600. Goal is 75cc/hr. No bowel sounds heard. Feedings to be held for residual of 100cc.\nENDO: Pt went back on insulin gtt at 0900. He is presently on 1.5u/hr with stable BS between 125-140.\nSKIN: Coccyx area remains very reddened with rashy appearance. Postion changed Q 2 hrs and area rubbed with aloe-vest barrier cream. He gets ointment to eyes.\nNEURO: Pt unresponsive. His face would grimace with mouth care and suctioning, but no movement of limbs seen. He has diminished gag and cough reflex. He conts on fentanyl at 150mic/hr and versed at 5mg hr. No boluses required.\nSOCIAL: Pts wife in to visit. She seems to understand plan for high risk angioplasty. She is concerned about long term prognosis. Her husband would not want to be keep on life support or in debilitated condition in nursing home.\nA: Levo restarted at low dose/Pt neg for the day\nP: Contineu with dialysis protocol with next labs due at 2100. REmove ~ 100cc/hr as pressure tolerates.Restart argatroban if PTT lowers. Cont with VAP bundle. Start decreasing sedation to see if pt will move. Monitor pulses and IABP site. Check finger stick Q 1 hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-05 00:00:00.000",
"description": "Report",
"row_id": 1285837,
"text": "ccu nsg progress note.\no:neuro=lightly sedated w propofol gtt. responsive @ x's-nodding head to questions-not consistant. easily agitated w decrease in gtt.\n pulm=intubated & sedated-only vent chg--decreased peep from 8 to 5. gd abg/sats. breath sounds=deminished/course throughout. sx-@x's copious amts watery white secretions. abundant oral secretions.\n cv=very labile bp-requiring freq adjustment of dopa gtt to maint adeq maps. dopa gtt presently @ 8mcg/kg/min. iabp 1:1 chged to 1:2 x4hrs w stable maps/pad/co-ci/svr--placed back on 1:1 to rest. heparin gtt restarted-follow up ptt-130. heparing gtt stopped @ 0545. r fem site w ooze-pressure dsg applied. vasc aware/seen.\n gi=tpn as ordered. tf held due to significant amt ogt drainage. hypoactive bowel sounds. wo stool.\n endo=insulin gtt titrate to maint adeq bs.\n renal=cvvhdf-filter cloted 0100-resumed 0300. presently pfr set to keep i&o essentially equal due to increased requirement of dopa (decreased maps). gtts-cal gluc & k-adjusted to am labs.\n id=afebrile.\n skin=coccyx w duoderm.\n\na:requiring increased dose dopa to maint adeq maps. contin ooze from r fem site. unable to start tf due to signif drainage from ogt. present keeping i&o equal due to decreased maps.\n\np:contin present managment. ?attempt wean/dc iabp. increase pfr as tolerated. contin freq (q1hr) bs. support pt/family as indicated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-05 00:00:00.000",
"description": "Report",
"row_id": 1285838,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-05 00:00:00.000",
"description": "Report",
"row_id": 1285839,
"text": "CCU NURSING 0700-1900\nS. REMAINS INTUBATES/SEDATED, NODDING HEAD APPROPRIATELY TO QUESTIONS\n\nO. NEURO: SEDATION CHANGED FROM PROPOFOL TO FENTANYL 50-100MCGS, VERSED 2MCG IV, PT MORE AWAKE OFF/ON - MAE ON BED SLIGHTLY TO COMMAND, NODDING HEAD APPROPRIATELY AND ATTEMPTING TO MOUTH WORDS WHEN FAMILY VISITING; + COUGH, + GAG\n\nCV: REMAINS ON IABP AT 1:1, BP VERY LABILE AND SENSITIVE TO CHANGES IN DOPAMINE GTT, DOPAMINE AS HIGH AS 12MCGS IN AM - NOW TOLERATING DOPA AT 8MCGS/KG SINCE PROPOFOL OFF WITH MARGINAL MAPS; HR 90'S - 100'S SR,ST; RARE PVC, PAP'S 38-40'S/18-22 CVP 5-9, UNABLE TO \nCO/CI 4.5-4.7/2.0 SVR 800-1000; R GROIN SITE W/SIGNIFICANT BLEED THIS AM - PRESSURE DSG TAKEN DOWN, PRESSURE HELD BY RN X 15 MIN - REDRESED W/NEW PRESSURE DSG - SINCE THEN SITE D+I; HEPARIN WAS OFF AT TIME FOR PTT 132; HEPARIN HELD UNTIL REPEAT PTT 30'S - THEN RESTARTED AT 1230 - 300U/HR W/PTT NOW 47.9; DP PULSES DOP/DOP, PT ABS/DOP, CPK FLAT\n\nRESP: REMAINS INTUBATED, FIO2 40%/500X14 5PEEP W/ ABG 7.40/39/127\nLUNGS DIMINISHED AND COARSE THROUGHOUT, LARGE AMTS THICK TAN SPUTUM AND AT TIMES, COPIOUS SECRETIONS OF CLEAR THICK IN BACK OF THROAT;\nSATS 100%\n\nRENAL: CONTINUES IN CVVH MODE - SETTINGS UNCHANGED - GOAL = EVEN FOR TODAY GIVEN TENUOUS BLOOD PRESSURE STATUS; PT APPROX NEG 500CC FOR DAY SINCE MN; CALCIUM GLUCONATE AND KCL GTTS INFUSING AND TITRATED TO LYTE LEVELS\nHEME: HCT 28 - 26 IN PM\n\nGI: TPN INFUSING, TUBE FEEDS HELD SECONDARY TO LARGE RESIDUALS OF CLEAR TO BILEOUS W/BROWN FLECKS - GUIAC POSITIVE, RECEIVING REGLAN Q 6HR, ON CARAFATE QID, SENNA GIVEN X1 TODAY, NO STOOL, ABSENT TO HYPOACTIVE BOWEL SOUNDS, ABDOMEN REMAINS SOFT, NON-TENDER\n\nENDO: INSULIN GTT CONTINUES - SS INSULIN RUNNING 8-6UNITS/HR W/FS RUNNING 85-130\n\nGU: FOLEY IN PLACE - DRAINING SM AMTS AMBER URINE ~10CC/HR\n\nSOCIAL: WIFE IN TO VISIT W/OTHER FAMILY MEMBERS, TALKED W/MD'S - TEAM ADDRESSED POSSIBILITY OF TRACH/PEG - WIFE NOT SURE THIS IS WHAT PT WOULD WANT, DISCUSSION TO CONTINUE; FAMILY WILL THINK ABOUT IT\n\nA: REMAINS IABP//VENT/PRESSOR DEPENDENT POST-HIGH RISK STENT PLACEMENT ON \n\nP: CONTINUE IABP AT 1:1, ATTEMPT WEAN DOPAMINE AS BP TOLERATES, FOLLOW HEMODYNAMICS, CONSIDER ADDING DOPAMINE IF REMAINS HYPOTENSIVE OR CI DROPS LOWER; CONT KEEPING PT EVEN UNLESS BP IMPROVES, FOLLOW Q 1HR FS, CONT VENT SUPPORT UNTIL ABLE TO WEAN IABP, CONT KEEP FAMILY INFORMED OF PT'S CONDITION; CONT TALKS REGARDING PLAN OF CARE FOR PT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-06 00:00:00.000",
"description": "Report",
"row_id": 1285840,
"text": "Resp. care\nPt hemodynamics remain too unstable for active weaning. But his trigering of the ventilator & his good lung compliance indicate that he may tolerate the changing of his vent. mode to a moderate level of PS/CPAP with out compermiseing his hemodynamis status. possibaly a PS of 12-14cm/H2O to maitain a Vt of about 500ml per breath. He continues to be 1:1 on IABP and is still on CVVHD he is also getting pressors. Thus RSBI was held this AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-06 00:00:00.000",
"description": "Report",
"row_id": 1285841,
"text": "ccu nsg progressn ote.\n heme=transfused w 1urbc for hct 26-repeats wo signif increase. ptt theraputic on heparin gtt-300u/hr.\n\na:requiring freq adjustment of dopa gtt to maint adeq maps.\ntolerating slow increase in pfr.\n\np:contin present management. support pt's wife re:decision involving trach/peg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-24 00:00:00.000",
"description": "Report",
"row_id": 1285795,
"text": "Resp Care\nPt remains intubated. Current vent settings: A/C 500 x 24 8PEEP 50%.\ndecreased PEEP from 10 to 8. Increased FIO2 from 40% to 50% due to current ABG of: 7.40/34/69/22. MDI's given. Pt still being assessed by cardio thoracic team for possible surgery. Pt still on paralytics. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-24 00:00:00.000",
"description": "Report",
"row_id": 1285796,
"text": "SR 80S C EPISODES OF V BIGEMINNY ,IABP TO RUN IN OPERATOR MODE DURING THAT TIME ,OTHERWISE AUTO PILOT .IABP MAP 61 TO 81 ,DOPAMINE REMAINS 15 MICS,LEVOPHED WEANED TO .021 MIC/KG.CI 2,7,SVR 711.PADS 26 TO 41.MVSAT 58.PEDALS BY DOPPLER.AGGATROBAN STARTED IN PLACE OF HEPARIN .\nHCT 26 ,TO GET UNIT PC.EVAL BY CT SX\n\n\nVENT WEANED TO 8PEEP/40%/500/24 ABG WORSE,7.40/34/66/22/94 .BACK TO 50%.BS DIMINISHED ,SX BLOOD TINGED YELLOW\n\nOG DRAINED 300CC GREEN,NO BS,KUB DONE\n\nURINE AMBER C SEDIMENT 5 TO 35 CC/HR.FILTER ON CRRT CHANGED TO ELIMINATE HEPARIN.PFR 140 TO 200.\n\nCISATRACURIUM .06 ,4 TWICTHES TO 40 MA TOF L THUMB,150 FENTANYL,5 VERSED .BP RISES C NOXIOUS STIMULI.WIFE UPDATED BY ATTNDING .\n\n SLOW PRESSER,VENT WEAN,CVVHD\n\nWEAN LEVO AS \nRECHECK PTT,LYTES\nAT LEAST 50CC/HR NEG ON CVVHD\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-04 00:00:00.000",
"description": "Report",
"row_id": 1285832,
"text": "resp Care\nPt returned from or. Placed on 100% same vent settings (see carevue). Suciotned mod of blood-tinged to tan secretions. Abgs wnl. Weaning on fio2. Plan to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-25 00:00:00.000",
"description": "Report",
"row_id": 1285797,
"text": "ccu nsg progress note.\n68 yo male transfered from osh w pulm edema requiring intubation. recently dced w nstemi. card cath sever 3vd w pulm hypertension, significant mr, & elevated -wo intervention-iabp placed & admitted to ccu. problems--resp failure requiring intubation & sedation/paralytic to maint adequate abg/sat.--cardiogenic shock requiring iabp & pressors. renal failure/volume overloaded requiring cvvhdf. csurg following-? when more stable.\n\no:neuro=paralyzed-cisatracurium & sedated-fent/versed. train of 4-l ulnar---4 twitches @ 40ma.\n pulm=improving metabolic acidosis-vent adjusted accordingly. present setting-ac/500x21/50%/+10 w acceptable abg & sats. breath sounds= deminished throughout. sx=thick tannish/sl bl tinged secretions-mod amt.\n cv=hemody stable on iabp 1:1. levo weaned & dced. tolerating slow dopa wean. presently on dopa for bp support & argatroban (?hit) for anticoagulation.\n gi=npo. ogt to lis-signif amt bilious drainage. trace guiac positive.\n renal=cvvhdf-slow fluid removal & correction of bun/creat. following ica & k q6hrs-rxing w contin calcium & k gtts. lactic acid decreasing.\n endo=insulin gtt to maint tight control. gtt presently at 2u/hr- increased to to bs 138.\n id=afebrile. on abx x2-ceftiaxone & vanco (dosed/level-dose given @ 0200).\n heme=tx w 1urbc for hct-26--repeat hct 28.\n\na:improving metabolic acidosis. tolerating slow pressor wean/fluid removal. afebrile on abx-lastest cultures pending.\n\np:contin present management. ?wean paralytic. ?wean fio2/peep as tolerated. ?contin slow dopa wean. reck ptt & electrolytes @ approx 0800. follow fsbs-adjust gtt accordingly. ?tx to hct >30. support pt/family as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-25 00:00:00.000",
"description": "Report",
"row_id": 1285798,
"text": "Respiratory Therapy\n\nPt remains orally intubated/sedated/chemically paralyzed. Continues on A/C ventilation w/ PIP/Pplat = 28/20. RR dropped to 18 d/t resp alkalosis per ABG. ABG now WNL w/ 8L/M Ve. SpO2 90s. PEEP remains at 10cm. MDIs given as ordered, scant to no secretions suctioned. IABP in place, on CVVHD. See resp flowsheet for specifics.\n\nPlan: maintain support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-04 00:00:00.000",
"description": "Report",
"row_id": 1285833,
"text": "ccu nsg progress note.\n68 yo male s/p high cardiac cath intervention to diagonal & lad-rotational atherectomy w bms placement .\n\no:neuro=arousable to noxious stimuli only. does not follow commands. mildly sedated w propofol gtt-25mcg/kg/min w gd effect. see flow sheet for complete neuro assessment.\n pulm=intubated/vented. present settings-ac/500x14/40%/+8 w adeq abg/sats. breath sounds=deminished throughout. sx-mod tannish secretions. contin on abx for vap. mod amt oral secretions-mouth care done & ett rotated.\n cv=hemody stable on iabp 1:1 & dopa gtt-titrated to maint iabp maps >60-presently @ 5mcg/kg/min. pads low 30's. ci 2.65-3.27. access-iabp l fem (central lumen clotted-capped off-team aware), paline lsc, & aline r radial. r/l fem sites-old ooze--presently c&d. pulses r-dop/ absent & l d/d-feet cool/pale. heparin gtt started @ 2300-1000u/hr- am ptt >150--gtt stopped @ 0615 for 1hr.\n gi=npo. ogt-bilious guiag neg. tpn infusing as ordered.\n renal=restarted cvvhdf (presently wo dialysis)-pfr 250ml/hr. presently neg, but sifnif positive past 24hrs (received 3l ivf, 2urbc, 2u platlets, & 250ml contrast). see flow sheet for hrly data. am creat 2.1. cal gluc/k adjusted to am labs.\n heme=am hct 25 (26). wo obvious source bl. to be tx w 1urbc.\n endo=insulin gtt adjusted to q1hr bs-presently @ 12u/hr w last bs-120's.\n id=hypotermic-bair hugger added. abx as ordered. vanco level sent w am labs.\n skin=duodern to coccyx area.\n social=wife in-met w md's. updated re:intervention & status.\n\na:labile bp-requiring adjustment of dopa dose freq. tolerating fio2 wean w gd abg/sats. tolerating pfr of 250ml/hr. bs controlled w insulin gtt.\n\np:contin present management. maint adeq sedation. contin wean dopa as tolerated. ?maintain status quo-s/p high risk intervention. ?add tf w gradual dc tpn. to be tx w 1urbc. contin q1hr bs-adjust insulin gtt accordingly. next lab draw 1000. support pt/wife as indicated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-02 00:00:00.000",
"description": "Report",
"row_id": 1285824,
"text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. FI02 decreased to .50 following am ABGs. Lungs dim bilat. Sxd mod amt thin yellow secretions. Culture sent. No RSBI this am. Plan is for procedure in OR this am which was deferred on .\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-02 00:00:00.000",
"description": "Report",
"row_id": 1285825,
"text": "CCU progress note 7a-7p\n\nEVENTS: Pt awake this morning - appropriately nodding head to questions and obeying simple commands. wife in to visit this evening. pt moved to larger CCU room to accomodate all equipment + new kinair bed. Placed on kinair bed. restarted this afternoon since OR/high risk cath postponed - planned for tomorrow. all lines and dsgs changed. fiberoptic IABP machine changed to arrow IABP (non-fiberoptic). pt has better urine output today.\n\nNEURO: remains off sedation since yesterday afternoon. pt finally awake. nodding appropriately to questions. obeying simple commands. able to wiggle extremities. attempts to lift up arms. wife in to visit - very happy with pt being awake. wife assisting pt in doing some physical therapy of arms and fingers (passive/active range of motion) - pt very weak and stiff.\n\nID: afebrile today. Tmax 97. ABX: on cipro + cefepime. prn vanco dosing.\n\nRESP: LS diminished. sx mod amts thick tan secretions. spec sent to lab this afternoon. RR decreased to 14 and Fio2 decreased to 40%. AC 500x14 40% 5 peep. pm ABG: 7.41/34/97/22.\n\nCARDIAC: SR 70-80s freq BIGEMINY + PVCs. run of 9 beats VT this morning. Argatroban off at 8am, but OR cancelled and Argatroban restarted at 0.050mcg/k/min. Attempted to wean Dopamine but only able to get to 7mcq/k/min from 8mcq - pt remains very dependent on dopamine. On , , lipitor. Surgery to notify team regarding time to turn off Argatroban. HCT remains low - slightly lower that yesterday - slow trending down over past few days. HCT 25.6 this evening - discussed w/ CCU team - to give 1 U PRBCs tonite. Cardiac Calcs: PaSat 60%. PA 44/22(30) CVP 11. CO 6.5 CI 2.88 SVR 763. IABP remains 1:1 - fair augmentation. good waveform.\n\nACCESS: R radial ALINE. R femoral PA line. R femoral IABP. L s/c TLC. L femoral double lumen dialysis cath.\n\nGI/GU: foley patent - improved urine output - amber w/ sediment. abd soft distended hypo bs. no bm. OGT patent - bilious residuals this morning - given reglan and no residuals this evening. ?restart tube feeds tomorrow after OR procedure in addition to TPN. to start TPN this evening (day 1). sulcrate.\n\nENDO: FS Q1-2H for INSULIN gtt.\n\nRENAL: down this morning at 930am and pt moved to larger CCU room. Restarted once confirmed that pt wasn't going to OR this afternoon at 3pm. no Dialysate. Replacement fluids 1500cc. Fluid removal goal 50-100 as tolerated. Ca + KCL replacement gtts running per sliding scale and q6h labs. Cr 2.7.\n\n\nPLAN: NPO after midnite. con't . q6h labs. wean Dopamine as tolerated. IABP 1:1. FS q1-2h for insulin gtt. OR for high risk PCI w/ ECMO assist sometime in am. blood bank has blood products on hold. argatroban off sometime tomorrow morning - OR case planned for 1pm. Start TPN this evening. 1u PRBCs overnite.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-02 00:00:00.000",
"description": "Report",
"row_id": 1285826,
"text": "resp care\nremains intub/vented in ac mode. few changes made today per abgs. sxned for small amt tannish sputum. c/w vent support awaiting procedure in o.r.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-03 00:00:00.000",
"description": "Report",
"row_id": 1285827,
"text": "Resp Care\nPt remains on vent. Intubated with 7.5 ett @ 25, patent and secure. Suctioned mod amt yellow secretions, which later became blood-tinged due to pulm. edmema. Mdis given. Peep increased due to low poa2 and pulm. edmema. Rsbi 57. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-03 00:00:00.000",
"description": "Report",
"row_id": 1285828,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P 3VD/PREOP STENT\n\nS- INTUBATED- NODDING HEAD YES/NO TO QUESTIONS APPROPRIATELY\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS ON DOPA GTT/IABP 1:1 MODE. FAIR AUGMENTATION- MAPS- 70-100. REMAINS ON ARGATROBAN 0.05- TO INCREASE TO 0.06 CURRENTLY FOR PTT- 53 THIS AM. REMAINS ON K/CA GTT AS ORDERED WITH THERAPY.\nHR- 80-90'S, MUCH VEA- BIGEMINY- NO RUNS VT.\nPT DENIES CP.\nABLE TO WEAN DOWN DOPA TO 5 FROM 8MCG.\n-CURRENTLY DOWN TO 3MCG , AS PT BP HAS BECOME ON HTN SIDE OVER PAST 1-2 HOURS. ATTEMPTED TO WEAN OFF COMPLETELY- BUT DIPPED BP TOO MUCH WITH THAT.\n\n PT 1 U PRBC 8P-12A. HCT- 25.6 PRE/28.9 POST.\n\n PT REMAINS ON VENT SUPPORT- 40-500-14 5 PEEP.\n\nISSUE THIS EARLY AM- 3:30A- FOUND TO HAVE PULM EDEMA TYPE SPTUM- RED FROTHY.\n\nSX SEVERAL TIMES. ADDED PEEP FOR TOTAL 8 PEEP AS WELL AS D/C DOPA FOR MAPS 110-120'S. ABOUT TO ADD TNG , BUT FOUND THAT PT COULDN'T TOLERATE DROP DOPA FROM 5MCG-TO ALL OFF. ADDED BACK DOPA 3-5 MCG, O2 SATS 94- UP TO 100%.\n=INCREASED PT FLOW RATE AS WELL -BACK UP TO 250CC/HOUR FROM 100CC/HOUR IN ATTEMPTS TO PULL OFF MORE FLUID.\nSTAT CXR OBTAINED CURRENTLY AS WELL. CHECKED EKG FOR ISCHMEMIA (-).\nPT PAD UNCHANGED FROM EARLIER IN SHIFT- 22-25. UNABLE TO MEASURE CVP( DEDICATED LINE TO TPN).\nCURRENTLY AWAIT RESULTS OF CXR.\nPAD RELATIVELY UNCHANGED.\n\nID- AFEBRILE CURRENTLY. 97.9 PO.\nREMAINS ON CEFAPIME/CIPRO FOR (+) SPUTUM.\n\nGU/ PT REMAINS ON UNTIL OR TODAY 1PM.\nPRISMA 2 K- REPLACEMENT SOLUTION 1500CC/HOUR, HOLDING DIALYSIS.\nGOAL (-)50-100C. BLOOD FLOW RATE- 120CC/ PT FLOW RATE 100-250. INCREASED PT FLOW RATE DURING PRBC TRANSFUSION AS WELL AS THIS EARLY MORNING WITH SUPPOSED PULM EDEMA EPISODE. HAVE MAINTAINED I/O (-)50-100 THIS SHIFT. 20-50CC/HOUR URINE OUT VIA CATHETER.\n\nGI= OG TUBE IN PLACE- NPO.\nHOLDING REGLAN D/T NPO.\nSTARTED ON TPN YESTERDAY- NO CHANGE IN DOSE/RATE CURRENTLY.\nREMAINS ON INSULIN GTT- CURRENTLY OFF FOR BLOOD SUGAR DOWN TO 74.\nOVERALL- HAD BEEN ON .5U/HOUR.\n(+) BOWEL SOUND BUT NO STOOL\nCOLACE AS ORDERED/SUCRALFATE.\n\n\n\n PT OPENING LOOKING OVER TOWARDS THE SPEAKER.\nWIFE HERE, WITH SISTER THAT JUST FLEW IN FROM PA.\nALL AWARE OF PLAN OF CARE AND OR/STENT TODAY.\nPT OFF FENTANYL, VERSED.\nLOOSELY TIED LEFT HAND, AS FOUND TO BE DRIFTING UP TOWARDS ETT WITH LEFT HAND.\n\nSKIN- COCCYX DUODERM FOR REDNESS AREA.\nMULTIPODUS BOOTS IN PLACE, ON KINAIR BED.\n\nLINES- REMAINS WITH RT FEMORAL IABP/PA LINE; LEFT FEMORAL DIALYSIS CATHETER; RT RADIAL ALINE; LEFT IJ TLC//\n\n PT AWAKENS TO NOISE/LIGHTS/CALLING NAME.\nOPENING EYES SPONTANEOUSLY- APPEARS TO UNDERSTAND QUESTIONS.\nNODDING APPROPRIATLY TO QUESTIONS. WIFE/SIS IN LAW HERE TO VISIT.\nAPPEAR TO UNDERSTAND PLAN FOR TODAY/\nPT DENIES COUGHING/ATTEMPTING TO MOVE LEGS A LITTLE/MOVE AROUND IN BED- CAUSING SOME ALARMS FOR .\nOFF ALL SEDATION CURRENTLY.\n\nA/ PT S/P CV SHOCK/3 VD CURRENTLY REMAINS ON PRESSOR/IABP/VENT SUPPORT.\n FOR DIALYSIS.\n\nEPISODE OF PULM EDEMA IN SPITE OF MAKING I/O (-) WITH .\nREPSONDING WELL TO INCREASING P\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-03 00:00:00.000",
"description": "Report",
"row_id": 1285829,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P 3VD/PREOP STENT\n(Continued)\nT FLOW RATE AND INCREASING PEEP.\n\nCONTINUE TO WATCH HEMODYNAMICS- WEAN OFF DOPA AS ABLE. PLAN FOR OR TODAY FOR STENT WITH ECMO. NPO AFTER MN , TO DISCUSS D/C OF AGARTROBAN AT AM ROUNDS. ALL LABS FOR PLT/PBRC SENT .\n\nCOMFORT/SKIN CARE- CONSIDER LOW DOSE SEDATION FOR COMFORT- MULTIPLE LINES/PROLONGED BEDREST. WITH INCREASED ALERTNESS, PT SEEMS A BIT MORE RESTLESS/UNCOMFORTABLE- MAKING ALARM WITH MOVEMENT OF LEGS FREQUENTLY/ARCH BACK TO GET COMFORTABLE.\n\nCONTINUE ANTIBX AS ORDERED- WATCH FOR FURTHER FEVER. ON/OFF BAIR HUGGER DEPENDING ON TEMP/COMFORT LEVEL.\n\nCONTINUE Q 1-2 HOUR BLOOD SUGAR CHECKS- ON INSULIN GTT.\n\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\n\nOBSERVE CLOSELY FOR ANY FURTHER PULM EDEMA/RESP DISTRESS.\nKEEP I/O (-) AS ORDERED VIA MACHINE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-03 00:00:00.000",
"description": "Report",
"row_id": 1285830,
"text": "CCU NSG- ADDENDUM 6AM\n\nS/O- CXR EXAMINED BY TEAM- FOUND TO BE SIMILAR TO AM- NOT FLORID CHF/PULMONARY EDEMA BY CXR- ? POSSIBLE BLOODY SECRETIONS R/T INFECTION/ON AGATROBAN.\nA/P- CONTINUE PULM TOILET/KEEP AIRWAY CLEAR- OBSERVE FOR AMT/FREQ BLOODY SECRETIONS.\nTO START VANCO FOR GM (+) COCCI SPUTUM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-03 00:00:00.000",
"description": "Report",
"row_id": 1285831,
"text": "CCU progress note 7a-3p\n\nEVENTS: Sent pt to OR @ 3pm for high risk PCI w/ ECMO. d/c'd at 12pm.\n\nNEURO: nodding appropriately. off sedation. mouthing words this morning. wiggles all extremities to command - very weak. pt is BLIND.\nSOCIAL: wife called this morning. to come in this evening post procedure.\n\nACCESS: R radial Aline. R femoral IABP. R femoral PA line. L s/c TLC. L femoral dialysis double lumen line.\n\nCARDIAC: SR 70s w/ freq PACs + vent Bigem. IABP 1:1. PAD 16 CO 7.6 CI 3.36. PAsat 70%. unable to wean dopamine - Dopamine @ 4mcg/k/min. Argatroban d/c'd at 10am. pt HIT negative. + , Lipitor.\n\nRESP: AC 500x14 40% Peep 8. Sats 100%. sx mod amts thick tan secretions. had bloody secretions early morning. LS scattered rhonchi to diminished.\n\nID: wbc 13.5. abx: vanco, cefepime, cipro. Tmax 98.2.\n\nRENAL: foley patent. ~15cc/hr amber urine w/ sediment. d/c'd at 12pm.\nGI: abd soft, distended. hypo BS. no BM. colace, senna today. on carfate.\nENDO: FS q1H for INSULIN gtt.\n\nPLAN: to OR/CATH for high risk PCI w/ ECMO support this afternoon. to return to CCU post op - then restart . con't hemodynamic support/meds. emotional support to wife.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-09 00:00:00.000",
"description": "Report",
"row_id": 1285855,
"text": "CCU Progress Note:\n\nS- \"I want to go home!\"\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SR-ST with rare PVC noted- HR 91-105- ABP 95-127/47-58 MAPs 58-76 on dopamine gtt- weaned down to 4mcq/kg/min- PAS 31-36 PAD 15-18\nCVP 6-8- last CO 5.5 CI 2.35 SVR 945- Hct trending down- last 26.3- T&C sent- transfuse 1u PRBC's when available- PTT 50.5- heparin 300u/hr infusing via CVVHD- K 4.4 KCL gtt @ 20cc/hr- ionized Ca 1.21 Ca gtt @ 25cc/hr.\n\nresp- In O2 4L via NC- last ABG 7.43-36-%-lung sounds coarse, diminished @ bases- SpO2 98-100%- last mixed venous 57%.\n\nneuro- feeling a better today & verbalizing wish to go home- A&O X2- moving all extremities- pleasant & cooperative- follows command.\n\ngi- abd soft (+) bowel sounds- taking small amts Po without incident-\n1 mod loose grn/brn colored stool- quiac (+)- con't on insulin gtt @ 1u/hr- glucose range 108-121.\n\ngu- foley draining scant amt conc amber brown colored urine- con't on CVVHD- CCU team in this am & decision made to wean Pt off dopamine gtt rather than take off 50cc/hr- running Pt even- able to wean Pt to 4mcq/kg/min- If Pt able to be off pressors, CVVHD will be D/ Pt will go to IR for tunneled line placement for dialysis access.\n\nId- T Max 98.2 Core- WBC 12.9- nafacillin D/C'd.\n\nskin- duoderm on coccyx intact- skin care given PRN- on air mattress.\n\nA- tolerating weaning pressor.\n\nP- transfuse 1u PRBC's tonight- wean off dopamine gtt if able- ? D/C CVVHD- D/C PA line tonight- If stable overnight, Pt to go down to IR for renal access cath- encourage increase Po intake & once lines D/C'd, increase activity- offer emotional support to Pt & family- keep them updated on plan of care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-10 00:00:00.000",
"description": "Report",
"row_id": 1285856,
"text": "CCU NPN 1900-0700\nS: \"What am I doing wrong...can you get me out of the hallway..can I get something to knock me out?\"\n\nO: Please see careview for VS and additional data.\n\nCV: HR 83-101 NSR/ST rare to frequent PVC's noted, received pt on dopamine gtt 3 mcg/kg/min-> gtt weaned off with MAPs > 60 for approx 3 hours, CO 5.5/CI 2.35/SVR 844, CCU intern aware. Pt MAPs dropping to 53, CCU intern notified, PFR decreased to 0 and dopamine gtt resumed at 2 mcg/kg/min, dopa gtt attempted to be weaned several times, but pt MAPs would drop 48-50's during sleep, PFR remained at 0, dopa gtt would resume. Pt increasing + approx 700 cc at 0400, PAD 21, CVP 11, Dr. notified, plan is to continue with low dose dopa and fluid goal 0-500 cc + at this time per Dr. . Maps 48-75, PAD's 15-21, CVP 7-11. Pt rec'd 1 unit PRBC's last night for HCt 26.3, Hct 29 off mixed venous approx 30 mins after transfusion, am labs sent, Hct 25.6, Dr. aware, repeat Hct sent, lytes pending. Bilateral pedal pulses dopplerable, R & L femoral sites, a-line and PA line sites CDI. Heparin 300 units/hr infusing pre-filter via CVVHD with therapeutic PTT. KCL and calcium continue to infuse IV via sliding scale.\n\nResp: Pt LS clear to diminished at RLL, O2 sats 100% on 4L n.c, RR 24-30 at rest, up to high 30's with turning, pt tachypneic with position changes, briefly hypotensive x2 with turning side to side, resolved at rest when supine or on right side. Most recent ABG 7.41/34/95/-.\n\nGU/GI: Pt cont on CVVH PFR 0-150, received pt with goal to run even so as to allow for dopamine gtt titration off, dopa gtt off with PFR at 50, pt -126 cc at midnoc, as pt had large brown/green liquid stool at approx , CCU intern aware. Pt cont with guiac + stools-had 1 sm and 1 med brown/green liquid stools with sm pellets . Pt with scant u/o see flowsheet. Please see careview flowsheet for additional CVVH data, pt to go to IR today for tunneled dialysis line and CVVHD to be dc'd this am-continued as pt cont on dopamine. Pt abd soft, + Bs x4, pt juice and pills last eve. Pt continues on TPN.\n\nNeuro: Pt A& O x2-3, pt a day or two behind (thinks /28th), but able to recall correct date when reminded. Pt received trazadone 25 mg last night, pt appeared to have slept for approx 1 hour, pt awoken somewhat disoriented, verbalized he thought he was in the hallway, pt crying, verbalized desire to go back to bed (pt was in bed)-pt oriented to surroundings and noises he was hearing, emotional support given. Pt calm throughout remainder of night. Pt dozing intermittently throughout night, of note, pt noted to have eyes halfway open and at times open while sleeping (pt verbalized he had been sleeping to confirm). Pt MAE, able to move arm and bend R leg in direction of turn, assists minimally, follows commands.\n\nENDO: FS 95-128, pt continues on insulin gtt, presently 0.5 units/hr.\n\nID: pt afebrile, WBC 14.4 (up from 12.9 yesterday).\n\nSkin/Access: Pt duoderm off coccyx with stool earlier\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-10 00:00:00.000",
"description": "Report",
"row_id": 1285857,
"text": "CCU NPN 1900-0700\nAddendum: repeat HCt 24.5, pt ordered for 2 units PRBC's, 1st unit presently infusing. PFR decreased to 0 per CCU intern and resident as pt could use volume MD's. Awaiting further per CCU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-10 00:00:00.000",
"description": "Report",
"row_id": 1285858,
"text": "CCU NPN 1900-0700\n(Continued)\nin eve, unable to fully assess site as pt hypotensive with turn, able to visualize two reddened appearing open patches on R and L buttock, area cleansed and duoderm applied. pt continues with PA line, pa line will most likely need to be changed over wire as pt has no other access for TPN/blood infusions. L femoral dialysis line to be changed to tunnelled line today.\n\nSocial: No calls or visitors .\n\nA/P: 68 y/o male briefly weaned off dopa gtt last eve, restarted for MAps 50's, pt exceeded goal of even at midnoc, pt -126 cc, pt now + this am on CVVH as MAPs decreased and dopamine gtt resumed. Cont to monitor pt hemodynamics-wean dopamine to off for MAPs >60. ? DC Pa line today once pt hemodynamically stable off dopa gtt, ? change to central line. Cont to monitor resp status, pt tachypneic at times with turning and hypotesive briefly in early evening with turning-advance pt activity as . Cont to advance diet as pt . Cont to provide emotional support to pt, contact social worker for pt's needs now that pt extubated and able to communicate. Awaiting further per CCU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-10 00:00:00.000",
"description": "Report",
"row_id": 1285859,
"text": "CCU NSG NOTE: ALT IN CV/RENAL\nS: \"I'll get that line, and if we want to we can quit later\".\nO: For complete VS see CCU flow sheet.\nSTATUS: Patient and wife had long discussion about goals of care, and immediate plans. They decided to have tunneled catheter placed for long term dialysis with the knowledge if it becomes too much he can quit. He and his wife also decided that at this point he should be DRN/DNI. Order has been written. Both patient and his wife understand what that means.\nID: Pt afebrile. WBC 14.5 (14.3). He is off all ABX.\nCV: Dopamine was again weaned off from low level of 2 mic/kilo at 11:20. Maps occasionally have dipped into 50s but quickly come up with stimulation, and occasionally on their own. PAP has ranged 30-40/12-22, with CVP 5-14. His last CO/CI at 1600 was 7.0/2.9/594. HR has been in 80-90 with very frequent PVCs, including runs of ventricular bigeminy and trigeminy, but no couplets or runs of VT seen. At 1850 pt had self-limiting run of SVT. Last K+ is 5.4. All pulses dopplerable, feet warm and CSM nl.\nHEME: Pt received a total of 3 U of PRBC since last evening until 11am today when the 3rd unit infused. Crit at 1600 was 27.8. It was 29.5 between the 2nd and 3rd unit.\nRENAL: Pt had tunneled dialysis line placed in angio today. Heparin, pre-filter was shut off at 0900 both for line placement and crit drop. He tolerated proceedure very well receiving .5mg versed and 12.5mg fentanyl. He did not drop his pressure and maps remained in the mid to high 60s. CVVVH was d/c and blood returned at 1530 just prior to going to angio. Both potassium and calcium drips were stopped. He still has dialysis line in L groin. Renal will not remove it prior to tomorrow.\nNew line is clean and dry. Catheter is ready to use and pt will likely receive HD tomorrow. Due to drops in BP overnight and the 3 units of blood pt is now 1 liter pos for the day.\nRESP: Pt was SOB overnight, but with increase in CVVH removal rate during late am and afternoon RR has come down and he has been sating 97-100% on RA. Breath sounds very decreased.\nGI: Pt NPO for line placement. No stool, no nausea, no foul flatus. Pt continues on TPN.\nENDO: Insulin gtt was shut off for FS in 80s at 1200. It has not been restarted. Pt being changed to ss reg insulin coverage. Last FS at 1800 was 121.\nSKIN: Pt now has stage 1 breakdown around coccyx area. Wound was worsened when duoderm removed. Area cleansed with wound cleanser, barrier wipe applied and allyvn dsg put on. Moiture barrier cream applied to buttock area. Pt remains on air-bed. Now that he is no longer receiving CVVH he can go side to side.\nMS: Pt is A & O X 3. He occasionally becomes mildly disoriented, confusing dreams with reality, but is quickly re-oriented. He has been tearful a few times, being overwhelmed by all that is happening, but quickly recovers with support. He is very anxious about all that is going on and both needs and responds to emotional support. His wife is a strong support for him and he would like to talk with her wheneve\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-29 00:00:00.000",
"description": "Report",
"row_id": 1285814,
"text": "ccu nsg progress note.\n68yo male to from osh for pulm edema requiring intubation. cardiac cath=sever 3vd w 4+mr, pulm hyper- tension, & elevated -rxed w iabp placement & pressor support. subsequently volume overloaded-cvvhdf initiated. evaluated by csurg- cabg & avr--refused due to overall physical status-?high risk intervention .\n\no:neuro=minimally sedated-versed 0.5mg/hr--off fentanyl since . minimally responsive to noxious-moves r arm only & grimaces.\n pulm=intubated/vented w present settings-ac/500x16/40%/+5 w am abg- 7.41/30/125/20. breath sounds=deminished throughout. minimal tannish secretions.\n cv=continues on iabp 1:1 w maps 60-70 & pads 16-19. contin on dopa gtt-weaned from 10-6mcg & levophed gtt @ 0.032mcg. argatroban gtt @ 0.050mcg w am ptt-72.0. rhythm sr w episodes of ventricular bigeminy- pvc not generating pulse pressure/subsequently no augmented beat w pvc. r/l fem sites c&d. pulses dopplerable +4.\n gi=npo. absent bowel sounds. wo stool.\n renal=remains on cvvhdf wo dialysis mode. removing approx 50ml/hr- neg 1.6l for past 24hrs. minimal dark urine from foley.\n endo=insulin gtt w controlled bs.\n id=afebrile. abx as ordered.\n\na:minimal response to noxious stim-off fentanyl since days . overall fluid status -7l.\n\np:contin present management. ?intervention to 3vd in cath lab-. support pt/family as indicated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-29 00:00:00.000",
"description": "Report",
"row_id": 1285815,
"text": "CCU Nursing Progress Note 0700-1900\nS: no verbal response.\n\nO: see CCU flow sheet for complete objective data\n\nCV: BP very labile, esp with position changes. Levo weaned to off over course of shift, Dopamine remains @ 6 mcg/kg/min. MAP 62-98 on IABP 1:1, falls to 40 when turned on left side, MAP 10 points lower when IABP placed on 1:2. PAD 15-17, RA , CO/CI/SVR off of levo: 5.9/2.61, SVR 610. HR 70-80's NSR with occ PVC's. Argatroban @ 0.05 mcg/kg/min, PTT PND, plt 47-48 (54). Hct 27.4 (27.6). Plan for high risk interventional procedure tomorrow, ? time.\n\nIABP pulled back by cardiology fellow ~4 cm. dp/pt dopplerable bilaterally. Feet warm, cap refill > 3 sec. Hands cool bilaterally, radial pulses dopplerable. cap refill > 3 sec.\n\nCRRT: plan as per CCU team--keep pt. even today. CRRT: replacement @ 1500cc/hour, no dialysate, Blood flow 100cc/hour. For several hours today, did not remove any fluid as BP very labile with position changes. Remainder of day, removed fluid to keep pt. ~ even. K and Calcium gtts titrated according to protocol. Clots visible in filter. Due to be changed @ 0700--do not prime with Heparin d/t HIT profile. BUN 26, Cr 2.4, repeat PND. Making ~ 75 cloudy amber urine over course of day.\n\nResp: lungs with diminished breath sounds. Remains on 40%-500-16AC, 5 PEEP. Breathing 0-8 breathes over vent. Last ABG 7.43/32/101/22/-1 98%. ETS--> scant whitish secretions.\n\nNeuro: intitially not moving extremities,not even to pain, later in day moving left arm up in air in response to oral care. Slightly turns head, grimaces with oral care. No pupil right eye, left eye pupil ~2mm, very sluggishly reactive. Versed gtt decreased by 20% (0.5 mg/hour-->0.4 mg/hour).\n\nGI: abdomen obese with hypoactive bowel sounds. OGT asps--> 30cc bile. TF (probalance started) @ 10 cc/hour, on reglan 5mg IV q 6 hours while on TF. TF to stop at midnight for interventional procedure tomorrow. No stool.\n\nEndo: on insulin gtt units/hour, BS checked q 1-2 hours, BS~ 100-150.\n\nID: t max 96.7 po, WBC 6.7. On cipro and cefepine. TLC site slightly pink. Other lines look clean.\n\nskin: multipodous boots on, coccyx area is very red, but not broken. Position changes limited d/t hypotension--only able to turn slightly off of back. Not stable enough to transfer to other type of bed. Please order pressure reducing bed in am so that pt. can be placed on it when he returns from interventional procedure tomorrow.\n\nAccess: L SC TLC, Left fem dialysis cath, Right fem PA cath, right fem IABP, Right radial a-line\n\nSocial: wife in to visit. Wife spoke with intern re:. Wife home for the evening. Dr. given wife's telephone # so he can call her with the cardiology plan.\n\nA: very labile BP, not tolerating position changes, limiting ability to remove fluid with CRRT. Continues to be very sedated 24 hours off of fentanyl although does have more spontaneous resps today. Bowel sounds a bit more active today off of fentanyl, tolerating TF\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-29 00:00:00.000",
"description": "Report",
"row_id": 1285816,
"text": "CCU Nursing Progress Note 0700-1900\n(Continued)\nthus far. Impaired skin integrity d/t hemodynamic compromise, immobility and decreased nutritional intake.\n\nP: stop Tf @ midnight for interventional procedure. Order pressure reducing bed in am. Titrate dopamine for MAP >60. check with HO re: ? transfusion. Continue to CRRT to keep I/O ~ even as hemodynamics allow. Reduce sedation further in several hours if still sedate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-29 00:00:00.000",
"description": "Report",
"row_id": 1285817,
"text": "Respiratory care\nPt remains on a/c without changes. Suctioned min amts of white secrections. Plan to go to cath lab tommorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-01 00:00:00.000",
"description": "Report",
"row_id": 1285818,
"text": "RESP CARE: pt remains intubated/on vent on settings per carevue. Lungs dim bibasilar. Sxd small amts yellow sputum. Pa02-113 on .50/5 pEEP. No RSBI due to planned OR procedure this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-01 00:00:00.000",
"description": "Report",
"row_id": 1285819,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ 3VD; HYPOTN/CV SHOCK\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS PRESSOR/IABP DEPENDANT- DROPPING MAP EASILY WITH ANY INTERRUPTION IN IABP OR DOPA GTT- EVEN WITH CHANGING OF TUBING.\nMAPS OVERALL 60-80'S BUT WITH TURNING ON SIDE- DROPPING TO 40-50'S- REQUIRING INCREASE DOPA DOSE TRANSIENTLY. DOPA 6 MCG/KG- INCREASED BRIEFLY TO 10 MCG/KG. CO/CI/SVR= 5.8/2.5/400 THIS AM. REMAINS OFF LEVO GTT ALL EVENING/ MORNING. BILATERAL GROIN SITES D/I- PULSES DOPPLERABLE.\nPAD-18-20, CVP-.\n\nRESP- INTUBATED - 40-500-16 PEEP-5. O2 SATS 99-100%. SX FOR SCANT YELLOWISH SPUTUM, DIM BREATH SOUNDS.\nRESP RATE IN SYNCH WITH VENT- AT TIMES BREATHING RATE OVER VENT.\nGOOD ABG- 7.42-39-151 100%.\n\nID- AFEBRILE- CEFAPIME/CEFTRIAXONE FOR ENTEROCOCCUS IN SPUTUM.\nBAIR HUGGER ON STANDBY CURRENTLY\n\nGI- HIGH RESIDUALS- TUBE FEEDS 10CC/HOUR WITH 90CC RESIDUALS. NPO AFTER MN- HELD FEEDS 8PM.\nHYPOACTIVE BOWEL SOUNDS. NO STOOL . REMAINS ON CARAFATE, REGLAN WHILE FEEDING.\nOG TUBE PATENT, CHECKED PLACEMENT PER PROTOCOL\nPT IN INSULIN GTT/PROTOCOL- BLOOD SUGARS 100-120- REMAINS ON 1.5-2U.\n\n PT REMAINS ON KEEPING I.O EVEN- NO DIALYSIS. REPLACEMENT WITH K2- AT 1500CC/HOUR- PFR- 100CC. SEE FLOWSHEET FOR VALUES.\nACCESS SITE WNL. NO ISSUES WITH OCCLUSION/FILTER CLOTTING.\nOF NOTE- FILTER TO BE CHANGED THIS AM- BUT TO BE D/C PREOP ON WAY TO OR AT NOONTIME. PT PUTTING OUT SMALL AMT URINE VIA FOLEY CATH.\nREMAINS ON CA/K REPLACEMENT PER PROTOCOL- CHECKING LABS Q 6 HOUR AS ORDERED PER ORDERS. WITH PT OCCLUDING .\n\n PT OPENING EYES AT TIMES, VERY SEDATE, RELATIVELY NONRESPONSIVE.\nMOVING UPPER EXTREMITIES SLIGHTLY, COUGHING WITH STIMULATION.\nOPENING EYES WITH STIMULATION AS WELL. REMAINS ONLY ON VERSED 0.4MG/HOUR- D/C FENT GTT .\n\n WIFE CALLED TO GET CONSENT FOR OR PROCEDURE TODAY.\nCCU TEAM AND DR CALLED HER AS WELL.\nNO FURTHER CALLS FROM HER THIS SHIFT.\nAPPEARS TO UNDERSTAND PLAN OF CARE.\n\nA/ PT S/P MI; HYPOTENSION; 3VD- CURRENTLY REMAINS VENT/PRESSOR/IABP DEPENDANT.\nTO ATTEMPT HIGH RISK PERCUTANEOUS CARDIOLOLGY PROCEDURE IN OR UNDER BYPASS/ECMO.\n\nCONTINUE TO KEEP MAP>60 ON DOPA- INCREASE GTT AS NEEDED INSTEAD OF ADDING BACK LEVO. KEEP IABP ON 1:1. NPO AFTER MN- D/C ARGATROBAN 8AM AS ORDERED PREOP.\n\nCONTINUE TO MAINTAIN UNTIL OR CASE.\nGOAL FOR I.O - EVEN.\n\nCONTINUE TO REPLETE CA/K AND KEEP BS UNDER CONTROL ON INSULIN GTT.\n\nCONTINUE TO OBSERVE MENTAL STATUS/LEVEL OF REPSONSIVENESS.\nKEEP COMFORTABLE ON VERSED GTT.\nKEEP FAMILY AWARE OF PLAN OF CARE.\nOR TO FOLLOW CASE TODAY.\nCONTINUE ANTIBX AS ORDERED- OBSERVE FOR ANY FURTHER FEVER SPIKE.\nBAIR HUGGER AS NEEDED ON .\nCONTINUE TO ATTEMPT TO KEEP PT EVEN ON THERAPY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-01 00:00:00.000",
"description": "Report",
"row_id": 1285820,
"text": "CCU progress note 7a-7p\n\nEVENTS: turned off this afternoon in preparation for OR - late this afternoon OR (for high risk PCI w/ ecmo support) on hold due to hypotension, low CI and low Po2 - increased FIO2 requirements. Titrating Dopamine + FIO2. Family aware - wife coming in this evening to visit. Still awaiting decision from Dr . To restart tonite.\n\nNEURO: not really waking up - opened eyes all morning, some twitching, withdrew to nail bed stimuli on both hands, did not obey commands. Versed was at 0.5mg/hr. After low BP + low PaO2 pt less responsive even with Versed off since 3pm.\n\nFULL CODE status.\n\nRESP: LS clear, dim. some frothy secretions this afternoon. thick yellow this morning. AC 500x16 now 60%(40) 5 peep. sats 98-100% all day. Oral care q4h per VAP protocol.\n\nID: afebrile. hypothermic this morning 94 orally - placed back on bair hugger - for temps 96 - finally after CVVHD off pt temp up to 99.1 - bair hugger turned off- 2hrs later temp up to 99.9 off bair hugger. watch Temp overnite ?pan cx if >101. abx: cipro + cefepime.\n\nCARDIAC: SR 70s this morning w/ bigem PVCs w/ corresponding dropping of SBP/MAPs. this afternoon after dopamine increased from 6mcg/k/min up as high as 15mcg/k/min SR/ST 80s-105 w/ occasional PVCs rare bigem. noted short run SVT. IABP remains 1:1. fair augmentation at times. 4pm cardiac calcs: PA 42/20(30) CVP 5 CO 6.7 CI 2.96 SVR 645 w/ PAsat 62 (Pasat as low as 42 during the day). Argatroban off since 8am ?restart if pt does not go for procedure today - new sliding scale in chart. PEDAL PULSES: unable to dopple R PT - difficult to dopple L PT. easily dopplerable DPs.\n\nGI/GU: foley patent, scant amts dk amber/brownish urine w/ sediment. abd distended, hypo BS - no BM - on colace . OGT patent. NPO today for ?OR. restart reglan if TF restarted. Nutrition on consult for TPN ?start in am. restart tonite - q6h labs (abg, IonCa, lytes, HCT, PTT).\n\nENDO: FS q1-2H - INSULIN gtt.\n\nRENAL: on all day - goal even to 50 negative - Renal stating to have goal fluid removal rate increased to 50cc/hr if BP tolerates. No dialysate. Replacement @ 1500cc/hr. restart Ca + KCL gtts w/ . q6h labs during .\n\nPLAN: watch Temp ?pan culture. con't abx. restart . TPN to be started in am. ?attempt restart of TF overnite. restart argatroban. con't IABP 1:1. cardiac calcs q4h. ?OR for PCI intervention tonite or in am - awaiting decision from Dr .\nACCESS LINES: R femoral PA line (blue swan), R femoral IABP. R radial Aline. L s/c TLC. L femoral double lumen dialysis line. ?HIT not using heparin for flushing or instilling in dialysis port or for priming machine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-01 00:00:00.000",
"description": "Report",
"row_id": 1285821,
"text": "resp care\nremains intubated/on full ventilatory support in ac mode. required increased fio2 for worsening oxygenation. small amts secretions. awaiting o.r procedure. refer to flow sheet for further info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-02 00:00:00.000",
"description": "Report",
"row_id": 1285822,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CV SHOCK/3VD/PNA\n\n PT REMAINS SEDATE /NOT COMMUNICATING.\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT ON IABP 1:1 MODE VIA RT GROIN SITE. MAPS REMAIN 60-100 ON DOPA GTT. ABLE TO WEAN DOWN DOPA FROM 12 MCG TO 8 MCG THIS SHIFT. DROPPED MAP WITH ATTEMPT TO WEAN BACK DOWN TO 6 MCG AS YESTERDAY'S DOSE.\nSEE FLOWSHEET FOR IABP VALUES. GOOD AUGMENTATION, INCONSISTENT SYSTOLIC UNLOADING. HR- 80-90 ST, REMAINS WITH FREQ PVC/BIGEMINY IN SPITE OF NML ELECTROLYTES- K- 4.1, CA- 1.20, MG- 2.0. PT RESTARTED ON CA/K GTT ONCE REINITIATED 12AM.\nCURRENTLY RECHECKING LYTES/AM LABS.\nGROIN SITES CLEAN/PULSES DOPPLERABLE.\nCHECKED EVENING CPK AS WELL AS EKG TO R/O ICHEMIA AS CAUSE OF DROP IN MAPS/O2 YESTERDAY- ALL (-).\nRESTARTED ARGATROBAN 10PM AT 0.05 MCG WITHOUT BOLUS, AS IT WAS DECIDED HE WAS NOT GOING FOR PROCEDURE/OR BY 9:30PM.\nNPO AFTER MN AND WILL REASSESS FOR POSSIBLE HIGH RISK INTERVENTION WITH ECMO.\n\nRESP- REMAINS INTUBATED- 60-500-16-5 PEEP. BREATHING OVER VENT SLIGHTLY AT TIMES, O2 SATS GOOD- 99-100%.\nSX FOR SCANT TANNISH SPUTUM- DIM BREATH SOUNDS AT BASES.\n\nID- LOW GRADE TEMP- 99.9- SPIKING UP TO 100.8 PO 10P- PAN CULTURED AND GIVEN 1 DOSE VANCO.\nREMAINS ON CEFAPIME AND CIPRO.\n\n PT REMAINS NPO AFTER MN FOR POSSIBLE OR /PROCEDURE TODAY THAT WAS DEFERRED FROM YESTERDAY D/T ISSUES WITH DROP IN SATS/CI.\n(+) BOWEL SOUNDS, NO STOOL. HOLDING REGLAN, REMAINS ON CARAFATE.\nREMAINS ON INSULIN GTT 1-2.5U/HOUR.\nPLAN FOR TPN PROBABLY ONCE PROCEDURE/OR TRIP COMPLETE.\n\nGU/ PT RESTARTED ON 12AM S/P D/C FOR OR/PROCEDURE.\nCURRENTLY ON PT REMOVAL RATE 110CC/HOUR, BLOOD FLOW RATE 100CC/HOUR. REPLACEMENT 1500CC/HOUR- K2 PRISMASATE. DIALYSIS HELD. NO ANTICOAG VIA MACHINE. ( PT ON ARGATROBAN SYSTEMICALLY)\nFOLEY CATH- PUTTING SMALL AMT URINE- SENT UA/C AND S.\n\nLINES- RT FEMORAL IABP/PA LINE. RT RADIAL ALINE. LEFT SC TLC. TRANSDUCING FOR CVP.\nLEFT FEMORAL DIALYSIS CATHETER.\n\n PT WITH OPEN EYES, BUT NOT FOLLOWING COMMANDS, NOT TRACKING VOICE.\nWIFE IN EARLIER THIS EVE AND CALLED 3AM.\nAWARE THAT PLAN FOR PROCEDURE DEFERRED D/T CLINICAL CONDITION. TO REASSESS TODAY.\nOFF ALL SEDATION.- HELD VERSED AS OF .\n\n PT TURNED, DUODERM TO COCCYX FOR RED/PURP DISCOLORATION.\nTO GO ON KINAIR BED ONCE LARGER ROOM OPENS UP ACROSS THE WITH C/O PT PLANNED TO GET BED TODAY. UNABLE TO FIT BED AND PUMPS/IAPB/ IN SMALL ROOM #19 CURRENTLY.\nSOME LABILE BP WITH TURNING- INCONSISTENTLY.\n\nA/ PT S/P MI/SHOCK REQUIRING IABP//PRESSORS/ETT FOR OVER 1 WEEK- CURRENTLY ABLE TO WEAN DOWN PRESSOR AND REMAIN HEMODYNAMICALLY STABLE.\nPT SPIKING TEMP TODAY- PAN CULTURED AND GIVEN 1 DOSE VANCO.\nSEDATION D/C AND PT MORE AWAKE BUT NOT DOING PURPOSEFUL MOVEMENT/COMMUNICATION CURRENTLY.\nPLAN FOR OR /PROCEDURE TODAY. NPO AFTER MN- CHECK WITH TEAM RE: STOP ARGATROBAN THIS AM. REQUIRE CARDIOLOGY CONSENT ONLY IF PT GOES.\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS/RESP STATUS. CONTINUE PRESSOR WEAN AS TOLERATED. PULMONARY TOILET/DIURESIS AS NEEDED.\nCONTINUE WITH GOAL OF I/O EVEN/ NO DIALYSIS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-02 00:00:00.000",
"description": "Report",
"row_id": 1285823,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CV SHOCK/3VD/PNA\n(Continued)\nP PT COMFORTABLE, BUT ATTEMPT TO KEEP OFF SEDATION TO BETTER ASSESS PT UNDERLYING MENTAL STATUS.\nKEEP WIFE AWARE OF PLAN OF CARE.\n? PLAN FOR PICC FOR TPN ONCE THIS PROCEDURE COMPLETE.\nCONTINUE SKIN CARE/ CHANGE BED TO KINAIR THIS AM.\nCHECK LABS CURRENTLY/REPLETE LYTES AS ORDERED- KEEP BLOOD SUGARS UNDER BETTER CONTROL WITH INSULIN GTT PER PROTOCOL. CHECK PTT - KEEP ARGATROBAN AT THERAPEUTIC LEVELS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-23 00:00:00.000",
"description": "Report",
"row_id": 1285791,
"text": "SR NO ECT.IABP 1 TO 1.GOOD AUGMENTATION.BP LABILE.NEO CHANGED TO LEVOPHED.REMAINS ON DOPAMINE.BP 60S TO 160S SYSTOLIC .WEANED AS TOLERATED BUT BP WOULD SUDDENLY DROP FROM 120 TO 60 SYSTOLIC.PTT 150.ADJUSTED PER PROTOCOL .NO BLEEDING FROM EITHER GROIN .DP BY DOPPLER .\n\nPT AUTO PEEPING,PARALYZED C CISATRACURIUM.ABG SLOWLY IMPROVING TO 7.26/34/94/16/96.WEANED TO 80%.500 TV/24/12 PEEP,SX MN ET,SX BLOODY FROM MOUTH.\n\nOG IN PLACE ,HYPOACTIVE BS .\n\nHUO 15CC BLOODY URINE .CVVH CHANGED TO CVVHD .GETTING 120CC/HR,PFR SET AT 150 .\n\nPT INCREASED TO 5 MG VERSED ,150 MIC FENTANYL BEFORE BEING PARALYZED .PT HAD UPPER EXTREMITY TREMORS .4 TWITCHES L ULNAR NERVE 40 MA TO4\nNOT RESPONSIVE .WIFE VISITED,SEEN BY \n\nCARDIGENIC SHOCK,ACIDOTIC,SOME IMPROVEMENT C DIALYSIS AND CONTROL OF AUTO PEEP\n\nWEAN PRESSERS AS TOL\nFOLLOW FLUID STATUS , BE ABLE TO REMOVE FLUID LATER\nRECHECK PTT 11PM\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-23 00:00:00.000",
"description": "Report",
"row_id": 1285792,
"text": "Resp Care\nPt remains intubated. Current vent settings : A/C 500 x 24 12PEEP 60%.\nPT paralyzed due to auto peep and vent dysnchrony. MDI's given. Current ABG: 7.26/34/94/16. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-24 00:00:00.000",
"description": "Report",
"row_id": 1285793,
"text": "ccu nsg progress note.\no:neuro=paralized w cisatricurium 0.06mg.kg/hr w train of 4 causing twitching l thumb @ 40ma. sedated w fent 150mcg/hr & versed 5mg/hr. see flow sheet fro remainder of assessment.\n pulm=intubated & vented w present settings-ac/500x24/40% (@ 0530)/ +10 w acceptable abg & sats upper 90's. breath sounds=deminished throughout. sx-tannish blood tinged secretions.\n cv=essentially hemody stable throughout shift on dopa @ 15mcg/kg/min & levo initially @ 0.2 weaned to 0.043mcg/kg/min w iabp maps 70-80, pads 25-30, & last co/ci/svr 6.9/3.05/719. episode of ventricular bigeminy-significant for iabp not being able to augment pvc due to minimal pulse pressure (trouble shotted w clinical rep) - despite inability to augment remained hemody stable. pulses dopplerable pt's only-feet cool/pale. r/l fem site-old ooze. ptt continuously >100-gtt decreased to 100u @ 0500. dic screen sent.\n gi=npo. ngt to sx intermittently-watery initially brownish fl w subsequent chg to bilious.\n renal=cvvhdf pfr gradually increase to present 200ml/hr. remain overall i&o positive. am creat 3.0. k & calcium gtts titrated to labs. see flow sheet for hourly data.\n id=hypothermic-bair hugger. vanco level-7.3---recieved dose 0200. contin on ceftriaxone.\n endo=recieved 20u glargine @ 2200. riss fs chged to q4hr for tighter control.\n social=wife called in am-update given.\n\na:tolerating fio2 & peep wean. tolerating levo wean. starting to get neg fl balance.\n\np:contin present managment. dc levo when able. wean dopa as tolerated. reck ptt-0900. next lab draw 1000. support pt/family as indicated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-24 00:00:00.000",
"description": "Report",
"row_id": 1285794,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with the FIO2 decreased to 40% and the PEEP decreased to 10 cm. Latest abg result determined a partially compenasated metabolic acidemia with very good oxygenation (on 50% FIO2).\n\nNo RSBI measured due to the level of PEEP and the fact of being on paralytic agents.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-28 00:00:00.000",
"description": "Report",
"row_id": 1285808,
"text": "CCU NURSING PROGRESS NOTE\nS:INTUBATED\nO:CARDIOGENIC SHOCK, 3VD, ACUTE ON CHRONIC RENAL FAILURE REQUIRING CVVH AND PRESSORS.\n:SEDATION DECREASED VERSED TO 2MG/HR, FENTANYL DOWN TO 25MCG/HR. PT GRIMACING DURING MOUTH CARE. SQUEEZED W/ RIGHT HAND X1, BUT DID NOT REPEAT. SOME GROSS MOTOR MOVEMENT OF L ARM ON BED. NOT MOVING LE.\n\nCV: 70S HAVING MORE FREQ PACS THIS AM. CHEM PENDING, CONTINUES ON POTASSIUM, CALCIUM AND K+PHOS REPLACEMENT. REMAINS ON DOPA AT 10, LEVOPHED HAS BEEN INCREASED THROUGH THE NOC UP TO 0.03MCG/KG/MIN.\nDISTAL PULSES BY . IABP W/ GOOD AUGMENTATION, SEE CARE VUE FOR BP, BUT HAS BEEN TRENDING LOWER. PAD 22-26. C1 STABLE AT 2.3. SVR 677. BILAT GROIN DSG D+I. DISTAL PULSES BY .\n\nRESP:VENT W/O CHANGES. AC/40/500/16/8/98/, LS VERY DIM AT BASES W/ BRONCHIAL BS AT L BASE, COARSE BS IN UPPER AIRWAY. SUCTIONED FOR PALE TAN. NARES DRG THICK YELL. SPUTUM POS FOR ENTEROBACTER, ON ABX.\n+EDEMA IN EXTREM, WHICH HAS DECREASED. VAP BUNBLE.\n\nGI:CONT TO HAVE HIGH RESID, RESTARTED ON REGLAN.\n\nGU:OLIGURIC AMBER URINE\nID;AFEBRILE, WBC FLAT, ON DBL ABX\n\nSKIN:RED RASH AT BUTTOCKS. ANTIFUNGAL CREAM APPLIED. RIGHT HEEL W/ RASH. MPB ON. PT TURNED AND REPOSITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-28 00:00:00.000",
"description": "Report",
"row_id": 1285809,
"text": "addendum:A/P: REMAINS HEMODYNAMICALLY DEPENDANT ON LEVOPHED AND DOPAMINE. PT DOES NOT TOLERATE TURNING SIDE TO SIDE, BECOMES HYPOTENSIVE AND REQUIRED AN INCREASE IN LEVOPHED GTT. PT NEG 2L AS OF 11PM LAST NOC. ATTEMPTING TO RUN EVEN ON CVVH. CONSIDER DECREASING PEEP DOWN TO 5, AND CONTINUE TO FOLLOW ABGS AND LYTES. NOT ABLE TO START TF D/T PERSISTANTLY HIGH RESIDUALS. PT WAS RESTARTED ON REGLAN. CONSIDER A GI CONSULT AND FOLLOW LFTS. PT FOR POSSIBLE HIGH RISK ANGIO ON TUES. MRS UPDATED ON PT'S NOC. SEE CARE VUE FOR ADDITIONAL INFO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-28 00:00:00.000",
"description": "Report",
"row_id": 1285810,
"text": "Respiratory care\npt remains on a/c vent with peep decreased to 5cm. abg reflect sl metabolic acidosis, Pt rmains on balloon pump, Plan to continue full support as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-28 00:00:00.000",
"description": "Report",
"row_id": 1285811,
"text": "CCU NSG NOTE: ALT IN CV/RESP/RENAL\nADDENDUM: GI: Pt still not tolerating tube feeds. ~500cc of light green watter removed from stomach. PO meds being given but may be pulled out when tube is aspirated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-28 00:00:00.000",
"description": "Report",
"row_id": 1285812,
"text": "CCU NSG NOTE: ALT IN CV/RESP/RENAL\nO: For complete VS see CCU flow sheet. This 68y old male with hx of MI ~3 weeks ago that was medically managed went to OSH ~1 week ago with acute sob. He was found to be having MI, intubated and to cath lab. There he was in cardiogenic shock and IABP was placed and he was started on pressures. Cath showed 3VD and 4+ MR. intervention was done and he was transferred to CCU with consult to CT . They have since declined to operate due to his serious condition. High risk angioplasty may be attempt .\nID: Pt has been afebrile to hypothermic. Tmax today was 98.9R. he conts on cipro and cefepine. Blood cultures were sent off aline and triple lumen.\nCV: Despite maximal care pt remains hemodynamically labile and extremely pressure and movement dependent. He will at times drop maps as low as 40s with position changes, but will usually come back up within a few minutes. If dopamine should be paused he can quickly drop maps to 30-40 and require bolus to come back up. He is presently on 10mic/kilo of dopamine and .02mic/kilo of levofed. He remains on IABP 1:1 with good augmentation and unloading points. Maps generally in 60-80. PAPs are decreasing with ultrafiltration and now range 40s/16-20 with CVP 6-8. Last CO/CI 5.7/2.5 with SVR 758. Argantroban was off from 7 to 9am and restarted at .05 mic/kilo. Repeat PTT was 73.8. Both groins are dry and pulses all dopplerable. Feet warm, CSM nl.\nRESP: Peep was dropped from 8 to 5 today on AC 500 X 16 with him now occasionally overbreathing, 40%. Gas was 7.34/41/87/23. Breath sounds are decreased and he is being suctioned for thick yellow sputum in small to mod amt. He has cough. VAP bundle conts per protocol\nRENAL: Pt conts to be ultrafiltrated. We are taking off ~50cc/hr. he is presently 1200 neg for the day and 7 liters neg LOS. Lytes are being repleated per protocol and he conts on Calcium and potassium gtts.\nENDO: Insulin gtt restarted at 8am. Sugars in nl range on 1.5 units/hr.\nSKIN: Pt has red rash in groin and around coccyx. Area less inflammed today. Aloevest anti-fungal being applied. No other breakdown.\nSEDATION/MS: Sedation is at a minimum. he is now on only versed .5mg/hr. Fentanyl is off. He follows no commands, will grimace with mouth care and suctioning, and was seen to move both upper extremities. No movement seen in lower extremities.\nSOCIAL: Wife waiting to speak with Dr about prospects of high risk intervention. She is well aware of how unstable her husband is and how little he has improved with IABP and dialysis. Her husband would not like to live in nursing home or have poorer quality of life than he had before. Wife is the proxy. She will come in ~10-11am tomorrow, but would come in earlier if necessary and can be reached by phone.\nA: Continued hemodynamic instability on maximum support\nP: ? intervention tomorrow. Continue with supportive care. Re-sedate if pt wakes up and is uncomfortable or unable to tolerate~ vent. Cont to try to take off ~50cc/hr wi\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-28 00:00:00.000",
"description": "Report",
"row_id": 1285813,
"text": "CCU NSG NOTE: ALT IN CV/RESP/RENAL\n(Continued)\nth ultrafiltration. Cont with position changes as tolerated. Support wife.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-06 00:00:00.000",
"description": "Report",
"row_id": 1285844,
"text": "Respiratory Care\nPt remains intubated with a #7.5 ETT 25 @ lip. Vent changes were A/C to PSV due to spont breathing. Later in the shift required to be placed back onto A/C due to hemo dyn problems. sounds were course t/o. Suctioned for mod-cop thk yellow secretions. MDI's were given with good effect. Last ABG was WNL. Care plan is to continue to wean settings as and continue to trial PSV as . Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-07 00:00:00.000",
"description": "Report",
"row_id": 1285845,
"text": "Resp. care\nBS equal bilateraly. With occasonal light but coarse wheezes which inprve some post sx. pt sxed for a small bloody plug during the shift. His hemodynamic condition remains poor with Dopamine at 10 and IABP @ 1:1 No RSBI done today\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-07 00:00:00.000",
"description": "Report",
"row_id": 1285846,
"text": "CCU NPN 1900-0700\nO:\n\nhemodynamically unstable tonight. MAPS labile, dropping to 50's with increase in PFR. dopa titrated to keep MAPS >60-65. attempted to start milrinone at 2200- started IVBolus but MAP dropping to 50 within 5min. milrinone was stopped and dopa titrated up to 20mcq/k/min. PFR at 0cc. maintained on 20mcq dopa and 0 PFR until ~ 0200 when tolerated slow wean of dopa.\ncurrently at 16mcq/k/min with MAP 65-70. good augmentation and syst/diast. unloading. IABP 1:1.\nBP very labile and not tolerating dopamine bag change or stop.\n\nHR up to 120, but coming down to 110 with dopa wean. no VEA.\non KCL/Ca gluconate gtts per protocol. lytes q6hr.\n\nPAD 18-20. CVP 6-9. MVO2 62-70. C.O. 7.2/3.1/822\n\nheparin gtt adjusted and currently at 500u/hr. PTT pnd at 0400.\n\ntransfused 1UPRBC - post HCT 0200 29. AM pnd.\n\nright fem. (echmo site) D/I/soft. no hematoma.\nleft fem. IABP/dialysis site D/I. pulses doppler DP/absent PT. feet cool.\n\nResp: LS diminished. no vent changes. RR 18-21. breathing over vent. suctioned for thick yellow secretions, changing to blood tinged with small clots noted at 0400.\n\nGU: foley draining small amts. 5-10cc/hr.\nGI: NPO. TPN at 83cc/hr. hypoactive BS. no stool. on reglan and colace.\nneuro: fent. . to 50mcq/hr d/t hypotension. remains on versed 2mg/hr also. responding to verbal/physical stimuation occas. will open eyes, try to squeeze hand to command, bring arms up toward face. especially does not like mouth/oral care.\n\nskin: duoderm replace on coccyx breakdown. area ~ 5x5cm , stage 2, red, small amt. of bleeding. ? skin care consult.\n\nwife called and updated. she is still concerned about decision for trach and states she knows husband would not want that.\n\nA: unstable, did not tolerate milrinone trial. dopa increased.\nP: attempt to increase PFR to maintain 0-50cc negative/hr per renal note .\n- titrate dopa to keep MAPS >60.\n- follow lytes, PTT/HCT.\nfamily support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-07 00:00:00.000",
"description": "Report",
"row_id": 1285847,
"text": "Respiratory Care Note\nPt received on AC as noted with no vent changes this shift. BS coarse bilaterally which improve with suctioning and MDI's. Pt suctioned for moderate amts bloody secretions with several clots/plugs. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-07 00:00:00.000",
"description": "Report",
"row_id": 1285848,
"text": "IABP DC 5PM.HYPOTENSIVE DURING REMOVAL,BP SUPPORTED C LEVOPHED AND DOPAMINE AS NEEDED .PFR DROPPED TO 0.NO BLEEDING OR HEMATOMA .DP BY DOPPLER.CI 2.4 C IABP AT 1 TO 4,SVR 1033 .EARLIER IN DAY FAILED DOBUTAMINE TRIAL D/T HYPOTENSION .SR TO ST NO ECT.PADS 17 T0 20 .CVP 6,HCT HOLDING 30 TO 29.DID NOT TURNING ,HYPOTENSIVE .\n\nCMV NO VENT CHANGES,SATS 100%,SX BRB.\n\nOG CLAMPED ON AND OFF DURING DAY ,650CC RESIDUAL,NO BS .REGLAN,SENACOT GIVEN\n\n AT 180CC PFR MOST OF DAY TO RUN EVEN I/O TILL IABP DC WHEN DROPPED TO 0 FOR HYPOTENSION.\n\nFENTANYL 50 ,VERSED 2 MG ,PT RESPONSIVE, TO WIFE.SOCIAL SERVICE TO SEE WIFE FOR COPING C GRIM PRONOSIS .\n\nWBC 20,PAN CX\n\nINSULIN DRIP FOR BS 98 130 4.5 TO 5 UNITS\n\nPRESSER DEPENDENT .PLAN TO WEAN VENT TOMORROW,\n\nCALL WIFE IF CONDITION DETERIORATES\nWEAN DOPA,LEVO IF ABLE\nINCREASE PFR TO RUN EVEN IF ABLE\nREGLAN FOR HIGH RESIDUALS\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-08 00:00:00.000",
"description": "Report",
"row_id": 1285849,
"text": "CCU NPN 1900-0700\nO: 68yo male admitted with CP/SOB, cath showing 3VD. CV shock/intubated/IABP and req. . not surgical candidate. underwent atherectomy and BMS placement to LAD/Diag with OR backup. required echmo post cath and returned to CCU post cath on dopa/IABP. was continued to run even to slighly negative as tolerated.\nfailed IABP wean , then failed milrinone trial (hypotension) that eve. Trail of dobutamine also failed with hypotension. has required dopamine 10-20mcq since cath. IABP was successfully d/c'd afternoon.\n\novernight:\n\nID: afeb. contin. on nafcillin. sputum with MSSA(+). vanco was d/c'd.\nCV: HR 106-112ST. no VEA. BP 92/51-135/65 MAPs 60-87. dopa 15mcq weaned to 13mcq/k/min. labile BP with turns/suctioning etc. also drops when dopa is off for short time.\nPAD 23-27. CVP 5-10. C.O. 6.8/3/1047. MVO2 62.\n\ncontinues on CVVHF. filter clotted off at 2100 requiring restart at 2300. PFR started at 0 ->170 in attempt to keep even. pt. is currently ~ 400cc neg. but this is due mainly to large amt. of GI output from OGT.\ncontin. on K+ and Cagluconate gtts per protocol.\nheparin protocol pre filter currently at 600units/hr. adjusted per /heparin protocol.\n\nResp: changed over to CPAP/PS ~ 12am. /.40. ABG 7.40/40/132. suctioned for small to mod. amts thick blood tinged secretions. LS diminished. RSBI ~ 50 this AM. RR 10-15. Tv 500-700. appears comfortable.\n\nGU: u/o 10-15/hr. Cr ~ 2.2 (down from peak ~ 4 on admit)...\nGI: abd soft, obese. OGT to LIS draining total 700cc green bile over 12hours. no stool. contin. reglan IV. TF on hold. TPN at 83cc/hr.\n\nendo: FS 90-120's. insulin gtt at 1unit/hr.\nneuro: pt. responds to name, open eyes and nods approp. to questions. mildly anxious at times, but responds well to voice prompts. able to squeeze bilat. hands, move legs to commands. c/o discomfort mostly r/t ETT. fentanyl at 50mcq/hr, versed decreased to 1mg/hr.\n\nskin: duoderm intact on coccyx. did not visualize. heels intact.\nanemia: HCT 29 . pnd today. last transfusion was . started on epogen per renal recs.\n\nA/: tolerating very slow dopa wean. still with episodes of hypotension\n - contin. CVVHF tolerating PFR 170.\n - doing well on PS 10/5. plan SBT this morning and possible extubation.\ncontin. monitoring PADs, C.O. contin. to wean dopa as tolerated. follow renal recs. follow K+/Ca+/heparin protocols.\nmonitor GI aspirates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-08 00:00:00.000",
"description": "Report",
"row_id": 1285850,
"text": "Resp. care\nBS equal with occasonal wheezes. IABP was dc/ed during day shift of . He remains on dopamine for his BP & is still getting CVVHD. He seems very awake & alert. At present his condition while still critical seems stable enough to begin the weaning process. To this end his mode was changed from A/C to PS/CPAP at about midnight. And a RSBI was obtained this morning with incorageing results. He was suctioned during the shift for small, to moderate amounts of blood tinged sputum but no plugs were noticed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-08 00:00:00.000",
"description": "Report",
"row_id": 1285851,
"text": "CCU NSG NOTE: ALT IN CV/RENAL\nS: \"I feel good\".\nO: FOr complete VS see CCU flow sheet. THis 68y old male with hx IDDM, PVD, HH and MI X 4week ago and was being medically managed came to , intubated with acute pulmonary edema in cardiogenic shock on . He had IABP placed.HE had 3 VD with severe MR was consulted and felt pt not CABG/valve candidate. Pt started CVVHD, and has remained on pressures througout his stay. On he went to OR suite and on ecmo received BM stents or LAD and diag. He had been unstable since and little fluid was taken off with dialysis. IABP removed . He failed trials of dobutamine and milrinone. He conts on alpha range dopamine and \rCVVHD.\nID: Pt afebrile. WBC 15.9. He conts on nafcillin QID.\nCV: Pt remains dopa dependent. Dose lowered from 13 to 11mic/kilo today. HR remains elevated 110-115 with rare PVCs. BP has ranged 107-115/40-50s. PAP 30-40/12-15. CVP 5-8. Unable to . CO/CI on 11mic/kilo of dopa were 5.2/2.2/985, down from when he was on IABP. Groin site dry with suture at IABP site. All pulses dopplerable, feet warm, CSM nl for pt. He started SQ heparin, and is being heparinized thru filter of dialysis. However PTT was 106.5 and heparin was shut off at 1730. It will be held until next PTT at after talking with renal fellow.\nRESP: Pt was extubated at 1030 after over 2 hors on spontaneous breathing trial. He continues to be comfortable on 50% face tent with last gas 7.43/38/85/26. BS are decreased with some course sound heard in middle lobes.\nRENAL: Pt conts on CVVH. He has been positive over the past 5 days due to instablility with proceedure. We have been trying to take off ~50cc/hr and he has been tolerating it. Renal would like us to continue pushing to try to make him 1.5 to 2 liters neg tomorrow. He is presently 600cc neg for the day. He conts to be Calcium and potassium replaced per protocol.Dialysis catheter has difficulty functioning with pt on L side or if HOB is too high. This was discussed with renal fellow. Pt needs a dialysis line not in his groin so he can begin moving more and sitting up.\nGI: NG tube pulled with ET tube. Pt was continueing to have large residuals prior to tube being pulled. He has since had jello and custard and was able to easily swallow liquids and has no c/o of nausea or bloating. He can take pills po. Bowel sounds cont very diminished.\nSKIN: Duoderm remains in tact on coccyx area. All other prominences remain without breakdown. He is turned Q 2.\nENDO: Pt conts on insulin gtt at 1u/hr with minor variations.\nMS: Sedation weaned prior to tube being pulled and shut off prior. He is A & O X 3!!. His voice is strong and he is conversant with family. He says he feels well. His strength if very diminished and he can barely lift arms off bed and cannot hold them. He can move R leg more than L, but L has dialysis catheter in it.\nSOCIAL: Wife in to visit. Over the next day or 2 wife intends to talk about plan of care. For the present he remains a full code.\nA: Contd requirement for\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-08 00:00:00.000",
"description": "Report",
"row_id": 1285852,
"text": "CCU NSG NOTE: ALT IN CV/RENAL\n(Continued)\nhigh dose pressures/successful extubation\nP: Cont to try to keep pt at least 50cc neg each hour. Follow protocol for labs. Assist pt with position changes. Finger sticks Q 1hr. Monitor pt taking pos. Keep careful I & O.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-09 00:00:00.000",
"description": "Report",
"row_id": 1285853,
"text": "CCU NPN 1900-0700\nS: \"It's ...can you take this mask off me?\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 107-119 ST, no ectopy noted, ABP 112-150/53-65 MAPs 69-85, pt dopamine gtt decreased to 10 mcg/kg/min with CO 5.7/CI 2.44.SVR 828 MVO2 60%. PAD's 14-20, PA line not wedged as was unable to be wedged during prior shift, CVP 5-8. R groin, L groin and PA line sites all CDI, bilateral pedal pulses dopplerable, extremeties warm. Am HCT 27 (down from 29.1), pt had epogen last noc, K 4.4, Mg 2.0.\n\n\nResp: Received pt on face tent 40% 10L, pt with c/o mask being uncomfortable, discussed with resp therapy-pt placed on 4L n.c with O2 sats 100%, ABG to be obtained this am. Pt enc to deep breathe as able (pt kinks off machiine with coughing). Pt noted for frequent dry cough in evening to less frequent . RR 20's O2 sats 100%, pt 15-30 degress as able with L femoral dialysis line and running. No c/o SOB. LS clear to diminished at RLL.\n\nGU: Pt continues on CVVH, PFR 160-250, no clots present, see flowsheet for dialysis data, goal pt -50 cc/hr, pt -470 cc at midnoc (goal -500 cc at midnoc CCU MD note). Pt continues on heparin via machine pre-fliter, PTT elevated to 110 at 2040, heparin gtt off and renal fellow paged, gtt off until concentraion of heparin changed and gtt able to be decreased below 500 units/hr. PTT 73.7, heparin turned down to 300 units/hr on machine, PTT d/t be drawn at 1000. Pt u/o 5-11 cc/hr. Pt has high access pressures/kinked line when pt coughs and per report when pt is turned on left side. Pt continues to have calcium and potassium repleted per protocol, replacement soln at 1500 ml/hr. BUN 41, creatinine 2.5.\n\nGI: Pt abd soft, + hypoactive BS, no stool this shift, pt cont on IV reglans and PO colace. Pt took pills and water without difficulty. pt continues on TPN.\n\nENDO: FS 102-124, insulin gtt continues at 1 unit/hr.\n\nNeuro/Skin: Pt A&O x3, cooperative with care, at times asking appropriate questions regarding care. Pt MAE, lifts and holds RUE, LUE and RLE, moves LLE on bed, exam difficult as pt has L femoral line in. pt needs encouragement to turn in bed. Pt coccyx covered with intact duoderm, site not visualized, no further breakdown noted. Pt slept intermittently . Pt is blind, eye drops given as ordered.\n\nID: Pt afebrile, T max 98.3, WBC 12.9, pt cont on nafacillin Q 6 hours, bair hugger on for pt comfort.\n\nSocial: No calls or visitors .\n\nA/P: 68 y/o male s/p cardiogenic shock/IABP/pressor dependent, on ECMO with BMS placed to LAD and diag, failed dobutamine and milrinone trials, IABP dc'd on , pt extubated yesterday am . , pt fluid status negative via CVVH, dopa gtt weaned to 10 mcg/kg/min. Cont to monitor pt hemodynamcics-wean dopa gtt for MAps> 60 and as CO/CI . Cont to monitor resp status, ABGs, enc deep breathing and coughing as able. Cont to monitor CVVH, fluid removal as ordered and pt , ? change to different location tunneled line in f\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-09 00:00:00.000",
"description": "Report",
"row_id": 1285854,
"text": "CCU NPN 1900-0700\n(Continued)\nuture so pt activity can be advanced. Cont to monitor neuro status, cont to enc PO intake as pt , ? increased bowel regimen,advance diet and activity as . Cont to provide emotional support to pt, awaiting further per CCU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-06 00:00:00.000",
"description": "Report",
"row_id": 1285842,
"text": "ccu nsg progressn ote.\no:neuro=sedated w fent/versed gtts w effect. arousable. attempts to follow simple commands-inconsistantly. moves alle xtrem on bed-attempting @ x's to get hand to ett.\n pulm=remains intubated/vented w unchg vent settings. breath sounds= deminished throughout. sx-mod amts watery white secretions. increased oral secretions. gd abg/sats.\n cv=hemody unstable. requiring freq adjustments of dopa gtt to maint adeq sats. dopa presently @ 8mcg was as high as 10mcg. iabp 1:1 w gd augmentation & sys/ unloading. fem sites-c&d. pulses dopplerable x4.\n gi=remains on tf. contin bilious drainage from ogt. wo stool. hypoactive bowel sounds.\n endo=insulin gtt-adjusted to bs.\n renal=cvvhdf initially pfr=0, gradually increased as bp tolerated. presently pfr=200. see flow sheet for hrly #'s. calcium/k gtts infusing-adjusted to am labs.\n id=afebrile.\n labs=am sent.\n social=wife called updated x2. wife unsure re:trach/peg. feels pt would not want either & would not want to live w decreased quality of lif\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-22 00:00:00.000",
"description": "Report",
"row_id": 1285786,
"text": "Resp Care\n\nPt admitted from OSH c/o SOB and was transferred here for emergent Cath with balloon pump in place vented on full support with no changes made since pt arrived in ICU. BS dim and tight with difficulty ventilating due to increased agitation. Albuterol inhalers administered with good effect noted. ETT secured and patent. Will cont with vent support and make changes accordingly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-22 00:00:00.000",
"description": "Report",
"row_id": 1285787,
"text": "ccu nursing progress note\npls see fhpa for details of admit.\n\ns: orally intubated and sedated\no: pls see carevue flowsheet for complete vs/data/events\narrived from cath lab at 5:20pm. 68yr old male who presented to w acute pulm edema req intubation, bp dropped and pressors started. medflighted to for urgent cath. cath noted severe 3vd and mod to severe mr of 60 w v waves. pressors weaned off, trans on nipride and ntg, then dopa req to be resumed. iabp placed. quinton cath placed for crrt.\n\nid: temp is low, 92 ax, not registering rectally. placed on bair hugger for warming.\ncv: hr 68-90s sr, occ pvc. iabp 1:1, maps 70-100. weaned dopa from 13mcg/kg/min to 7.5. instructed not to go further in weaning d/t in lab had sign drop in hr than bp when dopa <10 per dr .\nplacing radial aline for bp monitoring and abgs.\nr and l fem sites are oozing slightly. dsgs changed. r knee immobilizer in place. pulses are by doppler. feet are cool to cold and pale.\nheparin to start at 1300unit/hr.\nresp: ac 550 x20. 100%. not overbreathing. abg: 7.30/38/89/19/-6\nsxn'd for thin bldy secretions.\ngi: npo. ogt in place. needs to be confirmed by cxray which was done. had sm amt stool, brn.\nendo: bs >300 in lab. 192 here covered per ss.\ngu: sm amt bld tinged urine. plan to start crrt this eve.\nskin: has l sc tlc from osh, placed in er at . r fem iabp and venous cortis/pa cath. l w quinton.\nms: sedated w versed at 5mg/hr from lab. pt moves upper extrem, responds to painful stimuli.\nsocial: family updated by dr . awaiting to see pt as team placing line.\na: cardiogenic shock. acute pulm edema. 3vd and severe mr. iabp, crrt. awaiting surgery.\np: follow hemodynamics, dopamine to support bp/co. follow volume status. initiate crrt and follow per parameters. monitor for bleeding complications, check ptt on heparin. med for comfort. support and info to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-23 00:00:00.000",
"description": "Report",
"row_id": 1285788,
"text": "Resp Care Note, Pt remains on current vent settings. Vent changes made per ABG. No A-line placed. Difficult stick.Suctioned for scant secretions. MDI'S given.Pt hemodynamics unstable on IABP.Sedated with fentanyl and midazolam. Getting dopamine,neosynephrine,heparin .On CVVHD.ABG metabolic acidosis.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-23 00:00:00.000",
"description": "Report",
"row_id": 1285789,
"text": "CCU NPN 1900-0700\nO:\n68yo male with IDDM, HTN, s/p recent STEMI, who presented to OSH with acute SOB, pulm. edema. electively intubated in OSH, on pressors, transferred to for cath.\ncath showing severe 3VD, mild AI, mod MR. 60- down to 30 after IABP placed. started on dopa after hypotension following versed bolus.\nhas hx CRI with baseline Cr 4.0, renal consuled for possible CRRT. decision made to start CVVH tonight.\n\nID: overnight, initially hypothermic temp. 94.3-97. bearhugger on til 0300. temp. 99 at 0400. BC x2, urine sent. no sputum to send. left SC CL placed in EW at OSH- and other lines- given dose vanco and started on ceftriax q24hr.\n\nCV: IABP 1:1. Map 65-100. systolic unloading 4-12pts. good augmentation. HR 75-91.\nPA 55-70/31-40. MVO2 50-57. C.O. 4.0-4.4/1.7-1.95.\n\ninitially on dopa 5-7.5mcq/k/min. started on CVVH at 2200 and tolerated for first couple hours. dropping maps in eve req. inc. in dopa to 16mcq/..\nevent at 0200: maps acutely dropping to 45-50, hr 60. sats 85%. dopa up to 20mcq/, neo started/bolused at maxed at 4mcq/k/min. also given dose of vasopressin 40units x1. map coming up within 15min. stat echo negative for tamponade. CRRT removal rate was decreased to 0cc/hr.\ncurrently on dopa 10mcq/k/min and neo 3mcq/k/min. MAP 98.\nheparin gtt was started at - PTT >150. held x1 hr and decreased per protocol at 0530\nCPK 911-884.\nK+ 5.6. ionized Ca 1.06 on Cagluonate gtt per CRRT protocol.\n\nResp: AC 550x24/10peep/100%. last ABG 7.28/40/86. sats 100%. suctioned for minimal secretions. LS course.\n\nGU: CRRT initiated at 2200 with goal (-) 50cc/hr. did not tolerate with hypotension episodes x3 during night. currently is at 0cc fluid removal rate. u/o 5-30cc/hr. pink to dark amber. cr 4.1\n\nGI: OGT was advanced approx. 3 inches per radiology request. minimal bile aspirates. obese abd. hypo to absent BS. no stool.\n\nNeuro: pt. has been blind x4 years per wife. right pupil reactive, left pupil neg. responds to painful stim. with occas. upper extrem. movement, overbreathing vent, abd breathing and upper extrem. tremors. fent. gtt started and titrated to 75mc/hr. versed at 4mg/hr.\ndoes not open eyes or respond to command. hands restrained for safety.\n\nskin: intact.\n\nA: cardiogenic shock with acidosis/hypoxia requiring 2 pressors.\nnot tolerating CRRT- active but on 0cc fluid removal rate d/t hypotension.\nhypothermia- cultured, antibiotics.\nP: follow lytes, CRRT protocol. contin. dopa/neo for hypotension. heparin gtt. follow C.O./Paps. CPK's trending down. titrate fent/versed for comfort.\nrenal following for recs. attempt. fluid removal when bp stable.\nfollow for neuro change. wife spoke with md and called once during night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-02-23 00:00:00.000",
"description": "Report",
"row_id": 1285790,
"text": "CCU NPN addendum\nMrs. requested that pt's wedding band be removed. She took the ring home with her eve.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-13 00:00:00.000",
"description": "Report",
"row_id": 1285868,
"text": "Nursing Note 7a-7p\nS: \"Please don't forget about me...\"\nO: See careview fore complete obj data.\nNeuro- A+Ox2-3, awoke confused/anxious looking for his wife. to reorient & calm. Spoke to wife on phone. By noon wife @ bedside & pt more relaxed/appropriate. Given prozac, refused prn xanax. No c/o c-pain/sob.\nCV- In SR w/rare PVCs, HR 80s-90s. ABPs stable 113-137/60s-70s, no fluid boluses given. Lopressor d/c'd & held his Captopril per team. Started on HD @ 1700, goal -1L, BPs stable. CVPs 15-19. L SC TLCL to be d/c'd post HD. R SC dialysis line cd+i.\nResp- LSC-> diminished in bases. Remains on 2L nc w/sats >95%.\nID- Afeb, wbc 12.4, conts on Nafcillin for PNA.\nGI/GU- Obese, +bs no bm. Drinking fluids & sm amts of diet.\nVoiding only scant amts of brown/sediment urine, Cre 4.3\nEndo- Sugars covered per RISS.\nSkin- Allevyn dsg intact to coccyx ulcer. Remains in a Kinaire bed.\nA/P: BPs remain stable, d/c'd BB & held ACE. HCT 28.5, recieving HD tx w/ goal fluid removal only -1L. Cont plan of care, monitoring pressures, blood sugars & provide emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-14 00:00:00.000",
"description": "Report",
"row_id": 1285869,
"text": "ccu nsg progress note.\no:neuro=responsive. appropriate @ x's-forgetful, not always remembering where he's @, & very emotional @ x's.\n renal=hd removed 1l. tolerated well. wo episode hypotension. minimal uo-dark bloody.\n labs=am sent.\n\na:tolerating hd. sl altered mental status-?related to prolonged icu stay.\n\np:contin w present management. support pt/wife as indicated. ?call-out.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-10 00:00:00.000",
"description": "Report",
"row_id": 1285860,
"text": "CCU NSG NOTE: ALT IN CV/RENAL\n(Continued)\nr a decision regarding his care needs to be made.\nA: New tunneled dialysis line/CVVH off/large increase in ectopy/DNR/DNI\nP: Continue turning patient side to side. Swan will be changed to triple lumen tonight. Try to get dialysis line out of L groin. Monitor I & O closely. Continue to check crit and lytes. SUpport pt and wife.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-11 00:00:00.000",
"description": "Report",
"row_id": 1285861,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CV SHOCK\n\nS- \" I AM IN ....I NEED THE FIRE DEPT HERE..I HAVE CHEST PAIN\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS OFF DOPA GTT - WEANED EARLIER ON DAY SHIFT. MAINTAINING BP- 104/44- 123/49 VIA RT RADIAL ALINE. HR- 90'S SR, ST- OCCASIONAL VEA. AWAIT RESULTS OF AM LABS/LYTES. PT COMFORTABLE ALL NITE BUT 6:10 AM- C/O CHEST PAIN- BILATERAL BREAST AREAS- APPEARS TO TRACE DOWN FROM BILATERAL LINE INSERTION SITES. HO CALLED, EKG DONE- VSS.\nNO APPARENT ACUTE ISCHEMIA BY EKG. PT FALLING BACK ASLEEP EASILY.\n\n PT DOING OFF O2- DIM SOUNDS- COMFORTABLE WITH O2 SATS >97%. OFF SINCE FRIDAY AFTERNOON- PLAN S/P TUNNEL CATHTER OF YESTERDAY TO START HD- ? TODAY.\nNO SIGN DISTRESS/FAILURE.\n\nID- AFEBRILE CURRENTLY\nNAFCILLIN D/C - NO FURTHER ANTIBX.\n\nGU- SEE ABOVE- D/C FOR TUNNEL CATHETER IN IR YESTERDAY.\nSUCCESSFUL LINE PLACEMENT RT SC. D/C OLD DIALYSIS LINE LEFT GROIN WITHOUT PROBLEM. SITE D/I. 5-10CC/HOUR URINE OUT VIA FOLEY CATH.\n\n ONCE PT ABLE TO SIT UP S/P GROIN LINE D/C AND PA LINE D/C WITH TRIPLE LUMEN INSERTED OVER WIRE- TAKING SIPS WATER/ICE CHIPS.\n(+) BOWEL SOUNDS, NO STOOL THIS SHIFT.\nPROTONIX. REMAINS ON TPN AS ORDERED. TO D/C PHOSPHOROUS IN THE MIX, AS PT OFF .\n\nLINES- SEE ABOVE- NEW TUNNEL CATH FOR HD INSERTED AT IR FRIDAY- RT IJ.\nOLD LINE D/C LEFT GROIN. REMAINS WITH RT RADIAL ALINE. SWITCHED PA LINE FOR TRIPLE LUMEN OVER WIRE- LEFT SC SITE.\nBLEEDING AT SITE- REDRESSED WITH SURGIFOAM/TEGEDERM.\n\nSKIN- COCCYX DECUBITUS- DRESSED WITH ALLEVYN. NO DRAINAGE/INTACT.\nAIR BED/MULTIPODUS BOOTS. TURNED FREQUENTLY.\n\n PT SLEEPING ON/OFF- NOT MUCH TOLERANCE TO PAIN OVERNITE- CRYING/EMOTIONAL AT TIMES. CRYING WITH SC SHOT/TAPE PULLED OFF/DSG REDRESSED ETC. ENCOURAGED OVER THE POSITIVE STEPS HE HAS MADE UNDER HIS LONG LONG COURSE HERE IN ICU. ASKING FOR HIS WIFE, AT TIMES SAYING HE IS IN , ASKING FOR FIRE DEPT THIS AM WHEN HE C/O CP.\nREMINDED HE IS IN ICU .\nWIFE STATED HE HAD A LONG HARD DAY YESTERDAY- CAN GET ANXIOUS/EMOTIONAL. SHE WILL BE IN LATER THIS MORNING.\n\nA/ PT S/P LONG COURSE IN ICU S/P MI/SHOCK/STENT CURRENTLY STABLE HEMODYNAMICALLY OFF IABP/PRESSORS AND EXTUBATED..\n\nISSUES RE: COPING/PAIN CONTROL...\n\nCONTINUE TO MONITOR HEMODYNAMICS/RESP STATUS. OPTIMIZE RATE/PRESSURE PRODUCT. KEEP MAP> 60. AM EKG/CXR. FURTHER W/U CHEST PAIN IF REOCCURS.\nCONTINUE NUTRITION/ CONSIDER ADVANCING DIET PO. CLOSE MONITORING.\n? FORMAL SWALLOW STUDY.\nKEEP PT FREE OF ANXIETY/FREE OF PAIN. PT REMAINS DNR/DNI.\nPLAN FOR HD ? TODAY/THIS W/E.\nKEEP WIFE INFORMED RE: PLAN OF CARE AS WELL AS PT HIMSELF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-11 00:00:00.000",
"description": "Report",
"row_id": 1285862,
"text": "resp care\norders changed from mdi to nebs. pt appears labored with decreased bs on right. fair aeration on left without wheezing. admin unit dose ipratropium bromide and albuterol via neb. sats 97% on room air. pt reports some relief although no change is aeration post neb. hr 92%, rr 24. cough is of fair strength but nonproductive. will follow q6h as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-11 00:00:00.000",
"description": "Report",
"row_id": 1285863,
"text": "CCU Nursing Progress Note 0700-1900\nS: without c/o cp; slight SOB.\n\nO see CCU flow sheet for complete objective data\n\nCV: started on captopril 6.25 mg po tid, tolerated well without drop in BP. BP 112-134/45-57. HR. 85-94 NSR with occ PVC's including v-bigeminy. Right femoral artery sutures intact. Site clean, open to air. Left femoral artery site with slight ooze this am. Site clean, without further oozing. Feet warm with good movement. OOB to Chair (via lift), tolerated well.\n\nResp: lungs with faint exp wheezing. Given atrovent MDI, but poor insp effort. MDI changed to neb. Given atrovent and albuterol via neb by RT with decreased wheezing. Sats remain >97% on RA.\n\nGI: remains on TPN @ 83 cc/hour. Tolerating soft solids, but poor appetite. Abdomen soft, +BS, no stool. BS 189--> 2 Units reg insulin.\n\nGU: foley draining small amounts amber urine. No HD as of yet.\n\nSkin: allevyn dressing intact. No other signs of breakdown.\n\nNeuro: Alert and oriented X2. Consistently thinks he is at home in , interprets sounds in his room to be his cats. Oriented to time and person. MAE.\n\nAccess: R SC dialysis site clean, no ooze. L SC TLC site clean, no ooze. R radial a-line clean.\n\nSocial: wife in to visit, updated on .\n\nA: stable, tolerating ACE-I and ^ activity level.\n\nP: continue to monitor HR/Rhythm/BP. OOB to C again in am, have PT eval on Monday. Enc. po's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-12 00:00:00.000",
"description": "Report",
"row_id": 1285864,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CV SHOCK; RENAL FX\n\nS- \" ARE YOU LOCKING UP NOW?\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS FREE OF CHEST PAIN, OR RESP DISTRESS.\nVSS- HR- 90'S ST, MUCH VEA, ONE RUN, NONSUSTAINED. LYTES CHECKED- WNL.\nREMAINS WITHOUT HYPOTENSION OFF DOPA ( D/C ).\nNO ISSUES CURRENTLY- TOLERATING CAPTOPRIL 6.25 TID.\n\n PT ON 2L NP, NO SOB- DIMINISHED BREATH SOUNDS THROUGHOUT- ENCOURAGED TO DEEP BREATHE/PREVENT ATELECTASIS.\nO2 SATS MID 90'S.\nNO COUGH, NO SPUTUM PRODUCTION.\nSOME PARADOXICAL BREATHING WITH ANXIETY- NO CHANGE IN SATS OR CLINICAL STATUS. WITH SLEEP- BREATHING PATTERN SUBSIDING.\n\nID- AFEBRILE\n\nGU/RENAL- UO- MINIMAL- SEE FLOWSHEET- UNDERWENT HEMODIALYSIS 6-8:30PM- TOOK OFF 1500CC LITERS. TOLERATING ENTIRE SESSION WITHOUT EVENT.\n\nGI- TAKING MEDS/FLUIDS THIS SHIFT. REMAINS ON TPN 83CC/HOUR.\nTOLERATING INCREASED DIET BUT NO EATING ON THIS SHIFT CURRENTLY.\n(+) BOWEL SOUNDS, NO STOOL. REMAINS ON PROTONIX.SS INSULIN QID.\n\nLINES- RT SC DIALYSIS LINE- PATENT/FLUSHED POST DIALYSIS.\nLEFT SC TLC- REMAINS D/I AFTER SOME BLEEDING AT SITE S/P CHANGE OVER WIRE FROM PA LINE.\nGROIN SITES D/I - PULSES PRESENT.\n\nSKIN- COCCYX DECUBITUS- ALLEVYN DSG PRESENT- NO DRAINAGE AROUND- REMAINS PATENT.\n\n PT INITIALLY BECOMING VERY WEEPY, EASILY EMOTIONAL/UPSET.\nWIFE STATED TO RN EARLIER THAT HE HAS XANAX PRESCRIPTION AND HAS ANXIETY- TAKES OCCASIONALLY. GIVEN 0.25 XANAX PO-QHS- SLEPT MOST OF NITE.\nSOME CONFUSION( PRE MED) AS TO PLACE- ASKING IF \" WE ARE ALL SAFE AND LOCKED UP\"..ETC...REORIENTED BUT CONTINUES TO GET CONFUSED.\nOVERALL RESTFULL NITE WITH XANAX- NO FURTHER WEEPY EPISODES.\n\nA/ PT S/P LONG COURSE MI C/B CV SHOCK/RESP FX/ACUTE ON CHRONIC RENAL FX- CURRENTLY DOING WELL ON CV MEDS/HEMODYALYSIS.\nCONTINUES WITH SOME ALTERED MENTAL STATUS/ALTERED COPING/ANXIETY- REPSONDING WELL TO XANAX.\n\nCONTINUE TO OPTIMIZE CV STATUS- WITH ACE. ? CONSIDER ADDING LOW DOSE B BLOCKER TODAY? KEEP LYTES WNL- REPLETE AS NEEDED.\n\nCONTINUE TO ENCOURAGE INCREASE ACTIVITY DURING THE DAY- DEEP BREATHE/COUGH TO PREVENT ATELECTASIS/OPTIMIZE RESP STATUS.\n\nMAXIMIZE NUTRITION WITH TPN AND INCREASING PO INTAKE AS TOLERATED.\nCONTINUE ON SS INSULIN.\n\nCONTINUE TO ASSESS MENTAL STATUS/ KEEP REORIENTING AS NEEDED. XANAX AS NEEDED FOR EPISODIC ANXIETY.\n\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-12 00:00:00.000",
"description": "Report",
"row_id": 1285865,
"text": "Respiratory therapy Pt presents on n/c in NAD, BS clear bilaterally W diminished bases. Nebs given W no change in aeration.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-12 00:00:00.000",
"description": "Report",
"row_id": 1285866,
"text": "PT HYPOTENSIVE TO 79 SYSTOLIC P 12 NOON LOPRESSER 12.5 MG AND BEING HOYERED OOB. 500CC FLUID GIVEN,HCT 26 .UNIT PACK CELLS WAS ABOUT TO BE GIVEN WHEN BP STABLIZED .PT C/O SOB.TO AVOID FLUID OVERLOAD BLOOD ON HOLD UNLESS BP BECOMES UNSTABLE .IT WILL BE GIVEN TOMORROW C DIALYSIS.NSR C MUCH VEA,LYTES WNL .\n\nSAT 95 TO 100 RM AIR TO 2LNP,BS DIMINISHED .\n\nTPN DC TO STIMULATE APPETITE .TAKING FLUIDS NOT SOLIDS.\n\nMIN URINE VIA FOLEY .\n\nPT LETHARGIC ,WEEPING.PROZAC ORDERED BUT WIFE TO HAVE PT TAKE IT.WILL DISCUSS C DR .\n\nHYPOTENSIVE POST DIALYSIS NOT CARDIAC MEDS\n\nTRANSFUSE UNIT PC IF BECOMES HYPOTENSIVE AGAIN\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-03-13 00:00:00.000",
"description": "Report",
"row_id": 1285867,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CAD/MI C/B CV SHOCK\n\nS- \" WHERE IS MY WIFE, I AM SURE SHE HAS ANOTHER JOB..SHE LEAVES ME HERE, I AM ALL ALONE( CRYING) I AM ALL ALONE..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n OVERALL, PT HEMODYNAMICALLY STABLE AFTER HYPOTENSION S/P LOPRESSOR NOON DOSE. HR- 90'S SR/ST, MUCH VEA- BP- 89/50-108/61. HOLDING CAPOPRIL DOSE CURRENTLY AND D/C LOPRESSOR.\nBY LATER IN PT DEVELOPING HYPOTENSION WITH MAPS LESS THAN 60.\n11P- GIVEN 250CC/NS BOLUS. NO FURTHER PROLONGED HYPOTENSIVE EVENTS.\nDENIES CP. HAS CHEST WALL PAIN YESTERDAY BUT DETERMINED TO BE RIB/MUSCULAR IN ORIGIN.\n\nRESP- COMFORTABLE ON 2L NP. DIMINISHED BREATH SOUNDS THROUGHOUT, OCCASIONAL NONPRODUCTIVE COUGH.\n2 L NP.\n\nID- AFEBRILE- S/P PNA- HAD BEEN ON NAFCILLIN- NO ISSUES CURRENTLY.\n\nGU/RENAL- LAST HD SATURDAY- TOOK OFF 1.5L. ISSUES AFTER CV MEDS SUNDAY WITH HYPOTENSION. TODAY DUE FOR ANOTHER HD RUN. CURRENTLY HOLDING ALL CV MEDS. UO VIA FOLEY CATH 5-10CC/HOUR.\n\nLINES- RT SC DIALYSIS CATHETER- NEW FROM FRIDAY- PLACED IN IR.\nLEFT SC TLC- CHANGED OVER WIRE FRIDAY AS WELL FROM PA LINE.\n\nGI- TPN D/C SUNDAY IN ATTEMPTS TO INCREASE PT APPETITE.\nREMAINS ON SS REG INSULIN. 2U AS NEEDED. TAKING SIPS WATER/MEDS WITHOUT PROBLEM. HAS NOT HAD FORMAL SPEECH/SWALLOW STUDY OF NOTE.\nNO STOOL THIS SHIFT.\n\n PT WITH SOME CONFUSION AS WELL AS EMOTIONAL LABILITY/DEPRESSION.\nAT TIMES, JOKING A BIT THEN WITHIN SAME SENTENCE/THOUGHT - WEEPY AND CRYING. STATING HE KNOWS HIS WIFE \" HAS ANOTHER JOB\" AND THAT IS WHY SHE LEAVES HIM HERE ALL ALONE. \"IT IS A SECRET BUT I KNOW\". SOMETIMES VERY PARANOID ABOUT THE NEED TO BE LOCKED IN AND SAFE - ASKING IF \" WE ARE LOCKED IN TONITE\" OR OTHERS PLANNING TO LEAVE HIM ALONE AND IT IS A PLOT AGAINST HIM IN A WAY. DISORIENTED TO PLACE FREQUENTLY. APPEARS TO MOST OF THE TIME UNDERSTAND THE STAFF ARE DR/RN, AND WIFE WHEN SHE COMES IN TO VISIT. PT STARTED ON PROZAC BUT BY REPORT, WIFE RELUCTANT TO HAVE PT START ON IT, SO NO DOSE GIVEN.\nPT GIVEN 0.25 XANAX AT BEDTIME AND REPEATED AGAIN LATER IN NITE.\nINSOMNIA UNLIKE LAST NITE.\n\nNO CALLS AS OF YET FROM WIFE.\n\nA/ PT S/P LONG ICU COURSE RECOVERING FROM MI/CHF/RENAL FX- ACUTE ON CHRONIC C/B SHOCK/PNA/RESP FX - CURRENTLY EXPERIENCING SOME HYPOTENSION.\n\nDISCUSS PLAN FOR UF OUT WITH RENAL BEFORE DIALYSIS TODAY.\nCONTINUE TO HOLD CV MEDS IN MEANTIME.\nSMALL FLIUD BOLUSES AS NEEDED TO KEEP MAP >60 ESPECIALLY WITH S/P STENTS LAD.\nCONTINUE INCREASE ACTIVITY/DIET. GET PT INVOLVED IF NOT ALREADY CONSULTED. CONTINUE TO HELP PT STAY ORIENTED AND GIVE SUPPORT WITH WEEPY /EMOTIONAL EPISODES. CONSIDER PSYCH/SOC SERVICE CONSULT.\nRE-CONSIDER PROZAC QD. CONTINUE XANAX TID AS NEEDED.\nCONTINUE NUTRITION/SKIN CARE.MAINTAIN PATENCY OF LINES.\n\nCONTINUE DISCHARGE PLANNING /REHAB SCREENING.\nKEEP PT /WIFE AWARE OF PLAN OF CARE.\n"
}
] |
5,270 | 112,684 | The patient was initially admitted to the Medical Intensive Care Unit for close monitoring and management of his GI bleed. 1. Heme. The patient was anemic secondary to brisk gastrointestinal bleeding. There was no suggestion of coagulopathy secondary to his laboratories. He was transfused for a hematocrit greater than 28 throughout his stay. The patient underwent a tagged red blood cell scan on hospital day two, which was negative for any evidence of continued brisk bleeding. His hematocrit was checked serially throughout his stay. The patient's hematocrit eventually stabilized to a level of 28.9. However, on hospital day four, the patient was found to be orthostatic and therefore was further transfused another unit of packed red blood cells with resolvement of his symptoms. Patient's hematocrit then stabilized out at a level greater than 30 to approximately 32 for the remainder of his stay. The patient received a total of 5 units of packed red blood cells with hematocrit stabilized to 35 on discharge. 2. Cardiovascular. During the patient's MICU stay, he was monitored on Telemetry without incident. Electrocardiogram was performed and was normal with a heart rate of 90 beats per minute and normal sinus rhythm. There were no ST elevations or depressions and there were no T-wave inversions. No other evidence of cardiac injury secondary to his anemia. 3. Gastrointestinal. As stated before, the patient underwent TAG red blood cell scan on which was negative for any acute gastrointestinal bleed. The patient was begun on Protonix for GI prophylaxis. On , patient was scheduled to undergo enteroscopy, however, the patient was unable to tolerate the procedure secondary to inability to appropriately be sedated. Therefore, the examination was halted as it was not deemed safe to continue. Subsequently, the patient was deemed hemodynamically stable and was transferred to the regular Medicine floor on . As per stated above in the laboratories on admission, the patient was found to be hepatitis B and hepatitis C positive. Also he had evidence of having hepatitis A in the past. He does have normal LFTs. Hepatitis C viral load was sent and per the result was not detected via HCV RNA PCR. On , the patient underwent a Meckel scan to rule out possible gastrointestinal bleed for Meckel's diverticulum. The scan was negative for Meckel's diverticulum. The patient had no further episodes of bright red blood per rectum subsequent to being transferred out of the Medical Intensive Care Unit on . The patient's diet was initially NPO and was advanced slowly to clears and then regular diet. He tolerated that well, and again continued to have normal bowel movements throughout his stay. The patient will have further followup as an outpatient with his gastroenterologist, Dr. . Please note that the patient was followed by the Gastroenterology Service throughout his entire stay at . The patient did undergo a colonoscopy during his admission. This showed diverticulae, however, did not show any source of active bleeding. This examination was performed prior to the attempt at the enteroscopy. 4. FEN. Patient was aggressively hydrated on initial admission to the Emergency Department. Throughout his stay his diet was gradually advanced. On discharge, he was tolerating a full diet and was hemodynamically stable. | Approved: TUE 7:06 PM West RADLINE ; A radiology consult service. Hct of 28.7 immediately post transfusion. Plan to clean out and colonoscopy in am., hct q4h.Fluids- #8L NS^ @125/h, voiding.Heme-Hct q4h; has received 3u PRBC in ED, 1unit available @1800. s/p bleed rectallyd: pt hemodynmically stable. Approved: 4:07 PM West RADLINE ; A radiology consult service. HCT STABLE AT 29.2-30.1. pt transfered cc720 for furhter observation. PT THEN HAD COLONOSCOPY WHICH SHOWED SM DIVERTICULI BUT NO ACTIVE BLEEDING. npo and transfered to endoscopy unit for upper endoscopy. BRBPRD: NEURO: PT A&O X3. Total 8L NS, 3 u PRBC.Neuro- Alert and oriented x3, good historian, oriented to MICU routine.REsp- sat 98 RA; RR12-13, BS clear throughout.CV- 120/60, 86-90 nsr. EKG done- prelim- no changes.GI- + BS, soft- non distended Sl tender @ LLQ. GI ahs consulted in MICU. ?colonoscopy if not clear. /nkg , M.D. /nkg , M.D. WILL FOLLOW ELECTROLYTES AS ORDERED.CV: HR 70-80'S AND SBP 100-124. IMPRESSION: Normal Meckel's scan. MECKEL'S SCAN Clip # Reason: GI BLEED. NEUROLOGICALLY INTACT.RESP: ON ROOM AIR O2 SAT>95% AND LUNGS CLEAR ON AUSCULTATION.GI: PT HAS BEEN NPO FOR W/U OF SOURCE FOR BRBPR. NWH admission x2 w/o confirmed dx; Hospital admission .Awoke this am w/ feeling of rectal pressure like diarrhea as in past, went to work, had episode of BRBPR walking to work, syncope, EMS, ED. was given 1 unit PRBC's. ABD BENIGN ON EXAM.GU: VOIDING QS CELAR YELLOW URINE. WILL FOLLOW HCTS Q 12 HRS AND NOTIFY MEDICAL TEAM IF HCT DROPS OF HE STARTS REBLEEDING. Evaluate for bleed source. Extremely fatigued.CVS: See carevue flowsheet. taking go-lytely very slowly overnight. Normal ECG. ?tagged RBC study today.CNS: Alert, oriented and cooperative. , M.D. , M.D. GI BLEEDING STUDY Clip # Reason: GI BLEEDING. DIET NOW ADVANCED TO CLEAR LIQS AND WILL NEED TO KEEP NPO AFTER 2400 FOR ? To hear preliminary results, prior to transcription, call the Radiology Listen Line . To hear preliminary results, prior to transcription, call the Radiology Listen Line . MG REPELTED WITH 2 GMS IVPB AND CA REPLACED WITH 2 HMS CA GLUCONATE IVPB. INTERPRETATION: Following intravenous injection of Tc-m pertechnetate, serial images over the abdomen were obtained in anterior and posterior projections. Hct also dropped from 29.2 to 27 and pt. MICU Nursing Admission Note 180032 y/o male w/ hx of BRBPR x3 episodes over 12m, hx diverticulosis, ? Evaluate for bleeding location. Sinus rhythm. MICU A Nursing Progress Note (0700-1900)GI: Pt. Hct of 28 this AM. hct stable at 28. no obvious signs of bleeding. Informed as to MICU routine, MICU A phone # given. PHYSICAL EXAM: Please note that during the study the patient passed a bowel movement that was free of blood. IMPRESSION: No definite scintigraphic evidence of acute GI bleed. INITIALLY THIS AM PT WAS PASSING TEA COLORED LIQ STOOL WITH SM CLOTS. CV VERY STABLE AND WILL FOLLOW CLOSELY OVERNOCSOCIAL: WIFE IN TO VISIT AND HAS BEEN UPDATED . MICU A Nursing Progress Note (1900-0700)Pt. ENDOSCOPY IN THE AM AND PT ALSO GO FOR ANGIOGRAPHY. Hepatitis, IVDuse ~10 years ago. INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-m, blood flow and delayed images of the abdomen for 90 minutes were obtained. Nausea has subsided, no stool. BUN/CREAT WNR.IV: IV INITIALLY NS WITH 40 MEQ INFUSING AT 125CC'S/HR BUT RATE HAS NOW BEEN DECREASED B/CAUSE OF PO INTAKE. Hemodynamically stable without any orthostatic changes.RESP: Lungs clear. He is putting out liquid BRBPR with some clots...has not cleared at all. FINAL REPORT HISTORY: Thirty-two year old male with BRBPR and multiple diverticuli seen on colonoscopy. PT TRANSPORTED TO NUCLEAR MED FOR RED TAG STUDY WHICH WAS NEG FOR IDENTIFYING SOURCE OF BLEEDING. NPO since midnight for mesenteric angiogram today. No definite site of acute GI bleed was identified on today's study. Blood flow images show symmetric flow of tracer in the great vessels of the abdomen and pelvis and focal accumulation of tracer in the region of the bladder and penis. Sats in the mid 90's on room air.SOCIAL: Wife called x 1 overnight and was updated by nursing. | 8 | [
{
"category": "Radiology",
"chartdate": "2109-01-08 00:00:00.000",
"description": "MECKEL'S SCAN",
"row_id": 781201,
"text": "MECKEL'S SCAN Clip # \n Reason: GI BLEED.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thirty-two year old male with BRBPR and multiple diverticuli seen on\n colonoscopy. Evaluate for bleed source.\n\n INTERPRETATION: Following intravenous injection of Tc-m pertechnetate, serial\n images over the abdomen were obtained in anterior and posterior projections.\n Blood flow images show no definite scintigraphic evidence of a Meckel's\n diverticulum or ectopic gastric mucosa. No definite bleeding source is\n identified.\n\n IMPRESSION: Normal Meckel's scan. /nkg\n\n\n , M.D.\n , M.D. Approved: TUE 7:06 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": "2109-01-03 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 780717,
"text": "GI BLEEDING STUDY Clip # \n Reason: GI BLEEDING.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thirty-two year old male with bright red blood per rectum and h/o\n same, diverticuli in past. Evaluate for bleeding location.\n\n PHYSICAL EXAM: Please note that during the study the patient passed a bowel\n movement that was free of blood.\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and delayed images of the abdomen for 90\n minutes were obtained. Additional lateral views of the pelvis were obtained.\n\n Blood flow images show symmetric flow of tracer in the great vessels of the\n abdomen and pelvis and focal accumulation of tracer in the region of the bladder\n and penis. No definite site of acute GI bleed was identified on today's study.\n\n Delayed blood pool images likewise show focal accumulation of blood in the\n region of the bladder and penis.\n\n IMPRESSION: No definite scintigraphic evidence of acute GI bleed. /nkg\n\n\n , M.D.\n , M.D. Approved: 4:07 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-01-02 00:00:00.000",
"description": "Report",
"row_id": 1331880,
"text": "MICU Nursing Admission Note 1800\n\n32 y/o male w/ hx of BRBPR x3 episodes over 12m, hx diverticulosis, ? Hepatitis, IVDuse ~10 years ago. NWH admission x2 w/o confirmed dx; Hospital admission .\nAwoke this am w/ feeling of rectal pressure like diarrhea as in past, went to work, had episode of BRBPR walking to work, syncope, EMS, ED. Total 8L NS, 3 u PRBC.\n\nNeuro- Alert and oriented x3, good historian, oriented to MICU routine.\nREsp- sat 98 RA; RR12-13, BS clear throughout.\nCV- 120/60, 86-90 nsr. EKG done- prelim- no changes.\nGI- + BS, soft- non distended Sl tender @ LLQ. GI ahs consulted in MICU. Plan to clean out and colonoscopy in am., hct q4h.\nFluids- #8L NS^ @125/h, voiding.\nHeme-Hct q4h; has received 3u PRBC in ED, 1unit available @1800.\n Wife and friend visiting upon admission. Informed as to MICU routine, MICU A phone # given.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-01-03 00:00:00.000",
"description": "Report",
"row_id": 1331881,
"text": "MICU A Nursing Progress Note (0700-1900)\n\nGI: Pt. taking go-lytely very slowly overnight. He is putting out liquid BRBPR with some clots...has not cleared at all. Hct also dropped from 29.2 to 27 and pt. was given 1 unit PRBC's. Hct of 28.7 immediately post transfusion. ?colonoscopy if not clear. ?tagged RBC study today.\n\nCNS: Alert, oriented and cooperative. Extremely fatigued.\n\nCVS: See carevue flowsheet. Hemodynamically stable without any orthostatic changes.\n\nRESP: Lungs clear. Sats in the mid 90's on room air.\n\nSOCIAL: Wife called x 1 overnight and was updated by nursing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-01-03 00:00:00.000",
"description": "Report",
"row_id": 1331882,
"text": "BRBPR\nD: NEURO: PT A&O X3. PLEASANT AND COOPERATIVE. NEUROLOGICALLY INTACT.\n\nRESP: ON ROOM AIR O2 SAT>95% AND LUNGS CLEAR ON AUSCULTATION.\n\nGI: PT HAS BEEN NPO FOR W/U OF SOURCE FOR BRBPR. HCT STABLE AT 29.2-30.1. NO C/O N/V. INITIALLY THIS AM PT WAS PASSING TEA COLORED LIQ STOOL WITH SM CLOTS. PT TRANSPORTED TO NUCLEAR MED FOR RED TAG STUDY WHICH WAS NEG FOR IDENTIFYING SOURCE OF BLEEDING. PT THEN HAD COLONOSCOPY WHICH SHOWED SM DIVERTICULI BUT NO ACTIVE BLEEDING. PT TOLERATED BOTH PROCEDURES WELL. DIET NOW ADVANCED TO CLEAR LIQS AND WILL NEED TO KEEP NPO AFTER 2400 FOR ? ENDOSCOPY IN THE AM AND PT ALSO GO FOR ANGIOGRAPHY. WILL FOLLOW HCTS Q 12 HRS AND NOTIFY MEDICAL TEAM IF HCT DROPS OF HE STARTS REBLEEDING. ABD BENIGN ON EXAM.\n\nGU: VOIDING QS CELAR YELLOW URINE. BUN/CREAT WNR.\n\nIV: IV INITIALLY NS WITH 40 MEQ INFUSING AT 125CC'S/HR BUT RATE HAS NOW BEEN DECREASED B/CAUSE OF PO INTAKE. MG REPELTED WITH 2 GMS IVPB AND CA REPLACED WITH 2 HMS CA GLUCONATE IVPB. WILL FOLLOW ELECTROLYTES AS ORDERED.\n\nCV: HR 70-80'S AND SBP 100-124. CV VERY STABLE AND WILL FOLLOW CLOSELY OVERNOC\n\nSOCIAL: WIFE IN TO VISIT AND HAS BEEN UPDATED . PT REMAINS A FULL CODE AND WILL OFFER EMOTIONAL SUPPORT TO PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-01-04 00:00:00.000",
"description": "Report",
"row_id": 1331883,
"text": "MICU A Nursing Progress Note (1900-0700)\n\nPt. hemodynamically stable throughout the night. Nausea has subsided, no stool. Hct of 28 this AM. NPO since midnight for mesenteric angiogram today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-01-04 00:00:00.000",
"description": "Report",
"row_id": 1331884,
"text": "s/p bleed rectally\nd: pt hemodynmically stable. hct stable at 28. no obvious signs of bleeding. npo and transfered to endoscopy unit for upper endoscopy. pt transfered cc720 for furhter observation.\n"
},
{
"category": "ECG",
"chartdate": "2109-01-02 00:00:00.000",
"description": "Report",
"row_id": 167365,
"text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n"
}
] |
16,378 | 179,705 | The patient was admitted and underwent orthotopic deceased donor liver transplant, piggyback, portal vein to portal vein anastomosis, common bile duct to common bile duct anastomosis without a T tube, donor common hepatic artery to recipient common hepatic artery end-to-end. Operative findings were notable for a cirrhotic liver with a large lesion in the right lobe of his liver consistent with prior radiofrequency ablation site. The omentum was stuck to this lesion. He had mild portal hypertension. He had no other significant abnormalities. No T tube was placed. Two 19 drains were placed and brought through separate stab incisions. Intraoperatively, the patient received 7000 cc of Plasma-Lyte, 3 units of fresh frozen plasma, 2 units of platelets, 1 unit of cryo, 500 cc of albumin and made 750 cc of urine. The patient was transferred to the surgical intensive care unit in stable condition. A post-transplant ultrasound showed patent transplant vasculature except right hepatic artery not visualized. It also showed higher than normal velocities in the portal vein. CXR - NGT coiled in stomach, Swan in PA, density LLL. HBV DNA non-detectable. On POD 1, an ultrasound was repeated which showed patent hepatic vasculature, with normal waveforms. A 5.5 x 2.7 cm subhepatic collection consistent with postop changes. On POD 7, an ultrasound was again performed which showed all hepatic vessels to be patent. Return of bowel function was noted on POD 2 and the patient's diet was advanced. The lateral drain was removed on POD 4 and a 3-0 silk suture was used to close the site. The medial drain was removed on POD 7. The hospital course has been complicated by high blood sugars to the 200's. The patient was changed to a diabetic diet and was consulted. The patient was placed on a stricter sliding scale and started on a nighttime dose of Lantus. The patient is being discharged on POD 7 with minimal pain, ambulating without difficulty, and tolerating a regular diet. | Physiologicmitral regurgitation is seen (within normal limits). Normal ascending aortadiameter. Patent hepatic vasculature, with normal waveforms. Normaldescending aorta diameter. Normalregional LV systolic function. Unchanged subhepatic fluid collection consistent with postoperative change. Significant PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The main hepatic artery at the hilum is patent and demonstrates normal waveform. Mild to moderateeccentric pulmonic regurgitation is seen.Post transplant, pt is on phenylepherine infusion. The mitral valveappears structurally normal with trivial mitral regurgitation. PhysiologicMR (within normal limits). Normal aortic arch diameter. There are simple atheroma in thedescending thoracic aorta. Abdominal incision with primary dsg intact; small amount serosang drainage noted on incision. FINDINGS: The middle hepatic, right hepatic, and left hepatic veins are patent and demonstrate normal directional flow. Short (<140ms) transmitral E-wave decel time.TRICUSPID VALVE: Normal tricuspid valve leaflets. Hct stable; see CareVue for labs. The right anterior and posterior, main, and left portal veins are patent and demonstrate normal directional flow. OR UNEVENTFUL, TOLERATE PROCEDURE WELL.RECEIVED COLLOID/CRYSTALLOID PER FLOW SHEET.NEUR--ON PROPOFOL AT 30 MCG/KG. The left ventricular cavity sizeis normal. The hepatic veins are patent with normal direction of flow. Respiratory CarePt weaned and extubated without incident weaned to 3l/m. The main, right, and left hepatic arteries are well seen and patent with normal waveforms. INCISION CLEAN/DRY/APPROXIMATED WITH TEGADERM DRESSING. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). The left hepatic artery demonstrates a normal waveform with visualization of the left hepatic artery into the substance of the left hepatic lobe. The left hepatic artery, middle hepatic artery, and right hepatic artery are patent with appropriate brisk systolic upstroke, robust diastolic flow, and resistive indices ranging from 0.50 through 0.67. Evaluate valvular function, ventricular function, aortic atheroma, r/o ASD (suspicion on TTE, but not conclusive)Height: (in) 67Weight (lb): 148BSA (m2): 1.78 m2BP (mm Hg): 116/60HR (bpm): 98Status: InpatientDate/Time: at 11:37Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Transgastric views are nowlimited, but overall biventricular function appears preserved. A 5.5 x 2.7 cm subhepatic collection consistent with postoperative changes. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. . TREATED WITH SLIDING SCALE.ID--ON UNSYN. Left portal vein and right portal vein are patent with appropriate waveforms. The middle, right, and left hepatic veins are patent, with appropriate direction of flow. Addendum:Low urine output at 0500 (17mL); Dr. notified. Right ventricular chambersize and free wall motion are normal. The patient was under general anesthesia throughout theprocedure.Conclusions:The left atrium is moderately dilated. ABG on current vent setting showed compensated metabolic alkalosis. Addendum to NPN:Foley intact. FINDINGS: The transplant liver is normal in echotexture. There is noaortic valve stenosis. Normal interatrial septum.No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.LEFT VENTRICLE: Normal LV wall thickness. The main hepatic artery and left hepatic artery are patent, with appropriate direction of flow. The hepatic veins are patent with appropriate waveforms. CCO IN PLACE WITH APPROPRIATE POST TRANSPLANT NUMBERS. AMOUNTS SEROUS--SERO SANG DRAINAG.GU--FOLEY IN PLACE. Patent hepatic and portal veins. IMPRESSION: Patent transplant vasculature except right hepatic artery not visualized. Normal LV cavity size. JPx2 to bulb suction with serosang drainage; JP drains emptied q1hr as ordered. Thoracic aorta is mildly tortuous. The portal vein is patent with hepatopetal flow. 2 JPS TO BLUB SUCTION, DRAINING SMALL-MOD. Monitor neuro and respiratory status. Again seen is a 5.3 cm x 5.2 cm x 3.1 cm complex collection in the subhepatic region which is not significantly changed. IMPRESSION: AP chest compared to : Tip of the right jugular line projects over the mid SVC. Remaining exam isunchanged. Abdomen softly distended w/ absent bowel sound. Anastomotic sites appear intact. Sinus rhythmNormal ECGSince previous tracing of , no significant change The main portal vein, right and left portal vein branches are patent, with appropriate direction of flow. Continue ICU care and treatment. Regional left ventricular wall motion is normal. Main portal vein is patent with appropriate waveform and velocity. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Aortic contours are intact. The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation. HR 80s-low 100s (NSR/sinus tach with rare PVCs). No c/o nausea. Latest abg results determined a very mild metabolic alkalemia with very good oxygenation on the current settings. No atrial septal defect or patentforamen ovale is seen by 2D, color Doppler or saline contrast with maneuvers.Left ventricular wall thicknesses are normal. Pulmonary vascular congestion has cleared since . Scant amount of secretions suctioned down ETT. See CareVue for details on CO/CI/SVR. Extubate this AM. Platelet x1 given; post transfusion platelet: 93. Normal waveforms seen within the main and left hepatic arteries with patent right hepatic artery at the hilum and non-visualization of right hepatic artery signal on the substance of the right lobe, due to the presence of a single anastomosis this may be technical, and further correlation with liver function tests is recommended. Lungs are clear, without evidence of consolidation or effusion or CHF. FINDINGS: Post transplant liver echotexture is unremarkable. Per Dr. , not wedge! PAP 18-30s/13-19; Dr. aware of low PA numbers. INDICATION: Status post liver biopsy. Lungs clear. Mouth care performed per VAP prevention protocol. Heart size is normal. CXRAY DONE POST OP. ABP 110-130s/60s-70s. Ppf gtt stopped at 0600; pt on spontaneous breathing trial. The heart is normal in size. RIC dsg changed x1. Notify HO if uo <30cc/hr. ?change CCO/PA line to triple lumen central line today. Wean off Ppf and extubate this morning. I certifyI was present in compliance with HCFA regulations. The right hepatic artery is seen at the hilum, however, no good right hepatic arterial signal is demonstrated within the substance of the right lobe with minimal diastolic flow is seen within the right hepatic artery near the hilum, given that there is single arterial anastomosis, these findings may be technical in nature and close interval followup is recommended. | 15 | [
{
"category": "Radiology",
"chartdate": "2134-03-17 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 953525,
"text": " 11:15 AM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: elevation of alk phos and alt today. please assess arterial/\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with liver tx for HBV cirrhosis 2 days postop\n\n REASON FOR THIS EXAMINATION:\n elevation of alk phos and alt today. please assess arterial/venous flow as well\n as for intraductal dilatation\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Liver Doppler dated \n\n COMPARISON: Liver Doppler dated and .\n\n INDICATION: 47-year-old female with liver transplant for hep B cirrhosis,\n postop with elevation of alk phos and ALT today. Please assess\n arterial/venous flow.\n\n FINDINGS: The middle hepatic, right hepatic, and left hepatic veins are\n patent and demonstrate normal directional flow. The right anterior and\n posterior, main, and left portal veins are patent and demonstrate normal\n directional flow. The main hepatic artery at the hilum is patent and\n demonstrates normal waveform. The left hepatic artery demonstrates a normal\n waveform with visualization of the left hepatic artery into the substance of\n the left hepatic lobe. The right hepatic artery is seen at the hilum,\n however, no good right hepatic arterial signal is demonstrated within the\n substance of the right lobe with minimal diastolic flow is seen within the\n right hepatic artery near the hilum, given that there is single arterial\n anastomosis, these findings may be technical in nature and close interval\n followup is recommended. Again seen is a 5.3 cm x 5.2 cm x 3.1 cm complex\n collection in the subhepatic region which is not significantly changed.\n\n IMPRESSION:\n\n 1. Patent hepatic and portal veins. Normal waveforms seen within the main\n and left hepatic arteries with patent right hepatic artery at the hilum and\n non-visualization of right hepatic artery signal on the substance of the right\n lobe, due to the presence of a single anastomosis this may be technical, and\n further correlation with liver function tests is recommended.\n\n 2. Unchanged subhepatic fluid collection consistent with postoperative\n change.\n\n These findings were discussed with Dr. by Dr. at completion of\n the exam.\n\n\n\n\n (Over)\n\n 11:15 AM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: elevation of alk phos and alt today. please assess arterial/\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-22 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 954098,
"text": " 8:50 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: S/PLIVER TX EVAL FOR VESSELS PATENCY\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with liver tx on for HBV cirrhosis postop U/S have\n failed to showed blood flow within R liver parenchyma\n\n REASON FOR THIS EXAMINATION:\n Follow-up evaluation of previous non-visualization of right hepatic artery\n signal on the substance of the right lobe,\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old status post liver transplant on for hepatitis B\n cirrhosis, postop ultrasound failed to demonstrate right hepatic arterial\n patency.\n\n TRANSPLANT DOPPLER LIVER ULTRASOUND: -scale images of the liver were not\n acquired. Main portal vein is patent with appropriate waveform and velocity.\n Left portal vein and right portal vein are patent with appropriate waveforms.\n The left hepatic artery, middle hepatic artery, and right hepatic artery are\n patent with appropriate brisk systolic upstroke, robust diastolic flow, and\n resistive indices ranging from 0.50 through 0.67. The IVC is patent. The\n hepatic veins are patent with appropriate waveforms.\n\n IMPRESSION: Unremarkable Doppler liver transplant ultrasound, demonstrating\n patent hepatic arteries, portal veins, and hepatic veins with appropriate\n waverforms. Findings discussed with Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-15 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 953303,
"text": " 3:47 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: NEW TRANSPLANT CHECK FLOW\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with liver tx\n REASON FOR THIS EXAMINATION:\n flow\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male post liver transplant for evaluation of flow.\n\n COMPARISON: .\n\n FINDINGS: Post transplant liver echotexture is unremarkable. There are no\n focal lesions or fluid collections. Anastomotic sites appear intact. The\n middle, right, and left hepatic veins are patent, with appropriate direction\n of flow. The main portal vein, right and left portal vein branches are\n patent, with appropriate direction of flow. Portal venous velocities\n are in the 80-100 cm/sec range, which is higher than normally expected. The\n main hepatic artery and left hepatic artery are patent, with appropriate\n direction of flow. The right hepatic artery is not visualized.\n\n IMPRESSION: Patent transplant vasculature except right hepatic artery not\n visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 953367,
"text": " 9:21 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new line\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with liver tx and R IJ exchange today\n REASON FOR THIS EXAMINATION:\n new line\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:28 A.M., .\n\n HISTORY: Liver transplant and right IJ line exchange.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the right jugular line projects over the mid SVC. No mediastinal\n widening, new pleural effusion or pneumothorax. Lung volumes are low, but\n improved while bibasilar atelectasis is stable. Pulmonary vascular congestion\n has cleared since . Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-15 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 953209,
"text": " 4:30 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: END STAGE LIVER DISEASE\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man pre-op for liver transplant\n REASON FOR THIS EXAMINATION:\n eval for acute pulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with preop for liver transplant.\n\n PA AND LATERAL CHEST RADIOGRAPH: There is no prior chest radiograph for\n comparison. The heart is normal in size. Thoracic aorta is mildly tortuous.\n Lungs are clear, without evidence of consolidation or effusion or CHF.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 953300,
"text": " 3:22 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with liver tx and R IJ\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Status post liver biopsy.\n\n A single AP view of the chest was obtained supine on at 15:30 hours\n and compared with a prior radiograph performed at 04:29 hours, the same\n morning. The patient is status post abdominal surgery. The heart is not\n enlarged. The patient is intubated with an ET tube with the tip approximately\n 5.2 cm above the carina. A Swan-Ganz catheter is in place with its tip in the\n right pulmonary artery. Nasogastric tube is present with its tip coiled in\n the fundus of the stomach. A surgical drain is in the upper portion of the\n abdomen in the right upper quadrant adjacent to the liver.\n\n Examination of the lungs shows some patchy increased density in the left base\n with obscuration of the medial portion of the left hemidiaphragm and of the\n descending aorta consistent with early airspace disease/atelectasis in the\n left lower lobe.\n\n IMPRESSION:\n 1. Status post abdominal surgery with liver transplant with drains in the\n upper abdomen.\n 2. Patchy density developing in the left base consistent with airspace\n disease/atelectasis developing at the left lower lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-16 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 953363,
"text": " 9:07 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: please re-evaluate for patency (hep a not seen yesterday)\n Admitting Diagnosis: END STAGE LIVER DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with liver tx\n\n REASON FOR THIS EXAMINATION:\n please re-evaluate for patency (hep a not seen yesterday)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old man status post liver transplant.\n\n FINDINGS: The transplant liver is normal in echotexture. There is a\n subhepatic collection measuring 5.5 x 2.7 cm, which was not well seen on prior\n examination. The portal vein is patent with hepatopetal flow. The main,\n right, and left hepatic arteries are well seen and patent with normal\n waveforms. Resistive indices range from 0.67 to 0.86. The hepatic veins are\n patent with normal direction of flow.\n\n IMPRESSION:\n 1. Patent hepatic vasculature, with normal waveforms. The main, left, and\n right hepatic arteries are well seen on this exam.\n 2. A 5.5 x 2.7 cm subhepatic collection consistent with postoperative\n changes.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-03-15 00:00:00.000",
"description": "Report",
"row_id": 82992,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraop liver transplant. Evaluate valvular function, ventricular function, aortic atheroma, r/o ASD (suspicion on TTE, but not conclusive)\nHeight: (in) 67\nWeight (lb): 148\nBSA (m2): 1.78 m2\nBP (mm Hg): 116/60\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 11:37\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. . Physiologic\nMR (within normal limits). Short (<140ms) transmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure.\n\nConclusions:\nThe left atrium is moderately dilated. No atrial septal defect or patent\nforamen ovale is seen by 2D, color Doppler or saline contrast with maneuvers.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. Physiologic\nmitral regurgitation is seen (within normal limits). Mild to moderate\neccentric pulmonic regurgitation is seen.\n\nPost transplant, pt is on phenylepherine infusion. Transgastric views are now\nlimited, but overall biventricular function appears preserved. There is no\nchange in valvular function. Aortic contours are intact. Remaining exam is\nunchanged. All findings discussed with surgeons at the time of the exam.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2134-03-15 00:00:00.000",
"description": "Report",
"row_id": 200729,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-15 00:00:00.000",
"description": "Report",
"row_id": 1476748,
"text": "FOCUS: CONDITION UPDATE\nSEE FLOW SHEET FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nD: PATIENT S/P LIVER TRANSPLANT FOR HEP B CHIRROSIS AND HEPATOCELLULAR CARCIMONA. OR UNEVENTFUL, TOLERATE PROCEDURE WELL.\nRECEIVED COLLOID/CRYSTALLOID PER FLOW SHEET.\nNEUR--ON PROPOFOL AT 30 MCG/KG. SLOWLY WAKING UP THIS AFTERNOON, MOVING ALL EXTREMITIES, RESPONDS TO PAIN, PUPILS 2MMEQUAL AND REACTIVE.\nCV--CARDIAC NUMBERS STABLE. CCO IN PLACE WITH APPROPRIATE POST TRANSPLANT NUMBERS. CXRAY DONE POST OP. WILL RECEIVE 2 U PRBC THIS PM FOR HCT OF 24.\nGI--NGT TO LCWS. ABD. ULTRASOUND DONE THIS AFTERNOON. INCISION CLEAN/DRY/APPROXIMATED WITH TEGADERM DRESSING. 2 JPS TO BLUB SUCTION, DRAINING SMALL-MOD. AMOUNTS SEROUS--SERO SANG DRAINAG.\nGU--FOLEY IN PLACE. DRAINING LARGE AMOUNTS OF CLEAR YELLOW URINE.\nENDO--BLOOD SUGARS ELEVATED. TREATED WITH SLIDING SCALE.\nID--ON UNSYN. AFEBRILE\nSOCIAL--HAVE NOT HEARD FROM ANY FAMILY. WILL PROBABLY NEED CHINESE TRANSLATOR FOR WIFE WHEN SHE VISITS.\nPLAN: CHECK LABS 4 HRS. AND PRN\n MONTIOR I/O, MONITOR JP FOR ANY INCREASE IN DRAINAGE\n KEEP SEDATED OVERNIGHT ON PROPOFOL, NO VENT WEANING UNTIL AM.\n CALL HO/TRANSPLANT TEAM WITH ANY CHANGES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-16 00:00:00.000",
"description": "Report",
"row_id": 1476749,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt lightly sedated on Ppf gtt @ 20mcg/kg/min while intubated. Pt easily arousable to voice. Follows commands. Nods/shakes head to questions. Writes on clipboard at times to make needs known. Emotional support provided to pt. Morphine 2mg IV given for abdominal pain w/ +effect. RN asked pt q1hr if in pain; pt denied having pain and denied needing pain med most of the time. Able to sleep most of the night. PERRLA (2-3mm bilat; briskly reactive). Moves all extremities in bed. Afebrile. HR 80s-low 100s (NSR/sinus tach with rare PVCs). ABP 110-130s/60s-70s. CVP 9-13. PAP 18-30s/13-19; Dr. aware of low PA numbers. PAP systolic 18-20s this morning. SVO2 83-89. See CareVue for details on CO/CI/SVR. Per Dr. , not wedge! Unasyn 3grams IV q6hr x 4 doses. Hepatitis B Immune Globulin will be given @ 0600 per Dr. . Insulin gtt started per Dr. d/t BS 260s-280s (see CareVue for specifics). Dr. notified of continued hyperglycemia (BS >200) and insulin gtt up to 12units/hr. Per Dr. , D5 1/2NS decreased to 10cc/hr and 1/2NS started at 90cc/hr. BS checked q1hr while on insulin gtt; continue to monitor. Platelet x1 given; post transfusion platelet: 93. Hct stable; see CareVue for labs. Lactic acid down to 2.5. Lungs clear. Pt weaned to CPAP: 40%, PEEP 5, PS 5. ABG on current vent setting showed compensated metabolic alkalosis. O2 sat >/= 97%. Thick, white secretions from oral suction. Scant amount of secretions suctioned down ETT. Mouth care performed per VAP prevention protocol. Plan to extubate this morning. Abdomen softly distended w/ absent bowel sound. NGT to low continuous suction w/ green, bilious drainage. No c/o nausea. No bowel movement this shift. Abdominal incision with primary dsg intact; small amount serosang drainage noted on incision. JPx2 to bulb suction with serosang drainage; JP drains emptied q1hr as ordered. No pressure sores noted. Pt turned and repositioned frequently to maintain skin integrity. CCO/PA dsg changed x2 d/t +bleeding from insertion site. RIC dsg changed x1. No family members called overnight. Interpreter needed when pt's wife visits d/t wife is non-English speaking.\n Plan: Monitor VS, I's and O's, labs. Wean off Ppf and extubate this morning. Monitor ABGs closely. Monitor neuro and respiratory status. ?change CCO/PA line to triple lumen central line today. Check BS q1hr while on insulin gtt. Update pt and family on plan of care. Provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-16 00:00:00.000",
"description": "Report",
"row_id": 1476750,
"text": "Addendum to NPN:\nFoley intact. UO at beginning of shift was >100cc/hr, but urine output decreased to 30-70cc/hr. Dr. notified of decrease in urine output. No new interventions ordered. Notify HO if uo <30cc/hr. Urine is clear, amber in color.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-16 00:00:00.000",
"description": "Report",
"row_id": 1476751,
"text": "Respiratory Care:\nPatient was able to wean from A/C ventilatory support to CPAP/PSV and an FIO2 of 40%. Latest abg results determined a very mild metabolic alkalemia with very good oxygenation on the current settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-16 00:00:00.000",
"description": "Report",
"row_id": 1476752,
"text": "Addendum:\nLow urine output at 0500 (17mL); Dr. notified. No new interventions at this time. Per , discuss low urine output with transplant team during morning rounds. UO at 0600 was 22mL; continue to monitor. Ppf gtt stopped at 0600; pt on spontaneous breathing trial. Extubate this AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-03-16 00:00:00.000",
"description": "Report",
"row_id": 1476753,
"text": "Respiratory Care\nPt weaned and extubated without incident weaned to 3l/m.\n"
}
] |
25,415 | 159,774 | 1. urosepsis - Pt was admitted to MICU, where a central line was placed for IVF, and vanco/zosyn was started given her history of Klebsiella UTI and a UA here consistent with UTI. She received 6L IVF in the first few hours, but then was in net even fluid balance and was transferred to the floor. Urine cultures were consistent with contamination, but pt responded to IV Zosyn with a down-trending of her fever curve and WBC count. She was initially placed on vancomycin and Zosyn; the former was discontinued shortly thereafter. Pt was hydrated with additional IVF while on the floor. A repeat UA showed a marked decrease in the degree of pyuria, as well as decreased hematuria. She was felt to be responding to the Zosyn clinically, and therefore a PICC was placed for the remainder of her antibiotics; she will get a 2-week course total. 2. left lower lobe pneumonia - Pt was noted to have a new infiltrate on CXR. She was being covered with Zosyn for the urosepsis as above, and was otherwise asymptomatic and satting well. This was not thought to be the major source of infection causing her sepsis. 3. hypertension - Pt was noted to be hypertensive on the floor. Her metoprolol had been held previously in the setting of her sepsis, and this was restarted as she became more hemodynamically stable and was clearly resolved from a sepsis perspective. Her BB was uptitrated to 50mg po bid, but this may need to be increased even further as an outpatient. 4. metabolic acidosis - Pt noted to have a bicarb of 15 on presentation, likely due to lactic acidosis. Her albumin was "normal," but in the setting of such hemoconcentration, this was probably an overestimation. After fluid resuscitation and improvement in her hemodynamic status, her bicarb came back to her baseline of about 20. This is likely from chronic kidney disease, as her baseline Cr at this point is 1.0, probably representing a low GFR as pt has very little muscle mass. Of note, her urine bicarb was very low, arguing against urine bicarbonate losses. 5. acute renal failure - with fluid resuscitation, pt's Cr decreased from 1.9 back down to her baseline. Her underlying chronic kidney disease is likely due to hypertension. Interestingly, she initially had glycosuria, suggesting hyperglycemia, but was found to have normal fingersticks. Subsequent UA showed clearing of glycosura. 6. jaw pain - Pt reported jaw pain, which has been going on for days to weeks (different stories from pt and from patient's sister). Jaw pain was worse with moving her jaw. A head CT and sinus CT did not reveal any significant etiologies of jaw pain, such as a mass; there was a maxillary retention cyst noted and R sphenoid opacification. This should therefore be followed up further as an outpatient if jaw pain still continues to be an issue. At this point, it seems most consistent with TMJ. 7. question of diabetes - per report, this was steroid-induced. Pt was euglycemic for the few days prior to her discharge. At that point, fingersticks and sliding scale insulin were discontinued. 8. Osteoarthritis/Rheumatoid arthritis: Patient's back pain is at baseline and controlled with fentanyl patch. She was continued on her home regimen of 50mcg q72hours, as well as tylenol prn for pain. 9. - Pt was placed on SQ heparin, PPI, bowel regimen. 10. Dispo - Pt will return back to the nursing home. | Compared to theprevious tracing atrial tachycardia is no longer present.TRACING #1 There is a calcific density in an opacified right sphenoid sinus. Moves upper extrem weakly, rt lower extrem. COMPARISON: Chest x-ray dated . but has since cleared with fluids and abx. There is passage of contrast into the sigmoid colon. Recieved doses of flagyl, levo, vanco, and zosyn. Nbp 130's to 140's systolic. A right- sided IJ central venous line is seen terminating in the proximal right atrium, and should be withdrawn a few centimeters. IMPRESSION: 1) Central venous line in proximal right atrium; this should be withdrawn a few centimeters. Ems noted neuro exam normal, was tachycardic with elev.rr. Sinus rhythm with atrial premature beats. COMPARISON: abdomen and pelvis CT. ABDOMEN CT WITHOUT IV CONTRAST: There is a rounded pleural-based density at the uppermost image in the lingula. IMPRESSION: Right maxillary sinus retention cyst and right sphenoid opacification. Note is made of residual contrast in the colon. Sinus rhythm with atrial premature beat. Nebs given with relief, EKG performed and chest xray ordered. The nasogastric tube has been removed. TECHNIQUE: Axial and coronal contiguous images of the sinuses were obtained. SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: There is left lower lobe atelectasis. Note is made of small lung volumes with bibasilar atelectasis. was tachycardic to 140's, rectal temp 102.2, normotensive 140's systolic with rr in the 40's. CT SINUS: Minimal mucosal thickening, which may represent a small retention cyst is seen in the right maxillary sinus. FINDINGS: PICC line from the left arm is terminating in upper SVC. Markedly tortuous aorta with tracheal deviation. Presept cath in rt i.j., site has some blood but dose not appear to be bleeding presently. This was present on the prior study and is unchanged in the interval and is likely consistent with a simple cyst. The abdominal aorta is calcified and markedly ectatic and tortuous. GI/GU: Abdomen soft with + bs. Again note is made of marked tortuosity of thoracic aorta with tracheal deviation. If necessary, please repeat PA and lateral chest radiograph. Low voltage in the precordial leads.Early transition. Sigmoid and descending colon diverticuli are present. CV: Sinus rhythm to sinus tachycardia with rare to occn pac's, rate high 90's to low 110's. Again, note is made of marked tortuosity of the thoracic aorta. need for speech and swallow f/u chest xray 99.8 rectal. Unbroken deep pressure sore. There is small bilateral pleural effusion. 2) Continued left lower lobe atelectasis. The right jugular IV catheter terminates in the right atrium. Neuro: Alert to person time and place although dose have hx of dementia and delerium. Also up to perivaginal area with vulva engorgement. The density of brain parenchyma is within normal limits. ID: Pan cx in e.w. 2) Small pulmonary parenchymal density in the lingula, only partially visualized. There are small bilateral pleural effusions. Skin eval ordered. Bibasilar atelectasis is present. TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast. Markedly tortuous aorta. Respiratory: Lung sounds are clear in lt upper and diminished in lt lower, expiratory wheezes throughout rt fields. neb tx given. is contracted, lt le is extended. There is a decreased attenuation in the parenchymal tissue adjacent to the ventricles, consistent with chronic small vessel ischemic infarct. IMPRESSION: Left lower lobe atelectasis. Mild congestive heart failure with cardiomegaly. Alb./atr. Fentanyl patch changed. REASON FOR THIS EXAMINATION: with gastrograffin: eval for perf, intra-abdominal infection No contraindications for IV contrast FINAL REPORT INDICATION: Sepsis. The ventricles and sulci are prominent, consistent with age- related involutional change. The stomach and small bowel appears normal. There is prominence of the pulmonary vasculature and cardiomegaly indicating mild congestive heart failure. Placed on contact precautions for klebsiella that is resistant to some abx. cva. The osseous structures are osteopenic. Arrived to e.w. Persistent left lower lobe consolidation, which cannot be fully assessed due to markedly dilated gastric gas and elevated left hemidiaphragm. Next dose at . ct obtained, inital read shows no acute process. Ngt d/c'd by team on arrivaql to micu after ct results called. Need for breakthrough pain med Monitor resp status Advance diet as tolerated- ? A nasogastric tube is seen coursing below the diaphragm. IMPRESSION: 1. Lung sounds clear at times, other times sounds very tight with expiratory wheezes relieved with nebs. There is a 2.3 x 2.2 cm rounded low-attenuation structure within the mid portion of the left kidney. 1:27 PM CHEST (PORTABLE AP) Clip # Reason: please check picc tip position. Cxr showed air level in stomach along with clear lungs so abd. Svo2 in 70's to low 80's. Because of gastric gas is markedly dilated and left hemidiaphragm is elevated, previously noted left lower lobe consolidation is probably persistent, but cannot be fully assessed on this film. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained without intravenous contrast and with oral contrast. # 18 angio in lt fa and # 20angio in rt hand. A nasogastric tube is present with tip in the distal stomach. The rectum and bladder are normal. Compared with the previous study at roughly 1:30 p.m., the right IJ catheter has been removed. #4f, picc cath for abx's. | 14 | [
{
"category": "Nursing/other",
"chartdate": "2126-05-04 00:00:00.000",
"description": "Report",
"row_id": 1593928,
"text": "MICU NURSING ADMISSION NOTE. 1700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Arrived to e.w. from nursing home via ems for c/c of change in ms, ? cva. Ems noted neuro exam normal, was tachycardic with elev.rr. On arrival to e.w. was tachycardic to 140's, rectal temp 102.2, normotensive 140's systolic with rr in the 40's. Lactate was 6.6, must protocol initiated. All baseline measure labs drawn in e.w., ivf initated, cxr obtained. Cxr showed air level in stomach along with clear lungs so abd. ct obtained, inital read shows no acute process. Upon completion of ct pt arrived to MICU A at 1700.\n On arrival to micu labs were drawn, svo2 monitor calibrated all general orders carried out. Fentanyl patch changed. Mushroom catheter inserted for loose green stool and c-diff obbtained and sent. Placed on contact precautions for klebsiella that is resistant to some abx. Antifungal barrier cream applied to gluteal, perianal and upper hip area's for what appears to be possible fungal rash. Skin eval ordered.\n\n Neuro: Alert to person time and place although dose have hx of dementia and delerium. Speach is clear and is able to make needs known verbally. Is pleasant and cooperative with care. Moves upper extrem weakly, rt lower extrem. is contracted, lt le is extended. has been bedridden for past two years since suffering a broken rt hip that was managed medically. Temperature max. 99.8 rectal. Oral temp was 95.\n\n Respiratory: Lung sounds are clear in lt upper and diminished in lt lower, expiratory wheezes throughout rt fields. Alb./atr. neb tx given. O2 saturation 95-100% on 3l nc. Arrived on nrb with sats of 100%. Resident reports was 95% on ra in e.w. Cxr shows clear fields. No cough noted. Svo2 in 70's to low 80's.\n\n CV: Sinus rhythm to sinus tachycardia with rare to occn pac's, rate high 90's to low 110's. Nbp 130's to 140's systolic. Presently has received seven liters ns prior to micu. Cvp 8. # 18 angio in lt fa and # 20angio in rt hand. Presept cath in rt i.j., site has some blood but dose not appear to be bleeding presently.\n\n GI/GU: Abdomen soft with + bs. Moderate green loose stool, c-diff sent. Ngt d/c'd by team on arrivaql to micu after ct results called. Pt reports eats normal diet, takes pills crushed in apple sauce. Foley catheter patent and draining clear yellow urine. Reportedly was thick and pussy in e.w. but has since cleared with fluids and abx.\n\n Integ: Lg area's of bruising or rash with shiny red/purple skin that coveres bilateral gluteals and hip area's along with perianal area. Also up to perivaginal area with vulva engorgement. Covered area's with antifungal barrier cream but further skin tx will be required. Frequent trns and keeping off area's involved as best possible.\n\n ID: Pan cx in e.w. Recieved doses of flagyl, levo, vanco, and zosyn. Zosyn to be given every 8 hours. Next dose at .\n\n Plan: Tx cvp as required. Continue abx. Next lab draw for must protocol at 2100, the\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-05-04 00:00:00.000",
"description": "Report",
"row_id": 1593929,
"text": "MICU NURSING ADMISSION NOTE. 1700-1900\n(Continued)\nn 0100 then 0500 then 0900.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-05-05 00:00:00.000",
"description": "Report",
"row_id": 1593930,
"text": "MICU Nursing Progress Notes 1900-0700\nPt continues on septic protocol, however afebrile overnight, lactates trending down. 1 500cc bolus given overnight for CVP 7 with good response. Magnesium and calcium repleted last night. 40 MEQ of K ordered - 20 MEQ hanging now, will need second 20 MEQ.\n\nAt approx 5-5:30 pt c/o R side mouth painful and chest tightness. Nebs given with relief, EKG performed and chest xray ordered. ? Pain due to skin around R IJ pulling. Able to fall back asleep with resolution in chest tightness..\n\nNeuro: Pt alert and oriented to person and knows she is in a hospital. Pleasant and cooperative with care. Able to sleep most of night. Does have pain with turns related to stiff painful joints. Area on buttocks is also painful to touch. Fentanyl patch in place.\n\nResp: Sats 97-100% on 3L NC. Lung sounds clear at times, other times sounds very tight with expiratory wheezes relieved with nebs. Coughing up small amts thick white, blood tinged secretions. RR teens to low 20's. SVO2 high 70's to mid 80's.\n\nCV: HR 80's-110 NSR-ST with PAC's. BP 90's-110's/40's-50's. CVP's run overnight. CVP goal greater than 8.\n\nGI: Pt diet changed to clear liqs. Swallowed pills crushed in applesauce without difficulty. +BS, abd soft, nontender, No BM this shift.\n\nGU: Foley drg cloudy light yellow urine. UO approx 30 cc hour.\n\nSkin: Buttocks, lower back, upper thighs, perianal, labial area- reddish purple without broken areas. Skin is shiny and tight appearing- ? Unbroken deep pressure sore. Frequent turns, antifungal and barrier cream applied frequently. Will need skin consult and special skin bed. Also noted area on R inner calf- which also looks to be skin breakdown as well from legs being contracted in there position. Pillow applied to help relieve pressure.\n\nEndo: BG WNL.\n\nSocial: No calls/visits overnight.\n\nPlan: Continue septic protocol until 11 am.\n Labs 0900\n Frequent skin care\n ? Need for breakthrough pain med\n Monitor resp status\n Advance diet as tolerated- ? need for speech and swallow\n f/u chest xray\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 864581,
"text": " 10:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with tachycardia\n REASON FOR THIS EXAMINATION:\n eval for chf, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with tachycardia. Evaluate for pneumonia.\n\n COMPARISON: .\n\n SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: There is left lower lobe\n atelectasis. The aorta is unfolded. Heart size is unchanged. No\n consolidations are seen. Severe degenerative changes seen in the right\n humerus. Note is made of a large amount of air in the stomach.\n\n IMPRESSION: Left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-04 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 864609,
"text": " 3:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: with gastrograffin: eval for perf, intra-abdominal infection\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with sepsis.\n REASON FOR THIS EXAMINATION:\n with gastrograffin: eval for perf, intra-abdominal infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis.\n\n TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained\n without intravenous contrast and with oral contrast.\n\n COMPARISON: abdomen and pelvis CT.\n\n ABDOMEN CT WITHOUT IV CONTRAST: There is a rounded pleural-based density at\n the uppermost image in the lingula. This measures 1.2 x 1.4 cm. Bibasilar\n atelectasis is present. There are small bilateral pleural effusions.\n Evaluation of the abdominal organs is limited due to lack of intravenous\n contrast, patient motion, and streak artifact from the patient's arm at her\n side. No focal liver or gallbladder abnormalities are present. The pancreas\n is unremarkable. The liver and adrenal glands appear normal. There is a 2.3\n x 2.2 cm rounded low-attenuation structure within the mid portion of the left\n kidney. This was present on the prior study and is unchanged in the interval\n and is likely consistent with a simple cyst. Multiple renal calculi are\n present within the right kidney. These were also seen on the prior study.\n There is no hydronephrosis.\n\n A nasogastric tube is present with tip in the distal stomach. The stomach and\n small bowel appears normal. There is passage of contrast into the sigmoid\n colon. Sigmoid and descending colon diverticuli are present. There is no\n evidence of diverticulitis. No intraabdominal free air or free fluid is\n present. The abdominal aorta is calcified and markedly ectatic and tortuous.\n\n PELVIS CT WITHOUT IV CONTRAST: Evaluation of the deep pelvic structures is\n slightly limited due to streak artifact from the patient's right hip\n prosthesis. The pelvic loops of small bowel are unremarkable. The rectum and\n bladder are normal. There is a Foley within the bladder. There is no free\n fluid or free air in the pelvis. No loculated collections are present.\n\n Degenerative changes are present throughout the axial skeleton.\n\n IMPRESSION:\n 1) No perforation. No intraabdominal source of infection identified.\n 2) Small pulmonary parenchymal density in the lingula, only partially\n visualized. This may be a focus of rounded atelectasis or may be a small\n mass. Further evaluation with followup chest x-ray is recommended. A\n (Over)\n\n 3:57 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: with gastrograffin: eval for perf, intra-abdominal infection\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n followup chest CT may also be considered.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 864941,
"text": " 6:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls evaluate for mass or other lesion causing pain\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with right sided facial pain increasing in surface area and\n intensity\n REASON FOR THIS EXAMINATION:\n pls evaluate for mass or other lesion causing pain\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of increasing right-sided facial pain.\n\n COMPARISON: Study from .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n CT HEAD WITHOUT IV CONTRAST: No intraparenchymal, subarachnoid or subdural\n hemorrhage. The ventricles and sulci are prominent, consistent with age-\n related involutional change. There is a decreased attenuation in the\n parenchymal tissue adjacent to the ventricles, consistent with chronic small\n vessel ischemic infarct. No intracranial mass effect. The -white\n differentiation is preserved. The density of brain parenchyma is within\n normal limits. The soft tissue and osseous structures are normal. In the\n visualized portions of the axillary, sphenoid and frontal sinuses, no soft\n tissue density or air fluid levels are identified.\n\n IMPRESSION: No intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 864595,
"text": " 12:51 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: line placement: right IJ, ngt\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with sepsis.\n REASON FOR THIS EXAMINATION:\n line placement: right IJ, ngt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with sepsis, now with line placement.\n\n COMPARISON: Two hours prior.\n\n SINGLE PORTABLE AP ERECT VIEW OF THE CHEST: There has been no significant\n interval change in the appearance of the lungs or the heart shadow. A right-\n sided IJ central venous line is seen terminating in the proximal right atrium,\n and should be withdrawn a few centimeters. A nasogastric tube is seen\n coursing below the diaphragm. No pneumothorax is identified on either side.\n\n IMPRESSION:\n 1) Central venous line in proximal right atrium; this should be withdrawn a\n few centimeters. This was discussed with Dr. at approximately 2:30\n p.m. on . No pneumothorax is seen.\n\n 2) Continued left lower lobe atelectasis. Remainder of the exam not\n significantly changed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 864644,
"text": " 6:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with sepsis. Copious sputum production. Want to evaluate for\n infiltrate.\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with sepsis, sputum.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed and compared with\n the previous study dated yesterday.\n\n There is increased patchy opacity in the left lower lobe indicating pneumonia.\n There is prominence of the pulmonary vasculature and cardiomegaly indicating\n mild congestive heart failure. There is small bilateral pleural effusion.\n Again, note is made of marked tortuosity of the thoracic aorta.\n\n The right jugular IV catheter terminates in the right atrium. The nasogastric\n tube has been removed. Note is made of residual contrast in the colon.\n\n Again, note is made of severe degenerative changes of the bilateral shoulder\n joints with chronic rotator cuff disease.\n\n IMPRESSION: Left lower lobe pneumonia. Mild congestive heart failure with\n cardiomegaly. Markedly tortuous aorta.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 865033,
"text": " 1:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please check picc tip position. #4f, picc cath for\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with sepsis. Copious sputum production. Want to evaluate for\n infiltrate.\n REASON FOR THIS EXAMINATION:\n please check picc tip position. #4f, picc cath for abx's. please page\n beeper # with wet read asap. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with sepsis. PICC line placement.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Chest x-ray dated .\n\n FINDINGS: PICC line from the left arm is terminating in upper SVC. No\n pneumothorax. Again note is made of marked tortuosity of thoracic aorta with\n tracheal deviation. Note is made of small lung volumes with bibasilar\n atelectasis. Because of gastric gas is markedly dilated and left\n hemidiaphragm is elevated, previously noted left lower lobe consolidation is\n probably persistent, but cannot be fully assessed on this film. Again note\n is made of dislocated right shoulder with degenerative changes and chronic\n rotator cuff disease.\n\n IMPRESSION:\n 1. PICC line from the left arm terminating in SVC. No pneumothorax.\n 2. Markedly tortuous aorta with tracheal deviation.\n 3. Persistent left lower lobe consolidation, which cannot be fully assessed\n due to markedly dilated gastric gas and elevated left hemidiaphragm. If\n necessary, please repeat PA and lateral chest radiograph.\n\n The information has been communicated with the IV access team.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 865062,
"text": " 3:48 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: reevaluate PICC placement s/p removal of adjacent central li\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with urosepsis on IV antibx\n REASON FOR THIS EXAMINATION:\n reevaluate PICC placement s/p removal of adjacent central line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post central line removal. Assess for PICC line position.\n\n PORTABLE CHEST AT 4:00 P.M. Compared with the previous study at roughly 1:30\n p.m., the right IJ catheter has been removed. There is no significant\n interval change in the position of the left arm PICC line with its tip\n projecting at the mid SVC level.\n\n No other significant changes or acute process is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-05-07 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 864943,
"text": " 6:13 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: pls evaluate for mass or other lesion causing pain\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with right sided facial pain increasing in surface area and\n intensity\n REASON FOR THIS EXAMINATION:\n pls evaluate for mass or other lesion causing pain\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of increasing right facial pain.\n\n TECHNIQUE: Axial and coronal contiguous images of the sinuses were obtained.\n\n CT SINUS: Minimal mucosal thickening, which may represent a small retention\n cyst is seen in the right maxillary sinus. No mucosal thickening or air-fluid\n levels are identified in the left maxillary sinus, frontal sinus, ethmoid air\n cells. There is a calcific density in an opacified right sphenoid sinus. The\n soft tissue and osseous structures are normal. No fracture is identified. The\n osseous structures are osteopenic. No soft tissue inflammatory stranding or\n fluid collections are identified.\n\n IMPRESSION: Right maxillary sinus retention cyst and right sphenoid\n opacification. No other abnormalities evident. MRI should be considered for\n further evaluation.\n\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-05 00:00:00.000",
"description": "Report",
"row_id": 311312,
"text": "Sinus rhythm with atrial premature beats. Low voltage in the precordial leads.\nEarly transition. Compared to the previous tracing of no significant\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-04 00:00:00.000",
"description": "Report",
"row_id": 311313,
"text": "Sinus rhythm with atrial premature beat. Early transition. Compared to the\nprevious tracing atrial tachycardia is no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2126-05-04 00:00:00.000",
"description": "Report",
"row_id": 311314,
"text": "Atrial tachycardia probably sinus tachycardia with atrial premature complexes\nSince previous tracing, rate faster\n\n"
}
] |
17,155 | 160,858 | The patient is an 86 y/o woman who presents to DMC 3 weeks s/p CABG from rehab with a reported history since discharge of pulmonary embolism, left middle cerebral artery stroke and purulent drainage emanating from her median sternotomy for the past week. After discussion with multiple consulting services: neurology, infectious disease and vascular surgery. The patient was deemed to only have active infectious mediastinitis and positive blood cultures consistent with methicillin sensitive staphylococcus aureus. The patient had a CT scan of the chest that showed a small fluid collection inferior the sternum. The patient TTE that did not show evidence of endocarditis of vegetations on the patients valves. On hospital day 2 the patient was afebrile, WBC 8500, blood cultures pending dressing changes instituted twice daily. The patient was started on vancomycin and kept in the intensive care unit for observation. The patient was also started on a heparin drip while in the ICU for anticoagulation for PE. The patient was transferred to a telemetry hospital floor, he anticoagulation was maintained with Lovenox. She received vancomycin for her positive blood cultures. Her median sternotomy wound was changed twice daily and gradually improved. She remained afebrile with stable vital signs. She did not undergo any surgical procedures while she was at DMC. Imaging of her carotids via CTA did not reveal a carotid dissection. TTE did reveal vegetations on her valves nonetheless the patients positive blood cultures were treated with vanco (MSSA) and her mediastinitis was treated with dressing changes. | Subcentimeter reactive lymph nodes are seen in the mediastinum (unchanged). Mucosal thickening, likely inflammatory in origin, is noted in the sphenoid and right maxillary sinuses, unchanged from prior study. BS checks done q6hr, covered with RISS. Unchanged inflammatory process around sternotomy, in the anterior and superior mediastinum. There are bilateral pleural effusions, left greater than right and mild subsegmental atelectatic changes bilaterally. HYPO BSP. Submitted late and out of sequenceSinus rhythmProbable left atrial abnormalityPoor R wave progression with late precordial QRS transition - consider prioranteroseptal myocardial infarction although is nondiagnosticNonspecific lateral T wave abnormalitiesSince previous tracing of , ventricular ectopy absent Unchanged subsegmental atelectasis in the right lower base. RT NECK HEMATOMA W/OUT CHANGE THIS SHIFT, TENDER TO PALP. Cholelithiasis. Bilateral pleural effusions with bibasilar subsegmental atelectasis, left greater than right. CSRU NSG:NEURO: A&OX3, mild dysphasia, difiiculty finding words at times. Plavix d/c'd. Repositioned q2h and prn.ASSESS: Stable.PLAN: ? +RUE weakness.CV: SR, PVC's and short runs rapid a-fib in am. CR 0.7.GI: Abdomen soft, NT, +BSX4Q. AM ptt pending.Pulm: LS CTAB, non-productive cough. Imaging at OSH reportedly showed "left cerebellar infarcts" and dissection of left ICA to level of circle of . IVF d/c'd.GU: F/C d/c'd at 0100, pt is by 0900.Skin: MSI open in 2 areas, packed with NS/gauze, draining moderate amt of SS material. There are unchanged inflammatory changes about the sternum, through the anterior and superior mediastinum with inflammatory stranding, presence of heterogenous soft tissue and fluid collections with foci of air bubbles Partially visualized there is edema and increase in the volume of the right distal sternocleidomastoid muscle. RT HAND GRASP WEAK (AS PER PRE ADM). No stool.INTEG: Duoderm to coccyx is D/I.ENDO: 1200 hr FSBG 271, Dr. informed. Right groin ecchymoric, soft.Endo: RISS, frequent coverage needed.labs: stable heme and chems; coags pending.P: transfer F2. Denies pain.CV: HR 60-70's NSR, rare PVC noted. FINDINGS: The patient is status post CABG. Sinus rhythm with PVCs.Poor R wave progression - probable normal variantLateral ST-T changes may be due to myocardial ischemiaSince last ECG, no significant change Nonenhanced and enhanced images through the chest were obtained followed by enhanced images through the abdomen and pelvis. BS checks done q6hr, covered with RISS as needed. NPO EXCEPT MEDS TODAY. (Over) 3:27 PM CTA NECK W&W/OC & RECONS; CT 100CC NON IONIC CONTRAST Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: r/o carotid dissection CTA Admitting Diagnosis: STERNAL WOUND INFECTION Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) Coronal and sagittal reformatted images were obtained. INR 1.9, Coumadin 2mg po given . HAS NOT VOIDED YET COCCYX DUEDERM REMOVED 4CMX2CM REDDENED BROKEN AREA NOTED CLEANSED AND DUODERM REAPPLIED. Coccyx with stage II pressure sore, duoderm to area. CONT TO MONITOR VS/HEMOS. PainfreeCV: NSR, variable VEA, AEA. IMPRESSION: Deep watershed infarcts in the left cerebral hemisphere of undetermined age. WILL NEED DEBRIDE AT SOME POINT.ASSESS: STABLE DAY.PLAN: MRA THIS PM TO ASSESS CAROTID DISSECT-> THEN ? Moderate degenerative changes are seen throughout the spine and the pubic symphysis. There are curvilinear hyperdense areas in the periphery of the uterus, likely represent calcification of the arcuate vessels. Sternal wound now appears free of purulence. Transfers with one assist.CV: SR, rare PVC's. BS wnl; no BM.GU: voiding QS, clear urineskeletal: sternal wounds pink, granulating; min s/s drainage. transition to coumadin. 4:16 AM CT CHEST W/CONTRAST; CT RECONSTRUCTION Clip # CT 150CC NONIONIC CONTRAST Reason: mediastinitis? W-D DSG X3 TODAY FOR MOD AMTS SEROSANG TO PURULENT DNG. (with purulent sternal drainage) No contraindications for IV contrast FINAL REPORT INDICATION: Fever, sternal discharge, right neck pain. Cont to have mild expressive aphasia. maintained on npo, ivf infusing as ordered, foley cath inserted, autodiuresing excessively. Non-specificST-T wave changes. K 3.3 this am, pt is rec'ing KCl 10meq ivpb x2. There are coronary calcifications. 11:07 PM CHEST (PORTABLE AP) Clip # Reason: effusion? LSCTAB with dim bases. CT REFORMATS: Coronal and sagittal reformatted images were essential in (Over) 4:16 AM CT CHEST W/CONTRAST; CT RECONSTRUCTION Clip # CT 150CC NONIONIC CONTRAST Reason: mediastinitis? The visualized paranasal sinuses show a mucosal retention cyst within the right maxillary and sphenoid sinuses. PLAVIX AND LOPRESSOR GIVEN. Sinus disease as described above. Old anterolateral wall myocardial infarction. TENDER WITH DSG CHANGE OTHERWISE DENIES PAIN.ID: AFEB. WITH OPENING OF INCISION ^ PAIN HAS DENIED PAIN SINCE.A: STERNAL WOUND INFECTION, CVA WITH RIGHT HAND WEAKNESS, DYSPNEA WITH BIBASILAR CRACKLES.P: MONITOR COMFORT, HR AND RYTHYM, SBP, WOUND DRAINAGE, RESP STATUS-CHECK CXR RESULTS, NEURO STATUS, I+O- OBTAIN UA, LABS PENDING. | 19 | [
{
"category": "ECG",
"chartdate": "2166-11-16 00:00:00.000",
"description": "Report",
"row_id": 204454,
"text": "Submitted late and out of sequence\nSinus rhythm\nProbable left atrial abnormality\nPoor R wave progression with late precordial QRS transition - consider prior\nanteroseptal myocardial infarction although is nondiagnostic\nNonspecific lateral T wave abnormalities\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2166-11-17 00:00:00.000",
"description": "Report",
"row_id": 204455,
"text": "Sinus rhythm. Old anterolateral wall myocardial infarction. Non-specific\nST-T wave changes. Compared to the previous tracing no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-11-07 00:00:00.000",
"description": "Report",
"row_id": 204456,
"text": "Sinus rhythm with PVCs.\nPoor R wave progression - probable normal variant\nLateral ST-T changes may be due to myocardial ischemia\nSince last ECG, no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-10 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 891025,
"text": " 3:26 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n -59 DISTINCT PROCEDURAL SERVICE; CTA ABD W&W/O C & RECONS\n CT PELVIS W/CONTRAST\n Reason: r/o dissection\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fever, sternal discharge\n\n REASON FOR THIS EXAMINATION:\n r/o dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest CTA.\n\n HISTORY: 85-year-old woman with fever, sternal discharge, rule out\n dissection.\n\n TECHNIQUE: Multidetector CT through the chest, abdomen and pelvis.\n Nonenhanced and enhanced images through the chest were obtained followed by\n enhanced images through the abdomen and pelvis. Coronal and sagittal\n reformations are also provided.\n\n Comparison is made with prior study dated .\n\n CHEST AND ABDOMEN CT ANGIOGRAM AND RECONSTRUCTIONS: The aorta is normal in\n caliber without evidence of dissection. The ascending aorta measures 37 mm,\n the proximal abdominal aorta measures up to 25 mm. The main branches of the\n aortic arch, the celiac, SMA, single right renal artery, duplicated left renal\n artery and are widely patent. There is an IVC filter in place.\n\n CHEST CT WITH AND WITHOUT CONTRAST: The airways are patent. Interval\n decrease in size in the left pleural effusion. Unchanged subsegmental\n atelectasis in the right lower base. New patchy areas of ground-glass opacity\n are seen in the left lower lobe that might correspond to inflammatory process.\n The heart and great vessels are unremarkable. There are coronary\n calcifications. Subcentimeter reactive lymph nodes are seen in the\n mediastinum (unchanged). There are unchanged inflammatory changes about the\n sternum, through the anterior and superior mediastinum with inflammatory\n stranding, presence of heterogenous soft tissue and fluid collections with\n foci of air bubbles\n\n Partially visualized there is edema and increase in the volume of the right\n distal sternocleidomastoid muscle.\n\n ABDOMEN CT: In segment 4b of the liver, a 14 x 18 mm, hypodense, nonenhancing\n area with fluid-filled attenuation is seen. There is no bile duct\n dilatation. There are multiple stones in the gallbladder. The spleen,\n pancreas and adrenal glands are unremarkable. There are bilateral extrarenal\n pelvis with calcified stones in its interior in the right side measuring 10\n mm, in the left side measuring 3 and 5 mm. In the upper pole of the left\n (Over)\n\n 3:26 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n -59 DISTINCT PROCEDURAL SERVICE; CTA ABD W&W/O C & RECONS\n CT PELVIS W/CONTRAST\n Reason: r/o dissection\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n kidney, there is a 14-mm cortical cystic lesion. In the left upper collecting\n system, there is a 3-mm, nonobstructing stone. In the left lower collecting\n system, there is a 7-mm nonobstructing stone. There is no free air or free\n fluid within the abdomen. The unenhanced bowel loops are unremarkable. There\n is no lymphadenopathy.\n\n PELVIC CT: The sigmoid colon is unremarkable. The uterus is not enlarged\n with a small, hypodense, round, focal lesions in relation with fibroids. There\n are curvilinear hyperdense areas in the periphery of the uterus, likely\n represent calcification of the arcuate vessels. There is a moderate pocket of\n air in the bladder likely due to instrumentation. There is no free fluid.\n There is no lymphadenopathy.\n\n BONE WINDOWS: The patient is S/P sternotomy with no erosive changes seen\n within the sternum. Moderate degenerative changes are seen throughout the\n spine and the pubic symphysis. There is right hip arthroplasty. There are no\n concerning bone lesions.\n\n IMPRESSION:\n 1. There is no evidence of aortic dissection.\n\n 2. Unchanged inflammatory process around sternotomy, in the anterior and\n superior mediastinum.\n\n 3. Interval decrease in size in the left pleural effusion. Atelectasis and\n ground-glass opacities in the left lower lobe, correlate clinically question\n infection.\n\n 4. Unchanged hypodense lesion in segment 4b of the liver likely represents\n cyst\n\n 5. Bilateral kidney stones.\n\n 6. Cholelithiasis.\n\n 7. Fibroid uterus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-10 00:00:00.000",
"description": "CTA NECK W&W/OC & RECONS",
"row_id": 891026,
"text": " 3:27 PM\n CTA NECK W&W/OC & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o carotid dissection CTA\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fever, sternal discharge\n\n REASON FOR THIS EXAMINATION:\n r/o carotid dissection CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 85-year-old man with fever and sternal discharge. A recent CT\n of the chest and lower neck, performed on showed evidence of\n a sternal wound infection with extension of infectious phlegmon into the right\n sternocleidomastoid muscle.\n\n COMPARISONS: .\n\n TECHNIQUE: Axial CT images of the neck were obtained following administration\n of IV Optiray . Sagittal and coronal reconstructions were also performed.\n Maximum intensity projections of the internal carotid arteries were also\n performed as three-dimensional volume-rendered reconstructions.\n\n FINDINGS: The lung apices appear clear other than for minimal atelectasis.\n Again noted is a similar appearance of an abscess along the upper margin of\n the sternum. The patient is status post sternotomy. As seen previously, the\n abscess extends along the right sternocleidomastoid muscle up to the mastoid\n process on the right. The whole length of this muscle is similarly expanded\n with outer thickening and intense enhancement, which surrounds a central\n region of fluid. Fat stranding is seen adjacent to this muscle as well, but\n there is no extension of the abscess outside of the muscle. The common\n carotid, internal and external carotid arteries appear normally bilaterally on\n the CT angiogram, and the internal and external jugular veins also appear\n patent. There is no definite lymphadenopathy.\n\n Mucosal thickening, likely inflammatory in origin, is noted in the sphenoid\n and right maxillary sinuses, unchanged from prior study. The visualized\n paranasal sinuses are unremarkable. The partially visualized intracranial\n contents show no abnormality.\n\n IMPRESSION:\n 1. Abscess with a similar appearance, which extends from the right clavicle,\n and interclavicular notch region, throughout the right sternocleidomastoid\n muscle.\n 2. No evidence of carotid dissection by CT. Because of recent infarcts, and\n an outside vascular ultrasound study, concern was raised about carotid\n dissection. The findings of this study were discussed with on\n the morning of , and we anticipate the arrival of the\n vascular ultrasound images for review and correlation with this study.\n (Over)\n\n 3:27 PM\n CTA NECK W&W/OC & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o carotid dissection CTA\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 891155,
"text": " 1:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placement r bas picc for abx. call beeper 9-243\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CABG sternal wound infection\n\n REASON FOR THIS EXAMINATION:\n please check placement r bas picc for abx. call beeper with wet read\n asap thanks\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest port line placement.\n\n COMPARISON: at 23:28.\n\n INDICATION: CABG, please check right PICC.\n\n FINDINGS: A right PICC catheter tip projects in the right atrium\n approximately 2 cm distal to the cavoatrial junction. No pneumothorax, no\n pleural effusions. The lungs are clear. The cardiac and mediastinal\n silhouettes are stable. This finding was discussed with the IV team.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-08 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 890814,
"text": " 7:57 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA CAROTID/VERTEBRAL W/O CONTRAST\n Reason: Assess distribution of infarcts, assess acuity, assess for a\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman status post CABG complicated by right arm weakness\n and aphasia . Imaging at OSH reportedly showed \"left cerebellar infarcts\"\n and dissection of left ICA to level of circle of . CT scan here with\n multiple infarcts in left MCA/PCA/PICA territories.\n REASON FOR THIS EXAMINATION:\n Assess distribution of infarcts, assess acuity, assess for any new infarcts\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN AND MRA OF THE CERVICAL AND INTRACRANIAL VASCULATURE\n\n INDICATION: Outside hospital report shows left cerebellar infarctions and\n dissection of the left internal carotid artery to the level of the circle of\n . Evaluate for infarction and patency of the left cervical and\n intracranial circulation.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were obtained.\n\n 2D and 3D time-of-flight MR angiography of the cervical vasculature was\n performed. Three-dimensional time-of-flight MR angiography of the circle of\n was performed. Multiplanar reformatted images and source image data of\n both are reviewed.\n\n The outside study is not available for comparison, and comparison is made to\n the CT scan of .\n\n The patient was claustrophobic and unable to lie still for the study so images\n are somewhat limited by motion artifact.\n\n Scans of the brain demonstrate multiple areas of increased T2 signal as well\n as diffusion signal hyperintensity, in the left subcortical cerebral white\n matter. Both posterior frontal and temporal lobe white matter is affected,\n and signal abnormality extends toward the internal capsule, but is not clearly\n involving the internal capsule at the level of the deep structures.\n Hypodensity is identified in this location on the CT scan.\n\n Additional small areas of infarction are observed within the cerebellar\n hemispheres, especially on the left, but there is no diffusion signal\n abnormality associated with these to indicate that they are recent. No\n abnormal intracranial susceptibility artifact.\n\n Ventricular size and shape is normal. There is no shift of midline\n structures.\n\n MR angiographic images of the cervical vasculature demonstrate flow in both\n carotid and vertebral arteries. Due to motion artifact, it is not possible to\n identify areas of vascular narrowing or irregularity.\n (Over)\n\n 7:57 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA CAROTID/VERTEBRAL W/O CONTRAST\n Reason: Assess distribution of infarcts, assess acuity, assess for a\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MR angiographic views of the intracranial circulation demonstrate flow in both\n intracranial vertebral arteries, the basilar artery, both internal carotid\n arteries and anterior and middle cerebral arterial branches as well as within\n the posterior cerebral arteries. There is irregularity of flow signal in the\n carotid siphons, suggesting atherosclerotic narrowing. Dense carotid\n calcifications are visible on the CT scan in these locations.\n\n IMPRESSION:\n MRI of the brain demonstrates recent infarctions in the left cerebral white\n matter. These may be watershed in nature.\n\n MRA of the cervical vasculature demonstrates flow in the major branches of the\n carotid and vertebral system, but detailed evaluation is not possible due to\n motion artifact.\n\n MRA of the circle of demonstrates flow in the proximal branches of this\n circulation.\n\n Report of these findings was provided by Dr. at 2:45 a.m. on .\n\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890721,
"text": " 11:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion?\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CABG\n\n REASON FOR THIS EXAMINATION:\n effusion?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old woman with status post CABG to evaluate for effusion.\n\n CHEST X-RAY AP PORTABLE VIEW.\n\n Comparison done to the chest x-ray of .\n\n FINDINGS: The patient is status post CABG. The cardiomediastinal silhouette\n is stable. There is a small left pleural effusion but there is no\n pneumothorax.\n\n IMPRESSION: Small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 890734,
"text": " 4:15 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: intracranial bleed?\n Admitting Diagnosis: STERNAL WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fever, sternal discharge\n\n REASON FOR THIS EXAMINATION:\n intracranial bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, right extremity weakness x1 week.\n\n There are multiple small indistinct hypodensities within the subcortical white\n matter in the left cerebral hemisphere in the deep watershed distribution..\n There is no hemorrhage, mass effect, shift of normally midline structures, or\n hydrocephalus. The ventricles and sulci are normal in size. The surrounding\n osseous and soft tissue structures are unremarkable. The visualized paranasal\n sinuses show a mucosal retention cyst within the right maxillary and sphenoid\n sinuses.\n\n IMPRESSION: Deep watershed infarcts in the left cerebral hemisphere of\n undetermined age. MRI may help for further evaluation if clinically indicated.\n No hemorrhage, mass effect, or midline shift. Sinus disease as described\n above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-08 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 890735,
"text": " 4:16 AM\n CT CHEST W/CONTRAST; CT RECONSTRUCTION Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: mediastinitis? (with purulent sternal drainage)\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Field of view: 35.8 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with fever, sternal discharge\n\n REASON FOR THIS EXAMINATION:\n mediastinitis? (with purulent sternal drainage)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, sternal discharge, right neck pain.\n\n TECHNIQUE: Multidetector CT images were obtained from the skull base to the\n upper abdomen with 100 cc of Optiray nonionic contrast. Coronal and sagittal\n reformatted images were obtained.\n\n CT OF THE NECK WITH CONTRAST: There is asymmetric enlargement of the right\n sternocleidomastoid muscle from the mastoid process of the skull to its\n insertion onto the clavicle and sternum. There is an enhancing low-density\n fluid collection extending along its length. The great arteries and veins of\n the neck are patent and appear unremarkable. Multiple small anterior triangle\n lymph nodes are identified, but none meet the CT criteria for pathologic\n enlargement. A small mucous polyp is seen in the right maxillary\n sinus. Otherwise, the soft tissue and osseous structures of the neck are\n unremarkable.\n\n CT OF THE CHEST WITH CONTRAST: The patient is status post median sternotomy.\n There is inflammatory fat standing, heterogeneous soft tissue density, and\n small fluid pockets most consistent with a phlegmon extending from the\n sternoclavicular joints and manubrium to the inferior border of the sternum as\n well as into the anterior and superior mediastinal regions. There are multiple\n foci of air within this collection. The visualized great vessels show\n atherosclerotic calcification within the aorta, and coronary artery\n calcifications. Otherwise the heart and great vessels are unremarkable. The\n airways are patent to the segmental level bilaterally. There are bilateral\n pleural effusions, left greater than right and mild subsegmental atelectatic\n changes bilaterally. Limited images of the upper abdomen show a low density\n 1.1 x 1.7 cm lesion in the anterior right liver lobe, which may represent a\n focus of infection. The visualized portions of the pancreas, spleen, and\n stomach are unremarkable. There are no pathologically enlarged axillary,\n hilar, or mediastinal lymphadenopathy, however small lymph nodes are seen in\n the aortopulmonary and precarinal regions.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. No\n erosive changes are seen within the sternum. Degenerative changes are seen\n within the visualized thoracolumbar spine.\n\n CT REFORMATS: Coronal and sagittal reformatted images were essential in\n (Over)\n\n 4:16 AM\n CT CHEST W/CONTRAST; CT RECONSTRUCTION Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: mediastinitis? (with purulent sternal drainage)\n Admitting Diagnosis: STERNAL WOUND INFECTION\n Field of view: 35.8 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n delineating the anatomy and pathology of this case, specifically the precise\n locations of the mediastinal fluid collections and extension of these\n collections superiorly. Value grade V.\n\n IMPRESSION:\n\n 1. Inflammatory changes containing heterogenous soft tissue, small fluid\n collections, and foci of gas about the sternum with extension into the\n anterior and superior mediastinem most likely represent a combination of post-\n operative changes/hematoma and infectious phlegmon formation. Mediastinitis\n cannot be excluded. Enlargement and focal low attenuation in the\n right sternocleidomastoid muscle is uspicious for infection.\n\n 2. Bilateral pleural effusions with bibasilar subsegmental atelectasis, left\n greater than right.\n\n 3. 1.7 x 1.1 cm hypodensity within the anterior right lobe of the liver -- an\n infectious focus should be considered in the differential.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-09 00:00:00.000",
"description": "Report",
"row_id": 1487372,
"text": "CSRU NSG ADDENDUM:\n\nFSBG 54, 100cc OJ given. Patient remains A&OX3. F/U FSBG 70, supper given, A/O. Sternal wound now appears free of purulence. Both open areas are pink and clean with serous exudate. Lower open area appeared purulent this morning during dressing change.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-10 00:00:00.000",
"description": "Report",
"row_id": 1487373,
"text": "CSRU NPN 7p-7a\nNeuro: sleeping most of shift. When awake, oriented x3. Cont to have mild expressive aphasia. Able to MAE, but right hand unable to grasp, which is same as admission. Denies pain.\n\nCV: HR 60-70's NSR, rare PVC noted. SBP 80-110's, MAPs high 50's to 60's. Afebrile. Heparin gtt decreased to 750 units/hr per Dr. . AM ptt pending.\n\nPulm: LS CTAB, non-productive cough. On RA with O2 sats in mid 90's.\n\nGI: Abd soft, NT, +BS. Takes pills without difficulty. BS checks done q6hr, covered with RISS as needed. No bm since prior to admission. IVF d/c'd.\n\nGU: F/C d/c'd at 0100, pt is by 0900.\n\nSkin: MSI open in 2 areas, packed with NS/gauze, draining moderate amt of SS material. Coccyx with stage II pressure sore, duoderm to area. Right forearm with small skin tear and also phlebitis from PIV.\n\nPlan: ? if pt can tx out today. Dsg changes tid. Pt still being evaluated for surgical debridement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-10 00:00:00.000",
"description": "Report",
"row_id": 1487374,
"text": "CSRU NSG:\nNEURO: A&OX3, mild dysphasia, difiiculty finding words at times. LUE weakness persists. Examined by neurology. Transfers with one assist.\n\nCV: SR, rare PVC's. VSS. Plavix d/c'd. INR 1.9, Coumadin 2mg po given . K 3.9 in afternoon. HCT 28.7.\n\nPULM: SpO2 93-97% on room air. LS clr at tops with dim bases, +RLL fine crackles do not clear with cough. C/DB encouraged, patient compliant to 700cc.\n\nGU: Voids in urinal. Urine is clr, yellow, output QS. CR 0.7.\n\nGI: Abdomen soft, NT, +BSX4Q. Eats 25-50% X 2 meals. No stool.\n\nINTEG: Stage 2 to coccyx, duoderm intact. Repositioned q2h and prn.\n\nASSESS: Stable.\n\nPLAN: ? transfer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-11 00:00:00.000",
"description": "Report",
"row_id": 1487375,
"text": "RN shift note\nneuro: AAO x 3; vague at times, some word searching. RUE weakness, min grip. Painfree\n\nCV: NSR, variable VEA, AEA. SBP 90-120. Pulses palp throughout. Heparin gtt @ 750cc.\n\npulm: BS CTA anteriorly. crackles right base, diminished left base. sat drops to 92 on RA when asleep, 95-96 on 2l. Non-productive cough.\n\nGI: abd soft, non-tender. BS wnl; no BM.\n\nGU: voiding QS, clear urine\n\nskeletal: sternal wounds pink, granulating; min s/s drainage. Hematoma right neck soft, tender. Right groin ecchymoric, soft.\n\nEndo: RISS, frequent coverage needed.\n\nlabs: stable heme and chems; coags pending.\n\nP: transfer F2. Cont heparin, ? transition to coumadin. Cont TID wound wet to dry dressings. Start rehab.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-08 00:00:00.000",
"description": "Report",
"row_id": 1487369,
"text": "csru update\nNEURO: ALERT/ORIENTED. RT HAND GRASP WEAK (AS PER PRE ADM). SPEECH CLEAR AND APPROP. PERL. MAE WELL. (PT W/ CAROTID DISSECT PER OSH TESTING).\n\nCV: VSS AS PER FLOWSHEET. IVF AT 70CC/HR. NSR W/ RARE PVC. PLAVIX AND LOPRESSOR GIVEN. NO NEW ISSUES. RT NECK HEMATOMA W/OUT CHANGE THIS SHIFT, TENDER TO PALP. EXTREMS WARM, PULSES EASILY PALP.\n\nRESP; LUNGS ESSENTIALLY CLEAR BILAT, FEW CRACKLES LEFT BASE AT TIMES. O2 2L N/C. FAIR NON PRODUCTIVE COUGH.\n\nGI/GU: ABD SOFT. HYPO BSP. NPO EXCEPT MEDS TODAY. IVF @ 70CC/HR. UOP QS.\n\nSKIN: OPEN AREA X2 ON STERNAL WOUND. TOP WOUND ABLE TO PACK W/ 1 2X2, THE BOTTOM 2 2X2. W-D DSG X3 TODAY FOR MOD AMTS SEROSANG TO PURULENT DNG. TENDER WITH DSG CHANGE OTHERWISE DENIES PAIN.\n\nID: AFEB. WBC WNL. VANCO INCREASE TO 1GM . WILL NEED DEBRIDE AT SOME POINT.\n\nASSESS: STABLE DAY.\n\nPLAN: MRA THIS PM TO ASSESS CAROTID DISSECT-> THEN ? ANTICOAGULATION ETC. PT REQUESTING PRE MED FOR EXAM. CONT TO MONITOR VS/HEMOS. NPO.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-09 00:00:00.000",
"description": "Report",
"row_id": 1487370,
"text": "CSRU NPN 7p-7a\nNeuro: Pt slept soundly most of shift. When awake, oriented x2-3, has expressive asphagia and is frustrated by it. Follows commands, able to MAE, but right hand weak and unable to grasp as per admission. PERRL. MRA of head/neck last pm revealed that there is no dissection.\n\nCV: HR 60's SR, rare PVC noted. K 3.3 this am, pt is rec'ing KCl 10meq ivpb x2. BP stable, MAPs did dip down to 50's with sleeping, but when awake, MAPs >60. Afebrile. Restarted on heparin gtt, am PTT not therapeutic, dose increased by 200units. Next PTT due at 12pm.\n\nPulm: LS with crackles in LLbase, otherwise CTA. O2 sat 95-100% on 2L NC. RR 20's.\n\nGI/GU: NPO for possible surgery today, did eat small meal before midnight. No problems with swallowing pills. BS checks done q6hr, covered with RISS. IVF at 70cc/hr. U/O 25-100cc/hr of clear yellow urine.\n\nSkin: MSI open in 2 areas, packed with wet to dry dsg. Large amt of drainage to site, dsg required frequent changes. Coccyx with duoderm to area.\n\nPlan: Surgery to eval pt this am, keep NPO until then. Follow PTTs. Recheck lytes this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-09 00:00:00.000",
"description": "Report",
"row_id": 1487371,
"text": "CSRU NSG:\n\nNEURO: A&OX3, mild, intermittent expressive aphasia - unable to find correct words at times. PERRL. +RUE weakness.\n\nCV: SR, PVC's and short runs rapid a-fib in am. 10:00am lopressor 25mg po given 0800hrs. 2GM magnesium IV, 10mEq KCL IV and 40mEq KCL po given per Dr. . 1200 hr PTT 140.9 reported to Dr. - specimen redrawn. New result is 41.0, heparin drip increased to 800 units/hr per Dr. . F/U K is 4.0, no ectopy at this time. HCT 27.4. WBC 8.5, differential added on to am labs per Dr. .\n\nPULM: SpO2 97% on O2 2l via NC. O2 removed d/t c/o discomfort with SpO2 95% on R/A. LSCTAB with dim bases. Strong, nonproductive cough.\n\nGU: Urine clr, yellow, output QS.\n\nGI: Abdomen soft, NT, +BSX4Q. Cardiac diet restarted per order Dr. . Eats 50% X 2 meals. No stool.\n\nINTEG: Duoderm to coccyx is D/I.\n\nENDO: 1200 hr FSBG 271, Dr. informed. Treated with 12UR insulin SQ, maintainance fluids changed to 0.45% NaCl sol'n. F/U FSBG is 161, Dr. informed.\n\nASSESS: VSS, WBC decreasing.\n\nPLAN: Continue antibiotics. Transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-07 00:00:00.000",
"description": "Report",
"row_id": 1487367,
"text": "STERNAL WOUND DRAINAGE\nS: \"NO I DON'T HAVE ANY PAIN NOW\"\nO: SR WITH MULTIFOCAL ISOLATED PVC'S NOTED. LABS PENDING. SBP PER FLOW. LARGE AMOUNT OF BLOODY PURELENT DRAINAGE NOTED , STERNAL WOUND OPENED FURTHER BY DR. AND C+S OBTAINED , REPACKED AND DSD APPLIED. EXTREMITIES WARM AND DRY.\n O2 APPLIED AT 3 L NP DUE TO PT C/O DYSPNEA,HOB TO 90 DEGREES. O2 SAT >94%. BS WITH BIBASILAR CRACKLES. RR 20'S. COUGHING WITHOUT RAISING. CXR DONE RESULTS PENDING.\n A+OX3, PLEASANT AND CALM, RIGHT HAND CAN LIFT OFF BED HOWEVER GRASP WEAK. LEFT GRASP STRONG AND RIGHT+LEFT LEGS CAN LIFT AND HOLD.PERL\n ABD SOFT, + BOWEL SOUNDS.\n HAS NOT VOIDED YET\n COCCYX DUEDERM REMOVED 4CMX2CM REDDENED BROKEN AREA NOTED CLEANSED AND DUODERM REAPPLIED.\n WITH OPENING OF INCISION ^ PAIN HAS DENIED PAIN SINCE.\nA: STERNAL WOUND INFECTION, CVA WITH RIGHT HAND WEAKNESS, DYSPNEA WITH BIBASILAR CRACKLES.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, WOUND DRAINAGE, RESP STATUS-CHECK CXR RESULTS, NEURO STATUS, I+O- OBTAIN UA, LABS PENDING. AS PER ORDERS. ? CT OF CHEST\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-08 00:00:00.000",
"description": "Report",
"row_id": 1487368,
"text": "csru update\nNSR 60s, rate occassionally drops to high 50s SB, multifocal pvc's present despite replacing lytes. sbp 90s-120s. bibasalar crackles present, sa02 96-100% on 3l/nc, pt unable to tolerate height of bed lower than 45deg. mae's with right arm weakness, ao x3, pleasant and cooperates with care. chest/head/neck ct done, awaiting review. sternal wound oozy, pt advised caution with arm movements/activities. position changes done, duoderm intact at coocyx. right neck swollen, hematoma present, pt verbalized pain around the area. maintained on npo, ivf infusing as ordered, foley cath inserted, autodiuresing excessively. daughter phoned, updated\n\nplan: follow-up ct result\n ?anticoagulate/ dvt prophylaxis\n sternal dressing w>d tid\n maintain on npo until further orders\n asess resp status\n"
}
] |
30,484 | 167,881 | She was admitted to cardiac surgery in preparation for surgery. She was seen by neurology and underwent MRA brain. Chest CT was done to evaluated her coronaries. She was started on IV heparin as she stopped her coumadin preoperatively. She was taken to the operating room on where she underwent a bilateral thoracoscopic MAZE and LAA resection. She was transferred to the ICU in stable condition. She had bilateral subcutaneous pain pumps. She was extubated in the OR but was reintubated for agitation. She was again extubated on POD #1. Her pain pumps and chest tubes were dc'd. She had intermittent rapid atrial fibrillation and was restarted on amiodarone and coumadin. She was seen by electrophysiology for difficult rate control. She was transferred to the floor on POD #3. She was followed closely by electrophysiology and her medications were adjusted. Echo on showed no pericardial effusion and she was ready for discharge home. | The right ventricular end-diastolic volume index was normal. Mild (1+) mitral regurgitation is seen.The estimated pulmonaryartery systolic pressure is normal. Normal aortic arch diameter. Normal left ventricular cavity size with normal regional left ventricular systolic function. The left ventricular end-diastolic dimension index and end-diastolic volume index were normal. Normal right ventricular cavity size and systolic function. Previously described right internal jugular approach central venous line remains in unchanged position and the tip is overlying the area of right atrium. The main pulmonary artery diameter index was normal. The main pulmonary artery diameter index was normal. Plate atelectasis on the right lung base unchanged. Evaluation of the lung parenchyma reveals minimal dependent changes. Endotracheal tube is in standard position, right internal jugular vascular catheter terminates near the junction of the superior vena cava and right atrium, and bilateral chest tubes are in place. There is mild irregularity throughout the course of the left middle cerebral artery, without focal stenosis or occlusion, most consistent with chronic atherosclerotic changes. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The circulation is right dominant with a large PDL supplying the inferior surface of the left ventricle. Pericardial effusion.Height: (in) 68Weight (lb): 220BSA (m2): 2.13 m2BP (mm Hg): 122/60HR (bpm): 76Status: InpatientDate/Time: at 08:45Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. The aortic valve was tri-leaflet with normal valve area. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild mitral regurgitation. Moderate right and severe left atrial enlargement. The left ventricular mass index was normal. Otherwise, normal chest radiograph. The coronary sinus diameter was normal. Diffuse atherosclerotic changes in the left MCA, without focal stenosis or occlusion. The ascending aorta is mildly dilated.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic stenosis. The indexed diameters of the ascending and descending thoracic aorta were normal. The indexed diameters of the ascending and descending thoracic aorta were normal. Status post right-sided chest tube removal. Mildly dilated ascendingaorta. No LA mass/thrombus (best excluded by TEE).LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). Borderline size of the cardiac silhouette without signs of decompensation or overhydration. Right-sided IJ line is unchanged with its tip projected over the proximal SVC. The right coronary artery shows a small amount of noncalcified plaque that would not appear significant. Trace aortic regurgitation is seen. Moderate gastric distention. Normal descending aorta diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Suboptimalimage quality - poor subcostal views.Conclusions:The left atrium is mildly dilated. Right ventricular chambersize and free wall motion are normal. Mild pulmonary vascular congestion is unchanged. FINDINGS: In comparison with the study of earlier in the day, the left chest tube has been removed. Mild [1+] TR. The pericardial thickness was normal. WEAN ON CPAP MODE, EXTUBATE THIS AM. effort.GI) pt. Compared to the previous tracing of nosignificant change.TRACING #1 Plan is to wean and extubate. Compared to the previous tracing sinus rhythm has replacedatypical atrial flutter. T waves, however, are now inverted inleads I, aVL and V3-V6. Sinus rhythm. MAG REPLETED. Variant RSR' pattern in leads V1-V2. Vent settings were adjusted per ABGs. palpable pulses, sbp 100's. See carevue for details. See carevue for details. had episode of PAF treated w/ Lopressor IV. Atypical atrial flutter with variable block with well-controlled ventricularresponse. BLBS diminished, suctioned for small yellow secretions, pt notted to be on ETT whire suctioning, ETT was retaped and propery secured. L RADIAL ALINE POSITIONAL ALL SHIFT. Lopressor po given, pt converted to sr 70's-80's. RESP ACIDOSIS IMPROVED. will cont to monitor. PAF. pt. Pt. Pt. Falls asleep for periods of time.GU) adequate huo.Pain) managed with Toradol & sc Dilaudid. Advance activity OOB and to advance po intake if pt. Probable atrial flutter which is atypical with variable block. BP by cuff >95syst.Pulm) pt. 7a-7pneuro: a+ox3, mae, follows commands, up to chair and commode w/ assist x1, pain well controlled w/ dilaudid po, pain pumps d/ced this amcv: sr 80s throughout morning, on leaving room for transfer to F6, rhythm changed to ST 120s, pt asymptomatic, lopressor 5mg iv 1, pt's rhythm then changed to afib 105-135 unresponsive to lopressor 5mg iv x5 and 2x 150mg amio boluses, pt asymptomatic w/ afib, amio gtt started, sbp 105-125 even w/ st/afib, afebresp: lungs dim bilat, 02 sats>94% on 3L nc, is to 375, weak nonproductive coughgi: abdomen soft, absent bowel sounds, poor appetite, fingersticks ssri, c/o nausea this am-helped by compazine (though pt became very drowsy), c/o nausea this pm-helped by zofrangu: foley d/ed this pm, pt voiding in commode at bedsidelabs: repleted k/caplan: pulmonary toilet, continue amio gtt, ? painfree. OOB TO CHAIR ONCE EXTUBATED. Since theprevious tracing of atrial flutter is new. has bilat. ABDOMEN SOFT, NO BOWEL SOUNDS.RENAL: FOLEY TO CD, ADEQUATE HUO. Non-specific low amplitude T wave inleads aVL and V5-V6. LUNGS DIMINISHED BASES. dietary consult, continue compazine/zofran as needed Compared to the previoustracing of the rhythm has changed. Consider anterolateral process.TRACING #2 more lopressor to slow heart rate?, activity as tolerated, transfer to 6 once hr consistently <100, ? VERSED 0.5MG IV X 2, FENTANYL 50MCG IVP BETWEEN 0600 AND 0630, RESTARTED AT 0.7MCG/KG, PROPOFOL WEANED OFF NP WITH BETTER ANXIETY CONTROL.PULM: SIMV MODE SINCE 2300, VT 550, RATE 14, PEEP 10. resp care - Pt received from OR intubated with #7.0ETT, 20@teeth, and placed on PSV. Neuro) pt.drowsy but awakens easily. DC CHEST TUBES LATER TODAY IF NO AIR LEAKS. Resp CarePt maintained on mech vent, with vent settings changed from AC to SIMV secondary to ABGs see flowsheet. ? ? UNABLE TO ASPIRATE BLD BACK SINCE ~0500 DESPITE REDRESSING. Atrial fibrillation with rapid ventricular response. | 24 | [
{
"category": "Radiology",
"chartdate": "2125-03-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1007965,
"text": " 11:12 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with s/p maze\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: PA and lateral chest.\n\n INDICATION: Status post maze.\n\n PA and lateral views of the chest are obtained on at 11:16 hours and\n compared with the prior radiograph performed at 21:01 hours. The lung\n volumes have improved since the prior examination. Bibasilar atelectasis,\n however, persists. There is mild blunting of the left costophrenic angle on\n both the AP and lateral views, consistent with small left pleural effusion.\n Right-sided IJ line is unchanged with its tip projected over the proximal SVC.\n Mild pulmonary vascular congestion is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1007557,
"text": " 12:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx chest tube on water seal - please do at 12 noon\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with s/p maze\n REASON FOR THIS EXAMINATION:\n ? ptx chest tube on water seal - please do at 12 noon\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube on water seal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the study of , there is no evidence of\n pneumothorax. Little overall change in the appearance of the heart and lungs\n in this patient with relatively low lung volumes. The endotracheal tube has\n been removed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-13 00:00:00.000",
"description": "MR CARDIAC W/FLOW/VEL P/P CONTRAST",
"row_id": 1007216,
"text": " 10:50 AM\n MR CARDIAC W/FLOW/ /P CONTRAST; MRA CHEST W&W/O CONTRAST Clip # \n Reason: PRE PV ABLATION\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: MAGNEVIST Amt: 40CC .2\n ______________________________________________________________________________\n FINAL REPORT\n Patient Name: , \n\n MR#: Status: Outpatient\n Study Date: \n Indication: 52-year-old woman with atrial fibrillation status post pulmonary\n vein isolation in and referred for evaluation of pulmonary\n veins prior to MAZE procedure.\n Requesting Physician: . , Dr. \n Height (in): 68\n Weight (lbs): 220\n Body Surface Area (m2): 2.19\n\n Hemodynamic Measurements\n Measurement Result\n Systemic Blood Pressure (mmHg) 103/84\n Heart Rate (bpm) 72\n\n Rhythm: Atrial Fibrillation\n\n CMR Measurements\n Measurement Result Female Normal\n Range\n LV End-Diastolic Dimension (mm) *55 <55\n LV End-Diastolic Dimension Index (mm/m2) 25 <33\n LV End-Systolic Dimension (mm) 39\n LV End-Diastolic Volume (ml) *160 <143\n LV End-Diastolic Volume Index (ml/m2) 73 <78\n LV End-Systolic Volume (ml) 71\n LV Stroke Volume (ml) 89\n LV Ejection Fraction (%) *56 >56\n LV Anteroseptal Wall Thickness (mm) *10 <10\n LV Inferolateral Wall Thickness (mm) *9 <9\n LV Mass (g) 92\n LV Mass Index (g/m2) 42 <60\n\n RV End-Diastolic Volume (ml) 156\n RV End-Diastolic Volume Index (ml/m2) 71 <103\n RV End-Systolic Volume (ml) 73\n RV Stroke Volume (ml) 83\n RV Ejection Fraction (%) 53 >49\n\n Aortic Valve Area (2-D) (cm2) 3.9 >3.0\n Aortic Valve Area Index (cm2/m2) 1.8\n\n Ascending Aorta diameter (mm) *36 <35\n (Over)\n\n 10:50 AM\n MR CARDIAC W/FLOW/ /P CONTRAST; MRA CHEST W&W/O CONTRAST Clip # \n Reason: PRE PV ABLATION\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: MAGNEVIST Amt: 40CC .2\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Ascending Aorta diameter Index (mm/m2) 16 <21\n Transverse Aorta diameter (mm) 28 <31\n Descending Aorta diameter (mm) *25 <25\n Descending Aorta Index (mm/m2) 11 <15\n Main Pulmonary Artery diameter (mm) *29 <27\n Main Pulmonary Artery diameter Index (mm/m2) 13 <15\n Left Atrium (Parasternal Long Axis) (mm) *47 <40\n Left Atrium (4-Chamber) (mm) ***66 <52\n Left Atrium Volume (ml) 128\n Left Atrium Volume Index (ml/m2) 58\n Right Atrium (4-Chamber) (mm) **69 <50\n Pericardial Thickness (mm) 2 <4\n Coronary Sinus diameter (mm) 11 <15\n\n Pulmonary Vein Dimensions\n Left Upper (mm) 13x6\n Left Lower (mm) 21x11\n Right Lower (mm) 22x18\n Right Upper (mm) 18x18\n PV Cross-Sectional Area\n Left Upper (mm2) 78\n Left Lower (mm2) 192\n Right Lower (mm2) 289\n Right Upper (mm2) 258\n * = Mildly abnormal, ** =moderately abnormal, *** = severely abnormal\n CMR Technical Information:\n CMR Technologists: Goddu, RT\n Nursing support: , RN\n\n eGFR: 93ml/min\n Total Gd-DTPA (Magnevist ) contrast: 40 ml (0.2 mmol/kg)\n Injection site: Right antecubital vein\n\n Complications: None.\n\n 1) Structure: Axial dual-inversion T1-weighted images of the myocardium were\n obtained without spectral fat saturation pre-pulses in 5 mm contiguous slices.\n 2) Function: Breath-hold cine SSFP images were acquired in the left\n ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8\n mm slices with 2 mm gaps), sagittal and coronal orientations of the left\n ventricular outflow tract, and aortic valve short axis orientations. Breath-\n hold real time SSFP images were acquired in the left ventricular 2-chamber, 4-\n chamber, and mid-papillary short axis slices.\n 3) Pulmonary Vein MRA: First pass angiography of the pulmonary veins (PV) was\n obtained after administration of a bolus of gadopentetate dimeglumine 0.2\n (Over)\n\n 10:50 AM\n MR CARDIAC W/FLOW/ /P CONTRAST; MRA CHEST W&W/O CONTRAST Clip # \n Reason: PRE PV ABLATION\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: MAGNEVIST Amt: 40CC .2\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mmol/kg (40 ml Magnevist solution). Multiplanar reconstructions of the\n pulmonary veins were generated and assessed on a workstation.\n 4) : Late gadolinium enhancement (LGE) images were obtained using\n a 3D free-breathing ECG-gated segmented inversion-recovery TFE acquisition in\n the axial plane 20 minutes after injection of a total of 0.2 mmol/kg\n gadopentetate dimeglumine (40 ml Magnevist solution) with spectral fat\n saturation pre-pulses.\n\n\n Findings:\n Structure and Function\n There was normal epicardial fat distribution. The pericardial thickness was\n normal. There were no pericardial or pleural effusions. The origin of the\n right coronary artery was identified in its customary position. The origin of\n the left coronary artery was not well visualized. The indexed diameters of\n the ascending and descending thoracic aorta were normal. The main pulmonary\n artery diameter index was normal. The left atrial AP dimension was mildly\n increased. The right and left atrial lengths in the 4-chamber view were\n moderately and severely increased, respectively. The coronary sinus diameter\n was normal.\n The left ventricular end-diastolic dimension index and end-diastolic volume\n index were normal. The calculated left ventricular ejection fraction was low-\n normal at 56% with normal regional systolic function. The anteroseptal and\n inferolateral wall thicknesses were top-normal. The left ventricular mass\n index was normal. The right ventricular end-diastolic volume index was\n normal. The calculated right ventricular ejection fraction was normal at 53%,\n with normal free wall motion.\n The aortic valve was tri-leaflet with normal valve area.\n\n Pulmonary Vein MR Angiography\n Two right-sided pulmonary veins and two left-sided pulmonary veins were\n identified, all entering the left atrium (dimensions listed above). The left\n upper pulmonary vein was narrowed at its ostium into the proximal segment with\n an increase in its caliber more distally, consistent with stenosis from a\n previous catheter-based ablation procedure (no prior CMR study here). The\n multiplanar reconstructions confirmed the above findings.\n\n Left Atrial Fibrosis\n High-resolution late gadolinium enhancement images of left atrium\n demonstrated extensive focal enhancement of the posterior atrial wall and\n ostia of the left upper, left lower, right upper, and right lower pulmonary\n veins.\n\n Impression:\n 1. Normal size and orientation of the pulmonary veins without MR evidence of\n (Over)\n\n 10:50 AM\n MR CARDIAC W/FLOW/ /P CONTRAST; MRA CHEST W&W/O CONTRAST Clip # \n Reason: PRE PV ABLATION\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: MAGNEVIST Amt: 40CC .2\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n anomalous pulmonary venous return.\n 2. The left upper pulmonary vein was narrowed at its ostium into the proximal\n segment with an increase in its caliber more distally. This may represent\n stenosis from a previous catheter-based ablation procedure.\n 3. Extensive focal hyperenhancement of the posterior atrial wall and ostia of\n the left upper, left lower, right upper, and right lower pulmonary veins\n consistent with scarring/fibrosis likely due to previous catheter-based\n ablations.\n 4. Normal left ventricular cavity size with normal regional left ventricular\n systolic function. The LVEF was low-normal at 56%.\n 5. Normal right ventricular cavity size and systolic function. The RVEF was\n normal at 53%.\n 6. The indexed diameters of the ascending and descending thoracic aorta were\n normal. The main pulmonary artery diameter index was normal.\n 7. Moderate right and severe left atrial enlargement.\n\n The images were reviewed by Drs. , , , and\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1007108,
"text": " 6:59 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: s/p cva\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p cva\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 52-year-old female, status post CVA.\n\n COMPARISON: None available.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging, including\n diffusion-weighted imaging. Gadolinium-enhanced post-contrast imaging was\n also performed. 3D time-of-flight MR arteriography of the circle of \n was also performed. 2D time-of-flight MR arteriography of the neck, and\n gadolinium-enhanced MRA of the neck was also performed.\n\n FINDINGS: There is abnormal gyriform enhancement, and corresponding\n restricted diffusion signal along the sylvian fissure in the left temporal\n lobe, most consistent with a luxury perfusion pattern related to subacute\n infarct in this region. There is associated FLAIR signal hyperintensity in\n surrounding cortex, most consistent with edema.\n\n There is no evidence of hemorrhage, mass, mass effect, or new/acute\n infarction. No other diffusion abnormalities are detected. No other areas of\n abnormal enhancement following contrast administration are seen.\n\n There is mild irregularity throughout the course of the left middle cerebral\n artery, without focal stenosis or occlusion, most consistent with chronic\n atherosclerotic changes. Otherwise, the intracranial vertebral and internal\n carotid arteries of their major branches appear normal without evidence of\n stenosis, occlusion, or aneurysm formation.\n\n In the neck, the carotid and vertebral arteries are visualized from their\n origins to their intracranial courses, and showed no evidence of stenosis or\n occlusion.\n\n\n IMPRESSION:\n 1. Subacute infarction in the left middle cerebral artery territory, with\n luxury perfusion and gyriform enhancement along the sulci in the sylvian\n fissure, and changes consistent with gliosis in adjacent brain tissue.\n 2. Diffuse atherosclerotic changes in the left MCA, without focal stenosis or\n occlusion.\n (Over)\n\n 6:59 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: s/p cva\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-12 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1007099,
"text": " 4:53 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Preoperative.\n\n COMPARISON: No comparison available.\n\n Borderline size of the cardiac silhouette without signs of decompensation or\n overhydration. Otherwise, normal chest radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-13 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1007236,
"text": " 12:23 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o cad\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL ADDENDUM\n CHEST CT WITH CONTRAST MATERIAL\n\n ADDENDUM: The cardiac images were segregated and form the basis of this\n report. The cardiac images were acquired in a retrospective gated fashion at\n 10% intervals throughout the cardiac cycle. The calcium score was 0\n indicating little likelihood of coronary artery disease. The functional\n studies reveal an ejection fraction of 52%, EDV 96 mL, EFV 46 mL, SV 50 mL,\n cardiac output 6.0 liters per minute and cardiac index of 2.7 liters per\n minute per meter squared. The circulation is right dominant with a large PDL\n supplying the inferior surface of the left ventricle. The left main is\n slightly elongated giving rise to the LAD. A large OM1 extends over the\n lateral surface of the left ventricle. There is a very small ramus branch.\n The LAD is diminutive in size. The right coronary artery shows a small amount\n of noncalcified plaque that would not appear significant. There is a slight\n degree of motion, however, with EKG editing , the study is quite nice, even\n though the patient was fibrillating with a heart rate ranging between 88 and\n 109.\n\n CONCLUSION: No evidence of significant coronary artery disease and no\n evidence of calcification.\n\n\n\n\n\n\n\n 12:23 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o cad\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL ADDENDUM\n\n\n\n ADDENDUM:\n\n Diameter of the proximal left superior pulmonary vein measures 11 x 5 mm. The\n diameter of the proximal left inferior pulmonary vein measures 21 x 12 mm. The\n diameter of the right inferior pulmonary vein measures 19 x 17 mm. The\n diameter of the right superior pulmonary vein measures 21 x 16 mm at its\n proximal extent. Please see imaging lab reporting tool for further detail.\n\n\n 12:23 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o cad\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL INDICATION: .\n\n TECHNIQUE: 0.625-mm helically acquired images are obtained through the thorax\n with intravenous contrast. Multiplanar reformations are provided for\n interpretation.\n\n FINDINGS: Pulmonary arteries appear grossly unremarkable. No significant\n hilar or mediastinal lymphadenopathy is identified. Questionable small defect\n within the region of the left atrium from prior intervention. This is seen in\n the area of image #29 of series 11. Evaluation of the lung parenchyma reveals\n minimal dependent changes. Lungs are otherwise grossly clear.\n\n Visualized portions of the upper abdomen are grossly unremarkable.\n\n There is a low-attenuation lesion extending from the inferior aspect of the\n left lobe of the thyroid gland. This measures 11 x 10 mm. Ultrasound may be\n used for further characterization as clinically indicated.\n\n No suspicious lytic or blastic bony lesions are identified.\n\n IMPRESSION:\n 1. Grossly unremarkable examination. Please refer to _____\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1007458,
"text": " 6:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx, assess ett/line placement\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman s/p B thoracotomy/Maze/LAA resection\n REASON FOR THIS EXAMINATION:\n r/o ptx, assess ett/line placement\n ______________________________________________________________________________\n WET READ: KLMn WED 6:50 PM\n Limited study due to patient rotation and exclusion of the lateral right\n hemithorax. ETT 3.6 cm above carina, RIJ central line tip appears to project\n over SVC, bilateral chest tubes: tip on right projecting over medial lung\n base, and on left projecting over medial midlung. Stomach distended with gas.\n Pulmonary vascular prominence bilaterally with patchy opacities in both bases.\n\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, :\n\n COMPARISON: .\n\n INDICATION: Status post cardiovascular surgery.\n\n Endotracheal tube is in standard position, right internal jugular vascular\n catheter terminates near the junction of the superior vena cava and right\n atrium, and bilateral chest tubes are in place. No pneumothorax is\n identified, but the periphery of the right lung has been excluded from the\n study, precluding assessment for basilar and lateral pneumothorax. Lung\n volumes are low. Cardiomediastinal contours appear similar to the\n preoperative study allowing for this factor. Bibasilar atelectasis has\n developed, worse on the left than the right. Moderate gastric distention.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1007625,
"text": " 4:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p rt chest tube removal\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with s/p maze\n REASON FOR THIS EXAMINATION:\n s/p rt chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post MAZE. Status post right-sided chest tube removal.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-upright position is analyzed in direct comparison with a preceding\n similar study with an approximate two hours time interval. The right-sided\n chest tube has now been removed and no pneumothorax has developed. Plate\n atelectasis on the right lung base unchanged. No gross new pulmonary\n abnormalities are seen. Previously described right internal jugular approach\n central venous line remains in unchanged position and the tip is overlying the\n area of right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1007599,
"text": " 2:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p lt ct removal ? ptx\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with s/p maze\n REASON FOR THIS EXAMINATION:\n s/p lt ct removal ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the study of earlier in the day, the left chest\n tube has been removed. No convincing evidence of pneumothorax. Atelectatic\n changes are again seen at both bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1007641,
"text": " 8:44 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p MAZE w/nausea and vomiting r/o ileus/obstruction\n Admitting Diagnosis: ATRIAL FIBRILLATION\\THORACOSCOPIC MAZE PROCEDURE LEFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p MAZE w/nausea and vomiting r/o ileus/obstruction\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:01 P.M., \n\n HISTORY: Nausea and vomiting following maze procedure.\n\n IMPRESSION: AP chest compared to as late as 4:55 p.m.:\n\n Lung volumes have improved, previous mild pulmonary edema has resolved to the\n point of vascular congestion. Severe bibasilar atelectasis is only improved\n slightly. Heart size difficult to assess but probably smaller than it was on\n earlier studies and there is no longer mediastinal vascular engorgement. No\n pneumothorax and minimal if any pleural effusion noted. Right jugular line\n ends at the superior cavoatrial junction. Subdiaphragmatic region is\n difficult to see, but the stomach appears to be distended.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-03-19 00:00:00.000",
"description": "Report",
"row_id": 85324,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/p Maze. Atrial fibrillation. Left ventricular function. Pericardial effusion.\nHeight: (in) 68\nWeight (lb): 220\nBSA (m2): 2.13 m2\nBP (mm Hg): 122/60\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 08:45\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. No LA mass/thrombus (best excluded by TEE).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views.\n\nConclusions:\nThe left atrium is mildly dilated. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). Left ventricular wall\nthickness, cavity size, and global systolic function are normal (LVEF>55%).\nDue to suboptimal technical quality (no apical or subcostal windows), a focal\nwall motion abnormality cannot be fully excluded. Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Transmitral Doppler could not be\nassess due to absence of apical windows, but there appears to be atrial\nmechanical function on M-mode of the mitral leaflets. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen.The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Preserved global biventricular systolic\nfunction. Mild mitral regurgitation. Trace 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": "Nursing/other",
"chartdate": "2125-03-15 00:00:00.000",
"description": "Report",
"row_id": 1654867,
"text": "SEVERAL ATTEMPTS TO WEAN OFF PROPOFOL TO EXTUBATE. PT IS AWAKE BUT MAE, FOLLOWS COMMANDS BUT AGITATED, BITING ON ETT, TACHYPNIEC, LOW VOLUMES, HYPERTENSIVE, ABG SHOWING RESP ACIDOSIS. ATTEMPTED TO WEAN WITH BUT PT HYPOTENSIVE AND CONTINUES TO BE RESTLESS. MD AWARE, RESEDATED WITH PROPOFOL FOR THE NIGHT. OFF. WILL ATTEMPT TO WEAN AGAIN IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-15 00:00:00.000",
"description": "Report",
"row_id": 1654868,
"text": "Resp Care\nPt maintained on mech vent, with vent settings changed from AC to SIMV secondary to ABGs see flowsheet. pt's ABGs improved with the changes. BLBS diminished, suctioned for small yellow secretions, pt notted to be on ETT whire suctioning, ETT was retaped and propery secured. will cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-14 00:00:00.000",
"description": "Report",
"row_id": 1654865,
"text": "resp care - Pt received from OR intubated with #7.0ETT, 20@teeth, and placed on PSV. BLBS were clear. Vent settings were adjusted per ABGs. See carevue for details. Plan is to wean and extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-15 00:00:00.000",
"description": "Report",
"row_id": 1654869,
"text": "S/P BILATERAL THORASCOPIC MAZE PROCEDURE, PLACEMENT BILATERAL SC CATHETERS TO PUMPS FOR PAIN CONTROL, BUPIVACAINE INFUSING AT 4CC/HR.\n\nNEURO: ORALLY INTUBATED, RESTLESS/AGITATED WHEN LIGHTENED FROM PROPOFOL, REQUIRING FREQUENT BOLUSES FOR DANGEROUSLY AGITATED STATES THROUGHOUT NOC. VERSED 0.5MG IV X 2, FENTANYL 50MCG IVP BETWEEN 0600 AND 0630, RESTARTED AT 0.7MCG/KG, PROPOFOL WEANED OFF NP WITH BETTER ANXIETY CONTROL.\n\nPULM: SIMV MODE SINCE 2300, VT 550, RATE 14, PEEP 10. RESP ACIDOSIS IMPROVED. LUNGS DIMINISHED BASES. NO SECRETIONS OBTAINED WHEN SX'D. R CHEST TUBE TO DRY SX, MINIMAL SEROSANGUINOUS DRAINAGE, NO AIR LEAK OR CREPITUS. L CHEST TUBE TO DRY SX, MINIMAL SERSOANGUINOUS DRAINAGE, NO AIR LEAK OR CREPITUS. BOTH CHEST TUBES TO H20 SEAL AT 0600 BY NP. BILATERAL THORASCOPIC CATHETERS TO PUMPS WITH BUPIVACAINE AT 4CC/HR FOR PAIN CONTROL.\n\nCV: NSR, ONE SHORT BURST ? PAF. MAG REPLETED. L RADIAL ALINE POSITIONAL ALL SHIFT. UNABLE TO ASPIRATE BLD BACK SINCE ~0500 DESPITE REDRESSING. HO AWARE. BP'S MONITORED BY CUFF. NEO GTT STARTED ~ 0530 FOR MAP < 60. PEDAL PULSES PALPATED.\n\nENDO: INSULIN GTT STARTED FOR BS > 120 PER PROTOCOL.\n\nGI: OGT PLACED, BILIOUS RETURNS. ABDOMEN SOFT, NO BOWEL SOUNDS.\n\nRENAL: FOLEY TO CD, ADEQUATE HUO. BUN/CREATININE WNL.\n\nSOCIAL: HUSBAND, DAUGHTER VISITED UNTIL ~ 2130 AND CALLED IN FOR UPDATE.\n\nPLAN: FOR ANXIETY CONTROL. WEAN ON CPAP MODE, EXTUBATE THIS AM. ? DC CHEST TUBES LATER TODAY IF NO AIR LEAKS. OOB TO CHAIR ONCE EXTUBATED. ? TRANSFER TO 6 LATER TODAY IF PLAN ACHIEVED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-15 00:00:00.000",
"description": "Report",
"row_id": 1654870,
"text": "resp care - Pt was extubated without incident and is now on 6L NC. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-16 00:00:00.000",
"description": "Report",
"row_id": 1654871,
"text": "Neuro) pt.drowsy but awakens easily. Can verbalize her needs but has a difficult time due to expressive aphasia. Repeats words over and over.\nMoves extr equally during pivot back to bed.\n\nCV) Pt. had episode of PAF treated w/ Lopressor IV. pt. unable take PO due to persistent nausea; treated with Compazine & Zofran. BP by cuff >95syst.\n\nPulm) pt. coughing while using slinting pillow. Cough moist but not\nvery productive. O2 at 3l NP. Breath sounds decreased at bases due to poor insp. effort.\n\nGI) pt. having nausea with \"wretching\". No vomiting but responds well to antiemetics. Falls asleep for periods of time.\n\nGU) adequate huo.\n\nPain) managed with Toradol & sc Dilaudid. Pt. has bilat. SC pain pumps with Bupivicaine but not effective keeping pt. painfree. Pt. states that her pain is at all times although pt. is observed to sleep in long naps and moves herself in bed when coughing.\n\nEndo) blood sugars treated with SSRI.\n\nPlan) pain management. Glucose management. Advance activity OOB and to advance po intake if pt. is free of nausea.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-16 00:00:00.000",
"description": "Report",
"row_id": 1654872,
"text": " 7a-7p\nneuro: a+ox3, mae, follows commands, up to chair and commode w/ assist x1, pain well controlled w/ dilaudid po, pain pumps d/ced this am\n\ncv: sr 80s throughout morning, on leaving room for transfer to F6, rhythm changed to ST 120s, pt asymptomatic, lopressor 5mg iv 1, pt's rhythm then changed to afib 105-135 unresponsive to lopressor 5mg iv x5 and 2x 150mg amio boluses, pt asymptomatic w/ afib, amio gtt started, sbp 105-125 even w/ st/afib, afeb\n\nresp: lungs dim bilat, 02 sats>94% on 3L nc, is to 375, weak nonproductive cough\n\ngi: abdomen soft, absent bowel sounds, poor appetite, fingersticks ssri, c/o nausea this am-helped by compazine (though pt became very drowsy), c/o nausea this pm-helped by zofran\n\ngu: foley d/ed this pm, pt voiding in commode at bedside\n\nlabs: repleted k/ca\n\nplan: pulmonary toilet, continue amio gtt, ? more lopressor to slow heart rate?, activity as tolerated, transfer to 6 once hr consistently <100, ? dietary consult, continue compazine/zofran as needed\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-17 00:00:00.000",
"description": "Report",
"row_id": 1654873,
"text": "7p-7a\nNeuro: Pt a/ox3, mae's, follows commands, pt c/o incisional pain dilaudid given with good relief.\n\nCV: pt in afib 120's-150 md aware, amio drip at 1mg for 6 hours, then changed to 0.5mg. Lopressor po given, pt converted to sr 70's-80's. palpable pulses, sbp 100's. see flowsheet\n\nResp: ls clear/ dim, enc is, sats 94% on 3lnc. prod cough thick white sputum, ? nebs\n\nEndo: regular insulin sliding scale per cvicu protocol\n\nSkin: see flowsheet\n\nSocial: husband called updated on poc\n\nPlan: transfer to 6 in am, continue amio drip, then start po amio, lopressor tid ? increase dose if sbp>90, pain mgmt\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-03-14 00:00:00.000",
"description": "Report",
"row_id": 1654866,
"text": "Neuro: waking anxious, is on prop at 30 and mae to command, morphine for pain and has bilat sc pain pumps at sites, ? may need precidex vs is unable to understand communication due to aphasia and difficulty finding words from stroke in past.\n\nCardiac: nsr with no ectopy, bp's all wnl's, palpible pedial pulses, skin warm and dry and intact, afebrile,+3 edema in extremities.\n\nResp: see abgs is slow to wean from vent lungs are coarse and no air leak in ct system that is draining scant serosang, cxray is pending.\n\nSkin: bilat sites with dsds that are cdi, bilat ct dsds are cdi.\n\nGi/Gu: npo, came out with no og tube, abd is firm team aware -due to past pmhx surgery, making 30 or >/hr of u/o.\n\nSocial: family in to visit and updated, will be back later to visit.\n\nPlan: will ask for precidex order as patient does need, wean to extubate.\n"
},
{
"category": "ECG",
"chartdate": "2125-03-18 00:00:00.000",
"description": "Report",
"row_id": 213400,
"text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of the rhythm has changed.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-03-14 00:00:00.000",
"description": "Report",
"row_id": 213401,
"text": "Sinus rhythm. Compared to the previous tracing sinus rhythm has replaced\natypical atrial flutter. T waves, however, are now inverted in\nleads I, aVL and V3-V6. Consider anterolateral process.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-03-13 00:00:00.000",
"description": "Report",
"row_id": 213402,
"text": "Atypical atrial flutter with variable block with well-controlled ventricular\nresponse. Variant RSR' pattern in leads V1-V2. Minimal ST segment depressions\nwhich are non-specific in leads V3-V6. Non-specific low amplitude T wave in\nleads aVL and V5-V6. Compared to the previous tracing of no\nsignificant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-03-12 00:00:00.000",
"description": "Report",
"row_id": 213403,
"text": "Probable atrial flutter which is atypical with variable block. Since the\nprevious tracing of atrial flutter is new.\n\n"
}
] |
98,283 | 133,329 | The patient was admitted on and, later that day, was taken to the operating room by Dr. for a right above the knee amputation and removal of hardware without complication. Please see operative report for details. Postoperatively the patient was admitted to the ICU for hypotension. She was transiently on pressors. The patient was initially treated with a PCA followed by PO pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as coumadin for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident on POD#1. The Foley catheter was removed without incident. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. The patient was followed by the nephrology and dialysis services and underwent hemodialysis as an inpatient. On POD1 the patient became hypotensive after hemodialysis and responded to and IV fluid bolus. She was transferred to the floor on POD2. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services or rehabilitation in a stable condition. The patient's weight-bearing status was nonweight bearing. | Toleraing dialysis, although BP drop usually associated with dialysis runs --> plan to run even I/O. In the OR, expericenced hypotension during procedure. # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). TITLE: Chief Complaint: hypotension HPI: 67 yo F with DM2 with neuropathy, ESRD on HD (MWF but will need HD tomorrow), HTN, s/p urostomy and colostomy who was admitted for R AKA after prior R TKR s/p distal femoral periprosthetic fracture (s/p open reduction and internal fixation with plate, which later lost fixation) and persistent diabetic foot ulcers. Mepiplex on heal changed this AM and coccyx mepiplex changed yesterday Response: Skin remain impaired Plan: New KinAir bed needs to be ordered. Mepiplex on heal changed this AM and coccyx mepiplex changed yesterday Response: Skin remain impaired Plan: New KinAir bed needs to be ordered. Mepiplex on heal changed this AM and coccyx mepiplex changed yesterday Response: Skin remain impaired Plan: New KinAir bed needs to be ordered. # Hyperlipidemia: - will continue home statin dose . Plan: Continue tele & q 2 hr vs X48 hrs postop .H/O renal failure, End stage (End stage renal disease, ESRD) Assessment: Patient usually receives dialysis @ in MA (M-W-F @ 0600). Plan: Continue tele & q 2 hr vs X48 hrs postop .H/O renal failure, End stage (End stage renal disease, ESRD) Assessment: Patient usually receives dialysis @ in MA (M-W-F @ 0600). Plan: Continue tele & q 2 hr vs X48 hrs postop .H/O renal failure, End stage (End stage renal disease, ESRD) Assessment: Patient usually receives dialysis @ in MA (M-W-F @ 0600). Plan: Continue tele & q 2 hr vs X48 hrs postop .H/O renal failure, End stage (End stage renal disease, ESRD) Assessment: Patient usually receives dialysis @ in MA (M-W-F @ 0600). # Dispo: monitor overnight in , likely transfer to ortho tomorrow if stable ICU Care Nutrition: Comments: NPO for now Glycemic Control: Comments: lantus and SSI Lines: 18 Gauge - 09:39 PM Prophylaxis: DVT: Boots(Systemic anticoagulation: Coumadin) Stress ulcer: VAP: Comments: Communication: ICU consent signed Comments: Code status: Full code Disposition: ICU In the OR, expericenced hypotension during procedure. In the OR, expericenced hypotension during procedure. In the OR, expericenced hypotension during procedure. with episodes of hypotension during HD but Pt. with episodes of hypotension during HD but Pt. Likely baseline anemia from ESRD. Likely baseline anemia from ESRD. Likely baseline anemia from ESRD. Intraoperative transient hypotension, required intermittent phenylephrine intraoperatively. # Hyperlipidemia: - will continue home statin dose . Toleraing dialysis, although BP drop usually associated with dialysis runs --> plan to run even I/O. # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . # Peripherial vascular disease: has stenosis of right axillary artery, s/p 1 month tx of plavix - continue statin - may need futher plavix tx as out pt - continue ASA . RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). Kayexalate DVT prophylaxis. # Dispo: monitor overnight in , likely transfer to ortho tomorrow if stable ICU Care Nutrition: Comments: NPO for now Glycemic Control: Comments: lantus and SSI Lines: 18 Gauge - 09:39 PM Prophylaxis: DVT: Boots(Systemic anticoagulation: Coumadin) Stress ulcer: VAP: Comments: Communication: ICU consent signed Comments: Code status: Full code Disposition: ICU ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU resident for key portions of the services provided. | 37 | [
{
"category": "Nursing",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581969,
"text": "67 yo F with DM2 with neuropathy, ESRD on HD, HTN, s/p urostomy and\n colostomy who was admitted for R AKA after prior R TKR s/p distal\n femoral periprosthetic fracture (s/p open reduction and internal\n fixation with plate, which later lost fixation) and persistent diabetic\n foot ulcers. She was wheelchair bound at and admitted for elective\n AKA. In the OR, experienced hypotension during procedure. She received\n 1400 of crystalloid, 1 unit of PRBCs, and Neo boluses. Anesthesia\n requested overnight monitoring due to hypotension with SBP 70\ns. She\n was extubated after the procedure without difficulty\n Now pt hemodynamically stable and called to ortho for HD\n and further management.\n H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has graft on left arm. M/W/F HD schedule, however, got HD yesterday\n due to schedule conflicts but no fluid removed. Hypotensive episode\n yesterday and overnight with SBP 70\ns but responded to IVF and now with\n SBP 85-115, mentating and no c/o dizziness. HR SR 70-80\ns without\n ectopy. Unable to get AM labs---should get with HD today. Urostomy in\n place draining yellow urine. Colostomy also in place with golden brown\n stool. Pt\ns appetite has been poorer than baseline with low FS, lantus\n fixed dose on board. Sp02 95% on RA, lungs clear, diminished at bases.\n Dry non productive cough present\n Action:\n Hemodynamic monitoring. Encouraged PO intake with frequent FS, latest\n 89 and pt ate breakfast with encouragement. Only able to get CBC this\n AM. Encouraged CDB and IS use.\n Response:\n Pt remains hemodynamically stable. Finger sticks WNL.\n Plan:\n HD today, needs labs drawn. Encourage PO intake with frequent FS. IVF\n as needed, avoid if mentating and alert\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt receiving PRN morphine with IV morphine for breakthrough pain for\n pain from AKA. Pt c/o incisional pain after receiving percocet at\n 4 AM.\n Action:\n Gave 2 mg IV morphine for pain- pt stated it has not worked in the\n past.\n Response:\n Pain level responded appropriately--- pain, tolerable per pt.\n Plan:\n Continue to monitor and treat pain level appropriately\n Impaired Skin Integrity\n Assessment:\n Low grade temp 99.8 orally. Right AKA covered with dsg- not assessed.\n Pt has old pressure ulcer on left heel that is scabbed over with\n peeling skin around edges, no drainage present- covered with mepiplex\n and elevated. Coccyx also covered with mepiplex as skin has small\n blister present with surrounding skin pink but blanchable.\n Action:\n Frequent turns keep pressure off pressure points, kinair bed being\n used. Mepiplex on heal changed this AM and coccyx mepiplex changed\n yesterday\n Response:\n Skin remain impaired\n Plan:\n New KinAir bed needs to be ordered. Wound consult ordered- needs to be\n seen by them.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n RIGHT LOWER EXTREMITY FAILED FIXATION/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 92.7 kg\n Daily weight:\n 94.8 kg\n Allergies/Reactions:\n Penicillins\n swelling\n itchi\n Precautions:\n PMH: Anemia, Diabetes - Insulin, Renal Failure\n CV-PMH: Angina, CAD, Hypertension, PVD\n Additional history: pt. with complications after fx of right knee, s/p\n R TKR, DM2 w/neuropathy, ESRD on HD, GERD. In wheelchair X3 yrs. R\n foot & lower leg weighed 5.5kg.\n Surgery / Procedure and date: right aka, removal of hardware righ femur\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:58\n Temperature:\n 99.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 92% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 48 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 08:28 AM\n Potassium:\n 5.9 mEq/L\n 08:28 AM\n Chloride:\n 102 mEq/L\n 08:28 AM\n CO2:\n 27 mEq/L\n 08:28 AM\n BUN:\n 42 mg/dL\n 08:28 AM\n Creatinine:\n 6.9 mg/dL\n 08:28 AM\n Glucose:\n 78 mg/dL\n 08:28 AM\n Hematocrit:\n 26.1 %\n 08:28 AM\n Finger Stick Glucose:\n 84\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: cc6\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581821,
"text": "Chief Complaint: Hypotension post-operative (s/p right AKA)\n I saw and examined the patient, and was physically present with the ICU\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 Experienced some hypotension overnight, but improved with iv fluid\n bolus.\n Denies dyspnea. Lying supine.\n Describes post-op right leg (phantom) pain.\n Toleraing dialysis, although BP drop usually associated with dialysis\n runs --> plan to run even I/O.\n Mentating clearly.\n History obtained from Medical records\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:15 AM\n Dextrose 50% - 07:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: right leg (phantom)\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 74 (70 - 109) bpm\n BP: 111/89(95) {58/33(48) - 117/89(100)} mmHg\n RR: 14 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 530 mL\n 459 mL\n PO:\n 360 mL\n TF:\n IVF:\n 530 mL\n 74 mL\n Blood products:\n Total out:\n 0 mL\n 160 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 530 mL\n 299 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese, colostomy & ileostomy\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand, right AKA\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.6 g/dL\n 390 K/uL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 26.1 %\n 11.0 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n WBC\n 11.0\n Hct\n 28\n 26.1\n Plt\n 390\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n 67 yof DM, ESRD on HD, and leg fracture, now s/p AKA of right leg -->\n post-op hypotension\n HYPOTENSION -- multifactorial, intravascular volume shifts, medications\n (narcotics) and dialysis. iv fluid responsive. Monitor BP, maintain\n MAP > 60 mmHg.\n HYPOXEMIA -- minimal supplimental oxygen requirement. Denies dyspnea.\n Unclear if pt has hx of sleep apena (mentioned in medical records.\n Incentive spirometry.\n SURGICAL AKA -- AKA: s/p surgery, had chonic fracture of femur with\n broken plate for last 3 year. Monitor post-op. Optimize pain regimen\n per Orthopedic Surgery. Low dose coumadin.\n RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). Renally dose\n meds, will decrease gabapentin\n NIDDM -- monitor glucose, maintin <150\n GERD -- continue PPI\n PVD -- continue statin\n HYPERKALEMIA 0-- HD.\n ANEMIA -- baseline. Serial Hct.\n COLOSTOMy -- Routine colostomy care.\n FLUIDS -- may be intravascular depleted. need net positive fluid.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581944,
"text": "H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has graft on left arm. M/W/F HD schedule, however, got HD yesterday\n due to schedule conflicts but no fluid removed. Hypotensive episode\n yesterday and overnight with SBP 70\ns but responded to IVF and now with\n SBP 95-115. HR SR 70-80\ns without ectopy. Unable to get AM\n labs---should get with HD today. Illeoconduit in place draining yellow\n urine. Colostomy also in place with golden brown stool. Pt\ns appetite\n has been poorer than baseline with low FS, lantus fixed dose on board\n Action:\n Hemodynamic monitoring. Encouraged PO intake with frequent FS, latest\n 89 and pt ate breakfast with encouragement. Only able to get CBC this\n AM\n Response:\n Pt remains hemodynamically stable. Finger sticks WNL.\n Plan:\n HD today, needs labs drawn. Encourage PO intake with frequent FS. IVF\n as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt receiving PRN morphine with IV morphine for breakthrough pain for\n pain from AKA. Pt c/o incisional pain after receiving percocet at\n 4 AM.\n Action:\n Gave 2 mg IV morphine for pain- pt stated it has not worked in the\n past.\n Response:\n Pt\ns pain\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581946,
"text": "H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has graft on left arm. M/W/F HD schedule, however, got HD yesterday\n due to schedule conflicts but no fluid removed. Hypotensive episode\n yesterday and overnight with SBP 70\ns but responded to IVF and now with\n SBP 95-115. HR SR 70-80\ns without ectopy. Unable to get AM\n labs---should get with HD today. Illeoconduit in place draining yellow\n urine. Colostomy also in place with golden brown stool. Pt\ns appetite\n has been poorer than baseline with low FS, lantus fixed dose on board.\n Sp02 95% on RA, lungs clear, diminished at bases. Dry non productive\n cough present\n Action:\n Hemodynamic monitoring. Encouraged PO intake with frequent FS, latest\n 89 and pt ate breakfast with encouragement. Only able to get CBC this\n AM. Encouraged CDB and IS use.\n Response:\n Pt remains hemodynamically stable. Finger sticks WNL.\n Plan:\n HD today, needs labs drawn. Encourage PO intake with frequent FS. IVF\n as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt receiving PRN morphine with IV morphine for breakthrough pain for\n pain from AKA. Pt c/o incisional pain after receiving percocet at\n 4 AM.\n Action:\n Gave 2 mg IV morphine for pain- pt stated it has not worked in the\n past.\n Response:\n Pain level responded appropriately--- pain, tolerable per pt.\n Plan:\n Continue to monitor and treat pain level appropriately\n Impaired Skin Integrity\n Assessment:\n Low grade temp 99.8 orally. Right AKA covered with dsg- not assessed.\n Pt has old pressure ulcer on left heel that is scabbed over with\n peeling skin around edges, no drainage present- covered with mepiplex\n and elevated. Coccyx also covered with mepiplex as skin has small\n blister present with surrounding skin pink but blanchable.\n Action:\n Frequent turns keep pressure off pressure points, kinair bed being\n used. Mepiplex on heal changed this AM and coccyx mepiplex changed\n yesterday\n Response:\n Skin remain impaired\n Plan:\n New KinAir bed needs to be ordered. Wound consult ordered- needs to be\n seen by them.\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581947,
"text": "67 yo F with DM2 with neuropathy, ESRD on HD, HTN, s/p urostomy and\n colostomy who was admitted for R AKA after prior R TKR s/p distal\n femoral periprosthetic fracture (s/p open reduction and internal\n fixation with plate, which later lost fixation) and persistent diabetic\n foot ulcers. She was wheelchair bound at and admitted for elective\n AKA. In the OR, experienced hypotension during procedure. She received\n 1400 of crystalloid, 1 unit of PRBCs, and Neo boluses. Anesthesia\n requested overnight monitoring due to hypotension with SBP 70\ns. She\n was extubated after the procedure without difficulty\n Now pt hemodynamically stable and called to ortho for HD\n and further management.\n H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has graft on left arm. M/W/F HD schedule, however, got HD yesterday\n due to schedule conflicts but no fluid removed. Hypotensive episode\n yesterday and overnight with SBP 70\ns but responded to IVF and now with\n SBP 95-115. HR SR 70-80\ns without ectopy. Unable to get AM\n labs---should get with HD today. Urostomy in place draining yellow\n urine. Colostomy also in place with golden brown stool. Pt\ns appetite\n has been poorer than baseline with low FS, lantus fixed dose on board.\n Sp02 95% on RA, lungs clear, diminished at bases. Dry non productive\n cough present\n Action:\n Hemodynamic monitoring. Encouraged PO intake with frequent FS, latest\n 89 and pt ate breakfast with encouragement. Only able to get CBC this\n AM. Encouraged CDB and IS use.\n Response:\n Pt remains hemodynamically stable. Finger sticks WNL.\n Plan:\n HD today, needs labs drawn. Encourage PO intake with frequent FS. IVF\n as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt receiving PRN morphine with IV morphine for breakthrough pain for\n pain from AKA. Pt c/o incisional pain after receiving percocet at\n 4 AM.\n Action:\n Gave 2 mg IV morphine for pain- pt stated it has not worked in the\n past.\n Response:\n Pain level responded appropriately--- pain, tolerable per pt.\n Plan:\n Continue to monitor and treat pain level appropriately\n Impaired Skin Integrity\n Assessment:\n Low grade temp 99.8 orally. Right AKA covered with dsg- not assessed.\n Pt has old pressure ulcer on left heel that is scabbed over with\n peeling skin around edges, no drainage present- covered with mepiplex\n and elevated. Coccyx also covered with mepiplex as skin has small\n blister present with surrounding skin pink but blanchable.\n Action:\n Frequent turns keep pressure off pressure points, kinair bed being\n used. Mepiplex on heal changed this AM and coccyx mepiplex changed\n yesterday\n Response:\n Skin remain impaired\n Plan:\n New KinAir bed needs to be ordered. Wound consult ordered- needs to be\n seen by them.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n RIGHT LOWER EXTREMITY FAILED FIXATION/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 92.7 kg\n Daily weight:\n 94.8 kg\n Allergies/Reactions:\n Penicillins\n swelling\n itchi\n Precautions:\n PMH: Anemia, Diabetes - Insulin, Renal Failure\n CV-PMH: Angina, CAD, Hypertension, PVD\n Additional history: pt. with complications after fx of right knee, s/p\n R TKR, DM2 w/neuropathy, ESRD on HD, GERD. In wheelchair X3 yrs. R\n foot & lower leg weighed 5.5kg.\n Surgery / Procedure and date: right aka, removal of hardware righ femur\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:58\n Temperature:\n 99.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 92% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 48 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 08:28 AM\n Potassium:\n 5.9 mEq/L\n 08:28 AM\n Chloride:\n 102 mEq/L\n 08:28 AM\n CO2:\n 27 mEq/L\n 08:28 AM\n BUN:\n 42 mg/dL\n 08:28 AM\n Creatinine:\n 6.9 mg/dL\n 08:28 AM\n Glucose:\n 78 mg/dL\n 08:28 AM\n Hematocrit:\n 26.1 %\n 08:28 AM\n Finger Stick Glucose:\n 84\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581879,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt. with ESRD on HD. schedule Pt w/ episode of hypotension to 70\n systolic\n Action:\n On HD MWF but had it yesterday surgery interfering w/ schedule .Pt\n received 500 cc nss bolus\n Response:\n Pt now normotensive\n Plan:\n Monitor fluid intake. Check on next HD , fluid bolus for hypotension\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. s/p R AKA on . no c/o pain this shift.\n Action:\n Assessed for pain and offered med PRN\n Response:\n Cont to deny pain\n Plan:\n Cont. to asses for pain and medicate PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n BS @ 2200 151\n Action:\n Restarted diet standing dose of glargine\n Response:\n BS stable no s/s hypo or hyperglycemia\n Plan:\n Cont to monitor FSBS cover w/ SS\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581945,
"text": "H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has graft on left arm. M/W/F HD schedule, however, got HD yesterday\n due to schedule conflicts but no fluid removed. Hypotensive episode\n yesterday and overnight with SBP 70\ns but responded to IVF and now with\n SBP 95-115. HR SR 70-80\ns without ectopy. Unable to get AM\n labs---should get with HD today. Illeoconduit in place draining yellow\n urine. Colostomy also in place with golden brown stool. Pt\ns appetite\n has been poorer than baseline with low FS, lantus fixed dose on board.\n Sp02 95% on RA, lungs clear, diminished at bases. Dry non productive\n cough present\n Action:\n Hemodynamic monitoring. Encouraged PO intake with frequent FS, latest\n 89 and pt ate breakfast with encouragement. Only able to get CBC this\n AM. Encouraged CDB and IS use.\n Response:\n Pt remains hemodynamically stable. Finger sticks WNL.\n Plan:\n HD today, needs labs drawn. Encourage PO intake with frequent FS. IVF\n as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt receiving PRN morphine with IV morphine for breakthrough pain for\n pain from AKA. Pt c/o incisional pain after receiving percocet at\n 4 AM.\n Action:\n Gave 2 mg IV morphine for pain- pt stated it has not worked in the\n past.\n Response:\n Pain level responded appropriately--- pain.\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581943,
"text": "H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has graft on left arm. M/W/F HD schedule, however, got HD yesterday\n due to schedule conflicts. Hypotensive episode yesterday and overnight\n from HD with SBP 70\ns but responded to IVF and now with SBP 95-115. HR\n SR 70-80\ns without ectopy. Unable to get AM labs---should get with HD\n today. Illeoconduit in place draining yellow urine. Colostomy also in\n place with golden brown stool.\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581927,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -HD on \n -pressures steady with one drop to systolic of 79, improved with 500 cc\n bolus\n -expect floor transfer on if pressures remain stable\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dextrose 50% - 07:00 AM\n Morphine Sulfate - 09:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.2\n HR: 86 (70 - 86) bpm\n BP: 113/23(45) {70/23(34) - 137/89(95)} mmHg\n RR: 15 (10 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 1,341 mL\n 30 mL\n PO:\n 480 mL\n TF:\n IVF:\n 836 mL\n 30 mL\n Blood products:\n Total out:\n 615 mL\n 0 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 726 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 390 K/uL\n 8.6 g/dL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 26.1 %\n 11.0 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n WBC\n 11.0\n Hct\n 28\n 26.1\n Plt\n 390\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p R AKA\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n .H/O DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transferred to in setting of hypotension.\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus, bp improved to 90s-119 with bolus and stable\n since. have been secondary to fluid loss during procedure combined\n with sedation medications. Per pt has baseline BP 90-100, likely in\n setting of being HD pt with fistula.\n - pt receiving 500 cc bolus in hemodialysis this AM\n - will monitor BPs off HD prior to floor transfer\n - if pressors are needed will need to place central line\n .\n # Hypoxia: She has new oxygen requirement post op however is sating\n well now. No Cxr today however clinically patient does not seem fluid\n overloaded. Missed her regular HD on Monday, going for HD today.\n Unclear if pt has hx of sleep apena, was in records, but pt unaware of\n this hx. No wheezing on exam.\n - HD today\n - oxgygen as needed to keep sats >92%\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho recs femur xray today, pending\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n .\n # Pain: Pt c/o leg pain and phantom foot pain.\n - increase gabapentin as needed\n - dc Tylenol, start percocet for pain\n - morphine IV PRN for breakthrough pain\n - heat packs/ice packs\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag\n - monitor UO\n - HD today\n - renally dose meds\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units), will increase dose as needed with increasing PO\n intake\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n - start diabetic renal diet today\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - HD today\n - monitor on tele\n .\n # Anemia: hct of 26 today, likely secondary to surgical blood loss and\n baseline anemia secondary to renal failure\n - monitor hct\n - transfuse if evidence of bleeding\n - active type and screen\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 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": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581682,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns-80\ns SR no ectopy BP\n 77/45 upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient usually receives dialysis @ in\n MA (M-W-F @ 0600). Last dialyzed on Sat . Serum K was\n 6.0 on . Intern informed.\n Action:\n Received 30Gm kayexalate.\n Response:\n Unable to draw blood. Intern & resident aware. Blood to be drawn\n pre-dialysis by dialysis RN.\n Plan:\n Hemodialysis Tx today.\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581685,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns-80\ns SR no ectopy BP\n 77/45 upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient usually receives dialysis @ in\n MA (M-W-F @ 0600). Last dialyzed on Sat . Serum K was\n 6.0 on . Intern informed.\n Action:\n Received 30Gm kayexalate.\n Response:\n Unable to draw blood. Intern & resident aware. Blood to be drawn\n pre-dialysis by dialysis RN.\n Plan:\n Hemodialysis Tx today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o phantom limb pain postop. Pain was\n\n on a 1-10 scale\n @ 2040. Again c/o pain @ 0100.\n Action:\n Received 1 mg IV morphine q 30min X3 2040-2130 w/relief of pain, down\n to no pain. Required only 1mg IV morphine X 2.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581690,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns-80\ns SR no ectopy BP\n 77/45 upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient usually receives dialysis @ in\n MA (M-W-F @ 0600). Last dialyzed on Sat . Serum K was\n 6.0 on . Intern informed.\n Action:\n Received 30Gm kayexalate.\n Response:\n Unable to draw blood. Intern & resident aware. Blood to be drawn\n pre-dialysis by dialysis RN.\n Plan:\n Hemodialysis Tx today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o phantom limb pain postop. Pain was\n\n on a 1-10 scale\n @ 2040. Again c/o pain @ 0100.\n Action:\n Received 1 mg IV morphine q 30min X3 2040-2130 w/relief of pain, down\n to no pain. Required only 1mg IV morphine X 2.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581691,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns-80\ns SR no ectopy BP\n 77/45 upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient usually receives dialysis @ in\n MA (M-W-F @ 0600). Last dialyzed on Sat . Serum K was\n 6.0 on . Intern informed.\n Action:\n Received 30Gm kayexalate.\n Response:\n Unable to draw blood. Intern & resident aware. Blood to be drawn\n pre-dialysis by dialysis RN.\n Plan:\n Hemodialysis Tx today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o phantom limb pain postop. Pain was\n\n on a 1-10 scale\n @ 2040. Again c/o pain @ 0100.\n Action:\n Received 1 mg IV morphine q 30min X3 2040-2130 w/relief of pain, down\n to no pain. Required only 1mg IV morphine X 2 @ 0100\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581674,
"text": "67 yr old woman s/p R total knee replacement broke her R leg.\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581677,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns- SR no ectopy BP 77/systolic\n upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP 98-110\ns/systolic for the rest of the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581676,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581679,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns- SR no ectopy BP 77/38\n upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581681,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns-80\ns SR no ectopy BP\n 77/45 upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-20 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 581639,
"text": "TITLE:\n Chief Complaint: hypotension\n HPI:\n 67 yo F with DM2 with neuropathy, ESRD on HD (MWF but will need HD\n tomorrow), HTN, s/p urostomy and colostomy who was admitted for R AKA\n after prior R TKR s/p distal femoral periprosthetic fracture (s/p open\n reduction and internal fixation with plate, which later lost fixation)\n and persistent diabetic foot ulcers. She was wheelchair bound at \n and admitted for elective AKA. In the OR, expericenced hypotension\n during procedure. She received 1400 of crystalloid, 1 unit of PRBCs.\n Anesthia requested overnight monitoring due to hypotension, to SBPs 77.\n She was given neo boluses in the OR. She was extubated after the\n proceudure but required a face mask. Her removed foot 5.5 kg weighed.\n .\n On arrival to the , pt was sleepy but arrousable. BP was 77 and\n given a 500ml NS bolus, then in 90s to 110s. HR was in low 100s then in\n 80s. Pt became more awake and complained on pain in her left arm. No\n chest pain, no SOB, no abd pain, and minimal leg pain. Does not feel\n dizzy or lightheadedness. 95% on face mask with 6 liters, then 100% on\n 4 liters.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications:\n Fosrenol 1000 mg daily wiht meals\n ASA 81 mg daily\n Nexium 40 mg daily\n Gabapentin 100 mg TID\n Simvastatin 20 mg daily\n Lantus 16 units q evening\n Amaryl 6 mg MWF with breakfast\n Zoloft 25 mg daily\n Ativan 1 mg po qid prn anxiety\n Vicodin 1-2 tabs q4 hr prn\n .\n Past medical history:\n Family history:\n Social History:\n -DM with neuropathy, nephropathy, on insulin with ulcers on rt foot\n -ESRD on HD MWF\n -Dyslipidemia\n -GERD\n -Peripheral vascular disease, right axillary artery stenosis in\n , tx with 1 month of plavix\n -Hypertension, however, per pt BP has been in 90s\n -s/p R TKR s/p distal femoral periprosthetic fracture in (s/p open\n reduction and internal fixation with plate, which later lost fixation),\n pt in wheelchair for 3 years\n -s/p urostomy and colostomy\n Hx of DM, cancer, GI disorders, and heart disease\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: - non-smoker, no etoh use, no drug use\n - divorced\n - Daughter lives in , , HCP\n - has been living in nursing home in wheelchair\n Review of systems:\n Flowsheet Data as of 10:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 78 (78 - 109) bpm\n BP: 102/55(66) {58/35(48) - 102/55(66)} mmHg\n RR: 17 (14 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 514 mL\n PO:\n TF:\n IVF:\n 514 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 514 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n VS: 98.1, 78, 102/55, 18, 100% on 4 liters, mask\n GEN: groggy but conversational, NAD, obese\n HEENT: MMM, clear OP\n NECK: supple, no LAD\n CHEST: CTA in anterior\n CV: RRR, no M\n ABD: ileostomy and urostomy pouches present with stool and urine, soft,\n NT, decreased BS\n EXT: clean large bandage on right AKA site, left leg in boot, no c/c/e,\n moving left toes\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: K -5.4\n hb- 10.4\n Imaging: wet read by me-\n some pulmonary edema bilaterally, mainly at bases\n ECG: NSR at 86 bpm, normal axis, normal intervals, wide P wave in II,\n and biphasic in V1 suggesting enlarge Left atrium. Tall T waves in\n precordial leads, similar to EKG on \n Assessment and Plan\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transfered to in setting of hypotension\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus. have been secondary to fluid loss during\n procedure combined with sedation medications. Per pt has baseline BP\n 90-100, likely in settin of being HD pt with fistula.\n - IVF bolus if needed, with careful monitoring of resp status\n - may need a-line if BP is low again\n - monitoring overnight\n - if pressors are needed will need to place central line\n .\n # Hypoxia: She has new oxygen requirment post op. Unclear baseline\n sats. CXR appears to be slightly fluid overloaded. Was given blood and\n fluids to improve BP. Missed her regular HD today. Unclear if pt has hx\n of sleep apena, was in records, but pt unaware of this hx. No wheezing\n on exam\n - HD in AM\n - oxgygen as needed to keep sats >92%\n - may need CPAP if worsens\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho recs\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n - X-ray of femur tomorrow\n .\n # Arm pain: post op discomfort in left arm. be secondary to\n surgical positioning.\n - tylenol\n - morphine PRN\n - heat packs/ice packs\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag\n - monitor UO\n - contact renal to arrange HD for AM\n - renally dose meds, will decrease gabapentin\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units, half of home dose for now while NPO)\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - monitor K, recheck tonight\n - EKG monitoring\n - monitor on tele\n - HD in AM\n .\n # Anemia: hct of 31 pre-op today, was given 1 unit of blood in OR.\n Unclear the estimated blood loss. Likely baseline anemia from ESRD.\n - monitor hct\n - transfuse if evidence of bleeding\n - activ type and screen\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n .\n # FEN: NPO for tonight, in AM if stable\n - monitor lytes\n .\n # PPx:\n - starting coumadin, and pneumoboots\n - on home PPI\n .\n # Communication: (HCP, daughter) \n .\n # CODE: full, confirmed\n .\n # Dispo: monitor overnight in , likely transfer to ortho tomorrow\n if stable\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Comments: lantus and SSI\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-20 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 581641,
"text": "TITLE:\n Chief Complaint: hypotension\n HPI:\n 67 yo F with DM2 with neuropathy, ESRD on HD (MWF but will need HD\n tomorrow), HTN, s/p urostomy and colostomy who was admitted for R AKA\n after prior R TKR s/p distal femoral periprosthetic fracture (s/p open\n reduction and internal fixation with plate, which later lost fixation)\n and persistent diabetic foot ulcers. She was wheelchair bound at \n and admitted for elective AKA. In the OR, expericenced hypotension\n during procedure. She received 1400 of crystalloid, 1 unit of PRBCs.\n Anesthia requested overnight monitoring due to hypotension, to SBPs 77.\n She was given neo boluses in the OR. She was extubated after the\n proceudure but required a face mask. Her removed foot 5.5 kg weighed.\n .\n On arrival to the , pt was sleepy but arrousable. BP was 77 and\n given a 500ml NS bolus, then in 90s to 110s. HR was in low 100s then in\n 80s. Pt became more awake and complained on pain in her left arm. No\n chest pain, no SOB, no abd pain, and minimal leg pain. Does not feel\n dizzy or lightheadedness. 95% on face mask with 6 liters, then 100% on\n 4 liters.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications:\n Fosrenol 1000 mg daily wiht meals\n ASA 81 mg daily\n Nexium 40 mg daily\n Gabapentin 100 mg TID\n Simvastatin 20 mg daily\n Lantus 16 units q evening\n Amaryl 6 mg MWF with breakfast\n Zoloft 25 mg daily\n Ativan 1 mg po qid prn anxiety\n Vicodin 1-2 tabs q4 hr prn\n .\n Past medical history:\n Family history:\n Social History:\n -DM with neuropathy, nephropathy, on insulin with ulcers on rt foot\n -ESRD on HD MWF\n -Dyslipidemia\n -GERD\n -Peripheral vascular disease, right axillary artery stenosis in\n , tx with 1 month of plavix\n -Hypertension, however, per pt BP has been in 90s\n -s/p R TKR s/p distal femoral periprosthetic fracture in (s/p open\n reduction and internal fixation with plate, which later lost fixation),\n pt in wheelchair for 3 years\n -s/p urostomy and colostomy\n Hx of DM, cancer, GI disorders, and heart disease\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: - non-smoker, no etoh use, no drug use\n - divorced\n - Daughter lives in , , HCP\n - has been living in nursing home in wheelchair\n Review of systems:\n Flowsheet Data as of 10:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 78 (78 - 109) bpm\n BP: 102/55(66) {58/35(48) - 102/55(66)} mmHg\n RR: 17 (14 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 514 mL\n PO:\n TF:\n IVF:\n 514 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 514 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n VS: 98.1, 78, 102/55, 18, 100% on 4 liters, mask\n GEN: groggy but conversational, NAD, obese\n HEENT: MMM, clear OP\n NECK: supple, no LAD\n CHEST: CTA in anterior\n CV: RRR, no M\n ABD: ileostomy and urostomy pouches present with stool and urine, soft,\n NT, decreased BS\n EXT: clean large bandage on right AKA site, left leg in boot, no c/c/e,\n moving left toes\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: K -5.4\n hb- 10.4\n Imaging: wet read by me-\n some pulmonary edema bilaterally, mainly at bases\n ECG: NSR at 86 bpm, normal axis, normal intervals, wide P wave in II,\n and biphasic in V1 suggesting enlarge Left atrium. Tall T waves in\n precordial leads, similar to EKG on \n Assessment and Plan\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transfered to in setting of hypotension\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus. have been secondary to fluid loss during\n procedure combined with sedation medications. Per pt has baseline BP\n 90-100, likely in settin of being HD pt with fistula.\n - IVF bolus if needed, with careful monitoring of resp status\n - may need a-line if BP is low again\n - monitoring overnight\n - if pressors are needed will need to place central line\n .\n # Hypoxia: She has new oxygen requirment post op. Unclear baseline\n sats. CXR appears to be slightly fluid overloaded. Was given blood and\n fluids to improve BP. Missed her regular HD today. Unclear if pt has hx\n of sleep apena, was in records, but pt unaware of this hx. No wheezing\n on exam\n - HD in AM\n - oxgygen as needed to keep sats >92%\n - may need CPAP if worsens\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho recs\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n - X-ray of femur tomorrow\n .\n # Arm pain: post op discomfort in left arm. be secondary to\n surgical positioning.\n - tylenol\n - morphine PRN\n - heat packs/ice packs\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag\n - monitor UO\n - contact renal to arrange HD for AM\n - renally dose meds, will decrease gabapentin\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units, half of home dose for now while NPO)\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - monitor K, recheck tonight\n - EKG monitoring\n - monitor on tele\n - HD in AM\n .\n # Anemia: hct of 31 pre-op today, was given 1 unit of blood in OR.\n Unclear the estimated blood loss. Likely baseline anemia from ESRD.\n - monitor hct\n - transfuse if evidence of bleeding\n - activ type and screen\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n .\n # FEN: NPO for tonight, in AM if stable\n - monitor lytes\n .\n # PPx:\n - starting coumadin, and pneumoboots\n - on home PPI\n .\n # Communication: (HCP, daughter) \n .\n # CODE: full, confirmed\n .\n # Dispo: monitor overnight in , likely transfer to ortho tomorrow\n if stable\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Comments: lantus and SSI\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 67 yo F with DM2 with neuropathy, ESRD on HD, HTN, s/p urostomy and\n colostomy who was admitted for elective R AKA after prior R\n TKR. Intraoperative transient hypotension, required intermittent\n phenylephrine intraoperatively. Lowest documented SBP ~80, but\n apparently had SBP as low as 60 as procedure was ending and transfering\n to ICU. 600cc EBL. 1U PRBC given in addition to 800cc NS, 600cc LR.\n 1.8L/1.7L. Usually gets HD MWF but did not have HD today, last HD was\n Saturday and planned for tomorrow.\n Denies dyspnea, N/V. C/O pain in right (amputated) LE and foot.\n Otherwise neg in detail.\n Exam: Vitals now 112/41 76 100% on RA.\n Appears well. No resp distress or cough. RRR. CTA anteriorly with good\n air movement. Abd NABS, soft, NDNT. Ileostomy and urostomy stomas\n clean, draining. Right LE stump dry, no e/o bleeding in wound dressing.\n LLE in and SCD. No edema.\n K 5.4 this morning. EKG with slightly elevated symmetric Ts, though\n not sig changed from her baseline.\n Hypotension. Transient, intraop, likely med effect and fluid\n shifts. Now normotensive (at her baseline) with gentle hydration.\n CXR with fluid overload. Gently hydrated (received 500cc NS\n on arrival here.) Plan for HD tomorrow. If hypoxemia worsens can\n consider diuyresis but is on minimal supplemental oxygen.\n Hyperkalemia. Recheck K now. Kayexalate\n DVT prophylaxis. Ortho plans for 6wks coumadin.\n Neurontin for neuropathic pain.\n Critically ill, hypotensive though improving 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 23:27 ------\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581708,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns-80\ns SR no ectopy BP\n 77/45 upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient usually receives dialysis @ in\n MA (M-W-F @ 0600). Last dialyzed on Sat . Serum K was\n 6.0 on . Intern informed.\n Action:\n Received 30Gm kayexalate.\n Response:\n Unable to draw blood. Intern & resident aware. Blood to be drawn\n pre-dialysis by dialysis RN.\n Plan:\n Hemodialysis Tx today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o phantom limb pain postop. Pain was\n\n on a 1-10 scale\n @ 2040. Again c/o pain @ 0100 which was .\n Action:\n Received 1 mg IV morphine q 30min X3 2040-2130 w/relief of pain, down\n to no pain. Required only 1mg IV morphine X 2 @ 0100& 0115, again\n dropped to no pain.\n Response:\n Reduced pain from to 0/10 w/3mg IV morphine. Reduced pain\n to 0/10 w/2mg IV morphine. As patient is on hemodialysis & over 60yrs,\n she is more sensitive to sedative effects of narcotics.\n Plan:\n Give 1mg IV morphine @ a time. Monitor for sedation.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n FS 118-59. No Sx w/FS 59.\n Action:\n Given 8 units lantus @ HS . Given 120cc apple juice @ midnight for\n FS 78. Given 240cc apple juice @ 0615 for FS 59. Given juice per MICU\n intern & resident to cover FS.\n Response:\n FS 61 @ 0700. Given\n amp D50 IV @ 0700.\n Plan:\n Advance diet as soon as surgery team says OK. Check FS again.\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581735,
"text": "Chief Complaint: Hypotension post-operative (s/p right AKA)\n I saw and examined the patient, and was physically present with the ICU\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 Experienced some hypotension overnight, but improved with iv fluid\n bolus.\n Denies dyspnea. Lying supine.\n Describes post-op right leg (phantom) pain.\n Toleraing dialysis, although BP drop usually associated with dialysis\n runs --> plan to run even I/O.\n Mentating clearly.\n History obtained from Medical records\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:15 AM\n Dextrose 50% - 07:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: right leg (phantom)\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 74 (70 - 109) bpm\n BP: 111/89(95) {58/33(48) - 117/89(100)} mmHg\n RR: 14 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 530 mL\n 459 mL\n PO:\n 360 mL\n TF:\n IVF:\n 530 mL\n 74 mL\n Blood products:\n Total out:\n 0 mL\n 160 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 530 mL\n 299 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese, colostomy & ileostomy\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand, right AKA\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.6 g/dL\n 390 K/uL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 26.1 %\n 11.0 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n WBC\n 11.0\n Hct\n 28\n 26.1\n Plt\n 390\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n 67 yof DM, ESRD on HD, and leg fracture, now s/p AKA of right leg -->\n post-op hypotension\n HYPOTENSION -- multifactorial, intravascular volume shifts, medications\n (narcotics) and dialysis. iv fluid responsive. Monitor BP, maintain\n MAP > 60 mmHg.\n HYPOXEMIA -- minimal supplimental oxygen requirement. Denies dyspnea.\n Unclear if pt has hx of sleep apena (mentioned in medical records.\n Incentive spirometry.\n SURGICAL AKA -- AKA: s/p surgery, had chonic fracture of femur with\n broken plate for last 3 year. Monitor post-op. Optimize pain regimen\n per Orthopedic Surgery. Low dose coumadin.\n RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). Renally dose\n meds, will decrease gabapentin\n NIDDM -- monitor glucose, maintin <150\n GERD -- continue PPI\n PVD -- continue statin\n HYPERKALEMIA 0-- HD.\n ANEMIA -- baseline. Serial Hct.\n COLOSTOMy -- Routine colostomy care.\n FLUIDS -- may be intravascular depleted. need net positive fluid.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581737,
"text": "Chief Complaint: s/p AKA, concern for hypotension post surgery\n Hour Events:\n EKG - At 09:00 PM\n - titrated to 2 liters NC\n - K was 6.0, gave Sodium Polystyrene Sulfonate 30g\n - BP stablized in 100s\n -hypoglycemia to 59, given an amp of D50\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 70 (70 - 109) bpm\n BP: 108/35(53) {58/33(48) - 117/55(100)} mmHg\n RR: 10 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 530 mL\n 415 mL\n PO:\n 360 mL\n TF:\n IVF:\n 530 mL\n 55 mL\n Blood products:\n Total out:\n 0 mL\n 160 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 530 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n Gen: Alert, oriented, appropriate\n HEENT: MMM, EOMI\n Pulm: CTA B\n Ab: soft, NT, +BS\n Ext: RLE well wrapped, L in pneumoboot and wrapped.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 6.0 mEq/L\n 99 mEq/L\n 139 mEq/L\n 28\n [image002.jpg]\n 11:46 PM\n Hct\n 28\n Other labs: Lactic Acid:1.3 mmol/L\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p R AKA\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n .H/O DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transferred to in setting of hypotension.\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus, bp improved to 90s-119 with bolus and stable\n since. have been secondary to fluid loss during procedure combined\n with sedation medications. Per pt has baseline BP 90-100, likely in\n setting of being HD pt with fistula.\n - pt receiving 500 cc bolus in hemodialysis\n -will monitor BPs off HD prior to floor transfer\n - if pressors are needed will need to place central line\n .\n # Hypoxia: She has new oxygen requirement post op. Unclear baseline\n sats. CXR appears to be slightly fluid overloaded. Was given blood and\n fluids to improve BP. Missed her regular HD on Monday, going for HD\n today. Unclear if pt has hx of sleep apena, was in records, but pt\n unaware of this hx. No wheezing on exam.\n - HD in AM\n - oxgygen as needed to keep sats >92%\n - may need CPAP if worsens\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho recs\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n - X-ray of femur today\n .\n # Pain: Pt c/o leg pain and phantom foot pain.\n - increase gabapentin as needed\n - dc Tylenol, start percocet for pain\n - morphine IV PRN for breakthrough pain\n - heat packs/ice packs\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag\n - monitor UO\n - contact renal to arrange HD for AM\n - renally dose meds, will decrease gabapentin\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units), will increase dose with PO intake\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n -start diabetic renal diet today\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - monitor K, recheck tonight\n - EKG monitoring\n - monitor on tele\n - HD in AM\n .\n # Anemia: hct of 31 pre-op today, was given 1 unit of blood in OR.\n Unclear the estimated blood loss. Likely baseline anemia from ESRD.\n - monitor hct\n - transfuse if evidence of bleeding\n - activ type and screen\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581807,
"text": "67 yo F with DM2 with neuropathy, ESRD on HD (MWF but will need HD\n tomorrow), HTN, s/p urostomy and colostomy who was admitted for R AKA\n after prior R TKR s/p distal femoral periprosthetic fracture (s/p open\n reduction and internal fixation with plate, which later lost fixation)\n and persistent diabetic foot ulcers. She was wheelchair bound at \n and admitted for elective AKA. In the OR, expericenced hypotension\n during procedure. She received 1400 of crystalloid, 1 unit of PRBCs.\n Anesthia requested overnight monitoring due to hypotension, to SBPs 77.\n She was given neo boluses in the OR. She was extubated after the\n proceudure but required a face mask. Pt. received 500cc FB upon\n arriving to MICU and BP 100\ns systolic overnight.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt. with ESRD on HD.\n Action:\n HD today.\n Response:\n Pt. with episodes of hypotension during HD but Pt. alert and oriented.\n No fluid removal at today HD session due to hypotension.\n Plan:\n Monitor fluid intake. Nest HD per Renal team.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. s/p R AKA on . C/O pain at stump and also phantom foot\n pain.\n Action:\n Medicated with Morphine 1mg IV but once Pt. on HD Pt. did to notice\n much relief. Started on Percocet PO.\n Response:\n Pt. states pain is much improved 0-4/10 and tolerable. Napping on/off.\n Plan:\n Cont. to asses for pain and medicate PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n BS low this morning to 50\ns requiring\n amp of D50. Pt. NPO overnight\n and received Glargine last night.\n Action:\n Restarted diet this morning. Frequent FS checks.\n Response:\n BS stable at 131 and 146 at noon. Pt. ate lunch.\n Plan:\n Cont. to follow FS and SS as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581697,
"text": "Chief Complaint: s/p AKA\n 24 Hour Events:\n EKG - At 09:00 PM\n - titrated to 2 liters NC\n - K was 6.0, gave Sodium Polystyrene Sulfonate 30g\n - BP stablized in 100s\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 70 (70 - 109) bpm\n BP: 108/35(53) {58/33(48) - 117/55(100)} mmHg\n RR: 10 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 530 mL\n 415 mL\n PO:\n 360 mL\n TF:\n IVF:\n 530 mL\n 55 mL\n Blood products:\n Total out:\n 0 mL\n 160 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 530 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\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 6.0 mEq/L\n 99 mEq/L\n 139 mEq/L\n 28\n [image002.jpg]\n 11:46 PM\n Hct\n 28\n Other labs: Lactic Acid:1.3 mmol/L\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p R AKA\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n .H/O DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transfered to in setting of hypotension\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus. have been secondary to fluid loss during\n procedure combined with sedation medications. Per pt has baseline BP\n 90-100, likely in settin of being HD pt with fistula.\n - IVF bolus if needed, with careful monitoring of resp status\n - may need a-line if BP is low again\n - monitoring overnight\n - if pressors are needed will need to place central line\n .\n # Hypoxia: She has new oxygen requirment post op. Unclear baseline\n sats. CXR appears to be slightly fluid overloaded. Was given blood and\n fluids to improve BP. Missed her regular HD today. Unclear if pt has hx\n of sleep apena, was in records, but pt unaware of this hx. No wheezing\n on exam\n - HD in AM\n - oxgygen as needed to keep sats >92%\n - may need CPAP if worsens\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho recs\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n - X-ray of femur tomorrow\n .\n # Arm pain: post op discomfort in left arm. be secondary to\n surgical positioning.\n - tylenol\n - morphine PRN\n - heat packs/ice packs\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag\n - monitor UO\n - contact renal to arrange HD for AM\n - renally dose meds, will decrease gabapentin\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units, half of home dose for now while NPO)\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - monitor K, recheck tonight\n - EKG monitoring\n - monitor on tele\n - HD in AM\n .\n # Anemia: hct of 31 pre-op today, was given 1 unit of blood in OR.\n Unclear the estimated blood loss. Likely baseline anemia from ESRD.\n - monitor hct\n - transfuse if evidence of bleeding\n - activ type and screen\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 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": "2109-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581788,
"text": "Chief Complaint: s/p AKA, concern for hypotension post surgery\n Hour Events:\n EKG - At 09:00 PM\n - titrated to 2 liters NC\n - K was 6.0, gave Sodium Polystyrene Sulfonate 30g\n - BP stablized in 100s\n -hypoglycemia to 59, given an amp of D50\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.6\nC (96\n HR: 70 (70 - 109) bpm\n BP: 108/35(53) {58/33(48) - 117/55(100)} mmHg\n RR: 10 (9 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 530 mL\n 415 mL\n PO:\n 360 mL\n TF:\n IVF:\n 530 mL\n 55 mL\n Blood products:\n Total out:\n 0 mL\n 160 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 530 mL\n 255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n Gen: Alert, oriented, appropriate\n HEENT: MM dry, EOMI\n Pulm: CTA B\n CV: RRR, no MRG\n Ab: soft, NT, +BS\n Ext: RLE well wrapped, L in pneumoboot and wrapped.\n Skin: no lesions or rashes appreciated\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 6.0 mEq/L\n 99 mEq/L\n 139 mEq/L\n 28\n [image002.jpg]\n 11:46 PM\n Hct\n 28\n Other labs: Lactic Acid:1.3 mmol/L\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p R AKA\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n .H/O DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transferred to in setting of hypotension.\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus, bp improved to 90s-119 with bolus and stable\n since. have been secondary to fluid loss during procedure combined\n with sedation medications. Per pt has baseline BP 90-100, likely in\n setting of being HD pt with fistula.\n - pt receiving 500 cc bolus in hemodialysis this AM\n - will monitor BPs off HD prior to floor transfer\n - if pressors are needed will need to place central line\n .\n # Hypoxia: She has new oxygen requirement post op however is sating\n well now. No Cxr today however clinically patient does not seem fluid\n overloaded. Missed her regular HD on Monday, going for HD today.\n Unclear if pt has hx of sleep apena, was in records, but pt unaware of\n this hx. No wheezing on exam.\n - HD today\n - oxgygen as needed to keep sats >92%\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho recs femur xray today, pending\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n .\n # Pain: Pt c/o leg pain and phantom foot pain.\n - increase gabapentin as needed\n - dc Tylenol, start percocet for pain\n - morphine IV PRN for breakthrough pain\n - heat packs/ice packs\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag\n - monitor UO\n - HD today\n - renally dose meds\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units), will increase dose as needed with increasing PO\n intake\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n - start diabetic renal diet today\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - HD today\n - monitor on tele\n .\n # Anemia: hct of 26 today, likely secondary to surgical blood loss and\n baseline anemia secondary to renal failure\n - monitor hct\n - transfuse if evidence of bleeding\n - active type and screen\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n ICU Care\n Nutrition: renal diet\n Glycemic Control: lantus, ISS\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: warfarin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor tomorrow\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581907,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -HD on \n -pressures steady with one drop to systolic of 79, improved with 500 cc\n bolus\n -expect floor transfer on if pressures remain stable\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dextrose 50% - 07:00 AM\n Morphine Sulfate - 09:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.2\n HR: 86 (70 - 86) bpm\n BP: 113/23(45) {70/23(34) - 137/89(95)} mmHg\n RR: 15 (10 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 1,341 mL\n 30 mL\n PO:\n 480 mL\n TF:\n IVF:\n 836 mL\n 30 mL\n Blood products:\n Total out:\n 615 mL\n 0 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 726 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 390 K/uL\n 8.6 g/dL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 26.1 %\n 11.0 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n WBC\n 11.0\n Hct\n 28\n 26.1\n Plt\n 390\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p R AKA\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n .H/O DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 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": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581840,
"text": "67 yo F with DM2 with neuropathy, ESRD on HD (MWF but will need HD\n tomorrow), HTN, s/p urostomy and colostomy who was admitted for R AKA\n after prior R TKR s/p distal femoral periprosthetic fracture (s/p open\n reduction and internal fixation with plate, which later lost fixation)\n and persistent diabetic foot ulcers. She was wheelchair bound at \n and admitted for elective AKA. In the OR, expericenced hypotension\n during procedure. She received 1400 of crystalloid, 1 unit of PRBCs.\n Anesthia requested overnight monitoring due to hypotension, to SBPs 77.\n She was given neo boluses in the OR. She was extubated after the\n proceudure but required a face mask. Pt. received 500cc FB upon\n arriving to MICU and BP 100\ns systolic overnight.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt. with ESRD on HD.\n Action:\n HD today.\n Response:\n Pt. with episodes of hypotension during HD but Pt. alert and oriented.\n No fluid removal at today HD session due to hypotension.\n Plan:\n Monitor fluid intake. Nest HD per Renal team.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. s/p R AKA on . C/O pain at stump and also phantom foot\n pain.\n Action:\n Medicated with Morphine 1mg IV but once Pt. on HD Pt. did to notice\n much relief. Started on Percocet PO.\n Response:\n Pt. states pain is much improved 0-4/10 and tolerable. Napping on/off.\n Plan:\n Cont. to asses for pain and medicate PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n BS low this morning to 50\ns requiring\n amp of D50. Pt. NPO overnight\n and received Glargine last night.\n Action:\n Restarted diet this morning. Frequent FS checks.\n Response:\n BS stable at 131 and 146 at noon. BS at 1730 67. Pt. is eating supper.\n Plan:\n Cont. to follow FS and SS as ordered.\n Pt. with old pressure ulcer to L heel. Duoderm gel appleied and\n covered with dsg. Pt. also has small bliser like open area to\n coccyx area. dsg. Applied. Wound care consult in place for\n rec. on treatment of L heel ulcer.\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 582002,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Tolerated dialysis yesterday, experienced hypotension, but tolerated.\n Pt. states she has baseline relatively low BP.\n Appears much improved today.\n History obtained from Medical records\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: Right limb ( Phantom)\n Flowsheet Data as of 12:01 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 81 (77 - 87) bpm\n BP: 88/31(45) {79/23(41) - 137/60(70)} mmHg\n RR: 13 (11 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 1,341 mL\n 59 mL\n PO:\n 480 mL\n TF:\n IVF:\n 836 mL\n 59 mL\n Blood products:\n Total out:\n 615 mL\n 100 mL\n Urine:\n 115 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 726 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese, Colostomy, ileostomy\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing,\n Right AKA with surgical bandage\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 8.1 g/dL\n 343 K/uL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 25.3 %\n 12.1 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n 09:00 AM\n WBC\n 11.0\n 12.1\n Hct\n 28\n 26.1\n 25.3\n Plt\n 390\n 343\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n 67 yof DM, ESRD on HD, and leg fracture, now s/p AKA of right leg -->\n post-op hypotension\n HYPOTENSION -- multifactorial, intravascular volume shifts, medications\n (narcotics) and dialysis. iv fluid responsive. Monitor BP, maintain\n MAP > 60 mmHg.\n HYPOXEMIA -- minimal supplimental oxygen requirement. Denies dyspnea.\n Unclear if pt has hx of sleep apena (mentioned in medical records.\n Incentive spirometry.\n SURGICAL AKA -- AKA: s/p surgery, had chonic fracture of femur with\n broken plate for last 3 year. Monitor post-op. Optimize pain regimen\n per Orthopedic Surgery. Low dose coumadin for DVT prophylaxis.\n RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). Renally dose\n meds, will decrease gabapentin\n NIDDM -- monitor glucose, maintin <150\n GERD -- continue PPI\n PVD -- continue statin\n HYPERKALEMIA -- HD.\n ANEMIA -- baseline. Serial Hct.\n COLOSTOMy -- Routine colostomy care.\n FLUIDS -- may be intravascular depleted. need net positive fluid.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581975,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Tolerated dialysis yesterday, experienced hypotension, but tolerated.\n Pt. states she has baseline relatively low BP.\n Appears much improved today.\n History obtained from Medical records\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:26 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: Right limb ( Phantom)\n Flowsheet Data as of 12:01 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 81 (77 - 87) bpm\n BP: 88/31(45) {79/23(41) - 137/60(70)} mmHg\n RR: 13 (11 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 1,341 mL\n 59 mL\n PO:\n 480 mL\n TF:\n IVF:\n 836 mL\n 59 mL\n Blood products:\n Total out:\n 615 mL\n 100 mL\n Urine:\n 115 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 726 mL\n -41 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)\n Distended, No(t) Tender: , Obese, Colostomy, ileostomy\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing,\n Right AKA with surgical bandage\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 8.1 g/dL\n 343 K/uL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 25.3 %\n 12.1 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n 09:00 AM\n WBC\n 11.0\n 12.1\n Hct\n 28\n 26.1\n 25.3\n Plt\n 390\n 343\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n 67 yof DM, ESRD on HD, and leg fracture, now s/p AKA of right leg -->\n post-op hypotension\n HYPOTENSION -- multifactorial, intravascular volume shifts, medications\n (narcotics) and dialysis. iv fluid responsive. Monitor BP, maintain\n MAP > 60 mmHg.\n HYPOXEMIA -- minimal supplimental oxygen requirement. Denies dyspnea.\n Unclear if pt has hx of sleep apena (mentioned in medical records.\n Incentive spirometry.\n SURGICAL AKA -- AKA: s/p surgery, had chonic fracture of femur with\n broken plate for last 3 year. Monitor post-op. Optimize pain regimen\n per Orthopedic Surgery. Low dose coumadin for DVT prophylaxis.\n RENAL FAILURE -- ESRD on HD --> for HD today (scheduled). Renally dose\n meds, will decrease gabapentin\n NIDDM -- monitor glucose, maintin <150\n GERD -- continue PPI\n PVD -- continue statin\n HYPERKALEMIA 0-- HD.\n ANEMIA -- baseline. Serial Hct.\n COLOSTOMy -- Routine colostomy care.\n FLUIDS -- may be intravascular depleted. need net positive fluid.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581976,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -HD on \n -pressures steady with one drop to systolic of 79, improved with 500 cc\n bolus\n -expect floor transfer on if pressures remain stable\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dextrose 50% - 07:00 AM\n Morphine Sulfate - 09:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.2\n HR: 86 (70 - 86) bpm\n BP: 113/23(45) {70/23(34) - 137/89(95)} mmHg\n RR: 15 (10 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 1,341 mL\n 30 mL\n PO:\n 480 mL\n TF:\n IVF:\n 836 mL\n 30 mL\n Blood products:\n Total out:\n 615 mL\n 0 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 726 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General: A+O x3, NAD\n CV: RRR S1 S2, no murmurs auscultated\n Resp: CTAB\n Abdomen: soft/NT/ND +BS\n Ext: AKA site C/D/I with no surrounding erythema\n Labs / Radiology\n 390 K/uL\n 8.6 g/dL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 26.1 %\n 11.0 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n WBC\n 11.0\n Hct\n 28\n 26.1\n Plt\n 390\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p R AKA\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n .H/O DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transferred to in setting of hypotension.\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus, bp improved to 90s-119 with bolus and stable\n since. have been secondary to fluid loss during procedure combined\n with sedation medications. Per pt has baseline BP 90-100, likely in\n setting of being HD pt with fistula.\n - pt receiving 500 cc bolus in hemodialysis this AM\n - will monitor BPs off HD prior to floor transfer\n - if pressors are needed will need to place central line\n .\n # Hypoxia: She has new oxygen requirement post op however is sating\n well now. No Cxr today however clinically patient does not seem fluid\n overloaded. Missed her regular HD on Monday, going for HD today.\n Unclear if pt has hx of sleep apena, was in records, but pt unaware of\n this hx. No wheezing on exam.\n - HD today\n - oxgygen as needed to keep sats >92%\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho recs femur xray today, pending\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n .\n # Pain: Pt c/o leg pain and phantom foot pain.\n - increase gabapentin as needed\n - dc Tylenol, start percocet for pain\n - morphine IV PRN for breakthrough pain\n - heat packs/ice packs\n #Fever: up to 103 this am with moderate leukocytes\n - blood cx, urine cx\n -incentive spirometry for possible atelectasis- related fever\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag. Nephro following\n - monitor UO\n - HD today\n - renally dose meds\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units), will increase dose as needed with increasing PO\n intake\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n - start diabetic renal diet today\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - HD today\n - monitor on tele\n .\n # Anemia: hct of 26 today, likely secondary to surgical blood loss and\n baseline anemia secondary to renal failure\n - monitor hct\n - transfuse today\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n ICU Care\n Nutrition: normal renal diet\n Glycemic Control: SSI\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: stable, can transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2109-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581989,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -HD on \n -pressures steady with one drop to systolic of 79, improved with 500 cc\n bolus\n -expect floor transfer on if pressures remain stable\n Allergies:\n Penicillins\n swelling\n itchi\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dextrose 50% - 07:00 AM\n Morphine Sulfate - 09:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.2\n HR: 86 (70 - 86) bpm\n BP: 113/23(45) {70/23(34) - 137/89(95)} mmHg\n RR: 15 (10 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 92.7 kg\n Total In:\n 1,341 mL\n 30 mL\n PO:\n 480 mL\n TF:\n IVF:\n 836 mL\n 30 mL\n Blood products:\n Total out:\n 615 mL\n 0 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 726 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General: A+O x3, NAD, sitting in bed with no discomfort\n HEENT: moist mucous membranes, oropharynx clear, left EJ peripheral\n line in place with no signs of infection.\n CV: RRR S1 S2, systolc murmur\n Resp: CTAB, no wheezes or rhonchi, intermittant crackle in lower lung\n fields\n Abdomen: soft/NT/ND +BS\n Ext: Right AKA site C/D/I with no surrounding erythema. No edema or\n cyanosis in Left lower extremity, pulse felt in left lower extremity.\n Labs / Radiology\n 343 K/uL\n 8.1 g/dL\n 78 mg/dL\n 6.9 mg/dL\n 27 mEq/L\n 5.9 mEq/L\n 42 mg/dL\n 102 mEq/L\n 141 mEq/L\n 25.3\n 12.1 K/uL\n [image002.jpg]\n 11:46 PM\n 08:28 AM\n WBC\n 11.0\n Hct\n 28\n 26.1\n Plt\n 390\n Cr\n 6.9\n Glucose\n 78\n Other labs: PT / PTT / INR:12.5/27.2/1.1, ALT / AST:, Alk Phos / T\n Bili:104/0.2, Lactic Acid:1.3 mmol/L, LDH:132 IU/L, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n s/p R AKA\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n .H/O DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Pt is 67 yo f with hx of DM, ESRD on HD, and leg fracture, now s/p AKA\n of right leg and transferred to in setting of hypotension.\n .\n # Hypotension: BP was in upper 70s in OR, improved from high 80s to low\n 100s with 500ml bolus, bp improved to 90s-119 with bolus and stable\n since. have been secondary to fluid loss during procedure combined\n with sedation medications. Per pt has baseline BP 90-100, likely in\n setting of being HD pt with fistula.\n - pt received HD on , with one episode SBP=70 afterwards, responded\n well to 500 cc bolus of fluids. Will monitor, continuous and/or bolus\n not needed at this time.\n - no need for pressors at this time\n - PICC to be placed for access.\n .\n # Hypoxia: New post-op O2 requirement noticed after surgery, not\n requiring O2 currently with good O2 sats. HD yesterday, planned for\n today to maintain volume status. Pt with no known OSA.\n - HD yesterday and planned for today, \n - oxgygen as needed to keep sats >92%\n - incentive spirometry\n .\n # AKA: s/p surgery, had chonic fracture of femur with broken plate for\n last 3 year. Wheelchair bound.\n - ortho to review femur xray done . Patient emotionally labile in\n regards to losing her right leg.\n - wound care\n - Coumadin 1.5 mg - 2 mg, 2-2.5, x 6 weeks\n - social work consult\n # Pain: Pt c/o leg pain and phantom foot pain. Pt states pain not\n controlled, but vitals within normal range.\n - increase gabapentin as needed within renal dosing guidelines.\n Consider supplemental dose after HD.\n - continue percocet\n - morphine IV PRN for breakthrough pain\n - heat packs/ice packs\n #Fever: up to 100.3 this am with moderate leukocytosis (12.1)\n - blood cx, urine cx\n -incentive spirometry for possible atelectasis- related fever\n .\n # ESRD on HD: Normal HD is MWF, missed regular HD today. Likely the\n reason potassium is elevated. Also would explain edema on CXR. Makes\n some urine output in urostomy bag. Nephro following\n - monitor UO\n - HD planned for today\n - renally dose meds\n .\n # DM on insulin: Long standing DM, complicated by nephropathy,\n neuropathy, and vascular disease\n - lantus (on 8 units), will increase dose as needed with increasing PO\n intake\n - SSI Q6H with humalong\n - gabapentin and ASA and statin\n - start diabetic renal diet today\n .\n # GERD:\n - continue PPI\n .\n # Peripherial vascular disease: has stenosis of right axillary artery,\n s/p 1 month tx of plavix\n - continue statin\n - may need futher plavix tx as out pt\n - continue ASA\n .\n # Hyperkalemia: K likely elevated in setting of renal failure\n - HD today\n - monitor on tele\n .\n # Anemia: hct of 26 today, likely secondary to surgical blood loss and\n baseline anemia secondary to renal failure\n - monitor hct\n - transfuse 1 unit PRBCs today prior to transfer\n .\n # Colostomy:\n - colostomy care\n .\n # Hyperlipidemia:\n - will continue home statin dose\n ICU Care\n Nutrition: normal renal diet\n Glycemic Control: SSI\n Lines:\n 18 Gauge - 09:39 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: stable, can transfer to floor after transfusion\n"
},
{
"category": "ECG",
"chartdate": "2109-05-20 00:00:00.000",
"description": "Report",
"row_id": 233480,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085165,
"text": " 8:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulmonary edema\n Admitting Diagnosis: RIGHT LOWER EXTREMITY FAILED FIXATION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with DM, admitted for AKA, now s/p procedure with hypoxia.\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetes, postoperatively with hypoxia, to evaluate for pulmonary\n edema.\n\n FINDINGS: In comparison with study of , there is increasing\n indistinctness of engorged pulmonary vessels, consistent with the clinical\n impression of elevated pulmonary venous pressure. Atelectatic changes and\n probably small effusions are seen at both bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-05-21 00:00:00.000",
"description": "R FEMUR (AP & LAT) RIGHT",
"row_id": 1085304,
"text": " 3:37 PM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: evaluate for post op changes\n Admitting Diagnosis: RIGHT LOWER EXTREMITY FAILED FIXATION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Do NOT do portable film; patient needs to go downstairs to radiology. 67 year\n old woman with hx of DM, s/p AKA on .\n REASON FOR THIS EXAMINATION:\n evaluate for post op changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Amputation. Assess postoperative change.\n\n Four radiographs of the right thigh demonstrate the patient to be status post\n above-the-knee amputation, new when compared with . Air and surgical\n clips are seen along the surgical bed, unexpected postoperative finding.\n Dense atherosclerotic calcifications are again noted. The right femoral head\n contour is smooth.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-05-20 00:00:00.000",
"description": "R LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT",
"row_id": 1085158,
"text": " 6:54 PM\n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT Clip # \n Reason: HARDWARE REMOVAL\n Admitting Diagnosis: RIGHT LOWER EXTREMITY FAILED FIXATION/SDA\n ______________________________________________________________________________\n FINAL REPORT\n Lower extremity fluoro was performed without radiologist present. One second\n of fluoro time was used. No films submitted.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2109-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581694,
"text": "67 yr old woman s/p R total knee replacement broke her R leg. Had R\n AKA w/removal of hardware . PMH: diabetes, ESRD on HD, PVD/PAD,\n CAD, GERD.\n Problem\n s/p R AKA\n Assessment:\n R stump initial dressing: D&I. HR: 70\ns-80\ns SR no ectopy BP\n 77/45 upon arrival to MICU.\n Action:\n Received 500cc LR bolus\n Response:\n BP remained > 100/systolic after bolus was complete, for the rest of\n the night.\n Plan:\n Continue tele & q 2 hr vs X48 hrs postop\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient usually receives dialysis @ in\n MA (M-W-F @ 0600). Last dialyzed on Sat . Serum K was\n 6.0 on . Intern informed.\n Action:\n Received 30Gm kayexalate.\n Response:\n Unable to draw blood. Intern & resident aware. Blood to be drawn\n pre-dialysis by dialysis RN.\n Plan:\n Hemodialysis Tx today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o phantom limb pain postop. Pain was\n\n on a 1-10 scale\n @ 2040. Again c/o pain @ 0100 which was .\n Action:\n Received 1 mg IV morphine q 30min X3 2040-2130 w/relief of pain, down\n to no pain. Required only 1mg IV morphine X 2 @ 0100& 0115, again\n dropped to no pain.\n Response:\n Reduced pain from to 0/10 w/3mg IV morphine. Reduced pain\n to 0/10 w/2mg IV morphine. As patient is on hemodialysis & over 60yrs,\n she is more sensitive to sedative effects of narcotics.\n Plan:\n Give 1mg IV morphine @ a time. Monitor for sedation.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n FS 118-59. No Sx w/FS 59.\n Action:\n Given 8 units lantus @ HS . Given 120cc apple juice @ midnight for\n FS 78. Given 240cc apple juice @ 0615 for FS 59. Given juice per MICU\n intern & resident to cover FS.\n Response:\n FS\n Plan:\n Advance diet as soon as surgery team says OK.\n"
}
] |
24,812 | 138,436 | Respiratory - The baby initially had some tachypnea with respiratory rates as high as the 70s. He required nasal cannula oxygen for a few hours. Respiratory distress resolved within 24 hours and respiratory rates have been comfortable in the 30s to 60s with clear and equal breath sounds. Oxygen saturations have been greater than 95 percent, and oxygen saturation monitor was discontinued on day of life #4. There has been no evidence of apnea of prematurity. Cardiovascular - APs have ranged from 130s to 140s with pressure 59/39 with a mean of 45 to 71/34 with a mean of 47. There has been no murmur and the baby has remained hemodynamically stable. There was peripheral intravenous access obtained initially which has now been discontinued. Fluids, electrolytes and nutrition - Initial dextrose stick was 38 and intravenous was placed with D10/W at 60 cc/kg/day. Baby was NPO. Was started on feeds at day of life #1 with 40 cc per kilo of premature Enfamil 20. Total fluids have been advanced and currently are at 140 cc/kg of breast milk or premature Enfamil 20 calories. The baby is taking some feeds orally, the remainder is pg. He takes approximately half volume or more p.o. each feed at this time, and needs to continue to improve immature feeding skills. The baby has had normal urine and stool output throughout the hospitalization. Current weight at the time of discharge is 2925 grams. Gastrointestinal - Bilirubin peak was noted to be 9.7/0.3 on day of life #4. Baby is mildly jaundiced on examination. He did not receive phototherapy. Hematologic - Initial white count was 11.3 with 34 polys and 0 bands. Hematocrit was 50.2 percent, and platelets of 281,000. The baby has received no products in this hospitalization. Infectious disease - The baby had cultures which were sent to the laboratory on admission which has remained no growth to date. There have been no antibiotics administered. The baby remains clinically well. Neurologic - The baby was -bedding in an open bed with twin and is maintaining a temperature in open crib. The baby has had a normal neurologic examination. He is appropriate for gestational age. Sensory - Audiology, hearing screen was performed with automated auditory brain stem response and passed bilaterally. Ophthalmology, this baby is not a candidate for an eye examination at this time. | Wakes forfeeds. Sootheswell with pacifier. Will transfer to when bed available.A: Stable. Updated at bedside. Remainder suplementedby gavage. Min aspirates. Wakesfor some feeds. wakes for feeds, a/a withcares, settles well in between, fonts soft/flat, bringshands to mouth, likes pacifier. tosupport nutritional needs.4infant remains swaddled in , cobedding with sibbling,temp. Abdomen soft/round, good bs, V&S (hemenegative).G/D: Temp stable swaddled in , cobedding w/sibling. stable, a/a with cares, settles well in between, fontssoft/flat, brings hands to mouth, likes pacifier. Abdomen soft/round,good bs, V&S (heme negative).G/D: Temp stable swaddled in OAC, cobedding w/sibling. Given Hep B info sheet. PKU sent. Upadated atbedside by this RN, asking appropriate questions. Updated at the bedsideregarding status and plan of care by RN . Nospits, minimal aspirates. Inf had Hep B today. P:cont. P:cont. P:cont.to support nutritional needs.4remains in OAC, temp. NURSING PROGRESS NOTE3. Plan to visit and sign consent. to update. NPN 1900-0700FEN: Attempts to PO Q feed, slightly uncoordinated. Abdomen soft/round, good bs,voiding, no stool thus far.G/D: Temp stable swaddled in OAC cobedding w/sibling. handlethe care well. Mother discharged yesterday.A: Stable. Continue tosupport and keep informed. soft, bs+, no loops, max asp. Offered bottle each time. passed hearing.A/P: Infant working up on PO feeds. States that her milk is starting to come in. visiting. I agree with PCA note and assessment. BS active. Wakes for all feeds. See Checklist. F/NTOLERATING GAVAGE FEEDINGS, VOIDING AND STOOLING.4. I have examined this infant. Bili not yet requiring treatment.A: Stable. LOVING AND INVOLVED.ADDENDUM:COLOR IS JAUNDICED, LAB HOLIDAY TODAY. Transfer packet has been started and consent still needs to be obtained. Improving pos. Support given. stable, occ. Newborn Med AttendingDOL#4. Neonatology NP NotePEswaddled in open cribAFOF, sutures opposedcomfortable respirations in room air, lungs clear/=RRR, no murmur, pink and well perfusedabdomen soft, nontender and nondistended, active bowel soundsactive with good tone. G&DAGA.5. Bili drawn at 1 700 9.7,0.3 up from 9.5, 0.3. Mom D/C'd home today. Neonatology AttendingDOL 7 CGA 35 6/7 weeksExam AF soft, flat, clear bs, no murmur, benign abd, ngt in placeStable in RA. : Both in for most of day. abd. Wt 2855 grams (down 5).Bili 9.7/0.3Hearing screen passed. : Mom in X1, updated at bedside by this RN, askingappropriate questions. Likes hispacifier. Questions answered. Curious.A: Appropriate behavior. Pediatrician will be Dr. at . Needs to learn to feed.P: Monitor Encourage pos as tolerated To when bed available PCA 1900-07003CW 2875g down 30g, TF 140cc/kg/d of PE/BM20=70cc q4h, infantbottling 37-40cc q4h with good coordination and remaindergavaged. Stooling. Stooling. Stooling. P: Continue to supportdevelopmentally needs.Parenting: Both in at 8:00am. P:cont to support growthand development.5 no known contact from thus far this shift. I spoke w/the overnight and they expressed a desire to keep here at and are reluctant to transfer him to . Sucksactively on pacifier, brings hands to face for comfort. P:cont.to support growth and development.5mom and dad called, updated by nurse. V&S (heme negative).G/D: Temp stable swaddled in OAC, cobedding w/sibling. Well staurated and perfused. Stable temp cobedding with sib. Abd benign, vdg and passingmec stools. A: loving concerned family P: cont tosupport, update. Cor nl s1s2 w/o murmurs. PIV--H/L'ed atbeginning of shift and has been flushed and remains patent.Wt is down 100gms=2895.#4Infant remains in an open crib swaddled with boundaries.Temp hs been stable. Both fed and heldinfants. HEENT WNL. Warmer shut offand pt swaddled. A&A w/cares, wakes forsome feeds. Hips normal.Initial BS 38. Now stable in RA. Given BBo2 and stim. Updates given. Skin w/o leisons. Temp stable swaddled on off warmer. NPN#3Infant remains on TF=80cc/k. Infant is voidingand stooling; heme neg. jaundiced-bili sent andpending. DEV O/A remains in an OAC cobedding with histwin, stable temp. Noemesis or aspirates. DS stable 78. Abdomensoft/round, good bs. He isalert and active w/ cares. PCA NoteI have examined pt. & agree w/ PCA's assessment above. V&S (meconium).G/D: Received pt nested on radiant warmer. Sucks eagerly on thepacifier. LS clear/=. Stooling (heme neg). PKU sent. Initial D/S 38 --> recieved 6ccbolus of D10W. NPO at present IVF for maintenance of BS. Neonatology - NNP Progress Note is active with good tone. Clinicla and non-invasive monitroring of resp status. Problem resolved.FEN: Started to PO this shift. All po overnight but needing some pg today. P:Support and update. Low but finite risk of sepsis.P Admit NICU. Lung sounds areclear and equal with mild SC/IC retractions. Update given.They needsome assistance with cares. Rxed with Mag sulfate initially then weaned. Neuro non-focal and age aprpopriate. well, 1 sm, asp thus far. A: Appropriate P: Monitor. Belly soft, no loops.P cont to offer PO's as .4. Nursing Transfer NoteThis infant remains in RA. needingmuch reassurance about infant's bottling. Continue tosupport parents and keep informed. Waking up and demandingfeeds q3 1/2h. visiting and up to date.A: Stable. Beginning feeds. transitional period. Guiac neg stools. MOTHER ADMITTED TO MWH AT END OF WITH same rexd with tocolysis and BMZ. Pt. Nursing Progress Note#3 O: TF inc to 80cc/k/d; prsently has IV D10W infusing atfull amt 80cc/k/d. P: Encourage POfeeds. VitaminK and erythromycin given. Testes descendedbilaterally. NPN Addendum3.FEN: Infant's BW 3005g. Wt 2895 grams (down 100).Temp stable in crib.Bili 5.8/0.3 visiting and up to date.A: Stable. Minimal aspirates. Neonatology-NNP PRogress NotePE: on an open warmer, in room air, bundled, bbs cl=, rrr s1s2no murmur, abd soft, cord drying, tested in scrotum bilatally, afso,active with careSee attending note for plan Anus patent. Resp status precludes feeds so IB bolus D10W givena dn IVF started.A- Well apeparing preterm infant with mild resp distress during transitional period. Sucks pacifier eagerly. Encourage to ask questions andparticipate in care. Mother requesting SW consult.A: TTN resolved. Delivery today for worsening of BP/UA.Prenatal screens complete and unremarkabel.GBS +.IN DR from c-section. Temp wnl in opencrib. Likes pacifier. Patient is stable and ready fortransfer to -SCN. | 40 | [
{
"category": "Nursing/other",
"chartdate": "2177-06-21 00:00:00.000",
"description": "Report",
"row_id": 2012788,
"text": "NPN 1900-0700\n\n\nFEN: Attempts to PO Q feed, slightly uncoordinated. No\nspits, minimal aspirates. Abdomen soft/round, good bs,\nvoiding, no stool thus far.\n\nG/D: Temp stable swaddled in OAC cobedding w/sibling. Wakes\nfor some feeds, sleeps well in between. Loves pacifier!\nBrings hands to face for comfort.\n\n: Mom in X1, updated at bedside by this RN, asking\nappropriate questions. Verbalized being sad about going home\ntomorrow without babies. Started discharge teaching and\npreparing Mom for going home without babies.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-21 00:00:00.000",
"description": "Report",
"row_id": 2012789,
"text": "Newborn Med Attending\n\nDOL#4. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. Bili=9.5. WT=2860 no change, on 100 cc/kg/d BM/PE20 PO/PG. passed hearing.\nA/P: Infant working up on PO feeds. Increase TF to 120 cc/kg/d.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-21 00:00:00.000",
"description": "Report",
"row_id": 2012790,
"text": "I have examined this infant. I agree with PCA note and assessment. Bili drawn at 1 700 9.7,0.3 up from 9.5, 0.3. Inf had Hep B today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-21 00:00:00.000",
"description": "Report",
"row_id": 2012791,
"text": "NICU NURSING PROGRESS NOTE:\nFEN.O: TF increased to 120cc/k/d of BM20 or E20, 60cc Q4\nhrs. Offered bottle each time. Bottling slightly\nuncoordinated, taking between 30-45cc. Remainder suplemented\nby gavage. Abd exam is soft, no loops. BS active. No spits.\nVoiding and stooling. Min aspirates. A: Tolerating feeds.\nP: Continue to encourage PO feedings.\n\nG/D.O: is cobedding with his twin sister in open crib.\nMaintaining temps. Active and alert with cares. Wakes for\nfeeds. Sleeps peacefuly in between cares. Likes his\npacifier. Curious.\nA: Appropriate behavior. P: Continue to support\ndevelopmentally needs.\n\nParenting: Both in at 8:00am. Updated at the bedside\nregarding status and plan of care by RN . Dad\ndid temp and diaper, then he bottled . handle\nthe care well. Later in the evening called to toget\nupdated on twins. Loving and involving . Continue to\nsupport and keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-22 00:00:00.000",
"description": "Report",
"row_id": 2012792,
"text": "NPN 1900-0700\n\n\nFEN: Attempts PO Q feed, taking approximately half of needed\nvolume. No spits, minimal aspirates. Abdomen soft/round,\ngood bs, V&S (heme negative).\n\nG/D: Temp stable swaddled in OAC, cobedding w/sibling. Wakes\nfor some feeds. A&A w/cares, sleeps well in between. Soothes\nwell with pacifier.\n\n: No contact thus far. Mom D/C'd home today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-22 00:00:00.000",
"description": "Report",
"row_id": 2012793,
"text": "Neonatology Attending\n\nDOL 5 CGA 35 4/7 weeks\n\nStable in RA. No A/B.\n\nBP 71/34 mean 47\n\nOn 120 cc/kg/d BM/PE 20 ~ po. Voiding. Stooling. Wt 2855 grams (down 5).\n\nBili 9.7/0.3\n\nHearing screen passed. Hep B vaccine given. PKU sent.\n\n visiting. Mother discharged yesterday.\n\nA: Stable. No spells. Improving pos. Bili not needing treatment.\n\nP: Monitor\n Encourage pos as tolerated\n Increase to 140 cc/kg/d\n No further bili checks\n Arrange circ if desire\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-22 00:00:00.000",
"description": "Report",
"row_id": 2012794,
"text": "Nursing Progress Note\nAddendum: Mom stated they do not wish to have .\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-20 00:00:00.000",
"description": "Report",
"row_id": 2012781,
"text": "PCA 1900-0700\n\n\n3\nBW 3005g, CW 2895g, TF 100cc/kg/d of PE/BM20=50cc q4h,\ninfant bottled 35cc and 32cc with good coordiantion\nremainsder gavaged. abd soft, bs+, no loops, max asp 4.4cc,\nno spits, voiding qs, no stool thus far this shift. P:cont.\nto support nutritional needs.\n\n4\nremains in OAC, temp. stable, occ. wakes for feeds, a/a with\ncares, settles well in between, fonts soft/flat, brings\nhands to mouth, likes pacifier. P:cont to support growth\nand development.\n\n5 no known contact from thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-20 00:00:00.000",
"description": "Report",
"row_id": 2012782,
"text": "NPN 1900-0700\nI have examined this infant and agree with note and assessment of PCA, .\n\nWill draw state screen and a bili level with next cares.\n\nMom was in to visit briefly during the night. Updated at bedside. Is pumping. States that her milk is starting to come in. Would like to try to pump babies to breast today. Given Hep B info sheet. Has a family meeting today at 1330. Will sign consent for hep B and state screen after family meeting when dad is here.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-20 00:00:00.000",
"description": "Report",
"row_id": 2012783,
"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 good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-20 00:00:00.000",
"description": "Report",
"row_id": 2012784,
"text": "Neonatology Attending\n\nDOL 3 CGA 35 3/7 weeks\n\nStable in RA. No A/B.\n\nOn 100 cc/kg/d BM/PE20. Requiring some gavage feeds. Taking 32-36 cc of 50 cc feed. Voiding. Stooling. Wt 2860 grams (down 35).\n\nBili 9.5/0.3\n\nStable temp in crib.\n\nFamily visiting. Family meeting today at 1:30. Bili not yet requiring treatment.\n\nA: Stable. Needs to learn to feed.\n\nP: Monitor\n Encourage pos as tolerated\n Family meeting today\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-20 00:00:00.000",
"description": "Report",
"row_id": 2012785,
"text": "Neonatology Attending--Family Meeting\n\nHad family meeting with both , NNP , RN, Shealeagh SW and myself to discuss status, plans and discharge criteria. Questions answered. Support given. Pediatrician will be Dr. at .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-20 00:00:00.000",
"description": "Report",
"row_id": 2012786,
"text": "Neonatology NP Note\nFamily meeting held with Dr. , , RN, SW, myself and both .\nDiscussed: events leading to delivery, excellent progress thus far, need for maturation of feeding skills prior to discharge, adjustment after mom discharged from hospital. See Checklist.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-20 00:00:00.000",
"description": "Report",
"row_id": 2012787,
"text": "NURSING PROGRESS NOTE\n\n\n3. F/N\nTOLERATING GAVAGE FEEDINGS, VOIDING AND STOOLING.\n4. G&D\nAGA.\n5. SOCIAL\nFAMILY MEETING TODAY. LOVING AND INVOLVED.\nADDENDUM:\nCOLOR IS JAUNDICED, LAB HOLIDAY TODAY.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-23 00:00:00.000",
"description": "Report",
"row_id": 2012801,
"text": "Neonatology-NNP Progress Note\nPE: remains in his open crib, cobedding with hjis sister, in room air, bbs cl=, rrr s1s2no murmur, abd soft, nontender, V&S, gavage tube in place, active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-24 00:00:00.000",
"description": "Report",
"row_id": 2012802,
"text": "PCA 1900-0700\n\n\n3\nCW 2875g down 30g, TF 140cc/kg/d of PE/BM20=70cc q4h, infant\nbottling 37-40cc q4h with good coordination and remainder\ngavaged. abd. soft, bs+, no loops, max asp. 1.0cc, no\nspits, voiding qs, no stool thus far this shift. P:cont. to\nsupport nutritional needs.\n\n4\ninfant remains swaddled in , cobedding with sibbling,\ntemp. stable, a/a with cares, settles well in between, fonts\nsoft/flat, brings hands to mouth, likes pacifier. P:cont.\nto support growth and development.\n\n5\nmom and dad called, updated by nurse. P:cont. to update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-24 00:00:00.000",
"description": "Report",
"row_id": 2012803,
"text": "NPN 1900-0700\nI have examined this infant and agree with the assessment and plan of care as outlined by , PCA. I spoke w/the overnight and they expressed a desire to keep here at and are reluctant to transfer him to . were reassured about the level and quality of care at that facility and it was suggested that they tour the facility this morning if possible. Transfer packet has been started and consent still needs to be obtained.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-24 00:00:00.000",
"description": "Report",
"row_id": 2012804,
"text": "Neonatology Attending\n\nDOL 7 CGA 35 6/7 weeks\n\nExam AF soft, flat, clear bs, no murmur, benign abd, ngt in place\n\nStable in RA. No A/B.\n\nBP 63/41 mean 56\n\nOn 140 cc/kg/d BM/PE 20 taking ~ po. Voiding. Stooling. Wt 2875 grams (down 30).\n\nCobedding with sister.\n\n visiting and up to date. Sister is going home today. Will transfer to when bed available.\n\nA: Stable. Needs to learn to feed.\n\nP: Monitor\n Encourage pos as tolerated\n To when bed available\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-24 00:00:00.000",
"description": "Report",
"row_id": 2012805,
"text": "NPN 0700-1900\n\n\nFEN: Learning to PO feed, attempts w/each feeding. BF X1 and\ndid excellent! Abdomen soft/round, good bs, V&S (heme\nnegative).\n\nG/D: Temp stable swaddled in , cobedding w/sibling. A&A\nw/cares, sleeps well in between. Wakes for all feeds. Sucks\nactively on pacifier, brings hands to face for comfort.\n\n: Both in for most of day. Upadated at\nbedside by this RN, asking appropriate questions. Did lots\nof discharge teaching, taking sibling home today.\nDiscussed transferring to , consented but a\nlittle apprehensive. Plan to visit and sign consent.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-24 00:00:00.000",
"description": "Report",
"row_id": 2012806,
"text": "CPR Class Note\n\nO: Both took CPR class today. Please see note in Girl, twin 1, chart for details of class.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-17 00:00:00.000",
"description": "Report",
"row_id": 2012772,
"text": "NPN Addendum\n\n\n3.FEN: Infant's BW 3005g. Infant is currently on IVF @\n60cc/kg/day of D10W via PIV in right hand. PIV is infusing\nwell without incident. Initial D/S 38 --> recieved 6cc\nbolus of D10W. Follow-up D/S 86, then 93. Infant offered\nbottle NNP order, took 7cc of PE 20cal/oz. Abdomen is\nsoft and round with active bowel sounds, no loops. He is\nvoiding (1.1cc/kg/hr x 6hrs), no stool. Continue to monitor\nFEN status, weight gain, and D/S.\n\n4.DEV: Infant nested on radiant warmer with environmentally\nunstable temps, warmer adjusted as appropriate. Infant is\nalert and active, drowsy at times. Testes descended\nbilaterally. Mongolian spot present on sacral area.\nFontanels soft and flat with approximated sutures. Vitamin\nK and erythromycin given. Continue to support growth and\ndevelopment.\n\n5.Social: Dad in to visit with infant. Mother called\nseveral times for updates. Parents are loving and\nappropriate, asking appropriate questions. Continue to\nsupport parents and keep informed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-18 00:00:00.000",
"description": "Report",
"row_id": 2012776,
"text": "Nursing Progress Note\n\n\n#3 O: TF inc to 80cc/k/d; prsently has IV D10W infusing at\nfull amt 80cc/k/d. Bottled 20cc this morning but only 10cc\nat second feed. DS stable 78. Abd benign, vdg and passing\nmec stools. starting to get sl. jaundiced-bili sent and\npending. A: slow po feeds P: bottle as , need to\nplace feeding tube if not bottling well. wean IV as .\n#4 O: alert w/cares, waking on own but not staying awake for\nfeeding. Temp stable swaddled on off warmer. pacifier to\nsettle.P: move to crib pending bili results/need for\nphototx. bottle as \n#5 O: dad in this morning, later again w/mom. \nupdated in full re: what baby needs to do to go home, aware\nthat there is good chance he will not be ready for d/c when\nmom goes home on Sat. A: loving concerned family P: cont to\nsupport, update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-19 00:00:00.000",
"description": "Report",
"row_id": 2012777,
"text": "NPN\n\n\n#3\nInfant remains on TF=80cc/k. Infant continues to take all\nfeedings by bottle and has taken ~35-40cc of PE20 q4 hours.\nAbd is soft and round; voiding and stooling. PIV--H/L'ed at\nbeginning of shift and has been flushed and remains patent.\nWt is down 100gms=2895.\n\n#4\nInfant remains in an open crib swaddled with boundaries.\nTemp hs been stable. Infant is alert with cares; waking\n~3-4 hours and appears to be hungry. Sucks eagerly on the\npacifier. Bottles well initially; tires easily and needs\nencouragement to finish.\n\n#5\n were up last evening for cares. Dad took temp and\nchanged the diaper. Very appropriate with infant. Bottled\ninfant and talking to him. Both are hoping infants\ncan go home with mom on Saturday. are aware that\nthey need to bring car seats in for testing. do not\nwant infant to have a circumcision.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-19 00:00:00.000",
"description": "Report",
"row_id": 2012778,
"text": "Neonatology Attending\n\nDOL 2 CGA 35 1/7 weeks\n\nStable in RA. No A/B.\n\nBP 62/34 mean 48\n\nOn 80 cc/kg/d PE/BM20 po. IV heplocked at 9 pm last night. Just taking minimum (slowing down at end of feed). Voiding. Stooling. DS 82. Wt 2895 grams (down 100).\n\nTemp stable in crib.\n\nBili 5.8/0.3\n\n visiting and up to date.\n\nA: Stable. Just taking minimum.\n\nP: Monitor\n Increase to 100 cc/kg/d\n Family meeting tomorrow at 1:30\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-19 00:00:00.000",
"description": "Report",
"row_id": 2012779,
"text": "Neonatology-NNP Progress Note\n\nPE: remains in his open crib, in room air, bbs cl=, rrr s1s2no murmur,abd soft, nontender, V&S, afso, activew ithcare\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-19 00:00:00.000",
"description": "Report",
"row_id": 2012780,
"text": "NPN 7a-7p\n\n\n3) TF increased to 100cc/kg/day. Ng placed r/t unable to\nmake min. Infant needed a gavage this aft. after bottling.\nbottling 35-50cc of PE 20 every 4 hours. Abdomen soft and\nbenign. voiding and stooling. continue to asess.\n4) infant alert and active with cares. Waking for feedings.\nSleeping well between swaddled in an open crib. temps\nstable. Loves pacifier. Color jaundiced. Bili increased to\n8.5 and 0.3 this aft. continue to support dev.needs.\n5) in to visit with cares. Update given.They need\nsome assistance with cares. Both fed and held\ninfants. Family meeting scheduled for 1:30 pm tomorrow.\nContinue to keep them well informed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-18 00:00:00.000",
"description": "Report",
"row_id": 2012773,
"text": "NPN 1900-0700\n\n1 Infant with Potential Sepsis\n2 Respiratory\n\nRESP: RA, LS C/=, no retractions, no increased work of\nbreathing. No spells, not on caffeine. Problem resolved.\n\nFEN: Started to PO this shift. Attempted X2 with better\ncoordination the 2nd time. D10 infusing via PIV in right\nhand. Abdomen soft/round, good bs. V&S (meconium).\n\nG/D: Received pt nested on radiant warmer. Warmer shut off\nand pt swaddled. Temp remains stable. A&A w/cares, wakes for\nsome feeds. Loves sucking on pacifier and brings hands to\nmouth for comfort.\n\nPARENTS: Dad in several times, updated by this RN. Mom in X1\non way downstairs to room from L&D. She too was updated by\nthis RN. Plan to visit in AM.\n\nPlease see Parent/Social note on #1, for\nadditional information regarding family.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n 2 Respiratory; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-18 00:00:00.000",
"description": "Report",
"row_id": 2012774,
"text": "Neonatology Attending\n\nDOL 1 CGA 35 weeks\n\nRequired O2 yesterday for 5 hrs. Now stable in RA. Sats 97-100%. R 40s-60s.\n\nNo murmur. BP 59/39 mean 45\n\nOn 60 cc/kg/d with IV D10W. Feeding 4-20 cc q feed. Voiding. Stooling. Wt 2995 grams (down 10).\n\nCBC and BC done. wbc 11.4 (36P/0B) hct 50.2 plt 281 No antibiotics.\n\nStable temp in off warmer.\n\nParents visiting and up to date. They are anxious re whether babies will be discharged with mother. Mother requesting SW consult.\n\nA: TTN resolved. Beginning feeds. Ruling out for sepsis off antibiotics.\n\nP: Monitor\n Increase to 80 cc/kg/d\n Feed as tolerated\n Check bili\n Family meeting soon\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-18 00:00:00.000",
"description": "Report",
"row_id": 2012775,
"text": "Neonatology-NNP PRogress Note\n\nPE: on an open warmer, in room air, bundled, bbs cl=, rrr s1s2no murmur, abd soft, cord drying, tested in scrotum bilatally, afso,active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-17 00:00:00.000",
"description": "Report",
"row_id": 2012770,
"text": "Neonatology\nPatient is 3005 gram product of 34 wk twin gestation born to 36 yo G^ P2 WOMAN WHOSE PREGANNCY WAS COMPLICATED BY PIH AND PTL. MOTHER ADMITTED TO MWH AT END OF WITH same rexd with tocolysis and BMZ. Transferred to at 34 weeks. Rxed with Mag sulfate initially then weaned. Monitoried in house. Delivery today for worsening of BP/UA.\n\nPrenatal screens complete and unremarkabel.\nGBS +.\n\nIN DR from c-section. Apgars 8,9. Given BBo2 and stim. Brought to NICU after visting with parents.\n\nOn exam pink active non-dysmorphic infant. Well staurated and perfused. Skin w/o leisons. HEENT WNL. Cor nl s1s2 w/o murmurs. Lungs clear, mild tachypnea. Generally comfortable apepaRING. Abdomen benign. GEnitalia nl preemie male. Testes high in canals bilaterally. Anus patent. Spine intact. Neuro non-focal and age aprpopriate. Hips normal.\n\nInitial BS 38. Resp status precludes feeds so IB bolus D10W givena dn IVF started.\n\nA- Well apeparing preterm infant with mild resp distress during transitional period. transitional period. Most likely possibility is RFLF although mild HMD a possibility. Low but finite risk of sepsis.\n\nP Admit NICU.\n Clinicla and non-invasive monitroring of resp status.\n NPO at present\n IVF for maintenance of BS.\n CBC diff, BC, no abx unless cbc abnormal or sx develop.\n Close monitoring of BS\n Usual attention to metabolic issues and bili.\nParents aware of status and p[.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-22 00:00:00.000",
"description": "Report",
"row_id": 2012795,
"text": "Nursing Progress Note\n\n\n3. FEN O/A TF incr today to 140cc/kg/day of BM or PE20.\nInf PO/PG, being offerred PO q feeding. well, 1 sm\n, asp thus far. Mom put inf to breast, inf showed\nno interest. Inf voiding, stooling. Belly soft, no loops.\nP cont to offer PO's as .\n4. DEV O/A remains in an OAC cobedding with his\ntwin, stable temp. Likes pacifier. P cont to assess dev\nneeds.\n5. O/A Mom and Dad in for visit and cares with 2\nolder sisters. Updates given. Family participated in care\nof twins. P support, educate.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-22 00:00:00.000",
"description": "Report",
"row_id": 2012796,
"text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. No spells. He is tolerating po/pg feeds of E20/breast milk. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp cobedding with sib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-23 00:00:00.000",
"description": "Report",
"row_id": 2012797,
"text": "NPN 1900-0700\n\n\nFEN: Tolerating PO/PG feeds well, no spits or aspirates.\nSlightly uncoordinated w/bottles, tires easily. Abdomen\nsoft/round, good bs. V&S (heme negative).\n\nG/D: Temp stable swaddled in OAC, cobedding w/sibling. Wakes\nfor all feeds, sleeps well in between. Loves pacifier!\nBrings hand to face for self-comfort.\n\n: No contact thus far.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-23 00:00:00.000",
"description": "Report",
"row_id": 2012798,
"text": "Neonatology Attending\n\nDOL 6 CGA 35 5/7 weeks\n\nStable in RA. No A/B.\n\nOn 140 cc/kg/d BM/PE 20 ~ po. Voiding. Stooling. Wt 2905 grams (up 20).\n\nHearing screen passed. PKU sent. Hep B vaccine given.\n\n visiting and up to date.\n\nA: Stable. Needs to learn to feed.\n\nP: Monitor\n Start iron and trivisol\n Encourage pos\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-23 00:00:00.000",
"description": "Report",
"row_id": 2012799,
"text": "PCA Note\n\n\nFEN: TF 140cc/k/d of BM/PE20 = 70cc Q4 PO/PG. Infant\nbottling 43-50cc thus far. Tolerating feeds well; no spits.\nAbd. soft, round, +BS bilat., no loops. Infant is voiding\nand stooling; heme neg. Minimal aspirates. Continue to\nencourage PO's.\n\nDEV: Infant swaddled and cobedding with twin sister in .\nTemps remain stable. Alert and active with cares. MAE.\nWaking for feeds and remains calm and quiet when awake.\nEnjoys his pacifier. Tires with feeding. Continue to\nsupport developmental needs.\n\nSOCIAL: Mom and dad in this afternoon. Mom held infant.\nBoth asking appropriate questions about infant's progress.\nEager for to be discharged. Dad has a strong\npersonality and seems to be dominant over mom. needing\nmuch reassurance about infant's bottling. Will continue to\nsupport and update as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-23 00:00:00.000",
"description": "Report",
"row_id": 2012800,
"text": "PCA Note\nI have examined pt. & agree w/ PCA's assessment above. In addition notified of possible transfer to hospital since sister will be going home tomorrow & hospital will be more convenient for them. will be in tomorrow & want to discuss this w/ the attending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-17 00:00:00.000",
"description": "Report",
"row_id": 2012771,
"text": "NPN \n\n1 Infant with Potential Sepsis\n2 Respiratory\n3 FEN\n4 DEV\n5 Social\n\n1.Sepsis: CBC with Differential and blood culture drawn and\nsent. CBC not shifted. Please see laboratory for details.\nInfant remains free of overt signs and symptoms of sepsis.\nContinue to monitor for s/s of sepsis.\n\n2.Resp: Infant admitted to NICU in RA, remained so for 2\nhours, then placed in NC at 1200 noon for 02 sats< 95%.\nInfant currently in NC 25-50cc, Fi02 100%. Lung sounds are\nclear and equal with mild SC/IC retractions. RRs 40s-80s,\n02 sats> 91%. No spells thus far this shift. Continue to\nmonitor respiratory status.\n\n\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Respiratory; added\n Start date: \n 3 FEN; added\n Start date: \n 4 DEV; added\n Start date: \n 5 Social; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-25 00:00:00.000",
"description": "Report",
"row_id": 2012807,
"text": "3. FEN O: Abdomen soft and round, assessment unremarkable.\nTaking 70cc BM 20 po q4h. Eager suck with good seal.\nNippled well,needing a little more encouragement with last\n10cc of feeding. Waking up 1/2h before feeding due. No\nemesis or aspirates. Voiding and stooling with diaper\nchanges. Guiac neg stools. Current wgt: 2.925 ^50g. A:\nNippled well on nights. Tolerating feeds. P: Encourage PO\nfeeds. Monitor for feeding intolerance. Consider ad lib\nfeeds if infant continues to nipple well and demanding\nfeeds.\n4. G&D O: Active and alert. Waking up and demanding\nfeeds q3 1/2h. Sucks pacifier eagerly. Temp wnl in open\ncrib. A: Appropriate P: Monitor. Comfort measures.\n5. SOCIAL O: No social contact thus far this shift. P:\nSupport and update. Encourage to ask questions and\nparticipate in care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-25 00:00:00.000",
"description": "Report",
"row_id": 2012808,
"text": "Neonatology Attending\n\nDOL 8 CGA 36 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 70/33 mean 50.\n\nOn 140 cc/kg/d BM 20. All po overnight but needing some pg today. Voiding. Stooling (heme neg). Wt 2925 grams (up 50).\n\n up to date. Sib went home yesterday. No beds available at .\n\nA: Stable. Needs to learn to feed.\n\nP: Monitor\n Encourage pos\n To when bed available\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-06-25 00:00:00.000",
"description": "Report",
"row_id": 2012809,
"text": "Nursing Transfer Note\n\n\nThis infant remains in RA. RR ~30-50's. No increase work\nof breathing noted. LS clear/=. No A&B's noted. He is\npink/slightly jaundiced, warm and well perfused. HR\n~130-140's. No murmur. BP 70/33-50. Birth weight 3005gms.\nCurrent weight 2925gms (+50). TF 140cc/kg/d of BM20 =70cc Q\n4hrs. He is takeing PO/PG feeds. Pt. took ~50cc PO x2\ntoday with the remainder gavaged each time. Abdomen is\nsoft, pink, +BS, no loops/spits noted. He is voiding/\npassing stool well. Temps stable in an open crib. He is\nalert and active w/ cares. Patient is stable and ready for\ntransfer to -SCN. are aware of this plan\nand consent to transfer is signed in chart.\n\n\n"
}
] |
15,471 | 163,559 | The patient was admitted to the Medical Intensive Care Unit on the 18th, had gotten 2 units of packed red blood cells with stable hematocrit thereafter with no further episodes of bleeding. Was transferred to the floor for observation overnight before discharge on . The patient received intravenous hydration with hematocrit drifting down to the low 30s, but no further episodes of bright red blood per rectum. | SUPINE AND UPRIGHT ABDOMEN, TWO VIEWS: The bowel gas pattern is within normal limits. Assess for free air and ischemic bowel. The remainder of the mesentery surrounding the large intestine appears normal. Lungs clear to aus.LINES: functional #18 each antec.ID: 99.2 po. Abd soft, dis with +BS. Free air FINAL REPORT HISTORY: Lower GI bleed. MICU NSG PROG NOTE: AM'SRemains stable s/p gi bleed. Mild sigmoid and descending colon diverticulitis without abcess or free fluid. Sinus tachycardiaSlight precordial T wave notching -is nonspecific - could be within normallimitsSince previous tracing of : slight T changes present LS clear bil. The small bowel appears grossly normal. On abx for abd infection.ASSESS: stable s/p gi bleed. 1:23 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: ? There is a 1cm retroperitoneal lymph node. The mediastinal structures are within normal limits. HCT pnd. Free air, signs of ischemic bowel FINAL REPORT HISTORY: Lower GI bleed, abdominal pain. The pancreas and spleen are normal. IMPRESSION: Unremarkable chest. 1:23 AM CHEST (SINGLE VIEW) Clip # Reason: ? Pt received barrium sulfate x3 at bedside.Skin: Intact.Plan: cont supportive care and update pt and family on planof care..... The adrenal glands are normal. No pneumatosis is appreciated. IMPRESSION: 1. 82 nsr, 110/59.RESP: briefly on nc for anemia, now sats 98% on room air. CT ABDOMEN AFTER IV CONTRAST: There is dependent atelectasis at the lung bases. The heart is normal in size. SPO2 97-99%. Good wt bearing and steady on feet.CARDIAC: stable. Pt currently NPO. The liver is normal. The gallbladder has been removed and clips are seen within the gallbladder fossa. 7p-7a Nursing Note:Please see carevue for objective data:Neuro: Pt A/O X3. Last stool 0730. The kidneys are equal in size and shape and show equal uptake and excretion of IV contrast. Coronal reformats are constructed. Assess for free air. The coronal reformats confirm the above findings. There are clips in the right upper quadrant from prior cholecystectomy. Tol well. No cought or resp distress noted. (2 units prbc this am). AP UPRIGHT CHEST, ONE VIEW: There are no prior studies available for comparison. TECHNIQUE: Helically acquired CT images are obtained through the abdomen and pelvis after 150 cc Optiray nonionic IV contrast. Seen by GI. NPO. NPO. The lungs are clear. recommending surgical consult.PAIN: demerol 25mg x2 today for good pain control.NEURO: intactACTIVITY: not orthostatic, got oob to chair x 1 1/2 hr. NBP 90-110's/40-60's. No evidence of active bleeding presently.VSS. No suspicious lytic or blastic lesions are seen within the osseous structures. GAS. ABG in night, see carevue.CV: Tele: NSR without ectopy. 2 PIV's in place and receiving NS @125cc/hr. Has significantly less abd pain/cramping since am but still requesting infrequent pain med for abd. Pt scheduled for CT of abd and pelvis with contrast this am to R/O ischemic colitis. No destructive bony lesions are seen. There are no pleural effusions. HR 80-90's. CT PELVIS AFTER IV CONTRAST: The enteric contrast is seen within the large bowel. MAE. There is no bone destruction or free air seen below the diaphragms. There is subtle stranding and thickening along the sigmoid colon and a more focal area of stranding is seen along the descending colon (series 2, image 38). 2. Surgical consult. Pt assists with turning. Optiray was infused at less than the 2.5 cc/sec as dictated by protocol because the patient has had prior episodes of emesis following the infusion of nonionic contrast. IMPRESSION: No radiographic evidence of bowel ischemia or free air. There are no dilated loops of small or large bowel or evidence of free intraperitoneal air. Pt cont with GI bleed, voiding dark bloody mucous stool x2. No evidence of ischemic bowel. Pt has family and will be in today.Resp: Maintained on RA. Abdominal pain. There are no pelvic masses or enlarged of the lymph nodes. The bladder is collapsed. Multiple diverticula throughout the large intestine. For surgical consult tomorrow re: resection for infection/diverticulitis/gi bleed.ROS:GI: Has received total 3 u prbc since admission. Potential for further bleeding.PLAn: monitor hct. There is no free air or ascites. Pt received 1L NS over 60min for SBP in 90's.GI/GU: Pt adm with GI bleed and to nuclear med last night for emergent abd bleed. There are innumerable diverticula throughout the large intestine. Pt medicated with 50mg IV fentanyl as mentioned above for abd cramping and pain. hct bumped from 26 to 32. 7:38 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: ?ischemic bowel Field of view: 40 Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 50 year old woman with LGI bleed, pain REASON FOR THIS EXAMINATION: ?ischemic bowel No contraindications for IV contrast FINAL REPORT INDICATION: Lower GI bleed and lower abdominal pain. | 6 | [
{
"category": "Radiology",
"chartdate": "2115-02-24 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 779793,
"text": " 7:38 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: ?ischemic bowel\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with LGI bleed, pain\n REASON FOR THIS EXAMINATION:\n ?ischemic bowel\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lower GI bleed and lower abdominal pain.\n\n TECHNIQUE: Helically acquired CT images are obtained through the abdomen and\n pelvis after 150 cc Optiray nonionic IV contrast. Optiray was infused at less\n than the 2.5 cc/sec as dictated by protocol because the patient has had prior\n episodes of emesis following the infusion of nonionic contrast.\n\n Coronal reformats are constructed.\n\n CT ABDOMEN AFTER IV CONTRAST: There is dependent atelectasis at the lung\n bases. The liver is normal. The gallbladder has been removed and clips are\n seen within the gallbladder fossa. The pancreas and spleen are normal. The\n adrenal glands are normal. The kidneys are equal in size and shape and show\n equal uptake and excretion of IV contrast. There is a 1cm retroperitoneal\n lymph node.\n\n CT PELVIS AFTER IV CONTRAST: The enteric contrast is seen within the large\n bowel. The small bowel appears grossly normal. There are innumerable\n diverticula throughout the large intestine. There is subtle stranding and\n thickening along the sigmoid colon and a more focal area of stranding is seen\n along the descending colon (series 2, image 38). The remainder of the\n mesentery surrounding the large intestine appears normal. There is no free air\n or ascites. The bladder is collapsed. There are no pelvic masses or enlarged\n of the lymph nodes. No suspicious lytic or blastic lesions are seen within the\n osseous structures.\n\n The coronal reformats confirm the above findings.\n\n IMPRESSION:\n 1. Multiple diverticula throughout the large intestine. Mild sigmoid and\n descending colon diverticulitis without abcess or free fluid.\n 2. No evidence of ischemic bowel.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-24 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 779784,
"text": " 1:23 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ? Free air, signs of ischemic bowel\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with LGI bleed, pain\n REASON FOR THIS EXAMINATION:\n ? Free air, signs of ischemic bowel\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lower GI bleed, abdominal pain. Assess for free air and ischemic\n bowel.\n\n SUPINE AND UPRIGHT ABDOMEN, TWO VIEWS: The bowel gas pattern is within normal\n limits. There are no dilated loops of small or large bowel or evidence of free\n intraperitoneal air. No pneumatosis is appreciated. There are clips in the\n right upper quadrant from prior cholecystectomy. No destructive bony lesions\n are seen.\n\n IMPRESSION: No radiographic evidence of bowel ischemia or free air. Patient is\n scheduled to have a CT scan of the abdomen and pelvis later today.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-02-24 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 779783,
"text": " 1:23 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: ? Free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with LGI bleed, pain\n REASON FOR THIS EXAMINATION:\n ? Free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lower GI bleed. Abdominal pain. Assess for free air.\n\n AP UPRIGHT CHEST, ONE VIEW: There are no prior studies available for\n comparison. The heart is normal in size. The lungs are clear. There are no\n pleural effusions. The mediastinal structures are within normal limits. There\n is no bone destruction or free air seen below the diaphragms.\n\n IMPRESSION: Unremarkable chest.\n\n"
},
{
"category": "ECG",
"chartdate": "2115-02-23 00:00:00.000",
"description": "Report",
"row_id": 251726,
"text": "Sinus tachycardia\nSlight precordial T wave notching -is nonspecific - could be within normal\nlimits\nSince previous tracing of : slight T changes present\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-24 00:00:00.000",
"description": "Report",
"row_id": 1462959,
"text": "7p-7a Nursing Note:\nPlease see carevue for objective data:\n\nNeuro: Pt A/O X3. MAE. Obeys and follows all commands. Pt assists with turning. Medicated x2 with 50mg IV fentanyl for abd pain with good effect. Pt has family and will be in today.\n\nResp: Maintained on RA. LS clear bil. RR teens-20's. SPO2 97-99%. No cought or resp distress noted. ABG in night, see carevue.\n\nCV: Tele: NSR without ectopy. HR 80-90's. NBP 90-110's/40-60's. 2 PIV's in place and receiving NS @125cc/hr. Pt received 1L NS over 60min for SBP in 90's.\n\nGI/GU: Pt adm with GI bleed and to nuclear med last night for emergent abd bleed. Pt currently NPO. Abd soft, dis with +BS. Pt medicated with 50mg IV fentanyl as mentioned above for abd cramping and pain. Pt cont with GI bleed, voiding dark bloody mucous stool x2. Pt scheduled for CT of abd and pelvis with contrast this am to R/O ischemic colitis. Pt received barrium sulfate x3 at bedside.\n\nSkin: Intact.\n\nPlan: cont supportive care and update pt and family on plan\nof care.....\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2115-02-24 00:00:00.000",
"description": "Report",
"row_id": 1462960,
"text": "MICU NSG PROG NOTE: AM'S\nRemains stable s/p gi bleed. No evidence of active bleeding presently.\nVSS. For surgical consult tomorrow re: resection for infection/diverticulitis/gi bleed.\n\nROS:\n\nGI: Has received total 3 u prbc since admission. (2 units prbc this am). hct bumped from 26 to 32. HCT pnd. Passed large amnt maroon stool through night. Last stool 0730. Has significantly less abd pain/cramping since am but still requesting infrequent pain med for abd. NPO. Seen by GI. recommending surgical consult.\n\nPAIN: demerol 25mg x2 today for good pain control.\n\nNEURO: intact\n\nACTIVITY: not orthostatic, got oob to chair x 1 1/2 hr. Tol well. Good wt bearing and steady on feet.\n\nCARDIAC: stable. 82 nsr, 110/59.\n\nRESP: briefly on nc for anemia, now sats 98% on room air. Lungs clear to aus.\n\nLINES: functional #18 each antec.\n\nID: 99.2 po. On abx for abd infection.\n\nASSESS: stable s/p gi bleed. Potential for further bleeding.\n\nPLAn: monitor hct. due for check midnight. GAS. NPO. Surgical consult.\n"
}
] |
32,412 | 130,271 | 55yoM with AIDS, CD4 count 45 on , last viral load 1,560 p/w fevers, chills, night sweats, cough, and diarrhea, admitted to MICU for diarrha work-up and rule out TB. . 1. Fevers, diarrhea, night sweats: Pt has been on with most recent CD4 count in of 48 and VL 1,560. He has a history of multiple AIDS-defining illnesses including PCP, , and . He came in with a complaint of approximately 2 weeks of fevers & diarrhea. In ED, he was febrile to 104, tachycardic in the 90s-100s. He was given 2L IVF after which his pressures dropped to 80s-90s systolic. Lactate was 1.8 and Cr at baseline. He received an additional 3.5L IVF with SBP rise to 120s, HR 80s. Received levaquin for diarrhea and respiratory symptoms (cough). He defervesced to 100.3 in the ED. Also had nausea but no vomiting, no headache. He was admitted to MICU for rule out TB and GI infectious work up. CXR was negative. CT scan of the chest, abdomen, and pelvis revealed progression of adenopathy in the epicardium, upper abdominal retroperitoneum and epigastrium. Differential diagnosis radiologically included infectious etiology or lymphoproliferative disorder. . Given intermittent (Pt reports history of non-compliance with medication) and prolonged depressed CD4 counts, there was concern for initial manifestation of AIDS-defining lymphoma or malignancy, or TB or other opportunistic infection. Stool cultures, afb smears, PCP smears, ova and parasite evaluations were all performed. Infectious disease team followed the patient throughout his course. Labs still pending are acid fast culture, HISTOPLASMA ANTIGEN, EBV PCR, ASPERGILLUS GALACTOMANNAN ANTIGEN, PARVOVIRUS B19 ANTIBODIES (IGG & IGM), COCCIDIOIDES ANTIBODY, Bartonella hensalae/ IgG/IgM Antibody Panel Pertinent negative results are listed below: -CXR negative -UA clear -cryptococcal antigen negative -pneumocystic jirovecii carinii negative -cyclospora negative -cryptosporidium negative -giardia negative -O&P negative -c. diff negative -acid fast smear - negative x3 - not detected -Legionella urinary antigen negative . 2. Renal failure. Pt has chronic renal failure. He has one kidney; the other kidney was donated to his brother >20 yrs prior. His baseline cr ranges from about 2-2.5, with worsening over previous 2 yrs. UA showed significant proteinuria, no whites. His urine output was maintained. Renal U/S ruled out obstructive uropathy. Possible causes, as per outpatient notes include: FSGS HIV, nephropathy, prior IV heroin use, renal ablation, FSGS kidney donation , membranous nephropathy hepatitis B infection. . 3. HIV - Patient has a history of non-compliance with his medications. He reports he has been taking his for previous 2 months and for 1 out of the last 1.5 years. While in the hospital, patient was maintained on his outpatient therapy and Bactrim prophylaxis for PCP. for prophylaxis was discussed, given patient's most recent CD4 count <50. It was decided that this should be held until blood cultures return negative. It should be started as an outpatient by his primary care physician when all cultures are negative. . 4. Hyponatremia: Sodium 129. Etiologies include hyervolemic, hypovolemic or euvolemic hyponatremia. Pt has little evidence of third spacing to suggest hypervolemia with decreased circulating volume: No dependent edema. No ascites. Pt does have some scattered crackles over lung bases bilaterally. Most likely etiology is hypovolemic hyponatremia. Causes include renal loss and extra-renal losses. Expect Una>20 and FEna>1% with renal etiology. Una 89, Fena calculated at 2.85%, both consistent with renal loss. Given Pt's HIV history with chronic renal failure, HIV nephropathy likely. GI losses could also be contributing given Pt's recent history of diarrhea (expect Una<10 and Fena<1% with GI etiology). Patients sodium corrected with normal saline. . 5. Anemia: Patient's Hct ranged from 28-31. MCV was normal, and iron studies revealed low iron (18), high TIBC (138), high ferritin (1492). Low iron with high ferritin with a normocytic anemia is consistent with anemia of chronic disease. Haptoglobin <20 and retic count 1.0. Low haptoglobin suggests possible hemolytic anemia. Low retic count suggests there might be a hematologic component of the anemia. Differential did not show schistocytes. Etiology can be further pursued by outpatient team. . 6. Metabolic Acidosis: Patient's bicarbonate was 14 with a normal anion gap, consistent with a Non anion gap acidosis. Most likely etiologies are GI losses (given Pt's h/o diarrhea) and RTA (either defective distal H+ secretion or decresed proximal bicarb reabsorption). Acidosis corrected with normal saline. . Full code during admission and time of discharge . The discharge summary was discussed and reviewed in full by medical resident , MD. | Diarrhea X 2. non-productive cough.CV: NSR-ST 91-105. LS essentially cta. Multiple Cx's pnding. Able to at bedside, however, reports dizziness. ID consulted, following.A/P: Fevers/Rigoring- ID consulted. Admitting Diagnosis: FEVER FINAL REPORT (Cont) and seminal vesicles, rectum and sigmoid colon appear unremarkable. CT w/ pul. Received Demerol 12.5mg x3 with good effect for rigors.Resp: LS CTA. Cardiomediastinal silhouette is within normal limits. Received Demerol 12.5mg X 2 for rigors with desired effect.RESP: Room air sats 97-100. nodules, improved from scan. Voiding adeq. Intermittent c/o HA, relieved for short time with Tylenol. hcp is dtr listed in fhpa. continues to have HA, not responsive to tylenol. Coronal and sagittal reformations are provided. Influenza negative. uop good per bedside urinal. sm amt of stool early in shift to commode w/minimal assist. Bibasilar infrahilar opacification is attributable to atelectasis. On antiviral. Did note to desat. Sinus tachycardia. Voiding wnl. A small linear density, likely calcified, could be postoperative (2:67). + BS. TB vs. GI . Sinus rhythm with slowing of the rate as compared with prior tracingof . hr 70-80's nsr w/o ectopy. Denies any CP or cardiac symptoms.RESP: RA. cough. C/O HA and medicated with tylenol which was initiated as an ATC med.CV: NSR with HR 86-96, no ectopy. rr 22-31GI/GU: abd soft, non-distended. draining sm. Febrile from 99-103 responding well to tylenol q 6hrs RTC. Apart from coronary artery calcifications, the heart and pericardium, and central airways, appear unremarkable. Has had freq and almost constant diarrhea. In the left lower lobe, a 3-mm noncalcified nodule is seen (2:39). Mush. no pain reported.cv/resp- bp stable 1teen-120's sys. 3:44 AM CHEST (PORTABLE AP) Clip # Reason: assess for infiltrate, effusion. pt is npo for now. Low CD4 count. Occ. F/U on cx data. A right axillary node that was previously enlarged in , has decreased in size. NPN 7a-7pPlease see carevue and FHP for additional data.Full CodeCrixivan AllergyNeuro: AOx3. Compared to the previous tracingof no diagnostic interim change.TRACING #1 Pan cx in ED .C/V: HR 90s-100s, SR. BP 130s-150s.GI/GU: PO intake without issue but decreased appetite. with Demerol/Tylenol for rigors/fevers. No contraindications for IV contrast FINAL REPORT INDICATION: HIV and CD4 48 on HAART with fevers, chills, and diarrhea. Respiratory Care:Pt seen for sputum induction. There is a 4-mm nodule in the right middle lobe (2:28) with additional tiny noncalcified nodules seen bilaterally in subpleural location (2:24, 26). to mod. IMPRESSION: 1. attributed to flu like sympotms. In , innumerable nodules were present bilaterally, a pattern that has nearly entirely resolved. Cont. Cont. Occasional dry cough. CONTRAST: Oral contrast only. ?probable c/o to medical floor in the am. Awaiting TB/PCP cx data. Pt reports being more sob than baseline, but stable since admit. using urinal to void w/o incident. Evaluate for acute process. Nursing Note: 0700-1900NEURO: A&O X 3; pleasant/cooperative. No abx at this time,likely viral. CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The bladder, distal ureters, prostate (Over) 4:20 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # CT PELVIS W/O CONTRAST Reason: concern for lymphoma, systemic aids-defining illness. Nasal aspirate for flu sent and pnd.ID: Tmax 103.2 PO; receiving Ibuprofen with good effect. Pt has one kidney.ID: only low grades overnight. Awaiting cx data. cath. Mult tests sent and pending. Pleural effusion if present, is not appreciable. admitted to micu for r/o TB and further gi infectious w/u.ROS pt very pleasant and cooperative. The left kidney appears unremarkable. Differential diagnosis includes infectious etiology or lymphoproliferative disorder. CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Allowing for non-contrast technique, the liver, pancreas, and adrenal glands appear unremarkable. Fever and diarrhea. C/O headache and thought to be associated with flu symptoms. Concern for lymphoma systemic age-defining illness. to send stool for multiple studies when available.id- afebrile once in micu, had prev received a gram of tylenol in the er. Normal tracing. Surgical clips are noted in the right upper quadrant. COMPARISON: . COMPARISON: . PA AND LATERAL RADIOGRAPHS OF THE CHEST: Lungs volumes are low; however, the lungs are clear. Sbp 115-140. Linear atelectasis or scarring is present in the right lower lobe, with additional areas of dependent atelectasis bilaterally. IMPRESSION: No acute cardiopulmonary process. cultures drawn and pending from the er.plan f/u on cultures as available. a bit to 95% with exertion, (feet dangling at bedside). The appendix is normal. TECHNIQUE: Axial MDCT images were obtained from the lung apices to the pubic symphysis without intravenous contrast. alert and oriented x3. Slight, nonprod. Transfer note completed. Pt induced for 40min with hypertonic saline. Independent with all. Progression of adenopathy in the epicardium, upper abdominal retroperitoneum and epigastrium. Lungs clear. Needs urine spec-awaiting next void to collect. Remains on respiratory isolation. taking fluids in well, also continued maint ivf x 1 more liter overnight. | 12 | [
{
"category": "Radiology",
"chartdate": "2111-02-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1001544,
"text": " 4:20 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: concern for lymphoma, systemic aids-defining illness.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with hic, cd4 48 on haart with fevers, chills, diarrhea.\n REASON FOR THIS EXAMINATION:\n concern for lymphoma, systemic aids-defining illness.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV and CD4 48 on HAART with fevers, chills, and diarrhea.\n Concern for lymphoma systemic age-defining illness.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung apices to the pubic\n symphysis without intravenous contrast. Coronal and sagittal reformations are\n provided.\n\n CONTRAST: Oral contrast only.\n\n CT CHEST WITHOUT INTRAVENOUS CONTRAST: Mediastinal and hilar lymph nodes are\n numerous, but do not meet CT criteria for pathologic enlargement. There are\n no pathologically enlarged axillary nodes. A right axillary node that was\n previously enlarged in , has decreased in size. A small cluster of\n epicardial nodes measures up to 8 mm in short axis dimension and is increased\n in size. Apart from coronary artery calcifications, the heart and pericardium,\n and central airways, appear unremarkable. Linear atelectasis or scarring is\n present in the right lower lobe, with additional areas of dependent\n atelectasis bilaterally. In the left lower lobe, a 3-mm noncalcified nodule is\n seen (2:39). There is a 4-mm nodule in the right middle lobe (2:28) with\n additional tiny noncalcified nodules seen bilaterally in subpleural location\n (2:24, 26). In , innumerable nodules were present bilaterally, a pattern\n that has nearly entirely resolved. No areas of consolidation or ground- glass\n opacification are identified. There is no pleural or pericardial effusion.\n\n CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Allowing for non-contrast technique,\n the liver, pancreas, and adrenal glands appear unremarkable. There is\n splenomegaly, with the spleen measuring 15 cm. There has been prior right\n nephrectomy with multiple surgical clips in the renal fossa. No masses are\n identified in the nephrectomy bed. A small linear density, likely calcified,\n could be postoperative (2:67). The left kidney appears unremarkable. Numerous\n enlarged lymph nodes are present about the lesser curvature, celiac axis, and\n in the periportal and peripancreatic retroperitoneum. The largest individual\n node measures 2.9 x 1.8 cm (2:52). Review of previous CT of ,\n shows that these nodes have increased uniformly in size and number. There is\n no evidence of bowel obstruction. The appendix is normal. No ascites or free\n intraperitoneal air.\n\n CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The bladder, distal ureters, prostate\n (Over)\n\n 4:20 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: concern for lymphoma, systemic aids-defining illness.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and seminal vesicles, rectum and sigmoid colon appear unremarkable. There are\n no pathologically enlarged pelvic or inguinal lymph nodes.\n\n BONE WINDOWS: No lesions worrisome for osseous metastatic disease are\n identified.\n\n IMPRESSION:\n 1. Bilateral subcentimeter pulmonary nodules could relate to an infectious or\n inflammatory process, but are much improved from prior CT of . No\n pulmonary consolidation to suggest pneumonia.\n\n 2. Progression of adenopathy in the epicardium, upper abdominal\n retroperitoneum and epigastrium. Differential diagnosis includes infectious\n etiology or lymphoproliferative disorder.\n\n 3. Splenomegaly, increased from .\n\n Results discussed with at 8 PM on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-01-31 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1001445,
"text": " 3:35 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with HIV and fever ? source, no cough or significant pulm\n findings\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old with HIV and fever. Evaluate for acute process.\n\n COMPARISON: .\n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: Lungs volumes are low; however, the\n lungs are clear. The pleura surfaces are smooth, with no effusion or\n pneumothorax. Cardiomediastinal silhouette is within normal limits. Surgical\n clips are noted in the right upper quadrant.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1001480,
"text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusion.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with hiv, cd4 count 48, with fevers, diarrhea, cough.\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusion.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:23 A.M. \n\n HISTORY: HIV. Low CD4 count. Fever and diarrhea.\n\n IMPRESSION: AP chest compared to through 23:\n\n Progressive distention of mediastinal veins suggest volume overload also\n responsible for increased cardiac diameter and pulmonary vascular engorgement,\n though there is no clear pulmonary edema. Bibasilar infrahilar opacification\n is attributable to atelectasis. Pleural effusion if present, is not\n appreciable. No pneumothorax.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-01 00:00:00.000",
"description": "Report",
"row_id": 1672690,
"text": "micu nursing admission note\nPt is a lovely 55 yo male w/aids, most recent cd4 ct of 45 on intermittant haart therapy. h/o pcp and cmv pancreatitis presents tonight to the er w/ 1 week of fevers/chills and night sweats, 2 days of diarreah and cough. Fevers to 102 and fatigue as well over past 5 d. Pt received 4l of ivf in the er, bp dropping his bp x1 to the mid 80's. admitted to micu for r/o TB and further gi infectious w/u.\n\nROS\n\n pt very pleasant and cooperative. able to walk from hallway stretcher to bed inside room. alert and oriented x3. hcp is dtr listed in fhpa. no pain reported.\n\ncv/resp- bp stable 1teen-120's sys. hr 70-80's nsr w/o ectopy. pt sats 99% on room air. rr elevated 20's, once settled though he has a rr of 18-22. l/s clear.\n\ngi/gu- reports feeling hungry. pt is npo for now. using urinal to void w/o incident. no stool. to send stool for multiple studies when available.\n\nid- afebrile once in micu, had prev received a gram of tylenol in the er. cultures drawn and pending from the er.\n\nplan f/u on cultures as available. ?probable c/o to medical floor in the am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-03 00:00:00.000",
"description": "Report",
"row_id": 1672696,
"text": "Nursing Progress Note 1900-0700 hours:\n** full code\n\n** allergy: crixin\n\n** access: 2 piv's\n\nPls see admit note/FHP for data and hx\n\nNEURO: A & O x3. Pleasant, cooperative. Able to dangle legs on side of bed 9though at times gets dizzy). Moves self in bed. C/O HA and medicated with tylenol which was initiated as an ATC med.\n\nCV: NSR with HR 86-96, no ectopy. Denies any CP or cardiac symptoms.\n\nRESP: RA. Lungs clear. Occasional dry cough. Does appear as though his breathing is somewhat labored but he verbalized that this has been the case since he has been sick. Sats are 93-99%. rr 22-31\n\nGI/GU: abd soft, non-distended. Has had freq and almost constant diarrhea. + BS. Mushroom cath placed yesterday and remains in place and draining stool-came dislodged when pt stood up to urinate-replaced. voids clear, yellow urine in bottle. Needs urine spec-awaiting next void to collect. Pt has one kidney.\n\nID: only low grades overnight. Cont to follow cx data -needs 2 more TB inductions. Remains on isolation for airborne. Mult tests sent and pending. On antiviral. tylenol atc.\n\nSOCIAL: pt has supports, has girlfriend, children-talks on the phone with them.\n\nPLAN: -Cont to follow cx data\n -R/O TB\n -cont med regimen and icu supportive care\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-01 00:00:00.000",
"description": "Report",
"row_id": 1672691,
"text": "Respiratory Care Note\nNasal Aspirate and Nasal Swab done for respiratory viruses - sent to lab. Pt given neb with 3% hypertonic saline solutions for induced sputum for AFB and PCP. sent to lab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-01 00:00:00.000",
"description": "Report",
"row_id": 1672692,
"text": "Nursing Note: 0700-1900\nNEURO: A&O X 3; pleasant/cooperative. Independent with all. C/O headache and thought to be associated with flu symptoms. Received Demerol 12.5mg X 2 for rigors with desired effect.\n\nRESP: Room air sats 97-100. LS essentially cta. Slight, nonprod. cough. AFB for r/o TB sent; first of 3. Nasal aspirate for flu sent and pnd.\n\nID: Tmax 103.2 PO; receiving Ibuprofen with good effect. Pan cx in ED .\n\nC/V: HR 90s-100s, SR. BP 130s-150s.\n\nGI/GU: PO intake without issue but decreased appetite. Voiding wnl. Diarrhea X 2. Abdominal/chest CT scan done.\n\nENDO: Sliding scale coverage if needed.\n\nDISPO: Full code; called out to but decision made to keep overnight due to increased temp and rigors. Transfer note completed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-02 00:00:00.000",
"description": "Report",
"row_id": 1672693,
"text": "micu npn 1900-0700\nPlease see carevue flowsheet for all objective data\n\nPatient overnight waking up after having night sweats. Febrile from 99-103 responding well to tylenol q 6hrs RTC. taking fluids in well, also continued maint ivf x 1 more liter overnight. uop good per bedside urinal. sm amt of stool early in shift to commode w/minimal assist. demerol x1 for severe rigors at time of night sweats. continues to have HA, not responsive to tylenol. attributed to flu like sympotms. hr and bp have been elevated as temp has been up most of night.\nstable.\nprobable out to medical floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-02 00:00:00.000",
"description": "Report",
"row_id": 1672694,
"text": "Respiratory Care:\nPt seen for sputum induction. Pt induced for 40min with hypertonic saline. Specimen # 2 was obtained and sent to lab. Pt tolerated well, no bronchial spasm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-02 00:00:00.000",
"description": "Report",
"row_id": 1672695,
"text": "NPN 7a-7p\nPlease see carevue and FHP for additional data.\nFull Code\nCrixivan Allergy\n\nNeuro: AOx3. Pleasant,cooperative with care. MAE. Able to at bedside, however, reports dizziness. Intermittent c/o HA, relieved for short time with Tylenol. Received Demerol 12.5mg x3 with good effect for rigors.\nResp: LS CTA. Pt reports being more sob than baseline, but stable since admit. Sats 95-100% on RA. Did note to desat. a bit to 95% with exertion, (feet dangling at bedside). CT w/ pul. nodules, improved from scan. Occ. non-productive cough.\nCV: NSR-ST 91-105. No ectopy noted. Sbp 115-140. LR at 125 an hour for hydration.\nGI/GU: Abd soft, +BS. Mush. cath. draining sm. to mod. amounts of golden, liquid stool. Voiding adeq. amounts of clear, yellow urine.\nSkin: W/D/I.\nID: tmax.102.7 Given Tylenol Q 6hrs,plan to increase dosage order to Q 4hrs. Multiple Cx's pnding. Remains on respiratory isolation. Influenza negative. Awaiting TB/PCP cx data. ID consulted, following.\nA/P: Fevers/Rigoring- ID consulted. TB vs. GI . Awaiting cx data. No abx at this time,likely viral. Cont. with Demerol/Tylenol for rigors/fevers. F/U on cx data. Cont. providing supportive care.\n"
},
{
"category": "ECG",
"chartdate": "2111-02-01 00:00:00.000",
"description": "Report",
"row_id": 114178,
"text": "Sinus rhythm with slowing of the rate as compared with prior tracing\nof . Otherwise, no No diagnostic interval change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2111-01-31 00:00:00.000",
"description": "Report",
"row_id": 114179,
"text": "Sinus tachycardia. Normal tracing. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #1\n\n"
}
] |
32,079 | 148,974 | He was admitted to the Trauma Service. He was transferred to the Trauma ICU for close monitoring. Neurosurgery, Orthopedics and Plastics were consulted given his injuries. Serial head CT scans were followed and remained stable. He was loaded with Dilantin and will continue on this for an additional 4 weeks following discharge. There were no reported seizure activity throughout his hospital stay. He did experience intermittent headaches and initially required IV narcotics. He was later changed to oral pain medications; Fioricet was also added. He will follow up in clinic for repeat head imaging in 1 month. Initially it was felt that his facial fractures would be repaired during this hospital stay. But because of the orbital fracture and concern for cranial nerve injury (II & III), it was recommneded by Opthamology, who were also consulted; that he follow up as an outpatient to make sure that the cranial nerve deficits were resolving. he will come back as an outpatient to clinic for discussions surrounding need for definitive repair of the facial fractures. Orthopedics was consulted for the left wrist and scaphoid fractures; he was taken to the operating room for ORIF of these fractures. There were no intraoperative complications. He will follow up in clinic as an outpatient. He was evaluated by Physical and Occupational therapy and was cleared for discharge to home on HD #7. | There is a longitudinal fracture of the right temporal bone, extending anteriorly along the greater of sphenois adjacent to the inferior orbitalfissure and eventually toward the petrous apex, where it terminates and does not appear to involve the squamous portion of the temporal bone. Nondisplaced ulnar styloid fracture. CT FACIAL BONES WITHOUT IV CONTRAST: Multiple right facial fractures are identified. Lucencies of the distal pole and waist of the scaphoid are concerning for nondisplaced fractures. Mild adjacent edema and mass effect on frontal of right lateral ventricle. Oblique zygomatic fracture, and non-displaced temporal bone fracture. Hemorrhage surrounding right masseter. Right temporal epidural hematoma. There is an oblique fracture of the right zygomatic arch, which appears to involve the zygomaticosphenoid suture. Mutliple left facial fractures separately reported on CT sinus/mandible. Comminuted anterior clinoid process fracture. In addition, there is a suggestion of lucency projecting over the distal pole of the scaphoid as well as at the scaphoid waist, which are concerning for a nondisplaced scaphoid fractures. There is fracture of the anterior clinoid process. Comminuted medial and lateral, anterior and posterior maxillary sinus fractures. IMPRESSION: Unchanged right frontal and temporal epidural hematomas and small subdural hematoma along the tentorium. IMPRESSION: Unchanged right frontal and temporal epidural hematomas. Multiple facial fractures separately reported on CT sinus/mandible. FINAL REPORT (Cont) There are soft-tissue changes in the right tympanic cavity. Extensive facial bone fractures and dense opacification within the right maxillary sinus and ethmoid air cells is unchanged. (Over) 2:26 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: Eval. There is mild surrounding edema and mass effect upon the frontal of the right lateral ventricle. Right frontal epidural hematoma. Right frontal and temporal epidural hematomas are again visualized, measuring 7 mm at the right frontal, and 12 mm at the right temporal site. Mild adjacent edema and mass effect on frontal of right lateral ventricle. Mild adjacent edema and mass effect on frontal of right lateral ventricle. Mild adjacent edema and mass effect on frontal of right lateral ventricle. ISSUES: 1. epidural hematoma 2. multiple facial fx, orbit fx 3. Hemorrhage surrounding right masseter. Hemorrhage surrounding right masseter. Hemorrhage surrounding right masseter. Brimonidine Tartrate 0.15% Ophth. Brimonidine Tartrate 0.15% Ophth. Sedation d/cd, pt Extubated. Epidural hematoma 2. Epidural hematoma 2. Epidural hematoma 2. Comminuted anterior clinoid process fracture. Comminuted anterior clinoid process fracture. Comminuted anterior clinoid process fracture. Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL REPORT (Cont) Neurologic: Extubated and AOx3, NOT narcotized Neuro checks, dilantin Pain: , dilaudid; Cardiovascular on re-presentation tachycardic and normotensive. s/p ORIF of L arm but now with sudden hypoxia and tachycardia. Hemorrhage into right maxillary, sphenoid, ethmoid, and frontal sinuses. Hemorrhage into right maxillary, sphenoid, ethmoid, and frontal sinuses. Hemorrhage into right maxillary, sphenoid, ethmoid, and frontal sinuses. prn dilaudi ivp for breakthrough pain. Chlorhexidine Gluconate 0.12% Oral Rinse 4. Obtaining EKG Pulmonary: extubated, but sudden de-sat with large A-A gradient and tachycardia on floor, OK on NRB, STAT CXr and CTA ?PE. Hypertension- SBP > 130 Action: Q1H neuro exams, repeat Head CT obtained, HOB > 30, prophylactic dilantin. Neurologic: Extubated Neuro checks, dilantin Pain: , dilaudid; . Comminuted non-displaced fracture of the ulnar volar aspect of the lunate. Newly apparent small subdural hematoma layering over the falx. Sedation d/cd, pt Extubated. Sedation d/cd, pt Extubated. Sedation d/cd, pt Extubated. Neurologic: Extubated and AOx3, NOT narcotized Neuro checks, dilantin Pain: , dilaudid; Cardiovascular: nitroprusside as needed to maintain SBP < 130, on re-presentation tachycardic and normotensive. ISSUES: 1. epidural hematoma 2. multiple facial fx, orbit fx 3. Neurologic: Extubated Neuro checks, dilantin Pain: , dilaudid; . Hemorrhage surrounding right masseter. Hemorrhage surrounding right masseter. Hemorrhage surrounding right masseter. prn dilaudi ivp for breakthrough pain. prn dilaudi ivp for breakthrough pain. prn dilaudi ivp for breakthrough pain. Mild adjacent edema and mass effect on frontal of right lateral ventricle. Mild adjacent edema and mass effect on frontal of right lateral ventricle. Mild adjacent edema and mass effect on frontal of right lateral ventricle. OR for LUE repair (ORIF radial fracture) OR for LUE repair (ORIF radial fracture) Brimonidine Tartrate 0.15% Ophth. Brimonidine Tartrate 0.15% Ophth. Hypertension- SBP > 130 Action: Q1H neuro exams, repeat Head CT obtained, HOB > 30, prophylactic dilantin. Hypertension- SBP > 130 Action: Q1H neuro exams, repeat Head CT obtained, HOB > 30, prophylactic dilantin. Hypertension- SBP > 130 Action: Q1H neuro exams, repeat Head CT obtained, HOB > 30, prophylactic dilantin. Epidural hematoma 2. Comminuted anterior clinoid process fracture. Comminuted anterior clinoid process fracture. Comminuted anterior clinoid process fracture. 31 min ------ Protected Section Addendum Entered By: , MD on: 09:25 ------ Chlorhexidine Gluconate 0.12% Oral Rinse 4. Cont to maintain SBP < 130 w/ prn hydralazine. | 42 | [
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032180,
"text": " 2:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval. for fracture, etc.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with trauma\n REASON FOR THIS EXAMINATION:\n Eval. for fracture, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc FRI 5:03 AM\n Right frontal and temporal epidural hematomas. Hemorrhage surrounding right\n masseter. Mild adjacent edema and mass effect on frontal of right\n lateral ventricle. Mutliple left facial fractures separately reported on CT\n sinus/mandible. Hemorrhage into right maxillary, sphenoid, ethmoid, and\n frontal sinuses.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old male who fell 14 feet from a tree.\n\n COMPARISON: Concurrent CT facial bones and CT C-spine, CT torso.\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: Please note that multiple facial fractures are\n better evaluated and separately reported on concurrent CT of the facial bones.\n There is a right frontal epidural hematoma measuring approximately 3.5 x 1.9\n cm in greatest transverse dimension (2:16). There is mild surrounding edema\n and mass effect upon the frontal of the right lateral ventricle. There\n is also a temporal component of the epidural hematoma measuring approximately\n 2.5 x 1.2 cm (2:10). There is a large superficial hemorrhage/hematoma\n overlying the right maxilla, were multiple fractures are identified. There is\n no evidence of subarachnoid hemorrhage or intraventricular hemorrhage.\n\n IMPRESSION:\n 1. Right frontal epidural hematoma. Small amount of air also seen in\n hematoma.\n 2. Right temporal epidural hematoma.\n 3. Multiple facial fractures separately reported and better evaluated on\n concurrent CT facial bones.\n\n Findings posted to ED dashboard at the time of scanning completion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1032181,
"text": " 2:26 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Eval. for fracture, etc.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with trauma\n REASON FOR THIS EXAMINATION:\n Eval. for fracture, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc FRI 4:49 AM\n Multiple right facial fractures, including superior, inferior, lateral, and\n medial orbital fractures. Comminuted medial and lateral, anterior and\n posterior maxillary sinus fractures. Comminuted anterior clinoid process\n fracture. Oblique zygomatic fracture, and non-displaced temporal bone\n fracture. Transverse fracture between teeth 5 and 4. Associated\n hemorrhage into sinues. Discussed with Dr. at 3:20 am\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old male with trauma. Please evaluate for fracture.\n\n COMPARISON: Concurrent CT head, spine as well as torso.\n\n TECHNIQUE: Axial imaging was performed through the facial bones without IV\n contrast. Coronal and sagittal reformations were provided.\n\n CT FACIAL BONES WITHOUT IV CONTRAST: Multiple right facial fractures are\n identified.\n\n There is a longitudinal fracture of the right temporal bone, extending\n anteriorly along the greater of sphenois adjacent to the inferior\n orbitalfissure and eventually toward the petrous apex, where it terminates and\n does not appear to involve the squamous portion of the temporal bone. There\n are comminuted fractures of the lateral, medial, posterior, superior and\n inferior orbital walls. There is associated extraconal retrobulbar air and\n extensive subcutaneous gas. There are soft-tissue changes in the\n superior aspect of orbit indicating hematoma obscuring the superior\n rectus muscle. There is also fracture of the superior orbital ridge which\n extends to the frontal sinus, with hemorrhage in the right frontal sinus.\n A tiny amount of pneumocephalus is seen adjacent to the inner table near\n right frontal sinus. There is fracture of the medial wall, lateral, anterior\n and posterior walls of the maxillary sinus. There is extensive hemorrhage\n within the right maxillary sinus with air also present. There is fracture of\n the anterior clinoid process. There is an oblique fracture of the right\n zygomatic arch, which appears to involve the zygomaticosphenoid suture. There\n is also a fracture of the right maxilla between teeth 4 and 5. No\n discrete tooth fracture is identified. There is no appreciable mandibular\n fracture. There is hemorrhage surrounding the right masseter, as well as\n extensive subcutaneous hemorrhage overlying the right maxilla.\n\n There is subcutaneous emphysema adjacent to left temporal bone in\n the parapharyngeal region. No definite fracture of left temporal\n bone seen.\n (Over)\n\n 2:26 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Eval. for fracture, etc.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There are soft-tissue changes in the right tympanic cavity.\n\n IMPRESSION:\n 1. Multiple right facial fractures, extensively involving the orbital walls\n and maxillary walls.\n 2. Right temporal bone fracture extending toward petrous apex.\n 3. Hemorrhage into right frontal sinus.\n 4. Right-sided fracture of the maxilla between teeth 4 and 5.\n 9. Oblique fracture of the zygomatic arch.\n\n Additional findings of epidural hematoma are made on concurrent head CT\n reported separately. Findings posted to ED dashboard and discussed with Dr.\n at the time of scan completion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1032182,
"text": " 2:26 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval. for fracture, etc.\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with trauma\n REASON FOR THIS EXAMINATION:\n Eval. for fracture, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc FRI 4:51 AM\n No evidence of traumatic injury to C/A/P\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old male with trauma (fell 14 feet out of tree and had\n multiple facial fractures).\n\n COMPARISON: Concurrent CT head, facial bones, and C-spine.\n\n TECHNIQUE: Axial imaging was performed from the thoracic inlet to the pubic\n symphysis following the uneventful administration of IV contrast.\n\n CT CHEST WITH IV CONTRAST: There is no rib fracture or pneumothorax. The\n heart, aorta, and great vessels are unremarkable. The patient is intubated,\n with the endotracheal tube in satisfactory position. A nasogastric tube\n courses into the stomach. The lungs are clear.\n\n CT ABDOMEN WITH IV CONTRAST: There is no splenic or liver laceration. The\n kidneys are unremarkable. The pancreas, adrenal glands, large bowel, and\n small bowel are unremarkable. There is no lymphadenopathy, intra-abdominal\n hemorrhage, or free air.\n\n CT PELVIS WITH IV CONTRAST: The rectum and sigmoid colon demonstrates a\n moderate amount of stool. There is no evidence of bladder injury. There is\n air in the bladder from instrumentation.\n\n The osseous structures are unremarkable, with no evidence of spinal or hip\n fracture.\n\n IMPRESSION:\n\n No evidence of traumatic injury to the chest, abdomen, or pelvis.\n\n Findings discussed with Dr. at the time of scan completion, and\n findings were posted to the ED dashboardc.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1032183,
"text": " 2:34 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA/ 20FT FALL\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 23-year-old male with 20-foot fall.\n\n COMPARISON: None available.\n\n SINGLE TRAUMA VIEW OF THE CHEST: The heart is not enlarged. The\n cardiomediastinal contour is normal. There is no displaced rib fracture or\n pneumothorax. The patient is intubated with ET tube in satisfactory position.\n Osseous structures are unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary process or traumatic injury\n of the chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1032184,
"text": " 2:59 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Eval. for fracture, etc.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with trauma\n REASON FOR THIS EXAMINATION:\n Eval. for fracture, etc.\n ______________________________________________________________________________\n WET READ: RSRc FRI 4:52 AM\n No traumatic injury to Cspine. Multiple facial fractures separately reported\n on CT sinus/mandible.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old male with trauma. Please evaluate for fracture.\n\n COMPARISON: Concurrent CT C-spine and CT head and CT torso.\n\n TECHNIQUE: Axial imaging was performed from the skull base to the\n cervicothoracic junction without IV contrast. Coronal and sagittal\n reformations were provided.\n\n CT C-SPINE WITHOUT IV CONTRAST: Multiple facial fractures are incompletely\n imaged, and better evaluated on concurrent CT facial bones. Findings are\n separately reported there. There is no fracture or malalignment of the\n cervical spine. The patient is intubated and an NG tube is in place, with\n apparent satisfactory position. Given presence of endotracheal tube, it is\n difficult to evaluate for prevertebral soft tissue swelling. However, the\n soft tissues appear unremarkable. The visualized lung apices are clear.\n\n IMPRESSION: No evidence of traumatic injury to the cervical spine. Findings\n posted to the ED dashboard at the time of scan completion and discussed with\n Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032210,
"text": " 6:13 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: reassess R epidural at 6 AM \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with\n REASON FOR THIS EXAMINATION:\n reassess R epidural at 6 AM \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AKSb FRI 12:45 PM\n PFI: Unchanged right frontal and temporal epidural hematomas. Newly apparent\n small subdural hematoma layering over the falx. Unchanged extensive facial\n bone fractures characterized on recent facial bone CT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old with right epidural hematoma\n\n COMPARISON: Non-contrast head CT four hours prior.\n\n NON-CONTRAST HEAD CT: No significant change from three hours prior in the\n right frontal and temporal epidural hematomas, measuring 10 mm in the\n prefrontal space and 13 mm in the middle cranial fossa. There is newly\n The ventricles are normal in size and configuration, and there is no\n intraventricular hemorrhage.\n\n Extensive facial bone fractures and dense opacification within the right\n maxillary sinus and ethmoid air cells is unchanged. Soft tissue hematoma\n overlying the right maxilla has increased slightly in extent.\n\n IMPRESSION: Unchanged right frontal and temporal epidural hematomas. Newly\n apparent small subdural hematoma layering over the falx. Unchanged extensive\n facial bone fractures as extensively characterized on recent facial bone CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032211,
"text": ", W. TSICU 6:13 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: reassess R epidural at 6 AM \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with\n REASON FOR THIS EXAMINATION:\n reassess R epidural at 6 AM \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Unchanged right frontal and temporal epidural hematomas. Newly apparent\n small subdural hematoma layering over the falx. Unchanged extensive facial\n bone fractures characterized on recent facial bone CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "L WRIST, AP & LAT VIEWS LEFT",
"row_id": 1032199,
"text": " 4:20 AM\n WRIST, AP & LAT VIEWS LEFT Clip # \n Reason: TRAUMA EVAL FOR FX\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with trauma\n REASON FOR THIS EXAMINATION:\n Eval. for fracture, etc.\n ______________________________________________________________________________\n FINAL REPORT\n LEFT WRIST, THREE VIEWS\n\n INDICATION: Trauma. Evaluate for fracture.\n\n FINDINGS: There is a comminuted intra-articular fracture of the distal left\n radius with dorsal angulation of the distal radial articular surface. There\n is mild impaction as well. A mildly displaced ulnar styloid fracture is also\n seen. In addition, there is a suggestion of lucency projecting over the\n distal pole of the scaphoid as well as at the scaphoid waist, which are\n concerning for a nondisplaced scaphoid fractures. Improved evaluation of\n these areas could be achieved with dedicated scaphoid views.\n\n IMPRESSION:\n 1. Comminuted intraarticular fracture of the distal left radius with dorsal\n angulation of the distal radial articular surface.\n 2. Nondisplaced ulnar styloid fracture.\n 3. Lucencies of the distal pole and waist of the scaphoid are concerning for\n nondisplaced fractures. Increased sensitivity for detection of fracture in\n this area could be achieved with dedicated scaphoid views or cross-sectional\n imaging.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1033098,
"text": " 3:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma pt with new confusion. hx of EDH.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with\n REASON FOR THIS EXAMINATION:\n trauma pt with new confusion. hx of EDH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old man with new confusion, trauma with extra-axial\n hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: There has been no interval change since the prior study. Right\n frontal and temporal epidural hematomas are again visualized, measuring 7 mm\n at the right frontal, and 12 mm at the right temporal site. Subdural hematoma\n layering over the right tentorium is unchanged. There are no new foci of\n hemorrhage. There is no edema, shift of normally midline structures, or\n evidence of major vascular territorial infarct. The basilar cisterns are\n preserved.\n\n Numerous right facial fractures are again visualized, with blood in the\n right maxillary sinus, right ethmoid and left sphenoid air cells.\n\n IMPRESSION: No interval change.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032258,
"text": " 9:56 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: eval for interval change. 12pm if possible\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20M, s/p fall from 2 story house; R fronto-temporal epidural hematoma, fx of R\n temporal bone + roof and lateral wall of the orbit; multi facial fx; moves all\n 4 ext.; Right pupil anisocoria\n REASON FOR THIS EXAMINATION:\n eval for interval change. 12pm if possible\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old male, status post two-storey fall with epidural\n hematomas and multiple fractures. Evaluate for interval change.\n\n COMPARISON: Non-contrast head CT performed six and nine hours prior.\n\n NON-CONTRAST HEAD CT: There is again no interval change in the moderate-sized\n right frontal and temporal epidural hematomas with local mass effect on the\n subjacent sulci, but no shift of the normally midline structures. Small\n subdural hematoma layering along the tentorium is also unchanged. Basal\n cisterns are preserved. Ventricular size is stable, and there is no\n intraventricular extension of hemorrhage.\n\n Extensive facial bone fractures involving the right maxillary sinus, right\n orbit, right temporal bone and extending into the right frontal sinus are\n stable with persistent opacification of multiple sinuses as detailed on recent\n prior facial bone CT.\n\n IMPRESSION: Unchanged right frontal and temporal epidural hematomas and small\n subdural hematoma along the tentorium. Facial bone fractures as detailed on\n recent facial bone CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032523,
"text": " 4:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Why is he desating?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with desating on RA TO 66%\n REASON FOR THIS EXAMINATION:\n Why is he desating?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Desaturation.\n\n REFERENCE EXAM: .\n\n FINDINGS: The endotracheal tube has been removed. There is a new right lower\n lobe infiltrate and a new small effusion. The left lung is clear. There is\n no pneumothorax.\n\n IMPRESSION: New right-sided infiltrate likely pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-23 00:00:00.000",
"description": "L WRIST, AP & LAT VIEWS LEFT",
"row_id": 1032421,
"text": " 8:53 AM\n WRIST, AP & LAT VIEWS LEFT; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: FX REPAIR IN THE OR\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n\n WRIST FILMS ON \n\n HISTORY: ORIF.\n\n FINDINGS: Eight films from the OR demonstrate interval placement of distal\n radius plate and screws as well as a screw through the scaphoid.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032669,
"text": " 6:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate consolidation\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with desats 88-89% when asleep, consolidation RLL, LLL on CTA\n \n REASON FOR THIS EXAMINATION:\n evaluate consolidation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf MON 11:36 AM\n PFI: Bilateral lung consolidation, more prominent in the lower lobes, with\n associated small pleural effusion bilaterally. Compared to chest x-ray from\n , the opacification in the left lung is more prominent. Comparing\n to the CTA from , grossly there is no change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old man with desaturation of 88-89% when asleep,\n consolidation in right lower lobe and left lower lobe on CTA. Please evaluate\n consolidation.\n\n TECHNIQUE: Portable chest x-ray was obtained.\n\n COMPARISON: Chest x-ray from and CTA from .\n\n FINDINGS: There is bilateral opacification of the lung with blunting of the\n costophrenic angles. This finding is consistent with bilateral consolidation,\n mainly in the lower lobes with bilateral pleural effusion, as seen on the CTA\n from . Comparing to the chest x-ray from , the\n opacification on the left is more prominent. The heart silhouette is\n unchanged compared to the previous scan. The visualized osseous and soft\n tissue structures are unchanged compared to the previous chest x-ray.\n\n IMPRESSION: Bilateral lung consolidation, most prominent in the lower lobes,\n with associated bilateral pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032670,
"text": ", W. PACU 6:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate consolidation\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with desats 88-89% when asleep, consolidation RLL, LLL on CTA\n \n REASON FOR THIS EXAMINATION:\n evaluate consolidation\n ______________________________________________________________________________\n PFI REPORT\n PFI: Bilateral lung consolidation, more prominent in the lower lobes, with\n associated small pleural effusion bilaterally. Compared to chest x-ray from\n , the opacification in the left lung is more prominent. Comparing\n to the CTA from , grossly there is no change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1032534,
"text": " 5:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with sudden hypoxia, tachycardia, no other complaints\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl SUN 5:46 AM\n extensive consolidtion RLL, LLL, with mulitiple well defined foci of airspace\n consolidation RML, RUL, LUL. Small to moderate bilateral pleural effusions.\n No PE.\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE CHEST FOR PE\n\n HISTORY: 23-year-old male with sudden hypoxia, tachycardia, no other\n complaints. Evaluate for PE.\n\n COMPARISON: CT torso trauma .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the lungs\n following administration of 100 mL of Optiray intravenous contrast as per\n standard institution PE protocol. Multiplanar coronal and sagittal\n reformatted images, as well as oblique MIP images were generated.\n\n FINDINGS: There is no pulmonary embolism.\n\n There is new, extensive dense consolidation and fluid within the dependent\n portions of the right and left lower lobes, left greater than right, and fluid\n layering dependently along the major fissures. Additional foci of patchy\n airspocy cosolidation involve the anterior lungs. There are bilateral pleural\n effusions. These findings are new in comparison to .\n\n There is no mediastinal or hilar lymphadenopathy. There is no pericardial\n effusion. The heart is normal.\n\n Limited imaging through the upper abdomen is unremarkable.\n\n BONE WINDOWS: No fracture or suspicious lytic or blastic osseous lesion is\n identified.\n\n IMPRESSION: New dense consolidation and fluid of the right and left\n lower lobes, with patchy aisrpace opacities anteriorly. Findings may\n represent aspiration. ARDS is less likely as the patient is not intubated.\n Findings were discussed with Dr. on at 0900am.\n (Over)\n\n 5:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032413,
"text": " 7:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for any progression of hematoma.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with R epidural hematoma and facial fx\n REASON FOR THIS EXAMINATION:\n please eval for any progression of hematoma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 10:08 AM\n Essentially unchanged head CT, with possible mild decrease in size of right\n temporal hematoma and no change in right frontal subdural hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old male with right epidural hematoma and facial fractures.\n Please evaluate for change in hematoma.\n\n COMPARISON: Head CT without IV contrast one day prior.\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: A right temporal subdural hematoma previously\n measuring 13 mm, now measures 8 mm, and appears slightly decreased. A right\n frontal hematoma previously measuring 8 mm, now measures 7 mm, and is likely\n not changed in size. There is no interval development of new hemorrhage.\n Multiple right facial fractures previously seen and separately reported on CT\n sinus/mandible are again identified. There persists hemorrhage within the\n right maxillary sinus, with locules of air also in the sinus as well as\n subcutaneous gas and a small amount of pneumocephalus adjacent to the right\n temporal subdural hematoma.\n\n There is no change in the degree of surrounding mass effect. There has been\n no development of shift of the normally midline structures. Small subdural\n hematoma layering along the tentorium is also unchanged. The basal cisterns\n are preserved. There is no evidence of intraventricular extension of\n hemorrhage.\n\n IMPRESSION:\n\n 1. No significant change in right frontal subdural hematoma.\n\n 2. Likely small decrease in size of right temporal subdural hematoma.\n\n 3. No evidence of additional new hemorrhage or development of increased mass\n effect or shift of midline structures.\n (Over)\n\n 7:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for any progression of hematoma.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032414,
"text": ", W. TSICU 7:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for any progression of hematoma.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with R epidural hematoma and facial fx\n REASON FOR THIS EXAMINATION:\n please eval for any progression of hematoma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Essentially unchanged head CT, with possible mild decrease in size of right\n temporal hematoma and no change in right frontal subdural hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-09-22 00:00:00.000",
"description": "CT UP EXT W/O C",
"row_id": 1032371,
"text": " 8:52 PM\n CT UP EXT W/O C Clip # \n Reason: Left HAND and HAND fracture anatomy\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man sp 20 foot fall with left wrist fracture s/p closed reduction\n in TICU\n REASON FOR THIS EXAMINATION:\n Left HAND and HAND fracture anatomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE LEFT WRIST AND HAND \n\n CLINICAL INFORMATION: Fracture anatomy. Status post 20-foot fall with left\n wrist fracture status post closed reduction.\n\n TECHNIQUE:\n\n Multidetector CT performed of the left wrist with 1.25-mm sections with\n sagittal and coronal reformatted images.\n\n FINDINGS:\n\n There is a comminuted impacted fracture of the distal radius which is intra-\n articular. There is dorsal angulation of the major distal fracture fragments.\n There is no significant displacement. There is mild distraction of the major\n distal fracture fragment dorsally approximately 5 mm.\n\n In addition, there is a non-displaced fracture of the ulnar styloid. There is\n neutral ulnar variance.\n\n There is a non-displaced fracture of the volar aspect of the lunate. This\n fracture is comminuted and there are multiple tiny 1 to 2 mm fracture\n fragments arising from the ulnar volar aspect of the lunate. In addition,\n there is a non-displaced fracture through the waist of the scaphoid that also\n extends into the distal pole of the scaphoid. No other fractures are\n identified in the carpus. The metacarpals are intact. Evaluation of the soft\n tissues demonstrates a large degree of edema about the hand and the wrist. The\n study is suboptimal for evaluation of the tendons and ligaments. However\n there does appear to be a great deal of edema about the abductor pollicis\n longus and extensor pollicis brevis. There is also moderate edema about the\n extensor carpi radialis longus and brevis.\n\n IMPRESSION:\n 1. Comminuted impacted intra-articular distal radial fracture with residual\n dorsal angulation of the major distal fracture fragments.\n 2. Non-displaced ulnar styloid fracture.\n 3. Comminuted non-displaced fracture of the ulnar volar aspect of the lunate.\n 4. Non-displaced fracture of the waist and distal pole of the scaphoid.\n (Over)\n\n 8:52 PM\n CT UP EXT W/O C Clip # \n Reason: Left HAND and HAND fracture anatomy\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412534,
"text": "23 y.o.m. s/p fall off 2 story balcony; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; Right pupil anisocoria. No PMH.\n Fracture, other- L extremity and mult R facial fractures\n Assessment:\n Swelling and discomfort r/t L extremity fx and R facial fxs\n Action:\n L wrist reduced and casted by ortho for stabilization and comfort,\n Dilaudid PCA pump initiated, ice packs applied to R face, frequent\n repositioning for comfort\n Response:\n Swelling to R face decreased, pain well controlled w/ PCA\n Plan:\n To OR tomorrow for further stabilization of L extremity, obtain CT of L\n extremity this evening, cont to keep L arm elevated, csm, apply\n ice packs to R face, cont pain mgmt, ? prn dilaudi ivp for breakthrough\n pain.\n Frontal and temporal epidural hematoma\n Assessment:\n Limited neuro exam due to sedation/intubation. R pupil\n sluggish.\n Hypertension- SBP > 130\n Action:\n Q1H neuro exams, repeat Head CT obtained, HOB > 30,\n prophylactic dilantin. Sedation d/c\nd, pt Extubated. Optho consult\n obtained, started on eye drops to relieve R ophthalmic pressure.\n Hydralazine given to maintain SBP < 130 per NSurg\n Response:\n Neuro exam intact, pupil remains sluggish.\n SBP within parameters.\n Plan:\n Cont Q1H neuro exams, ? repeat head CT , cont to keep HOB\n > 30.\n Cont to maintain SBP < 130 w/ prn hydralazine.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412592,
"text": "Intracerebral hemorrhage (ICH); frontal and temporal epidural hematoma\n Assessment:\n Neuro exam remains intact\n Action:\n Q4H neuro exams, routine head CT obtained this am, prophylactic\n dilantin, maintain SBP < 160 per NSurg, HOB > 30.\n Response:\n Head CT stable, neuro exam intact\n Plan:\n Cont neuro exams as appropriate, cont dilantin for seizure prophylaxis,\n treat SBP if > 160, cont to keep HOB > 30.\n Fracture, other; L ulnar/radial fx & mult facial fxs\n Assessment:\n Swelling and comfort improving to LUE and facial fxs\n Action:\n To OR this am for ORIF of LUE, + csm- although c/o some tingling to L\n fingers, elevating LUE on pillows, ice packs applied to face and LUE\n for swelling, pain adequately controlled with Dilaudid PCA, ? OR on wed\n for fixation of facial fxs.\n Response:\n Swelling continues to improve to face/LUE\n Plan:\n Cont csm assessments, elevated LUE, cont pain control with Dilaudid\n PCA, apply ice to face/L extremity as necessary, f/u with plastics in\n regard to fixation of facial fxs.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412593,
"text": "Demographics\n Attending MD:\n W.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 67 kg\n Daily weight:\n 67.1 kg\n Allergies/Reactions:\n No Known Drug Allergies Precautions:\n None\n PMH: None\n Additional history: None\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:115\n D:44\n Temperature:\n 100.4\n Arterial BP:\n S:131\n D:54\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 120 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 0% %\n 24h total in:\n 2,460 mL\n 24h total out:\n 1,555 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:06 AM\n Potassium:\n 3.8 mEq/L\n 03:06 AM\n Chloride:\n 107 mEq/L\n 03:06 AM\n CO2:\n 23 mEq/L\n 03:06 AM\n BUN:\n 9 mg/dL\n 03:06 AM\n Creatinine:\n 0.8 mg/dL\n 03:06 AM\n Glucose:\n 148 mg/dL\n 03:06 AM\n Hematocrit:\n 32.1 %\n 03:06 AM\n Finger Stick Glucose:\n 133\n 02:00 PM\n Valuables / Signature\n Patient valuables: None\n Clothes: Sent home with: family\n Wallet / Money: No money / wallet\n Transferred from: TSICU, CC568\n Transferred to: 11\n Date & time of Transfer: at 1530\n Intracerebral hemorrhage (ICH); frontal and temporal epidural hematoma\n Assessment:\n Neuro exam remains intact\n Action:\n Q4H neuro exams, routine head CT obtained this am, prophylactic\n dilantin, maintain SBP < 160 per NSurg, HOB > 30.\n Response:\n Head CT stable, neuro exam intact\n Plan:\n Cont neuro exams as appropriate, cont dilantin for seizure prophylaxis,\n treat SBP if > 160, cont to keep HOB > 30.\n Fracture, other; L ulnar/radial fx & mult facial fxs\n Assessment:\n Swelling and comfort improving to LUE and facial fxs\n Action:\n To OR this am for ORIF of LUE, + csm- although c/o some tingling to L\n fingers, elevating LUE on pillows, ice packs applied to face and LUE\n for swelling, pain adequately controlled with Dilaudid PCA, ? OR on wed\n for fixation of facial fxs.\n Response:\n Swelling continues to improve to face/LUE\n Plan:\n Cont csm assessments, elevated LUE, cont pain control with Dilaudid\n PCA, apply ice to face/L extremity as necessary, f/u with plastics in\n regard to fixation of facial fxs.\n"
},
{
"category": "Physician ",
"chartdate": "2119-09-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 412661,
"text": "TSICU\n HPI:\n HPI: 23M, s/p fall from 2 story house; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; moves all 4 ext.; Right pupil anisocoria;\n .\n ISSUES:\n 1. epidural hematoma\n 2. multiple facial fx, orbit fx\n 3. Left arm/wrist injury\n 4. hypoxia\n Chief complaint:\n s/p fall (20 feet); hypoxia\n PMHx:\n none\n Current medications:\n Bacitracin Ointment 4. Brimonidine Tartrate 0.15% Ophth. 5. Calcium\n Gluconate\n 6. Clindamycin 7. Famotidine 8. HYDROmorphone (Dilaudid) 9.\n HYDROmorphone (Dilaudid) 10. HYDROmorphone (Dilaudid)\n 11. HydrALAzine 12. Insulin 13. Magnesium Sulfate 14.\n MethylPREDNISolone Sodium Succ 15. Ondansetron\n 16. Phenytoin 17. Prochlorperazine 18. Sodium Chloride 0.9% Flush 19.\n Timolol Maleate 0.5%\n 24 Hour Events:\n )extubated, c-spine cleared\n Started solumedrol 250 mg Q6 hr for 48 hours\n ORIF of L wrist with ORTHO\n () on floor, hypoxic to 75% off o2, initally only up to 90% on NRB\n with pao2 of 61, slowly up to 98% on NRB\n Post operative day:\n POD#1 - ORIF of LUE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 12:03 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:30 AM\n Hydromorphone (Dilaudid) - 12:01 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.3\n HR: 121 (93 - 121) bpm\n BP: 134/63(78) {104/44(61) - 135/63(78)} mmHg\n RR: 25 (10 - 25) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.1 kg (admission): 67 kg\n Height: 65 Inch\n Total In:\n 3,557 mL\n 2 mL\n PO:\n 50 mL\n Tube feeding:\n IV Fluid:\n 3,507 mL\n 2 mL\n Blood products:\n Total out:\n 1,995 mL\n 60 mL\n Urine:\n 1,595 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,562 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic @ 130\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 194 K/uL\n 11.5 g/dL\n 148 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.1 %\n 20.4 K/uL\n [image002.jpg]\n 07:15 AM\n 07:34 AM\n 10:28 AM\n 03:06 AM\n WBC\n 17.5\n 20.4\n Hct\n 34.1\n 32.1\n Plt\n 217\n 194\n Creatinine\n 0.7\n 0.8\n TCO2\n 24\n 18\n Glucose\n 134\n 148\n Other labs: PT / PTT / INR:13.0/25.8/1.1, Lactic Acid:2.3 mmol/L,\n Albumin:4.0 g/dL, Ca:8.6 mg/dL, Mg:1.8 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR pending\n CTA pending\n Head CT:WET: Unchanged right frontal and temporal epidural\n hematomas. Newly apparent small subdural hematoma layering over the\n falx. Unchanged extensive facial bone fractures characterized on recent\n facial bone CT\n Comminuted intraarticular fracture of the distal left radius with\n dorsal angulation of the distal radial articular surface.\n 2. Nondisplaced ulnar styloid fracture.\n 3. Lucencies of the distal pole and waist of the scaphoid are\n concerning for nondisplaced fractures.\n head ct: Right frontal and temporal epidural hematomas.\n Hemorrhage surrounding right masseter. Mild adjacent edema and mass\n effect on frontal of right lateral ventricle. Mutliple left facial\n fractures separately reported on CT sinus/mandible. Hemorrhage into\n right maxillary, sphenoid, ethmoid, and frontal sinuses.\n CT chest/abd/pelvis: NEG\n CT C-spine: NEG\n CT sinus/mandible: Multiple right facial fractures, including\n superior, inferior, lateral, and medial orbital fractures. Comminuted\n medial and lateral, anterior and posterior maxillary sinus fractures.\n Comminuted anterior clinoid process fracture. Oblique zygomatic\n fracture, and non-displaced temporal bone fracture. Transverse fracture\n between teeth 5 and 4. Associated hemorrhage into sinuses.\n Right EYE pharmacologically dilated midrazel/phenylephrine\n Microbiology: none\n ECG: pending\n Assessment and Plan\n Assessment and Plan: 20 y/o M s/p 20feet fall, w/ epidural hematoma,\n mult facial fx and orbital injuries. s/p ORIF of L arm but now with\n sudden hypoxia and tachycardia. Worrisome for PE, other acute process.\n Neurologic: Extubated and AOx3, NOT narcotized\n Neuro checks, dilantin\n Pain: , dilaudid;\n Cardiovascular on re-presentation tachycardic and normotensive.\n Obtaining EKG\n Pulmonary: extubated, but sudden de-sat with large A-A gradient and\n tachycardia on floor, OK on NRB, STAT CXr and CTA ?PE. CTA neg for\n PE. Posterior consolidation. OOB CPT O2\n Gastrointestinal / Abdomen: soft NTTP\n Nutrition: Advance diet\n Renal: Foley, Foley, adequate UOP\n Hematology: monitor hct\n Endocrine: RISS\n Infectious Disease: WBC elevated on solumedrol for 48 hrs\n Lines / Tubes / Drains: PIVx2, foley\n Wounds: Dry dressings, dry dressings\n Imaging: CXR, CTA PE\n Fluids: NS @100cc/hr\n Consults: Trauma surgery, Ortho, Ophthalmology\n Billing Diagnosis: (Respiratory distress), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 412682,
"text": "HPI: 23M, s/p fall from 2 story house; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; moves all 4 ext.; Right pupil anisocoria which is now\n resolved.\n ISSUES:\n 1. Epidural hematoma\n 2. Multiple facial fx, orbit fx\n 3. Left arm/wrist injury\n 4. Hypoxia\n Pt was transferred to CC6 PM. Pt was found sleeping with O2 mask\n off. SaO2 66%. Pt complaining of SOB and tachypneanic. LS clear. On NRB\n sat 90%. PaO2 60\ns. Transferred to TSICU for further monitoring and\n r/o PE. CTA negative for PE but shows right lung consolidation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt comfortable on NRB, sats are 99%-100%, non-productive cough.\n Action:\n Changed to high flow neb and weaned to 60% FiO2, Chest PT, Coughing and\n Deep Breathing, and IS performed and activity advanced to chair.\n Response:\n Oxygen saturation is >95%, pt adequate, non-productive cough. Pt\n compliant with respiratory care.\n Plan:\n Continue pulmonary toileting and continue to wean down the FiO2 as\n tolerated. Monitor oxygen saturation.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 412686,
"text": "HPI: 23M, s/p fall from 2 story house; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; moves all 4 ext.; Right pupil anisocoria which is now\n resolved.\n ISSUES:\n 1. Epidural hematoma\n 2. Multiple facial fx, orbit fx\n 3. Left arm/wrist injury\n 4. Hypoxia\n Pt was transferred to CC6 PM. Pt was found sleeping with O2 mask\n off. SaO2 66%. Pt complaining of SOB and tachypneanic. LS clear. On NRB\n sat 90%. PaO2 60\ns. Transferred to TSICU for further monitoring and\n r/o PE. CTA negative for PE but shows right lung consolidation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt comfortable on NRB, sats are 99%-100%, non-productive cough.\n Action:\n Changed to high flow neb and weaned to 60% FiO2, Chest PT, Coughing and\n Deep Breathing, and IS performed and activity advanced to chair.\n Response:\n Oxygen saturation is >95%, pt adequate, non-productive cough. Pt\n compliant with respiratory care.\n Plan:\n Continue pulmonary toileting and continue to wean down the FiO2 as\n tolerated. Monitor oxygen saturation.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 412689,
"text": "HPI: 23M, s/p fall from 2 story house; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; moves all 4 ext.; Right pupil anisocoria which is now\n resolved.\n ISSUES:\n 1. Epidural hematoma\n 2. Multiple facial fx, orbit fx\n 3. Left arm/wrist injury\n 4. Hypoxia\n Pt was transferred to CC6 PM. Pt was found sleeping with O2 mask\n off. SaO2 66%. Pt complaining of SOB and tachypneanic. LS clear. On NRB\n sat 90%. PaO2 60\ns. Transferred to TSICU for further monitoring and\n r/o PE. CTA negative for PE but shows right lung consolidation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt comfortable on NRB, sats are 99%-100%, non-productive cough.\n Action:\n Changed to high flow neb and weaned to 50% FiO2 then to cool neb at\n 50%, Chest PT, Coughing and Deep Breathing, and IS performed and\n activity advanced to chair.\n Response:\n Oxygen saturation is >95%, pt adequate, non-productive cough. Pt\n compliant with respiratory care. When eating nasal cannula with meals\n at 4L at sats at 95%\n Plan:\n Continue pulmonary toileting and continue to wean down the FiO2 as\n tolerated. Monitor oxygen saturation.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 67 kg\n Daily weight:\n 67.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: None\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:58\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n High flow neb\n O2 saturation:\n 96% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 860 mL\n 24h total out:\n 515 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 01:48 PM\n Potassium:\n 4.2 mEq/L\n 01:48 PM\n Chloride:\n 104 mEq/L\n 01:48 PM\n CO2:\n 27 mEq/L\n 01:48 PM\n BUN:\n 18 mg/dL\n 01:48 PM\n Creatinine:\n 0.9 mg/dL\n 01:48 PM\n Glucose:\n 107 mg/dL\n 01:48 PM\n Hematocrit:\n 29.2 %\n 01:48 PM\n Finger Stick Glucose:\n 117\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: cell phone and candy with patient\n Clothes: Sent home with: parents\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Trauma \n Transferred to: CC6\n Date & time of Transfer: 16:45\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 412681,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt comfortable on NRB, sats are 99%-100%\n Action:\n Changed to high flow neb and weaned to 60% FiO2, Chest PT, Coughing and\n Deep Breathing, and IS performed\n Response:\n Oxygen saturation is >95%, pt adequate\n Plan:\n Continue pulmonary toileting and continue to wean down the FiO2 as\n tolerated. Monitor oxygen saturation.\n"
},
{
"category": "Physician ",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 412573,
"text": "TITLE:\n TSICU\n HPI:\n 23M, s/p fall from 2 story house; R fronto-temporal epidural hematoma,\n fx of R temporal bone + roof and lateral wall of the orbit; multi\n facial fx; moves all 4 ext.; Right pupil anisocoria;\n Chief complaint:\n s/p fall (20 feet)\n PMHx:\n none\n Current medications:\n Bacitracin Ointment 4. Brimonidine Tartrate 0.15% Ophth. 5. Calcium\n Gluconate\n 6. Clindamycin 7. Famotidine 8. HYDROmorphone (Dilaudid) 9.\n HYDROmorphone (Dilaudid) 10. HYDROmorphone (Dilaudid)\n 11. HydrALAzine 12. Insulin 13. Magnesium Sulfate 14.\n MethylPREDNISolone Sodium Succ 15. Ondansetron\n 16. Phenytoin 17. Prochlorperazine 18. Sodium Chloride 0.9% Flush 19.\n Timolol Maleate 0.5%\n 24 Hour Events:\n EXTUBATION - At 03:00 PM\n INVASIVE VENTILATION - STOP 03:00 PM\n extubated, c-spine cleared\n Started solumedrol 250 mg Q6 hr for 48 hours\n Consulted orthopedics who plan on surgery ultimately but first required\n a closed fixation of the left wrist\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 03:00 PM\n Hydromorphone (Dilaudid) - 04:59 PM\n Famotidine (Pepcid) - 08:00 PM\n Hydralazine - 09:00 PM\n Other medications:\n Flowsheet Data as of 05:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.1\nC (98.8\n HR: 102 (83 - 122) bpm\n BP: 116/51(69) {104/50(69) - 144/89(106)} mmHg\n RR: 12 (10 - 22) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67 kg (admission): 67 kg\n Height: 65 Inch\n Total In:\n 3,135 mL\n 553 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,135 mL\n 553 mL\n Blood products:\n Total out:\n 4,489 mL\n 565 mL\n Urine:\n 4,339 mL\n 565 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -1,354 mL\n -12 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 315 (245 - 315) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 10 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.40/28/254/23/-5\n Ve: 3.8 L/min\n PaO2 / FiO2: 508\n Physical Examination\n General Appearance: No acute distress\n HEENT: right eye swollen shut with orbital hematoma\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 194 K/uL\n 11.5 g/dL\n 148 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.1 %\n 20.4 K/uL\n [image002.jpg]\n 07:15 AM\n 07:34 AM\n 10:28 AM\n 03:06 AM\n WBC\n 17.5\n 20.4\n Hct\n 34.1\n 32.1\n Plt\n 217\n 194\n Creatinine\n 0.7\n 0.8\n TCO2\n 24\n 18\n Glucose\n 134\n 148\n Other labs: PT / PTT / INR:13.0/25.8/1.1, Lactic Acid:2.3 mmol/L,\n Ca:8.6 mg/dL, Mg:1.8 mg/dL, PO4:2.9 mg/dL\n Imaging: Head CT:WET: Unchanged right frontal and temporal epidural\n hematomas. Newly apparent small subdural hematoma layering over the\n falx. Unchanged extensive facial bone fractures characterized on recent\n facial bone CT\n Comminuted intraarticular fracture of the distal left radius with\n dorsal angulation of the distal radial articular surface.\n 2. Nondisplaced ulnar styloid fracture.\n 3. Lucencies of the distal pole and waist of the scaphoid are\n concerning for nondisplaced fractures.\n head ct: Right frontal and temporal epidural hematomas.\n Hemorrhage surrounding right masseter. Mild adjacent edema and mass\n effect on frontal of right lateral ventricle. Mutliple left facial\n fractures separately reported on CT sinus/mandible. Hemorrhage into\n right maxillary, sphenoid, ethmoid, and frontal sinuses.\n CT chest/abd/pelvis: NEG\n CT C-spine: NEG\n CT sinus/mandible: Multiple right facial fractures, including\n superior, inferior, lateral, and medial orbital fractures. Comminuted\n medial and lateral, anterior and posterior maxillary sinus fractures.\n Comminuted anterior clinoid process fracture. Oblique zygomatic\n fracture, and non-displaced temporal bone fracture. Transverse fracture\n between teeth 5 and 4. Associated hemorrhage into sinuses.\n Assessment and Plan\n Assessment and Plan: 20 y/o M s/p 20feet fall, w/ epidural hematoma,\n mult facial fx and orbital injuries.\n Neurologic: Extubated\n Neuro checks, dilantin\n Pain: , dilaudid; .\n CT Left wrist and hand prior to surgery\n Cardiovascular: nitroprusside as needed to maintain SBP < 130, prn\n hydralazine\n Pulmonary: extubated\n Gastrointestinal / Abdomen:\n Nutrition: NPO, for surgery today\n Renal: Foley, follow UOP\n Hematology: follow am HCT\n Endocrine: RISS\n Infectious Disease: WBC elevated on solumedrol for 48 hrs\n Lines / Tubes / Drains: a-line, PIVx2, foley\n Wounds: MRS \n Imaging: Wrist/hand CT \n Fluids: diet post op\n Consults: Neuro surgery, Ortho\n Billing Diagnosis: (Hemorrhage, NOS: Subdural), Multiple injuries\n (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:32 AM\n Arterial Line - 06:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 412482,
"text": "TSICU\n HPI:\n 20M, s/p fall from 2 story house; R fronto-temporal epidural hematoma,\n fx of R temporal bone + roof and lateral wall of the orbit; multi\n facial fx; moves all 4 ext.; Right pupil anisocoria\n Chief complaint:\n s/p fall (20 feet)\n PMHx:\n none\n Current medications:\n 1. 2. 1000 mL NS 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.\n Clindamycin 5. Famotidine 6. Fentanyl Citrate\n 7. HYDROmorphone (Dilaudid) 8. Nitroprusside Sodium 9. Phenytoin 10.\n Phenytoin 11. Propofol 12. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:07 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:30 AM\n Other medications:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.6\nC (97.9\n HR: 85 (80 - 103) bpm\n BP: 141/71(89) {141/71(89) - 141/71(89)} mmHg\n RR: 14 (14 - 14) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 670 mL\n PO:\n Tube feeding:\n IV Fluid:\n 670 mL\n Blood products:\n Total out:\n 0 mL\n 2,350 mL\n Urine:\n 2,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,678 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 17 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.4 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: left pupil 2mm, reactive; right pupil 2mm, trace reactive;\n large right periorbital hematoma. right epistaxis\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), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: warm/dry\n Neurologic: Moves all extremities, purposeful movements all 4\n extremities\n Labs / Radiology\n [image002.jpg]\n Imaging: head ct: Right frontal and temporal epidural hematomas.\n Hemorrhage surrounding right masseter. Mild adjacent edema and mass\n effect on frontal of right lateral ventricle. Mutliple left facial\n fractures separately reported on CT sinus/mandible. Hemorrhage into\n right maxillary, sphenoid, ethmoid, and frontal sinuses.\n CT chest/abd/pelvis: NEG\n CT C-spine: NEG\n CT sinus/mandible: Multiple right facial fractures, including\n superior, inferior, lateral, and medial orbital fractures. Comminuted\n medial and lateral, anterior and posterior maxillary sinus fractures.\n Comminuted anterior clinoid process fracture. Oblique zygomatic\n fracture, and non-displaced temporal bone fracture. Transverse fracture\n between teeth 5 and 4. Associated hemorrhage into sinuses.\n Assessment and Plan\n Assessment and Plan: 20 y/o M s/p 20feet fall, w/ epidural hematoma,\n mult facial fx and orbital injuries.\n Neurologic: Neuro checks Q: 1 hr, f/u phenytoin level; fentanyl for\n pain, propofol sedation.\n Cardiovascular: strict BP control, keep SBP < 130, use nipride if\n needed.\n Pulmonary: Cont ETT\n Gastrointestinal / Abdomen: OGT in place\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: monitor hct\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: NS, 100cc/hr\n Consults: Neuro surgery, Trauma surgery, Ortho, Plastics,\n Ophthalmology, f/u recs by ortho, optho, neurosurg\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 412483,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt admitted to Unit s/p fall. Pt currently intubated with a\n size 7.5ETT on AC settings. Pt bs clear, pt suction for small bloody\n secretion. Please refer to resp. flowsheet for more information.\n"
},
{
"category": "Physician ",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 412489,
"text": "TSICU\n HPI:\n 20M, s/p fall from 2 story house; R fronto-temporal epidural hematoma,\n fx of R temporal bone + roof and lateral wall of the orbit; multi\n facial fx; moves all 4 ext.; Right pupil anisocoria\n Chief complaint:\n s/p fall (20 feet)\n PMHx:\n none\n Current medications:\n 1. 2. 1000 mL NS 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.\n Clindamycin 5. Famotidine 6. Fentanyl Citrate\n 7. HYDROmorphone (Dilaudid) 8. Nitroprusside Sodium 9. Phenytoin 10.\n Phenytoin 11. Propofol 12. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:07 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:30 AM\n Other medications:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 36.6\nC (97.9\n HR: 85 (80 - 103) bpm\n BP: 141/71(89) {141/71(89) - 141/71(89)} mmHg\n RR: 14 (14 - 14) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 670 mL\n PO:\n Tube feeding:\n IV Fluid:\n 670 mL\n Blood products:\n Total out:\n 0 mL\n 2,350 mL\n Urine:\n 2,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,678 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 17 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.4 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: left pupil 2mm, reactive; right pupil 2mm, trace reactive;\n large right periorbital hematoma. right epistaxis\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), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: warm/dry\n Neurologic: Moves all extremities, purposeful movements all 4\n extremities\n Labs / Radiology\n [image002.jpg]\n Imaging: head ct: Right frontal and temporal epidural hematomas.\n Hemorrhage surrounding right masseter. Mild adjacent edema and mass\n effect on frontal of right lateral ventricle. Mutliple left facial\n fractures separately reported on CT sinus/mandible. Hemorrhage into\n right maxillary, sphenoid, ethmoid, and frontal sinuses.\n CT chest/abd/pelvis: NEG\n CT C-spine: NEG\n CT sinus/mandible: Multiple right facial fractures, including\n superior, inferior, lateral, and medial orbital fractures. Comminuted\n medial and lateral, anterior and posterior maxillary sinus fractures.\n Comminuted anterior clinoid process fracture. Oblique zygomatic\n fracture, and non-displaced temporal bone fracture. Transverse fracture\n between teeth 5 and 4. Associated hemorrhage into sinuses.\n Assessment and Plan\n Assessment and Plan: 20 y/o M s/p 20feet fall, w/ epidural hematoma,\n mult facial fx and orbital injuries.\n Neurologic: Neuro checks Q: 1 hr, f/u phenytoin level; fentanyl for\n pain, propofol sedation.\n Cardiovascular: strict BP control, keep SBP < 130, use nipride if\n needed.\n Pulmonary: Cont ETT\n Gastrointestinal / Abdomen: OGT in place\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: monitor hct\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: NS, 100cc/hr\n Consults: Neuro surgery, Trauma surgery, Ortho, Plastics,\n Ophthalmology, f/u recs by ortho, optho, neurosurg\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n ------ Protected Section ------\n Pt seen and examined. Agree with the above. He follows commands\n well. Will obtain f/u CT scan prior to extubation Time spent. 31 min\n ------ Protected Section Addendum Entered By: , MD\n on: 09:25 ------\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412565,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Remains neurologically intact\n Action:\n Neuro checks q 1 hour, Bedrest, HOB maintained at 30 degrees, Dilantin\n 100mg IV q 8 hours, SBP maintained < 130, quiet environment maintained\n Response:\n Patient\ns neuro status remained stable, resting in naps throughout\n night\n Plan:\n Continue q 1 hour Neuro checks, Dilantin as ordered. Maintain SBP< 130.\n Repeat Head CT today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Effective pain management\n Action:\n Using Dilaudid PCA effectively with ongoing education and\n reinforcement. Ice packs to right eye/face. Left arm splint intact,\n elevated on pillows\n Response:\n Adequate pain management reported by patient, VSS. rested in naps\n overnight.\n Plan:\n Continue Dilaudid PCA, ice packs, left arm splint and elevation\n Fracture, other\n Assessment:\n Left arm immobilized with splint. CSM intact to LUE.\n Action:\n Left arm immobilization and elevation maintained. CT LUE done \n evening. CSM checks q 1 hour.\n Response:\n Adequate CSM maintained to LUE.\n Plan:\n Continue to LUE immobilization, elevation and CSM checks. OR for LUE\n repair (ORIF radial fracture)\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412566,
"text": "HPI:\n 23 yo male, s/p fall from 2 story house; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx.; Right pupil anisocoria on admission, now resolved.\n Left radial fracture.\n Chief complaint:\n s/p fall (20 feet)\n Intracerebral hemorrhage (ICH)\n Assessment:\n Remains neurologically intact\n Action:\n Neuro checks q 1 hour, Bedrest, HOB maintained at 30 degrees, Dilantin\n 100mg IV q 8 hours, SBP maintained < 130, quiet environment maintained\n Response:\n Patient\ns neuro status remained stable, resting in naps throughout\n night\n Plan:\n Continue q 1 hour Neuro checks, Dilantin as ordered. Maintain SBP< 130.\n Repeat Head CT today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Effective pain management\n Action:\n Using Dilaudid PCA effectively with ongoing education and\n reinforcement. Ice packs to right eye/face. Left arm splint intact,\n elevated on pillows\n Response:\n Adequate pain management reported by patient, VSS. rested in naps\n overnight.\n Plan:\n Continue Dilaudid PCA, ice packs, left arm splint and elevation\n Fracture, other\n Assessment:\n Left arm immobilized with splint. CSM intact to LUE.\n Action:\n Left arm immobilization and elevation maintained. CT LUE done \n evening. CSM checks q 1 hour.\n Response:\n Adequate CSM maintained to LUE.\n Plan:\n Continue to LUE immobilization, elevation and CSM checks. OR for LUE\n repair (ORIF radial fracture)\n"
},
{
"category": "Physician ",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 412550,
"text": "TITLE:\n TSICU\n HPI:\n 23M, s/p fall from 2 story house; R fronto-temporal epidural hematoma,\n fx of R temporal bone + roof and lateral wall of the orbit; multi\n facial fx; moves all 4 ext.; Right pupil anisocoria;\n Chief complaint:\n s/p fall (20 feet)\n PMHx:\n none\n Current medications:\n Bacitracin Ointment 4. Brimonidine Tartrate 0.15% Ophth. 5. Calcium\n Gluconate\n 6. Clindamycin 7. Famotidine 8. HYDROmorphone (Dilaudid) 9.\n HYDROmorphone (Dilaudid) 10. HYDROmorphone (Dilaudid)\n 11. HydrALAzine 12. Insulin 13. Magnesium Sulfate 14.\n MethylPREDNISolone Sodium Succ 15. Ondansetron\n 16. Phenytoin 17. Prochlorperazine 18. Sodium Chloride 0.9% Flush 19.\n Timolol Maleate 0.5%\n 24 Hour Events:\n EXTUBATION - At 03:00 PM\n INVASIVE VENTILATION - STOP 03:00 PM\n extubated, c-spine cleared\n Started solumedrol 250 mg Q6 hr for 48 hours\n Consulted orthopedics who plan on surgery ultimately but first required\n a closed fixation of the left wrist\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 03:00 PM\n Hydromorphone (Dilaudid) - 04:59 PM\n Famotidine (Pepcid) - 08:00 PM\n Hydralazine - 09:00 PM\n Other medications:\n Flowsheet Data as of 05:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.1\nC (98.8\n HR: 102 (83 - 122) bpm\n BP: 116/51(69) {104/50(69) - 144/89(106)} mmHg\n RR: 12 (10 - 22) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67 kg (admission): 67 kg\n Height: 65 Inch\n Total In:\n 3,135 mL\n 553 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,135 mL\n 553 mL\n Blood products:\n Total out:\n 4,489 mL\n 565 mL\n Urine:\n 4,339 mL\n 565 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -1,354 mL\n -12 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 315 (245 - 315) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 0%\n PIP: 10 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.40/28/254/23/-5\n Ve: 3.8 L/min\n PaO2 / FiO2: 508\n Physical Examination\n General Appearance: No acute distress\n HEENT: right eye swollen shut with orbital hematoma\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 194 K/uL\n 11.5 g/dL\n 148 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.1 %\n 20.4 K/uL\n [image002.jpg]\n 07:15 AM\n 07:34 AM\n 10:28 AM\n 03:06 AM\n WBC\n 17.5\n 20.4\n Hct\n 34.1\n 32.1\n Plt\n 217\n 194\n Creatinine\n 0.7\n 0.8\n TCO2\n 24\n 18\n Glucose\n 134\n 148\n Other labs: PT / PTT / INR:13.0/25.8/1.1, Lactic Acid:2.3 mmol/L,\n Ca:8.6 mg/dL, Mg:1.8 mg/dL, PO4:2.9 mg/dL\n Imaging: Head CT:WET: Unchanged right frontal and temporal epidural\n hematomas. Newly apparent small subdural hematoma layering over the\n falx. Unchanged extensive facial bone fractures characterized on recent\n facial bone CT\n Comminuted intraarticular fracture of the distal left radius with\n dorsal angulation of the distal radial articular surface.\n 2. Nondisplaced ulnar styloid fracture.\n 3. Lucencies of the distal pole and waist of the scaphoid are\n concerning for nondisplaced fractures.\n head ct: Right frontal and temporal epidural hematomas.\n Hemorrhage surrounding right masseter. Mild adjacent edema and mass\n effect on frontal of right lateral ventricle. Mutliple left facial\n fractures separately reported on CT sinus/mandible. Hemorrhage into\n right maxillary, sphenoid, ethmoid, and frontal sinuses.\n CT chest/abd/pelvis: NEG\n CT C-spine: NEG\n CT sinus/mandible: Multiple right facial fractures, including\n superior, inferior, lateral, and medial orbital fractures. Comminuted\n medial and lateral, anterior and posterior maxillary sinus fractures.\n Comminuted anterior clinoid process fracture. Oblique zygomatic\n fracture, and non-displaced temporal bone fracture. Transverse fracture\n between teeth 5 and 4. Associated hemorrhage into sinuses.\n Assessment and Plan\n Assessment and Plan: 20 y/o M s/p 20feet fall, w/ epidural hematoma,\n mult facial fx and orbital injuries.\n Neurologic: Extubated\n Neuro checks, dilantin\n Pain: , dilaudid; .\n CT Left wrist and hand prior to surgery\n Cardiovascular: nitroprusside as needed to maintain SBP < 130, prn\n hydralazine\n Pulmonary: extubated\n Gastrointestinal / Abdomen:\n Nutrition: NPO, for surgery today\n Renal: Foley, follow UOP\n Hematology: follow am HCT\n Endocrine: RISS\n Infectious Disease: WBC elevated on solumedrol for 48 hrs\n Lines / Tubes / Drains: a-line, PIVx2, foley\n Wounds: MRS \n Imaging: Wrist/hand CT \n Fluids: NS\n Consults: Neuro surgery, Ortho\n Billing Diagnosis: (Hemorrhage, NOS: Subdural), Multiple injuries\n (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:32 AM\n Arterial Line - 06:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412643,
"text": "HPI: 23M, s/p fall from 2 story house; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; moves all 4 ext.; Right pupil anisocoria which is now\n resolved.\n ISSUES:\n 1. Epidural hematoma\n 2. Multiple facial fx, orbit fx\n 3. Left arm/wrist injury\n 4. Hypoxia\n Pt was transferred to CC6 PM. Pt was found sleeping with O2 mask\n off. SaO2 66%. Pt complaining of SOB and tachypneanic. LS clear. On NRB\n sat 90%. PaO2 60\ns. Transferred to TSICU for further monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear. SaO2 98% on NRB. RR 17. Pt stating he is not as SOB although\n very anxious. Xray showing right sided white out.\n Action:\n Chest xray, chest CTA. Maintaining adequate oxygenation.\n Response:\n SaO2 remaining greater than 96%. RR WNL. Pt feeling comfortable.\n Plan:\n Awaiting CTA results to form further plan. Cont to maintain\n oxygenation. Support patient as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412538,
"text": "23 y.o.m. s/p fall off 2 story balcony; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; Right pupil anisocoria. No PMH.\n Fracture, other- L extremity and mult R facial fractures\n Assessment:\n Swelling and discomfort r/t L extremity fx and R facial fxs\n Action:\n L wrist reduced and casted by ortho for stabilization and comfort,\n Dilaudid PCA pump initiated, ice packs applied to R face, frequent\n repositioning for comfort\n Response:\n Swelling to R face decreased, pain well controlled w/ PCA\n Plan:\n To OR tomorrow for further stabilization of L extremity, obtain CT of L\n extremity this evening, cont to keep L arm elevated, csm, apply\n ice packs to R face, cont pain mgmt, ? prn dilaudi ivp for breakthrough\n pain.\n Frontal and temporal epidural hematoma\n Assessment:\n Limited neuro exam due to sedation/intubation. R pupil\n sluggish.\n Hypertension- SBP > 130\n Action:\n Q1H neuro exams, repeat Head CT obtained, HOB > 30,\n prophylactic dilantin. Sedation d/c\nd, pt Extubated. Optho consult\n obtained, started on eye drops to relieve R ophthalmic pressure.\n Hydralazine given to maintain SBP < 130 per NSurg\n Response:\n Neuro exam intact, pupil remains sluggish.\n SBP within parameters.\n Plan:\n Cont Q1H neuro exams, ? repeat head CT , cont to keep HOB\n > 30.\n Cont to maintain SBP < 130 w/ prn hydralazine.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412611,
"text": "Demographics\n Attending MD:\n W.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 67 kg\n Daily weight:\n 67.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n PMH: None\n Additional history: None\n Surgery / Procedure and date: ORIF of LUE\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:56\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 116 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 3,370 mL\n 24h total out:\n 1,775 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:06 AM\n Potassium:\n 3.8 mEq/L\n 03:06 AM\n Chloride:\n 107 mEq/L\n 03:06 AM\n CO2:\n 23 mEq/L\n 03:06 AM\n BUN:\n 9 mg/dL\n 03:06 AM\n Creatinine:\n 0.8 mg/dL\n 03:06 AM\n Glucose:\n 148 mg/dL\n 03:06 AM\n Hematocrit:\n 32.1 %\n 03:06 AM\n Finger Stick Glucose:\n 133\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Transferred from: TSICU- CC568\n Transferred to: CC616\n Date & time of Transfer: 12:00 AM\n Intracerebral hemorrhage (ICH); frontal and temporal epidural hematoma\n Assessment:\n Neuro exam remains intact\n Action:\n Q4H neuro exams, routine head CT obtained this am, prophylactic\n dilantin, maintain SBP < 160 per NSurg, HOB > 30.\n Response:\n Head CT stable, neuro exam intact\n Plan:\n Cont neuro exams as appropriate, cont dilantin for seizure prophylaxis,\n treat SBP if > 160, cont to keep HOB > 30.\n Fracture, other; L ulnar/radial fx & mult facial fxs\n Assessment:\n Swelling and comfort improving to LUE and facial fxs\n Action:\n To OR this am for ORIF of LUE, + csm- although c/o some tingling to L\n fingers, elevating LUE on pillows, ice packs applied to face and LUE\n for swelling, pain adequately controlled with Dilaudid PCA, ? OR on wed\n for fixation of facial fxs.\n Response:\n Swelling continues to improve to face/LUE\n Plan:\n Cont csm assessments, elevated LUE, cont pain control with Dilaudid\n PCA, apply ice to face/L extremity as necessary, f/u with plastics in\n regard to fixation of facial fxs.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412612,
"text": "Demographics\n Attending MD:\n W.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 67 kg\n Daily weight:\n 67.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n PMH: None\n Additional history: None\n Surgery / Procedure and date: ORIF of LUE\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:56\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 116 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 3,370 mL\n 24h total out:\n 1,775 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:06 AM\n Potassium:\n 3.8 mEq/L\n 03:06 AM\n Chloride:\n 107 mEq/L\n 03:06 AM\n CO2:\n 23 mEq/L\n 03:06 AM\n BUN:\n 9 mg/dL\n 03:06 AM\n Creatinine:\n 0.8 mg/dL\n 03:06 AM\n Glucose:\n 148 mg/dL\n 03:06 AM\n Hematocrit:\n 32.1 %\n 03:06 AM\n Finger Stick Glucose:\n 133\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Transferred from: TSICU- CC568\n Transferred to: CC616\n Date & time of Transfer: 12:00 AM\n Intracerebral hemorrhage (ICH); frontal and temporal epidural hematoma\n Assessment:\n Neuro exam remains intact\n Action:\n Q4H neuro exams, routine head CT obtained this am, prophylactic\n dilantin, maintain SBP < 160 per NSurg, HOB > 30.\n Response:\n Head CT stable, neuro exam intact\n Plan:\n Cont neuro exams as appropriate, cont dilantin for seizure prophylaxis,\n treat SBP if > 160, cont to keep HOB > 30.\n Fracture, other; L ulnar/radial fx & mult facial fxs\n Assessment:\n Swelling and comfort improving to LUE and facial fxs\n Action:\n To OR this am for ORIF of LUE, + csm- although c/o some tingling to L\n fingers, elevating LUE on pillows, ice packs applied to face and LUE\n for swelling, pain adequately controlled with Dilaudid PCA, ? OR on wed\n for fixation of facial fxs.\n Response:\n Swelling continues to improve to face/LUE\n Plan:\n Cont csm assessments, elevated LUE, cont pain control with Dilaudid\n PCA, apply ice to face/L extremity as necessary, f/u with plastics in\n regard to fixation of facial fxs.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412613,
"text": "Demographics\n Attending MD:\n W.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 67 kg\n Daily weight:\n 67.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n PMH: None\n Additional history: None\n Surgery / Procedure and date: ORIF of LUE\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:56\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 116 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 3,370 mL\n 24h total out:\n 1,775 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:06 AM\n Potassium:\n 3.8 mEq/L\n 03:06 AM\n Chloride:\n 107 mEq/L\n 03:06 AM\n CO2:\n 23 mEq/L\n 03:06 AM\n BUN:\n 9 mg/dL\n 03:06 AM\n Creatinine:\n 0.8 mg/dL\n 03:06 AM\n Glucose:\n 148 mg/dL\n 03:06 AM\n Hematocrit:\n 32.1 %\n 03:06 AM\n Finger Stick Glucose:\n 133\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Transferred from: TSICU- CC568\n Transferred to: CC616\n Date & time of Transfer: 12:00 AM\n Intracerebral hemorrhage (ICH); frontal and temporal epidural hematoma\n Assessment:\n Neuro exam remains intact\n Action:\n Q4H neuro exams, routine head CT obtained this am, prophylactic\n dilantin, maintain SBP < 160 per NSurg, HOB > 30.\n Response:\n Head CT stable, neuro exam intact\n Plan:\n Cont neuro exams as appropriate, cont dilantin for seizure prophylaxis,\n treat SBP if > 160, cont to keep HOB > 30.\n Fracture, other; L ulnar/radial fx & mult facial fxs\n Assessment:\n Swelling and comfort improving to LUE and facial fxs\n Action:\n To OR this am for ORIF of LUE, + csm- although c/o some tingling to L\n fingers, elevating LUE on pillows, ice packs applied to face and LUE\n for swelling, pain adequately controlled with Dilaudid PCA, ? OR on wed\n for fixation of facial fxs.\n Response:\n Swelling continues to improve to face/LUE\n Plan:\n Cont csm assessments, elevated LUE, cont pain control with Dilaudid\n PCA, apply ice to face/L extremity as necessary, f/u with plastics in\n regard to fixation of facial fxs.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412536,
"text": "23 y.o.m. s/p fall off 2 story balcony; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; Right pupil anisocoria. No PMH.\n Fracture, other- L extremity and mult R facial fractures\n Assessment:\n Swelling and discomfort r/t L extremity fx and R facial fxs\n Action:\n L wrist reduced and casted by ortho for stabilization and comfort,\n Dilaudid PCA pump initiated, ice packs applied to R face, frequent\n repositioning for comfort\n Response:\n Swelling to R face decreased, pain well controlled w/ PCA\n Plan:\n To OR tomorrow for further stabilization of L extremity, obtain CT of L\n extremity this evening, cont to keep L arm elevated, csm, apply\n ice packs to R face, cont pain mgmt, ? prn dilaudi ivp for breakthrough\n pain.\n Frontal and temporal epidural hematoma\n Assessment:\n Limited neuro exam due to sedation/intubation. R pupil\n sluggish.\n Hypertension- SBP > 130\n Action:\n Q1H neuro exams, repeat Head CT obtained, HOB > 30,\n prophylactic dilantin. Sedation d/c\nd, pt Extubated. Optho consult\n obtained, started on eye drops to relieve R ophthalmic pressure.\n Hydralazine given to maintain SBP < 130 per NSurg\n Response:\n Neuro exam intact, pupil remains sluggish.\n SBP within parameters.\n Plan:\n Cont Q1H neuro exams, ? repeat head CT , cont to keep HOB\n > 30.\n Cont to maintain SBP < 130 w/ prn hydralazine.\n"
},
{
"category": "Nursing",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412537,
"text": "23 y.o.m. s/p fall off 2 story balcony; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; Right pupil anisocoria. No PMH.\n Fracture, other- L extremity and mult R facial fractures\n Assessment:\n Swelling and discomfort r/t L extremity fx and R facial fxs\n Action:\n L wrist reduced and casted by ortho for stabilization and comfort,\n Dilaudid PCA pump initiated, ice packs applied to R face, frequent\n repositioning for comfort\n Response:\n Swelling to R face decreased, pain well controlled w/ PCA\n Plan:\n To OR tomorrow for further stabilization of L extremity, obtain CT of L\n extremity this evening, cont to keep L arm elevated, csm, apply\n ice packs to R face, cont pain mgmt, ? prn dilaudi ivp for breakthrough\n pain.\n Frontal and temporal epidural hematoma\n Assessment:\n Limited neuro exam due to sedation/intubation. R pupil\n sluggish.\n Hypertension- SBP > 130\n Action:\n Q1H neuro exams, repeat Head CT obtained, HOB > 30,\n prophylactic dilantin. Sedation d/c\nd, pt Extubated. Optho consult\n obtained, started on eye drops to relieve R ophthalmic pressure.\n Hydralazine given to maintain SBP < 130 per NSurg\n Response:\n Neuro exam intact, pupil remains sluggish.\n SBP within parameters.\n Plan:\n Cont Q1H neuro exams, ? repeat head CT , cont to keep HOB\n > 30.\n Cont to maintain SBP < 130 w/ prn hydralazine.\n"
},
{
"category": "Physician ",
"chartdate": "2119-09-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 412625,
"text": "TSICU\n HPI:\n HPI: 23M, s/p fall from 2 story house; R fronto-temporal epidural\n hematoma, fx of R temporal bone + roof and lateral wall of the orbit;\n multi facial fx; moves all 4 ext.; Right pupil anisocoria;\n .\n ISSUES:\n 1. epidural hematoma\n 2. multiple facial fx, orbit fx\n 3. Left arm/wrist injury\n 4. hypoxia\n Chief complaint:\n s/p fall (20 feet); hypoxia\n PMHx:\n none\n Current medications:\n Bacitracin Ointment 4. Brimonidine Tartrate 0.15% Ophth. 5. Calcium\n Gluconate\n 6. Clindamycin 7. Famotidine 8. HYDROmorphone (Dilaudid) 9.\n HYDROmorphone (Dilaudid) 10. HYDROmorphone (Dilaudid)\n 11. HydrALAzine 12. Insulin 13. Magnesium Sulfate 14.\n MethylPREDNISolone Sodium Succ 15. Ondansetron\n 16. Phenytoin 17. Prochlorperazine 18. Sodium Chloride 0.9% Flush 19.\n Timolol Maleate 0.5%\n 24 Hour Events:\n )extubated, c-spine cleared\n Started solumedrol 250 mg Q6 hr for 48 hours\n ORIF of L wrist with ORTHO\n () on floor, hypoxic to 75% off o2, initally only up to 90% on NRB\n with pao2 of 61, slowly up to 98% on NRB\n Post operative day:\n POD#1 - ORIF of LUE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 12:03 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:30 AM\n Hydromorphone (Dilaudid) - 12:01 PM\n Other medications:\n Flowsheet Data as of 04:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.4\nC (99.3\n HR: 121 (93 - 121) bpm\n BP: 134/63(78) {104/44(61) - 135/63(78)} mmHg\n RR: 25 (10 - 25) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.1 kg (admission): 67 kg\n Height: 65 Inch\n Total In:\n 3,557 mL\n 2 mL\n PO:\n 50 mL\n Tube feeding:\n IV Fluid:\n 3,507 mL\n 2 mL\n Blood products:\n Total out:\n 1,995 mL\n 60 mL\n Urine:\n 1,595 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,562 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachycardic @ 130\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 194 K/uL\n 11.5 g/dL\n 148 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 107 mEq/L\n 139 mEq/L\n 32.1 %\n 20.4 K/uL\n [image002.jpg]\n 07:15 AM\n 07:34 AM\n 10:28 AM\n 03:06 AM\n WBC\n 17.5\n 20.4\n Hct\n 34.1\n 32.1\n Plt\n 217\n 194\n Creatinine\n 0.7\n 0.8\n TCO2\n 24\n 18\n Glucose\n 134\n 148\n Other labs: PT / PTT / INR:13.0/25.8/1.1, Lactic Acid:2.3 mmol/L,\n Albumin:4.0 g/dL, Ca:8.6 mg/dL, Mg:1.8 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR pending\n CTA pending\n Head CT:WET: Unchanged right frontal and temporal epidural\n hematomas. Newly apparent small subdural hematoma layering over the\n falx. Unchanged extensive facial bone fractures characterized on recent\n facial bone CT\n Comminuted intraarticular fracture of the distal left radius with\n dorsal angulation of the distal radial articular surface.\n 2. Nondisplaced ulnar styloid fracture.\n 3. Lucencies of the distal pole and waist of the scaphoid are\n concerning for nondisplaced fractures.\n head ct: Right frontal and temporal epidural hematomas.\n Hemorrhage surrounding right masseter. Mild adjacent edema and mass\n effect on frontal of right lateral ventricle. Mutliple left facial\n fractures separately reported on CT sinus/mandible. Hemorrhage into\n right maxillary, sphenoid, ethmoid, and frontal sinuses.\n CT chest/abd/pelvis: NEG\n CT C-spine: NEG\n CT sinus/mandible: Multiple right facial fractures, including\n superior, inferior, lateral, and medial orbital fractures. Comminuted\n medial and lateral, anterior and posterior maxillary sinus fractures.\n Comminuted anterior clinoid process fracture. Oblique zygomatic\n fracture, and non-displaced temporal bone fracture. Transverse fracture\n between teeth 5 and 4. Associated hemorrhage into sinuses.\n Right EYE pharmacologically dilated midrazel/phenylephrine\n Microbiology: none\n ECG: pending\n Assessment and Plan\n Assessment and Plan: 20 y/o M s/p 20feet fall, w/ epidural hematoma,\n mult facial fx and orbital injuries. s/p ORIF of L arm but now with\n sudden hypoxia and tachycardia. Worrisome for PE, other acute process.\n Neurologic: Extubated and AOx3, NOT narcotized\n Neuro checks, dilantin\n Pain: , dilaudid;\n Cardiovascular: nitroprusside as needed to maintain SBP < 130, on\n re-presentation tachycardic and normotensive. Obtaining EKG\n Pulmonary: extubated, but sudden de-sat with large A-A gradient and\n tachycardia on floor, OK on NRB, STAT CXr and CTA ?PE.\n Gastrointestinal / Abdomen: soft NTTP\n Nutrition: NPO\n Renal: Foley, Foley, adequate UOP\n Hematology: monitor hct\n Endocrine: RISS\n Infectious Disease: WBC elevated on solumedrol for 48 hrs\n Lines / Tubes / Drains: PIVx2, foley\n Wounds: Dry dressings, dry dressings\n Imaging: CXR, CTA PE\n Fluids: NS @100cc/hr\n Consults: Trauma surgery, Ortho, Ophthalmology\n Billing Diagnosis: (Respiratory distress), Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2119-09-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 412531,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 61.7 None\n Ideal tidal volume: 246.8 / 370.2 / 493.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient traveled to Cat Scan for head scan then, weaned from sedation\n and ventilator and extubated at 1345 to 50% cool mist via facetent now\n is on room air, doing fine.\n"
}
] |
76,994 | 173,769 | 82yo male with ESRD on HD, HTN, DM2 admitted for shortness of breath 1. Pulmonary Edema with acute on chronic diastolic heart failure: Patient admitted with SOB pulmonary edema and volume overload which improved with hemodialysis on his usual schedule. Per discussion with renal, it is possible they were underdialyzing him and he needs more agressive dialysis. He was continued on his usual HD schedule here (T/Th/Sat) and was extubated without difficulty and satting mid to high 90s on room air at time of discharge. He had an ECHO which revealed "Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function and diastolic dysfunction. Since he was mildly hypertensive, his was uptitrated. He was ruled out for MI. He should continue on low salt cardiac diabetic renal diet to avoid issues with volume overload in the future. 2. Respiratory Failure: Improved as above with dialysis. He did not have any focal infiltrates or fever to suggest leukocytosis. He was also given albuterol and ipratropium nebs as needed for wheezing as he is on Advair but he is unsure why he is on this medication. 3. COPD/Asthma: Patient continued to wheeze during his admission. Unclear pulmonary history and PCP was on vacation so we were unable to obtain further information regarding his pulmonary status. He was continued on advair and albuterol/ipratropium nebs. 4. Hypercholesterolemia: Continued Simvastatin at home dose 5. Hypertension: Continued amlodipine, labetalol, valsartan. Patient on olmesartan at home but substituted for valsartan in house. Valsartan increased to 160mg daily. 6. ESRD on HD: He was continued on his hemodialysis on Tu/Thurs/Sat schedule. 7. Type 2 Diabetes Mellitus, uncontrolled and with complications: Continue insulin + SS. Lantus dose decreased at night for low blood sugar in am 8. Diarrhea: Pt was having loose stools on . C. diff toxin was ordered but not sent. He should have C diff checked if diarrhea recurs although he has not been on antibiotics here and did not have a leukocytosis. | - wean NC as tolerated - f/u read of CXR from yesterday and today - d/t both LLL volume loss on CXR and nodules appreciated to left of hilar region, order PA and lateral CXR today # Hypercholesterolemia: Continue Simvastatin # Hypertension: Continue amlodipine, labetalol, olmesartan. Given albuterol and atrovent nebs Q4 prn for wheezes. I/E wheezes after extubation, alb/atr nebs x 2 Response: Wheezes cleared after nebs. I/E wheezes after extubation, alb/atr nebs x 2 Response: Wheezes cleared after nebs. I/E wheezes after extubation, alb/atr nebs x 2 Response: Wheezes cleared after nebs. S/p intubation on , now extubated on . Respiratory failure, acute (not ARDS/) Assessment: Pt emergently intubated in ED for increased WOB likely related to fluid overload. Prophylaxis: Subcutaneous heparin, famotidine . Prophylaxis: Subcutaneous heparin, famotidine . Prophylaxis: Subcutaneous heparin, famotidine . Remainder of issues per ICU team. ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 03:03 PM Code status: Full code Disposition :Transfer to floor # Hypercholesterolemia: Continue Simvastatin # Hypertension: Continue amlodipine, labetalol, olmesartan. # Hypercholesterolemia: Continue Simvastatin # Hypertension: Continue amlodipine, labetalol, olmesartan. Response: Repeat FS 104 after juice. Response: Repeat FS 104 after juice. Response: Repeat FS 104 after juice. Action: Started on IV propofol for hopefully short intubation. Dialysis as above. Dialysis as above. Dialysis as above. Disposition: to floor today now s/p extubation ICU Care Lines: 18 Gauge - 03:03 PM Code status: Full code Action: Able to extubate after fluid removal Response: No S/S pulmonary edema Plan: Monitor resp status, ? Action: Able to extubate after fluid removal Response: No S/S pulmonary edema Plan: Monitor resp status, ? Action: Able to extubate after fluid removal Response: No S/S pulmonary edema Plan: Monitor resp status, ? Action: Able to extubate after fluid removal Response: No S/S pulmonary edema Plan: Monitor resp status, ? - f/u renal recs - use interpreter to d/w patient regarding etiology for pulmonary edema (?med non-compliance, ?diet indiscretion) - HD tomorrow # Respiratory Failure: Appears at this time to be secondary to volume overload as above. Wean O2 Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney disease) Assessment: HD done at bedside, able to remove 4.5L fluid, fluid removal limited by BP decreasing to 100s/ during HD. Shortness of breath.Weight (lb): 176BP (mm Hg): 173/73HR (bpm): 66Status: InpatientDate/Time: at 15:34Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). There is an anterior space which most likely representsa fat pad.IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved globaland regional biventricular systolic function. S/p intubation on , now extubated on . The aortic knob is calcified. The aortic knob is calcified. Respiratory failure, acute (not ARDS/) Assessment: Pt emergently intubated in ED for increased WOB likely related to fluid overload. Dialysis as above. Dialysis as above. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. # Respiratory Failure: Appears at this time to be secondary to volume overload as above. Action: Able to extubate after fluid removal Response: No S/S pulmonary edema Plan: Monitor resp status, ? The aortic root is mildly dilated atthe sinus level. PORTABLE AP CHEST RADIOGRAPH: There are bilateral peripheral and perihilar interstitial opacities, with Kerley B lines noted, compatible with diffuse interstitial edema. Trivial mitral regurgitation is seen. Again noted, there are moderate bilateral peripheral and perihilar interstitial opacities, suggestive of fluid overload. Prophylaxis: Subcutaneous heparin, famotidine . Prophylaxis: Subcutaneous heparin, famotidine . The patient was extubated in the meantime interval with removal of the NG tube. - wean NC as tolerated - f/u read of CXR from yesterday and today # Hypercholesterolemia: Continue Simvastatin # Hypertension: Continue amlodipine, labetalol, olmesartan. The aorta is calcified. Physiologic TR.Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Action: Started on IV propofol for hopefully short intubation. # Hypercholesterolemia: Continue Simvastatin # Hypertension: Continue amlodipine, labetalol, olmesartan. Trace bilateral pleural effusions. No PS.Physiologic PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is normal in size. Pt then fatigued and was intubated. Pt then fatigued and was intubated. Pt then fatigued and was intubated. RV hypertrophy.AORTA: Mildly dilated aortic sinus. CXR consistent with pulmonary edema. CXR consistent with pulmonary edema. Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Status post intubation with endotracheal tube terminating 5.4 cm above the level of the carina. Status post intubation with visualized endotracheal tube terminating 5.8 cm above the level of the carina. Persistent moderate pulmonary edema and bilateral pleural effusions. There is mild pulmonary arterysystolic hypertension. Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney disease) Assessment: Action: Response: Plan: Heart failure (CHF), Diastolic, Acute on Chronic Assessment: Action: Response: Plan: | 25 | [
{
"category": "Physician ",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 609105,
"text": "Chief Complaint: Respiratory Failure, Pulmonary edema, chronic renal\n insufficiency\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n HD yesterday - 4.5L off\n Extubated post-HD last PM --> did well overnight\n 24 Hour Events:\n INVASIVE VENTILATION - START 02:15 PM\n INVASIVE VENTILATION - STOP 10:00 PM\n History obtained from Medical records, icu team\n Patient unable to provide history: Language barrier\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Edema\n Respiratory: No(t) Tachypnea\n Genitourinary: Dialysis\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 73 (53 - 81) bpm\n BP: 161/56(82) {107/45(66) - 162/62(85)} mmHg\n RR: 14 (12 - 20) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 105 mL\n 360 mL\n PO:\n 360 mL\n TF:\n IVF:\n 105 mL\n Blood products:\n Total out:\n 4,515 mL\n 95 mL\n Urine:\n 15 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,410 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 495 (446 - 495) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 13 cmH2O\n Plateau: 16 cmH2O\n SpO2: 94%\n ABG: 7.42/58/78./35/10\n Ve: 6.2 L/min\n PaO2 / FiO2: 197\n Physical Examination\n General Appearance: No(t) No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered but not taking large breaths)\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.4 g/dL\n 203 K/uL\n 58 mg/dL\n 3.7 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 18 mg/dL\n 98 mEq/L\n 139 mEq/L\n 35.7 %\n 9.9 K/uL\n [image002.jpg]\n 09:27 PM\n 03:53 AM\n WBC\n 9.9\n Hct\n 35.7\n Plt\n 203\n Cr\n 3.7\n TCO2\n 39\n Glucose\n 58\n Other labs: PT / PTT / INR:12.2/30.0/1.0, Ca++:7.5 mg/dL, Mg++:1.6\n mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n 82 yo man with ESRD admitted with pulm edema, resolved after HD. Now\n extubated\n - Will call out to the floor but remain in house for 1 more HD session\n tomorrow.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:03 PM\n Code status: Full code\n Disposition :Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609106,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 02:15 PM\n INVASIVE VENTILATION - STOP 10:00 PM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 66 (53 - 81) bpm\n BP: 145/46(71) {107/45(66) - 162/62(85)} mmHg\n RR: 15 (12 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 105 mL\n 360 mL\n PO:\n 360 mL\n TF:\n IVF:\n 105 mL\n Blood products:\n Total out:\n 4,515 mL\n 15 mL\n Urine:\n 15 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,410 mL\n 345 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 495 (446 - 495) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 13 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.42/58/78./35/10\n Ve: 6.2 L/min\n PaO2 / FiO2: 197\n Physical Examination\n GEN: Denies SOB, pain.\n CV: RRR, no m/r/g\n PULM: Poor inspiratory effort, and instructions to breathe deeply are\n difficult to convey d/t language barrier. No crackles auscultated.\n ABD: Soft, nt, nd.\n EXTR: Without edema.\n SKIN: Soft edematous region on posterior neck. Seborrheic keratoses\n present.\n Labs / Radiology\n 203 K/uL\n 11.4 g/dL\n 58 mg/dL\n 3.7 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 18 mg/dL\n 98 mEq/L\n 139 mEq/L\n 35.7 %\n 9.9 K/uL\n [image002.jpg]\n 09:27 PM\n 03:53 AM\n WBC\n 9.9\n Hct\n 35.7\n Plt\n 203\n Cr\n 3.7\n TCO2\n 39\n Glucose\n 58\n Other labs: PT / PTT / INR:12.2/30.0/1.0, Ca++:7.5 mg/dL, Mg++:1.6\n mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n 82 y/o male with ESRD on dialysis with volume overload.\n # Volume Overload/Pulmonary edema: The patient is now s/p urgent\n dialysis. He appeared to be anuric as he has not responded to any of\n the diuretic treatments administered. He does not have any electrolyte\n imbalances at this time; diuresis done for volume overload. 4.5kg\n removed on .\n - f/u renal recs\n - use interpreter to d/w patient regarding etiology for pulmonary edema\n (?med non-compliance, ?diet indiscretion)\n - HD tomorrow\n # Respiratory Failure: Appears at this time to be secondary to volume\n overload as above. No evidence of infiltrate or fever suggestive of\n infectious process. CXR consistent with pulmonary edema. Dialysis as\n above. S/p intubation on , now extubated on .\n - wean NC as tolerated\n - f/u read of CXR from yesterday and today\n - d/t both LLL volume loss on CXR and nodules appreciated to left of\n hilar region, order PA and lateral CXR today\n # Hypercholesterolemia: Continue Simvastatin\n # Hypertension: Continue amlodipine, labetalol, olmesartan. Per renal,\n if need incr BP control, incr .\n # DM: Continue insulin + SS\n FEN: No IVF, replete electrolytes (replete K and Mg this AM), advance\n diet as tolerated now s/p extubation\n .\n Prophylaxis: Subcutaneous heparin, famotidine\n .\n Access: Peripherals\n .\n Code: Full.\n .\n Communication: Family \n .\n Disposition: to floor today now s/p extubation\n ICU Care\n Lines:\n 18 Gauge - 03:03 PM\n Code status: Full code\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609026,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n failure, Chronic (Chronic failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with fluid overload. STAT HD session once arrived to unit.\n Action:\n Per HD nurse pt to have 5kg removed this session.\n Response:\n HD currently being run, tolerating well, maintain good blood pressure.\n Plan:\n Fluid removal as BP tolerates.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt emergently intubated in ED for increased WOB likely related to fluid\n overload. Lungs sounds clear in all fields. Vent settings CMV\n 40%/500*12/+5. Pt initially sedated from intubation meds, waking up\n and now agitated with ETT, restless, attempting to pull at ETT. Unable\n to assess mental status due to language barrier.\n Action:\n Started on IV propofol for hopefully short intubation. Soft wrist\n restraints applied bilaterally for pt safety.\n Response:\n Continues to be restless despite propofol drip.\n Plan:\n Re-assess respiratory status once HD finishes, will need Cantonese\n interpreter, extubated when possible.\n"
},
{
"category": "Respiratory ",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 609024,
"text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 77 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt admitted from outside dialysis unit with severe SOB prompting a to\n call 911.He came here and was intubated and t/ferred to\n MICU 6 for follow up. Started on dialysis here to remove aprox 6+ L. of\n fluid. My be corrected and moved to\nhome\n tomorrow.\n, RRT 17:42\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609075,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 12, +5, 40%. Breath sounds clear, Occ 1-3 breaths\n over rate on propofol gtt.\n Action:\n Labetolol given via OGT prior to extubation as BP 140s-150s/ on 45 mcg\n propofol. ABG 7.42/58/79/39. Propofol gtt shut off -.> pt eyes open,\n following commands, extubated to 40% FT @ 2200. I/E wheezes after\n extubation, alb/atr nebs x 2\n Response:\n Wheezes cleared after nebs. No resp distress. RR teens, sats 96-97%.\n Slept all night. Weaned to 2L NC this AM with sats high 90s.\n Plan:\n Monitor resp status. Nebs prn. Wean O2\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD done at bedside, able to remove 4.5L fluid, fluid removal limited by\n BP decreasing to 100s/ during HD.\n Action:\n Able to extubate after fluid removal\n Response:\n No S/S pulmonary edema\n Plan:\n Monitor resp status, ? if will need another HD today vs Thursday\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609077,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 12, +5, 40%. Breath sounds clear, Occ 1-3 breaths\n over rate on propofol gtt.\n Action:\n Labetolol given via OGT prior to extubation as BP 140s-150s/ on 45 mcg\n propofol. ABG 7.42/58/79/39. Propofol gtt shut off -.> pt eyes open,\n following commands, extubated to 40% FT @ 2200. I/E wheezes after\n extubation, alb/atr nebs x 2\n Response:\n Wheezes cleared after nebs. No resp distress. RR teens, sats 96-97%.\n Slept all night. Weaned to 2L NC this AM with sats high 90s.\n Plan:\n Monitor resp status. Nebs prn. Wean O2\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD done at bedside, able to remove 4.5L fluid, fluid removal limited by\n BP decreasing to 100s/ during HD.\n Action:\n Able to extubate after fluid removal\n Response:\n No S/S pulmonary edema\n Plan:\n Monitor resp status, ? if will need another HD today vs Thursday\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSBS 116 @ 2200 last night. Pt NPO after extubation o/n. Lantus held\n Action:\n FSBS 66 this AM. Serum glucose 58. Pt took large glass of apple juice.\n No S/S hypoglycemia.\n Response:\n Repeat FS 104 after juice.\n Plan:\n Follow blood sugars. Resume diet today.\n"
},
{
"category": "Physician ",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 609006,
"text": "Chief Complaint: Pulmonary edema\n HPI:\n 82 y/o male ESRD on dialysis. Presented to dialysis with shortness of\n breath to an extent where he could not get dialysis. Weight at\n dialysis was 6.8kg above dry weight. Transferred to ED for further\n care, on presentation noted elevated JVP, pulmonary edema. In the ED,\n initial vs were: 97.1 58 110/58 100. Got 3 doses of SL NTG, 40 IV\n Lasix, placed on non-invasive but tidal volumes in 150's and tiring.\n Droped RR to 8, was intubated. Renal was consulted for urgent\n dialysis. Transferred to ICU for further care.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n NephroVites 1\n Simvastatin 20 QHS\n Trazadone 20 QHS\n IC Amlodipine 10 Daily\n Labetolol 600 \n Olmesartan 20mg Daily\n Renagel 400mg TID prior to meals\n Lantus 8U daily\n Advair\n Past medical history:\n Family history:\n Social History:\n ESRD\n Diabetes\n Hypertension\n Hypercholesterolemia\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Cantonese speaking only\n Review of systems:\n Flowsheet Data as of 03:01 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 58 () bpm\n BP: 110/48\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.8 kg (admission): kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 19 cmH2O\n SpO2: 93%\n Ve: 5.7 L/min\n Physical Examination\n General Appearance: No acute distress, intubated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Warm, Xerosis\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 224\n 4.7\n 28\n 32\n 97\n 3.8\n 137\n 37.1\n 8.8\n [image002.jpg]\n Assessment and Plan\n 82 y/o male with ESRD on dialysis with volume overload.\n # Volume Overload: The patient is being evaluated right now for urgent\n dialysis. He appears to be anuric as he has not responded to any of\n the diuretic treatments administered. He does not have any electrolyte\n imbalances at this time.\n # Respiratory Failure: Appears at this time to be secondary to volume\n overload as above. No evidence of infiltrate or fever suggestive of\n infectious process. CXR consistent with pulmonary edema. Dialysis as\n above.\n # Hypercholesterolemia: Continue Simvastatin\n # Hypertension: Continue amlodipine, labetalol, olmesartan.\n # DM: Continue insulin + SS\n FEN: No IVF, replete electrolytes, NPO at this time\n .\n Prophylaxis: Subcutaneous heparin, famotidine\n .\n Access: peripherals\n .\n Code: Full.\n .\n Communication: Family \n .\n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: Discussed with family.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Physician Admission Note - MICU",
"row_id": 609011,
"text": "Chief Complaint: Pulmonary edema\n HPI:\n 82 y/o male ESRD on dialysis. Presented to dialysis with shortness of\n breath to an extent where he could not get dialysis. Weight at\n dialysis was 6.8kg above dry weight. Transferred to ED for further\n care, on presentation noted elevated JVP, pulmonary edema. In the ED,\n initial vs were: 97.1 58 110/58 100. Got 3 doses of SL NTG, 40 IV\n Lasix, placed on non-invasive but tidal volumes in 150's and tiring.\n Droped RR to 8, was intubated. Renal was consulted for urgent\n dialysis. Transferred to ICU for further care.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n NephroVites 1\n Simvastatin 20 QHS\n Trazadone 20 QHS\n IC Amlodipine 10 Daily\n Labetolol 600 \n Olmesartan 20mg Daily\n Renagel 400mg TID prior to meals\n Lantus 8U daily\n Advair\n Past medical history:\n Family history:\n Social History:\n ESRD\n Diabetes\n Hypertension\n Hypercholesterolemia\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Cantonese speaking only\n Review of systems:\n Flowsheet Data as of 03:01 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 58 () bpm\n BP: 110/48\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66.8 kg (admission): kg\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: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 19 cmH2O\n SpO2: 93%\n Ve: 5.7 L/min\n Physical Examination\n General Appearance: No acute distress, intubated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Warm, Xerosis\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 224\n 4.7\n 28\n 32\n 97\n 3.8\n 137\n 37.1\n 8.8\n [image002.jpg]\n Assessment and Plan\n 82 y/o male with ESRD on dialysis with volume overload.\n # Volume Overload: The patient is being evaluated right now for urgent\n dialysis. He appears to be anuric as he has not responded to any of\n the diuretic treatments administered. He does not have any electrolyte\n imbalances at this time.\n # Respiratory Failure: Appears at this time to be secondary to volume\n overload as above. No evidence of infiltrate or fever suggestive of\n infectious process. CXR consistent with pulmonary edema. Dialysis as\n above.\n # Hypercholesterolemia: Continue Simvastatin\n # Hypertension: Continue amlodipine, labetalol, olmesartan.\n # DM: Continue insulin + SS\n FEN: No IVF, replete electrolytes, NPO at this time\n .\n Prophylaxis: Subcutaneous heparin, famotidine\n .\n Access: peripherals\n .\n Code: Full.\n .\n Communication: Family \n .\n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: Discussed with family.\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for the key portions of the services provided. I agree with\n the note above, including the assessment and plan. To that I would add\n the following:\n This is an 82 yo man with ESRD who arrived at outpatient HD almost 7L\n above dry weight. Noted to be in respiratory distress and sent to ED.\n CXR c/w pulmonary edema. Intubated. Transferred up to the MICU for\n further management. Currently on HD with goal to get 5L off. Plan to\n extubate either this PM post-HD or in AM.\n Pt is critically ill. Time spent 32 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:49 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 609069,
"text": "Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Pt was extubated at 2200, tolerated well. Given albuterol and atrovent\n nebs Q4 prn for wheezes. Will continue to follow.\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609066,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 12, +5, 40%. Breath sounds clear, Occ 1-3 breaths\n over rate on propofol gtt.\n Action:\n Labetolol given via OGT prior to extubation as BP 140s-150s/ on45 mcg\n propofol. ABG 7.42/58/79/39. Propofol gtt shut off, pt eyes open,\n following commands, extubated to 40% FT. I/E wheezes after extubation,\n alb/atr nebs x 2\n Response:\n Wheezes cleared after nebs. No resp distress. RR teens, sats 96-97%.\n Slept all night.\n Plan:\n Monitor resp status. Nebs prn. Wean O2\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD done at bedside, able to remove 4.5L fluid, fluid removal limited by\n BP decreasing to 100s/ during HD.\n Action:\n Able to extubate after fluid removal\n Response:\n No S/S pulmonary edema\n Plan:\n Monitor resp status, ? if will need another HD today vs Thursday\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609070,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 12, +5, 40%. Breath sounds clear, Occ 1-3 breaths\n over rate on propofol gtt.\n Action:\n Labetolol given via OGT prior to extubation as BP 140s-150s/ on45 mcg\n propofol. ABG 7.42/58/79/39. Propofol gtt shut off, pt eyes open,\n following commands, extubated to 40% FT @ 2200. I/E wheezes after\n extubation, alb/atr nebs x 2\n Response:\n Wheezes cleared after nebs. No resp distress. RR teens, sats 96-97%.\n Slept all night. Weaned to 2L NC this AM with sats high 90s.\n Plan:\n Monitor resp status. Nebs prn. Wean O2\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD done at bedside, able to remove 4.5L fluid, fluid removal limited by\n BP decreasing to 100s/ during HD.\n Action:\n Able to extubate after fluid removal\n Response:\n No S/S pulmonary edema\n Plan:\n Monitor resp status, ? if will need another HD today vs Thursday\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 609170,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2l NC,SPO2 94%,RR in 16-20(Extubated last night,did well\n post extubation). Pt says doesn\nt understand eventhough he will respond\n appropriately to your questions.\n Action:\n Pt has strong cough expectorating yellow sputum. Tolerating diet.\n Response:\n C/O floor .\n Plan:\n Monitor vital signs,Wean Oxygenas needed. Awaiting for transfer\n orders.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with history of renal failure on HD TTHSa.HD done at bedside\n yesterday and removed 4.5L fluid\n Action:\n Contgive renahgel and phoslo. Renal following. Foley draining minimal\n amount yellow urine\n Response:\n Plan:\n Monitor renal function. HD tomorrow.\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSBS 116 @ 2200 last night. Pt NPO after extubation o/n. Lantus held\n Action:\n FSBS 66 this AM. Serum glucose 58. Pt took large glass of apple juice.\n No S/S hypoglycemia.\n Response:\n Repeat FS 104 after juice.\n Plan:\n Follow blood sugars. Resume diet today.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: chronic HD.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:51\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 433 mL\n 24h total out:\n 165 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:53 AM\n Potassium:\n 3.5 mEq/L\n 03:53 AM\n Chloride:\n 98 mEq/L\n 03:53 AM\n CO2:\n 35 mEq/L\n 03:53 AM\n BUN:\n 18 mg/dL\n 03:53 AM\n Creatinine:\n 3.7 mg/dL\n 03:53 AM\n Glucose:\n 58 mg/dL\n 03:53 AM\n Hematocrit:\n 35.7 %\n 03:53 AM\n Finger Stick Glucose:\n 111\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICu 681\n Transferred to:\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 609173,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2l NC,SPO2 94%,RR in 16-20(Extubated last night,did well\n post extubation). Pt says doesn\nt understand eventhough he will respond\n appropriately to your questions. Occasionaly he pulls off\n Monitors,wants to leave.\n Action:\n Pt has strong cough expectorating yellow sputum. Tolerating diet. BS\n covered with sliding scale. Zyprexa 2.5 mg given this morning for\n anxiety.\n Response:\n C/O floor.\n Plan:\n Monitor vital signs,Wean Oxygenas needed. Waiting for transfer\n orders.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with history of renal failure on HD TTHSa.HD done at bedside\n yesterday and removed 4.5L fluid\n Action:\n Cont renagel and phoslo. Renal following. Foley draining minimal\n amount yellow urine\n Response:\n Plan:\n Monitor renal function. HD tomorrow.\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSBS 116 @ 2200 last night. Pt NPO after extubation o/n. Lantus held\n Action:\n FSBS 66 this AM. Serum glucose 58. Pt took large glass of apple juice.\n No S/S hypoglycemia.\n Response:\n Repeat FS 104 after juice.\n Plan:\n Follow blood sugars. Resume diet today.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: chronic HD.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:51\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 433 mL\n 24h total out:\n 165 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:53 AM\n Potassium:\n 3.5 mEq/L\n 03:53 AM\n Chloride:\n 98 mEq/L\n 03:53 AM\n CO2:\n 35 mEq/L\n 03:53 AM\n BUN:\n 18 mg/dL\n 03:53 AM\n Creatinine:\n 3.7 mg/dL\n 03:53 AM\n Glucose:\n 58 mg/dL\n 03:53 AM\n Hematocrit:\n 35.7 %\n 03:53 AM\n Finger Stick Glucose:\n 111\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICu 681\n Transferred to: Cc716\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 609131,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on 2l NC,SPO2 94%,RR in 16-20(Extubated last night,did well\n post extubation).\n Action:\n Pt has strong cough expectorating yellow sputum. Tolerating diet.\n Response:\n C/O floor .\n Plan:\n Monitor resp status. Nebs prn.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n HD done at bedside, able to remove 4.5L fluid, fluid removal limited by\n BP decreasing to 100s/ during HD.\n Action:\n Able to extubate after fluid removal\n Response:\n No S/S pulmonary edema\n Plan:\n Monitor resp status, ? if will need another HD today vs Thursday\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSBS 116 @ 2200 last night. Pt NPO after extubation o/n. Lantus held\n Action:\n FSBS 66 this AM. Serum glucose 58. Pt took large glass of apple juice.\n No S/S hypoglycemia.\n Response:\n Repeat FS 104 after juice.\n Plan:\n Follow blood sugars. Resume diet today.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: chronic HD.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:51\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 433 mL\n 24h total out:\n 165 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:53 AM\n Potassium:\n 3.5 mEq/L\n 03:53 AM\n Chloride:\n 98 mEq/L\n 03:53 AM\n CO2:\n 35 mEq/L\n 03:53 AM\n BUN:\n 18 mg/dL\n 03:53 AM\n Creatinine:\n 3.7 mg/dL\n 03:53 AM\n Glucose:\n 58 mg/dL\n 03:53 AM\n Hematocrit:\n 35.7 %\n 03:53 AM\n Finger Stick Glucose:\n 111\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICu 681\n Transferred to:\n Date & time of Transfer: \n"
},
{
"category": "General",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Generic Note",
"row_id": 609054,
"text": "TITLE:\n 82 y/o male with ESRD on dialysis with volume overload.\n # Volume Overload: The patient is being evaluated right now for urgent\n dialysis. He appears to be anuric as he has not responded to any of\n the diuretic treatments administered. He does not have any electrolyte\n imbalances at this time.\n # Respiratory Failure: Appears at this time to be secondary to volume\n overload as above. No evidence of infiltrate or fever suggestive of\n infectious process. CXR consistent with pulmonary edema. Dialysis as\n above.\n # Hypercholesterolemia: Continue Simvastatin\n # Hypertension: Continue amlodipine, labetalol, olmesartan.\n # DM: Continue insulin + SS\n FEN: No IVF, replete electrolytes, NPO at this time\n .\n Prophylaxis: Subcutaneous heparin, famotidine\n .\n Access: peripherals\n .\n Code: Full.\n .\n Communication: Family \n .\n Disposition: pending clinical improvement\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609041,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 609030,
"text": "82M Cantonese speaking only who was brought by \"the ride\" to his outpt\n HD treatment today. Once checked in, pt noted to have wt up 6kg from\n baseline, RR 38, dyspnea, and hypertension to sbp 180's. Ambulance\n called, pt was administered 3 nitro tablets and lasix en route to\n . Placed on BIPAP in EW for SOB and O2 sats in high 80's on NRB.\n Pt then fatigued and was intubated. Transferred to MICU for stat HD and\n for further management.\n failure, Chronic (Chronic failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt with fluid overload. STAT HD session once arrived to unit.\n Action:\n Per HD nurse pt to have 5kg removed this session.\n Response:\n HD session complete, able to remove 4.5L, tolerated well, maintained\n good blood pressure.\n Plan:\n Labs in AM, ?dialysis tomorrow for additional fluid removal.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt emergently intubated in ED for increased WOB likely related to fluid\n overload. Lungs sounds clear in all fields. Vent settings CMV\n 40%/500*12/+5. Pt initially sedated from intubation meds, waking up\n and now agitated with ETT, restless, attempting to pull at ETT. Unable\n to assess mental status due to language barrier.\n Action:\n Started on IV propofol for hopefully short intubation. Soft wrist\n restraints applied bilaterally for pt safety.\n Response:\n Continues to be restless despite propofol drip.\n Plan:\n Re-assess respiratory status once HD finishes, will need Cantonese\n interpreter, extubated when possible.\n"
},
{
"category": "Physician ",
"chartdate": "2159-12-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 609095,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 02:15 PM\n INVASIVE VENTILATION - STOP 10:00 PM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 66 (53 - 81) bpm\n BP: 145/46(71) {107/45(66) - 162/62(85)} mmHg\n RR: 15 (12 - 20) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 105 mL\n 360 mL\n PO:\n 360 mL\n TF:\n IVF:\n 105 mL\n Blood products:\n Total out:\n 4,515 mL\n 15 mL\n Urine:\n 15 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,410 mL\n 345 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 495 (446 - 495) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 38\n PIP: 13 cmH2O\n Plateau: 16 cmH2O\n SpO2: 96%\n ABG: 7.42/58/78./35/10\n Ve: 6.2 L/min\n PaO2 / FiO2: 197\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 203 K/uL\n 11.4 g/dL\n 58 mg/dL\n 3.7 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 18 mg/dL\n 98 mEq/L\n 139 mEq/L\n 35.7 %\n 9.9 K/uL\n [image002.jpg]\n 09:27 PM\n 03:53 AM\n WBC\n 9.9\n Hct\n 35.7\n Plt\n 203\n Cr\n 3.7\n TCO2\n 39\n Glucose\n 58\n Other labs: PT / PTT / INR:12.2/30.0/1.0, Ca++:7.5 mg/dL, Mg++:1.6\n mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE I\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n 82 y/o male with ESRD on dialysis with volume overload.\n # Volume Overload/Pulmonary edema: The patient is now s/p urgent\n dialysis. He appeared to be anuric as he has not responded to any of\n the diuretic treatments administered. He does not have any electrolyte\n imbalances at this time; diuresis done for volume overload. 4.5kg\n removed on .\n - f/u renal recs\n - use interpreter to d/w patient regarding etiology for pulmonary edema\n (?meds, ?diet)\n - HD tomorrow\n # Respiratory Failure: Appears at this time to be secondary to volume\n overload as above. No evidence of infiltrate or fever suggestive of\n infectious process. CXR consistent with pulmonary edema. Dialysis as\n above. S/p intubation on , now extubated on .\n - wean NC as tolerated\n - f/u read of CXR from yesterday and today\n # Hypercholesterolemia: Continue Simvastatin\n # Hypertension: Continue amlodipine, labetalol, olmesartan. Per renal,\n if need incr BP control, incr .\n # DM: Continue insulin + SS\n FEN: No IVF, replete electrolytes, advance diet as tolerated now s/p\n extubation\n .\n Prophylaxis: Subcutaneous heparin, famotidine\n .\n Access: Peripherals\n .\n Code: Full.\n .\n Communication: Family \n .\n Disposition: to floor today now s/p extubation\n ICU Care\n Lines:\n 18 Gauge - 03:03 PM\n Code status: Full code\n"
},
{
"category": "Echo",
"chartdate": "2159-12-06 00:00:00.000",
"description": "Report",
"row_id": 88811,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nWeight (lb): 176\nBP (mm Hg): 173/73\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 15:34\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting\nLVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR. Prolonged (>250ms) transmitral E-wave decel\ntime.\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 normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular\nfilling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The right\nventricular free wall is hypertrophied. The aortic root is mildly dilated at\nthe sinus level. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is mild pulmonary artery\nsystolic hypertension. There is an anterior space which most likely represents\na fat pad.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Diastolic dysfunction. Dilated\naortic sinus.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2159-12-04 00:00:00.000",
"description": "Report",
"row_id": 232818,
"text": "Sinus rhythm. Prolonged P-R interval. Prolonged Q-T interval. Rightward axis\nconsistent with a left posterior hemiblock. Possible old anterior wall\nmyocardial infarction. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111292,
"text": " 12:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess cardiopulm status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with dyspnea\n REASON FOR THIS EXAMINATION:\n please assess cardiopulm status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old man with dyspnea and low O2 saturation.\n\n COMPARISON: None.\n\n PORTABLE AP CHEST RADIOGRAPH: There are bilateral peripheral and perihilar\n interstitial opacities, with Kerley B lines noted, compatible with diffuse\n interstitial edema. The vasculature is engorged. The costophrenic angles are\n blunted bilaterally, compatible with small pleural effusions. There is no\n pneumothorax. The cardiac size is in the upper normal limit. The aortic knob\n is calcified.\n\n IMPRESSION: Moderate pulmonary edema with bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111295,
"text": " 1:01 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with resp distress post intubation\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress post-intubation ETT placement.\n\n COMPARISON: Chest radiograph (about 10 minutes of\n interval).\n\n CHEST RADIOGRAPH PORTABLE AP VIEW: Patient is status post intubation, with\n endotracheal tube terminating about 6 cm above the level of the carina.\n Nasogastric tube is noted extending below the left hemidiaphragm, with the tip\n not visualized. Again noted, there are moderate bilateral peripheral and\n perihilar interstitial opacities, suggestive of fluid overload. There is\n persistent vascular engorgement and bilateral pleural effusions. The cardiac\n size is in the upper normal limit. The aortic knob is calcified. There is no\n pneumothorax.\n\n IMPRESSION:\n\n 1. Status post intubation with visualized endotracheal tube terminating 5.8\n cm above the level of the carina.\n\n 2. Persistent moderate pulmonary edema and bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111327,
"text": " 2:50 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with ET tube, OG tube\n REASON FOR THIS EXAMINATION:\n placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old male with endotracheal tube and orogastric tube\n placement.\n\n COMPARISON: Chest radiograph available from at 12:46 p.m.\n\n SINGLE AP VIEW OF THE CHEST:\n The patient is status post intubation and placement of an orogastric tube.\n The endotracheal tube terminates 5.4 cm above the level of the carina. The\n orogastric tube extends at least to the level of the stomach; however, the\n termination point is excluded from the study.\n\n The heart size is top normal, relatively unchanged since the prior exam. The\n aorta is calcified. Hazy opacifications in the perihilar regions are\n compatible with mild interstitial edema. There is no pneumothorax. The\n costophrenic angles are blunted bilaterally, suggestive of pleural effusions.\n The patient is slightly rotated to the left, however, despite this effect,\n there appears to be left lower lobe volume loss with obscuring of the left\n hemidiaphragm.\n\n IMPRESSION:\n 1. Status post intubation with endotracheal tube terminating 5.4 cm above the\n level of the carina.\n 2. Orogastric tube terminating within the stomach; however, the tip is\n excluded from the study.\n 3. Mild pulmonary edema.\n 4. Interval decrease in left lower lobe lung volume, continued followup\n recommended.\n 5. Trace bilateral pleural effusions.\n\n Findings discussed by Dr. with Dr. at 4:15PM .\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111344,
"text": " 10:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please eval progression/change in left lower lobe volume los\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with volume-overload.\n REASON FOR THIS EXAMINATION:\n Please eval progression/change in left lower lobe volume loss, and for any\n change in pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Volume overload, followup.\n\n Portable AP chest radiograph was compared to .\n\n The patient was extubated in the meantime interval with removal of the NG\n tube. Heart size is mildly enlarged but stable. There is no significant\n change in the left retrocardiac consolidation that may represent atelectasis\n or combination of atelectasis and infection. The pulmonary edema is mild,\n unchanged. There is most likely present bilateral pleural effusion and there\n is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-12-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1111529,
"text": " 7:06 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate left sided coin lesion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with heart failure, evaluate left sided coin lesions seen on\n portable xray.\n REASON FOR THIS EXAMINATION:\n evaluate left sided coin lesion\n ______________________________________________________________________________\n WET READ: RSRc WED 10:04 PM\n Improved left retrocardiac consolidation, similar mild pulmonary edema, new\n streaky atelectasis on the right. 9:40 p 12/9/9.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Heart failure.\n\n Comparison is made with prior study performed a day earlier.\n\n Improve left retrocardiac opacity consistent with improving atelectasis, there\n are new plate-like atelectasis in the right mid lung; right lower lobe\n aeration has also improved. Cardiomediastinal contours are unchanged, small\n bilateral pleural effusions are stable, there is no pneumothorax. Mild\n pulmonary edema is stable.\n\n"
}
] |
8,799 | 171,119 | 36F history of poorly controlled DM1, Barrett's esophagitis/gastritis, HTN, diastolic CHF with LVEF >60%, h/o PEA arrest in , here with symptoms consistent with gastroparesis flair and transferred to MICU for diabetic ketoacidosis with secondary issue of hemeatemsis likely from - tear. ACTIVE ISSUES # DKA: Poorly-controlled DM type one (last A1c 11). No clear precipitant (infectious, no pancreatitis, MI) other than stress. She had a slight leukocytosis on admission, but no other signs of infection. Patient was found to be in DKA with anion gap on hospital day 2, transferred to MICU where anion gap closed within one day. Started on Insulin drip with q1hr glucose checks, and insulin gtt . Remained on insulin drip due to intolerance of PO diet. Able to tolerate PO overnight , DC'd insulin gtt. While on the regular medicine floor, pt continued to tolerate po diet fairly well. Her blood sugar was well controlled with subcu insulin. # Gastroparesis - Patient's presenting symptoms were consistent with previous gastroparesis flairs (previously unresposive to Ativan, Reglan, Zofran, and erythromycin). Patient was able to tolerate PO's on . Currently nausea/vomiting is well-controlled in-hospital with clonidine patch and PRN Ativan, Zofran, and Dimenhydrinate. Her symptoms improved significantly after transferring the regular medicine floor. We discontinued her clonidine patch given the significant orthostatic hypotension. Her gastroparesis has a characteristic intermittent flare-up every two to three months. It is unclear the long term benefit of clonidine in her given for the most time in-between her flares, she is asymtpomatic. # Hypertensive Urgency - Patient had labile pressures while in the MICU with sBPs>200, which was controlled in MICU with labetolol drop and IV labetolol. Prior the transfer to the floor, patient was transitioned to amlodopine 5mg QD and clonidine patch with adequate control of BP. On discharge, her SBPs are 140s-160s. Pt had significant autonomic dysfunction likely in the setting of long-term poorly controlled diabetes. Her blood pressure medication has been weaned off by her PCP to prevent hypotension. After discussion with her PCP, decided to discontinue her blood pressure medication started as inpatient and continue outpatient followup. # Hypernatremia - Free water deficit of 1.2 was repleted with 1/2NS with slow correction of hypernatremia from 153 to 144 over 28 hours. On discharge, patient is asymptomatic with Na trending down to 139. # Anemia and Coffee ground emesis - Consistent with low-volume upper GI bleed from - tear. GI consult saw in-house, and recommended conservative management with pantoprazole. Throughout the hospital course, the patient remained hemodynamically stable with stable Hct27-30. Patient was placed on PPI and crossmatched with PIV in place. # - Baseline Cr 1.0. During this admission, Cr 1.2-1.8 most likely due to pre-renal etiology given poor PO intake and vomiting. Following IV hydration patient was noted to have a down trend in her BUN and . On discharge, BUN stable at 12-15, Cr at 1.2-1.5, iet. CHRONIC ISSUES # Depression / anxiety - continued on home Sertraline and Ativan # Neuropathy - continued on home gabapentin TRANSIONAL ISSUES # Code status: Full code # Pending studies: None # Medication changes: - Dimenhydrinate 50 mg PO PRN nausea/vomiting # FOLLOWUP PLAN - PCP followup on - diabetes followup on Attending addendum: After speaking with PCP, was decided to stop all blood pressure medications upon discharge as patient was profoundly orthostatic. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Gabapentin 800 mg PO HS 2. Sertraline 100 mg PO DAILY 3. Furosemide Dose is Unknown PO Frequency is Unknown 4. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Ferrous Sulfate 325 mg PO DAILY 6. Vitamin D Dose is Unknown PO DAILY 7. Calcium Carbonate Dose is Unknown PO Frequency is Unknown 8. Simvastatin 20 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Metoclopramide 10 mg PO Frequency is Unknown Discharge Medications: 1. Gabapentin 800 mg PO HS 2. Calcium Carbonate 500 mg PO QID:PRN upset stomach 3. Sertraline 100 mg PO DAILY 4. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Ferrous Sulfate 325 mg PO DAILY 6. Metoclopramide 10 mg PO HS:PRN heartburn 7. Omeprazole 40 mg PO DAILY 8. Atorvastatin 20 mg PO DAILY 9. Torsemide 10 mg PO DAILY 10. Vitamin D UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetic ketoacidosis with gastroparesis Secondary Diagnoses: Hypertensive urgency, anemia due to - tear, chronic kidney disease. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. , You were admitted at for nausea/vomiting. We found that you had diabetic ketoacidosis with gastroparesis and hypertensive urgency. You are now safe to go home. Please note that there is no changes in your medication. Please follow-up with your PCP . on at 8:20AM. Followup Instructions: Department: Endocrinology- Diabetes Center Name: Dr. for Dr. When: at 9:30 AM Location: DIABETES CENTER Address: ONE PLACE, , , Phone: Department: When: TUESDAY at 3:10 PM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage Department: When: MONDAY at 8:20 AM With: , MD Building: SC Clinical Ctr Campus: EAST Best Parking: Garage | The pre-existing right upper extremity PICC was left in place, although a new sterile dressing was applied. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the right basilic venous approach. Attempted bedside PICC placement, although line could only be threaded in halfway. The pre-existing PICC was left in place, although a new sterile dressing was applied. Poor R waveprogression in leads V1-V3, probably a normal variant. Cardiomediastinal silhouette is within normal limits. Borderline short P-R interval with no further evidence ofpre-excitation. Short P-R interval. Short P-R interval. Short P-R interval. Modest ST-T wave changes which are non-specific. 3:08 PM PICC LINE PLACMENT SCH Clip # Reason: Attempted bedside picc, threaded in but couldnt pass. Borderline lowQRS voltage. Non-specific ST-T wave changes in the anterior and lateralprecordial leads. Comparedto the previous tracing of there is no significant diagnostic change.TRACING #1 T wave abnormalities. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Compared to tracing #1 there is no significant diagnosticchange.TRACING #2 IMPRESSION: Patient unable to tolerate PICC exchange. Non-specific ST-T wavechanges. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. Please replace PICC. The PICC line is coiled in the right upper arm vein, the tip reaches the axilla but does not enter the thorax. FINDINGS: The lungs are unchanged. Final internal length is 31 cm, with the tip positioned in SVC. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. P Admitting Diagnosis: NAUSEA ********************************* CPT Codes ******************************** * PICC W/O PORT FEE ADJUSTED IN SPECIFIC SITUATION * **************************************************************************** FINAL REPORT INDICATION: History of gastroparesis and diabetic ketoacidosis. 4:35 PM PICC LINE PLACMENT SCH Clip # Reason: place PICC Admitting Diagnosis: NAUSEA This is a power pick ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. A timeout was performed. The lungs are clear of focal consolidation or effusion. There are vague rounded opacities projecting over the right mid-to-lower lung seen over the anterior and lateral ribs, suggesting healing fractures. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. TECHNIQUE: Using sterile technique and local anesthesia, the right basilic vein was punctured under direct ultrasound guidance using a micropuncture set. No acute cardiopulmonary process. Osseous and soft tissue structures are unremarkable. Sinus tachycardia at 127 beats per minute. FINDINGS: PA and lateral views of the chest are compared to previous exam from . ACCESS * **************************************************************************** MEDICAL CONDITION: 36 year old woman with difficult access, please place PICC line (bedside attempt failed) REASON FOR THIS EXAMINATION: place PICC FINAL REPORT PICC LINE PLACEMENT INDICATION: 36-year-old woman with difficulty access at the bedside, failed attempt.IV access needed for IV access. There is no other diagnostic change.TRACING #1 4:11 PM CHEST PORT. The line needs to be re-positioned. RADIOLOGISTS: Dr. , Dr. (the attending who was present and supervising throught out the procedure). RADIOLOGIST: Dr. , Dr. and Dr. performed the procedure. A peel-away sheath was then placed over a guidewire and a double lumen PICC line measuring 31 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. No evidence of complications. Non-specific ST-T wave changes in the anterior and lateral leads.Compared to the previous tracing of the sinus rate has increased by20 beats per minute with no other diagnostic change.TRACING #2 The procedure was explained to the patient. There were no immediate complications. LINE PLACEMENT Clip # Reason: please evaluate for picc line placement Admitting Diagnosis: NAUSEA MEDICAL CONDITION: 36 year old woman with dka REASON FOR THIS EXAMINATION: please evaluate for picc line placement FINAL REPORT CHEST RADIOGRAPH INDICATION: PICC line placement. While on the table, the patient began retching and subsequently had small volume coffee-ground emesis. COMPARISON: . Given her ongoing nausea and retching/vomiting, the patient elected to postpone the procedure. | 10 | [
{
"category": "ECG",
"chartdate": "2140-09-17 00:00:00.000",
"description": "Report",
"row_id": 181373,
"text": "Sinus tachycardia at 127 beats per minute. Short P-R interval. Borderline low\nQRS voltage. Non-specific ST-T wave changes in the anterior and lateral leads.\nCompared to the previous tracing of the sinus rate has increased by\n20 beats per minute with no other diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-16 00:00:00.000",
"description": "Report",
"row_id": 181374,
"text": "Sinus tachycardia. Borderline short P-R interval with no further evidence of\npre-excitation. Non-specific ST-T wave changes in the anterior and lateral\nprecordial leads. Compared to the previous tracing the sinus rate has\ndecreased by 15 beats per minute and the anterior and lateral ST-T wave changes\nare slightly less pronounced. There is no other diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-16 00:00:00.000",
"description": "Report",
"row_id": 181375,
"text": "Sinus tachycardia. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-15 00:00:00.000",
"description": "Report",
"row_id": 181376,
"text": "Sinus tachycardia. Modest ST-T wave changes which are non-specific. Compared\nto the previous tracing of there is no significant diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-20 00:00:00.000",
"description": "Report",
"row_id": 181135,
"text": "Sinus tachycardia. Short P-R interval. T wave abnormalities. Since the\nprevious tracing of the rate is faster.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-09-18 00:00:00.000",
"description": "Report",
"row_id": 181372,
"text": "Sinus rhythm at 90 beats per minute. Short P-R interval. Poor R wave\nprogression in leads V1-V3, probably a normal variant. Non-specific ST-T wave\nchanges. Compared to the previous tracing of the sinus rate has\ndecreased by 35 beats per minute with no other diagnostic change.\nTRACING #3\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-16 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1251842,
"text": " 3:08 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Attempted bedside picc, threaded in but couldnt pass. P\n Admitting Diagnosis: NAUSEA\n ********************************* CPT Codes ********************************\n * PICC W/O PORT FEE ADJUSTED IN SPECIFIC SITUATION *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of gastroparesis and diabetic ketoacidosis. Attempted\n bedside PICC placement, although line could only be threaded in halfway.\n Please replace PICC.\n\n RADIOLOGISTS: Dr. , Dr. (the attending who was present and\n supervising throught out the procedure).\n\n PROCEDURE/FINDINGS: The patient was brought to the angiography suite and\n placed on the table in a supine position. While on the table, the patient\n began retching and subsequently had small volume coffee-ground emesis. Given\n her ongoing nausea and retching/vomiting, the patient elected to postpone the\n procedure. The pre-existing right upper extremity PICC was left in place,\n although a new sterile dressing was applied.\n\n IMPRESSION: Patient unable to tolerate PICC exchange. The pre-existing PICC\n was left in place, although a new sterile dressing was applied.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1251851,
"text": " 4:11 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please evaluate for picc line placement\n Admitting Diagnosis: NAUSEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with dka\n REASON FOR THIS EXAMINATION:\n please evaluate for picc line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: The lungs are unchanged.\n\n The PICC line is coiled in the right upper arm vein, the tip reaches the\n axilla but does not enter the thorax. The line needs to be re-positioned. No\n evidence of complications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1251731,
"text": " 5:19 PM\n CHEST (PA & LAT) Clip # \n Reason: Eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with DMI and hyperglycemia.\n REASON FOR THIS EXAMINATION:\n Eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS\n\n HISTORY: 36-year-old female with diabetes and hyperglycemia.\n\n FINDINGS: PA and lateral views of the chest are compared to previous exam\n from . There are vague rounded opacities projecting over the\n right mid-to-lower lung seen over the anterior and lateral ribs, suggesting\n healing fractures. The lungs are clear of focal consolidation or effusion.\n Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: Multiple healing right-sided rib fractures. No acute\n cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-09-19 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1252162,
"text": " 4:35 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: place PICC\n Admitting Diagnosis: NAUSEA\n This is a power pick\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with difficult access, please place PICC line (bedside\n attempt failed)\n REASON FOR THIS EXAMINATION:\n place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: 36-year-old woman with difficulty access at the bedside, failed\n attempt.IV access needed for IV access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. , Dr. and Dr. performed the\n procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double lumen PICC line measuring 31 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen\n PICC line placement via the right basilic venous approach. Final internal\n length is 31 cm, with the tip positioned in SVC. The line is ready to use.\n\n"
}
] |
83,550 | 160,696 | This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in without any recurrence, and s/p cecectomy in for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. . #. COPD EXACERBATION: Pt with known history of COPD on no medications, last seen by Dr. 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg , and dextromethorphran 60 mg . She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation. Patient was discharged with close PCP . We also scheduled follow up with pulmonary w/outpatient PFTs to evaluate the severity of her COPD. . #. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of . WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #. TOBACCO ABUSE: Patient extensively counseled on smoking cessation. Social work was consulted and multiple resources presented to patient to successfully quit smoking. . #. RIGHT MEDIAL MALLELOUS PAIN: Injury to bilateral lower extremities during admission from O2 tank. Imaging negative for acute fractures/dislocations. The patient's pain was well controlled with ibuprofen and improved over the course of her admission. Pt denied any additional pain at time of discharge. . #. HYPERLIPIDEMIA. Stable, with no acute issues. Continued home atorvastatin 20 mg during admission. . The patient was given SC heparin for DVT prophylaxis. Communication was maintained with the patient and her daughter (HCP), (cell), (home). She was full code throughout her admission. | IMPRESSION: Mild degenerative change at the right talonavicular articulation. Mild prominence to the pulmonary vessels is redemonstrated, likely representing mild interstitial edema. There is mild degenerative change at the talonavicular articulation. Coarse interstitial markings are demonstrated throughout both lungs, which are mildly hyperinflated, also seen on the prior examination from , compatible with known COPD. Compared to the previous tracing of atrialfibrillation has been replaced by sinus tachycardia. RSR' pattern in lead V1,probable normal variant. The mortise is congruent. The mortise is congruent. Sinus tachycardia. T waveabnormalities. Borderline low limb lead voltage. Sinus rhythm. FINAL REPORT INDICATION: Bilateral ankle trauma. RSR' pattern in lead V1. Delayed R wave transition. The tibial plafond and talar dome are preserved. The tibial plafond and talar dome are preserved. Since the previous tracing of the rate is slower. THREE VIEWS OF THE RIGHT ANKLE: No fracture or dislocation. THREE VIEWS OF THE LEFT ANKLE: No fracture or dislocation. IMPRESSION: Multifocal pneumonia superimposed on COPD and mild interstitial edema. There are focal opacities within the right upper and bilateral lower lobes, accompanied by small right pleural effusion, concerning for pneumonia. 3:28 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna MEDICAL CONDITION: 72F p/w cough. COMPARISON: Chest radiograph available from and CT . UPRIGHT FRONTAL CHEST RADIOGRAPH: The heart size is normal. Initial pain, subsided, was able to bear weight, now with increased pain. REASON FOR THIS EXAMINATION: Acute injury/fracture to bilateral ankles s/p injury with O2 tank? There is no overlying soft tissue swelling. There is no overlying soft tissue swelling. No fracture or dislocation. TECHNIQUE: Three views of the left ankle and three views of right ankle were obtained. COMPARISON: None. SOB REASON FOR THIS EXAMINATION: r/o pna WET READ: LLTc SAT 4:40 PM Multifocal pna superimposed on chronic COPD. There is no pneumothorax. FINAL REPORT INDICATION: 72-year-old female presenting with cough. | 4 | [
{
"category": "Radiology",
"chartdate": "2198-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1170505,
"text": " 3:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72F p/w cough. SOB\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n WET READ: LLTc SAT 4:40 PM\n Multifocal pna superimposed on chronic COPD.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female presenting with cough.\n\n COMPARISON: Chest radiograph available from and CT .\n\n UPRIGHT FRONTAL CHEST RADIOGRAPH:\n The heart size is normal. Coarse interstitial markings are demonstrated\n throughout both lungs, which are mildly hyperinflated, also seen on the prior\n examination from , compatible with known COPD. There are focal\n opacities within the right upper and bilateral lower lobes, accompanied by\n small right pleural effusion, concerning for pneumonia. Mild prominence to\n the pulmonary vessels is redemonstrated, likely representing mild interstitial\n edema. There is no pneumothorax.\n\n IMPRESSION: Multifocal pneumonia superimposed on COPD and mild interstitial\n edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-01-15 00:00:00.000",
"description": "B ANKLE (AP, MORTISE & LAT) BILAT",
"row_id": 1170691,
"text": " 10:02 AM\n ANKLE (AP, MORTISE & LAT) BILAT Clip # \n Reason: Acute injury/fracture to bilateral ankles s/p injury with O2\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with COPD exacerbation, s/p O2 tank injury to L lateral and R\n medial ankles. Initial pain, subsided, was able to bear weight, now with\n increased pain.\n REASON FOR THIS EXAMINATION:\n Acute injury/fracture to bilateral ankles s/p injury with O2 tank?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral ankle trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Three views of the left ankle and three views of right ankle were\n obtained.\n\n THREE VIEWS OF THE RIGHT ANKLE: No fracture or dislocation. The mortise is\n congruent. The tibial plafond and talar dome are preserved. There is mild\n degenerative change at the talonavicular articulation. There is no overlying\n soft tissue swelling.\n\n THREE VIEWS OF THE LEFT ANKLE: No fracture or dislocation. The mortise is\n congruent. The tibial plafond and talar dome are preserved. There is no\n overlying soft tissue swelling.\n\n IMPRESSION: Mild degenerative change at the right talonavicular articulation.\n No fracture or dislocation.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-01-15 00:00:00.000",
"description": "Report",
"row_id": 111760,
"text": "Sinus rhythm. Borderline low limb lead voltage. RSR' pattern in lead V1. T wave\nabnormalities. Since the previous tracing of the rate is slower.\n\n"
},
{
"category": "ECG",
"chartdate": "2198-01-13 00:00:00.000",
"description": "Report",
"row_id": 111761,
"text": "Sinus tachycardia. Delayed R wave transition. RSR' pattern in lead V1,\nprobable normal variant. Compared to the previous tracing of atrial\nfibrillation has been replaced by sinus tachycardia.\n\n"
}
] |
42,073 | 174,038 | 76 yo F with lupus nephritis, CKD on HD, CAD s/p CABG, HTN, rectro-vag fistula who presented to the ER with likely GI bleeding of diverticular source admitted to the MICU for GI bleed, hypotension and respiratory failure. . # GI bleed: The patient presented to the ER with bright red blood per vagina mixed with feces while going to the bathroom. The patient has had h/o vaginal bleeding previously, but never to this extent. She also has a long history of urosepsis stool output from vagina from a known rectal vaginal fistula. CTA did not demonstrate active bleeding. No further BRBPR during her admission. Gyn, GI and Surgery were consulted in the ER and followed while in the MICU. The likely source of the bleeding was deemed to be from a diverticular bleed that was near the fistular opening. GI did not pursue colonoscopy at this time given patient's tenuous status. GYN stated the potential for fistula repair via a sub-total colectomy followed by exision of the fistula, should the patient stabilize clinically. Patient had no further bleeding after first night of admission and hematocrit was stable, but was critically ill throughout her stay so no surgical intervention or workup of the fistula was pursued. . # Hypoxic respiratory failure: In the ER she received 1.7L of fluid for hypotension and shortly thereafter the patient developed acute pulmonary edema and tachypnea. She received Bipap, nitro SL, and nitro gtt with no improvement. Her BP dropped to 80's/40's and she was intubated. She was sent to the MICU for management of her respiratory failure. Thoughts for her hypoxic respiratory failure included infection, hypervolemia, CHF exacerbation. Less likely TRALI or ARDS following blood transfusion since per ED report pt had received fluids prior to intubation. She remained intubated and sedated until she was terminally extubated at the decision of her family given her critical illness and lack of improvement. . # Septic Shock: On , pt had positive blood cultures that was + for with Urine cx showing E.Coli. Source of blood infection unclear, thought to be ascending urinary tract, vaginal infection given fistula or AV fistula source. No evidence of infection in AV fistula or any lines per transplant surgery. The patient was started on Micafungin. A TTE was performed which showed an echodensity and they could not rule out a vegetation. A TEE did not demonstrate any evidence of vegetation and AV graft showed no evidence of infection. Transplant surgery did not think the graft looked infected either. The patient was given Vanc/Cefepime/flagyl for broad-spectrum antibiotic coverage, then started on micafungin when grew in the bloodstream. OB/GYN and ID felt candidemia be secondary to source from fistula, and blood cultures cleared after she was started on micafungin. However, patient remained on double pressors and CVVH during MICU stay. Stress dose steroids were also tried one day prior to death. . # Rectovaginal fistula: The patient has a known diagnosis of rectovaginal fistula diagnosed in . Surgery, GI, and gyn consulted. No indication to repair while patient septic and intubated. . # CRF: Given hypotension, Pt did not undergo her usual Tues/Thurs/Sat HD and instead underwent CVVH for K,H+ clearance. When initially started on this on , she became hypothermic to 92 degrees and it was stopped. It was restarted the next day using a bear hugger and the patient maintained her temperature. Her medications were renally dosed. | Mild (1+) aortic regurgitation is seen. Mild (1+) central aortic regurgitation is seen. There is a minimally increased gradient consistent with minimalaortic valve stenosis. Normalascending aorta diameter. Unchanged moderate cardiomegaly with retrocardiac atelectasis. Significant PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: If clinically indicated, a transesophageal echocardiographicexamination is recommended.Conclusions:The left atrium is elongated. FINDINGS: An endotracheal tube, nasogastric tube and right internal jugular central line are in standard and unchanged positions. A secundum type atrial septal defect is present with left to rightflow at rest. A left pleural fluid has resolved. ]AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque. There is moderate pulmonaryartery systolic hypertension. Left axis deviation consistentwith left anterior fascicular block. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The aortic valve leaflets (3) are mildlythickened. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild aortic regurgitation withoutdiscrete vegetation. Moderate tosevere [3+] tricuspid regurgitation is seen. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Please note there is evidence of prior median sternotomy and CABG, the stigmata of which are stable. Presence of a small left pleural effusion cannot be excluded. The remainder of the examination is essentially unchanged and demonstrates the monitoring and support devices in place and areas of increased opacification in the retrocardiac region. Moderate to severe (3+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The tricuspidregurgitation jet is eccentric and directed toward the interatrial septum.There is moderate pulmonary artery systolic hypertension. Moderate pulmonary hypertension. Cannot exclude prior anteroseptal wall myocardial infarction, ageindeterminate. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildy dilated aortic root. PATIENT/TEST INFORMATION:Indication: EndocarditisHeight: (in) 61Weight (lb): 110BSA (m2): 1.47 m2BP (mm Hg): 124/60HR (bpm): 61Status: InpatientDate/Time: at 15:57Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. There is blunting of the right costophrenic angle, possibly indicating a small effusion. The rhythm appears to be atrialfibrillation. Borderline size of the cardiac silhouette. Aneccentric, posteriorly directed jet of moderate (2+) mitral regurgitation isseen. Since the previous tracing of ectopic atrial rhythm hasreplaced sinus rhythm, axis is more leftward and further ST-T wave changes arenow present. Normal tricuspid valve supporting structures.No TS. Newly appeared moderate right pleural effusion. IMPRESSION: Interval placement of endotracheal and nasogastric tubes in appropriate positions as above. Probable ectopic atrial rhythm with atrial premature beats and ventricularpremature beats. Consider anterior wall myocardial infarction ofindeterminate age, although is non-diagnostic. FINDINGS: As compared to the previous radiograph, the ET tube has been pulled back. Sinus tachycardia with atrial premature beats. IMPRESSION: Improved pulmonary edema and resolved left pleural effusion. Non-specific anteroseptal and lateralST-T wave changes. There is no pericardialeffusion.Compared with the findings of the prior study (images reviewed) of , the findings are similar.If clinically indicated, a transesophageal echocardiographic examination isrecommended.If clinically suggested, the absence of a vegetation by 2D echocardiographydoes not exclude endocarditis. There is a saccular aneurysm measuring 2.8 cm coming off the left lateral wall of the aorta and this is stable in size. Evaluate for aortoenteric fistula. Low normalLVEF. Left axis deviation be due toleft anterior fascicular block. The kidneys are atrophic with a very the thin cortical rim. There is atelectasis at the lung bases bilaterally. Minimal right basilar atelectasis is stable. These findings are suggestive of mild-to-moderate pulmonary edema. Right ventricular chamber size and freewall motion are normal. No PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Non-specific anterolateral ST-T wave changes. There is aortic tortuosity with calcified plaque seen at the arch. The aortic root is mildly dilated at the sinus level.The aortic valve leaflets (3) are mildly thickened. FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position. FINDINGS: There is a diffuse prominence of the interstitial markings, particularly at the hila with cephalization of flow and fluid within the interlobular septae at the lung bases. Extensive diverticulosis without evidence for diverticulitis. Mild volume overload changes are again present. The cardiomediastinal silhouette is stable. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 60Weight (lb): 130BSA (m2): 1.56 m2BP (mm Hg): 110/50HR (bpm): 90Status: InpatientDate/Time: at 12:42Test: Portable TEE (Congenital)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or theRA/RAA. FINDINGS: As compared to the previous radiograph, the monitoring and support devices are unchanged. Clinical correlation issuggested. There is normal enhancement of the small bowel and the colon. There is normal enhancement of the small bowel. Saccular infrarenal aortic aneurysm measuring up to 3 cm in diameter is stable in size. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Comparison is made to prior examination of . A right internal jugular approach central line has been placed consistent with the given history. FINAL REPORT CHEST RADIOGRAPH INDICATION: ET tube re-adjusted. Focal calcifications in aortic root. The left costophrenic angle is maintained. Normal mitralvalve supporting structures. Mild to moderate [+] TR.Eccentric TR jet. Left ventricular wall thicknesses are normal.The left ventricular cavity size is normal. Low QRS voltage in thelimb leads. Focal calcifications in ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Moderate (2+) MR. tothe eccentric MR jet, its severity be underestimated (Coanda effect).TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. [Intrinsic LV systolic functionlikely depressed given the severity of valvular regurgitation. FINDINGS: Transverse and sagittal images of the subcutaneous tissues surrounding the left upper extremity AV fistula were obtained. Normal LV cavity size. The mediastinum is stable in width. IMPRESSION: Volume overload likely from cardiogenic etiology. There is no pericardial effusion.IMPRESSION: Thickened mitral leaflets with moderate to severe mitralregurgitation, but no discrete vegetation. | 14 | [
{
"category": "Radiology",
"chartdate": "2101-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167076,
"text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with GIB, sepsis intubated with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Gastrointestinal bleeding, intubation, respiratory failure.\n Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are unchanged. In the interval, the pulmonary vessels have increased\n in diameter and peribronchial cuffing is seen. These findings are suggestive\n of mild-to-moderate pulmonary edema. Unchanged moderate cardiomegaly with\n retrocardiac atelectasis. Presence of a small left pleural effusion cannot be\n excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-12-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167484,
"text": " 3:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: progression?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman intubated\n REASON FOR THIS EXAMINATION:\n progression?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Intubation, evaluation of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. Newly appeared moderate right pleural\n effusion. Borderline size of the cardiac silhouette. Increasing left lower\n lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-12-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167516,
"text": " 8:30 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: confirm proper ET position?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with ET tube readjusted, pulled up 2cm.\n REASON FOR THIS EXAMINATION:\n confirm proper ET position?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: ET tube re-adjusted. Confirm proper position.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the ET tube has been pulled\n back. The tip of the tube now projects 3.5 cm above the carina. The lung\n bases bilaterally appear better ventilated. Otherwise there is no relevant\n change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1166890,
"text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess for pulm edema/infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with GI bleed and hypoxic resp failure requiring intubation\n after volume resuscitation, also w/ fevers\n REASON FOR THIS EXAMINATION:\n pls assess for pulm edema/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever and hypoxic respiratory failure requiring intubation.\n\n COMPARISON: CXR at 12:49 p.m. and 3:04 p.m.\n\n FINDINGS: An endotracheal tube, nasogastric tube and right internal jugular\n central line are in standard and unchanged positions. Pulmonary edema has\n probably improved. A left pleural fluid has resolved. Minimal right basilar\n atelectasis is stable. The cardiomediastinal silhouette is stable.\n\n IMPRESSION: Improved pulmonary edema and resolved left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-12-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1166815,
"text": " 2:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p intubation\n REASON FOR THIS EXAMINATION:\n Eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 15:04 HOURS\n\n HISTORY: Post-intubation.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Consistent with the given history, an endotracheal tube has been\n placed since the prior exam with the distal tip approximately 4.6 cm from the\n carina. A nasogastric tube has also been inserted coiling in the left upper\n quadrant with the side hole laterally. The patient is markedly rotated for\n the exam, limiting the utility. Mild volume overload changes are again\n present. There is blunting of the left costophrenic angle, though this be\n in part positional. Otherwise, the study is stable.\n\n IMPRESSION: Interval placement of endotracheal and nasogastric tubes in\n appropriate positions as above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-12-27 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1166814,
"text": " 2:52 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: please eval r/o aortoenteric fistula\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with rectovaginal fistula, vaginal bleed, s/p hysterectomy\n REASON FOR THIS EXAMINATION:\n please eval r/o aortoenteric fistula\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST\n\n INDICATION: A 77-year-old woman with rectovaginal fistula, vaginal bleeding,\n status post hysterectomy. Evaluate for aortoenteric fistula.\n\n TECHNIQUE: Multidetector scanning is performed from the diaphragm through the\n symphysis prior to and during dynamic injection of 80 mL of Optiray. Please\n note that the contrast was hand injected.\n\n CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Comparison is made to prior\n examination of . There is atelectasis at the lung bases bilaterally.\n The liver is without focal lesions. The patient is status post\n cholecystectomy. The spleen is unremarkable. Hypodense lesions in the spleen\n are felt to represent streak artifact. The pancreas is unremarkable. The\n adrenal glands are normal. The kidneys are atrophic with a very the thin\n cortical rim. Multiple cysts are seen in both kidneys, the largest in the\n left upper pole measuring 2.5 cm. There are extensive vascular\n calcifications. A punctate calcification in the left kidney at mid pole \n represent a tiny stone. There is a saccular aneurysm measuring 2.8 cm coming\n off the left lateral wall of the aorta and this is stable in size. There is\n normal enhancement of the small bowel. Several diverticula are noted\n throughout the colon.\n\n CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: A Foley catheter is noted in\n the bladder. On the contrast enhanced scan, opacified urine is seen in the\n bladder. There is normal enhancement of the small bowel and the colon. There\n is no free fluid in the pelvis. There is no evidence for active\n extravasation. Some enhancement along the known colovaginal fistula, which is\n likely due to inflammatory changes.\n\n On bone windows, there are degenerative changes in the lumbar spine. An old\n fracture of the sacrum is seen on the left.\n\n IMPRESSION:\n 1. No definite evidence for active extravasation in the region of the known\n colovaginal fistula.\n\n 2. Saccular infrarenal aortic aneurysm measuring up to 3 cm in diameter is\n stable in size.\n\n (Over)\n\n 2:52 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: please eval r/o aortoenteric fistula\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Extensive diverticulosis without evidence for diverticulitis.\n\n 4. Atrophic kidneys with multiple cysts bilaterally consistent with history\n of end-stage renal disease.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-12-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1166773,
"text": " 12:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with IJ\n REASON FOR THIS EXAMINATION:\n Eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 1249 HOURS.\n\n HISTORY: Internal jugular central line placement.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n The patient's left arm overlies the left lung, the lower aspect of the\n hemithorax obscuring visualization.\n\n FINDINGS: There is a diffuse prominence of the interstitial markings,\n particularly at the hila with cephalization of flow and fluid within the\n interlobular septae at the lung bases. These findings are consistent with\n volume overload. A right internal jugular approach central line has been\n placed consistent with the given history. The distal tip is projecting within\n the distal superior vena cava just proximal to the superior cavoatrial\n junction. There is no pneumothorax. The mediastinum is stable in width.\n There is aortic tortuosity with calcified plaque seen at the arch. The left\n costophrenic angle is maintained. There is blunting of the right costophrenic\n angle, possibly indicating a small effusion. No pneumothorax is evident.\n Please note there is evidence of prior median sternotomy and CABG, the\n stigmata of which are stable. There has been prior cholecystectomy.\n Degenerative changes are noted throughout the thoracic spine.\n\n IMPRESSION: Volume overload likely from cardiogenic etiology.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-01-02 00:00:00.000",
"description": "LP US EXTREMITY NONVASCULAR LEFT PORT",
"row_id": 1167679,
"text": " 11:18 AM\n US EXTREMITY NONVASCULAR LEFT PORT Clip # \n Reason: pls assess for e/o fluid collection or abscess involving L A\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with ESRD on HD p/w sepsis and fungemia. SOurce of infection\n unclear.\n REASON FOR THIS EXAMINATION:\n pls assess for e/o fluid collection or abscess involving L AV fistula\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old female with end-stage renal disease on hemodialysis\n with sepsis and fungemia. Evaluate for source of infection.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Transverse and sagittal images of the subcutaneous tissues\n surrounding the left upper extremity AV fistula were obtained. There is flow\n identified within the AV fistula on color Doppler imaging. No edema or\n discrete fluid collection is seen in the left arm.\n\n IMPRESSION: No fluid collection or evidence of abscess is seen at the site of\n the patient's left arm AV fistula.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-12-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1166962,
"text": " 1:21 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? placement of new dialysis catheter\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with new dialysis catheter placement. (Please obtain after\n dialysis line is placed)\n REASON FOR THIS EXAMINATION:\n ? placement of new dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dialysis catheter 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 upper portion of the SVC.\n The remainder of the examination is essentially unchanged and demonstrates the\n monitoring and support devices in place and areas of increased opacification\n in the retrocardiac region.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2102-01-02 00:00:00.000",
"description": "Report",
"row_id": 63886,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 60\nWeight (lb): 130\nBSA (m2): 1.56 m2\nBP (mm Hg): 110/50\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 12:42\nTest: Portable TEE (Congenital)\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: Secundum ASD.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%). [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.]\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. 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. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. No abscess of tricuspid valve. Mild to moderate [+] TR.\nEccentric TR jet. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: 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 under\ngeneral anesthesia throughout the procedure. No glycopyrrolate was\nadministered. No TEE related complications. The rhythm appears to be atrial\nfibrillation. Cardiology fellow involved with the patient's care was notified\nby telephone. MD caring for the patient was notified of the echocardiographic\nresults by e-mail. Bilateral pleural effusions.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. A secundum type atrial septal defect is present with left to right\nflow at rest. Overall left ventricular systolic function is normal (LVEF>55%).\n[Intrinsic function be depressed given the severity of mitral\nregurgitation.] There are simple atheroma in the descending thoracic aorta\ndown to 40cm from incisors. The aortic valve leaflets (3) are mildly\nthickened. No masses or vegetations are seen on the aortic valve. No aortic\nvalve abscess is seen. Mild (1+) central aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. No mass, vegetation or abscess is\nseen on the mitral valve. Moderate to severe (3+) mitral regurgitation is\nseen. There is no vegetation or abscess of the tricuspid valve. The tricuspid\nregurgitation jet is eccentric and directed toward the interatrial septum.\nThere is moderate pulmonary artery systolic hypertension. Pulmonic valve is\nnormal without vegetation/mass. No pulmonic regurgitation. There are bilateral\npleural effusions. There is no pericardial effusion.\n\nIMPRESSION: Thickened mitral leaflets with moderate to severe mitral\nregurgitation, but no discrete vegetation. Mild aortic regurgitation without\ndiscrete vegetation. Moderate pulmonary hypertension.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2101-12-29 00:00:00.000",
"description": "Report",
"row_id": 63887,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis\nHeight: (in) 61\nWeight (lb): 110\nBSA (m2): 1.47 m2\nBP (mm Hg): 124/60\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 15:57\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: Normal LV wall thickness. Normal LV cavity size. Low normal\nLVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Focal calcifications in aortic root. Normal\nascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. Minimal AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\nvalve supporting structures. No MS. Eccentric MR jet. Moderate (2+) MR. to\nthe eccentric MR jet, its severity be underestimated (Coanda effect).\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\nNo TS. Moderate to severe [3+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. No PS. Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: If clinically indicated, a transesophageal echocardiographic\nexamination is recommended.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is low normal (LVEF 50%). Right ventricular chamber size and free\nwall motion are normal. The aortic root is mildly dilated at the sinus level.\nThe aortic valve leaflets (3) are mildly thickened. No masses or vegetations\nare seen on the aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. There is a minimally increased gradient consistent with minimal\naortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse. An\neccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is\nseen. Due to the eccentric nature of the regurgitant jet, its severity be\nsignificantly underestimated (Coanda effect). An echodensity associated with\nthe anterior mitral leaflet, on its atrial aspect is seen, most likely\nrepresenting an acoustic artifact, but a vegetation cannot be excluded with\ncertainty. The tricuspid valve leaflets are mildly thickened. Moderate to\nsevere [3+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. No vegetation/mass is seen on the pulmonic\nvalve. Significant pulmonic regurgitation is seen. There is no pericardial\neffusion.\n\nCompared with the findings of the prior study (images reviewed) of , the findings are similar.\n\nIf clinically indicated, a transesophageal echocardiographic examination is\nrecommended.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2101-12-29 00:00:00.000",
"description": "Report",
"row_id": 124351,
"text": "Sinus tachycardia with atrial premature beats. Left axis deviation consistent\nwith left anterior fascicular block. Non-specific anteroseptal and lateral\nST-T wave changes. Compared to tracing #1 the axis is more leftward. Atrial\nectopy is more frequent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2101-12-29 00:00:00.000",
"description": "Report",
"row_id": 124352,
"text": "Sinus rhythm with frequent ventricular ectopy. Low QRS voltage in the\nlimb leads. Cannot exclude prior anteroseptal wall myocardial infarction, age\nindeterminate. Non-specific anterolateral ST-T wave changes. Compared to the\nprevious tracing of the findings are similar.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2101-12-28 00:00:00.000",
"description": "Report",
"row_id": 124399,
"text": "Probable ectopic atrial rhythm with atrial premature beats and ventricular\npremature beats. Low limb lead QRS voltage. Left axis deviation be due to\nleft anterior fascicular block. Consider anterior wall myocardial infarction of\nindeterminate age, although is non-diagnostic. Anterolateral lead ST-T wave\nabnormalities with borderline prolonged QTc interval be due to myocardial\nischemia or possible drug/electrolyte/metabolic effect. Clinical correlation is\nsuggested. Since the previous tracing of ectopic atrial rhythm has\nreplaced sinus rhythm, axis is more leftward and further ST-T wave changes are\nnow present.\n\n"
}
] |
60,274 | 167,972 | 44yo F with PSC cirrhosis, UC s/p colectomy and ileostomy, CML in remission on Gleevec, s/p recent admission for decompensation with encephalopathy, peristomal bleeding, and bacteremia with Strep Viridens, who during admission become febrile, hypotensive,and developed . She was treated with Ceftriaxone. Ascites fluid culture was negative and as well as TEE. Blood cultures remained neg (previous strep viridans), urine cultures grew yeast. Fluc was started. CXR was concerning for pulmonary source, but had no pulmonary symptoms. She responded well to aggressive fluid resuscitation and remained afebrile on Vanc/Zosyn/Azithromycin. Gleevec was held. Cr trended up in the setting of infection and hypotension. Patient stopped making urine despite aggressive fluid resuscitation. DDx: ATN vs HRS. Renal US was negative for hydronephrosis. Stoma bleed several times that responded to pressure and surgicel. She was transfused with several units of PRBC. She continued to decompensate and was transferred to the SICU on for CVVHD. On , a liver donor offer was available and accepted. On , she underwent liver transplant. Surgeon was Dr. . Please refer to operative note for further details. Postop, she was admitted to the SICU intubated. CVVHD continued. She was extubated the next day. Two JPs were draining non-bilious fluid. LFTs initially increased then trended down daily. Liver duplex demonstrated patent vasculature with good waveforms and no ductal dilatation. There was a perihepatic hematoma and a RLQ hematoma measuring 10.5cm x 11.4 cm x 7cm. Heparin was held. Medial JP output became bilious. An ERCP was done on showing a small amount of extravasation at the duct to duct anastomosis. A stent was placed. JP output was then non-bilious. LFTS continued to trend down. She was transferred out of the SICU. CVVHD was changed to hemodialysis which she continued to require as she was anuric. Temporary HD line was converted to a right IJ tunnelled line on . Urine output increased slightly to 100cc/day. Mental status improved as well as strength. Diet was advanced, but kcals were insufficient for metabolic needs. A post pyloric feeding tube was placed on postop day 2 and tube feeds continued. was consulted to assist with insulin recommendations for hyperglycemia. She was given small amounts sliding scale insulin. Glucoses were in the low 100s to low 200s. Abdominal drains were removed. Incision was intact with staples. These will be removed in outpatient clinic around postop day 21. Immunosuppression consisted of Cellcept which was well tolerated. Solumedrol was tapered to prednisone 20mg qd. This will decrease per protocol by 2.5mg every 10 days starting . Prograf was started on postop day 1. Doses were adjusted per trough. Goal was . Gleevec for h/o CML was on hold due to hepatotoxicity and renal clearance. Gleevec will remain on hold until renal function improves. This will be reviewed in f/u with Clinic. Physical therapy evaluated and recommended rehab. A bed was available at in . She will transfer there today. | Novegetation/mass on pulmonic valve.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Written informed consent was obtained from the patient. The right neck and the right arm with the indwelling PICC were prepped and draped in a sterile fashion. Mild(1+) mitral regurgitation is seen. Previously described non-specific anterior T wave inversionshave now resolved. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No AR.MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The ascending, transverse and descendingthoracic aorta are normal in diameter and free of atherosclerotic plaque to 30cm from the incisors. Compared to tracing #1 no diagnostic interval change.The Q-T interval is within normal limits.TRACING #2 Normal sinus rhythm with T wave inversions in leads V1-V2. The mitral valve leaflets arestructurally normal. Cannot excludeanteroseptal myocardial ischemia. Right ventricular chambersize and free wall motion are normal. Compared to the previous tracing of no diagnosticinterval change.TRACING #1 Mitral valve disease.Height: (in) 62Weight (lb): 145BSA (m2): 1.67 m2BP (mm Hg): 116/68HR (bpm): 82Status: InpatientDate/Time: at 12:11Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). Normal sinus rhythm. Normal sinus rhythm. Using sterile technique and local anesthesia, a guidewire was advanced through the indwelling right arm PICC line, and subsequently into the SVC under fluoroscopic guidance. No diagnostic abnormality compared to the previous tracingof . Echocardiographic results were reviewed bytelephone with the MD caring for the patient.Conclusions:No atrial septal defect is seen by 2D or color Doppler. The catheter was secured to the skin, flushed, and a sterile dressing applied. The aortic valve leaflets (3) appear structurally normalwith good leaflet excursion. The patent right internal jugular vein was accessed under ultrasound and fluoroscopic guidance with a micropuncture needle. Non-diagnostic Q waves in leads II, III, aVF and V4-V6.Vertical axis. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The catheter is ready to use. The catheter was secured to the skin utilizing 0 silk sutures. A preprocedural huddle and timeout were performed per protocol. Baseline artifact is new.Repolarization and depolarization patterns are otherwise similar. The patient will need a temporary dialysis line. Possibleprior inferolateral myocardial infarction, although the Q waves, while present,are quite small and may reflect septal depolarization. The needle was then exchanged for a micropuncture sheath. This was utilized to put through the SVC and into the IVC after appropriate measurements were taken. Overall leftventricular systolic function is normal (LVEF>55%). 8:18 AM TEMP DIALYSIS LINE PLCT Clip # Reason: will need temporary dialysis line Admitting Diagnosis: BACTEREMIA ********************************* CPT Codes ******************************** * NON-TUNNELED EXCH PERPHERAL W/O PORT * * -59 DISTINCT PROCEDURAL SERVICE FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. Serial dilations were performed utilizing 12 and 14-French dilators under fluoroscopy guidance. Sinus rhythm. Sinus rhythm. Borderline left atrial abnormality is present.Aside from the increase in heart rate these changes are not new. There is no pericardial effusion.IMPRESSION: No echocardiographic evidence for endocardits seen.Dr. A scout image was taken, which demonstrated the presence of the indwelling PICC at the midaxillary line. Q-T interval prolongation. PROCEDURE: Written informed consent was obtained from the patient after explaining the procedure, risks, benefits, and alternatives to it. Uncomplicated successful placement of a 15 cm 14.4-French temporary hemodialysis catheter through the right IJ with the tip in the distal SVC. Sinus tachycardia, rate 127. Borderline prolongation of the P-R interval. Compared to theprevious tracing of the Q-T interval is marginally prolonged. Baseline artifact. There were no immediate complications. Compared to the previous tracing of the T wave inversion in lead V2 is new. No aortic regurgitation is seen. Theother findings are similar. PATIENT/TEST INFORMATION:Indication: Endocarditis. RADIOLOGIST: Dr. (fellow) performed the procedure. I certify I was present incompliance with HCFA regulations. The old PICC line was then removed and a peel-away sheath was then placed over the guidewire. IMPRESSION: 1. (Over) 8:18 AM TEMP DIALYSIS LINE PLCT Clip # Reason: will need temporary dialysis line Admitting Diagnosis: BACTEREMIA FINAL REPORT (Cont) The peel-away sheath and guidewire were then removed. A new double-lumen PICC line measuring 41 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Uncomplicated fluoroscopically guided PICC line exchange for a new 5-French double lumen PICC line. ATEE was performed in the location listed above. The patient tolerated the procedure well. was notified by telephone. The posterior pharynx was anesthetizedwith 2% viscous lidocaine. Rightward axis is present raising question ofpotentially pulmonary embolism. The line is ready to use. No masses or vegetations onaortic valve. All wires were removed. Then, 15 cm 14.4-French temporary hemodialysis catheter was placed over the wire with the tip in the distal SVC. Final internal length is 41 cm, with the tip positioned in the SVC. | 9 | [
{
"category": "Radiology",
"chartdate": "2132-11-10 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1218410,
"text": " 8:18 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: will need temporary dialysis line\n Admitting Diagnosis: BACTEREMIA\n ********************************* CPT Codes ********************************\n * NON-TUNNELED EXCH PERPHERAL W/O PORT *\n * -59 DISTINCT PROCEDURAL SERVICE FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with end stage liver disease, now with renal failure.\n REASON FOR THIS EXAMINATION:\n will need temporary dialysis line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old woman with end-stage liver disease, now with renal\n failure and fluid overload. The patient will need a temporary dialysis line.\n\n RADIOLOGIST: Dr. (fellow) performed the procedure. Dr.\n (attending physician) reviewed the images and was present and\n supervised throughout the procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n fentanyl 100 mcg and Versed 2 mg throughout the total intraservice time of 25\n minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n\n PROCEDURE: Written informed consent was obtained from the patient after\n explaining the procedure, risks, benefits, and alternatives to it. The\n patient was brought to the angiographic suite and laid supine on the table.\n The right neck and the right arm with the indwelling PICC were prepped and\n draped in a sterile fashion. A preprocedural huddle and timeout were\n performed per protocol.\n\n The patent right internal jugular vein was accessed under ultrasound and\n fluoroscopic guidance with a micropuncture needle. The needle was then\n exchanged for a micropuncture sheath. This was utilized to put \n through the SVC and into the IVC after appropriate measurements were taken.\n Serial dilations were performed utilizing 12 and 14-French dilators under\n fluoroscopy guidance. Then, 15 cm 14.4-French temporary hemodialysis catheter\n was placed over the wire with the tip in the distal SVC. The catheter was\n secured to the skin utilizing 0 silk sutures. All wires were removed.\n\n A scout image was taken, which demonstrated the presence of the indwelling\n PICC at the midaxillary line. Using sterile technique and local anesthesia, a\n guidewire was advanced through the indwelling right arm PICC line, and\n subsequently into the SVC under fluoroscopic guidance. The old PICC line was\n then removed and a peel-away sheath was then placed over the guidewire. A new\n double-lumen PICC line measuring 41 cm in length was then placed through the\n peel-away sheath with its tip positioned in the SVC under fluoroscopic\n guidance. Position of the catheter was confirmed by a fluoroscopic spot film\n of the chest.\n (Over)\n\n 8:18 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: will need temporary dialysis line\n Admitting Diagnosis: BACTEREMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION:\n 1. Uncomplicated successful placement of a 15 cm 14.4-French temporary\n hemodialysis catheter through the right IJ with the tip in the distal SVC.\n The catheter is ready to use.\n\n 2. Uncomplicated fluoroscopically guided PICC line exchange for a new\n 5-French double lumen PICC line. Final internal length is 41 cm, with the tip\n positioned in the SVC. The line is ready to use.\n\n"
},
{
"category": "Echo",
"chartdate": "2132-10-31 00:00:00.000",
"description": "Report",
"row_id": 94070,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Mitral valve disease.\nHeight: (in) 62\nWeight (lb): 145\nBSA (m2): 1.67 m2\nBP (mm Hg): 116/68\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 12:11\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: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was monitored by a nurse e throughout the procedure. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. Echocardiographic results were reviewed by\ntelephone with the MD caring for the patient.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The ascending, transverse and descending\nthoracic aorta are normal in diameter and free of atherosclerotic plaque to 30\ncm from the incisors. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion. No masses or vegetations are seen on the aortic\nvalve. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. No mass or vegetation is seen on the mitral valve. Mild\n(1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic\nvalve. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence for endocardits seen.\n\nDr. was notified by telephone.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-26 00:00:00.000",
"description": "Report",
"row_id": 251021,
"text": "Sinus tachycardia, rate 127. Rightward axis is present raising question of\npotentially pulmonary embolism. Borderline left atrial abnormality is present.\nAside from the increase in heart rate these changes are not new.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-16 00:00:00.000",
"description": "Report",
"row_id": 251260,
"text": "Sinus rhythm. Previously described non-specific anterior T wave inversions\nhave now resolved. No diagnostic abnormality compared to the previous tracing\nof .\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-12 00:00:00.000",
"description": "Report",
"row_id": 251261,
"text": "Normal sinus rhythm with T wave inversions in leads V1-V2. Cannot exclude\nanteroseptal myocardial ischemia. Compared to the previous tracing of \nthe T wave inversion in lead V2 is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-11 00:00:00.000",
"description": "Report",
"row_id": 251262,
"text": "Baseline artifact. Q-T interval prolongation. Compared to the previous tracing\nof the rate is minimally faster. Baseline artifact is new.\nRepolarization and depolarization patterns are otherwise similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-05 00:00:00.000",
"description": "Report",
"row_id": 251263,
"text": "Sinus rhythm. Borderline prolongation of the P-R interval. Possible\nprior inferolateral myocardial infarction, although the Q waves, while present,\nare quite small and may reflect septal depolarization. Compared to the\nprevious tracing of the Q-T interval is marginally prolonged. The\nother findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-04 00:00:00.000",
"description": "Report",
"row_id": 251264,
"text": "Normal sinus rhythm. Compared to tracing #1 no diagnostic interval change.\nThe Q-T interval is within normal limits.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2132-11-03 00:00:00.000",
"description": "Report",
"row_id": 251265,
"text": "Normal sinus rhythm. Non-diagnostic Q waves in leads II, III, aVF and V4-V6.\nVertical axis. Compared to the previous tracing of no diagnostic\ninterval change.\nTRACING #1\n\n"
}
] |
19,296 | 181,850 | The patient is a 74 yo R-handed woman with paroxysmal Afibb, CAD, CHF, chronic osteomylelitis of the R-knee and recently diagnosed adenoma of the ampulla of Vater, who was transferred from an OSH for further workup and management of weakness. Her weakness started around the time that her adenoma was diagnosed, and slowly progressed. It involved lower somewhat more than her upper extremities. On exam, she is somewhat inattentive. Her strength is decreased distally as well as proximally. Neck flexors are weak as well. In addition, PP, vibration sense and proprioception was decreased, but this part of the exam was limited due to inattention and not reliable. The tone in her LE was increased, especially on the R. DTR were present. Few fasciculation R-triceps (not in tongue). She already has shortening of the achilles tendons due to her weakness. DDx: ALS, polyradiculopathy; paraneoplastic | There is a focus of hyperintensity on the short TR images in the C6 vertebral body, perhaps reflecting focal fat deposition or a small hemangioma. CT ABDOMEN WITHOUT AND WITH CONTRAST: There is atelectasis of the lung bases dependently, as before. FINDINGS: There is a wedged T11 vertebral body. Incidentally adjacent to the main portal vein medially within segment IV-B is a slightly heterogeneous area with foci that are hyperechoic. Single pass through the pelvis was made after contrast administration. Rule out malignancy or intracranial neoplastic process. AP SEMI-UPRIGHT VIEW OF THE CHEST: Median sternotomy wires and vascular clips are present, consistent with prior CABG. TECHNIQUE: Non-contrast axial head CT. T1 axial, sagittal and coronal images were obtained following gadolinium. IMPRESSION: 1) No pancreatic mass seen, though one is suspected with the biliary and pancreatic duct dilation. CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There are postoperative changes status post hernia repair in the right anterior pelvis. Resp CarePt received respiratory mechanics X2. There is descending colon and sigmoid diverticulosis without evidence of acute diverticulitis. Check INR after FFP infused.Check Vital Capacity and q4 hrs.Lumbar puncture by neuro when coags corrected. After administration of gadolinium intravenous contrast, sagittal short TR, short TE spin echo imaging was repeated. After administration of gadolinium intravenous contrast, sagittal short TR, short TE spin echo imaging was repeated. The distal left vertebral artery appears to be ending in posterior inferior cerebellar artery, a normal variation. It is mildly hypoechoic to the remainder of the liver with slight hyperechogenicity along its anterior surface. The patient is status post median sternotomy and CABG. Intrahepatic biliary ductal dilatation is unchanged as is pneumobilia. A small amount of linear atelectasis or scarring remains in the left midlung zone. It is only faintly hyperintense on the long TR images. IV inserted by Dr. .Action-1 more additional unit of FFP hung. There is pneumobilia and dilatation of the intra and extra hepatic ducts. Pt with history of pancreatic adenoma on ERCP. C/o constant soreness in BLE not new per pt. The extrahepatic bile ducts remain dilated to a similar extent down to the level of the distal intrapancreatic portion near the papilla where the extent is in unchanged position. Sagittal and axial imaging was performed with long TR, long TE fast spin echo and short TR, short TE spin echo technique. The spleen, adrenal glands are within normal limits. No contraindications for IV contrast FINAL REPORT MRI THORACIC SPINE WITHOUT AND WITH CONTRAST, . The right brachial vein was patent and compressible. There are focal low attenuation lesions within the kidneys bilaterally that likely represent cysts. Under fluoroscopic guidance, a 0.018 guide wire was advanced into the SVC. This raises the question that this is a metastasis, though edema from cholangitis is a consideration. FINAL REPORT INDICATION: Breathing problem. There are small mediastinal lymph nodes that do not meet CT criteria for pathology. Under ultrasonographic guidance, the right brachial vein was entered using a micropuncture sheath. Pt in SR on adm to SICU, this pm pt went into Afib with ventricular rate 102-106.Action-Pt given 2 units of FFP. STUDY: Pancreatic CTA. No definite pancreatic mass is seen, though one is suspected with the common bile duct and pancreatic duct dilation. A slight leftward deviation of the trachea is comparable to the study, allowing for differences in rotation. NPN (SEE CAREVUE FOR SPECIFICS) PT ALERT, MILD CONFUSION AT TIMES. Please See Carevue for Specifics.Neuro: A+OX3, MAE-upper ext stronger than lower, PERL, denies pain. Mild periventricular hyperintensities indicate small vessel disease. The larger lesion shows mild enhancement and may represnet focal hepatic edema from cholangitis or a metastatic focus. Moderate amount of stool in the colon and rectum. The pancreatic duct dilation is slightly increased from the prior study with unchanged biliary duct dilation with stent in place. Pt denies c/o HA, numbness/tingling.Afeb. Sagittal imaging was performed with long TR, long TE fast spin echo and short TR, short TE spin echo technique. There is a dominant 1.1 x 1.0 x 2.1 cm heterogeneous nodule in the mid pole of the left lobe. Vital Capacity and done by respiratory.Response-INR 2.0, Potassium low. Hydralazine IV admin x1 for SBP 170. Tylenol admin with poor effect. c/y/u.SKIN: Intact, no breakdown noted.POC: Monitor PTT, assist with ADL's. FINDINGS: Limited ultrasound of the liver shows the lesion within the right hepatic lobe, segment V/VIII immediately adjacent to a branch of the middle hepatic vein. TECHNIQUE: 64-MDCT axial images of the chest, abdomen and pelvis were obtained with IV contrast. CONCLUSION: Subacute to chronic T11 compression fracture. CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There are 2 hypodense areas within segment of the liver that were not well characterized in this study. Vertebral body signal intensity is otherwise normal. No contraindications for IV contrast FINAL REPORT INDICATION: Somnolence, fatigue, high INR. The pancreatic duct measures up to 11 mm in caliber within the body slightly less dilated in the tail. ADDENDUM Condition Update B:Please refer to careview.K=2.6 and hct dropped to 31.6. There is degenerative disc disease with mild encroachment on the spinal canal. There are mild atelectatic changes of the lungs. Condition Update A:Please refer to careview and remarks for details.Pt MAE upper > lower, following commands, PERL 3mm/3mm. Hct 31.6.Pt denies SOB, difficulty breathing. Desire biopsy. Since no suitable superficial veins were available, ultrasound was used for location of a suitable vein. | 17 | [
{
"category": "Nursing/other",
"chartdate": "2155-05-30 00:00:00.000",
"description": "Report",
"row_id": 1517067,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT, MILD CONFUSION AT TIMES. ABLE TO LIFT AND HOLD UPPER EXT, RIGHT LEG ABLE TO SLIGHTLY LIFT OFF BED, LEFT LEG STRONGER. PERRL.\nCV- BP STABLE IN 130-150 RANGE. RAPID A-FIB AT BEGINNING OF THE NIGHT, CONVERTED TO NSR AND REMAINED IN 50'S-60'S WITH OCCASIONAL PVCS. AM LYTES PENDING. REPEAT COAGS FOLLOWING FFP IN THE EVENING SHOWING INR 1.8, NO INTERVENTION AT THAT TIME. TWO UNITS OF FFP ORDERED THIS AM WITH LASIX IN BETWEEN, LP TO BE DONE THIS AM WHEN INR CORRECTED.\nRESP- LUNGS CLEAR, O2 SAT 99% WITHOUT O2. NIFS DONE OVERNIGHT AND NUMBERS VARYING DEPENDING ON PTS UNDERSTANDING AND LEVEL OF AROUSAL.\nGI/GU- ABD SOFT, SWALLOWING PILLS WELL WITH WATER. UOP ADEQUATE, CLEAR YELLOW.\nID- AFEBRILE\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-30 00:00:00.000",
"description": "Report",
"row_id": 1517068,
"text": "Please See Carevue for Specifics.\n\nNeuro: A+OX3, MAE-upper ext stronger than lower, PERL, denies pain. LP under fluoro on . MRI/MRA of head this afternoon. All results are pending.\n\nCardio: NSR, no ectopy, no edema, IV placed in right forearm without difficulty. Two units FFP for INR of 1.6. Heparin gtt started at 1800 at 1000units/hr as ordered. Recheck PTT at 2400.\n\nRespir: Lungs are clear. 98-100% on RA. See respi note for .\n\nGI: Abd is soft, small soft formed guaiac negative stool this afternoon. Tolerating clears and toasts.\n\nGU: foley. c/y/u.\n\nSKIN: Intact, no breakdown noted.\n\nPOC: Monitor PTT, assist with ADL's. Monitor hemodynamics. Continue to offer pt and pt family emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-31 00:00:00.000",
"description": "Report",
"row_id": 1517069,
"text": "Resp Care\nRespiratory mechanics performed X2 during shift when pt awake. Pt still having difficulty following instructions and decrease in from -30 last night to -12 this am most likely due to variable technique. Pt in NAD, SpO2 currently 97% on RA, BBS-CTA. Bag and mask at bedside. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-31 00:00:00.000",
"description": "Report",
"row_id": 1517070,
"text": "Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt MAE upper > lower, following commands, PERL 3mm/3mm. C/o constant soreness in BLE not new per pt. Tylenol admin with poor effect. Ultram 50mg admin and legs wrapped in warm blankets with good effect. Heat pack applied to lower back for chronic pain. Pt states she uses Darvocet at home for pain relief. Pt denies c/o HA, numbness/tingling.\n\nAfeb. Hydralazine IV admin x1 for SBP 170. Round the clock IV Lopressor admin. HR NSR 60-70's. Heparin gtt 1000 units/h infusing. PTT 50.8 in goal range. Hct 31.6.\n\nPt denies SOB, difficulty breathing. Please refer to RT note for detials.\n\nFoley insitu. U/O increases after IVPB meds admin. Stool softner and laxative held for loose stool. Guaiac neg. No difficulty swallowing meds/fluids/crackers.\n\nSkin intact. Pt declined mutipodus splints during night.\n\nPLAN: PTT at 0600, goal 40-60. monitor neuro exam, resp status, comfort level. Provide emotional support to pt and family. Encourage multipodus splint. Call H.O. for changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-31 00:00:00.000",
"description": "Report",
"row_id": 1517071,
"text": "ADDENDUM Condition Update B:\nPlease refer to careview.\n\nK=2.6 and hct dropped to 31.6. PO potassium 40mEq admin at 0450, and K rechecked. Repeat unchanged. PO potassium 40mEq admin at 0645.\n\nPLAN: Recheck hct and K at noon. PICC placement. Cont with previous plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-29 00:00:00.000",
"description": "Report",
"row_id": 1517065,
"text": "Focus-Condition Report\nData-Pt admitted this am directly from CT scan. Pt awake, oriented to person and place. Pt disoriented to date. Pt able to lift and hold upper extremities. Pt unable to lift lower extremities, if lifted up passively legs fall back down. Pt able to move legs on bed. Pt in SR on adm to SICU, this pm pt went into Afib with ventricular rate 102-106.\nAction-Pt given 2 units of FFP. Lasix 20mg IV given in between units.\nRepeat INR sent after infused.\nLopressor 5mg IV x2 given. Vital Capacity and done by respiratory.\nResponse-INR 2.0, Potassium low. Vital Capacity and unchanged form this am. Pt diuresed well from lasix. Pt is a very difficult stick for IV's and labs. IV inserted by Dr. .\nAction-1 more additional unit of FFP hung. Vitamin K 10mg SC given.\nKCL 40meq po given.\nResponse-Ongoing evaluation.\nPlan-Continue to monitor closely. Check INR after FFP infused.\nCheck Vital Capacity and q4 hrs.\nLumbar puncture by neuro when coags corrected.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-05-30 00:00:00.000",
"description": "Report",
"row_id": 1517066,
"text": "Resp Care\nPt received respiratory mechanics X2. Pt confused and having difficulty following instructions such as when to breath in/blow out and creating an airtight seal around mouthpiece, which makes results variable despite repeated attempts and encouragement. Pt in NAD, BBS CTA.\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-29 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 913341,
"text": " 1:07 AM\n MR W& W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: MRI C-spine with contrast; signal abnormality; neoplastic pr\n Admitting Diagnosis: PARAPLEGIA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with adenoma of pappilla of Vater; severe weakness with\n increased tone in LE; inattentive on exam\n REASON FOR THIS EXAMINATION:\n MRI C-spine with contrast; signal abnormality; neoplastic process\n ______________________________________________________________________________\n FINAL REPORT\n MR CERVICAL SPINE WITHOUT AND WITH CONTRAST, \n\n HISTORY: Severe weakness and increased tone in lower extremities.\n\n Sagittal imaging was performed with long TR, long TE fast spin echo and short\n TR, short TE spin echo technique. Axial imaging was performed with long TR,\n long TE fast spin echo and with gradient echo technique. After administration\n of gadolinium intravenous contrast, sagittal short TR, short TE spin echo\n imaging was repeated. No prior cervical spine imaging studies are available\n for comparison.\n\n FINDINGS: Alignment of the cervical spine is normal. There is a focus of\n hyperintensity on the short TR images in the C6 vertebral body, perhaps\n reflecting focal fat deposition or a small hemangioma. Vertebral body signal\n intensity is otherwise normal. There are degenerative changes of the\n intervertebral discs with loss of signal and loss of height, most prominent\n from C4 through C7. There are small intervertebral osteophytes at C5-6 and\n C6-7. These narrow the spinal canal but do not appear to encroach upon the\n spinal cord. The axial images are severely degraded by motion artifact and\n are nondiagnostic. Specifically, I cannot evaluate the neural foramina on\n this examination.\n\n There is no abnormal enhancement after contrast administration.\n\n CONCLUSION: Limited study due to motion artifact. There is degenerative disc\n disease with mild encroachment on the spinal canal. The suboptimal study\n prevents evaluation of the neural foramina. There is no abnormal enhancement\n after contrast administration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-29 00:00:00.000",
"description": "MR T-SPINE W &W/O CONTRAST",
"row_id": 913343,
"text": " 1:14 AM\n MR W &W/O CONTRAST Clip # \n Reason: please with gad!!!! indication of carnomatous meningitis?\n Admitting Diagnosis: PARAPLEGIA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with profound weakness; suspect paraneoplastic\n REASON FOR THIS EXAMINATION:\n please with gad!!!! indication of carnomatous meningitis?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI THORACIC SPINE WITHOUT AND WITH CONTRAST, .\n\n HISTORY: Profound weakness. Is there paraneoplastic syndrome versus\n carcinomatous meningitis?\n\n Sagittal and axial imaging was performed with long TR, long TE fast spin echo\n and short TR, short TE spin echo technique. After administration of\n gadolinium intravenous contrast, sagittal short TR, short TE spin echo imaging\n was repeated. No prior thoracic spine imaging studies are available for\n comparison.\n\n FINDINGS: There is a wedged T11 vertebral body. This maintains high signal\n intensity on the short TR images suggesting that it is not acute. It is only\n faintly hyperintense on the long TR images. However, this may represent a\n subacute or chronic fracture. There is deformity of the posterior margin of\n the vertebral body with bone protruding into the spinal canal. However, this\n does not contact the spinal cord. There is no abnormal enhancement after\n contrast administration. Specifically, there are no imaging findings to\n suggest carcinomatous meningitis.\n\n CONCLUSION: Subacute to chronic T11 compression fracture. Degenerative\n changes. No evidence of carcinomatous meningitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-06-03 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 913936,
"text": " 7:41 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC, already eval by PICC nursing\n Admitting Diagnosis: PARAPLEGIA\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 * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with generalized weakness, w/u in progress\n REASON FOR THIS EXAMINATION:\n Please place PICC, already eval by PICC nursing\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74y/o female with generalized weakness of unclear . The\n patient requires IV for medications.\n\n RADIOLOGISTS: This procedure was performed by Dr. and Dr. . Dr.\n , the attending radiologist, was present during the entire procedure\n supervising.\n\n PROCEDURE/FINDINGS: The patient was brought to the angiography table and\n placed in supine position. The right upper arm was prepped and draped in the\n standard sterile fashion. Since no suitable superficial veins were available,\n ultrasound was used for location of a suitable vein. The right brachial vein\n was patent and compressible. Under ultrasonographic guidance, the right\n brachial vein was entered using a micropuncture sheath. Under fluoroscopic\n guidance, a 0.018 guide wire was advanced into the SVC. Hard copy ultrasound\n images were obtained before and after venous access documenting vessel\n patency. Based on the markers on the guide wire, it was decided that the\n length of 36 cm would be suitable. The PICC line was then trimmed to length\n and advanced over a 4 French introducer sheath under fluoroscopic guidance.\n The tip of the line was placed in the superior SVC just above the right\n atrium. A final chest x- ray was obtained and demonstrated good position of\n the catheter. The line was flushed and secured to the skin with a StatLock\n device.\n\n IMPRESSION: Successful placement of 36 cm double lumen PICC line with the tip\n in the superior vena cava just above the right atrium. The line is ready for\n use.\n\n\n\n\n\n\n\n\n\n\n (Over)\n\n 7:41 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC, already eval by PICC nursing\n Admitting Diagnosis: PARAPLEGIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-30 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 913595,
"text": " 2:46 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: ? intracranial neoplastic process?\n Admitting Diagnosis: PARAPLEGIA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with pancreatic cancer; severe weakness; inattentive on exam.\n Rule out malignancy\n REASON FOR THIS EXAMINATION:\n ? intracranial neoplastic process?\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of brain and MRA of the head.\n\n CLINICAL INFORMATION: Patient with pancreatic cancer, severe weakness. Rule\n out malignancy or intracranial neoplastic process.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were obtained before gadolinium. T1 axial, sagittal\n and coronal images were obtained following gadolinium. 3D time-of-flight MRA\n of the circle of was acquired.\n\n FINDINGS: BRAIN MRI:\n\n The diffusion images demonstrate no evidence of slow diffusion to indicate\n acute infarct. There is mild prominence of ventricles and sulci. Mild\n periventricular hyperintensities indicate small vessel disease. There is no\n midline shift or hydrocephalus. Following gadolinium administration, no\n evidence of abnormal parenchymal, vascular or meningeal enhancement\n identified. Mild changes of small vessel disease are also seen within the\n brain stem.\n\n IMPRESSION: Mild changes of small vessel disease. No evidence of acute\n infarct. No enhancing brain lesions.\n\n MRA OF THE HEAD:\n\n Head MRA demonstrates normal flow signal within the arteries of anterior and\n posterior circulation. The distal left vertebral artery appears to be ending\n in posterior inferior cerebellar artery, a normal variation. The MRA is\n slightly limited by motion.\n\n IMPRESSION: Slightly limited MRA of the head demonstrate no significant\n abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-06-02 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 913879,
"text": " 3:30 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: Please eval for any underlying occult malignancy\n Admitting Diagnosis: PARAPLEGIA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with new severe generalized weakness of unclear etiology\n REASON FOR THIS EXAMINATION:\n Please eval for any underlying occult malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old female with severe generalized weakness. Rule out\n malignancy.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: 64-MDCT axial images of the chest, abdomen and pelvis were\n obtained with IV contrast. Oral contrast was also administered.\n\n CT OF THE CHEST WITH IV CONTRAST: There is no significant axillary\n lymphadenopathy. There are small mediastinal lymph nodes that do not meet CT\n criteria for pathology. The largest lymph node measures 6 mm. The patient is\n status post median sternotomy and CABG. The right lobe of the thyroid is\n mildly enlarged and contains several nodules. The largest nodule measures 1\n cm. Correlation with ultrasound could be performed.\n\n Examination of the lung windows demonstrate no lung nodules or masses. There\n are mild atelectatic changes of the lungs.\n\n CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There are 2 hypodense areas\n within segment of the liver that were not well characterized in this\n study. The largest one measures 2.0 x 1.6 cm (image2, 46). A smaller one\n measures 6 mm and is too small to characterize (image 2, 47). There is\n pneumobilia and dilatation of the intra and extra hepatic ducts. There is a\n stent within the biliary tree. Correlate with prior ERCP. The portal vein is\n patent. The spleen, adrenal glands are within normal limits. There is a\n small hypodense area in the upper pole of the right kidney measuring 6 mm and\n is too small to characterize. The left kidney is normal. The pancreatic duct\n is dilated measuring up to 7 mm. However, no definite pancreatic masses\n identified in this study.\n\n No obvious retroperitoneal lymphadenopathy is seen.\n\n CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There are postoperative changes\n status post hernia repair in the right anterior pelvis. There is a Foley\n catheter within the urinary bladder. The uterus and adnexa are unremarkable.\n There is no free fluid in the pelvis. Moderate amount of stool in the colon\n and rectum.\n\n BONE WINDOWS: Patient is status post median sternotomy. The patient is also\n (Over)\n\n 3:30 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: Please eval for any underlying occult malignancy\n Admitting Diagnosis: PARAPLEGIA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n status post posterior fixation of the spine. No suspicious destructive lesions\n are seen.\n\n IMPRESSION:\n 1. Two hypodense liver lesions concerning for metastatic disease. This could\n be confirmed with ultrasound.\n 2. Biliary and pancreatic duct dilatation with a stent. No definite pancreatic\n mass is identified in this study.\n 3. Nodular thyroid with multiple nodules, the largest one measuring 10 mm.\n Ultrasound could be performed if indicated.\n 4. Diverticulosis, without evidence of diverticulitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-06-11 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 915074,
"text": " 5:54 PM\n CTA ABD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: please eval for pancreatic mass\n Admitting Diagnosis: PARAPLEGIA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with pancreatic mass, biopsied, suspected to be carcinoma--\n for surgical eval?\n REASON FOR THIS EXAMINATION:\n please eval for pancreatic mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient with pancreatic mass that was biopsied and\n suspected to be carcinoma. Surgical evaluation for extent of disease and\n resectability.\n\n STUDY: Pancreatic CTA.\n\n TECHNIQUE: Axial multidetector CT of the abdomen was performed before and\n twice after the uneventful intravenous administration of 150 cc Optiray.\n Single pass through the pelvis was made after contrast administration. Axial\n and coronal reformats were made as well as 3D reformats.\n\n COMPARISON: .\n\n CT ABDOMEN WITHOUT AND WITH CONTRAST:\n There is atelectasis of the lung bases dependently, as before. No effusions.\n The two hypodense lesions within segment IV of the liver are unchanged in size\n and appearance. The larger lesion shows mild enhancement and may\n represnet focal hepatic edema from cholangitis or a metastatic focus. The\n smaller lesion is too small to characterize. No new liver lesions.\n Intrahepatic biliary ductal dilatation is unchanged as is pneumobilia. The\n extrahepatic bile ducts remain dilated to a similar extent down to the level\n of the distal intrapancreatic portion near the papilla where the extent is in\n unchanged position. No definite pancreatic mass is seen, though one is\n suspected with the common bile duct and pancreatic duct dilation. The\n pancreatic duct measures up to 11 mm in caliber within the body slightly less\n dilated in the tail. This appears mildly increased since the prior study.\n Within the pancreatic tail, there is a 5 mm round fluid attenuation lesion\n that could represent side branch IPMT or another pancreatic cystic lesion.\n\n The spleen, bilateral adrenal glands and bowel within the abdomen are normal\n in appearance. There are focal low attenuation lesions within the kidneys\n bilaterally that likely represent cysts. Otherwise, the kidneys appear\n normal. No lymphadenopathy within the abdomen by CT size criteria, though\n there are sub-cm lymph nodes within the portacaval space and retroperitoneum.\n There is descending colon and sigmoid diverticulosis without evidence of acute\n diverticulitis.\n\n BONE WINDOWS:\n There is an old compression fracture at T11 with focal kyphosis. There is L3-\n (Over)\n\n 5:54 PM\n CTA ABD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: please eval for pancreatic mass\n Admitting Diagnosis: PARAPLEGIA\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n L5 fusion, as before. There is grade I-II anterolisthesis of L4 on L5, as\n before. No suspicious lytic or sclerotic bone lesions.\n\n\n IMPRESSION:\n 1) No pancreatic mass seen, though one is suspected with the biliary and\n pancreatic duct dilation. The pancreatic duct dilation is slightly increased\n from the prior study with unchanged biliary duct dilation with stent in place.\n\n 2) Two hypodense liver lesions within segment 4, with the larger 2 cm lesion\n showing mild enhancement. This raises the question that this is a\n metastasis, though edema from cholangitis is a consideration. Even though the\n biopsy was negative, a short term follow up of this lesion is recommended in\n weeks to assess for interval change in case there was biopsy sampling\n error.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 913371,
"text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA?\n Admitting Diagnosis: PARAPLEGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with breathing problem. About to go to the unit. Needs urgent\n CXR.\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Breathing problem.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT VIEW OF THE CHEST: Median sternotomy wires and vascular clips\n are present, consistent with prior CABG. A fracture of the most superior\n sternal wire has developed as well as a possible fracture of the second most\n superior wire. A slight leftward deviation of the trachea is comparable to\n the study, allowing for differences in rotation. This would most\n commonly be due to enlargement of the right lobe of the thyroid. A small\n amount of linear atelectasis or scarring remains in the left midlung zone. The\n lungs are otherwise clear. Mild-to-moderate cardiomegaly is stable.\n\n IMPRESSION: No significant change in the appearance of the lungs to explain\n patient's breathing problems.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-05-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 913373,
"text": " 8:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Intracranial bleed? mass?\n Admitting Diagnosis: PARAPLEGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with somnolence, fatigue; INR 5;\n REASON FOR THIS EXAMINATION:\n Intracranial bleed? mass?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Somnolence, fatigue, high INR.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial head CT.\n\n FINDINGS: There is no evidence for intracranial hemorrhage. There is no mass\n effect or shift of normally midline structures. Periventricular white matter\n hypodensities as a sequelae of chronic small vessel infarction. There are\n bilateral lacunar infarcts within the basal ganglia. There is mild mucosal\n thickening of the visualized portions of the maxillary sinus. The mastoid air\n cells are well pneumatized. The osseous structures are unremarkable.\n\n IMPRESSION: No evidence for intracranial hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-06-04 00:00:00.000",
"description": "THYROID U.S.",
"row_id": 914140,
"text": " 1:42 PM\n THYROID U.S. Clip # \n Reason: BIOPSY/PT HAD CT THAT SHOWED THYROID NODULES\n Admitting Diagnosis: PARAPLEGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with thyroid nodules.\n REASON FOR THIS EXAMINATION:\n Biopsy?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old with thyroid nodules.\n\n No prior studies for comparison.\n\n THYROID ULTRASOUND: The right lobe measures 2.1 x 2.4 x 5.3 cm. The left\n lobe measures 1.9 x 2.1 x 5.3 cm. Both lobes are heterogeneous with multiple\n masses. There is a large 1.2 x 1.0 x 1.4 cm right colloid cyst. There is a\n dominant 1.1 x 1.0 x 2.1 cm heterogeneous nodule in the mid pole of the left\n lobe.\n\n IMPRESSION: Multinodular goiter.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-06-04 00:00:00.000",
"description": "BX-NEEDLE LIVER BY RADIOLOGIST",
"row_id": 914141,
"text": " 1:42 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # MOD SEDATION, FIRST 30 MIN.\n Reason: eval liver lesion for possible biopsy for tissue diagnosis.\n Admitting Diagnosis: PARAPLEGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with h/o chronic weight loss, s/p ERCP with biopsy and\n biliary stenting now presenting with possible paraneoplastic syndrome,\n hypodense lesions on liver.\n REASON FOR THIS EXAMINATION:\n eval liver lesion for possible biopsy for tissue diagnosis. Pt with history of\n pancreatic adenoma on ERCP.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient with pancreatic adenoma on biopsy from obstructing\n biliary lesion. Hypodense lesion in the liver is concerning for metastasis.\n Desire biopsy.\n\n PROCEDURE: Targeted liver biopsy by radiology with ultrasound guidance.\n\n TECHNIQUE:\n After the procedural technique, benefits, and risks (pneumothorax, bleeding,\n infection) were explained to the patient, the patient gave written consent to\n proceed. Appropriate site in the right upper quadrant was marked on the skin\n surface for access to the lesion. Right upper quadrant was prepared and\n draped in the usual sterile fashion. 1% lidocaine was administered\n subcutaneously and to the liver capsule. A small skin was made, and\n through it, an 18-gauge core biopsy needle was introduced into the liver with\n the help of an ultrasound guide. Two biopsies of the lesion were made on two\n separate passes with ultrasound guidance. Cytology was present and was given\n the tissue samples. Hemostasis was achieved after the procedure, and there\n were no immediate complications.\n\n Dr. , attending radiologist, was personally present for the\n entire procedure and performed a preprocedure timeout. Moderate sedation was\n provided by the administration of one dose of 50 mcg of fentanyl intravenously\n and one intravenous dose of Versed 1 mg. There was a total intraservice time\n of 25 minutes during which the patient's hemodynamic parameters were\n continuously monitored by a nurse trained in conscious sedation.\n\n FINDINGS:\n Limited ultrasound of the liver shows the lesion within the right hepatic\n lobe, segment V/VIII immediately adjacent to a branch of the middle hepatic\n vein. It is mildly hypoechoic to the remainder of the liver with slight\n hyperechogenicity along its anterior surface. It measures 2.7 cm in size in\n greatest dimension. Later images show biopsy needle within the lesion on two\n subsequent passes. Incidentally adjacent to the main portal vein medially\n within segment IV-B is a slightly heterogeneous area with foci that are\n hyperechoic. This may represent changes from recent biliary procedure and\n cholangitis, though this is uncertain.\n\n IMPRESSION:\n (Over)\n\n 1:42 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # MOD SEDATION, FIRST 30 MIN.\n Reason: eval liver lesion for possible biopsy for tissue diagnosis.\n Admitting Diagnosis: PARAPLEGIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Successful targeted biopsy of right hepatic lesion seen on CT.\n\n"
}
] |
12,058 | 140,092 | This -year-old man with a history of three vessel coronary artery disease, aortic regurgitation, mitral regurgitation was admitted emergently following a hypotensive episode on the floor. He showed ST depressions in leads V4 through V6 following a dose of hydralazine. His problems included the following: 1. Cardiac. The patient was continued on aspirin, Lipitor, and a low dose beta blocker, during his stay. He had several episodes of supraventricular tachycardia and he was placed on amiodarone which controlled the SVT. 2. Pulmonary. The patient was ventilated throughout his stay. On , an attempt was made to wean him off the ventilator. He became hypotensive, tachycardiac, and his oxygen saturations dropped significantly. He was placed back on BIPAP. Following a discussion with his family, it was determined that they would make him a Do No Resuscitate, Do Not Intubate. A chest x-ray revealed a likely aspiration pneumonia in the lower lobe of his left lung. 3. Infection. The patient was placed on a broad-spectrum of antibiotics to cover his infection. Unfortunately, the patient continues to decompensate and he passed away on . He was in the CCU from to when he passed away likely secondary to a combination of sepsis and respiratory arrest. , M.D. Dictated By: MEDQUIST36 D: 10:04 T: 10:14 JOB#: | There is severe regional left ventricularsystolic dysfunction.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: mid anteroseptal - hypokinetic; basal inferolateral -akinetic; mid inferolateral - akinetic;RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Normal sinus rhythmPossible anterior infarct - age undeterminedInferior/lateral ST-T changes may be due to myocardial ischemiaRepolarization changes may be partly due to rhythmLow QRS voltages in limb leadsSince previous tracing of , Q-Tc appears prolonged and ST-T waveabnormalities less marked There is moderatepulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:The left atrium is normal in size. Multifocal atrial rhythmPossible RVH with secondary ST-T changesAnterior and lateral ST-T changes suggest myocardial injury/ischemiaSince previous tracing of , no significant change Sinus bradycardia - supraventricular extrasystoles Inferior/lateral ST-T changes may be due to myocardial ischemiaSince previous tracing of rate slower Atrial fibrillation with slow ventricular responseInferior/lateral ST-T changes are nonspecificRepolarization changes may be partly due to rhythmSince previous tracing of , no significant change Mild (1+) mitral regurgitation isseen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. The aortic valveis not well seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Left ventricular wall thicknesses arenormal. Atrial fibrillationExtensive ST-T changes may be due to myocardial ischemiaRepolarization changes may be partly due to rhythmLow QRS voltages in limb leadsSince last ECG, no significant change There is moderate pulmonary artery systolic hypertension. Mild (1+) mitral regurgitation isseen. Myocardial infarction.BP (mm Hg): 107/49HR (bpm): 75Status: InpatientDate/Time: at 15:03Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. There is mildthickening of the mitral valve chordae. Sinus rhythm with frequent multifocal atrial premature beatsAnterolateral ST-T changes may be due to myocardial ischemiaSince the previous tracing of atrial premature beats are seenDecreased ST-T waev abnormalities Pulm=intubated & vented w present settings-cpap/ps-. pressor-dopa weaned & dced. rate controlled w po amiodarone. INTUBATED WO INCIDENT. a-line l-rad. RESP. BUN/CREAT 29/1.3. off heparin-?HIT. Abg results 7.44, 32, 141, 22, 0. CCU NSG PROGRESS NOTE.O:NEURO=SEDATED-FENT & VERSED GTT. mod pulm systolic HTN.O:Neuro=off . s/p arrestccu npno- afebrile. adeq uo. ADEQ UO. amiodarone gtt dced-started on po. CARE NOTEPT. GI=OGT PLACED-BILIOUS GUIAC POS. CODE STATUS-FULL.A:RI W POS TROP/CK. Pulm=remains intubated & vent. Abg results 7.45, 33, 121, 24. ID=AFEB. Pt. Pt. Pt. aline d/c'd. DETURES REMOVED. recheck with ho in am. TOL. EKG -> st depressions in 2,3,F. sl improvement in responsiveness off .P:contin present management. POST INTUBATION CXR DONE-ETT ADVANCED 2CM.O:NEURO=SEDATED. PRESSOR DEPENDENT. RESP TO CHANGE TO PS WEAN AND ASSESS TOL. CV=remains AF w controlled hr. CK'S FALLING, MB'S/TROPONIN PND.RESP: FENT TURNED OFF, VERSED TO 2MG/HR. GU=foley. GU=FOLEY. FOLLOW TEMPS AND WBC ON ABX. SX-SNT BL TINGED SECRETIONS. ABG'S PENDING. breath sounds=course throughout. BREATH SOUNDS=COURSE THROUGHOUT. WILL CHANGE TO PS AND ASSESS. RENAL=FOLEY. TROPONIN 4.9 - 14.5 W CK/MB 283/39. ?lipirudin-to be discussed @ rounds. t/f held for extubation and after for now d/t risk of needing reintubation. Bs clear L Lung. Bs clear L Lung. GI=pedi feeding tude. follow low bp on captopril. ID=low grade t. abx-levoflox & flagyl. AM AGG PENDING. RESPONDS TO NOXIOUS STIM. am abg-pending. CCU NPN 0900-1400S/O: PT REMAINS INTUBATEDCV: DOPA WEANED TO OFF, ATTEMPTED TO LEVO BUT MAP<60. follow resp status, enc cough, deep breathing, nt sx prn. CV=REQUIRING PRESSOR SUPPORT TO MAINT ADEQ MAPS-DOPA @ 10MCG/KG/MIN & LEVO PRESENTLY @ 0.4MCG/KG/MIN. L-HEARING AIDE REMOVED. ID=LOW GRADE T-99.9 PO. HCT 40.0 - 35.6. r-fem mlc dced & tip sent for culture. Labs=am sent. Labs=am sent. arms.skin- cont. sats high 90s. Tolerating well. with generalized edema, esp hands/arms. ASSESS MS WEARS OFF. k-4.2, hct 29. plts 95, hit neg per ho. follow plts, bldy urine. 3 hypertensive-rxed w hydral iv w subsequent hypotension- requiring pressors & ivf & acute ekg chgs-non /intervention candidate from previous cath 01 transfered to CCu for further management. started on s/c heparin q8h. SPUTUM SENT.DISPOSITION: M.D. LEVO TITRATED UP. Resp. Resp. RESP. hypo BS. RE-INTUBATION. remains on Levoflox and Flagyl.CARDIAC: AFib 80-90s. Cx sent. PT STARTED ON LEVO. SUCTION NASALTRACH. Cont PSV. PT REMAINS ON TRIPLE ABX. TEMP MAX 100.8 PR. D: Pt. Replaced on AC.40/600/10/5 x2hrs, change position to Lside down, retry PSV after 30 min @ 1630> successful and maintained. A-LINE INSERTED VIA R RADIAL. M.D. M.D. CAPTOPRIL HELD.RESP: EXTUBATED ON DAYS. CARE NOTEpt. CPK on decline, Trop on rise. Pt. Pt. to start TF tonite: promote w/ fibre @ 10cc/hr. with intermitent periods tachypnia +- tachycardia. Cont PSV HR DOWN. BLD CULT DRAWN AND SENT. ABG'S FOLLOWED CLOSLEY. cont vent support. PROPOFOL @ 10MCG/KG/MIN.A; HYPOTENSIVE REQUIERING PRESSORS. Sxn for mod. RR DOWN AFTER ADDITION OF PROPOFOL. HR 100-107 afib cont. PT REMAINS IN A-FIB. CPAP+PS 15,PEEP 5. SEPSIS. MULTILUMEN INSERTED VIA L GROIN. etiology. NOW HAS ADEQUATE BP'S WITH MAP'S73-83.CURRENTLY LEVO @ .258 MCG/KG/MIN. CCU progress note 7a-7pRESP: see above resp note, remains vented on PS 15/5 40%.NEURO: pt not 'waking' up. IR noted that pt had very small stomach when contrast flushed thru NGT - watch residuals.PLAN: start TF tonite. ALTERED RESP STATUS/MASK VENTILATION. 'S IN TO EVALUATE PT. RR still in the high 30's. RR coming down to high 20's. WILL NEED CLARIFICATION AS STATUS CHANGES.GI: TF HELD. CCU Progress Note:S- intubated & sedated.o- see flowsheet for all objective data.cv- Tele: A fib no ectopy- HR 95-114 L radial A-line B/P 90-106/39-52 con't on levo gtt @ .3mcq/kg/min- U/O down between 1 & 2am- 500cc fld bolus given- K 5 Hct 35.9resp- on vent AC 40%/600/10/5- last ABG 7.40-35-118-22 Lung sounds on L coarse S/P R pneumonectomy- suctioned sm amt blood tinged/tan colored mucous- SaO2 95-100%- RR > 35 @ 2am despite versed bolus- HO called & fentanyl gtt restarted @ 25mcq/hr.gi- abd soft (+) bowel sounds- no stool this shift- Plan is for gastric tube placement by IR .gu- foley draining clear yellow urine- U/O down @ 1&2am- 500cc fld bolus ordered & given- U/O up (+) 500cc since 12am.id- T 99.7-99.8 PO con't on flagy & levofloxacin for asp pnx.neuro- sedated on versed gtt @ 2mg/hr & fentanyl 25mcq/hr- minimal movement noted- PERL- (+) cough - responds to painful stimuli.A- failed weaningP- monitor vs, lung sounds L, I&O, & labs- plan is to decrease to attempt weaning- assess mental status as wears off- offer emotional support to family & keep them updated on plan of care- TO IR today for gastric tube placement. | 42 | [
{
"category": "Echo",
"chartdate": "2141-03-22 00:00:00.000",
"description": "Report",
"row_id": 103746,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nBP (mm Hg): 107/49\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 15:03\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\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is severe regional left ventricular\nsystolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: mid anteroseptal - hypokinetic; basal inferolateral -\nakinetic; mid inferolateral - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. The aortic valve\nis not well seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nthickening of the mitral valve chordae. Mild (1+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is moderate\npulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality 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. There is severe regional\nleft ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include lateral akinesis and septal and apical\nakinesis/hypokinesis. Views are technically suboptimal for assessment of\nsegmental wall motion; estimated ejection fraction ?15%. Right ventricular\nchamber size is normal. Right ventricular free wall motion was not fully\nvisualized. The aortic valve leaflets are mildly thickened. The aortic valve\nis not well seen. No aortic regurgitation identified in suboptimal views. The\nmitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is\nseen. There is moderate pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-25 00:00:00.000",
"description": "Report",
"row_id": 299188,
"text": "Atrial fibrillation\nExtensive ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-24 00:00:00.000",
"description": "Report",
"row_id": 299189,
"text": "Sinus rhythm with frequent multifocal atrial premature beats\nAnterolateral ST-T changes may be due to myocardial ischemia\nSince the previous tracing of atrial premature beats are seen\nDecreased ST-T waev abnormalities\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-23 00:00:00.000",
"description": "Report",
"row_id": 299190,
"text": "Sinus rhythm. Low limb lead voltage. P-R interval 0.14. ST segment depression\nin leads I, aVL and V3-V6 as previously recorded on . There is no\ndiagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-22 00:00:00.000",
"description": "Report",
"row_id": 299191,
"text": "Normal sinus rhythm\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in limb leads\nSince previous tracing of , Q-Tc appears prolonged and ST-T wave\nabnormalities less marked\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-19 00:00:00.000",
"description": "Report",
"row_id": 299192,
"text": "Multifocal atrial rhythm\nPossible RVH with secondary ST-T changes\nAnterior and lateral ST-T changes suggest myocardial injury/ischemia\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-20 00:00:00.000",
"description": "Report",
"row_id": 299193,
"text": "Multifocal atrial rhythm\nPossible right ventricular hypertrophy\nLateral ST-T changes suggest myocardial injury/ischemia\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-18 00:00:00.000",
"description": "Report",
"row_id": 299194,
"text": "Atrial fibrillation with slow ventricular response\nInferior/lateral ST-T changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-19 00:00:00.000",
"description": "Report",
"row_id": 299195,
"text": "Multifocal atarial rhythm\nPossible RVH with secondary ST-T changes\nLateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince previous tracing of : rhythm changes\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-18 00:00:00.000",
"description": "Report",
"row_id": 299196,
"text": "Sinus arrhythmia\n- borderline first degree A-V block\nPossible RVH with secondary ST-T changes\nMarked ST depression in V lead, consider recent infarction\nLateral ST-T changes suggest myocardial injury/ischemia\nSince previous tracing of anterior ST-T wave abnormalities more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-18 00:00:00.000",
"description": "Report",
"row_id": 299197,
"text": "Multifocal atrial rhythm\nExtensive ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince previous tracing of : rhythm changes and ST-T wave abnormalities\nmore marked\n\n"
},
{
"category": "ECG",
"chartdate": "2141-03-18 00:00:00.000",
"description": "Report",
"row_id": 299414,
"text": "Sinus bradycardia\n - supraventricular extrasystoles\n Inferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing of rate slower\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-19 00:00:00.000",
"description": "Report",
"row_id": 1420898,
"text": "nursing progress note see careview for details.\n\nneuro:remains sedated on midazolam and fentanyl.pupils 2mm and perl.does not follow commands or move extremites due to sedation.\n\ncv:remains in atrial fib with variable rate 90 to 100 and has very short burst up to 130.has nsr with pacs for only short periods.had one episode of idioventricular rhythmn hr in the 60s with spontaneous drop of bp.remains on levophed at 0.4 mcg/kg/min and dopamine at 10mcg/kg/min. aline bp is lower than cuff bp at times.\n\nresp:remains intubated on cmv ,fio2 40%,resp rate 12,with 5cm of peep.breath sounds absent on right side and breath sounds coarse to clear on left side.sp02 99%.et tube suctioned for large amount of thick bloody secretions.\n\ngi:abd soft with positive bowel sounds present.ogt to lis drainaing moderate amount of bloody tinged to old dark bloody drainage.placement verified auscultation.\n\ngu:foley to cd draining moderate amount of yellow urine with sediment.\n\nid:temp elevated to 100.8 r.pan cultured.\n\nsocial:wife and son in to visit.updated on pts condition by md.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-20 00:00:00.000",
"description": "Report",
"row_id": 1420899,
"text": "Resp Care Note:\n\nPt cont intub sedated on mech vent as per Carevue. Lung sounds ess clear L suct sm th bldy sput. No vent changes made overnoc. Cont mech vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-20 00:00:00.000",
"description": "Report",
"row_id": 1420900,
"text": "CCU NSG PROGRESS NOTE.\nO:NEURO=SEDATED-FENT & VERSED GTT.\n PULM=INTUBATED & VENTED-SETTINGS---AC/600X12/40%/+5 W SATS UPPER 90'S. AM AGG PENDING. SX-SNT BL TINGED SECRETIONS.\n CV=REMAINS AF W OCC PVC'S. DOPA DECREASED FROM 10-3MCG/KG/MIN. LEVO UNCHGED 0.40MCG/KG/MIN. VARIABLE BP, BUT TOLERTING SLOW DOPA WEAN.\n GI=OGT-LIS BILIOUS W OLD BLOOD.\n GU=FOLEY. ADEQ UO.\n ID=AFEB. CULTURED .\n HEME=2300 HCT-35.8.\n\nA:TOLERATING SLOW DOPA WEAN.\n\nP:CONTIN PRESENT MANAGEMENT. SUPPORT AS INDICATED. ?DISCUSSION W FAMILY-WIFE & SON-RE:CODE STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-20 00:00:00.000",
"description": "Report",
"row_id": 1420901,
"text": "CCU NPN 0900-1400\nS/O: PT REMAINS INTUBATED\n\nCV: DOPA WEANED TO OFF, ATTEMPTED TO LEVO BUT MAP<60. PT CONT IN AF, RATE 70'S-90'S. CK/MB/TROPONIN ADDED ON TO 0400 LABS. CK'S FALLING, MB'S/TROPONIN PND.\n\nRESP: FENT TURNED OFF, VERSED TO 2MG/HR. RESP TO CHANGE TO PS WEAN AND ASSESS TOL. SUCTIONED Q2-3H FOR THICK BLOODY SECRETIONS. NOT OVERBREATHING A/C OF 12 AT PRESENT. SATS IN HIGH 90'S. NO SIGNS OF CHF.\n\nID: AFEB PO. TO START ON LEVO AND FLAGYL IV FOR PROPHELAXIS OF PRESUMED ASPIRATION PRIOR TO INTUBATION.\n\nGI: OGT OUT, MULTIPLE ATTEMPTS TO PLACE UNSUCCESSFUL SO FAR. PT SEEMS TO HAVE OBSTRUCTION IN POST PHARYNX. POS BS, NO STOOL.\n\nGU: DRAINING CLEAR URINE, POS FOR TODAY.\n\nNEURO: FENT OFF, WEANING VERSED AS TOL. PT WITH POS COUGH, MOVING HANDS TO NOXIOUS STIMULI, ACTIONS PURPOSEFUL AT TIMES. OTHERWISE, APPEARS SEDATED WITH MINIMAL MOVEMENT.\n\nSOCIAL: WIFE HERE IN AM, ASKING MANY QUESTIONS. WILL SPEAK TO DOCTORS TODAY. NO PHONE CALLS.\n\nA/P: ABLE TO WEAN FENT AND DOPA, UNABLE TO WEAN LEVO AT ALL. WILL CHANGE TO PS AND ASSESS. FOLLOW TEMPS AND WBC ON ABX. ASSESS MS WEARS OFF. KEEP FAMILY INFORMED OF PROGRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-20 00:00:00.000",
"description": "Report",
"row_id": 1420902,
"text": "RESP. CARE NOTE\nPT. WEANED TO CPAP + PS AT 1417, 15/5 40%. VT- 450-500. RR,15-19, PT. TOL. WELL. ABG'S PENDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-24 00:00:00.000",
"description": "Report",
"row_id": 1420920,
"text": "CCU Nsg Progress Note.\nBrief Hospital HX:admitted to 3 from ew w cp releived w sl ntg. 3 hypertensive-rxed w hydral iv w subsequent hypotension- requiring pressors & ivf & acute ekg chgs-non /intervention candidate from previous cath 01 transfered to CCu for further management. intubated for airway protection. rx aggressively for hypotension & ekg chgs.\n pressor-dopa weaned & dced. remained on levophed.\n all dced-fent & versed. wo improvement in responsiveness.\n CT head-wo acute intracranial hemmorrhage or mass effect.\n Echo-sever regional LV systolic dysfunction. ?EF 15%. mod pulm systolic HTN.\n\nO:Neuro=off . ?sl more responsive. does not respond or follow verbal stimuli.\n Pulm=remains intubated & vent. settings/abg-see care view. sats upper 90's. breath sounds=course throughout. sx-mod amt white secretions.\n CV=remains in AF. rate controlled w po amiodarone. off heparin-?HIT. ?lipirudin-to be discussed @ rounds.\n Access=peripheral lines x2. r-fem mlc dced & tip sent for culture. a-line l-rad.\n GI=pedi feeding tude. tf-promote w fiber @ 10ml/hr.\n GU=foley. adeq uo.\n Labs=am sent.\n Code Status=remains full code.\n\nA:remains intubated. sl improvement in responsiveness off .\n\nP:contin present management. contin discussion w family re:code status.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-24 00:00:00.000",
"description": "Report",
"row_id": 1420921,
"text": "s/p arrest\nccu npn\no- afebrile. cv- hr 90s-114 af vs mat, no vea. bp 93-111/. k-4.2, hct 29. plts 95, hit neg per ho. aline d/c'd. started on agatroban at 2mic/kg/min. ptt sent at 1700 and pnd. started on captopril.\nresp- on psv and more awake. sats high 90s. weaned to and extubated at 2:30pm. on cool neb. last abg done on 40% neb- 76,32,7.44. sats mid to high 90s. l/s coarse. sx'd in am for thick tan via ett, has cough, prod at times tan sputum. rr high at times pre extubation 20s-30s, since rr 30s, 40s at times. urine bloody this pm, ho aware, at least 40cc/hr.\ngi- abd soft with hypoactive b. sounds. has pedi tube, clogs easily. t/f held for extubation and after for now d/t risk of needing reintubation. recheck with ho in am. no bm.\nms- awake in am looking to voice, trying to mouth words at times.\nafter extubation, looks to voice, rarely trying to speak but unable to understand. not following commands well. moving extremities esp. arms.\nskin- cont. with generalized edema, esp hands/arms. cont with fingers/toes/heels cyanotic. no breakdown noted. on 1st step mattress. repos side to side to back with skin care q2-3hrs.\nsocial- wife/son in, status, plan explained to pt/ by rn/mds.\na- extubated, more awake.\np- check ptt, f/u with ho. follow resp status, enc cough, deep breathing, nt sx prn. follow plts, bldy urine. follow low bp on captopril.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-18 00:00:00.000",
"description": "Report",
"row_id": 1420896,
"text": "CCU NSG ADMIT NOTE\nPt is yo male admitted to 3 today after c/o cp at home, sob, unrelieved w/ 3sl ntg. + troponin 4.4, ck neg.\n\nPMH: CAD, cath ' 70% LAD, 90% RCA., htn, MR, lung CA s/p r pneumenectomy, ^ chol.\n\nOn floor pt had bp 200/120, given 30 mg Hydralazine. bp dropped to 80/50, pt c/o cp. EKG -> st depressions in 2,3,F. Pt given 1mg mso4, ns w/o, started on dopamine 5mcg->10mcg. w/ sbp ^100. Integrelin staarted at 10cc, heparin started at 100u/hr. Pt briefly had bradycardia to 20's, ^ to 70's w/o intervention. pads placed. Sats 93% on 100% nrb. Pt transferred to CCU.\n\nPt arrived to CCU, w/ hr 70 sr, bp 102/58, sat 100% on nrb. Aline and TLC placed. Pt's hr down to 25, pt vomited, and hr ^ 70 w/o intervention.\n\nResident has spoken to pt's wife, and pt is full code at this time.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-19 00:00:00.000",
"description": "Report",
"row_id": 1420897,
"text": "CCU NSG PROGRESS NOTE.\nEVENT=INTUBATED BY ANESTHESIA FOR AIRWAY PROTECTION-MED W ETOMIDATE FOR INTUBATION. INTUBATED WO INCIDENT. POST INTUBATION CXR DONE-ETT ADVANCED 2CM.\n\nO:NEURO=SEDATED. RESPONDS TO NOXIOUS STIM.\n PULM=VENT SETTINGS-AC/600X12/40%/+5 W LAST ABG-7.33/47/121/26/-1 W SATS UPPER 90'S. BREATH SOUNDS=COURSE THROUGHOUT. SX-SCANT BLOODY SECRETIONS.\n CV=REQUIRING PRESSOR SUPPORT TO MAINT ADEQ MAPS-DOPA @ 10MCG/KG/MIN & LEVO PRESENTLY @ 0.4MCG/KG/MIN. BP VARIABLE @ X'S REQUIRING TRANSIENT INCREASES IN PRESSORS. TRANSIENTLY ON NTG-DCED DUE TO DECREASE MAPS & INCREASED PRESSOR REQUIREMENTS. EPISODES OF BRADYCARDIA-RELATED TO GAGGING- RESULTING IN SIGNIF DECREASE IN BP. TROPONIN 4.9 - 14.5 W CK/MB 283/39. HEPARIN DECREASED TO 800U @ 0330 FOR PTT 106.1. INTEG @ 2MCG/KG/MIN.\n GI=OGT PLACED-BILIOUS GUIAC POS. BLOODY @ X'S-?RELATED TO ORAL OOZE (POST INTUBATION). HCT 40.0 - 35.6.\n RENAL=FOLEY. DECREASED UO. BOLUSED W 500ML X1-0000 WO SIGNIF INCREASE IN UO. BUN/CREAT 29/1.3.\n ID=LOW GRADE T-99.9 PO.\n MISC=ORAL OOZE-?RELATED TO INTUBATION. DETURES REMOVED. L-HEARING AIDE REMOVED.\n SOCIAL=MDS/RN TALKED W FAMILY-WIFE & SON--UPDATES GIVEN.\n CODE STATUS-FULL.\n\nA:RI W POS TROP/CK. PRESSOR DEPENDENT. EPISODES OF BRADYCARDIA/ HYPOTENSION-RELATED TO VAGAL EVENT.\n\nP:CONTIN PRESENT MANAGEMENT. ATTEMPT TO WEAN PRESSORS AS TOLERATED. FOLLOW LABS. NEXT LAB DRAW 0800-HCT/CK. ?DISCUSSION RELATED TO CODE STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-23 00:00:00.000",
"description": "Report",
"row_id": 1420915,
"text": "CCU Nsg Progress Note.\no:Neuro=unresponsive to verbal stim. only responds w grimace to noxious stim.\n Pulm=intubated & vented w present settings-cpap/ps-. cats upper 90's. am abg-pending. sx-lg thin white secretions. episode of increased rr to high 30's-wo cause-self limiting.\n CV=remains AF w controlled hr. amiodarone gtt dced-started on po.\n GI=tf started @ -promote w fiber @ 10ml/hr (order not to increase).\n GU=adequate uo.\n Misc=toes/fingeres-mottled w darkish discoloring @ tips.\n ID=low grade t. abx-levoflox & flagyl.\n Labs=am sent.\n Social=remains full code.\n\nA:off -remains unresponsive.\n\nP:contin present management. need to address code status & short/long term prognosis w family-wife & son.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-23 00:00:00.000",
"description": "Report",
"row_id": 1420916,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Pt. appears comfortable on Psv. Current settings Psv 15, Cpap 5, Fio2 40%. Pt. maintaining vols 500's with RR 11-19. Bs clear L Lung. Sx'd for scant amount thick white sputum. Abg results 7.44, 32, 141, 22, 0. No further changes made. Plan: Continue with Psv and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-23 00:00:00.000",
"description": "Report",
"row_id": 1420917,
"text": "nursing progress note see careview for details\n\nneuro:appears to be awakening more moves left leg to purposeful movement,bending up both arms now appears purposeful.left eye reacts to light but right eye does not appear to react or possible sluggishly.pupils do appear equal in size.\n\ncv:remains in atrial fib rate 85 to 100,bp stable at 110 to 130 systolic.both feet cool to touch at toes with bildp and pt pulses by doppler.hands warm but fingers cyanotic.\n\nresp:on cpap with 15 of ps and 5 of peep,put on 100% while team is attempting to place central access.breath sounds absent on right side and coarse on left side.suctioned for moderate amount of thick white sputum.resp rate 15 to 30,sp02 96 to 98%.\n\n\ngi:feeding tube was clogged but after gentle irrigation was able to open ,tube feed continues at 10cc.abd soft with positive bowel sounds present.no stool today.\n\ngu:foley to cd draining god amounts of clear urine.\n\nendocrine:blood sugars being followed closely had glucose of 32 treated with one amp of dextrose but now wnl.\n\nsocial:son was called by md to update him on fathers condition.wife was in to visit today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-23 00:00:00.000",
"description": "Report",
"row_id": 1420918,
"text": "update; had multiple attemps to put in central line ,right ij and right sc was not successful.chest xray done and hct checked.appears to be awakening more ,question if it is purposeful.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-24 00:00:00.000",
"description": "Report",
"row_id": 1420919,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Vent settings Psv 15, Cpap 5, Fio2 40%. Tolerating well. Spont vols of 500's. RR 17-27. Bs clear L Lung. Minimal secretions. Sx'd for sm amount of thick white sputum. Abg results 7.45, 33, 121, 24. Pt. unresponsive. No further changes made. Continue with mechanical support and attempt to wean Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-22 00:00:00.000",
"description": "Report",
"row_id": 1420911,
"text": "CCU Progress Note:\n\nS- intubated\n\nO- see flowsheet for all objective data.\n\ncv- Tele: Afib no ectopy- HR 74-90 L radial A-line B/P 95-120/42-54 levo gtt @ .103mcq/kg/min- weaned off during night, however had to go back on due to low B/P- con't on amniodarone gtt @ 1mg/min- Hct 30.5 1u PRBC's ordered & given- K 4.8\n\nresp- con't on vent CPAP 5/15/40%- ABG 7.44-32-165-99%- attempted to decrease PS during night, but not tolerated- RR upper 30's-low 40's- propafol gtt started- no difference noted in RR- propafol gtt D/C'd-SaO2 96-100%.\n\nneuro- remains sedated- unresponsive- pupils large(5mm) & react sluggishly to light- (+) cough & gag reflex.\n\ngi- abd soft (+) bowel - To have gastric tube placed by IR- Po meds held or changed to IV - no stool this shift.\n\ngu- foley draining conc tea colored urine in sm amts- 500cc fld bolus given @ 2am- u/o 30cc/hr since- BUN 45 Crea 1.3\n\n\nid- T max 100- (+) blood cultures- gm (+) rods noted- blood cultures repeated X2- WBC 10.\n\nA- failed weaning\n\nP- monitor vs, lung sounds, I&O, & labs- wean off levo gtt if tolerated- assess mental status as wears off- ? tube feedings once tube placed- offer emotional support to family- keep them updated on care- con't to try weaning off vent.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-22 00:00:00.000",
"description": "Report",
"row_id": 1420912,
"text": "Addendum: fingers & toes cyanotic- B/P now 114/50- Levo gtt decreased to .052mcq/kg/min.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-22 00:00:00.000",
"description": "Report",
"row_id": 1420913,
"text": "Resp. Care Note\nPt remains intubated and vented on settings PSV 15 peep 5 and 40% with TV 500-600 range and RR 20's. Pt transported to CT scan in AM and then to fluro in afternoon for NG tube placement. Pt fairly calm most of the shift, RSBI done- 122. Pt given trial on PSV 12. After 1 1/2 hours RR up to 40's and TV low 300's. ABG sent and was good but PSV ^ back to 15 with Pt's RR coming back down to the 20's. Sxn for mod. amounts of light tan secretions. cont vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-22 00:00:00.000",
"description": "Report",
"row_id": 1420914,
"text": "CCU progress note 7a-7p\nRESP: see above resp note, remains vented on PS 15/5 40%.\n\nNEURO: pt not 'waking' up. remains off since yesterday morning. does not pull away from noxious stimuli, but does grimmace. opens eyes spontaneously now. pupils 5mm sluggish. wife in to visit during the day. HEAD CT done this morning - still needs to be read by radiologist, but seemed negative.\n\nID: tmax 99.4. BC grew gram + rods, recultured last evening. remains on Levoflox and Flagyl.\n\nCARDIAC: AFib 80-90s. Remains on [email protected]/min. Given 1 unit of PRBCs overnite, pm HCT stable at 32. SBP 100-120s, weaned off LEVO at 5pm this evening. started on s/c heparin q8h. R femoral TLC patent, L radial aline patent. ECHO done this afternoon ~EF 15%.\n\nGI/GU: foley patent. U/O 20-30cc during day. abd soft. hypo BS. NGT placed under fluoro in interventional radiology. to start TF tonite: promote w/ fibre @ 10cc/hr. IR noted that pt had very small stomach when contrast flushed thru NGT - watch residuals.\n\n\nPLAN: start TF tonite. monitor VS. plan to try to wean vent again tomorrow - especially if pt starts to respond more positively to stimuli. need to start PO AMIO!\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-26 00:00:00.000",
"description": "Report",
"row_id": 1420925,
"text": "CCU NPN\nYO ADMITTED WITH CHEST PAIN WITH HX OF 3VD. BECAME HYPOTENSIVE ON FLOOR ADMITTED TO CCU FOR MANAGEMENT. DECISION WAS MADE TO MAKE PT COMFORT MEASURES. HE WAS PLACED ON MSO4 AT 2MG/HR AND PRESSORS WERE WEANED TO OFF. HR 70-80'S AND BP 40'S MOST OF SHIFT UNTIL APPROX 4:20AM, DECREASE HR AND THEN BP. PT PASSED AT 4:30AM, TEAM AND FAMILY AWARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-21 00:00:00.000",
"description": "Report",
"row_id": 1420907,
"text": "NPN 07--1500;\n\nNEURO; RECEIVED SEDATED AND UNRESPONSIVE ON FENTENYL AND VERSED.VEERSED D/C AT 930. FENTENYL D/C'D AT 1130. AT PRESENT ATTEMPTS TO OPEN EYES WITH STERNAL RUB ,NO RESPONSE TO DEEP PAINFUL STIMULI PERLA 4MM SLUGGISH.\n\nRESP; ATTEMPTED TO WEAN TO EXTUBATION. PS 15-10. FAILED DUE TO HIGH RR 38-45,TV , ABG WNL, BUT HR GOING TO 130' -140'S,THEREFORE RETURNED TO PS 15 RR TO , TV 600.SATS REMAINED 99-100% HR TO 90-100, SUCTIONED Q2 THICK GREEN SECRETIONS.POS COUGH AND GAG.\n\nCVS; TMAX 99.4 PO, AFIB 91- 144 WHEN TRYING TO WEAN, BOLUSED WITH 150 MGS AMIODERONE AND STARTED ON DRIP AT 1 MG/MIN FOR 6 HOURS AT 1500. TO GO TO .5 MG/MMIN AT 2100. BP MAP >65 ON LEVO ABLE TO WEAN FROM .3-.13 MCGS/KG/MIN.\n\nGU; POOR U/O, 20-25 MLS/HR. BUT I.V INTAKE LOW REPEAT HCT SENT WILL POSS GIVE SOME PRBC.\n\nGI; NGT PLACEMENT UNDER FLEURO CANCELLED DUE TO ATTEMPT TO WEAN, ARRANGED FOR 9 AM TOMORROW, MEDS CHANGED TO I.V FOR NOW.BELLY SOFT POS BOWEL SOUNDS. NO STOOL NO FLATUS.\n\nSKIN; WNL.\n\nSOC; WIFE INTO VISIT AND UPDATED WITH PPT'S CURRENT CONDITION.FELT THAT HE DID NOT LOOK AS GOOD TODAY AS HE DID YESTERDAY.\n\nPLAN; TO ATTEMPT TO WEAN WHEN MORE AWAKE.PLACCE NGT UNDER FLUORO AT 0900 TOMORROW, CONTINUE TO WEAN LEVO AS TOLERATED FOR MAP .65.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-21 00:00:00.000",
"description": "Report",
"row_id": 1420908,
"text": "Resp. Care Note\npt intubated and vented on current settings PSV 20 peep 5 and 40%. Pt received on PSV 15 with TV 600 and RR 12-16. RSBI 136. Pt weaned from PSV 15-10 and TV dropped to 300-400 and RR 30. Did fairly well on this for a while, good ABG but then became very tachypneic to RR 40, improved on PSV 15 for a while but then again dev. ^RR and PSV ^ 20. Currently on PSV 20 TV 700 and RR 10. Rest overnight and reassess in AM for wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-21 00:00:00.000",
"description": "Report",
"row_id": 1420909,
"text": "D: Pt. with intermitent periods tachypnia +- tachycardia. Tachypnia relieved with increase in pressure support - please see RT note.Tachycardia resolves spontaneously. Neuro status unchanged with acception that pt occasionaly opens eyes spontaneously. Pts son phoned in and gave permission for blood transfusion. Pressor support unchanged, UO 20-30cc/hr.\n\nP: Continue full support, transfuse 1UPRBC, notify team of any change.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-22 00:00:00.000",
"description": "Report",
"row_id": 1420910,
"text": "Resp Care Note:\n\nPt cont on mech vent as per Carevue. Lung sounds ess clear L suct mod th pale yellow sput. Pt periodically increases RR and drops Vt for no apparent reason ? etiology. Cont PSV\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-20 00:00:00.000",
"description": "Report",
"row_id": 1420903,
"text": "RESP. CARE NOTE\npt. increased rr 35, decreased vt-200, hr 150. placed back\non a/c rate of 10. M.D. notified cxr planned, will attempt\nto wean again this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-25 00:00:00.000",
"description": "Report",
"row_id": 1420922,
"text": "NSG NOTE\n\nCV: HYPOTENSIVE ON EVES. MAPS DOWN TO 50. HOUSE STAFF NOTIFIED OF FINDINGS. M.D.'S IN TO EVALUATE PT. GIVEN NS BOLUS X500CC GIVEN WITH LITTLE EFFECT. PT STARTED ON LEVO. ? SEPSIS. A-LINE INSERTED VIA R RADIAL. MULTILUMEN INSERTED VIA L GROIN. LEVO TITRATED UP. NOW HAS ADEQUATE BP'S WITH MAP'S73-83.CURRENTLY LEVO @ .258 MCG/KG/MIN. PT REMAINS IN A-FIB. HR AS HIGH AS 120. IMPROVING AFTER STARTING . HR NOW 89-90'S. AMIODARONE INCREASED TO 400MG . EKG COMPLETED DURING HYPOTENSIVE STATE SHOWING ST DEPRESSIONS IN V2-V4. REMAINS ON ARGATROBAN @ 2MCG/KG ( HELD DURING LINE INSERTION). CAPTOPRIL HELD.\n\nRESP: EXTUBATED ON DAYS. RR- 30-40'S (PT HAS HAD HIGH RR). ABG'S FOLLOWED CLOSLEY. BECOMING MORE ACIDOTIC ON 40% FM. SATS DROPPING. CXR SHOWING FAILURE. LASIX TOTAL 80MG AND MSO4 4MG TOTAL GIVEN WITH GOOD RESPONCE. PT PLACED ON MASK VENTILATION. CPAP+PS 15,PEEP 5. IMPROVING AND PT COMFORT. RR DOWN AFTER ADDITION OF PROPOFOL. SUCTION NASALTRACH. FOR THICK TAN TO YELLOW SECRETIONS.\n\nID: ? HYPOTENSION D/T SEPSIS. TEMP MAX 100.8 PR. PT REMAINS ON TRIPLE ABX. BLD CULT DRAWN AND SENT. SPUTUM SENT.\n\nDISPOSITION: M.D.'S SPOKE WITH SON X3 OVERNOC TO UPDATE,OFFER SUPPORT AND CLARIFY CODE STATUS. PT IS NOT TO BE DEFIBRILLATED. WILL NEED CLARIFICATION AS STATUS CHANGES.\n\nGI: TF HELD. ? RE-INTUBATION. ABD SOFT. HYPOACTIVE BS.\n\nGU: URINE AMBER WITH SEDIMENT. MODERATE DIURESIS AFTER LASIX GIVEN.\n\nSKIN: MULTIPLE BRUISING. INTACT\n\nLABS: HCT 30\n PTT 72.8 NO HEPARIN IN LINES D/T HIT\n BS 149\n LACTIC ACID 2.1\n\nNEURO: OPENS EYES TO VOICE. INAPPRP. SOUNDS. DOES NOT FOLLOW COMMANDS. AGITATED AFTER MASK VENTILATION APPLIED. TRYING TO SIT UP IN BED. PROPOFOL GTT STARTED WITH EXCELLENT EFFECT. HR DOWN. APPEARS MORE COMFORTABLE. PROPOFOL @ 10MCG/KG/MIN.\n\nA; HYPOTENSIVE REQUIERING PRESSORS. ALTERED RESP STATUS/MASK VENTILATION.\n\n; CON'T PER NSG JUDGEMENT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-25 00:00:00.000",
"description": "Report",
"row_id": 1420923,
"text": "Respiratory Care:\n\nPatient extubated . Pt. increased WOB with RR 40's. Worsening hypotension. Increased secretions. Frequent NTS for sm amounts of thick white/tan sputum. Cx sent. Pt. put on mask ventilation. Vent settings initially Psv 10, Cpap 5, Fio2 100%. RR still in the high 30's. given via nurse. Psv also increased to 15 in attempt to decrease RR. RR coming down to high 20's. Spont vols 500-600's. PaO2 248. Fio2 weaned to 60%. No further changes made. Continue with mask ventilation as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-25 00:00:00.000",
"description": "Report",
"row_id": 1420924,
"text": "CCU NPN: please see flowsheet for objectuve data\n\n yo gentleman with CAD,sepsis. Dr spoke with son and wife,pt made DNR and weaned off levo. continues on all other medication\n\nCardiac: levo now off MAPS 43-57 HR 70's AF,cont on amiodorone po BID\n\nResp: now on 100% NRB,unable to get ABG's and sats unreliable,NST suctioned X1 for scant white\n\nGU: UO adequate\n\nGI: NPO except meds\n\nNeuro: Morphine started at 2mg/hr,weaning off propofol\n\nHeme: remains on agratroban\n\nID: cont on flagyl,levo and vanco,Tmax 96.3 po\n\nSocial: wife and son in to visit spoke with \n\nA/P: keep pt comfortable\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-20 00:00:00.000",
"description": "Report",
"row_id": 1420904,
"text": "CCU- Nursing Progress Note 3-11p\n y/o male admitted to floor w/ CP, hypotensive s/p hydralazine for BP control, EKG changes, bradycardic, intub for airway protection. Tx to CCU .\nNeuro-\nCont to be adequately sedated on versed @2mg/hr, responsive to pain w/ w/d. No spont movement. PERLA 3mm/bsk.\n\nResp- s/p R pneumonectomy,therefore does not tol R side down.\nPSV trial @ 1415 tol well for 90 min on R side when ^ rr30, hr 150. Replaced on AC.40/600/10/5 x2hrs, change position to Lside down, retry PSV after 30 min @ 1630> successful and maintained. MAP =, Tv= 530-630. Sx for med amt blood tinge sputum q3-4hr, much less later this evening.\nCV- Dopamine weaned off during day; Levophed ^ 1.0m/k/m w/ BP 95-110. 500ccIVB given @1600> Levo weaned to .3m/k/m slowly over evening w/ BP 100/50. Goal= keep MAP>65. HR 100-107 afib cont. CPK on decline, Trop on rise. Heparin being held per GI bld-see below\n\nFLuids/renal- u/o post 500 cc bolus= 30-40 cc/hr, imprved from day.\n\nGI-bloody secretions from mouth s/p og tube placement attempt have mostly cleared. Plan for gastric tube placement by IR .\n\nID- 99-100 on flagyl and levofloxacin for asp pnx. Was pan cultured \n Wife called and informed of status. Son and grandson in to visit @1800- informed in detail of status, progress and plan.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-21 00:00:00.000",
"description": "Report",
"row_id": 1420905,
"text": "Resp Care Note:\n\nPt cont intub and sedated on mech vent as per Carevue. Lung sounds sl coarse L improve with suct sm th tan sput. Pt required more due to tachypnea and falling O2 sats. No vent changes required overnoc once sedated adequately. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-03-21 00:00:00.000",
"description": "Report",
"row_id": 1420906,
"text": "CCU Progress Note:\n\nS- intubated & sedated.\n\no- see flowsheet for all objective data.\n\ncv- Tele: A fib no ectopy- HR 95-114 L radial A-line B/P 90-106/39-52 con't on levo gtt @ .3mcq/kg/min- U/O down between 1 & 2am- 500cc fld bolus given- K 5 Hct 35.9\n\nresp- on vent AC 40%/600/10/5- last ABG 7.40-35-118-22 Lung sounds on L coarse S/P R pneumonectomy- suctioned sm amt blood tinged/tan colored mucous- SaO2 95-100%- RR > 35 @ 2am despite versed bolus- HO called & fentanyl gtt restarted @ 25mcq/hr.\n\ngi- abd soft (+) bowel sounds- no stool this shift- Plan is for gastric tube placement by IR .\n\ngu- foley draining clear yellow urine- U/O down @ 1&2am- 500cc fld bolus ordered & given- U/O up (+) 500cc since 12am.\n\nid- T 99.7-99.8 PO con't on flagy & levofloxacin for asp pnx.\n\nneuro- sedated on versed gtt @ 2mg/hr & fentanyl 25mcq/hr- minimal movement noted- PERL- (+) cough - responds to painful stimuli.\n\nA- failed weaning\n\nP- monitor vs, lung sounds L, I&O, & labs- plan is to decrease to attempt weaning- assess mental status as wears off- offer emotional support to family & keep them updated on plan of care- TO IR today for gastric tube placement.\n"
}
] |
28,166 | 123,110 | 62 yof A-fib (s/p ablation) h/o IVDA, tricuspid valve replacement x 3 who was transferred from for management of septic shock, respiratory failure, and TV endocarditis with septic pulmonary emboli. . # Candidemia: Source is candidal endocarditis complicating IVDU. Severe sepsis on admission now resolved. Last positive Bcx was . Continued ambisome (day 1 = ) + Micafungin (day 1 = ) added by ID due to ongoing fungimia. Per ID plan is to continue this course for minimum of 14 days from first day of neg cultures () before considering switching to oral fluconazole which may have to be continued for life if no Surgery. - No surgery teams will intervene for removal of hardware (epicardial leads, spinal stimulator) at this time given comorbidities, history of repeated drug use. - Last day of ambisome on . - Continue micafungin for at least 3 more months. . #Respiratory status: Extubated , most likely due to involvement of lungs with septic emboli + fluid overload. O2 requirement weaned with diuresis. Stable now. Current deficits are most likely to underlying lung involvement with septic emboli and some amount of right ventricular overload from pulmonary hypertension. Her furosemide dose is a moving target, and we've been using 20-40mg daily. Her pulmonary edema has improved, but we're cautious of overdiuresing given her soft pressures. - continue weaning O2 as possible. . #Tricuspid valve endocarditis: CT surgery: not surgical candidate at this time - retinoscopy negative for x2 (last retinal exam on ) . #Cavitary Pulmonary Lesions: Most likely septic emboli. Continued anti-fungals as above. . # abnormal LFT??????s: HBV/HCV serology neg. Initially thought to have some cholesatsis to liver congestion. RUQ US on was non-concerning. AST/ALT/Bili have normalized but Alk phos rising. Most likely this is from ambisome which will be stopped shortly - continue to trend LFT??????s QOD . #DIC/Thrombocytopenia: consumptive process evidenced by low fibrinogen, elevated INR, low platelets, pos hemolysis labs. also have element of shearing from vegetations + BM suppression given her illness + sequestartion from minimally enlarged spleen (13.5cm per US ) likely to right heart failure and congestion. Over time with resolution of infection, her numbers have improved. Her platelets are steadily climbing. Her fibrinogen is normal. Her FDP has improved. . # right LE edema: LENI was negative. have some venous stasis complicating large right groin hematoma due to multiple attempts at femoral access in OSH. She has heart failure and hasn't been up around and moving which is causing the bilateral edema. It is worse on right though. . # right renal hydronephrosis: renal function is normal. Right hydronephrosis is stable. . #Fluctuance over t/l spine in the area of the spinal stimulator: spinal abscess was ruled out by imaging. No hardware removal at this time. . # Acute on chronic systolic and diastolic heart failure: LVEF now 55% with some degree of right ventricular interdependence. - started lisinopril 2.5mg. Uptitrate as pressures tolerate. - Lasix 20mg daily. . # Social: brother who lives in is HCP, has not seen patient during entire hospital course. Patient??????s two other brothers live in . Her partner of 30 years has not visited or called during this admission. Her son lives in . - get HCP paperwork from Brother (all contact numbers in team census). . # Nutrition: - continued tube feeds still needs Dobhoff. - continued advancing PO diet to regular - with soft solids for dysphagia and thin liquids. - continued thiamine and MVI and zinc for healing . . # FEN: no IVF, replete electrolytes as needed, # Prophylaxis: Pneumoboots for now , no heparin while active DIC # access: PICC planned for today, will d/c art line. # Communication: (daughter currently using her friend's phone): (son from Ca) daughter three brothers , and : used to work for Trap Company Partner is and pts home number is where he stays--gets home from work 7pm brother in and HCP (home: , cell: ), . # Code: DNR/DNI. Pt with capacity. Understands her illness. Able to describe what happened to her heart. The necessity of antifungals. The danger of IV drugs. The inability to surgically intervene on her heart and back at this time. . Transitional: One more day of ambisome on . Continue micafungin. Monitor nutrition. Dobhoff placed on . Will need to be taken out per . Needs rehab. | There is nopericardial effusion.IMPRESSION: Prosthetic tricuspid valve endocarditis with severe regurgitation.Moderately dilated right ventricle with moderate global systolic dysfunction.Normal global and regional left ventricular systolic function.Compared with the prior study (images reviewed) of , right ventricleis smaller and biventricular systolic function has slightly improved. Abnormal diastolic septal motion/position consistent with RVvolume overload.AORTIC VALVE: Mildly thickened aortic valve leaflets. Dilated right ventricle with severe systolicdysfunction.Compared with the prior study (images reviewed) of , there is a newvegetation on the tricuspid bioprosthesis. FINDINGS: There has been interval removal of the endotracheal tube and nasogastric tube. There is abnormaldiastolic septal motion/position consistent with right ventricular volumeoverload. Trace aorticregurgitation is seen. There is mild functional tricuspid stenosis. TSI demonstratessignificant LV dyssynchrony with significant septal wall contraction delay(vs. lateral wall).RIGHT VENTRICLE: Markedly dilated RV cavity. Trace aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. The right ventricular cavityis moderately dilated with moderate global free wall hypokinesis. FINDINGS: A left internal jugular central line ends in the upper SVC. Cardiac silhouette remains enlarged and is accompanied by pulmonary vascular congestion and mild edema. FINAL REPORT INDICATION: Endocarditis with shock. There is mild pulmonary artery systolichypertension. Left ventricular function.BP (mm Hg): 107/50HR (bpm): 60Status: InpatientDate/Time: at 00:45Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated coronary sinus (diameter >15mm).LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. Mild PA systolic hypertension. Right renal hydronephrosis is seen. Bilateral pleural effusions and atelectasis within the partially imaged portion of the lungs. Bilateral pleural effusions and atelectasis within the partially imaged portion of the lungs. Abioprosthetic tricuspid valve is present. FINDINGS: Left PICC terminates low within the body of the right atrium, directed towards the tricuspid valve plane. Improved, moderate right pleural effusion and pulmonary edema. Diffuse anasarca and abdominal ascites. Diffuse anasarca and abdominal ascites. Stable severe DJD is noted in the lower lumbar spine. Severetricuspid regurgitation is seen. Right ventricle is more dilated andhypokinetic and LV function is not as vigorous. Improvement in left lung edema. The aortic valve leaflets are mildly thickened (?#). Fluctuance felt over region of spinal stimulator. As compared to the prior examination, a portion of the lead has been removed. As compared to the prior examination, a portion of the lead has been removed. As compared to the prior examination, a portion of the lead has been removed. Right renal hydronephrosis. Right renal hydronephrosis. PATIENT/TEST INFORMATION:Indication: Right Heart FunctionHeight: (in) 62Weight (lb): 140BSA (m2): 1.64 m2BP (mm Hg): 97/54HR (bpm): 59Status: InpatientDate/Time: at 10:12Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (>2.1cm) with >50%decrease with sniff (estimated RA pressure (5-10 mmHg).LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). REASON FOR THIS EXAMINATION: progression of opacities FINAL REPORT CHEST RADIOGRAPH INDICATION: Remote tricuspid valve replacement, endocarditis. Moderate right-sided hydronephrosis is noted. Small right pleural effusion. Right ventricularconduction delay with possible right ventricular pressure and/or volumeoverload. Moderate right hydronephrosis. Sinus rhythm with atrial premature beats. FINDINGS: Left PICC has been withdrawn and now terminates in the lower superior vena cava just above the junction of the right atrium. Borderline left atrialabnormality. Compared to the previous tracing of nosignificant difference. Collapsed gallbladder with marked wall thickening, which is nonspecific in appearance. Sinus tachycardia with premature atrial and ventricular complexes. Right axis deviation. Right axis deviation. Right axis deviation. Ventricular ectopy. Low voltage.Compared to the previous tracing of low voltage is new.TRACING #1 There is a small strip of essentially anechoic material suggesting fluid without internal vascularity in the subcutaneous tissues, maximally measuring 4 mm AP. Incomplete right bundle-branch block. Probableright ventricular hypertrophy. Imaged paranasal sinuses and mastoid air cells appear well aerated. Small-to-moderate amount of ascites is noted. Atrial ectopy. Sinus tachycardia. Small-to-moderate amount of ascites. COMPARISONS: Head CT from OSCH, dated . The P-R intervalis short without evidence of pre-excitation. Non-specific ST-T wave changes. Non-specific ST-T wave changes. Sinus rhythm with frequent atrial ectopy. Sinus rhythm with frequent atrial ectopy. Remote tricuspid valve replacement. Multifocal nodular opacities with cavitation in the right upper lobe are consistent with known septic emboli. Endocarditis. Compared tothe previous tracing of atrial and ventricular ectopy are new. Non-specific ST segment changes in the inferolateral leads.Compared to the previous tracing of the findings are similar. Basal cisterns are patent. NG tube tip is out of view below the diaphragm. Left internal jugular line ends in the left brachiocephalic vein. Mild small vessel ischemic disease. Spleen measures 13.6 cm, mild splenomegaly. Assess for DVT. Rightwardaxis. Diffuse low voltage. Mild confluent hypodensities in periventricular white matter distribution likely represents sequela of mall vessel ischemic disease. Incompleteright bundle-branch block. Incompleteright bundle-branch block. septic emboli CONTRAINDICATIONS for IV CONTRAST: recent RF FINAL REPORT INDICATION: Patient with history of endocarditis who is now intubated with unequal pupils. Low voltage. Broken sternal wires are demonstrated. Prominent sulci and ventricles, likely age-related involutional changes. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. Left PICC tip is in the lower SVC. Imaged intra-abdominal aorta and IVC are normal in caliber. Small right pleural effusion is also seen. The NG tube tip is most likely in the stomach, its tip not seen on the current radiograph. IMPRESSION: 1. IMPRESSION: 1. FINDINGS: -scale and color son of the region of fluctuance in the patient's lower back were performed. The left internal jugular line tip is at the level of mid brachiocephalic vein. AP radiograph of the chest was compared to . Extensive nodulation and cavitation in the lungs due to septic emboli unchanged. | 27 | [
{
"category": "Radiology",
"chartdate": "2188-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222991,
"text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrates?\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yof A-fib (s/p ablation) h/o IVDA, remote tricuspid valvue replacement x 3\n who is transffered from for TV endocarditis.\n REASON FOR THIS EXAMINATION:\n infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of AFib, IVDA, remote\n tricuspid valve replacement, and endocarditis for interval change.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There has been interval removal of the endotracheal tube and\n nasogastric tube. Otherwise, left internal jugular central venous line with\n the tip at the mid brachiocephalic vein and broken sternal wires remain\n stable. There is new right middle lobe opacity suggestive of a right middle\n lobe pneumonia. Otherwise, multiple previously visualized cavitated lesions\n throughout the lungs including cavitated right upper lung lesion are better\n demonstrated on prior CT from . Mild improvement in left lung\n edema. Cardiomediastinal silhouette remains stable.\n\n IMPRESSION:\n\n 1. New right middle lobe pneumonia.\n\n 2. Improvement in left lung edema.\n\n 3. Multiple previously visualized cavitated lesions throughout the lungs\n including cavitated right upper lung lesion are better demonstrated on prior\n CT from .\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-12-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1223943,
"text": " 9:01 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: l dl power picc 45cm iv \n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with picc\n REASON FOR THIS EXAMINATION:\n l dl power picc 45cm iv \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH OF \n\n COMPARISON: chest x-ray.\n\n FINDINGS: Left PICC terminates low within the body of the right atrium,\n directed towards the tricuspid valve plane. Withdrawal by about 6 cm is\n suggested to ensure placement in the lower superior vena cava, as discussed by\n telephone with IV nurse, Carmal, at 9:20 a.m. on . Cardiac\n silhouette remains enlarged and is accompanied by pulmonary vascular\n congestion and mild edema. As compared to the previous study, there has been\n marked improved aeration in the left lower lobe, and a lesser degree of\n improvement in aeration in the right base as well. Numerous nodular foci of\n consolidation are again demonstrated, some with cavitation, most consistent\n with septic emboli in the setting of a history of endocarditis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223147,
"text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression of opacities\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yof A-fib (s/p ablation) h/o IVDA, remote tricuspid valvue replacement x 3\n who is transffered from for TV endocarditis.\n REASON FOR THIS EXAMINATION:\n progression of opacities\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Remote tricuspid valve replacement, endocarditis.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is an increase in\n density of the opacities at the right lung base. Otherwise, the radiograph is\n unchanged, with widespread severe parenchymal abnormalities in both lungs.\n The size of the cardiac silhouette is mildly enlarged. The left internal\n jugular vein catheter is in unchanged position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223328,
"text": " 8:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with TV endocarditis and pulmonary septic emboli\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tricuspid valve endocarditis and pulmonary septic emboli.\n Evaluate for change.\n\n COMPARISONS: Chest radiograph . Chest radiograph . Chest radiograph . Chest CT .\n\n FINDINGS: A left internal jugular central line ends in the upper SVC. A\n fracture of the most superior sternal wire is unchanged. The other sternal\n wires are intact. A sharp interface projecting over the lateral right lung is\n likely a skinfold, but a repeat chest radiograph carefully positioned should\n be able to exclude pneumothorax. The moderate right pleural effusion is\n smaller. Moderate pulmonary edema has slightly improved. Septic\n emboli--multiple peripheral nodules, some cavitary--are stable. No new\n nodules or consolidations are present. The cardiomediastinal silhouette is\n mildly enlarged and unchanged.\n\n IMPRESSION:\n 1. Probable right apical skinfold. Recommend repeat chest radiograph to\n exclude pneumothorax.\n 2. Improved, moderate right pleural effusion and pulmonary edema.\n 3. Stable septic emboli.\n\n Results were telephoned to Dr. at 10 am on by Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-12-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1224567,
"text": " 2:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary edema, septic emobli\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with endocarditis and septic emboli.\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema, septic emobli\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: esophagitis with septic emboli.\n\n FINDINGS: In comparison with study of , there is some increase in the\n diffuse bilateral pulmonary opacifications. Again there is enlargement of the\n cardiac silhouette with findings consistent with a combination of pulmonary\n edema and multiple septic emboli. Monitoring and support devices remain in\n place.\n\n IMPRESSION: Worsening diffuse bilateral pulmonary opacifications consistent\n with septic emboli and the pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223402,
"text": " 4:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: -hoff placement\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with endocarditis\n REASON FOR THIS EXAMINATION:\n -hoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate Dobbhoff.\n\n COMPARISON: Chest radiograph, .\n\n FINDINGS: The Dobbhoff is coiled in the esophagus. A fracture of the most\n superior sternal wire is stable. The other sternal wires are intact. There\n has been a slight increase in size of left pleural effusion. Small right\n pleural effusion is unchanged. Multiple pulmonary nodules are again noted and\n unchanged.\n\n IMPRESSION:\n 1. Dobbhoff tube coiled in the esophagus.\n 2. Slight increase in size of left pleural effusion.\n\n Results were paged to Dr. at 5:00 p.m. on by Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223670,
"text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any pulm edema\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yof A-fib (s/p ablation) h/o IVDA, remote tricuspid valvue replacement x 3\n who is transffered from for TV endocarditis.\n REASON FOR THIS EXAMINATION:\n any pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:36 A.M. ON \n\n HISTORY: Intravenous drug abuser with remote tricuspid valve replacement.\n Tricuspid endocarditis and pulmonary edema.\n\n IMPRESSION: AP chest compared to through 11:\n\n Radiodensity in the left lower hemithorax is increasing, and could be due to\n combination of an enlarging moderate left pleural effusion and left lower lobe\n consolidation. Heterogeneity in the right lung could be due in part to small\n cavities or lung nodules, at least one of which, a 5 cm-wide cavitary lesion\n in the right upper lobe, is larger and more readily visible today projected\n over the first anterior interspace than it was on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-23 00:00:00.000",
"description": "CT T-SPINE W/ CONTRAST",
"row_id": 1222898,
"text": " 11:14 AM\n CT T-SPINE W/ CONTRAST; CT L-SPINE W/ CONTRAST Clip # \n Reason: is there a c,t,l spine abscess?\n Admitting Diagnosis: SEPTIC SHOCK\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with shock and fluctuance over the spinal stimulator device.\n REASON FOR THIS EXAMINATION:\n is there a c,t,l spine abscess?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa 9:29 PM\n 1. Increased sclerosis and collapse of vertebral bodies in the lower lumbar\n spine at L2 through the lumbosacral junction. No focal fluid collection or\n evidence of abscess formation. These findings could represent chronic\n osteomyelitis.\n\n 2. Diffuse anasarca and abdominal ascites. Decreased delineation of\n paraspinal muscles in the lumbar spine could represent edema or muscle\n atrophy.\n\n 3. Previously placed spinal stimulator lead within the spinal canal with lead\n extending to the subcutaneous tissues. As compared to the prior examination,\n a portion of the lead has been removed.\n\n 4. Right renal hydronephrosis.\n\n 5. Bilateral pleural effusions and atelectasis within the partially imaged\n portion of the lungs.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endocarditis with shock. Fluctuance felt over region of spinal\n stimulator. Evaluation for evidence of abscess.\n\n TECHNIQUE: Multidetector helical CT scan of the lower thoracic and lumbar\n spine was obtained after the administration of 100 cc IV Omnipaque contrast.\n Coronal and sagittal reformations were prepared.\n\n COMPARISON: CT scan dated .\n\n FINDINGS: As compared to the prior examination there is increased sclerosis\n throughout the lumbar spine extending from L2 to the lumbosacral junction as\n compared to the CT of . The L2 and L3 vertebral bodies are essentially\n fused with complete loss of the disc space. L4 and L5 also demonstrate\n continued loss of disc space and early fusion. No focal fluid collection is\n identified, though these findings could represent chronic osteomyelitis.\n\n There is acute kyphosis at the L2/L3 level which is also new from the prior\n examination. Additionally scoliosis of the lumbar spine with apex to the\n right at L3 is progressed.\n\n The patient is status post multiple laminectomies which appear similar to the\n (Over)\n\n 11:14 AM\n CT T-SPINE W/ CONTRAST; CT L-SPINE W/ CONTRAST Clip # \n Reason: is there a c,t,l spine abscess?\n Admitting Diagnosis: SEPTIC SHOCK\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prior examination. Leads from a spinal stimulator are seen within the spinal\n canal at the T11/T12 level with a wire extending posteriorly at T12/L1,\n terminating within the subcutaneous tissues. As compared to the prior\n examination, a portion of the lead has been removed.\n Stable severe DJD is noted in the lower lumbar spine.\n\n As compared to the prior examination, paraspinal musculature at the level of\n the lumbar spine and posterior to the sacrum demonstrates decreased\n delineation of muscle fibers which could represent edema or muscle atrophy.\n Extensive diffuse anasarca is seen within the superficial soft tissues.\n Additionally, there is intra-abdominal ascites which is partially imaged.\n\n Right renal hydronephrosis is seen. There are bilateral pleural effusions and\n compressive atelectasis; however, the lungs are only partially imaged. An\n esophageal catheter is also partially imaged. There are diffuse vascular\n calcifications.\n\n IMPRESSION:\n 1. Increased sclerosis and collapse of vertebral bodies in the lower lumbar\n spine at L2 through the lumbosacral junction. No focal fluid collection or\n evidence of abscess formation. These findings could represent chronic\n osteomyelitis, less likely neoplasm.\n\n 2. Diffuse anasarca and abdominal ascites. Decreased delineation of\n paraspinal muscles in the lumbar spine could represent edema or muscle\n atrophy.\n\n 3. Previously placed spinal stimulator lead within the spinal canal with lead\n extending to the subcutaneous tissues. As compared to the prior examination,\n a portion of the lead has been removed.\n\n 4. Right renal hydronephrosis.\n\n 5. Bilateral pleural effusions and atelectasis within the partially imaged\n portion of the lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1222558,
"text": " 6:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ET + OT + left IJ placement\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with TV endocarditis, new transfer from OSH\n REASON FOR THIS EXAMINATION:\n ET + OT + left IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:35 P.M., \n\n HISTORY: Tricuspid valve endocarditis.\n\n IMPRESSION: AP chest compared to through at 12:21 p.m.:\n\n Endotracheal tube has been withdrawn from the right main bronchus to standard\n position in the trachea. Most of the widespread pulmonary opacification is\n edema, worsened since earlier in the day. Additionally, there are small focal\n lesions probably representing a disseminated infection. Small left pleural\n effusion has increased. Heart size is normal. Left jugular line ends in the\n left brachiocephalic vein. Sternal wires are fractured and misaligned, but\n unchanged since at least . Nasogastric tube passes into the\n stomach and out of view. Epicardial pacer leads unchanged in position since\n . No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-29 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1223787,
"text": " 12:02 PM\n PORTABLE ABDOMEN Clip # \n Reason: ileus? obstruction?\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with TV endocarditis, not tolerating tube feeds\n REASON FOR THIS EXAMINATION:\n ileus? obstruction?\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL PLAIN FILM, AT 12:02\n\n CLINICAL INDICATION: 62-year-old with TV endocarditis, not tolerating tube\n feeds, question obstruction, question ileus.\n\n Comparison is made to the patient's previous study of .\n\n Single portable view of the abdomen dated at 12:02 p.m. is\n submitted. The lung bases are not entirely included and the left lateral\n abdomen is also not included.\n\n IMPRESSION:\n\n There is a paucity of gas within the abdomen, although some gas is seen within\n non-distended loops of bowel. The distal end of a feeding tube is seen coiled\n within the stomach. There are marked degenerative and postoperative changes\n of the lower lumbar spine. Surgical clips are seen overlying both inguinal\n regions. Spinal stimulator is seen overlying the lower thoracic spine.\n Followup imaging should be considered if the patient's symptoms persist.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223788,
"text": " 12:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with TV endocarditis, bilpneumonia, pul congestion\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM AT 1208\n\n CLINICAL INDICATION: 62-year-old with tricuspid valve endocarditis and\n bilateral pneumonia, pulmonary congestion, assess for interval change.\n\n Comparison is made to the patient's previous study of at 1136.\n\n Portable semi-erect chest film dated at 1208 is submitted.\n\n IMPRESSION:\n\n 1. A Dobbhoff feeding tube is seen coursing below the diaphragm with the tip\n coiled within the stomach. There has been a prior median sternotomy with one\n of the more superior sternotomy wires fractured but unchanged. Diffuse\n bilateral airspace process which is essentially unchanged with more focal\n consolidation at the left base which could reflect atelectasis and/or\n effusion, although pneumonia cannot be excluded. Pulmonary edema could also\n have this appearance. Therefore, clinical correlation is advised. The\n cavitary lesions which were seen on a CT of are not well appreciated\n on the current plain film study. Heart remains enlarged. Overall, likely no\n significant interval change since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223412,
"text": " 4:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: -hoff placement\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with endocarditis\n REASON FOR THIS EXAMINATION:\n -hoff placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess Dobbhoff placement.\n\n Comparison is made with prior study performed 20 minutes earlier.\n\n Dobbhoff tube has been repositioned, now the tip is in the stomach. There are\n no other acute interval changes.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2188-12-04 00:00:00.000",
"description": "Report",
"row_id": 78382,
"text": "PATIENT/TEST INFORMATION:\nIndication: Right Heart Function\nHeight: (in) 62\nWeight (lb): 140\nBSA (m2): 1.64 m2\nBP (mm Hg): 97/54\nHR (bpm): 59\nStatus: Inpatient\nDate/Time: at 10:12\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\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (>2.1cm) with >50%\ndecrease with sniff (estimated RA pressure (5-10 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderately dilated RV cavity.\nModerate global RV free wall hypokinesis.\n\nAORTIC VALVE: Trace AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Bioprosthetic tricuspid valve (TVR). Large vegetation on\ntricuspid valve. Severe [4+] TR. Mild PA systolic hypertension. Given severity\nof TR, PASP may be underestimated due to elevated RA pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: 3D imaging performed with multiplanar reconstructions\ngenerated and confirmed on an independent workstation. Ascites.\n\nConclusions:\nThe estimated right atrial pressure is 5-10 mmHg. Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%). Right ventricular chamber size is normal. The right ventricular cavity\nis moderately dilated with moderate global free wall hypokinesis. Trace aortic\nregurgitation is seen. Trivial mitral regurgitation is seen. A bioprosthetic\ntricuspid valve is present. There is a large (1.8 x 1.1 cm) vegetation on the\ntricuspid valve. There is mild functional tricuspid stenosis. Severe [4+]\ntricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. [In the setting of at least moderate to severe tricuspid\nregurgitation, the estimated pulmonary artery systolic pressure may be\nunderestimated due to a very high right atrial pressure.] There is no\npericardial effusion.\n\nIMPRESSION: Prosthetic tricuspid valve endocarditis with severe regurgitation.\nModerately dilated right ventricle with moderate global systolic dysfunction.\nNormal global and regional left ventricular systolic function.\n\nCompared with the prior study (images reviewed) of , right ventricle\nis smaller and biventricular systolic function has slightly improved. Severe\ntricuspid regurgitation is seen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2188-11-21 00:00:00.000",
"description": "Report",
"row_id": 78383,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Endocarditis. H/O cardiac surgery. Left ventricular function.\nBP (mm Hg): 107/50\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 00:45\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated coronary sinus (diameter >15mm).\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Mildly depressed LVEF. TSI demonstrates\nsignificant LV dyssynchrony with significant septal wall contraction delay\n(vs. lateral wall).\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall\nhypokinesis. Abnormal diastolic septal motion/position consistent with RV\nvolume overload.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations\non aortic valve. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Moderately thickened tricuspid valve leaflets. Bioprosthetic\ntricuspid valve (TVR). Moderate vegetation on tricuspid valve. Mild to\nmoderate [+] TR. [Due to acoustic shadowing, the severity of tricuspid\nregurgitation may be significantly UNDERestimated.]\n\nPULMONIC VALVE/PULMONARY ARTERY: No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate. Emergency\nstudy performed by the cardiology fellow on call. Left pleural effusion.\n\nConclusions:\nThe coronary sinus is dilated (diameter >15mm), likely as a result of high\nright atrial pressures. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is mildly depressed (LVEF= 40-50%). The right ventricular cavity is\nmarkedly dilated with severe global free wall hypokinesis. There is abnormal\ndiastolic septal motion/position consistent with right ventricular volume\noverload. The aortic valve leaflets are mildly thickened (?#). No masses or\nvegetations are seen on the aortic valve. Trace aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. The tricuspid valve leaflets are moderately thickened. A\nbioprosthetic tricuspid valve is present. There is a moderate vegetation on\nthe tricuspid valve. No vegetation/mass is seen on the pulmonic valve. There\nis no pericardial effusion.\n\nIMPRESSION: Endocarditis of the bioprosthetic tricuspid valve with at least\nmild to moderate regurgitation. Dilated right ventricle with severe systolic\ndysfunction.\n\nCompared with the prior study (images reviewed) of , there is a new\nvegetation on the tricuspid bioprosthesis. Right ventricle is more dilated and\nhypokinetic and LV function is not as vigorous.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-12-01 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1223963,
"text": " 11:53 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: any signs of cirrhosis, splenomegaly, or hydronephrosis?\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yof A-fib (s/p ablation) h/o IVDA, remote tricuspid valvue replacement x 3\n who is transffered from for TV endocarditis, found to be\n fungemic, thrombocytpenic\n REASON FOR THIS EXAMINATION:\n any signs of cirrhosis, splenomegaly, or hydronephrosis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of atrial fibrillation and endocarditis.\n\n COMPARISONS: CT abdomen and pelvis of .\n\n FINDINGS:\n\n Liver demonstrates normal echotexture without focal lesions. There is no\n evidence of intrahepatic or extrahepatic biliary duct dilatation. CBD is of\n normal caliber measuring 7 mm. Portal vein is patent demonstrating\n hepatopetal flow. Gallbladder is collapsed with marked wall edema. There are\n no gallstones within its lumen. Pancreas is unremarkable, its tail is\n obscured by overlying bowel gas.\n\n The right kidney measures 12 cm. Moderate right-sided hydronephrosis is\n noted. Left kidney measures 11.1 cm without hydronephrosis, renal masses, or\n nephrolithiasis. Small-to-moderate amount of ascites is noted. Spleen\n measures 13.6 cm, upper limits of normal. Small right pleural effusion is\n also seen. Imaged intra-abdominal aorta and IVC are normal in caliber.\n\n IMPRESSION:\n\n 1. Moderate right hydronephrosis.\n\n 2. Small-to-moderate amount of ascites.\n\n 3. Small right pleural effusion.\n\n 4. Spleen measures 13.6 cm, mild splenomegaly.\n\n 5. Collapsed gallbladder with marked wall thickening, which is nonspecific in\n appearance. The gallbladder wall edema is most likely due to passive\n congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-12-01 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1223964,
"text": " 11:54 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RLE SWELLING, ANY SIGNS OF DVT\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with fungemic endocarditis presenting with right lower\n extremity swelling\n REASON FOR THIS EXAMINATION:\n any signs of DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with right lower extremity edema. Assess for DVT.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n -scale and color Doppler images of bilateral common femoral, right\n superficial femoral, deep femoral, popliteal and calf veins were obtained.\n Normal flow, compressibility and augmentation was demonstrated throughout.\n\n IMPRESSION:\n\n No evidence of deep venous thrombosis in the right lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-12-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1225354,
"text": " 7:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulmonary edema, septic emboli\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with endocarditis with worsening shortness of breath\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema, septic emboli\n ______________________________________________________________________________\n WET READ: KKgc WED 9:42 PM\n Multifocal nodular opacities, with a cavitation in the RUL, c/w known septic\n emboli. Superimposed moderate pulmonary edema, slightly improved since the\n prior study. LUE PICC in cavo-atrial junction\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Patient with question of septic emboli, \n endocarditis, worsening shortness of breath.\n\n Comparison is made to prior study, .\n\n Moderate pulmonary edema has improved. Multifocal nodular opacities with\n cavitation in the right upper lobe are consistent with known septic emboli.\n Left PICC tip is in the lower SVC. NG tube tip is out of view below the\n diaphragm. Cardiomegaly is stable. Bibasilar consolidations larger on the\n right have improved from the left. There is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-12-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1223956,
"text": " 11:09 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PICC line placemet\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with PICC pulled 6 cm\n REASON FOR THIS EXAMINATION:\n PICC line placemet\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Radiograph earlier the same date.\n\n FINDINGS: Left PICC has been withdrawn and now terminates in the lower\n superior vena cava just above the junction of the right atrium. Exam is\n otherwise not appreciably changed since the previous study of earlier the same\n date.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-12-06 00:00:00.000",
"description": "US EXTREMITY NONVASCULAR",
"row_id": 1224716,
"text": " 6:19 PM\n US EXTREMITY NONVASCULAR Clip # \n Reason: please ultrasound area of fluctuance over back to assess for\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with endocarditis and worsening back pain.\n REASON FOR THIS EXAMINATION:\n please ultrasound area of fluctuance over back to assess for fluid\n pocket/abscess for possible drainage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with endocarditis and worsening back\n pain. Evaluate area of fluctuance over the back to assess for abscess.\n\n FINDINGS: -scale and color son of the region of fluctuance in the\n patient's lower back were performed. There is a small strip of essentially\n anechoic material suggesting fluid without internal vascularity in the\n subcutaneous tissues, maximally measuring 4 mm AP. No substantial or\n drainable fluid collection is identified.\n\n IMPRESSION: Trace superficial fluid at the area of fluctuance on the\n patient's lower back, only 4 mm in width, along the subcutaneous fat.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223348,
"text": " 10:44 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: reasses upper density\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yof A-fib (s/p ablation) h/o IVDA, remote tricuspid valvue replacement x 3\n who is transffered from for TV endocarditis.\n REASON FOR THIS EXAMINATION:\n reasses upper density\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:38 A.M. ON \n\n HISTORY: Atrial fibrillation. IVDA. Remote tricuspid valve replacement.\n Endocarditis.\n\n IMPRESSION: AP chest compared to through at 8:28 a.m.:\n\n Upright radiograph shows there is no pneumothorax. Mild-to-moderate pulmonary\n edema has worsened since earlier in the day. Extensive nodulation and\n cavitation in the lungs due to septic emboli unchanged. Small bilateral\n pleural effusions have increased. Overall heart size is normal. Sternal\n wires are reasonably well aligned despite a fracture of the first and what may\n be a residual fragment interposed between the first and second wires. Left\n internal jugular line ends in the left brachiocephalic vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222755,
"text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval study,et placement\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n interval study,et placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after ET tube placement.\n\n AP radiograph of the chest was compared to .\n\n The ET tube tip is 4.5 cm above the carina. The left internal jugular line\n tip is at the level of mid brachiocephalic vein. The NG tube tip is most\n likely in the stomach, its tip not seen on the current radiograph.\n Cardiomediastinal silhouette is unchanged as well as there is no change in\n widespread parenchymal consolidations involving both lungs bilaterally.\n Broken sternal wires are demonstrated.\n\n Cavitated right upper lung lesion is better assessed on the chest CT from\n as well as additional cavitated lesions widespread throughout\n the lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-11-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1222572,
"text": " 9:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? septic emboli\n Admitting Diagnosis: SEPTIC SHOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with TV endocarditis, intubated, ventilated, unequal pupils\n REASON FOR THIS EXAMINATION:\n ? septic emboli\n CONTRAINDICATIONS for IV CONTRAST:\n recent RF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of endocarditis who is now intubated with\n unequal pupils. Assess for septic emboli.\n\n COMPARISONS: Head CT from OSCH, dated .\n\n TECHNIQUE: MDCT-acquired contiguous images through the brain were obtained\n without intravenous contrast at 5-mm slice thickness.\n\n FINDINGS:\n\n There is no evidence of acute intracranial hemorrhage, mass effect or shift of\n normally 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, likely age-related involutional changes. Mild\n confluent hypodensities in periventricular white matter distribution likely\n represents sequela of mall vessel ischemic disease. Basal cisterns are\n patent. There is no hydrocephalus.\n\n Imaged paranasal sinuses and mastoid air cells appear well aerated. No acute\n fracture is seen.\n\n IMPRESSION:\n\n 1. No evidence of acute intracranial process.\n\n 2. Prominent sulci and ventricles, likely age-related involutional changes.\n\n 3. Mild small vessel ischemic disease.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2188-12-04 00:00:00.000",
"description": "Report",
"row_id": 181659,
"text": "Sinus tachycardia with premature atrial and ventricular complexes. Rightward\naxis. Incomplete right bundle-branch block. Borderline left atrial\nabnormality. Non-specific ST segment changes in the inferolateral leads.\nCompared to the previous tracing of the findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-11-25 00:00:00.000",
"description": "Report",
"row_id": 181660,
"text": "Sinus tachycardia. Ventricular ectopy. Atrial ectopy. The P-R interval\nis short without evidence of pre-excitation. Right axis deviation. Probable\nright ventricular hypertrophy. Non-specific ST-T wave changes. Compared to\nthe previous tracing of atrial and ventricular ectopy are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-11-22 00:00:00.000",
"description": "Report",
"row_id": 181883,
"text": "Sinus rhythm with atrial premature beats. Rightward axis. Right ventricular\nconduction delay with possible right ventricular pressure and/or volume\noverload. Diffuse low voltage. Compared to the previous tracing of no\nsignificant difference.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-11-21 00:00:00.000",
"description": "Report",
"row_id": 181884,
"text": "Sinus rhythm with frequent atrial ectopy. Right axis deviation. Incomplete\nright bundle-branch block. Low voltage. Compared to the previous tracing\nof there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2188-11-20 00:00:00.000",
"description": "Report",
"row_id": 181885,
"text": "Sinus rhythm with frequent atrial ectopy. Right axis deviation. Incomplete\nright bundle-branch block. Non-specific ST-T wave changes. Low voltage.\nCompared to the previous tracing of low voltage is new.\nTRACING #1\n\n"
}
] |
12,451 | 130,918 | # meningitis - likely extension from otitis media. WBC count and diff c/w bacterial meningitis, as well as very elevated protein, though gram stains from OSH have been negative thus far. S pneumo, H flu high on list of possibilities. Meningococcus less likely as no rash and extension from otitis media would be an unlikely route of infection from meningococcus. Doubt Lyme given extension from otitis media and wrong time of year. - cont with ceftriaxone and vanco for now to cover bacterial pathogens - pneumococcus seems most likely given origin of otitis media - cont with IV decadron 10mg IV q6 as OSH + S.Pneumo - HSV PCR/Lyme pending - if gram negative rods show up on gram stain, would give intrathecal gent - U HCG - @ OSH - ID on consult, appreciate recs - PICC for outpt. IVabx. - D/W ID, per OSH records of pan sensitive S. Pneumo, pt to receive outpt. dose of steroid at home tomorrow and 11 additional of Ceftriaxone 2grams . - Pt will f/u in one week for labs and check up with PCP, . . # L mastoid opacification - - ENT on consult, appreciate recs - surgical intervention likely not needed per ENT as not c/w mastoiditis per se - no further interventions, pt will f/u with PCP, OM already drained per ENT recs. | BP 101/69-110/66.GI: Abd soft with + bowel snds. Note: pt has her menses.ID: Afebrile in am, now temp 98.9ax. pt taking po fluids tol well. only significant PMH: sinusitis. Head CT for sinusiti pending. Findings consistent with acute otitis media. IV abx given a/o. Pt reports slight HOH L ear. B/P 107/64. Lung sounds clear throughout.CV: HR 79-102SR without VEA. ENT consult done. Coronal reformats are obtained. Today she had med-sized formed, brown BM X 2, guaiac neg.GU: Urine yellow/clear, and pt has voided in adequate amt since foley D/C'd. Pt on Zosyn, Vanco, and Acyclovir, cultures sent results pending. Temp upon arrival at OSH 104 po. FINDINGS: A left-sided PICC catheter is identified with its distal tip terminating within the right atrium, repositioning is recommended. Findings consistent with acute otitis media and possible mastoiditis. warm and pink, cap refill <2sec, pulses +3 bilat.ID: CSF obtained upon admission purulent, returned WBC>8000 diff: 100% polys. Acute bilateral maxillary sinusitis. There is mild mucosal thickening involving frontal sinus. CSF from OSH gram stain neg, + for staph/pneumo. TECHNIQUE: CT sinus without intravenous contrast. Presented to ER at OSH with c/o ear pain. Fluid is present in the right mastoid air cells. AP UPRIGHT CHEST RADIOGRAPH. TECHNIQUE: Head CT without contrast. IMPRESSION: Left-sided PICC catheter terminating within right atrium. ext. The density values of brain parenchyma are within normal limits. LINE PLACEMENT Clip # Reason: left picc-52cm. Advance diet as tol. There is mild mucosal thickening involving the sphenoid sinus. Has rec'd Ibuprofen @ 1300 for C/O dull HA . IMPRESSION: 1. IMPRESSION: 1. There is opacification of the mastoid air cells on the right, as well as fluid and mucosal thickening in right middle air, consistent with acute otitis media and possible mastoiditis on the right, for detail description see CT sinus report. Repositioning recommended for standard positioning. There is a mucosal thickening/fluid in the right middle ear, consistent with acute otitis media. temp remains 100.4 at this time.GI: Abdomen soft/nontender w/ normal BS x 4quads.GU: foley cath patent draining 350ml clear yellow urine.Skin: pink W/D intact.Plan: cont IV abx and fluid for support. CBC, Chem. Pt reports only fair appetite. Pt slightly flushed. Sinus disease, involving maxillary, frontal, ethmoid and sphenoid sinuses. FINDINGS: There is opacification of majority of the mastoid air cells on the right. Cardiomediastinal silhouette and hilar contours are unremarkable. There are air fluid levels and mucosal thickening in the maxillary sinuses bilaterally, left greater than right. Mucosal thickening involving frontal, ethmoid and sphenoid sinuses. There are bilateral fluid levels in the maxillary sinuses, as well as mucosal thickening involving ethmoid, sphenoid and frontal sinuses. pt arrived in MICU at 20:45 VS: 107/64, HR 92 NSR, RR 18, O2 sat 99% on R/A temp 100.4 po.ROSNeuro: A/O x3, sleepy/ lethargic, somewhat slow to respond. Transfers to commode with minimal assist.Resp: O2 sat 98-99% on RA with RR 13-20 and regular. Lamina papyracea is intact. All ext moderate and equalPulm: LS: all fields CTA, breathing reg/unlabored O2 sat 99% on R/A.cardiac: NSR HR 90-96bpm, 2 #20ga IV's in bilat a/c's with abx/fluids infusing. The -white matter differentiation is preserved. pt recieved morphine for c/o HA w/ some effect, Ibuprofen given at 0500 for HA reducing pain from to . sent, results pending.Plan: cont IV abx, monitor pain level give tylenol/ Ibuprofen as indicated. follows commands, PEARLS. Tip? Tip? There is opacification of several ethmoid air cells, and mucosal thickening in the frontal sinus. 9:18 AM CHEST PORT. Pt initially somulent with severe HA and temp, this am much improved with MS @ baseline.Neuro: AAO X 3, dozing intermit but easily woken. Husband @ bedside.Plan: Transfer to floor, Cont antibiotic tx. Pt cont on Vancomycin, Ceftriaxone, Dexamethasone.Social: Pt is married with 2 children, 2 and 5yo. LP/MRI done and pt transferred to for further eval/ treatment for meningitis. Nurse Progress NoteUpdate: pt recieved 1000ml fluid bolus, also K+ repleted w/ 40meq KCL in 500ml NS. Nursing Progress/Transfer note 0700-1300Pt admitted from OSH to MICU-6 with suspected bacterial meningitis. 2. 2. change abx if needed with culture results. Zosyn 3.375g, and acyclovir 500mg. COMPARISON: Not available. COMPARISON: Not available. The ostiomeatal units are not patent bilaterally. The surrounding osseous structures and soft tissues are unremarkable. Head CT done upon arrival to , also pt recieved addtional antibiotics: Vancomycin 250mg for a total of 1g. Pt denies nausea and diet has been advanced to house diet as tolerated. pt recieved antibiotics and pain meds at OSH and upon arrival to ED her temp was 100.4. Question bone destruction. FINDINGS: There is no hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. 7:41 PM CT HEAD W/O CONTRAST Clip # Reason: LT FACIAL DROOP, MENINGITIS MEDICAL CONDITION: 31 year old woman with meningitis on LP with left facial droop REASON FOR THIS EXAMINATION: eval for abscess No contraindications for IV contrast FINAL REPORT CT HEAD WITHOUT CONTRAST. Findings discussed with IV nursing, , on date of exam at approximately 10:20 a.m. No pulmonary edema or pleural effusions. There is no evidence of pneumothorax, and the lungs are otherwise clear. No evidence of osseous destruction. | 6 | [
{
"category": "Radiology",
"chartdate": "2123-05-08 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 957819,
"text": " 7:41 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: mastoiditis on MRI, examinationi of left mastoid for bone de\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with mastoiditis and meningitis\n REASON FOR THIS EXAMINATION:\n mastoiditis on MRI, examinationi of left mastoid for bone destruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SINUS WITHOUT CONTRAST\n\n INDICATION: 31-year-old woman with mastoiditis and meningitis. Question bone\n destruction.\n\n COMPARISON: Not available.\n\n TECHNIQUE: CT sinus without intravenous contrast. Coronal reformats are\n obtained.\n\n FINDINGS: There is opacification of majority of the mastoid air cells on the\n right. There is no evidence of osseous destruction. There is a mucosal\n thickening/fluid in the right middle ear, consistent with acute otitis media.\n There is mild mucosal thickening involving frontal sinus. There are air fluid\n levels and mucosal thickening in the maxillary sinuses bilaterally, left\n greater than right. There is opacification of several ethmoid air cells, and\n mucosal thickening in the frontal sinus. There is mild mucosal thickening\n involving the sphenoid sinus.\n\n The ostiomeatal units are not patent bilaterally. Lamina papyracea is intact.\n\n IMPRESSION:\n 1. Findings consistent with acute otitis media. Fluid is present in the\n right mastoid air cells. No evidence of osseous destruction.\n 2. Acute bilateral maxillary sinusitis. Mucosal thickening involving\n frontal, ethmoid and sphenoid sinuses.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 957818,
"text": " 7:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: LT FACIAL DROOP, MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with meningitis on LP with left facial droop\n REASON FOR THIS EXAMINATION:\n eval for abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: Not available.\n\n TECHNIQUE: Head CT without contrast.\n\n FINDINGS: There is no hemorrhage, mass effect, shift of normally midline\n structures or hydrocephalus. The -white matter differentiation is\n preserved. The density values of brain parenchyma are within normal limits.\n\n The surrounding osseous structures and soft tissues are unremarkable. There\n is opacification of the mastoid air cells on the right, as well as fluid and\n mucosal thickening in right middle air, consistent with acute otitis media and\n possible mastoiditis on the right, for detail description see CT sinus report.\n There are bilateral fluid levels in the maxillary sinuses, as well as mucosal\n thickening involving ethmoid, sphenoid and frontal sinuses.\n\n There is no evidence of abscess.\n\n IMPRESSION:\n\n 1. Findings consistent with acute otitis media and possible mastoiditis.\n\n 2. Sinus disease, involving maxillary, frontal, ethmoid and sphenoid sinuses.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-05-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 957960,
"text": " 9:18 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: left picc-52cm. Tip?\n Admitting Diagnosis: MENINGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with\n REASON FOR THIS EXAMINATION:\n left picc-52cm. Tip?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 31-year-old female with PICC placement.\n\n No prior comparison exams are available.\n\n AP UPRIGHT CHEST RADIOGRAPH.\n\n FINDINGS: A left-sided PICC catheter is identified with its distal tip\n terminating within the right atrium, repositioning is recommended. There is\n no evidence of pneumothorax, and the lungs are otherwise clear.\n Cardiomediastinal silhouette and hilar contours are unremarkable. No\n pulmonary edema or pleural effusions.\n\n IMPRESSION:\n\n Left-sided PICC catheter terminating within right atrium. Repositioning\n recommended for standard positioning.\n\n Findings discussed with IV nursing, , on date of exam at approximately\n 10:20 a.m.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-09 00:00:00.000",
"description": "Report",
"row_id": 1425317,
"text": "Nurse Progress Note\nUpdate: pt recieved 1000ml fluid bolus, also K+ repleted w/ 40meq KCL in 500ml NS. IV abx given a/o. pt recieved morphine for c/o HA w/ some effect, Ibuprofen given at 0500 for HA reducing pain from to . ENT consult done. pt taking po fluids tol well. CBC, Chem. sent, results pending.\n\nPlan: cont IV abx, monitor pain level give tylenol/ Ibuprofen as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-09 00:00:00.000",
"description": "Report",
"row_id": 1425318,
"text": "Nursing Progress/Transfer note 0700-1300\nPt admitted from OSH to MICU-6 with suspected bacterial meningitis. CSF from OSH gram stain neg, + for staph/pneumo. Pt initially somulent with severe HA and temp, this am much improved with MS @ baseline.\n\nNeuro: AAO X 3, dozing intermit but easily woken. Has rec'd Ibuprofen @ 1300 for C/O dull HA . Pt reports slight HOH L ear. Transfers to commode with minimal assist.\n\nResp: O2 sat 98-99% on RA with RR 13-20 and regular. Lung sounds clear throughout.\n\nCV: HR 79-102SR without VEA. BP 101/69-110/66.\n\nGI: Abd soft with + bowel snds. Pt denies nausea and diet has been advanced to house diet as tolerated. Pt reports only fair appetite. Today she had med-sized formed, brown BM X 2, guaiac neg.\n\nGU: Urine yellow/clear, and pt has voided in adequate amt since foley D/C'd. Note: pt has her menses.\n\nID: Afebrile in am, now temp 98.9ax. Pt slightly flushed. Pt cont on Vancomycin, Ceftriaxone, Dexamethasone.\n\nSocial: Pt is married with 2 children, 2 and 5yo. Husband @ bedside.\n\nPlan: Transfer to floor, Cont antibiotic tx. Advance diet as tol.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-05-08 00:00:00.000",
"description": "Report",
"row_id": 1425316,
"text": "Admission note\nEvents: Pt is a 31yo female who was being treated at home for URI with oral abx. Presented to ER at OSH with c/o ear pain. Temp upon arrival at OSH 104 po. LP/MRI done and pt transferred to for further eval/ treatment for meningitis. only significant PMH: sinusitis. pt recieved antibiotics and pain meds at OSH and upon arrival to ED her temp was 100.4. Head CT done upon arrival to , also pt recieved addtional antibiotics: Vancomycin 250mg for a total of 1g. Zosyn 3.375g, and acyclovir 500mg. pt arrived in MICU at 20:45 VS: 107/64, HR 92 NSR, RR 18, O2 sat 99% on R/A temp 100.4 po.\n\nROS\n\nNeuro: A/O x3, sleepy/ lethargic, somewhat slow to respond. follows commands, PEARLS. All ext moderate and equal\n\nPulm: LS: all fields CTA, breathing reg/unlabored O2 sat 99% on R/A.\n\ncardiac: NSR HR 90-96bpm, 2 #20ga IV's in bilat a/c's with abx/fluids infusing. B/P 107/64. ext. warm and pink, cap refill <2sec, pulses +3 bilat.\n\nID: CSF obtained upon admission purulent, returned WBC>8000 diff: 100% polys. Head CT for sinusiti pending. Pt on Zosyn, Vanco, and Acyclovir, cultures sent results pending. temp remains 100.4 at this time.\n\nGI: Abdomen soft/nontender w/ normal BS x 4quads.\n\nGU: foley cath patent draining 350ml clear yellow urine.\n\nSkin: pink W/D intact.\n\nPlan: cont IV abx and fluid for support. change abx if needed with culture results.\n\n"
}
] |
86,209 | 117,573 | 43 year old F with history of AIDS (last CD4 count 6), ESRD on HD, herpes zoster ophthalmicus c/b post-herpetic neuralgia presenting with worsening right facial pain with blurry vision, dizziness, and hypotension. | Sinus rhythm. Sinus rhythm. Baseline artifact. R wave progression is earlier.TRACING #1 Compared to the previoustracing of sinus rhythm has replaced atrial fibrillation. Atrial fibrillation. Since theprevious tracing atrial fibrillation is new. The tracing is within normal limits. Since the previoustracing of the P-R interval is shorter. Borderline rapid ventricular response. Probably normal tracing. | 3 | [
{
"category": "ECG",
"chartdate": "2123-08-25 00:00:00.000",
"description": "Report",
"row_id": 258164,
"text": "Sinus rhythm. The tracing is within normal limits. Compared to the previous\ntracing of sinus rhythm has replaced atrial fibrillation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-23 00:00:00.000",
"description": "Report",
"row_id": 258165,
"text": "Atrial fibrillation. Borderline rapid ventricular response. Since the\nprevious tracing atrial fibrillation is new. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2123-08-23 00:00:00.000",
"description": "Report",
"row_id": 258370,
"text": "Baseline artifact. Sinus rhythm. Probably normal tracing. Since the previous\ntracing of the P-R interval is shorter. R wave progression is earlier.\nTRACING #1\n\n"
}
] |
19,391 | 145,500 | 79yo man with severe COPD, CHF presented with worsening dyspnea, cough, hypotension. 1. Hypotension/sepsis Initial differential included sepsis/distributive shock, hypovolemia, cardiogenic. He responded to IVF volume resuscitation. He was covered with broad spectrum abx, with linezolid, levaquin, and flagyl. Cortisol level was sent. He was pan-cultured for infectious etiology. He met inclusion criteria for SIRS/sepsis by virtue of his WBC with 39% bandemia, elevated lactate, and tachycardia/tachypnea, and was managed with aggressive volume resuscitation, broad spectrum antibiotics. He did not require pressors. His course was complicated by acute renal failure with BUN/Crn elevated to 52/1.0, which was likely pre-renal azotemia. Ultimately, his infectious sources included MRSA in his sputum cultures, as well as c. diff colitis. CT was consistent with c. diff colitis. Family meeting was held, and it was made clear that the patient was thereafter comfort measures only. He passed away on at 545. Family declined a post-mortem examination. | PT ABLE TO MAE.GU/GI: ABD SOFTLY DISTENDED WITH +BS. cont on levo, flagyl, linezolid.A/P; Tenueous resp status. Did tol brief trial of nasal bi-pap X 1/2 hr. 4 7a-7pPt slowly decompensating throughout shift. Resp CarePt receiving atrovent nebs-tol well. Pr remains DNR/DNIUO minimally improved after last fld bolus. pt hypotensive x1 during shift. Edema noted to be worse since taking care of pt 24 hrs ago, +2 edema to bue, +3 to scrotum and ble.gi: pt tolerating sips occasionally throughout shift. audible wet breath sounds.cv: pt remains in a-fib throughout shift. C/o thirstGiven 2.5L NS fld boluses with slight improvement in UO. perrlaresp: lungs rhoncherous throughout. NASAL CANNULA @ 3L INSITU WHEN BIPAP OFF. PT WAS GIVEN VIT K PO. diarrhea is slowing down. When off bi-pap pt tachypnic and labored, agonal at times. Pt c/o pressure & feeeling the nede to void. ON ADMISSION TO THE ED HE WAS HYPOTENSIVE WITH B/P 80'S. still slightly tachycardic, pt was able to take 1800 po dilt. when off bi-pap pt using pursed lip breathing throughout shift. COUMADIN ON HOLD SECONDARY TO INR 5.4. pupils reactive.resp: pt's lungs clear throughout upper lobes, dimished in bases. Pt'sAfeb. Pt breathing labored at rest, increased with minimal activity.BS coarse. edema +4 throughout. will hold of tube feedings until abd assessed. PT ALSO RECIEVED FLUID BOLUS X2 FOR LOW U/O.RESP: LUNGS COARSE THROUGHOUT, VERY DIM WITH INTERMITTENT WHEEZES. Two small episodes of diarrhea. pt having loose stools throughout shift, specimen sent for c-diff. VSS stable throughout.Oliguric. receiving neb tx's per r.t. pt clearly verbalized on previous shift DNI. Pt in NARD on 3LPM N/C. not able to obtain spo2 pleth throughout entire shift, tried multiple pulse ox's, md's aware.cv: pt remains in a-fib throughout shift, also appears to be a-flutter at times. LUNG CONTINUE TO BE COARSE. Oriented to person, place & usually monthg, yr. Occas slightly off with date. Respiratory CarePt recieved 2.5mg atrovent via aerosol mask as noted in carevue, BS coarse rales t/o R > L. No change post treatment. MED WITH MORPHINE 1MG WITH RELIEF NOTED. Pt to recieve a thorocentesis. chest p.t. 4 7a-7p.pt went for picc line placement and pedi feeding tube placement in ir today, as well as for CT abd/pelvis.neuro: pt remains lethargic throughout shift, arousable to pain and mvmt. BS rhonchi and oxegenation adequate on 2-3L nc UO now bloody.Remains in AF. CXR SHOW SMALL LEFT PLEURAL EFFUSION AND LINIAR OPACITIES IN THE LLL.PMH:COPD,GERD,ANEMIA,A FIB ON COUMADIN,HTN,CAD,PULM HTN,EF 45-55%,PROSTATE CA S/P RT, MRSA PNA.ALLERGIES: ALLBUTEROL(TACHYCARDIA).NEURO:PT A/OX3 PAIN.ABLE TO MAE.RESP:LS EXP WHEEZING WITH RONCHI BILAT. pt afebrile throughout shift. pt afebrile throughout shift. lungs coarse throughout, rhonchii and crackles noted in b bases. Will continue bronchodilator therapy and intermittent bipap. sbp 80-120.gi: pt had pedi-tube placed. 4 7a-7pneuro: pt remains a&o x3 throughout shift, cooperative c care, mae. BUN 35, creat 0.8. BP stable.C-diff positive. pt receiving inhalers and neb tx's as ordered. received 1L fluid bolus with good effect. SEE FLOWSHEET FOR FURTHER DETAILS.GI- ABDOMEN DISTENDED AND FIRM. RV functiondepressed.AORTA: Normal aortic root diameter. Again, the proximal sigmoid colon and left colon demonstrates an edematous wall. COMPARISON: CTA of the abdomen without and with intravenous contrast . The aortic valve leaflets are mildlythickened. The right ventricular cavity is dilated.Right ventricular systolic function appears depressed. IMPRESSION: 1) Decreased left pleural effusion. MR present but cannot be quantified.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. BOWEL SOUNDS HYPOACTIVE. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Transverse colon is not dilated, however, at the splenic flexure the wall of the descending colon is edematous, and the bowel wall edema extends into the sigmoid colon. PATIENT/TEST INFORMATION:Indication: Left ventricular function.HR (bpm): 110Status: InpatientDate/Time: at 15:37Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. 4+PITTING EDEMA. Background emphysema is again noted. SCROTUM 4+ EDEMA. CT OF THE PELVIS WITH CONTRAST: The rectum is unremarkable. Again, intra- abdominal ascites is noted. There has been interval development of a small left pleural effusion. Mildly thickened aortic valveleaflets. SINGLE FRONTAL VIEW OF THE CHEST: There are bilateral pleural effusions and interval development of left lower lobe opacity. There is interval development of an ill-defined right infrahilar opacity. Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY FINAL REPORT (Cont) The left basilic vein was patent and compressible. IMPRESSION: Interval development of small left pleural effusion. Given the pelvic ascites. Mild mitralannular calcification. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Pulmonary vasculature is within normal limits. This may represent interval treatment of this aneurysm. There isborderline pulmonary artery systolic hypertension. COMPARISON: Radiograph dated . Normaltricuspid valve supporting structures. The tip of the catheter is present in the superior vena cava. Atrial fibrillationPossible anteroseptal myocardial infarction - age undeterminedNonspecific ST-T changesSince previous tracing, the heart rate is slower, ventricular premature complexabsent Unchanged outer dimensions of the abdominal aortic aneurysm with decreased size of the patent lumen to 2.3 x 2.3 cm from 3.2 x 3.2 cm. IMPRESSION: 1) Bilateral pleural effusions. TECHNIQUE: CT of the abdomen and pelvis was performed without and with intravenous contrast. There is intrapelvic fluid. Small bilateral adjacent pleural effusions. ptx, etc FINAL REPORT HISTORY: Status post thoracentesis. After the wire was removed, a hand injection of contrast demonstrated the tip to be positioned within the stomach. The left ventricular cavity sizeis normal. | 28 | [
{
"category": "Nursing/other",
"chartdate": "2161-03-10 00:00:00.000",
"description": "Report",
"row_id": 1518042,
"text": "ADMISSION NOTE:\n\nTHE PT WAS AT HOME WITH A THREE DAY HX OF SOB AND DIARRHEA. ON ADMISSION TO THE ED HE WAS HYPOTENSIVE WITH B/P 80'S. CXR SHOW SMALL LEFT PLEURAL EFFUSION AND LINIAR OPACITIES IN THE LLL.\n\nPMH:COPD,GERD,ANEMIA,A FIB ON COUMADIN,HTN,CAD,PULM HTN,EF 45-55%,PROSTATE CA S/P RT, MRSA PNA.\nALLERGIES: ALLBUTEROL(TACHYCARDIA).\n\nNEURO:PT A/OX3 PAIN.ABLE TO MAE.\n\nRESP:LS EXP WHEEZING WITH RONCHI BILAT. O2 SAT 98% ON 3L VIA NC. HHN ON NIGHTS WITH GOOD EFFECT.\n\nCV:A FIB HR 85-120 NO ECTOPY NOTED. COUMADIN ON HOLD SECONDARY TO INR 5.4. PHYTONADIONE 10MG PO. B/P 109/50. TOTAL 6L FLUID IN ED.\n\nGI/GU: ORAL MUCOSA VERY DRY. ABLE TO TOL LIQUIDS AND PILLS. +BS NO BM. FOLEY CATH DARK YELLOW URINE 25-30CC/HR.\n\nSKIN:INTACT.\n\nENDO:FS Q6H.\n\nPOC:PO ABX GIVEN.NS AT 100CC/HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-10 00:00:00.000",
"description": "Report",
"row_id": 1518043,
"text": "Resp Care\n\nPt receiving atrovent nebs tolerated well. BS rhonchi and oxegenation adequate on 2-3L nc\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-11 00:00:00.000",
"description": "Report",
"row_id": 1518048,
"text": " 4 ICU NPN 0700-1900\nWearing 2L NP with sats high 90's. Pt breathing labored at rest, increased with minimal activity.BS coarse. Unable to tol c-pap. Did tol brief trial of nasal bi-pap X 1/2 hr. with some improvement. L pleural tap for 500 cc done at bedside. VSS stable throughout.\n\nOliguric. BUN 35, creat 0.8. C/o thirstGiven 2.5L NS fld boluses with slight improvement in UO. Pt c/o pressure & feeeling the nede to void. Foley catheter irrigated, catheter changed. UO now bloody.\n\nRemains in AF. No VEA noted. HR ~100-120's, occas to 140's. Given dilt 10mg X1, 15mg X1 with improvement in rate. Cont on lopressor. BP stable.\n\nC-diff positive. Two small episodes of diarrhea. OB negative. Abd soft, distended. Positive BS. NPo at present.\n\nDozing when left alone. Oriented to person, place & usually monthg, yr. Occas slightly off with date. AT X's when pt beginning to doze off he will talk in his sleep. He is aware he is doing this when he is awakened.\n\nDr , med student & this RN discussed with pt his wishes if need intubate given tenueous resp status. He was adamant that he not be intubatedwhen asked several times as to wether he wanted to be intubated. Pt appeared very appropriate, orientted during this conversation. Pt's\n\nAfeb. cont on levo, flagyl, linezolid.\n\nA/P; Tenueous resp status. Encourage Bi-pap as much as tol. Cont to assess. Pr remains DNR/DNI\nUO minimally improved after last fld bolus. Give additional 500 cc bolus.\nCont to asses MS.\nSupport to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-12 00:00:00.000",
"description": "Report",
"row_id": 1518049,
"text": "Respiratory Care\nPt recieved 2.5mg atrovent via aerosol mask as noted in carevue, BS coarse rales t/o R > L. No change post treatment. Pt refused BIPAP early in shift, Tried it for 15 mins at 11pm and than tol well after recieving Morphine, on settings of with 3 l/m O2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-12 00:00:00.000",
"description": "Report",
"row_id": 1518050,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 87/68-108/51. AFIB WITH HR RANGING FROM 89-120. PT WAS INCREASING H/R TO 130-140 RANGE, CARDIZEM 30MG PO AND GTT STARTED AT 10MG HR, TITRATED TO 15MG AND FINALLY DOWN TO 5MG WHERE IT REMAINS. PT ALSO RECIEVED FLUID BOLUS X2 FOR LOW U/O.\n\nRESP: LUNGS COARSE THROUGHOUT, VERY DIM WITH INTERMITTENT WHEEZES. O2 ON AT 2L N/C. MED WITH MORPHINE 1MG WITH RELIEF NOTED. PT WAS ABLE TO REST ON CPAP THROUGHOUT NIGHT.\n\nNEURO: INTACT. INTERMITTENT SHORT PERIODS OF SLIGHTY CONFUSION. NO PAIN NOTED. PT ABLE TO MAE.\n\nGU/GI: ABD SOFTLY DISTENDED WITH +BS. TAKING PO FLUIDS IN SMALL AMTS. FOLEY PATENT DRAINING DARK MAROON COLORED URINE, IN LESS THAN ADEQUATE AMTS. FOLEY IRRIGATED TO ENSURE PATENCY.\n\nPLAN: CONT TO SUPPORT RESP EFFORT. MAINTAIN COMFORT. PT IS DNR , PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-12 00:00:00.000",
"description": "Report",
"row_id": 1518051,
"text": "Resp Care\nPt receiving atrovent nebs-tol well. Wore Bipap machine this morning for 4 hours-tol well, but refused in afternoon. Sats in low 90s on 3 L NC. Will continue bronchodilator therapy and intermittent bipap.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-12 00:00:00.000",
"description": "Report",
"row_id": 1518052,
"text": " 4 7a-7p\nPt slowly decompensating throughout shift. family at bedside and in waiting room\n\nneuro: pt a&o x1, pt quite lethargic throughout am, responding to pain only, more aware this afternoon, a&o x1, recognized family, following comands. perrla. md's unsure as to why decompensating neurologically over past 24 hrs. performed venous abg to assess co2, non-significant.\n\nresp: pt tolerated bi-pap for approx 3 hrs this am. When off bi-pap pt tachypnic and labored, agonal at times. extremely sob c any movement, turning or activity. chest p.t. performed this am by physical therapist, pt did not tolerate well, took approx 20 minutes for pt's rr to return to baseline. Audible wet breath sounds noted throughout shift. +cough although unable to bring up any secretions. lungs coarse throughout, rhonchii and crackles noted in b bases. when off bi-pap pt using pursed lip breathing throughout shift. receiving neb tx's per r.t. pt clearly verbalized on previous shift DNI. Venous abg obtained this afternoon, see careview, 7.31, 35, 34. pt did receive morphine x1 and rested quite well. md's attempted abg multiple times yesterday and today but unable. not able to obtain spo2 pleth throughout entire shift, tried multiple pulse ox's, md's aware.\n\ncv: pt remains in a-fib throughout shift, also appears to be a-flutter at times. rate 70-100's this am, now becoming 100-110. started on po dilt and iv dilt dc'd at 1300. pt also on lopressor po. pt afebrile throughout shift. pt hypotensive x1 during shift. received 1L fluid bolus with good effect. sbp 90-120 throughout shift. Edema noted to be worse since taking care of pt 24 hrs ago, +2 edema to bue, +3 to scrotum and ble.\n\ngi: pt tolerating sips occasionally throughout shift. able to take po's this am, refused this afternoon. PPN ordered today, +bs, no diarrhea throughout shift. using ssi for bs. pt hypoglycemic this afternoon at 64, received amp D50/\n\ngu: foley cath draining less than adequate amounts of red/brown cloudy urine throughout shift, md's aware, received total of 1.5L fluid bolus.\n\niv: Picc requested for today, but will not happen until tomorrow, pt has piv x2.\n\nplan: monitor uop and resp status. if able to tolerate, pt does well on bi-pap, medicated last evening c ms iv and pt rested extremely well. family's contact #'s in med book, contact or if necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-12 00:00:00.000",
"description": "Report",
"row_id": 1518053,
"text": "update\npt started on ppn via l hand piv at 41cc/hr. bi-pap applied at 1830 after 2mg ms iv given, pt tolerating well thus far. still slightly tachycardic, pt was able to take 1800 po dilt. wife at bedside, needs much reassurance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-13 00:00:00.000",
"description": "Report",
"row_id": 1518054,
"text": " 4 MICU/SICU NURSING PROGRESS NOTE ( @ 1900H TO @ 0700H) :\n\n79 YEAR OLD MALE PATIENT ADMITTED FROM ER. PT PRESENTED TO ER COMPLAINING OF 3 DAY HISTORY OF SOB AND DIARRHEA. SBP 80'S. NS IV GIVEN X6 LITERS. CXR SHOWS SMALL PLEURAL EFFUSSION. INR ON ADMIT WAS 5.4. PT WAS GIVEN VIT K PO. DOCUMENTED HISTORY OF COPD, GERD, ANEMIA, AFIB WITH COUMADIN THERAPY, PULMONARY HTN, AAA, EF 45-55%, MR 3+, PROSTATE CA S/P RESECTION, MRSA RESP, SMOKER X40 YEARS AND QUIT 20 YEARS AGO, HOME OXYGEN.\n\nNEURO - PT HAS GARBLED SPEACH AT TIMES. OTHER TIMES HE MOUTHS WORDS. APPEARS TO GET CONFUSED AND RESTLESS AT TIMES. UNABLE TO DRINK FROM STRAW TONIGHT AND MEDS CHANGED TO IV. SEE FLOWSHEET FOR DETAILS.\n\nCARDIAC - AFIB. BP IN 80'S WITH DECREASED URINE OUTPUT AT BEGINNING OF MY SHIFT. FLUID BOLUS 500CC NS IV GIVEN. BLOOD PRESSURE IMPROVED. DILTIAZEM GTT @ 5MG/H STARTED AT 0100H BECAUSE PT UNABLE TO DRINK THROUGH STRAW TO TAKE PO MEDS. SEE FLOW SHEET FOR FURTHER DETAILS.\n\nRESP - ATTEMPTED BIPAP X2 TONIGHT. 1ST TIME PT WAS ON BIPAP AT CHANGE OF SHIFT AND TOOK IT OFF AT APPROXIMATELY 2030H. 2ND TIME BIPAP WAS PLACED AROUND 0130H AND PT TOOK IT OFF AT ~0245H. NASAL CANNULA @ 3L INSITU WHEN BIPAP OFF. LUNG CONTINUE TO BE COARSE. ENCOURAGEMENT TO COUGH AND DEEP BREATH. PT REFUSES TO COUGH UP SECRETIONS. REFUSES SUCTIONING. SEE FLOW SHEET FOR FURTHER DETAILS.\n\nGI - BOWEL SOUNDS PRESENT. NO BOWEL MOVEMENT TONIGHT. SEE FLOWSHEET FOR FURTHER DETAILS.\n\nGU - FOLEY INSITU. VERY LOW URINE OUTPUT. HO AWARE. FLUID BOLUS NS 500CC IV X2 GIVEN OVERNIGHT. LITTLE EFFECT NOTED ON OUTPUT. URINE DID GET LESS CONCENTRATED WITH BOLUSES. SEE FLOWSHEET FOR FURTHER DETAILS.\n\nINTEG - SKIN WEEPING FROM OLD IV SITES AND BLOOD DRAW SITES. COCCYX NOTED TO HAVE BLISTERS AND TEGADERM APPLIED. SEE FLOWSHEET FOR FURTHER DETAILS.\n\nACCESS - LEFT WRIST SALINE LOCK INFILTRATED AND REMOVED. NEW SALINE LOCK # 20 GAUGE PLACED IN LEFT FOREARM. PLAN TO PUT PICC LINE TODAY.\n\nID - CONTINUES ANTIBIOTICS. AFEBRILE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-10 00:00:00.000",
"description": "Report",
"row_id": 1518044,
"text": " 4 7a-7p\nneuro: pt remains a&o x3 throughout shift, cooperative c care, mae. perrla\n\nresp: lungs rhoncherous throughout. +productive cough. Sats remains stable on 2 l nc throughout shift. pt receiving inhalers and neb tx's as ordered. pt remains on abx for pneumonia tx\n\ncv: pt remains in a-fib throughout shift. rate greater than 130 x2 during shift, received 5mg lopressor iv for both episodes with good results. bp stable throughout shift. pt remains afebrile throughout shift\n\ngi: pt tolerating prudent diet well, appetite minimal. pt c/o mouth sores, received viscous lidocaine swish and reports much relief. able to place dentures afterward. pt having loose stools throughout shift, specimen sent for c-diff. +bs. diarrhea is slowing down. pt swallowing well.\n\ngu: foley cath putting out small amounts of amber urine.\n\npiv x2, pt had po k, iv mag and iv ca gluc repleated throughout day\n\nskin : 3 small blisters noted to coccyx, cream applied. pnemoboots in place.\n\nfamily at bedside this afternoon, daughter and wife. pt denies pain throughout shift. see careview for ssi.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-11 00:00:00.000",
"description": "Report",
"row_id": 1518045,
"text": "Resp Care Note:\n\nPt seen for administration of Atrovent via HHN/aerosol mask. Lung sounds insp rales not clearing with cough. ABGs compensated metabolic acidosis with good oxygenation. Pt in NARD on 3LPM N/C.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-11 00:00:00.000",
"description": "Report",
"row_id": 1518046,
"text": "npn 7p-7a (see also careview flownotes for objective data)\n\ndx: pna--sepsis\n\nnight significant for pt developing confusion; ABG drawn to check for hypoxia--negative; PCO2 somewhat low, showing pt attempting to compensate with repirations for metabolic acidosis;\n early yest aft/eve pt asked for sleeping pill to assist sleep; took only half per self, therefore took 2.5 mg Ambien at 22:00; by 23:00 pt very mildly confused, easily re-oriented;\n pt took other half of sleeping pill at approx 02:15 with lopressor dose at that time; pt more confused during the night;\n\npt also with intermittent rapid respirations to 30's, plus low Temp; extremities cool to touch, pleth for O2 sat variable;\n\nalso received rapid rate IVF boluses during the night, for low urine ouput, and recurrent a-fib w/ v-response to 140's/140's; pt w/ 3+ MR, therefore concern for rapid IVF boluses is if pt would develop lung conjestion d/t card failure;\n\nmushroom cath attempted because of liquid diarrhea--pt resistant; requested bedpand following; did pass very small amount thick stool; mushroom cath removed;\n\npt receiving IV Abx;\n\nASSESSMENT:\nPt's s/s and physical exam (restlessness, cool extremities, hypothermia, low urine output) suggests possible continued progression of sepsis;\n\nPLAN:\nAdditional IVF bolus infusing at approx 06:30;\n\na.m. dose lopressor given at 06:15 MD request--to be continued at q 8 hrs (tid) as ordered;\n\nclose observation;\n\ncheck results a.m. labs;\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-11 00:00:00.000",
"description": "Report",
"row_id": 1518047,
"text": "Resp Care\n\nAttempted to use mask ventilation but was not tolerated by pt. Tried nasal bipap which was tolerated but had to drop IPAP to 5 and EPAP to 4. Sop2 on 3l 97%. Pt to recieve a thorocentesis. BS coarse\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-13 00:00:00.000",
"description": "Report",
"row_id": 1518055,
"text": " 4 7a-7p.\npt went for picc line placement and pedi feeding tube placement in ir today, as well as for CT abd/pelvis.\n\nneuro: pt remains lethargic throughout shift, arousable to pain and mvmt. does not open eyes. pupils reactive.\n\nresp: pt's lungs clear throughout upper lobes, dimished in bases. weak cough, non-productive. pt's sats stable throughout shift on 2l nc, cpap dc'd. audible wet breath sounds.\n\ncv: pt remains in a-fib throughout shift. attempting to control rate with dilt gtt when bp allows, rate 80-130 throughout shift. pt afebrile throughout shift. edema +4 throughout. skin weeping on upper extremities. sbp 80-120.\n\ngi: pt had pedi-tube placed. contines to receive ppn throughout shift, will start on tpn this evening. abd becoming more firm and distended throughout shift. ct abd/pelvis c oral and iv contrast performed, inflammation r/o obstruction. no bm during shift. will hold of tube feedings until abd assessed. surgical consult called. following bs c ssi.\n\ngu: uop minimal throughout shift, remains dark amber c sediment. pt received lasix 40mg iv x1 c 100 cc uop noted.\n\niv: rua piv x1, double lumen picc in place.\n\nsoc: multiple family members at bedside throughout shift, wife, dtr and grandchildren. family meeting c md's x2 during shift to discuss plan of care and possible cmo status. will continue to follow. family extremely appropriate and supportive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-14 00:00:00.000",
"description": "Report",
"row_id": 1518056,
"text": "MICU/SICU NURSING PROGRESS NOTE FOR /05 @ 1900H TO /05 @ 0700H.\n\nSEE NOTE FOR PREVIOUS NIGHT TO READ ABOUT HISTORY.\n\n*PT COMFORT MEASURES ONLY AS OF 1945H . ALL MEDS D/C'D AT THIS TIME INCLUDING CARDIZEM GTT AND TPN. MORPHINE GTT ORDERED AND STARTED AT 2100H. FAMILY AT BEDSIDE THROUGHOUT EVENING. IN TO GIVE PT LAST RIGHTS.\n\n PT SLEEPING ALL SHIFT. RESPONDS TO PAIN TO NAIL BEDS. I DID NOTICE ATTEMPT TO SQUEEZE MY HANDS UPON INITIAL ASSESSMENT WHEN ASKED. NO FURTHER ATTEMPT TO FOLLOW COMMANDS. FLEX-WITHDRAWS TO PRESSURE APPLIED TO NAILS BEDS AND HE ALSO OPENS HIS EYES. NODS HEAD APPRORIATELY TO QUESTIONS. INCOMPREHENSIBLE SOUNDS WHEN ATTEMPTS TO SPEAK. UNABLE TO ASSESS ORIENTATION BECAUSE PT NOT TALKING. DOES APPEAR TO KNOW HIS FAMILY WHEN THEY SPEAK TO HIM. DOES APPEAR TO KNOW THAT I AM HIS NURSE. MORPHINE GTT STARTED AT 1MG/H AT 2100H. PT RESTING COMFORTABLY. SEE FLOWSHEET FOR FURTHER DETAILS.\n\nCARDIAC - MONITORING AFIB WITH OCCASSIONAL PVC'S. HR 90 - 130'S. SBP 80-90'S. 4+PITTING EDEMA. SCROTUM 4+ EDEMA. PULSES ALL PALPABLE. SKIN COLOR DUSKY. BOTTOMS OF FEET PURPLE IN COLOR. CARDIZEM GTT D/C'D AT 1945H. SEE FLOWSHEET FOR FURTHER DETAILS.\n\nRESP- REMAINS ON 2L NC. O2 SAT >94%. LUNGS CLEAR WITH RHONCHI THROUGHOUT ON EXPIRATION. PT NOT COUGHING. REFUSES SUCTIONING. REFUSES MOUTHCARE. SEE FLOWSHEET FOR FURTHER DETAILS.\n\nGI- ABDOMEN DISTENDED AND FIRM. BOWEL SOUNDS HYPOACTIVE. TENDER TO TOUCH (FACIAL GRIMACES WHEN ASSESSING BOWEL SOUNDS). NO BOWEL MOVEMENT TONIGHT. DOBHOFF FEEDING TUBE REMAINS IN PLACE. PLACEMENT VERIFIED WITH AUDIBLE AIR BOLUS. SEE FLOWSHEET FOR FURTHER DETAILS.\n\nGU- FOLEY INSITU. DRAINING DARK YELLOW CLOUDY URINE (<30CC/H).\n\nINTEGUMENT - CONTINUES TO HAVE BLISTERS X3 ON COCCYX AREA. NEW TEGADERM APPLIED TO AREA. CONTINUE TO TURN Q2-3 HOURS. PT DOES NOT LIKE TO TURN. REFUSING BEDBATH AND MOUTH CARE.\n\nACCESS - LEFT UPPER ARM DOUBLE LUMEN PICC LINE INSITU. LEFT UPPER ARM #22 SALINE LOCK INSITU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-14 00:00:00.000",
"description": "Report",
"row_id": 1518057,
"text": " 4 ICU NPN 0700-1900\n Remains on morphine sulfate gtt at 1mg hr. Initially attempting to open eyes when name called & moaning when turned.Tjis afternoon pt not attempting to open eyes or raise eyebrows when name called nor does he moan when turned. SBP 60-99 (last sbp 99). HR 107-140 AF with occas VEA. NGT & foley catheter d/c'd.\nWife & mult family members at bedside.\nA/P: Pt appears comfortable on morphine sulfate gtt.\nSupportt to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2161-03-15 00:00:00.000",
"description": "Report",
"row_id": 1518058,
"text": "npn\nat 450 pt hr noted to be decreased to 80's from 120 range, hr quickly dropped to 50's and then to 20. no rr noted, Dr. notified. Pt pronounced at 520am. Family notified and awaiting there arrival to view pt.\n"
},
{
"category": "Echo",
"chartdate": "2161-03-13 00:00:00.000",
"description": "Report",
"row_id": 95659,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 15:37\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function\ndepressed.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\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. MR present but cannot be quantified.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. Suboptimal image quality - poor subcostal views.\n\nConclusions:\nImage quality is technically very limited. The left atrium is normal in size.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Overall left ventricular systolic\nfunction appears normal (LVEF>55%). The right ventricular cavity is dilated.\nRight ventricular systolic function appears depressed. The number of aortic\nvalve leaflets cannot be determined. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mitral regurgitation is present but cannot be quantified. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , the technically suboptimal quality of the present study\nprecludes meanigful comparison.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 863122,
"text": " 2:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with increased SOB\n\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old man with increased shortness of breath.\n\n COMPARISON: Multiple chest radiographs, most recent dated .\n\n CHEST AP: Cardiac, mediastinal, and hilar contours are stable. Pulmonary\n vasculature is within normal limits. Background emphysema is again noted.\n Linear densities in the left lower lobe are again noted. There has been\n interval development of a small left pleural effusion. Osseous and\n soft-tissue structures are stable.\n\n IMPRESSION: Interval development of small left pleural effusion. Linear\n opacities in the left lower lung field may represent atelectasis or\n infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 863301,
"text": " 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening infiltrate\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with hx of COPD and recurrent PNA admitted for increaseing\n SOB\n REASON FOR THIS EXAMINATION:\n worsening infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of COPD and recurrent pneumonia, admitted with increasing\n shortness of breath.\n\n COMPARISON: Radiograph dated .\n\n SINGLE FRONTAL VIEW OF THE CHEST: There are bilateral pleural effusions and\n interval development of left lower lobe opacity. There is interval\n development of an ill-defined right infrahilar opacity. No evidence of\n pneumothorax. The cardiac and mediastinal contours are stable.\n\n IMPRESSION:\n 1) Bilateral pleural effusions.\n 2) Interval development of bibasilar opacities consistent with atelectasis or\n pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 863400,
"text": " 6:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx, etc\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with hx of COPD and recurrent PNA admitted for increaseing\n s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n ? ptx, etc\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis. History of COPD and recurrent pneumonia.\n\n COMPARISON: 10 hours earlier on .\n\n FINDINGS: AP upright portable view. The left pleural effusion is decreased\n in size compared to the previous upright view of . There is no\n pneumothorax. No right pleural effusion is appreciated. There is partial\n improvement in aeration of the right and left lower lobes. Heart and\n mediastinal contours appear stable.\n\n IMPRESSION:\n 1) Decreased left pleural effusion. No pneumothorax.\n 2) Partial improvement in right and left lower lobe aeration.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-03-13 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 863612,
"text": " 11:34 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc line. thank you.\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -51 MULTI-PROCEDURE SAME DAY *\n * FLUOR GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n * C1751 CATH ,/CENT/MID(NOT D INT/SHTH EP FXD CURVE NOT PEEL AW *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man w/ pna, on intermittent cpap requiring more iv acess.\n REASON FOR THIS EXAMINATION:\n please place picc line. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with pneumonia and need for intravenous access and\n possible TPN.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. \n . Dr. , the staff radiologist, was present and supervising\n throughout. The patient was placed supine on the angiography table. His left\n upper extremity was prepped and draped in the standard sterile fashion. Since\n no suitable superficial vein was visible, ultrasound was used for localization\n of an appropriate vein. The left basilic vein was patent and compressible.\n The skin and subcutaneous tissues were anesthetized with 3 cc of 1% lidocaine.\n Using ultrasound guidance, the left basilic vein was accessed with a 21 gauge\n micropuncture needle. Hard copies of ultrasound images were obtained, before\n and after establishing an access documenting vessel patency. A .018 guide\n wire was advanced through the access needle into the superior vena cava under\n fluoroscopic visualization. The skin entry site was incised with a #11 blade\n scalpel. The access needle was replaced with a 4.5 French micropuncture\n sheath. Based on the markers on the guide wire, it was determined that a\n length of 36 cm would be appropriate. The PICC line was then trimmed to length\n and advanced over the guide wire, through the peel-away sheath, into the\n superior vena cava under fluoroscopic guidance. The guide wire and peel-away\n sheath were removed. The catheter was flushed, capped, and heplocked. It was\n secured to the skin using a StatLock device.\n\n FINDINGS: A final AP chest x-ray was obtained, demonstrating the tip of the\n catheter to be present in the superior vena cava.\n\n COMPLICATIONS: None.\n\n MEDICATIONS: 1% lidocaine.\n\n IMPRESSION: Successful placement of a 36 cm 5 French dual lumen PICC line via\n the left basilic vein. The tip of the catheter is present in the superior\n vena cava. The catheter is ready for immediate use.\n (Over)\n\n 11:34 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place picc line. thank you.\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-03-13 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 863613,
"text": " 12:17 PM\n N-G TUBE PLACEMENT Clip # \n Reason: please place dob hof tube for GI feeding. thank you.\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n Contrast: CONRAY Amt: 10\n ********************************* CPT Codes ********************************\n * -INTESTINAL TUBE PLACEMENT (W/FL -51 MULTI-PROCEDURE SAME DAY *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with pna requiring intermittent cpap, unable to feed self.\n REASON FOR THIS EXAMINATION:\n please place dob hof tube for GI feeding. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with pneumonia and inability to eat. Please place\n postpyloric feeding tube.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the staff radiologist, was present and supervising\n throughout. The patient was placed supine on the angiography table. Attempts\n were made to advance a lubricated 8-French - feeding tube over\n a wire through each nare. These, however, were unsuccessful, as the tube was\n consistently coiling in the patient's mouth. An attempt was then made to\n advance a 5-French C2 Cobra glide catheter over a 0.035 glidewire into the\n esophagus. Again, this was unsuccessful. A repeat attempt was then made\n using the lubricated 8-French feeding tube with the patient in the seated\n position. This was finally successful, and the catheter was advanced over the\n wire, into the gastric lumen. After the wire was removed, a hand injection of\n contrast demonstrated the tip to be positioned within the stomach. The wire\n was then readvanced, and with peristalsis, the catheter tip was eventually\n directed beyond the pylorus into the proximal duodenum. After a final\n fluoroscopic spot image was obtained, demonstrating the appropriate position\n of the catheter tip, the catheter was capped and was secured to the nose using\n benzoin and Steri-Strips. There were no procedural complications.\n\n CONTRAST: 10 cc of full strength Optiray 320.\n\n IMPRESSION: Successful placement of an 8-French - postpyloric\n feeding tube with the tip positioned in the proximal duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-03-13 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 863638,
"text": " 3:27 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: SEPSIS EVALUATE FOR INTRAABD PATHOLOGY\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n Field of view: 40 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man admitted for sepsis.\n REASON FOR THIS EXAMINATION:\n Please evaluate for intraabdominal pathology.\n CONTRAINDICATIONS for IV CONTRAST:\n increasing Cr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 79-year-old man with sepsis.\n\n TECHNIQUE: CT of the abdomen and pelvis was performed without and with\n intravenous contrast. Oral contrast was administered.\n\n COMPARISON: CTA of the abdomen without and with intravenous contrast\n .\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: The patient has\n large bilateral pleural effusions. Again noted are emphysematous changes\n bilaterally, which have not significantly changed since the prior exam. There\n are no focal areas of consolidation to suggest pneumonia. The heart and\n pericardium are unremarkable. There has been interval development of ascites.\n The liver, gallbladder, and visualized spleen are unremarkable. The adrenal\n glands, and right kidney are unremarkable. The left kidney again shows a\n large low attenuation rounded lesion at the lower pole, which has not changed.\n Again, noted is mild prominence of the pancreatic duct that was seen on the\n prior exam, however, the previously described hypodensity at the junction of\n the pancreatic tail and body is not appreciated on this exam. An NG tube is\n seen coursing through the stomach and into the duodenum. The remainder of the\n stomach and small bowel are unremarkable. The right colon is filled with\n fluid. Transverse colon is not dilated, however, at the splenic flexure the\n wall of the descending colon is edematous, and the bowel wall edema extends\n into the sigmoid colon. The sigmoid colon is collapsed. Again, intra-\n abdominal ascites is noted. There is no mesenteric or retroperitoneal\n lymphadenopathy identified. The infrarenal abdominal aortic aneurysm is\n stable in size, however, the lumen has decreased in size to 2.3 x 2.3 cm from\n 3.2 x 3.2 cm. There may have been interval intervention. There is no\n periaortic hemorrhage identified.\n\n CT OF THE PELVIS WITH CONTRAST: The rectum is unremarkable. Again, the\n proximal sigmoid colon and left colon demonstrates an edematous wall. Multiple\n diverticula are seen throughout the sigmoid colon, without evidence for\n diverticulitis. There is intrapelvic fluid. There is no appreciable pelvic\n or inguinal lymphadenopathy. The visualized bladder is unremarkable. The\n distal ureters are not well seen. Given the pelvic ascites.\n\n BONE WINDOWS: There are degenerative changes in the right hip and lumbar\n (Over)\n\n 3:27 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: SEPSIS EVALUATE FOR INTRAABD PATHOLOGY\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n Field of view: 40 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n spine. Again within the left posterior iliac bone is a well defined lytic\n region with overlying normal cortex, which is unchanged from the prior exam.\n\n IMPRESSION:\n 1. Descending colon bowel wall edema with a fluid filled ascending colon\n suspicious for colitis. The most probable etiology for this finding is\n infectious, given this patient's known positivity for Clostridium difficile\n stool toxin. Additionally, inflammation and ischemia should be considered.\n Clinical correlation is recommended.\n\n 2. Unchanged outer dimensions of the abdominal aortic aneurysm with decreased\n size of the patent lumen to 2.3 x 2.3 cm from 3.2 x 3.2 cm. This may\n represent interval treatment of this aneurysm.\n\n 3. Interval development of intra-abdominal and intrapelvic ascites.\n\n 4. Bilateral lungs showing emphysematous changes and large bilateral pleural\n effusions.\n\n At the conclusion of this examination, these findings were telephoned to the\n resident caring for the patient Dr. .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 863602,
"text": " 10:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pulmonary edema, pna\n Admitting Diagnosis: HYPOTENSION;SEPSIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with hx of COPD and recurrent PNA admitted for shortness\n of breath\n REASON FOR THIS EXAMINATION:\n Please evaluate for pulmonary edema, pna\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n COMPARISON: .\n\n INDICATION: Shortness of breath.\n\n The exam is limited due to rotation of the patient. Cardiac and mediastinal\n contours are stable allowing for this factor. There are worsening opacities\n at both lung bases, and there are also apparent partially layering pleural\n effusions bilaterally.\n\n As compared to recent serial chest radiographs, similar opacity has developed\n on the film of at 7:30 a.m. and subsequently improved at a later time\n the same date.\n\n IMPRESSION: Recurrent worsening bibasilar opacities, which may be due to\n atelectasis or recurrent aspiration. Small bilateral adjacent pleural\n effusions.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2161-03-11 00:00:00.000",
"description": "Report",
"row_id": 261852,
"text": "Atrial fibrillation with rapid ventricular response\nConsider anterior myocardial infarction - age undetermined\nLow QRS voltages in limb leads\nNonspecific T wave changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2161-03-10 00:00:00.000",
"description": "Report",
"row_id": 261853,
"text": "Atrial fibrillation\nPossible anterior infarct - age undetermined\nNonspecific ST-T wave changes\nLow QRS voltages in limb leads\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2161-03-09 00:00:00.000",
"description": "Report",
"row_id": 261854,
"text": "Atrial fibrillation\nPossible anteroseptal myocardial infarction - age undetermined\nNonspecific ST-T changes\nSince previous tracing, the heart rate is slower, ventricular premature complex\nabsent\n\n"
}
] |
17,708 | 105,798 | 1. Cardiac: Ischemia; the patient had an anterior ST elevation myocardial infarction with a cardiac catheterization notable for three vessel disease. He is status post a proximal left anterior descending coronary artery stent. The patient did well post catheterization. He was maintained on aspirin and Plavix to complete a thirty day course of Plavix. His CKs peaked at 1432, his peak index was 14.2. He had no further dynamic electrocardiogram changes. His lipid panel revealed a total cholesterol of 153, LDL of 88, HDL 43, triglycerides of 108. He was maintained on Lipitor for his dyslipidemia. Regarding his ischemia, the plan was to medically manage him presently and bring him back for an elective coronary artery bypass graft in four to six weeks following completion of a thirty day course of Plavix. Pump; on a transthoracic echocardiogram was obtained. It demonstrated a left ventricular ejection fraction of 30% with left ventricular systolic function moderately to severely depressed secondary to severe hypokinesis of the anterior septum and anterior free wall. Apical akinesis was also noted (no thrombus was seen). Also there was mid ventricular plus apical segments and inferior plus posterior wall hypokinesis. There was 1+ mitral regurgitation. The patient was maintained on beta blockers and ace inhibitors as his blood pressure and heart rate tolerated. He was continued on heparin following his catheterization for his apical akinesis. He was slowly transitioned to Coumadin for discharge. Coumadin will resume until a week prior to surgery. Rhythm; the patient had a few runs of nonsustained ventricular tachycardia following his anterior ST elevation myocardial infarction. the longest of these runs were approximately seven beats in the immediate post catheterization. He had no further episodes noted on telemetry for the rest of his hospitalization. The patient also had a signal average electrocardiogram performed by Dr. . He will follow up with a T wave alternans study following his coronary artery bypass graft. The decision was made not to stress him with T wave alternans study preoperatively given his three vessel disease. From a rhythm standpoint, there will be consideration of ICD placement post coronary artery bypass graft given his EF of 30%. Again this consideration will be post coronary artery bypass graft. The patient was evaluated by physical therapy during this admission and deemed to have return to his baseline level of function and safe to go home. | "O- PT HEMODYNAMICALLY STABLE S/P STENT TO LAD.HR- 75-85 SR, NO VEA. Mild (1+) mitral regurgitation is seen. Myocardial infarction.Height: (in) 71Weight (lb): 211BSA (m2): 2.16 m2BP (mm Hg): 127/60Status: InpatientDate/Time: at 09:28Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. nursings/p stent to lad 9/29.3 vessel dz.history aaa repair,cad,smoker,htn,minuero---a+ox4 denies ha,dizziness,cp and sob.+ext mvt and sensation x4.no deficits.resp---on r/a sats 92-94%.no sob.+air exchange all lobes diminshed lower lobes.no cough.cv---+pulses x4.palapble.+circ check.+1 lower ext edema.skin norm and dry.all monitors on with alarms set.gi---tol po well.npo post mn on /2.no n/v.gu--good u/o no diuretics.voids.cl yellowiv---piv x2 sites ngative good blood return x2.heparin gtt per protocol at 1050u/hrmeds---adjusted to increased doses captoten25mg tid and lopressor 75mg .hr and bp stable.skin----rash present bilat groin and periarea.hydrocortisone cream effective per pt.plan----tranfer to floor when bed.stress test and eval cabg??? Sinus rhythmSince last ECG, no significant change Sinus rhythmSince last ECG, no significant change CCU NSG PROGRESS NOTE 7P-11P- S/P ACUTE MI/STENT LADS- " CAN I GET UP AND WALK AROUND"O- SEE FLOWSHEET FOR OBJECTIVE DATACV- VS REMAIN STABLE- HR- 70'S SR, NO VEABP- 110-130/60. HR 60-70's NSR no ectopy. "CV: NSR HR 66-89 no ectopy. There is nomitral valve prolapse. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:The left atrium is normal in size. Pt is essentially euvolemic at this time.ACCESS: 2 peripheral IVs intact and working well.STATUS: full codeA: stable s/p stent to LADTolerating cardiac meds.P: awaiting echo tomorrow for evaluation for potential CABG. Ck's trending down.P: f/u with PTT results. TO CONTINUE TO INCREASE DOSES OF ACE/B BLOCK.GROIN SITES DRY/INTACT- SMALL REDDENED AREA IN FOLDS OF GROIN BILATERALLY-NO CHANGE THIS SHIFT.DENIES ITCHINESS/IRRITATION.PULSES ALL (+) HCT STABLE.CPK'S CONTINUE TO PEAK- 1400'S LAST EVE- AM PENDING.HEPARIN GTT 900 WITH PTT- 60.INTEGRILLEN D/C 11:30 P AS ORDERED.DENIES ALL ELBOW PAIN/NO CHEST PAIN OR SOB.RESP- LUNGS CLEAR- O2 SATS MID TO HIGH 90'S ON 2 L NP.ID- LOW GRADE- 99 T MAX PO.GI- TAKING IN CRACKERS/PO MEDS/LIX. Sats 93-94% on RA.GI: Abd softly distended with +BS. Themidventricular and apical segments of the inferior and posterior walls arealso severely hypokinetic; the apex is akinetic (no thrombus seen). Pt denies feelings of SOB.CARDIAC: s/p stent to LAD. OLD- NOT CULPRIT LESION, NO INTERVENTION.PT HEMODYNAMICALLY TOLERATED CATH WITHOUT INCIDENT.SHEATHS PRESENT IN RT GROIN 7F ART/8F VENOUS.FAMILY TOLD CURRENT PLAN BY CV FELLOW.AWAIT ARRIVAL OF PT BACK TO CCU. Pt painfree on hep gtt. Sinus rhythm- first degree A-V blockProbable old inferior infarctProbable old anterior myocardial infarction with ST segment elevationconsistent with aneurysmLow QRS voltages CCU NSG PROGRESS NOTE 7P-7A/ S/P MI; STENT TO LADS- " HOW AM I DOING? No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Sinus rhythm - first degree A-V blockIndeterminate frontal QRS axisProbable anteroseptal infarct - age undetermined - possible acute/recent Lateral T wave changes offer additional evidence of ischemiaLow QRS voltages in precordial leadsConsider prior inferior myocardial infarctionSince previous tracing of : intraventricular conduction delay decreasedand further precordial ST-T wave changes seen Sinus rhythm - first degree A-V blockAnteroseptal infarct - probably acute - clinical correlation is suggestedProbable old inferior infarctLow QRS voltages in limb leadsIncomplete right bundle branch blockSince previous tracing of : further precordial ST-T wave changes TOLERATING CAPTOPRIL 25 TID/ LOPRESSOR 75 .HEPARIN AT 1050U/HR.AMBULATING AROUND ROOM, AND UP TO CHAIR TODAY.THIS EVE, AMBULATING UP AROUND UNIT,TOLERATING INCREASE ACTIVITY WITHOUT ISSUES.RESP- LUNGS CLEAR, NOT WEARING O2- O2 SATS- MID 90'S.ID- AFEBRILE- REMAINS WITH RASH AT BILATERAL GROINS- HYDROCORT CREME PRN.GU- GOOD UO VIA URINAL.I/O (-) 800CC.GI- TAKING IN MEDS/PO LIX.NO ISSUES. Right groin art/venous sheaths dc'd at 11am without incident. NTG dc'd. Conts on ASA and plavix po. ccu progress note 7a-7pUneventful day. Left ventricular wall thicknesses arenormal. (+) BOWEL SOUNDS- NO STOOL THIS SHIFT.SLIGHT NAUSEA AFTER POTASSIUM DOSES X 2- RELIEVED AFTER CRACKERS.GU- GOOD UO VIA FOLEY CATH- 50-60/HOUR. -LOS.ID: T max 99.1. The aortic valve leaflets are mildlythickened. There is mild mitral annular calcification. Pt tolerated increased activity well.PULM: LS diminished bibasilary. To be started on Coumadin tonite. Sinus rhythm- first degree A-V blockIndeterminate frontal QRS axisProbable anteroseptal infarctLow limb leads voltageLateral ST elevation - probable lateral extension of infarctLateral T wave changes offer additional evidence of ischemiaSince previous tracing, R' in leads V1 - V2 are new probably related to leadposition Cont cardiac rehab/teaching . +BS. Cont per hep ss. On Lopressor 75mg po BID. HE WAS BRIEFLY PAIN FREE AFTER 2 DOSES MS04 IVP AND INCREASING HIS TNG GTT TO 1.2 MCG/KG. Cooperative with care.RESP: LS clear. Abd soft NT. BP 114-127/59-63. Overall leftventricular systolic function is moderately-to-severely depressed secondary tosevere hypokinesis of the anterior septum and anterior free wall. right groin without s/s bleeding or hematoma. Monitor BP/HR on po cardiac regimen. start ace inhibitor. There is no aortic valve stenosis.No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no resting left ventricular outflowtract obstruction.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: The number of aortic valve leaflets cannot be determined. The tips of the papillary musclesare calcified. +palpable bilateral pedal pulses. CCU NURSING PROGRESS NOTE 7A-7PNEURO: Pt alert and oriented x3. Pt denies pain. Captopril 25mg po TID. HE HAD RECEIVED SOME MS04 AND SL TNG THROUGHOUT HIS STAY THERE AS WELL WITH WAXING/ PAIN AT ELBOW AREA.PT WAS TO FOR EMERGENT CATH /EVAL.HE ARRIVED AT 3AM WITH MILD ELBOW PAIN AND EKG THAT REVEALED ST ELEVATION ANTERIORLY AND PRWP. Pt denies n/v. RECEIVED LAST OF 80 MEQ KCL DOSE FOR K- 3.3 LAST EVE.ALL AM LABS PENDING.BP- 120-140/ - INCREASED LOPRESSOR 25-50 AND STARTED CAPTOPRIL 6.25-TOLERATED WELL- INCREASED THIS AM TO 12.5. | 15 | [
{
"category": "Echo",
"chartdate": "2199-09-16 00:00:00.000",
"description": "Report",
"row_id": 72872,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 71\nWeight (lb): 211\nBSA (m2): 2.16 m2\nBP (mm Hg): 127/60\nStatus: Inpatient\nDate/Time: at 09:28\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: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is mildly dilated. Overall left ventricular systolic\nfunction is severely depressed. There is no resting left ventricular outflow\ntract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\nNo aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. There is no significant mitral stenosis. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. Overall left\nventricular systolic function is moderately-to-severely depressed secondary to\nsevere hypokinesis of the anterior septum and anterior free wall. The\nmidventricular and apical segments of the inferior and posterior walls are\nalso severely hypokinetic; the apex is akinetic (no thrombus seen). Right\nventricular chamber size and free wall motion are normal. The number of aortic\nvalve leaflets cannot be determined. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-15 00:00:00.000",
"description": "Report",
"row_id": 171991,
"text": "Sinus rhythm\n - first degree A-V block\nAnteroseptal infarct - probably acute - clinical correlation is suggested\nProbable old inferior infarct\nLow QRS voltages in limb leads\nIncomplete right bundle branch block\nSince previous tracing of : further precordial ST-T wave changes\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-16 00:00:00.000",
"description": "Report",
"row_id": 171992,
"text": "Sinus rhythm\n- first degree A-V block\nIndeterminate frontal QRS axis\nProbable anteroseptal infarct\nLow limb leads voltage\nLateral ST elevation - probable lateral extension of infarct\nLateral T wave changes offer additional evidence of ischemia\nSince previous tracing, R' in leads V1 - V2 are new probably related to lead\nposition\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-15 00:00:00.000",
"description": "Report",
"row_id": 171993,
"text": "Sinus rhythm\n- first degree A-V block\nProbable old inferior infarct\nProbable old anterior myocardial infarction with ST segment elevation\nconsistent with aneurysm\nLow QRS voltages\n\n\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-15 00:00:00.000",
"description": "Report",
"row_id": 171994,
"text": "Sinus rhythm\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-15 00:00:00.000",
"description": "Report",
"row_id": 171995,
"text": "Sinus rhythm\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-17 00:00:00.000",
"description": "Report",
"row_id": 171990,
"text": "Sinus rhythm\n - first degree A-V block\nIndeterminate frontal QRS axis\nProbable anteroseptal infarct - age undetermined - possible acute/recent\n Lateral T wave changes offer additional evidence of ischemia\nLow QRS voltages in precordial leads\nConsider prior inferior myocardial infarction\nSince previous tracing of : intraventricular conduction delay decreased\nand further precordial ST-T wave changes seen\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-15 00:00:00.000",
"description": "Report",
"row_id": 1494818,
"text": "CCU NSG ACCEPTANCE NOTE 3A-4:30A/ ACUTE MI\n\nS/O- PLEASE SEE NSG FHPA FOR DETAILS R/T HPI/PMH AS WELL AS CCU TEAM/FELLOW NOTES.\nIN BRIEF, THIS IS A 75 YR OLD PT THAT WAS INITIALLY ADMITTED TO HOSPITAL FOR C/O LEFT ELBOW PAIN/ST ELEVATIONS ANTERIORLY.\nHE WAS INITIALLY TREATED WITH LOPRESSOR/TNG/ASA AND ADMITTED TO THE STEP DOWN CV UNIT..2ND CPK WAS (+) AND PT WAS TO THEIR ICU WHERE HE WAS HEPARINIZED AND STARTED ON IV TNG. HE HAD RECEIVED SOME MS04 AND SL TNG THROUGHOUT HIS STAY THERE AS WELL WITH WAXING/ PAIN AT ELBOW AREA.\nPT WAS TO FOR EMERGENT CATH /EVAL.\nHE ARRIVED AT 3AM WITH MILD ELBOW PAIN AND EKG THAT REVEALED ST ELEVATION ANTERIORLY AND PRWP. IT WAS DECIDED TO SEND PT TO CATH LAB FOR EMERGENT CATH. HE WAS BRIEFLY PAIN FREE AFTER 2 DOSES MS04 IVP AND INCREASING HIS TNG GTT TO 1.2 MCG/KG. UPON TRANSFER TO CATH LAB, PT HAD SOME MILD ELBOW PAIN RETURNING.\nPT WAS NPO AND STARTED ON IVF AND FOLEY CATH WAS INSERTED PRIOR TO SENDING TO CATH LAB.\nLUNGS EXAM WAS CLEAR AND PT WAS COMFORTABLE BUT FOR THE ELBOW DISCOMFORT.\nPT WAS GIVEN 15 MG SERAX FOR MILD ANXIETY AND FAMILY WAS PRESENT.\nALL APPEAR TO UNDERSTAND REASON FOR TRANSFER/CATH AND CURRENT PLAN OF CARE.\n\nA/ PT ADMITTED TO CATH LAB FOR CATH S/P R/I AMI\nAWAIT CATH REPORT.\n\nCYCLE CPK'S , KEEP FREE OF ISCHEMIC PAIN.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\nAWAIT CATH LAB REPORT/PLAN.\n\nADDENDUM-\nREPORT \nPT WITH TO LAD STENTED\nREMAINS WITH OLD RCA LESION, SOME COLLATERALS.\nPROX LCX WITH ? OLD- NOT CULPRIT LESION, NO INTERVENTION.\nPT HEMODYNAMICALLY TOLERATED CATH WITHOUT INCIDENT.\nSHEATHS PRESENT IN RT GROIN 7F ART/8F VENOUS.\nFAMILY TOLD CURRENT PLAN BY CV FELLOW.\nAWAIT ARRIVAL OF PT BACK TO CCU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-15 00:00:00.000",
"description": "Report",
"row_id": 1494819,
"text": "CCU NURSING PROGRESS NOTE 7A-7P\n\nNEURO: Pt alert and oriented x3. Sleeping in long naps most of the day, however easily arousable. Cooperative with care.\n\nRESP: LS clear. Sats 95% on 2L NC. Pt denies feelings of SOB.\n\nCARDIAC: s/p stent to LAD. Right groin art/venous sheaths dc'd at 11am without incident. +palpable bilateral pedal pulses. right groin without s/s bleeding or hematoma. BP 120/50's. HR 60-70's NSR no ectopy. NTG dc'd. Pt denies any CP, or elbow pain (presenting discomfort). Started on 25mg po lopressor. Tolerating well. Heparin gtt restarted at 2:30pm at 900u/hr for apical akinesis. Integrelin gtt infusing at 15cc/hr -> to be dc'd at 11:30pm.\nPt awaiting TEE tomorrow to determine need for CABG to other vessels.\nK+ 3.3. Rec'd 40meq po KCL (to receive additional 40meq at 8pm).\n\nGI: Tolerating cardiac diet this evening. Taking po liquids. Abd soft NT. +BS. no stool.\n\nGU: foley draining clear yellow urine. Rec'g d5 1/2NS @ 125cc/hr x1.5L. Pt is essentially euvolemic at this time.\n\nACCESS: 2 peripheral IVs intact and working well.\n\nSTATUS: full code\n\nA: stable s/p stent to LAD\nTolerating cardiac meds.\n\nP: awaiting echo tomorrow for evaluation for potential CABG.\n ? start ace inhibitor.\n d/c integrelin at 11:30pm.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-17 00:00:00.000",
"description": "Report",
"row_id": 1494825,
"text": "CCU NSG PROGRESS NOTE 7P-11P- S/P ACUTE MI/STENT LAD\n\nS- \" CAN I GET UP AND WALK AROUND\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\nCV- VS REMAIN STABLE- HR- 70'S SR, NO VEA\nBP- 110-130/60. TOLERATING CAPTOPRIL 25 TID/ LOPRESSOR 75 .\nHEPARIN AT 1050U/HR.\nAMBULATING AROUND ROOM, AND UP TO CHAIR TODAY.\nTHIS EVE, AMBULATING UP AROUND UNIT,\nTOLERATING INCREASE ACTIVITY WITHOUT ISSUES.\n\nRESP- LUNGS CLEAR, NOT WEARING O2- O2 SATS- MID 90'S.\n\nID- AFEBRILE- REMAINS WITH RASH AT BILATERAL GROINS- HYDROCORT CREME PRN.\n\nGU- GOOD UO VIA URINAL.\nI/O (-) 800CC.\n\nGI- TAKING IN MEDS/PO LIX.\nNO ISSUES.\n\n PT ALERT AND ORIENTED\nGOOD SPIRITS THIS EVE.\n\nA/ PT HEMODYNAMICALLY STABLE S/P MI\n\nPLAN TO GO HOME TO AWAIT POSSIBLE SURGERY/CABG\nCONTINUE TO INCREASE ACTIVITY/MONITOR FOR ANY S/SX ISCHEMIA.\nCONTINUE TEACHING /SUPPORT.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-16 00:00:00.000",
"description": "Report",
"row_id": 1494820,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P MI; STENT TO LAD\n\nS- \" HOW AM I DOING?\"\n\nO-\n\n PT HEMODYNAMICALLY STABLE S/P STENT TO LAD.\nHR- 75-85 SR, NO VEA. RECEIVED LAST OF 80 MEQ KCL DOSE FOR K- 3.3 LAST EVE.\nALL AM LABS PENDING.\nBP- 120-140/ - INCREASED LOPRESSOR 25-50 AND STARTED CAPTOPRIL 6.25-TOLERATED WELL- INCREASED THIS AM TO 12.5. TO CONTINUE TO INCREASE DOSES OF ACE/B BLOCK.\nGROIN SITES DRY/INTACT- SMALL REDDENED AREA IN FOLDS OF GROIN BILATERALLY-NO CHANGE THIS SHIFT.DENIES ITCHINESS/IRRITATION.\nPULSES ALL (+) HCT STABLE.\nCPK'S CONTINUE TO PEAK- 1400'S LAST EVE- AM PENDING.\nHEPARIN GTT 900 WITH PTT- 60.\nINTEGRILLEN D/C 11:30 P AS ORDERED.\nDENIES ALL ELBOW PAIN/NO CHEST PAIN OR SOB.\n\nRESP- LUNGS CLEAR- O2 SATS MID TO HIGH 90'S ON 2 L NP.\n\nID- LOW GRADE- 99 T MAX PO.\n\nGI- TAKING IN CRACKERS/PO MEDS/LIX.\n(+) BOWEL SOUNDS- NO STOOL THIS SHIFT.\nSLIGHT NAUSEA AFTER POTASSIUM DOSES X 2- RELIEVED AFTER CRACKERS.\n\nGU- GOOD UO VIA FOLEY CATH- 50-60/HOUR.\n\n PT ALERT/ORIENTED X 3- SLEPT ALL DAY AFTER RETURNED FROM CATH 7AM.\nWORRIED ABOUT NOT SLEEPING ALL NITE- GIVEN 15 SERAX- GOOD SLEEP ALL NITE.\nNO CALLS FROM FAMILY THIS SHIFT.\n\nA/ PT CURRENTLY MEDICAL REGIMEN S/P STENT LAD.\nNO ISCHEMIA/PAIN\n\nCONTINUE TO INCREASE MEDS AS TOLERATED TO MAXIMIZE RPP.\nINCREASE ACTIVITY THIS AM.\nCONTINUE HEPARIN- CHECK AM PTT/LYTES- ADJUST/REPLETE AS NEEDED.\nCONTINUE SUPPORT/TEACHING- C/O TO FLOOR ONCE MEDICALLY STABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-16 00:00:00.000",
"description": "Report",
"row_id": 1494821,
"text": "CCU Nursing Progress Note 7a-7p:\n\nS: \"I thought I was going home today.\" \"Can I play golf on Thursday?\"\n\nCV: NSR HR 66-89 no ectopy. BP 114-127/59-63. Pt denies pain. Conts on ASA and plavix po. Pt tolerating increased doses of captopril 25mg and lopressor 75mg po. Peak CK 1432 now 896.\nHep gtt increased to 1050/hr(900u) and rec'd 1100u bolus for PTT 52.7. PTT checked at 5pm await results. Cont per hep ss. No signs of bleeding noted. Palpable pulses. Bilateral groins with red rash ?allergy to betadine per team.\nMg 1.9 pt rec'd 800mg mg oxide. Phos 2.5 pt rec'd 3 packets of n. phos. Pt had echo await results.\nOOB to chair with one assist x 4hrs. Pt tolerated increased activity well.\n\nPULM: LS diminished bibasilary. Denies SOB. Sats 93-94% on RA.\n\nGI: Abd softly distended with +BS. Pt denies n/v. No stool. Tolerating cardiac diet for all three meals.\n\nGU: Foley d/c'd. Pt voiding large amts of clear yellow urine. -LOS.\n\nID: T max 99.1. WBC 10.0\n\nPROPH: hep gtt.\n\nLINES: 2 PIV flushing w/o incidence.\n\nSOCIAL: Pt has wife and eight children/21 grandchildren.\n\nDISPO: Full Code\n\nA: 75 y/o male with anterior MI/3VD s/p PTCA/stent to LAD. Pt painfree on hep gtt. Ck's trending down.\n\nP: f/u with PTT results. Monitor BP/HR on po cardiac regimen. Cont cardiac rehab/teaching . Transfer to Far when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-16 00:00:00.000",
"description": "Report",
"row_id": 1494822,
"text": "Addendum to Nursing Progress Note:\nPTT 65.4 at 5pm no change in hep gtt per ss. Cont per plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-17 00:00:00.000",
"description": "Report",
"row_id": 1494823,
"text": "nursing\ns/p stent to lad 9/29.3 vessel dz.history aaa repair,cad,smoker,htn,mi\nnuero---a+ox4 denies ha,dizziness,cp and sob.+ext mvt and sensation x4.no deficits.\nresp---on r/a sats 92-94%.no sob.+air exchange all lobes diminshed lower lobes.no cough.\ncv---+pulses x4.palapble.+circ check.+1 lower ext edema.skin norm and dry.all monitors on with alarms set.\ngi---tol po well.npo post mn on /2.no n/v.\ngu--good u/o no diuretics.voids.cl yellow\niv---piv x2 sites ngative good blood return x2.heparin gtt per protocol at 1050u/hr\nmeds---adjusted to increased doses captoten25mg tid and lopressor 75mg .hr and bp stable.\nskin----rash present bilat groin and periarea.hydrocortisone cream effective per pt.\nplan----tranfer to floor when bed.stress test and eval cabg????\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-09-17 00:00:00.000",
"description": "Report",
"row_id": 1494824,
"text": "ccu progress note 7a-7p\nUneventful day. Physical Therapy in to work with patient today. OOB, steady gait. transfer to floor bed, called out. Family in to visit.\n\nVSS. On Lopressor 75mg po BID. Captopril 25mg po TID. To be started on Coumadin tonite. Surgery consulted, awaiting decision on whether patient is a surgical candidate for CABG or treat medically to cardiac rehab.\n\n\n"
}
] |
21,015 | 180,668 | Summary of major hospital events: HD #1. Upon arrival on the patient was critically ill with an elevated potassium and an acute renal failure. The patient was admitted to the intensive care unit after a CT angiogram showed that the left profunda was widely opened, but his femoral anterior tibial artery bypass was occluded. He did have distal flow. On the right side he had a small clot in the proximal profunda with good distal flow and flow in the leg. On exam the patient initially had cool legs which were mottled, but as his blood pressure began to resolve, the only cool part of his legs were the feet below the ankles. He had no signals. He had palpable femorals only. Extensive discussions were held with the family and the decision was made to observe on heparin and try to resuscitate him to get him in a more stable condition for the operating room. His initial CK was 110. Over the course of the evening, the patient began to do better and had controlled blood sugars with a potassium in the normal range and his creatinine came down to the 2 range. His CK started to rise and his feet did not improve, so he was taken urgently to the operating room on HD #2. HD #2. On he underwent bilateral graft thrombectomies, bilateral leg fasciotomies, right common femoral atherectomy with bovine pericardial patch angioplasty, and angiogram demonstrating no flow through the right femoral-popliteal bypass graft with insufficient runoff through the right popliteal supplied by the right profunda. HD #4. On he had an right lower extremity angiogram via the left brachial artery showing showing a patent profunda with branches supplying a small peroneal artery with no outflow. Based on these findings we concluded that he will most likely require a below-knee amputation in the near future. HD#10: Patient underwent a R BKA. Please see Dr. operative note for details. Patient tolerated the procedure well, transferred to the PACU and then to VICU. APS was consulted. Dilaudid PCA and ketamine drip was started post op and continued to POD4. Pain medication transitioned to PO ms contin and dilaudid on POD4. Pain controlled prior to discharge. Diet was advanced. Pt consulted to assist in strength training and mobility. HD#12: Patient underwent angioplasty of left common femoral artery and angioplasty of left femoral to anterior tibial bypass graft. Received perioperative HCO3 infusion. Pt tolerated the procedure well, transferred to PACU and then to VICU in stable condition. Again, diet was advanced and pain controlled with first ketamine drip and IV PCA and then po dilaudid MS contin. | Abgs acceptable, fio2 and peep weaned by resp rx. FSG > 180s, CK continue to trend up, chloride ^ Action: Propofol weaned off. FSG > 180s, CK continue to trend up, chloride ^ Action: Propofol weaned off. FSG > 180s, CK continue to trend up, chloride ^ Action: Propofol weaned off. Chief complaint: PMHx: Current medications: 1. Metoprolol Tartrate 19. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Doppler pulses L-foot. Chlorhexidine Gluconate 0.12% Oral Rinse 5. Hypoactive BS 4Qs. PredniSONE 18. PredniSONE 18. Heparin gtt w/subtheraputic PTT. Heparin gtt w/subtheraputic PTT. Heparin gtt w/subtheraputic PTT. Renal failure, acute (Acute renal failure, ARF) Assessment: Adequate uo, creat down to 1.8. k stable at 4.2 Action: Maintenance iv at 150cc/hr Response: Plan: Follow electrolytes and renal function indicators Pain control (acute pain, chronic pain) Assessment: Initially on fentanyl gtt at 25 mcg, and propofol 35 mcg, became more hypertensive, light, and agitated. adeq uo, urinalysis and culture sent, creat 3.3 on adm, now 2.8. ETT good placement Fluids: Currently NS will change to LR given elevated chloride. ETT good placement Fluids: Currently NS will change to LR given elevated chloride. Lactate WNL. Action: Fluids bolus 1.5 l given post-op for trending BP <110 syst and CVP 8-9. 50y/o M. S/p#2 Bilateral Lower extremities Thrombectomies & Fasciotomies () Afebrile. Ciprofloxacin 9. Metoprolol Tartrate 16. Metoprolol Tartrate 16. PP check Q1hr. Famotidine 10. FSG 130 Plan: Pain mngt. SR 70-80, SBP 140-170mmHg; Lopressor and Hydralazine IV with mild effect. CK's remain elevated/creatinine trending down. Renal failure, acute (Acute renal failure, ARF) Assessment: Adequate uo, creat down to 1.8. k stable at 4.2 Action: Response: Plan: Follow electrolytes and renal function indicators Pain control (acute pain, chronic pain) Assessment: Action: Response: Plan: .H/O diabetes Mellitus (DM), Type I Assessment: Action: Response: Plan: Chlorhexidine Gluconate 0.12% Oral Rinse 8. Abgs acceptable, fio2 and peep weaned by resp rx. Given versed and fentanyl bolus pre dressing change. Bolus IV fentanyl for Dressing changes Response: Rated pain tolerable. adeq uo, urinalysis and culture sent, creat 3.3 on adm, now 2.8. Hypertension, benign Assessment: Received pt this AM with SBP 150s. SR 70-80, SBP 140-170mmHg; Lopressor and Hydralazine IV with mild effect. Action: Fentanyl bolus given pre dsg change and with activity. Metoprolol Tartrate 19. left groin incision CDI Neurologic: (Responds to: Unresponsive), Sedated, on propofol and fentanyl will lighten sedation today Labs / Radiology 113 K/uL 10.4 g/dL 105 mg/dL 1.8 mg/dL 23 mEq/L 4.3 mEq/L 35 mg/dL 112 mEq/L 144 mEq/L 30.8 % 13.9 K/uL [image002.jpg] 09:20 AM 10:34 AM 11:45 AM 11:48 AM 02:53 PM 03:04 PM 08:25 PM 08:44 PM 03:10 AM 03:15 AM WBC 15.4 13.9 Hct 33 35 31.5 30.6 30.2 30.8 Plt 122 121 113 Creatinine 2.2 2.2 1.9 1.8 TCO2 25 25 25 28 26 24 Glucose 127 157 190 189 105 Other labs: PT / PTT / INR:11.5/50.8/1.0, CK / CK-MB / Troponin T:2983/3/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase / Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L, Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:3.1 mg/dL Assessment and Plan PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, .H/O DIABETES MELLITUS (DM), TYPE I Assessment and Plan: 50yoM s/p bilat thrombectomies and fasciotomies, now POD1 hemodynamically stable. Left pleural effusion cleared. Left pleural effusion cleared. Left SFA occluded at origin on left fem-AT graft (profunda origin preserved) with similar minimal filling of tibio-peroneal trunk. Right internal jugular catheter ends in the mid SVC. Thrombosis of the right femoral-popliteal, and left femoral-anterior tibial grafts with minimal reconstitution at the level of the tibioperoneal trunks bilaterally via collaterals. (Side of cut down).MD aware. (Side of cut down).MD aware. Moderate bibasilar atelectasis. Since that time, a right IJ catheter has been placed. Monophasic waveforms indicate presence of some baseline underlying ischemia of the left lower extremity distal to the popliteal artery. The tip terminates at the superior vena cava. Fluids bolus given (Total 1.75 ml N/S). Fluids bolus given (Total 1.75 ml N/S). Bil Palpable femoral pulses. Bil Palpable femoral pulses. Hct stable 30.5. Hct stable 30.5. FINAL REPORT CHEST PORTABLE AP. Endotracheal tube terminates within the mid trachea, and the bronchi are patent to the subsegmental level. Well-defined hypoattenuating linear area within the left cerebellar hemisphere is likely related to an old infarct (2:7). Action: Fluids bolus for low BP. Consider left atrial abnormality. There is mild fluid overload with patchy left retrocardiac and right infrahilar opacities, which could reflect areas of atelectasis. Endotracheal tube terminates at the thoracic inlet. A linear density projecting to the left of the thoracic spine is likely extrinsic. NS Response: Last PTT therapeutic. Arrives on profopol. Arrives on profopol. Already Intubated. Already Intubated. Graft velocities range from a minimum of 45 cm/sec to a maximum of 76 cm/sec, the former occurring at the distal graft anastomosis with the native vessel. Lactate WNL. Lactate WNL. Since , the patient was extubated and the nasogastric tube was removed. Sinus rhythm. There is moderate bibasilar atelectasis. Dressings reinforced once bil. Endotracheal tube is at the thoracic inlet in appropriate position. Mild fluid overload with patchy bibasilar opacities, could reflect areas of atelectasis. The left common femoral artery is patent until just past the SFA/profunda bifurcation. | 41 | [
{
"category": "Respiratory ",
"chartdate": "2184-02-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 369757,
"text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369840,
"text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Right foot continues cold, mottled, pulseles with Doppler popliteal and\n palp fem. left foot with Doppler dp and pt, popliteal and palp fem,\n warm and pinker. Dressings on fasciotomy sites intact, little new\n drainage.\n Action:\n Venodyne boot ordered for right leg, but left off per vasc resident.\n Multipodus splints on. Heparin gtt continued at 750 units, goal 60-80.\n Response:\n Ptt 50.8, gtt increased to 850 units.\n Plan:\n Recheck ptt in 6 hr.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate uo, creat down to 1.8. k stable at 4.2\n Action:\n Maintenance iv at 150cc/hr\n Response:\n Plan:\n Follow electrolytes and renal function indicators\n Pain control (acute pain, chronic pain)\n Assessment:\n Initially on fentanyl gtt at 25 mcg, and propofol 35 mcg, became more\n hypertensive, light, and agitated.\n Action:\n Bolus of 50 mcg of fentanyl given and gtt increased to 50 mcg/hr.\n propofol gtt continues at 50 mcg now. Versed order obtained and given\n x 1 for agitation.\n Response:\n Appears to be more comfortable, fewer episodes of hypertension.\n Plan:\n Maintain gtt at 50 mcg and increase if needed.\n .H/O diabetes Mellitus (DM), Type I\n Assessment:\n Glucose labile, see flow sheet.\n Action:\n Insulin gtt titrated for glucose management.\n Response:\n Currently in insulin gtt at 4 units.\n Plan:\n Check glucose q 1 hr, titrate gtt as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369934,
"text": "50y/o M. S/p#2 Bilateral Lower extremities Thrombectomies &\n Fasciotomies ()\n Afebrile. MAE\ns. Somewhat lethargic, easily arousable this evening.\n Frequent RN supervision. Bouts of agitation and stated frustration,\n Haldol 1-2mg IV administered with good effect. Reassurances given. LSC\n bilaterally. RA sats 97-100%. SR 70-80, SBP 140-170mmHg; Lopressor and\n Hydralazine IV with mild effect. LR200cc/hr. Heparin gtt to\n 1400units/hr. Fentanyl 100mcg/hr. 0000hr IVF to 100cc/hr and added\n Sodium bicarb at 100cc/hr. Insulin gtt started due to an increase in\n FSBS (secondary to IVF-D5 based solutions). Doppler pulses L-foot.\n R-foot PP absent, foot is cold to touch. Hypoactive BS 4Q\ns. Foley\n catheter draining clear yellow urine. Good diuresis 300-400cc/hr.\n Family updated this HS by phone.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n No doplerable pulses R- foot, cold to touch. L-foot pink and warm,\n Doppler pulses DP/PT .+CSM bilateral LE. Bilateral LE fasciotomy DSD\n CDI.\n Action:\n Legs elevated on pillows. Multipodus boots. PP check Q1hr. Heparin\n gtt increased at HS. PTT 40-50sec.\n Response:\n R-Foot remains cold to touch. MD notified and aware.\n Plan:\n Continue to monitor. Mucomist via NG prep for angiogram this am\n Hyperglycemia\n Assessment:\n FSBS >120mgdL with D5 IV solutions\n Action:\n Insulin gtt per CVICU protocol\n Response:\n Good glycemic control attained\n Plan:\n Continue to monitor for FSBS\n Hypertension, benign\n Assessment:\n SBP>160mmHg\n Action:\n Lopressor 5mg IV increased to Q4hr. hydralazine IV.\n Response:\n Remains hypertensive 150-160mmHg\n Plan:\n Continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Bilateral LE pain\n Action:\n Fentanyl gtt @100mcg/hr\n Response:\n Tolerable pain at rest; bolus IV needed for change of position,\n hygiene.\n Plan:\n Continue to assess and monitor for acute changes\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369814,
"text": "Left for OR @ 7:15 am today. Retuns to CVICU @ 11:45am. Bilateral\n Thrombectomy LE, Bilateral fasciotomy and angiogram. Cut down done\n right leg. OR uneventful. 2 units of RBC given intra-op.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n OR today. Doppler pulses regain on left foot (DP\ns only) but not on\n right foot. Boot feet cold and mottled, but right foot colder than left\n with cyanosis. Right upper quadrant has moderate indurations. (Side of\n cut down)>MD aware. Hct stable 30.5. No echymosis or redness. Bil\n Palpable femoral pulses.\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Admission BUN/Creat 57/3.8. Renal function improves. Last BUN/ Creat\n 42/2.2. Good U/O. K stable. CVP 9-12. CPK rising as anticipated.\n Action:\n Fluids bolus 1.5 l given post-op for trending BP <110 syst and CVP 8-9.\n N/S @ 150 ml/hr\n Response:\n Good response to fluids. Lactate WNL.\n Plan:\n Monitor U/O and renal functions closely.\n Pain control (acute pain, chronic pain)\n Assessment:\n VS and grimacing with turns.\n Action:\n Fentanyl drip and propofol. Reposition Q 2 hrs.\n Response:\n VS stable without grimacing after interventions.\n Plan:\n Pain management. Reposition Q 2 hrs. Fentanyl for pain.\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369905,
"text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Sedated on Propofol. Fentanyl gtt for pain mngt\n Intubated on Vent. Breath sounds clear. Sx thick tan\n VSS.CVP 0-7. No doplerable pulses in right foot, Right \n pulse doplerable. Cap refill on right foot > 3 seconds and cool to\n touch. Sensation present in bilateral LE. Bilateral LE faciotomy drsg\n . Heparin gtt w/subtheraputic PTT.\n Abd soft w/hypo BS. sump via right nare to LCS\n draining bile.\n Foley patent draining clear yellow urine in QS.\n FSG > 180\ns, CK continue to trend up, chloride ^\n Action:\n Propofol weaned off. c/o generalized discomfort.\n Extubated to cool neb and weaned to NC and then to off\n Multi podis boots bilaterally. Ntg paste dc\nd. IV fluids\n changed to LR and rate ^ to 200. 500 CC fluid bolus. Heparin gtt rate\n ^.\n IV + SQ insulin\n Response:\n Moaning. Verbalizes w/difficulties initially but able to\n verbalize more freely by days end., repetitive speech pattern. Oriented\n to name only. Delay in verbal responses. c/o generalized discomfort.\n Restless and fidgety in bed, fentanyl gtt ^ to 100 mcg/hr. Midaz prn\n Sats 94% or >. No resp distress noted, = rise and fall of\n chest.\n Color improving in right foot. Capillary refill on right\n toes now < 3 seconds. ?PT pulse doplerable on right venous VS: arterial\n FSG 130\n Plan:\n Pain mngt. Frequent reorientation and monitor neurological\n status. PTT d/t be drawn at 1900 w/goal of 60-80\n Pulmonary toilet, mobilize in bed as much as able.\n CMS checks to LEs. Angio gram premedicate w/mucomist\n and NaCO3- tonight at midnoc and in AM.\n CK q 8 hrs d/t be drawn at . (will draw both at 1900)\n Daily Tacrolimus level q AM.\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369907,
"text": "s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration, ? sepsis\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by wound\n exploration ', Cadaveric pancreas transplant ', L CEA '\n (), Right common femoral artery to above-knee popliteal artery\n bypass graft with 8 mm ringed PTFE ', Right second toe amputation\n ', cataracts ', R wrist ', Left common femoral artery to\n above-knee popliteal artery bypass graft with 8-mm ringed PTFE ',\n Repair of incisional hernia ', L fem-AT bypass with PTFE graft ,\n pancreas explant ', vitrectomy '.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Sedated on Propofol. Fentanyl gtt for pain mngt\n Intubated on Vent. Breath sounds clear. Sx thick tan\n VSS.CVP 0-7. No doplerable pulses in right foot, Right \n pulse doplerable. Cap refill on right foot > 3 seconds and cool to\n touch. Sensation present in bilateral LE. Bilateral LE faciotomy drsg\n . Heparin gtt w/subtheraputic PTT.\n Abd soft w/hypo BS. sump via right nare to LCS\n draining bile.\n Foley patent draining clear yellow urine in QS.\n FSG > 180\ns, CK continue to trend up, chloride ^\n Action:\n Propofol weaned off. c/o generalized discomfort.\n Extubated to cool neb and weaned to NC and then to off\n Multi podis boots bilaterally. Ntg paste dc\nd. IV fluids\n changed to LR and rate ^ to 200. 500 CC fluid bolus. Heparin gtt rate\n ^.\n IV + SQ insulin\n Response:\n Moaning. Verbalizes w/difficulties initially but able to\n verbalize more freely by days end., repetitive speech pattern. Oriented\n to name only. Delay in verbal responses. c/o generalized discomfort.\n Restless and fidgety in bed, fentanyl gtt ^ to 100 mcg/hr. Midaz prn\n Sats 94% or >. No resp distress noted, = rise and fall of\n chest.\n Color improving in right foot. Capillary refill on right\n toes now < 3 seconds. ?PT pulse doplerable on right venous VS: arterial\n FSG 130\n Plan:\n Pain mngt. Frequent reorientation and monitor neurological\n status. PTT d/t be drawn at 1900 w/goal of 60-80\n Pulmonary toilet, mobilize in bed as much as able.\n CMS checks to LEs. Angio gram premedicate w/mucomist\n and NaCO3- tonight at midnoc and in AM.\n CK q 8 hrs d/t be drawn at . (will draw both at 1900)\n Daily Tacrolimus level q AM.\n"
},
{
"category": "Nutrition",
"chartdate": "2184-02-10 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 369992,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 50yo man s/p bilat thromectomies/fasciotomies, now POD #2, pt extubated\n yesterday, remains NPO for thrombectomy today. Pt screen today per ICU\n protocol, will f/u re diet adv/po , need nutritional support if\n unable to diet advance. Please page if has ?\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369779,
"text": "Ekg st to 115, no ectopy, 5 mg Lopressor given at 2400, rate down to\n 90s, no effect on sbp. 1000cc ns bolus given before dose to see if\n tachycardia were volume related, with slight drop to 107. cvp up from\n 7 to 12 with volume. Sbp stable unless light, then htn to 160s.\n adeq uo, urinalysis and culture sent, creat 3.3 on adm, now 2.8.\n Temp 101.2, spont dropped to 98.8. glucose managed per protocol, see\n flow sheet for details. K up to 6.0, responded to bicarb and insulin,\n now 4.2. ca and mg repleted. Breath sounds clear, scant white\n secretions suctioned from ett, sputum culture sent. Abgs acceptable,\n fio2 and peep weaned by resp rx. Abd soft, faint to no bowel sounds\n heard. Ogt to lws, 200cc pale green drainage. Feet cold and mottled\n bilat. Palpable fem pulses bilat, popilteal pulses present by Doppler\n bilat. Dp and pt pulses absent bilat. Sedated with propofol, with\n fent gtt for comfort. Responds to voice, opens eyes to command and\n follows other commands inconsistently, have seen all extremities move\n both to command and spont. Pupils 2-3mm, brisk. Skin is intact on\n back and buttocks, heel. Has purple middle toe which he stubbed last\n week, according to mother. : follow electrolytes and rx as\n needed. Monitor renal function. Sedate and maintain fent gtt for\n comfort. Monitor circ status of both legs. Probable tripto or for\n intervention in am. Reassure and update family as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369889,
"text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Sedated on Propofol. Fentanyl gtt for pain mngt\n Intubated on Vent. Breath sounds clear. Sx thick tan\n VSS.CVP 0-7. No doplerable pulses in right foot, Right pulse\n doplerable. Cap refill on right foot > 3 seconds and cool to touch.\n Sensation present in bilateral LE. Bilateral LE faciotomy drsg .\n Heparin gtt w/subtheraputic PTT.\n Abd soft w/hypo BS. sump via right nare to LCS draining bile.\n Foley patent draining clear yellow urine in QS.\n FSG > 180\ns, CK continue to trend up, chloride ^\n Action:\n Propofol weaned off. c/o generalized discomfort.\n Extubated to cool neb and weaned to NC 4 L/min.\n Multi podis boots bilaterally. Ntg paste dc\nd. IV fluids changed to LR\n and rate ^ to 200. 500 CC fluid bolus. Heparin gtt rate ^.\n IV + SQ insulin\n Response:\n Moaning. Verbalizes w/difficulties, repetitive speech pattern. Oriented\n to name only. Delay in verbal responses. c/o generalized discomfort.\n Restless and fidgety in bed.\n Sats 95% or >. No resp distress noted, = rise and fall of chest.\n Color improving in right foot. Capillary refill on right toes now < 3\n seconds.\n FSG 130\n Plan:\n Pain mngt. Frequent reorientation and monitor neurological status. PTT\n d/t be drawn at 1900 w/goal of 60-80\n Pulmonary toilet, mobilize in bed as much as able.\n CMS checks to LEs. Angio gram premedicate w/mucomist and NaCO3-\n tonight and in AM.\n CK q 8 hrs d/t be drawn at .\n Daily Tacrolimus level q AM.\n"
},
{
"category": "Physician ",
"chartdate": "2184-02-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 369963,
"text": "CVICU\n HPI:\n POD#2\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration, ? sepsis\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40 daily, Plavix 75 daily (held), Zemplar 1mcg\n daily, Lantus 32U daily, Cialis 20mg every three days, Humalog\n SS, Bactrim 80-400 M-W-F, ASA 325 daily (held), Lisinopril 20\n daily, Fosamax 70 qweek, Prednisone 5 daily, Metoprolol 100 BD,\n Percocet prn, Amlodipine 10 daily, Gabapentin 10 daily, Prograf\n 4mg \n 50M with B/L synthetic vascular bypass grafts, now with acute occlusion\n in the setting of severe dehydration.\n Chief complaint:\n PMHx:\n Current medications:\n 1. 1000 mL LR 2. 150 mEq Sodium Bicarbonate/ 1000 mL D5W 3.\n Acetylcysteine 20% 5. Ciprofloxacin 6. Famotidine 7. Fentanyl Citrate\n 8. Heparin 9. HydrALAzine 10. HydrALAzine 11. Influenza Virus Vaccine\n 12. Insulin 13. MetRONIDAZOLE (FLagyl) 14. Metoprolol Tartrate 15.\n Metoprolol Tartrate 16. Midazolam 17. PredniSONE 18. Tacrolimus 19.\n Vancomycin\n 24 Hour Events:\n EXTUBATION - At 12:25 PM\n INVASIVE VENTILATION - STOP 12:25 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:15 AM\n Vancomycin - 08:00 PM\n Ciprofloxacin - 10:20 PM\n Metronidazole - 05:30 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Fentanyl - 100 mcg/hour\n Heparin Sodium - 1,400 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:27 PM\n Fentanyl - 04:00 AM\n Metoprolol - 04:00 AM\n Insulin - Regular - 05:00 AM\n Hydralazine - 06:20 AM\n Midazolam (Versed) - 06:30 AM\n Other medications:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 86 (75 - 93) bpm\n BP: 164/51(78) {143/51(78) - 177/6,657(106)} mmHg\n RR: 23 (13 - 23) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 1 (-1 - 15) mmHg\n Total In:\n 6,201 mL\n 1,929 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,201 mL\n 1,829 mL\n Blood products:\n Total out:\n 4,620 mL\n 2,560 mL\n Urine:\n 4,170 mL\n 2,560 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 1,581 mL\n -631 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n PS : 12 cmH2O\n FiO2: 40%\n SPO2: 96%\n ABG: 7.38/35/130/26/-3\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, Significant pain\n in rt foot with limited movement\n Labs / Radiology\n 139 K/uL\n 10.0 g/dL\n 128 mg/dL\n 1.4 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 22 mg/dL\n 108 mEq/L\n 144 mEq/L\n 28.4 %\n 12.7 K/uL\n [image002.jpg]\n 11:45 AM\n 11:48 AM\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n 09:34 AM\n 04:30 AM\n WBC\n 15.4\n 13.9\n 12.7\n Hct\n 31.5\n 30.6\n 30.2\n 30.8\n 28.4\n Plt\n 122\n 121\n 113\n 139\n Creatinine\n 2.2\n 2.2\n 1.9\n 1.8\n 1.4\n TCO2\n 25\n 28\n 26\n 24\n 22\n Glucose\n 190\n 189\n 105\n 106\n 128\n Other labs: PT / PTT / INR:11.5/42.1/1.0, CK / CK-MB / Troponin\n T:3671/3/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:8.4 mg/dL, Mg:1.5 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n HYPERGLYCEMIA, HYPERTENSION, BENIGN, PERIPHERAL VASCULAR DISEASE (PVD)\n WITH CRITICAL LIMB ISCHEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), .H/O PERIPHERAL\n VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, .H/O DIABETES\n MELLITUS (DM), TYPE I\n Assessment and Plan: Extubated. To angio today with possible\n thrombectomy for cold pulseless right foot.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, Start PO beta blocker.\n Pulmonary: OOB and CPT\n Gastrointestinal / Abdomen:\n Nutrition: D/C NGT\n Renal: Foley, Adequate UO, Bicarbonate infusion for renal protection\n Hematology: Serial Hct\n Endocrine: Insulin drip\n Infectious Disease: Continue abx today and then stop\n Lines / Tubes / Drains: Foley, D/C a-line\n Wounds:\n Imaging:\n Fluids: LR, Continue IV fluids\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Acute renal failure\n ICU Care\n Nutrition: Allow diet after procedure\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:15 PM\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Arterial Line - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2184-02-10 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 369965,
"text": "CVICU\n HPI:\n POD#2\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50M with B/L synthetic vascular bypass grafts, now with acute occlusion\n in the setting of severe dehydration.\n PMHx:\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40 daily, Plavix 75 daily (held), Zemplar 1mcg\n daily, Lantus 32U daily, Cialis 20mg every three days, Humalog\n SS, Bactrim 80-400 M-W-F, ASA 325 daily (held), Lisinopril 20\n daily, Fosamax 70 qweek, Prednisone 5 daily, Metoprolol 100 BD,\n Percocet prn, Amlodipine 10 daily, Gabapentin 10 daily, Prograf\n 4mg \n Current medications:\n Acetylcysteine 20% 4. Chlorhexidine Gluconate 0.12% Oral Rinse 5.\n Ciprofloxacin 6. Famotidine 7. Fentanyl Citrate 8. Heparin 9.\n HydrALAzine 10. HydrALAzine 11. Influenza Virus Vaccine 12. Insulin 13.\n MetRONIDAZOLE (FLagyl) 14. Metoprolol Tartrate 15. Metoprolol Tartrate\n 16. Midazolam 17. PredniSONE 18. Tacrolimus 19. Vancomycin\n 24 Hour Events:\n EXTUBATION - At 12:25 PM\n INVASIVE VENTILATION - STOP 12:25 PM\n Post operative day:\n POD#2\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50M with B/L synthetic vascular bypass grafts, now with acute occlusion\n in the setting of severe dehydration.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:15 AM\n Vancomycin - 08:00 PM\n Ciprofloxacin - 10:20 PM\n Metronidazole - 05:30 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Fentanyl - 100 mcg/hour\n Heparin Sodium - 1,400 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:27 PM\n Fentanyl - 04:00 AM\n Metoprolol - 04:00 AM\n Insulin - Regular - 05:00 AM\n Hydralazine - 06:20 AM\n Midazolam (Versed) - 06:30 AM\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.9\nC (98.4\n HR: 86 (75 - 93) bpm\n BP: 164/51(78) {143/51(78) - 177/6,657(106)} mmHg\n RR: 23 (13 - 23) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 1 (-1 - 15) mmHg\n Total In:\n 6,201 mL\n 1,929 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,201 mL\n 1,829 mL\n Blood products:\n Total out:\n 4,620 mL\n 2,560 mL\n Urine:\n 4,170 mL\n 2,560 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 1,581 mL\n -631 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n PS : 12 cmH2O\n FiO2: 40%\n SPO2: 96%\n ABG: 7.38/35/130/26/-3\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: open fasciotomies bilat calves-draining serous fluid. Rt groin\n incision CDI\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, able to grossly\n move left foot, cannot move toes\n Labs / Radiology\n 139 K/uL\n 10.0 g/dL\n 128 mg/dL\n 1.4 mg/dL\n 26 mEq/L\n 3.1 mEq/L\n 22 mg/dL\n 108 mEq/L\n 144 mEq/L\n 28.4 %\n 12.7 K/uL\n [image002.jpg]\n 11:45 AM\n 11:48 AM\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n 09:34 AM\n 04:30 AM\n WBC\n 15.4\n 13.9\n 12.7\n Hct\n 31.5\n 30.6\n 30.2\n 30.8\n 28.4\n Plt\n 122\n 121\n 113\n 139\n Creatinine\n 2.2\n 2.2\n 1.9\n 1.8\n 1.4\n TCO2\n 25\n 28\n 26\n 24\n 22\n Glucose\n 190\n 189\n 105\n 106\n 128\n Other labs: PT / PTT / INR:11.5/42.1/1.0, CK / CK-MB / Troponin\n T:3671/3/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:8.4 mg/dL, Mg:1.5 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n HYPERGLYCEMIA, HYPERTENSION, BENIGN, PERIPHERAL VASCULAR DISEASE (PVD)\n WITH CRITICAL LIMB ISCHEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), .H/O PERIPHERAL\n VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, .H/O DIABETES\n MELLITUS (DM), TYPE I\n Assessment and Plan: 50yo man s/p bilat thromectomies/fasciotomies.\n Hemodynamically stable-extubated for angio and possible further\n thrombectomy today.\n Neurologic: Pain controlled, Pain controlled with percocet/morphine\n Cardiovascular: start ASA and statin likely resume plavix after angio\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: NPO, for angio/thrombectomy\n Renal: Foley, Adequate UO, continue to monitor bun/creat/cpk\n Hematology: stable hct\n Endocrine: Insulin drip\n Infectious Disease: GNRods/GPC in sputum.\n CXR without infiltrates\n WBC 12.7\n on Vanco/Flagyl/Cipro\n Lines / Tubes / Drains: Foley, Aline\n Rt IJ/TLC\n Wounds: bilat fasciotomies w/serous drainage\n Imaging: LE angiogram today\n Fluids: LR, D5 with bicarb today\n Consults: Vascular surgery, Transplant, Nephrology\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:15 PM\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Arterial Line - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2184-02-11 00:00:00.000",
"description": "Generic Note",
"row_id": 370084,
"text": "TITLE:\n CVICU\n HPI:\n POD 3\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration,\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABGx3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40', Plavix 75', Zemplar 1mcg QD, Lantus 32U qd, Cialis\n 20mg Q3days, Humalog SS, Bactrim 80-400 M-W-F, ASA 325', Lisinopril\n 20', Fosamax 70 qwk, Prednisone 5', Metoprolol 100\", Percocet prn,\n Amlodipine 10', Gabapentin 10', Prograf 4\"\n Chief complaint:\n PMHx:\n Current medications:\n 1. 1000 mL LR 3. Acetylcysteine 20% 4. Aspirin 5. Atorvastatin 6.\n Calcium Gluconate 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8.\n Ciprofloxacin 9. Famotidine 10. Fentanyl Citrate 11. Haloperidol 12.\n Heparin 13. HydrALAzine 14. Influenza Virus Vaccine 15. Insulin 16.\n Magnesium Sulfate 17. MetRONIDAZOLE (FLagyl) 18. Metoprolol Tartrate\n 19. Midazolam 20. Potassium Chloride 21. PredniSONE\n 22. Tacrolimus 23. Vancomycin\n 24 Hour Events:\n OR SENT - At 10:15 AM\n OR RECEIVED - At 12:08 PM\n ARTERIAL LINE - STOP 12:45 PM\n Post operative day:\n POD#1 - L brachial arteriogram\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 PM\n Ciprofloxacin - 10:23 PM\n Metronidazole - 07:00 AM\n Infusions:\n Fentanyl - 55 mcg/hour\n Insulin - Regular - 3 units/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Fentanyl - 03:29 PM\n Famotidine (Pepcid) - 06:10 PM\n Haloperidol (Haldol) - 08:17 PM\n Insulin - Regular - 05:58 AM\n Hydralazine - 06:45 AM\n Other medications:\n Flowsheet Data as of 09:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37\nC (98.6\n HR: 94 (77 - 108) bpm\n BP: 154/69(88) {121/54(63) - 167/75(94)} mmHg\n RR: 19 (13 - 28) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 0 (-1 - 16) mmHg\n Total In:\n 7,319 mL\n 1,599 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 7,199 mL\n 1,499 mL\n Blood products:\n Total out:\n 5,105 mL\n 790 mL\n Urine:\n 4,655 mL\n 790 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,214 mL\n 809 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (RLE: No movement)\n Labs / Radiology\n 142 K/uL\n 10.2 g/dL\n 310 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 25 mg/dL\n 100 mEq/L\n 137 mEq/L\n 30.9 %\n 9.0 K/uL\n [image002.jpg]\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n 09:34 AM\n 04:30 AM\n 01:15 PM\n 03:04 AM\n WBC\n 13.9\n 12.7\n 9.0\n Hct\n 30.6\n 30.2\n 30.8\n 28.4\n 30.9\n Plt\n 121\n 113\n 139\n 142\n Creatinine\n 2.2\n 1.9\n 1.8\n 1.4\n 1.4\n 1.7\n TCO2\n 28\n 26\n 24\n 22\n Glucose\n 189\n 105\n 106\n 128\n 310\n Other labs: PT / PTT / INR:12.3/67.5/1.0, CK / CK-MB / Troponin\n T:2665/17/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:8.6 mg/dL, Mg:2.0 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ACUTE CONFUSION, HYPERGLYCEMIA, HYPERTENSION, BENIGN, PERIPHERAL\n VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA,\n .H/O DIABETES MELLITUS (DM), TYPE I\n Assessment and Plan: Continues to have ischemic right foot. Angio\n yesterday showed no treatable lesion\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, D/C fentanyl\n infusion. P/O pain meds\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: OOB and CPT\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Allow diet\n Renal: Foley, Adequate UO, Continue IVF\n Hematology:\n Endocrine: Insulin drip, Start Lantis\n Infectious Disease: Check cultures, No evidence of infection. D/C abx\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CXR today\n Fluids: LR, 125 cc/hr\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op complication\n ICU Care\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n"
},
{
"category": "Physician ",
"chartdate": "2184-02-09 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 369860,
"text": "CVICU\n HPI:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration, ? sepsis\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40 daily, Plavix 75 daily (held), Zemplar 1mcg\n daily, Lantus 32U daily, Cialis 20mg every three days, Humalog\n SS, Bactrim 80-400 M-W-F, ASA 325 daily (held), Lisinopril 20\n daily, Fosamax 70 qweek, Prednisone 5 daily, Metoprolol 100 BD,\n Percocet prn, Amlodipine 10 daily, Gabapentin 10 daily, Prograf\n 4mg \n PMHx:\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n Current medications:\n Tacrolimmus, Prednisone, Zosyn, Flagyl, Ciprofloxcin, Famotidine,\n Metoprolol, NTG, Midazolam\n 24 Hour Events:\n OR RECEIVED - At 11:25 AM\n ARTERIAL LINE - START 11:45 AM\n EKG - At 05:30 PM\n post-op\n Post operative day:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:15 AM\n Ciprofloxacin - 10:30 PM\n Metronidazole - 06:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 850 units/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:00 PM\n Insulin - Regular - 04:25 AM\n Metoprolol - 06:00 AM\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.9\nC (98.4\n HR: 79 (69 - 96) bpm\n BP: 113/51(70) {104/46(65) - 169/73(109)} mmHg\n RR: 16 (12 - 19) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 5 (5 - 13) mmHg\n Total In:\n 10,625 mL\n 1,580 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,965 mL\n 1,580 mL\n Blood products:\n 600 mL\n Total out:\n 3,895 mL\n 1,000 mL\n Urine:\n 1,915 mL\n 900 mL\n NG:\n 920 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 6,730 mL\n 580 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/42/147/23/-2\n Ve: 8.5 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: No acute distress, intubated-sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, no bowel sounds\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: fasciotomies bilatat. left groin incision CDI\n Neurologic: (Responds to: Unresponsive), Sedated, on propofol and\n fentanyl will lighten sedation today\n Labs / Radiology\n 113 K/uL\n 10.4 g/dL\n 105 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 112 mEq/L\n 144 mEq/L\n 30.8 %\n 13.9 K/uL\n [image002.jpg]\n 09:20 AM\n 10:34 AM\n 11:45 AM\n 11:48 AM\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n WBC\n 15.4\n 13.9\n Hct\n 33\n 35\n 31.5\n 30.6\n 30.2\n 30.8\n Plt\n 122\n 121\n 113\n Creatinine\n 2.2\n 2.2\n 1.9\n 1.8\n TCO2\n 25\n 25\n 25\n 28\n 26\n 24\n Glucose\n 127\n 157\n 190\n 189\n 105\n Other labs: PT / PTT / INR:11.5/50.8/1.0, CK / CK-MB / Troponin\n T:2983/3/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL\n LIMB ISCHEMIA, .H/O DIABETES MELLITUS (DM), TYPE I\n Assessment and Plan: 50yoM s/p bilat thrombectomies and fasciotomies,\n now POD1 hemodynamically stable. CK's remain elevated/creatinine\n trending down. Will lighten sedation and wean ventilator as tolerated\n today\n Neurologic: NOw sedated with propofol and fentanyl, will lighten\n sedation to assess neuro status and pain level today. Stop prpofol\n continue fentanyl and titirate to control pain\n Cardiovascular: Beta-blocker, start ASA and statin, hold Plavix until\n decision about amputation. Heparin titrate to target PTT 60-80\n Pulmonary: Spontaneous breathing trial, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen:\n Nutrition: NPO, pending extubation trial\n Renal: Foley, Adequate UO, follow creatinine, tacrolimus levels.\n Renally dose all medication\n Hematology: stable hct\n Endocrine: Insulin drip\n Infectious Disease: Sputum with 3+GNR, 2+ yeast, 2+ GPC\n urine-negative\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: bilat fasciotomies with dressings\n Left groin wound dressing-CDI\n Imaging: CXR with small left effusion. ETT good placement\n Fluids: Currently NS will change to LR given elevated chloride.\n Check and replete electrolyes this AM and PM\n Consults: Vascular surgery, CT surgery, Nephrology\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:16 PM\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Arterial Line - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2184-02-09 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 369861,
"text": "CVICU\n HPI:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration, ? sepsis\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40 daily, Plavix 75 daily (held), Zemplar 1mcg\n daily, Lantus 32U daily, Cialis 20mg every three days, Humalog\n SS, Bactrim 80-400 M-W-F, ASA 325 daily (held), Lisinopril 20\n daily, Fosamax 70 qweek, Prednisone 5 daily, Metoprolol 100 BD,\n Percocet prn, Amlodipine 10 daily, Gabapentin 10 daily, Prograf\n 4mg \n PMHx:\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n Current medications:\n Tacrolimmus, Prednisone, Zosyn, Flagyl, Ciprofloxcin, Famotidine,\n Metoprolol, NTG, Midazolam\n 24 Hour Events:\n OR RECEIVED - At 11:25 AM\n ARTERIAL LINE - START 11:45 AM\n EKG - At 05:30 PM\n post-op\n Post operative day:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:15 AM\n Ciprofloxacin - 10:30 PM\n Metronidazole - 06:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 850 units/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:00 PM\n Insulin - Regular - 04:25 AM\n Metoprolol - 06:00 AM\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.9\nC (98.4\n HR: 79 (69 - 96) bpm\n BP: 113/51(70) {104/46(65) - 169/73(109)} mmHg\n RR: 16 (12 - 19) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 5 (5 - 13) mmHg\n Total In:\n 10,625 mL\n 1,580 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,965 mL\n 1,580 mL\n Blood products:\n 600 mL\n Total out:\n 3,895 mL\n 1,000 mL\n Urine:\n 1,915 mL\n 900 mL\n NG:\n 920 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 6,730 mL\n 580 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/42/147/23/-2\n Ve: 8.5 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: No acute distress, intubated-sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, no bowel sounds\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: fasciotomies bilatat. left groin incision CDI\n Neurologic: (Responds to: Unresponsive), Sedated, on propofol and\n fentanyl will lighten sedation today\n Labs / Radiology\n 113 K/uL\n 10.4 g/dL\n 105 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 112 mEq/L\n 144 mEq/L\n 30.8 %\n 13.9 K/uL\n [image002.jpg]\n 09:20 AM\n 10:34 AM\n 11:45 AM\n 11:48 AM\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n WBC\n 15.4\n 13.9\n Hct\n 33\n 35\n 31.5\n 30.6\n 30.2\n 30.8\n Plt\n 122\n 121\n 113\n Creatinine\n 2.2\n 2.2\n 1.9\n 1.8\n TCO2\n 25\n 25\n 25\n 28\n 26\n 24\n Glucose\n 127\n 157\n 190\n 189\n 105\n Other labs: PT / PTT / INR:11.5/50.8/1.0, CK / CK-MB / Troponin\n T:2983/3/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL\n LIMB ISCHEMIA, .H/O DIABETES MELLITUS (DM), TYPE I\n Assessment and Plan: 50yoM s/p bilat thrombectomies and fasciotomies,\n now POD1 hemodynamically stable. CK's remain elevated/creatinine\n trending down. Will lighten sedation and wean ventilator as tolerated\n today\n Neurologic: NOw sedated with propofol and fentanyl, will lighten\n sedation to assess neuro status and pain level today. Stop prpofol\n continue fentanyl and titirate to control pain\n Cardiovascular: Beta-blocker, start ASA and statin, hold Plavix until\n decision about amputation. Heparin titrate to target PTT 60-80\n Pulmonary: Spontaneous breathing trial, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen:\n Nutrition: NPO, pending extubation trial\n Renal: Foley, Adequate UO, follow creatinine, tacrolimus levels.\n Renally dose all medication\n Hematology: stable hct\n Endocrine: Insulin drip\n Infectious Disease: Sputum with 3+GNR, 2+ yeast, 2+ GPC\n urine-negative\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: bilat fasciotomies with dressings\n Left groin wound dressing-CDI\n Imaging: CXR with small left effusion. ETT good placement\n Fluids: Currently NS will change to LR given elevated chloride.\n Check and replete electrolyes this AM and PM\n Consults: Vascular surgery, CT surgery, Nephrology\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:16 PM\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Arterial Line - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2184-02-09 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 369862,
"text": "CVICU\n HPI:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration, ? sepsis\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40 daily, Plavix 75 daily (held), Zemplar 1mcg\n daily, Lantus 32U daily, Cialis 20mg every three days, Humalog\n SS, Bactrim 80-400 M-W-F, ASA 325 daily (held), Lisinopril 20\n daily, Fosamax 70 qweek, Prednisone 5 daily, Metoprolol 100 BD,\n Percocet prn, Amlodipine 10 daily, Gabapentin 10 daily, Prograf\n 4mg \n PMHx:\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n Current medications:\n Tacrolimmus, Prednisone, Zosyn, Flagyl, Ciprofloxcin, Famotidine,\n Metoprolol, NTG, Midazolam\n 24 Hour Events:\n OR RECEIVED - At 11:25 AM\n ARTERIAL LINE - START 11:45 AM\n EKG - At 05:30 PM\n post-op\n Post operative day:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:15 AM\n Ciprofloxacin - 10:30 PM\n Metronidazole - 06:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 850 units/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:00 PM\n Insulin - Regular - 04:25 AM\n Metoprolol - 06:00 AM\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.9\nC (98.4\n HR: 79 (69 - 96) bpm\n BP: 113/51(70) {104/46(65) - 169/73(109)} mmHg\n RR: 16 (12 - 19) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 5 (5 - 13) mmHg\n Total In:\n 10,625 mL\n 1,580 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,965 mL\n 1,580 mL\n Blood products:\n 600 mL\n Total out:\n 3,895 mL\n 1,000 mL\n Urine:\n 1,915 mL\n 900 mL\n NG:\n 920 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 6,730 mL\n 580 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/42/147/23/-2\n Ve: 8.5 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: No acute distress, intubated-sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, no bowel sounds\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: fasciotomies bilatat. left groin incision CDI\n Neurologic: (Responds to: Unresponsive), Sedated, on propofol and\n fentanyl will lighten sedation today\n Labs / Radiology\n 113 K/uL\n 10.4 g/dL\n 105 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 112 mEq/L\n 144 mEq/L\n 30.8 %\n 13.9 K/uL\n 09:20 AM\n 10:34 AM\n 11:45 AM\n 11:48 AM\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n WBC\n 15.4\n 13.9\n Hct\n 33\n 35\n 31.5\n 30.6\n 30.2\n 30.8\n Plt\n 122\n 121\n 113\n Creatinine\n 2.2\n 2.2\n 1.9\n 1.8\n TCO2\n 25\n 25\n 25\n 28\n 26\n 24\n Glucose\n 127\n 157\n 190\n 189\n 105\n Other labs: PT / PTT / INR:11.5/50.8/1.0, CK / CK-MB / Troponin\n T:2983/3/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL\n LIMB ISCHEMIA, .H/O DIABETES MELLITUS (DM), TYPE I\n Assessment and Plan: 50yoM s/p bilat thrombectomies and fasciotomies,\n now POD1 hemodynamically stable. CK's remain elevated/creatinine\n trending down. Will lighten sedation and wean ventilator as tolerated\n today\n Neurologic: NOw sedated with propofol and fentanyl, will lighten\n sedation to assess neuro status and pain level today. Stop prpofol\n continue fentanyl and titirate to control pain\n Cardiovascular: Beta-blocker, start ASA and statin, hold Plavix until\n decision about amputation. Heparin titrate to target PTT 60-80\n Pulmonary: Spontaneous breathing trial, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen:\n Nutrition: NPO, pending extubation trial\n Renal: Foley, Adequate UO, follow creatinine, tacrolimus levels.\n Renally dose all medication\n Hematology: stable hct\n Endocrine: Insulin drip\n Infectious Disease: Sputum with 3+GNR, 2+ yeast, 2+ GPC\n urine-negative\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: bilat fasciotomies with dressings\n Left groin wound dressing-CDI\n Imaging: CXR with small left effusion. ETT good placement\n Fluids: Currently NS will change to LR given elevated chloride.\n Check and replete electrolyes this AM and PM\n Consults: Vascular surgery, CT surgery, Nephrology\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:16 PM\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Arterial Line - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2184-02-09 00:00:00.000",
"description": "Generic Note",
"row_id": 369863,
"text": "TITLE: Intensivist Daily Note\n CVICU\n HPI:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration, ? sepsis\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40 daily, Plavix 75 daily (held), Zemplar 1mcg\n daily, Lantus 32U daily, Cialis 20mg every three days, Humalog\n SS, Bactrim 80-400 M-W-F, ASA 325 daily (held), Lisinopril 20\n daily, Fosamax 70 qweek, Prednisone 5 daily, Metoprolol 100 BD,\n Percocet prn, Amlodipine 10 daily, Gabapentin 10 daily, Prograf\n 4mg \n PMHx:\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABG x 3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n Current medications:\n Tacrolimmus, Prednisone, Zosyn, Flagyl, Ciprofloxcin, Famotidine,\n Metoprolol, NTG, Midazolam\n 24 Hour Events:\n OR RECEIVED - At 11:25 AM\n ARTERIAL LINE - START 11:45 AM\n EKG - At 05:30 PM\n post-op\n Post operative day:\n POD#1\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:15 AM\n Ciprofloxacin - 10:30 PM\n Metronidazole - 06:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 850 units/hour\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 05:00 PM\n Insulin - Regular - 04:25 AM\n Metoprolol - 06:00 AM\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.9\nC (98.4\n HR: 79 (69 - 96) bpm\n BP: 113/51(70) {104/46(65) - 169/73(109)} mmHg\n RR: 16 (12 - 19) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 5 (5 - 13) mmHg\n Total In:\n 10,625 mL\n 1,580 mL\n PO:\n Tube feeding:\n IV Fluid:\n 9,965 mL\n 1,580 mL\n Blood products:\n 600 mL\n Total out:\n 3,895 mL\n 1,000 mL\n Urine:\n 1,915 mL\n 900 mL\n NG:\n 920 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n 6,730 mL\n 580 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 24 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/42/147/23/-2\n Ve: 8.5 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: No acute distress, intubated-sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, no bowel sounds\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Skin: fasciotomies bilatat. left groin incision CDI\n Neurologic: (Responds to: Unresponsive), Sedated, on propofol and\n fentanyl will lighten sedation today\n Labs / Radiology\n 113 K/uL\n 10.4 g/dL\n 105 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 35 mg/dL\n 112 mEq/L\n 144 mEq/L\n 30.8 %\n 13.9 K/uL\n [image002.jpg]\n 09:20 AM\n 10:34 AM\n 11:45 AM\n 11:48 AM\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n WBC\n 15.4\n 13.9\n Hct\n 33\n 35\n 31.5\n 30.6\n 30.2\n 30.8\n Plt\n 122\n 121\n 113\n Creatinine\n 2.2\n 2.2\n 1.9\n 1.8\n TCO2\n 25\n 25\n 25\n 28\n 26\n 24\n Glucose\n 127\n 157\n 190\n 189\n 105\n Other labs: PT / PTT / INR:11.5/50.8/1.0, CK / CK-MB / Troponin\n T:2983/3/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL\n LIMB ISCHEMIA, .H/O DIABETES MELLITUS (DM), TYPE I\n Assessment and Plan: 50yoM s/p bilat thrombectomies and fasciotomies,\n now POD1 hemodynamically stable. CK's remain elevated/creatinine\n trending down. Will lighten sedation and wean ventilator as tolerated\n today\n Neurologic: NOw sedated with propofol and fentanyl, will lighten\n sedation to assess neuro status and pain level today. Stop prpofol\n continue fentanyl and titirate to control pain\n Cardiovascular: Beta-blocker, start ASA and statin, hold Plavix until\n decision about amputation. Heparin titrate to target PTT 60-80\n Pulmonary: Spontaneous breathing trial, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen:\n Nutrition: NPO, pending extubation trial\n Renal: Foley, Adequate UO, follow creatinine, tacrolimus levels.\n Renally dose all medication\n Hematology: stable hct\n Endocrine: Insulin drip\n Infectious Disease: Sputum with 3+GNR, 2+ yeast, 2+ GPC\n urine-negative\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: bilat fasciotomies with dressings\n Left groin wound dressing-CDI\n Imaging: CXR with small left effusion. ETT good placement\n Fluids: Currently NS will change to LR given elevated chloride.\n Check and replete electrolyes this AM and PM\n Consults: Vascular surgery, CT surgery, Nephrology\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:16 PM\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Arterial Line - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Billing diagnosis- Acute Renal Failure. Acute Respiratory Failure\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369956,
"text": "50y/o M. S/p#2 Bilateral Lower extremities Thrombectomies &\n Fasciotomies ()\n Afebrile. MAE\ns. Somewhat lethargic, easily arousable this evening.\n Frequent RN supervision. Bouts of agitation and stated frustration,\n Haldol 1-2mg IV administered with good effect. Reassurances given. LSC\n bilaterally. RA sats 97-100%. SR 70-80, SBP 140-170mmHg; Lopressor and\n Hydralazine IV with mild effect. LR200cc/hr. Heparin gtt to\n 1400units/hr. Fentanyl 100mcg/hr. 0000hr IVF to 100cc/hr and added\n Sodium bicarb at 100cc/hr. Insulin gtt started due to an increase in\n FSBS (secondary to IVF-D5 based solutions). Doppler pulses L-foot.\n R-foot PP absent, foot is cold to touch. Hypoactive BS 4Q\ns. Foley\n catheter draining clear yellow urine. Good diuresis 300-400cc/hr.\n Family updated this HS by phone.\n Scheduled for Angiogram R-LE and tentative thrombectomy in the same\n extremity this am on \n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n No doplerable pulses R- foot, cold to touch. L-foot pink and warm,\n Doppler pulses DP/PT .+CSM bilateral LE. Bilateral LE fasciotomy DSD\n CDI.\n Action:\n Legs elevated on pillows. Multipodus boots. PP check Q1hr. Heparin\n gtt increased at HS. PTT 40-50sec.\n Response:\n R-Foot remains cold to touch. MD notified and aware.\n Plan:\n Continue to monitor. Mucomist via NG prep for angiogram this am\n Hyperglycemia\n Assessment:\n FSBS >120mgdL with D5 IV solutions\n Action:\n Insulin gtt per CVICU protocol\n Response:\n Good glycemic control attained\n Plan:\n Continue to monitor for FSBS\n Hypertension, benign\n Assessment:\n SBP>160mmHg\n Action:\n Lopressor 5mg IV increased to Q4hr. hydralazine IV.\n Response:\n Remains hypertensive 150-160mmHg\n Plan:\n Continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Bilateral LE pain\n Action:\n Fentanyl gtt @100mcg/hr\n Response:\n Tolerable pain at rest; bolus IV needed for change of position,\n hygiene.\n Plan:\n Continue to assess and monitor for acute changes\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370082,
"text": "50 M with B/L occluded bypass grafts, severe dehydration\n POD 3\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABGx3 ', Living related kidney transplant complicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370083,
"text": "50 M with B/L occluded bypass grafts, severe dehydration\n POD 3\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABGx3 ', Living related kidney transplant complicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n Hyperglycemia\n Assessment:\n increased FSBS >120mgdL due to d5 IV based solutions\n Action:\n Restarted Insulin gtt and titrated rate and administered bolus doses\n according to CVICU protocol.\n D/c IV Antibiotics\n Lantus Insulin 20units SC administered\n Diet advanced\n Response:\n FSBS <120mgdL\n Plan:\n Continue monitoring FSBS. Encourage PO intake\n Hypertension, benign\n Assessment:\n SBP 150-180mmHg\n Action:\n Lopressor 50mg PO BID\n Administered IV Hydralazine PRN\n Pain control\n Response:\n BP decreased to 130-140\ns range\n Plan:\n Continue to monitor SBP\n Pain control (acute pain, chronic pain)\n Assessment:\n Stated incisional pain R-L LE\n Action:\n Patient receiving IV Fentanly at 55mcgl for leg pain this am\n Percocet PO for breakthrough pain.\n Bolus IV fentanyl for Dressing changes\n Response:\n Rated pain tolerable.\n Plan:\n Continue to assess and document accordingly\n Acute Confusion\n Assessment:\n Oriented x2. Anxious and could become impulsive/belligerent at times\n Action:\n Notified team concerning these issues.\n Reassurances given\n Frequent Rn supervision/support\n Haldol IV PRN\n Response:\n Patient fell asleep after PO dose of Percocet.\n Calm and cooperative\n Plan:\n Continue to reorient patient to time, place and events surrounding\n hospitalization\n Bed alarm on and side rails up\n Conceal IV\n Demographics\n Attending MD:\n L.\n Admit diagnosis:\n ISCHEMIC LEGS\n Code status:\n Full code\n Height:\n Admission weight:\n 75 kg\n Daily weight:\n 85.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin, Renal Failure\n CV-PMH: CAD, Hypertension, MI, PVD\n Additional history: GERD,Transplant pancreatectomy for peritonitis\n (unsuccessful-still using insulin) ,Left fem-AT bypass ,Left\n fem- bypass ,Right fem- bypass ,Left carotid\n endarterectomy Cadaveric pancreas transplant ,Living related\n kidney transplant ,Toe amputation. Left eye cataract extraction.\n CABG .Left carotid endo\n Surgery / Procedure and date: OR: Bilateral Lower Extremity\n thrombectomy,Bilateral fasciotomies and Angiogram. Cut down on right\n leg.Arrives on Propofol. Aline placed in OR. Was arleady intubated\n before OR. 3.5 L Fluids and 2 units RBC given. No issues.Regained\n doppler pulses(DP) on left foot. No pulses on right foot. Right foot\n cyanotic and cold. Patient had hit his middle toe on right foot\n (echymotic on arrival).\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:133\n D:110\n Temperature:\n 98\n Arterial BP:\n S:180\n D:68\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 97 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,812 mL\n 24h total out:\n 1,400 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 03:04 AM\n Potassium:\n 3.9 mEq/L\n 03:04 AM\n Chloride:\n 100 mEq/L\n 03:04 AM\n CO2:\n 22 mEq/L\n 03:04 AM\n BUN:\n 25 mg/dL\n 03:04 AM\n Creatinine:\n 1.7 mg/dL\n 03:04 AM\n Glucose:\n 310 mg/dL\n 03:04 AM\n Hematocrit:\n 30.9 %\n 03:04 AM\n Finger Stick Glucose:\n 73\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: VICU\n Date & time of Transfer: 1545hr\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369759,
"text": "Ekg st to 115, no ectopy, 5 mg Lopressor given at 2400, rate down to\n 90s, no effect on sbp. 1000cc ns bolus given before dose to see if\n tachycardia were volume related, with slight drop to 107. cvp up from\n 7 to 12 with volume. Sbp stable unless light, then htn to 160s.\n adeq uo, urinalysis and culture sent, creat 3.3 on adm, now 2.8.\n Temp 101.2, spont dropped to 98.8. glucose managed per protocol, see\n flow sheet for details. K up to 6.0, responded to bicarb and insulin,\n now 4.2. ca and mg repleted. Breath sounds clear, scant white\n secretions suctioned from ett, sputum culture sent. Abgs acceptable,\n fio2 and peep weaned by resp rx. Abd soft, faint to no bowel sounds\n heard. Ogt to lws, 200cc pale green drainage. Feet cold and mottled\n bilat. Palpable fem pulses bilat, popilteal pulses present by Doppler\n bilat. Dp and pt pulses absent bilat. Sedated with propofol, with\n fent gtt for comfort. Responds to voice, opens eyes to command and\n follows other commands inconsistently, have seen all extremities move\n both to command and spont. Pupils 2-3mm, brisk. Skin is intact on\n back and buttocks, heel. Has purple middle toe which he stubbed last\n week, according to mother\n"
},
{
"category": "Respiratory ",
"chartdate": "2184-02-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 369844,
"text": "Demographics\n Day of intubation: \n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370050,
"text": "Hyperglycemia\n Assessment:\n FS increased to 400\ns after patient received 3 IV antibiotics mixed in\n D5W\n Action:\n Restarted Insulin gtt and titrated rate and administered bolus doses\n according to hourly FS per unit protocol.\n Response:\n FS decreased <250\n Plan:\n Continue insulin gtt and check hourly FS\n Hypertension, benign\n Assessment:\n SBP increased 160\ns from 140\ns after patient received po Lopressor 50mg\n Action:\n Administered IV Hydralazine\n Response:\n BP decreased to 120-s-130\ns at rest\n With exertion and moaning due to leg pain, BP increased 150\n Plan:\n Tx hypertensive BP with IV Hydralazine \n Pain control (acute pain, chronic pain)\n Assessment:\n Patient frequently moaning out loud due to bilateral leg pain and\n unable to score pain due to confusion\n Action:\n Patient receiving IV Fentanly at 55mcgl for leg pain\n Response:\n Patient continues to moan and c/o leg pain\n Plan:\n Titrate IV Fentanyl to reduce leg pain\n Acute Confusion\n Assessment:\n At onset of shift, patient was not oriented to time/place.\n He was combative, verbally abusive towards the staff and uncooperative\n with patient care\n Action:\n Notified team concerning confusion. Tx patient with IV Haldol x2 doses.\n Response:\n Patient fell asleep. Later during the shift, he became more cooperative\n and pleasant. But he remains disoriented to time and place. He does not\n remember having surgery\n Plan:\n Continue to reorient patient to time, place and events surrounding\n hospitalization\n Bed alarm on and side rails up\n Conceal IV\n"
},
{
"category": "Physician ",
"chartdate": "2184-02-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 370061,
"text": "CVICU\n HPI:\n POD 3\n s/p (B)LE Thrombectomies/(B)LE Fasciotomies-\n 50 M with B/L occluded bypass grafts, severe dehydration,\n PMH: HTN, DM, GERD, OA, gastroparesis, PVD\n PSH: CABGx3 ', Living related kidney transplant coplicated by\n wound exploration ', Cadaveric pancreas transplant ', L CEA\n ' (), Right common femoral artery to above-knee\n popliteal artery bypass graft with 8 mm ringed PTFE ', Right\n second toe amputation ', cataracts ', R wrist ', Left\n common femoral artery to above-knee popliteal artery bypass graft\n with 8-mm ringed PTFE ', Repair of incisional hernia ', L\n fem-AT bypass with PTFE graft , pancreas explant ',\n vitrectomy '\n : Lipitor 40', Plavix 75', Zemplar 1mcg QD, Lantus 32U qd, Cialis\n 20mg Q3days, Humalog SS, Bactrim 80-400 M-W-F, ASA 325', Lisinopril\n 20', Fosamax 70 qwk, Prednisone 5', Metoprolol 100\", Percocet prn,\n Amlodipine 10', Gabapentin 10', Prograf 4\"\n Chief complaint:\n PMHx:\n Current medications:\n 1. 1000 mL LR 3. Acetylcysteine 20% 4. Aspirin 5. Atorvastatin 6.\n Calcium Gluconate 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8.\n Ciprofloxacin 9. Famotidine 10. Fentanyl Citrate 11. Haloperidol 12.\n Heparin 13. HydrALAzine 14. Influenza Virus Vaccine 15. Insulin 16.\n Magnesium Sulfate 17. MetRONIDAZOLE (FLagyl) 18. Metoprolol Tartrate\n 19. Midazolam 20. Potassium Chloride 21. PredniSONE\n 22. Tacrolimus 23. Vancomycin\n 24 Hour Events:\n OR SENT - At 10:15 AM\n OR RECEIVED - At 12:08 PM\n ARTERIAL LINE - STOP 12:45 PM\n Post operative day:\n POD#1 - L brachial arteriogram\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 PM\n Ciprofloxacin - 10:23 PM\n Metronidazole - 07:00 AM\n Infusions:\n Fentanyl - 55 mcg/hour\n Insulin - Regular - 3 units/hour\n Heparin Sodium - 1,500 units/hour\n Other ICU medications:\n Fentanyl - 03:29 PM\n Famotidine (Pepcid) - 06:10 PM\n Haloperidol (Haldol) - 08:17 PM\n Insulin - Regular - 05:58 AM\n Hydralazine - 06:45 AM\n Other medications:\n Flowsheet Data as of 09:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37\nC (98.6\n HR: 94 (77 - 108) bpm\n BP: 154/69(88) {121/54(63) - 167/75(94)} mmHg\n RR: 19 (13 - 28) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 85.3 kg (admission): 75 kg\n CVP: 0 (-1 - 16) mmHg\n Total In:\n 7,319 mL\n 1,599 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 7,199 mL\n 1,499 mL\n Blood products:\n Total out:\n 5,105 mL\n 790 mL\n Urine:\n 4,655 mL\n 790 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,214 mL\n 809 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -\n Dorsalis pedis: Absent), (Pulse - Posterior tibial: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (RLE: No movement)\n Labs / Radiology\n 142 K/uL\n 10.2 g/dL\n 310 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 25 mg/dL\n 100 mEq/L\n 137 mEq/L\n 30.9 %\n 9.0 K/uL\n [image002.jpg]\n 02:53 PM\n 03:04 PM\n 08:25 PM\n 08:44 PM\n 03:10 AM\n 03:15 AM\n 09:34 AM\n 04:30 AM\n 01:15 PM\n 03:04 AM\n WBC\n 13.9\n 12.7\n 9.0\n Hct\n 30.6\n 30.2\n 30.8\n 28.4\n 30.9\n Plt\n 121\n 113\n 139\n 142\n Creatinine\n 2.2\n 1.9\n 1.8\n 1.4\n 1.4\n 1.7\n TCO2\n 28\n 26\n 24\n 22\n Glucose\n 189\n 105\n 106\n 128\n 310\n Other labs: PT / PTT / INR:12.3/67.5/1.0, CK / CK-MB / Troponin\n T:2665/17/<0.01, ALT / AST:34/39, Alk-Phos / T bili:52/0.9, Amylase /\n Lipase:68/7, Lactic Acid:1.3 mmol/L, Albumin:3.5 g/dL, LDH:229 IU/L,\n Ca:8.6 mg/dL, Mg:2.0 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ACUTE CONFUSION, HYPERGLYCEMIA, HYPERTENSION, BENIGN, PERIPHERAL\n VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA, PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n .H/O PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA,\n .H/O DIABETES MELLITUS (DM), TYPE I\n Assessment and Plan: Continues to have ischemic right foot. Angio\n yesterday showed no treatable lesion\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, D/C fentanyl\n infusion. P/O pain meds\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: OOB and CPT\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Allow diet\n Renal: Foley, Adequate UO, Continue IVF\n Hematology:\n Endocrine: Insulin drip, Start Lantis\n Infectious Disease: Check cultures, No evidence of infection. D/C abx\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CXR today\n Fluids: LR, 125 cc/hr\n Consults: Vascular surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op complication\n ICU Care\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 05:16 PM\n Multi Lumen - 07:34 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370049,
"text": "Hyperglycemia\n Assessment:\n FS increased to 400\ns after patient received 3 IV antibiotics mixed in\n D5W\n Action:\n Restarted Insulin gtt and titrated rate and administered bolus doses\n according to hourly FS per unit protocol.\n Response:\n FS decreased <250\n Plan:\n Continue insulin gtt and check hourly FS\n Hypertension, benign\n Assessment:\n SBP increased 160\ns from 140\ns after patient received po Lopressor 50mg\n Action:\n Administered IV Hydralazine\n Response:\n BP decreased to 120-s-130\ns at rest\n With exertion and moaning due to leg pain, BP increased 150\n Plan:\n Tx hypertensive BP with IV Hydralazine \n Pain control (acute pain, chronic pain)\n Assessment:\n Patient frequently moaning out loud due to bilateral leg pain and\n unable to score pain due to confusion\n Action:\n Patient receiving IV Fentanly at 55mcgl for leg pain\n Response:\n Patient continues to moan and c/o leg pain\n Plan:\n Titrate IV Fentanyl to reduce leg pain\n Acute Confusion\n Assessment:\n At onset of shift, patient was not oriented to time/place.\n He was combative, verbally abusive towards the staff and uncooperative\n with patient care\n Action:\n Notified team concerning confusion. Tx patient with IV Haldol x2 doses.\n Response:\n Patient fell asleep. Later during the shift, he became more cooperative\n and pleasant. But he remains disoriented to time and place. He does not\n remember having surgery\n Plan:\n Continue to reorient patient to time, place and events surrounding\n hospitalization\n Bed alarm on and side rails up\n Conceal IV\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370043,
"text": "Hyperglycemia\n Assessment:\n FS increased to 400\ns after patient received 3 IV antibiotics mixed in\n D5W\n Action:\n Restarted Insulin gtt and titrated rate and administered bolus doses\n according to hourly FS per unit protocol.\n Response:\n FS decreased <250\n Plan:\n Continue insulin gtt and check hourly FS\n Hypertension, benign\n Assessment:\n SBP increased 160\ns from 140\ns after patient received po Lopressor 50mg\n Action:\n Administered IV Hydralazine\n Response:\n BP decreased to 120-s-130\ns at rest\n With exertion and moaning due to leg pain, BP increased 150\n Plan:\n Tx hypertensive BP with IV Hydralazine \n Pain control (acute pain, chronic pain)\n Assessment:\n Patient frequently moaning out loud due to bilateral leg pain and\n unable to score pain due to confusion\n Action:\n Patient receiving IV Fentanly at 55mcgl for leg pain\n Response:\n Patient continues to moan and c/o leg pain\n Plan:\n Titrate IV Fentanyl to reduce leg pain\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369839,
"text": "Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Right foot continues cold, mottled, pulseles with Doppler popliteal and\n palp fem. left foot with Doppler dp and pt, popliteal and palp fem,\n warm and pinker. Dressings on fasciotomy sites intact, little new\n drainage.\n Action:\n Venodyne boot ordered for right leg, but left off per vasc resident.\n Multipodus splints on. Heparin gtt continued at 750 units, goal 60-80.\n Response:\n Ptt 50.8, gtt increased to 850 units.\n Plan:\n Recheck ptt in 6 hr.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate uo, creat down to 1.8. k stable at 4.2\n Action:\n Response:\n Plan:\n Follow electrolytes and renal function indicators\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369741,
"text": ".H/O peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt admitted to CVICU for bilateral leg ischemia, on heparin drip (goal\n 60-80), prop for sedation, and maintenance fluid of NS at 125ml/hr; Pt\n sedated on prop, PERRLA, moves upper EXT, did not awaken; Intubated in\n ED as he became unresponsive, on CMV, 80%, 12 PEEP, rate 20, Vt 550ml,\n lung sounds clear; NSR in 90s, without ectopy, SBP >90, no pressors,\n R/L fem by Doppler, no pulses distal to femorals, cool/dusky lower\n EXTs, R foot appears worse than L foot; OGT to LCS, abd soft/nontender,\n hypo BS; Foley to gravity draining yellow/clear urine, creat 3.3; BG\n >300\n Action:\n Heparin drip for goal of 60-80, Prop for sedation, needs IV Access and\n Arterial line prior to ?OR for angiogram tonight; ?insulin drip\n Response:\n Last PTT was 111, plan to shut heparin drip off for 1 hr and restart at\n 800units/hr at , attempting to get invasive lines, needs insulin\n order\n Plan:\n Continue to monitor hemodynamics, urine outputs, needs invasive lines,\n continue heparin/prop drips, ?to OR for angiogram\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370028,
"text": "Hypertension, benign\n Assessment:\n Received pt this AM with SBP 150s. SR no ectopy, 70s-80s. On fentanyl\n gtt for pain.\n Action:\n Continued with fentanyl gtt. Received one dose IV lopressor and given\n 50 mg lopressor down NGT.\n Response:\n SBP down to 130s transiently. Bolus of IV fentanyl given. SBP 120-140\n this afternoon. Fentanyl at 50 mcg/hr via gtt.\n Plan:\n Next dose PO lopressor at . Pt taking Pos without difficulty. Wean\n fentanyl gtt off. ? change to oral pain meds.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n Pt to OR today for arteriogram and possible thrombectomy. R lower\n extremity remains cool and ashen in color with absent PT/DP pulses.\n Dopplerable pulses to LLE. Dopplerable popliteal pulses bilaterally.\n Given mucomyst 2 doses prior to a-gram. LR at 100 mL/hr changed to 125\n mL/hr post procedure. Bicarb gtt off 6 hrs post procedure. Moves LLE on\n bed. Very little movement of RLE noted. CKs trending down.\n Action:\n To OR for arteriogram. Tolerated well. No intervention done. L brachial\n approach. Heparin gtt restarted at 1400 at 1400 units/hr. Bilat\n fasciotomy dsgs changed this afternoon wet to dry. Given versed and\n fentanyl bolus pre dressing change.\n Response:\n Next ptt at 2200. Tolerated dsg change with minimal discomfort.\n Plan:\n Continue to monitor CSM in BLE. ? R BKA in future. Q8hr CKs. Continue\n IVF.\n Pain control (acute pain, chronic pain)\n Assessment:\n Fentanyl gtt at 100 mcg/hr. Pt moans and grimaces with turns.\n Action:\n Fentanyl bolus given pre dsg change and with activity. Gtt down to 50\n mcg/hr this afternoon.\n Response:\n Pt reports decrease in pain.\n Plan:\n Wean fentanyl gtt off and change to PO pain meds now that tolerating\n POs.\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369822,
"text": "\n OR @ 7:15 am . Already Intubated. Returns to CVICU @ 11:45am. Bilateral\n Thrombectomy Lower Ext, Bilateral fasciotomy and angiogram. Cut down\n done right leg. OR uneventful. 2 units of RBC given intra-op for EBL\n 600 ml. Arrives on profopol.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n OR today. Post-op: Doppler pulse on left foot (DP\ns only) but not on\n right foot. Boot feet cold and mottled, but right foot colder and paler\n compared to left. Right upper quadrant has moderate indurations\n mid-tie. (Side of cut down).MD aware. Hct stable 30.5. No ecchymosis or\n redness noted. Bil Palpable femoral pulses. Dressings reinforced once.\n BP down <110 syst with CVP 8-9.\n Action:\n Nitropast applied to both feet Q 6 hrs. Pulse checks Q1-2 hrs.\n Multipodus boots. Heel off bed. Heparin drip restarted @ 750 unit/hr.\n Fluids bolus given (Total 1.75 ml N/S). Insulin drip per protocol.\n Stopped to dropping BS.\n Response:\n Last PTT therapeutic (Goal 60-80). BP and CVP response well to fluids.\n Plan:\n PTT Q 6 hrs. BP goal 110-150 syst. Frequent pulse checks. Skin care.\n Monitor BS-IDD.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Admission BUN/Creat 57/3.8. Renal functions improve. Last BUN/ Creat\n 42/2.2. Good U/O (60-110 cc/hr). K stable. CVP 9-12. CPK rising as\n anticipated. (2200).\n Action:\n Fluids bolus for low BP. N/S @ 150 ml/hr maintenance.\n Response:\n Good response to fluids. Lactate WNL. Renal function continues to\n improve. Good U/O.\n Plan:\n Monitor U/O and renal functions closely. Monitor labs. Cycle CPK Q 8\n hrs.\n Pain control (acute pain, chronic pain)\n Assessment:\n VS and grimacing with turns.\n Action:\n Fentanyl drip and Propofol. Reposition Q 2 hrs.\n Response:\n VS stable without grimacing after interventions.\n Plan:\n Pain management. Reposition Q 2 hrs. Fentanyl for pain.\n"
},
{
"category": "Respiratory ",
"chartdate": "2184-02-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 369736,
"text": "Demographics\n Day of intubation: \n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: ? Procedure / OR\n later tonight to remove embolus form legs, Hemodynamic instability\n"
},
{
"category": "Nursing",
"chartdate": "2184-02-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 369820,
"text": " :\n OR @ 7:15 am . Already Intubated. Stable.but without pulses in both\n feet. Renal function improved since admission. Returns to CVICU @\n 11:45am. Bilateral Thrombectomy Lower Ext, Bilateral fasciotomy and\n angiogram. Cut down done right leg. OR uneventful. 2 units of RBC given\n intra-op for EBL 600 ml. Arrives on profopol.\n Peripheral vascular disease (PVD) with critical limb ischemia\n Assessment:\n OR today. Post-op: Doppler pulse on left foot (DP\ns only) but not on\n right foot. Boot feet cold and mottled, but right foot colder and paler\n compared to left. Right upper quadrant has moderate indurations\n mid-tie. (Side of cut down).MD aware. Hct stable 30.5. No ecchymosis or\n redness noted. Bil Palpable femoral pulses. Dressings reinforced once\n bil. BP down <110 syst with CVP 8-9.\n Action:\n Nitropast applied to both feet Q 6 hrs. Pulse checks Q1-2 hrs.\n Multipodus boots. Heel off bed. Heparin drip restarted @ 750 unit/hr.\n Fluids bolus given (Total 1.75 ml N/S). NS\n Response:\n Last PTT therapeutic. Goal 60-80.\n Plan:\n PTT Q 6 hrs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Admission BUN/Creat 57/3.8. Renal functions improve. Last BUN/ Creat\n 42/2.2. Good U/O (60-110 cc/hr). K stable. CVP 9-12. CPK rising as\n anticipated. (2200).\n Action:\n Fluids bolus 1.5 l given post-op for trending BP <110 syst and CVP 8-9.\n N/S @ 150 ml/hr\n Response:\n Good response to fluids. Lactate WNL.\n Plan:\n Monitor U/O and renal functions closely. Monitor labs. Cycle CPK Q 8\n hrs.\n Pain control (acute pain, chronic pain)\n Assessment:\n VS and grimacing with turns.\n Action:\n Fentanyl drip and propofol. Reposition Q 2 hrs.\n Response:\n VS stable without grimacing after interventions.\n Plan:\n Pain management. Reposition Q 2 hrs. Fentanyl for pain.\n"
},
{
"category": "ECG",
"chartdate": "2184-02-07 00:00:00.000",
"description": "Report",
"row_id": 134699,
"text": "Sinus tachycardia. Consider left atrial abnormality. Consider left\nventricular hypertrophy. ST-T wave abnormalities. Since the previous tracing\nof the heart rate has increased.\n\n"
},
{
"category": "ECG",
"chartdate": "2184-02-07 00:00:00.000",
"description": "Report",
"row_id": 134700,
"text": "Sinus rhythm. Non-specific inferior and lateral ST-T wave changes. Compared\nto the previous tracing of the findings are similar.\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1068972,
"text": " 8:08 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: assess placement of line\n Admitting Diagnosis: ISCHEMIC LEGS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p placement of RIJ CVL\n REASON FOR THIS EXAMINATION:\n assess placement of line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Status post placement of right IJ catheter.\n\n FINDINGS:\n\n Comparison is made to the prior study of the same day from 12:41 hours. Since\n that time, a right IJ catheter has been placed. The tip terminates at the\n superior vena cava. Endotracheal tube terminates at the thoracic inlet.\n Nasogastric tube courses below the diaphragm, but the tip is not seen.\n Nasogastric tube has also been placed since the prior study. The lungs are\n grossly clear. Cardiomediastinal silhouette is unremarkable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1068930,
"text": " 11:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with altered mental status after heparin drip started\n REASON FOR THIS EXAMINATION:\n ?bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AKSb SAT 1:20 PM\n No acute hemorrhage or other acute pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old with altered mental status after heparin drip\n started. Evaluate for bleed.\n\n No prior examinations.\n\n NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage.\n Periventricular hypoattenuation is worse on the right compared to the left,\n but likely related to chronic microvascular ischemic disease. No definite\n evidence of acute major vascular territorial infarction. Well-defined\n hypoattenuating linear area within the left cerebellar hemisphere is likely\n related to an old infarct (2:7). There are severe vascular calcifications\n within the cavernous carotid arteries and left vertebral artery. The lenses\n are absent. There is mild-to-moderate opacification of the ethmoidal air\n cells. The mastoid air cells are clear. The calvarium and soft tissues are\n unremarkable.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage.\n\n 2. Moderate chronic microvascular ischemic disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069037,
"text": " 1:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT/line position\n Admitting Diagnosis: ISCHEMIC LEGS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p (B)LE thrombectomy/fasciotomy\n REASON FOR THIS EXAMINATION:\n ETT/line position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Check endotracheal tube and line position, status post\n bilateral lower extremity thrombectomy and fasciotomy.\n\n FINDINGS:\n\n Comparison is made to the prior study from . Endotracheal tube is at\n the thoracic inlet in appropriate position. Nasogastric tube and right IJ\n catheter are also appropriately positioned. Heart is top normal in size.\n There is a small left pleural effusion. There is mild atelectasis at the left\n lung base. Right lung is relatively clear.\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-13 00:00:00.000",
"description": "ART DUP EXT LO UNI;F/U",
"row_id": 1070039,
"text": " 2:35 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: graft survillance on LEFT ONLY. Right is too painful to do a\n Admitting Diagnosis: ISCHEMIC LEGS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p Left common femoral artery to above-knee popliteal artery\n bypass graft with 8-mm ringed PTFE ' who had graft occlusion s/p\n thrombecctomy\n REASON FOR THIS EXAMINATION:\n graft survillance on LEFT ONLY. Right is too painful to do an ultrasound on\n ______________________________________________________________________________\n FINAL REPORT\n ARTERIAL STUDY DATED 27\n\n HISTORY: Left common femoral to above-knee popliteal bypass graft with PTFE\n in , status post thrombectomy, assess for patency.\n\n FINDINGS: The peak systolic velocity within the left common femoral artery is\n 238 cm/sec and that at the proximal graft anastomosis with this vessel, 154\n cm/sec. Graft velocities range from a minimum of 45 cm/sec to a maximum of 76\n cm/sec, the former occurring at the distal graft anastomosis with the native\n vessel. Peak systolic velocity within the native popliteal artery is 47\n cm/sec.\n\n All waveforms of note, are monophasic.\n\n IMPRESSION: Widely patent left common femoral to popliteal bypass graft.\n Monophasic waveforms indicate presence of some baseline underlying ischemia of\n the left lower extremity distal to the popliteal artery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1068929,
"text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with fever, hypotension\n REASON FOR THIS EXAMINATION:\n ?acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old male with fever and hypotension, evaluate for acute\n process.\n\n COMPARISON: .\n\n SINGLE AP VIEW OF THE CHEST: An endotracheal tube tip lies 5 cm from the\n carina. Median sternotomy wires appear grossly intact. The heart is mildly\n enlarged in size. There is mild fluid overload with patchy left retrocardiac\n and right infrahilar opacities, which could reflect areas of atelectasis.\n However, early infiltrate or aspiration cannot be excluded. No pleural\n effusion or pneumothorax is identified. A linear density projecting to the\n left of the thoracic spine is likely extrinsic.\n\n IMPRESSION:\n 1. Endotracheal tube 5 cm from carina.\n 2. Mild fluid overload with patchy bibasilar opacities, could reflect areas\n of atelectasis. Early infiltrate or aspiration cannot be excluded.\n 3. Linear density projecting over the left of the spine, may be external to\n the patient. Attention on follow-up studies.\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-07 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1068939,
"text": " 1:03 PM\n CT CHEST W/CONTRAST; CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONSClip # \n Reason: ?fever source, ?open grafts bilateral legs\n Contrast: VISAPAQUE Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with hypotension, fever, prostate biopsy 2days ago; s/p\n bilateral fem/, with no distal pulses palpable.\n REASON FOR THIS EXAMINATION:\n ?fever source, ?open grafts bilateral legs\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AKSb SAT 5:11 PM\n Occlusion of both grafts -\n Right occluded at distal common femoral artery, just before SFA/profunda\n branch point with reconstitution of profunda via collaterals. Also minimal\n refilling of tibio-peroneal trunk via small profunda branches.\n\n Left SFA occluded at origin on left fem-AT graft (profunda origin preserved)\n with similar minimal filling of tibio-peroneal trunk.\n\n No acute intra-abdominal pathology. Moderate atherosclerotic disease in SMA,\n no evidence of bowel ischemia. RLQ renal transplant unremarkable.\n\n Moderate bibasilar atelectasis.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old with hypotension, fever, and prostate biopsy two days\n ago with no palpable postop pulses. Evaluate for open grafts and fever\n source.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector helical scanning of the abdomen, pelvis, and lower\n extremities was performed prior to and following the administration of IV\n Optiray contrast. Delayed images were also obtained through the abdomen,\n pelvis, and lower extremities. Further delayed images are obtained through\n the chest.\n\n There is moderate bibasilar atelectasis. No pleural effusion. The heart is\n enlarged, and there are multiple clips from prior CABG as well as median\n sternotomy wires. The thoracic aorta is of normal caliber. The main\n pulmonary artery is enlarged measuring 3.8 cm, indicating underlying pulmonary\n arterial hypertension. Small mediastinal lymph nodes do meet CT criteria for\n pathologic enlargement. There is retrosternal soft tissue in the anterior\n mediastinum, which may represent rebound thymic tissue, however, should be\n watched closely. Endotracheal tube terminates within the mid trachea, and the\n bronchi are patent to the subsegmental level.\n\n CTA OF THE ABDOMEN: The liver, spleen, gallbladder, adrenal glands, and\n shrunken native kidneys are unremarkable. There is mildly prominent\n enhancement of the small bowel loops, likely due to arterial phase. No\n (Over)\n\n 1:03 PM\n CT CHEST W/CONTRAST; CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONSClip # \n Reason: ?fever source, ?open grafts bilateral legs\n Contrast: VISAPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n definite evidence of bowel wall thickening. The abdominal aorta is of normal\n caliber, however, has moderately extensive atherosclerotic calcification.\n There is a band-like focal stenosis at the origin of the celiac artery. There\n is also significant plaque within the proximal superior mesenteric artery\n which severely attenuates the vessel; however, the vessel remains patent. The\n is also patent.\n\n CT OF THE PELVIS: The appendix is normal. Transplanted kidney in the right\n lower quadrant enhances normally, and the renal artery which arises from the\n right external iliac artery is patent. Arterial outpouching from the left\n external iliac artery is due to a residual stump from prior pancreatic\n transplant. There is no pelvic free fluid or lymphadenopathy. Foley catheter\n and air are seen within the bladder.\n\n CTA OF THE LOWER EXTREMITIES: The very distal right common femoral artery is\n completely thrombosed. The right femoral popliteal graft arises from the\n thrombosed right common femoral artery, and there is no contrast seen within\n the graft. The right profunda opacifies via collaterals and maintains patency\n throughout the thigh. The right fem- graft is completely thrombosed\n extending into the native popliteal artery. Within the upper calf, there is\n minimal reconstitution of within the tibioperoneal trunk, likely from tiny\n collaterals from the profunda branches. Evaluation is limited due to\n extensive calcification within these vessels.\n\n On the left, there is a similar picture. The left common femoral artery is\n patent until just past the SFA/profunda bifurcation. The profunda is patent.\n The left superficial femoral artery is patent very proximally, however,\n thromboses as soon as it enters the fem anterior tibial graft. An additional\n abandoned fem- graft is noted, however, is completely thrombosed. The left\n profunda opacifies many deep perforating branches. The graft extends into the\n left anterior tibial artery, which is also thrombosed. There is minimal\n contrast opacification within the tibioperoneal trunk, likely due to profunda\n branches, also challenging to assess given the extent of vascular\n calcification. There is a moderate amount of subcutaneous edema involving the\n lower aspect of the left leg and extending into the left ankle.\n\n IMPRESSION:\n\n 1. Thrombosis of the right femoral-popliteal, and left femoral-anterior\n tibial grafts with minimal reconstitution at the level of the tibioperoneal\n trunks bilaterally via collaterals. The profunda arteries are patent\n bilaterally.\n\n 2. Unchanged plaque/thrombus within the SMA which attenuate the vessel,\n however, not significantly changed since . No evidence of bowel\n ischemia.\n (Over)\n\n 1:03 PM\n CT CHEST W/CONTRAST; CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONSClip # \n Reason: ?fever source, ?open grafts bilateral legs\n Contrast: VISAPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Unremarkable right lower quadrant renal transplant.\n\n 4. Anterior mediastinal soft tissue which may represent thymic rebound. Close\n interval followup is recommended.\n\n 5. Bibasilar atelectasis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1071274,
"text": " 12:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: ISCHEMIC LEGS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with low grade fever\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 4:50 PM\n PFI: Left lower lobe atelectasis significantly improved. Left pleural\n effusion cleared. No new consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n REASON FOR EXAM: 50-year-old man with low-grade fever, rule out pneumonia.\n\n Since , the patient was extubated and the nasogastric tube was\n removed. Right internal jugular catheter ends in the mid SVC. Clips are in\n the left neck.\n\n Left pleural effusion cleared and left lower lobe atelectasis significantly\n improved. There is no new focal area of consolidation and no other change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1071275,
"text": ", L. VSURG VICU 12:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: ISCHEMIC LEGS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with low grade fever\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left lower lobe atelectasis significantly improved. Left pleural\n effusion cleared. No new consolidation.\n\n"
}
] |
84,461 | 150,956 | Patient is a 66M with PMHx sig. for DM, HTN, recent onset atrial fibrillation on coumadin, PVD with chronic LE ulcers and cellulitis who was transferred from Hospital for angiogram of bilateral lower extremities. Upon hospitalization at , patient rapidly developed symptoms of shock requiring transfer to the ICU. He subsequently had a prolonged hospital course complicated by hospital aquired pneumonia, acute renal failure with trial of hemodialysis, persistent encephalopathy. Eventually medical comorbidies were stabilized, allowing angiogram and subsequent angioplasty of right lower extremity on . 1. Multifactorial Shock: Soon after admission to , patient developed isolated hypotension requiring vasopressors despite no response in HR (though blocked by amiodarone and carvediol). Etiology thought to be multifactorial from iatrogenic adrenal insufficiency (on chronic steriods) and septic shock secondary to hospital aquired pneumonia. He had beta streptococcus in blood cultures x2, treated with 5 day course of Vanc/Zosyn. Only had TTE at OSH that showed no vegetations. His BLE remained the presumed source of infection. Also had an HD line at OSH. He is hypoxic and CXR with worsening infiltrates. He has been repeatedly C. diff negative. There may also have been a componenent of hypovolemia as had low urine output on arrival to the MICU as compared to previous days but likely due to ARF. The patient was put on stress dose steroids (hydrocortisone and fludrocortisone) for adrenal insufficiency given history of chronic prednisone use. EKG difficult to interpret but CEs flat so unlikely cardiogenic shock. Amiodarone was held and has not been restarted at the point. Pt did have a brief pressor requirement. Pt was briefly intubated for hypercarbic respiratory failure from and extubated without complication. Carvedilol was held while hypotensive but has been restarted. Pt was put on vancomycin and zosyn on but zosyn was switched to clinda and cipro on out of concern that the zosyn was causing marrow suppression. A CT scan of torso showed bilateral consolidations. ECHO showed moderately dilated LV and RV, normal LV systolic function, mildly depressed RV function, mild AS, moderate PA systolic HTN. Pt was put back on home dose of steroids on . Blood, stool and sputum cultures no growth. Urine did show funguria. His blood pressure and hemodynamic status improved while here. Upon discharge, he was hemodynamically stable and mental status was improved. 2. Acute mental status changes: On admission, patient had progressive encephalopathy with waxing and consciousness and poor attention. Initially, while the patient was in the intensive care unit, altered mental status was felt to be secondary to narcotic and sedative requirement. All CNS- altering medication were stopped, residual delerium attributed to toxic metabolic syndrome with uremia, hyperammonemia, hypercapnia and hypernatremia. Repeat head CTs (, ) through hospital course were negative for intracranial process and neurologic exam remained nonfocal throughout (although motor and sensory exam was limited by mental status). Course was punctuated by several episodes of profound lethargy with hypercapnea (CO2 in 60s) secondary to hypoventilation. These acute decompensations in mental status resolved with application of the patient's CPAP machine. Chronic progression of encephalopathy corresponded to rising uremia from acute renal injury. Patient was initiated on a course of hemodialysis and BUN fell from 100s to 40s. With reversal of metabolic abnormalities, patient's mental status improved significantly but he remained disoriented with severe short term memory deficits and evidence of frontal slowing. Due to persistent mental status changes an MRI was pursued, showing multiple subacute and chronic cortical infarcts. His mental status improved while here. Upon discharge, he was alert and oriented x 3. 3. Peripheral Vacular Disease with chronic lower extremity ulcers: Got Vanc/zosyn from , zosyn switched to clinda and cipro on . Transfered from outside hospital for angiogram of bilateral lower extremities. X-rays showed bony erosion from gouty tophi but no evidence of osteomyelitis. Throughout hospital course, the patient was followed by vascular surgery. On , once other medical problems had been stabilized, patient had CO2 angiogram with angioplasty of left anterior tibial artery. Subsequently developed a wound infection in right dorsal ulcer, put on 1 week course of ciprofloxacin for wound culture growing serratia. Last day of cipro (250mg q12 hr) is . Vascular surgery followed patient and recommended continuing wet-to-dry dressing changes over debrided areas and adaptic/kerlix over the remainder of his legs. He is to follow-up with Dr. in late /early . 4. Acute on chronic renal failure: Upon transfer to , patient was initiallly anuric. Likely repeat ATN after hypotensive episodes. FeUrea 30% consistent with prerenal etiology. Urine output picked up throughout ICU stay. Pt given albumin x4 with good response. On transfer to the floor, patient once again developed rising BUN and creatinine with FeNa < 1%, suggestive of intravascular depletion despite patient edematous state. At the same time, patient developed an erythematous rash, peripheral and urinary eosinophils. Due to concern of allergic interstitial nephritis, omeprazole was discontinued. BUN and creatinine continued to rise, peaking at 100s and 2.5 respectively, when hemodialysis trial was initiated. HD was discontinued once BUN decreased to 40s. Creatinine stabilized at baseline of 1.5- 1.7. 5. Pancytopenia: According to primary care provider, had progressive thrombocytopenia for the previous two years. Extensive evaluation of thrombocytopenia was negative for other signs or symptoms of TTP, HIT, or DIC. Zosyn, ranitidine (later restarted for stress ulcer prophylaxis), colchicine, allopurinol were discontinued. Peripheral smear with anisocytosis, burr cells and tear drop cells suggestive of myelodysplastic syndrome although diagnostic bone marrow biopsy not performed given acute illness. Blood counts were monitored throughout hospital stay and remained relatively stable. Regarding his thrombocytopenia that began at OSH, he had HIT and ADAMTS13 sent which were both negative. There were no schistocytes on smear. It is thought this is secondary to MDS. Initially, on transfer to the floor, the patient had a slow GI bleed with guiac positive stools. He was initially placed on omeprazole for stress ulcer prophylaxis in the setting of chronic steriod use, but this was transitioned to ranitidine secondary to concern for acute interstitial nephritis (see below). He did receive a total of 2U pRBC for transfusion parameters of Hct < 21. By time of discharge, no further evidence of active bleed. 6. Atial Fibrillation: Transferred from outside hospital with new diagnosis of atrial fibrillation s/p cardioversion on coumadin. Transitioned to heparin gtt on admission to in expectation for upcoming surgical intervention by vascular surgery. Heparin drip was stopped over inital concern for HIT, patient in normal sinus rhthym with PVCs. It was determined patient did not have HIT. Patient's bleeding resolved and patient was resumed on coumadin 5mg daily (bridged with heparin gtt). 7. Hypothermia: On patient developed hypothermia with minimum temperature of 91. Etiology unclear, although maintained high suspicion for sepsis given pancytopenia. Most likely source remained leg ulcers, especially given evidence of active/ recurrent osteomyelitis on x-ray. Infectious disease evaluation including blood cultures, AFB and fungal remained negative. Temperature returned back to normal and was 97.3 on discharge. 8. Gout: stopped home allopurinol and colchicine. no evidence of active flare 9. Diabetes on insulin: Continued on insulin regimen receiving lantus 10 units at night with an humalog insulin sliding scale. | # Anemia: Will follow # Anticoagulation: A fib and h/o DVT. # Anemia: Will follow # Anticoagulation: A fib and h/o DVT. First MICU stay for hypotension, hypercarbic respiratory failure, and altered mental status. First MICU stay for hypotension, hypercarbic respiratory failure, and altered mental status. First MICU stay for hypotension, hypercarbic respiratory failure, and altered mental status. First MICU stay for hypotension, hypercarbic respiratory failure, and altered mental status. HPI: 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulitis, beta streptococcal septic shock complicated by ATN requiring HD, afib s/p cardioversion who was transferred from Hospital for angiogram of BLEs, then transferred to MICU for hypotension and worsening mental status; now extubated, off pressors, doing well Altered mental status (not Delirium) Assessment: pt is alert and orientated x1 had difficulty in telling date, time and place Action: pt oriented to location and time, pt able to follow commands, Response: while in room ab Plan: Decubitus ulcer (Present At Admission) Assessment: Action: Response: Plan: GBS sepsis: afebrile, normotensive. #Hypercapnic respiratory failureresp status stable s/p extubation but remains volume overload - albumin/lasix to diurese -1L x 24 hrs -wean O2 as tolerated to maintain sat>92% -ABX as above -transitioned to bolus sedation -encourage CPAP use . #Hypercapnic respiratory failureresp status stable s/p extubation -wean O2 as tolerated to -ABX as above -transitioned to bolus sedation -encourage CPAP use . #Hypercapnic respiratory failure stable resp status s/p extubation -wean O2 as tolerated to -ABX as above -transitioned to bolus sedation -encourage CPAP use . #Hypercapnic respiratory failure stable resp status s/p extubation -wean O2 as tolerated to -ABX as above -transitioned to bolus sedation -encourage CPAP use . #Shock pressor requirement decreased; multifactorial due to sepsis (likely sources are nonhealing skin wounds and pneumonia given CT findings) and relative adrenal insufficiency; TTE showed mod dilated LV/RV with nl LV systolic function and mildly depressed RV function, mild AS, mod pulm HTN (TR grad 42 mmHg) -cont vanc/zosyn (day 2) tailor ABX according to Cx data -cont hydro/fludrocort -wean levophed for goal MAP> 60-65 -volume repletion to goal CVP 8-12 -repeat ScVO2, consider transfusion if <70 -cont hold amiodarone, carvediolol . Assessment and Plan ALTERED MENTAL STATUS (NOT DELIRIUM) DECUBITUS ULCER (PRESENT AT ADMISSION) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ) HYPOTENSION (NOT SHOCK) SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION) ACIDOSIS, RESPIRATORY 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and recurrent cellulitis admitted to OSH with beta streptococcal bacteremia and septic shock complicated by ATN requiring HD & AFib s/p cardioversion admitted to the MICU for recurrent shock. Defer to vascular regarding LE and feet ulcers at this time. Per MICU resident, bracycardia overnight thought to be Propofol gtt . #Shock pressor requirement decreased; multifactorial due to sepsis (likely sources are nonhealing skin wounds and pneumonia given CT findings) and relative adrenal insufficiency; TTE showed mod dilated LV/RV with nl LV systolic function and mildly depressed RV function, mild AS, mod pulm HTN (TR grad 42 mmHg) -cont vanc/zosyn (day 2) tailor ABX according to Cx data -cont hydro/fludrocort -wean levophed for goal MAP> 60-65 -volume repletion to goal CVP 8-12 -repeat ScVO2, consider transfusion if <70 -cont hold amiodarone, carvediolol . #Shock pressor requirement decreased; multifactorial due to sepsis (likely sources are nonhealing skin wounds and pneumonia given CT findings) and relative adrenal insufficiency; TTE showed mod dilated LV/RV with nl LV systolic function and mildly depressed RV function, mild AS, mod pulm HTN (TR grad 42 mmHg) -cont vanc/zosyn (day 2) tailor ABX according to Cx data -cont hydro/fludrocort -wean levophed for goal MAP> 60-65 -volume repletion to goal CVP 8-12 -repeat ScVO2, consider transfusion if <70 -cont hold amiodarone, carvediolol . There is a trivial/physiologic pericardialeffusion.IMPRESSION: Moderately dilated left and right ventricles with normal leftventricular systolic function and mildly depressed right ventricular function.Mild aortic stenosis. [Intrinsic RV systolic function likely more depressed given theseverity of TR].AORTA: Normal aortic diameter at the sinus level. There is thesuperficial appearance of bidirectional ventricular tachycardia but this isunlikely to be the case. Decubitus ulcer (Present At Admission) Assessment: Pt with Action: Response: Plan: Renal failure, acute (Acute renal failure, ARF) Assessment: Action: Response: Plan: Sepsis, Severe (with organ dysfunction) Assessment: Action: Response: Plan: Hypotension (not Shock) Assessment: Action: Response: Plan: BLE ulcerations covered with adaptic and dsd. Note is made of an asymmetry of the right and left subclavian venous waveforms; this is of indeterminate clinical significance. Sinus rhythm with ventricular premature beats in a bigeminal pattern.Left atrial abnormality. Their character is perivascular and most likely they represent pulmonary edema. IMPRESSION: AP and lateral chest reviewed in the absence of prior chest radiographs: Lung volumes are very low. Moderate cardiomegaly with dilatation and prominence of the upper lobe pulmonary vasculature, suggests mild congestive cardiac failure. Normal sinus rhythm with frequent ventricular premature contractions in atrigeminal pattern with right bundle-branch block and non-specific secondaryST-T wave abnormalities. Note is made of a small fat-containing umbilical hernia. FINDINGS: Endotracheal tube and nasogastric tube have been removed. CT ABDOMEN WITHOUT CONTRAST: Nasogastric tube terminates in the distal stomach. CT CHEST WITHOUT CONTRAST: An endotracheal tube terminates ~5.3 cm above the carina. Pulmonary edema has resolved, but pulmonary vascular congestion, hilar dilatation and cardiomegaly persists and there is probably a small-to-moderate right pleural effusion collecting posteriorly. Intrapelvic loops of bowel demonstrate diverticulosis without diverticulitis. A small fat-containing umbilical hernia is unchanged. Small right pleural effusion is likely, decreased since . The ventricles and sulci are slightly prominent, appropriate for mild age-related global atrophy, unchanged. There remains a right-sided central venous catheter with the distal lead tip in the mid SVC. IMPRESSION: AP chest compared to : Dobbhoff tube has been replaced by a standard nasogastric tube which passes into the stomach and out of view before the tip returns to the left upper quadrant. Stable size of infrarenal abdominal aortic aneurysm. FINDINGS: In comparison with study of , the right IJ catheter has been removed and replaced with a right subclavian PICC line, which extends to the lower portion of the SVC. | 140 | [
{
"category": "Respiratory ",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600899,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Hemodynimic instability, Underlying illness not resolved\n Comments: Pt intubated for hypercarbic resp failure.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 600897,
"text": "Chief Complaint: Hypotension\n HPI:\n Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n .\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. At the time, VS were: HR 60, BP 90/60-115/70, RR12, 96%\n on 4L. This morning he was again found to be minimally responsive and\n then hypotensive with systolic in 70s; HR was maintained in 50-60s.\n Repeat ABG was 7.34/44/82. Blood cultures were sent. Patient is not\n making urine.\n Patient admitted from: \n Patient unable to provide history: Delirius\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Vancomycin - 01:15 PM\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency (baseline cr 1.7), Stage III\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n N/C\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient lives with his wife in . Owns a liquor store.\n He smoked 4ppd x 40 years, quit 4 years ago. Per surgical admission\n note, he drinks 1-3 drinks/day, ~5 days per week.\n Review of systems:\n Cardiovascular: No(t) Chest pain, Edema\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: Foley\n Psychiatric / Sleep: Delirious\n Flowsheet Data as of 03:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 59 (59 - 76) bpm\n BP: 97/43(61) {76/38(51) - 114/48(68)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,936 mL\n PO:\n TF:\n IVF:\n 2,136 mL\n Blood products:\n Total out:\n 0 mL\n 20 mL\n Urine:\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,916 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 99%\n ABG: 7.17/57/120/20/-8\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: Overweight / Obese, edematous\n Eyes / Conjunctiva: Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n irregular, brady\n Peripheral Vascular: (Right radial pulse: Absent), (Left radial pulse:\n Absent), (Right DP pulse: Absent), (Left DP pulse: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar)\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+, venous stasis changes with erytham, eschar on R\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Oriented (to): self, Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 82 K/uL\n 9.1 g/dL\n 98 mg/dL\n 2.3 mg/dL\n 97 mg/dL\n 20 mEq/L\n 113 mEq/L\n 5.3 mEq/L\n 139 mEq/L\n 28.8 %\n 8.6 K/uL\n [image002.jpg]\n \n 2:33 A10/22/ 09:28 AM\n \n 10:20 P10/22/ 01:56 PM\n \n 1:20 P10/22/ 01:57 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 3.9\n 8.6\n Hct\n 23.7\n 28.8\n Plt\n 54\n 82\n Cr\n 2.3\n TropT\n 0.38\n TC02\n 22\n Glucose\n 98\n Other labs: CK / CKMB / Troponin-T:76//0.38, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Lactic Acid:0.8\n mmol/L, Ca++:7.5 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR: worsening pulmonary edema\n OSH ECHO : LVEF 40%. Hypokinetic septal and apex. Mild,\n concentric LVH. Doppler data most consistent with mild diastolic\n dysfunction. Nl RV. Mild AS. Est 1.1 cm2.\n No clear evidence of vegetations.\n OSH L Knee x-ray : Large left knee joint effusion and degenerate\n changes.\n Microbiology: Blood culture from R antecubital and R hand .\n Blood culture negative.\n C. diff x4 negative\n L knee aspirate gram stain wtih many WBCs, no organisms;\n culture NGTD. WBC , 98% Polys, 1%L, 1%M, urate crystals, no\n calcium pyrophosphate, RBC \n ECG: NSR with RBBB and multiple PVCs\n Assessment and Plan\n Patient is a 66M with PMHx sig. for DM, HTN, h/o DVT on coumadin, PVD\n with chronic LE ulcers and cellulitis, who initially went to \n for his LE ulcers, found to have beta streptococcal septic shock\n complicated by ATN requiring HD, afib s/p cardioversion who was\n transferred from Hospital for angiogram of BLEs, then\n transferred to MICU for hypotension and worsening mental status.\n .\n #. Hypotension: Patient has isolated hypotension requiring\n vasopressors despite no response in HR (though blocked by amiodarone\n and carvediol). This is most likely septic shock though afebrile. He\n had beta streptococcus in blood cultures x2, treated with 5 day course\n of Vanc/Zosyn. Only had TTE at OSH that showed no vegetations. His\n BLE remain a source of infection. Also had an HD line at OSH. He is\n hypoxic and CXR with worsening infiltrates. He has been repeatedly C.\n diff negative. be hypovolemia as has low urine output today\n compared to previous days but likely due to ARF. Consider adrenal\n insufficiency given history of prednisone. EKG difficult to interpret\n but CEs flat so unlikely cardiogenic.\n - hold amiodarone, carvediolol\n - cont. levophed, goal MAP of 60-65\n - check CVP, IVFs for goal of 8\n - check delta D/delta T\n - check mixed venous sat, if <70, transfusion PRBCs\n - start vanc/zosyn\n - check U/A, UCx, sputum cx\n - follow bcxs\n - check AM cortisol, was on prednisone at OSH for ?gout flare (unclear\n if he was on this at home)\n - started on dexamethasone, fludrocortisone\n - ECHO, will need TEE eventually\n - CT chest/abdomen without IV contrast\n .\n #. Hypoxia: Pt has worsening bilateral infiltrates on CXR. Likely\n pulmonary edema in setting of AS and ARF, difficult to assess for\n consolidation.\n - Intubate as has worsening pulmonary edema.\n - need HD for UF.\n - Covering nosocomial pneumonia as above\n .\n #. Acute mental status changes: Likely delirious from narcotics in\n setting of acute on chronic renal failure, infection. Also hypotensive\n overnight.\n - CT head\n - treat infection as above\n .\n #. Acute on chronic renal failure: Currently anuric. Likely repeat\n ATN after hypotensive episodes today.\n - send urine for lytes, sed, eos if makes urine\n - Avoid nephrotoxins\n - Renal following, appreciate recs\n .\n #. Thrombocytopenia: Trend began at OSH. Had HIT and ADAMTS13 sent,\n both negative. No schistocytes on smear, which is reassuring against\n TTP (along with nonremarkable ADAMTS13).\n - monitor platelet count\n - f/u DIC labs\n .\n #. Anemia: Unclear cause at this time.\n - monitor HCT\n - hemolysis labs, retic count\n - guaiac stools\n - transfuse for <21 or mixed venous O2 sat <70\n .\n #. PVD with bilateral LE cellulitis/ulcers:\n - cont. Vanc/zosyn\n - Vascular surgery following\n - Wound care consult\n .\n #. Gout:\n - cont allopurinol but hold colchicine\n .\n #. Diabetes on insulin:\n - cont. on insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #. Afib, newly diagnosed: currently in NSR with multiple PVCs\n - observe on levophed\n - hold coumadin, heparin gtt\n .\n #. H/o DVT: on coumadin at home\n - hold coumadin, heparin gtt\n .\n #FEN: IVFs for CVP goal of 8, monitor/replete electrolytes, may need\n TFs\n #PPX: heparin gtt, bowel regimen, and ranitidine\n #ACCESS: RIJ CVL\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Physician Fellow / Attending Admission Note - MICU",
"row_id": 600903,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Vancomycin - 01:15 PM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1) Chronic renal insufficiency (baseline creatinine 1.7) with ATN at\n Hospital in early transiently requiring HD.\n 2) OSA on CPAP, he is not consistently compliant\n 3) Gout on allopurinol and colchicine, s/p knee arthrocentesis at\n Hospital\n 4) Ulcerative colitis\n 5) IDDM\n 6) Hypertension\n 7) A fib with RVR s/p cardioversion at on \n 8) PVD with chronic lower extremity ulcers for the prior 10 years with\n chronic ulcers\n 9) H/o DVT on Warfarin\n 10) Obesity\n 11) Anemia\n unknown baseline\n Could not obtain depressed mental status.\n Per medical records as patient cannot provide history:\n Occupation: Retired, previously owned a liquor store.\n Drugs: N/A\n Tobacco: Quit smoking 40 years ago.\n Alcohol: Varying estimates\n from glasses of bourbon a day to\nonly\n on weekends.\n Other:\n Review of systems: Patient cannot provide a review of systems \n depressed mental status.\n Flowsheet Data as of 01:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 59 (59 - 76) bpm\n BP: 96/44(61) {76/38(51) - 114/48(68)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,861 mL\n PO:\n TF:\n IVF:\n 2,061 mL\n Blood products:\n Total out:\n 0 mL\n 20 mL\n Urine:\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,841 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General: Obese, chronically ill appearing, arousable to noxious stimuli\n but non-sensical and disoriented. No respiratory distress.\n HEENT: PERRL. Anicteric sclera. OP clear without apparent thrush or\n exudate on limited exam. No appreciable cervical or clavicular\n adenopathy, but very obese neck.\n Lungs: Limited exam as patient cannot sit up and does not take deep\n breaths due to depressed mental status. No obvious focal wheezing or\n crackles.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not apparently\n tender. Could not appreciate HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Arousable to noxious stimuli but not meaningfully interactive.\n Moving all extremities spontaneously.\n Labs / Radiology\n 54 K/uL\n 23.7 %\n 7.9 g/dL\n 98 mg/dL\n 2.3 mg/dL\n 97 mg/dL\n 20 mEq/L\n 113 mEq/L\n 5.3 mEq/L\n 139 mEq/L\n 3.9 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n 09:28 AM\n WBC\n 3.9\n Hct\n 23.7\n Plt\n 54\n Cr\n 2.3\n TropT\n 0.38\n Glucose\n 98\n Other labs:\n CK / CKMB / Troponin-T:76//0.38,\n Ca++:7.5 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status and\n hypotension.\n 1) Hypotension: The differential diagnosis of his hypotension is\n broad, including distributive shock (sepsis, adrenal insufficiency,\n hypothyroidism), cardiogenic (depressed EF of 40% with LV hypokinesis\n on a TTE), obstructive ( 1.1 cm^2 on the TTE), or\n hypovolumic (he is clearly whole body overloaded but certainly may be\n intravascularly deplete.)\n With regard to possible septic physiology, we will provide broad\n spectrum antibiotics to cover potential nosocomial pathogens (Vanc and\n Zosyn) and investigate possible sources of a sepsis syndrome. His lower\n extremities are certainly a possible source and Vascular\ns input\n regarding the likelihood of these chronic ulcers contributing to a\n systemic infection will be sought. His chest x-ray demonstrates\n increased bilateral opacities that are likely pulmonary edema, but with\n his depressed mental status superimposed aspiration pneumonitis /\n pneumonia is a possibility. We will pursue an abdominal and chest CT\n scan to assess for an infectious source of his possible septic\n physiology. Finally, we\nve placed a central venous catheter with which\n we will follow CVP and SvO2 as surrogates of his volume status and\n peripheral oxygen up-take.\n He has been on Prednisone for an uncertain amount of time, we will\n provide him with empiric corticosteroids and check a random cortisol to\n further assess for possible adrenal insufficiency. Would send a TSH as\n well.\n With regard to possible cardiogenic shock, we will repeat a TTE\n today. In addition, if his hemodynamic picture remains unclear, a\n and/or a PA catheter could be considered.\n With regard to possible obstructive shock, his was 1.1 cm^2 at\n the OSH on \n if this has progressed, it could be contributing\n more to his hypotension. PE is less likely given he has been on\n Warfarin (although his INR today is subtherapeutic.)\n With regard to his volume status, he is clearly whole body volume\n overloaded but his intravascular status is unclear. check his CVP\n and SvO2. Follow UOP, although this is complicated by his concomitant\n renal dysfunction.\n 2) Depressed mental status: Multifactorial in nature with his\n hypotension, acute renal failure, multiple organ dysfunction, acute\n respiratory acidosis and medication effects. Will address his\n underlying processes. Given he is undergoing a chest / abdomen CT we\n will scan his head as well. His overall mental status concerning and\n given concerns regarding his inability to protect his airway and a\n progressive acute respiratory acidosis, we will plan on an elective\n intubation this afternoon.\n 3) Thrombocytopenia: Unclear etiology. This has progressed from\n (platelets were 130 on .) and now are in the 40-50s. His\n HIT Ab and his -TS 13 study were normal. Multiple DIC and\n hemolysis labs are pending. No indication for transfusion at this time.\n 4) F/E/N: Follow his\nlytes. Correct elevated K. Anticipate\n starting TFs.\n 5) Anemia: Follow his H/H. Hemolysis labs pending (we \n clinically suspect any significant hemoptysis.)\n 6) IDDM: RSSI with an insulin gtt if his sugar is >180. Goal range\n will be 110-180.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation: 20 Gauge - 09:14 AM, 22 Gauge -\n 09:14 AM and Multi Lumen - 10:40 AM\n Comments:\n Prophylaxis:\n DVT: systemic anticoagulation\n Stress ulcer: H2 blocker\n VAP: Bundle will be ordered\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU for now\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 604158,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n This is a 66 y/o male with PMHx of DM, HTN, DVT on coumadin, and PVD\n with chronic LE ulcers and cellulitis who was transferred from the\n medical floor for hypoxia. The patient was admitted to on\n with worsening LE edema and ulcers. Tx to MICU for\n septic shock group B strep bacteremia thought ulcers. This was\n c/b afib with RVR requiring cardioversion on , started on\n amio/coumdin, and ATN requiring 2 sessions of HD. Transferred here to\n Vascular service for LE angiogram.\n Soon after arriving here, became unresponsive and found to be\n hypotensive and in hypercarbic respiratory failure requiring intubation\n and MICU stay. At that time, started on seroids for\n adrenal insufficiency as well as clinda/cipro. S/p 8 day course for\n HAP. Back on medical floor, his subsequent hospital course was\n complicated by altered mental status, thought encephalopathy from\n infection, hypernatremia, and uremia, as well as acute on chronic renal\n failure being followed by Nephrology. This morning, the patient was\n found to be unresponsive and hypoxic. Transferred to MICU for further\n management.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:43 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n Non-contributory.\n Occupation: Owns liquor store.\n Drugs: Denies\n Tobacco: 4 ppd x 40 years, quit \n Alcohol: drinks/day\n Other: Lives with wife in .\n Review of systems:\n Flowsheet Data as of 04:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 89 (88 - 98) bpm\n BP: 114/37(55) {106/29(49) - 122/67(76)} mmHg\n RR: 23 (15 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 72 Inch\n Total In:\n 38 mL\n PO:\n TF:\n IVF:\n 38 mL\n Blood products:\n Total out:\n 0 mL\n 115 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -78 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.31/53/49/22/0\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 47 K/uL\n 27.7 %\n 8.5 g/dL\n 100 mg/dL\n 2.4 mg/dL\n 92 mg/dL\n 22 mEq/L\n 117 mEq/L\n 4.7 mEq/L\n 150 mEq/L\n 4.2 K/uL\n [image002.jpg]\n 11:46 AM\n 12:02 PM\n 01:55 PM\n WBC\n 4.2\n Hct\n 27.7\n Plt\n 47\n Cr\n 2.4\n TropT\n 0.53\n TC02\n 27\n 27\n 28\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:49//0.53, Lactic Acid:0.8 mmol/L,\n Mg++:2.5 mg/dL\n Imaging: CXR - ...\n Microbiology: Data ...\n Assessment and Plan\n 66M with PMHx sig. for DM, HTN, h/o DVT on coumadin, PVD with chronic\n LE ulcers and cellulitis, who initially went to for his LE\n ulcers, found to have beta streptococcal septic shock complicated by\n ATN requiring HD and afib s/p cardioversion who was transferred from\n Hospital for angiogram of BLEs. First MICU stay \n for hypotension, hypercarbic respiratory failure, and altered mental\n status. Back on floor, ongoing altered mental status and then found to\n be unresponsive and hypoxic requiring another transfer to MICU.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:24 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 604168,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n This is a 66 y/o male with PMHx of DM, HTN, DVT on coumadin, and PVD\n with chronic LE ulcers and cellulitis who was transferred from the\n medical floor for hypoxia. The patient was admitted to on\n with worsening LE edema and ulcers. Tx to MICU for\n septic shock group B strep bacteremia thought ulcers. This was\n c/b afib with RVR requiring cardioversion on , started on\n amio/coumdin, and ATN requiring 2 sessions of HD. Transferred here to\n Vascular service for LE angiogram.\n Soon after arriving here, became unresponsive and found to be\n hypotensive and in hypercarbic respiratory failure requiring intubation\n and MICU stay. At that time, started on seroids for\n adrenal insufficiency as well as clinda/cipro. S/p 8 day course for\n HAP. Back on medical floor, his subsequent hospital course was\n complicated by altered mental status, thought encephalopathy from\n infection, hypernatremia, and uremia, as well as acute on chronic renal\n failure being followed by Nephrology. This morning, the patient was\n found to be unresponsive and hypoxic. Transferred to MICU for further\n management.\n On arrival, his VS were stable and mental status quickly returned to\n baseline. O2 also weaned down to baseline.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:43 PM\n Other medications:\n Pred 20mg QOD, SQ heparin, sevelamir, ranitidine, ASA, atorvastatin,\n RISS, MV,\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis on QOD steroids\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n Non-contributory.\n Occupation: Owns liquor store.\n Drugs: Denies\n Tobacco: 4 ppd x 40 years, quit \n Alcohol: drinks/day\n Other: Lives with wife in .\n Review of systems:\n Per family, patient has been altered since 2-3 days PTA at .\n Flowsheet Data as of 04:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 89 (88 - 98) bpm\n BP: 114/37(55) {106/29(49) - 122/67(76)} mmHg\n RR: 23 (15 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 72 Inch\n Total In:\n 38 mL\n PO:\n TF:\n IVF:\n 38 mL\n Blood products:\n Total out:\n 0 mL\n 115 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -78 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.31/53/49/22/0\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, Bandages on LE ulcers, L knee>R knee, impressive tophi\n Skin: Stage II decub on cocyx 6x6in\n Neurologic: Attentive, Poorly following commands, A&O x 1 (name)\n Labs / Radiology\n 47 K/uL\n 27.7 %\n 8.5 g/dL\n 100 mg/dL\n 2.4 mg/dL\n 92 mg/dL\n 22 mEq/L\n 117 mEq/L\n 4.7 mEq/L\n 150 mEq/L\n 4.2 K/uL\n [image002.jpg]\n 11:46 AM\n 12:02 PM\n 01:55 PM\n WBC\n 4.2\n Hct\n 27.7\n Plt\n 47\n Cr\n 2.4\n TropT\n 0.53\n TC02\n 27\n 27\n 28\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:49//0.53, Lactic Acid:0.8 mmol/L,\n Mg++:2.5 mg/dL\n Imaging: CXR\n large heart with pulmonary edema. TTE\n EF 65-70%\n Microbiology: U/A +, culture pending\n EKG: RBBB with L anterior fascicular block, Bigeminy\n at baseline\n Assessment and Plan\n 66M with PMHx sig. for DM, HTN, h/o DVT on coumadin, PVD with chronic\n LE ulcers and cellulitis, who initially went to for his LE\n ulcers, found to have beta streptococcal septic shock complicated by\n ATN requiring HD and afib s/p cardioversion who was transferred from\n Hospital for angiogram of BLEs. First MICU stay \n for hypotension, hypercarbic respiratory failure, and altered mental\n status. Back on floor, ongoing altered mental status and then found to\n be unresponsive and hypoxic requiring another transfer to MICU.\n # Hypoxia: Unclear precipitating event for transfer, although CXR\n appears unremarkable. Perhaps element of aspiration pneumonitis, now\n resolved. Back to baseline O2 requirement, likely from volume\n overload/atelectasis.\n - Nightly CPAP\n - Wean O2 as tolerated\n # Mental status: Likely multifactorial hypernatremia, uremia, high\n ammonia, and UTI or other source of infection. Past head CT\n unremarkable. No evidence of liver cirrhosis on previous imaging.\n - Check LFTs, lactulose enema\n -\n NS for hypernatremia\n - Consider HD for uremia\n renal aware\n - F/U urine cx, start cipro\n - Send blood cultures\n - No indication for further imaging or LP at this time\n - Repeat TSH as previous c/w hypothyroidism\n # ARF: Likely another course of ATN based on previous work-up.\n - Renal considering starting HD tomorrow\n - On\n NS for hypervolemic hypernatremia\n - 24 hour urine creatinine\n # UTI: On cipro\n # LE ulcers:\n - Clarify plan with vascular\n still needs venogram\n # Nutrition:\n - Plan for PICC line placement and initiation of TPN\n # Thrombocytopenia: Work-ed up by heme in the past. Thought due to\n sepsis. Will follow.\n # Anemia: Will follow\n # Anticoagulation: A fib and h/o DVT. Will hold until after PICC line\n and possible HD line, then start IV heparin gtt.\n ICU Care\n Nutrition: PO, but not taking in sufficient calories\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:24 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 604162,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n This is a 66 y/o male with PMHx of DM, HTN, DVT on coumadin, and PVD\n with chronic LE ulcers and cellulitis who was transferred from the\n medical floor for hypoxia. The patient was admitted to on\n with worsening LE edema and ulcers. Tx to MICU for\n septic shock group B strep bacteremia thought ulcers. This was\n c/b afib with RVR requiring cardioversion on , started on\n amio/coumdin, and ATN requiring 2 sessions of HD. Transferred here to\n Vascular service for LE angiogram.\n Soon after arriving here, became unresponsive and found to be\n hypotensive and in hypercarbic respiratory failure requiring intubation\n and MICU stay. At that time, started on seroids for\n adrenal insufficiency as well as clinda/cipro. S/p 8 day course for\n HAP. Back on medical floor, his subsequent hospital course was\n complicated by altered mental status, thought encephalopathy from\n infection, hypernatremia, and uremia, as well as acute on chronic renal\n failure being followed by Nephrology. This morning, the patient was\n found to be unresponsive and hypoxic. Transferred to MICU for further\n management.\n On arrival, his VS were stable and mental status quickly returned to\n baseline.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:43 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis on QOD steroids\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n Non-contributory.\n Occupation: Owns liquor store.\n Drugs: Denies\n Tobacco: 4 ppd x 40 years, quit \n Alcohol: drinks/day\n Other: Lives with wife in .\n Review of systems:\n Flowsheet Data as of 04:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 89 (88 - 98) bpm\n BP: 114/37(55) {106/29(49) - 122/67(76)} mmHg\n RR: 23 (15 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 72 Inch\n Total In:\n 38 mL\n PO:\n TF:\n IVF:\n 38 mL\n Blood products:\n Total out:\n 0 mL\n 115 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -78 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.31/53/49/22/0\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminsed R base, otherwise clear :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, Bandages on LE ulcers\n Skin: Stage II decub on cocyx 6x6in\n Neurologic: Attentive, Poorly following commands, A&O x 1\n Labs / Radiology\n 47 K/uL\n 27.7 %\n 8.5 g/dL\n 100 mg/dL\n 2.4 mg/dL\n 92 mg/dL\n 22 mEq/L\n 117 mEq/L\n 4.7 mEq/L\n 150 mEq/L\n 4.2 K/uL\n [image002.jpg]\n 11:46 AM\n 12:02 PM\n 01:55 PM\n WBC\n 4.2\n Hct\n 27.7\n Plt\n 47\n Cr\n 2.4\n TropT\n 0.53\n TC02\n 27\n 27\n 28\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:49//0.53, Lactic Acid:0.8 mmol/L,\n Mg++:2.5 mg/dL\n Imaging: CXR\n large heart with pulmonary edema.\n Microbiology: U/A +, culture pending\n Assessment and Plan\n 66M with PMHx sig. for DM, HTN, h/o DVT on coumadin, PVD with chronic\n LE ulcers and cellulitis, who initially went to for his LE\n ulcers, found to have beta streptococcal septic shock complicated by\n ATN requiring HD and afib s/p cardioversion who was transferred from\n Hospital for angiogram of BLEs. First MICU stay \n for hypotension, hypercarbic respiratory failure, and altered mental\n status. Back on floor, ongoing altered mental status and then found to\n be unresponsive and hypoxic requiring another transfer to MICU.\n # Mental status: Likely multifactorial hypernatremia, uremia, high\n ammonia, and UTI or other source of infection.\n - Check LFTs, start lactulose\n -\n NS for hypernatremia\n - Consider HD for uremia\n renal aware\n - F/U urine cx, start abx\n # ARF:\n - Renal considering starting HD tomorrow\n # LE ulcers:\n - Clarify plan with vascular\n still needs venogram\n # Nutrition:\n - Plan for PICC line placement and initiation of TPN\n ICU Care\n Nutrition: PO, but not taking in sufficient calories\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:24 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 604163,
"text": "66 yo male admitted originally from Hospital. Multiple\n medical problems including: OSA, DM, chronic leg ulcers. Current\n hospital course complicated by hypothermia, prolonged encephalopathy,\n and renal failure. Triggered this AM on CC7 for O2 sats 87-88 despite\n being placed on CPAP, and somnolence. Transferred to MICU for further\n monitoring.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Uses CPAP at night but not always compliant.\n Triggered this AM on floor for sats down to the 80s and somnolence.\n Action:\n Arrived to MICU on NRB with sats 100%.\n Titrated O2 to 1L and room air within 1 hour of admission.\n Response:\n Sats mid 90s while awake and low 90s while asleep.\n Plan:\n CPAP overnight.\n Renal following. Will restart 24 hr urine collection here in MICU and\n continue until @ 1600.\n Urine output marginal. Family stating that he received four sessions\n of HD at Hospital. Will continue to evaluate renal function.\n Plan to call out to floor tomorrow if remains stable.\n Has no safety awareness and has history of pulling out IVs. Patient\n lethargic but arousable; oriented Xs .\n"
},
{
"category": "Physician ",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 604207,
"text": "Chief Complaint:\n HPI:\n This is a 66 yom with hx of DM, HTN, afib, h/o DVT on coumadin, and PVD\n with chronic LE ulcers and cellulitis who was transferred from the\n medical floor for hypoxia.\n Patient has had a prolonged hospital course over the past month. He\n was initially admitted to on with worsening LE ulcers and\n LE edema. At , he was treated in the MICU for septic shock \n GBS bacteremia which was thought to be to his LE ulcers. His course\n was complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on . He was started on amiodarone and coumadin\n for his afib.\n Patient was transferred here for LE angiogram. He was admitted to the\n Vascular service. On the first night of admission, the patient became\n unresponsive to sternal rub. He received Narcan 0.4 mg x 2 with\n response. Narcotics were discontinued. ABG on CPAP was 7.35/41/56. At\n the time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. The morning\n of transfer to the ICU, he was again found to be minimally responsive\n and then hypotensive with systolic in 70s; HR was maintained in 50-60s.\n Repeat ABG was 7.34/44/82. He was intubated on and extubated on\n . He was started on stress dose steroids (hydrocortisone and\n fludrocortisone) for adrenal insufficiency given history of chronic\n prednisone use. He was started on vancomycin and zosyn on but\n zosyn was switched to clinda and cipro on out of concern that the\n zosyn was causing marrow suppression. He was treated for an 8 day\n course for HAP.\n Hospital course has been complicated by AMS. This has been thought \n to encephalopathy from infection, hypernatremia and uremia. Patient\n has with Acute on Chronic Renal Failure and is being followed by the\n Neprhology team.\n This morning the patient was found to be unresponsive. Noted to be\n hypoxic with O2 sat in 80s. he was placed on a NRB with increase in O2\n sat to 100%. ABG was done which showed 7.31/48/50. He was transferred\n to the MICU for further care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Miconazole Powder 2% 1 Appl TP TID fungal rash\n Miconazole 2% Cream 1 Appl TP :PRN fungal rash\n Acetaminophen 650 mg PO Q6H:PRN pain /fever\n Multivitamins 1 TAB PO/NG DAILY\n Albuterol Inhaler PUFF IH Q4H:PRN sob/wheezing\n Nystatin-Triamcinolone Cream 1 Appl TP :PRN rash\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, dyspnea\n Aspirin 81 mg PO/NG DAILY\n PredniSONE 20 mg PO EVERY OTHER DAY\n Atorvastatin 80 mg PO/NG HS\n Ranitidine 150 mg PO/NG DAILY\n Heparin 5000 UNIT SC TID\n Insulin SC\n Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency (baseline cr 1.7), Stage III\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n Non-contributory\n Patient lives with his wife in . Owns a liquor store. He\n smoked 4ppd x 40 years, quit 4 years ago. Per surgical admission note,\n he drinks 1-3 drinks/day, ~5 days per week.\n Review of systems:\n Flowsheet Data as of 10:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 87 (87 - 98) bpm\n BP: 115/43(60) {93/25(42) - 126/67(76)} mmHg\n RR: 19 (15 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 72 Inch\n Total In:\n 413 mL\n PO:\n TF:\n IVF:\n 413 mL\n Blood products:\n Total out:\n 0 mL\n 220 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 193 mL\n Respiratory\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.31/53/49/23/0\n PaO2 / FiO2: 98\n Physical Examination\n T= 96.8 BP= 98 HR= 122/65 RR= 20 O2= 100% NRB\n GENERAL: Elderly Male, somnolent, opens eyes to questions, AAOx1 to\n self\n HEENT: NCAT, PERRLA, MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly\n CARDIAC: NSR, + S1, S2. No murmurs, rubs or \n LUNGS: +decreased breath sounds at right base\n ABDOMEN: NABS, Soft, NT, ND\n EXTREMITIES: +bandages around bilateral legs, +2 pitting edema of\n bilateral ankles\n SKIN: +sacral ulceration\n NEURO: A&Ox1. unable to assess CN Preserved sensation throughout. \n strength throughout. + reflexes, equal BL. Normal coordination. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 47 K/uL\n 8.5 g/dL\n 97\n 2.3 mg/dL\n 94 mg/dL\n 23 mEq/L\n 118 mEq/L\n 4.8 mEq/L\n 153 mEq/L\n 27.7 %\n 4.2 K/uL\n [image002.jpg]\n \n 2:33 A11/9/ 11:46 AM\n \n 10:20 P11/9/ 12:02 PM\n \n 1:20 P11/9/ 01:55 PM\n \n 11:50 P11/9/ 07:15 PM\n \n 1:20 A11/9/ 10:00 PM\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 4.2\n Hct\n 27.7\n Plt\n 47\n Cr\n 2.4\n 2.3\n TropT\n 0.53\n 0.60\n TC02\n 27\n 27\n 28\n Glucose\n 100\n 98\n 97\n Other labs: CK / CKMB / Troponin-T:58//0.60, Lactic Acid:0.8 mmol/L,\n Mg++:2.6 mg/dL\n STUDIES:\n CXR:\n IMPRESSION: Interval worsening of the mild-to-moderate cardiogenic\n pulmonary edema.\n .\n ECHO :\n The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy. The left ventricular cavity is moderately\n dilated. Regional left ventricular wall motion is normal. There is mild\n global left ventricular hypokinesis (LVEF = 40-45 %). The right\n ventricular cavity is mildly dilated with borderline normal free wall\n function. Intrinsic function may be more depressed given the severity\n of tricuspid regurgitation. The aortic valve leaflets are moderately\n thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2).\n No aortic regurgitation is seen. The mitral valve leaflets are\n structurally normal. There is trivial mitral regurgitation. Moderate\n [2+] tricuspid regurgitation is seen. There is moderate pulmonary\n artery systolic hypertension. There is no pericardial effusion.\n .\n Compared with the prior study (images reviewed) of , the left\n ventricular cavity size is smaller with mild global hypokinesis, the\n severity of tricuspid regurgitation is increased, and the rhythm is now\n sinus with ventricular bigeminy. The severity of aortic stenosis and\n estimated PA systolic pressure are similar.\n .\n Renal U/S :\n IMPRESSION:\n 1. Markedly limited study, but no hydronephrosis or renal stone.\n 2. Echogenic renal parenchyma consistent with medical renal disease\n Assessment and Plan\n .H/O OBSTRUCTIVE SLEEP APNEA (OSA)\n Patient is a 66M with PMHx sig. for DM, HTN, h/o DVT on coumadin, PVD\n with chronic LE ulcers and cellulitis, who initially went to \n for his LE ulcers, found to have beta streptococcal septic shock\n complicated by ATN requiring HD, afib s/p cardioversion who was\n transferred from Hospital for angiogram of BLEs, who was\n treated in the MICU for sepsis, on medical floor who now returns to\n MICU for hypoxia.\n #. Hypoxia: Unclear cause, concern for aspiration initially but CXR\n with no signs of aspiration. ABG shows pO2 of 50 with Pulse Oximetry\n measuring O2 sat of 95% which do no corrleate. A total of 3 ABGs taken\n with similar results, unlikely venous. Unclear what the cause of the\n discrepancy is.\n -- cont to monitor, saturating well on room air\n #. Acute mental status changes: Likely toxic-metabolic from Uremia.\n Renal team is planning on placing HD line tomorrow. Other possibility\n in includes hepatic encephalopathy. patient has elevated INR, with\n thrombocytopenia which raises the possibility of liver disease. CT\n done on shows no signs of cirrhosis. UA done today shows +UTI,\n will start Cipro\n - f/u Renal recs\n - possible HD line placement tomorrow\n - repeat LFTs\n - trial of lactulose\n - start Cipro IV for treatment of UTI\n - f/u Urine cultures\n - start 1/2 NS\n .\n #. Acute on chronic renal failure: Currently with improved Urine\n output. ARF thought to be to ATN. Renal following\n - Avoid nephrotoxins\n - Renal following, appreciate recs\n .\n #. Thrombocytopenia: Trend began at OSH. ruled out for HIT. ?Liver\n disease.\n - monitor platelet count\n .\n #. Anemia: HCT stable, cont to monitor\n .\n #. PVD with bilateral LE cellulitis/ulcers:\n - Vascular surgery following\n - Wound care consult\n .\n #. Gout:\n - cont allopurinol\n .\n #. Diabetes on insulin:\n - HISS, Glargine\n .\n #. Afib: currently in NSR with bigeminy\n - hold coumadin, start heparin gtt tomorrow after HD line placement\n .\n #. H/o DVT: on coumadin at home being held currently. will plan to\n start Hep gtt tomorrow\n - hold coumadin, start heparin gtt tomorrow after HD line placement\n .\n #FEN: IVFs, monitor/replete electrolytes\n #PPX: bowel regimen, and ranitidine\n #ACCESS: PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: medical floor\n"
},
{
"category": "Nursing",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 604189,
"text": "66 yo male admitted originally from Hospital. Multiple\n medical problems including: OSA, DM, chronic leg ulcers. Current\n hospital course complicated by hypothermia, prolonged encephalopathy,\n and renal failure. Triggered this AM on CC7 for O2 sats 87-88 despite\n being placed on CPAP, and somnolence. Transferred to MICU for further\n monitoring.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Uses CPAP at night but not always compliant.\n Triggered this AM on floor for sats down to the 80s and somnolence.\n Action:\n Arrived to MICU on NRB with sats 100%.\n Titrated O2 to 1L and room air within 1 hour of admission.\n Response:\n Sats mid 90s while awake and low 90s while asleep.\n Plan:\n CPAP overnight.\n Renal following. Will restart 24 hr urine collection here in MICU and\n continue until @ 1600.\n Urine output marginal. Family stating that he received four sessions\n of HD at Hospital. Will continue to evaluate renal function\n with possible need for HD.\n Plan to call out to floor tomorrow if remains stable.\n Has no safety awareness and has history of pulling out IVs. Patient\n lethargic but arousable; oriented Xs .\n Order for PICC placement.\n Order for HD line in IR.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601596,
"text": "Chief Complaint: Hypotension\n 24 Hour Events:\n -vanco held for supratherapeutic trough, dose changed to 500 mg q24\n -hydrocort tapered to 50 mg q12\n -d/c'd fluconazole\n -picc placement deferred given has central line and only needs 4 more\n days of ABX\n -started PO diet\n -restarted carvedilol 6.25 \n -gave D5W x 2L to address free H20 deficit\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 02:00 AM\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 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 81 (78 - 95) bpm\n BP: 135/48(76) {124/40(67) - 174/84(114)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 10 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,252 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,252 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 37 K/uL\n 7.5 g/dL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs: PT / PTT / INR:18.5/85.4/1.7, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5 %, D-dimer:1397 ng/mL,\n Fibrinogen:565 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252\n IU/L, Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Microbiology: Repeat UCx NGTD\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n #Multifactorial shock\n resolved, now off pressors x 12 hrs; attributed\n to sepsis (with likely sources being nonhealing skin wounds and\n pneumonia, given CT findings) and relative adrenal insufficiency; TTE\n showed mod dilated LV/RV with nl LV systolic function and mildly\n depressed RV function, mild AS, mod pulm HTN (TR grad 42 mmHg), making\n cardiogenic shock less likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspiration PNA\n -f/u repeat UCx\n -begin tapering corticosteroids, d/c fludrocort\n -restart amiodarone, carvediolol when hemodynamically stable x 24 hrs\n off pressors\n #Hypercapnic respiratory failure\n resp status stable s/p extubation\n ; euvolemic over the past 24 hrs\n -albumin, lasix prn for volume goal even\n -wean O2 as tolerated to maintain sat>92%\n -ABX as above\n -encourage CPAP use, wife plans to bring in home unit\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -renally dose meds\n #Thrombocytopenia\n unclear etiology, most likely bone marrow\n suppression from sepsis as well as possible drug-induced\n thrombocytopenia; HIT and ADAMTS13 negative at OSH; no e/o DIC by labs\n -repeat CBC in PM\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n #. Gout:\n - cont allopurinol\n - hold colchicine\n #. DM\n - cont. basal, sliding scale insulin\n - following, appreciate recs\n #.Afib s/p cardioversion\n currently in sinus\n -restarted on carvediolol\n -hold amiodarone\n -hold coumadin, heparin gtt\n #DVT\n -heparin gtt, cont hold coumadin\n #FEN: I&O goal of even, monitor/replete electrolytes; ADAT, monitor for\n s/sx aspiration\n #PPX: heparin gtt, H2blocker; OOB to chair, PT C/S\n #ACCESS: RIJ CVL, PIV; d/c A-line\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: transfer to floor if stable today\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 604176,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n This is a 66 y/o male with PMHx of DM, HTN, DVT on coumadin, and PVD\n with chronic LE ulcers and cellulitis who was transferred from the\n medical floor for hypoxia. The patient was admitted to on\n with worsening LE edema and ulcers. Tx to MICU for\n septic shock group B strep bacteremia thought ulcers. This was\n c/b afib with RVR requiring cardioversion on , started on\n amio/coumdin, and ATN requiring 2 sessions of HD. Transferred here to\n Vascular service for LE angiogram.\n Soon after arriving here, became unresponsive and found to be\n hypotensive and in hypercarbic respiratory failure requiring intubation\n and MICU stay. At that time, started on seroids for\n adrenal insufficiency as well as clinda/cipro. S/p 8 day course for\n HAP. Back on medical floor, his subsequent hospital course was\n complicated by altered mental status, thought encephalopathy from\n infection, hypernatremia, and uremia, as well as acute on chronic renal\n failure being followed by Nephrology. This morning, the patient was\n found to be unresponsive and hypoxic. Transferred to MICU for further\n management.\n On arrival, his VS were stable and mental status quickly returned to\n baseline. O2 also weaned down to baseline.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:43 PM\n Other medications:\n Pred 20mg QOD, SQ heparin, sevelamir, ranitidine, ASA, atorvastatin,\n RISS, MV,\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis on QOD steroids\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n Non-contributory.\n Occupation: Owns liquor store.\n Drugs: Denies\n Tobacco: 4 ppd x 40 years, quit \n Alcohol: drinks/day\n Other: Lives with wife in .\n Review of systems:\n Per family, patient has been altered since 2-3 days PTA at .\n Flowsheet Data as of 04:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 89 (88 - 98) bpm\n BP: 114/37(55) {106/29(49) - 122/67(76)} mmHg\n RR: 23 (15 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 72 Inch\n Total In:\n 38 mL\n PO:\n TF:\n IVF:\n 38 mL\n Blood products:\n Total out:\n 0 mL\n 115 mL\n Urine:\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -78 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.31/53/49/22/0\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, Bandages on LE ulcers, L knee>R knee, impressive tophi\n Skin: Stage II decub on cocyx 6x6in\n Neurologic: Attentive, Poorly following commands, A&O x 1 (name)\n Labs / Radiology\n 47 K/uL\n 27.7 %\n 8.5 g/dL\n 100 mg/dL\n 2.4 mg/dL\n 92 mg/dL\n 22 mEq/L\n 117 mEq/L\n 4.7 mEq/L\n 150 mEq/L\n 4.2 K/uL\n [image002.jpg]\n 11:46 AM\n 12:02 PM\n 01:55 PM\n WBC\n 4.2\n Hct\n 27.7\n Plt\n 47\n Cr\n 2.4\n TropT\n 0.53\n TC02\n 27\n 27\n 28\n Glucose\n 100\n Other labs: CK / CKMB / Troponin-T:49//0.53, Lactic Acid:0.8 mmol/L,\n Mg++:2.5 mg/dL\n Imaging: CXR\n large heart with pulmonary edema. TTE\n EF 65-70%\n Microbiology: U/A +, culture pending\n EKG: RBBB with L anterior fascicular block, Bigeminy\n at baseline\n Assessment and Plan\n 66M with PMHx sig. for DM, HTN, h/o DVT on coumadin, PVD with chronic\n LE ulcers and cellulitis, who initially went to for his LE\n ulcers, found to have beta streptococcal septic shock complicated by\n ATN requiring HD and afib s/p cardioversion who was transferred from\n Hospital for angiogram of BLEs. First MICU stay \n for hypotension, hypercarbic respiratory failure, and altered mental\n status. Back on floor, ongoing altered mental status and then found to\n be unresponsive and hypoxic requiring another transfer to MICU.\n # Hypoxia: Unclear precipitating event for transfer, although CXR\n appears unremarkable. Perhaps element of aspiration pneumonitis, now\n resolved. Back to baseline O2 requirement, likely from volume\n overload/atelectasis.\n - Nightly CPAP if tolerated without sedation\n - Wean O2 as tolerated, check BNP\n # Mental status: Likely multifactorial hypernatremia, uremia, high\n ammonia, hypotension and UTI or other source of infection. Past head\n CT unremarkable. No evidence of liver cirrhosis on previous imaging.\n - Check LFTs, lactulose enema\n -\n NS for hypernatremia\n - Consider HD for uremia\n renal aware\n - F/U urine cx, start cipro\n - Send blood cultures\n - No indication for further imaging or LP at this time\n - Repeat TSH as previous c/w hypothyroidism\n # ARF: Likely another course of ATN based on previous work-up.\n - Renal considering starting HD tomorrow for uremia, volume overload.\n need pressor support to allow slow fluid removal.\n - On\n NS for hypervolemic hypernatremia\n - 24 hour urine creatinine\n # UTI: On cipro\n # LE ulcers:\n - Clarify plan with vascular\n still needs venogram once HD started\n # Nutrition:\n - Plan for PICC line placement and initiation of TPN to help augment\n nutritional stores\n # Thrombocytopenia: Work-ed up by heme in the past. Thought due to\n sepsis. Will follow.\n # Anemia: Will follow\n # Anticoagulation: A fib and h/o DVT. Will hold until after PICC line\n and possible HD line, then start IV heparin gtt.\n ICU Care\n Nutrition: PO, but not taking in sufficient calories\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:24 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin after procedures\n completed)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 604138,
"text": ".H/O obstructive sleep apnea (OSA)\n Assessment:\n Uses CPAP at night but not always compliant.\n Triggered this AM on floor for sats down to the 80s and somnolence.\n Action:\n Arrived to MICU on NRB with sats 100%.\n Titrated O2 to 1L and room air within 1 hour of admission.\n Response:\n Sats mid 90s while awake and low 90s while asleep.\n Plan:\n CPAP overnight.\n"
},
{
"category": "Nursing",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 604140,
"text": "66 yo male admitted originally from Hospital. Multiple\n medical problems including: OSA, DM, chronic leg ulcers. Current\n hospital course complicated by hypothermia, prolonged encephalopathy,\n and renal failure. Triggered this AM on CC7 for O2 sats 87-88 despite\n being placed on CPAP, and somnolence. Transferred to MICU for further\n monitoring.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Uses CPAP at night but not always compliant.\n Triggered this AM on floor for sats down to the 80s and somnolence.\n Action:\n Arrived to MICU on NRB with sats 100%.\n Titrated O2 to 1L and room air within 1 hour of admission.\n Response:\n Sats mid 90s while awake and low 90s while asleep.\n Plan:\n CPAP overnight.\n Started 24 hour urine collection on floor but will have to restart here\n in MICU.\n"
},
{
"category": "Nursing",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 604123,
"text": ".H/O obstructive sleep apnea (OSA)\n Assessment:\n Uses CPAP at night but not always compliant.\n Triggered this AM on floor for sats down to the 80s and somnolence.\n Action:\n Arrived to MICU on NRB with sats 100%.\n Titrated O2 down to room air within 1 hour of admission.\n Response:\n Sats mid 90s while awake and low 90s while asleep.\n Plan:\n CPAP overnight.\n"
},
{
"category": "Nursing",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 604211,
"text": "66 yo male admitted originally from Hospital. Multiple\n medical problems including: OSA, DM, chronic leg ulcers. Current\n hospital course complicated by hypothermia, prolonged encephalopathy,\n and renal failure. Triggered this AM on CC7 for O2 sats 87-88 despite\n being placed on CPAP, and somnolence. Transferred to MICU for further\n monitoring.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Uses CPAP at night but not always compliant.\n Triggered this AM on floor for sats down to the 80s and somnolence.\n Action:\n Arrived to MICU on NRB with sats 100%.\n Titrated O2 to 1L and room air within 1 hour of admission.\n Response:\n Sats mid 90s while awake and low 90s while asleep.\n Plan:\n CPAP overnight.\n Altered mental status\n Assessment:\n Received patient who is lethargic & Oriented to self only. Patient does\n not follow commands but moves extremities at times. Denies pain. ?\n encephalopathy. Restraints applied bilat for patient\ns safety as he\n has H/O pulling out the tubes.\n Action:\n Patient has been kept NPO. No PO meds given at this time. NG in place.\n X-ray done to confirm the placement. Blood sent at 200 hrs. Na : 153 (\n up from 150\ns). 0.45% NS stopped . Order for Lactulose.\n Response:\n Lactulose to be given after NG tube placement confirmed.\n Plan:\n Cont monitoring his mental status. Lytes to be sent at AM. Plan for\n PICC placement.\n Renal failure\n Assessment:\n Family stated that he received four sessions of HD at \n Hospital\n Action:\n Renal following. Restarted 24 hr urine collection here in MICU and\n continue until @ 1600.\n Response:\n Urine output lower marginal.\n Plan:\n Plz cont with 24 hr urine collection here in MICU. Possible need for HD\n line placement in IR .\n"
},
{
"category": "Nursing",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 604212,
"text": "66 yo male admitted originally from Hospital. Multiple\n medical problems including: OSA, DM, chronic leg ulcers. Current\n hospital course complicated by hypothermia, prolonged encephalopathy,\n and renal failure. Triggered this AM on CC7 for O2 sats 87-88 despite\n being placed on CPAP, and somnolence. Transferred to MICU for further\n monitoring.\n .H/O obstructive sleep apnea (OSA)\n Assessment:\n Uses CPAP at night but not always compliant.\n Triggered this AM on floor for sats down to the 80s and somnolence.\n Received on 2 L Nasal cannula.\n Action:\n O2 weaned off.\n Response:\n Sats mid 90s while awake and low 90s while asleep.\n Plan:\n CPAP overnight.( Uses own machine).\n Altered mental status\n Assessment:\n Received patient who is lethargic & Oriented to self only. Patient does\n not follow commands but moves extremities at times. Denies pain. ?\n encephalopathy. Restraints applied bilat for patient\ns safety as he\n has H/O pulling out the tubes.\n Action:\n Patient has been kept NPO. No PO meds given at this time. NG in\n place.N.\n X-ray done to confirm the NG tube placement. Blood sent at 200 hrs.\n Na : 153 ( up from 150\ns). 0.45% NS stopped . Order for Lactulose.\n Response:\n Lactulose to be given after NG tube placement confirmed.\n Plan:\n Cont monitoring his mental status. Lytes to be sent at AM. Plan for\n PICC placement.\n Renal failure\n Assessment:\n Family stated that he received four sessions of HD at \n Hospital\n Action:\n Renal following. Restarted 24 hr urine collection here in MICU and\n continue until @ 1600.\n Response:\n Urine output lower marginal.\n Plan:\n Plz cont with 24 hr urine collection here in MICU. Possible need for HD\n line placement in IR .\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CELLULITIS;LEFT LOWER EXTREMITY ULCER\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 130.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:93\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SA (Sinus Arrhythmia)\n O2 delivery device:\n CPAP mask\n O2 saturation:\n 98% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 413 mL\n 24h total out:\n 245 mL\n Pertinent Lab Results:\n Sodium:\n 153 mEq/L\n 07:15 PM\n Potassium:\n 4.8 mEq/L\n 07:15 PM\n Chloride:\n 118 mEq/L\n 07:15 PM\n CO2:\n 23 mEq/L\n 07:15 PM\n BUN:\n 94 mg/dL\n 07:15 PM\n Creatinine:\n 2.3 mg/dL\n 07:15 PM\n Glucose:\n 97\n 10:00 PM\n Hematocrit:\n 27.7 %\n 12:02 PM\n Finger Stick Glucose:\n 100\n 06:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 07\n Transferred to: CC 712\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601437,
"text": "HPI:\n 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulitis,\n beta streptococcal septic shock complicated by ATN requiring HD, afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place\n Action:\n pt oriented to location and time, pt able to follow commands,\n Response:\n while in room ab\n Plan:\n Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 601658,
"text": "66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 601659,
"text": "66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care.\n Altered mental status (not Delirium)\n Assessment:\n Pt alter and awake orientated x1-2\n Action:\n Pt reorientatedx3\n Response:\n No change in mental status still forgets after reorientated\n Plan:\n Continue to reorient pt to time and place\n Decubitus ulcer (Present At Admission)\n Assessment:\n Decube ulcer improving\n Action:\n Ulcer dressing changed by wound care nurse with wound\n cleanser and aquacel ag applied dsd applied. Also adaptic to no\n weeping areas\n Response:\n More drainage noted on rt foot, rt posterior knee area still bleeding\n at times. Fungal rasg improving\n Plan:\n Continue with wound care recommendations change dressing as needed,\n antifungal cream to buttocks\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 601660,
"text": "66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care. Pt was extubated on sat\n \n Altered mental status (not Delirium)\n Assessment:\n Pt alter and awake orientated x1-2\n Action:\n Pt reorientatedx3\n Response:\n No change in mental status still forgets after reorientated\n Plan:\n Continue to reorient pt to time and place\n Decubitus ulcer (Present At Admission)\n Assessment:\n Decube ulcer improving\n Action:\n Ulcer dressing changed by wound care nurse with wound\n cleanser and aquacel ag applied dsd applied. Also adaptic to no\n weeping areas\n Response:\n More drainage noted on rt foot, rt posterior knee area still bleeding\n at times. Fungal rasg improving\n Plan:\n Continue with wound care recommendations change dressing as needed,\n antifungal cream to buttocks\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt having bleeding from nose, pt on a heparin drip at 1000u/hr, pt\n coughing up tan sputum, pt on 35% shovel mask to 2L n/c lung sounds\n decreased in bases, pt picking at nose and incouraged to leave nose\n alone\n Action:\n Heparin drip stopped at 1230 pm, pt\ns drip restarted at 14:30 and pt\n started on ciipro and clindamycin po\n Response:\n Pt afebrile, wbc 3.3\n Plan:\n Encourage plum toilet, will repeat ptt this evening and check hct\n this afternoon.\n"
},
{
"category": "Rehab Services",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Generic Note",
"row_id": 601661,
"text": "TITLE:\n RSD OT: orders for consult received, full evaluation to be filed upon\n completion. Thanks for this referral.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 601663,
"text": "66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care. Pt was extubated on sat\n \n Altered mental status (not Delirium)\n Assessment:\n Pt alter and awake orientated x1-2\n Action:\n Pt reorientatedx3\n Response:\n No change in mental status still forgets after reorientated\n Plan:\n Continue to reorient pt to time and place\n Decubitus ulcer (Present At Admission)\n Assessment:\n Decube ulcer improving\n Action:\n Ulcer dressing changed by wound care nurse with wound\n cleanser and aquacel ag applied dsd applied. Also adaptic to no\n weeping areas\n Response:\n More drainage noted on rt foot, rt posterior knee area still bleeding\n at times. Fungal rasg improving\n Plan:\n Continue with wound care recommendations change dressing as needed,\n antifungal cream to buttocks\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt having bleeding from nose, pt on a heparin drip at 1000u/hr, pt\n coughing up tan sputum, pt on 35% shovel mask to 2L n/c lung sounds\n decreased in bases, pt picking at nose and incouraged to leave nose\n alone\n Action:\n Heparin drip stopped at 1230 pm, pt\ns drip restarted at 14:30 and pt\n started on ciipro and clindamycin po\n Response:\n Pt afebrile, wbc 3.3\n Plan:\n Encourage plum toilet, will repeat ptt this evening and check hct\n this afternoon.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n CELLULITIS;LEFT LOWER EXTREMITY ULCER\n Code status:\n Height:\n 72 Inch\n Admission weight:\n 123.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma, Diabetes - Insulin, Renal Failure\n CV-PMH: Arrhythmias, PVD\n Additional history: strep sepsis from osh ll ulcers, ulcerative\n colitis, gout, sacral decub ulcers, osa, dm, htn, afib,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:58\n Temperature:\n 96.9\n Arterial BP:\n S:150\n D:66\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 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 40% %\n 24h total in:\n 2,909 mL\n 24h total out:\n 1,360 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 03:32 AM\n Potassium:\n 4.3 mEq/L\n 03:32 AM\n Chloride:\n 114 mEq/L\n 03:32 AM\n CO2:\n 22 mEq/L\n 03:32 AM\n BUN:\n 82 mg/dL\n 03:32 AM\n Creatinine:\n 2.0 mg/dL\n 03:32 AM\n Glucose:\n 200 mg/dL\n 03:32 AM\n Hematocrit:\n 22.7 %\n 03:32 AM\n Finger Stick Glucose:\n 206\n 12:00 PM\n Valuables / Signature\n Patient valuables: glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu7\n Transferred to: cc621\n Date & time of Transfer: 1600\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601086,
"text": "TODAY: Pt bradycardic at the start of the shift in the low to mid 40\n had been bradycardic overnight, MICU resident aware. Per MICU\n resident, bracycardia overnight thought to be Propofol gtt .\n Thought to be Propofol gtt, however noted to begin having frequent\n ventricular bigeminy. EKG obtained and electrolytes drawn. K is down to\n 4.6.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. Also\n noted to have yeast rash in peri area. BLE with multiple areas of\n ulceration\n vascular following. R arm edematous and weeping serous\n fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated. Remains fluid overloaded, however\n UOP is picking up. Renal following.\n Action:\n UOP and Electrolytes monitored. Pt received a total of 80mg Lasix IVP\n today. Per renal team, no immediate plans to dialyze at this time.\n Response:\n Pt responded to Lasix with 260mL UOP. K remains elevated.\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n ..\n Action:\n Abx as ordered. Blood cultures sent this AM.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed gtt 0.056mcg/kg/min. SBP sustained in the\n 1teens to 120\ns this AM.\n Action:\n Levophed gtt weaned as tolerated.\n Response:\n Pt is currently on 0.032mcg/kg/min Levophed. SBP is in the 120\ns and\n MAP is low 60\n Plan:\n Titrate Levophed gtt to maintain MAPS at goal >60.\n Acidosis, Respiratory\n Assessment:\n Received pt vented on CMV 50%/550/20/5. O2 sats 98-100%. Pt not OBV.\n AM ABG 7.30/34/113.\n Action:\n Sedation decreased and pt placed on CPAP 40% 10/5.\n Response:\n Reflective ABG when initially placed on CPAP 7.26/44/94. Sedation\n weaned off and pt more alert. Repeat ABG once pt more alert\n 7.28/41/129. Pt appears to be comfortable on CPAP. Denies any\n difficulty breathing. RR in the teens and spo2 95-100%.\n Plan:\n Wean vent as tolerated by pt. Monitor ABG\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601323,
"text": "66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure. Resp\n failure req intubation x 48 hrs. Now extubated yesterday, doing well.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt coccyx dressing changed overnight. Appears to looks slightly better\n that on day of admission. Dressings on legs intact.\n Action:\n Leg dressing no oozing noted, no odor, remains on iv antibiotics\n Response:\n Pt afebrile, legs seem to be improving per previous dsg change. As\n above coccyx looking skl better. Yeast around perineum and coccyx\n dressing much improved\n Plan:\n Continue with qd dsg changes to bilat legs, and prn to coccyx\n Hypotension (not Shock)\n Assessment:\n Received on 0.02 mcg/kg/min of Levophed. Bp good\n Action:\n Levo off at 2100 with infusion of albumin.\n Response:\n Bp much improved overnight. Levophed off most of night.\n Plan:\n Continue albumin x5 doses\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt lung sounds decreased throughout sats high 90\n Action:\n Pt weaned and extubated yesterday, on 3l n/c now\n Response:\n Pt tolerated wean of fio2\n Plan:\n Will follow o2 sats , refused cpap ovenright\n Urine culture sent last evening\n Tongue noted to be making odd movements, did not look swollen per se as\n appears to be in proportion with the rest of his body Ho aware.\n"
},
{
"category": "Nutrition",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 601666,
"text": "Subjective\n Decreased appetite,\nI have diarrhea\". \"I don't need those\" (when\n asked about taking po supplements)\n Objective\n Pertinent medications: Heparin drip, ALbumin, ABX, Prednisone, HISS,\n Glargine 30 units at HS\n Labs:\n Value\n Date\n Glucose\n 200 mg/dL\n 03:32 AM\n Glucose Finger Stick\n 206\n 12:00 PM\n BUN\n 82 mg/dL\n 03:32 AM\n Creatinine\n 2.0 mg/dL\n 03:32 AM\n Sodium\n 147 mEq/L\n 03:32 AM\n Potassium\n 4.3 mEq/L\n 03:32 AM\n Chloride\n 114 mEq/L\n 03:32 AM\n TCO2\n 22 mEq/L\n 03:32 AM\n PO2 (arterial)\n 149 mm Hg\n 11:50 AM\n PO2 (venous)\n 59 mm Hg\n 02:03 PM\n PCO2 (arterial)\n 41 mm Hg\n 11:50 AM\n PCO2 (venous)\n 69 mm Hg\n 02:03 PM\n pH (arterial)\n 7.30 units\n 11:50 AM\n pH (venous)\n 7.13 units\n 02:03 PM\n pH (urine)\n 5.5 units\n 08:04 PM\n CO2 (Calc) arterial\n 21 mEq/L\n 11:50 AM\n CO2 (Calc) venous\n 24 mEq/L\n 02:03 PM\n Albumin\n 1.8 g/dL\n 04:58 AM\n Calcium non-ionized\n 9.4 mg/dL\n 03:32 AM\n Phosphorus\n 3.5 mg/dL\n 03:32 AM\n Magnesium\n 2.5 mg/dL\n 03:32 AM\n Total Bilirubin\n 1.1 mg/dL\n 01:56 PM\n WBC\n 3.3 K/uL\n 03:32 AM\n Hgb\n 7.5 g/dL\n 03:32 AM\n Hematocrit\n 22.7 %\n 03:32 AM\n Current diet order / nutrition support: Diet: Low sodium, heart\n healthy/diabetic\n GI: soft/distended, (+) bowel sounds; liquid stool\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: Low po intake, wounds\n Estimation of current intake: Inadequate\n Specifics:\n 66 YO male with chronic lower extremity ulcers and cellulitis who was\n admitted to on and subsequently transferred here on\n to the Vascular Surgery service for possible lower extremity\n angiogram and consideration of a lower extremity revascularization\n procedure. Extubated , tube feed never started. Diet advanced to\n above . RN, patient picked at breakfast and had\n ,\n sips of gingerale and ice cream at lunch with much encouragement.\n Concerned with ability to meet nutrition needs with po\ns given\n decreased appetite and intake. Spoke with patient about importance of\n adequate nutrition to help with wound healing.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: encourage\n po\n Oral supplements: Boost Glucose Control TID\n Tube feeding recommendations: If po\ns do not improve,\n recommend supplemental nutrition support\n Check chemistry 10 panel daily\n BS management\n follow \ns recommendations\n Will follow\n page if questions *\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601386,
"text": "Chief Complaint: respiratory failure, shock\n 24 Hour Events:\n -Extubated\n -started fluconazole for funguria ( UCx >100K yeast)\n -started albumin IV bid x4 doses\n -levophed off at 2100\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:24 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.7\n HR: 68 (60 - 87) bpm\n BP: 118/45(69) {72/24(37) - 159/71(100)} mmHg\n RR: 13 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 16 (3 - 29)mmHg\n Total In:\n 2,370 mL\n 135 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 135 mL\n Blood products:\n 100 mL\n Total out:\n 2,135 mL\n 360 mL\n Urine:\n 1,435 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n -225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 676 (676 - 879) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 0 cmH2O\n FiO2: 40%\n SpO2: 99%\n ABG: 7.30/41/149/23/-5\n Ve: 6.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 47 K/uL\n 7.9 g/dL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: portable CXR\n The ET tube tip is 6.4 cm above the carina. The NG tube tip passes\n below the inferior margin of the study. The right internal jugular line\n tip is at the\n level of mid SVC. Only the upper and mid portion of the lungs have been\n included in the field of view with the lung bases not imaged. The upper\n lungs are essentially clear although mild pulmonary edema cannot be\n excluded.\n Repeated radiograph including the lung bases is highly recommended.\n Microbiology: 3:58 pm URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ):\n YEAST. >100,000 ORGANISMS/ML..\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n now off pressors; attributed to sepsis (with\n likely sources being nonhealing skin wounds and pneumonia, given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg), making cardiogenic shock less\n likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspirationl PNA\n -cont fluconazole (day 2), repeat UCx\n -add on differential to CBC\n -cont hydro/fludrocort\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\n stable resp status s/p extubation\n \n -wean O2 as tolerated to\n -ABX as above\n -transitioned to bolus sedation\n -encourage CPAP use\n .\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -cont lasix and albumin\n -volume goal even\n -renally dose meds\n .\n #Thrombocytopenia\n unclear etiology; HIT and ADAMTS13 negative at OSH;\n no e/o DIC by labs\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n -or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: ICU\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601387,
"text": "Chief Complaint: respiratory failure, shock\n 24 Hour Events:\n -Extubated\n -started fluconazole for funguria ( UCx >100K yeast)\n -started albumin IV bid x4 doses\n -levophed off at 2100\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:24 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.7\n HR: 68 (60 - 87) bpm\n BP: 118/45(69) {72/24(37) - 159/71(100)} mmHg\n RR: 13 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 16 (3 - 29)mmHg\n Total In:\n 2,370 mL\n 135 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 135 mL\n Blood products:\n 100 mL\n Total out:\n 2,135 mL\n 360 mL\n Urine:\n 1,435 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n -225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 676 (676 - 879) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 0 cmH2O\n FiO2: 40%\n SpO2: 99%\n ABG: 7.30/41/149/23/-5\n Ve: 6.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 47 K/uL\n 7.9 g/dL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: portable CXR\n The ET tube tip is 6.4 cm above the carina. The NG tube tip passes\n below the inferior margin of the study. The right internal jugular line\n tip is at the\n level of mid SVC. Only the upper and mid portion of the lungs have been\n included in the field of view with the lung bases not imaged. The upper\n lungs are essentially clear although mild pulmonary edema cannot be\n excluded.\n Repeated radiograph including the lung bases is highly recommended.\n Microbiology: 3:58 pm URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ):\n YEAST. >100,000 ORGANISMS/ML..\n Sputum Cx\nGRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n now off pressors; attributed to sepsis (with\n likely sources being nonhealing skin wounds and pneumonia, given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg), making cardiogenic shock less\n likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspirationl PNA\n -cont fluconazole (day 2), repeat UCx\n -add on differential to CBC\n -cont hydro/fludrocort\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\n stable resp status s/p extubation\n \n -wean O2 as tolerated to\n -ABX as above\n -transitioned to bolus sedation\n -encourage CPAP use\n .\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -cont lasix and albumin\n -volume goal even\n -renally dose meds\n .\n #Thrombocytopenia\n unclear etiology; HIT and ADAMTS13 negative at OSH;\n no e/o DIC by labs\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n -or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: ICU\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601388,
"text": "Chief Complaint: respiratory failure, shock\n 24 Hour Events:\n -Extubated\n -started fluconazole for funguria ( UCx >100K yeast)\n -started albumin IV bid x4 doses\n -levophed off at 2100\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:24 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.7\n HR: 68 (60 - 87) bpm\n BP: 118/45(69) {72/24(37) - 159/71(100)} mmHg\n RR: 13 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 16 (3 - 29)mmHg\n Total In:\n 2,370 mL\n 135 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 135 mL\n Blood products:\n 100 mL\n Total out:\n 2,135 mL\n 360 mL\n Urine:\n 1,435 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n -225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 676 (676 - 879) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 0 cmH2O\n FiO2: 40%\n SpO2: 99%\n ABG: 7.30/41/149/23/-5\n Ve: 6.6 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral 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 anteriorly)\n Abdominal: Soft, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 47 K/uL\n 7.9 g/dL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: portable CXR\n The ET tube tip is 6.4 cm above the carina. The NG tube tip passes\n below the inferior margin of the study. The right internal jugular line\n tip is at the\n level of mid SVC. Only the upper and mid portion of the lungs have been\n included in the field of view with the lung bases not imaged. The upper\n lungs are essentially clear although mild pulmonary edema cannot be\n excluded.\n Repeated radiograph including the lung bases is highly recommended.\n Microbiology: 3:58 pm URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ):\n YEAST. >100,000 ORGANISMS/ML..\n Sputum Cx\nGRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n now off pressors; attributed to sepsis (with\n likely sources being nonhealing skin wounds and pneumonia, given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg), making cardiogenic shock less\n likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspirationl PNA\n -cont fluconazole (day 2), repeat UCx\n -add on differential to CBC\n -cont hydro/fludrocort\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\n stable resp status s/p extubation\n \n -wean O2 as tolerated to\n -ABX as above\n -transitioned to bolus sedation\n -encourage CPAP use\n .\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -cont lasix and albumin\n -volume goal even\n -renally dose meds\n .\n #Thrombocytopenia\n unclear etiology; HIT and ADAMTS13 negative at OSH;\n no e/o DIC by labs\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n -or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: ICU\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601390,
"text": "Chief Complaint: respiratory failure, shock\n 24 Hour Events:\n -Extubated\n -started fluconazole for funguria ( UCx >100K yeast)\n -started albumin IV bid x4 doses\n -levophed off at 2100\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:24 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: Denies chest pain, cough, shortness of breath, abd\n pain, nausea\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.7\n HR: 68 (60 - 87) bpm\n BP: 118/45(69) {72/24(37) - 159/71(100)} mmHg\n RR: 13 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 16 (3 - 29)mmHg\n Total In:\n 2,370 mL\n 135 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 135 mL\n Blood products:\n 100 mL\n Total out:\n 2,135 mL\n 360 mL\n Urine:\n 1,435 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n -225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 99% 3L\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral 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: diminished at bases\n Abdominal: Soft, NTND Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Awake, alert, conversing appropriately, oriented to person\n only\n Labs / Radiology\n 47 K/uL\n 7.9 g/dL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: portable CXR\n The ET tube tip is 6.4 cm above the carina. The NG tube tip passes\n below the inferior margin of the study. The right internal jugular line\n tip is at the\n level of mid SVC. Only the upper and mid portion of the lungs have been\n included in the field of view with the lung bases not imaged. The upper\n lungs are essentially clear although mild pulmonary edema cannot be\n excluded.\n Repeated radiograph including the lung bases is highly recommended.\n Microbiology: 3:58 pm URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ):\n YEAST. >100,000 ORGANISMS/ML..\n Sputum Cx\nGRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n now off pressors; attributed to sepsis (with\n likely sources being nonhealing skin wounds and pneumonia, given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg), making cardiogenic shock less\n likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspirationl PNA\n -cont fluconazole (day 2), repeat UCx\n -add on differential to CBC\n -cont hydro/fludrocort\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nresp status stable s/p extubation\n \n -wean O2 as tolerated to\n -ABX as above\n -transitioned to bolus sedation\n -encourage CPAP use\n .\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -cont lasix and albumin\n -volume goal even\n -renally dose meds\n .\n #Thrombocytopenia\n unclear etiology; HIT and ADAMTS13 negative at OSH;\n no e/o DIC by labs\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n -or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes; sips, ADAT, monitor for s/sx\n aspiration\n #PPX: heparin gtt, H2blocker; OOB to chair, PT C/S\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: ICU\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601391,
"text": "Chief Complaint: respiratory failure, shock\n 24 Hour Events:\n -Extubated\n -started fluconazole for funguria ( UCx >100K yeast)\n -started albumin IV bid x4 doses\n -levophed off at 2100\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:24 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: Denies chest pain, cough, shortness of breath, abd\n pain, nausea\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.7\n HR: 68 (60 - 87) bpm\n BP: 118/45(69) {72/24(37) - 159/71(100)} mmHg\n RR: 13 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 16 (3 - 29)mmHg\n Total In:\n 2,370 mL\n 135 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 135 mL\n Blood products:\n 100 mL\n Total out:\n 2,135 mL\n 360 mL\n Urine:\n 1,435 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n -225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 99% 3L\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral 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: diminished at bases\n Abdominal: Soft, NTND Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Awake, alert, conversing appropriately, oriented to person\n only\n Labs / Radiology\n 47 K/uL\n 7.9 g/dL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: portable CXR\n The ET tube tip is 6.4 cm above the carina. The NG tube tip passes\n below the inferior margin of the study. The right internal jugular line\n tip is at the\n level of mid SVC. Only the upper and mid portion of the lungs have been\n included in the field of view with the lung bases not imaged. The upper\n lungs are essentially clear although mild pulmonary edema cannot be\n excluded.\n Repeated radiograph including the lung bases is highly recommended.\n Microbiology: 3:58 pm URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ):\n YEAST. >100,000 ORGANISMS/ML..\n Sputum Cx\nGRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n now off pressors; attributed to sepsis (with\n likely sources being nonhealing skin wounds and pneumonia, given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg), making cardiogenic shock less\n likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspiration PNA\n -cont fluconazole (day 2), repeat UCx\n -add on differential to CBC\n -cont hydro/fludrocort\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nresp status stable s/p extubation\n but remains volume overload\n - albumin/lasix to diurese -1L x 24 hrs\n -wean O2 as tolerated to maintain sat>92%\n -ABX as above\n -transitioned to bolus sedation\n -encourage CPAP use\n .\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -renally dose meds\n .\n #Thrombocytopenia\n unclear etiology; HIT and ADAMTS13 negative at OSH;\n no e/o DIC by labs\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n -or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes; sips, ADAT, monitor for s/sx\n aspiration\n #PPX: heparin gtt, H2blocker; OOB to chair, PT C/S\n #ACCESS: RIJ CVL, PIV; d/c A-line\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: ICU\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 601414,
"text": "Chief Complaint:\n HPI:\n 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulitis,\n beta streptococcal septic shock complicated by ATN requiring HD, afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well:\n 24 Hour Events:\n -started fluc after foley change\n -off norepi since 9pm yest\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:42 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n heparin gtt, vanco, fluc, albumin x4, riss, hydrocort, zantac, zosyn,\n tricor, allupur, nystatin, atorvastatin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: No(t) OG / NG tube\n Nutritional Support: No(t) NPO\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.3\nC (95.5\n HR: 85 (66 - 87) bpm\n BP: 172/84(114) {109/33(60) - 172/84(114)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 10 (3 - 17)mmHg\n Total In:\n 2,370 mL\n 502 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 402 mL\n Blood products:\n 100 mL\n 100 mL\n Total out:\n 2,135 mL\n 480 mL\n Urine:\n 1,435 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n 22 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 40%\n SpO2: 97%\n ABG: 7.30/41/149/23/-5\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), irreg\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 )\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 7.9 g/dL\n 47 K/uL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: cxr: rll opacity\n Microbiology: all neg\n Assessment and Plan\n 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulitis,\n beta streptococcal septic shock complicated by ATN requiring HD, afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well.\n Shock physiology likely multifactorial from lung, possible cellulitis,\n and possible adrenal insufficiency. Will finish an 8-day course of abx\n for presumed HAP/VAP, and titrate steroids to off over several days.\n Need further discussion with vascular about additional studies and\n dispo.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601416,
"text": "Chief Complaint: respiratory failure, shock\n 24 Hour Events:\n -Extubated\n -started fluconazole for funguria ( UCx >100K yeast)\n -started albumin IV bid x4 doses\n -levophed off at 2100\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:24 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: Denies chest pain, cough, shortness of breath, abd\n pain, nausea\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.7\n HR: 68 (60 - 87) bpm\n BP: 118/45(69) {72/24(37) - 159/71(100)} mmHg\n RR: 13 (11 - 25) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 16 (3 - 29)mmHg\n Total In:\n 2,370 mL\n 135 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 135 mL\n Blood products:\n 100 mL\n Total out:\n 2,135 mL\n 360 mL\n Urine:\n 1,435 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n -225 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 99% 3L\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral 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: diminished at bases\n Abdominal: Soft, NTND Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Awake, alert, conversing appropriately, oriented to person\n only\n Labs / Radiology\n 47 K/uL\n 7.9 g/dL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: portable CXR\n The ET tube tip is 6.4 cm above the carina. The NG tube tip passes\n below the inferior margin of the study. The right internal jugular line\n tip is at the\n level of mid SVC. Only the upper and mid portion of the lungs have been\n included in the field of view with the lung bases not imaged. The upper\n lungs are essentially clear although mild pulmonary edema cannot be\n excluded.\n Repeated radiograph including the lung bases is highly recommended.\n Microbiology: 3:58 pm URINE Source: Catheter.\n **FINAL REPORT **\n URINE CULTURE (Final ):\n YEAST. >100,000 ORGANISMS/ML..\n Sputum Cx\nGRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n resolved, now off pressors x 12 hrs; attributed\n to sepsis (with likely sources being nonhealing skin wounds and\n pneumonia, given CT findings) and relative adrenal insufficiency; TTE\n showed mod dilated LV/RV with nl LV systolic function and mildly\n depressed RV function, mild AS, mod pulm HTN (TR grad 42 mmHg), making\n cardiogenic shock less likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspiration PNA\n -hold vanco today, restart in AM at 500 mg q24h\n -would favor d/c\ning fluconazole as no strict indications for systemic\n antifungal and is clinically improved\n -repeat UCx\n -add on differential\n -begin tapering corticosteroids\n -restart amiodarone, carvediolol when hemodynamically stable x 24 hrs\n off pressors\n .\n #Hypercapnic respiratory failure\n resp status stable s/p extubation\n ; euvolemic over the past 24 hrs\n -albumin, lasix prn for volume goal even\n -wean O2 as tolerated to maintain sat>92%\n -ABX as above\n -encourage CPAP use, wife plans to bring in home unit\n .\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -renally dose meds\n .\n #Thrombocytopenia\n unclear etiology, most likely bone marrow\n suppression from sepsis as well as possible drug-induced\n thrombocytopenia; HIT and ADAMTS13 negative at OSH; no e/o DIC by labs\n -repeat CBC in PM\n -cont monitor, transfuse for plts <10K or active bleeding\n .\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. basal, sliding scale insulin\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt, cont hold coumadin\n .\n #FEN: monitor/replete electrolytes; sips, ADAT, monitor for s/sx\n aspiration\n #PPX: heparin gtt, H2blocker; OOB to chair, PT C/S\n #ACCESS: RIJ CVL, PIV; d/c A-line if remains hemodynamically stable\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: ICU, consider transfer in AM\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601552,
"text": "66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulites,\n beta streptococcal septic shock complicated by ATN requiring HD, Afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place. No changed in mental status. Pt has no c/o of pain\n Action:\n Needs to be oriented in place frequent\n Response:\n No changes in mental status, orinted in him self\n Plan:\n Pt alittle clearer now\n Decubitus ulcer (Present At Admission)\n Assessment:\n Multiple ulcer. Most dressing intact\n Action:\n Aquacell ag applied to open area, nystatin to yeast areas and covered\n with dsd, r leg dressing changed according to RN wound care\n Response:\n Pt still has open area but yeast seems to be clearing\n Plan:\n Continue with wound care recomentadtions\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n pt anterior lungs clear , decreased in bases\n Action:\n Pt weaned to 2L n/c sats 97% , pt desat to 86-87%while o 2 off, pt\n refused put CPAP, MD aware\n Response:\n Pt tolerates turning good, sat remains <90%\n Plan:\n Incourage pul toilet, will start insentive spiromatry with pt,\n incourage pt to get oob daily\n Cont Heparin , PTT in therapeutic range.\n Start D 5% fro elevated NA.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601155,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. yeast\n rash in peri area. BLE with multiple areas of ulceration\n vascular\n following. R arm edematous and weeping serous fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated, however trending downward with PM\n lytes. Remains fluid overloaded, however UOP is picking up. Renal\n following.\n Action:\n UOP and Electrolytes monitored. Pt received a total of 80mg Lasix IVP\n today. Per renal team, no immediate plans to dialyze at this time.\n Response:\n Pt responded to Lasix with 260mL UOP. K trending downward.\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n .\n Action:\n Abx as ordered. Blood cultures sent this AM.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed gtt 0.056 mcg/kg/min. SBP sustained in the\n 1teens to 120\ns this AM.\n Action:\n Levophed gtt weaned as tolerated.\n Response:\n Pt is currently on 0.032mcg/kg/min Levophed. SBP is in the 120\ns and\n MAP is low 60\n Plan:\n Titrate Levophed gtt to maintain MAPS at goal >60.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601082,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. Also\n noted to have yeast rash in peri area. BLE with multiple areas of\n ulceration\n vascular following. R arm edematous and weeping serous\n fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated. Remains fluid overloaded, however\n UOP is picking up. Renal following.\n Action:\n UOP and Electrolytes monitored. Pt received a total of 80mg Lasix IVP\n today. Per renal team, no immediate plans to dialyze at this time.\n Response:\n Pt responded to Lasix with 260ml UOP. K remains elevated.\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n ..\n Action:\n Abx as ordered. Blood cultures sent this AM.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed gtt 0.056mcg/kg/min. SBP sustained in the\n 1teens to 120\ns this AM.\n Action:\n Levophed gtt weaned as tolerated.\n Response:\n Pt is currently on 0.032mcg/kg/min Levophed. SBP is in the 120\ns and\n MAP is low 60\n Plan:\n Titrate Levophed gtt to maintain MAPS at goal >60.\n Acidosis, Respiratory\n Assessment:\n Received pt vented on CMV 50%/550/20/5. O2 sats 98-100%\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601621,
"text": "Chief Complaint: Hypotension\n 24 Hour Events:\n -vanco held for supratherapeutic trough, dose changed to 500 mg q24\n -hydrocort tapered to 50 mg q12\n -d/c'd fluconazole\n -picc placement deferred given has central line and only needs 4 more\n days of ABX\n -started PO diet\n -restarted carvedilol 6.25 \n -gave D5W x 2L to address free H20 deficit\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 02:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n No pain, CP, SOB, N/V, abdominal pain, LE pain.\n Just feels tired.\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 81 (78 - 95) bpm\n BP: 135/48(76) {124/40(67) - 174/84(114)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 10 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,252 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,252 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n Gen: No acute distress\n CV: irregular, grade II/VI systolic murmur at RUSB\n Pulm: CTAB\n Abd: +BS, soft, NT, ND\n Ext: 2+ edema, BLE ulcers\n Labs / Radiology\n 37 K/uL\n 7.5 g/dL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs: PT / PTT / INR:18.5/85.4/1.7, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5 %, D-dimer:1397 ng/mL,\n Fibrinogen:565 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252\n IU/L, Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Microbiology: Repeat UCx NGTD\n 3:58 pm SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH Commensal Respiratory Flora.\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n #Multifactorial shock\n resolved, now off pressors x 36 hrs; attributed\n to sepsis (with likely sources being nonhealing skin wounds and\n pneumonia/aspiration, given CT findings) and relative adrenal\n insufficiency; TTE showed mod dilated LV/RV with nl LV systolic\n function and mildly depressed RV function, mild AS, mod pulm HTN (TR\n grad 42 mmHg), making cardiogenic shock less likely\n -appreciate vascular surgery recs\n -cont vanc, change zosyn to cipro/clinda (day ) given likely that\n zosyn causing thrombocytopenia for nosocomia/aspiration PNA\n -change hydrocort back to home prednisone 10 mg daily (20 mg QOD)\n -consider eval for osteo underlying skin wounds\n #Hypercapnic respiratory failure\n resp status stable s/p extubation\n ; <1L positive in 24 hrs euvolemic over the past 24 hrs\n - lasix prn for volume goal even to -500 cc x 24 hrs\n -wean O2 as tolerated to maintain sat>92%\n -ABX as above\n -encourage CPAP use, wife plans to bring in home unit\n #Chronic renal failure\n nonoliguric, Cr stable at baseline ; most\n attributable to ATN from shock\n -appreciate renal recs\n -renally dose meds\n #Thrombocytopenia\n unclear etiology, most likely bone marrow\n suppression from sepsis as well as possible drug-induced\n thrombocytopenia. Vanc causes immune-thrombocytopenia and\n thrombocytopenia, Zosyn has also been associated with thrombocytopenia\n but only in case reports. Zoysn does cause pancytopenia, high risk in\n renal failure patients. HIT and ADAMTS13 negative at OSH; no e/o DIC\n by labs.\n -change abx, as above\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n #. Gout:\n - cont allopurinol\n - hold colchicine\n #. DM\n - cont. basal, sliding scale insulin\n - following, appreciate recs\n #.Afib s/p cardioversion\n currently in sinus\n -restarted on carvediolol\n -cont hold amiodarone\n -hold coumadin, heparin gtt pending possible angiogram\n #DVT\n -heparin gtt, cont hold coumadin pending vascular recs\n #FEN: ADAT, monitor for s/sx aspiration\n #PPX: heparin gtt, H2blocker; OOB to chair, PT C/S\n #ACCESS: RIJ CVL, PIV; d/c A-line\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: stable for transfer to floor today\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: stable for transfer to floor today\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 601648,
"text": "66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601538,
"text": "66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulites,\n beta streptococcal septic shock complicated by ATN requiring HD, Afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place. No changed in mental status\n Action:\n Needs to be orieted in place frequent\n Response:\n No changes in mental status\n Plan:\n Pt alittle clearer now\n Decubitus ulcer (Present At Admission)\n Assessment:\n Multiple ulcer. Most dressing intact\n Action:\n Aquacell ag applied to open area, nystatin to yeast areas and covered\n with dsd, r leg dressing changed according to RN wound care\n Response:\n Pt still has open area but yeast seems to be clearing\n Plan:\n Continue with wound care recomentadtions\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n pt anterior lungs clear , decreased in bases\n Action:\n Pt weaned to 2L n/c sats 97% , pt desat to 86-87%while o 2 off, pt\n refused put CPAP, MD aware\n Response:\n Pt tolerates turning good, sat remains <90%\n Plan:\n Incourage pul toilet, will start insentive spiromatry with pt,\n incourage tpt to get oob daily\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601630,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status,\n worsened renal function and hypotension.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Zosyn - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 07:23 AM\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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (78 - 95) bpm\n BP: 144/56(87) {124/40(67) - 174/84(114)} mmHg\n RR: 17 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,424 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,424 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 1,024 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General: Obese, intubated, opens eyes to voice and answers questions\n yes / no. .\n HEENT: ETT in place. PERRL. Anicteric sclera.\n Lungs: Anterior exam with no crackles or obvious wheezing. Good air\n movement.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not tender. No\n appreciable HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Moves all extremities. Answers yes / no questions\n appropriately.\n Labs / Radiology\n 7.5 g/dL\n 37 K/uL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n Differential-Neuts:83.5 %, Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5\n %,\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs:\n PT / PTT / INR:18.5/85.4/1.7,\n CK / CKMB / Troponin-T:76//0.38,\n Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L,\n Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601632,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status,\n worsened renal function and hypotension.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Zosyn - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 07:23 AM\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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (78 - 95) bpm\n BP: 144/56(87) {124/40(67) - 174/84(114)} mmHg\n RR: 17 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,424 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,424 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 1,024 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General: Obese, intubated, opens eyes to voice and answers questions\n yes / no. .\n HEENT: ETT in place. PERRL. Anicteric sclera.\n Lungs: Anterior exam with no crackles or obvious wheezing. Good air\n movement.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not tender. No\n appreciable HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Moves all extremities. Answers yes / no questions\n appropriately.\n Labs / Radiology\n 7.5 g/dL\n 37 K/uL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n Differential-Neuts:83.5 %, Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5\n %,\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs:\n PT / PTT / INR:18.5/85.4/1.7,\n CK / CKMB / Troponin-T:76//0.38,\n Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L,\n Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n 66 yo male with chronic renal insufficiency, PVD with cellulitis,\n course at OSH notable for GBS sepsis, acute on chronic renal\n insufficiency /ATN, afib requiring cardioversion. MICU course notable\n for mulitfactorial shock (sepsis/adrenal/cardiogenic), respiratory\n failure requiring intubation/mechanical ventilation\n 1. Acute respiratory failure: extuabated, on minimal oxygen, wean as\n tolerated\n 2. GBS sepsis: afebrile, normotensive. Plan at least 2 wk course of\n antibiotics- has been on vanco/zosyn, but will switch to\n vanco/cipro/clinda due to pancytopenia. Need to calrify further\n imaging/plans with vascular surgery\n 3. Pancytopenia: suspect medication-induced, will dc zosyn for\n cipro/clinda and follow counts\n 4. Adrenal insufficiency: improved, taper to maintenance regimen of\n pred 20 mg every other day, dc fluddro\n 5. afib: in sinus rhythm, keep off amiodarone\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition : Floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601472,
"text": "HPI:\n 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulites,\n beta streptococcal septic shock complicated by ATN requiring HD, Afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place\n Action:\n pt oriented to location and time, pt able to follow commands,\n Response:\n Pt able to state time and person at 1600\n Plan:\n Pt alittle clearer now\n Decubitus ulcer (Present At Admission)\n Assessment:\n Ulcer cleaned still has open area which still bleeds,\n Action:\n Aquacell ag applied to open area, nystatin to yeast areas and covered\n with dsd\n Response:\n Pt still has open area but yeast seems to be clearing\n Plan:\n Continue with wound care recomentadtions\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n pt anterior lungs clear , decreased in bases\n Action:\n Pt weaned to 2L n/c sats 97% pt oob\nchair x3 hrs\n Response:\n Pt tol well in chair, is more sob when turning in bed and when flat\n Plan:\n Incourage pul toilet, will start insentive spiromatry with pt,\n incourage tpt to get oob daily\n Pt c/o pain this afternoon, was given percocet 1 tab, for leg/ coccyx\n pain,with good effect\n Pt toel oob but did have some bleeding from Lt heal and rt posterior\n knee area from friction of moving\n Also noted that bleeding from rt naries, and bleeding around foley,\n pt remains on heparin drip at 1000 units/hr will check ptt this\n afternoon, at 12pm leg dressing changed and above bleeding noted,\n other areas dry, area cleaned with wound cleanser and adaptic applies\n with dsd.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601527,
"text": "66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulites,\n beta streptococcal septic shock complicated by ATN requiring HD, Afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place. No changed in mental status\n Action:\n Needs to be orieted in place frequent\n Response:\n No changes in mental status\n Plan:\n Pt alittle clearer now\n Decubitus ulcer (Present At Admission)\n Assessment:\n Ulcer cleaned still has open area which still bleeds,\n Action:\n Aquacell ag applied to open area, nystatin to yeast areas and covered\n with dsd\n Response:\n Pt still has open area but yeast seems to be clearing\n Plan:\n Continue with wound care recomentadtions\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n pt anterior lungs clear , decreased in bases\n Action:\n Pt weaned to 2L n/c sats 97% , pt desat to 86-87%while o 2 off\n Response:\n Pt tolerates turning good, sat remains <90%\n Plan:\n Incourage pul toilet, will start insentive spiromatry with pt,\n incourage tpt to get oob daily\n"
},
{
"category": "Respiratory ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Generic Note",
"row_id": 601528,
"text": "TITLE:\n Resp Care\n Patient again refused to wear cpap machine, even though it is his own\n from home. (never wears it at home also)\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601604,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Zosyn - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 07:23 AM\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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (78 - 95) bpm\n BP: 144/56(87) {124/40(67) - 174/84(114)} mmHg\n RR: 17 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,424 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,424 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 1,024 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.5 g/dL\n 37 K/uL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n Differential-Neuts:83.5 %, Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5\n %,\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs:\n PT / PTT / INR:18.5/85.4/1.7,\n CK / CKMB / Troponin-T:76//0.38,\n Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L,\n Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601605,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status,\n worsened renal function and hypotension.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Zosyn - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 07:23 AM\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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (78 - 95) bpm\n BP: 144/56(87) {124/40(67) - 174/84(114)} mmHg\n RR: 17 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,424 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,424 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 1,024 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General: Obese, intubated, opens eyes to voice and answers questions\n yes / no. .\n HEENT: ETT in place. PERRL. Anicteric sclera.\n Lungs: Anterior exam with no crackles or obvious wheezing. Good air\n movement.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not tender. No\n appreciable HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Moves all extremities. Answers yes / no questions\n appropriately.\n Labs / Radiology\n 7.5 g/dL\n 37 K/uL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n Differential-Neuts:83.5 %, Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5\n %,\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs:\n PT / PTT / INR:18.5/85.4/1.7,\n CK / CKMB / Troponin-T:76//0.38,\n Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L,\n Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601608,
"text": "Chief Complaint: Hypotension\n 24 Hour Events:\n -vanco held for supratherapeutic trough, dose changed to 500 mg q24\n -hydrocort tapered to 50 mg q12\n -d/c'd fluconazole\n -picc placement deferred given has central line and only needs 4 more\n days of ABX\n -started PO diet\n -restarted carvedilol 6.25 \n -gave D5W x 2L to address free H20 deficit\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 02:00 AM\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 No pain, CP, SOB, N/V, abdominal pain, LE pain.\n Just feels tired.\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 81 (78 - 95) bpm\n BP: 135/48(76) {124/40(67) - 174/84(114)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 10 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,252 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,252 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Gen: No acute distress\n CV: irregular, grade II/VI systolic murmur at RUSB\n Pulm: CTAB\n Abd: +BS, soft, NT, ND\n Ext: 2+ edema, BLE ulcers\n Labs / Radiology\n 37 K/uL\n 7.5 g/dL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs: PT / PTT / INR:18.5/85.4/1.7, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5 %, D-dimer:1397 ng/mL,\n Fibrinogen:565 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252\n IU/L, Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Microbiology: Repeat UCx NGTD\n 3:58 pm SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH Commensal Respiratory Flora.\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n #Multifactorial shock\n resolved, now off pressors x 12 hrs; attributed\n to sepsis (with likely sources being nonhealing skin wounds and\n pneumonia/aspiration, given CT findings) and relative adrenal\n insufficiency; TTE showed mod dilated LV/RV with nl LV systolic\n function and mildly depressed RV function, mild AS, mod pulm HTN (TR\n grad 42 mmHg), making cardiogenic shock less likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspiration PNA\n -f/u repeat UCx\n -begin tapering corticosteroids, d/c fludrocort\n -restart amiodarone, carvediolol when hemodynamically stable x 24 hrs\n off pressors\n #Hypercapnic respiratory failure\n resp status stable s/p extubation\n ; euvolemic over the past 24 hrs\n -albumin, lasix prn for volume goal even\n -wean O2 as tolerated to maintain sat>92%\n -ABX as above\n -encourage CPAP use, wife plans to bring in home unit\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -renally dose meds\n #Thrombocytopenia\n unclear etiology, most likely bone marrow\n suppression from sepsis as well as possible drug-induced\n thrombocytopenia. Vanc causes immune-thrombocytopenia and\n thrombocytopenia, Zosyn has also been associated with thrombocytopenia\n but only in case reports. HIT and ADAMTS13 negative at OSH; no e/o DIC\n by labs.\n -consider d/c\ning vanc\n -repeat CBC in PM\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n #. Gout:\n - cont allopurinol\n - hold colchicine\n #. DM\n - cont. basal, sliding scale insulin\n - following, appreciate recs\n #.Afib s/p cardioversion\n currently in sinus\n -restarted on carvediolol\n -hold amiodarone\n -hold coumadin, heparin gtt\n #DVT\n -heparin gtt, cont hold coumadin\n #FEN: I&O goal of even, monitor/replete electrolytes; ADAT, monitor for\n s/sx aspiration\n #PPX: heparin gtt, H2blocker; OOB to chair, PT C/S\n #ACCESS: RIJ CVL, PIV; d/c A-line\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: transfer to floor if stable today\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601609,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status,\n worsened renal function and hypotension.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Zosyn - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 07:23 AM\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 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 86 (78 - 95) bpm\n BP: 144/56(87) {124/40(67) - 174/84(114)} mmHg\n RR: 17 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,424 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,424 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 1,024 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General: Obese, intubated, opens eyes to voice and answers questions\n yes / no. .\n HEENT: ETT in place. PERRL. Anicteric sclera.\n Lungs: Anterior exam with no crackles or obvious wheezing. Good air\n movement.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not tender. No\n appreciable HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Moves all extremities. Answers yes / no questions\n appropriately.\n Labs / Radiology\n 7.5 g/dL\n 37 K/uL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n Differential-Neuts:83.5 %, Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5\n %,\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs:\n PT / PTT / INR:18.5/85.4/1.7,\n CK / CKMB / Troponin-T:76//0.38,\n Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L,\n Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601610,
"text": "Chief Complaint: Hypotension\n 24 Hour Events:\n -vanco held for supratherapeutic trough, dose changed to 500 mg q24\n -hydrocort tapered to 50 mg q12\n -d/c'd fluconazole\n -picc placement deferred given has central line and only needs 4 more\n days of ABX\n -started PO diet\n -restarted carvedilol 6.25 \n -gave D5W x 2L to address free H20 deficit\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 02:00 AM\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 No pain, CP, SOB, N/V, abdominal pain, LE pain.\n Just feels tired.\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 81 (78 - 95) bpm\n BP: 135/48(76) {124/40(67) - 174/84(114)} mmHg\n RR: 13 (13 - 23) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 10 (-1 - 23)mmHg\n Total In:\n 1,765 mL\n 1,252 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,445 mL\n 1,252 mL\n Blood products:\n 200 mL\n Total out:\n 1,102 mL\n 400 mL\n Urine:\n 1,102 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 663 mL\n 852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Gen: No acute distress\n CV: irregular, grade II/VI systolic murmur at RUSB\n Pulm: CTAB\n Abd: +BS, soft, NT, ND\n Ext: 2+ edema, BLE ulcers\n Labs / Radiology\n 37 K/uL\n 7.5 g/dL\n 200 mg/dL\n 2.0 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 82 mg/dL\n 114 mEq/L\n 147 mEq/L\n 22.7 %\n 3.3 K/uL\n [image002.jpg]\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n 04:06 PM\n 03:32 AM\n WBC\n 3.3\n 6.7\n 2.6\n 4.1\n 3.3\n Hct\n 24.3\n 27.7\n 22.8\n 24.0\n 22.7\n Plt\n 66\n 71\n 47\n 50\n 37\n Cr\n 2.2\n 2.2\n 1.9\n 1.9\n 2.0\n TCO2\n 21\n 20\n 22\n 21\n Glucose\n 9\n 200\n Other labs: PT / PTT / INR:18.5/85.4/1.7, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:83.5 %,\n Band:0.0 %, Lymph:6.7 %, Mono:9.2 %, Eos:0.5 %, D-dimer:1397 ng/mL,\n Fibrinogen:565 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252\n IU/L, Ca++:9.4 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Microbiology: Repeat UCx NGTD\n 3:58 pm SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH Commensal Respiratory Flora.\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n #Multifactorial shock\n resolved, now off pressors x 12 hrs; attributed\n to sepsis (with likely sources being nonhealing skin wounds and\n pneumonia/aspiration, given CT findings) and relative adrenal\n insufficiency; TTE showed mod dilated LV/RV with nl LV systolic\n function and mildly depressed RV function, mild AS, mod pulm HTN (TR\n grad 42 mmHg), making cardiogenic shock less likely\n -appreciate vascular surgery recs\n -cont vanc/zosyn (day ) for nosocomia/aspiration PNA\n -f/u repeat UCx\n -begin tapering corticosteroids, d/c fludrocort\n -restart amiodarone, carvediolol when hemodynamically stable x 24 hrs\n off pressors\n #Hypercapnic respiratory failure\n resp status stable s/p extubation\n ; euvolemic over the past 24 hrs\n -albumin, lasix prn for volume goal even\n -wean O2 as tolerated to maintain sat>92%\n -ABX as above\n -encourage CPAP use, wife plans to bring in home unit\n # Acute on chronic renal failure\n nonoliguric, Cr stable; most\n attributable to ATN from shock\n -appreciate renal recs\n -renally dose meds\n #Thrombocytopenia\n unclear etiology, most likely bone marrow\n suppression from sepsis as well as possible drug-induced\n thrombocytopenia. Vanc causes immune-thrombocytopenia and\n thrombocytopenia, Zosyn has also been associated with thrombocytopenia\n but only in case reports. Zoysn does cause pancytopenia, high risk in\n renal failure patients. HIT and ADAMTS13 negative at OSH; no e/o DIC\n by labs.\n -consider changing abx\n -repeat CBC in PM\n -cont monitor, transfuse for plts <10K or active bleeding\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -repeat PM Hct, transfuse for <21 or evidence of active bleeding\n -guaiac stools\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n #. Gout:\n - cont allopurinol\n - hold colchicine\n #. DM\n - cont. basal, sliding scale insulin\n - following, appreciate recs\n #.Afib s/p cardioversion\n currently in sinus\n -restarted on carvediolol\n -hold amiodarone\n -hold coumadin, heparin gtt\n #DVT\n -heparin gtt, cont hold coumadin\n #FEN: I&O goal of even, monitor/replete electrolytes; ADAT, monitor for\n s/sx aspiration\n #PPX: heparin gtt, H2blocker; OOB to chair, PT C/S\n #ACCESS: RIJ CVL, PIV; d/c A-line\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife \n #DISPOSITION: transfer to floor if stable today\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 601232,
"text": "Chief Complaint: respiratory failure, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 66M with DM, htn, dvts, LE ulces, septic shock at OSH with new afib,\n ARF requiring HD briefly, initially transferred to vascular, the to ICU\n and intubated with worsening pulmonary edema and hypotension.\n 24 Hour Events:\n EKG - At 01:57 PM\n - weaning levophed, off this am\n - switched to bolus sedation; awake this am\n History obtained from Patient\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Piperacillin - 08:00 AM\n Vancomycin - 09:51 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 01:40 PM\n Midazolam (Versed) - 12:25 AM\n Other medications:\n allopur, tricor, , , vanco 1q24, norepi, heparin,\n hydrocort, zantac, chlorhex\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain\n Genitourinary: No(t) Foley\n Signs or concerns for abuse : No\n Pain: Moderate\n Pain location: abdomen\n Flowsheet Data as of 10:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 60 (55 - 81) bpm\n BP: 72/24(37) {72/24(37) - 148/68(87)} mmHg\n RR: 13 (8 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 12 (6 - 29)mmHg\n Total In:\n 1,558 mL\n 1,220 mL\n PO:\n TF:\n IVF:\n 1,498 mL\n 1,100 mL\n Blood products:\n Total out:\n 2,690 mL\n 640 mL\n Urine:\n 1,690 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,132 mL\n 580 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 879 (596 - 879) mL\n PS : 10 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.30/43/109/21/-4\n Ve: 8.7 L/min\n PaO2 / FiO2: 273\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), irregular\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender: mild\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 66 K/uL\n 149 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 88 mg/dL\n 112 mEq/L\n 143 mEq/L\n 24.3 %\n 3.3 K/uL\n [image002.jpg]\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n WBC\n 5.4\n 3.3\n Hct\n 28.3\n 24.3\n Plt\n 62\n 66\n Cr\n 2.3\n 2.2\n 2.2\n TCO2\n 19\n 20\n 19\n 17\n 21\n 20\n 22\n Glucose\n \n Other labs: PT / PTT / INR:21.3/63.8/2.0, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:7.8 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n Microbiology: bcx: pending (OSH to be reviewed)\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n 66M with DM, htn, dvts, LE ulces, septic shock at OSH with new afib,\n ARF requiring HD briefly, initially transferred to vascular, the to ICU\n and intubated with worsening pulmonary edema and hypotension.\n Hemodynamically he is labile, likely ongoing sepsis, though with very\n little pressor requirement. Will avoid additional fluid. As needed will\n consider albumin. Continue pressors as needed. Abx and steroids to\n continue for now but will consider change in coverage and discuss with\n vascular source control, etc. Fluid balance goal is even to negative.\n Reason for respiratory failure is not entirely clear, but lung\n mechanics and gas exchange are likely adequate. Will do an SBT and\n check ABG, and then extubate.\n Renal function has improved and remains stable. Other issues stable\n see resident note for plans.\n ICU Care\n Nutrition: npo for possible extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601233,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:57 PM\n - weaning levophed\n - switched to bolus sedation\n - Lasix for I&O goal of -1L\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:40 PM\n Midazolam (Versed) - 12:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 72 (45 - 81) bpm\n BP: 128/59(80) {91/31(49) - 148/68(87)} mmHg\n RR: 14 (8 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (2 - 19)mmHg\n Total In:\n 1,558 mL\n 203 mL\n PO:\n TF:\n IVF:\n 1,498 mL\n 203 mL\n Blood products:\n Total out:\n 2,690 mL\n 490 mL\n Urine:\n 1,690 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,132 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 800 (550 - 800) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.30/43/109/21/-4\n Ve: 8.1 L/min\n PaO2 / FiO2: 273\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral 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 anteriorly)\n Abdominal: Soft, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 66 K/uL\n 8.1 g/dL\n 149 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 88 mg/dL\n 112 mEq/L\n 143 mEq/L\n 24.3 %\n 3.3 K/uL\n [image002.jpg]\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n WBC\n 5.4\n 3.3\n Hct\n 28.3\n 24.3\n Plt\n 62\n 66\n Cr\n 2.3\n 2.2\n 2.2\n TCO2\n 19\n 20\n 19\n 17\n 21\n 20\n 22\n Glucose\n \n Other labs: PT / PTT / INR:21.3/63.8/2.0, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:7.8 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n Imaging: CXR -\n The ET tube tip is 5.2 cm above the carina. The NG tube tip is most\n likely in\n the stomach. The right internal jugular line tip is at the level of mid\n SVC.\n Cardiomediastinal silhouette is grossly unchanged. Left retrocardiac\n consolidation has slightly increased in the interim. The right basilar\n opacity is less distinctive on the current study compared to the prior\n imaging\n that might be due to slightly different projection. The minimal pleural\n effusion demonstrated on chest CT is not visible on the current\n radiograph.\n Microbiology: All Cx - NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n pressor requirement decreased; due to sepsis\n (likely sources are nonhealing skin wounds and pneumonia given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg)\n -f/u cultures\n -d/w vascular surgery re: debridement for source control\n -cont vanc/zosyn (day 3) tailor ABX according to Cx data after 48-72\n hrs\n -cont hydro/fludrocort\n -wean levophed for goal MAP> 60-65\n -volume repletion to goal CVP 8-12\n -repeat ScVO2, consider transfusion if <70\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nshunting of blood away from diaphragm\n due to septic shock, respiratory muscle fatigue, and resulting\n hypercarbia; element of hypoxemia likely due to volume overload and PNA\n -SBT with ABG\n -ABX as above\n -transitioned to bolus sedation\n .\n # Acute on chronic renal failure\n nonoliguric, most attributable to\n ATN from shock\n -appreciate renal recs\n -cont monitor\n -renally dose meds\n .\n #Thrombocytopenia\n count stable; HIT and ADAMTS13 negative at OSH; no\n e/o DIC by labs\n -cont monitor.\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -Hct today\n -guaiac stools\n -transfuse for <21 or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -cont monitor while on pressors\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, nutrition C/S for TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\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:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601234,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:57 PM\n - weaning levophed\n - switched to bolus sedation\n - Lasix for I&O goal of -1L\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:40 PM\n Midazolam (Versed) - 12:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 72 (45 - 81) bpm\n BP: 128/59(80) {91/31(49) - 148/68(87)} mmHg\n RR: 14 (8 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (2 - 19)mmHg\n Total In:\n 1,558 mL\n 203 mL\n PO:\n TF:\n IVF:\n 1,498 mL\n 203 mL\n Blood products:\n Total out:\n 2,690 mL\n 490 mL\n Urine:\n 1,690 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,132 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 800 (550 - 800) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.30/43/109/21/-4\n Ve: 8.1 L/min\n PaO2 / FiO2: 273\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral 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 anteriorly)\n Abdominal: Soft, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 66 K/uL\n 8.1 g/dL\n 149 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 88 mg/dL\n 112 mEq/L\n 143 mEq/L\n 24.3 %\n 3.3 K/uL\n [image002.jpg]\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n WBC\n 5.4\n 3.3\n Hct\n 28.3\n 24.3\n Plt\n 62\n 66\n Cr\n 2.3\n 2.2\n 2.2\n TCO2\n 19\n 20\n 19\n 17\n 21\n 20\n 22\n Glucose\n \n Other labs: PT / PTT / INR:21.3/63.8/2.0, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:7.8 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n Imaging: CXR -\n The ET tube tip is 5.2 cm above the carina. The NG tube tip is most\n likely in\n the stomach. The right internal jugular line tip is at the level of mid\n SVC.\n Cardiomediastinal silhouette is grossly unchanged. Left retrocardiac\n consolidation has slightly increased in the interim. The right basilar\n opacity is less distinctive on the current study compared to the prior\n imaging\n that might be due to slightly different projection. The minimal pleural\n effusion demonstrated on chest CT is not visible on the current\n radiograph.\n Microbiology: All Cx - NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n pressor requirement decreased; due to sepsis\n (likely sources are nonhealing skin wounds and pneumonia given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg)\n -f/u cultures\n -d/w vascular surgery re: debridement for source control\n -cont vanc/zosyn (day 3) tailor ABX according to Cx data after 48-72\n hrs\n -cont hydro/fludrocort\n -wean levophed for goal MAP> 60-65\n -volume repletion to goal CVP 8-12\n -repeat ScVO2, consider transfusion if <70\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nshunting of blood away from diaphragm\n due to septic shock, respiratory muscle fatigue, and resulting\n hypercarbia; element of hypoxemia likely due to volume overload and PNA\n -SBT with ABG\n -ABX as above\n -transitioned to bolus sedation\n .\n # Acute on chronic renal failure\n nonoliguric, most attributable to\n ATN from shock\n -I&O goal of even, use lasix and albumin if needed\n -appreciate renal recs\n -cont monitor\n -renally dose meds\n .\n #Thrombocytopenia\n count stable; HIT and ADAMTS13 negative at OSH; no\n e/o DIC by labs\n -cont monitor.\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -Hct today\n -guaiac stools\n -transfuse for <21 or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -hold carvediolol and amiodarone\n -cont monitor while on pressors\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, nutrition C/S for TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\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:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601292,
"text": "HPI:\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt coccyx dressing intact, leg dressing changed at 1500 rt arm dsg\n changed at 9 am, pulses by Doppler see assessment\n Action:\n Leg dressing no oozing noted, no ordor, pt remains on iv antibiotics\n Response:\n Pt afebrile, legs seem to be improving\n Plan:\n Continue with dsg changes and daily coccyx dsg change\n Hypotension (not Shock)\n Assessment:\n Pt dropped bo this morning to 60\ns systolic\n Action:\n Pt boluses with a liter ivf, cvp 10- 15, no improvement pt needed to\n restart norepi drip, pt now on .04mcg/kg /min\n Response:\n Pt\ns Bp very labile anyplace from 90-160/systolic\n Plan:\n Have been able to wean pt\ns drip throughout the day\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt lung sounds decreased throughout sats 97%\n Action:\n Pt weaned and extubated this morning, pt on 40% shovel mask and now\n on 3l n/c\n Response:\n Pt tolerated wean of fio2\n Plan:\n Will follow o2 sats , will need cpap tonight\n Noted that post extubation that pt tongue is swollen, wife in room and\n she staid this has been an issue since pt was in osh, pt able to\n swallow clear liquids with no issue this afternoon, pt seems to have\n random tongue moments, I spoke with Dr \n and asked her to go\n see pt.\n Pt has some oozing from around foley, foley seems to have cause some\n trauma at head of penis from pressure. Area cleaned and nystatin to\n penis area.\n Per id , foley cath changed and pt started on po fluconazole urine\n sent this afternoon\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601470,
"text": "HPI:\n 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulitis,\n beta streptococcal septic shock complicated by ATN requiring HD, afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place\n Action:\n pt oriented to location and time, pt able to follow commands,\n Response:\n Pt able to state time and person at 1600\n Plan:\n Pt alittle clearer now\n Decubitus ulcer (Present At Admission)\n Assessment:\n Ulcer cleaned still has open area which still bleeds,\n Action:\n Aquacell ag applied to open area, nystatin to yeast areas and covered\n with dsd\n Response:\n Pt still has open area but yeast seems to be clearing\n Plan:\n Continue with wound care recomentadtions\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601523,
"text": "66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulites,\n beta streptococcal septic shock complicated by ATN requiring HD, Afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place. No changed in mental status\n Action:\n Needs to be orieted in place frequent\n Response:\n No changes in mental status\n Plan:\n Pt alittle clearer now\n Decubitus ulcer (Present At Admission)\n Assessment:\n Ulcer cleaned still has open area which still bleeds,\n Action:\n Aquacell ag applied to open area, nystatin to yeast areas and covered\n with dsd\n Response:\n Pt still has open area but yeast seems to be clearing\n Plan:\n Continue with wound care recomentadtions\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n pt anterior lungs clear , decreased in bases\n Action:\n Pt weaned to 2L n/c sats 97% pt oob\nchair x3 hrs\n Response:\n Pt tol well in chair, is more sob when turning in bed and when flat\n Plan:\n Incourage pul toilet, will start insentive spiromatry with pt,\n incourage tpt to get oob daily\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601570,
"text": "66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulites,\n beta streptococcal septic shock complicated by ATN requiring HD, Afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well\n Altered mental status (not Delirium)\n Assessment:\n pt is alert and orientated x1 had difficulty in telling date, time and\n place. No changed in mental status. Pt has no c/o of pain\n Action:\n Needs to be oriented in place frequent\n Response:\n No changes in mental status, oriented in him self\n Plan:\n Pt alittle clearer now\n Decubitus ulcer (Present At Admission)\n Assessment:\n Multiple ulcer. Most dressing intact\n Action:\n Aquacell ag applied to open area, nystatin to yeast areas and covered\n with dsd, r leg dressing changed according to RN wound care\n Response:\n Pt still has open area but yeast seems to be clearing\n Plan:\n Continue with wound care recomentadtions\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n pt anterior lungs clear , decreased in bases\n Action:\n Pt weaned to 2L n/c sats 97% , pt desat to 86-87%while o 2 off, pt\n refused put CPAP, MD aware\n Response:\n Pt tolerates turning good, sat remains <90%\n Plan:\n Incourage pul toilet, will start insentive spiromatry with pt,\n incourage pt to get oob daily\n Cont Heparin , PTT in therapeutic range.\n Start D 5% fro elevated NA.\n Overnight u/o dropped to 0, foley flushed with good response.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601022,
"text": "Chief Complaint: shock\n 24 Hour Events:\n -R IJ CVL placed\n -intubated for hypercarbic resp failure\n -started stress-dose steroids (hydrocort + fludro) for AM cortisol 18.4\n -CT torso & head ordered for workup of infectious source showed\n bilateral consolidations, AAA (4.4 cm)\n -warfarin d/c'd in favor of heparin gtt in case needs procedures\n -TTE showed mod dilated LV and RV, nl LV systolic function, mildly\n depressed RV function, mild AS, mod PA sHTN\n -propofol gtt switched to fentanyl/versed due to bradycardia\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.09 mcg/Kg/min\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unable to obtain due to sedation\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 54 (43 - 76) bpm\n BP: 139/57(84) {76/38(51) - 139/57(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 8 (5 - 25)mmHg\n Total In:\n 4,099 mL\n 396 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 396 mL\n Blood products:\n Total out:\n 428 mL\n 420 mL\n Urine:\n 428 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 99%\n ABG: 7.26/40/282/19/-8\n Ve: 8.7 L/min\n PaO2 / FiO2: 564\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: PERRL\n Cardiovascular: regular brady no m/r/g\n Respiratory / Chest: diminished at bases\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+, venous stasis changes with erythema\n Neurologic: Responds to: Verbal stimuli, pain\n Labs / Radiology\n 62 K/uL\n 9.3 g/dL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n Glucose\n 98\n 142\n 190\n 226\n Other labs: PT / PTT / INR:19.7/89.9/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:5.0 mg/dL\n Imaging: CT TORSO\n 1. Bilateral pulmonary consolidations with small pleural effusions as\n above,\n possibly infectious given the provided history, though in this patient\n with a\n nasogastric tube as well as an endotracheal tube, aspiration is another\n consideration.\n 2. Extensive atherosclerotic disease involving the coronary arteries as\n well\n as involving an abdominal aortic aneurysm measuring 44 mm in greatest\n diameter.\n Microbiology: 3:58 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n 11:57 pm STOOL CONSISTENCY: WATERY\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Shock\n pressor requirement decreased; multifactorial due to sepsis\n (likely sources are nonhealing skin wounds and pneumonia given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg)\n -cont vanc/zosyn (day 2) tailor ABX according to Cx data\n -cont hydro/fludrocort\n -wean levophed for goal MAP> 60-65\n -volume repletion to goal CVP 8-12\n -repeat ScVO2, consider transfusion if <70\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nshunting of blood away from diaphragm\n due to septic shock, respiratory muscle fatigue, and resulting\n hypercarbia; element of hypoxemia likely due to volume overload and PNA\n -repeat ABG (0436 gas drawn on 100%FiO2 when being suctioned)\n -ABX as above\n -consider lasix bolus if oxygenation acutely worsens\n .\n # Acute on chronic renal failure\n nonoliguric, most attributable to\n ATN from shock\n -will d/w renal re need for CVVH based on trend of renal indices\n .\n #Thrombocytopenia\n count stable; HIT and ADAMTS13 negative at OSH; no\n e/o DIC by labs\n -cont monitor.\n #Anemia: Hct stable, no e/o hemolysis by labs\n -daily Hct\n -guaiac stools\n -transfuse for <21 or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -cont monitor while on pressors\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, nutrition C/S for TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition: monitor/replete electrolytes, nutrition C/S for TF\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: heparin IV\n Stress ulcer: H2blocker\n VAP: Bundle\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601025,
"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 ARTERIAL LINE - START 10:29 AM\n MULTI LUMEN - START 10:40 AM\n INVASIVE VENTILATION - START 03:00 PM\n SPUTUM CULTURE - At 04:05 PM\n URINE CULTURE - At 04:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 45 (43 - 76) bpm\n BP: 119/46 {76/38 - 143/57} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 2 (2 - 25)mmHg\n Total In:\n 4,099 mL\n 462 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 462 mL\n Blood products:\n Total out:\n 428 mL\n 525 mL\n Urine:\n 428 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.30/34/113/19/-8\n Ve: 8.7 L/min\n PaO2 / FiO2: 226\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 62 K/uL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n 17\n Glucose\n 98\n 142\n 190\n 226\n Other labs: PT / PTT / INR:19.7/89.9/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n HYPOTENSION (NOT SHOCK)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, RESPIRATORY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601046,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure. His\n course at Hospital from \n notable for blood\n cultures on admission (, 2 out of 4 bottles) growing out group B\n Strep for which he was greated with a 5 day course of Vanc / Zosyn. He\n apparently was \"septic\" and in the ICU. He also developed acute renal\n failure attributed to ATN for which he required transient dialysis, but\n has since been liberated from diaysis. It is not clear if the ATN was\n septic physiology or another process. He developed new A fib with\n RVR requiring d/c cardioversion on and subsequent initiation of\n Amio (he was already on Warfarin for a h/o DVTs.) Finally, he had a\n right knee arthrocentesis consistent with gout for which he was started\n on colchicine and prednisone. He was transferred to on to\n the Vascular Surgery service for possible lower extremity\n revascularization. On overnight, he was found to be minimally\n responsive to sternal rub and was dosed with Narcan 0.4mg x 2 with some\n improvement in his level of consciousness. At that time, his ABG was\n 7.35 / 41 / 56 on CPAP (which he is on at baseline) with an unclear\n FiO2, his SBP was 90 with a HR of 60. He was given two 500cc boluses\n for the borderline SBP. This morning () he was again found to be\n minimally responsive with a HR of 60, SBP in the 70s, and an ABG of\n 7.34 / 44 / 82. He was transferred to the MICU for further evaluation\n and care. Here we placed a line (CVP 16 and SvO2 85%) and he was\n intubated for respiratory acidosis and decreased mental status. Right\n now, his picture is of course multifactorial shock but primarily\n distributive (with a flavor of cardiogenic [EF 40% with apical\n hypokinesis from TTE] and obstructive [ 1.1 cm^2.]) He is on\n low-dose Levophed, getting corticosteroids (random cortisol of 18) and\n broad spectrum antibiotics.\n 24 Hour Events:\n ARTERIAL LINE - START 10:29 AM\n MULTI LUMEN - START 10:40 AM\n INVASIVE VENTILATION - START 03:00 PM\n SPUTUM CULTURE - At 04:05 PM\n URINE CULTURE - At 04:05 PM\n TTE\n CHEST / ABDOMEN CT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 1:15PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n (Versed - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Miconazole powder and cream\n Allopurinol 150mg q24h\n d/c today\n Tricor\n Calcium acetate TID\n d/c today\n Lipitor 80mg q24h\n RSSI\n Lantus 15mg\n Provigil 100mg q24h\n d/c today\n Vanc 1gm IV q24h (day 2)\n Zosyn 2.25mg IV q6h (day 2)\n Levophed 0.68\n Florinef 0.5mg q24h\n Heparin subQ\n Zantac 150mg q24h\n Hydrocort 50mg q6h\n Versed gtt 0.5mg / hr\n Fentanyl gtt 25mcg / hr\n Peridex\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 45 (43 - 76) bpm\n BP: 119/46 {76/38 - 143/57} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 2 (2 - 25)mmHg\n Total In:\n 4,099 mL\n 462 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 462 mL\n Blood products:\n Total out:\n 428 mL\n 525 mL\n Urine:\n 428 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.30 / 34 / 113\n Ve: 8.7 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General: Obese, chronically ill appearing, arousable to noxious stimuli\n but non-sensical and disoriented. No respiratory distress.\n HEENT: PERRL. Anicteric sclera. OP clear without apparent thrush or\n exudate on limited exam. No appreciable cervical or clavicular\n adenopathy, but very obese neck.\n Lungs: Limited exam as patient cannot sit up and does not take deep\n breaths due to depressed mental status. No obvious focal wheezing or\n crackles.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not apparently\n tender. Could not appreciate HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Arousable to noxious stimuli but not meaningfully interactive.\n Moving all extremities spontaneously.\n Labs / Radiology\n 9.3 g/dL\n 62 K/uL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n Sputum gram stain (): No organisms\n Blood cultures (, ): NGTD\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n 17\n Glucose\n 98\n 142\n 190\n 226\n Other labs:\n PT / PTT / INR:19.7/89.9/1.8,\n CK / CKMB / Troponin-T:76//0.38, Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, LDH:252 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status and\n hypotension.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Baseline creatinine 1.7, now up to 2.3. He is making some urine. Follow\n Renal recs.\n HYPOTENSION (NOT SHOCK)\n Hypotension: The differential diagnosis of his hypotension is broad,\n including distributive shock (sepsis, adrenal insufficiency,\n hypothyroidism), cardiogenic (depressed EF of 40% with LV hypokinesis\n on a TTE), obstructive ( 1.1 cm^2 on the TTE), or\n hypovolumic (he is clearly whole body overloaded but certainly may be\n intravascularly deplete.)\n superimposed aspiration pneumonitis / pneumonia is a possibility. We\n will pursue an abdominal and chest CT scan to assess for an infectious\n source of his possible septic physiology. Finally, we\nve placed a\n central venous catheter with which we will follow CVP and SvO2 as\n surrogates of his volume status and peripheral oxygen up-take.\n He has been on Prednisone for an uncertain amount of time, we will\n provide him with empiric corticosteroids and check a random cortisol to\n further assess for possible adrenal insufficiency. Would send a TSH as\n well.\n With regard to possible cardiogenic shock, we will repeat a TTE\n today. In addition, if his hemodynamic picture remains unclear, a\n and/or a PA catheter could be considered.\n With regard to possible obstructive shock, his was 1.1 cm^2 at\n the OSH on \n if this has progressed, it could be contributing\n more to his hypotension. PE is less likely given he has been on\n Warfarin (although his INR today is subtherapeutic.)\n With regard to his volume status, he is clearly whole body volume\n overloaded but his intravascular status is unclear. check his CVP\n and SvO2. Follow UOP, although this is complicated by his concomitant\n renal dysfunction.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n With regard to possible septic physiology, we will provide broad\n spectrum antibiotics to cover potential nosocomial pathogens (Vanc and\n Zosyn) and investigate possible sources of a sepsis syndrome. His lower\n extremities are certainly a possible source and Vascular\ns input\n regarding the likelihood of these chronic ulcers contributing to a\n systemic infection will be sought. His chest x-ray demonstrates\n increased bilateral opacities that are likely pulmonary edema, but with\n his depressed mental status\n ALTERED MENTAL STATUS\n Multifactorial in nature with his hypotension, acute renal failure,\n multiple organ dysfunction, acute respiratory acidosis and medication\n effects. Will address his underlying processes. Given he is undergoing\n a chest / abdomen CT we will scan his head as well. His overall mental\n status concerning and given concerns regarding his inability to protect\n his airway and a progressive acute respiratory acidosis, we will plan\n on an elective intubation this afternoon.\n ACIDOSIS, RESPIRATORY\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Intubated, sedated, oxygenation improved.\n INSULIN DEPENDENT DIABETES\n RSSI with an insulin gtt if his sugar is >180. Goal range will be\n 110-180.\n THROMBOCYTOPENIA\n Unclear etiology. This has progressed from (platelets were 130\n on .) and now are in the 40-50s. His HIT Ab and his -TS 13\n study were normal. Multiple DIC and hemolysis labs are pending. No\n indication for transfusion at this time.\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: 20 Gauge - 09:14 AM, 22 Gauge - 09:14 AM,\n Arterial Line - 10:29 AM, Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition :ICU for now\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601047,
"text": "Chief Complaint: shock\n 24 Hour Events:\n -R IJ CVL placed\n -intubated for hypercarbic resp failure\n -started stress-dose steroids (hydrocort + fludro) for AM cortisol 18.4\n -CT torso & head ordered for workup of infectious source showed\n bilateral consolidations, AAA (4.4 cm)\n -warfarin d/c'd in favor of heparin gtt in case needs procedures\n -TTE showed mod dilated LV and RV, nl LV systolic function, mildly\n depressed RV function, mild AS, mod PA sHTN\n -propofol gtt switched to fentanyl/versed due to bradycardia\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.09 mcg/Kg/min\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unable to obtain due to sedation\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 54 (43 - 76) bpm\n BP: 139/57(84) {76/38(51) - 139/57(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 8 (5 - 25)mmHg\n Total In:\n 4,099 mL\n 396 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 396 mL\n Blood products:\n Total out:\n 428 mL\n 420 mL\n Urine:\n 428 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 99%\n ABG: 7.26/40/282/19/-8\n Ve: 8.7 L/min\n PaO2 / FiO2: 564\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: PERRL\n Cardiovascular: regular brady no m/r/g\n Respiratory / Chest: diminished at bases\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+, venous stasis changes with erythema\n Neurologic: Responds to: Verbal stimuli, pain\n Labs / Radiology\n 62 K/uL\n 9.3 g/dL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n Glucose\n 98\n 142\n 190\n 226\n Other labs: PT / PTT / INR:19.7/89.9/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:5.0 mg/dL\n Imaging: CT TORSO\n 1. Bilateral pulmonary consolidations with small pleural effusions as\n above,\n possibly infectious given the provided history, though in this patient\n with a\n nasogastric tube as well as an endotracheal tube, aspiration is another\n consideration.\n 2. Extensive atherosclerotic disease involving the coronary arteries as\n well\n as involving an abdominal aortic aneurysm measuring 44 mm in greatest\n diameter.\n Microbiology: 3:58 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n 11:57 pm STOOL CONSISTENCY: WATERY\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n pressor requirement decreased; due to sepsis\n (likely sources are nonhealing skin wounds and pneumonia given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg)\n -cont vanc/zosyn (day 2) tailor ABX according to Cx data after 48-72\n hrs\n -cont hydro/fludrocort\n -wean levophed for goal MAP> 60-65\n -volume repletion to goal CVP 8-12\n -repeat ScVO2, consider transfusion if <70\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nshunting of blood away from diaphragm\n due to septic shock, respiratory muscle fatigue, and resulting\n hypercarbia; element of hypoxemia likely due to volume overload and PNA\n -PSV trial\n -repeat ABG (0436 gas drawn on 100%FiO2 when being suctioned)\n -ABX as above\n -lasix boluses to goal neg 1-2L today\n -transition to bolus sedation\n .\n # Acute on chronic renal failure\n nonoliguric, most attributable to\n ATN from shock\n -appreciate renal recs\n -cont monitor\n .\n #Thrombocytopenia\n count stable; HIT and ADAMTS13 negative at OSH; no\n e/o DIC by labs\n -cont monitor.\n #Anemia: Hct stable, no e/o hemolysis by labs\n -daily Hct\n -guaiac stools\n -transfuse for <21 or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -cont monitor while on pressors\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, nutrition C/S for TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition: monitor/replete electrolytes, nutrition C/S for TF\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: heparin IV\n Stress ulcer: H2blocker\n VAP: Bundle\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601048,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure. His\n course at Hospital from \n notable for blood\n cultures on admission (, 2 out of 4 bottles) growing out group B\n Strep for which he was greated with a 5 day course of Vanc / Zosyn. He\n apparently was \"septic\" and in the ICU. He also developed acute renal\n failure attributed to ATN for which he required transient dialysis, but\n has since been liberated from diaysis. It is not clear if the ATN was\n septic physiology or another process. He developed new A fib with\n RVR requiring d/c cardioversion on and subsequent initiation of\n Amio (he was already on Warfarin for a h/o DVTs.) Finally, he had a\n right knee arthrocentesis consistent with gout for which he was started\n on colchicine and prednisone. He was transferred to on to\n the Vascular Surgery service for possible lower extremity\n revascularization. On overnight, he was found to be minimally\n responsive to sternal rub and was dosed with Narcan 0.4mg x 2 with some\n improvement in his level of consciousness. At that time, his ABG was\n 7.35 / 41 / 56 on CPAP (which he is on at baseline) with an unclear\n FiO2, his SBP was 90 with a HR of 60. He was given two 500cc boluses\n for the borderline SBP. This morning () he was again found to be\n minimally responsive with a HR of 60, SBP in the 70s, and an ABG of\n 7.34 / 44 / 82. He was transferred to the MICU for further evaluation\n and care. Here we placed a line (CVP 16 and SvO2 85%) and he was\n intubated for respiratory acidosis and decreased mental status. Right\n now, his picture is of course multifactorial shock but primarily\n distributive (with a flavor of cardiogenic [EF 40% with apical\n hypokinesis from TTE] and obstructive [ 1.1 cm^2.]) He is on\n low-dose Levophed, getting corticosteroids (random cortisol of 18) and\n broad spectrum antibiotics.\n 24 Hour Events:\n ARTERIAL LINE - START 10:29 AM\n MULTI LUMEN - START 10:40 AM\n INVASIVE VENTILATION - START 03:00 PM\n SPUTUM CULTURE - At 04:05 PM\n URINE CULTURE - At 04:05 PM\n TTE\n CHEST / ABDOMEN CT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 1:15PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Versed - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Miconazole powder and cream\n Allopurinol 150mg q24h\n d/c today\n Tricor\n Calcium acetate TID\n d/c today\n Lipitor 80mg q24h\n RSSI\n Lantus 15mg\n Provigil 100mg q24h\n d/c today\n Vanc 1gm IV q24h (day 2)\n Zosyn 2.25mg IV q6h (day 2)\n Levophed 0.68\n Florinef 0.5mg q24h\n Heparin subQ\n Zantac 150mg q24h\n Hydrocort 50mg q6h\n Versed gtt 0.5mg / hr\n Fentanyl gtt 25mcg / hr\n Peridex\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 45 (43 - 76) bpm\n BP: 119/46 {76/38 - 143/57} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 2 (2 - 25)mmHg\n Total In:\n 4,099 mL\n 462 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 462 mL\n Blood products:\n Total out:\n 428 mL\n 525 mL\n Urine:\n 428 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.30 / 34 / 113\n Ve: 8.7 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General: Obese, chronically ill appearing, arousable to noxious stimuli\n but non-sensical and disoriented. No respiratory distress.\n HEENT: PERRL. Anicteric sclera. OP clear without apparent thrush or\n exudate on limited exam. No appreciable cervical or clavicular\n adenopathy, but very obese neck.\n Lungs: Limited exam as patient cannot sit up and does not take deep\n breaths due to depressed mental status. No obvious focal wheezing or\n crackles.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not apparently\n tender. Could not appreciate HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Arousable to noxious stimuli but not meaningfully interactive.\n Moving all extremities spontaneously.\n Labs / Radiology\n 9.3 g/dL\n 62 K/uL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n Sputum gram stain (): No organisms\n Blood cultures (, ): NGTD\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n 17\n Glucose\n 98\n 142\n 190\n 226\n Other labs:\n PT / PTT / INR:19.7/89.9/1.8,\n CK / CKMB / Troponin-T:76//0.38, Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, LDH:252 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status and\n hypotension.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Baseline creatinine 1.7, now up to 2.3. He is anasarcic; we will\n attempt to diurese as able, hs urine sodium is <10 which implies\n intravascular depletion and a pre-renal physiology, but he is massively\n whole-body volume overloaded. With diuretics, we may be able to\n mobilize third-spaced fluid. He may need a lasix gtt depending on his\n hemodynamics. Goal for today would be -1L.\n HYPOTENSION (NOT SHOCK)\n His hypotension has improved with pressors and steroids. The underlying\n etiology is thought to be distributive in nature, with a potential\n contribution of adrenal insufficiency. His TTE makes a primary\n cardiogenic process very unlikely. There is no compelling data for an\n obstructive process. During the course of the day, we will wean\n pressors as able, continue glucocorticoids and follow his CVP / SvO2.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Continuing broad spectrum antibotics at this time; awaiting cultures to\n guide therapy. His pan-scan did not reveal an obvious infectious\n source.\n ALTERED MENTAL STATUS\n His initial altered mental status on presentation was likely due to\n hypotension, medication effects and critical illness.\n ACIDOSIS, RESPIRATORY\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Intubated, sedated, oxygenation improved. He is now on PSV and\n tolerating it well.\n INSULIN DEPENDENT DIABETES\n RSSI with an insulin gtt if his sugar is >180. Goal range will be\n 110-180.\n THROMBOCYTOPENIA\n Unclear etiology. This has progressed from (platelets were 130\n on .) and now are in the 40-50s. His HIT Ab and his -TS 13\n study were normal. Multiple DIC and hemolysis labs are pending. No\n indication for transfusion at this time.\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: 20 Gauge - 09:14 AM, 22 Gauge - 09:14 AM,\n Arterial Line - 10:29 AM, Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition :ICU for now\n Total time spent:\n"
},
{
"category": "Nutrition",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 601051,
"text": "Subjective\n Patient intubated.\n Seen by R.D. , reported poor po's x3 months and 27# wt loss\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n \n 121.4 kg*\n ICU - 123.7 kg\n 36.2*\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 150%*\n 90.9 kg per admit wt\n ) 133.7 kg\n 91%\n Diagnosis: BLE cellulitis\n PMHx: 1) Chronic renal insufficiency (baseline creatinine 1.7) with ATN\n at Hospital in early transiently requiring HD.\n 2) OSA on CPAP, he is not consistently compliant\n 3) Gout on allopurinol and colchicine, s/p knee arthrocentesis at\n Hospital\n 4) Ulcerative colitis\n 5) IDDM\n 6) Hypertension\n 7) A fib with RVR s/p cardioversion at on \n 8) PVD with chronic lower extremity ulcers for the prior 10 years with\n chronic ulcers\n 9) H/o DVT on Warfarin\n 10) Obesity\n 11) Anemia\n unknown baseline\n Food allergies and intolerances: none noted\n Pertinent medications: versed drip, fentanyl drip, norepinephrine drip,\n Normal saline @ 10ml/hr, HISS, Glargine 15 units at HS, Calcium\n Acetate, Ranitidine, ABX\n Labs:\n Value\n Date\n Glucose\n 226 mg/dL\n 04:14 AM\n Glucose Finger Stick\n 239\n 06:00 AM\n BUN\n 93 mg/dL\n 04:14 AM\n Creatinine\n 2.3 mg/dL\n 04:14 AM\n Sodium\n 140 mEq/L\n 04:14 AM\n Potassium\n 5.5 mEq/L\n 04:14 AM\n Chloride\n 112 mEq/L\n 04:14 AM\n TCO2\n 19 mEq/L\n 04:14 AM\n PO2 (arterial)\n 94. mm Hg\n 09:33 AM\n PO2 (venous)\n 59 mm Hg\n 02:03 PM\n PCO2 (arterial)\n 44 mm Hg\n 09:33 AM\n PCO2 (venous)\n 69 mm Hg\n 02:03 PM\n pH (arterial)\n 7.26 units\n 09:33 AM\n pH (venous)\n 7.13 units\n 02:03 PM\n pH (urine)\n 5.0 units\n 03:58 PM\n CO2 (Calc) arterial\n 21 mEq/L\n 09:33 AM\n CO2 (Calc) venous\n 24 mEq/L\n 02:03 PM\n Calcium non-ionized\n 8.0 mg/dL\n 04:14 AM\n Phosphorus\n 5.0 mg/dL\n 04:14 AM\n Magnesium\n 2.1 mg/dL\n 04:14 AM\n Total Bilirubin\n 1.1 mg/dL\n 01:56 PM\n WBC\n 5.4 K/uL\n 04:14 AM\n Hgb\n 9.3 g/dL\n 04:14 AM\n Hematocrit\n 28.3 %\n 04:14 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, (+) bowel sounds; golden liquid stool\n Skin: stage III intergluteal, several stage II and III on coccyx\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: NPO, prolonged poor po's PTA, wt loss, wounds\n Estimated Nutritional Needs\n Calories: -2275 (22-23 cal/kg)\n Protein: 109-136 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 66 YO male transferred to after long stay at outside hospital for\n treatment of chronic bilateral LE ulcers and cellulitis. Nutrition\n originally consulted for pressure ulcers and calorie counts to\n assess po intake. Transferred to MICU for hypotension and decreased\n mental status. Intubated and sedated. Also, (+) PNA and volume\n overload. Consulted for tube feed recommendations, OGT in place \n RN. Agree with enteral nutrition as soon as possible given history of\n poor po\ns + wt loss + wounds.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement:\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 601054,
"text": "* initial nutrition assessment in paper chart *\n Subjective\n Patient intubated.\n Seen by R.D. , reported poor po's x3 months and 27# wt loss\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n \n 121.4 kg*\n ICU - 123.7 kg\n 36.2*\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 150%*\n 90.9 kg per admit wt\n ) 133.7 kg\n 91%\n Diagnosis: BLE cellulitis\n PMHx: 1) Chronic renal insufficiency (baseline creatinine 1.7) with ATN\n at Hospital in early transiently requiring HD.\n 2) OSA on CPAP, he is not consistently compliant\n 3) Gout on allopurinol and colchicine, s/p knee arthrocentesis at\n Hospital\n 4) Ulcerative colitis\n 5) IDDM\n 6) Hypertension\n 7) A fib with RVR s/p cardioversion at on \n 8) PVD with chronic lower extremity ulcers for the prior 10 years with\n chronic ulcers\n 9) H/o DVT on Warfarin\n 10) Obesity\n 11) Anemia\n unknown baseline\n Food allergies and intolerances: none noted\n Pertinent medications: versed drip, fentanyl drip, norepinephrine drip,\n Normal saline @ 10ml/hr, HISS, Glargine 15 units at HS, Calcium\n Acetate, Ranitidine, ABX\n Labs:\n Value\n Date\n Glucose\n 226 mg/dL\n 04:14 AM\n Glucose Finger Stick\n 239\n 06:00 AM\n BUN\n 93 mg/dL\n 04:14 AM\n Creatinine\n 2.3 mg/dL\n 04:14 AM\n Sodium\n 140 mEq/L\n 04:14 AM\n Potassium\n 5.5 mEq/L\n 04:14 AM\n Chloride\n 112 mEq/L\n 04:14 AM\n TCO2\n 19 mEq/L\n 04:14 AM\n PO2 (arterial)\n 94. mm Hg\n 09:33 AM\n PO2 (venous)\n 59 mm Hg\n 02:03 PM\n PCO2 (arterial)\n 44 mm Hg\n 09:33 AM\n PCO2 (venous)\n 69 mm Hg\n 02:03 PM\n pH (arterial)\n 7.26 units\n 09:33 AM\n pH (venous)\n 7.13 units\n 02:03 PM\n pH (urine)\n 5.0 units\n 03:58 PM\n CO2 (Calc) arterial\n 21 mEq/L\n 09:33 AM\n CO2 (Calc) venous\n 24 mEq/L\n 02:03 PM\n Calcium non-ionized\n 8.0 mg/dL\n 04:14 AM\n Phosphorus\n 5.0 mg/dL\n 04:14 AM\n Magnesium\n 2.1 mg/dL\n 04:14 AM\n Total Bilirubin\n 1.1 mg/dL\n 01:56 PM\n WBC\n 5.4 K/uL\n 04:14 AM\n Hgb\n 9.3 g/dL\n 04:14 AM\n Hematocrit\n 28.3 %\n 04:14 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, (+) bowel sounds; golden liquid stool\n Skin: stage III intergluteal, several stage II and III on coccyx\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: NPO, prolonged poor po's PTA, wt loss, wounds\n Estimated Nutritional Needs\n Calories: -2275 (22-25 cal/kg)\n Protein: 109-136 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 66 YO male transferred to after long stay at outside hospital for\n treatment of chronic bilateral LE ulcers and cellulitis. Nutrition\n originally consulted for pressure ulcers and calorie counts to\n assess po intake. Transferred to MICU for hypotension and decreased\n mental status; multifactorial shock. Intubated and sedated. Also, (+)\n PNA, ARF and volume overload. Consulted for tube feed recommendations,\n OGT in place RN. Agree with enteral nutrition as soon as possible\n given history of poor po\ns + wt loss + wounds. Noted elevated FSBG.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: begin Novasource Renal at\n 15ml/hr, advance as tolerated to goal of 45ml/hr + 30g Beneprotein =\n 2267 calories (25 calories/kg adjusted body wt) and 106g protein\n (~1.2g/kg adjusted body wt)\n 1. Check residuals, hold tube feed if greater than 200ml\n 2. Multivitamin / Mineral supplement: via tube feed\n Check chemistry 10 panel daily\n BS management especially with initiation of enteral\n nutrition\n following\n Will follow, page if questions *\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601057,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure. His\n course at Hospital from \n notable for blood\n cultures on admission (, 2 out of 4 bottles) growing out group B\n Strep for which he was greated with a 5 day course of Vanc / Zosyn. He\n apparently was \"septic\" and in the ICU. He also developed acute renal\n failure attributed to ATN for which he required transient dialysis, but\n has since been liberated from diaysis. It is not clear if the ATN was\n septic physiology or another process. He developed new A fib with\n RVR requiring d/c cardioversion on and subsequent initiation of\n Amio (he was already on Warfarin for a h/o DVTs.) Finally, he had a\n right knee arthrocentesis consistent with gout for which he was started\n on colchicine and prednisone. He was transferred to on to\n the Vascular Surgery service for possible lower extremity\n revascularization. On overnight, he was found to be minimally\n responsive to sternal rub and was dosed with Narcan 0.4mg x 2 with some\n improvement in his level of consciousness. At that time, his ABG was\n 7.35 / 41 / 56 on CPAP (which he is on at baseline) with an unclear\n FiO2, his SBP was 90 with a HR of 60. He was given two 500cc boluses\n for the borderline SBP. This morning () he was again found to be\n minimally responsive with a HR of 60, SBP in the 70s, and an ABG of\n 7.34 / 44 / 82. He was transferred to the MICU for further evaluation\n and care. Here we placed a line (CVP 16 and SvO2 85%) and he was\n intubated for respiratory acidosis and decreased mental status. Right\n now, his picture is of course multifactorial shock but primarily\n distributive (with a flavor of cardiogenic [EF 40% with apical\n hypokinesis from TTE] and obstructive [ 1.1 cm^2.]) He is on\n low-dose Levophed, getting corticosteroids (random cortisol of 18) and\n broad spectrum antibiotics.\n 24 Hour Events:\n ARTERIAL LINE - START 10:29 AM\n MULTI LUMEN - START 10:40 AM\n INVASIVE VENTILATION - START 03:00 PM\n SPUTUM CULTURE - At 04:05 PM\n URINE CULTURE - At 04:05 PM\n TTE\n CHEST / ABDOMEN CT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 1:15PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Versed - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Miconazole powder and cream\n Allopurinol 150mg q24h\n d/c today\n Tricor\n Calcium acetate TID\n d/c today\n Lipitor 80mg q24h\n RSSI\n Lantus 15mg\n Provigil 100mg q24h\n d/c today\n Vanc 1gm IV q24h (day 2)\n Zosyn 2.25mg IV q6h (day 2)\n Levophed 0.68\n Florinef 0.5mg q24h\n Heparin subQ\n Zantac 150mg q24h\n Hydrocort 50mg q6h\n Versed gtt 0.5mg / hr\n Fentanyl gtt 25mcg / hr\n Peridex\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 45 (43 - 76) bpm\n BP: 119/46 {76/38 - 143/57} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 2 (2 - 25)mmHg\n Total In:\n 4,099 mL\n 462 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 462 mL\n Blood products:\n Total out:\n 428 mL\n 525 mL\n Urine:\n 428 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.30 / 34 / 113\n Ve: 8.7 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General: Obese, intubated, opens eyes to voice and answers questions\n yes / no. .\n HEENT: ETT in place. PERRL. Anicteric sclera.\n Lungs: Anterior exam with no crackles or obvious wheezing. Good air\n movement.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not tender. No\n appreciable HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Moves all extremities. Answers yes / no questions appropriately.\n Labs / Radiology\n 9.3 g/dL\n 62 K/uL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n Sputum gram stain (): No organisms\n Blood cultures (, ): NGTD\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n 17\n Glucose\n 98\n 142\n 190\n 226\n Other labs:\n PT / PTT / INR:19.7/89.9/1.8,\n CK / CKMB / Troponin-T:76//0.38, Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, LDH:252 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status,\n worsened renal function and hypotension.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Baseline creatinine 1.7, now up to 2.3. He is anasarcic; we will\n attempt to diurese as able, hs urine sodium is <10 which implies\n intravascular depletion and a pre-renal physiology, but he is massively\n whole-body volume overloaded. With diuretics, we may be able to\n mobilize third-spaced fluid. He may need a lasix gtt depending on his\n hemodynamics. Goal for today would be -1L.\n HYPOTENSION (NOT SHOCK)\n His hypotension has improved with pressors and steroids. The underlying\n etiology is thought to be distributive in nature, with a potential\n contribution of adrenal insufficiency. His TTE makes a primary\n cardiogenic process very unlikely. There is no compelling data for an\n obstructive process. During the course of the day, we will wean\n pressors as able, continue glucocorticoids and follow his CVP / SvO2.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Continuing broad spectrum antibotics at this time; awaiting cultures to\n guide therapy. His pan-scan did not reveal an obvious infectious\n source. Will continue the antibiotics and follow cultures with a goal\n of de-escalating if there is no microbiologic evidence of infection.\n ALTERED MENTAL STATUS\n His initial altered mental status on presentation was likely due to\n hypotension, medication effects and critical illness.\n ACIDOSIS, RESPIRATORY\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Intubated, sedated, oxygenation improved. He is now on PSV and\n tolerating it well. We will decrease his PS during the course of the\n day. Will change his sedation to intermittent boluses rather than\n continuous infusion as he may be able to be extubated soon.\n INSULIN DEPENDENT DIABETES\n RSSI with an insulin gtt if his sugar is >180. Goal range will be\n 110-180.\n THROMBOCYTOPENIA\n Unclear etiology. This has progressed from (platelets were 130\n on .) and now are in the 40-50s. His HIT Ab and his -TS 13\n study were normal. Multiple DIC and hemolysis labs are pending. No\n indication for transfusion at this time.\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Lantus / RSSI\n Lines: 20 Gauge - 09:14 AM, 22 Gauge - 09:14 AM,\n Arterial Line - 10:29 AM, Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: Zantac\n VAP: Bundle ordered\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition :ICU for now\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601126,
"text": "TODAY: Pt bradycardic at the start of the shift in the low to mid 40\n had been bradycardic overnight, MICU resident aware. Per MICU\n resident, bracycardia overnight thought to be Propofol gtt .\n Sedation was switched to Fentanyl and Versed with liitle effect. Once\n sedation weaned off today, pt\ns HR increased to 50\ns-70\ns. Noted to\n begin having frequent ventricular bigeminy, then this evening\n ventricular trigeminy. EKG obtained and electrolytes drawn. K is down\n to 4.6.\n Pt also remains on heparin gtt for PMH afib and DVT. Pt\ns PTT at 1100\n was 123.2. Heparin gtt stopped for one hour per SS order and restarted\n at 1200 at 1000 units/hour. PTT from 1800 pending.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. Also\n noted to have yeast rash in peri area. BLE with multiple areas of\n ulceration\n vascular following. R arm edematous and weeping serous\n fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated, however trending downward with PM\n lytes. Remains fluid overloaded, however UOP is picking up. Renal\n following.\n Action:\n UOP and Electrolytes monitored. Pt received a total of 80mg Lasix IVP\n today. Per renal team, no immediate plans to dialyze at this time.\n Response:\n Pt responded to Lasix with 260mL UOP. K trending downward.\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n .\n Action:\n Abx as ordered. Blood cultures sent this AM.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed gtt 0.056 mcg/kg/min. SBP sustained in the\n 1teens to 120\ns this AM.\n Action:\n Levophed gtt weaned as tolerated.\n Response:\n Pt is currently on 0.032mcg/kg/min Levophed. SBP is in the 120\ns and\n MAP is low 60\n Plan:\n Titrate Levophed gtt to maintain MAPS at goal >60.\n Acidosis, Respiratory\n Assessment:\n Received pt vented on CMV 50%/550/20/5. O2 sats 98-100%. Pt not OBV.\n AM ABG 7.30/34/113.\n Action:\n Sedation decreased and pt placed on CPAP 40% 10/5.\n Response:\n Reflective ABG when initially placed on CPAP 7.26/44/94. Sedation\n weaned off and pt more alert. Repeat ABG once pt more alert\n 7.28/41/129. Pt appears to be comfortable on CPAP. Denies any\n difficulty breathing. RR in the teens and spo2 95-100%.\n Plan:\n Wean vent as tolerated by pt. Monitor ABG\n evening ABG pending.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600937,
"text": "Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. Transferred to the VICU for further care at 0400. At the\n time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. Later on this\n morning he was again found to be minimally responsive and then\n hypotensive with systolic in 70s; HR was maintained in 50-60s. Repeat\n ABG was 7.34/44/82. Blood cultures were sent. Patient is not making\n urine.\n Intubated this afternoon for arf. Heparin gtt started for afib\n (coumadinized at home) contrast infusing for CT of torso this PM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n No uop since transfer to micu 0900.\n Action:\n Cont ivf\ns now on levophed at 0.3 mcg/kg/min for map>60\n Response:\n Pt ahs started to put out sm amt urine, sent for cx\n Plan:\n Cont to follow. Renal following ?may need dialysis again (needed in\n past at osh this admission)\n Acidosis, Respiratory\n Assessment:\n Pt awake, confused, responsive this am. More lethargic as day went on.\n Acidotic to 7.13\n Action:\n Intubated this afternoon\n Response:\n Abg pending, hemodynamically more stable. Remains on levo. Remains\n vented on propofol\n Plan:\n Wean vent as tolerated. Ct this pm, vascular following for leg ulcers\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2 and stage 3 ulcers to coccys. Unstageable larger area\n around these ones. And yeasty erythemous skin around that.\n Action:\n Wound care RN up to see this am, took measurements of wound. Incident\n report filed. Kinair bed ordered.\n Response:\n Following\n Plan:\n As above\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600940,
"text": "Initial - CCC\n Date: \n Signed by , RN,BSN,CWOCN on at 10:10 am\n Affiliation: \n Reason for Consult:Impairment in Skin Integrity-B/L LE's and\n feet, coccyx\n Reason for admission: Cellulitis/LE ulcers\n PMH:Streptococcal sepsis, transient shock and acute tubular\n necrosis (anuria, hyperkalemia, metabolic acidosis) requiring\n fluid, antibiotic, pressors and renal replacement therapy.\n 2. chronic renal insufficiency\n 3. Obstructive sleep apnea w/baseline apnea hypopnea index of 33.\n Patient noncompliant with C-PAP use at home\n 4. Gout-on allopurinol, colchicine\n 5. Obesity\n 6. Ulcerative colitis\n 7. Diabetics mellitus- on Lantus and sliding scale Humulin\n 8. Hypertension\n 9. Fib during admission requiring -on Coreg, amiodarone\n 10. DVT-on Coumadin\n 11. Protein calorie malnutrition\n 12. Decreased ADS-will need PT/OT\n 13. Anemia-requiring prior transfusions\n 14. Bilateral LE ulcers, sacral decub ulcers\n Allergies:NKDA\n Meds: Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR\n Aspirin 81 mg PO DAILY @ 0921\n Acetaminophen 650 mg PO Q6H:PRN pain /fever\n Insulin SC (per Insulin Flowsheet)\n Atorvastatin 80 mg PO DAILY\n Calcium Acetate mg PO TID W/MEALS\n Pantoprazole 40 mg PO Q24H\n Provigil *NF* 200 mg Oral daily\n Tricor *NF* 145 mg Oral qd\n Allopurinol 150 mg PO DAILY\n Heparin 5000 UNIT SC TID 10\n Colchicine 0.6 mg PO DAILY\n Warfarin MD to order daily dose PO DAILY16\n Miconazole 2% Cream 1 Appl TP \n Miconazole Powder 2% 1 Appl TP TID fungal rash\n Nutrition:NPO\n Labs: WBC 5.2 HCT 25.9 Alb none reported Glucose 97 INR 1.7\n Score:9\n LE Pulses: nonpalpable foot pulses\n RN obtained by doppler Left foot-DP, PT PT only\n Art studies ordered for today\n History and previous treatment of the :\n 66 yr old male transferred to from Hospital with\n cellulitis and multiple nonhealing lower extremity ulcerations.\n Vascular service has evaluated his LE ulcers and is currently\n working up with Arterial studies. The RLE ulcerations are worse\n than on the left lower leg. Both LE's have brawny, erythemic\n tissue discolorations with induration. He is c/o increased pain\n with movement of his LE's.\n The right foot has full thickness brown/yellow necrotic ulcers\n extending over the dorsum of the foot medial to lateral,\n posterior LE including posterior knee, Achilles and heel. There\n are interdigital ulcerations between the 2nd, 3rd and 4th toes.\n There are also ulcerations at the toe tips, 2nd and 3rd toes-dry\n necrotic.\n The left heel has a necrotic black ulceration approx 4 x 4 cm.\n The inferior aspect of the ulcer is open with pink tissue. There\n are several full thickness ulcers along the lateral LE.\n Coccyx: entire affected area is approx. 16.5 x 12 cm of erythemic\n tissue with fungal involvement\n Intergluteal cleft Stage III,that is approx 8 x 0.2 cm with\n yellow/red (75%/25%) bed, irregular edges.\n Left aspect of coccyx: several Stage II and Stage III ulcers,\n with irregular edges, covering an area of 6 x 8 cm\n Right aspect of coccyx: Stage III ulcer approx 8 x 5 cm with\n irregular edges, adjacent to this there is an area of\n intact hyperpigmented tissue sites, possible deep tissue injury.\n There are three sites darkly pigmented.\n The coccyx ulcerated sites are draining serosang drainage with no\n odor. There is no induration, edema, or fluctuance to the tissue\n at this site.\n B/L groin/scrotum/posterior thighs: erythemic tissue with fungal\n involvement.\n RN reports the patient has been incontinent of stool,\n C-Diff neg. Staff will monitor output today and determine if he\n meets criteria for a fecal management system.\n He has an indwelling Foley catheter in place.\n Goals of care:prevention of infection and further tissue\n breakdown\n Recommendations: Pressure relief per pressure ulcer guidelines\n Support surface: Air bed\n Turn and reposition every 1-2 hours and prn off back\n Heels off bed surface at all times\n Multipodis Splints to B/L LE's\n Moisturize B/L LE's and feet, periwound tissue with Aloe\n Vesta Moisture Barrier Ointment.\n Defer to vascular regarding LE and feet ulcers at this time.\n Coccyx: Commercial cleanser or normal saline to cleanse\n all open wounds.\n Pat the tissue dry with dry gauze.\n Apply Antifungal Moisture Barrier Ointment to the periwound\n tissue with each drg change.\n Apply Aquacel AG 4 x 4 dressings to open ulcers along the left,\n intergluteal and right coccyx and barely dampen with normal\n saline.\n Cover with dry gauze, Sorfsorb sponge\n Secure with Softcloth tape. apply Pink waterproof tape\n along the inferior aspect of the dressing to prevent stool\n contamination.\n Change dressing daily\n Foam cleansing to B/L groin/scrotum/posterior and medial\n thighs/perianal tissue.\n Apply Antifungal Critic Aid Clear Moisture Barrier Ointment.\n Please discontinue Miconazole 2% powder and cream. The\n antifungal critic aid clear has 2% miconazole in it and serves as\n a barrier as well.\n Monitor stool output and assess need for containment with either\n the FIP or FMS.\n Support nutrition and hydration.\n Notify MD care nurse or skin deteriorates.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601028,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure. His\n course at Hospital from \n notable for blood\n cultures on admission (, 2 out of 4 bottles) growing out group B\n Strep for which he was greated with a 5 day course of Vanc / Zosyn. He\n apparently was \"septic\" and in the ICU. He also developed acute renal\n failure attributed to ATN for which he required transient dialysis, but\n has since been liberated from diaysis. It is not clear if the ATN was\n septic physiology or another process. He developed new A fib with\n RVR requiring d/c cardioversion on and subsequent initiation of\n Amio (he was already on Warfarin for a h/o DVTs.) Finally, he had a\n right knee arthrocentesis consistent with gout for which he was started\n on colchicine and prednisone. He was transferred to on to\n the Vascular Surgery service for possible lower extremity\n revascularization. On overnight, he was found to be minimally\n responsive to sternal rub and was dosed with Narcan 0.4mg x 2 with some\n improvement in his level of consciousness. At that time, his ABG was\n 7.35 / 41 / 56 on CPAP (which he is on at baseline) with an unclear\n FiO2, his SBP was 90 with a HR of 60. He was given two 500cc boluses\n for the borderline SBP. This morning () he was again found to be\n minimally responsive with a HR of 60, SBP in the 70s, and an ABG of\n 7.34 / 44 / 82. He was transferred to the MICU for further evaluation\n and care. Here we placed a line (CVP 16 and SvO2 85%) and he was\n intubated for respiratory acidosis and decreased mental status. Right\n now, his picture is of course multifactorial shock but primarily\n distributive (with a flavor of cardiogenic [EF 40% with apical\n hypokinesis from TTE] and obstructive [ 1.1 cm^2.]) He is on\n low-dose Levophed, getting corticosteroids (random cortisol of 18) and\n broad spectrum antibiotics.\n 24 Hour Events:\n ARTERIAL LINE - START 10:29 AM\n MULTI LUMEN - START 10:40 AM\n INVASIVE VENTILATION - START 03:00 PM\n SPUTUM CULTURE - At 04:05 PM\n URINE CULTURE - At 04:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 1:15PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n (Versed - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 45 (43 - 76) bpm\n BP: 119/46 {76/38 - 143/57} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 2 (2 - 25)mmHg\n Total In:\n 4,099 mL\n 462 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 462 mL\n Blood products:\n Total out:\n 428 mL\n 525 mL\n Urine:\n 428 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.30/34/113/19/-8\n Ve: 8.7 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General: Obese, chronically ill appearing, arousable to noxious stimuli\n but non-sensical and disoriented. No respiratory distress.\n HEENT: PERRL. Anicteric sclera. OP clear without apparent thrush or\n exudate on limited exam. No appreciable cervical or clavicular\n adenopathy, but very obese neck.\n Lungs: Limited exam as patient cannot sit up and does not take deep\n breaths due to depressed mental status. No obvious focal wheezing or\n crackles.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not apparently\n tender. Could not appreciate HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Arousable to noxious stimuli but not meaningfully interactive.\n Moving all extremities spontaneously.\n Labs / Radiology\n 9.3 g/dL\n 62 K/uL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n 17\n Glucose\n 98\n 142\n 190\n 226\n Other labs:\n PT / PTT / INR:19.7/89.9/1.8,\n CK / CKMB / Troponin-T:76//0.38, Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, LDH:252 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status and\n hypotension.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Baseline creatinine 1.7, now up to 2.3. He is making some urine. Follow\n Renal recs.\n HYPOTENSION (NOT SHOCK)\n Hypotension: The differential diagnosis of his hypotension is broad,\n including distributive shock (sepsis, adrenal insufficiency,\n hypothyroidism), cardiogenic (depressed EF of 40% with LV hypokinesis\n on a TTE), obstructive ( 1.1 cm^2 on the TTE), or\n hypovolumic (he is clearly whole body overloaded but certainly may be\n intravascularly deplete.)\n superimposed aspiration pneumonitis / pneumonia is a possibility. We\n will pursue an abdominal and chest CT scan to assess for an infectious\n source of his possible septic physiology. Finally, we\nve placed a\n central venous catheter with which we will follow CVP and SvO2 as\n surrogates of his volume status and peripheral oxygen up-take.\n He has been on Prednisone for an uncertain amount of time, we will\n provide him with empiric corticosteroids and check a random cortisol to\n further assess for possible adrenal insufficiency. Would send a TSH as\n well.\n With regard to possible cardiogenic shock, we will repeat a TTE\n today. In addition, if his hemodynamic picture remains unclear, a\n and/or a PA catheter could be considered.\n With regard to possible obstructive shock, his was 1.1 cm^2 at\n the OSH on \n if this has progressed, it could be contributing\n more to his hypotension. PE is less likely given he has been on\n Warfarin (although his INR today is subtherapeutic.)\n With regard to his volume status, he is clearly whole body volume\n overloaded but his intravascular status is unclear. check his CVP\n and SvO2. Follow UOP, although this is complicated by his concomitant\n renal dysfunction.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n With regard to possible septic physiology, we will provide broad\n spectrum antibiotics to cover potential nosocomial pathogens (Vanc and\n Zosyn) and investigate possible sources of a sepsis syndrome. His lower\n extremities are certainly a possible source and Vascular\ns input\n regarding the likelihood of these chronic ulcers contributing to a\n systemic infection will be sought. His chest x-ray demonstrates\n increased bilateral opacities that are likely pulmonary edema, but with\n his depressed mental status\n ALTERED MENTAL STATUS\n Multifactorial in nature with his hypotension, acute renal failure,\n multiple organ dysfunction, acute respiratory acidosis and medication\n effects. Will address his underlying processes. Given he is undergoing\n a chest / abdomen CT we will scan his head as well. His overall mental\n status concerning and given concerns regarding his inability to protect\n his airway and a progressive acute respiratory acidosis, we will plan\n on an elective intubation this afternoon.\n ACIDOSIS, RESPIRATORY\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Intubated, sedated, oxygenation improved.\n INSULIN DEPENDENT DIABETES\n RSSI with an insulin gtt if his sugar is >180. Goal range will be\n 110-180.\n THROMBOCYTOPENIA\n Unclear etiology. This has progressed from (platelets were 130\n on .) and now are in the 40-50s. His HIT Ab and his -TS 13\n study were normal. Multiple DIC and hemolysis labs are pending. No\n indication for transfusion at this time.\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: 20 Gauge - 09:14 AM, 22 Gauge - 09:14 AM,\n Arterial Line - 10:29 AM, Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition :ICU for now\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601206,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:57 PM\n - weaning levophed\n - switched to bolus sedation\n - Lasix for I&O goal of -1L\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 01:40 PM\n Midazolam (Versed) - 12:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 72 (45 - 81) bpm\n BP: 128/59(80) {91/31(49) - 148/68(87)} mmHg\n RR: 14 (8 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 11 (2 - 19)mmHg\n Total In:\n 1,558 mL\n 203 mL\n PO:\n TF:\n IVF:\n 1,498 mL\n 203 mL\n Blood products:\n Total out:\n 2,690 mL\n 490 mL\n Urine:\n 1,690 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,132 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 800 (550 - 800) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.30/43/109/21/-4\n Ve: 8.1 L/min\n PaO2 / FiO2: 273\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral 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 anteriorly)\n Abdominal: Soft, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 66 K/uL\n 8.1 g/dL\n 149 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 88 mg/dL\n 112 mEq/L\n 143 mEq/L\n 24.3 %\n 3.3 K/uL\n [image002.jpg]\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n WBC\n 5.4\n 3.3\n Hct\n 28.3\n 24.3\n Plt\n 62\n 66\n Cr\n 2.3\n 2.2\n 2.2\n TCO2\n 19\n 20\n 19\n 17\n 21\n 20\n 22\n Glucose\n \n Other labs: PT / PTT / INR:21.3/63.8/2.0, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:7.8 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n Imaging: CXR -\n The ET tube tip is 5.2 cm above the carina. The NG tube tip is most\n likely in\n the stomach. The right internal jugular line tip is at the level of mid\n SVC.\n Cardiomediastinal silhouette is grossly unchanged. Left retrocardiac\n consolidation has slightly increased in the interim. The right basilar\n opacity is less distinctive on the current study compared to the prior\n imaging\n that might be due to slightly different projection. The minimal pleural\n effusion demonstrated on chest CT is not visible on the current\n radiograph.\n Microbiology: All Cx - NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Multifactorial shock\n pressor requirement decreased; due to sepsis\n (likely sources are nonhealing skin wounds and pneumonia given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg)\n -cont vanc/zosyn (day 3) tailor ABX according to Cx data after 48-72\n hrs\n -cont hydro/fludrocort\n -wean levophed for goal MAP> 60-65\n -volume repletion to goal CVP 8-12\n -repeat ScVO2, consider transfusion if <70\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nshunting of blood away from diaphragm\n due to septic shock, respiratory muscle fatigue, and resulting\n hypercarbia; element of hypoxemia likely due to volume overload and PNA\n -PSV trial\n -ABX as above\n -lasix boluses to goal neg 1-2L today\n -transitioned to bolus sedation\n .\n # Acute on chronic renal failure\n nonoliguric, most attributable to\n ATN from shock\n -appreciate renal recs\n -cont monitor\n .\n #Thrombocytopenia\n count stable; HIT and ADAMTS13 negative at OSH; no\n e/o DIC by labs\n -cont monitor.\n #Anemia: Hct trending down, no e/o hemolysis by labs\n -daily Hct\n -guaiac stools\n -transfuse for <21 or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -cont monitor while on pressors\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, nutrition C/S for TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\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:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600993,
"text": "Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. Transferred to the VICU for further care at 0400. At the\n time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. Later on this\n morning he was again found to be minimally responsive and then\n hypotensive with systolic in 70s; HR was maintained in 50-60s. Repeat\n ABG was 7.34/44/82. Blood cultures were sent. Patient is not making\n urine.\n Intubated this afternoon for arf. Heparin gtt started for afib\n (coumadinized at home) contrast infusing for CT of torso this PM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt started making urine, approx 60-70/hr. urine is amber with some old\n clots and sediment. Pts\n K+ 5.7 at 8pm.\n Action:\n Pt received on .3mcq of levophed and able to titrate down to .09mcq\n pt received 2 doses of kayexolate.\n Response:\n Foley cath draining 60-70cc/hr of amber colored urine. Pt has\n responded with lrg stool output. Awaiting K+ level from this am labs.\n Plan:\n Cont to follow renal status, Renal following ?may need dialysis again\n (needed in past at osh this admission)\n Acidosis, Respiratory\n Assessment:\n Pt received on vent 50% x 16 550 +5 peep, abg on these settings\n 7.19/49/88. pt received sedated on propofol. Pt responding to painful\n stimuli.\n Action:\n Resp rate inc to 20, pt has been sx for small amt\ns of thick yellow\n secretions. Lung sounds coarse and diminished at the bases. Propofol\n changed to versed and fent .\n Response:\n Repeat abg 7.24/43/91. maintaining o2 sat\n s in the high 90\ns. pt is\n more easily aroused and seems to follow simple commands.\n Plan:\n Wean vent as tolerated.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2 and stage 3 ulcers to coccys. Unstageable larger area\n around these ones. And yeasty erythemous skin around that. Pt oozing\n lrg amt\ns of serous fluid from left arm.\n Action:\n Wound care RN up to see this am, took measurements of wound. Incident\n report filed. Pt placed on kinair bed and all dressing to ulcers have\n been cleansed and redressed.\n Response:\n Following\n Plan:\n Turn pt freq.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601003,
"text": "Chief Complaint: shock\n 24 Hour Events:\n -R IJ CVL placed\n -intubated for hypercarbic resp failure\n -started stress-dose steroids (hydrocort + fludro) for AM cortisol 18.4\n -CT torso & head ordered for workup of infectious source showed\n bilateral consolidations, AAA (4.4 cm)\n -warfarin d/c'd in favor of heparin gtt in case needs procedures\n -TTE showed mod dilated LV and RV, nl LV systolic function, mildly\n depressed RV function, mild AS, mod PA sHTN\n -propofol gtt switched to fentanyl/versed due to bradycardia\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 54 (43 - 76) bpm\n BP: 139/57(84) {76/38(51) - 139/57(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 8 (5 - 25)mmHg\n Total In:\n 4,099 mL\n 396 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 396 mL\n Blood products:\n Total out:\n 428 mL\n 420 mL\n Urine:\n 428 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 99%\n ABG: 7.26/40/282/19/-8\n Ve: 8.7 L/min\n PaO2 / FiO2: 564\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 62 K/uL\n 9.3 g/dL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n Glucose\n 98\n 142\n 190\n 226\n Other labs: PT / PTT / INR:19.7/89.9/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:5.0 mg/dL\n Imaging: CT TORSO\n 1. Bilateral pulmonary consolidations with small pleural effusions as\n above,\n possibly infectious given the provided history, though in this patient\n with a\n nasogastric tube as well as an endotracheal tube, aspiration is another\n consideration.\n 2. Extensive atherosclerotic disease involving the coronary arteries as\n well\n as involving an abdominal aortic aneurysm measuring 44 mm in greatest\n diameter.\n Microbiology: 3:58 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n 11:57 pm STOOL CONSISTENCY: WATERY\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Shock\n pressor requirement decreased; multifactorial due to sepsis\n (likely sources are nonhealing skin wounds and pneumonia given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg)\n -cont vanc/zosyn (day 2) tailor ABX according to Cx data\n -cont hydro/fludrocort\n -wean levophed for goal MAP> 60-65\n -volume repletion to goal CVP 8-12\n -repeat ScVO2, consider transfusion if <70\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nshunting of blood away from diaphragm\n due to septic shock, respiratory muscle fatigue, and resulting\n hypercarbia; element of hypoxemia likely due to volume overload and PNA\n -repeat ABG (0436 gas drawn on 100%FiO2 when being suctioned)\n -ABX as above\n -consider lasix bolus if oxygenation acutely worsens\n .\n # Acute on chronic renal failure\n nonoliguric, most attributable to\n ATN from shock\n -will d/w renal re need for CVVH based on trend of renal indices\n .\n #Thrombocytopenia\n count stable; HIT and ADAMTS13 negative at OSH; no\n e/o DIC by labs\n -cont monitor.\n #Anemia: Hct stable, no e/o hemolysis by labs\n -daily Hct\n -guaiac stools\n -transfuse for <21 or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -cont monitor while on pressors\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, nutrition C/S for TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition: monitor/replete electrolytes, nutrition C/S for TF\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: heparin IV\n Stress ulcer: H2blocker\n VAP: Bundle\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601014,
"text": "Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. Transferred to the VICU for further care at 0400. At the\n time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. Later on this\n morning he was again found to be minimally responsive and then\n hypotensive with systolic in 70s; HR was maintained in 50-60s. Repeat\n ABG was 7.34/44/82. Blood cultures were sent. Patient is not making\n urine.\n Intubated this afternoon for arf. Heparin gtt started for afib\n (coumadinized at home) contrast infusing for CT of torso this PM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt started making urine, approx 60-70/hr. urine is amber with some old\n clots and sediment. Pts\n K+ 5.7 at 8pm.\n Action:\n Pt received on .3mcq of levophed and able to titrate down to .09mcq\n pt received 2 doses of kayexolate.\n Response:\n Foley cath draining 60-70cc/hr of amber colored urine. Pt has\n responded with lrg stool output. Awaiting K+ level from this am labs.\n K+ 5.4 this am, pt received another dose of kayexolate.\n Plan:\n Cont to follow renal status, Renal following ?may need dialysis again\n (needed in past at osh this admission)\n Acidosis, Respiratory\n Assessment:\n Pt received on vent 50% x 16 550 +5 peep, abg on these settings\n 7.19/49/88. pt received sedated on propofol. Pt responding to painful\n stimuli.\n Action:\n Resp rate inc to 20, pt has been sx for small amt\ns of thick yellow\n secretions. Lung sounds coarse and diminished at the bases. Propofol\n changed to versed and fent .\n Response:\n Repeat abg 7.24/43/91. maintaining o2 sat\n s in the high 90\ns. pt is\n more easily aroused and seems to follow simple commands.\n Plan:\n Wean vent as tolerated.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2 and stage 3 ulcers to coccys. Unstageable larger area\n around these ones. And yeasty erythemous skin around that. Pt oozing\n lrg amt\ns of serous fluid from left arm.\n Action:\n Wound care RN up to see this am, took measurements of wound. Incident\n report filed. Pt placed on kinair bed and all dressing to ulcers have\n been cleansed and redressed.\n Response:\n Following\n Plan:\n Turn pt freq.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601020,
"text": "Chief Complaint: shock\n 24 Hour Events:\n -R IJ CVL placed\n -intubated for hypercarbic resp failure\n -started stress-dose steroids (hydrocort + fludro) for AM cortisol 18.4\n -CT torso & head ordered for workup of infectious source showed\n bilateral consolidations, AAA (4.4 cm)\n -warfarin d/c'd in favor of heparin gtt in case needs procedures\n -TTE showed mod dilated LV and RV, nl LV systolic function, mildly\n depressed RV function, mild AS, mod PA sHTN\n -propofol gtt switched to fentanyl/versed due to bradycardia\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 01:15 PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 54 (43 - 76) bpm\n BP: 139/57(84) {76/38(51) - 139/57(84)} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 99%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 8 (5 - 25)mmHg\n Total In:\n 4,099 mL\n 396 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 396 mL\n Blood products:\n Total out:\n 428 mL\n 420 mL\n Urine:\n 428 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 99%\n ABG: 7.26/40/282/19/-8\n Ve: 8.7 L/min\n PaO2 / FiO2: 564\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: PERRL\n Cardiovascular: regular brady no m/r/g\n Respiratory / Chest: diminished at bases\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+, venous stasis changes with erythema\n Neurologic: Responds to: Verbal stimuli, pain\n Labs / Radiology\n 62 K/uL\n 9.3 g/dL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n Glucose\n 98\n 142\n 190\n 226\n Other labs: PT / PTT / INR:19.7/89.9/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:8.0 mg/dL, Mg++:2.1\n mg/dL, PO4:5.0 mg/dL\n Imaging: CT TORSO\n 1. Bilateral pulmonary consolidations with small pleural effusions as\n above,\n possibly infectious given the provided history, though in this patient\n with a\n nasogastric tube as well as an endotracheal tube, aspiration is another\n consideration.\n 2. Extensive atherosclerotic disease involving the coronary arteries as\n well\n as involving an abdominal aortic aneurysm measuring 44 mm in greatest\n diameter.\n Microbiology: 3:58 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n 11:57 pm STOOL CONSISTENCY: WATERY\n **FINAL REPORT **\n CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n BCx NGTD\n Assessment and Plan\n 66M with DM, DVT on coumadin, PVD with chronic nonhealing LE ulcers and\n recurrent cellulitis admitted to OSH with beta streptococcal bacteremia\n and septic shock complicated by ATN requiring HD & AFib s/p\n cardioversion admitted to the MICU for recurrent shock.\n .\n #Shock\n pressor requirement decreased; multifactorial due to sepsis\n (likely sources are nonhealing skin wounds and pneumonia given CT\n findings) and relative adrenal insufficiency; TTE showed mod dilated\n LV/RV with nl LV systolic function and mildly depressed RV function,\n mild AS, mod pulm HTN (TR grad 42 mmHg)\n -cont vanc/zosyn (day 2) tailor ABX according to Cx data\n -cont hydro/fludrocort\n -wean levophed for goal MAP> 60-65\n -volume repletion to goal CVP 8-12\n -repeat ScVO2, consider transfusion if <70\n -cont hold amiodarone, carvediolol\n .\n #Hypercapnic respiratory failure\nshunting of blood away from diaphragm\n due to septic shock, respiratory muscle fatigue, and resulting\n hypercarbia; element of hypoxemia likely due to volume overload and PNA\n -repeat ABG (0436 gas drawn on 100%FiO2 when being suctioned)\n -ABX as above\n -consider lasix bolus if oxygenation acutely worsens\n .\n # Acute on chronic renal failure\n nonoliguric, most attributable to\n ATN from shock\n -will d/w renal re need for CVVH based on trend of renal indices\n .\n #Thrombocytopenia\n count stable; HIT and ADAMTS13 negative at OSH; no\n e/o DIC by labs\n -cont monitor.\n #Anemia: Hct stable, no e/o hemolysis by labs\n -daily Hct\n -guaiac stools\n -transfuse for <21 or mixed venous O2 sat <70\n .\n #PVD with bilateral LE cellulitis/ulcers\n -appreciate vascular & wound care c/s\n .\n #. Gout:\n - cont allopurinol\n - hold colchicine\n .\n #. DM\n - cont. on current basal, sliding scale insulin regimen\n - consider insulin gtt if not well controlled\n - following, appreciate recs\n .\n #.Afib s/p cardioversion\n currently in sinus\n -cont monitor while on pressors\n -hold coumadin, heparin gtt\n .\n #DVT\n -heparin gtt & hold coumadin in case procedure required\n .\n #FEN: monitor/replete electrolytes, nutrition C/S for TF\n #PPX: heparin gtt, H2blocker\n #ACCESS: RIJ CVL, A-line, PIV\n #CODE STATUS: FULL\n #EMERGENCY CONTACT: wife\n #DISPOSITION: ICU\n ICU Care\n Nutrition: monitor/replete electrolytes, nutrition C/S for TF\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: heparin IV\n Stress ulcer: H2blocker\n VAP: Bundle\n Code status: FULL\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601200,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601203,
"text": "66M transafer from osh with worsening LE ulcers and LE edema. pt was\n in the MICU with septic shock from blood cultures positive for GBS\n on , has completed a course of ABX (5 days vanc/zosyn), source felt\n to be from ulcers. His course was complicated by ATN requiring 2\n sessions of HD and afib with RVR s/p cardioversion on (and\n found to have elevated troponins) and initiation of amiodarone and\n coumadin. Pt on the floor found to be minimally responsive and then\n hypotensive with systolic in 70s; Patient not making urine. Intubated\n once in the micu for worsening metabolic process and decreased\n responsiveness\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. yeast\n rash in peri area. BLE with multiple areas of ulceration\n vascular\n following. R arm edematous and weeping serous fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated, however trending downward with PM\n lytes. Remains fluid overloaded, however UOP is picking up. Renal\n following.\n Action:\n UOP and Electrolytes monitored. No further lasix. no immediate plans to\n dialyze at this time.\n Response:\n K trending downward. Conts to diurese\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n .\n Action:\n Abx as ordered.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Levophed gtt 0.04 mcg/kg/min. SBP sustained in the 1teens to 120\n Action:\n Levophed gtt weaned to off mult times.\n Response:\n Pt is currently on 0.04mcg/kg/min Levophed. SBP is in the 120\ns and MAP\n is low 60\ns. with d/c of goo. Pt drops to the mid 70\ns sys and maps 40\n Plan:\n Titrate Levophed gtt to maintain MAPS at goal >60.\n ------ Protected Section ------\n Able to wean levophed to off at 0400\n ------ Protected Section Addendum Entered By: , RN\n on: 06:50 AM ------\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600925,
"text": "Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. Transferred to the VICU for further care at 0400. At the\n time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. Later on this\n morning he was again found to be minimally responsive and then\n hypotensive with systolic in 70s; HR was maintained in 50-60s. Repeat\n ABG was 7.34/44/82. Blood cultures were sent. Patient is not making\n urine.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n No uop since transfer to micu 0900.\n Action:\n Response:\n Plan:\n Acidosis, Respiratory\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600926,
"text": "Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. Transferred to the VICU for further care at 0400. At the\n time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. Later on this\n morning he was again found to be minimally responsive and then\n hypotensive with systolic in 70s; HR was maintained in 50-60s. Repeat\n ABG was 7.34/44/82. Blood cultures were sent. Patient is not making\n urine.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n No uop since transfer to micu 0900.\n Action:\n Response:\n Plan:\n Acidosis, Respiratory\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600928,
"text": "Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. Transferred to the VICU for further care at 0400. At the\n time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. Later on this\n morning he was again found to be minimally responsive and then\n hypotensive with systolic in 70s; HR was maintained in 50-60s. Repeat\n ABG was 7.34/44/82. Blood cultures were sent. Patient is not making\n urine.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n No uop since transfer to micu 0900.\n Action:\n Cont ivf\ns now on levophed at 0.3 mcg/kg/min for map>60\n Response:\n Pt ahs started to put out sm amt urine, sent for cx\n Plan:\n Cont to follow. Renal following ?may need dialysis again (needed in\n past at osh this admission)\n Acidosis, Respiratory\n Assessment:\n Pt awake, confused, responsive this am. More lethargic as day went on.\n Acidotic to 7.13\n Action:\n Intubated this afternoon\n Response:\n Abg pending, hemodynamically more stable. Remains on levo\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600988,
"text": "Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n At , pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. Transferred to the VICU for further care at 0400. At the\n time, VS were: HR 60, BP 90/60-115/70, RR12, 96% on 4L. Later on this\n morning he was again found to be minimally responsive and then\n hypotensive with systolic in 70s; HR was maintained in 50-60s. Repeat\n ABG was 7.34/44/82. Blood cultures were sent. Patient is not making\n urine.\n Intubated this afternoon for arf. Heparin gtt started for afib\n (coumadinized at home) contrast infusing for CT of torso this PM\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n No uop since transfer to micu 0900.\n Action:\n Cont ivf\ns now on levophed at 0.3 mcg/kg/min for map>60\n Response:\n Pt ahs started to put out sm amt urine, sent for cx\n Plan:\n Cont to follow. Renal following ?may need dialysis again (needed in\n past at osh this admission)\n Acidosis, Respiratory\n Assessment:\n Pt awake, confused, responsive this am. More lethargic as day went on.\n Acidotic to 7.13\n Action:\n Intubated this afternoon\n Response:\n Abg pending, hemodynamically more stable. Remains on levo. Remains\n vented on propofol\n Plan:\n Wean vent as tolerated. Ct this pm, vascular following for leg ulcers\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2 and stage 3 ulcers to coccys. Unstageable larger area\n around these ones. And yeasty erythemous skin around that.\n Action:\n Wound care RN up to see this am, took measurements of wound. Incident\n report filed. Kinair bed ordered.\n Response:\n Following\n Plan:\n As above\n"
},
{
"category": "Respiratory ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600995,
"text": "Demographics\n Day of mechanical ventilation: 2\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 601269,
"text": "Chief Complaint: respiratory failure, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 66M with DM, htn, dvts, LE ulces, septic shock at OSH with new afib,\n ARF requiring HD briefly, initially transferred to vascular, the to ICU\n and intubated with worsening pulmonary edema and hypotension.\n 24 Hour Events:\n EKG - At 01:57 PM\nExtubated this morning\n Still requiring levophed intermittently\n History obtained from Patient\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Piperacillin - 08:00 AM\n Vancomycin - 09:51 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 01:40 PM\n Midazolam (Versed) - 12:25 AM\n Other medications:\n allopur, tricor, , , vanco 1q24, norepi, heparin,\n hydrocort, zantac, chlorhex\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain\n Genitourinary: No(t) Foley\n Signs or concerns for abuse : No\n Pain: Moderate\n Pain location: abdomen\n Flowsheet Data as of 10:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.5\n HR: 60 (55 - 81) bpm\n BP: 72/24(37) {72/24(37) - 148/68(87)} mmHg\n RR: 13 (8 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 12 (6 - 29)mmHg\n Total In:\n 1,558 mL\n 1,220 mL\n PO:\n TF:\n IVF:\n 1,498 mL\n 1,100 mL\n Blood products:\n Total out:\n 2,690 mL\n 640 mL\n Urine:\n 1,690 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,132 mL\n 580 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 879 (596 - 879) mL\n PS : 10 cmH2O\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 19\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.30/43/109/21/-4\n Ve: 8.7 L/min\n PaO2 / FiO2: 273\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), irregular\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Tender: mild\n Extremities: Right lower extremity edema: 3+, Left lower extremity\n edema: 3+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 66 K/uL\n 149 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 88 mg/dL\n 112 mEq/L\n 143 mEq/L\n 24.3 %\n 3.3 K/uL\n [image002.jpg]\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n WBC\n 5.4\n 3.3\n Hct\n 28.3\n 24.3\n Plt\n 62\n 66\n Cr\n 2.3\n 2.2\n 2.2\n TCO2\n 19\n 20\n 19\n 17\n 21\n 20\n 22\n Glucose\n \n Other labs: PT / PTT / INR:21.3/63.8/2.0, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, LDH:252 IU/L, Ca++:7.8 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n Microbiology: bcx: pending (OSH to be reviewed)\n Assessment and Plan\n 66M with DM, htn, dvts, LE ulces, septic shock at OSH with new afib,\n ARF requiring HD briefly, initially transferred to vascular, the to ICU\n and intubated with worsening pulmonary edema and hypotension.\n SEPSIS\n -remains pressor dependent albeit at low levels\n -source of sepsis\n lower extremities ulcers vs. other\n -empiric abx vanc/zosyn pending culture data guidance\n Respiratory failure\n -extubated successfully this morning\nRenal\n -function has improved and remains stable\nDecubitus ulcers\nSevere PVD\n -vascular following, considering BPG at some point in future\n For full details, please refer to resident note.\n ICU Care\n Nutrition: npo for possible extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Generic Note",
"row_id": 601336,
"text": "TITLE:\n Resp Care\n Patient refused to wear his cpap tonight despite any attempts at\n persuasion. Currently wearing 2 liters O2 with O2 sats of 98-100%.\n States that he will wear his own home unit when his wife brings it\n in.\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 601451,
"text": "Chief Complaint:\n HPI:\n 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulitis,\n beta streptococcal septic shock complicated by ATN requiring HD, afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well:\n 24 Hour Events:\n -started fluc after foley change\n -off norepi since 9pm yest\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Piperacillin/Tazobactam (Zosyn) - 08:13 PM\n Vancomycin - 09:51 AM\n Piperacillin - 08:42 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n heparin gtt, vanco, fluc, albumin x4, riss, hydrocort 50 q6h, zantac,\n zosyn, tricor, allupur, nystatin, atorvastatin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: No(t) OG / NG tube\n Nutritional Support: No(t) NPO\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.3\nC (95.5\n HR: 85 (66 - 87) bpm\n BP: 172/84(114) {109/33(60) - 172/84(114)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 72 Inch\n CVP: 10 (3 - 17)mmHg\n Total In:\n 2,370 mL\n 502 mL\n PO:\n TF:\n IVF:\n 2,150 mL\n 402 mL\n Blood products:\n 100 mL\n 100 mL\n Total out:\n 2,135 mL\n 480 mL\n Urine:\n 1,435 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 235 mL\n 22 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 40%\n SpO2: 97%\n ABG: 7.30/41/149/23/-5\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), irreg\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 )\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Musculoskeletal: Muscle wasting, Unable to stand, Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds\n Labs / Radiology\n 7.9 g/dL\n 47 K/uL\n 87 mg/dL\n 1.9 mg/dL\n 23 mEq/L\n 3.2 mEq/L\n 83 mg/dL\n 115 mEq/L\n 147 mEq/L\n 22.8 %\n 2.6 K/uL\n [image002.jpg]\n 04:36 AM\n 06:58 AM\n 09:33 AM\n 11:31 AM\n 01:45 PM\n 05:49 PM\n 04:58 AM\n 11:50 AM\n 03:47 PM\n 04:53 AM\n WBC\n 3.3\n 6.7\n 2.6\n Hct\n 24.3\n 27.7\n 22.8\n Plt\n 66\n 71\n 47\n Cr\n 2.2\n 2.2\n 1.9\n TCO2\n 19\n 17\n 21\n 20\n 22\n 21\n Glucose\n 228\n 149\n 87\n Other labs: PT / PTT / INR:19.3/82.3/1.8, CK / CKMB /\n Troponin-T:76//0.38, Alk Phos / T Bili:/1.1, Differential-Neuts:79.2 %,\n Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %, D-dimer:1397 ng/mL, Fibrinogen:565\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.8 g/dL, LDH:252 IU/L, Ca++:8.3\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Imaging: cxr: rll opacity increased cf/ \n Microbiology: all neg. Group B strep from blood from \n Assessment and Plan\n 66M with DM, HTN, h/o DVT, PVD with chronic LE ulcers and cellulitis,\n beta streptococcal septic shock complicated by ATN requiring HD, afib\n s/p cardioversion who was transferred from Hospital for\n angiogram of BLEs, then transferred to MICU for hypotension and\n worsening mental status; now extubated, off pressors, doing well.\n Shock physiology likely multifactorial from lung, possible cellulitis,\n and possible adrenal insufficiency. Will finish an 8-day course of abx\n for presumed HAP/VAP, and titrate steroids to off over several days.\n Would diurese to 0.5-1 L negative. Being tx for pneumonina with\n vanc/zosyn. Meds need to be renally dosed.\n Need further discussion with vascular about additional studies and\n dispo.\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines:\n Arterial Line - 10:29 AM\n Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :patient is critically ill. If remains stable can transfer\n to floor.\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601159,
"text": "66M transafer from osh with worsening LE ulcers and LE edema. pt was\n in the MICU with septic shock from blood cultures positive for GBS\n on , has completed a course of ABX (5 days vanc/zosyn), source felt\n to be from ulcers. His course was complicated by ATN requiring 2\n sessions of HD and afib with RVR s/p cardioversion on (and\n found to have elevated troponins) and initiation of amiodarone and\n coumadin. Pt on the floor found to be minimally responsive and then\n hypotensive with systolic in 70s; Patient not making urine. Intubated\n once in the micu for worsening metabolic process and decreased\n responsiveness\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. yeast\n rash in peri area. BLE with multiple areas of ulceration\n vascular\n following. R arm edematous and weeping serous fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated, however trending downward with PM\n lytes. Remains fluid overloaded, however UOP is picking up. Renal\n following.\n Action:\n UOP and Electrolytes monitored. No further lasix. no immediate plans to\n dialyze at this time.\n Response:\n K trending downward. Conts to diurese\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n .\n Action:\n Abx as ordered.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Levophed gtt 0.04 mcg/kg/min. SBP sustained in the 1teens to 120\n Action:\n Levophed gtt weaned to off mult times.\n Response:\n Pt is currently on 0.04mcg/kg/min Levophed. SBP is in the 120\ns and MAP\n is low 60\ns. with d/c of goo. Pt drops to the mid 70\ns sys and maps 40\n Plan:\n Titrate Levophed gtt to maintain MAPS at goal >60.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601271,
"text": "HPI:\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Pt coccyx dressing intact, leg dressing changed at 1500 rt arm dsg\n changed at 9 am, pulses by Doppler see assessment\n Action:\n Leg dressing no oozing noted, no ordor, pt remains on iv antibiotics\n Response:\n Pt afebrile, legs seem to be improving\n Plan:\n Continue with dsg changes and daily coccyx dsg change\n Hypotension (not Shock)\n Assessment:\n Pt dropped bo this morning to 60\ns systolic\n Action:\n Pt boluses with a liter ivf, cvp 10- 15, no improvement pt needed to\n restart norepi drip, pt now on .04mcg/kg /min\n Response:\n Pt\ns Bp very labile anyplace from 90-160/systolic\n Plan:\n Have been able to wean pt\ns drip throughout the day\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt lung sounds decreased throughout sats 97%\n Action:\n Pt weaned and extubated this morning, pt on 40% shovel mask and now\n on 3l n/c\n Response:\n Pt tolerated wean of fio2\n Plan:\n Will follow o2 sats , will need cpap tonight\n Noted that post extubation that pt tongue is swollen, wife in room and\n she staid this has been an issue since pt was in osh, pt able to\n swallow clear liquids with no issue this afternoon, pt seems to have\n random tongue moments, I spoke with Dr \n and asked her to go\n see pt.\n Pt has some oozing from around foley, foley seems to have cause some\n trauma at head of penis from pressure. Area cleaned and nystatin to\n penis area\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Physician Fellow / Attending Admission Note - MICU",
"row_id": 600906,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Vancomycin - 01:15 PM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1) Chronic renal insufficiency (baseline creatinine 1.7) with ATN at\n Hospital in early transiently requiring HD.\n 2) OSA on CPAP, he is not consistently compliant\n 3) Gout on allopurinol and colchicine, s/p knee arthrocentesis at\n Hospital\n 4) Ulcerative colitis\n 5) IDDM\n 6) Hypertension\n 7) A fib with RVR s/p cardioversion at on \n 8) PVD with chronic lower extremity ulcers for the prior 10 years with\n chronic ulcers\n 9) H/o DVT on Warfarin\n 10) Obesity\n 11) Anemia\n unknown baseline\n Could not obtain depressed mental status.\n Per medical records as patient cannot provide history:\n Occupation: Retired, previously owned a liquor store.\n Drugs: N/A\n Tobacco: Quit smoking 40 years ago.\n Alcohol: Varying estimates\n from glasses of bourbon a day to\nonly\n on weekends.\n Other:\n Review of systems: Patient cannot provide a review of systems \n depressed mental status.\n Flowsheet Data as of 01:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 59 (59 - 76) bpm\n BP: 96/44(61) {76/38(51) - 114/48(68)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,861 mL\n PO:\n TF:\n IVF:\n 2,061 mL\n Blood products:\n Total out:\n 0 mL\n 20 mL\n Urine:\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,841 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General: Obese, chronically ill appearing, arousable to noxious stimuli\n but non-sensical and disoriented. No respiratory distress.\n HEENT: PERRL. Anicteric sclera. OP clear without apparent thrush or\n exudate on limited exam. No appreciable cervical or clavicular\n adenopathy, but very obese neck.\n Lungs: Limited exam as patient cannot sit up and does not take deep\n breaths due to depressed mental status. No obvious focal wheezing or\n crackles.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not apparently\n tender. Could not appreciate HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Arousable to noxious stimuli but not meaningfully interactive.\n Moving all extremities spontaneously.\n Labs / Radiology\n 54 K/uL\n 23.7 %\n 7.9 g/dL\n 98 mg/dL\n 2.3 mg/dL\n 97 mg/dL\n 20 mEq/L\n 113 mEq/L\n 5.3 mEq/L\n 139 mEq/L\n 3.9 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n 09:28 AM\n WBC\n 3.9\n Hct\n 23.7\n Plt\n 54\n Cr\n 2.3\n TropT\n 0.38\n Glucose\n 98\n Other labs:\n CK / CKMB / Troponin-T:76//0.38,\n Ca++:7.5 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status and\n hypotension.\n 1) Hypotension: The differential diagnosis of his hypotension is\n broad, including distributive shock (sepsis, adrenal insufficiency,\n hypothyroidism), cardiogenic (depressed EF of 40% with LV hypokinesis\n on a TTE), obstructive ( 1.1 cm^2 on the TTE), or\n hypovolumic (he is clearly whole body overloaded but certainly may be\n intravascularly deplete.)\n With regard to possible septic physiology, we will provide broad\n spectrum antibiotics to cover potential nosocomial pathogens (Vanc and\n Zosyn) and investigate possible sources of a sepsis syndrome. His lower\n extremities are certainly a possible source and Vascular\ns input\n regarding the likelihood of these chronic ulcers contributing to a\n systemic infection will be sought. His chest x-ray demonstrates\n increased bilateral opacities that are likely pulmonary edema, but with\n his depressed mental status superimposed aspiration pneumonitis /\n pneumonia is a possibility. We will pursue an abdominal and chest CT\n scan to assess for an infectious source of his possible septic\n physiology. Finally, we\nve placed a central venous catheter with which\n we will follow CVP and SvO2 as surrogates of his volume status and\n peripheral oxygen up-take.\n He has been on Prednisone for an uncertain amount of time, we will\n provide him with empiric corticosteroids and check a random cortisol to\n further assess for possible adrenal insufficiency. Would send a TSH as\n well.\n With regard to possible cardiogenic shock, we will repeat a TTE\n today. In addition, if his hemodynamic picture remains unclear, a\n and/or a PA catheter could be considered.\n With regard to possible obstructive shock, his was 1.1 cm^2 at\n the OSH on \n if this has progressed, it could be contributing\n more to his hypotension. PE is less likely given he has been on\n Warfarin (although his INR today is subtherapeutic.)\n With regard to his volume status, he is clearly whole body volume\n overloaded but his intravascular status is unclear. check his CVP\n and SvO2. Follow UOP, although this is complicated by his concomitant\n renal dysfunction.\n 2) Depressed mental status: Multifactorial in nature with his\n hypotension, acute renal failure, multiple organ dysfunction, acute\n respiratory acidosis and medication effects. Will address his\n underlying processes. Given he is undergoing a chest / abdomen CT we\n will scan his head as well. His overall mental status concerning and\n given concerns regarding his inability to protect his airway and a\n progressive acute respiratory acidosis, we will plan on an elective\n intubation this afternoon.\n 3) Thrombocytopenia: Unclear etiology. This has progressed from\n (platelets were 130 on .) and now are in the 40-50s. His\n HIT Ab and his -TS 13 study were normal. Multiple DIC and\n hemolysis labs are pending. No indication for transfusion at this time.\n 4) F/E/N: Follow his\nlytes. Correct elevated K. Anticipate\n starting TFs.\n 5) Anemia: Follow his H/H. Hemolysis labs pending (we \n clinically suspect any significant hemoptysis.)\n 6) IDDM: RSSI with an insulin gtt if his sugar is >180. Goal range\n will be 110-180.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation: 20 Gauge - 09:14 AM, 22 Gauge -\n 09:14 AM and Multi Lumen - 10:40 AM\n Comments:\n Prophylaxis:\n DVT: systemic anticoagulation\n Stress ulcer: H2 blocker\n VAP: Bundle will be ordered\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU for now\n Total time spent: 60 min\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Physician Fellow / Attending Admission Note - MICU",
"row_id": 600907,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure.\n His course at Hospital from \n was notable for\n the following:\n 1) Blood cultures on admission (, 2 out of 4 bottles) grew\n out group B Strep for which he was greated with a 5 day course of Vanc\n / Zosyn. He is noted in some notes to be\nin severe sepsis\n and was\n cared for in the ICU.\n 2) Acute renal failure attributed to ATN for which he required\n transient dialysis, but has since been liberated from diaysis. It is\n not clear if the ATN was septic physiology or another process.\n 3) New A fib with RVR requiring d/c cardioversion on and\n subsequent initiation of Amio (he was already on Warfarin for a h/o\n DVTs.)\n 4) Right knee arthrocentesis consistent with gout for which he\n was started on colchicine and prednisone.\n Last night, he was found to be minimally responsive to sternal rub and\n was dosed with Narcan 0.4mg x 2 with some improvement in his level of\n consciousness. At that time, his ABG was 7.35 / 41 / 56 on CPAP (which\n he is on at baseline) with an unclear FiO2, his SBP was 90 with a HR of\n 60. He was given two 500cc boluses for the borderline SBP. This morning\n () he was again found to be minimally responsive with a HR of 60,\n SBP in the 70s, and an ABG of 7.34 / 44 / 82. He was transferred to\n the MICU for further evaluation and care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Vancomycin - 01:15 PM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1) Chronic renal insufficiency (baseline creatinine 1.7) with ATN at\n Hospital in early transiently requiring HD.\n 2) OSA on CPAP, he is not consistently compliant\n 3) Gout on allopurinol and colchicine, s/p knee arthrocentesis at\n Hospital\n 4) Ulcerative colitis\n 5) IDDM\n 6) Hypertension\n 7) A fib with RVR s/p cardioversion at on \n 8) PVD with chronic lower extremity ulcers for the prior 10 years with\n chronic ulcers\n 9) H/o DVT on Warfarin\n 10) Obesity\n 11) Anemia\n unknown baseline\n Could not obtain depressed mental status.\n Per medical records as patient cannot provide history:\n Occupation: Retired, previously owned a liquor store.\n Drugs: N/A\n Tobacco: Quit smoking 40 years ago.\n Alcohol: Varying estimates\n from glasses of bourbon a day to\nonly\n on weekends.\n Other:\n Review of systems: Patient cannot provide a review of systems \n depressed mental status.\n Flowsheet Data as of 01:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 59 (59 - 76) bpm\n BP: 96/44(61) {76/38(51) - 114/48(68)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,861 mL\n PO:\n TF:\n IVF:\n 2,061 mL\n Blood products:\n Total out:\n 0 mL\n 20 mL\n Urine:\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,841 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General: Obese, chronically ill appearing, arousable to noxious stimuli\n but non-sensical and disoriented. No respiratory distress.\n HEENT: PERRL. Anicteric sclera. OP clear without apparent thrush or\n exudate on limited exam. No appreciable cervical or clavicular\n adenopathy, but very obese neck.\n Lungs: Limited exam as patient cannot sit up and does not take deep\n breaths due to depressed mental status. No obvious focal wheezing or\n crackles.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not apparently\n tender. Could not appreciate HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Arousable to noxious stimuli but not meaningfully interactive.\n Moving all extremities spontaneously.\n Labs / Radiology\n 54 K/uL\n 23.7 %\n 7.9 g/dL\n 98 mg/dL\n 2.3 mg/dL\n 97 mg/dL\n 20 mEq/L\n 113 mEq/L\n 5.3 mEq/L\n 139 mEq/L\n 3.9 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n 09:28 AM\n WBC\n 3.9\n Hct\n 23.7\n Plt\n 54\n Cr\n 2.3\n TropT\n 0.38\n Glucose\n 98\n Other labs:\n CK / CKMB / Troponin-T:76//0.38,\n Ca++:7.5 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status and\n hypotension.\n 1) Hypotension: The differential diagnosis of his hypotension is\n broad, including distributive shock (sepsis, adrenal insufficiency,\n hypothyroidism), cardiogenic (depressed EF of 40% with LV hypokinesis\n on a TTE), obstructive ( 1.1 cm^2 on the TTE), or\n hypovolumic (he is clearly whole body overloaded but certainly may be\n intravascularly deplete.)\n With regard to possible septic physiology, we will provide broad\n spectrum antibiotics to cover potential nosocomial pathogens (Vanc and\n Zosyn) and investigate possible sources of a sepsis syndrome. His lower\n extremities are certainly a possible source and Vascular\ns input\n regarding the likelihood of these chronic ulcers contributing to a\n systemic infection will be sought. His chest x-ray demonstrates\n increased bilateral opacities that are likely pulmonary edema, but with\n his depressed mental status superimposed aspiration pneumonitis /\n pneumonia is a possibility. We will pursue an abdominal and chest CT\n scan to assess for an infectious source of his possible septic\n physiology. Finally, we\nve placed a central venous catheter with which\n we will follow CVP and SvO2 as surrogates of his volume status and\n peripheral oxygen up-take.\n He has been on Prednisone for an uncertain amount of time, we will\n provide him with empiric corticosteroids and check a random cortisol to\n further assess for possible adrenal insufficiency. Would send a TSH as\n well.\n With regard to possible cardiogenic shock, we will repeat a TTE\n today. In addition, if his hemodynamic picture remains unclear, a\n and/or a PA catheter could be considered.\n With regard to possible obstructive shock, his was 1.1 cm^2 at\n the OSH on \n if this has progressed, it could be contributing\n more to his hypotension. PE is less likely given he has been on\n Warfarin (although his INR today is subtherapeutic.)\n With regard to his volume status, he is clearly whole body volume\n overloaded but his intravascular status is unclear. check his CVP\n and SvO2. Follow UOP, although this is complicated by his concomitant\n renal dysfunction.\n 2) Depressed mental status: Multifactorial in nature with his\n hypotension, acute renal failure, multiple organ dysfunction, acute\n respiratory acidosis and medication effects. Will address his\n underlying processes. Given he is undergoing a chest / abdomen CT we\n will scan his head as well. His overall mental status concerning and\n given concerns regarding his inability to protect his airway and a\n progressive acute respiratory acidosis, we will plan on an elective\n intubation this afternoon.\n 3) Thrombocytopenia: Unclear etiology. This has progressed from\n (platelets were 130 on .) and now are in the 40-50s. His\n HIT Ab and his -TS 13 study were normal. Multiple DIC and\n hemolysis labs are pending. No indication for transfusion at this time.\n 4) F/E/N: Follow his\nlytes. Correct elevated K. Anticipate\n starting TFs.\n 5) Anemia: Follow his H/H. Hemolysis labs pending (we \n clinically suspect any significant hemoptysis.)\n 6) IDDM: RSSI with an insulin gtt if his sugar is >180. Goal\n range will be 110-180.\n 7) Acute renal failure: His creatinine is worse than his baseline\n of ~1.7; more concerningly, his urine output has been minimal since\n having arrived in the MICU. We appreciate Renal\ns assistance and\n barring a significant change in his course, anticipate RRT.\n ICU \n Nutrition:\n Glycemic Control:\n Lines / Intubation: 20 Gauge - 09:14 AM, 22 Gauge -\n 09:14 AM and Multi Lumen - 10:40 AM\n Comments:\n Prophylaxis:\n DVT: systemic anticoagulation\n Stress ulcer: H2 blocker\n VAP: Bundle will be ordered\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: ICU for now\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Physician Fellow / Attending Admission Note - MICU",
"row_id": 600890,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 66yo man with a h/o DM, hypertension, DVT on Wafarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n . On admission, 2 out of 4 blood cultures grew beta-Strep for\n Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n .\n At . pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. At the time, VS were: HR 60, BP 90/60-115/70, RR12, 96%\n on 4L. This morning he was again found to be minimally responsive and\n then hypotensive with systolic in 70s; HR was maintained in 50-60s.\n Repeat ABG was 7.34/44/82. Blood cultures were sent. Patient is not\n making urine.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Vancomycin - 01:15 PM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency (baseline cr 1.7), Stage III\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n Anemia\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 01:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 59 (59 - 76) bpm\n BP: 96/44(61) {76/38(51) - 114/48(68)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,861 mL\n PO:\n TF:\n IVF:\n 2,061 mL\n Blood products:\n Total out:\n 0 mL\n 20 mL\n Urine:\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,841 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\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 54 K/uL\n 23.7 %\n 7.9 g/dL\n 98 mg/dL\n 2.3 mg/dL\n 97 mg/dL\n 20 mEq/L\n 113 mEq/L\n 5.3 mEq/L\n 139 mEq/L\n 3.9 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n 09:28 AM\n WBC\n 3.9\n Hct\n 23.7\n Plt\n 54\n Cr\n 2.3\n TropT\n 0.38\n Glucose\n 98\n Other labs:\n CK / CKMB / Troponin-T:76//0.38,\n Ca++:7.5 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Multi Lumen - 10:40 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Physician Fellow / Attending Admission Note - MICU",
"row_id": 600891,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 66yo man with a h/o DM, hypertension, DVT on Wafarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n . On admission, 2 out of 4 blood cultures grew beta-Strep for\n Patient is a 66M with PMHx sig. for DM, HTN, recent afib, h/o DVT on\n coumadin, and PVD with chronic LE ulcers and cellulitis who was\n transferred from Hospital for angiogram of BLEs. He had been\n admitted at on with worsening LE ulcers and LE edema. He\n had a 10 year history of bilateral LE ulcers with eschar on the R leg\n accompanied with pain worse wtih ambulation.\n .\n At . pt was in the MICU with septic shock from blood\n cultures positive for GBS on , has completed a course of ABX (5\n days vanc/zosyn), source felt to be from ulcers. His course was\n complicated by ATN requiring 2 sessions of HD and afib with RVR s/p\n cardioversion on (and found to have elevated troponins) and\n initiation of amiodarone and coumadin.\n .\n Here, patient was scheduled for LE angiogram today. Nephrology was\n consulted for recommendations with angiogram. However, overnight, the\n patient was unresponsive to sternal rub. He received Narcan 0.4 mg x 2\n with response. Narcotics were discontinued. ABG on CPAP was\n 7.35/41/56. At the time, VS were: HR 60, BP 90/60-115/70, RR12, 96%\n on 4L. This morning he was again found to be minimally responsive and\n then hypotensive with systolic in 70s; HR was maintained in 50-60s.\n Repeat ABG was 7.34/44/82. Blood cultures were sent. Patient is not\n making urine.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Penicillin G potassium - 01:15 PM\n Vancomycin - 01:15 PM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Chronic renal insufficiency (baseline cr 1.7), Stage III\n OSA on CPAP\n Gout on allopurinol and colchicine\n Ulcerative colitis\n Diabetes on insulin\n HTN\n Afib, newly diagnosed\n PVD with chronic lower extremity ulcers\n H/o DVT- on coumadin\n Obesity\n Anemia\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 01:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 59 (59 - 76) bpm\n BP: 96/44(61) {76/38(51) - 114/48(68)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 100%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,861 mL\n PO:\n TF:\n IVF:\n 2,061 mL\n Blood products:\n Total out:\n 0 mL\n 20 mL\n Urine:\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,841 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\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 54 K/uL\n 23.7 %\n 7.9 g/dL\n 98 mg/dL\n 2.3 mg/dL\n 97 mg/dL\n 20 mEq/L\n 113 mEq/L\n 5.3 mEq/L\n 139 mEq/L\n 3.9 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n 09:28 AM\n WBC\n 3.9\n Hct\n 23.7\n Plt\n 54\n Cr\n 2.3\n TropT\n 0.38\n Glucose\n 98\n Other labs:\n CK / CKMB / Troponin-T:76//0.38,\n Ca++:7.5 mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 09:14 AM\n 22 Gauge - 09:14 AM\n Multi Lumen - 10:40 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601079,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. Also\n noted to have yeast rash in peri area. BLE with multiple areas of\n ulceration\n vascular following. R arm edematous and weeping serous\n fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated. Remains fluid overloaded, however\n UOP is picking up. Renal following.\n Action:\n UOP and Electrolytes monitored. Pt received a total of 80mg Lasix IVP\n today. Per renal team, no immediate plans to dialyze at this time.\n Response:\n Pt responded to Lasix with 260ml UOP. K remains elevated.\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n ..\n Action:\n Abx as ordered. Blood cultures sent this AM.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed gtt 0.056mcg/kg/min. SBP sustained in the\n 1teens to 120\ns this AM.\n Action:\n Levophed gtt weaned as tolerated.\n Response:\n Pt is currently on 0.028mcg/kg/min Levophed. SBP is in the 120\ns and\n MAP is low 60\n Plan:\n Titrate Levophed gtt to maintain MAPS >60.\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601074,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. Also\n noted to have yeast rash in peri area. BLE with multiple areas of\n ulceration\n vascular following. R arm edematous and weeping serous\n fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated. Remains fluid overloaded, however\n UOP is picking up. Renal following.\n Action:\n UOP and Electrolytes monitored. Pt received a total of 80mg Lasix IVP\n today. Per renal team, no immediate plans to dialyze at this time.\n Response:\n Pt responded to Lasix with 260ml UOP. K remains elevated.\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n ..\n Action:\n Abx as ordered. Blood cultures sent this AM.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed gtt 0.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 601071,
"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 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure. His\n course at Hospital from \n notable for blood\n cultures on admission (, 2 out of 4 bottles) growing out group B\n Strep for which he was greated with a 5 day course of Vanc / Zosyn. He\n apparently was \"septic\" and in the ICU. He also developed acute renal\n failure attributed to ATN for which he required transient dialysis, but\n has since been liberated from diaysis. It is not clear if the ATN was\n septic physiology or another process. He developed new A fib with\n RVR requiring d/c cardioversion on and subsequent initiation of\n Amio (he was already on Warfarin for a h/o DVTs.) Finally, he had a\n right knee arthrocentesis consistent with gout for which he was started\n on colchicine and prednisone. He was transferred to on to\n the Vascular Surgery service for possible lower extremity\n revascularization. On overnight, he was found to be minimally\n responsive to sternal rub and was dosed with Narcan 0.4mg x 2 with some\n improvement in his level of consciousness. At that time, his ABG was\n 7.35 / 41 / 56 on CPAP (which he is on at baseline) with an unclear\n FiO2, his SBP was 90 with a HR of 60. He was given two 500cc boluses\n for the borderline SBP. This morning () he was again found to be\n minimally responsive with a HR of 60, SBP in the 70s, and an ABG of\n 7.34 / 44 / 82. He was transferred to the MICU for further evaluation\n and care. Here we placed a line (CVP 16 and SvO2 85%) and he was\n intubated for respiratory acidosis and decreased mental status. Right\n now, his picture is of course multifactorial shock but primarily\n distributive (with a flavor of cardiogenic [EF 40% with apical\n hypokinesis from TTE] and obstructive [ 1.1 cm^2.]) He is on\n low-dose Levophed, getting corticosteroids (random cortisol of 18) and\n broad spectrum antibiotics.\n 24 Hour Events:\n ARTERIAL LINE - START 10:29 AM\n MULTI LUMEN - START 10:40 AM\n INVASIVE VENTILATION - START 03:00 PM\n SPUTUM CULTURE - At 04:05 PM\n URINE CULTURE - At 04:05 PM\n TTE\n CHEST / ABDOMEN CT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 01:15 PM\n Penicillin G potassium - 1:15PM\n Piperacillin - 02:07 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Versed - 2 mg/hour\n Heparin Sodium - 1,500 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Miconazole powder and cream\n Allopurinol 150mg q24h\n d/c today\n Tricor\n Calcium acetate TID\n d/c today\n Lipitor 80mg q24h\n RSSI\n Lantus 15mg\n Provigil 100mg q24h\n d/c today\n Vanc 1gm IV q24h (day 2)\n Zosyn 2.25mg IV q6h (day 2)\n Levophed 0.68\n Florinef 0.5mg q24h\n Heparin subQ\n Zantac 150mg q24h\n Hydrocort 50mg q6h\n Versed gtt 0.5mg / hr\n Fentanyl gtt 25mcg / hr\n Peridex\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 45 (43 - 76) bpm\n BP: 119/46 {76/38 - 143/57} mmHg\n RR: 20 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n CVP: 2 (2 - 25)mmHg\n Total In:\n 4,099 mL\n 462 mL\n PO:\n TF:\n IVF:\n 3,179 mL\n 462 mL\n Blood products:\n Total out:\n 428 mL\n 525 mL\n Urine:\n 428 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,671 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.30 / 34 / 113\n Ve: 8.7 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General: Obese, intubated, opens eyes to voice and answers questions\n yes / no. .\n HEENT: ETT in place. PERRL. Anicteric sclera.\n Lungs: Anterior exam with no crackles or obvious wheezing. Good air\n movement.\n CV: S1S2 regular rate and rhythm with frequent extra beats, III/VI SEM\n at the base. No rubs / gallops.\n Ab: Very obese. Positive bowel sounds. Non-distended. Not tender. No\n appreciable HSM.\n Skin: Multiple scattered erythematous non-blanching lesions of <1cm in\n size. Scattered bruising.\n Ext: Anasarca with upper and lower extremity 3+ pitting edema. Chronic\n lower extremity ulcers.\n Neuro: Moves all extremities. Answers yes / no questions\n appropriately.\n Labs / Radiology\n 9.3 g/dL\n 62 K/uL\n 226 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 93 mg/dL\n 112 mEq/L\n 140 mEq/L\n 28.3 %\n 5.4 K/uL\n [image002.jpg]\n Differential-Neuts:79.2 %, Lymph:9.0 %, Mono:8.1 %, Eos:3.3 %,\n Sputum gram stain (): No organisms\n Blood cultures (, ): NGTD\n 09:28 AM\n 01:56 PM\n 01:57 PM\n 06:34 PM\n 08:25 PM\n 08:30 PM\n 11:47 PM\n 04:14 AM\n 04:36 AM\n 06:58 AM\n WBC\n 3.9\n 8.6\n 5.4\n Hct\n 23.7\n 28.8\n 28.3\n Plt\n 54\n 82\n 62\n Cr\n 2.3\n 2.4\n 2.3\n 2.3\n TropT\n 0.38\n TCO2\n 22\n 20\n 19\n 20\n 19\n 17\n Glucose\n 98\n 142\n 190\n 226\n Other labs:\n PT / PTT / INR:19.7/89.9/1.8,\n CK / CKMB / Troponin-T:76//0.38, Alk Phos / T Bili:/1.1,\n D-dimer:1397 ng/mL, Fibrinogen:565 mg/dL,\n Lactic Acid:1.3 mmol/L, LDH:252 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 66yo man with a h/o DM, hypertension, DVT on Warfarin, PVD with chronic\n lower extremity ulcers and cellulitis who was admitted to on\n and subsequently transferred here on to the Vascular\n Surgery service for possible lower extremity angiogram and\n consideration of a lower extremity revascularization procedure now\n transferred to the MICU today () with decreased mental status,\n worsened renal function and hypotension.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n Baseline creatinine 1.7, now up to 2.3. He is anasarcic; we will\n attempt to diurese as able, hs urine sodium is <10 which implies\n intravascular depletion and a pre-renal physiology, but he is massively\n whole-body volume overloaded. With diuretics, we may be able to\n mobilize third-spaced fluid. He may need a lasix gtt depending on his\n hemodynamics. Goal for today would be -1L.\n HYPOTENSION (NOT SHOCK)\n His hypotension has improved with pressors and steroids. The underlying\n etiology is thought to be distributive in nature, with a potential\n contribution of adrenal insufficiency. His TTE makes a primary\n cardiogenic process very unlikely. There is no compelling data for an\n obstructive process. During the course of the day, we will wean\n pressors as able, continue glucocorticoids and follow his CVP / SvO2.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Continuing broad spectrum antibotics at this time; awaiting cultures to\n guide therapy. His pan-scan did not reveal an obvious infectious\n source. Will continue the antibiotics and follow cultures with a goal\n of de-escalating if there is no microbiologic evidence of infection.\n ALTERED MENTAL STATUS\n His initial altered mental status on presentation was likely due to\n hypotension, medication effects and critical illness.\n ACIDOSIS, RESPIRATORY\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n Intubated, sedated, oxygenation improved. He is now on PSV and\n tolerating it well. We will decrease his PS during the course of the\n day. Will change his sedation to intermittent boluses rather than\n continuous infusion as he may be able to be extubated soon.\n INSULIN DEPENDENT DIABETES\n RSSI with an insulin gtt if his sugar is >180. Goal range will be\n 110-180.\n THROMBOCYTOPENIA\n Unclear etiology. This has progressed from (platelets were 130\n on .) and now are in the 40-50s. His HIT Ab and his -TS 13\n study were normal. Multiple DIC and hemolysis labs are pending. No\n indication for transfusion at this time.\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Lantus / RSSI\n Lines: 20 Gauge - 09:14 AM, 22 Gauge - 09:14 AM,\n Arterial Line - 10:29 AM, Multi Lumen - 10:40 AM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: Zantac\n VAP: Bundle ordered\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition :ICU for now\n Total time spent: 40 min\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601072,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601075,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with stage 2/3 ulcers to coccyx, surrounding area unstageable. Also\n noted to have yeast rash in peri area. BLE with multiple areas of\n ulceration\n vascular following. R arm edematous and weeping serous\n fluid\n sm tear noted.\n Action:\n Dsg to coccyx changed per wound care reccs. BLE ulcerations covered\n with adaptic and dsd. RUE tear covered with adaptic and wrapped with\n DSD. Antifungal cream applied to peri area.\n Response:\n Ongoing.\n Plan:\n Dsg changes QD and PRN. Wound care reccs in posted in pt\ns room.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN and Cr continue to be elevated. Remains fluid overloaded, however\n UOP is picking up. Renal following.\n Action:\n UOP and Electrolytes monitored. Pt received a total of 80mg Lasix IVP\n today. Per renal team, no immediate plans to dialyze at this time.\n Response:\n Pt responded to Lasix with 260ml UOP. K remains elevated.\n Plan:\n Continue to diurese as tolerated by SBP. Goal is for pt to be 1L\n negative/day.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt thought to be septic decubitis ulcers and PNA visualized on CT\n ..\n Action:\n Abx as ordered. Blood cultures sent this AM.\n Response:\n WBC remains WNL. Afebrile. Cultures without growth to date.\n Plan:\n Monitor WBC, temp and f/u culture data.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed gtt 0.056mcg/kg/min.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601073,
"text": "Decubitus ulcer (Present At Admission)\n Assessment:\n Pt with\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Echo",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Report",
"row_id": 88192,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function. Pulmonary hypertension.\nHeight: (in) 74\nWeight (lb): 286\nBSA (m2): 2.53 m2\nBP (mm Hg): 112/54\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 15:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe rhythm appears to be ventricular bigeminy.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Normal\nregional LV systolic function. Mild global LV hypokinesis. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction. [Intrinsic RV systolic function likely more depressed given the\nseverity of TR].\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification.\nTrivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent ventricular premature beats.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is moderately dilated. Regional left\nventricular wall motion is normal. There is mild global left ventricular\nhypokinesis (LVEF = 40-45 %). The right ventricular cavity is mildly dilated\nwith borderline normal free wall function. Intrinsic function may be more\ndepressed given the severity of tricuspid regurgitation. The aortic valve\nleaflets are moderately thickened. There is mild aortic valve stenosis (valve\narea 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal. There is trivial mitral regurgitation. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the left\nventricular cavity size is smaller with mild global hypokinesis, the severity\nof tricuspid regurgitation is increased, and the rhythm is now sinus with\nventricular bigeminy. The severity of aortic stenosis and estimated PA\nsystolic pressure are similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Report",
"row_id": 88193,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease.\nHeight: (in) 74\nWeight (lb): 270\nBSA (m2): 2.47 m2\nBP (mm Hg): 110/45\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 16:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Normal\nregional LV systolic function. Overall normal LVEF (>55%). TDI E/e' >15,\nsuggesting PCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS (area 1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is moderately dilated.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg). The right\nventricular cavity is moderately dilated with mild global free wall\nhypokinesis. The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are moderately thickened. There is mild aortic valve\nstenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Moderately dilated left and right ventricles with normal left\nventricular systolic function and mildly depressed right ventricular function.\nMild aortic stenosis. Moderate pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Report",
"row_id": 233165,
"text": "Underlying atrial mechanism is unclear but probably sinus tachycardia,\nrate 108, with borderline first degree A-V block and ventricular bigeminy.\nThere is right bundle-branch block with left anterior hemiblock. Compared to\nthe previous tracing of normal sinus rhythm has given way to sinus\ntachycardia and, in consequence, there is more ventricular ectopy. There is the\nsuperficial appearance of bidirectional ventricular tachycardia but this is\nunlikely to be the case. There is also possible prior anteroseptal myocardial\ninfarction in both tracings.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-09 00:00:00.000",
"description": "Report",
"row_id": 233166,
"text": "Sinus rhythm with P-R interval prolongation at 0.23 seconds. Frequent\nventricular premature beats with intermittent ventricular bigeminy. Left atrial\nabnormality. Right bundle-branch block with borderline left axis deviation.\nPrimary lateral ST-T wave abnormalities that could be due to myocardial\nischemia, etc. Relatively low limb lead voltage. Compared to the previous\ntracing of lateral ST-T wave changes may be somewhat more prominent\nwithout diagnostic change. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Report",
"row_id": 233395,
"text": "Baseline artifact. Regularly irregular rhythm, possibly sinus with\nP-R interval prolongation. Intraventricular conduction delay of right\nbundle-branch block type with ventricular premature beats which show inferior\naxis and left bundle-branch block. Since the previous tracing of \nthere may be no significant change. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-20 00:00:00.000",
"description": "Report",
"row_id": 233163,
"text": "Wide complex tachycardia suggestive of atrial tachycardia with frequent\nventricular premature beats and underlying right bundle-branch block with left\nanterior fascicular block. Compared to the previous tracing of there is\nno change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-14 00:00:00.000",
"description": "Report",
"row_id": 233164,
"text": "Normal sinus rhythm with frequent ventricular premature beats in a bigeminal\npattern. There is P-R interval prolongation at 210 milliseconds. Complete right\nbundle-branch block with QRS duration of 190 milliseconds. Tendency toward low\nvoltage in the standard leads. Compared to the previous tracing of the\nrate is slower and there is somewhat less ventricular ectopy.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-08 00:00:00.000",
"description": "Report",
"row_id": 233391,
"text": "Sinus rhythm with ventricular premature beats in a bigeminal pattern.\nLeft atrial abnormality. Right bundle-branch block. Low QRS voltage.\nDiffuse ST-T wave changes are primary and are non-specific. Since the previous\ntracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-10-03 00:00:00.000",
"description": "Report",
"row_id": 233392,
"text": "Sinus rhythm with bigeminal ventricular premature beats. Right bundle-branch\nblock. Non-specific ST-T wave changes. Compared to the previous tracing\nof no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-09-25 00:00:00.000",
"description": "Report",
"row_id": 233396,
"text": "Normal sinus rhythm with frequent ventricular premature contractions in a\ntrigeminal pattern with right bundle-branch block and non-specific secondary\nST-T wave abnormalities. No previous tracing available for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-09-27 00:00:00.000",
"description": "Report",
"row_id": 233393,
"text": "Sinus rhythm with frequent ventricular premature beats. Probable first degree\nA-V block. Intraventricular conduction delay. Non-specific ST-T wave\nabnormalities. Low QRS voltages in the precordial leads. Compared to the\nprevious tracing of ventricular ectopy seen previously has increased.\nClinical correlation and repeat tracing are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-09-26 00:00:00.000",
"description": "Report",
"row_id": 233394,
"text": "Sinus rhythm. P-R interval prolongation. Left axis deviation. Right\nbundle-branch block. ST-T wave abnormalities. Conducted complexes have\nlow voltage. Since the previous tracing there are fewer ventricular premature\nbeats.\nTRACING #2\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-02 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 1104941,
"text": " 2:17 PM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: r/o clot\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man transferred from MICU after multifactorial shock and with\n thrombocytopenia, now with swelling of LUE\n REASON FOR THIS EXAMINATION:\n r/o clot\n ______________________________________________________________________________\n WET READ: JKSd WED 4:09 PM\n No dvt.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66 year old man transferred from MICU after multifactorial shock\n and with thrombocytopenia, now with swelling of left upper extremity.\n\n FINDINGS: Greyscale and Doppler son of the left subclavian, internal\n jugular, axillary, basilic, brachials, and cephalic veins were performed.\n There is normal compressibility, flow and augmentation. Note is made of an\n asymmetry of the right and left subclavian venous waveforms; this is of\n indeterminate clinical significance. However, both demonstrate good\n respiratory variability.\n\n IMPRESSION: No evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104344,
"text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess interval change\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with sepsis, intubated.\n REASON FOR THIS EXAMINATION:\n pls assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation, to evaluate for change.\n\n FINDINGS: Endotracheal tube and nasogastric tube have been removed. Right\n central catheter again extends to the mid portion of the SVC. The\n opacification at the left base is somewhat less than on the previous study.\n Remainder of the examination is essentially unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-26 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1103994,
"text": " 8:10 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious focus\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n Field of view: 55\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with septic shock, ARF; please give PO contrast\n REASON FOR THIS EXAMINATION:\n eval for infectious focus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:15 PM\n 1. Bilateral pulmonary consolidations with small pleural effusions as above,\n possibly infectious given the provided history, though in this patient with a\n nasogastric tube as well as an endotracheal tube, aspiration is another\n consideration.\n\n 2. Extensive atherosclerotic disease involving the coronary arteries as well\n as involving an abdominal aortic aneurysm measuring 44 mm in greatest\n diameter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Septic shock.\n\n COMPARISON: Radiographs of the chest earlier on the same date.\n\n TECHNIQUE: Axial CT images were acquired through the torso in the absence of\n intravenous contrast. Note that contrast was withheld secondary to elevated\n creatinine at the time of image acquisition. Coronal and sagittal reformatted\n images were also reviewed.\n\n CT CHEST WITHOUT CONTRAST: An endotracheal tube terminates ~5.3 cm above the\n carina. Precise details in the upper chest are obscured secondary to patient\n positioning. Bilateral lower lobe consolidations are visualized, with less\n confluent consolidations also seen posteriorly in the upper lobes bilaterally.\n There are small pleural effusions bilaterally. There is no pericardial\n effusion. The heart and great vessels reveal extensive atherosclerotic\n coronary arterial calcification as well as calcification at the aortic\n annulus. There is no axillary lymphadenopathy. A prominent subcarinal node\n measures 11 mm in shortest cross-sectional diameter.\n\n CT ABDOMEN WITHOUT CONTRAST: Nasogastric tube terminates in the distal\n stomach. Otherwise, the stomach, duodenum, splenule, spleen, pancreas,\n adrenal glands, kidneys, gallbladder, and liver are unremarkable. There is no\n free gas or fluid in the abdomen. Note is made of a small fat-containing\n umbilical hernia. Regional vascular structures are notable for extensive\n atherosclerotic calcification as well as focal infrarenal aneurysmal dilation\n of the aorta, which at greatest point measures 44 x 36 mm in cross-sectional\n area (2:84). There is no retroperitoneal or mesenteric lymphadenopathy.\n\n CT PELVIS WITHOUT CONTRAST: The urinary bladder contains a Foley catheter and\n (Over)\n\n 8:10 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious focus\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n Field of view: 55\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n a small amount of free gas. The prostate and seminal vesicles are\n unremarkable. The rectum, colon, and appendix are also normal. There is no\n free gas or fluid in the pelvis. There is no pelvic or inguinal\n lymphadenopathy.\n\n OSSEOUS FINDINGS: Partial fusion is noted at the sacroiliac joints\n bilaterally. The spine contains numerous sclerotic foci, possibly bone\n islands. There is no suspicious sclerotic or lytic lesion. Healed fracture\n deformities are seen at the fourth, fifth, sixth and seventh ribs,\n bilaterally.\n\n IMPRESSION:\n 1. Bilateral pulmonary consolidations with small pleural effusions as above,\n possibly infectious given the provided history, though, given the distribution\n in this patient with a nasogastric tube as well as an endotracheal tube,\n aspiration is another consideration.\n 2. Extensive atherosclerotic disease involving the coronary arteries as well\n as the aorta.\n 3. Infrarenal abdominal aortic aneurysm measuring 44 mm in greatest diameter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-26 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1103955,
"text": " 4:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ETT placement\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p ET intubation\n REASON FOR THIS EXAMINATION:\n eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST with comparison study of earlier the same date.\n\n INDICATION: Endotracheal tube placement.\n\n FINDINGS: Endotracheal tube terminates about 6 cm above the carina. New\n nasogastric tube terminates below the diaphragm. There has been improvement\n in degree of pulmonary edema. Small left pleural effusion and adjacent left\n basilar lung opacification appear more prominent than on the recent\n radiograph, but comparison is limited by differences in patient positioning.\n Attention to this area on the next followup radiograph suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-26 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1103995,
"text": ", D. MED MICU-7 8:10 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for infectious focus\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n Field of view: 55\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with septic shock, ARF; please give PO contrast\n REASON FOR THIS EXAMINATION:\n eval for infectious focus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Bilateral pulmonary consolidations with small pleural effusions as above,\n possibly infectious given the provided history, though in this patient with a\n nasogastric tube as well as an endotracheal tube, aspiration is another\n consideration.\n\n 2. Extensive atherosclerotic disease involving the coronary arteries as well\n as involving an abdominal aortic aneurysm measuring 44 mm in greatest\n diameter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106458,
"text": " 3:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary edema, assess for pulmonary infection\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with prolonged hospitalization now with hypothermia, ,\n encephalopathy.\n REASON FOR THIS EXAMINATION:\n assess for pulmonary edema, assess for pulmonary infection\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Prolonged hospitalization, now presenting with hypothermia, acute\n renal insufficiency, and encephalopathy.\n\n COMPARISON: Chest radiograph from and .\n\n SINGLE AP CHEST RADIOGRAPH: Smooth mediastinal widening is related to\n mediastinal fat deposition. Moderate cardiomegaly with dilatation and\n prominence of the upper lobe pulmonary vasculature, suggests mild congestive\n cardiac failure. Small right pleural effusion and the left retrocardiac lower\n lobe atelectasis is stable since the prior study.\n\n IMPRESSION: Findings suggestive of cardiomegaly with mild cardiac failure.\n\n The findings were discussed with Dr. at 4:25 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1103992,
"text": " 8:09 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls assess for bleed or other gross pathology.\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with acute mental status changes.\n REASON FOR THIS EXAMINATION:\n pls assess for bleed or other gross pathology.\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:03 PM\n PFI: No acute intracranial process and right paranasal sinus disease as\n above.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial CT images were acquired through the head in a contiguous\n fashion in the absence of intravenous contrast.\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or\n vascular territorial infarction. The ventricles and sulci are normal in size\n and configuration. Note is made of a cavum septum pellucidum. Extracranial\n soft tissue structures are unremarkable. Included osseous structures reveal\n no fracture. The paranasal sinuses are notable for opacification of the right\n anterior ethmoid air cells as well as right frontal sinus.\n\n IMPRESSION: No acute intracranial process and right paranasal sinus disease\n as above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104214,
"text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess interval change\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with shock, intubated.\n REASON FOR THIS EXAMINATION:\n pls assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Patient in shock, intubated.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 6.4 cm above the carina. The NG tube tip passes below the\n inferior margin of the study. The right internal jugular line tip is at the\n level of mid SVC. Only the upper and mid portion of the lungs have been\n included in the field of view with the lung bases not imaged. The upper\n lungs are essentially clear although mild pulmonary edema cannot be excluded.\n Repeated radiograph including the lung bases is highly recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1103993,
"text": ", D. MED MICU-7 8:09 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls assess for bleed or other gross pathology.\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with acute mental status changes.\n REASON FOR THIS EXAMINATION:\n pls assess for bleed or other gross pathology.\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n PFI REPORT\n PFI: No acute intracranial process and right paranasal sinus disease as\n above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104030,
"text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man intubated for septic shock\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient intubated for septic shock.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 5.2 cm above the carina. The NG tube tip is most likely in\n the stomach. The right internal jugular line tip is at the level of mid SVC.\n Cardiomediastinal silhouette is grossly unchanged. Left retrocardiac\n consolidation has slightly increased in the interim. The right basilar\n opacity is less distinctive on the current study compared to the prior imaging\n that might be due to slightly different projection. The minimal pleural\n effusion demonstrated on chest CT is not visible on the current radiograph.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1103601,
"text": " 7:42 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for atelectasis, pneumonia, pulmonary functi\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man transferred from OSH with h/o sepsis, pneumonia.\n REASON FOR THIS EXAMINATION:\n Please evaluate for atelectasis, pneumonia, pulmonary function.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Sepsis and pneumonia.\n\n IMPRESSION: AP and lateral chest reviewed in the absence of prior chest\n radiographs:\n\n Lung volumes are very low. Mediastinal widening is marked but symmetric. The\n patient is obese and therefore much of the widening is due to fat deposition\n but adenopathy could be present and the contour of the thoracic aorta is\n nearly entirely obscured. Heart is enlarged but the contours are similarly\n obscured. Gaseous distention of bowel loops in the upper abdomen is not fully\n imaged. There is no free subdiaphragmatic gas, and no pneumothorax or pleural\n effusion. Upper lungs are clear. Lower lungs are largely obscured.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-24 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1103611,
"text": " 9:26 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: ? DVT\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with swollen LUE s/p PICC removal at OSH\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n WET READ: JXKc TUE 10:31 PM\n No left upper extremity DVT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with swollen left upper extremity, status post PICC\n removal.\n\n No prior studies available for comparison.\n\n FINDINGS: Grayscale and color Doppler son of the left internal jugular,\n subclavian, axillary, brachials, basilic, and cephalic veins were obtained.\n There is normal compressibility, flow and augmentation, though Doppler\n waveforms are slightly limited due to patient agitation during the study. A\n comparison image of the right subclavian vein was also subsequently unable to\n be obtained.\n\n IMPRESSION: No DVT of the left upper extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1103885,
"text": " 11:37 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line placement\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with R IJ cvl\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Placement of right internal jugular central venous line, check\n position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Identified is a central venous line approached\n via the right internal jugular route and is seen to overlie the superior\n mediastinum structures reaching the level of the carina. No pneumothorax is\n present. When comparison is made with the next previous chest examination of\n , marked progression of bilateral pulmonary densities are\n noted. Their character is perivascular and most likely they represent\n pulmonary edema. Possibility of widespread bilateral inflammatory processes\n cannot be entirely excluded. As the clinical status of the patient is unknown\n to the observer appropriate clinical correlation of the made findings is\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-25 00:00:00.000",
"description": "ART EXT (REST ONLY)",
"row_id": 1103653,
"text": " 8:30 AM\n ART EXT (REST ONLY) Clip # \n Reason: check both LE's\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with bilateral LE ulcers and pulseless R foot\n REASON FOR THIS EXAMINATION:\n check both LE's\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lower extremity ulcers and no pulses.\n\n FINDINGS: The patient did not desire to complete the entire study, thus\n segmental pressures on the right were not performed. On the left, the ABI is\n 0.67 based on the PT artery, that based on the DP artery is falsely elevated\n due to vessel non-compressibility. Waveforms are triphasic at the femoral\n levels, on the left at the tibial levels, all waveforms are monophasic and\n that at the DP level on the right is absent. The volume recordings are in\n with the Doppler tracings.\n\n IMPRESSION: Limited study demonstrating significant bilateral inflow disease\n from the superficial femoral arteries, distally. There is also significant\n bilateral tibial disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-13 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1106697,
"text": " 11:02 AM\n RENAL U.S. Clip # \n Reason: r/o hydronephrosis\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with type 2 DM, HTN, PVD with long complicated hospital course\n now with renal insufficiency\n REASON FOR THIS EXAMINATION:\n r/o hydronephrosis\n ______________________________________________________________________________\n WET READ: ENYa SUN 11:17 AM\n Limited study by body habitus and pt's suboptimal positioning. In the\n suboptimally visualized kidneys, no evidence of hydronephrosis or stone.\n Indwelling Foley in the bladder.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old man with type 2 diabetes, hypertension, peripheral\n vascular disease, with long complicated hospital course, now with renal\n insufficiency. Assess for hydronephrosis.\n\n COMPARISON: None.\n\n RENAL ULTRASOUND STUDY: The study is markedly limited by patient's body\n habitus and inability to optimally position. Allowing for the limitations,\n the visualized right and left kidneys measure 12.6 cm and 12.0 cm,\n respectively. The renal parenchyma is diffusely echogenic bilaterally. There\n is no evidence of hydronephrosis or renal stone. An indwelling Foley catheter\n is noted in the bladder.\n\n IMPRESSION:\n\n 1. Markedly limited study, but no hydronephrosis or renal stone.\n 2. Echogenic renal parenchyma consistent with medical renal disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1106693,
"text": " 10:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for acute intercranial process\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with prolonged hospital course now with persistent altered\n mental status\n REASON FOR THIS EXAMINATION:\n assess for acute intercranial process\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal insufficiency\n ______________________________________________________________________________\n WET READ: ENYa SUN 10:39 AM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old man, with prolonged hospital course, now with persistent\n altered mental status, assess for acute intracranial process.\n\n COMPARISON: Non-contrast head CT on .\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the head.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or\n major vascular territorial infarcts. The ventricles and sulci are slightly\n prominent, appropriate for mild age-related global atrophy, unchanged. There\n is also unchanged configuration of cavum septum pellucidum. The -white\n matter differentiation is well preserved. There is no shift of normally\n midline structures. There are scattered opacification of the ethmoid air\n cells. The remaining paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION: No acute intracranial process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-13 00:00:00.000",
"description": "B FOOT AP,LAT & OBL BILAT",
"row_id": 1106694,
"text": " 10:20 AM\n FOOT AP,LAT & OBL BILAT; ANKLE (AP, MORTISE & LAT) BILAT Clip # \n Reason: assess for osteomyelitis\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with prolonged hospital course and chronic leg ulcers\n REASON FOR THIS EXAMINATION:\n assess for osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chronic leg ulcers, assessment for osteomyelitis.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: Extensive vascular calcifications. Soft tissue defect at the\n lateral aspect of the left foot, approximately 8 cm above the ankle. No\n evidence of cortical destruction in this area. Small plantar and large dorsal\n calcaneal spur. Extensive degenerative changes at the level of the ankle, the\n talonavicular joint and the forefoot.\n\n There is extensive soft tissue swelling at the medial aspect of the basal\n joint of the first toe on both the left and the right side and on the lateral\n aspect of the fifth toe on both the right and the left side. At the level of\n the basal and distal joint of these two toes, there is loss of cortical\n structure and fragmentation of the calcified bone components. Chronic\n osteomyelitis is thus likely. On the left, similar changes affect the most\n distal parts of the fifth toe. On the right, the distal parts of the fifth\n toe show sclerotic bone defects suggesting healed lesions. Similar defects\n are seen at the periphery of the second and fourth toe, right. The right\n periphery of the first toe shows a mixture of sclerotic and lytic lesions\n suggesting active disease.\n\n IMPRESSION: Bilateral extensive vascular calcifications. Bilateral massive\n degenerative diseases in the region of the forefoot.\n\n Bilateral soft tissue swelling at the medial aspect of the first and the\n lateral aspect of the fifth toe, with accompanying cortical defects, partly\n combined to sclerotic regions, suggesting either active or recurrent\n osteomyelitis. Similar but less extensive lesions are seen in the distal\n parts of the first and fifth toe on the right and at the distal parts of the\n second and fourth toe on the right, as well as at the distal parts of the\n fourth toe on the left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1104718,
"text": " 10:54 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pls assess tip of 46cm RUE PICC; call # with wet\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with newly placed Right PICC\n REASON FOR THIS EXAMINATION:\n pls assess tip of 46cm RUE PICC; call # with wet read thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with study of , the right IJ catheter has\n been removed and replaced with a right subclavian PICC line, which extends to\n the lower portion of the SVC. Allowing for lower lung volumes, there is\n probably little change in the basilar opacifications at the left. The\n pulmonary vascularity is within normal limits.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104809,
"text": " 9:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? worsening pulm edema\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with sob\n REASON FOR THIS EXAMINATION:\n ? worsening pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:34 P.M. ON \n\n HISTORY: Shortness of breath, question worsening edema.\n\n IMPRESSION: AP chest compared to :06 a.m.\n\n Pulmonary edema has resolved, but pulmonary vascular congestion, hilar\n dilatation and cardiomegaly persists and there is probably a small-to-moderate\n right pleural effusion collecting posteriorly. Infrahilar opacification in\n both lower lungs is probably atelectasis, increased since , but\n stable over the course of the day. Widening of the mediastinum is probably\n due to combination of dilated vessels and fat deposition. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-28 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1109012,
"text": " 5:40 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: better characterization of AAA\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with prolonged hospital course with saccular aneurysm visulized\n on angiogram\n REASON FOR THIS EXAMINATION:\n better characterization of AAA\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency\n ______________________________________________________________________________\n WET READ: JKSd MON 7:34 PM\n No change in size of infrarenal AAA. Small bilateral pleural effusions, R>L,\n remain stable in size.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with prolonged hospital course with saccular\n aneurysm visualized on angiogram. For better characterization of AAA.\n\n COMPARISON: CT torso of .\n\n TECHNIQUE: Axially acquired images were obtained through the abdomen and\n pelvis without contrast. Coronal and sagittal reformatted images were also\n obtained.\n\n FINDINGS: Evaluation is somewhat limited due to artifact from overlying arms\n and lack of IV contrast. The lung bases again demonstrate bilateral pleural\n effusions, right greater than left with adjacent bibasilar consolidations,\n which are improved and may represent compressive atelectasis although an\n underlying infectious process cannot be excluded. Coronary artery and aortic\n calcifications are again noted. A small amount of fluid is noted within the\n subcutaneous tissues overlying the lower left ribs, likely dependent in\n nature.\n\n The non-contrast appearance of the adrenal glands, pancreas, stomach,\n gallbladder, liver, and kidneys are within normal limits. The spleen is mildy\n enlarged, but stable. Intra-abdominal loops of bowel are also within normal\n limits. There is no free air or free fluid. There is no retroperitoneal or\n mesenteric lymphadenopathy. A small fat-containing umbilical hernia is\n unchanged. There is extensive calcification of the abdominal vasculature.\n\n Again seen is an infrarenal abdominal aortic aneurysm which measures 4.1 x 3.4\n cm in its greatest axial diameter (2:53). This is stable in size since the\n previous study.\n\n CT OF THE PELVIS WITHOUT CONTRAST: The rectum and prostate are unremarkable.\n A Foley catheter is noted within a decompressed bladder. Small foci of\n non-dependent air within the bladder are likely due to instrumentation.\n Intrapelvic loops of bowel demonstrate diverticulosis without diverticulitis.\n There is no free air or fluid. Extensive vascular calcification of the pelvic\n arteries is again seen.\n (Over)\n\n 5:40 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: better characterization of AAA\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No suspicious osseous lesions are identified. Extensive\n degenerative changes are again noted. Again seen are old rib fractures\n bilaterally.\n\n IMPRESSION:\n 1. Stable size of infrarenal abdominal aortic aneurysm.\n 2. Small bilateral pleural effusions, right greater than left, unchanged in\n size since the previous study. Slightly improved bibasilar consolidations.`\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-11-02 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1109703,
"text": " 4:30 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for CVA, microangiopathic disease\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with severe atherosclerosis, type 2 DM, chronic prednisone use\n with prolonged hospital course and persistent mental status changes\n REASON FOR THIS EXAMINATION:\n assess for CVA, microangiopathic disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SUN 11:41 AM\n PFI: No acute infarct seen. Multiple small cortical infarcts are noted which\n appear subacute to chronic. Limited post-gadolinium images demonstrate no\n obvious enhancement.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with severe atherosclerotic disease.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility, and diffusion\n axial images of the brain were acquired before gadolinium. T1 axial and MP-\n RAGE sagittal images acquired following gadolinium.\n\n FINDINGS: Diffusion images demonstrate no evidence of acute infarct. There\n are multiple foci of hyperintensity seen in the cortical region of both\n cerebral hemispheres including both frontal lobes and parietal lobes. These\n findings indicate small cortical infarcts which in absence of diffusion\n abnormalities are likely subacute or chronic. There are mild-to-moderate\n changes of small vessel disease and brain atrophy seen. There is no midline\n shift or hydrocephalus. A cavum septum pellucidum and cavum vergae are\n incidentally noted. Following gadolinium enhancement, the images which are\n limited by motion demonstrate no obvious enhancement.\n\n IMPRESSION: No acute infarct seen. Multiple small cortical infarcts are\n noted which appear subacute to chronic. Limited post-gadolinium images\n demonstrate no obvious enhancement.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-11-02 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1109704,
"text": ", B. MED CC7A 4:30 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for CVA, microangiopathic disease\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with severe atherosclerosis, type 2 DM, chronic prednisone use\n with prolonged hospital course and persistent mental status changes\n REASON FOR THIS EXAMINATION:\n assess for CVA, microangiopathic disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No acute infarct seen. Multiple small cortical infarcts are noted which\n appear subacute to chronic. Limited post-gadolinium images demonstrate no\n obvious enhancement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107660,
"text": " 12:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?correct NG tube placement\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with complicated medical hx and encephalopathy w repositioning\n of NG tube\n REASON FOR THIS EXAMINATION:\n ?correct NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 66-year-old man with complicated medical history and encephalopathy.\n Evaluate for nasogastric tube placement.\n\n FINDINGS: Comparison is made to prior chest radiograph, .\n\n The tip and side port of the nasogastric tube are below the gastroesophageal\n junction in the fundus of the stomach. This could be advanced a few\n centimeters for more optimal placement. There is no free intra-abdominal air.\n There is minimal blunting of the left CP angle. The cardiac silhouette is\n enlarged but stable.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107711,
"text": " 3:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia.\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with prolonged hospital course, now with cough, fever and\n oxygen requirment\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 66-year-old man with prolonged hospital course, now with cough,\n fever and increased oxygen requirement.\n\n FINDINGS: Comparison is made to prior study from .\n\n The feeding tube has been removed in the interim. There remains a right-sided\n central venous catheter with the distal lead tip in the mid SVC. There is\n cardiomegaly which is stable. There are no signs of focal consolidation or\n overt pulmonary edema. Small pleural effusions are seen.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106835,
"text": " 11:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for aspiration, PNA, pulmonary edema\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with AMS, acute hypoxia today\n REASON FOR THIS EXAMINATION:\n eval for aspiration, PNA, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: AMS, acute hypoxia, evaluation for aspiration.\n\n COMPARISON: , at 9:09 a.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate cardiomegaly with evidence of overhydration. Unchanged\n retrocardiac opacity. No safe evidence of aspiration associated changes. In\n the interval, no parenchymal opacities have newly occurred.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106802,
"text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ? aspiration\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with suspected aspiration.\n\n COMPARISON: Chest radiograph from and .\n\n SINGLE AP SUPINE CHEST RADIOGRAPH: Stable mediastinal widening is related to\n mediastinal fat deposition. Bilateral low lung volumes are again noted.\n Stable moderate cardiomegaly with increased interstitial markings and dilated\n pulmonary vasculature, suggests mild-to-moderate cardiogenic pulmonary edema.\n Small left pleural effusion may be present. A left lower lobe opacity, most\n likely atelectasis, is stable since the prior study. The right pleural\n surface is smooth, and no evidence of pleural effusion.\n\n IMPRESSION: Interval worsening of the mild-to-moderate cardiogenic pulmonary\n edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1107030,
"text": " 12:56 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 48cm SL R brachial PICC placed ? tip\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new PICC\n REASON FOR THIS EXAMINATION:\n 48cm SL R brachial PICC placed ? tip\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest port line placement.\n\n REASON FOR EXAM: New PICC line.\n\n FINDINGS: In comparison to the previous chest radiograph earlier today mild\n upper lobe vascular congestion with dependent edema and presence of moderate\n cardiomegaly is stable.\n\n The new right PICC line tip is at the low SVC with no pneumothorax. NG tube\n is seen to the gastroesophageal junction but is difficult to visualize below\n that level, a abdominal plain film will be useful to accurately locate the tip\n of the NG tube.\n\n IMPRESSION:\n\n Satisfactory placement of new right PICC line otherwise unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107383,
"text": " 1:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for NGT placement\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with multiple medical problems with persistent AMS, ARF and\n chronic leg ulcers\n REASON FOR THIS EXAMINATION:\n assess for NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple medical problems, NG tube placement.\n\n COMPARISON: .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: An orogastric tube is seen with its\n tip projecting below the diaphragm and out of field of view. A right internal\n jugular hemodialysis catheter is again seen with its tip in the upper SVC.\n Otherwise no significant change with bibasal opacities likely reflecting\n atelectasis, no large effusion and no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1107248,
"text": " 5:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 66 year old man with right IJ Hemodialysis catheter placemen\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with right IJ Hemodialysis catheter placement for catheter\n position and r/o pneumothorax\n REASON FOR THIS EXAMINATION:\n 66 year old man with right IJ Hemodialysis catheter placement for catheter\n position and r/o pneumothorax\n ______________________________________________________________________________\n WET READ: SBNa WED 5:52 PM\n Right IJ HD catheter terminates in upper svc. Otherwsie, no sig change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hemodialysis catheter placement.\n\n FINDINGS: In comparison with study of , there has been placement of a\n right IJ hemodialysis catheter that extends to the upper portion of the SVC.\n Otherwise, little change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-18 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1107479,
"text": " 8:56 AM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: RUE SWELLING DST TO ACF IV, R/O DVT\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with prolonged hospital course now with RUE swelling distal to\n peripheral IV\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n UNILATERAL UPPER EXTREMITY VEINS ON THE RIGHT\n\n MEDICAL HISTORY: A 66-year-old man with prolonged hospital course, now with\n right upper extremity swelling, distal to the peripheral IV. Rule out DVT.\n\n FINDINGS: There are normal venous waveforms in both subclavian veins.\n\n A central venous line is seen in the right internal jugular vein, with no\n thrombosis seen in this vein. This vein compresses completely and\n demonstrates normal flow within it.\n\n The right axillary vein, right brachial vein, right basilic vein, and right\n cephalic vein compress completely and augment well, with no evidence of venous\n thrombosis.\n\n Note is made of a peripheral intravenous line in the right brachial vein.\n\n At the site of the swelling, there is evidence of edema of the soft tissues.\n No focal collection or mass seen in this region.\n\n CONCLUSION:\n 1. No ultrasound evidence of deep venous thrombosis or superficial venous\n thrombosis of the right upper extremity.\n\n 2. Subcutaneous edema at the site of swelling.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107796,
"text": " 6:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: feeding tube placement\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new dophof tube placement\n REASON FOR THIS EXAMINATION:\n feeding tube placement\n ______________________________________________________________________________\n WET READ: GWp SUN 8:03 PM\n Dobhoff below diaphragm - in essentially unchanged CXR GWlms\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of feeding tube placement.\n\n Portable AP chest radiograph was compared to obtained at\n 03:16 a.m.\n\n The Dobbhoff tube tip is in the proximal stomach, most likely in the fundus.\n There is no short interval change in the cardiomediastinal silhouette, but the\n bilateral opacities have increased and might be associated with areas of\n aspiration vs interval development of pulmonary edema. Small bilateral pleural\n effusion is most likely present. The right internal jugular line tip is at the\n level of mid SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106951,
"text": " 12:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval NGT placement\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with NGT placement\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: The nasogastric tube extends at least to the mid body of the\n stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107942,
"text": " 6:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for placement of Dophoff tube\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with partially self - removed Dophoff tube\n REASON FOR THIS EXAMINATION:\n assess for placement of Dophoff tube\n ______________________________________________________________________________\n WET READ: IPf MON 10:12 PM\n NG tube with tip at the stomach. No significant interval change in the\n opacification at the lung bases.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:17 P.M. ON \n\n HISTORY: Self removal Dobbhoff tube. Assess tube placement.\n\n IMPRESSION: AP chest compared to :\n\n Dobbhoff tube has been replaced by a standard nasogastric tube which passes\n into the stomach and out of view before the tip returns to the left upper\n quadrant. The extent of redundancy is therefore impossible to assess. Right\n jugular line introducer ends in the upper SVC. Small right pleural effusion\n is likely, decreased since . Mild-to-moderate bibasilar\n atelectasis stable. Upper lungs clear. No pneumothorax. Cardiac silhouette\n is probably top normal size and unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106948,
"text": " 10:58 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for NGT placement\n Admitting Diagnosis: CELLULITIS;LEFT LOWER EXTREMITY ULCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with NGT placed\n REASON FOR THIS EXAMINATION:\n 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, a lateral view\n attempts to demonstrate the tip of the nasogastric tube, but the device is\n lost in the upper abdomen. A repeat study using abdominal technique would be\n helpful for determining tube position.\n\n\n"
}
] |
23,081 | 180,381 | Mrs. was admitted and underwent a cerebral angiogram with a balloon test occlusion (BTO) of the left internal carotid artery with the assistance of anesthesia. She tolerated the temporary occlusion for 25 minutes without neurological deficit. This included a hypotensive challenge via intravenous nitroglycerin during which her systolic pressure was decreased below 100mmHg. After successful BTO, the wide-necked aneurysm was coiled loosely using Matrix platinum coils to form a scaffold and to prevent distal embolization of proximal embolic materials that would be subsequently used to occlude the parent vessel proximally. The left ICA was then occluded from an endovascular approach. Post-operatively, she was admitted to the ICU for close neurological monitoring. Her vital signs were stable. She was afebrile. She continued with the left eye ptosis. The lungs were clear. Neurologically, awake, alert and oriented times three, following commands. Speech was fluent. Continues with strength 5/5 in all muscle groups with no drift. She was continued to be monitored in the Intensive Care Unit. She was kept with strict blood pressure control to 130 to 160 range at all times, flat bedrest until the sheath was removed and she was an aspirin postoperatively. On postoperative day Number 1, she was oriented times three moving all extremities, following commands. Speech intact. The groin had no hematoma. She had positive pedal pulses. She was out of bed, ambulating in the afternoon on postoperative day Number 1. She was transferred to the regular floor, to Stepdown on postoperative day Number 2. She remained neurologically stable. She did have a couple of episodes of hypotension down to the 90s. She did have her Foley catheter discontinued on , but was unable to void. The new Foley catheter was replaced. She did have blood-tinged urine thought to be traumatic and had problems with hyponatremia and was started on salt tabs 3 grams p.o. t.i.d. for a sodium level of 133. On , the patient complained of mild erythema, sore throat. A throat culture was sent and is negative to date. The patient has a history of first degree atrioventricular block. PR interval was elongated. Blood pressure was running in the 90s to 150s. Her antihypertensive medication was stopped. Her intravenous fluids stopped on , and her blood pressure has been in the normal range 130 to 160. Vital signs have remained stable. She has been afebrile. | After administration of gadolinium intravenous contrast, sagittal, axial, and coronal short TR, short TE spin echo imaging was performed. Accordingly she underwent a diagnostic angiogram which revealed a presence of a giant left internal carotid artery cavernous segment aneurysm which is fusiform and not amenable to simple coil embolization. This was followed by successful coil embolization and coil occlusion of the left internal carotid artery after treatment of the left internal carotid artery cavernous aneurysm. To that end a series of coils were deployed into the aneurysm. At this point decision was made to proceed with coil embolization of the aneurysm followed by sacrifice of the left internal carotid artery. FINDINGS: There are susceptibility artifacts in the left cavernous sinus compatible with a history of aneurysm coiling. The activated (Over) 10:45 AM /CERB UNI Clip # Reason: Embolization of a left intracranial aneurysm. POSTOPERATIVE DIAGNOSIS: Same status post (1) balloon test occlusion with hypotensive challenge of the left internal carotid artery with serial neurological examination, (2) status post coil embolization of the left internal carotid artery intracranial cavernous aneurysm using a series of detachable endovascular coils, (3) status post proximal occlusion of the left internal carotid artery and carotid sacrifice, (4) status post contralateral angiography revealing excellent cross-filling with no further opacification of the treated aneurysm. REASON FOR THIS EXAMINATION: Embolization of a left intracranial aneurysm. R fem angio site pressure dsg intact. After obtaining access into the left common carotid artery the left internal carotid artery was catheterized and an angiographic run was performed of the left internal carotid artery with three-dimensional rotational angiography which revealed the fusiform wide-necked aneurysm of the horizontal caverous portion of the carotid artery. Our attention was turned to more proximal portion of the aneurysm and at this point a series of coils including hydrogel coils were employed in order to effect closure of the vessel and sacrifice of the left internal carotid artery. Next, a diagnostic catheter was used to selectively catheterize the following vessels: left common carotid artery, left internal carotid artery, right common carotid artery. FINAL REPORT PREOPERATIVE DIAGNOSIS: Giant fusiform symtomatic left internal carotid artery cavernous aneurysm in patient with progressive cranial nerve neuropathy and ptosis. At this point the catheter was placed in the right common carotid artery where an angiographic run was performed and this showed excellent cross-filling from the right internal carotid artery across the anterior communicating artery to perfuse the left hemisphere. Assess aneurysm. Note is made of tortuous thoracic aorta. STRICT SBP CONTROL 120-160 (NEO/NIPRIDE AS NEEDED), REPEAT COAGS AND HCT, MONITOR RT GROIN ANGIO SITE FOR BLEEDING AND HEMATOMA. Comparison to a carotid arteriogram of . 10:45 AM /CERB UNI Clip # Reason: Embolization of a left intracranial aneurysm. Nursing Progress NotePlease see carvue for specifics.Neuro: Pt remains neuro intact. Note is made scoliosis. tnf to floor once BP stable w/o nipride. Is easily redirected.CV: Parameters for SBP 120-160 pt requiring nipride to maintain these parameters. PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.ADMITTED FROM ANGIO AT 10PM FOR ELECTIVE ANEURYSM COILING.NEURO: A&O X3, APPROPRIATE CONVERSATION, MAE SPONT/PURP, FOLLOWING COMMANDS, PERL, LT EYE IS SHUT BUT PT ABLE TO OPEN IT SLIGHTLY, SYMMETRICAL STRENGTH.CV: HR 60-70'S, NSR, NO ECTOPY, SBP PARAMETERS 120-160 STRICTLY, NEO/NIPRIDE TITRATED ACCORDINGLY. A 19-gauge single-wall needle was then used to puncture the right common femoral artery, and upon the return of brisk arterial , 6 Fr vascular sheath was inserted over a guide wire and kept on a heparinized saline drip. She underwent this procedure with heparinization. ANESTHESIA: Monitored anesthesia care. , Contrast: OPTIRAY Amt: 350 FINAL REPORT (Cont) unforeseen complications, including the risk of coma and even death, were outlined. At this point the temporary balloon was deflated having established that she had tolerated successfully the balloon occlusion of her left internal carotid artery. Accordingly decision was made to deploy an Amplatz vascular occlusion device into the left internal carotid artery in the cervical segment. There is high-signal intensity in the periventricular and subcortical white matter on the long TR images compatible with chronic small-vessel ischemia. PALPAPLE DP/PTP PULSES, ANGIO SITE STARTED OOZING BLOOD AND SOFT HEMATOMA IN RT GROIN NOTED. Note is made of surgical clips in the left axilla. 12:11 AM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # MRA BRAIN W/O CONTRAST Reason: assess aneurysm Admitting Diagnosis: ANEURYSM/SDA Contrast: MAGNEVIST Amt: 11 MEDICAL CONDITION: year old woman with left carotid aneurysm coiled REASON FOR THIS EXAMINATION: assess aneurysm No contraindications for IV contrast FINAL REPORT HISTORY: Left carotid aneurysm coiled. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2120-02-07 00:00:00.000",
"description": "Report",
"row_id": 1563921,
"text": "STATUS\nD: NEURO INTACT..P=RL ORIENTED X3 FOLLOWS COMMANDS MOVES ALL EXTREM'S EQUALLY..ABLE TO RAISE HOB 30DEGREES PER DR \nA: HEPARIN GTT OFF FOR PTT >150..RESTARTED @ 400U WHEN PTT 60'S.. CONTINUES TO OOZE FROM RT GROIN SITE PRESSURE DSG CHANGED X3..HCT 27 GIVEN 1U PC REPEAT HCT 27 2nd U PC UP..GIVEN 20MGM LASIX FOR DROPPING HUO'S WITH GOOD EFFECT..K+ REPLETED..HEPARIN GTT DC'D @ 1800 DUE TO CONTINUED OOZING & DROPPING HCT..STARTED ON PO'S TOL WELL\nR: CONTINUES WITH RT GROIN OOZE..HO AWARE\nP: PRESSURE DSG TO RT GROIN..MONITOR COAG'S & HCT'S CLOSELY\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-02-08 00:00:00.000",
"description": "Report",
"row_id": 1563922,
"text": "Nursing Progress Note\nPlease see carvue for specifics.\nNeuro: Pt remains neuro intact. Follows commands appropriately. MAE. Is A+OX3 is slighty confused place when woken up does need a few min to get her bearings. Is easily redirected.\nCV: Parameters for SBP 120-160 pt requiring nipride to maintain these parameters. +PP + CSM to Bilat LE. R fem angio site pressure dsg intact. Site stopped oozing early in am. Pt receive 2 units of PRBC's crit ^ to 34. Given 20 of lasix w/results Pt remains afebrile. IVF running at 100cc/hr.\nResp: No issues. On 2lNC lungs clear and sats >95%.\nGI: Abd soft NT + BS no BM. Tolerating kosher diet well.\nGU: Foley to gravity drng adequate amts of lt yellow urine.\nID: Pt afebrile no abx therapy at this time\nPlan: Cont with neuro checks. Cont to maintain BP parameters. ? tnf to floor once BP stable w/o nipride. Cont with current plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-02-07 00:00:00.000",
"description": "Report",
"row_id": 1563920,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nADMITTED FROM ANGIO AT 10PM FOR ELECTIVE ANEURYSM COILING.\n\nNEURO: A&O X3, APPROPRIATE CONVERSATION, MAE SPONT/PURP, FOLLOWING COMMANDS, PERL, LT EYE IS SHUT BUT PT ABLE TO OPEN IT SLIGHTLY, SYMMETRICAL STRENGTH.\n\nCV: HR 60-70'S, NSR, NO ECTOPY, SBP PARAMETERS 120-160 STRICTLY, NEO/NIPRIDE TITRATED ACCORDINGLY. HEP GTT INFUSING AT 700 U/HR W/ PTT 150, REPEAT PTT AT 2AM 150 (PTT CONFIRMED W/ PERIPHERAL STICK)--DR. AND DR. AWARE, HEP GTT STOPPED. DR. AWARE AND HEP GTT TO REMAIN OFF W/ REPEAT COAGS TO BE CHECKED. PALPAPLE DP/PTP PULSES, ANGIO SITE STARTED OOZING BLOOD AND SOFT HEMATOMA IN RT GROIN NOTED. DR. , DR. AND DR. AWARE.\n\nRESP: LUNG SOUNDS CLEAR, NO SOB, RR 3-19, O2 SAT 96-100% ON 2L VIA NC.\n\nGI: ABD SOFT NT/ND + BOWEL SOUNDS.\n\nGU: FOLEY DRAINING 80-320CC/HR CLEAR LIGHT YELLOW URINE.\n\nID: TMAX 98.9, PT REQUIRED FOR TEMP.\n\nPLAN: MONIOTR VS, LABS, NEURO STATUS. STRICT SBP CONTROL 120-160 (NEO/NIPRIDE AS NEEDED), REPEAT COAGS AND HCT, MONITOR RT GROIN ANGIO SITE FOR BLEEDING AND HEMATOMA. CONT CURRENT MGMT.\n"
},
{
"category": "Radiology",
"chartdate": "2120-02-11 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 856390,
"text": " 12:11 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: assess aneurysm\n Admitting Diagnosis: ANEURYSM/SDA\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with left carotid aneurysm coiled\n REASON FOR THIS EXAMINATION:\n assess aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left carotid aneurysm coiled. Assess aneurysm.\n\n TECHNIQUE: Sagittal and axial short TR, short TE spin echo imaging was\n performed through the brain. Axial imaging was performed with long TR, long\n TE fast spin echo, FLAIR, gradient echo, and diffusion technique. After\n administration of gadolinium intravenous contrast, sagittal, axial, and\n coronal short TR, short TE spin echo imaging was performed. A\n three-dimensional time-of-flight MR arteriogram was performed. Comparison to\n a carotid arteriogram of .\n\n FINDINGS:\n\n There are susceptibility artifacts in the left cavernous sinus compatible with\n a history of aneurysm coiling. There is no evidence of flow in the left\n internal carotid artery. The susceptibility artifacts prevent evaluation of\n any possibility of residual filling of the left cavernous carotid aneurysm.\n The images of the right internal carotid artery and its intracranial branches\n and the posterior circulation appear normal. There is no evidence of\n infarction in the brain. There is mild prominence of the ventricles and sulci\n compatible with age. There is high-signal intensity in the periventricular\n and subcortical white matter on the long TR images compatible with chronic\n small-vessel ischemia.\n\n IMPRESSION:\n\n No evidence of hemorrhage or infarction. Apparent occlusion of the left\n internal carotid artery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-02-06 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 855876,
"text": " 10:45 AM\n /CERB UNI Clip # \n Reason: Embolization of a left intracranial aneurysm. , \n Contrast: OPTIRAY Amt: 350\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL ENDOVASC TEMPORY VESSEL OCCL *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CATH, TRANSLUM ANGIO NONLASER *\n * CATH, TRANSLUM ANGIO NONLASER C1760 CLOSURE DEVICE VASC IMP/INS *\n * C1760 CLOSURE DEVICE VASC IMP/INS C1760 CLOSURE DEVICE VASC IMP/INS *\n * C1887 CATH GUIDING INFUS/PERF C1887 CATH GUIDING INFUS/PERF *\n * C1887 CATH GUIDING INFUS/PERF C1894 INT/SHTH NOT/GUID EP NON-LASER *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with aneurysm.\n REASON FOR THIS EXAMINATION:\n Embolization of a left intracranial aneurysm. , Start time 1:30.\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Giant fusiform symtomatic left internal carotid artery\n cavernous aneurysm in patient with progressive cranial nerve neuropathy and\n ptosis.\n\n POSTOPERATIVE DIAGNOSIS: Same status post (1) balloon test occlusion with\n hypotensive challenge of the left internal carotid artery with serial\n neurological examination, (2) status post coil embolization of the left\n internal carotid artery intracranial cavernous aneurysm using a series of\n detachable endovascular coils, (3) status post proximal occlusion of the left\n internal carotid artery and carotid sacrifice, (4) status post contralateral\n angiography revealing excellent cross-filling with no further opacification of\n the treated aneurysm.\n\n ANESTHESIA: Monitored anesthesia care.\n\n INDICATION: Ms. is a -year-old woman who has been complaining of\n progressive left eye ptosis. Accordingly she underwent a diagnostic angiogram\n which revealed a presence of a giant left internal carotid artery cavernous\n segment aneurysm which is fusiform and not amenable to simple coil\n embolization. Accordingly she is undergoing this procedure for multiple\n reasons. One is to perform balloon test occlusion of the left internal carotid\n artery and determine whether she will tolerate sacrifice of that vessel and\n also if she can tolerate that then she will undergo coil embolization of the\n aneurysm followed by sacrifice of the carotid artery.\n\n CONSENT: The patient and her daughter and her son-in-law were given a full and\n complete explanation of the procedure. Specifically, the indications, risks,\n benefits, and alternatives to the procedure were explained in detail. In\n addition, the possible complications, such as the risk of bleeding, infection,\n stroke, neurological deficit or deterioration, groin hematoma, and other\n (Over)\n\n 10:45 AM\n /CERB UNI Clip # \n Reason: Embolization of a left intracranial aneurysm. , \n Contrast: OPTIRAY Amt: 350\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unforeseen complications, including the risk of coma and even death, were\n outlined. The patient and her daughter and her son-in-law understood and\n wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin areas was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial , 6 Fr vascular sheath was inserted over a guide wire and\n kept on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: left common carotid artery,\n left internal carotid artery, right common carotid artery. After obtaining\n access into the left common carotid artery the left internal carotid artery\n was catheterized and an angiographic run was performed of the left internal\n carotid artery with three-dimensional rotational angiography which revealed\n the fusiform wide-necked aneurysm of the horizontal caverous portion of the\n carotid artery. At this point an MIP balloon was inserted into the left\n internal carotid artery and after heparinization and establishment of a\n neurological baseline the balloon was inflated and the patient underwent\n serial neurological examination over a period of 20 minutes with her \n pressure maintained at a normal baseline. After 20 minutes she underwent a 10\n minute hypertensive challenge were her systolic pressure was decreased to\n below 100 mmHg. She tolerated the procedure with no change in her neurological\n examination and no weakness of her right arm, no speech difficulty and no\n other detectable neurological changes. At this point the temporary balloon was\n deflated having established that she had tolerated successfully the balloon\n occlusion of her left internal carotid artery. At this point decision was made\n to proceed with coil embolization of the aneurysm followed by sacrifice of the\n left internal carotid artery. To that end a series of coils were deployed into\n the aneurysm. After a scaffold was obtained into the aneurysm which was made\n with Matrix bioactive coils in order to encourage a thrombotic reaction. Our\n attention was turned to more proximal portion of the aneurysm and at this\n point a series of coils including hydrogel coils were employed in order to\n effect closure of the vessel and sacrifice of the left internal carotid\n artery. A multitude of coils were deployed. However sluggish flow could still\n be seen passing through. Accordingly decision was made to deploy an Amplatz\n vascular occlusion device into the left internal carotid artery in the\n cervical segment. Subsequently a more proximal tandem device was also deployed\n and just proximal to the occlusion device a series of coils were deployed.\n This resulted in effective halt of the flow into the left internal carotid\n artery. At this point the catheter was placed in the right common carotid\n artery where an angiographic run was performed and this showed excellent\n cross-filling from the right internal carotid artery across the anterior\n communicating artery to perfuse the left hemisphere. The patient suffered no\n neurological consequence and was neurologically stable throughout the\n procedure. She underwent this procedure with heparinization. The activated\n (Over)\n\n 10:45 AM\n /CERB UNI Clip # \n Reason: Embolization of a left intracranial aneurysm. , \n Contrast: OPTIRAY Amt: 350\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n clotting time was greater than 230 seconds. At the end of the procedure she\n was taken to intensive care in stable condition.\n\n IMPRESSION: Successful performance of a balloon test occlusion of the left\n internal carotid artery which was tolerated well despite a hypotensive\n challenge. This was followed by successful coil embolization and coil\n occlusion of the left internal carotid artery after treatment of the left\n internal carotid artery cavernous aneurysm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 856131,
"text": " 9:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for cardiopulm dz\n Admitting Diagnosis: ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with carotid aneurysm\n REASON FOR THIS EXAMINATION:\n Eval for cardiopulm dz\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A -year-old woman with carotid aneurysm.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n There is no previous chest radiograph for comparison.\n\n FINDINGS:\n\n The heart is normal in size. Note is made of tortuous thoracic aorta.\n Bilateral lungs are clear. There is no evidence of CHF. No evidence of\n pneumonia is identified. Note is made of surgical clips in the left axilla.\n\n Note is made scoliosis.\n\n IMPRESSION:\n\n Tortuous aorta. No acute cardiopulmonary process.\n\n\n"
}
] |
64,550 | 141,935 | 53yo F with a history of respiratory distress status post tracheotomy complicated by tracheal stenosis, chronic kidney disease on peritoneal dialysis, and hypertension who was admitted to on for bleeding from the trach site, hemoptysis, and SOB, who was transferred to for tracheal stenosis and need for tracheotomy replacement and brochoscopy by Interventional Pulmonology. . # Tracheal stenosis: The patient has a history of tracheal stenosis due to a fractured tracheal ring and prolonged intubation. She presented to with hemoptysis which resolved at presentation from the OSH for tracheal stenosis assessment. On admission, her oxygen saturations were normal with 35% oxygen by trach mask. A CT scan of the chest which showed tracheamalacia. On hospital day 2 she had a bronchoscopy which revealed severe supraglottic edema. Her Portex/ TTS #7.0 was changed to a Portex cuffed #6.0, and she tolerated the procedure well. On the medicine floors, she had no respiratory complaints and continued to have good oxygen saturation. . # ESRD on peritoneal dialysis: At , the patient received alternating doses of 2.5% and 4.25% dextrose dialysate Q6H. Renal was consulted and she received PD while in the MICU. She continued to receive PD on the medical floors with 2.5% dialysate. On the PD catheter fell out of its connector (but did not fall out of the patient's abdomen). The patient received vancomycin and ciprofloxacin x 1 as peritonitis prophylaxis, was monitored for signs and symptoms of peritonitis, and underwent ascitic fluid analysis x 2. She did not develop peritonitis. The PD catheter was replaced without complication. The patient also developed hyponatremia ot 126. Nephrology recommended workup for pseudohyponatremia (Posm,Uosm,lipid panel, serum protein), which is still pending. Patient was on fluid restriction (<1000mL/day) in hospital for hyponatremia, and nephrology recommends continuing this in rehab. Sevelamer was initiated to control serum phosphate. Additionally, the patient was started on Nephrocaps. . # HTN: Her BP was elevated on admission and was transiently high to a maximum systolic pressure of 178 before stabilizing below 150. She continued to receive amlodipine and metoprolol. . # Bipolar disorder: The patient's mood was stable during admission. She was continued on lithium and olanzapine. . # Restless leg syndrome: Well controlled with olanzapine during this hospitalization. . # Anemia: The patient is anemic at baseline. Iron studies were sent, which were consistent with anemia of chronic admission and did not suggest iron deficiency anemia. Accordingly, ferrous sulfate was discontinued. . # Thyroid nodule: A nodule was detected on CT scan. The patient will follow up with her primary care physician for further workup of this problem. . # Dispo: rehab at # Labs pending at discharge: Posm, Uosm, lipid panel, serum protein | Morgagni hernia and moderated sized sliding hiatus hernia. Moderate sized hital hernia noted. Please do airway Admitting Diagnosis: TRACHEAL STENOSIS Field of view: 38 FINAL REPORT (Cont) small scattered mediastinal lymph nodes are seen which do not meet pathological size criteria by CT. Cardiomegaly noted. There is atherosclerotic calcification of the aortic arch. Eval stenosis and for other acute process. Limited section of abdomen reveal presence of ascites. IMPRESSION: Tracheomalacia and subglottic tracheal stenosis. Morgagni hernia with peritoneal fat and ascites as its content is seen. 12:06 AM CT TRACHEA W/O C W/3D REND Clip # Reason: Eval stenosis and for other acute process. Left anterior fascicular block. Lines and tubes: Tracheostomy tube is in standard placement. The trachea inferior to endotracheal tube collases during expiration. Multiple (Over) 12:06 AM CT TRACHEA W/O C W/3D REND Clip # Reason: Eval stenosis and for other acute process. In dynamic expiration phase, the tracheal caliber is narrowed by anterior displacement of the posterior wall throughout its length and caliber is reduced to 9.8 x 4.7 mm with a calculated area of 74.4 mm2 at the level of aortic arch. Main pulmonary artery and thoracic aorta are normal by caliber. SEMI-UPRIGHT AP VIEW OF THE CHEST: A new right PICC follows a normal course to the mid clavicle then courses superiorly into the right internal jugular vein. TECHNIQUE: MDCT acquisitions of the trachea and chest were performed without intravenous contrast administration at maximum inspiration and dynamic forced expiration. Normal compressibility, wall-to-wall color flow, and augmentation were seen in the right internal jugular, axillary, brachial, basilic, and cephalic veins. PICC line was identified in the basilic and axillary veins although not seen in the mid subclavian or internal jugular vein. IMPRESSION: No evidence of right upper extremity deep venous thrombosis. Atherosclerotic changes are seen in coronary arteries and thoracic and abdomen aorta. REASON FOR THIS EXAMINATION: Eval stenosis and for other acute process. Right Morgagni hernia is better evaluated on recent CT. Considering the clinical history, this most likely represents changes secondary to renal osteodystrophy. One of the upper pole cyst in right side in hyperdense. FINDINGS: Real-time Grayscale and color Doppler evaluation of the right internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins was performed. CONTRAINDICATIONS for IV CONTRAST: Renal failure WET READ: JEKh FRI 5:21 AM 1. trach in place. For example, the proximal right main bronchus during inspiration measures 7.7 mm and during expiration the caliber is 6.4 mm.Similarly on the left side proximal main broncus measures 6.0mm in inspiration and 5.4mm during expiration. Non-specific inferior ST-T wavechange. Visualised sections of liver, spleen and pancreas are normal.Cortical irregularites, scarring and punctate calcifications are seen in bilateral kidneys s/o chronic renal changes. 5. large fat/fluid containing morgagni hernia. During inspiration the trachea is notably rounded in cross-sectional configuration measuring 12.9 x 13.1 cm with a calculated area of 151.3 mm2. Enlarged left lobe of the thyroid with small ill-defined focal hypodensity measuring 5 x 3 mm. Multiple renal cortical and exophytic cysts are seen bilateraly. 4. no pleural/pericardial effusion. 4:46 PM UNILAT UP EXT VEINS US RIGHT Clip # Reason: PT WITH RUE SWELLING, R/O ? LUNGS AND AIRWAYS: There is a diffuse concentric wall thickening involving the upper trachea with 4 mm thickness. Pt is with trach, cannot travel, please do bedside. Delayed precordial R wave transition. FINAL REPORT INDICATION: History of tracheal stenosis, to evaluate for stenosis and other process. MEDIASTINUM: The left lobe of the thyroid is enlarged, and there is a small ill-defined focal hypodensity measuring 5 x 3 mm in the left lobe. Tracheostomy is in satisfactory position. Sinus rhythm. 3. mild dependent atelectasis but no condolidation. No large right pleural effusion is present. There is Sub-glotic tracheal stenosis with transverse diameter of 5mm. COMPARISON: No prior comparison CT studies available. There is no significant expiratory collapse in bilateral main and distal bronchi. Cardiomediastinal silhouette is similar to prior. Ascites. There is at least a small left effusion. Normal color flow within the right subclavian vein, symmetric to the left. There is slightly increased interstitial opacity and vascular engorgement compatible with mild to moderate pulmonary edema. DVT. REASON FOR THIS EXAMINATION: r/o ? SOFT TISSUES: Soft tissues are unremarkable. Largest on the right side measures 11 x 12mm and on the left 2.7 x 2.3cm. A thyoid ultrasound may be suggested for further evaluation. Please do airway protocol. Please do airway protocol. PLEURA: No evidence of effusion or pneumothorax. right arm DVT WET READ: RBLd SAT 8:56 PM no evidence of right upper extremity DVT FINAL REPORT EXAM: Right upper extremity Doppler ultrasound. | 4 | [
{
"category": "Radiology",
"chartdate": "2198-07-14 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1197729,
"text": " 4:46 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: PT WITH RUE SWELLING, R/O ? RIGHT ARM DVT\n Admitting Diagnosis: TRACHEAL STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with ESRD on PD, HTN, s/p right-sided PICC now pulled down to\n midline with asymmetric right arm swelling, ? DVT. PICC was in the IJ at one\n point so please evaluate IJ as well. Pt is with trach, cannot travel, please do\n bedside. Thanks!\n REASON FOR THIS EXAMINATION:\n r/o ? right arm DVT\n ______________________________________________________________________________\n WET READ: RBLd SAT 8:56 PM\n no evidence of right upper extremity DVT\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Right upper extremity Doppler ultrasound.\n\n CLINICAL INFORMATION: 53-year-old female with history of end-stage renal\n disease status post right-sided PICC, now with asymmetric right arm swelling,\n question DVT.\n\n COMPARISON: None.\n\n FINDINGS: Real-time Grayscale and color Doppler evaluation of the right\n internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins\n was performed. Normal compressibility, wall-to-wall color flow, and\n augmentation were seen in the right internal jugular, axillary, brachial,\n basilic, and cephalic veins. Normal color flow within the right subclavian\n vein, symmetric to the left. PICC line was identified in the basilic and\n axillary veins although not seen in the mid subclavian or internal jugular\n vein.\n\n IMPRESSION: No evidence of right upper extremity deep venous thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-07-13 00:00:00.000",
"description": "CT TRACHEA W/O C W/3D REND",
"row_id": 1197465,
"text": " 12:06 AM\n CT TRACHEA W/O C W/3D REND Clip # \n Reason: Eval stenosis and for other acute process. Please do airway\n Admitting Diagnosis: TRACHEAL STENOSIS\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with tracheal stenosis, trached. Eval stenosis and for other\n acute process. Please do airway protocol.\n REASON FOR THIS EXAMINATION:\n Eval stenosis and for other acute process. Please do airway protocol.\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n WET READ: JEKh FRI 5:21 AM\n 1. trach in place.\n 2. bronchial tree open.\n 3. mild dependent atelectasis but no condolidation.\n 4. no pleural/pericardial effusion.\n 5. large fat/fluid containing morgagni hernia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of tracheal stenosis, to evaluate for stenosis and other\n process.\n\n TECHNIQUE: MDCT acquisitions of the trachea and chest were performed without\n intravenous contrast administration at maximum inspiration and dynamic forced\n expiration.\n\n COMPARISON: No prior comparison CT studies available.\n\n Lines and tubes: Tracheostomy tube is in standard placement.\n\n LUNGS AND AIRWAYS: There is a diffuse concentric wall thickening involving\n the upper trachea with 4 mm thickness. There is Sub-glotic tracheal stenosis\n with transverse diameter of 5mm. The trachea inferior to endotracheal tube\n collases during expiration. During inspiration the trachea is notably rounded\n in cross-sectional configuration measuring 12.9 x 13.1 cm with a calculated\n area of 151.3 mm2. In dynamic expiration phase, the tracheal caliber is\n narrowed by anterior displacement of the posterior wall throughout its length\n and caliber is reduced to 9.8 x 4.7 mm with a calculated area of 74.4 mm2 at\n the level of aortic arch. There is no significant expiratory collapse in\n bilateral main and distal bronchi. For example, the proximal right main\n bronchus during inspiration measures 7.7 mm and during expiration the caliber\n is 6.4 mm.Similarly on the left side proximal main broncus measures 6.0mm in\n inspiration and 5.4mm during expiration.\n\n Both lungs are clear. There is no consolidation or atelectasis.\n\n PLEURA: No evidence of effusion or pneumothorax.\n\n MEDIASTINUM: The left lobe of the thyroid is enlarged, and there is a small\n ill-defined focal hypodensity measuring 5 x 3 mm in the left lobe. Multiple\n (Over)\n\n 12:06 AM\n CT TRACHEA W/O C W/3D REND Clip # \n Reason: Eval stenosis and for other acute process. Please do airway\n Admitting Diagnosis: TRACHEAL STENOSIS\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n small scattered mediastinal lymph nodes are seen which do not meet\n pathological size criteria by CT. Cardiomegaly noted. No evidence of\n pericardial effusion. Atherosclerotic changes are seen in coronary arteries\n and thoracic and abdomen aorta. Main pulmonary artery and thoracic aorta are\n normal by caliber. Morgagni hernia with peritoneal fat and ascites as its\n content is seen. Moderate sized hital hernia noted.\n\n Abdomen: The CT protocol is not dedicated for evaluation of abdomen. Limited\n section of abdomen reveal presence of ascites. Visualised sections of liver,\n spleen and pancreas are normal.Cortical irregularites, scarring and punctate\n calcifications are seen in bilateral kidneys s/o chronic renal changes.\n Multiple renal cortical and exophytic cysts are seen bilateraly. Largest on\n the right side measures 11 x 12mm and on the left 2.7 x 2.3cm. One of the\n upper pole cyst in right side in hyperdense.\n\n SOFT TISSUES: Soft tissues are unremarkable.\n\n\n BONES: There is diffuse generalized increase in the bone density.\n Considering the clinical history, this most likely represents changes\n secondary to renal osteodystrophy.\n\n IMPRESSION:\n\n Tracheomalacia and subglottic tracheal stenosis.\n\n Both lungs are clear. No consolidation or atelectasis.\n\n Enlarged left lobe of the thyroid with small ill-defined focal hypodensity\n measuring 5 x 3 mm. A thyoid ultrasound may be suggested for further\n evaluation.\n\n Ascites.\n\n Morgagni hernia and moderated sized sliding hiatus hernia.\n\n Chronic renal changes with generalized increased bone density s/o renal\n osteodystrophy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2198-07-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1197598,
"text": " 3:51 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check POWER PICC tip 47 cm right basilic please page\n Admitting Diagnosis: TRACHEAL STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with new line placement\n REASON FOR THIS EXAMINATION:\n please check POWER PICC tip 47 cm right basilic please page with wet read\n thanks \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female status post new PICC placement.\n\n COMPARISON: .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: A new right PICC follows a normal course\n to the mid clavicle then courses superiorly into the right internal jugular\n vein. Tracheostomy is in satisfactory position.\n\n Lung volumes are low. There is at least a small left effusion. No large\n right pleural effusion is present. There is no pneumothorax.\n Cardiomediastinal silhouette is similar to prior. There is atherosclerotic\n calcification of the aortic arch. There is slightly increased interstitial\n opacity and vascular engorgement compatible with mild to moderate pulmonary\n edema. Right Morgagni hernia is better evaluated on recent CT.\n\n Findings discussed with Dr. by phone at 4:30 p.m. on .\n\n"
},
{
"category": "ECG",
"chartdate": "2198-07-12 00:00:00.000",
"description": "Report",
"row_id": 203180,
"text": "Sinus rhythm. Left anterior fascicular block. Non-specific inferior ST-T wave\nchange. Delayed precordial R wave transition. No previous tracing available\nfor comparison.\n\n"
}
] |
18,194 | 152,192 | NEUROLOGY: Mr. was admitted to the TSICU for close monitoring of his respiratory function following the diagnosis of extensive left-sided chest injuries. The patient's mental status remained stable throughout his hospital stay. His pain was controlled with fentanyl as needed. This was supplemented by the placement of an epidural on HD#3 once his spine was cleared. ## ORTHO: The patient injuries were mainly localized at the left side of his chest with multiple rib fractures, a clavicular and scapular fracture. This was managed with agressive pain control as discussed above and a sling to control the clavicular fracture. ## PULMONARY: The patient's oxygen saturation fluctuated during the course of his ICU stay and he often required CPAP at night when his saturations would drop to the mid-high 80s. He otherwise did well on a NRB mask with saturations in the high 90s. The patient also had difficulty coughing and required regular physical therapy support. This improved after removal of his chest tube on HD#7. On day of discharge, the patient had saturations in the mid-90s on 5L NC. ## CARDIAC: The patient's coronary artery disease was stable during his hospital stay. He was initially placed on iv metoprolol and subsequently on his usual regimen of carvedilol, losartan, lipitor when he was able to take oral medications. His ECGs and enzymes remained within normal range during his stay with us. ## INFECTIOUS DISEASE: The patient developed a mild RLL infiltrate on HD#9 which was treated with levofloxacin. The patient remained afebrile throughout his stay. He will continue his antibiotic therapy for 6 days after discharge. ## The patient was discharged on HD#11 in stable condition, able to ambulate on his own and with oxygen saturations in the mid-high 90s on 5L NC. He will transition in a rehabilitation facility prior to returning home. Instruction were given to return to the Trauma, Orthopedic and Ophthalmology clinics for follow up. | LS CLEAR UPPER AND DIM @BASESCV: BP STABLE AND HR WITH RARE PVCS, ON LOPRESSOR AS ORDEREDNEURO: GROSSLY INTACT, STILL HAS C COLLAR ON, MAE =, IN PAIN WHILE TURNED. CHEST X-RAY WAS DONE TO R/O INCREASING PNEUMO-WAS NEGATIVE.CHEST TUBE IS INTACT, DRESSING WAS A BIT SATURATED AND WAS CHANGED, DRAINED SMALL AMNT S/S SECRETIONS. USES PCA OCCASIONALY.GETS AGGITATED , TRYING TO PULL MASK ANDLINES OUT-RESTRAINEDLABS: SEE ABGS IN CAREVUESKIN : INTACTGI: TOLERATES LIQUIDS WELL, DENIES NAUSEAPLAN: D/C COLLAR PAIN CONTROL PULM MANAGAMENT K+ repleted earlier today.ID...Tmax 99.8. Pneumoboots on.ENDO...Blood sugars <110. ABG's stable----with oxygenation improving slightly--see careview for specifics. L CT placed back on suction per Dr. orders. Pnuemoboots intact.ID: TMAX 99.0. Abd softly distended with hypoactive BS.GU...Foley to gravity with adequate clear yellow urine output--40-80cc/hr. Pt has remained on 12 PS, 5 PEEP, .80 FI02 with improving ABGs. Replete lytes accordingly. Bupivicaine epidural continues with good effect, pt denies pain. , MD aware and discussed changing frequency to q 8 hrs.Resp: Lung sounds clear. Recieved BP meds. Updated on status.PLAN....Tenative resp status. CHEST DRAINING NIL PLACED TO H20 SEAL, SITE OOZING MODERATE BLOOD NEW DSD PLACE.. PATIETN WITH MIAMIJ COLLAR IN PPLACE C/O OF NECK BEING SORE WHEN RN PLACES O2 BACK ON. PATIENT'S PAIN WELL CONTROLLED ON PCA..SINCE STARTING AT 1230 PM HAS RECEIVED 11MG 11INJECTIONS/15 ATTEMPTS. CONTINOUS IV HYDRATION NS AT 100CC/HR.. AS NOTED STARTED ON PCA PUMP WITH GOOD RESULTS. GI CLEAR LIQUIDS TOLERATING FINE. Frequent enc to c+db. Resp Care Note,Pt started on NIV due to worsening ABG'S.Some improvement in PaO2.Will cont to monitor resp status.Plan to MRI @ some point. SC Heparin TID. No abx coverage.ENDO: BS covered per RISS.GI: Abd soft, slightly distended. J collar in place.Pain management major issue. CT site intact, no crepitus noted.CV: Sinus Arrthymia 70-80's with frequent PVC's. Pt started on NIV for worsening ABG'S. LS: clear, diminished at bases. Placed on cpap with good results. ppp bilat, a line placed with resp distress event, bp stable at rest.gi: belly distended, soft this am, bm x3 after suppos, and enemas x2. o2 sats stable, rr tachypneic only with movement or cough. pt denies sob, distress.cv: bp stable, a line waveform dampened, eventually unable to draw blood, site d/c'd this pm. nursing prog noteevents: pt changed to face mask o2 this am, immediately becoming tachycardic, tachypneic, o2 sats initially stable. left chest tube to h20 seal this am, site benign. OOB/ambulate as tolerated. lopressor XL held this am, note initial hypotension after epidural concentration changed. minimal edema to extrem. denies nausea, tol cardiac diet well. LS: clear, diminished at bases. cxr obtained this am.cv: as above, hypertensive with agitation, hr sinus arrhythmia with many pvc's noted baseline. left CT to water seal this am, sanguinous output noted. pain well controlled w/ bupiv. No abx coverage at this time.ENDO: FS covered per RISS - no coverage needed this shift.GI: Abd soft, slightly distended. confusion persists, pain well controlled with epidural. decompensation this am. Note is made left subcutaneous emphysema. scant crepitus this am, negative this pm. hr sinus arrhythmia, pvc's freq. Pneumoboots intact. ppp bilat.gi: belly soft, nt/nd. ls clear to bilat upper lobes, dimin to bilat bases. No crepitus noted.CV: Sinus arrythmia 80's with frequent PVC's. Positive fluid staus for the day ~ 1L. abg obtained after mask replaced, wnl, although note rr remained 30s with shallow breaths noted at the time. The visualized portions of the paranasal sinuses are normally aerated. tylenol given for comfort.endo: bg's stable, covered per riss.skin: perineal area reddened, barrier cream prn. pt with worsening agitation, o2 sats, tachypnea, tachycardia, hypertension, although denying pain to chest/rib fx sites, perseverating on moving bowels. right eye drainage improved, no exudate noted today. creat 1.8..stable. T/Sicu Nsg Note0700>>EVENTS: Mask ventilation support removed ~ 0800 and remains off at this time. Again demonstrated is a left superior chest tube in stable and satisfactory position. There has been equivocal interval development of small bilateral pleural effusions as both hemidiaphragms are obscured. 6) Left hepatic low density round lesion, which may represent a simple hepatic cyst. A high density small left pleural fluid collection is demonstrated, which may represent hemothorax. 5) Small high density left pleural fluid collection, which may represent hemothorax. A left sided superior chest tube is noted. IMPRESSION: 1) Small left anterobasal pneumothorax with pneumomediastinum and a large amount of left chest wall subcutaneous emphysema. A lucency is seen within the left femoral head, of unclear significance. There are bilateral pleural effusions with bibasilar atelectasis, also unchanged. AP SUPINE VIEW OF THE CHEST: The study is limited by overlying trauma board. Several tiny hypodensities which are sub-cm in size are noted within the (Over) 1:27 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: FELL CHEST ABD INJURIES Field of view: 45 Contrast: OPTIRAY Amt: 150 FINAL REPORT *ABNORMAL! LS diminished t/o, clear upper right lobe, non-productive congested cough, suctioned by resp. REFERENCE EXAM: FINDINGS: There has been interval removal of the left chest tube. There is a lucency within the medial aspect of the left femoral head, of unclear significance. There is significant amount of subcutaneous emphysema from the skull base and extending inferiorly to at least the T2 vertebral body which was the lower level included in this imaging. | 48 | [
{
"category": "Nursing/other",
"chartdate": "2120-04-05 00:00:00.000",
"description": "Report",
"row_id": 1501675,
"text": "RESP CARE: Pt traveled to CT and back on 100% NRB without incident. Pt became confused with decreased 02 sats after pulling off 02 mask at 2200. Placed on Bipap with face mask. Sats not improving, lungs congested. Pt sxd lg amt thick yellow sputum, culture sent. When pt placed back on Bipap 02 sats improved to 99%. Pt has remained on 12 PS, 5 PEEP, .80 FI02 with improving ABGs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-02 00:00:00.000",
"description": "Report",
"row_id": 1501662,
"text": "Resp Care Note, Pt placed on NIV for a few hours overnight for decreased SATS and ^ PaCo2.Now on NRB with good sat. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-02 00:00:00.000",
"description": "Report",
"row_id": 1501663,
"text": "PER TRAUMA TEAM CHANGED TO J COLLAR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-02 00:00:00.000",
"description": "Report",
"row_id": 1501664,
"text": "PATIENT WITH LOTS OF PAIN THIS AM, GIVEN TOTAL OF 200MCG FENTANYL IV STRATED ON PCA PUMP MSO4 WITH GOOD RESULTS SLEEPING AT 1400!!!, IMROVING ABG'S PLANNING TO SEND ABG AT 1430, PRESENTLY ON FIO2 50% SHOVEL 4LNP WITH SATS AT 96% OR BETTER RR 24-28, BILATERAL BS CLEAR BUT VERY DIMISHED AT BASES. CHEST DRAINING NIL PLACED TO H20 SEAL, SITE OOZING MODERATE BLOOD NEW DSD PLACE.. PATIETN WITH MIAMIJ COLLAR IN PPLACE C/O OF NECK BEING SORE WHEN RN PLACES O2 BACK ON. CONTINOUS IV HYDRATION NS AT 100CC/HR.. AS NOTED STARTED ON PCA PUMP WITH GOOD RESULTS. GU ADEQUATE U/O. GI CLEAR LIQUIDS TOLERATING FINE. K 3.6 10MEQ KCL IV GIVEN PLAN TO RECHECK THIS PM.. HEPARIN SC/VENODYNE BOOTS ON.. ABLE TO BE ON RSIDE THIS PM. COWORKER, WIFE AND DAUGHTER INTO VISIT. ?? INCREASE LOPRESSOR DOSE INCREASED SBP TO 150-160.. AT PRESENT NO EPIDURAL TO BE DONE ANESTHESIA WANTS TOTALLY CLEARANCE BEFORE PLACING EPIDURAL\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-02 00:00:00.000",
"description": "Report",
"row_id": 1501665,
"text": "PLAN TO GO MRI THIS EVENING\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-02 00:00:00.000",
"description": "Report",
"row_id": 1501666,
"text": "ADDENUM ABG/K PENDING, AWAITING MRI. PATIENT SAYS HE IS SEEING \"THINGS\"\" ON THE CEILING... PATIENT'S PAIN WELL CONTROLLED ON PCA..SINCE STARTING AT 1230 PM HAS RECEIVED 11MG 11INJECTIONS/15 ATTEMPTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-02 00:00:00.000",
"description": "Report",
"row_id": 1501667,
"text": "ALSO TOLERATING CLEAR LIQUIDS, OJ/JELLO\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-03 00:00:00.000",
"description": "Report",
"row_id": 1501668,
"text": "Resp Care Note,Pt started on NIV due to worsening ABG'S.Some improvement in PaO2.Will cont to monitor resp status.Plan to MRI @ some point.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-03 00:00:00.000",
"description": "Report",
"row_id": 1501669,
"text": "ASSESSMENT AS NOTED\n\nRES: WAS HYPOXIC LAST NIGHT WITH RISING CO2 LEVELS, WAS PUT ON BIPAP 80% AND WAS ENCOURAGED CCOUGH AND DEEP BREATHING.CO2 WAS DOWN TO 42. CHEST X-RAY WAS DONE TO R/O INCREASING PNEUMO-WAS NEGATIVE.CHEST TUBE IS INTACT, DRESSING WAS A BIT SATURATED AND WAS CHANGED, DRAINED SMALL AMNT S/S SECRETIONS. LS CLEAR UPPER AND DIM @BASES\n\nCV: BP STABLE AND HR WITH RARE PVCS, ON LOPRESSOR AS ORDERED\n\nNEURO: GROSSLY INTACT, STILL HAS C COLLAR ON, MAE =, IN PAIN WHILE TURNED. USES PCA OCCASIONALY.GETS AGGITATED , TRYING TO PULL MASK ANDLINES OUT-RESTRAINED\n\nLABS: SEE ABGS IN CAREVUE\n\nSKIN : INTACT\n\nGI: TOLERATES LIQUIDS WELL, DENIES NAUSEA\n\nPLAN: D/C COLLAR\n PAIN CONTROL\n PULM MANAGAMENT\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-03 00:00:00.000",
"description": "Report",
"row_id": 1501670,
"text": "TSICU NPN 0700-1900)\nREVIEW of SYSTEMS:\n\n\nNeuro....Alert to person, and time. Needs frequent reorientation to place and events. Following simple commands. Brief periods of confusion where he takes off oxygen and says, \" get up.\" Reorients easily. Interacts well with family. Moves all extremities---weaker with LUE due to fx's. J collar in place.\n\nPain management major issue. Epidural catheter placed per APS, early this afternoon. Bupivicane only in epidural bag. Pt reports better relief with epidural when at rest--pain level . Continuing PCA morphine and scheduled oxycodone from prior to epidural placement also. Pain level severe with any movement, turning, activity--. Epidural rate increased to 8 with more room to titrate up.\n\nRESP.....Tenative resp status----Taken off bipap this am. Placed on NC at 4L and hi flow face mask at 80%. Not able to wean today, but did not worsen. O2 sats >93%. RR 20-low 30's. Very shallow resp's. Pt does not do well with any DB or IS. ABG's stable----with oxygenation improving slightly--see careview for specifics. No cough effort. Desats very quickly when oxygen off. L CT placed back on suction per Dr. orders. 70cc serosang drainage.\n\nCV.....NSR with increasing ecopy this evening--PVC/PAC's. Lytes sent at 1800. HR 80-90's. BP 110-130's/60's. LR at 125cc/hr. Lopressor dosing increased to 7.5mg Q6hrs.\n\nGI....Taking in water. Team did not want to advance too much due to poor resp status. Abd softly distended with hypoactive BS.\n\nGU...Foley to gravity with adequate clear yellow urine output--40-80cc/hr. K+ repleted earlier today.\n\nID...Tmax 99.8. No abx coverage. Face very red and flushed this evening.\n\nHEME....Heparin subq. Pneumoboots on.\n\nENDO...Blood sugars <110. No sliding scale ordered.\n\nSKIN...Ecchymosis to L shoulder. Epidural catheter with small amt of serosang drg at insertion site. Backside otherwise intact. Able to sit and dangle at side of bed for epidural cath placement. PT to see in am for eval.\n\nSOCIAL... wife and children in for visit. Updated on status.\n\nPLAN....Tenative resp status. Needs close monitoring. Aggressive pulmonary toilet--pt needs lots of encourgement and reminding. Pain management and control--can increase epidural if needed. Replete lytes accordingly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-04 00:00:00.000",
"description": "Report",
"row_id": 1501671,
"text": "Pt started on NIV for worsening ABG'S. Placed on cpap with good results. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-01 00:00:00.000",
"description": "Report",
"row_id": 1501660,
"text": "Nursing Admission\nPt admitted from EW, pt awake alert and oreinted moving all 4 extremities to commnad, pt is on log roll precautions and is C collored. Pt had fallen from a deck 7 feet, landing on his Left side, injuries include left rib fractures , left scapula fracture and left clavicle fracture, left pneumothorax with chest tube placement at OSH and bruising of his left kidney.Pt was med flighted to .\npt hemodynamically stable on admission in NSR, pt on 100% rebreather with sats of 96-98%, breathing without distress and no c/o of SOB, pt has clear to diminished breath sounds in bases, min bloody drainage from chest tube , no air leak noted, on 20cm suction. pt has subQ emphesema in left shoulderas well as bruising . pt ABG 7.29-54-98-1.Pt medicated for pain with dilaudid with good effect.pt family in to visit, they were given pamphlet on TSICU, telephone number to call and instructed to have a spokesperson.\nA/P- Monitor and assess pulmonary and CV stautus post fall. Follow up on scans of cspine and TLS. Cont to medicate for pain.\n+\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-02 00:00:00.000",
"description": "Report",
"row_id": 1501661,
"text": "ROS:\n\nNeuro: Intact. Nausea w/hydromorphone, changed to fentanyl w/+ effect. C/o itching in face (around face mask), benadryl 25 mg iv x's 1 w/relief of itching.\n\nCV: RSR w/ PVCs, PACs. VSS, see flow record for details. Has right radial ABP line. On metoprolol 5mg q 6 hr. 0200 dose held until 0600 when bp was higher. When dose given at bp dropped < 100 and began having ectopy. , MD aware and discussed changing frequency to q 8 hrs.\n\nResp: Lung sounds clear. On 100% NRB w/sats 94->96%. Earlier in shift placed on mask ventilation because sats dropped to 92% on 100% NRB and when O2 taken off by patient desats to 85% immediately and then takes several minutes to recover to 90%. Frequent enc to c+db. Does well w/deep breathing but does very poor at coughing. Has left chest tube to 20cm sx, no air leak, fluctuation in tube, but has + sub q air.\n\nGI: Abd soft w/active BS though out. Nausea as noted above.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nLabs: Mag and K repleted.\n\nSocial: Family here at beggining of shift.\n\nPLan: Pulmonary toileting, Comfort, Monitor, mobilization.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-06 00:00:00.000",
"description": "Report",
"row_id": 1501681,
"text": "TSICU NPN 1900-0700\n\n\nEVENTS: Pt A&OX2 at start of shift with increased confusion as evening progressed. At 2130, pt very agitated and combative, pulling of face mask, stating \"get me out of here, I'm leaving.\" Pt placed on mask ventilation and Haldol given with good effect for an hour. Pt once again became agitated, pulling at lines, pulling vent mask off at 2230 - recieved additional haldol with good effect.\n\nNEURO: Pt slept on and off throughout night (after recieving haldol)- remains confused when awake. MAE, following commands inconsistantly. Bupivicaine epidural continues with good effect, pt denies pain. J collar intact.\n\nRESP: Placed on mask ventilation at 2130, no respiratory distress noted after placement. SATS 96-100%. LS: clear, diminished at bases. Weak cough. Left CT to suction while on mask ventilation. CT site intact, no crepitus noted.\n\nCV: Sinus Arrthymia 70-80's with frequent PVC's. SBP 120-130's. Recieved BP meds. SC Heparin TID. Pnuemoboots intact.\n\nID: TMAX 99.0. No abx coverage.\n\nENDO: BS covered per RISS.\n\nGI: Abd soft, slightly distended. HH diet, pt refused dinner. Boost with meals. Positive BS. Colace . No stool overnoc. Protonix for GI propholaxis.\n\nGU: Foley draining clear yellow urine. Adequate UO. Lytes WNL.\n\nSKIN: Left shoulder right inner thigh with ecchymotic areas. Backside intact. Epidural site intact.\n\nSOCIAL: Wife into visit at beginning of shift.\n\nPLAN: Monitor neuro status, pulm toliet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-06 00:00:00.000",
"description": "Report",
"row_id": 1501682,
"text": "RESP CARE: Pt placed on Bipap early in shift due to agitation, pulling off 02 with desaturation noted. Remained on Bipap all night, SEE CAREVUE\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-06 00:00:00.000",
"description": "Report",
"row_id": 1501683,
"text": "patient is now off NoN-Invasive ventilation;he is placed on cool mist @ 60%.Complaining of abdominal pain,breathing 38 breaths per minute.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-06 00:00:00.000",
"description": "Report",
"row_id": 1501684,
"text": "Patient back on Non-Invasive ventilation desaturated to 87% but alert and coop.Sat back to 95% post pre-oxygenation.Now on 60% good VT will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-06 00:00:00.000",
"description": "Report",
"row_id": 1501685,
"text": "nursing prog note\nevents: pt changed to face mask o2 this am, immediately becoming tachycardic, tachypneic, o2 sats initially stable. pt c/o \" belly cramping\" to abdomen, stated \" i have to go to the bathroom!\" to commode, unable to move bowels. pt with worsening agitation, o2 sats, tachypnea, tachycardia, hypertension, although denying pain to chest/rib fx sites, perseverating on moving bowels. after multiple supplements, pt able to move bowels, resp status worsening. pt returned to cpap+ps mask ventilation with o2 sats 88%, rr 40s.\n\nneuro: pt remains oriented only x2, confused to place, situation at times. hallucinations somewhat improved, although agitation worsening with resp. decompensation this am. moving x3, left arm with sling. follows commands when agitation under control. haldol effective for control of agitation.\n\nresp: as above, returned to cpap+ps mask at 1230, pt much more comfortable, o2 sats, rr immediately improved. pt stated he felt much better with mask ventilation. abg obtained after mask replaced, wnl, although note rr remained 30s with shallow breaths noted at the time. follow up abg's remain stable, after NT sx, pt much more comfortable, able to rest this pm. sx for sm amts thick yellow/white secretions. cx obtained. currently resting comfortably with mask, o2 sats wnl, rr mid 20s. left chest tube to h20 seal this am, site benign. cxr obtained this am.\n\ncv: as above, hypertensive with agitation, hr sinus arrhythmia with many pvc's noted baseline. note episode ventric. bigeminy this pm, resolved after few minutes. HO aware, will monitor. note also one episode at 1600 of self limiting SVT, lasting 8-10beats. HO also aware. no further ectopic events. ppp bilat, a line placed with resp distress event, bp stable at rest.\n\ngi: belly distended, soft this am, bm x3 after suppos, and enemas x2. bs present, + flatus.\n\ngu: foley patent, po lasix restarted per pt's home routine. diuresed well for shift, clear yellow urine.\n\nid: tmax 101.6 this aft, pan cx obtained. wbc stable this am. tylenol given for comfort.\n\nendo: bg's stable, covered per riss.\n\nskin: perineal area reddened, barrier cream prn. right eye drainage improved, no exudate noted today. sclera slightly reddened. hematoma to left shoulder area slightly more edematous, bruising healing. ct dsg remains c/d/i.\n\nsocial: wife in to visit shortly this am, updates provided.\n\na/p: 68 yo male s/p multiple rib fx, pneumotx, scapula, clavicle fx. continued tenuous resp status, requiring prolonged cpap mask ventilation, not tolerating face mask o2 today. currently abg's stable although with significant effort on pt's part. confusion persists, pain well controlled with epidural. cont to closely monitor resp status, follow abg's, lytes, abd exam. manage agitation w/ prn meds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-05 00:00:00.000",
"description": "Report",
"row_id": 1501676,
"text": "TSICU NPN 2300-0700\nEVENTS 1900-2300: Pt had complained about seeing 'black spots' on previous shift - opthomology consulted -- pt's pupils dilated and assessed. Per opthomology, no significant abnormalities. Pt then taken for head CT (due to seeing spots) -- results pending. At 2200, Pt became confused, SATS decreased, requiring pt to be placed on mask ventilation. SATs and ABG's then improved.\n\nREVIEW OF SYSTEMS:\n\nNEURO: Pt slept for most of shift. When awoken for neuro assessment, pt A&OX1-2, unaware of surroundings. Reorientated well at times, other times becoming very agitated stating \"I have to get out of here\". Following commnands inconsistantly. Moving all extremities with good strength. Pain management: Bupivicain epidural @ 10cc/hr. Morphine PCA (pt not using), PRN Dilaudid ordered. Tylenol 1 gm Q8/hr, Oxycontine 20mg . J collar intact.\n\nRESP: Mask ventilation overnoc with SATS 94-98%. ABG's at pt's baseline. LS: clear, diminished at bases. Left CT to suction while on mask ventilation. No crepitus noted.\n\nCV: Sinus arrythmia 80's with frequent PVC's. SBP 90-130's. Right radial arterial line very positional, dampens at times. Pneumoboots intact. SC Heparin TID.\n\nID: TMAX 98.5. No abx coverage at this time.\n\nENDO: FS covered per RISS - no coverage needed this shift.\n\nGI: Abd soft, slightly distended. Positive BS. HH diet. Protonix for GI propholaxis. No stool overnoc.\n\nGU: Foley draining clear yellow urine. Adequate UO. Lytes WNL.\n\nSKIN: L shoulder and R inner thigh wtih ecchymotic areas. No breakdown noted to backside. Epidural site intact.\n\nSOCIAL: No contact from family overnoc.\n\nPLAN: Monitor mental status\nPulm toliet, monitor resp status, wean oxygenation at tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-05 00:00:00.000",
"description": "Report",
"row_id": 1501677,
"text": "t-sicu nsg note:\npt somewhat confused but cooperative, went to head ct tol well, ~1hr after returning pt woke up and pulled off o2 mask, began desating to 88 and became combative, refusing to allow o2 mask back on, received 1mg iv haldol x2 and soft wrist restraints. qtc documented as 0.35-0.40 prior to haldol dose. abg revealed pao2=61 pco2=51 pt placed on bipap ventillation and settled out, able to sleep. vss see flowsheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-05 00:00:00.000",
"description": "Report",
"row_id": 1501678,
"text": "\nPT MAINTAINED OFF OF BIPAP ON 80% COOL AEROSOL. OOB WITH GOOD SATS AND STABLE VITALS. MENTALLY PT DOING BETTER TODAY AND IS COMMUNICATING WITH RESPECT TO QUESTIONS ASKED. B.S. BILAT WITH SOME SCAT RONCHI. PT HAS POOR COUGH BUT SAYS HE WILL DO BETTER. PT DID SMOKE UP UNTIL ADMISSION BUT DENIES EVER TAKING ANY BREATHING MEDICATION. PLAN IS TO CONT. WITH THE BIPAP AT NIGHT WITH AEROSOL DURING THE DAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-05 00:00:00.000",
"description": "Report",
"row_id": 1501679,
"text": "nursing prog note\nneuro: pt remains oriented x2, confused to place. visual hallucinations continue, pt states he sees trains, tracks, and electrical wires throughout room. when asked, pt can state the month, that he is in a hospital (does not know name). moving x3, left arm in sling when oob. epidural concentration doubled this am per APS, tol well, pain very well controlled. po narcotics d/c'd, dilaudid used only once for breakthrough. sensation intact from epidural distally. nicotine patch started to help manage agitation.\n\nresp: bipap removed this am, pt tol face mask o2 well for day. o2 sats stable, rr tachypneic only with movement or cough. at rest rate 20s. ls clear to bilat upper lobes, dimin to bilat bases. cough poor, aggressive teaching with IS today with much difficulty, d/t pt's confusion. able to reach 250-300mL with IS at best. encouraged cough as well, somewhat improved. left CT to water seal this am, sanguinous output noted. scant crepitus this am, negative this pm. no fluct. to chamber. pt denies sob, distress.\n\ncv: bp stable, a line waveform dampened, eventually unable to draw blood, site d/c'd this pm. cuff pressures correlating well prior to removing a line. lopressor XL held this am, note initial hypotension after epidural concentration changed. bp improved at this time. hr sinus arrhythmia, pvc's freq. minimal edema to extrem. ppp bilat.\n\ngi: belly soft, nt/nd. +flatus. denies nausea, tol cardiac diet well. appetite fair. tol po fluids well.\n\ngu: foley patent for clear yellow urine, qs.\n\nid: tmax 99 today, wbc stable.\n\nendo: bg's elevated this pm, covered per riss.\n\nskin: no new issues.\n\nsocial: wife and daughter in law in to visit today, supportive. all ques answered, updates provided. family very concerned regarding pt's confusion/hallucinations.\n\na/p: s/p fall, sustaining left rib fx, pneumotx, left clavicle,scapula fxs. tol supplem. o2 well today, needs continued aggressive pulm toilet, IS usage. pain well controlled w/ bupiv. epidural. minimal narcotics at this time d/t confusion. full icu monitoring, cont. pulm toilet/teaching.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-05 00:00:00.000",
"description": "Report",
"row_id": 1501680,
"text": "nursing note addendum\nneuro: note on prev. exam pt c/o \"seeing spots\", note no further c/o vision disturbances. pupils at this time perrla, size 2-3mm bilat.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-04 00:00:00.000",
"description": "Report",
"row_id": 1501672,
"text": "1900-0730\nNPN/ROS:\n\nneuro: patient alert, following commands, confused at times but reorients easily. moves all extremities with good strength. +CSM, epidural at 8cc/hr of bupivicaine with adequate pain control: denies numbness/tingling to extremities, no motor or sensation deficit, patient also with Morphine PCA for pain; hitting button only when encouraged, c-collar on.\n\nCV: Stable, SR with occasional PVCs, metoprolol and coreg as ordered, aline very positional, mag repleted,\n\n**RESP: patient had been maintaining 02 sat 94-96% with high flow mask and 4L NC, but began to desat into lower 90s, high 80s with worsening ABG> was placed on mask ventilation for increasing pCO2, LS clear but diminished, shallow respirations without mask ventilation adn RR into 30s, on maskventilation RR 20-24, patient appears in less respiratory distress. CT remains to 20cm suction, dressing changed\n\nGI: no issues, tolerating clear lix without n/v, +hypo BS, colace as ordered\n\nGU: foley with good urine out\n\nENDO: no active issues\n\nID: tmax 100.1, no active issues\n\nSKIN: large hematoma to left shoulder/axillary area, epidural site with small amount of s/s drainage\n\nplan: continue pain control, OOB as tolerated, encourage c&db, pulmonary toilet, wean o2 requirements as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-04 00:00:00.000",
"description": "Report",
"row_id": 1501673,
"text": "T/Sicu Nsg Note\n0700>>\n\nEVENTS: Mask ventilation support removed ~ 0800 and remains off at this time.\n Pain mngmnt adjusted\n Cervical spoine ext/flexion films done- pnd- collar remains in place\n Diet advanced w/supplements\n Tolerated OOB>chair and short ambulation activities.\n\nNeuro- sleepy; confused, oriented x1-2; follows consistently. Dry wit. Reorients w/explanation. No sensory/motor deficits with epidural rx. Pain mngmnt with ongoing adjustments & evaluation: PCA cont but pt requires reminders/encouragement to use; epidural changed to .05%(.1%) with increase in rate to 10cc/hr; tylenol 1GM po q8/hr ATC started; oxycontin 20 mg continues. Pt has difficulty rating pain- needs urging to be specific. Pain remains in Left chest/shoulder, is sharp, and remains mod to severe in severity. Pain increases with movement/activity. Pt continues to splint and become tense with moving activities. Pt very cooperative with care. Pt does not offer complaints and needs encouragement to report discomfort.\n..epidural site wnl, small amount of old bloody drainage under tegaderm.\n\nCVS- NSR with frequent pvc's; electrolytes repleted. Toprol XL 50 mg started today. BP >100/systolic with dips into 90's after toprol dosing. fluid bolus 250cc x1 for low BP.\n\nRenal- adequate hourly u/o. Positive fluid staus for the day ~ 1L.\n creat 1.8..stable.\n IVF @ kvo rate.\n\nRESP- Mask ventilation overnight for desaturation & increased WOB. Changed to High flow neb with face tent @ 95%/15L with 4L NC. RR remains in high teens to low 20's with no c/o SOB or resp distress.\nBreath sounds are clear to coarse with diminished bases L>R. Left pleural chest tube is to water seal while maintaning spontaneouis ventilation- no fluctuation, no air leak, no crepitus appreciated.\nABG within pt's acceptable baseline range. Cough is , NP/congested. Pt with ongoing splinting with deep breathing. IS use with volumes 250 to ~ 600cc x few.\n\nID- low grade temp; wbc 11; no antibiotics\n\nHeme- no issues\n\nEndo- ssri coverage started; 2 units regular insulin x2 for blood sugars in 135 range.\n\nGI- diet advance to healthy heart diet with BOOST & high calorie fruit supplements. Pt tolerating diet well; mostly liquids; diminished appetite. Protonix. Abd is soft/distended w/hypoactive bowel sounds. No flatus/stool.\n\nSkin- intact with previously noted contused areas on left shoulder and right inner knee area. Extremities are warm with palpable pulses. No skin breakdown on back. Pt occasional warm/flushed/with moist skin.\n** Pt c/o rigth eye pain. right eye noted to be red & irritated with scant amt of pale yellow drainage. ICU H.O. notified and exam performed. Optho consult pnd. Pt also c/o seeing dots or a dot; no other visual disturbances.\n\n wife, visited this afternoon. Condition update provided. Spokesperson issue settled: wife is to be only spokesperson. All other inquiries will be referred to pt's wife for updates.\nPt has 3 children of his own & 2 step child\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-04 00:00:00.000",
"description": "Report",
"row_id": 1501674,
"text": "T/Sicu Nsg Note\n(Continued)\nren. Current marriage is of 20 years. Wife is dealing with pt's situation appropriately and does not feel over stressed. Pt's children have called today to obtain updates and ask to speak with MD. As stated, wife want s all relative inquiries to go through her.\n\nAssess- s/p fall with left rib fx, left clavicular fx, left scapula fx and Left pneumothorax. Pt with impaired gas exchange related to injuries and complicated by pain & splinting.\n confusion ? related to narcotic, low O2, sleep deprivation\n impaired mobility related to injuries.\n\nPlan- cont to rx & evaluate pain status\n pulmonary toilet with mobilization, IS, coughing & deep breathing.\n assess need for rest with mask ventilation during night.\n OOB/ambulate as tolerated.\n nutrition support w/supplements.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858194,
"text": " 3:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumo with decreased oxygen sats\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall, multiple rib fx\n\n REASON FOR THIS EXAMINATION:\n r/o pneumo with decreased oxygen sats\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall with multiple rib fractures.\n\n COMPARISON: at 13:23.\n\n SUPINE AP VIEW OF THE CHEST: The patient is rotated. Again demonstrated is a\n left superior chest tube in stable and satisfactory position. The heart is\n enlarged. The mediastinal and hilar contours are unchanged. Again\n demonstrated are bilateral ill-defined diffuse air-space opacities, left\n greater than right, which may represent atelectatic changes. Blunting of the\n left costophrenic angle is also again redemonstrated. No definite\n pneumothorax is seen. Bullae within the right apex is noted. A large amount\n of left-sided subcutaneous emphysema is again demonstrated.\n\n IMPRESSION: No significant interval change since the prior study. No\n definite pneumothorax identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 859369,
"text": " 6:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for acute cardiopulm process\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with multiple rib fxs now c/o substernal CP\n REASON FOR THIS EXAMINATION:\n Eval for acute cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old male with multiple rib fractures, now with substernal\n chest pain.\n\n Portable AP view of the chest dated , is compared with the same\n examination from 2 days prior. Allowing for the patient change in position,\n there has been no significant change. Again, noted is cardiomegaly with mild\n congestive heart failure. Again, noted are bilateral pleural effusions with\n bibasilar atelectasis or consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858965,
"text": " 10:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progressive eval of pulmonary status\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall, multiple rib fx, ptx with chest tube pulled yesterday\n\n REASON FOR THIS EXAMINATION:\n progressive eval of pulmonary status\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Status post fall with multiple rib fractures. Chest tubes removed\n yesterday.\n\n COMPARISON: .\n\n Compared to the prior study, there has been no interval change. A left-sided\n chest had been noted in place on , but was not present on .\n There is no pneumothorax. There has been an increase in the degree of\n blunting of the left costophrenic angle, most consistent with a pleural\n effusion. The right lateral lung was not included on the prior study and is\n included on today's study. The infiltrate in the right lower lobe is\n essentially unchanged.\n\n IMPRESSION: No pneumothorax.\n\n Increased size of the left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858565,
"text": " 10:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary eval, ptx eval\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall, multiple rib fx, ptx, now w/low O2 (pain vs. expanding ptx)\n\n REASON FOR THIS EXAMINATION:\n pulmonary eval, ptx eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old male status post fall, multiple rib fractures.\n\n TECHNIQUE: Portable AP chest radiographs.\n\n The comparison is made with a prior chest radiograph dated .\n\n FINDINGS: Again, note is made of tortuous aorta. The heart is mildly\n enlarged in size. The left-sided chest tube remains in place. Note is made\n left subcutaneous emphysema. No pneumothorax was identified on this chest\n radiograph. Note is made of bilateral pleural effusion with atelectasis.\n Note is made of mild CHF, which is slightly improved compared to the prior\n study.\n\n IMPRESSION: Bilateral pleural effusion with atelectasis, with improved CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-04 00:00:00.000",
"description": "C-SPINE FLEX AND EXT ONLY 2 VIEWS",
"row_id": 858605,
"text": " 3:03 PM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: stability\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with fall, persistent pain, CT Cspine neg\n REASON FOR THIS EXAMINATION:\n stability\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post fall. Persistent pain. Negative CT. Question\n instability.\n\n CERVICAL SPINE, LATERAL, FLEXION AND EXTENSION ON : Acquired images\n are very limited. Only C1 through C3-4 intervertebral disk spaces are\n visualized. There is no prevertebral soft-tissue swelling. No evidence for\n listhesis.\n\n IMPRESSION: Severely limited exam. Only C1 through C3-4 are visualized. No\n instability at these levels.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 858643,
"text": " 8:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: seeing spots centrally\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n seeing spots centrally\n CONTRAINDICATIONS for IV CONTRAST:\n elevated Cr\n ______________________________________________________________________________\n WET READ: 9:17 PM\n negative.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 68-year-old male status post fall.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect,\n shift of normally midline structures, or major vascular territorial infarcts.\n The -white matter differentiation is preserved. The ventricles are of\n normal size. The cisterns are patent. The visualized portions of the\n paranasal sinuses are normally aerated.\n\n IMPRESSION: There is no evidence of acute intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-01 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 858174,
"text": " 1:29 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: FELL NECKINJURYR/OFX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall from height\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YOf MON 2:14 PM\n Preliminary report: Left clavicular fracture as well as fracture of 1st, 2nd.\n and 3rd ribs on the left side. Probably fracture of the left\n scapula, this was not fully image. Probable bilateral pneumothorax.\n Significant amount of subcutaneous air. Recosntructions still pending.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Status post fall from height, 65-year-old male patient, assess\n for fractures.\n\n TECHNIQUE: Axial images were obtained from the skull vertex to the upper\n thoracic spine. Coronal and sagittal reconstructions were subsequently\n performed.\n\n FINDINGS: Vertebral bodies are well aligned with no evidence of subluxation.\n No vertebral body fractures are visualized. Diffuse degenerative changes and\n facet arthropathy is seen throughout the cervical spine. Small posterior\n osteophyte is seen at the level of C3-C4 but with no significant canal\n stenosis. There is significant amount of subcutaneous emphysema from the\n skull base and extending inferiorly to at least the T2 vertebral body which\n was the lower level included in this imaging. There is subcutaneous air seen\n in prevertebral space, just posterior to the esophagus, adjacent to the\n trachea and in the supraclavicular region. Multiple fractures are identified,\n including the left clavicle, first, second, third ribs on the left side and\n probable of the scapula on the left side. Probable pneumothorax is seen\n bilaterally.\n\n IMPRESSION: No vertebral body fractures identified. Significant amount of\n subcutaneous emphysema. Fractures of the left clavicle, first, second, third\n left ribs, and probable left scapula. Probable bilateral pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-01 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 858171,
"text": " 1:27 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: FELL CHEST ABD INJURIES\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall\n REASON FOR THIS EXAMINATION:\n r/o aortic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDdp MON 2:17 PM\n small left anterobasal pneumothorax with pneumomediastinum and large amount of\n left chest wall subcutaneous emphysema. no aortic injury. bibasilar\n atelectasis. small left intraparenchymal renal hematoma, but vessels are\n intact. left clavicle and left 1-7th rib fractures.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Trauma, S/P fall.\n\n TECHNIQUE: MDCT acquired contiguous axial images from the lung apices to the\n pubic symphysis were obtained following the administration of 150 cc of IV\n Optiray. Non-ionic contrast was administered secondary to trauma protocol.\n Coronal and sagittal reconstructions were performed.\n\n CT OF THE CHEST WITH IV CONTRAST: Large amount of left chest wall\n subcutaneous emphysema is demonstrated as well as moderate amount of\n pneumomediastinum. A small left anterobasal pneumothorax is present. A left-\n sided chest tube is demonstrated with tip within the left anterior apex.\n\n The heart, pericardium, and great vessels are all unremarkable. The aorta is\n intact throughout without evidence of aneurysmal dilatation or intimal flap.\n There is no mediastinal hematoma demonstrated. A high density small left\n pleural fluid collection is demonstrated, which may represent\n hemothorax.\n\n Lung window images demonstrate several bullae bilaterally. Additionally there\n is bibasilar collapse/consolidation noted. The airways are patent to the\n level of segmental bronchi bilaterally.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: A small semi-circular high density fluid\n collection is noted within the posterior aspect of the left kidney, likely\n representing a left intraparenchymal or subcapsular hematoma. The left renal\n hilum is intact, and both kidneys enhance symmetrically.\n\n Within the left lobe of the liver, there is a 2.5 x 2.6 cm well-circumscribed\n low attenuation lesion present, which may represent a simple cyst. The liver\n is otherwise unremarkable without evidence of acute traumatic injury. The\n gallbladder, pancreas, spleen, adrenal glands, stomach, and loops of large and\n small bowel are within normal limits.\n\n Several tiny hypodensities which are sub-cm in size are noted within the\n (Over)\n\n 1:27 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: FELL CHEST ABD INJURIES\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n periphery of the right kidney, which are too small to fully characterize, but\n might represent renal cysts. There is no free air or free fluid. The\n abdominal aorta is intact throughout without evidence of dissection or\n aneurysmal dilatation. A large amount of mural calcifications are present.\n\n CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is noted within the\n bladder which otherwise appears unremarkable. The sigmoid colon contains\n several diverticulae without evidence of diverticulitis. Pelvic loops of\n bowel are otherwise within normal limits. The prostate, seminal vesicles are\n unremarkable. There is no free fluid. No pelvic or inguinal lymphadenopathy\n is demonstrated.\n\n BONE WINDOWS: Fractures of the left clavicle, left scapula, and left 1st\n through 7th ribs are noted.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in\n delineating the pneumomediastinum, and left pneumothorax, and left\n subcutaneous emphysema.\n\n IMPRESSION: 1) Small left anterobasal pneumothorax with pneumomediastinum\n and a large amount of left chest wall subcutaneous emphysema.\n\n 2) Bibasilar consolidation/collapse.\n\n 3) Left clavicular, left scapular, fracture and fractures through the left\n 1st through 7th ribs.\n\n 4) Left renal hematoma, primarily intraparenchymal/subcapsular in location.\n Left renal hilar vessels are intact. Both kidneys enhance symmetrically.\n\n 5) Small high density left pleural fluid collection, which may represent\n hemothorax.\n\n 6) Left hepatic low density round lesion, which may represent a simple\n hepatic cyst.\n\n 7) These findings were discussed immediately with Dr. , the trauma\n resident caring for the patient at the time of this examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858377,
"text": " 10:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change in ptx\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall, multiple rib fx, ptx, now w/low O2 (pain vs. expanding ptx)\n\n REASON FOR THIS EXAMINATION:\n interval change in ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65 y/o man status post fall with multiple rib fractures and\n pneumothorax. Now with new low oxygenation and chest pain. Please evaluate\n change and pneumothorax.\n\n Single AP view of the chest dated at 23:09 is compared with portable AP\n chest x-ray of and the CTA of the chest . The left chest tube is\n stable in position. There has been little change in the bilateral ill-defined\n air space disease left greater than right. There has been equivocal interval\n development of small bilateral pleural effusions as both hemidiaphragms are\n obscured. There is no identifiable pneumothorax. The heart and mediastinal\n contours have not changed. The pulmonary vasculature is unchanged, and there\n is no evidence of CHF.\n\n IMPRESSION: Equivocal interval development of small pleural effusions. No\n pneumothorax, pneumonia, or CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-08 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 859004,
"text": " 2:12 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: dvt?\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with fall from deck, in ICU, ?dvt\n REASON FOR THIS EXAMINATION:\n dvt?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, leg pain. Assess for DVT.\n\n BILATERAL LOWER EXTREMITY VEINS ULTRASOUND: -scale and color Doppler\n images of both common femoral, superficial femoral, and popliteal veins were\n obtained. Normal waveforms, compressibility, and augmentation were\n demonstrated. No intraluminal thrombus was identified.\n\n IMPRESSION: No evidence of lower extremity DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 859103,
"text": " 8:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall, multiple rib fx, ptx with chest tube pulled yesterday\n\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old man status post fall with pneumothorax. Status post\n removal of chest tube.\n\n AP view of the chest dated is compared with the same\n examination of the prior day. There has been no significant interval change.\n There is no pneumothorax. Again noted is cardiomegaly with congestive heart\n failure. There are bilateral pleural effusions with bibasilar atelectasis,\n also unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-01 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 858170,
"text": " 1:23 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: FALL\n ______________________________________________________________________________\n FINAL REPORT\n EU Critical.\n\n HISTORY: Trauma. Fall.\n\n AP SUPINE VIEW OF THE CHEST: The study is limited by overlying trauma board.\n A left-sided chest tube is seen terminating near the left apex. There is mild\n cardiomegaly. The mediastinum appears slightly widened, which may be due to\n supine positioning and low lung volumes. Low lung volumes are present\n bilaterally. There are ill-defined bilateral air space opacities, which may\n represent atelectasis or pulmonary contusions. There is blunting of the left\n costophrenic angle. No definite pneumothorax is seen. A large amount of\n subcutaneous emphysema is seen along the lateral chest wall.\n\n AP SUPINE VIEW OF THE PELVIS: No definite fracture or dislocation is\n identified. There is a lucency within the medial aspect of the left femoral\n head, of unclear significance. The sacral struts are intact. The sacroiliac\n and hip joints bilaterally appear preserved.\n\n IMPRESSION: 1. Possible mediastinal widening, which may be due to patient\n positioning. CT of the chest is recommended for further evaluation.\n\n 2. Ill-defined bilateral air space opacities, left greater than right, which\n may represent pulmonary contusion vs. atelectasis.\n\n 3. No definite pneumothorax identified.\n\n 4. A large amount of left-sided subcutaneous emphysema within the left\n lateral chest wall.\n\n 5. No definite fracture or dislocation noted within the pelvis. A lucency is\n seen within the left femoral head, of unclear significance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858877,
"text": " 11:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumo s/p ct removal\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall, multiple rib fx\n\n REASON FOR THIS EXAMINATION:\n ? pneumo s/p ct removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall with multiple rib fractures, status post chest tube\n removal.\n\n REFERENCE EXAM: \n\n FINDINGS: There has been interval removal of the left chest tube. No\n pneumothorax is identified. The right lateral lung is off the film. However,\n in the right lower lobe is new alveolar infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858795,
"text": " 9:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx follow up\n Admitting Diagnosis: STATUS POST FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall, multiple rib fx, ptx, now w/low O2 (pain vs. expanding ptx)\n\n REASON FOR THIS EXAMINATION:\n ptx follow up\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Followup pneumothorax.\n\n The left chest tube proximal port is near the chest wall. There is decreased\n subcutaneous emphysema compared to the film from 2 days ago. There continues\n to be some ill-defined opacity in the right lower lung, left lower lung, left\n upper lung. There has been some interval clearing at the right base.\n Compared to the film from 2 days ago, the right lower low is better aerated,\n but the left lower lobe shows decreased aeration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-04-01 00:00:00.000",
"description": "T-SPINE",
"row_id": 858179,
"text": " 2:06 PM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65M s/p fall from height\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma, fall from height.\n\n THORACIC SPINE, 2 VIEWS: Several displaced left sided rib fractures are noted\n through the left first through 7th posterior ribs as well as the left\n clavicle. The thoracic vertebral bodies appear normal in height without\n evidence of fracture or malalignment. The intervertebral disc spaces are\n preserved. A left sided superior chest tube is noted.\n\n LUMBAR SPINE, 2 VIEWS: No fracture or dislocation is noted within the\n lumbosacral spine. The vertebral body heights and intervertebral disc spaces\n are preserved. The visualized SI and hip joints appear unremarkable.\n Previously described lucency through the left femoral head is no longer\n appreciated on the AP view.\n\n IMPRESSION: 1) No fracture or malalignment within the thoracic or\n lumbar vertebral bodies.\n 2) Several displaced left sided rib fractures and left clavicular fracture.\n\n"
},
{
"category": "ECG",
"chartdate": "2120-04-11 00:00:00.000",
"description": "Report",
"row_id": 191564,
"text": "Sinus rhythm with ventricular premature beats. First degree A-V heart block.\nIntraventricular conduction delay. Left axis deviation. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-09 00:00:00.000",
"description": "Report",
"row_id": 1501691,
"text": "1900-0730\nNPN review of systems:\n\nneuro: alert and oriented x3, c/o left chest pain with movement and coughing, started fentanyl patch last night at midnight with fair relief, still receiving ultram and tylenol ATC for pain control, states pain is a with coughing/movement, otherwise completely neurologically intact, moving all extremities with good strength, oob ambulating in unit, oob to chair with assist of one\n\nCV: stable, HR 70s-80s, SR, occasional pvcs, +pp, lytes/hct stable\n\nRESP: ls clear, diminished at bases, strong productive congested cough, maintaining 02 sat >93% on shovel mask at 60% and 2L NC\n\nGI: tolerating house diet, no n/v, good po intake, +BS, +flatus, abd s/nt/nd\n\nGU: foley catheter with good u/o\n\nskin: hematoma to left shoulder, sling on and intact, raised red rash to upper back.\n\nENDO: bs wnl, riss if needed\n\nID: afebrile, levoflox coverage\n\nplan: continue pulmonary toilet, encourage oob activity, ? floor transfer\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-07 00:00:00.000",
"description": "Report",
"row_id": 1501688,
"text": "Patient been on non-invasive ventilation for the past few days.Done very well todat vent is pulled.Patient on aerosol mask.Nasally suctioned *2 today once by RT the second time by RN for copious amount of thick green sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-08 00:00:00.000",
"description": "Report",
"row_id": 1501689,
"text": "TSICU NPN 7p-7a\nS/O\n\n pt oriented times three yet last evening had periods of inappropriate comments and mild confusion, Given 1mg haldol and pt slept well over night and is waking appropriately this AM and oriented times three and more appropriate. Pt c/o pain in left ribs, shoulder and arm, reports that pain is a 4 on scale of and that is tolerable for him. Medicated w/ ultram prn to keep pain under control.\n\n pt in sinus, occaisional APC/PVC, potassium repleted this AM per sliding scale. Pt on beta blocker. HR 60-70's over night, BP stable between 120-140, extremities warm and dry w/ easily palpable pulses.\n\n pt remained on a Hi flow neb via face tent set at 60% Fio2 w/ 4l NC over night. Saturating between 94-98%, ABG 7.41,50,82,33,+5 and RR 22-30, slightly labored w/ exertion yet settles. Breath sounds clear in upper lobes bilaterally yet diminished at bases. Pt w/ strong cough, productive of thick yellow sputum at times.\n\n pt taking PO's well over night, had some jello and custard and milk early in the eve, no BM tonight yet pt had gone yesterday and had no c/o abd pain, refused colace last eve.\n\n pt w/ brisk u/o via foley cath.\n\n pt very ecchymotic in left shoulder area, no breakdown noted otherwise.\n\nA/P- Stable night, able to remain off bipap, maintaining ventilation and o2 saturation at acceptable levels, pain fairly well controlled, pt able to sleep well, con't w/ pulmonary toilet, increase activity and diet as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-08 00:00:00.000",
"description": "Report",
"row_id": 1501690,
"text": "days\nn: pt aox3, pain to left chest, shoulder and back and increased with movement. tylenol 1 g q6 added to tramadol round the clock with better relief. Pt poor cough due to pain, mds aware and no narcotics given due to past loc changes with mso4. pt reports that pain is tolerable. oob to chair most of day with 2 assist, walked with pt.\nwife at bedside today.\n\ncv: nsr with occasional pvcs and pacs esp with stress. bp stable, aline positional and dsg reapplied today. + small edema noted in hands, +pp, bilateral ultrasound of legs to r/o dvt, clotting problems. Pt is \"hot\" all of the time, tmax 100.6, pt sweating intermittently. sq heparin and boots on. abx may be changed today per orders. rn to follow up.\n\nr: lungs dim in bases and cpt attemtpted and pt does not otlerate well to pain. IS encouraged and pt does not like to cough, but does have +prod cough this shift. o2sats low 90s on fm and nc, with dips to 87 without mask, pt is mouth breather. abg done, po2 lower today, mds aware and pulm toilet encouraged, pt does is to 250 with complaints q 1hr.\n\ngi/gu: pt tolerates reg diet with normal sugars. apetite fair. foley with clear yellow urine, lasix 30mg po given as ordered. pt with goo uop, abd soft but disteneded, nontender and +flatus.\n\ns ecchymosis noted alongleft flank and back, pt with red sweat rash noted on back, not itchy, powder applied. 2 hls patent, aline positional at times,.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-07 00:00:00.000",
"description": "Report",
"row_id": 1501686,
"text": "1900-0730\nNPN:\n\nROS:\n\nNEURO: patient alert but confused, following commands and easily reorients, epidural with bupivicaine running at 12cc/hr, patient denies pain at rest, says \"it only hurts a little when i move\" c-collar on.\n\nCV: HR 70s-80s, occasional PVCs, Aline with fling, pressures 150s/50s, NBP 130s/70s, lytes wnl, hct stable, p-boots, sub-q heparin as ordered\n\nRESP: taken off mask ventilation around 9pm for break, patient maintained 02 saturation above 95% with humidified highflow mask at 100%, and looked comfortable with breathing, was resting comfortably and had a normal respiratory pattern. ABG adequate on high flow mask, 02 percent decreased to 80% and patient continues to maintain sat greater than 95%. CHest tube to suction, dressing intact, no fluctuation, no air leak. LS diminished t/o, clear upper right lobe, non-productive congested cough, suctioned by resp. ffor copious amounts of thick, foul swelling, yellow sputum.\n\nGI: tolerating clear lix, c/o thirst, +bowel sounds, +flatus, lactulose and MOM continue as ordered\n\nGU: foley with good urine out.\n\nENDO: BS wnl, RISS for coverage if needed\n\nID: tmax 100.1, tylenol continues ATC, cultures from earlier today pending, WBC climbing.\n\nSKIN: large hematoma to left shoulder, swollen.\n\nplan: continue O2 wean, pulmonary toilet and close monitoring of resp. status, ?dc chest tube today per trauma team\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-04-07 00:00:00.000",
"description": "Report",
"row_id": 1501687,
"text": "nursing progress note\nneuro: pt very alert, oriented x3, conversation appropriate. moving x4, weak to ble. no c/o hallucinations, visual disturbances. perrla. c/o pain to left chest area/rib fx/ct site. upon exam, no level of anesthesia noted with epidural in place, catheter removed this am by APS. site with redness, scant superficial purulent drainage per fellow, tip sent for cx. ultram po started for pain control, very effective thus far. neck cleared clinically this am, collar removed.\n\nresp: pt tol face mask, o2 weaned to 60%. o2 sats stable. rr tachypneic with stimulation/movement, at best mid 20s. ls clear, dimin to bases bilat. cough much improved with removal of chest tube this am, expectorating large amts thick yellow/green secretions. nasally sx prn. abg's stable.\n\ncv: a line with fling, bp stable at rest, hypertensive with coughing,etc. sinus arrhythmia, many pvc's freq. note few episodes w/ couplets. ppp bilat, edema minimal.\n\ngi: belly soft, distended. bm x3 today, soft loose stools noted. tol cardiac diet well, denies n/v. good po fluid intake.\n\ngu: routine po dose lasix given this am, diuresing well, foley patent for clear yellow.\n\nendo: bg's remain elevated, regular insulin coverage prn.\n\nid: tmax 99 today, wbc rising. levaquin dosing started for empiric coverage. follow pending cx.\n\nskin: epidural site w/ sm amt redness, no further drainage noted, ota.\nchest tube site w/ dsd, intact. edema to left shoulder slightly improved.\n\nsocial: many family in to visit, supportive. updates provided, ques answered.\n\na/p: s/p fall, multiple rib fx, clavicle, scapula fx's, pneumotx to left side. much improved neuro status, pain well controlled w/ po meds. breathing improved, abg stable. pulm toilet much improved. ?transfer to floor within next 24h.\n"
}
] |
46,775 | 142,961 | 34 y.o. female with cerebral palsy who presented to hospital with 1 week of fevers, nausea, vomiting and rt back pain. She was found to have high grade obstruction of right kidney with renal stones. Pt was transferred to ICU after developing hypotension from urosepsis pyelonephritis with percutaneous nephrostomy tube placed with IR and then placed on antibiotics. Her MICU course was complicated by acute renal failure, pancreatitis and altered mental status. Pt's urospesis and altered mental status both improved on antibiotic treatment (cipro), for which she completed a full fourteen day course. Workup for pancreatitis revealed that the likely cause was gallstone pancreatitis. EUS performed rather than ERCP given that it is the safer procedure of the two to evaluate for ductal stones or anatomic anomalies. The patient did have a 2nd episode of pancreatitis which resolved within 1-2 days. The day prior to discharge the nephrostomy tube was accidentally dislodged when transferring the patient and it was replaced by IR. | Cholelithiasis. Cholelithiasis. Cholelithiasis. Tip obscured by spinal hardware, but extends at least to mid-SVC. R>L pleural effusions and pulm edema. Patient right nephrostomy tube in appropriate position. Replacement of a right-sided PICC with the tip in the lower SVC. Right pleural effusion. Right pleural effusion. NON-CONTRAST CT OF THE PELVIS: There is a moderate amount of pelvic ascites. Choledocalithiasis? Choledocalithiasis? -Moderate ascites in the abdomen extending into pelvis. Hydronephrosis and intrarenal calculi were seen. An initial spot fluoro image was taken which demonstrated nephrectomy catheter in the expected location. The right PICC line has been repositioned with its course currently continuing inferiorly towards the expected location of mid SVC. FINDINGS: One supine view of the abdomen is provided. The right ureter is dilated. Small amount of abdominal ascites is noted. COMPARISON: through , CT . FINDINGS: The pancreas is hyperechoic and enlarged, and slightly heterogeneous, compatible with known history of pancreatitis. Percutaneous pigtail nephrostomy tube overlies the right collecting system. Mild intrahepatic bile duct dilation. Mild intrahepatic bile duct dilation. Enlarged, hyperechoic, heterogenous pancreas, compatible with known history of pancreatitis. PICC LINE REPLACEMENT: Preprocedure fluoroscopic spot image demonstrated the pre-existing PICC line tip to project over the right axillary vein. FINDINGS: NON-CONTRAST CT OF THE ABDOMEN: There are bilateral pleural effusions, right greater than left, along with bibasilar atelectasis. NEPHROSTOGRAM: A preprocedure fluoroscopic spot image demonstrated a right nephrostomy catheter in appropriate location. The patient is after right percutaneous nephrostomy placement. There is a moderate right pleural effusion incompletely visualized on this film. There is a moderate amount of ascites and a right pleural effusion, as seen on the CT examination from . Stable small bilateral effusions and atelectasis. Stable small bilateral effusions and atelectasis. Stable small bilateral effusions and atelectasis. There is marked dextroscoliosis with fusion at multiple vertebral levels. COMPARISON: CT available from . A 1.2 cm calculus is seen in the right hemipelvis, likely in the within the obstructed right ureter. The severity of the edema is at least moderate, and most likely accompanied by bilateral pleural effusions. The lower abdomen and the indwelling nephrostomy tube were prepped and draped in the standard sterile fashion. Small-to-moderate bilateral pleural effusion is present. The main portal vein is patent, demonstrating proper hepatopetal flow. The main portal vein is patent, demonstrating proper hepatopetal flow. Spinal rods consistent with history of scoliosis. Previously described stabilization rods, right-sided pigtail drainage catheter, nephrostomy site, and right-sided PICC line are unchanged. Abdominal and pelvic ascites. IMPRESSION: Uncomplicated exchange of right 8 French percutaneous nephrostomy tube. Sterile dressings were applied. There is a Foley catheter in place. 7:49 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: PICC in correct position? Enlarged pancreas with slightly heterogeneous appearance of the body/tail, compatible with known pancreatitis. Right PIC catheter ends in the upper SVC. A right-sided nephrostomy tube is present. A small right pleural effusion is noted. Scant trace of ascites and right pleural effusion. Small-to-moderate bilateral pleural effusions, right greater than left, with adjacent areas of compressive atelectasis, unchanged. Small-to-moderate bilateral pleural effusions, right greater than left, with adjacent areas of compressive atelectasis, unchanged. There is a small right pleural effusion. A 1.3 x 0.9 cm focus within the right pelvis may represent a right ureteral stone, which is in unchanged position (2:57). A percutaneous right nephrostomy tube is in place. Marked right convex scoliosis noted. An additional right pelvic density may represent an obstructive right ureteral stone, stable. An additional right pelvic density may represent an obstructive right ureteral stone, stable. Moderate right pleural effusion. An antegrade nephrostogram was performed. FINDINGS: There is vacuo dilatation of the frontal of the right lateral ventricle with mild prominence of both lateral ventricles. COMPARISONS: CT abdomen and pelvis without contrast of . IMPRESSION: AP chest compared to : New nasogastric tube ends in the mid stomach. Cholelithiasis. Cholelithiasis. The right kidney is noted to be somewhat atrophic measuring 7.9 cm and the left kidney measures 10.2 cm. Right lower quadrant, moderate volume ascites. Post-procedure nephrostogram. The central venous catheter terminates within the right atrium. Moderate amount of ascites is seen within the pelvis, unchanged from prior exam. IMPRESSION: Unchanged size and location of the previously seen renal calculi, with the larger stone being within the right lower pole and the smaller stone in the distal right ureter. Antegrade nephrostogram. There is marked dextroscoliosis with fusion of multiple vertebral levels. Bilateral pleural effusions are redemonstrated, right greater than left, with adjacent areas of compressive atelectasis. Patient has an NG tube in place. An NG tube is present, tip extending beneath diaphragm. Small amount of ascites is seen within the abdomen. Foley catheter is in place. Right renal calculus with percutaneous nephrostomy tube in place, unchanged in position. Right renal calculus with percutaneous nephrostomy tube in place, unchanged in position. A 1.9 x 1 cm right renal stone is in unchanged position (2:49). StatLock and sterile dressings were applied. A percutaneous pigtail nephrostomy tube overlies the right collecting system. The bladder is empty with a Foley catheter in place, but there is a moderate amount of ascites seen in the right lower quadrant. Simple cyst in the left upper pole. COMPARISON: CT abdomen/pelvis from . COMPARISON: Abdomen CT, . The NG tube terminates in the stomach. The visible paranasal sinuses show left maxillary mucus retention cyst. The left kidney appears unremarkable. Markedly rotated positioning limits assessment of pleural and parenchymal detail. CHEST, SINGLE AP PORTABLE VIEW. Coronal and sagittal reformatted images were displayed. Low echoes within the pelvicaliceal system suggestive of purulent material. Sinus tachycardia. Sinus tachycardia. Found to be septic, hypertensive, requiring IV resuscitation. New right upper quadrant drainage catheter has been added. | 25 | [
{
"category": "Radiology",
"chartdate": "2137-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195780,
"text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for hypervolemia\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with cerebral palsy presents with sepsis pyelonephritis\n REASON FOR THIS EXAMINATION:\n Eval for hypervolemia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with sepsis due to\n pyelonephritis and suspected pulmonary edema.\n\n Single AP view of the chest was reviewed with no prior studies available for\n comparison.\n\n The patient is after right percutaneous nephrostomy placement. There is\n extensive scoliosis with evidence of prior thoracolumbar extensive spinal\n surgery. The patient is currently with interstitial pulmonary edema. The\n precise evaluation of the chest is difficult due to scoliosis and superimposed\n devices. The severity of the edema is at least moderate, and most likely\n accompanied by bilateral pleural effusions. No pneumothorax is present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197350,
"text": ", C. MED FA2 11:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new infiltrate/infection?\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with CP admitted to MICU for severe sepsis in the setting of\n pyelo c/b nephrolithiasis and pancreatitis\n REASON FOR THIS EXAMINATION:\n new infiltrate/infection?\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable small bilateral effusions and atelectasis. No new consolidation.\n 2. Mildly improved pulmonary vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197349,
"text": " 11:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new infiltrate/infection?\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with CP admitted to MICU for severe sepsis in the setting of\n pyelo c/b nephrolithiasis and pancreatitis\n REASON FOR THIS EXAMINATION:\n new infiltrate/infection?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:30 PM\n 1. Stable small bilateral effusions and atelectasis. No new consolidation.\n 2. Mildly improved pulmonary vascular congestion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, evaluate for infection.\n\n COMPARISON: through , CT .\n\n FINDINGS: Since , there is no change in small bilateral layering\n pleural effusions and associated atelectasis. No new consolidation is seen.\n Pulmonary vascular congestion is mildly improved. The right PICC is unchanged\n in position. Interval removal of the feeding tube. Spinal hardware is\n unchanged. A right nephrostomy pigtail catheter projects over the right\n abdomen.\n\n IMPRESSION:\n 1. Stable small bilateral effusions and atelectasis. No new consolidation.\n 2. Mildly improved pulmonary vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1195847,
"text": " 12:15 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r dl picc 40cm iv \n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl picc 40cm iv \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:22 P.M., \n\n HISTORY: New right PIC line.\n\n IMPRESSION: AP chest compared to , 5:08 a.m.\n\n The tip of the wire and the catheter of the PIC line appear to be coterminous,\n projecting over the thoracic inlet in the right brachiocephalic vein proximal\n to its termination with the left. Small-to-moderate bilateral pleural\n effusion is present. Severe infrahilar atelectasis is stable on the right,\n worse on the left. No pneumothorax. Heart size is normal. Stomach is at\n least moderately distended with gas.\n\n was paged as requested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-23 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1196029,
"text": " 2:14 PM\n URIN CATH REPLC Clip # \n Reason: Eval nephrostomy tube to eval for obstruction\n Admitting Diagnosis: PYLONEPHRITIS\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * PERC ASP/INJ RENAL CYST OR PEL -59 DISTINCT PROCEDURAL SERVICE *\n * ANTEGRADE UROGRAPHY -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 y.o. Female with Cerebral transferred from OSH with pyelonephritis \n obsrtuction s/p IR placed nephrostomy tube placement. Nephrostomy tube on the\n rt now with decreased output, just sediment not purulent drainage, Creatinine\n doubled concern for obstruction.\n REASON FOR THIS EXAMINATION:\n Eval nephrostomy tube to eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n URINARY CATHETER CHECK\n\n PICC LINE REPLACEMENT.\n\n INDICATION: Evaluate nephrostomy tube to eval for obstruction; place PICC.\n\n COMPARISON: .\n\n OPERATORS: Dr. (fellow) and Dr. (attending\n interventional radiologist), supervised the procedure.\n\n MEDICATIONS: Lidogel was used for local pain control. 1 mg of midazolam was\n administered.\n\n TECHNIQUE: After discussion of the procedures with the patient, verbal\n consent was obtained. The patient was brought to the angiography suite and\n placed supine on the imaging table. A preprocedure huddle and timeout were\n performed.\n\n NEPHROSTOGRAM: A preprocedure fluoroscopic spot image demonstrated a right\n nephrostomy catheter in appropriate location. Injection of contrast\n demonstrated appropriate position of pigtail within the pelvis as well as free\n flow from the catheter.\n\n PICC LINE REPLACEMENT:\n\n Preprocedure fluoroscopic spot image demonstrated the pre-existing PICC line\n tip to project over the right axillary vein. A 0.018 wire was advanced, PICC\n withdrawn, sheath placed, inner dilator removed, and a new 41 cm dual-lumen 5\n French PICC line advanced over the wire under fluoroscopic guidance. The tip\n is in the lower SVC. Both lumens aspirated and flushed easily. StatLock\n secured the PICC to the skin. Sterile dressings were applied.\n\n (Over)\n\n 2:14 PM\n URIN CATH REPLC Clip # \n Reason: Eval nephrostomy tube to eval for obstruction\n Admitting Diagnosis: PYLONEPHRITIS\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The patient tolerated both procedures well and there were no immediate post-\n procedure complications.\n\n FINDINGS:\n 1. Markedly abnormal right kidney demonstrating severe hydronephrosis,\n caliceal blunting consistent with chronic disease, and multiple filling\n defects consistent with stones.\n 2. Patient right nephrostomy tube in appropriate position.\n 3. Spinal rods consistent with history of scoliosis.\n 4. PICC replacement with tip in the lower SVC.\n\n IMPRESSION:\n 1. Patent nephrostomy tube with markedly abnormal right kidney consistent\n with chronic hydronephrosis and caliceal blunting. The previous ultrasound\n demonstrates severe cortical thinning. Low volume urine production would be\n expected.\n 2. Replacement of a right-sided PICC with the tip in the lower SVC. The tip\n is ready for use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197252,
"text": " 7:49 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PICC in correct position?\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with cerebral palsy, here with urosepsis, pancreatitis, AMS,\n now with PICC malpositioned\n REASON FOR THIS EXAMINATION:\n PICC in correct position?\n ______________________________________________________________________________\n WET READ: MLHh WED 8:35 PM\n R PICC repositioned, courses inferiorly in direction of SVC. Tip obscured by\n spinal hardware, but extends at least to mid-SVC.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Repositioning of PICC line.\n\n Portable AP chest radiograph was reviewed in comparison to several prior\n studies obtained the same day earlier.\n\n The right PICC line has been repositioned with its course currently continuing\n inferiorly towards the expected location of mid SVC. The NG tube tip is in\n the stomach. There is no change in the appearance of the lungs as compared to\n prior radiograph obtained slightly earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-24 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1196230,
"text": " 6:10 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please eval for RP bleed, other cause of abd/back pain\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman s/p nephrostomy tubes, now with abd pain.\n REASON FOR THIS EXAMINATION:\n Please eval for RP bleed, other cause of abd/back pain\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: GMSj WED 7:22 PM\n -Evaluation for final details is extremely limited by the non-contrast\n technique and significant streak artifact from thoracolumbar spine hardware.\n\n -Moderate ascites in the abdomen extending into pelvis. Attenuation values\n c/w simple fluid in the pelvis, but difficult to assess in upper abdomen due\n to streak artifact.\n\n -Relatively preserved retroperitoneal fat planes in the pelvis, though\n small/moderate retroperitoneal hemorrhage cannot be entirely excluded.\n\n -Right pigtail nephrostomy drain.\n\n -Large 16 x 12 mm hyperdense mass in right kidney - c/w stone.\n\n -13 x 8 mm calcified mass in right pelvis -- possible obstructing right distal\n ureter stone (2:55).\n\n -Cholelithiasis\n\n D/w Dr. at 7:15 pm on by telephone. GSenapati \n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 34-year-old female status post nephrostomy tube placement,\n now with abdominal pain.\n\n TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed without\n administration of intravenous or oral contrast.\n\n COMPARISON STUDY: Renal ultrasound from .\n\n FINDINGS:\n\n NON-CONTRAST CT OF THE ABDOMEN:\n\n There are bilateral pleural effusions, right greater than left, along with\n bibasilar atelectasis. There is diffuse artifact from extensive spinal\n hardware. The unenhanced appearance of the liver and spleen is unremarkable.\n Punctate gallstones are noted. Small amount of abdominal ascites is noted.\n There is no extraluminal gas seen. The left kidney is unremarkable. A\n (Over)\n\n 6:10 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please eval for RP bleed, other cause of abd/back pain\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n percutaneous nephrostomy tube is identified within the right renal pelvis,\n likely extending into the right ureter. There is a 1.7 cm calculus iss seen\n in the upper pole of the right kidney. The right ureter is dilated. Bowel\n loops are grossly normal in caliber.\n\n NON-CONTRAST CT OF THE PELVIS:\n\n There is a moderate amount of pelvic ascites. Bowel loops in the pelvis are\n normal in caliber. There is a Foley catheter in place. A 1.2 cm calculus is\n seen in the right hemipelvis, likely in the within the obstructed right\n ureter. There are no bladder calculi identified.\n\n OSSEOUS STRUCTURES:\n\n Extensive spinal fusion hardware is noted. No concerning lesions are seen in\n the bones.\n\n There is diffuse body wall anasarca.\n\n IMPRESSION:\n\n 1. Examination limited due to hardware artifact, but no definite evidence of\n retroperitoneal hematoma.\n 2. Abdominal and pelvic ascites.\n 3. Status post right percutaneous nephrostomy tube placement with a large\n calculus in the right kidney along with an additional calculus in the distal\n right ureter.\n 4. Cholelithiasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-08-08 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1198317,
"text": " 4:42 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for obstruction/perforation\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with h/o pancreatitis, c/o increasing abdominal pain.\n REASON FOR THIS EXAMINATION:\n eval for obstruction/perforation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of pancreatitis, complaining of abdominal pain. Please\n evaluate for obstruction OR perforation.\n\n FINDINGS: One supine view of the abdomen is provided. There is marked\n dextroscoliosis with fusion at multiple vertebral levels. Spinal rods are not\n fully evaluated on these radiographs. Percutaneous pigtail nephrostomy tube\n overlies the right collecting system. There is a moderate right pleural\n effusion incompletely visualized on this film. The bowel gas pattern is\n unremarkable. There are no dilated loops of bowel. There is no evidence of\n free air.\n\n IMPRESSION: Unremarkable bowel gas pattern. No evidence of free air seen on\n this supine film. If concern remains for a perforation, a left lateral\n decubitus film would be more sensitive.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-08-12 00:00:00.000",
"description": "CHG NEPHROTOMY/PYLOSTOMY TUBE",
"row_id": 1198898,
"text": " 5:13 PM\n URIN CATH REPLC Clip # \n Reason: need to replace/tube broke today\n Admitting Diagnosis: PYLONEPHRITIS\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * CHG NEPHROTOMY/PYLOSTOMY TUBE CHANGE PERC TUBE OR CATH W/CON *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n *** Please note correction under the heading PROCEDURE AND FINDINGS --\n\n This should read \" The patient was brought to the angiography suite and placed\n PRONE on the imaging table\"\n\n\n 5:13 PM\n URIN CATH REPLC Clip # \n Reason: need to replace/tube broke today\n Admitting Diagnosis: PYLONEPHRITIS\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with nephrolithiasis s/p PCN for pyelonephritis\n REASON FOR THIS EXAMINATION:\n need to replace/tube broke today\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 34-year-old woman with nephrolithiasis status post PCN for\n pyelonephritis.\n\n RADIOLOGIST: Dr. and , the attending\n radiologist, was present and supervising throughout.\n\n ANESTHESIA: Moderate sedation was provided with divided doses of 25 mcg of\n fentanyl throughout the intraservice time of 25 minutes. During which the\n patient's hemodynamic parameters were continuously monitored.\n\n PROCEDURE AND FINDINGS: After explaining the risks, benefits and alternatives\n of the procedure, written informed consent was obtained from the patient. The\n patient was brought to the angiography suite and placed supine on the imaging\n table. The lower abdomen and the indwelling nephrostomy tube were prepped and\n draped in the standard sterile fashion. Preprocedural timeout and huddle was\n performed per protocol.\n\n An initial spot fluoro image was taken which demonstrated nephrectomy catheter\n in the expected location. Then contrast was injected with the help of a\n dilator as the hub was sheared off before the patient got to the angio suite.\n wire was introduced into the nephrostomy tube under fluoro guidance,\n pigtail was straightened out and the wire coiled within the renal pelvis. The\n catheter was removed over the wire and a new 8 French nephrostomy catheter was\n advanced over the wire with the pigtail formed and locked in the renal\n pelvis. Injection of contrast confirmed the position of the catheter pigtail\n within the renal pelvis. The catheter was secured to the skin with 0 silk\n suture and a StatLock device. The catheter was then attached to a nephrostomy\n bag. The site was cleaned and sterile dressings were applied. The patient\n tolerated the procedure well and had no immediate complications.\n\n FINDINGS:\n 1. Hydronephrosis and intrarenal calculi were seen.\n 2. The initial catheter was coiled in the peripheral calix.\n 3. The new catheter was cut with the pigtail in the renal pelvis.\n\n IMPRESSION:\n Uncomplicated exchange of right 8 French percutaneous nephrostomy tube.\n (Over)\n\n 5:13 PM\n URIN CATH REPLC Clip # \n Reason: need to replace/tube broke today\n Admitting Diagnosis: PYLONEPHRITIS\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1196989,
"text": " 1:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls eval NG tube placement\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with new NG tube placement\n REASON FOR THIS EXAMINATION:\n Pls eval NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: A 34-year-old female patient with new NG tube placement, evaluate\n position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Comparison is made with a preceding similar\n examination of . Previously described stabilization rods,\n right-sided pigtail drainage catheter, nephrostomy site, and right-sided PICC\n line are unchanged. Pleural effusion is again present bilaterally and seems\n to have increased somewhat on the right side. An NG tube which already on the\n preceding examination had entered well into the stomach, has now progressed\n further, but its tip points in a reversed direction. Thus, it does not\n advance into the direction of the duodenum should this be the purpose of this\n examination. No other significant interval changes can be identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-27 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1196610,
"text": " 6:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: evaluate for cholelithiasis, gallstones\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with cholelithiasis, now with pancreatitis\n REASON FOR THIS EXAMINATION:\n evaluate for cholelithiasis, gallstones\n ______________________________________________________________________________\n WET READ: LLTc SAT 6:44 AM\n 1. Mild intrahepatic bile duct dilation.\n 2. 3 mm CBD. No ductal stones seen.\n 3. Enlarged pancreas with slightly heterogeneous appearance of the body/tail,\n compatible with known pancreatitis. THe pancreatic duct is not dilated.\n 4. Small amount of ascites.\n 5. Very large right renal stone, also seen on the CT examination from\n yesterday.\n 6. Cholelithiasis. Thickened gallbladder wall likely third spacing from\n neighboring ascites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old female with cholelithiasis, now with pancreatitis.\n\n COMPARISON: Ultrasound and CT available from .\n\n TECHNIQUE: Ultrasonography of the abdomen.\n\n FINDINGS:\n The pancreas is hyperechoic and enlarged, and slightly heterogeneous,\n compatible with known history of pancreatitis. The pancreatic duct does not\n appear dilated.\n\n Ascities is again seen. The liver echotexture is normal. Intrahepatic bile\n duct dilation is present and appears more conspicuous than the prior\n examination. The main portal vein is patent, demonstrating proper hepatopetal\n flow. The CBD is not dilated, measuring 3 mm; no choledocholithiasis is seen.\n Gallstones are present within a collapsed gallbladder. There is mild\n gallbladder wall thickening, likely from third-spacing. A massive right renal\n stone is better seen on the CT examination from .\n\n IMPRESSION:\n 1. Enlarged, hyperechoic, heterogenous pancreas, compatible with known\n history of pancreatitis. No pancreatic duct dilation is seen.\n 2. 3-mm CBD. No ductal stone seen.\n 3. Cholelithiasis, with no evidence of cholecystitis. Gallbladder wall\n thickening likely secondary to third spacing from neighboring ascites.\n 4. Small amount of ascites.\n 5. Mild intrahepatic bile duct dilation.\n (Over)\n\n 6:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: evaluate for cholelithiasis, gallstones\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197239,
"text": " 6:10 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PICC line in correct position?\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with cerebral palsy and urosepsis\n REASON FOR THIS EXAMINATION:\n PICC line in correct position?\n ______________________________________________________________________________\n WET READ: MLHh WED 6:43 PM\n R PICC In R IJV. R>L pleural effusions and pulm edema. Ho d/ \n 6:40p\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Urosepsis in a patient with cerebral palsy. New PICC\n 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 The right PICC line is currently malpositioned continuing towards the internal\n jugular vein. There is no change in bilateral pleural effusions, pulmonary\n edema, bibasilar consolidations and position of the nephrostomy as well as the\n extensive orthopedic spinal hardware.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-26 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1196463,
"text": " 2:33 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: Gallstone pancreatitis? Choledocalithiasis?\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34F with Cerebral Palsy who presented to hospital with 1 week of\n fevers, nausea, vomiting, rt back pain with cholelithiasis now with lipase and\n amylase elevation\n REASON FOR THIS EXAMINATION:\n Gallstone pancreatitis? Choledocalithiasis?\n ______________________________________________________________________________\n WET READ: LLTc FRI 4:28 AM\n 1. Moderate ascites. Right pleural effusion.\n 2. Cholelithiasis, no evidence of cholecystitis.\n 3. 3 mm CBD. No ductal stones seen. No intrahepatic bile duct dilation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old female with cerebral palsy who presented to \n Hospital with one week of fevers, nausea, vomiting, right back pain, with\n cholelithiasis. Now with elevated lipase and amylase.\n\n COMPARISON: CT available from .\n\n TECHNIQUE: Ultrasonography of the abdomen.\n\n FINDINGS: The liver echotexture is normal. There is no focal intrahepatic\n lesion or intrahepatic bile duct dilation. The main portal vein is patent,\n demonstrating proper hepatopetal flow. Appropriate flow directions and\n waveforms are demonstrated within the hepatic veins and portal veins. The CBD\n is not dilated, measuring 3 mm. The gallbladder is nondistended, and contains\n multiple small stones. There is a moderate amount of ascites and a right\n pleural effusion, as seen on the CT examination from .\n\n IMPRESSION:\n 1. Moderate ascites. Right pleural effusion.\n 2. Cholelithiasis.\n 3. No ductal stones seen. The CBD is not dilated, measuring 3 mm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-24 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 1196180,
"text": " 1:00 PM\n RENAL U.S. PORT Clip # \n Reason: evaluate for hydronephrosis\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with nephrostomy tube\n REASON FOR THIS EXAMINATION:\n evaluate for hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: A 35-year-old female with right nephrostomy tube.\n\n COMPARISON STUDIES: and .\n\n In comparison to the preliminary ultrasound imaging during placement of the\n percutaneous nephrostomy tube on , there has been nearly complete\n resolution of the hydronephrosis with only a mild amount of residual\n dilatation of the upper pole calix in the right kidney. The right kidney\n itself measures 9.4 cm in length and shows a reasonable amount of preserved\n parenchyma. Two large stones are seen in the mid and lower caliceal groups,\n the largest in the lower pole measuring 1.6 cm in diameter and a second 1.1 cm\n stone in the interpolar region. There is also what appears to be a third\n stone near the renal pelvis measuring 9 mm in diameter. There is no evidence\n of any perinephric fluid, but there is a moderate right pleural effusion\n noted.\n\n The left kidney measures 9.9 cm in length and shows no evidence of\n hydronephrosis or stones. There is a simple cyst in the upper pole measuring\n 2.5 cm in maximum diameter. There is a slightly full extrarenal pelvis noted.\n The bladder is empty with a Foley catheter in place, but there is a moderate\n amount of ascites seen in the right lower quadrant.\n\n CONCLUSION:\n 1. The pigtail catheter has resolved the marked right hydronephrosis with\n only minimal right upper pole caliectasis remaining. Several large right\n renal stones are noted, however.\n 2. Moderate right pleural effusion.\n 3. Right lower quadrant, moderate volume ascites.\n 4. No left renal stones or hydronephrosis noted. Simple cyst in the left\n upper pole.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1196508,
"text": " 10:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for NGT placement\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with sepsis, NGT placement\n REASON FOR THIS EXAMINATION:\n evaluate for NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:58 A.M. ON \n\n HISTORY: 34-year-old woman with sepsis. Assess NG tube placement.\n\n IMPRESSION: AP chest compared to :\n\n New nasogastric tube ends in the mid stomach. Moderate-to-large right pleural\n effusion has grown since , while previous pulmonary edema has improved.\n Persistent opacification at the base of the left lung is probably residual\n edema and atelectasis, though pneumonia is not excluded. Heart size is\n normal. Right PIC catheter ends in the upper SVC. New right upper quadrant\n drainage catheter has been added.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197095,
"text": " 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm PICC placement\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with urosepsis, PICC line accidentally pulled out a few cms.\n REASON FOR THIS EXAMINATION:\n Please confirm PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with urosepsis.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The NG tube tip is in the stomach. The right PICC line tip is more proximal\n than on the prior study, most likely either at the very proximal portion of\n subclavian vein were already in one of the tributaries since its course is\n more vertical as compared to the prior study. Repostiton to be considered.\n\n The nephrostomy on the right as well as several kidney stones are\n redemonstrated. Bilateral pleural effusions, right more than left as well as\n pulmonary edema are noted with pulmonary edema being more severe than on the\n prior examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-21 00:00:00.000",
"description": "INTRO CATH RENAL PELVIS FOR DRAINAGE",
"row_id": 1195764,
"text": " 11:38 PM\n PERC NEPHROSTO Clip # \n Reason: Placement of rt sided perc nephrostomy tube\n Admitting Diagnosis: PYLONEPHRITIS\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with h.o. cerebral palsy p/w rt sided abdominal pain, nausea,\n vomiting. Found to be septic requiring IVF resuscitation, OSH imaging shows\n chronic high grade obstruction of the right kidney w/ large calculi within the\n rt renal collecting system measuring 2.6cm. Rt renal colecting system shows pus\n REASON FOR THIS EXAMINATION:\n Placement of rt sided perc nephrostomy tube\n ______________________________________________________________________________\n FINAL REPORT\n PERCUTANEOUS NEPHROSTOMY\n\n INDICATION: 32-year-old woman with history of cerebral palsy, now with\n right-sided abdominal pain, nausea and vomiting. Found to be septic,\n hypertensive, requiring IV resuscitation.\n\n PROCEDURES:\n 1. Antegrade nephrostogram.\n 2. Placement of 8 French x 25 cm Flexima nephrostomy catheter, attached to a\n bag.\n 3. Post-procedure nephrostogram.\n\n OPERATORS: Dr. (fellow) and Dr. (attending\n interventional radiologist) who was present and supervising throughout the\n entire procedure.\n\n MEDICATIONS: 1% lidocaine was used for local pain control. The procedure was\n performed under general anesthesia.\n\n TECHNIQUE: After explanation of the procedure to the patient's sister and\n discussion of the risks, benefits and alternatives, witnessed verbal informed\n consent was obtained. The patient was brought to the angiography suite and\n placed prone on the imaging table. The right flank was prepped and draped in\n the usual sterile fashion. A preprocedure huddle and timeout were performed\n per medical protocol. General anesthesia was induced.\n\n Under ultrasound and fluoroscopic guidance, a 21-gauge needle was advanced\n into a right mid pole posterior calix after administration of 1% local\n lidocaine. Purulent, foul smelling urine emanated from the needle which was\n collected for culture and sensitivity. An antegrade nephrostogram was\n performed. After confirming satisfactory location, a 0.018 wire was advanced\n into the renal collecting system and the needle was exchanged for an AccuStick\n sheath. The wire was exchanged for a 0.035 wire and over this, an 8 French x\n 25 cm Flexima nephrostomy catheter was advanced after soft tissue dilatation.\n Over this, an 8 French x 25 cm Flexima nephrostomy catheter was advanced. The\n (Over)\n\n 11:38 PM\n PERC NEPHROSTO Clip # \n Reason: Placement of rt sided perc nephrostomy tube\n Admitting Diagnosis: PYLONEPHRITIS\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pigtail was formed in the right pelvis. Post-tube placement nephrostogram\n confirmed satisfactory location. The catheter was secured to the skin with\n sandal-type suture. StatLock and sterile dressings were applied. The\n catheter was attached to a bag. The patient tolerated the procedure well and\n there were no immediate post-procedure complications.\n\n FINDINGS:\n 1. Severe hydronephrosis with cortical thinning. Low echoes within the\n pelvicaliceal system suggestive of purulent material.\n 2. Large greater than 2-cm stone within a mid-pole calix.\n 3. Occlusion of the proximal right ureter with no flow distal to it.\n 4. Successful placement of a right 8 French x 25 cm Flexima nephrostomy\n catheter.\n 5. Grossly purulent urine sample sent for microbiologic analysis.\n 6. Post-tube placement nephrostogram demonstrating occlusion of the proximal\n ureter.\n\n IMPRESSION: Successful placement of a right-sided 8 French nephrostomy tube\n in an obstructed renal pelvis. Urine purulent with culture pending.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1196391,
"text": " 3:15 PM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for location of renal stones\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with renal stones\n REASON FOR THIS EXAMINATION:\n evaluate for location of renal stones\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate renal stones.\n\n COMPARISON: CT abdomen/pelvis from .\n\n FINDINGS: As seen on recent CT, there are two large renal calculi, one within\n the lower pole of the right kidney measuring 2.5 cm and the second within the\n distal right ureter, measuring 1.4 cm. No new renal calculi are identified.\n There is marked dextroscoliosis with fusion of multiple vertebral levels.\n Spinal rods are not fully evaluated on these radiographs. A percutaneous\n pigtail nephrostomy tube overlies the right collecting system. There is a\n small right pleural effusion.\n\n IMPRESSION: Unchanged size and location of the previously seen renal calculi,\n with the larger stone being within the right lower pole and the smaller stone\n in the distal right ureter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-26 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1196532,
"text": " 1:12 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evaluate for ascites, source of infection, airw/o IV contras\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with hydronephrosis, sepsis\n REASON FOR THIS EXAMINATION:\n evaluate for ascites, source of infection, airw/o IV contrast, po contrast\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: TXCf FRI 5:29 PM\n 1. Extremely limited study due to lack of intravenous contrast and extensive\n streak artifacts from spinal fusion hardware. Within this limitation, there\n is no significant change from exam.\n\n 2. Small-to-moderate bilateral pleural effusions, right greater than left,\n with adjacent areas of compressive atelectasis, unchanged.\n\n 3. Stable appearance of moderate ascites.\n\n 4. Right renal calculus with percutaneous nephrostomy tube in place,\n unchanged in position. An additional right pelvic density may represent an\n obstructive right ureteral stone, stable.\n\n 5. Cholelithiasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with sepsis unknown source.\n\n COMPARISONS: CT abdomen and pelvis without contrast of .\n\n TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis\n were obtained with oral contrast at 5-mm slice thickness. Coronal and\n sagittal reformatted images were displayed.\n\n FINDINGS:\n The study is markedly limited due to lack of intravenous contrast and\n extensive streak artifacts generated by spinal hardware.\n\n Bilateral pleural effusions are redemonstrated, right greater than left, with\n adjacent areas of compressive atelectasis. The central venous catheter\n terminates within the right atrium. The NG tube terminates in the stomach.\n\n The non-contrast appearance of the liver and spleen are unremarkable. A\n gallstone within the gallbladder lumen is redemonstrated. Small amount of\n ascites is seen within the abdomen. The left kidney appears unremarkable. A\n 1.9 x 1 cm right renal stone is in unchanged position (2:49). A percutaneous\n right nephrostomy tube is in place. There is no free air in the abdomen.\n Diffuse anasarca is unchanged from prior exam.\n\n\n (Over)\n\n 1:12 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: evaluate for ascites, source of infection, airw/o IV contras\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS:\n\n The bladder appears unremarkable. Foley catheter is in place. Moderate\n amount of ascites is seen within the pelvis, unchanged from prior exam. A 1.3\n x 0.9 cm focus within the right pelvis may represent a right ureteral stone,\n which is in unchanged position (2:57).\n\n OSSEOUS STRUCTURES:\n\n No suspicious lytic or sclerotic lesion is seen. Extensive spinal fusion\n hardware is redemonstrated.\n\n IMPRESSION:\n\n 1. Extremely limited study due to lack of intravenous contrast and extensive\n streak artifacts from spinal fusion hardware. Within this limitation, there\n is no significant change from exam.\n\n 2. Small-to-moderate bilateral pleural effusions, right greater than left,\n with adjacent areas of compressive atelectasis, unchanged.\n\n 3. Stable appearance of moderate ascites.\n\n 4. Right renal calculus with percutaneous nephrostomy tube in place,\n unchanged in position. An additional right pelvic density may represent an\n obstructive right ureteral stone, stable.\n\n 5. Cholelithiasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1196833,
"text": " 12:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for consolidation, infiltrate\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with urosepsis, now with wheezing\n REASON FOR THIS EXAMINATION:\n evaluate for consolidation, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Urosepsis, wheezing.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Bilateral spinal rods are present. An NG tube is present, tip extending\n beneath diaphragm. Markedly rotated positioning limits assessment of pleural\n and parenchymal detail. Allowing for this, there does appear to be increased\n retrocardiac density, consistent with left lower lobe collapse and/or\n consolidation. The possibility of small bilateral effusions cannot be\n excluded. ? upper zone re-distribution. No pneumothorax detected.\n\n A right-sided nephrostomy tube is present. Ovoid density adjacent to it may\n represent a large renal calculus. Marked right convex scoliosis noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-07-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1196531,
"text": " 1:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for hemorrhage, acute process\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with altered mental status, sepsis\n REASON FOR THIS EXAMINATION:\n evaluate for hemorrhage, acute process\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: ASpf FRI 7:13 PM\n Ex vacuo dilatation of the frontal of the right lateral ventricle is\n likely related to a chronic process. No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old woman with altered mental status and sepsis, evaluate\n for hemorrhage or acute process.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired through the head without contrast. Bone\n kernel reconstructions and multiplanar reformations were obtained and\n reviewed.\n\n FINDINGS:\n\n There is vacuo dilatation of the frontal of the right lateral ventricle\n with mild prominence of both lateral ventricles. No acute intracranial\n hemorrhage, large vascular territory infarct, shift of midline structures or\n mass is present. The visible paranasal sinuses show left maxillary mucus\n retention cyst. Patient has an NG tube in place. No fractures are present.\n\n IMPRESSION:\n\n Ex vacuo dilatation of the frontal of the right lateral ventricle is\n likely related to a chronic process. No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-08-08 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1198369,
"text": " 10:55 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: HX OF PANCREATITIS, R/O CHOLECYSTITIS\n Admitting Diagnosis: PYLONEPHRITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with resolving pancreatitis now with 10/10 RUQ pain\n REASON FOR THIS EXAMINATION:\n r/o cholecystis??\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 34-year-old female with resolving pancreatitis and right upper\n quadrant pain.\n\n COMPARISON: Abdomen CT, .\n\n FINDINGS: The hepatic architecture is normal in appearance and no focal liver\n lesion is identified. No biliary dilatation is seen and the common duct\n measures 0.4 cm. There are several small shadowing gallstones seen within the\n lumen of the gallbladder. The largest of these stones measures 0.3 cm. There\n is no gallbladder wall edema and no pericholecystic fluid is seen. The\n pancreas is unremarkable. The spleen is unremarkable and measures 9.6 cm. No\n hydronephrosis is seen. The right kidney is noted to be somewhat atrophic\n measuring 7.9 cm and the left kidney measures 10.2 cm. A large stone, which\n measures 2.3 cm, is again seen in the lower pole of the right kidney. The\n visualized portion of the IVC is unremarkable. No AAA is identified. There\n is a scant trace of ascites in the perihepatic space. A small right pleural\n effusion is noted.\n\n IMPRESSION:\n 1. Cholelithiasis with no sign of cholecystitis. No biliary dilatation.\n 2. Scant trace of ascites and right pleural effusion.\n 3. No hydronephrosis on limited views of the kidneys. A large right renal\n stone is again noted.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-07-31 00:00:00.000",
"description": "Report",
"row_id": 250390,
"text": "Sinus rhythm with slowing of the rate as compared with previous tracing\nof . There is diffuse low voltage. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2137-07-29 00:00:00.000",
"description": "Report",
"row_id": 250391,
"text": "Sinus tachycardia. Diffuse low voltage which was also recorded on .\nThere is baseline artifact. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2137-07-22 00:00:00.000",
"description": "Report",
"row_id": 250392,
"text": "Baseline artifact. Sinus tachycardia. Diffuse non-specific ST-T wave\nabnormalities, likely secondary to rate. No previous tracing available for\ncomparison.\n\n"
}
] |
6,603 | 119,185 | The patient is a 39 year old male with a history of cerebral palsy, mental retardation, seizure disorder on dilantin, keppra, and depakote as well a history of aspiration presents after 2 seizures at NH on the day of presentation with fever to 103.8 with ?aspiration on vanco/CTX/flagyl. . Plan: . # Seizure disorder - Valproic acid level subtherapeutic at 37. Dilantin level therapeutic at 12.6. Neurology was consulted and agreed with continuing current medications at current doses. Seizure likely in setting of subtherapeutic medications but also may occur in the setting of infection. There was no evidence of infection. - Ativan prn for seizure. - No further seizures during admission. . # Fever - Elevated WBC to 12 from 10 on presentation in the setting of recent seizure and possible aspiration during event with transient hypoxia and now RLL crackles. - Repeat CXR showed no evidence of pneumonia. Fever likely occurred in setting of seizure or aspiration pneumonitis. - The patient was started on vancomycin, ceftriaxone, flagyl in the ED. These were discontinued shortly after arriving in the MICU. - Given IVF in ED. . # Hypoxia - Now resolved. Sat'ing 99% on RA, 100% on 2 liters for comfort. Likely occurred in setting of aspiration during seizure. . # Mental disability - Continue psych home medications. . # History of aspiration - Maintain aspiration precautions. He was re-evaluated by speech and swallow with no change in his aspiration risk/diet. He is on a modified diet at NH: regular diet, pureed consistent with honey thickened liquids and yogurt with each meal with 1:1 supervision. - Aspiration precautions. . . #Code - DNR/DNI . #Dispo - Discharged to from MICU. . #Communication - With sister, . . | REMAINS ON ANTISEIZURE MEDS AND ATIVAN. NPO, ASPIRATION PRECAUTIONS. Right hemithorax is small and there is some decrease in aeration at the base, either atelectasis or conceivably effects of recent aspiration. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.GI/GU: ABD SOFT WITH +BS. OCCASIONAL CONGESTED NPONPRODUCTIVE COUGH.GI/GU: ABD SOFT WITH +BS. Aware that Pt is called out to floor.A: Hemodynamic and respiratory status stable. (+) bowel sounds. LS CLEAR WITH RIGHT BASILAR CRACKLES AND DIMINISHED ON THE LEFT. Afebrile.GI: Abdomen is soft. COPY OF DNR IN THE CHART. HOLDING ABX FOR NOW. Pleural effusion if any is minimal, on the right. NO CURRENT ABX TREATMENT.SKIN: W/D/I.ACCESS: PIV LEFT HAND.SOCIAL/DISPO: DNR/DNI. Palpable DP pulses bilaterally. Updated on Pt's status. AP chest compared to : Marked scoliosis distors the chest. BLD CX'S PENDING.SKIN: W/D/I.ACCESS: PIV X1.SOCIAL/DISPO: DNR/DNI (ORDER NEEDS TO BE WRITTEN, MD AWARE). The cardiomediastinal contour is unchanged since . NO ORDER IN POE, MD AWARE. PPP. Sinus tachycardia. DOES NOT FOLLOW COMMANDS, MOVES EXTREMITIES ALTHOUGH LIMITED CONTRACTURES. Followup advised. BP 111-154/86-110. COMPARISON: . MICU NPN 7P-7ANEURO: NO CHANGES. No ectopy. No significant change from the tracing of . Monitor as ordered. Tolerated medication better w/ custard. No obvious consolidation is identified. THANK YOU. VOIDING VIA COMDOM CATH, LT YELLOW AND CLEAR.FEN: STARTED ON NS @100CC/HR. U/A TO DRAW , MD AWARE WILL NEED FEM STICK. SBP=130s/140s. BP 126-150/92-111. . IMPRESSION: No definite evidence of pneumonia. SLEPT WELL.CARDIAC: HR 75-105 SR/ST WITH NO ECTOPY. AROUSES TO VOICE/STIMULUS. Aspirates when eatingP: Aspiration precautions. TAKING HONEY THICK LIQUIDS AT THE NH.ID: TMAX 98. Strong congested cough.CV: SR/ST. PPP.RESP: REMAINS ON ROOM AIR WITH RR 12-17 AND SATS 97-100%. LOCALIZES PAIN. LOCALIZES PAIN. No pneumothorax. Incomprehensible sounds. SOFT RESTRAINTS IN PLACE. NO SEIZURE ACTIVITY NOTED.CARDIAC: HR 120'S->94 ST/SR WITH NO ECTOPY. NPN: Review of SystemsNeuro: . LS WITH BIBASILAR CRACKLES. MICU ADMISSION NOTEPLEASE SEE FHP FOR ADMISSION DETAILS.NEURO: AROUSE TO STIMULI, . No pleural effusion is detected. Mild pulmonary vascular engorgement persists, but heart is normal size. CONDOM CATH IN PLACE VOIDING CLEAR YELLOW URINE.FEN: FINISHED NS @100CC/HR. Does not follow commands. Thetracing continues to show minor non-specific ST-T wave abnormalities which maybe due in part to the rapid rate. PATIENT CONTINUES TO COUGH WITH THESE MODIFICATIONS.ID: TMAX 96.4 AXILLARY. NO SIGNS OF BLEEDING.RESP: RECEIVED ON 2L N/C BUT ABLE TO MAINTAIN 100% ON RA. NO SEIZURE ACTIVITY NOTED. AP CHEST RADIOGRAPH: Somewhat limited study given patient's rotatory thoracolumbar dextroscoliosis with long surgical fixation device. Soft brown stool.GU: Clear yellow urine via condom catheterSkin: Intact. DSoft wrist restraints on d/t Pt attempting to pull at catheter and IV.Resp: Breathing unlabored. Sao2 on RA=100% w/ RR=13-18. MOVING ALL EXTREMTIES. aspiration REASON FOR THIS EXAMINATION: Please assess for infiltrate FINAL REPORT AP CHEST 4:04 HISTORY: Aspiration. No seizure activity observed. Rouses easily. WILL CONSULT NEURO FOR PROPER DOSAGING OF SEIZURE MEDS IN SETTING OF SUBTHERAPEUTIC VALPRAOTE LEVEL. Discuss plan of care w/ family. No pressure wounds present.Social: Sister has called. ?WHETHER HE CAN BE TRANSFERRED BACK TO REHAB INSTEAD. NO CONTACT FAMILY. Patient with fever of 103 and cough. LGE BROWN SOFT STOOL. ABLE TO GIVE MEDS IN CUSTARD AND SOME HONEY THICKENED WATER. Evaluate for pneumonia. Coughed when taking pills this morning w/ applesauce. RR 15-17. SMALL SOFT BROWN STOOL. SISTER HAS STATED THAT HE IS A DNR AND THAT SHE WANTS NO INVASIVE PROCEDURES DONE., BUT WANST HIM TO REMAIN COMFORTABLE. Sleeping much of the day. MICU 7 NPNFOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE AND PG 2 IN "NURSING TRANSFER NOTE SECTION " OF CAREVIEW AND "DISCHAGE PLANNING SECTION OF WEB PAGE. AWAITING BED ON THE FLOOR. 3:32 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for infiltrate Admitting Diagnosis: PNEUMONIA MEDICAL CONDITION: 39 yo M PMH MR/sz with fever, ? Case Manager consult for discharge to nursing home when ready. | 7 | [
{
"category": "Radiology",
"chartdate": "2194-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 965724,
"text": " 8:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 yo M PMH MR/sz fever 103 and cough\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 39-year-old male with past medical history of mitral\n regurg, and seizure. Patient with fever of 103 and cough. Evaluate for\n pneumonia.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH: Somewhat limited study given patient's rotatory\n thoracolumbar dextroscoliosis with long surgical fixation device. No obvious\n consolidation is identified. No pleural effusion is detected. The\n cardiomediastinal contour is unchanged since .\n\n IMPRESSION: No definite evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-07-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 965748,
"text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 yo M PMH MR/sz with fever, ? aspiration\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:04 \n\n HISTORY: Aspiration.\n\n AP chest compared to :\n\n Marked scoliosis distors the chest. Right hemithorax is small and there is\n some decrease in aeration at the base, either atelectasis or conceivably\n effects of recent aspiration. Followup advised. Mild pulmonary vascular\n engorgement persists, but heart is normal size. Pleural effusion if any is\n minimal, on the right. No pneumothorax.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-07-21 00:00:00.000",
"description": "Report",
"row_id": 1349391,
"text": "NPN: Review of Systems\nNeuro: . Incomprehensible sounds. Does not follow commands. Sleeping much of the day. Rouses easily. No seizure activity observed. DSoft wrist restraints on d/t Pt attempting to pull at catheter and IV.\n\n\nResp: Breathing unlabored. Sao2 on RA=100% w/ RR=13-18. Strong congested cough.\n\nCV: SR/ST. No ectopy. SBP=130s/140s. Palpable DP pulses bilaterally. Afebrile.\n\nGI: Abdomen is soft. (+) bowel sounds. Coughed when taking pills this morning w/ applesauce. Tolerated medication better w/ custard. Soft brown stool.\n\nGU: Clear yellow urine via condom catheter\n\nSkin: Intact. No pressure wounds present.\n\nSocial: Sister has called. Updated on Pt's status. Aware that Pt is called out to floor.\n\nA: Hemodynamic and respiratory status stable. Aspirates when eating\n\nP: Aspiration precautions. Monitor as ordered. Case Manager consult for discharge to nursing home when ready. Discuss plan of care w/ family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-07-22 00:00:00.000",
"description": "Report",
"row_id": 1349392,
"text": "MICU NPN 7P-7A\nNEURO: NO CHANGES. . AROUSES TO VOICE/STIMULUS. DOES NOT FOLLOW COMMANDS, MOVES EXTREMITIES ALTHOUGH LIMITED CONTRACTURES. LOCALIZES PAIN. SOFT RESTRAINTS IN PLACE. NO SEIZURE ACTIVITY NOTED. REMAINS ON ANTISEIZURE MEDS AND ATIVAN. SLEPT WELL.\n\nCARDIAC: HR 75-105 SR/ST WITH NO ECTOPY. BP 126-150/92-111. PPP.\n\nRESP: REMAINS ON ROOM AIR WITH RR 12-17 AND SATS 97-100%. LS CLEAR WITH RIGHT BASILAR CRACKLES AND DIMINISHED ON THE LEFT. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.\n\nGI/GU: ABD SOFT WITH +BS. LGE BROWN SOFT STOOL. CONDOM CATH IN PLACE VOIDING CLEAR YELLOW URINE.\n\nFEN: FINISHED NS @100CC/HR. ABLE TO GIVE MEDS IN CUSTARD AND SOME HONEY THICKENED WATER. PATIENT CONTINUES TO COUGH WITH THESE MODIFICATIONS.\n\nID: TMAX 96.4 AXILLARY. NO CURRENT ABX TREATMENT.\n\nSKIN: W/D/I.\n\nACCESS: PIV LEFT HAND.\n\nSOCIAL/DISPO: DNR/DNI. NO ORDER IN POE, MD AWARE. COPY OF DNR IN THE CHART. SISTER HAS STATED THAT HE IS A DNR AND THAT SHE WANTS NO INVASIVE PROCEDURES DONE., BUT WANST HIM TO REMAIN COMFORTABLE. AWAITING BED ON THE FLOOR. ?WHETHER HE CAN BE TRANSFERRED BACK TO REHAB INSTEAD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-07-22 00:00:00.000",
"description": "Report",
"row_id": 1349393,
"text": "MICU 7 NPN\nFOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE AND PG 2 IN \"NURSING TRANSFER NOTE SECTION \" OF CAREVIEW AND \"DISCHAGE PLANNING SECTION OF WEB PAGE. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2194-07-21 00:00:00.000",
"description": "Report",
"row_id": 1349390,
"text": "MICU ADMISSION NOTE\nPLEASE SEE FHP FOR ADMISSION DETAILS.\n\nNEURO: AROUSE TO STIMULI, . LOCALIZES PAIN. MOVING ALL EXTREMTIES. NO SEIZURE ACTIVITY NOTED.\n\nCARDIAC: HR 120'S->94 ST/SR WITH NO ECTOPY. BP 111-154/86-110. PPP. NO SIGNS OF BLEEDING.\n\nRESP: RECEIVED ON 2L N/C BUT ABLE TO MAINTAIN 100% ON RA. RR 15-17. LS WITH BIBASILAR CRACKLES. OCCASIONAL CONGESTED NPONPRODUCTIVE COUGH.\n\nGI/GU: ABD SOFT WITH +BS. SMALL SOFT BROWN STOOL. VOIDING VIA COMDOM CATH, LT YELLOW AND CLEAR.\n\nFEN: STARTED ON NS @100CC/HR. NPO, ASPIRATION PRECAUTIONS. TAKING HONEY THICK LIQUIDS AT THE NH.\n\nID: TMAX 98. HOLDING ABX FOR NOW. BLD CX'S PENDING.\n\nSKIN: W/D/I.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: DNR/DNI (ORDER NEEDS TO BE WRITTEN, MD AWARE). NO CONTACT FAMILY. U/A TO DRAW , MD AWARE WILL NEED FEM STICK. WILL CONSULT NEURO FOR PROPER DOSAGING OF SEIZURE MEDS IN SETTING OF SUBTHERAPEUTIC VALPRAOTE LEVEL.\n"
},
{
"category": "ECG",
"chartdate": "2194-07-20 00:00:00.000",
"description": "Report",
"row_id": 106689,
"text": "Sinus tachycardia. No significant change from the tracing of . The\ntracing continues to show minor non-specific ST-T wave abnormalities which may\nbe due in part to the rapid rate.\n\n"
}
] |
16,161 | 112,021 | The patient was admitted to the ICU where a ventricular drain was placed without complication. The patient also had an arterial line placed. Repeat head CT on the following day showed no significant change, and he tolerated an MRI without problem. The patient underwent an arteriogram on that showed no evidence of aneurysm, or vascular malformation. The patient was kept in the ICU with a ventricular drain in place, with pressure control, keeping his systolic pressure less than 150 until , when he had another repeat angiogram which again was negative for any vascular malformation or aneurysm. The patient was weaned off of nicardipine for pressure control and started on hydrochlorothiazide 25 mg po qd, and labetalol 300 mg po tid, keeping his systolic pressure less than 150. He was awake, alert and oriented x 3. No complaints. Face was symmetric. EOMS full. Grasp and strength in all extremities was . | Results pending.CV: NSR with no ectopy noted. Subarachnoid hemorrhage, appearing unchanged in quantity since the previous examination. TECHNIQUE: Non-contrast head CT. CT HEAD W/O CONTRAST: Comparison is made with prior CT head without contrast dated . +palp pedal pulses, no edema noted. Injection of the left common carotid artery is again within normal limits with no atherosclerotic disease. RESULTS: Injection of the bilateral common carotid arteries and bilateral (Over) 2:16 PM CAROT/CEREB Clip # Reason: S/P CLIPPING Admitting Diagnosis: SAH Contrast: NON IONIC Amt: 210 FINAL REPORT (Cont) external carotid show them to be within normal limits. +palp pedal pulses, no edema. Unchanged position of right ventricular catheter. Injection of the (Over) 7:52 PM CAROT/CEREB Clip # Reason: R/O SAH Admitting Diagnosis: SAH Contrast: OPTIRAY Amt: 220 FINAL REPORT (Cont) right common carotid artery shows normal bifurcation with no evidence of atherosclerosis or stenosis. Injection of the right internal carotid artery shows it to be free of aneurysmal dilatation. Pt continues to receive nimodipine 60 mg po q4hrs.Resp - LS clear. TECHNIQUE: Noncontrast head CT. Post Gadolinium administration sagittal and axial T1W images were performed. Blood is again seen within the lateral ventricles bilaterally, unchanged in appearance. RR 12-23 02 sats > 94 % RA.GI - Abd soft. Temperature 100.3 oral, Dr. made aware. Updated on pts condition.Plan: Titrate Nicardipine gtt as tolerated. K+ 4.5, Na 133.Resp: LS clear. ADEQAUTE HOURLY UO VIA FOLEY CATH AND BUN/CREAT WNR.ID: MAX TEMP=98.7 AND WBC=10.7. Pt additionally receiving nimodipine 60 mg po q 4hrs.Resp - LS clear. PT C/O DULL CONSTNAT HA AT LEVEL OF 1. Groin site d+i.Resp - LS clear. UO>170cc/hr.Skin: Head dressing intact. Tmax 100.6.Resp: LS clear, O2 sats in low 90's. MICU NPN Addendum: Pt returned from angio hypertensive with SBP 160's. Continues on dilantin IV.CV: BP 123-151/66-76, HR 56-76. 99.4 oral this am. Remains on Nicardipine gtt @ 10mg/hr. Titrate nicardipine as tolerated. Titrate nicardipine as tolerated. IF PT REQUIRES PERCOCET WILL PREMEDICATE WITH ZOFRAN SINCE PT IN THE PAST HAS GOTTEN NAUSEOUS FROM PERCOCET.GU: PT WITH ADEQUATE HOURLY UO. UO>100cc/hr.Skin: Intact.ID: Tmax 100.6. Angio site in R groin benign. 2 PIV's.ID: Remains on Cefazolin. NPN 7a-7pNeuro: A&O X 3, behavior appropriate. DILANTIN LEVEL TODAY =10.4. 3+ DP and PT pulses. HR 72-80 ABP 119-140's/70-80's. Tmax 99.1. WILL FOLLOW RESP STATUS.CV: HR 70-80'S WITH RARE PVC'S. Maintain SBP <150mmhg. CONTINUES TO RECEIVE NIFODIPINE 60 MG PO Q 4 HRS AS ORDERED. Lung sounds clear bilaterally.GI: Abdomen soft, ND, +BS. LUNGS CTA.CV : K+ 4.2. Tylenol 650mg given x 1 and Percocet 1 tab given with good effect.CV: NSR with no ectopy noted. LUNGS ESSENTIALLYU CLEAR ONAUSCULTATION. GI/GU; Abdomen soft with + bs. 02 sats > 95% on RA.GI - ABd soft. 1GU: ADEQAUTE HOURLY UO. O2 SATS>98&. Replete lytes prn. Nicardipine titrated to maintain SBP < 150. Mg 1.6 - will replete with 2 gms. Remains on ISS Q6 hours.GU: Foley cath with clear yellow urine. Pt remains a+o x 3. Since angio neg, team states SBP up to 170 will be tolerated. Remains on Nicardipine gtt @ 9mg/hr. Pt continues to c/o aching h/a. Pt c/o intermittent mild h/a. PT NOW WITH ADEQAUTE PO INTAKE. altered neuro statusD: NEURO: NEURO INTACT. Speech clear, HG =, Perrl. MAX TEMP=99.4 ORALLY WITH WBC=11.9.SOCIAL: PT IS A FULL CODE. LUNGS CTA AND PT CONTINUES TO USE INCENTIVE SPIROMETRY AT THE BEDSIDE.CV: NICARDIPINE GTT AS HIGH AS 11MG/HR TODAY AND WILL WEAN AS TOLERATED TO KEEP SBP< 150. MEDICATED X2 WITH RELIEF. O2 saturation 93-98% ra. PEARL, MAE, strengths equal. GI/GU: Abdomen soft with + bs. +BS. +BS. Remains on 1 Liter Fluid restriction.GU: Foley cath with clear yellow urine. UO>60cc/hr.Access: Aline with sharp waveform. Tolerating po's well. ABP 126-158/63-83. K+ 4.1. LUNGS CTA AND USING INCENTIVE SPIROMETRY AT BEDSIDE.CV: NICARDIPINE GTT WEANED DOWN TO 9 MG/HR TO KEEP SBP< 150. Abp in 140's to 160's systolic. Pt voiding 45-240ccs/hr via foley cath. Drain intact with 91cc of drainage. Dilantin dcd. K+ WNR. RR 16-24.GI: Abd soft, non-tender, +bs. CT of head in am. RR 16-23.GI: Abd soft, non-tender, +BS. Using IS and C/DB.GI: Abd soft, non-tender, +BS. | 36 | [
{
"category": "Radiology",
"chartdate": "2123-11-20 00:00:00.000",
"description": "SEL CATH 2ND ORDER",
"row_id": 808224,
"text": " 7:52 PM\n CAROT/CEREB Clip # \n Reason: R/O SAH\n Admitting Diagnosis: SAH\n Contrast: OPTIRAY Amt: 220\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: No evidence of intracranial aneurysm or\n arteriovenous malformation.\n\n ANESTHESIA: Conscious sedation.\n\n INDICATION: Mr. presented with a subarachnoid and is undergoing a\n cerebral angiogram to determine the source of this bleed.\n\n CONSENT: The patient and his wife and children were given a full and complete\n explanation of the procedure. Specifically the indications, risks, benefits,\n and alternatives to the procedure were explained in detail. In addition the\n possible complications such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death were outlined. The\n patient and his wife and children understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood, a 4 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Right subclavian artery, right vertebral artery, right common carotid artery,\n right internal carotid artery, right external carotid artery, left common\n carotid artery, left internal carotid artery, left external carotid artery,\n left subclavian artery, left vertebral artery.\n\n RESULTS: Injection of the right subclavian artery shows no evidence of\n atherosclerosis or stenosis and demonstrates a nondominant right vertebral\n artery which ends mostly in PICA with a small contribution to the basilar\n artery. In addition, note is made of a prominent posterior meningeal artery\n which does not appear to show high flow shunting, however. Injection of the\n (Over)\n\n 7:52 PM\n CAROT/CEREB Clip # \n Reason: R/O SAH\n Admitting Diagnosis: SAH\n Contrast: OPTIRAY Amt: 220\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right common carotid artery shows normal bifurcation with no evidence of\n atherosclerosis or stenosis. The external carotid injection shows no evidence\n abnormal arteriovenous shunting or anomalous anatomy. Injection of the right\n internal carotid artery with rotational angiography failed to demonstrate any\n evidence of aneurysm, and it shows flash filling of anterior communicating\n artery. Injection of the left common carotid artery is again within normal\n limits with no atherosclerotic disease. The external carotid artery injection\n shows no abnormal arteriovenous shunting or abnormal anatomy, and the internal\n carotid artery injection shows flow through bilateral distal ACA's via the\n anterior communicating artery with no obvious aneurysmal involvement. Finally\n injection of the left subclavian artery shows it to be within normal limits\n and a prominent left vertebral artery which is a dominant vertebral artery.\n The vertebrobasilar junction is normal with flash filling down into the\n diminutive right vertebral artery. The basilar trunk and its branches are\n within normal limits. The cervical course of the left vertebral artery is\n otherwise normal.\n\n IMPRESSION: No evidence of intracranial aneurysm or arteriovenous\n malformation to suggest the source of the patient's subarachnoid hemorrhage.\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 808265,
"text": " 11:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess extent of sub-arachnoid hemorrhage\n Admitting Diagnosis: SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with SAH\n REASON FOR THIS EXAMINATION:\n Please assess extent of sub-arachnoid hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Assess extent of subarachnoid hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n Comparison is made to the study from . hemorrhage in the\n basilar cisterns has decreased slightly, and there is prominent increase in\n the amount of subarachnoid blood within virtually every visualized fissure and\n sulcus posteriorly, including the Sylvian fissures bilaterally, the temporal,\n parietal, and occipital sulci. Again seen is intraventricular blood layering\n posteriorly within both occipital horns of the lateral ventricles. There is\n interval increase in the amount of intraventricular blood. There is no\n hydrocephalus. There is preservation of -white matter differentiation.\n\n IMPRESSION: No evidence of acute stroke. Interval decrease in amount of\n subarachnoid blood in basilar cisterns and subtentorially, with concomitant\n increase in amount of subarachnoid blood in the posterior fissures and sulci.\n Increased intraventricular blood layering posteriorly within both occipital\n horns of the lateral ventricles.\n Interval placement of the ventricular catheter via right frontal approach with\n tip in the right frontal .\n Findings were discussed with Dr. at 1 o'clock PM on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-20 00:00:00.000",
"description": "CT HEAD W/ CONTRAST",
"row_id": 808200,
"text": " 1:01 PM\n CT HEAD W/ CONTRAST; LAB RECONSTRUCTIONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: CT and CTA of head please to evaluate for aneurisms?\n Field of view: OP Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with sah\n\n REASON FOR THIS EXAMINATION:\n CT and CTA of head please to evaluate for aneurisms?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Subarachnoid hemorrhage.\n\n CTA with multiple projection reconstructions and additional 3-dimensional\n post-processing imaging.\n\n FINDINGS: There is no evidence of aneurysm. The pica origins are not well\n evaluated on the reconstructed images, but definite aneurysm is not suspected\n on the raw data axial sequences. A ventricular shunt catheter is in place\n within the right frontal .\n\n IMPRESSION: No definite evidence of aneurysm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 808196,
"text": " 11:17 AM\n CT HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: hydrocephalus 2 to SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with sah\n REASON FOR THIS EXAMINATION:\n hydrocephalus 2 to SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ESE SAT 11:36 AM\n SAH. Mild ventricular prominence. No herniation or midline shift.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Subarachnoid hemorrhage.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast.\n\n COMPARISONS: None.\n\n HEAD CT: There is extensive acute subarachnoid hemorrhage with blood\n visualized in the basilar cisterns bilaterally and along the sylvian fissures\n bilaterally. Blood is also seen tracking along the anterior brain stem. The\n ventricles are mildly prominent. A small amount of high attenuation substance\n is present in the occipital of the right lateral ventricle. This is\n possibly intraventricular hemorrhage. There is no shift of normally midline\n structures. The -white matter differentiation is preserved. There is no\n mass effect and there is no sulci effacement. There is no evidence of brain\n herniation. The osseous structures and mastoid air cells are unremarkable.\n There is opacification of several ethmoid air cells. The paranasal sinuses are\n otherwise unremarkable.\n\n IMPRESSION: No significant mass effect or evidence of herniation.\n Extensive subarachnoid hemorrhage in the basal cisterns. Possible early\n hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 808754,
"text": " 10:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: HX SAH,EVAL CHANGE\n Admitting Diagnosis: SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with SAH\n\n REASON FOR THIS EXAMINATION:\n r/o interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage, evaluate for interval change.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD W/O CONTRAST: Comparison is made with prior CT head without contrast\n dated . Again seen is extensive subarachnoid blood within\n the fissures and sulci posteriorly, which appears unchanged in quantity since\n the previous examination. Blood is again seen within the lateral ventricles\n bilaterally, unchanged in appearance. No new hemorrhage is identified. No\n hydrocephalus. A ventricular catheter is again seen entering via the right\n and terminating with tip in the right lateral ventricle. There is no\n intracranial mass lesion or shift of normally midline structures. There is\n preservation of -white matter differentiation. The surrounding osseous\n structures appear unchanged, without evidence of fracture. There is interval\n opacification of the left maxillary sinus, however, improvement in\n opacification of the ethmoid sinuses.\n\n IMPRESSION:\n\n 1. Subarachnoid hemorrhage, appearing unchanged in quantity since the previous\n examination. No new areas of hemorrhage identified. No aneurysm or other\n cause of subarachnoid hemorrhage identified.\n\n 2. Stable position of right ventricular catheter with tip in the right frontal\n .\n\n 3. Interval opacification of the left maxillary sinus, with improvement in\n ethmoidal opacification.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-12-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 809246,
"text": " 11:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess ventricular size, SAH\n Admitting Diagnosis: SAH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with SAH\n\n REASON FOR THIS EXAMINATION:\n please assess ventricular size, SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Subarachnoid hemorrhage, please assess ventricular size.\n\n CT HEAD WITHOUT CONTRAST:\n\n TECHNIQUE: Noncontrast CT of the head.\n\n FINDINGS: Comparison is made to previous films from . Again seen is\n minimal subarachnoid blood, appearing decreased in prominence since the\n previous examination and layering within the sulci of the frontal lobes at the\n vertex, more prominent on the right. There is no evidence of new intracranial\n hemorrhage. A small amount of hemorrhage is seen layering within the occipital\n of the left lateral ventricle, decreased in amount since the previous\n examination. No hydrocephalus is present. The venricular catheter remains in\n place with tip terminating in the right frontal , entering via the right\n frontal bone. There is no shift of normally midline structures. No evidence\n of acute minor or major vascular territorial infarct. The surrounding osseous\n structures appear unchanged. There is continued opacification of the left\n maxillary sinus.\n\n Of note, there is no evidence on this examination of an intracranial clip or\n coil. Previous history indicates that the patient is status post clipping\n procedure. Clinical correlation is recommended.\n\n IMPRESSION:\n\n 1. Interval decrease in prominence of tiny amount of residual subararchnoid\n blood, without evidence of new intracranial hemorrhage.\n\n 2. Unchanged position of right ventricular catheter.\n\n 3. Unchanged opacification of the left maxillary sinus.\n\n 4. No intracranial clip or metallic coil is detected. If the patient is\n status post clipping, as indicated on requisition for recent cerebral\n angiography, clinical correlation is recommended to explain the lack of\n visualization of the clip or coil.\n\n\n (Over)\n\n 11:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess ventricular size, SAH\n Admitting Diagnosis: SAH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-29 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 809033,
"text": " 2:16 PM\n CAROT/CEREB Clip # \n Reason: S/P CLIPPING\n Admitting Diagnosis: SAH\n Contrast: NON IONIC Amt: 210\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER 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 * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n * C1769 GUID WIRES INFU/PERF *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: No evidence of intracranial aneurysm, arteriovenous\n malformation or arteriovenous fistula.\n\n INDICATION: Mr. presented with a subarachnoid hemorrhage for which he\n required ventricular drain placement. He is undergoing a cerebral angiogram\n to rule out the presence of intracranial aneurysm or other vascular\n malformation which may have been thrombosed during the initial angiogram.\n\n CONSENT: The patient's wife was given a full and complete explanation of the\n procedure. Specifically the indications, risks, benefits, and alternatives to\n the procedure were explained in detail. In addition, the possible\n complications such as the risk of bleeding, infection, stroke, neurological\n deficit or deterioration, groin hematoma, and other unforeseen complications\n including the risk of coma and even death were outlined. The patient's wife\n understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin areas were prepped\n and draped in the usual sterile fashion. A 19 gauge single wall needle was\n then used to puncture the right femoral artery and upon the return of brisk\n arterial blood, a 4 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Right common carotid artery, right internal carotid artery, right external\n carotid artery, right subclavian artery, right vertebral artery, right\n thyrocervical trunk, right costocervical trunk, left common carotid artery,\n left internal carotid artery, left external carotid artery, left subclavian\n artery, left vertebral artery, left paracervical trunk.\n\n RESULTS: Injection of the bilateral common carotid arteries and bilateral\n (Over)\n\n 2:16 PM\n CAROT/CEREB Clip # \n Reason: S/P CLIPPING\n Admitting Diagnosis: SAH\n Contrast: NON IONIC Amt: 210\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n external carotid show them to be within normal limits. There is no evidence\n of atherosclerosis or stenosis. Injection of the right internal carotid\n artery shows it to be free of aneurysmal dilatation. Evaluation of\n the left internal carotid artery shows that the anterior cerebral artery A1\n segment on the left is dominant. There is no evidence of anterior\n communicating artery aneurysm. Injection of the right subclavian artery shows\n ______________________ and the right vertebral artery to be diminutive in\n caliber and to end mostly in the small contribution to the basilar artery.\n There is no evidence of intracranial aneurysm or vascular malformation.\n Injection of the left subclavian artery shows ___________________ and the left\n vertebral artery shows no evidence of stenosis at the origin of the left\n vertebral artery. The cervical vertebral artery caliber is normal. The left\n vertebral artery is dominant. There is no evidence of intracranial aneurysm.\n Injection of the right thyrocervical trunk and right costocervical trunk, and\n left paracervical trunk shows them to be normal with no evidence of abnormal\n shunting of cervical fistula.\n\n IMPRESSION: Negative cerebral angiogram for intracranial vascular\n malformation or aneurysm.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-11-21 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 808284,
"text": " 5:07 PM\n MR W& W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Please do MRI of the C-spine with gadolinium to assess for a\n Admitting Diagnosis: SAH\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with SAH and normal cerebral angiogram\n REASON FOR THIS EXAMINATION:\n Please do MRI of the C-spine with gadolinium to assess for arterio-venous\n malformation.\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL SPINE WITH CONTRAST:\n\n INDICATION: Subarachnoid hemorrhage, assess for arteriovenous malformation.\n\n T1 and T2 sagittal images of the cervical spine in addition to GRE axial\n images from C3 through T1 were obtained. Post Gadolinium administration\n sagittal and axial T1W images were performed.\n\n There is mild straightening of the normal lordotic curvature of the cervical\n spine. No abnormal enhancing lesions are seen within the cord or the canal of\n the cervical spine following Gadolinium administration. The cervicomedullary\n junction is patent. There is mild cervical spondylosis and moderate left-\n sided narrowing of the exit neural foramen at the C3-C4 level due to uncinate\n hypertrophy. Mild spinal canal stenosis is seen at C4-C5 and C5-C6 levels due\n to uncinate hypertrophy. Both levels reveal moderate narrowing of the exite\n neural foramina and desiccation of the disc space.\n\n There is shallow central disc osteophyte complex at C6-C7 level contacting the\n ventral aspect of the cord. Borderline stenosis of the canal is seen. Severe\n narrowing of the exit neural foramina is noted. C7-T1 level is unremarkable.\n There is no abnormal signal seen within the cervical cord itself.\n\n IMPRESSION: Moderate changes of cervical spondylosis and mild spinal canal\n stenosis at C4-C5, C5-C6 and C6-C7 levels. There is significant narrowing of\n the exit neural foramina at all three levels as described above. No abnormal\n enhancing lesions are seen within the cervical canal following Gadolinium\n administration. It should be noted that the patient has subarachnoid\n hemorrhage seen on a recent CT examination.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-21 00:00:00.000",
"description": "Report",
"row_id": 1473596,
"text": "NPN 1900-0700:\nNEURO: Pt went to angio at , where bleed was determined to be venous in origin. He tolerated the procedure very well and returned to MICU A about 2230. He remains sedated on Propofol gtt, which is stopped q1 hour to assess neuro status. When off Propofol he opens eyes on command, MAE, F/C consistently and strongly, nods to yes/no questions. PERRL. ICP 6-7 early in shift, now running 14-16 (NSURG resident Parvisi aware). Ventricular drain at 20cm H2O above tragus, draining small amounts blood-tinged fluid. Cont's q4 hour Nimodipine.\nRESP: No vent changes. ABG fine this AM. Occasionally coughs up small amount of secretions into ETT, but not suctioned d/t potential for increasing ICP. RSBI 38.7; SBT started at 0500.\nC-V: Pt required increased Propofol and addition of Nipride to keep SBP in target range of 100-130 for angio. After return to floor able to D/C Nipride and decrease Propofol. Of note, he had significant drop in BP to low 90's w/Dilantin bolus; rate of infusion slowed and meds weaned with good effect. HR remains 56-62, SB/SR, no VEA. CK's elevated. Right femoral angio site without bleeding or hematoma; pulses good all around.\nF/E: Conts NS at 90cc/hr; lytes repleted prn.\nGU: U/O 80cc/hr or more all night, clear yellow.\nGI: Belly soft, NT, ND w/active BS. No stool.\nID: Low-grade temp all shift; WBC normal. Continues on Cefazolin.\nENDO: SSRI q6 hours\nSKIN: intact\nACCESS: 3rd PIV placed\nSOCIAL: wife, 2 dtrs, sister-in-law here early. Wife and dtr stayed in waiting room. All are understandably anxious, asking good questions (many referred to NSURG). They are pleased to see him so responsive when Propofol is off.\n\nA: continues to do well\n\nP: continue hourly neuro checks; check PP's, groin site ; possible MRI of neck; plan to wean/extubate; control SBP 100-130; continue to support pt/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-21 00:00:00.000",
"description": "Report",
"row_id": 1473597,
"text": "Respiratory Care Note:\n Patient weaned and extubated this am without incident. Voice and cough intact. SpO2>97% on nasal O2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-21 00:00:00.000",
"description": "Report",
"row_id": 1473598,
"text": "Please refer to paper note in chart for events of day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-22 00:00:00.000",
"description": "Report",
"row_id": 1473599,
"text": "NPN 7p-7a MICU A\n\nNeuro: Awake and alert, x 3. MAE, strengths equal. PEARL, 2mm/bsk. Drain intact with 100cc of drainage.\n\nCV: NSR->SB with no ectopy noted. HR 54-67. Goal for SBP<140. Remains on Nipride gtt titrated down to 0.5mcg/kg/min. +palp pedal pulses, no edema noted. No c/o chest pain. ICP ranging . Drain intact with 100cc of drainage. NS @ 90cc/hr.\n\nResp: LS clear, dim at bases. O2 sats 94-96% on RA. Denies any SOB.\n\nGI: Abd soft, non-tender, +bs. No N/V. Tolerating clear liq diet without difficulty. advance as tolerated.\n\nGU: Foley cath intact with clear yellow urine. UO>40cc/hr.\n\nSkin: Dressing to drain on head C/D/I.\n\nFamily at bedside until midnight. Encouraged to allow pt to get some sleep. Pts ABP elevated with family in room last evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-29 00:00:00.000",
"description": "Report",
"row_id": 1473614,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt alert and oriented x 3. MAE. Treated with 650 mg po tylenol for h/a x 2 with temporary relief of h/a. Vent drain to 25 cm above tragus. Drain clamped at 2045 by neuro N.P. ICP recorded q 1 hr - ICP 10-18. Drain to be opened for ICP > 20 for 20 mins or if pt develops bad h/a and neurosurg should be notified. No sz activity noted. Dilantin level 7.6. Pt currently receiving 100 mg phenytoin q 8hrs.\n\nC-V - HR 68-80 SR BP 120-160/70-80. Nicardipine titrated to maintain SBP < 150. Nicardipine currently infusing at 10mg/hr. Pt continues to receive nimodipine 60 mg po q4hrs.\n\nResp - LS clear. 02 sat > 97% RA.\n\nGI - NPO after MN for angiogram today. Abd soft. +BS. No stool.\n\nF/E - Voiding 240-400ccs/hr via foley cath. Na 132 - IV NS with 40 kcl infusing at 90ccs/hr and pt rx with nacl 2 gm po qid.\n\nID - Afeb. WBC 10.6. Rx with iv kefzol q8hrs.\n\nSocial - Dtr visited last eve. Family will return today.\n\nA+P - Continue to monitor neuro status closely. Titrate nicardipine as indicated. Angiogram today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-29 00:00:00.000",
"description": "Report",
"row_id": 1473615,
"text": "MICU NPN -:\n\n Neuro: Ventriculostomy drain is clamped today--ICP being continuously monitored, if it goes >20 for >20 minutes, it should be reopened to drain. Neurosurgery to be notified in this event. ICP's ranging depending on pts position. Pt c/o mild headache today--medicated with tylenol X 2 with good relief. Neuro checks unchanged--pt alert and oriented X 3, pleasant and cooperative. Asking informed questions about his condition and POC.\n\n CV: AFebrile. NSR rate 70's. BP stable on 11 mg/hr nicardipine until this afternoon when BP began to increase to 150's (sustained)--nicardipne increased to 14 mg/hr and BP subsequently in 140's. Aline site pink with some drainage--SICU team evaluated site on rounds--plan is to d/c line after angio and replace if invasive cardiac monitoring is still needed. Sodium tabs continue 2 g QID--sodium check this afternoon with Na=132.\n\n Pulm: No active issues. Pt and using IS prn.\n\n GI: NPO today except medications. Pt had large soft brown BM on commode today. Plan to restart diet after procedure.\n\n GU: FOley to gravity. Plan to d/c foley 6 hours after procedure when pt able to be more mobile and use urinal. Urine is clear yellow.\n\n Access: new #22 PIV placed by IV today. #18 G PIV removed from pts L hand--skin is sl reddened and tender distal to this IV--will monitor closely for worsening.\n\n Family: Dtr at bedside for entire day--she is aware of POC and very involved.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-20 00:00:00.000",
"description": "Report",
"row_id": 1473594,
"text": "Respiratory Care Note:\n Patient admitted to MICU A post sub arachnoid hemorrhage with drainage tube placement. CT scans done without event. He awakens and responds appropriately off sedation. Presently on propofol infusion and SIMV. Plan to wean to PSV as tolerated. BS= bilat with good aeration, no wheezing or rhonchi noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-20 00:00:00.000",
"description": "Report",
"row_id": 1473595,
"text": "Please refer to admission history for events prior to admission. Pt is a 59 y/o healthy male who c/o severe HA today and found to have SAH. He was intubated and is to go for angio later today.\n Allergies: NKDA\n\n Neuro: Pt arrived off sedation--he was hypertensive, but awake and alert with no obvious neuro defacits. He could move all extremities strongly X 4 and to command. Nodding appropriately to yes/no questions. Pupils 2m/reactive. Ventric drain at 20 cm above tragus. ICP's checked q 30 minutes--ranging from . Pt started on propofol gtt for sedation while intubated (it has also had good effect on BP). Propofol gtt off q 1 hour for neuro checks. His checks have remained unchanged.\n\n CV: Pt afebrile. He is in SB with rate in 50's. No ectopy. BP initially high, then more stable on propofol in 120's. Nimodipine administered at 1600 with no discernable effect on BP. Access = 2 PIV's. Dilantin level subtherapeutic--additional dose to be given once available from pharmacy. Lytes currently being replaced per prn orders.\n\n Pulm: Pt vented on IMV, + cough. Lungs CTA. Anticipate extubation tommorrow if angio goes well tonight.\n\n GI: OGT in place. + plcmt via air bolus.\n\n GU: GOod clear yellow UOP via foley.\n\n Skin: Intact.\n\n FamilY: Wife, two dtr's at bedside. Very concerned and asking many qestions about pts prognosis and POC. Support and info given as able. Many questions referred to NSURG staff.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-12-01 00:00:00.000",
"description": "Report",
"row_id": 1473620,
"text": "NPN MICU A 7a-7p\n\nNeuro: Alert and oriented x3. PEARL MAE, strengths equal. Up OOB in chair for about 2 hours. C/O back pain and back spasms. Heating pad applied to back with little effect. Medicated with Tylenol for back pain. No c/o headache or discomfort. ICP 15-18. Drain clamped. CT of head this am. Results pending.\n\nCV: NSR with no ectopy noted. HR 66-75. SBP 132-171/71-83. Remains on Nicardipine gtt @ 5mg/hr. +palp pedal pulses, no edema. NS with 40KCL @ 90cc/hr.\n\nResp: LS clear, denies SOB. O2 sats 94-96%.\n\nGI: Abd soft, non-tender. +BS, -BM. Pt c/o not having an appetite but is tolerating a reg diet. Remains on Fluid restriction of 1000cc.\n\nGU: Foley cath with clear yellow urine. UO>60cc/hr.\n\nAccess: 2 PIV's. Aline intact.\n\nFamily: In room visiting pt most of day. Updated on pts progress.\n\nPlan: Remove drain pending Head CT results. Call out to floor when drain removed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-12-02 00:00:00.000",
"description": "Report",
"row_id": 1473621,
"text": "MICU NURSING PROGRESS NOTE. 1900-0700\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Alert and oriented x 3. Speach is clear and is able to make needs known verbally. Pupils 2mm and brisk. Moving all extrem. freely. Reports ha feeling much better after having percocet 1 tab po x 2, also helped with back pain a great deal. Eqaul grasp, strength and sensation bilat. upper and lower extrem. No neuro deficits noted. Ventricular drain removed at 2200 w/o incident, sutures placed by team. Tolerated well by pt and continues to remain neurologically stable. Temperature max. 99.1 oral.\n\n Respiratory: Lung sounds are clear and eqaul bilat. RR 10-20 and non labored, O2 saturation 94-97%.\n\n CV: Sinus rhythm with no ectopy noted, rate 60's to 80's. Abp 110's to 150's systolic. Nicardipine presently at 3mg/hr. Aline sharp but becoming difficult to draw off. IVF ns with 40meq kcl at 90cc/hr. Warm packs applied to infiltrate area on rt forearm.\n\n GI/GU: Abdomen soft with + bs. Tolerating po's well. No bm this shift. Foley catheter patent and draining lg amts clear yellow urine.\n\n Pain: Reports that percocet helped markedly as evidenced by bp and ability to rest in between neuro checks.\n\n Endocrine: Riss in use.\n\n Plan: Continue to monitor neuro status, wean off of nicardipine and monitor drain site. Arrange family meeting with nsicu team and Dr. . Family has expressed concerns about father and would like teams to explain plans, progress and expected outcomes as soon as possible.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-22 00:00:00.000",
"description": "Report",
"row_id": 1473600,
"text": "NPN 7a-7p\n\nNeuro: A&O X 3, behavior appropriate. Less h/a pain today . Tylenol given X 3. Dozing on and off. Speech clear, HG =, Perrl. ICP 8-11 with 110cc blood tinged drainage. No seizure activity noted. Continues on dilantin IV.\n\nCV: BP 123-151/66-76, HR 56-76. No peripheral edema. Tmax 99.1. Nipride gtt weaned off and nicardipine started at 11am at 5mg/hr, then titrated to 10mg/hr to keep SBP < 150. PIV (L)ac infiltrated with nicardipine infusing. Hot pack applied, swelling decreased. Pt has 3 other PIV's.\n\nResp: respirations regular, unlabored, O2 sats 97-99%. Denies SOB, cough. Pt aware of need to take frequent deep breaths. Lung sounds clear bilaterally.\n\nGI: Abdomen soft, ND, +BS. Diet advanced to regular but pt not hungry today. Ate half a bagel and drank lots of juice. Given Zofran X 1 for nausea with good effect.\n\nGU: Foley draining adequate amounts of clear yellow urine.\n\nEndo: FSBG 150 in am, 114 @ 1600. Covered for BS > 120.\n\nA: SAH\nP: Monitor neuros, ICP, ventricular drainage. Titrate nicardipine to SBP <150.\nA: Potential complications from immobility.\nP: Encourage C&DB, monitor resp status and temp, pneumo boots, OOB when drain removed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-23 00:00:00.000",
"description": "Report",
"row_id": 1473601,
"text": "MICU NURSING PROGRESS NOTE. 7PM TO 7AM.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Alert and oriented x 3, pleasant and cooperative. Speach is clear, speaking in full sentences and is able to make needs known verbally. Pupils are 2mm and brisk. = grasp bilat, = strenght bilat, symetrical facial expressions, good sensation all 4 extrem, no noticable deficits neurologically. Icp 8-12. Ventricular drain at 15cm, draining blood tinged fluid in good amts. No seizure activity noted. Only neurologic symptom is the continous headache which is reasonably well controlled with tylenol 650mg po every 4-6 hrs. Temperature max. 99.4 oral this am.\n\n Respiratory: Lung sounds are clear. RR 12-20 and non labored. O2 saturation 93-98% ra. Coughing and deep breathing encouraged. No cough noted, denies difficulty breathing or sob.\n\n CV: Sinus brady to sinus rhythm with no ectopy noted, rate high 50's to high 70's. Abp high 90's to low 140's systolic. Nicardipine drip decreased to 7.5mg/hr, tolerating change well. Goal bp < 150. Labs drawn this am. Ns with 40meq kcl at 90cc/hr.\n\n GI/GU; Abdomen soft with + bs. Tolerating po intake very well. Reports feeling nausea's, zofran iv with good effect for several hrs.\nReports last BM friday prior to admission. Foley catheter patent and draining clear yellow urine in adequate amts.\n\n Social: Wife and daughters in with pts through most of evening, went home to get some sleep.\n\n Plan: Continue monitoring icp and ventricular drain, call for no drainage. Maintain SBP <150mmhg. Encourage pulmonary toileting. Start pt on stool softener or laxative.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-29 00:00:00.000",
"description": "Report",
"row_id": 1473616,
"text": "MICU NPN Addendum:\n Pt returned from angio hypertensive with SBP 160's. Nicardipine titrated up to 15 mg/hr and subsequent BP in 150's. Neurosurg aware of BP--they would like BP near 150's, but up to 170's is acceptable.\n Aline resited--R site is pink with drainage. Tip sent for culture. New aline with good wave form.\n L wrist, above old #18g that was d/c'd today, reddened and appears to be phlebitic--SICU resident aware and pt remains on kefsol--ice packs applied for comfort.\n Angio site in R groin benign. + palpable pulses. Pt may have full bed mobility at 2300 (6 hours after hemostasis).\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-30 00:00:00.000",
"description": "Report",
"row_id": 1473617,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Ventriculostomy drain clamped shortly after pt returned from angio. Drained 10ccs blood-tinged fluid prior to be clamped. Vent drain 25 cm at the tragus and clamped. ICP readings recorded q 1 hr - ICP 14-17. Pt c/o intermittent mild h/a. Treated with tylenol x 3 during the course of the shift. Should ICP become> 20 for 20 mins or pt develop severe h/a, drain should be opened and team notified. Pt remains a+o x 3. MAE. No sz activity. Dilantin dcd. Discussed his feelings of frustration at being hospitalized for such an extended period. Given 5 mg ambien to help with sleep. Pt slept well for ~5 hrs.\n\nC-V - HR 60-80 SR, no ectopy. BP 130-155/60-70. Since angio neg, team states SBP up to 170 will be tolerated. Nicardipine titrated down to 10 mg/hr. 100 mg labetalol po administered last eve which appears to greatly help control BP. Labetalol to be given . 3+ DP and PT pulses. Groin site d+i.\n\nResp - LS clear. 02 sats > 95% on RA.\n\nGI - ABd soft. +BS. No stool. + flatus. Tolerating house diet without difficulty.\n\nF/E - TFB neg ~ 2 liters. Pt voiding 45-240ccs/hr via foley cath. Placed on po fluid restriction of 1000ccs for hyponatremia. In addition pt rx with 2 gms nacl q 6hrs. Na 135 this am.\n\nSkin - Left wrist remains erythematous and swollen, ice applied and arm elevated on pillow. Afeb. WBC 10.8. Rx wit kefzol q 8hrs.\n\nSocial - Dtr and wife stayed with pt most of the evening.\n\nA+P - Continue to monitor neuro status closely. Titrate nicardipine as tolerated. Emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-30 00:00:00.000",
"description": "Report",
"row_id": 1473618,
"text": "NPN MICU A 7a-7p\n\nNeuro: Alert and oriented x 3. PEARL, 2mm/bsk. MAE, strengths equal. Follows commands. Pleasant and very cooperative. ICP drain clamped. 25cm @ tragus. ICP ranged from . If >20 for 20 minutes than unclamp and call team.\n\nCV: NSR with no ectopy noted. HR 70-80. ABP 126-158/63-83. +palp pedal pulses. No edema. Remains on Nicardipine gtt @ 8mg/hr. Attempt to wean Nicardipine to off as tolerated. Groin site C/D/I. K+ 4.5, Na 133.\n\nResp: LS clear. Denies SOB. O2 sat 95-98%. RR 16-23.\n\nGI: Abd soft, non-tender, +BS. +BM. Tolerating hse diet without difficulty. Remains on 1 Liter Fluid restriction.\n\nGU: Foley cath with clear yellow urine. UO>60cc/hr.\n\nAccess: Aline with sharp waveform. 2 PIV's.\n\nID: Remains on Cefazolin. Afebrile. WBC's 10.8.\n\nSocial: Family in room with pt most of day. Updated on pts condition.\n\nPlan: Titrate Nicardipine gtt as tolerated. CT of head in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-12-01 00:00:00.000",
"description": "Report",
"row_id": 1473619,
"text": "MICU NURSING PROGRESS NOTE 1900-0700\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Alert and oriented x 3. Speach is clear and is able to make needs known verbally. Able to move all extrem. freely, equal grasp bilat, eqaul strength bilat, easily palpable pulses. good sensation all 4 extrem. Icp 13-18. Maintain icp < 20 mmhg, notify neuro team if icp 20 mmhg or greater for 20min, open drain. Reports slight ha as only neuro sx, medicated with tylenol x 1 for discomfort. Temperature 100.3 oral, Dr. made aware.\n\n Respiratory: Lung sounds are clear. RR 12-20 and non labored. O2 saturation 94-97% ra. No cough noted.\n\n CV: Sinus rhythm with no ectopy noted, rate 70's and 80's. Abp in 140's to 160's systolic. Nicardipine at 6mg /hr. Ivf ns with 40meq kcl at 90cc/hr. A line sharp, site wnl. Labs sent at 0500.\n\n GI/GU: Abdomen soft with + bs. 1 very lg soft formed brown bm. Tolerating po's well. Reports that he has not had much of an appettite lately, that he fees nauseas in the am's and that he just has not felt that hungry lately, will try to do better. Foley catheter patent and draining clear yellow urine in good amts.\n\n Social: Wife and daughter in for early evening, went home early.\n\n Plan: Ct this am, question possible drain removal as long as icp remains < 20mmhg, continue to wean nicardipine and attempt to wean ifv, monitor sodium level also.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-27 00:00:00.000",
"description": "Report",
"row_id": 1473610,
"text": "NPN MICU A 7p-7a\n\nNeuro: Alert and oriented x 3. PEARL 2-3mm/BSK. MAE, strengths equal. Drain intact with 91cc of drainage. C/O HA but is improved from past days. Tylenol 650mg given x 1 and Percocet 1 tab given with good effect.\n\nCV: NSR with no ectopy noted. HR 72-80 ABP 119-140's/70-80's. Remains on Nicardipine gtt @ 10mg/hr. Goal for SBP to be less than 150. ICP 10-14. +palp pedal pulses with no edema noted. Remains on NS with 40KCL @ 90cc/hr. Tmax 100.6.\n\nResp: LS clear, O2 sats in low 90's. Pt using IS and encourage to cough and deep breathe. 5am, pt desated to 87-88%. Pt able to cough up some sputum. O2 sats up to low 90's. 2L NC placed on pt, O2 sats now in mid 90's. RR 16-24.\n\nGI: Abd soft, non-tender, +bs. No Nausea. Tol reg diet without difficulty.\n\nGU: Foley cath with clear yellow urine. UO>170cc/hr.\n\nSkin: Head dressing intact. Aline dressing changed.\n\nAccess: 2 PIV's, Aline.\n\nPlan: Angio on , pt to be NPO on Sun night. Continue to monitor ICP, Keep SBP<150.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-27 00:00:00.000",
"description": "Report",
"row_id": 1473611,
"text": "altered neuro status\nD: NEURO: NEURO INTACT. NE NEURO DEFICITS. ICP DRAIN AT 20 CM AT TRAGUS AND HAS DRAINED A TOTAL OF 115CC'S SEROUS FLUID. PT STATES THAT HE HAS HAD A MUCH MORE COMFORTABLE DAY TODAY. MEDICATED X 2 WITH TYLENOL FOR C/O HEAD DISCOMFORT WITH GOOD RELIEF. DOSE STILL C/O NECK DISCOMFORT AND WARM PACKS APPLIEFD TO THE AREA PROVIDE SOME RELIEF. PLAN IS TO KEEP PT NPO AFTER MIDNOC SUN NOC FOR ANGIO ON . DILANTIN LEVEL TODAY =10.4. PT GIVEN ADDITIONAL DOSE OF DILANTIN 300MG PO AND STILL RECEIVING 100 MG IV TID.CONTIUE TO ASSESS PT'S MS AND FOLLOW DILANTIN LEVELS AS ORDERED.\n\nRESP: PT HAS NOT REQUIRED O2 TODAY WITH O2 SATS> 93%. LUNGS CTA AND USING INCENTIVE SPIROMETRY AT BEDSIDE.\n\nCV: NICARDIPINE GTT WEANED DOWN TO 9 MG/HR TO KEEP SBP< 150. ASLO RECEIVING NIMODIPINE 60 MG Q 4 HRS AS ORDERED. K+ WNL. HR 60-80'S WITHOUT ECTOPY.\n\nGI: ABD SOFT AND NONTENDER. NO STOOL OUTPUT. NO C/O N/V. APPETITE GOOD. HCT STABLE AT 38. 1\n\nGU: ADEQAUTE HOURLY UO. BUN AND CREAT WNR. NO ACTIVE ISSUES.\n\n\nID: RECEIVING CEFAZOLIN AS ORDERED. MAX TEMP=99.4 ORALLY WITH WBC=11.9.\n\nSOCIAL: PT IS A FULL CODE. HIS WIFE AND DAUGHTER BEEN AT THE BEDSIDE THROUGHOUT THE AFTERNOON AND HAVE BEEN UPDATED.LCONTINUE WITH PRESENT MEDICAL MANAGEMENT AND OFFER EMOTIONAL SUPPORT TO PT AND FAMILY.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-24 00:00:00.000",
"description": "Report",
"row_id": 1473605,
"text": "nursing note 0700hrs - 1600hrs\n\nneuro -overall no change with neuro status - full power in limbs alert/orientated x3 - c/o headache this am percocet with effect but did feel nauseated with med - relieved with anti - emetic but at this point did experience pressure at the back of the eyes and had rise in b/p >150 icp @20 - team informed nicardipine drip titrated up eventually symptoms relieved - no further episodes this pm\nlevel of drain elevated to 25cms by team this am - readings 15-20 aim for<20 drainage at 10-15cc per hr - dressing dry and intact\n\ncvs - b/p elevated this am when patient felt nauseated but settled with increase with nicardipine - gradually lowering drip to aim with systolic<150 but this pm blood pressure was borderline 150-155 systolic - again nicardipine drip increased to gain better control - reviewed by team to continue to titrate drip up as needed ? for team to introduce new await further review - presently at7.2mgs per hr\nh/r stable 60-80 bpm - no ectopics - k treated this am\nafebrile - ab's continue\ndilantin level therapeutic\n\ng/i - no bowel motion - does not feel uncomfortable - taking very little diet - but fluids well\n\ng/u - iv fluids continue at 90cc per hr - passing good amounts of urine\n\nskin - intact\n\nsocial - family visited\n\nplan - await repeat angiogram on friday\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-25 00:00:00.000",
"description": "Report",
"row_id": 1473606,
"text": "npn 7p-7a: (see careview flownotes for objective data)\n\ndx: SAH, ventricular drain;\n\nneuro:\nPERLA; A/O x3; moves all extremites equally and with purpose;\nvent drain remains 25 cm above tragus, draining acceptable volumes;\n\nc-v:\nb/p controlled with PO Nimopidine q 4 hrs as ordered, and Nicardipine gtt;\n\nresp:\nlungs clear bilat, O2 sat 95%, no change;\n\ng-i:\ntaking fair PO intake, bites food/fruit; c/o intermittent nausea since starting to take Percocet; received IV Zofran x 2 oavernight; taking adequate CLIQ with good toleration;\n FS's slightly elevated, received small doses RISS per SS;\n\ng-u/electrolyts:\nhad increased urine output x a few hours; therefore urine osm sent, result 263;\n\n\nsocial:\nwife present at bedside until h.s.\n\nPLAN:\nHopefully clamp vent drain today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-25 00:00:00.000",
"description": "Report",
"row_id": 1473607,
"text": "ALTERED MENTAL STATUS\nD: NEURO: PT A&O X3. FOLLOWS SIMPLE COMMANDS CONSITENTLY. PUPILS EQUALLY REACTIVE TO LIGHT. EQUAL STRENGTH TO EXTREMITIES BIL. DILANTIN LEVEL THIS AM= 8.5. PT LOADED WITH 300 MG IV DILANTIN AND CONT TO RECEIVE DILANTIN 100 MG Q 8 HRS AND WILL RECHECK LEVEL IN THE AM. ICP READINGS TODAY 14-16. CLAMPED DRAIN TO BRAIN BUT ICP CLIMBED TO >20 AND SBP ALSO INCREASED REQUIRING AN INCREASE IN THE NICARDIPINE GTT. PT C/O DULL CONSTNAT HA AT LEVEL OF 1. MEDICATED PT WITH 650 MG TYLENOL BUT WITH CLAMPING OF THE DRAIN HA LEVEL INCREASED TO 5. PT WAS MEDICATED WITH 2 MG IV ZOFRAN AND THEN WAS MEDICATED WITH 1 TAB OF PERCOCET WITH GOOD EFFECT. NEUROSURGERY WAS NOTIFIED AND THE CLAMP TO DRAIN WAS UNCLAMPED. CONTINUES TO DRAIN 4-20 CC'S BLOODY DRAINAGE AND HA DISCOMFORT HAS IMPROVED AND PRESENTLY PT STATES PT \"IS ALMOST GONE\". ? IF PT WILL STILL GO TO ANGIO TOMORROW SINCE PT DID NOT TOLERATE THE DRAIN BEING CLAMPED. WILL DISCUSS WITH THE TEAM.\n\nRESP: HAS NOT REQUIRED O2. O2 SATS>98&. LUNGS CTA.\n\nCV : K+ 4.2. NA=133 AND PT HAS BEEN STARTED ON 1 GM SODIUM CHLORIDE Q 6 HRS AND HE CONTINUES TO RECEIVE NS WITH 40 MQ KCL AT 90CC'S/HR. HR 60-70'S WITHOUT ECTOPY. SBP HAS CLIMBED AS HIGH AS 160 AND NICARDIPINE GTT NOW INFUSING AT 8MG/HR WITH GOAL TO KEEP SBP<150. PT ALSO RECEIVING NIMODIPINE 60 MG Q 4 HRS. WIL CONTINUE TO FOLLOW HEMODYNAMICS AND CAN INCREASE NICARDIPINE GTT TO 15MG/HR IF NEEDED TO OBTIAN GOAL OF SBP<150. WILL FOLLOW ELECTROLYTES AS ORRDERED AND REPLETE AS NEEDED.\n\nGI: PT TOLERATING BUT APPETITE POOR. NO C/O N/V BECAUSE PT WAS PREMEDICATED WITH ZOFRAN BEFORE RECEIVNG PERCOCET FOR HIS C/O HA.\n\nGU: ADEQUATE HOURLY UO. BUN=7 AND CREAT=0.8 WILL FOLLOW UO CLOSELY\n\nENDOCRINE: GAOL IS TO KEEP BLOOD SUGAR <130. CONTINUE TO CHECK BLOOD SUGARS Q 6 HRS AND TREAT WITH SSI AS ORDERED.\n\nID: MAX TEMP=99.5 WITH WBC=10.R. RECEIVING CEFAZOLIN Q 4 HRS AS ORDEDERED.\n\nSOCIAL: PT IS A FULL CODE. BOTH HIS DAUGHTER AND WIFE HAVE BEEN AT THE BEDSIDE THROUGHOUT THE AFTERNOON AND HAVE BEEN UPDATED. WILL CONTINUE TO KEEP THEM UPDATED AND WILL OFFER EMOTIONAL SUPPORT TO PT AND FAMILY. CONTINUE WITH PRESENT MEDICAL TX.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-26 00:00:00.000",
"description": "Report",
"row_id": 1473608,
"text": "npn 7p-7a(see also careview flownotes for objective data)\n\ndx: SAH; vent drain\n\nneuro:\nventricular drain re-clamped approx 23:00 last eve, pt tolerated well; ICP 15-17; no new severe h/a or nausea different than chronic for the past week;\n neuro exam stable; PERL; pt moves all extremities; stays supine because if pt turns on side, makes vent drain ICP become inaccurate;\n\n\nc-v:\nb/p stable, even with clamping of ICP drain; remains on antihypertensive PO meds and gtt;\n\n\nresp:\nno isssues;\n\ng-i:\nNPO MN for angio today s/p clamp of drain;\non FS, requiring low levels reg ins coverage;\n\ng-u:\nexcellent urine output via patent foley;\n\nsocial:\nwife called this a.m. for update; stated to tell her husband she would be in later after she sees the grandchildren;\n\nlabs:\na.m. labs again show sub therapeutic Dilantin level; others without significant abnormalities;\n\nPLAN:\nangio today\nNPO\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-26 00:00:00.000",
"description": "Report",
"row_id": 1473609,
"text": "altered neuro status\nD: PT A&O X3. PLEASANT AND COOPERATIVE. RELIABLE HISTORIAN. PT WITH EQUAL STRENGTH. PUPILS EQUALLY AND BRISKLY REACTIVE TO LIHT. PT TRANSPORTED TO RADIOLOGY FOR HEAD CT WITH RESULTS PENDING. UPON RETURN TO MICU ICP NOTED TO BE UP TO 25 WITH PT C/O HA WITH PRESSURE IN TEMPLE AREA AND PRESSURE \" BEHIND EYE BALLS\". SBP NOTED TO BE UP TO 165. MD NOTIFIED AND DRAIN UNCLAMPED AND HAS DRAINED A TOTAL OF 50CC'S OF SEROSANGUINOUS LIQ. ICP SINCE HAS BEEN 16-18. NICARDIPINE GTT RATE INCREASED TO KEEP SBP< 150. DILANTIN LEVEL THIS AM=9.9. PT STILL RECEIVING DILANTIN 100 MG IV TID AND ASL RECEIVED A 300 MG 1X DOSE AS ORDERED AND WILL CONTINUE TO FOLLOW LEVELS AS ORDERED. ANGIO SCHEDULED FOR TODAY NOT DONE BECAUSE OF SCHEDULING ISSUES. PT REFUSING PERCOCET FOR C/O HA DISCOMFORT BUT HAS RECEIVED 2 DOSES OF TYLENOL WITH ACCEPTABLE RELIEF ACCORDING TO PT.\n\nRESP: PT HAS NOT REQUIRED O2. LUNGS ESSENTIALLYU CLEAR ONAUSCULTATION. PT INSTRUCTED ON THE USE OF INCENTIVE SPIROMETRY TO PREVENT ATELECTASIS. WILL FOLLOW RESP STATUS.\n\nCV: HR 70-80'S WITH RARE PVC'S. K+ 4.1. NICARDIPINE GTT AS HIGH AS 11MG/HR NOW INFUSING AT 10 MG/HR TO KEEP SBP< 150. WILL FOLLOW HEMODYNAMICS AS ORDERED AND CAN INCREASE NICARDIPINE GTT AS HIGH AS 15 MG/HR IF NEEDED.\n\nGI: PT HAD BEEN NPO FOR ANGIO BUT THAT WAS D/C'D. PT NOW WITH ADEQAUTE PO INTAKE. NO C/O N/V. IF PT REQUIRES PERCOCET WILL PREMEDICATE WITH ZOFRAN SINCE PT IN THE PAST HAS GOTTEN NAUSEOUS FROM PERCOCET.\n\nGU: PT WITH ADEQUATE HOURLY UO. BUN AND CREAT WNR. NEED TO CHECK NA LEVEL Q 6 HRS. IF NA LEVEL < 131 FOR 2X'S PLAN IS TO START 3% NS AT 10CC'S/HR. WILL FOLLOW ELECTROLYTES CLOSELY.\n\nENDOCRINE. CHECKING BLOOD SUGARS Q 6 HRS AND ADMISNITERING SSI AS NEEDED.\n\nID: MAX TEMP=100.4 ORALLY AND WBC=10.7. CONTINUES OF CEFAZOLIN AS ORDERED.\nSOCIAL: WIFE HAS BEEN AT THE BEDSIDE THROUGHOUT THE AFTERNOON AND WAS UPDATED. NEUROLGY BY AND PT AND HIS WIFE THAT HEAD CT DONE EARLIER IS UNCHANGED. PLAN IS TO PREOP SUN NOC FOR ANGIO ON MONDAY. DRAIN TO HEAD NOW AT LEVEL OF 20 AT THE TRAGUS TO INCREASE THE AMT OF DRAINAGE. CONINTUE TO KEEP FAMILY UPDATED AND OFFER EMOTIONAL SUPPORT TO FAMILY. CONTINUE WITH PRESENT MEDICAL TX\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-28 00:00:00.000",
"description": "Report",
"row_id": 1473612,
"text": "NPN MICU A 7p-7a\n\nNeuro: Alert and oreinted x 3. PEARL, MAE, strengths equal. C/O HA and medicated with Tylenol 650mg x 3 with good effect. ICP 9-12.\n\nCV: NSR with no ectopy noted. HR 68-80. SBP to be <150. Remains on Nicardipine gtt @ 9mg/hr. +palp pedal pulses with no edema. Na 132, pt started on 3%NS @ 10cc/hr x 6hrs. Na 134 after 2 hours, and then 133 after 3 hours. 0445 Na pending. NS with 40KCL restarted @ 90cc/hr.\n\nResp: LS clear, denies SOB. O2 sat 92-96%. Using IS and C/DB.\n\nGI: Abd soft, non-tender, +BS. -BM. Tolerating Regular diet without difficulty. Remains on ISS Q6 hours.\n\nGU: Foley cath with clear yellow urine. UO>100cc/hr.\n\nSkin: Intact.\n\nID: Tmax 100.6. Remains on Cefazolin.\n\nSocial: No contact with family overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-28 00:00:00.000",
"description": "Report",
"row_id": 1473613,
"text": "ALTERED NEURO STATUS\nD: NEURO: PT NEUROLOGICALLY INTACT. OOB TO CHAIR ANDTOLERATED ACTIVITY WELL. HEAD DISCOMFORT HAS BEEN FROM 0-2. MEDICATED X2 WITH RELIEF. APPLYING WARM PACKS TO POSTERIOR NECK AREA FOR MUSCULAR DISCOMFORT WITH GOOD EFFECT. DRAIN TO HEAD REMAINS OPEN AND LEVEL CHANGED FROM 25 TO 20 CM AND LEVELED AT TRAGUS. CONTINUES TO DRAIN SEROSANG DRAINAGE-40CC'. PLAN IS TO REEVALUATE THIS EVENING AND THEY CLAMP DRAIN OVERNOC. WHEN THIS OCCURS IF PT'S LEVEL OF HEAD DISCOMFORT INCREASE IN INTENSITY OR IF HIS ICP CLIMBS TO > 20 WE SHOULD NOTIFY SICU MD. PLAN IS TO KEEP PT NPO AFTER MIDNOC FOR ANTICIPATED ANGIOGRAPHY TOMORROW.\n\n\nRESP: NO O2 REQUIRED WITH O2 SATS>97%. LUNGS CTA AND PT CONTINUES TO USE INCENTIVE SPIROMETRY AT THE BEDSIDE.\n\nCV: NICARDIPINE GTT AS HIGH AS 11MG/HR TODAY AND WILL WEAN AS TOLERATED TO KEEP SBP< 150. THIS GTT CAN BE INCREASED TO AS HIGH AS 15 MG/HR TO CONTOL SBP. CONTINUES TO RECEIVE NIFODIPINE 60 MG PO Q 4 HRS AS ORDERED. K+ WNR. WILL CONTINUE TO FOLLOW ELECTROLYTES. SODIUM TABS INCREASED TO 2 TABS QID. SBP 120-155. WITH HR 70-80'S.\n\n\nGI: PT WITH GOOD APPETITE TODAY. NO C/O N/V. ABD SOFT AND NONTENDER. POS BOWEL SOUNDS ON AUSCULTATION.NO STOOL OUTPUT TODAY.PT TO BE KEPT NPO AFTER MIDNOC FOR ANGIOGRAPHY.\n\n\nGU: RECEIVING NS WITH 40 MEQ KCL AT 90CC'S/HR. ADEQAUTE HOURLY UO VIA FOLEY CATH AND BUN/CREAT WNR.\n\nID: MAX TEMP=98.7 AND WBC=10.7. RECEIVING CEFAZOLIN AS ORDERED.\n\nSOCIAL: PT IS A FULL CODE. WIFE AND DAUGHTER IN TO VISIT AND WERE UPDATED. CONTINUE WITH PRESENT MEDICAL TX AND OFFER EMOTIONAL SUPPORT TO PT AND FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-23 00:00:00.000",
"description": "Report",
"row_id": 1473602,
"text": "nursing note 0700hrs - 1600hrs\n\nneuro - remains stable - full power in all 4 limbs -A/O x3 - speech clear - pupils equal and reactive - facially symmetrical\nhas continued c/o headache - team aware analgesia as perscribed no escalation with symptoms some relief with meds - drain remains insitu increased by team to 20cms and draining approx 10-15cc per hour - icp readings from - when elevated to 15 team informed no action taken to observe no further elevation at prsent\n\n\ncvs - attempted to reduce nicardipine and was successful for period of time then at approx 12md b/p started to rise >150 therfore infussion increased - along with oral meds has reduced and maintained<150 as per goal - attempting to further wean nicardipine\nafebrile - ab's as perscribed\nremains sinus\n\nresp - chest clear - sats >95% on room air\n\ng/i - taking some diet - no bowel motion - patient does not feel uncomfortable at this time\n\ng/u - urine output satisfactory - repeat k sent this pm\n\nskin - drain sight dry and intact - dressing from angio dry and intact - sacrum intact\n\nsocial - visited by daughters - who informed me that is probably more anxious today as his father is in hospital for an operation today as is his brother for treatment\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-23 00:00:00.000",
"description": "Report",
"row_id": 1473603,
"text": "add on note - plan for is to re-angio on friday\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-11-24 00:00:00.000",
"description": "Report",
"row_id": 1473604,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Remains alert and oriented x 3. MAE. Pupils 3 mm, equal bilat. No sz activity noted. Dilantin level 13.2 this am, receiving 100 mg IV tid. Ventricular drain remains at 20cm above tragus, draining 4 -14 ccs/hr blood tinged fluid. Dssg d+i. ICP 10-14. Pt continues to c/o aching h/a. Medicated with tylenol without relief. Order obtained for percocet. Pt given two doses ( total 3 tabs) with good effect. Able to sleep intermittently throughout the night.\n\nC-V - HR 64-76 SR with rare pvcs. BP 130-140/60-70. Nicardipine titrated to maintain SBP < 150. Nicardipine currently infusing at 6.0mg/hr. Pt additionally receiving nimodipine 60 mg po q 4hrs.\n\nResp - LS clear. RR 12-23 02 sats > 94 % RA.\n\nGI - Abd soft. +BS. Tolerating a great quantity of fluids. No stool. Colace given.\n\nF/E - NS with 40 meq kcl infusing at 90ccs/hr. K 3.4 last eve - repleted with 20 meq kcl iv. K 3.9 this am. Mg 1.6 - will replete with 2 gms. Urine output 60-320ccs/hr via foley cath.\n\nEndo - RISS\n\nSocial - Wife visited most of the evening. Pt anxious to go home\n\nA+P - Continue to monitor neuro status closely. Titrate nicardipine as tolerated. Replete lytes prn. Plan is for angiogram on . Emotional support to family.\n"
}
] |
6,503 | 114,310 | ED work up include CT 1. Findings consistent with severe CHF, with nutmeg liver and severe anasarca. 2. Moderate amount of free intraperitoneal fluid. 3. Air within the bladder. Correlate with urinalysis/culture to evaluate for gas- producing organism/cystitis. 4. No evidence of bowel obstruction. 5. Small amount of air adjacent to both inferior epigastric arteries, of unknown etiology. 6. Right renal and uterine/ovarian arteriovenous malformations. | CT OF ABDOMEN WITHOUT & WITH IV CONTRAST: There are areas of bibasilar atelectasis and nonspecific ground-glass opacity, which could be related to CHF. Small amount of air adjacent to both inferior epigastric arteries, of unknown etiology. * Question of adhesion, obstructions, or GYN or G/U pathology. Right renal and uterine/ovarian arteriovenous malformations. There is a right renal arteriovenous malformation. There are small bilateral pleural effusions. There is diffuse vascular calcification throughout the abdomen. Moderate amount of free intraperitoneal fluid. Sinus rhythm. Clinical correlation issuggested. There is diffuse anasarca. Also noted are several bubbles of air adjacent to the inferior epigastric arteries bilaterally. Left anterior fascicular block persists. There is a moderate amount of fluid in the abdomen. Please pg Med Stud A with questions. There is a small amount of air within the left femoral vein, likely related to femoral line insertion. Air within the bladder. Appearance of the uterus is unchanged. There is dramatic cardiomegaly. The gallbladder is unremarkable. Evaluate for obstruction or GU abnormality. On the initial contrast phase (which was a delayed phase), there is arterial enhancement with extensive back- pressure filling of the hepatic veins through the IVC. Both kidneys are small and atrophic. Extensive pelvic vascular calcifications are seen. COMPARISON: . No contraindications for IV contrast FINAL REPORT INDICATION: Abdominal pain. CT OF PELVIS WITH IV CONTRAST: There is a likely uterine/ovarian arteriovenous malformation on the right with early filling of the right ovarian vein. Findings consistent with severe CHF, with nutmeg liver and severe anasarca. There is a large amount of intraabdominal fluid, more than on the , study. 12:03 AM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT 100CC NON IONIC CONTRAST Reason: *Pt refusing to take contrast PO. 3. 4. * Question of adhesion, obs Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) 1. The adrenal glands, pancreas, stomach, and intraabdominal loops of small and large bowel are unremarkable. IMPRESSION: (Over) 12:03 AM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT 100CC NON IONIC CONTRAST Reason: *Pt refusing to take contrast PO. Thanks! 2. The bladder wall is thickened and air is contained within the bladder. The spleen is normal in size. Compared to the previous tracing of the limb lead voltagehas diminished the ST-T wave abnormalities persist, though are less prominentin leads I, aVL and V4-V6 suggesting resolution of prior lateral ischemicprocess. TECHNIQUE: Axial images of the abdomen and pelvis were acquired helically before and after administration of 100 cc of Optiray IV contrast in multiple phases. Air bubbles are also seen within a tubular structure near the base of the cecum, presumably the appendix. No suspicious lytic or sclerotic osseous lesions are identified. 5. No evidence of bowel obstruction. 6. REASON FOR THIS EXAMINATION: *Pt refusing to take contrast PO. An additional delay scan showed an enlarged liver with heterogeneous perfusion (nutmeg liver). There are no adnexal masses. There is no pericardial effusion. There is no bowel wall edema. Correlate with urinalysis/culture to evaluate for gas- producing organism/cystitis. The patient refused to drink oral contrast. BONE WINDOWS: Extensive dystrophic ossifications are seen about the right proximal femur. | 2 | [
{
"category": "Radiology",
"chartdate": "2100-07-11 00:00:00.000",
"description": "CT 100CC NON IONIC CONTRAST",
"row_id": 834403,
"text": " 12:03 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: *Pt refusing to take contrast PO.* Question of adhesion, obs\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with ESRD on HD, IDDM, chronic ab pain here with new abd\n pain, N/V.\n REASON FOR THIS EXAMINATION:\n *Pt refusing to take contrast PO.* Question of adhesion, obstructions, or GYN\n or G/U pathology. Please pg Med Stud A with questions. Thanks!\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain. Evaluate for obstruction or GU abnormality.\n\n TECHNIQUE: Axial images of the abdomen and pelvis were acquired helically\n before and after administration of 100 cc of Optiray IV contrast in multiple\n phases. The patient refused to drink oral contrast.\n\n COMPARISON: .\n\n CT OF ABDOMEN WITHOUT & WITH IV CONTRAST: There are areas of bibasilar\n atelectasis and nonspecific ground-glass opacity, which could be related to\n CHF. There is dramatic cardiomegaly. There is no pericardial effusion. There\n are small bilateral pleural effusions. On the initial contrast phase (which\n was a delayed phase), there is arterial enhancement with extensive back-\n pressure filling of the hepatic veins through the IVC. An additional delay\n scan showed an enlarged liver with heterogeneous perfusion (nutmeg liver).\n There is a large amount of intraabdominal fluid, more than on the , study. The spleen is normal in size. The adrenal glands, pancreas,\n stomach, and intraabdominal loops of small and large bowel are unremarkable.\n There is no bowel wall edema. Both kidneys are small and atrophic. There is a\n right renal arteriovenous malformation. There is diffuse vascular\n calcification throughout the abdomen. The gallbladder is unremarkable.\n\n CT OF PELVIS WITH IV CONTRAST: There is a likely uterine/ovarian\n arteriovenous malformation on the right with early filling of the right\n ovarian vein. Appearance of the uterus is unchanged. There are no adnexal\n masses. The bladder wall is thickened and air is contained within the bladder.\n Extensive pelvic vascular calcifications are seen. Also noted are several\n bubbles of air adjacent to the inferior epigastric arteries bilaterally. There\n is a small amount of air within the left femoral vein, likely related to\n femoral line insertion. Air bubbles are also seen within a tubular structure\n near the base of the cecum, presumably the appendix. There is a moderate\n amount of fluid in the abdomen. There is diffuse anasarca.\n\n BONE WINDOWS: Extensive dystrophic ossifications are seen about the right\n proximal femur. No suspicious lytic or sclerotic osseous lesions are\n identified.\n\n IMPRESSION:\n (Over)\n\n 12:03 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: *Pt refusing to take contrast PO.* Question of adhesion, obs\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Findings consistent with severe CHF, with nutmeg liver and severe anasarca.\n\n 2. Moderate amount of free intraperitoneal fluid.\n\n 3. Air within the bladder. Correlate with urinalysis/culture to evaluate for\n gas- producing organism/cystitis.\n\n 4. No evidence of bowel obstruction.\n\n 5. Small amount of air adjacent to both inferior epigastric arteries, of\n unknown etiology.\n\n 6. Right renal and uterine/ovarian arteriovenous malformations.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2100-07-10 00:00:00.000",
"description": "Report",
"row_id": 289144,
"text": "Sinus rhythm. Compared to the previous tracing of the limb lead voltage\nhas diminished the ST-T wave abnormalities persist, though are less prominent\nin leads I, aVL and V4-V6 suggesting resolution of prior lateral ischemic\nprocess. Left anterior fascicular block persists. Clinical correlation is\nsuggested.\n\n"
}
] |
87,266 | 124,989 | This is a 62 yo male with a history of jaundice secondary to dilated GB, s/p CCY and biliary stent placement in admitted for observation after repeat ERCP for stent removal and sphincterotomy. . Primary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS | # Hyperkalemia: Now normalized - check lytes . Otherwise normal ercp to third part of the duodenum Assessment and Plan ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. Otherwise normal ercp to third part of the duodenum Assessment and Plan ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. Otherwise normal ercp to third part of the duodenum Assessment and Plan ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. # Hypertension, Benign - Currently asymptomatic in setting of transfer with SBP of 180s. # Hypertension, Benign - Currently asymptomatic in setting of transfer with SBP of 180s. # Hypertension, Benign - Currently asymptomatic in setting of transfer with SBP of 180s. K- priot to procedure 4.2 Action: f/u lytes. K- prior to procedure 4.2 Action: F/u lytes. K- prior to procedure 4.2 Action: F/u lytes. K- prior to procedure 4.2 Action: F/u lytes. Previously troponin positive (cardiac source vs renal impairment) another set of CE sent. Previously troponin positive (cardiac source vs renal impairment) another set of CE sent. Previously troponin positive (cardiac source vs renal impairment) another set of CE sent. Previously troponin positive (cardiac source vs renal impairment) another set of CE sent. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. On epogen as outpatient per recent discharge summary. On epogen as outpatient per recent discharge summary. On epogen as outpatient per recent discharge summary. On epogen as outpatient per recent discharge summary. Pt first presented with jaundice and underwent ERCP at that time where was noted to have extrinsic compression of the mid CBD from a distended GB and received a stent. Pt first presented with jaundice and underwent ERCP at that time where was noted to have extrinsic compression of the mid CBD from a distended GB and received a stent. Pt first presented with jaundice and underwent ERCP at that time where was noted to have extrinsic compression of the mid CBD from a distended GB and received a stent. Per report number of melanotic stools in am. ST-T waveabnormalities have resolved. # Hypertension, Benign Currently normotensive. whether pt will need full dose as is now taking a diabetic clear liquid tray where earlier was receiving the standard tray. BS this am 230 given sheduled glargine and covered on riss. .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB) Assessment: HCT stable at 25. .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB) Assessment: HCT stable at 25. .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB) Assessment: HCT stable at 25. DM1, R arm fistula. DM1, R arm fistula. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. 62M ESRD admitted to unit for GIB following sphincterotomy and hyperkalemia. Cardio: BP 120-150s sys.. Hr 90-120s. On assessment abd soft distended positive for BS, NPO, no nausea or vomiting.` Action: Serial HCTs drawn. # Hyperkalemia: Now normalized, likely due to receiving blood products in setting of renal failure. On epogen as outpatient per recent discharge summary. BP and HR stable Cardio: BP 120-150s sys.. Hr 90-120s.Given Lopressor 50mg pox1 this am for tachycardia.. Left hand swollen elevated on pillows periph removed. BP and HR stable Cardio: BP 120-150s sys.. Hr 90-120s.Given Lopressor 50mg pox1 this am for tachycardia.. Left hand swollen elevated on pillows periph removed. Cardio: currently normotensive to hypertensive 120-150s. Cardio: currently normotensive to hypertensive 120-150s. - apprecaite ERCP recs, advance diet if ERCP agrees - q6 Hct today - PPi - Holding BP meds given bleed - Tele - Maintain Hct>21 . On assessment abd soft distended positive for BS, no nausea or vomiting.` Action: Serial HCTs drawn. MD made aware and resolved when trying to reproduce dizziness. MD made aware and resolved when trying to reproduce dizziness. MD made aware and resolved when trying to reproduce dizziness. MD made aware and resolved when trying to reproduce dizziness. MD made aware and resolved when trying to reproduce dizziness. Started on clear liquid diet Response: Repeat Hct 23.7 -25.3 Tolerating clear liquids denies nausea or pain Plan: Continue to monitor patient status, serial Hct q6next due at 21 00 and transfuse as needed( goal greater than 21.%) f/u GI recs. Started on clear liquid diet Response: Repeat Hct 23.7 -25.3 Tolerating clear liquids denies nausea or pain Plan: Continue to monitor patient status, serial Hct q6next due at 21 00 and transfuse as needed( goal greater than 21.%) f/u GI recs. | 23 | [
{
"category": "Nursing",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512350,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT stable at 25. Small melanotic stool x3 overnight. On assessment abd\n soft distended positive for BS, NPO, no nausea or vomiting.`\n Action:\n Serial HCTs drawn.\n Response:\n Repeat Hct 25.8\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 48/3.5 .\n Action:\n Urology placed coude cath 14F without difficulty and 575 of urine\n returned.\n Response:\n Continues to drain clear yellow urine in adequate amts via foley\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K on admission 5.8. Per report treated with insulin and D50. Kayexalate\n held / upcoming procedure. K- prior to procedure 4.2\n Action:\n F/u lytes.\n Response:\n Repeat K-3.3\nrepeat chemistry pending\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain.\n Resp: patient was intubated/paralyzed for procedure. Recovered in ICU\n and extubated at 1745. Currently on RA. Denies SOB.\n LS clear.\n Cardio: currently normotensive to hypertensive 120-150\ns. Hr 90-120\n No peripheral edema. Pulses present. Previously troponin positive\n (cardiac source vs renal impairment) another set of CE sent.\n IV access: 3 PIV patent.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 512404,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT stable at 25. Small melanotic stool x3 overnight. On assessment abd\n soft distended positive for BS, NPO, no nausea or vomiting.`\n Action:\n Serial HCTs drawn.\n Response:\n Repeat Hct 25.8\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 48/3.5 .\n Action:\n Urology placed coude cath 14F without difficulty and 575 of urine\n returned.\n Response:\n Continues to drain clear yellow urine in adequate amts via foley\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 4.9. Npo overnight except meds.\n Action:\n F/u lytes.\n Response:\n K stable.\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain. Pt. c/o severe\n dizziness when lying flat and turning to L side. MD made aware and\n resolved when trying to reproduce dizziness. BP and HR stable.\n Resp: Currently on RA. LS clear. Complaining of SOB around 5am and\n placed on cpap machine with good relief.\n Cardio: currently normotensive to hypertensive 120-150\ns. Hr 90-120\n Restarted on lopressor and given 50mg po this am. No peripheral edema.\n Pulses present. Old fistula to R arm bulging with positive\n bruit/thrill. No BP or blood draws to R arm.\n IV access: 3 PIV patent.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512313,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Assumed patient care at 1400 while patient was transferred to ERCP\n suite for procedure. HCT prior to procedure 29 s/p total of 4 units of\n RBC. Per report number of melanotic stools in am. On assessment abd\n soft distended positive for BS, NPO, no vomiting, no more melanotic\n stools noted.\n Action:\n Repeat hct q4hr, transfuse for goal >21. EGD done, no bleeding was\n noted and sphincterotomy site was cauterized again.\n Response:\n Repeat Hct 25.1\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 47/4.5 and elevated K. per report patient still make urine. No UOP\n since 2pm when assumed patient care.\n Action:\n While intubated condom cath applied, 500cc of NS given ( got another 1L\n during ERCP)\n Response:\n BUN/Cr- 46/2.9. no UOP\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K on admission 5.8. Per report treated with insulin and D50. Kayexalate\n held / upcoming procedure. K- prior to procedure 4.2\n Action:\n F/u lytes.\n Response:\n Repeat K-3.3\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain.\n Resp: patient was intubated/paralyzed for procedure. Recovered in ICU\n and extubated at 1745. Currently on RA. Denies SOB.\n LS clear.\n Cardio: currently normotensive to hypertensive 120-150\ns. Hr 90-120\n No peripheral edema. Pulses present. Previously troponin positive\n (cardiac source vs renal impairment) another set of CE sent.\n IV access: 3 PIV patent.\n Social: patient is a FULL CODE. Wife called updated by RN.\n"
},
{
"category": "Physician ",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 512240,
"text": "Chief Complaint: GI Bleed, Hyperkalemia\n HPI:\n 62M DM s/p renal transplant in admitted for ERCP and\n sphincterotomy. Pt first presented with jaundice and underwent\n ERCP at that time where was noted to have extrinsic compression of the\n mid CBD from a distended GB and received a stent. On underwent\n lap chole. Pt subsequently did well in the interim with exception of an\n admission to for LLQ pain () that resolved after\n admission. Imaging and cultures were negative during the admission.\n .\n The pt presented yesterday following repeat ERCP during which his stent\n and gallstone (6mm) were removed. Additionally and additionally\n received a sphincterotomy.\n .\n Following the procedure the pt complained of LUQ cramping and some\n nausea. Overnight the pt had 3 episodes of hematemesis and four\n episodes of BRBPR. The pt baseline HCT 23.1 to 20.5, received 2pRBC\n with bump to 23. Subsequently had additional episodes of hematemesis\n and melena but remained hemodynamically stable. Pt on beta-blocker as\n outpatient, but did not appear to receive a dose last PM. Labs on the\n floor notable for K of 6.6 with question ECG changese (symmetry of T\n waves), and per report was orthostatic following a 4th episode of\n melena (not quantified). The pt received a insulin with amp of D50, 2gm\n of Ca, Kayexelat 30mg. The pt had an additional unit or pRBCs hung and\n was transfered to the unit. PIVs in left arm.\n .\n Upon arrival to the unit the pt denies chest pain, palpitations,\n lightheadedness.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Azathioprine 50mg daily\n Tacrolimus 2mg \n Prednisone 5mg daily\n Bactrim TIW\n .\n Metoprolol 150mg \n Clonidine 0.2mg TID\n Lasix 20mg daily\n Prilosec 20mg daily\n .\n Atorvastatin 20mg daily\n Allopurinol 100mg daily\n Clonazepam 1mg daily\n Calcitriol 0.5mcg daily\n Vitamin D 50,000 units weekly\n Calcium Acetate 667mg TID\n Gabapentin 300mg daily\n Glargine 25 units \n Lumigan 1gtt to both eyes daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n # Diabetes Mellitus - diagnosed at age 10 y/o\n # Diabetic Nephropathy/end-stage renal disease transplanted in\n , on HD for 7 years prior to that.\n # prostate cancer, radical prostatectomy by Dr. in \n without recurrence\n # HTN\n # Gout\n # Hyperparathyroidism, parathyroidectomy ~12 yrs ago.\n # Hypercholesterolemia\n # Obstructive Sleep Apnea - no longer on CPAP\n PAST SURGICAL HISTORY:\n # s/p cadaveric renal transplant in \n # s/p prostectomy\n # s/p vitrectomy - left eye\n Mother - deceased, breast Ca.\n Father - deceased, s/p CVA.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married with 2 sons ages 40 and 23 y/o. Employed as an\n \"expediter\" at . Nonsmoker. Etoh - 1 glass wine/month, denies\n drug use\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, Emesis, Diarrhea\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Flowsheet Data as of 08:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 94 (94 - 94) bpm\n BP: 186/79(104) {186/79(104) - 186/79(104)} mmHg\n RR: 11 (11 - 11) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 385 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n 285 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 385 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, (Murmur:\n Systolic), 3/6 SEM over precordium\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ERCP report :\n A plastic stent placed in the biliary duct was found in the major\n papilla. Removed with snare Single 6 mm irregular stone seen at the\n lower third of the common bile duct. CBD was not dilated. Intrahepatic\n ducts were normal. Sphincterotomy was performed in the over an existing\n guidewire. No bleeding. The stone was disrupted and extracted\n successfully using a Spiral basket. Repeat sweeps x2, debris cleared.\n Otherwise normal ercp to third part of the duodenum\n Assessment and Plan\n ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following\n sphincterotomy and hyperkalemia.\n .\n # GIB: Currently hemodynamically stable with HR in 80s, SBP in 180s,\n receiving his 3rd and 4th units of pRBCs. DDx includes upper GIB (post\n spincterotomy, less likely PUD or erosive gastritis), less likely LGIB\n given hematemesis.\n - Type and Cross 4 units\n - 3 PIVs in LUE\n - PPi\n - ERCP aware and will take pt this AM\n - Holding BP meds given bleed\n - Tele\n - Maintain Hct>21\n .\n # Hyperkalemia: Repeat K of 5 following interventions.\n - Will check lytes following procedure.\n .\n # ESRD s/p Cadaveric Renal Transplant - Renal transplant team aware of\n pt. Pt receiving Azathioprine intravenously, however tacrolimus and\n prednisone can only be PO.\n - Azathioprine 50mg IV daily\n - Tacrolimus 2mg (per transplant fellow, no need to get tacrolimus\n level in AM)\n - Prednisone 5mg daily\n - Continue PPx with Bactrim TIW\n .\n # Hypertension, Benign - Currently asymptomatic in setting of transfer\n with SBP of 180s. Pt on clonidine with known risk for rebound\n hypertension.\n - Consider PRN hydralazine 5mg IV PRN SBP > 170 if\n - Clonidine 0.2mg TID following ERCP\n - Holding home metoprolol 150mg in AM\n # Anemia - Borderline macrocytic, iron studies () suggestive of\n anemia of chronic disease (renal disease). On epogen as outpatient per\n recent discharge summary. Additionally, had colonoscopy in \n without evidence of polyps, only with hemorrhoids and diverticulosis.\n - Keep Hct > 21\n - Discuss epogen and discuss with outpatient nephrologist.\n .\n # BPH - On tamsolusin 0.4mg daily\n .\n # Gout - Allopurinol 100mg daily\n # Hyperparathyroidism - Continue calcitriol 0.5 mcg daily, calcium\n acetate 667mg TID, Vit D 50,000 weekly\n # DM (insulin dependent) - RISS\n # Hyperlipidemia - Will restart statin once taking POs\n # Neuropathy - Restart Gabapentin 300mg once taking POs\n # Glaucoma - on lumigan 1gtt to both eyes daily\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 512242,
"text": "Chief Complaint: GI Bleed, Hyperkalemia\n HPI:\n 62M DM s/p renal transplant in admitted for ERCP and\n sphincterotomy. Pt first presented with jaundice and underwent\n ERCP at that time where was noted to have extrinsic compression of the\n mid CBD from a distended GB and received a stent. On underwent\n lap chole. Pt subsequently did well in the interim with exception of an\n admission to for LLQ pain () that resolved after\n admission. Imaging and cultures were negative during the admission.\n .\n The pt presented yesterday following repeat ERCP during which his stent\n and gallstone (6mm) were removed. Additionally and additionally\n received a sphincterotomy.\n .\n Following the procedure the pt complained of LUQ cramping and some\n nausea. Overnight the pt had 3 episodes of hematemesis and four\n episodes of BRBPR. The pt baseline HCT 23.1 to 20.5, received 2pRBC\n with bump to 23. Subsequently had additional episodes of hematemesis\n and melena but remained hemodynamically stable. Pt on beta-blocker as\n outpatient, but did not appear to receive a dose last PM. Labs on the\n floor notable for K of 6.6 with question ECG changese (symmetry of T\n waves), and per report was orthostatic following a 4th episode of\n melena (not quantified). The pt received a insulin with amp of D50, 2gm\n of Ca, Kayexelat 30mg. The pt had an additional unit or pRBCs hung and\n was transfered to the unit. PIVs in left arm.\n .\n Upon arrival to the unit the pt denies chest pain, palpitations,\n lightheadedness.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Azathioprine 50mg daily\n Tacrolimus 2mg \n Prednisone 5mg daily\n Bactrim TIW\n .\n Metoprolol 150mg \n Clonidine 0.2mg TID\n Lasix 20mg daily\n Prilosec 20mg daily\n .\n Atorvastatin 20mg daily\n Allopurinol 100mg daily\n Clonazepam 1mg daily\n Calcitriol 0.5mcg daily\n Vitamin D 50,000 units weekly\n Calcium Acetate 667mg TID\n Gabapentin 300mg daily\n Glargine 25 units \n Lumigan 1gtt to both eyes daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n # Diabetes Mellitus - diagnosed at age 10 y/o\n # Diabetic Nephropathy/end-stage renal disease transplanted in\n , on HD for 7 years prior to that.\n # prostate cancer, radical prostatectomy by Dr. in \n without recurrence\n # HTN\n # Gout\n # Hyperparathyroidism, parathyroidectomy ~12 yrs ago.\n # Hypercholesterolemia\n # Obstructive Sleep Apnea - no longer on CPAP\n PAST SURGICAL HISTORY:\n # s/p cadaveric renal transplant in \n # s/p prostectomy\n # s/p vitrectomy - left eye\n Mother - deceased, breast Ca.\n Father - deceased, s/p CVA.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married with 2 sons ages 40 and 23 y/o. Employed as an\n \"expediter\" at . Nonsmoker. Etoh - 1 glass wine/month, denies\n drug use\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, Emesis, Diarrhea\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Flowsheet Data as of 08:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 94 (94 - 94) bpm\n BP: 186/79(104) {186/79(104) - 186/79(104)} mmHg\n RR: 11 (11 - 11) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 385 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n 285 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 385 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, (Murmur:\n Systolic), 3/6 SEM over precordium\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ERCP report :\n A plastic stent placed in the biliary duct was found in the major\n papilla. Removed with snare Single 6 mm irregular stone seen at the\n lower third of the common bile duct. CBD was not dilated. Intrahepatic\n ducts were normal. Sphincterotomy was performed in the over an existing\n guidewire. No bleeding. The stone was disrupted and extracted\n successfully using a Spiral basket. Repeat sweeps x2, debris cleared.\n Otherwise normal ercp to third part of the duodenum\n Assessment and Plan\n ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following\n sphincterotomy and hyperkalemia.\n .\n # GIB: Currently hemodynamically stable with HR in 80s, SBP in 180s,\n receiving his 3rd and 4th units of pRBCs. DDx includes upper GIB (post\n spincterotomy, less likely PUD or erosive gastritis), less likely LGIB\n given hematemesis.\n - Type and Cross 4 units\n - 3 PIVs in LUE\n - PPi\n - ERCP aware and will take pt this AM\n - Holding BP meds given bleed\n - Tele\n - Maintain Hct>21\n .\n # Hyperkalemia: Repeat K of 5 following interventions.\n - Will check lytes following procedure.\n .\n # ESRD s/p Cadaveric Renal Transplant - Renal transplant team aware of\n pt. Pt receiving Azathioprine intravenously, however tacrolimus and\n prednisone can only be PO.\n - Azathioprine 50mg IV daily\n - Tacrolimus 2mg (per transplant fellow, no need to get tacrolimus\n level in AM)\n - Prednisone 5mg daily\n - Continue PPx with Bactrim TIW\n .\n # Hypertension, Benign - Currently asymptomatic in setting of transfer\n with SBP of 180s. Pt on clonidine with known risk for rebound\n hypertension.\n - Consider PRN hydralazine 5mg IV PRN SBP > 170 if\n - Clonidine 0.2mg TID following ERCP\n - Holding home metoprolol 150mg in AM\n # Anemia - Borderline macrocytic, iron studies () suggestive of\n anemia of chronic disease (renal disease). On epogen as outpatient per\n recent discharge summary. Additionally, had colonoscopy in \n without evidence of polyps, only with hemorrhoids and diverticulosis.\n - Keep Hct > 21\n - Discuss epogen and discuss with outpatient nephrologist.\n .\n # BPH - On tamsolusin 0.4mg daily\n .\n # Gout - Allopurinol 100mg daily\n # Hyperparathyroidism - Continue calcitriol 0.5 mcg daily, calcium\n acetate 667mg TID, Vit D 50,000 weekly\n # DM (insulin dependent) - RISS\n # Hyperlipidemia - Will restart statin once taking POs\n # Neuropathy - Restart Gabapentin 300mg once taking POs\n # Glaucoma - on lumigan 1gtt to both eyes daily\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 512249,
"text": "Chief Complaint: GI Bleed, Hyperkalemia\n HPI:\n 62M DM s/p renal transplant in admitted for ERCP and\n sphincterotomy. Pt first presented with jaundice and underwent\n ERCP at that time where was noted to have extrinsic compression of the\n mid CBD from a distended GB and received a stent. On underwent\n lap chole. Pt subsequently did well in the interim with exception of an\n admission to for LLQ pain () that resolved after\n admission. Imaging and cultures were negative during the admission.\n .\n The pt presented yesterday following repeat ERCP during which his stent\n and gallstone (6mm) were removed. Additionally and additionally\n received a sphincterotomy.\n .\n Following the procedure the pt complained of LUQ cramping and some\n nausea. Overnight the pt had 3 episodes of hematemesis and four\n episodes of BRBPR. The pt baseline HCT 23.1 to 20.5, received 2pRBC\n with bump to 23. Subsequently had additional episodes of hematemesis\n and melena but remained hemodynamically stable. Pt on beta-blocker as\n outpatient, but did not appear to receive a dose last PM. Labs on the\n floor notable for K of 6.6 with question ECG changese (symmetry of T\n waves), and per report was orthostatic following a 4th episode of\n melena (not quantified). The pt received a insulin with amp of D50, 2gm\n of Ca, Kayexelat 30mg. The pt had an additional unit or pRBCs hung and\n was transfered to the unit. PIVs in left arm.\n .\n Upon arrival to the unit the pt denies chest pain, palpitations,\n lightheadedness.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Azathioprine 50mg daily\n Tacrolimus 2mg \n Prednisone 5mg daily\n Bactrim TIW\n .\n Metoprolol 150mg \n Clonidine 0.2mg TID\n Lasix 20mg daily\n Prilosec 20mg daily\n .\n Atorvastatin 20mg daily\n Allopurinol 100mg daily\n Clonazepam 1mg daily\n Calcitriol 0.5mcg daily\n Vitamin D 50,000 units weekly\n Calcium Acetate 667mg TID\n Gabapentin 300mg daily\n Glargine 25 units \n Lumigan 1gtt to both eyes daily\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n # Diabetes Mellitus - diagnosed at age 10 y/o\n # Diabetic Nephropathy/end-stage renal disease transplanted in\n , on HD for 7 years prior to that.\n # prostate cancer, radical prostatectomy by Dr. in \n without recurrence\n # HTN\n # Gout\n # Hyperparathyroidism, parathyroidectomy ~12 yrs ago.\n # Hypercholesterolemia\n # Obstructive Sleep Apnea - no longer on CPAP\n PAST SURGICAL HISTORY:\n # s/p cadaveric renal transplant in \n # s/p prostectomy\n # s/p vitrectomy - left eye\n Mother - deceased, breast Ca.\n Father - deceased, s/p CVA.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married with 2 sons ages 40 and 23 y/o. Employed as an\n \"expediter\" at . Nonsmoker. Etoh - 1 glass wine/month, denies\n drug use\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, Emesis, Diarrhea\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Flowsheet Data as of 08:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 94 (94 - 94) bpm\n BP: 186/79(104) {186/79(104) - 186/79(104)} mmHg\n RR: 11 (11 - 11) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 385 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n 285 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 385 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, (Murmur:\n Systolic), 3/6 SEM over precordium\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: ERCP report :\n A plastic stent placed in the biliary duct was found in the major\n papilla. Removed with snare Single 6 mm irregular stone seen at the\n lower third of the common bile duct. CBD was not dilated. Intrahepatic\n ducts were normal. Sphincterotomy was performed in the over an existing\n guidewire. No bleeding. The stone was disrupted and extracted\n successfully using a Spiral basket. Repeat sweeps x2, debris cleared.\n Otherwise normal ercp to third part of the duodenum\n Assessment and Plan\n ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following\n sphincterotomy and hyperkalemia.\n .\n # GIB: Currently hemodynamically stable with HR in 80s, SBP in 180s,\n receiving his 3rd and 4th units of pRBCs. DDx includes upper GIB (post\n spincterotomy, less likely PUD or erosive gastritis), less likely LGIB\n given hematemesis.\n - Type and Cross 4 units\n - 3 PIVs in LUE\n - PPi\n - ERCP aware and will take pt this AM\n - Holding BP meds given bleed\n - Tele\n - Maintain Hct>21\n .\n # Hyperkalemia: Repeat K of 5 following interventions.\n - Will check lytes following procedure.\n .\n # ESRD s/p Cadaveric Renal Transplant - Renal transplant team aware of\n pt. Pt receiving Azathioprine intravenously, however tacrolimus and\n prednisone can only be PO.\n - Azathioprine 50mg IV daily\n - Tacrolimus 2mg (per transplant fellow, no need to get tacrolimus\n level in AM)\n - Prednisone 5mg daily\n - Continue PPx with Bactrim TIW\n .\n # Hypertension, Benign - Currently asymptomatic in setting of transfer\n with SBP of 180s. Pt on clonidine with known risk for rebound\n hypertension.\n - Consider PRN hydralazine 5mg IV PRN SBP > 170 if\n - Clonidine 0.2mg TID following ERCP\n - Holding home metoprolol 150mg in AM\n # Anemia - Borderline macrocytic, iron studies () suggestive of\n anemia of chronic disease (renal disease). On epogen as outpatient per\n recent discharge summary. Additionally, had colonoscopy in \n without evidence of polyps, only with hemorrhoids and diverticulosis.\n - Keep Hct > 21\n - Discuss epogen and discuss with outpatient nephrologist.\n .\n # BPH - On tamsolusin 0.4mg daily\n .\n # Gout - Allopurinol 100mg daily\n # Hyperparathyroidism - Continue calcitriol 0.5 mcg daily, calcium\n acetate 667mg TID, Vit D 50,000 weekly\n # DM (insulin dependent) - RISS\n # Hyperlipidemia - Will restart statin once taking POs\n # Neuropathy - Restart Gabapentin 300mg once taking POs\n # Glaucoma - on lumigan 1gtt to both eyes daily\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. This am feeling sl nauseated\n with sitting. Still passing melanotic stool. Access is three 20 g piv.\n 99.3 99 176/69\n Alert\n Chest\n clear w/o crackles\n CV 2/6 SEM\n Abd soft\n Hct 27 (after 3 U PRBC)\n K 5.8\n Likely post-sphincterotomy bleed. He is hemodyn stable but may still be\n bleeding. We have given an additional unit PRBC, we are r/o for MI and\n checking echo, holding on rx of K but following closely, monitoring UO\n closely. Transplant and Transplant Surgery aware. Plan for EGD/ERCP\n this am.\n Time spent 45 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 10:02 ------\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512312,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Assumed patient care at 1400 while patient was transferred to ERCP\n suite for procedure. HCT prior to procedure 29 s/p total of 4 units of\n RBC. Per report number of melanotic stools in am. On assessment abd\n soft distended positive for BS, NPO, no vomiting, no more melanotic\n stools noted.\n Action:\n Repeat hct q4hr, transfuse for goal >21. EGD done, no bleeding was\n noted and sphincterotomy site was cauterized again.\n Response:\n Repeat Hct 25.1\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 47/4.5 and elevated K. per report patient still make urine. No UOP\n since 2pm when assumed patient care.\n Action:\n While intubated condom cath applied, 500cc of NS given ( got another 1L\n during ERCP)\n Response:\n BUN/Cr- 46/2.9. no UOP\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K on admission 5.8. Per report treated with insulin and D50. kayexalate\n held / upcoming procedure. K- priot to procedure 4.2\n Action:\n f/u lytes.\n Response:\n Repeat K-3.3\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain.\n Resp: patient was intubated/paralyzed for procedure. Recovered in ICU\n and extubated at 1745. Currently on RA. Denies SOB.\n LS clear.\n Cardio: currently normotensive to hypertensive 120-150\ns. Hr 90-120\n No peripheral edema. Pulses present. Previously troponin positive\n (cardiac source vs renal impairment) another set of CE sent.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512321,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Assumed patient care at 1400 while patient was transferred to ERCP\n suite for procedure. HCT prior to procedure 29 s/p total of 4 units of\n RBC. Per report number of melanotic stools in am. On assessment abd\n soft distended positive for BS, NPO, no vomiting, no more melanotic\n stools noted.\n Action:\n Repeat hct q4hr, transfuse for goal >21. EGD done, no bleeding was\n noted and sphincterotomy site was cauterized again.\n Response:\n Repeat Hct 25.1\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 47/4.5 and elevated K. per report patient still make urine. No UOP\n since 2pm when assumed patient care.\n Action:\n While intubated condom cath applied, 500cc of NS given ( got another 1L\n during ERCP)\n Response:\n BUN/Cr- 46/2.9. No UOP -> bladder scanned for 328cc. catheterization\n trail failed (HX of prostate CA w/surgery)\n urology called to place\n foley.\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K on admission 5.8. Per report treated with insulin and D50. Kayexalate\n held / upcoming procedure. K- prior to procedure 4.2\n Action:\n F/u lytes.\n Response:\n Repeat K-3.3\nrepeat chemistry pending\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain.\n Resp: patient was intubated/paralyzed for procedure. Recovered in ICU\n and extubated at 1745. Currently on RA. Denies SOB.\n LS clear.\n Cardio: currently normotensive to hypertensive 120-150\ns. Hr 90-120\n No peripheral edema. Pulses present. Previously troponin positive\n (cardiac source vs renal impairment) another set of CE sent.\n IV access: 3 PIV patent.\n Social: patient is a FULL CODE. Wife called updated by RN.\n"
},
{
"category": "Physician ",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 512397,
"text": "Chief Complaint: GIB\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Hct stable overnight\n 24 Hour Events:\n INVASIVE VENTILATION - START 02:42 PM\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dextrose 50% - 03:55 PM\n Pantoprazole (Protonix) - 07:59 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea,\n Constipation, Brown stool OB+\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis, prosthesis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 92 (78 - 135) bpm\n BP: 138/41(65) {84/29(43) - 180/80(108)} mmHg\n RR: 18 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,054 mL\n 608 mL\n PO:\n TF:\n IVF:\n 2,394 mL\n 608 mL\n Blood products:\n 635 mL\n Total out:\n 705 mL\n 735 mL\n Urine:\n 705 mL\n 735 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,349 mL\n -127 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 18 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.49/32/509/20/2\n Ve: 7.9 L/min\n PaO2 / FiO2: 1,697\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 279 K/uL\n 230 mg/dL\n 3.5 mg/dL\n 20 mEq/L\n 4.9 mEq/L\n 48 mg/dL\n 113 mEq/L\n 145 mEq/L\n 23.7 %\n 4.3 K/uL\n [image002.jpg]\n 07:39 AM\n 10:08 AM\n 03:00 PM\n 03:16 PM\n 03:42 PM\n 04:28 PM\n 10:18 PM\n 03:32 AM\n 07:51 AM\n WBC\n 4.4\n 4.3\n Hct\n 26.7\n 29.0\n 18.1\n 25.1\n 25.2\n 25.8\n 23.7\n Plt\n 266\n 279\n Cr\n 3.8\n 2.9\n 3.8\n 3.5\n TropT\n 0.05\n 0.05\n 0.03\n TCO2\n 25\n Glucose\n 106\n 46\n 159\n 230\n Other labs: CK / CKMB / Troponin-T:24/2/0.03, ALT / AST:, Alk Phos\n / T Bili:74/0.7, Amylase / Lipase:31/17, Lactic Acid:0.8 mmol/L,\n Albumin:3.5 g/dL, LDH:241 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n .H/O GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n .H/O TRANSPLANT, KIDNEY (RENAL TRANSPLANT)\n .H/O HYPERTENSION, BENIGN\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n Hct has been stable for 24 hrs w/o transfusion. Stool now brown.\n Unclear where bleeding originated but sphincterotomy still seems most\n likely. Unclear why he had difficulty voiding last night but Urology\n recommended early removel\n ICU Care\n Nutrition:\n Comments: clear - advance\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:57 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512306,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Assumed patient care at 1400 while patient was transferred to ERCP\n suite for procedure. HCT prior to procedure 29 s/p total of 4 units of\n RBC. Per report number of melanotic stools in am. On assessment abd\n soft distended positive for BS, NPO, no vomiting, no more melanotic\n stools noted.\n Action:\n Repeat hct q4hr, transfuse for goal >21. EGD done, no bleeding was\n noted and sphincterotomy site was cauterized again.\n Response:\n Repeat Hct 25.1\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 47/4.5 and elevated K. per report patient still make urine. No UOP\n since 2pm when assumed patient care.\n Action:\n While intubated condom cath applied, 500cc of NS given ( got another 1L\n during ERCP)\n Response:\n pending\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512303,
"text": "NURING PROGRESS NOTE 0700-1200\n A&O x3. Denies pain. Received 4^th uPRBC with Hct up to 29. Passed\n liquid maroon stool x3. 1 episode of dizzyness when turned with\n associated nausea. Compazine x1 with gd effect. Plan for ERCP when\n hyperkalemia improved.\n K+ 5.8. Glucose 376. Given 10u insulin IV with K+ down to 4.2. Unable\n to take kayexelate d/t NPO for procedure. No UO since admit.\n Continue close monitoring of K+, glucose and Hct. ERCP on call. Treat\n with kayexelate after procedure. 3u PRBCs on hold in BB. Q6hr FSs.\n"
},
{
"category": "Physician ",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 512364,
"text": "TITLE:\n Chief Complaint: -Had ERCP saw \"erythema\" at the duodenal bulb, did\n some cauterization\n recs: strict NPO, IV PPI\n - at 0350 pt noted some vertigo symptoms when turning head left,\n -hallpike maneuver negative for nystagmus or vertigo\n - at 0419 pt complained of SOB wanted O2. Sat 100% on RA, lungs clear.\n EKG obtained and showed no acute ST changes, sinus tach. Given\n Metoprolol 25mg PO x 1 for HR 120s, BP 140s-150s. Pulmonary exam clear.\n Pt gets SOB at night, states he uses CPAP at home which helps.\n 24 Hour Events:\n INVASIVE VENTILATION - START 02:42 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:34 AM\n Dextrose 50% - 03:55 PM\n Pantoprazole (Protonix) - 07:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 80 (78 - 135) bpm\n BP: 130/53(71) {84/29(43) - 193/80(108)} mmHg\n RR: 4 (0 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,054 mL\n 608 mL\n PO:\n TF:\n IVF:\n 2,394 mL\n 608 mL\n Blood products:\n 635 mL\n Total out:\n 705 mL\n 495 mL\n Urine:\n 705 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,349 mL\n 113 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 18 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: 7.49/32/509/20/2\n Ve: 7.9 L/min\n PaO2 / FiO2: 1,697\n Physical Examination\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, (Murmur:\n Systolic), 3/6 SEM over precordium\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 279 K/uL\n 8.7 g/dL\n 230 mg/dL\n 3.5 mg/dL\n 20 mEq/L\n 4.9 mEq/L\n 48 mg/dL\n 113 mEq/L\n 145 mEq/L\n 25.8 %\n 4.3 K/uL\n [image002.jpg]\n 07:39 AM\n 10:08 AM\n 03:00 PM\n 03:16 PM\n 03:42 PM\n 04:28 PM\n 10:18 PM\n 03:32 AM\n WBC\n 4.4\n 4.3\n Hct\n 26.7\n 29.0\n 18.1\n 25.1\n 25.2\n 25.8\n Plt\n 266\n 279\n Cr\n 3.8\n 2.9\n 3.8\n 3.5\n TropT\n 0.05\n 0.05\n 0.03\n TCO2\n 25\n Glucose\n 106\n 46\n 159\n 230\n Other labs: CK / CKMB / Troponin-T:24/2/0.03, Lactic Acid:0.8 mmol/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following\n sphincterotomy and hyperkalemia.\n .\n # GIB: Pt underwent ERCP with cauterization of erythematous area at\n sphincter. Repeat Hcts post-procedure have been stable.\n - Type and Cross 4 units\n - 3 PIVs in LUE\n - PPi\n - Holding BP meds given bleed\n - Tele\n - Maintain Hct>21\n .\n # Hyperkalemia: Now normalized\n - check lytes \n .\n # ESRD s/p Cadaveric Renal Transplant - Renal transplant team aware of\n pt. Pt receiving Azathioprine intravenously, however tacrolimus and\n prednisone can only be PO.\n - Azathioprine 50mg IV daily\n - Tacrolimus 2mg \n - Prednisone 5mg daily\n - Continue PPx with Bactrim\n .\n # Hypertension, Benign\n Currently normotensive.\n - Consider PRN hydralazine 5mg IV PRN SBP > 170\n - holding clonidine and metoprolol, monitor vitals over day today and\n consider restarting in AM\n # Anemia - Borderline macrocytic, iron studies () suggestive of\n anemia of chronic disease (renal disease). On epogen as outpatient per\n recent discharge summary. Additionally, had colonoscopy in \n without evidence of polyps, only with hemorrhoids and diverticulosis.\n - Keep Hct > 21\n .\n # BPH - On tamsolusin 0.4mg daily\n .\n # Gout - Allopurinol 100mg daily\n # Hyperparathyroidism - Continue calcitriol 0.5 mcg daily, calcium\n acetate 667mg TID, Vit D 50,000 weekly\n # DM (insulin dependent) - RISS\n # Hyperlipidemia - Will restart statin once taking POs\n # Neuropathy - Restart Gabapentin 300mg once taking POs\n # Glaucoma - on lumigan 1gtt to both eyes daily\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512218,
"text": "62 yr M s/p ERCP, sphincterotomy, stent placement and stone removal\n . chronic hct drop since /09 31\n 20.5. Bloody stool x4 and\n bilious emesis x3, dizzy BP 130s-140s, O2 sat 96-100% on RA. K 6.6, D50\n and regular insulin given on floor. 2gm Ca gluconate hung on the flr\n and 2 units RBCs given hct prior to transfer 23.8. Additional unit RBC\n given on arrival.\n PMH: DM1, prostate CA/prostatectomy, HTN, gout,\n hyperparathyroidism/parathyroidectomy, OSA.\n Neuro: alert and oriented, low grade fever 99. no c/o pain or\n dizziness.\n Resp: LSC, O2 sat 100% on 2L NC. No c/o SOB or increased WOB.\n CV: HTN 170s, HR 80s. EKG done on flr prior to transfer. K 5.0\n GI/GU: Baseline Cr 4.0, s/p renal transplant . DM1, R arm fistula.\n Access: 20g PIV x3 in L arm. No BP or PIVs in R arm d/t fistula.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512217,
"text": "62 yr M s/p ERCP, sphincterotomy, stent placement and stone removal\n . chronic hct drop since /09 31\n 20.5. Bloody stool x4 and\n bilious emesis x3, dizzy BP 130s-140s, O2 sat 96-100% on RA. K 6.6, D50\n and regular insulin given on floor. 2gm Ca gluconate hung on the flr\n and 2 units RBCs given hct prior to transfer 23.8. Additional unit RBC\n given on arrival.\n PMH: DM1, prostate CA/prostatectomy, HTN, gout,\n hyperparathyroidism/parathyroidectomy, OSA.\n Neuro: alert and oriented, low grade fever 99. no c/o pain or\n dizziness.\n Resp: LSC, O2 sat 100% on 2L NC. No c/o SOB or increased WOB.\n CV: HTN 170s, HR 80s. EKG done on flr prior to transfer. K 5.0\n GI/GU: Baseline Cr 4.0, s/p renal transplant . DM1, R arm fistula.\n Access: 20g PIV x3 in L arm. No BP or PIVs in R arm d/t fistula.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 512452,
"text": " 62M ESRD admitted to unit for GIB following sphincterotomy stent\n placement and stone removal on . and hyperkalemia. Received a\n total of 4 units prbc with hct improving to 29.% Had repeat ERCP saw\n \"erythema\" at the duodenal bulb, did some cauterization . pt sedated\n and paralysed for procedure successfully extbated on evening of .\n - at 0350 pt noted some vertigo symptoms when turning head left,\n -hallpike maneuver negative for nystagmus or vertigo\n - at 0419 pt complained of SOB wanted O2. Sat 100% on RA, lungs clear.\n EKG obtained and showed no acute ST changes, sinus tach. Given\n Metoprolol 25mg PO x 1 for HR 120s, BP 140s-150s. Pulmonary exam clear.\n Pt gets SOB at night, states he uses CPAP at home which helps..\n Pt remained on ra throughout shift with sats 99-100% lung sounds are\n clear upper diminished at bases with strong productive cough of thick\n white secretions appears comfortable and in no distress denies pain or\n SOB\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT stable at 25. Small melanotic stool x3 overnight. On assessment abd\n soft distended positive for BS, no nausea or vomiting.` no stool today\n Action:\n Serial HCTs drawn.\n Started on clear liquid diet\n Response:\n Repeat Hct 23.7 -25.3\n Tolerating clear liquids denies nausea or pain\n Plan:\n Continue to monitor patient status,\n serial Hct q6next due at 21 00 and transfuse as needed( goal greater\n than 21.%)\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 48/3.5 .\n Low urine output\n Action:\n Urology placed coude cath 14F without difficultly last night\n Encouraged increased po intake\n Response:\n Continues to drain clear yellow urine\n u/o 20-30 mls/hr. team aware.\n Plan:\n Continue to monitor patient status, monitor renal function, f/u renal\n recs.\n Will not d/c foley at this time until pts u/o improves.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 5.8 on admission .\n Action:\n Checked lytes q8.\n Response:\n K stable. last k 4.1 at 1500 next due at\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain. Pt. c/o severe\n dizziness when lying flat and turning to L side. MD made aware and\n resolved when trying to reproduce dizziness. BP and HR stable\n Cardio: BP 120-150\ns sys.. Hr 90-120\ns.Given Lopressor 50mg pox1 this\n am for tachycardia.. Left hand swollen elevated on pillows periph\n removed. Pulses present.\n Old fistula to R arm bulging with positive bruit/thrill. No BP or\n blood draws to R arm.\n IV access: 2 PIV patent.\n BS this am 230 given sheduled glargine and covered on riss. 213 at 12md\n gave 4units humalog. At 1800 BS 83. pt is due glargine at bedtime ?\n whether pt will need full dose as is now taking a diabetic clear liquid\n tray where earlier was receiving the standard tray.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n EPIGASTRIC ABDOMINAL PAIN ERCP\n Code status:\n Height:\n Admission weight:\n 101.6 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin, GI Bleed\n CV-PMH: Hypertension\n Additional history: renal transplants \n prostectomy , prostate CA\n gout\n hyperparathyroidism, parathyroidectomy\n OSA\n hypercholesterolemia\n Surgery / Procedure and date: ERCP \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:89\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 30% %\n 24h total in:\n 3,108 mL\n 24h total out:\n 905 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:32 AM\n Potassium:\n 4.1 mEq/L\n 03:00 PM\n Chloride:\n 113 mEq/L\n 03:32 AM\n CO2:\n 20 mEq/L\n 03:32 AM\n BUN:\n 48 mg/dL\n 03:32 AM\n Creatinine:\n 3.5 mg/dL\n 03:32 AM\n Glucose:\n 230 mg/dL\n 03:32 AM\n Hematocrit:\n 25.2 %\n 02:47 PM\n Finger Stick Glucose:\n 178\n 08:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: transferred with pt.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 11 resisman\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 512352,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT stable at 25. Small melanotic stool x3 overnight. On assessment abd\n soft distended positive for BS, NPO, no nausea or vomiting.`\n Action:\n Serial HCTs drawn.\n Response:\n Repeat Hct 25.8\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 48/3.5 .\n Action:\n Urology placed coude cath 14F without difficulty and 575 of urine\n returned.\n Response:\n Continues to drain clear yellow urine in adequate amts via foley\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 4.9. Npo overnight except meds.\n Action:\n F/u lytes.\n Response:\n K stable.\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain. Pt. c/o severe\n dizziness when lying flat and turning to L side. MD made aware and\n resolved when trying to reproduce dizziness. BP and HR stable.\n Resp: Currently on RA. LS clear. Complaining of SOB around 5am and\n placed on cpap machine with good relief.\n Cardio: currently normotensive to hypertensive 120-150\ns. Hr 90-120\n Restarted on lopressor and given 50mg po this am. No peripheral edema.\n Pulses present. Old fistula to R arm bulging with positive\n bruit/thrill. No BP or blood draws to R arm.\n IV access: 3 PIV patent.\n"
},
{
"category": "Respiratory ",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 512343,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt seen for routine CPAP setup. Pt uses CPAP at home. Placed\n on Autoset #2.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 512429,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia. Had ERCP saw \"erythema\" at the duodenal bulb, did some\n cauterization\n recs: strict NPO, IV PPI\n - at 0350 pt noted some vertigo symptoms when turning head left,\n -hallpike maneuver negative for nystagmus or vertigo\n - at 0419 pt complained of SOB wanted O2. Sat 100% on RA, lungs clear.\n EKG obtained and showed no acute ST changes, sinus tach. Given\n Metoprolol 25mg PO x 1 for HR 120s, BP 140s-150s. Pulmonary exam clear.\n Pt gets SOB at night, states he uses CPAP at home which helps.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT stable at 25. Small melanotic stool x3 overnight. On assessment abd\n soft distended positive for BS, no nausea or vomiting.` no stool today\n Action:\n Serial HCTs drawn.\n Started on clear liquid diet\n Response:\n Repeat Hct 23.7 -25.3\n Plan:\n Continue to monitor patient status,\n serial Hct and transfuse as needed goal greater than 21.%\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 48/3.5 .\n Low urine output\n Action:\n Urology placed coude cath 14F without difficultly last night\n Encouraged increased po intake\n Response:\n Continues to drain clear yellow urine\n u/o 20-30 mls/hr.\n Plan:\n Continue to monitor patient status, monitor renal function, f/u renal\n recs.\n Will not d/c foley at this time until pts u/o improves.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 4.9.\n Action:\n Checked lytes q8.\n Response:\n K stable. last k 4.1 at 1500\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain. Pt. c/o severe\n dizziness when lying flat and turning to L side. MD made aware and\n resolved when trying to reproduce dizziness. BP and HR stable.\n Resp: Currently on RA. LS clear. Complaining of SOB around 5am and\n placed on cpap machine with good relief.\n Cardio: BP 120-150\ns sys.. Hr 90-120\ns. Restarted on lopressor and\n given 50mg po this am. left hand swollen elevated on pillow s periph\n removed. Pulses present.\n Old fistula to R arm bulging with positive bruit/thrill. No BP or\n blood draws to R arm.\n IV access: 2 PIV patent.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 512406,
"text": "62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia. Had ERCP saw \"erythema\" at the duodenal bulb, did some\n cauterization\n recs: strict NPO, IV PPI\n - at 0350 pt noted some vertigo symptoms when turning head left,\n -hallpike maneuver negative for nystagmus or vertigo\n - at 0419 pt complained of SOB wanted O2. Sat 100% on RA, lungs clear.\n EKG obtained and showed no acute ST changes, sinus tach. Given\n Metoprolol 25mg PO x 1 for HR 120s, BP 140s-150s. Pulmonary exam clear.\n Pt gets SOB at night, states he uses CPAP at home which helps.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT stable at 25. Small melanotic stool x3 overnight. On assessment abd\n soft distended positive for BS, no nausea or vomiting.`\n Action:\n Serial HCTs drawn.\n Started on clear liquid diet\n Response:\n Repeat Hct 23.7\n Plan:\n Continue to monitor patient status, f/u Hct and transfuse as needed.\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 48/3.5 .\n u/o 60 mls total for last 3 hours team awre\n Action:\n Urology placed coude cath 14F without difficultly.,\n Response:\n Continues to drain clear yellow urine in adequate amts via foley\n Plan:\n Continue to monitor patient status, f/u renal function, f/u renal recs.\n Will not d/c foley at this time until pts u/o improves.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 4.9. Npo overnight except meds.\n Action:\n F/u lytes.\n Response:\n K stable.\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain. Pt. c/o severe\n dizziness when lying flat and turning to L side. MD made aware and\n resolved when trying to reproduce dizziness. BP and HR stable.\n Resp: Currently on RA. LS clear. Complaining of SOB around 5am and\n placed on cpap machine with good relief.\n Cardio: currently normotensive to hypertensive 120-150\ns. Hr 90-120\n Restarted on lopressor and given 50mg po this am. No peripheral edema.\n Pulses present. Old fistula to R arm bulging with positive\n bruit/thrill. No BP or blood draws to R arm.\n IV access: 3 PIV patent.\n"
},
{
"category": "Nursing",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 512431,
"text": " 62M ESRD admitted to unit for GIB following sphincterotomy and\n hyperkalemia. Had ERCP saw \"erythema\" at the duodenal bulb, did some\n cauterization .\n - at 0350 pt noted some vertigo symptoms when turning head left,\n -hallpike maneuver negative for nystagmus or vertigo\n - at 0419 pt complained of SOB wanted O2. Sat 100% on RA, lungs clear.\n EKG obtained and showed no acute ST changes, sinus tach. Given\n Metoprolol 25mg PO x 1 for HR 120s, BP 140s-150s. Pulmonary exam clear.\n Pt gets SOB at night, states he uses CPAP at home which helps..\n Pt remained on ra throughout shift with sats 99-100% lung sounds are\n clear upper diminished at bases with strong productive cough of thick\n white secretions appears comfortable and in no distress denies pain or\n SOB\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT stable at 25. Small melanotic stool x3 overnight. On assessment abd\n soft distended positive for BS, no nausea or vomiting.` no stool today\n Action:\n Serial HCTs drawn.\n Started on clear liquid diet\n Response:\n Repeat Hct 23.7 -25.3\n Tolerating clear liquids denies nausea or pain\n Plan:\n Continue to monitor patient status,\n serial Hct q6next due at 21 00 and transfuse as needed( goal greater\n than 21.%)\n f/u GI recs.\n .H/O transplant, kidney (Renal transplant)\n Assessment:\n Patient with hx of renal failure s/p kidney transplant. Bun /Cr -\n 48/3.5 .\n Low urine output\n Action:\n Urology placed coude cath 14F without difficultly last night\n Encouraged increased po intake\n Response:\n Continues to drain clear yellow urine\n u/o 20-30 mls/hr. team aware.\n Plan:\n Continue to monitor patient status, monitor renal function, f/u renal\n recs.\n Will not d/c foley at this time until pts u/o improves.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 5.8 on admission .\n Action:\n Checked lytes q8.\n Response:\n K stable. last k 4.1 at 1500 next due at\n Plan:\n Continue to monitor Lytes. Renal follows.\n Neuro: alert oriented follows commands, denies pain. Pt. c/o severe\n dizziness when lying flat and turning to L side. MD made aware and\n resolved when trying to reproduce dizziness. BP and HR stable\n Cardio: BP 120-150\ns sys.. Hr 90-120\ns.Given Lopressor 50mg pox1 this\n am for tachycardia.. Left hand swollen elevated on pillows periph\n removed. Pulses present.\n Old fistula to R arm bulging with positive bruit/thrill. No BP or\n blood draws to R arm.\n IV access: 2 PIV patent.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n EPIGASTRIC ABDOMINAL PAIN ERCP\n Code status:\n Height:\n Admission weight:\n 101.6 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin, GI Bleed\n CV-PMH: Hypertension\n Additional history: renal transplants \n prostectomy , prostate CA\n gout\n hyperparathyroidism, parathyroidectomy\n OSA\n hypercholesterolemia\n Surgery / Procedure and date: ERCP \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:89\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 30% %\n 24h total in:\n 3,108 mL\n 24h total out:\n 905 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:32 AM\n Potassium:\n 4.1 mEq/L\n 03:00 PM\n Chloride:\n 113 mEq/L\n 03:32 AM\n CO2:\n 20 mEq/L\n 03:32 AM\n BUN:\n 48 mg/dL\n 03:32 AM\n Creatinine:\n 3.5 mg/dL\n 03:32 AM\n Glucose:\n 230 mg/dL\n 03:32 AM\n Hematocrit:\n 25.2 %\n 02:47 PM\n Finger Stick Glucose:\n 178\n 08:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: transferred with pt.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 11 resisman\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2160-01-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 512415,
"text": "TITLE:\n Chief Complaint: -Had ERCP saw \"erythema\" at the duodenal bulb, did\n some cauterization\n recs: strict NPO, IV PPI\n - at 0350 pt noted some vertigo symptoms when turning head left,\n -hallpike maneuver negative for nystagmus or vertigo\n - at 0419 pt complained of SOB wanted O2. Sat 100% on RA, lungs clear.\n EKG obtained and showed no acute ST changes, sinus tach. Given\n Metoprolol 25mg PO x 1 for HR 120s, BP 140s-150s. Pulmonary exam clear.\n Pt gets SOB at night, states he uses CPAP at home which helps.\n 24 Hour Events:\n INVASIVE VENTILATION - START 02:42 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:34 AM\n Dextrose 50% - 03:55 PM\n Pantoprazole (Protonix) - 07:59 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 80 (78 - 135) bpm\n BP: 130/53(71) {84/29(43) - 193/80(108)} mmHg\n RR: 4 (0 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,054 mL\n 608 mL\n PO:\n TF:\n IVF:\n 2,394 mL\n 608 mL\n Blood products:\n 635 mL\n Total out:\n 705 mL\n 495 mL\n Urine:\n 705 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,349 mL\n 113 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 600) mL\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 18 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: 7.49/32/509/20/2\n Ve: 7.9 L/min\n PaO2 / FiO2: 1,697\n Physical Examination\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, (Murmur:\n Systolic), 3/6 SEM over precordium\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 279 K/uL\n 8.7 g/dL\n 230 mg/dL\n 3.5 mg/dL\n 20 mEq/L\n 4.9 mEq/L\n 48 mg/dL\n 113 mEq/L\n 145 mEq/L\n 25.8 %\n 4.3 K/uL\n [image002.jpg]\n 07:39 AM\n 10:08 AM\n 03:00 PM\n 03:16 PM\n 03:42 PM\n 04:28 PM\n 10:18 PM\n 03:32 AM\n WBC\n 4.4\n 4.3\n Hct\n 26.7\n 29.0\n 18.1\n 25.1\n 25.2\n 25.8\n Plt\n 266\n 279\n Cr\n 3.8\n 2.9\n 3.8\n 3.5\n TropT\n 0.05\n 0.05\n 0.03\n TCO2\n 25\n Glucose\n 106\n 46\n 159\n 230\n Other labs: CK / CKMB / Troponin-T:24/2/0.03, Lactic Acid:0.8 mmol/L,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 62M ESRD admitted to unit for GIB following\n sphincterotomy and hyperkalemia.\n .\n # GIB: Pt underwent ERCP with cauterization of erythematous area at\n sphincter. Repeat Hcts post-procedure have been stable. Unclear where\n he was bleeding from, but appears to have resolved with normal\n nonbloody BM today.\n - apprecaite ERCP recs, advance diet if ERCP agrees\n - q6 Hct today\n - PPi\n - Holding BP meds given bleed\n - Tele\n - Maintain Hct>21\n .\n # Hyperkalemia: Now normalized, likely due to receiving blood products\n in setting of renal failure.\n - check lytes \n .\n # ESRD s/p Cadaveric Renal Transplant - Renal transplant team aware of\n pt.\n - Azathioprine 50mg IV daily\n - Tacrolimus 2mg \n - Prednisone 5mg daily\n - Continue PPx with Bactrim\n .\n # Hypertension, Benign\n Currently normotensive.\n - Consider PRN hydralazine 5mg IV PRN SBP > 170\n - holding clonidine and metoprolol, monitor vitals over day today and\n consider restarting in AM\n # Anemia - Borderline macrocytic, iron studies () suggestive of\n anemia of chronic disease (renal disease). On epogen as outpatient per\n recent discharge summary. Additionally, had colonoscopy in \n without evidence of polyps, only with hemorrhoids and diverticulosis.\n - Keep Hct > 21\n .\n # BPH - On tamsolusin 0.4mg daily\n .\n # Gout - Allopurinol 100mg daily\n # Hyperparathyroidism - Continue calcitriol 0.5 mcg daily, calcium\n acetate 667mg TID, Vit D 50,000 weekly\n # DM (insulin dependent) - RISS\n # Hyperlipidemia - Will restart statin once taking POs\n # Neuropathy - Restart Gabapentin 300mg once taking POs\n # Glaucoma - on lumigan 1gtt to both eyes daily\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "ECG",
"chartdate": "2160-01-12 00:00:00.000",
"description": "Report",
"row_id": 127040,
"text": "Sinus rhythm at upper limits of normal rate. Borderline short P-R interval.\nMinor ST-T wave abnormalities. Since the previous tracing of the rate\nis faster and right bundle-branch block is no longer seen. ST-T wave\nabnormalities have resolved. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-01-10 00:00:00.000",
"description": "Report",
"row_id": 127041,
"text": "Normal sinus rhythm. Frontal plane axis plus 30 degrees. Complete right\nbundle-branch block with QRS duration of 128 milliseconds. There is flat\nST segment depression in leads I, II, aVL and V4-V6. Compared to the previous\ntracing of Q-T interval prolongation is no longer present. The\nST segment depression noted above is new and the complete right bundle-branch\nblock is new. These changes may be related to myocardial ischemia.\n\n"
}
] |
17,966 | 194,273 | The patient was admitted to the cardiology service. The patient underwent cardiac catheterization on hospital day #1. This was significant for RCA stenosis of 70% and LAD stenosis of 90% and OM1 stenosis of 80% and OM2 stenosis of 60%. The patient tolerated this procedure well, was stabilized on aspirin, nitroglycerin drip, Zestril and a heparin drip. Hospital day #2, the patient was seen by for elevated blood glucose level resistant to insulin sliding scale. The patient was started on insulin drip for better glucose control. The patient was then seen by cardiothoracic surgery and evaluated for coronary artery bypass grafting. On hospital day #3, the patient was taken to the Operating Room where she underwent coronary artery bypass graft x4 with Dr. and the cardiothoracic team. The grafts were left internal mammary artery to LAD, left radial to OM, supraventricular tachycardia to AM and supraventricular tachycardia to diagonal. The patient tolerated this procedure well. She underwent an EVH on the right thigh with hybrid skip of the right calf. She was transferred to the cardiothoracic surgery Intensive Care Unit stable on propofol and nitroglycerin drip. The patient postoperatively has remained stable. The patient was extubated without incident. The patient remained hemodynamically stable although the first postoperative night remained tachycardic. The patient was managed with intervascular expansion with Hespan and heart rate responded appropriately. The patient was weaned of all drips. Hematocrit was stable at 22. The patient had episode of chest tightness on postoperative day #1. Echocardiogram was performed which was significant for improvement in inferior wall motion compared to the previous study on . The patient continued to remain hemodynamically stable. Electrocardiogram showed no significant changes. On postoperative day #3, the patient continued to remain afebrile and hemodynamically stable and was transferred to the floor for the remainder of her recovery. The patient was seen by physical therapy and this is currently a level 5 activity. Hematocrits remained stable with the last hematocrit being 24. The chest tube, wires and Foley were discontinued without incident. Her blood glucose levels have been followed by the Clinic, has remained in the 100s to 200s. The patient has been restarted on her fixed U-500 insulin dose in a sliding scale . The patient is tolerating a cardiac diet. Wounds remain clean, dry and intact. The patient stable, now ready for discharge home with follow up with Dr. in six weeks and follow up with Dr. in one week. | Mild (1+) mitralregurgitation is seen. PATIENT WARM, ALL VS STABLE.PATIENT REVERSED, PROPOFOL DC'D. problem swallowing thin liquid.cv: NSR/ST without ectopy. PATIENT/TEST INFORMATION:Indication: rising CPKs/p CABGHeight: (in) 65BP (mm Hg): 116/58HR (bpm): 95Status: InpatientDate/Time: at 16:41Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity size is normal. DSG C/D/I.GI-ABD SOFT, NT/ND. Left ventricular wall thicknesses and cavity size are normal.There is severe global left ventricular hypokinesis with focal near akinesisof the distal half of the anterior septum and anterior walls and apex. Sinus tachycardiaPossible anterior infarct - age undeterminedInferior/lateral ST-T changesSince previous tracing, , no significant change The interatrial septum is mildlyaneurysmal. 2) Satisfactory postoperative appearance with minimal atelectatic changes. Ct's w/ serousang dng. Dopplerable DP/PT bilat however right PT very faint. Sinus tachycardiaDiffuse ST-T abnormalities suggestive of ischemiaSince the tracing of , probable no significant change. 09.6-99. warm, dry, slight general edema. Theinteratrial septum is aneurysmal.LEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.There is severe global left ventricular hypokinesis.RIGHT VENTRICLE: Right ventricular chamber size is normal. , , FOLLOWS COMMANDS.CV: MP SR TO ST WITHOUT. Mild mitral regurgitation.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). There is stable mild widening of cardiac and mediastinal contours. Rightventricular systolic function appears depressed.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve is not well seen.MITRAL VALVE: The mitral valve leaflets are structurally normal.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. PULM HYGIENE. BS MONITORED Q 2HRS AND GTT TITRATED ACCORDINGLY.PLAN-CON'T WITH CURRENT PLAN. NEURO; LETHARGIC BUT ORIENTED AND FOLLOWS COMMANDS, MAE,CV; HR 80'S SR, C/O "CHEST PRESSURE" THIA AM, AND SEEN BY PA, STAT EKG DONE AND NO CHANGES, PT SL VAGUE WITH SX, WAS DOZING OFF AND ON PRIOR, STATED DISCOMF RT AND LEFT STERNAL AREA, 2 D ECHO DONE,NEO WEANED TO 0.62 MCG/KG/MIN, GOAL MAP < 60, ON INVESTIGATION DRUG CARIPORIDE, CPKS DRAWN TODAY, VERY ELEVATED, PT HAS R/I FOR MI, GENERALIZED EDEMA OF EXTREMITIES, PEDAL AND PT PULSES , MEDIC WITH TORADOL AND MORPHINE , RESTING AT PRESENT, NO C/O DISCOMFORT,RESPIR LUNGS CLEAR BUT DIM AT BASES, ON N/C AT 4/LMIN, EXPECTORATED SMALL AMT THICK YELLOW BROWN MUCOUSENDOCRINE; BS RANGE 150'S, INSULIN GTT ORIGINALLY AT 6 U/HR, NOW AT 5/ UN/HR AND FOLLOWING CLINIC GUIDELINESSKIN; ACE WRAP TO MAMMARY GRAFT SITE D/I, ELEVATED ON PILLOW, RT LEG ACE WRAP D/I HR 100'S, ST, NO ECTOPY. Mild (1+)mitral regurgitation is seen.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a low risk (prophylaxis not recommended). The mediastinal and hilar contours are normal. HR 90's NSR, no ectopy noted. Sinus tachycardiaPossible anterior infarct - age undeterminedInferior/lateral ST-T changes may be a normal variant for a female of this ageSince previous tracing, , no significant change The pulmonary vascularity is within normal limits. PA AND LATERAL CHEST: The heart size is upper limits of normal. FP good off Neo. There are bilateral pleural effusions unchanged in size from prior exam. Overall leftventricular systolic function is moderately depressed.RIGHT VENTRICLE: The right ventricular cavity is mildly dilated. PACER OFF, WIRES REMAIN IN.RESP-O2 SAT 96-98% 2LNC. TANSFUSIONS HO WILL DISCUSS WITH DR .GI: TOLERATING CLEAR LIQUIDS. Normal L. hand strength. IMMEDIATELY CAME BACK UP WHEN ACTIVITY STOPPED. LEFT ARM DSG C/D/I. DENIES CARDIAC COMPLAINTS. The left ventricular cavity size is normal. Regional rightventricular systolic function cannot be reliably assessed.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are structurally normal. PATIENT/TEST INFORMATION:Indication: Chest pain.Height: (in) 65Weight (lb): 170BSA (m2): 1.85 m2BP (mm Hg): 120/70HR (bpm): 90Status: InpatientDate/Time: at 15:36Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. Left radial pulse strong, dsd intact. The mediastinal and hilar contours are stable. POST OP/ICU COURSE OTHERWISE UNEVENTFUL. SKIN W+D. Sinus rhythmExtensive ST-T changes are abnormal for age/sexPoor R wave progressionSince previous tracing, , no significant change LS CTA, BUT DECREASED AT BASES. Rightventricular cavity size is normal. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic regurgitation.The mitral valve leaflets are structurally normal. Sternal, left arm, and leg incisions w/ dsgs dry and intact. C/O pain in left breast-relieved with MSO4 and Percocet. OOB WITH ENC AND ASSIST.COMFORT-PERCOCET PRN FOR INCISIONAL PAIN WITH ADEQ STATED EFFECT.SKIN-STERNAL DSG C/D/I. Wean neo as tol. +BS. + BS. Updated on pt's condition. MAE without difficulty.CV: CI 2.0. Sternal dsg. The lungs appear otherwise clear and the osseous structures are unremarkable. Overall left ventricularsystolic function is probably moderately depressed. +PP. Chest tubes intact - no air leak, no crepitus, draining serosanguios liquid, DSD -intact.resp; Clear lung sound bilaterally in upper lobes, dimish in lower lobes. CHEST TUBE REMAINS TO WATER SEAL.A: OOB LATER TODAY. There is no pericardial effusion.IMPRESSION: Severe global hypokinesis c/w diffuse process (multivessel CAD,toxin, metabolic, etc.) PAPABLE PULSES. Stiff L. arm and leg - movement stiff. Sinus rhythm. PT INITIALLY ON NEO, BUT SINCE WEANED OFF. ABD, chest, L.lower arm, R. leg - dressing intact, no drainage.Comfort verbally and explain all procedure.Plan: Monitor hemodynamic. CO stable. Went to OR for CABG x 4 LIMA to LAD, Left radial to OM, SVG to AM, SVG to Diag. NARD NOTED. Easily return to sleep after being awaken.Pain (Chest - no radiating,no pressure, with activities, Rate 6, instant relief with morphine (2); L. arm pain - with activities, Percocet given, relief).neuro: A+O X3. CONTINUE Q1HOUR BLOOD SUGARS.SKIN: INCISIONS CLEAN AND DRY MINIMAL DRAINAGE FROM LEFT ARM AND RIGHT LEG. SBP 130'S. Pacing wires intact -DSD. | 20 | [
{
"category": "Echo",
"chartdate": "2160-05-02 00:00:00.000",
"description": "Report",
"row_id": 62631,
"text": "PATIENT/TEST INFORMATION:\nIndication: rising CPK\ns/p CABG\nHeight: (in) 65\nBP (mm Hg): 116/58\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 16:41\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is moderately depressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is mildly dilated. Right\nventricular systolic function appears depressed.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve is not well seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is probably moderately depressed. An exact EF can not be\ncalculated. Anterior and apical akinesis with paradoxical septal motion is\npresent.\n2. In comparison to the previous study of , inferior wall motion may\nhave improved.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2160-04-29 00:00:00.000",
"description": "Report",
"row_id": 62702,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain.\nHeight: (in) 65\nWeight (lb): 170\nBSA (m2): 1.85 m2\nBP (mm Hg): 120/70\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 15:36\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. The\ninteratrial septum is aneurysmal.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nThere is severe global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Regional right\nventricular systolic function cannot be reliably assessed.\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 structurally normal. Mild (1+)\nmitral regurgitation is seen.\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 low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data. The cardiology fellow involved with the patient's care\nwas notified by telephone.\n\nConclusions:\nThe left atrium is normal in size. The interatrial septum is mildly\naneurysmal. Left ventricular wall thicknesses and cavity size are normal.\nThere is severe global left ventricular hypokinesis with focal near akinesis\nof the distal half of the anterior septum and anterior walls and apex. Right\nventricular cavity size is normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Severe global hypokinesis c/w diffuse process (multivessel CAD,\ntoxin, metabolic, etc.) Mild mitral regurgitation.\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": "2160-05-01 00:00:00.000",
"description": "Report",
"row_id": 118203,
"text": "Sinus rhythm\nExtensive ST-T changes are abnormal for age/sex\nPoor R wave progression\nSince previous tracing, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2160-04-29 00:00:00.000",
"description": "Report",
"row_id": 118204,
"text": "Sinus tachycardia\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes suggest myocardial injury/ischemia\nNo previous tracing\n\n"
},
{
"category": "ECG",
"chartdate": "2160-04-29 00:00:00.000",
"description": "Report",
"row_id": 118205,
"text": "Sinus tachycardia\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes may be a normal variant for a female of this age\nSince previous tracing, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2160-04-30 00:00:00.000",
"description": "Report",
"row_id": 118246,
"text": "Sinus tachycardia\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes\nSince previous tracing, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2160-05-04 00:00:00.000",
"description": "Report",
"row_id": 118201,
"text": "Sinus tachycardia\nDiffuse ST-T abnormalities suggestive of ischemia\nSince the tracing of , probable no significant change. Slight changes in\nprecordial leads probably due to lead positioning\n\n"
},
{
"category": "ECG",
"chartdate": "2160-05-02 00:00:00.000",
"description": "Report",
"row_id": 118202,
"text": "Sinus rhythm. No diagnostic change from the previous tracing of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-04-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 756610,
"text": " 9:13 AM\n CHEST (PA & LAT) Clip # \n Reason: chest pain, sob\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with h/o DM now with chest pain, sob, cath revealed 3 vessel\n cad\n REASON FOR THIS EXAMINATION:\n chest pain, sob\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain and SOB.\n\n No prior study is available for comparison.\n\n PA AND LATERAL CHEST: The heart size is upper limits of normal. The\n mediastinal and hilar contours are normal. The lungs are clear. There are no\n pleural effusions and no pneumothorax. The pulmonary vasculature is normal.\n No osseous abnormalities.\n\n IMPRESSION: Heart size is upper limits of normal in this otherwise normal\n chest radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-05-09 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 757357,
"text": " 2:24 PM\n CHEST (PA & LAT) Clip # \n Reason: 27 yo F s/p CABG c SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with h/o DM now with chest pain, sob, cath revealed 3 vessel\n cad\n REASON FOR THIS EXAMINATION:\n 27 yo F s/p CABG c SOB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27 y/o woman with diabetes. Now with chest pain, shortness of\n breath.\n\n Frontal and lateral chest radiographs were obtained. Comparison study dated\n .\n\n The cardiac silhouette appears mildly enlarged in this patient status post\n median sternotomy and CABG. The mediastinal and hilar contours are stable.\n There are bilateral pleural effusions unchanged in size from prior exam. There\n is also patchy bibasilar atelectasis which appears slightly increased since\n prior study. The pulmonary vascularity is within normal limits. The soft\n tissues and osseous structures are unremarkable.\n\n IMPRESSION: 1) Post surgical changes with small bilateral pleural effusions\n and patchy bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757005,
"text": " 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p removal of chest tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p removal of chest tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27 year old woman with diabetes status post bypass surgery and\n post removal of chest tube.\n\n COMPARISON: .\n\n AP UPRIGHT PORTABLE CHEST: Sternal wires and mediastinal clips have been\n placed in the interval. The cardiac and mediastinal contours are not changed\n allowing for differences in technique. There are linear atelectatic changes\n at the left base laterally and there is discoid atelectasis in the right upper\n lobe. No pleural effusions. The lungs appear otherwise clear and the osseous\n structures are unremarkable.\n\n IMPRESSION:\n\n 1) No pneumothorax post chest tube removal.\n\n 2) Satisfactory postoperative appearance with minimal atelectatic changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757087,
"text": " 1:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, : Compared to one day earlier.\n\n CLINICAL INDICATION: Clinical suspicion for pneumothorax. S/P recent\n coronary artery bypass surgery.\n\n The patient is s/p median sternotomy and coronary artery bypass surgery.\n There is stable mild widening of cardiac and mediastinal contours. There are\n increasing patchy opacities at the lung bases as well as areas of hazy\n increased opacity. No pneumothorax is evident.\n\n IMPRESSION:\n 1) No evidence of pneumothorax.\n 2) Patchy bibasilar opacities likely due to patchy atelectasis in this\n recently post operative patient.\n 3) Hazy increased opacity at the bases, which may reflect dense overlying\n breast tissue or small pleural effusions. Lateral view may be helpful if\n clinically warranted.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-02 00:00:00.000",
"description": "Report",
"row_id": 1498779,
"text": "CSRU TRANSFER NOTE\n\nMs. is a 27 year old woman w/ h/o IDDM since age 7 who presented to w/ 1 week hx of epigastric pain. Sent to for further evaluation. Elevated troponin and ECG changes suggestive of MI. Cath revealed severe 3VD, EF 25%, PCWP 32. Went to OR for CABG x 4 LIMA to LAD, Left radial to OM, SVG to AM, SVG to Diag. OR course stable.\n\nNKDA\n\nPMH: IDDM, elevated cholesterol.\n\nNeuro: Sleepy but easily arousable to voice. MAE without difficulty.\n\nCV: CI 2.0. HR 90's NSR, no ectopy noted. Nitro gtt off this am, po Imdur started. Cont's on Neo gtt at 0.75 mcg/kg/min. Cont's on cariporide per study at 21 cc/hr. Dopplerable DP/PT bilat however right PT very faint. Feet warm. Hct 22.2-no transfusion per attending. A wires don't capture. V wires capture at ma of 4.5 but do not sense therefore turned off. Ct's w/ serousang dng. + small airleak with cough.\n\nResp: BS diminished at bases. O2 sats stable on 4l NP.\n\nGI/GU: Abd large, soft. + BS. No nausea. u/o approx 30cc/hr clear yellow urine.\n\nID: Temp up to 101.1 last noc. Afebrile currently. No cx's sent. Vanco cont's.\n\nEndo: Insulin gtt titrated per protocol. Goal of glucose 100-150.\n\nSkin: Intact to back/buttocks. Sternal, left arm, and leg incisions w/ dsgs dry and intact. Noted that right shoulder painful and swollen this am-team aware, no treatment at this time. Pt is able to move right arm ok. Left arm w/ some numbness overnight but improved this am. + CSM to left arm.\n\nComfort: Med w/ percocet and toradol for pain. Pain control much improved since last night.\n\nSocial: Mom in visiting. Updated on pt's condition. Pt lives in . Is engineer.\n\nA: Small neo requirement. CO stable. Glucose controlled w/ insulin gtt. Pain control improved.\n\nP: To transfer to Nsicu for further management. Wean neo as tol. Blood draws and ECG's per expedition protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-02 00:00:00.000",
"description": "Report",
"row_id": 1498780,
"text": "NEURO; LETHARGIC BUT ORIENTED AND FOLLOWS COMMANDS, MAE,\n\nCV; HR 80'S SR, C/O \"CHEST PRESSURE\" THIA AM, AND SEEN BY PA, STAT EKG DONE AND NO CHANGES, PT SL VAGUE WITH SX, WAS DOZING OFF AND ON PRIOR, STATED DISCOMF RT AND LEFT STERNAL AREA, 2 D ECHO DONE,NEO WEANED TO 0.62 MCG/KG/MIN, GOAL MAP < 60, ON INVESTIGATION DRUG CARIPORIDE, CPKS DRAWN TODAY, VERY ELEVATED, PT HAS R/I FOR MI, GENERALIZED EDEMA OF EXTREMITIES, PEDAL AND PT PULSES , MEDIC WITH TORADOL AND MORPHINE , RESTING AT PRESENT, NO C/O DISCOMFORT,\n\nRESPIR LUNGS CLEAR BUT DIM AT BASES, ON N/C AT 4/LMIN, EXPECTORATED SMALL AMT THICK YELLOW BROWN MUCOUS\n\nENDOCRINE; BS RANGE 150'S, INSULIN GTT ORIGINALLY AT 6 U/HR, NOW AT 5/ UN/HR AND FOLLOWING CLINIC GUIDELINES\n\nSKIN; ACE WRAP TO MAMMARY GRAFT SITE D/I, ELEVATED ON PILLOW, RT LEG ACE WRAP D/I\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-03 00:00:00.000",
"description": "Report",
"row_id": 1498781,
"text": "S/P CABG\n\nPt is alert and oriented. C/O pain in left breast-relieved with MSO4 and Percocet. Pt slept for 3 hours.\n\nTemp 100.4-NSR no ectopy. Pacer off. FP good off Neo. CI>2.2. HCT 22. Pedal pulses palpable, ace wrap intact to right leg. Left radial pulse strong, dsd intact. Sternal dsg. dry and intact. Pt continues on study drug with MB=46.\n\n4L NP with clear lungs, sats 97%. Using I/S. Chest tube with small amt. serosanginous output.\n\nUrine output 35cc/hr.\n\nPt taking clear liquids well. Abd. soft.\n\nInsuling drip protoccol.\n\nMom and friend visiting and giving support.\n\nPlan: ?D/C swan and increase rehab.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-03 00:00:00.000",
"description": "Report",
"row_id": 1498782,
"text": "FOCUS: CONDITION UPDATE\nD: PATIENT S/P CABG . TODAY CORDIS/ALINE OUT. OOB TO CHAIR. COMPLAINING OF A LOT OF INCISIONAL PAIN AFTER TRIP TO CHAIR, YET VERY SLEEPY AND SOMULENENT. BLOOD SUGARS INCREASING DESPITE BEING ON INSULIN DRIP. WILL CHANGE IV AND RESTART IN NEW SITE--?INFILTRATION OF OLD SIDE. VSS--SEE FLOW SHEET. CHEST TUBE REMAINS TO WATER SEAL.\nA: OOB LATER TODAY. CHECK BLOOD SUGARS Q 1HR. INCREASE INSULIN DRIP AS NEEDED.\nR: STABLE. WOULD HAVE TRANSFERED TO FLOOR--NO BEDS AVAILABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-04 00:00:00.000",
"description": "Report",
"row_id": 1498783,
"text": "11P-7A: Full assessment in flow sheet.\n\nPt slept most of the night. Easily return to sleep after being awaken.\nPain (Chest - no radiating,no pressure, with activities, Rate 6, instant relief with morphine (2); L. arm pain - with activities, Percocet given, relief).\n\nneuro: A+O X3. Clear speech, follow directions. Normal L. hand strength. Stiff L. arm and leg - movement stiff. R. leg - stiff, limited movement, wiggle toes, +pulses equal bilaterally. problem swallowing thin liquid.\n\ncv: NSR/ST without ectopy. BP 120-140/66-70. RR 12-16 - SaO2-98-100%. 09.6-99. warm, dry, slight general edema. Pacing wires intact -DSD. Chest tubes intact - no air leak, no crepitus, draining serosanguios liquid, DSD -intact.\n\nresp; Clear lung sound bilaterally in upper lobes, dimish in lower lobes. 4LNC. no sob. encourage deep breath and coughing with blanket splint to abd.\n\ngu/gi: soft abd. +BSX4. no pain on palpation. no bm. foley patent - clear/yellow urine > 50 cc/hr.\n\nint: skin intact. ABD, chest, L.lower arm, R. leg - dressing intact, no drainage.\n\nComfort verbally and explain all procedure.\n\nPlan: Monitor hemodynamic. Transfer to floor ?\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-01 00:00:00.000",
"description": "Report",
"row_id": 1498777,
"text": "YOUNG BLACK FEMALE ADMITTED FROM OR SP CABG X 4, SEDATED ON IV PROPOFOL, IV NTG DUE TO RADIAL ARTERY. PATIENT WARM, ALL VS STABLE.\nPATIENT REVERSED, PROPOFOL DC'D. PATEIENT SLOW TO WAKE, STATES THAT SHE IS TIRED. , , FOLLOWS COMMANDS.\nCV: MP SR TO ST WITHOUT. PAPABLE PULSES. PACER ATTACHED BUT NEVER USED. ON INVESTIGATIONAL DRUG CARIPORIDE AT 21 CC QH. LAB WORK DRAWN AS ORDERED. CK, MB AND TROPONIN LEVELS ALSO DRAWN FOR HEPARIN STUDY.\nCT'S APTENT FOR SMALL AMT SERO-SANG.\nGI: OG IN PLACE, PATENT FOR BILIOUS, IV REGLAN GIVEN, CARAFATE GIVEN.\nGU: URINE ADEQUATE AMTS,CLEAR YELLOW, PREOP CREAT 1.1.\nFAMILY HERE\nPLAN: WEAN TO TRANSFER TO F 6 IN AM AFTER TRAUMA LINE OUT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-02 00:00:00.000",
"description": "Report",
"row_id": 1498778,
"text": "NEURO: PT AWAKE ALERT ORIENTED FOLLOWING COMMANDS. ANXIOUS AT TIMES\nRESP: PT ON OPEN FACE TENT UNTIL 0400 WHEN CHANGED TO 4L NP WITH O2 SAT 97%. SATS DID DIP WHEN TURNED SIDE TO SIDE IN BED PT VERY ANXIOUS MOANING AT TIME. IMMEDIATELY CAME BACK UP WHEN ACTIVITY STOPPED. CHEST TUBES DRAINING 50CC/HR OF SEROUSSANG. DRAINAGE.\nC/V: LAST EVENING PT IN A SINUS TACH RATE OF 100-120 GIVEN TOTAL OF 1L HESPAN WITH IMPROVEMENT IN HEART RATE BUT FOR 1/2 HOUR PERIOD OF TIME AT END OF HESPAN INFUSION PT RHYTHM CHANGED TO NODAL RATE IN THE 80'S BP DIPPED TO 70-80. ATTEMPTED TO A PACE BUT WIRES APPEARED NOT TO BE WORKING, ATTEMPTED TO V PACE BUT PRESSURE DID NOT TOLERATE IT. NEO DRIP STARTED AND TIRATED UP TO AROUND 1.5 MCG/KG/MIN AFTER 1/2 HOUR PT SPONTANEOUSLY CONVERTED BACK TO SINUS RHYTM RATE IN THE 90'S BP DID IMPROVE BUT PT STILL REQUIRED NEO DRIP AT 1MCG THROUGH NIGHT. CO/CI >2 PAD 18-22 AFTER VOLUME.HCT DOWN TO 22 THIS AM ? TANSFUSIONS HO WILL DISCUSS WITH DR .\nGI: TOLERATING CLEAR LIQUIDS. NO NAUSEA.\nGU: URINE OUTPUTS ADEQUATE.\nENDO: PT ON INSULIN DRIP TIRATED TO PROTOCOL PRESENTLY RUNNING AT 6U/HR. CONTINUE Q1HOUR BLOOD SUGARS.\nSKIN: INCISIONS CLEAN AND DRY MINIMAL DRAINAGE FROM LEFT ARM AND RIGHT LEG. PT C/O ALOT OF PAIN THIS AM IN RIGHT SHOULDER UPPER ARM. ARM VERY EDEMATOUS AND HARD NOTICABLE MORE SWOLLEN THEN LEFT SIDE. HO AWARE. ANTECUB IV CHECKED GOOD BLOOD RETURN.\nPAIN: WHEN AWAKE PT MOANING IN BED. MEDICATED LAST EVENING WITH 4MG MORPHINE WITH GOOD RELIEF PT SLEPT FOR 5 HOURS. PT TO PERCOCETS PO.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-05-04 00:00:00.000",
"description": "Report",
"row_id": 1498784,
"text": "nsg transfer note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 27 Y/O FEMALE S/P CABG X4 ON . PT EXTUBATED ON . PT INITIALLY ON NEO, BUT SINCE WEANED OFF. POST OP/ICU COURSE OTHERWISE UNEVENTFUL. PT ON INSULIN GTT FOR BS CONTROL. PE AS FOLLOWS:\n\nPMH: DM SINCE AGE 7; HIGH CHOLESTEROL; PREOP EF 25%.\n\nNKDA\n\nNEURO-A+OX3.\n\nCV-AFEBRILE. HR 100'S, ST, NO ECTOPY. SBP 130'S. SKIN W+D. +PP. DENIES CARDIAC COMPLAINTS. PACER OFF, WIRES REMAIN IN.\n\nRESP-O2 SAT 96-98% 2LNC. RR 10'S. LS CTA, BUT DECREASED AT BASES. USING IS WITH ENC. NARD NOTED. DENIES SOB/DOE. CT TO 20CM SXN WITH SEROUS DRG. NO AIR LEAK. NO CREPITUS. DSG C/D/I.\n\nGI-ABD SOFT, NT/ND. +BS. TOL PO'S WITHOUT N/V.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-PT VERY SLOW TO MOVE. OOB WITH ENC AND ASSIST.\n\nCOMFORT-PERCOCET PRN FOR INCISIONAL PAIN WITH ADEQ STATED EFFECT.\n\nSKIN-STERNAL DSG C/D/I. LEFT ARM DSG C/D/I. RIGHT LEG ACE WRAP C/D/I.\n\nENDO-PT ON INSULIN GTT. BS MONITORED Q 2HRS AND GTT TITRATED ACCORDINGLY.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. ASSESS PAIN CONTROL. MONITOR BS AND INSULIN GTT. ENC PO'S. ENC OOB. PULM HYGIENE. TRANSFER TO FLOOR WHEN BED AVAIL.\n"
}
] |
58,991 | 132,518 | The patient presented to pre-op on . Pt was evaluated by anaesthesia and taken to the operating room for laparoscopic sleeve gastrectomy and laparascopic cholecystectomy. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the for observation. On POD1, the patient's hematocrit trended downward to 28 (from 41.1 pre-op) with concomittant tachycardia to 110s and sanguinous JP drainage, therefore, she was transfused a total of 2 units of PRBCs; heparin was discontinued. Of note, on POD1, the patient complained of epigastric pain radiating to her left arm; an EKG was reassuring and troponin was within normal limits. An UGI series, also performed on POD1, was negative for a leak, therefore, her diet was advanced to stage 1, which was well tolerated. Urine output remained adequate and the patient was ambulating with assistance. On POD3, due to persistent mild tachycardia, sanguinous JP output and decreasing hematocrit levels to 25 requiring an additional 2 units of PRBCs, the patient returned to the operating room where she underwent an exploratory laparoscopy converted to laparotomy, abdominal washout, oversewing of the gastric sleeve staple line, evacuation of clot and liver biopsy; see operative note for details. Post-procedure the patient was transferred to the surgical intensive care unit for close observation. The patient remained stable in the ICU with resolution of tachycardia and stable hematocrit levels. Pain was well controlled with a dilaudid PCA. An NGT, placed intra-operatively was discontinued and methylene blue dye was administered orally without subsequent change in character of JP drain output, therefore, her diet was advanced to stage 1 and well tolerated. Also, given concern for local tissue ischemia of small portion of patient's wound, a few staples were removed and a dry dressing was applied and changed twice daily. On POD , the patient was transferred to the general surgical . While on the floor, she continued to have stable vital signs and hematocrit levels; subcutaneous heparin was resumed on . Her diet was advanced to Stage 3, which was well tolerated; FSBG was monitored and metformin was resumed at half dose upon discharge. The dilaudid PCA, IVF and foley were discontinued; po meds were initiated. PT evaluated the patient and provided acute treatment with recommendations for continued home PT upon discharge. OT was also consulted but did not identify any acute OT needs. On POD , the patient was discharged to home with visiting nursing services and home physical therapy. She continued to do well, was afebrile with stable vital signs. The patient was tolerating a stage 3 diet, ambulating, voiding without assistance, and pain was well controlled. Both JP drains were removed prior to discharge. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. She will follow-up with Dr. in clinic in 1 week. | WET READ VERSION #1 FINAL REPORT INDICATION: Assess for obstruction or leak status post sleeve gastrectomy. Delayed R wave transition. Left ventricular hypertrophy.Possible prior inferior myocardial infarction. IMPRESSION: Expected post-operative appearance of sleeve gastrectomy without obstruction or leak. Sinus tachycardia. Compared to the previoustracing of the ventricular rate is faster and the suggestion of apossible prior inferior myocardial infarction is new. 10:17 AM UGI SGL CONTRAST W/ KUB Clip # Reason: leak? Delayed R waveprogression was not previously seen. stricture? stricture? Contrast passed freely through the post-operative stomach, without evidence of leak. The patient was given Optiray and then thin barium to drink under flurosocopic observation. FINDINGS: A scout abdominal radiograph demonstrates a normal bowel gas pattern and no evidence of contrast in the abdomen. Admitting Diagnosis: MORBID OBESITY/SDA Contrast: OPTIRAY Amt: MEDICAL CONDITION: 51 year old woman with new gastric sleeve REASON FOR THIS EXAMINATION: leak? | 2 | [
{
"category": "ECG",
"chartdate": "2101-10-05 00:00:00.000",
"description": "Report",
"row_id": 244960,
"text": "Sinus tachycardia. Delayed R wave transition. Left ventricular hypertrophy.\nPossible prior inferior myocardial infarction. Compared to the previous\ntracing of the ventricular rate is faster and the suggestion of a\npossible prior inferior myocardial infarction is new. Delayed R wave\nprogression was not previously seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-05 00:00:00.000",
"description": "UGI SGL CONTRAST W/ KUB",
"row_id": 1254014,
"text": " 10:17 AM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: leak? stricture?\n Admitting Diagnosis: MORBID OBESITY/SDA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with new gastric sleeve\n REASON FOR THIS EXAMINATION:\n leak? stricture?\n ______________________________________________________________________________\n WET READ: TXPb WED 11:25 AM\n No leak or obstruction.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for obstruction or leak status post sleeve gastrectomy.\n\n FINDINGS:\n\n A scout abdominal radiograph demonstrates a normal bowel gas pattern and no\n evidence of contrast in the abdomen.\n\n The patient was given Optiray and then thin barium to drink under flurosocopic\n observation. Contrast passed freely through the post-operative stomach,\n without evidence of leak.\n\n IMPRESSION:\n\n Expected post-operative appearance of sleeve gastrectomy without obstruction\n or leak.\n\n"
}
] |
937 | 148,592 | The patient was admitted from an OSH for management of a large intra-parenchymal hemmorrhage. Patient patient had a poor neurologic examination on admission. The patient continued to deteriorate and on hospital day #5 was pronounced brain dead. As per the families wishes, he became an organ donor. | Sinus bradycardia with borderline 1st degree A-V block.Possible inferior infarct - age undeterminedAnterolateral ST-T changes are nonspecific Pneumomediastinum. BS auscultated reveal bilateral diminished sounds with noted aeration in apecies. Partial atelectasis involving the right lower lobe is noted. REC'ING MANNITOL IV PB AND DILANTIN IV.GI/GU: + BS NOTED. There is a right upper pneumomediastinum. NPNMICU7 PM - 7 AMRIGHT FRONTAL ICH WITH EXTENSION OF BLOOD INTO BOTH HEMISPHERES.REMAINS ORALLY INTUBATED ..OVERBREATHING OVER RATE ...SLIGHT MOVEMENT OF LOWER EXTREMITIES ..BRINGING RIGHT ARM UP TOWARD HEAD ..NO MOVEMENT TO LUEX OBSERVED. D/C'ED NGT THIS AM. Prior inferior myocardial infarction. DP/TP pulses doplarable bilat.GI/GU: Abd. Head CT consistent with multifocal acute bleeds.Neuro: Initially pt. Ambu/syringe @ hob. Ambu/syringe @ hob. Ambu/syringe @ hob. Previously seen small right superior pneumomediastinum is no longer visualized. OGT IN PLACE TO LWCS WITH BILIOUS DRAINAGE. CT results pending.ID: Tmax 99.2. OGT to low constant suction this AM now is just clamped. Left atrial abnormality. Vent setting changed after pt noted to be alkalotic. Guidelines to hold med in POE.CV: BP stable at one point, able to titrate NTG to off. Care transferred to N/SICU from T/SICU. K+ 3.1 rec'd a total of 60mEq KCL IV. Interval placement of right subclavian CVP line. LAST ABG SHOWED AN ALKALOAIA WITH GOOD OXYGENATION. Small right pleural effusion ? The tip is in the superior vena cava. Na+-141.Endo: FS's q6hr, 130-145 coverage as per S/S.Respir: Remains intubated on A/C 50%/450/12 Peep-5, with ABG- 7.52/30/112/2/25. AM ABG: 84/32/7.46.GI: Aspirates OB+, no BRB noted. Check lytes frequ and replete as needed. IMPRESSION: Endotracheal tube in good position. Written for Q4hr serial hcts. CT OF ABDOMEN WITHOUT IV CONTRAST: There are bilateral areas of consolidation at the lung bases. developed leakage from angio site, lt. sided facial droop & weakness. AM ABG's 7.46/32/84/23. There is effacement of the sulci, predominantly on the right side and poor -white matter differentiation of areas of both frontal lobes, and the right temporal lobe. Dr notified. There has been interval loss of the right hemidiaphragm due to partial atelectasis at the right lung base and or right pleural effusion. ICa+ 1.09, to rec 2amps CaGlu. The ET tube and the NG tube are in place. A repeat tracing ofdiagnostic quality is suggested. ARTERIAL BP 151/63 - 167/76. if it was up against the wall, OGT placed with good aspirates. RATE REDUCTION BUT PT HAS FIXED MIN. gastric aspiration, Dr. notified.CV: HR 40s-60s, sinus brady with occasional ventricular espace beats vs. PVCs, ABP 130s-160s, started on Nitro gtt titrated to keep SBP<140s, NBP 110s-130. In addition, since the prior study, there has been placement of a right subclavian CVP line. An NG tube is seen entering the nasopharynx. Sinus rhythm. Interval development of bilateral pulmonary vascular congestion and right lower lobe partial atelectasis with questionable associated right pleural effusion. MICU NPN FOR 7A-7P: NKDA FULL CODE PLEASE SEE CAREVUE FLOWSHEET FOR MORE DETAILSNEURO: ADEQUATELY SEDATED ON 35MCG/KG/MIN PROPOFOL GTT. similar secretions suctioned out from ETT, Dr. notified. Assess for pneumothorax. groin site c/d/i. Please recheck K+ later this am.Resp: Suctioned multiple times for mod amts of bile like material. BP VIA NBP 128/59 - 150/68. REMAINS ON NTG GTT AT 3MCG/KG/MIN TO MAINTAIN BP 120-160'S SYST. Stranding in the right inguinal region at the site of arterial graft. CONTS. FOLEY IN PLACE WITH ADEQUATE UO. HOLD SERUM OSM > 317 OR NA > 147. LATEST ABG IS 7.46/32/84/23. L/S course bilat, suctioning q3 for mod to lrge amt thick tan/bloody secretions. The predominant hemorrhage and likely source is within the right frontal lobe with intraventricular extension. SX FOR MOD AMTS. AFEBRILE. P-MICU NPN 7p-7aEvents: Able to wean NTG to off, only having to restart it later in the shift. HR 47-63. remains on Manitol q 6hrs, Dilanting 100mg q8.Resp: Vented on CMV, set rate 18, FiO2 50%, PEEP5, Vt 700. Plan to wean appropriately, possible psv today. Rec'ing IV Dilantin and Mannitol.C/V: Continues on IV NTG Gtt attempting to keep BP>140, @ present is on 3.0mcq/kq/min, HR 54-68 SR with freq PVC's. ASPIRATION PNA. +BS. male s/p occluded rt. SUCTIONED FOR SMALL-MOD. EKG performed due to low K+ and bradycardia. Multiple episodes of bradycardia. L SVC CENTRAL LINE PLACED BY SICU RESIDENT TODAY. No change noted, pt moving R side. soft with hypoactive BS's, no stool noted.GU: Lrge amt u/o due to Mannitol, started on D5LR with 40KCL@60cc/hr.BUN/CRE WNL. RSBI=74. TO MONITOR NEURO STATUS FREQUENTLY.ID: SCHEDULED TO START ON PIPERACILLIN FOR POSS. WITH CURRENT PLAN OF CARE. REASON FOR THIS EXAMINATION: assess for retroperitoneal bleed or hematoma No contraindications for IV contrast FINAL REPORT INDICATION: Intracranial hemorrhage with drop in hematocrit. Stranding is seen in the right inguinal region at the site of the arterial graft. However required to NTG to be restarted later in am for being consistantly hypertensive. There is stable opacification of the right maxillary sinus and there is mucoperiosteal thickening in the left maxillary sinus. AMT OF GREENISH BILE-LIKE SECRETIONS VIA ETT (ASPIRATION OF GASTRIC CONTENTS???) CONT. CONT. While back on propofol is unresponsive. RSBI=48. Since the prior study, there has been development of bilateral pulmonary vascular congestion and questionable right pleural effusion. Titrate NTG to maintain SBP<140. Evaluate for retroperitoneal hemorrhage. CT HEAD W/O CONTRAST: There is a large intraparenchymal hemmorhage within the right frontal lobe which extends into the intraventricular space. Assess for endotracheal tube placement and/or effusion/infiltrates. BS reveal bilateral clear sounds. Pt had been vomiting around NGT despite being on LIS. | 20 | [
{
"category": "Radiology",
"chartdate": "2163-01-21 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 852257,
"text": " 8:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for retroperitoneal bleed or hematoma\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with TPA induced bleeding intracranial, and now Hct drop 8\n points to 20, unclear source.\n REASON FOR THIS EXAMINATION:\n assess for retroperitoneal bleed or hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage with drop in hematocrit. Evaluate for\n retroperitoneal hemorrhage.\n\n TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained\n without oral or IV contrast.\n\n CT OF ABDOMEN WITHOUT IV CONTRAST: There are bilateral areas of consolidation\n at the lung bases. This could represent aspiration.\n\n There is a 1.4 x 2.4 cm area of low attenuation measuring 8 in the right\n lobe of the liver, representing a simple cyst. The spleen, pancreas, adrenals\n are unremarkable. The patient is status post cholecystectomy. A feeding tube\n is present in the stomach. Mild nonspecific perirenal stranding with multiple\n small areas of low attenuation in both kidneys representing simple cysts.\n There is no free air or free fluid. The abdominal loops of small and large\n bowel appear grossly unremarkable. There are extensive aortic calcifications\n with a aortobifemoral graft in place.\n\n CT OF PELVIS WITHOUT IV CONTRAST: Multiple diverticula are visualized in the\n sigmoid colon without evidence of diverticulitis. There is asymmetry of the\n pelvic muscles with the right iliacus and right thigh muscles appear larger\n than the left side. This may be seen in a patient with a prior stroke with\n hypertrophy of the unaffected side. There is no free air or free fluid.\n Stranding is seen in the right inguinal region at the site of the arterial\n graft.\n\n There are no suspicious lytic or blastic lesions in the osseous structures.\n\n IMPRESSION:\n No evidence of retroperitoneal hemorrhage. Stranding in the right inguinal\n region at the site of arterial graft. In the right clinical setting, a graft\n infection could have this appearance.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-01-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 852212,
"text": " 7:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval Bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with Head Bleed\n REASON FOR THIS EXAMINATION:\n Eval Bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n\n CLINICAL INDICATION: Unresponsive, intracranial hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial noncontrast MDCT images were obtained through the head\n without the administration of IV contrast.\n\n CT HEAD W/O CONTRAST: There is a large intraparenchymal hemmorhage within the\n right frontal lobe which extends into the intraventricular space. There is\n blood seen layering within the occipital horns of the lateral ventricles as\n well as the third ventricle. There are also smaller areas on intraparenchymal\n hemmorhage in the right frontal, temporal and parietal lobes. There is also\n subarachnoid hemorrhage seen overlying the left hemisphere and bilateral\n cerebral hemisphere posteriorly. There is no shift of normally midline\n structures. The intraparenchymal hemorrhages are causing surrounding edema and\n mild mass affect. There is effacement of the sulci, predominantly on the right\n side and poor -white matter differentiation of areas of both frontal\n lobes, and the right temporal lobe. The ambient cisterns appear patent and no\n impending herniation is identified.\n\n The right maxillary sinus is completely opacified and there is mucosal\n thickening within the left maxillary sinus and ethmoid air cells. An NG tube\n is seen entering the nasopharynx. No skull fracture is seen.\n\n IMPRESSION: Multiple, intraparenchymal hemorrhages involving the right\n frontal, parietal and temporal lobes with surrounding edema. The predominant\n hemorrhage and likely source is within the right frontal lobe with\n intraventricular extension. There is mass effect and edema, but no evidence of\n impending herniation at this time.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852218,
"text": " 9:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ET tube placement and for effusions/infiltrates\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with intracranial hemorrhage, s/p intubation\n REASON FOR THIS EXAMINATION:\n assess ET tube placement and for effusions/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage status post intubation. Assess for\n endotracheal tube placement and/or effusion/infiltrates.\n\n COMPARISON: There are no prior studies available for comparison.\n SINGLE AP VIEW OF THE CHEST: An endotracheal tube is seen approximately 3 cm\n superior to the carina. The nasogastric tube is seen curled within the fundus\n of the stomach with the tip projecting off the inferior portion of the screen.\n The cardiac silhouette is normal in size. The mediastinal and hilar contours\n are normal. The pulmonary vasculature is normal. No overt consolidation,\n infiltrates, or effusions are visualized in bilateral lungs. Surrounding soft\n tissue and osseous structures reveal diffuse degenerative joint disease along\n the thoracic spine.\n\n IMPRESSION: Endotracheal tube in good position. No overt congestive heart\n failure. No pleural effusions. No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-01-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852408,
"text": " 2:09 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for ptx\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with intracranial hemorrhage, s/p intubation with increasing\n wbc\n REASON FOR THIS EXAMINATION:\n assess for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 75-year-old with intracranial hemorrhage status post intubation.\n Assess for pneumothorax.\n\n Study was obtained at 14:25 hour and compared to a prior study earlier the\n same day. The ET tube and the NG tube are in place. In addition, since the\n prior study, there has been placement of a right subclavian CVP line. The tip\n is in the superior vena cava. Partial atelectasis involving the right lower\n lobe is noted. The lung fields appear to be less congested at this time.\n There is no evidence of pneumothorax. Previously seen small right superior\n pneumomediastinum is no longer visualized.\n\n IMPRESSION:\n\n No evidence of pneumothorax. Small right pleural effusion ?\n\n Interval placement of right subclavian CVP line.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-01-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852366,
"text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with intracranial hemorrhage, s/p intubation with increasing\n wbc\n REASON FOR THIS EXAMINATION:\n pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 25-year-old man with intracranial hemorrhage status post\n intubations, pneumonia ?\n\n Comparison was made to the prior study of . The endotracheal\n tube,NG-tube, and the feeding tube remain in place. Since the prior study,\n there has been development of bilateral pulmonary vascular congestion and\n questionable right pleural effusion. There has been interval loss of the\n right hemidiaphragm due to partial atelectasis at the right lung base and or\n right pleural effusion. There is a right upper pneumomediastinum.\n\n IMPRESSION:\n\n Worsening in overall appearance of the chest since the prior study as\n described above. Interval development of bilateral pulmonary vascular\n congestion and right lower lobe partial atelectasis with questionable\n associated right pleural effusion.\n\n Pneumomediastinum.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-01-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 852261,
"text": " 9:23 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval of SAH\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with SAH\n REASON FOR THIS EXAMINATION:\n eval of SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: This is a 75-year-old man with multiple intracranial hemorrhages,\n assess for change.\n\n TECHNIQUE: Axial 5-mm sections of the brain were obtained without IV contrast\n and compared to a prior noncontrast head CT dated .\n\n FINDINGS: There are innumerable intracerebral hemorrhages. There is a large\n intraparenchymal hemorrhage in the right frontal lobe, which extends to the\n septum pellucidum and fills a cavum vergae with blood. There is a large\n hemorrhage posterior to this in the right frontal lobe, which has a prominent\n amount of vasogenic edema around it and a hematocrit level within it. There\n are multiple other hemorrhages in the right occipital lobe and right temporal\n lobe as well. These hemorrhages have not significantly changed when compared\n to the prior study. There is blood layering in the occipital of the left\n lateral ventricle. There is also subarachnoid blood along the left cerebral\n hemisphere. When compared to the prior study dated , there has been a\n slight interval increase in the amount of mass effect on the right lateral\n ventricle and a mild increase in the amount of leftward shift of the normal\n midline structures. There is no evidence of uncal herniation or brain stem\n compression. There is stable opacification of the right maxillary sinus and\n there is mucoperiosteal thickening in the left maxillary sinus.\n\n IMPRESSION: Multiple intraparenchymal hemorrhages throughout the right\n cerebral hemisphere with associated subarachnoid hemorrhage, intraventricular\n hemorrhage, and blood filling a cavum vergae. The etiology of these\n intraparenchymal hemorrhages is unclear; however hemorrhagic metastases are in\n the differential diagnosis.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Report",
"row_id": 1274072,
"text": "Resp: pt on a/c 12/500/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. BS reveal bilateral clear sounds. No change noted, pt moving R side. ABG's 7.50/35/89/28, decrease in VT to 450 with current abg's 7.47/37/86/28. RSBI=74.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Report",
"row_id": 1274073,
"text": "NPN MICU-B 7A7PM\nS/O: NEURO: While on Propofol Gtt is unresponsive, with no movement of extremities noted. Neuro team requested propofol Gtt off, to do full neuro exam. Propofol stopped and became agitated moving R arm, and both lower extremties, but did not open eyes, did withdrawl to painful stimuli but unable to obey commands. Increased HR and RR and was very uncomfortable moving extremties about the bed, so Propofol was restarted with the SICU team doing an assessment no the Neuro team. While back on propofol is unresponsive. Rec'ing IV Dilantin and Mannitol.\n\nC/V: Continues on IV NTG Gtt attempting to keep BP>140, @ present is on 3.0mcq/kq/min, HR 54-68 SR with freq PVC's. K+ 3.1 rec'd a total of 60mEq KCL IV. ICa+ 1.09, to rec 2amps CaGlu. Repeat lytes due @ 8pm this evening.\n\nGI: Having dark red to dark bilious draninage noted from OGT, HCT 29.8. OGT to low constant suction this AM now is just clamped. soft with hypoactive BS's, no stool noted.\n\nGU: Lrge amt u/o due to Mannitol, started on D5LR with 40KCL@60cc/hr.\nBUN/CRE WNL. Na+-141.\n\nEndo: FS's q6hr, 130-145 coverage as per S/S.\n\nRespir: Remains intubated on A/C 50%/450/12 Peep-5, with ABG- 7.52/30/112/2/25. Spon RR 10-14, so sedation was increased and vent RR was decreased to 10. Will repeat ABG this evening. L/S course bilat, suctioning q3 for mod to lrge amt thick tan/bloody secretions. Sputum spec sent for C&S's.\n\nSocial: Daughter called and visited requested to have a family meeting @ somtime tommorrow but Neuro attending Dr cannot be there tomorrow so will try to set up one for Tuesday late morning, will talk to the other family members and call with a time tommorrow for Tuesday. Many family members in to visit and have been updated.\n\nA/P: Continue to assess Neuro status, Propofol as needed for comfort. Titrate NTG to maintain SBP<140. Check lytes frequ and replete as needed. Aggressive pulmonary toilet, assess O2sats and ABG's adjust vent settings as needed. Arrange family meeting to discuss prognosis and plan for Tuesday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Report",
"row_id": 1274074,
"text": "\nPT MAINTAINED ON A/C VENTILATION AT 50%. VITALS STABLE. B.S. BILAT AND MOSTLY CLEAR. PT LIGHTENED TODAY WITH NEURO EXAM SHOWING MOVEMENT IN ALL EXTREMETIES. PT FOR AGITATION. LAST ABG SHOWED AN ALKALOAIA WITH GOOD OXYGENATION. RATE REDUCTION BUT PT HAS FIXED MIN. VOL. SUGICAL TEAM WAITING FOR MONDAY TO DECIDE ANY INTERVENTION. PLAN IS TO CONT ON A/C VENTILATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Report",
"row_id": 1274075,
"text": "Resp: pt on a/c 10/450/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal mostly clear sounds with some coarse bs in bases. Suctioned for small amount of rusty secretions. AM ABG's 7.49/34/118/27 with no changes noc. Will continute to wean appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Report",
"row_id": 1274076,
"text": "NPN\nMICU\n7P - 7A\nLARGE ICH BLD WITH SEVERE NEUROLOGICAL DAMAGE\nS ORALLY INTUBATED AND SEDATED ON PROPOFOL\nCV HR 50-60'S SINUS BRADY...LYTES REPLETED THROUGHOUT THE NIGHT (CALCIUM/MGS04/K) IN THE SETTING OF MANNITOL Q6..SBP ON PROPOFOL AT 60 MCGS/IV NTG AT 1 MCG AND HYDRAL 20 Q6 ..130-160'S/60-70'S...\nRESP VENT SETTINGS 50%/ TV 450/ RATE OF 10/ OVERBREATHING 12..5 PEEP..LUNGS COARSE ..MINIMAL OUTPUT FROM ETT..ORAL SECRETIONS THICK BLD TINGED ...\nGI KEPT NPO..SMALL AMOUNT OF SOFT STOOL ..OB POS\nGU URINE OUTPUT BRISK\nID CONTINUES ON PIPERACILLIN ..LOW GRADE TEMP\nNEURO IN THE SETTING OF PROPOFOL WEAN ..PATIENT MOVES LOWER EXTREMITY SLIGHTLY ..AS WELL AS RIGHT UPPER EXTREMITY ..INTERMIT MOVES EXTREMITIES TO PAINFUL STIMULI ..BUT DOES NOT CLEARLY WITHDRAW OR LOCALIZE..PUPILS AND SLUGGISHLY REACTIVE TO LIGHT ...\nA NEUROLOGICALLY UNCHANGED\nP PROPOFOL OFF AT 0700 FOR NEURO/TSICU ROUNDS\nFAMILY MEETING WITH FAMILY/NEURO ATTENDING ON TUESDAY\nTEAM TO COMMUNICATE WITH FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Report",
"row_id": 1274069,
"text": "MICU NPN FOR 7A-7P: NKDA FULL CODE\n\n PLEASE SEE CAREVUE FLOWSHEET FOR MORE DETAILS\n\nNEURO: ADEQUATELY SEDATED ON 35MCG/KG/MIN PROPOFOL GTT. RESPONDS TO PAIN/STIMULI BY MOVING EXTREMITIES/WITHDRAWING. PUPILS REACTIVE AT 2MM SLUGGISH. CONTS. WITH NO MOVEMENT OF LEFT ARM AND WEAK MOVEMENT OF LEFT LEG. NO DEFICITS TO R EXTREMITIES. NO S/SX'S OF PAIN/DISCOMFORT. NO EVIDENCE OF SEIZURE ACTIVITY. EXTRA DOSE OF 300 MG DILANTIN GIVEN IVPB.\n\nRESP: REMAINS INTUBATED WITH NO VENT CHANGES MADE TODAY. ON A/C 12/500/.50/PEEP 5. LATEST ABG IS 7.46/32/84/23. LUNG SOUNDS ARE COARSE THROUGHOUT. SUCTIONED FOR SMALL-MOD. AMT OF GREENISH BILE-LIKE SECRETIONS VIA ETT (ASPIRATION OF GASTRIC CONTENTS???) Q-2-3HRS. SUCTIONED ORALLY SEVERAL TIMES FOR COPIOUS AMT OF THICK BLOOD-. SECRETIONS.\n\nCV: SB-SR WITH FREQUENT PVC'S AT TIMES. HR 47-63. BP VIA NBP 128/59 - 150/68. ARTERIAL BP 151/63 - 167/76. MADE A-LINE MONITOR PATIENT MONITOR TODAY. AFEBRILE. REMAINS ON NTG GTT AT 3MCG/KG/MIN TO MAINTAIN BP 120-160'S SYST. REPLETED KCL OF 2.8 WITH 40 MEQU IV VIA PERIPHERIAL. L SVC CENTRAL LINE PLACED BY SICU RESIDENT TODAY. MAINTAINANCE IV IS D5LR WITH 40 MEQU KCL AT 60CC/HR. REC'ING MANNITOL IV PB AND DILANTIN IV.\n\nGI/GU: + BS NOTED. ABD IS SOFT, DISTENDED. NO BM FOR MY TIME. OGT IN PLACE TO LWCS WITH BILIOUS DRAINAGE. D/C'ED NGT THIS AM. FOLEY IN PLACE WITH ADEQUATE UO. OB + VIA OGT.\n\nNEURO: NO REPEAT HEAD CT ORDERED TODAY. CONT. TO MONITOR NEURO STATUS FREQUENTLY.\n\nID: SCHEDULED TO START ON PIPERACILLIN FOR POSS. ASPIRATION PNA. NEEDS ID APPROVAL. AFEBRILE\n\nSKIN: INTACT WITH NO BREAKDOWN NOTED.\n\nPLAN: CONT. WITH CURRENT PLAN OF CARE. MONITOR PER PROTOCOL. CONT. TO CHECK SERUM OSM AND SODIUM 2HRS PRIOR TO ADMINISTRATING MANNITOL. HOLD SERUM OSM > 317 OR NA > 147. CHECK AND REPLETE ELECTROLYTES AS NEEDED. CHECK HCT DAILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Report",
"row_id": 1274070,
"text": "\nPT MAINTAINED ON A/C VENTILATION AT 50%. VITALS STABLE. NO NEW ABGS. B.S. BILAT AND MOSTLY CLEAR. SX FOR MOD AMTS. PT MENTALLY UNRESPONSIVE WITH PARALYSIS TO LEFT SIDE. PLAN IS TO CONT ON A/C VENTILATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Report",
"row_id": 1274071,
"text": "NPN\nMICU\n7 PM - 7 AM\nRIGHT FRONTAL ICH WITH EXTENSION OF BLOOD INTO BOTH HEMISPHERES.\nREMAINS ORALLY INTUBATED ..OVERBREATHING OVER RATE ...SLIGHT MOVEMENT OF LOWER EXTREMITIES ..BRINGING RIGHT ARM UP TOWARD HEAD ..NO MOVEMENT TO LUEX OBSERVED. PUPILS ARE PINPOINT AND SLUGGISHLY REACTIVE...UNABLE TO OBTAIN GOAL SBP OF << THAN 140/P DESPITE MAX AMOUNT OF IV NITRO INFUSING ..PROPOFOL INCREASED TO 60MCGS WITH SBP IN THE 130 RANGE ..\nCV REMAINS BADYCARDIC IN THE 40-50'S...\nK AND MG REPLETED IN THE SETTING OF RECEIVING MANNITOL Q6 ..\nRESP REMAINS ON AC RATE OF 12 ..TV DECREASED TO 450 FOR A PH OF 7.50..5 PEEP AND 50%..LUNGS COARSE..MINIMAL THICK WHITE SXNS VIA ETT ..THICK BLD TINGED ORAL SXNS\nGI BOWEL SOUNDS HYPOACTIVE ..OGT TO LISXN..NO STOOL\nHEME HCT 29\nID AFEBRILE ON PIPERACILLIN\nTUNED Q3\nTHIS RN SPOKE WITH PATIENT'S 3 DAUGHTERS WHO THEIR FATHERS' WISHES NOT TO PURSUE ANY NEUROSURGICAL INTERVENTION, AS HE HAS TOLD THEM THAT HE WOULD NOT WANT TO LIVE IN A VEGETATIVE STATE. THE GROWN CHILDREN WISH TO HAVE A FAMILY MEETING WITH NEUROSURGERY TO DISCUSS THE PROGNOSIS AND HIS QUALITY OF LIFE. THEY DO NOT WISH TO OBTAIN A TRACH OR PEG IN ACCORDANCE WITH HIS WISHES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Report",
"row_id": 1274067,
"text": "Resp: pt on a/c 18/700/+5/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral diminished sounds with noted aeration in apecies. Vent changes to decrease rr to 12/TV to 500 with reflect abg's. AM ABG's 7.46/32/84/23. RSBI=48. Plan to wean appropriately, possible psv today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Report",
"row_id": 1274068,
"text": "P-MICU NPN 7p-7a\nEvents: Able to wean NTG to off, only having to restart it later in the shift. Multiple episodes of bradycardia. Hypokalemic, receiving KCl replacement.\n\nSystems Review:\n\nNeuro: On propafol 20mcg/kg/min. Good strength noted in right UE, RLE with movement on the bed, no movement noted in LUE, and LLE with minimal movement in bed. Pupils, pinpoint, but reactive to light, +corneal reflexes. Movement inconsistent, does not follow commands. Neurology in this am to eval pt, propafol stopped at 0725. No seizure activity, receiving dilantin and mannito. Need to check Na+ and osmolarity 2hrs prior to hanging mannitol. Guidelines to hold med in POE.\n\nCV: BP stable at one point, able to titrate NTG to off. However required to NTG to be restarted later in am for being consistantly hypertensive. Currently on 2.0 mcg/kg/min. EKG performed due to low K+ and bradycardia. Currently receiving K+ replacement 40meq over 4hr. Please recheck K+ later this am.\n\nResp: Suctioned multiple times for mod amts of bile like material. Dr notified. Pt had been vomiting around NGT despite being on LIS. ? if it was up against the wall, OGT placed with good aspirates. Vent setting changed after pt noted to be alkalotic. Current settings 50%/500/x12 5peep. AM ABG: 84/32/7.46.\n\nGI: Aspirates OB+, no BRB noted. +BS. Received the 2nd unit of PRBC's last night with repeat HCT of 29. Written for Q4hr serial hcts. 6am 30, next due at 10am.\n\nGU: Good u/o via foley, clear yellow.\n\nSocial: 3 daughters into visit last night. Anxious and concern. Given emotional support as able. Con't to provide support.\n\nLines: One periperal blew.. replaced with a 20guage. Currently 4 peripheral IV's, aline.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Report",
"row_id": 191277,
"text": "Sinus rhythm. Left atrial abnormality. The tracing is of poor technical\nquality. Wandering baseline. Prior inferior myocardial infarction. Compared to\nthe previous tracing of the rate has increased. A repeat tracing of\ndiagnostic quality is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Report",
"row_id": 191278,
"text": "Sinus bradycardia with borderline 1st degree A-V block.\nPossible inferior infarct - age undetermined\nAnterolateral ST-T changes are nonspecific\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Report",
"row_id": 1274065,
"text": "Pt. is 75 y.o. male s/p occluded rt. fem bypass, lysed in cath lab. Pt. developed leakage from angio site, lt. sided facial droop & weakness. Head CT consistent with multifocal acute bleeds.\nNeuro: Initially pt. is resltess responding to Propofol boluses, started on Propofol gtt @ 20mcg/kg/min for better BP control due to agitation, minimal movement of left arm and leg noted, withdraws to painful stimuli on rt, facial grimacing and attempts to withdraw with nail bed pressure on lt. Pupils 1-2mm equal, reactive to light bilat, impaired cough/gag reflex. Repeat head CT shoew no change except for slight increase in cerebral edema per neuro team. Pt. remains on Manitol q 6hrs, Dilanting 100mg q8.\nResp: Vented on CMV, set rate 18, FiO2 50%, PEEP5, Vt 700. LS initially clear, coarse with bibasilar crackles at noon, MD aware. Suctioned for thick greenish secretions, ? gastric aspiration, Dr. notified.\nCV: HR 40s-60s, sinus brady with occasional ventricular espace beats vs. PVCs, ABP 130s-160s, started on Nitro gtt titrated to keep SBP<140s, NBP 110s-130. Usual dose of Lisinoprile and Hydrochlorothiazide given at noon due to ABP in 150s. Rt. groin site c/d/i. DP/TP pulses doplarable bilat.\nGI/GU: Abd. soft, nondistended nontender, hypoactive BS. NGT to MWS, green bilious secretions occasionally coming out from pt.'s mouth, lrg amount noted from mouth and nose while turning pt. similar secretions suctioned out from ETT, Dr. notified. Foley patent, clear yellow urine out 150-200cc/hr. Abd. CT results pending.\nID: Tmax 99.2. No IV abx. coverage.\nEndo: BS checked QID, covered with RI per sliding scale, BS 120s-150s.\nSocial: Family visited, updated on condition by Dr. and Dr. . Care transferred to N/SICU from T/SICU.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Report",
"row_id": 1274066,
"text": "Resp CAre\n\nPt remained intubated and on full vent support. Mode of ventilation A/C. Pt stable on current settings. Bs generally clear but becoming coarse in the latter part of the day\n"
}
] |
80,227 | 152,109 | IMPRESSION: 60M with PMH significant for hepatitis C, HLD who presented with chest pain, exertional dyspnea with EKG showing Mobitz I and non-specific ST changes which progressed to complete heart block, with suspected Lyme carditis. . # RHYTHM - The patient was admitted with evidence of second-degree AV block Mobitz I on EKG from the ED and non-specific ST changes which progressed to AV-dissociation and complete heart block. The patient reported having a recent left thigh erythema migrans and possible tick exposure 4 weeks prior to admission, suspicious for Lyme carditis. He was begun on empiric treatment for Lyme carditis with Ceftriaxone 2g IV Q24 hours for a planned course of 21-days. Following administration of antibiotics, his complete heart block resolved and the patient converted to a Mobitz I Wenchebach rhythm. His degree of block was seen to improve with antibiotics. His Babesia and Ehrlichia parasite smears were negative. His Lyme serologies were sent to for confirmatory testing. He was monitored on telemetry and his electrolytes were optimized. On , the patient was noted to be in Mobitz I (Wenkebach) on telemetry and contined IV Ceftriaxone. He completed 5-days of Ceftriaxone and was started on oral Doxycycline 100 mg PO twice daily on and will continue this dose for 21-days (end date ). . # CORONARIES - The patient has no documented history of CAD, and review of risk factors reveals: prior smoker, age, no strong family history, no diabetes or weight control issues, no HTN, only HLD controlled with statin. He has had no prior cardiac cath procedures, no prior stress testing. Although he was admitted for rhythm issues, his pain sounds suspicious for atypical anginal symptoms given the chest pain with exertion that is relieved with rest, and the exertional dyspnea -- but the cardiology team thought this could be attributed to his Lyme carditis too. On admission, his EKG showed non-specific ST changes and he had negative cardiac enzymes. Given low suspicion of on-going CAD, he was medically optimized with Aspirin 325 mg PO daily, we avoided AV nodal blockade with B-blocker given rhythm, we continued Pravastatin 20 mg PO daily. We also think he should consider stress testing given pre-test probability of coronary disease, but again our suspicion is low. . # PUMP - The patient has no history of CHF; a 2D-echo from showed no valvular disease, and a normal ejection fraction > 60% with no wall motion abnormalities. . # HYPERLIPIDEMIA - We continued his statin medication, Pravastatin 20 mg PO daily. . # HEPATITIS C - The patient had normal AST/ALTs from ; he presented with no jaundice or clinical symptoms; liver U/S has been reassuring in the past - AFP was normal in | Q-T interval prolongation. Marked sinus bradycardia with first degree A-V delay. Mobitz II second degree A-V block with non-conducted P waves and baselineP-R interval prolongation of 300 milliseconds. Inferior andanterolateral ST-T wave changes. 7:58 AM CHEST (PORTABLE AP) Clip # Reason: interval change? Non-specific inferior ST-T wave changes. A-V dissociation. A-V dissociation. A-V block is most likely type I with initial P-R intervalprolonged at 320 milliseconds followed by non-conducted P waves and thenjunctional escape beats. Prolonged Q-T interval.Compared to the previous tracing of evidence of type II second degreeA-V block persists.TRACING #1 Probable left ventricular hypertrophy. Inferior and anterolateral ST-T wavechanges. Second degree A-V block with one non-conducted P wave and baselineP-R interval of 300 milliseconds. FINDINGS: There is a new left-sided PICC line with tip just past midline in the superior vena cava. Cardiac and mediastinal silhouettes are similar to prior. Compared to tracing #3 complete A-V dissociation is now noted.TRACING #4 FINDINGS: The PICC line has been advanced and the tip is now just below the cavoatrial junction in the right atrium. A-V dissociation which may be due to third degree/complete A-V block.Intraventricular conduction delay. ProlongedP-R interval. Morbitz Type II second degree A-V block with non-conducted P waves. Left atrialabnormality. Slow initial R waveprogression. 11:44 AM CHEST (PA & LAT) Clip # Reason: r/o widened mediastinum, consolidation. Second degree A-V block type II (Mobitz II). Non-specific ST-T wave changes. Compared to tracing #6sinus rhythm has replaced A-V dissociation.TRACING #7 Second degree A-V block type II (Mobitz II) with prolonged P-R intervalat 320 milliseconds with two consecutive sinus beats followed by anon-conducted P wave in the initial part of the tracing. Baseline artifact. Anterolateral ST-T wave changeswhich may be related to myocardial ischemia. P-R intervalof 320 milliseconds. Compared to tracing #1 ST segment depression is morepronounced.TRACING #2 Inferior and anterolateralST segment depressions consistent with myocardial ischemia. There is then a sinusbeat followed by a non-conducted beat several times throughout the remainder ofthe tracing. 3:17 PM CHEST PORT. Atrial rate of 100. FINDINGS: PICC line tip is at the cavoatrial junction. Ventricular rate of 60. Compared to the previous tracing of the heart block is new but similar to what was seen on tracing of .TRACING #1 REASON FOR THIS EXAMINATION: r/o widened mediastinum, consolidation. FINAL REPORT CHEST ON HISTORY: Complete heart block, question interval change. Clinicalcorrelation is suggested. Compared to tracing #4 the findings aresimilar.TRACING #5 FINAL REPORT INDICATION: Chest pain earlier this morning. COMPARISON: . Cannot exclude complete heart block with junctional escaperhythm. Compared to the previous tracingof these findings are new. 8:20 PM CHEST PORT. Complex rhythm strip shows underlying sinus rhythm at arate of about 85 with second degree A-V block and intermittent junctionalescape beats. No significant change from previous tracing.TRACING #2 Clinical correlation is suggested. FINAL REPORT CHEST ON HISTORY: Long-term antibiotics, check PICC line tip. Average heart rate is about 57 per minute. Clinical correlation is suggested.Compared to tracing #2 the findings are similar.TRACING #3 To be at the cavoatrial junction, this would have to be advanced about 8 cm. IMPRESSION: No acute cardiopulmonary process. PA AND LATERAL VIEWS OF THE CHEST: The cardiac, mediastinal, and hilar contours are normal. There are no acute osseous findings. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: check picc tip placement-catheter exchange for malpositioned Admitting Diagnosis: CHEST PAIN MEDICAL CONDITION: 60 year old man with need for long term IV antibiotics REASON FOR THIS EXAMINATION: check picc tip placement-catheter exchange for malpositioned picc WET READ: NATg SUN 8:48 PM LUE picc is 7.9cm beyond the carina and should be withdrawn 3cm to be at the cavo-atrial junction. Compared to tracing #5 the findings are similar.TRACING #6 MEDICAL CONDITION: 60 year old man with chest pain earlier this AM. Lungs are clear. The lungs are clear. LINE PLACEMENT Clip # Reason: 49 cm left basilic Picc text tip placement to Admitting Diagnosis: CHEST PAIN MEDICAL CONDITION: 60 year old man with new Picc REASON FOR THIS EXAMINATION: 49 cm left basilic Picc text tip placement to FINAL REPORT CHEST ON HISTORY: New PICC line. There is no infiltrate. The lungs are clear, and the pulmonary vascularity is normal. There is no pneumothorax. No pleural effusion or pneumothorax is present. Admitting Diagnosis: CHEST PAIN MEDICAL CONDITION: 60 year old man with complete heart block REASON FOR THIS EXAMINATION: interval change? | 14 | [
{
"category": "Radiology",
"chartdate": "2194-08-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1205765,
"text": " 8:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: check picc tip placement-catheter exchange for malpositioned\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with need for long term IV antibiotics\n REASON FOR THIS EXAMINATION:\n check picc tip placement-catheter exchange for malpositioned picc\n ______________________________________________________________________________\n WET READ: NATg SUN 8:48 PM\n LUE picc is 7.9cm beyond the carina and should be withdrawn 3cm to be at the\n cavo-atrial junction.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Long-term antibiotics, check PICC line tip.\n\n FINDINGS: The PICC line has been advanced and the tip is now just below the\n cavoatrial junction in the right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1205468,
"text": " 11:44 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o widened mediastinum, consolidation.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with chest pain earlier this AM.\n REASON FOR THIS EXAMINATION:\n r/o widened mediastinum, consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain earlier this morning.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: The cardiac, mediastinal, and hilar\n contours are normal. The lungs are clear, and the pulmonary vascularity is\n normal. No pleural effusion or pneumothorax is present. There are no acute\n osseous findings.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1205741,
"text": " 3:17 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 49 cm left basilic Picc text tip placement to \n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 49 cm left basilic Picc text tip placement to \n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: New PICC line.\n\n FINDINGS: There is a new left-sided PICC line with tip just past midline in\n the superior vena cava. To be at the cavoatrial junction, this would have to\n be advanced about 8 cm. This finding was texted to the IV nurse, , at\n 4:15 p.m. on . The lungs are clear. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205806,
"text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with complete heart block\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Complete heart block, question interval change.\n\n FINDINGS: PICC line tip is at the cavoatrial junction. Cardiac and\n mediastinal silhouettes are similar to prior. Lungs are clear. There is no\n infiltrate.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-08 00:00:00.000",
"description": "Report",
"row_id": 165736,
"text": "Mobitz II second degree A-V block with non-conducted P waves and baseline\nP-R interval prolongation of 300 milliseconds. Anterolateral ST-T wave changes\nwhich may be related to myocardial ischemia. Clinical correlation is suggested.\nCompared to tracing #2 the findings are similar.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-12 00:00:00.000",
"description": "Report",
"row_id": 165730,
"text": "Morbitz Type II second degree A-V block with non-conducted P waves. Prolonged\nP-R interval. No significant change from previous tracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-11 00:00:00.000",
"description": "Report",
"row_id": 165731,
"text": "Second degree A-V block with one non-conducted P wave and baseline\nP-R interval of 300 milliseconds. Compared to the previous tracing of \nthe heart block is new but similar to what was seen on tracing of .\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-10 00:00:00.000",
"description": "Report",
"row_id": 165732,
"text": "Marked sinus bradycardia with first degree A-V delay. P-R interval\nof 320 milliseconds. Q-T interval prolongation. Compared to tracing #6\nsinus rhythm has replaced A-V dissociation.\nTRACING #7\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-09 00:00:00.000",
"description": "Report",
"row_id": 165733,
"text": "A-V dissociation which may be due to third degree/complete A-V block.\nIntraventricular conduction delay. Inferior and anterolateral ST-T wave\nchanges. Compared to tracing #5 the findings are similar.\nTRACING #6\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-09 00:00:00.000",
"description": "Report",
"row_id": 165734,
"text": "A-V dissociation. Atrial rate of 100. Ventricular rate of 60. Inferior and\nanterolateral ST-T wave changes. Compared to tracing #4 the findings are\nsimilar.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-09 00:00:00.000",
"description": "Report",
"row_id": 165735,
"text": "A-V dissociation. Cannot exclude complete heart block with junctional escape\nrhythm. Compared to tracing #3 complete A-V dissociation is now noted.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-08 00:00:00.000",
"description": "Report",
"row_id": 165971,
"text": "Second degree A-V block type II (Mobitz II). Inferior and anterolateral\nST segment depressions consistent with myocardial ischemia. Clinical\ncorrelation is suggested. Compared to tracing #1 ST segment depression is more\npronounced.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-08 00:00:00.000",
"description": "Report",
"row_id": 165972,
"text": "Second degree A-V block type II (Mobitz II) with prolonged P-R interval\nat 320 milliseconds with two consecutive sinus beats followed by a\nnon-conducted P wave in the initial part of the tracing. There is then a sinus\nbeat followed by a non-conducted beat several times throughout the remainder of\nthe tracing. Non-specific inferior ST-T wave changes. Prolonged Q-T interval.\nCompared to the previous tracing of evidence of type II second degree\nA-V block persists.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2194-08-08 00:00:00.000",
"description": "Report",
"row_id": 165973,
"text": "Baseline artifact. Complex rhythm strip shows underlying sinus rhythm at a\nrate of about 85 with second degree A-V block and intermittent junctional\nescape beats. A-V block is most likely type I with initial P-R interval\nprolonged at 320 milliseconds followed by non-conducted P waves and then\njunctional escape beats. Average heart rate is about 57 per minute. Left atrial\nabnormality. Probable left ventricular hypertrophy. Slow initial R wave\nprogression. Non-specific ST-T wave changes. Compared to the previous tracing\nof these findings are new. Clinical correlation is suggested.\n\n"
}
] |
60,739 | 180,716 | Hospital Course: This is an 87 yo M with multiple risk factors for CAD s/p NSTEMI demand ischemia from an acute GIB whose hospital course was complicated by a C. difficile infection and colonic perforation. Patient underwent an exp-lap with L colectomy, end colostomy, and pouch. He was transferred back to cardiology floor 8 days after surgery for management of volume overload, delerium, and acute on chronic renal failure. The patient was treated for all of these medical issues and was discharged to rehabilitation. | There is a trivial/physiologic pericardialeffusion. Trace aorticregurgitation is seen. Trace aortic regurgitation is seen. There is mild symmetric left ventricular hypertrophy with normalcavity size. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is mildly dilated. Normalregional LV systolic function. There is mild cortical atrophy with associated mild prominence of the extraaxial CSF spaces. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trivial mitral regurgitation is seen. Normal interatrial septum. There is minimal streaky density at the right base consistent with subsegmental atelectasis or scarring. Compared to the previoustracing of normal sinus rhythm has given way to sinus tachycardia. Slightly asymmetric opacity is seen in the right lower lung that might represent either partially resolved edema or focus of infection/aspiration. The ventricles and extra-axial CSF spaces and cerebral sulci are mildly prominent, likely related to mild diffuse parenchymal volume loss. Rhythm is probably periods of atrial flutter interrupted by pauses followed bya sinus beat and resumption of the tachyarrhythmiaDelayed R wave progression with late precordial QRS transitionModest ST-T wave changesThese findings are nonspecific but clinical correlation is suggestedSince previous tracing of , arrhythmia as outlined now present IV lasix gtt for CHF, now resolved per CXR. ECHO today revealing diastolic CHF. Due for EKG and TTE this AM. Reqing NIMV , weaned am . Reqing NIMV , weaned am . Elevated CK-MB/Troponin. Recheck K after stool= 4.1. Recheck K after stool= 4.1. ACCESS: PIV's PROPHYLAXIS: pneumoboots, PPI given GI bleed CODE: FULL code DISPO: CCU . Response: Repeat Hct 31.9 Plan: Continue protonix gtt. ECHO today revealing diastolic CHF. - d/c Vanc/Zosyn - transition to po Flagyl - F/u cultures # Acute on chronic diastolic CHF: Resolving. Med mgt of NSTEMI r/t GIB. Med mgt of NSTEMI r/t GIB. # HYPERKALEMIA: resolved with diuresis . # HYPERKALEMIA: resolved with diuresis . - Medically managed with ASA, Metoprolol, Statin # SINUS TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for pt) now resolved. His Bipap/ Mask ventilation was weaned am . His Bipap/ Mask ventilation was weaned am . Consider A aBlation if pt continues to have atrial tachy issues.Watch for any further CHF in setting of rapid rhythm epsisodes. Intestine, perforation of (perforation of hollow viscus) Assessment: s/p sigmoid colectomy, end illeostomy and hartmans pouch on Action: Fluid bolus given for low CVP and low UO. Found to be +C-diff- treated w/ PO vanco and IV flagyl. Response: -Minimal residuals from TF -Rectal tube DC -Post transfusion HCT 31.1 Plan: -Advance TF as tolerated -Monitor HCT QD Edema, peripheral Assessment: Pt with generalized anasarca Action: Lasix gtt DCd. Abd soft, distended -Hct trending down this am to 22.3 -Midline abd incision with small amts serous sanginous drainage. s/p sigmoid colectomy, end illeostomy and hartmans pouch on Action: abd firm and distended, hypoactive+ bs Abd inc draining moderate amt serosang output, dressing changed often. s/p sigmoid colectomy, end illeostomy and hartmans pouch on Action: abd firm and distended, hypoactive+ bs Abd inc draining moderate amt serosang output, dressing changed often. Intestine, perforation of (perforation of hollow viscus) Assessment: s/p sigmoid colectomy, end illeostomy and hartmans pouch on Action: Fluid bolus given for low CVP and low UO. Intestine, perforation of (perforation of hollow viscus) Assessment: 87 YO s/p sigmoid colectomy, end illeostomy and hartmans pouch on Action: Abd continues to be firm and distended, + bs + flatus. To OR emergently for xlap, colectomy, colostomy, s pouch for perforated divertic. Midline incision with mod amts serous sang drainage. Midline incision with mod amts serous sang drainage. Respiration / Gas Exchange, Impaired Clinical impression / Prognosis: 87 yo m admitted c NSTEMI s/p colectomy for perforated sigmoid. IV lasix gtt for CHF, now resolved per CXR. Tachycardia/ Hypertension Assessment: S/P NSTEMI this admission. - Medically managed with ASA, Metoprolol, Statin # TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for pt) now resolved. # HYPERKALEMIA: resolved with diuresis . Found to be +C-diff- treated w/ PO vanco and IV flagyl. Found to be +C-diff- treated w/ PO vanco and IV flagyl. Endoscopy when stable/afebrile. Last Cre 2.2 (3.0), has conts maintenance fluids infusing. s/p sigmoid colectomy, end illeostomy and hartmans pouch on Action: abd firm and distended, + bs + flatus. Last Cre 2.2 (3.0), has conts maintenance fluids infusing. Last Cre 2.2 (3.0), has conts maintenance fluids infusing. Last Cre 2.2 (3.0), has conts maintenance fluids infusing. C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile) Assessment: Abd distended/firm. - Medically managed with ASA, Metoprolol, Statin # SINUS TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for pt) now resolved. - Medically managed with ASA, Metoprolol, Statin # TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for pt) now resolved. - Medically managed with ASA, Metoprolol, Statin # SINUS TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for pt) now resolved. Action: Cont ASA/STATIN/ BB/Dilt. C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile) Assessment: Abd distended/firm. His Bipap/ Mask ventilation was weaned am . His Bipap/ Mask ventilation was weaned am . Med mgt of NSTEMI r/t GIB. Med mgt of NSTEMI r/t GIB. # HYPERKALEMIA: resolved with diuresis . - Medically managed with ASA, Metoprolol, Statin # TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for pt) now resolved. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Order date: @ 1246 17. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Order date: @ 1246 17. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR 10. | 222 | [
{
"category": "Echo",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Report",
"row_id": 86768,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 182\nBSA (m2): 1.92 m2\nBP (mm Hg): 107/32\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 14:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with 35-50% decrease during respiration (estimated RA pressure\n(0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mildly depressed\nLVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No masses or\nvegetations on aortic valve. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No masses or vegetations\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\nMild mitral annular calcification. Trivial MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is\n0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal\ncavity size. Overall left ventricular systolic function is mildly depressed\n(LVEF= 50 %). Right ventricular chamber size and free wall motion are normal.\nThe ascending aorta is mildly dilated. The aortic valve leaflets are\nmoderately thickened. No masses or vegetations are seen on the aortic valve.\nThere is no aortic valve stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. No masses or vegetations are seen\non the mitral valve, but cannot be fully excluded due to suboptimal image\nquality. Trivial mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\nCompared with the prior study (images reviewed) of , the left\nventricular function is mildly depressed. The severity of mitral regurgitation\nhas decreased. If clinically suggested, the absence of a vegetation by 2D\nechocardiography does not exclude endocarditis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Report",
"row_id": 86769,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease.\nHeight: (in) 66\nWeight (lb): 178\nBSA (m2): 1.91 m2\nBP (mm Hg): 129/53\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 11:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%). No resting LVOT\ngradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\n(+) MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nprobably normal. Overall left ventricular systolic function is normal\n(LVEF>55%). There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are moderately\nthickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Mild to moderate (+) mitral regurgitation is\nseen. The left ventricular inflow pattern suggests impaired relaxation. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046173,
"text": " 10:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man s/p sigmoidectomy for perforated diverticulitis, recieved 15\n liters of fluid postop, preparing for extubation\n REASON FOR THIS EXAMINATION:\n eval for pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preparing for extubation, to evaluate for pleural effusion.\n\n FINDINGS: In comparison with study of , there is little change in the\n appearance of the heart and lungs and the support and monitoring devices.\n Specifically, no evidence of pleural effusion, though this may be difficult in\n the absence of a lateral view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046861,
"text": " 2:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man s/p dobhoff tube placement\n REASON FOR THIS EXAMINATION:\n placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Dobbhoff tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the Dobbhoff tube is now in\n correct position. The tip projects over the proximal parts of the stomach.\n Otherwise, the radiograph is unchanged, no evidence of complications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1045481,
"text": " 1:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm position OGT\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with ex lap, left colectomy POD 1, OGT replaced\n REASON FOR THIS EXAMINATION:\n confirm position OGT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Explorative left, confirm OGT position.\n\n COMPARISON: , 3:48 a.m.\n\n FINDINGS: Status post reposition of the nasogastric tube. The tube is now in\n correct position. All other monitoring and support devices are also\n unremarkable. The transparency of the lung parenchyma is increased as\n compared to the previous examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1047052,
"text": " 1:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for acute intracranial process\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with NSTEMI c/b colonic perforation, c. diff infection, was\n verbal yesterday, AOx2, currently non-verbal and not responding to verbal\n commands from team\n REASON FOR THIS EXAMINATION:\n assess for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT BRAIN\n\n INDICATION: 87-year-old male, currently nonverbal and not responding to\n verbal commands.\n\n COMPARISON: CT brain, .\n\n FINDINGS: There has been no interval change from comparison examination.\n There is no evidence of intra/extra-axial hemorrhage, acute infarction, mass\n effect, or midline shift. There is mild cortical atrophy with associated mild\n prominence of the extraaxial CSF spaces. The paranasal sinuses and calvarium\n are unremarkable.\n\n IMPRESSION: No acute intracranial abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1045375,
"text": " 3:16 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: --- Patient is NOW in TSICU ---assess ETT, r/o pneumothorax,\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man s/p ex lap sigmoid colectomy for perf diverticulitis\n REASON FOR THIS EXAMINATION:\n --- Patient is NOW in TSICU ---assess ETT, r/o pneumothorax, CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative, to evaluate for tube placement.\n\n FINDINGS: In comparison with the study of , there is now an endotracheal\n tube in place with its tip approximately 3.5 cm above the carina. The tube\n appears to be pressing upon the right side of the trachea. Right IJ catheter\n extends to the mid to lower portion of the SVC, as does the left subclavian\n catheter. Low lung volumes are seen with some opacification at the left base\n behind the heart that could represent atelectasis or supervening pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-08 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 1043458,
"text": " 11:40 AM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: R/O DVT, PAIN\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with new leg pain, minor swelling.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: DSsd SAT 12:11 PM\n No DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New left lower extremity pain and minor swelling.\n\n FINDINGS: Grayscale, color and pulse wave Doppler son were performed in\n the left common femoral, superficial femoral, and popliteal veins. Normal\n flow, compressibility, waveforms, and augmentation are demonstrated. No\n intraluminal thrombus is identified.\n\n IMPRESSION: No left lower extremity DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1043298,
"text": " 12:55 PM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for change in CHF and ? infection\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with diastolic CHF exacerbation, poor oxygen sats, leukocytosis\n and low grade fever.\n REASON FOR THIS EXAMINATION:\n Please eval for change in CHF and ? infection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old man with diastolic chronic heart failure exacerbation\n and poor oxygen saturation with leukocytosis and low-grade fever, evaluate for\n change in CHF and question of infection.\n\n TECHNIQUE: PA and lateral chest radiograph.\n\n COMPARISON: Compared to chest radiograph from .\n\n FINDINGS: There is no gross change compared to the previous chest radiograph.\n There is stable pulmonary edema. There is no new focal consolidation.\n\n The mediastinal, hilar, and cardiac silhouette are unchanged.\n\n IMPRESSION: No significant interval change in the appearance of pulmonary\n edema. No new evidence of focal consolidation.\n\n Results were paged to .\n\n\n\n No significant interval change compared to .\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-13 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1044349,
"text": " 5:23 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: r/o free air, obstruction, please do supine and erect\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with CAD, afib, T2DM now with c.diff and worsening abdominal\n exam\n REASON FOR THIS EXAMINATION:\n r/o free air, obstruction, please do supine and erect\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 3:51 PM\n PFI: Mild diffuse small bowel dilatation and colonic haustral fold\n thickening, consistent with colitis. Findings are consistent with those on\n CT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old male with C. difficile and worsening abdominal pain.\n\n FINDINGS: Two views of the abdomen without prior comparison. There is\n nonspecific bowel gas pattern with air seen in multiple loops of mildly\n dilated small and large bowel. There is some suggestion of thickening of the\n large bowel haustral folds. There is no evidence for intraperitoneal free air\n or pneumatosis. There are no soft tissue calcifications. The osseous\n structures are unremarkable.\n\n IMPRESSION: Mild thickening of haustral folds. Air seen diffusely through\n mildly dilated loops of large and small bowel. Findings are consistent with\n colitis and associated ileus, better characterized on CT examination performed\n on at 21:09 hours.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1044835,
"text": " 12:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 43 cm 5 Fr DL Picc placed in left brachial vein, need Picc t\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 43 cm 5 Fr DL Picc placed in left brachial vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Line placement.\n\n FINDINGS: One semi-upright portable view. Comparison with . There is\n minimal streaky density at the right base consistent with subsegmental\n atelectasis or scarring. The lungs now appear otherwise clear. The heart and\n mediastinal structures are unchanged. A PICC line has been introduced on the\n left and extends into the left subclavian region with its tip projected over\n the left clavicle. There is no other significant change.\n\n IMPRESSION: Line placement as described. The PICC line terminates in an\n extrathoracic position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-14 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1044541,
"text": " 2:05 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: to evalute for ? diverticulitis vs fluid collection\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with c.diff colitis, read on previous CT scan did not have\n contrast through to rectum- per rads needs repeat to evalute for ?\n diverticulitis vs fluid collection\n REASON FOR THIS EXAMINATION:\n to evalute for ? diverticulitis vs fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf FRI 9:15 PM\n PFI: Eccentric segmental dilatation in the descending colon, which might be\n diverticulitis, but self-contained bowel perforation cannot be excluded.\n Giant diverticulum in the sigmoid colon. Severe pancolitis. Trace of\n ascites. Bilateral pleural effusion with adjacent small basilar atelectasis.\n No free air in the abdominal cavity. Results were discussed with Dr. \n and surgical consult was recommended.\n PFI VERSION #1 IPf FRI 8:47 PM\n PFI: Eccentric dilatation in the descending colon, which might be\n diverticulitis, but self-contained bowel perforation cannot be excluded.\n Giant diverticulum in the sigmoid colon. Severe pancolitis. Trace of\n ascites. Bilateral pleural effusion with adjacent small basilar atelectasis.\n No free air in the abdominal cavity. Results were discussed with Dr. \n and surgical consult was recommended.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old man with Clostridium difficile colitis, the previous CT\n scan did not have contrast throughout the rectum and per radiologist need to\n repeat to evaluate.\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic\n symphysis were displayed with 5-mm slice thickness without IV contrast and\n with previously administrated oral contrast. Coronal and sagittal reformatted\n images were displayed with 5-mm slice thickness.\n\n COMPARISON: Compared to CT abdomen from .\n\n FINDINGS: There are bilateral pleural effusions with adjacent basilar\n atelectasis. There is evidence of prior asbestos exposure with pleural\n thickening and calcium deposit. There are calcifications of the aortic valve\n and mitral valve.\n\n The liver and spleen are within normal limits. Pancreas shows atrophic\n changes within lower normal limits of size, and age appropriate. The stomach\n is distended. On the scout projection with we see bowel wall tumbprinting on\n descending colon suggestive of colitis. There is diffuse fat stranding\n surrounding the colon with wall thickening of the colon suggestive of\n pancolitis, with some relative preservation of the proximal colon.\n\n The small bowel is dilated, and now we see transition of contrast throughout\n (Over)\n\n 2:05 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: to evalute for ? diverticulitis vs fluid collection\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the small bowel and in the colon; complete small-bowel obstruction is excluded\n and the dilated small bowel loops are likely due to ileus.\n\n There are two areas of eccentric dilatation. The first area is on series\n 2:68, that is most typical of a giant sigmoid diverticulum. The second area\n of concern is on 2:60, where we do see asymmetrical appearance of the colon\n with wall thickening, and significant fat stranding. This finding might be\n suggestive of either diverticulitis, but focal perforation related to\n the patients colitis cannot be excluded.\n\n There is no free air in the abdominal cavity. There is evidence of\n diverticulosis in the large bowel. There is a trace of ascites. There is free\n air in the abdominal wall, 2:69, unchanged.\n\n There is a round hypodense focus in the left kidney, measuring 13 x 16 mm,\n unchanged. The right kidney appears grossly unremarkable. There is extensive\n calcification of blood vessels. There are no significantly enlarged\n mesenteric or retroperitoneal lymph nodes. There are significant degenerative\n changes of the lumbar spine. There are old rib fractures. There are\n degenerative changes of the hip joint bilaterally. There is fusion of the\n symphysis pubis.\n\n IMPRESSION:\n\n 1. Focus of eccentric dilatation of descending colon, in the left lower\n quadrant, with asymmetrical distribution of contrast and air and significant\n fat tissue stranding, which either represents acute diverticulitis or\n perforation realted to colitis. There is currently no evidence of freee\n intraperitoneal spillage or air. Surgical consult is recommended. Results\n were discussed with Dr. .\n\n 2. Second eccentric dilatation, which might be site of giant sigmoid\n diverticulum.No inflammation is seen around this and while contrast is seen\n within it it does not appear to represent an acute finding.\n\n 3. There is no small-bowel obstruction, the dilated loops of the small bowel\n are likely due to ileus.\n\n 4. Severe pancolitis-relative sparing proximally.\n\n 5. Bilateral pleural effusion with some adjacent small basilar atelectasis,\n and evidence of prior asbestos exposure.\n\n Results were discussed with Dr. and surgical consult was\n recommended. Results were also discussed with the surgical resident.\n\n (Over)\n\n 2:05 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: to evalute for ? diverticulitis vs fluid collection\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-14 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1044542,
"text": "diverticulitis, but self-contained bowel perforation cannot be excluded.\n Giant diverticulum in the sigmoid colon. Severe pancolitis. Trace of\n ascites. Bilateral pleural effusion with adjacent small basilar atelectasis.\n No free air in the abdominal cavity. Results were discussed with Dr. \n and surgical consult was recommended. Page: 4\n\n , M 87 () \n , D. 2:05 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: to evalute for ? diverticulitis vs fluid collection\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with c.diff colitis, read on previous CT scan did not have\n contrast through to rectum- per rads needs repeat to evalute for ?\n diverticulitis vs fluid collection\n REASON FOR THIS EXAMINATION:\n to evalute for ? diverticulitis vs fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Eccentric segmental dilatation in the descending colon, which might be\n diverticulitis, but self-contained bowel perforation cannot be excluded.\n Giant diverticulum in the sigmoid colon. Severe pancolitis. Trace of\n ascites. Bilateral pleural effusion with adjacent small basilar atelectasis.\n No free air in the abdominal cavity. Results were discussed with Dr. \n and surgical consult was recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-13 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1044386,
"text": " 8:50 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ATRIAL FIB, CAD ABD PAIN\n Admitting Diagnosis: CHEST PAIN\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with atrial fibrillation, CAD, recent NSTEMI now with c.diff\n and worsening abdominal examination\n REASON FOR THIS EXAMINATION:\n r/o colitis, obstruction, mesenteric ischemia\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 9:32 PM\n Diffuse stranding about the colon consistent with pan colitis. Given +\n cultures for C.Diff this is the most likely cause. Evaluation of the vessels\n for ischemic cause impossible given lack of contrast but not in the correct\n distribution. No evidence of perforation. Small bilateral effusions. Non-\n specific dilation4 of the small bowel to 3.6 cm. Healed left lateral rib\n fractures.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old man with AFib, CAD, recent NSTEMI and now with C.\n difficile and worsening abdominal examination. Rule out colitis, obstruction\n or mesenteric ischemia.\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic\n symphysis were displayed with 5-mm slice thickness with administration of oral\n contrast and no IV contrast due to patient's creatinine. Coronal and sagittal\n reformatted images were displayed with 5-mm slice thickness.\n\n COMPARISON: There is no previous CT for comparison.\n\n FINDINGS: There are bilateral pleural effusions with adjacent basilar\n atelectasis. There is evidence of prior asbestos exposure with pleural\n thickening and calcification. There are calcifications of the aortic valve\n and mitral valve.\n\n The liver and spleen are within normal limits. Pancreas shows atrophic\n changes, within lower normal limits of size. The stomach is distended.\n\n On the scout projections, we see thumbprinting on descending colon suggestive\n of colitis. There is diffuse fat stranding surrounding the colon with wall\n thickening of the colon suggestive of pancolitis, with some relative\n preservation of the proximal colon. There are 2 areas of eccentric dilatation\n of the colon where we do not see mucosa, raising the possibility of a small\n self-contained perforation, but it also might represent a large diverticulum,\n or diverticulitis 2:68 (sigmoid colon), and 2:57 (descending colon). There is\n no free air in the abdominal cavity.\n\n The small bowel is dilated, with some gradual transition of contrast, and\n distal small bowel is collapsed and we do not see contrast which might suggest\n (Over)\n\n 8:50 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ATRIAL FIB, CAD ABD PAIN\n Admitting Diagnosis: CHEST PAIN\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n incomplete small-bowel obstruction or ileus.\n\n There is evidence of diverticulosis in the large bowel. There is trace of\n ascites. There is free air in the abdominal wall, 2:68.\n\n There is a round hypodense focus in the left kidney, measuring 13 x 16 mm. The\n right kidney appears grossly unremarkable. There is extensive calcification\n of the blood vessels. There are no significant enlarged mesenteric or\n retroperitoneal lymph nodes.\n\n There are significant degenerative changes of the lumbar spine. There are old\n rib fractures. There are degenerative changes of the hip joints bilaterally.\n There is fusion of the symphysis pubis.\n\n IMPRESSION:\n\n 1. Severe predominalty distal colitis, with some relative preservation of the\n proximal colon.\n\n 2. Questionable incomplete small-bowel obstruction, or ileus.\n\n 3. Eccentric dilatation of the portions of the sigmoid and descending colon\n (locations given above), which might suggest small self-contained perforation\n or large diverticulum.\n\n 4. Trace of ascites.\n\n 5. Bilateral pleural effusion with some adjacent small basilar atelectasis,\n and evidence of prior asbestos exposure.\n\n 6. No free air in the peritoneal cavity. Air in the abdominal wall in the\n subcutanous tissue anteriorly.\n\n We recommend to repeat CT abdomen, to follow oral contrast distribution and to\n further evaluate items 2 and 3.\n\n Results were discussed with Dr. at 11:47 a.m.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-17 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1044990,
"text": " 11:13 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place double lumin PICC\n Admitting Diagnosis: CHEST PAIN\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with c. diff colitis, needs TPN, abx\n REASON FOR THIS EXAMINATION:\n Please place double lumin PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC EXCHANGE.\n\n INDICATION: Malposition of indwelling PICC line.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. performed the procedure. Dr. , the attending\n radiologist, supervised the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling left arm PICC, and subsequently into the SVC\n under fluoroscopic guidance. The old PICC line was then removed and a peel-\n away sheath was then placed over the guidewire. A new single-lumen PICC\n measuring 46 cm in length was then placed through the peel- away sheath with\n its tip positioned in the SVC under fluoroscopic guidance. Position of the\n catheter was confirmed by a fluoroscopic spot film of the chest.\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new\n single-lumen PICC. Final internal length is 46 cm, with the tip positioned in\n the SVC. The line is ready to use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1043864,
"text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with confusion and fever. Pt admitted for ACS sec to GI bleed.\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 12:40 PM\n PFI: No pulmonary edema or advanced CHF. No new infiltrates. Resolution of\n previous pulmonary edema of .\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Confusion and fever. Admitted for ACS with GI bleed. Evaluate\n for infiltrates.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-erect position is analyzed in direct comparison with a preceding similar\n study of . Heart size mildly enlarged but unchanged.\n Presently no evidence of pulmonary edema, acute infiltrates or pleural\n effusions that appear in the lateral pleural sinuses on this single view chest\n examination. Comparison with the next preceding study, the findings are\n rather unchanged.\n\n Review of previous chest examinations demonstrated an acute episode of typical\n central bilateral pulmonary edema which resolved gradually on the two\n following chest examinations of and .\n\n IMPRESSION: No evidence of pulmonary edema, or pleural effusion or acute\n infiltrates on single plain portable chest examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1043865,
"text": ", D. 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with confusion and fever. Pt admitted for ACS sec to GI bleed.\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pulmonary edema or advanced CHF. No new infiltrates. Resolution of\n previous pulmonary edema of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1042614,
"text": " 2:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna vs chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with fluid overload and nstemi transfer\n REASON FOR THIS EXAMINATION:\n eval for pna vs chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fluid overload from NSTEMI.\n\n COMPARISON: None.\n\n AP CHEST: Diffuse predominantly perihilar streaky interstitial opacities are\n consistent with acute pulmonary edema. Bilateral effusions are small. There is\n bibasilar atelectasis without definite underlying consolidation. Moderate\n cardiomegaly is noted.\n\n IMPRESSION: Acute CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-18 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1045358,
"text": " 10:43 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? Free air, acute changes. Please do 2 views.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with NSTEMI, C Diff colitis, with rigors and abdominal\n tenderness. Previous CT suggestive of possible diverticulitis, concerned now\n about perf.\n REASON FOR THIS EXAMINATION:\n ? Free air, acute changes. Please do 2 views.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old male with C. difficile colitis, now with rigors and\n abdominal pain. Previous CT suggested diverticulitis.\n\n FINDINGS: Two views of the abdomen in comparison to . There\n is a large amount of free air seen under the right hemidiaphragm. There is\n increased dilatation of multiple loops of small bowel measuring up to 5 cm.\n There is no bowel wall thickening, pneumatosis, or air-fluid levels. There is\n retained oral contrast. Osseous structures are unchanged.\n\n IMPRESSION:\n 1. Large amount of free air under the right hemidiaphragm.\n 2. Progressive dilatation of multiple loops of small bowel.\n\n Review of notes in OMR demonstrate these findings were known to hte\n treating physicians, and that the patient has already been taken to surgery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1044124,
"text": " 2:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o IC bleed\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with mental status changes, fevers\n REASON FOR THIS EXAMINATION:\n r/o IC bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old male patient, with mental status changes, fever, to\n evaluate for intracranial hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast CT of the head was performed.\n\n FINDINGS:\n\n There is no acute intracranial hemorrhage, mass effect, shift of normally\n midline structures or hydrocephalus. The ventricles and extra-axial CSF\n spaces and cerebral sulci are mildly prominent, likely related to mild diffuse\n parenchymal volume loss. Ossification of the transverse ligament is noted. No\n osseous lytic or sclerotic lesions are noted. The visualized portions of the\n paranasal sinuses are clear. The soft tissues of the scalp are unremarkable.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1042944,
"text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pulm edema and ? infiltrate\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with CHF exacerbation, leukocytosis\n REASON FOR THIS EXAMINATION:\n Please eval for pulm edema and ? infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:00 AM\n Improved pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: CHF exacerbation and leukocytosis.\n\n Comparison is made with prior studies including .\n\n Still mild, pulmonary edema has improved. Mild cardiomegaly is stable.\n Bilateral pleural effusions are small greater on the right side. Opacity in\n the right lower lobe that has slightly improved, still could be a focus of\n infection/aspiration and continously attention in this area should be\n paid.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2181-12-13 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1044350,
"text": ", D. 5:23 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: r/o free air, obstruction, please do supine and erect\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with CAD, afib, T2DM now with c.diff and worsening abdominal\n exam\n REASON FOR THIS EXAMINATION:\n r/o free air, obstruction, please do supine and erect\n ______________________________________________________________________________\n PFI REPORT\n PFI: Mild diffuse small bowel dilatation and colonic haustral fold\n thickening, consistent with colitis. Findings are consistent with those on\n CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-06 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1042988,
"text": " 10:53 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: eval for cirrhosis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with GI bleed, renal failure, h/o EtOH use.\n REASON FOR THIS EXAMINATION:\n eval for cirrhosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:23 PM\n Echogenic liver consistent with fatty infiltration. Please note, other forms\n of liver disease such as advanced hepatic fibrosis/cirrhosis cannot be\n excluded.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver/gallbladder ultrasound.\n\n INDICATION: 87-year-old male presenting with GI bleed, renal failure and\n history of ETOH use. Assess for cirrhosis.\n\n COMPARISONS: None.\n\n FINDINGS: The liver echotexture is heterogeneous and mildly echogenic. No\n focal lesion is identified. There is no intra- or extra-hepatic biliary\n dilatation. Normal hepatopetal flow is visualized. The pancreas is not well\n seen secondary to overlying bowel gas. The spleen is normal in size measuring\n 9.4 cm. The gallbladder is not distended and no gallstones are noted.\n\n The right kidney measures 10.2 cm and the left kidney measures 11.5 cm. A\n tiny, 6-mm anechoic focus is noted within the cortex of the mid pole of the\n right kidney and is compatible with a simple cyst. An adjacent echogenic\n focus may represent a small area of calcification versus stone. At the upper\n pole of the left kidney, there is a hypoechoic cyst measuring 1.8 x 1.8 x 1.7\n cm containing a small echogenic foci, likely calcification or stone. There is\n no hydronephrosis or renal masses.\n\n IMPRESSION: Mildly heterogeneous echogenic liver, which may be compatible\n with fatty infiltration. Please note, other forms of liver disease and more\n advanced liver disease such as hepatic fibrosis/cirrhosis cannot be excluded\n on the basis of this examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-06 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1042989,
"text": ", P. 10:53 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: eval for cirrhosis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with GI bleed, renal failure, h/o EtOH use.\n REASON FOR THIS EXAMINATION:\n eval for cirrhosis\n ______________________________________________________________________________\n PFI REPORT\n Echogenic liver consistent with fatty infiltration. Please note, other forms\n of liver disease such as advanced hepatic fibrosis/cirrhosis cannot be\n excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1042714,
"text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with CHF\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 10:28 AM\n Significant improvement of pulmonary edema with only mild failure currently\n present. Asymmetric right lower lung opacity that might represent evidence of\n pneumonia/aspiration or resolving edema. Attention to this area on the\n subsequent radiographs is recommended.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with congestive heart failure.\n\n Portable AP chest radiograph was compared to , obtained at\n 2:54 p.m.\n\n Significant improvement in pulmonary edema is demonstrated compared to the\n prior study with minimal evidence of failure still present on the current\n radiograph. Slightly asymmetric opacity is seen in the right lower lung that\n might represent either partially resolved edema or focus of\n infection/aspiration. Attention to this area on the subsequent studies is\n highly recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1042715,
"text": ", P. 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with CHF\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n PFI REPORT\n Significant improvement of pulmonary edema with only mild failure currently\n present. Asymmetric right lower lung opacity that might represent evidence of\n pneumonia/aspiration or resolving edema. Attention to this area on the\n subsequent radiographs is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1042945,
"text": ", P. 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pulm edema and ? infiltrate\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with CHF exacerbation, leukocytosis\n REASON FOR THIS EXAMINATION:\n Please eval for pulm edema and ? infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Improved pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046840,
"text": " 1:52 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: for dobhoff placement please make sure to image abdomen with\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with\n REASON FOR THIS EXAMINATION:\n for dobhoff placement please make sure to image abdomen with it\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 2:47 PM\n The Dobbhoff tube coiled in the midesophagus and will need to be\n re-positioned.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n HISTORY: 87-year-old man with Dobbhoff placement. Evaluate for position of\n Dobbhoff tube.\n\n COMPARISON: Multiple prior chest radiographs, most recent from at 1:04 p.m. The study was performed at 2:05 p.m.\n\n FINDINGS: The Dobbhoff tube is coiled in the mid to proximal esophagus and\n will need to be re-positioned.\n\n There is a right-sided central venous catheter whose tip projects over the mid\n SVC in unchanged position. There is stable cardiomegaly, the aortic arch is\n calcified and aorta is tortuous, all unchanged. There are low lung volumes\n however there are no pleural effusions. There is slight prominence to the\n pulmonary vasculature particularly on the left side which may be related to\n vascular crowding due to low lung volumes. There is minimal bibasilar\n atelectasis. No pneumothorax is seen.\n\n IMPRESSION:\n 1. Dobbhoff tube coiled in the mid to proximal esophagus and will need to be\n re-positioned.\n 2. Mild prominence of pulmonary vasculature which may be due to low lung\n volumes.\n 3. Bibasilar atelectasis.\n\n The findings of this study were communicated to Dr. by telephone\n at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-26 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1046841,
"text": ", A. TSICU 1:52 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: for dobhoff placement please make sure to image abdomen with\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with\n REASON FOR THIS EXAMINATION:\n for dobhoff placement please make sure to image abdomen with it\n ______________________________________________________________________________\n PFI REPORT\n The Dobbhoff tube coiled in the midesophagus and will need to be\n re-positioned.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046829,
"text": " 1:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of dophoff tube\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with\n REASON FOR THIS EXAMINATION:\n placement of dophoff tube\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 2:34 PM\n Dobbhoff tube's tip located in mid esophagus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old male. Evaluation for placement of Dobbhoff tube.\n\n FINDINGS: The tip of Dobbhoff tube is now located in mid esophagus and is\n mostly coiled in the mouth. Otherwise, unchanged appearance of the heart and\n lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046830,
"text": ", A. TSICU 1:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of dophoff tube\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with\n REASON FOR THIS EXAMINATION:\n placement of dophoff tube\n ______________________________________________________________________________\n PFI REPORT\n Dobbhoff tube's tip located in mid esophagus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046585,
"text": " 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check tube placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man s/p doboff tube placement\n REASON FOR THIS EXAMINATION:\n check tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff placement.\n\n FINDINGS: In comparison with the study of , there has been placement of\n the Dobbhoff tube, the tip of which appears to straddle the region of the\n esophagogastric junction. Otherwise, little change in the appearance of the\n heart and lungs.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-27 00:00:00.000",
"description": "Report",
"row_id": 223695,
"text": "Normal sinus rhythm, rate 104. Delayed precordial R wave progression.\nPossible anterior or anteroseptal myocardial infarction of indeterminate\nage. Non-specific repolarization abnormalities, most marked inferolaterally\nand anterolaterally, consistent with ischemia. Compared to the previous\ntracing of normal sinus rhythm has given way to sinus tachycardia.\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Report",
"row_id": 223696,
"text": "Sinus rhythm. Possible inferior myocardial infarction. Possible anterior\nmyocardial infarction. Diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of multiple abnormalities persist\nwithout major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Report",
"row_id": 223697,
"text": "Sinus rhythm. Low limb lead voltage. Non-specific ST-T wave abnormalities,\npossibly ischemic. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Report",
"row_id": 223698,
"text": "Sinus rhythm. Low limb lead voltage. Non-specific ST-T wave abnormalities,\npossibly ischemic. Compared to the previous tracing of sinus rhythm is\nnow present and anterior T wave inversions are more marked.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Report",
"row_id": 223699,
"text": "Rhythm is probably periods of atrial flutter interrupted by pauses followed by\na sinus beat and resumption of the tachyarrhythmia\nDelayed R wave progression with late precordial QRS transition\nModest ST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , arrhythmia as outlined now present\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-11 00:00:00.000",
"description": "Report",
"row_id": 223700,
"text": "Sinus rhythm. ST-T wave abnormalities. Since the previous tracing of \natrial fibrillation is no longer seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-08 00:00:00.000",
"description": "Report",
"row_id": 223701,
"text": "Atrial fibrillation with rapid ventricular response. Diffuse repolarization\nabnormalities likely related to rate and rhythm. Compared to the previous\ntracing of atrial fibrillation is new. Clinical correlation is\nsuggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Report",
"row_id": 223938,
"text": "Sinus tachycardia with ST segment depressions in leads I, aVL and V3-V6\nconsistent with active anteroseptal ischemic process in the context of the\nincrease in rate. Followup and clinical correlation are suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Report",
"row_id": 223939,
"text": "Sinus rhythm. Non-specific anterolateral ST-T wave changes as compared with\ntracing of .\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-04 00:00:00.000",
"description": "Report",
"row_id": 223940,
"text": "Sinus rhythm with slowing of the rate as compared with previous tracing\nof . Otherwise, no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2181-12-04 00:00:00.000",
"description": "Report",
"row_id": 223941,
"text": "Sinus tachycardia. Baseline artifact. Low precordial lead voltage.\nDelayed precordial R wave transition. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 642099,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 10:32 PM\n BLOOD CULTURED - At 01:40 AM\n EKG - At 02:35 AM\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 81 (73 - 85) bpm\n BP: 133/53(74) {114/50(66) - 139/64(80)} mmHg\n RR: 22 (20 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 14 mL\n 182 mL\n PO:\n 60 mL\n TF:\n IVF:\n 14 mL\n 122 mL\n Blood products:\n Total out:\n 1,100 mL\n 1,400 mL\n Urine:\n 300 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,087 mL\n -1,219 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 848 (710 - 848) mL\n PS : 12 cmH2O\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 20 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: ///21/\n Ve: 13.6 L/min\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 12cm but obscured by mask\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: Dullness at L base, rales way up bilaterally symmetrical\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 274 K/uL\n 10.6 g/dL\n 174 mg/dL\n 3.0 mg/dL\n 21 mEq/L\n 5.6 mEq/L\n 66 mg/dL\n 103 mEq/L\n 138 mEq/L\n 31.9 %\n 13.3 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n WBC\n 13.3\n Hct\n 31.9\n Plt\n 274\n Cr\n 3.0\n TropT\n 1.41\n Glucose\n 174\n Other labs: CK / CKMB / Troponin-T:528/39/1.41, Lactic Acid:1.6 mmol/L,\n Albumin:3.9 g/dL, Mg++:2.3 mg/dL\n Assessment and Plan\n 87 yoM w/ a h/o CKD presents with ACS in setting of severe anemia\n likely secondary to UGI bleed.\n .\n # CORONARIES: NSTEMI given lack of ST elevations on EKG, did have pain\n and positive troponins. He is high risk and ideally would undergo\n maximal medical therapy and undergo cardiac catheterization however he\n has a high risk given large GI bleed. In addition his symptoms began\n 48 hours ago and are likely secondary to his bleed rather than plaque\n rupture. Given bleed will need to medically manage.\n -high dose statin\n -low dose beta blocker, up titrate as tolerated\n -transfuse for hct < 30\n -start ACEi eventually when Cr stabilized and out of acute setting\n -aspirin 325mg daily\n -EKG in a.m.\n .\n # PUMP: obtain echo to evaluate EF as well as for valvular disease or\n possible complications of missed infarction. The patient is in acute\n heart failure with signs of both L and R heart failure. Lasix drip\n with goal diuresis 1 liter negative today.\n -continue BiPAP, with blood transfusions may need intubation if\n oxygenation worsens\n -BP currently normal, hold antihypertensives for now and start as\n needed\n .\n # RHYTHM: sinus rhythm, monitor on tele\n .\n # GI bleed: Melena with a hct drop. Likely bleeding source, given ACS\n will have to transfuse to goal HCT of 30.\n -maintain active type and screen\n -GI consult- f/u recs\n -protonix drip at 8mg / hr\n -2 large bore IVs (has 4 PIV now)\n -other causes for anemia would be chronic or possibly hemolysis\n -having hard stool now, seen by GI in ED, consented by GI for EGD in\n case, likely in future\n -? cirrhosis 30 years ago but hadn't had any further characterization,\n since then has cut down his drinking. will send albumin. No other\n stigmata of liver disease. Varicies are another possible source but\n cirrhosis / portal hypertension seems unlikely\n .\n # Acute on Chronic Renal failure: Given GI bleed and MI / CHF likely a\n result of pre-renal causes. (bleed vs. poor forward flow from CHF)\n FENA 23.9\n -send u/a and urine lytes\n -if not improving obtain renal ultrasound\n -baseline cr from 1 year ago was 1.6\n .\n # ANION GAP ACIDOSIS: anion gap is 18. Given CHF and bleed this is\n possibly due to a lactic acidosis.\n -send lactate and trend\n -glucose is 242, patient is possibly a diabetic but given this degree\n of hyperglycemia his gap is unlikely related to DKA. F/u U/a\n -another possibility would be uremia although lactic acidosis is still\n more likely.\n .\n # HYPERKALEMIA: possibly related to acute renal failure.\n -send p.m. hct, likely will come down with lasix drip\n -recheck p.m. potassium\n .\n # LEUKOCYTOSIS: likely as a result of acute MI however will need to\n rule out other causes.\n -f/u final read on CXR\n -send urine culture, u/a. Blood cultures, f/u final read of CXR\n -re-culture if , hold off on antibiotics for now but did\n recieve broad spectrum abx upon initial presentation.\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n -qid finger stick glucose\n -hold oral hypoglycemics\n .\n FEN: NPO for now in case of deterioration and need for intubation\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n DISPO: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:35 PM\n 18 Gauge - 10:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642087,
"text": "87 y/o male from OSH presented with NSTEMI secondary to acute GIB.\n Pulmonary edema on CXR.\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n SR on telemetry. No ectopy. Denies c/o CP. Desat to low 80s on NC,\n upper 80s on NRB. On CPAP ventilation. +4 pitting edema bilat lower\n extremities. Pulmonary edema on CXR. K+ 5.6. Elevated CK-MB/Troponin.\n Action:\n Started lasix gtt at 10 mg/hr for goal -1L today. Continue CPAP\n ventilation; weaning per O2 sats and pt condition. EKG done at bedside\n d/t hyperkalemia. Given 30 gm PO kayexelate.\n Response:\n -900 mL as of present. Tolerating weaning of FIO2 and PEEP while\n maintaining sats >94%. No response from kayexelate yet.\n Plan:\n Diurese -1L per team. Wean noninvasive ventilation as pt tolerates.\n Repeat K+. Watch CK-MB/Troponin trends. Due for EKG and TTE this AM.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with reported Hct from OSH 22.6 and melanic stool in ED.\n Action:\n Rec\nd bolus protonix 80 mg IV in ED followed by continuous infusion at\n 8 mg/hr. Transfused 2 units PRBCs.\n Response:\n Repeat Hct 31.9\n Plan:\n Continue protonix gtt. Goal to keep Hct > 30. GI consulted in , pt\n consented for EGD if necessary. Guaic stool x 3.\n Hyperglycemia\n Assessment:\n Glucose > 200.\n Action:\n Given humalog and glargine insulin at HS.\n Response:\n Glucose < 200. Goal < 150.\n Plan:\n Fingersticks ACHS. Humalog insulin sc per pt specific sliding scale.\n Glargine at HS.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642192,
"text": "87 y/o male presented to with chest pain/SOB since\n PM (took nitro SL x 2 with no relief). IN OSH ED, given 40 mg\n furosemide x 2, TN I = 3.94, CK 500s, CK MB 34, Hct 22. Transferred to\n ED with NSTEMI, no EKG changes. K 5.8 even after IV lasix-> Given\n kaexeylate. +GIB, GI team following. Given 2 units PRBC last evening.\n Req\ning NIMV , weaned am . IV lasix gtt/ IV protonix\n gtt.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Cardiac enzymes trending downward. BP 120s-140s/80s. HR 90-100s ST on\n lopressor 12.5 TID. EKG with no acute changes. CP and abdominal pain\n free.\n Action:\n Continued to trend enzymes. Daily EKG. Assessed for CP. Med mgt of\n CAD. Lopressor increased to 25mg TID. ECHO today revealing diastolic\n CHF.\n Response:\n Enzymes trending downward. EKG without change. Pain free.\n Plan:\n Medical mgt of ACS/CAD. Baby ASA in setting GIB. Continue to cycle\n CE\ns. Daily EKGs. Assess for CP. Monitor response to increased\n lopressor.\n Pulmonary edema/ Diastolic Heart Failure\n Assessment:\n LS rales\n up bilaterally, exp. wheezing. SPO2 100% NIMV. +Dry non\n productive cough (pt stated cough usually productive at home). Bilat\n pitting LE edema to mid-calf, worse at ankles, +. Dyspnea and desat\n 88-90% with minimal exertion.\n Action:\n CXR today w/ pulmonary edema. IV lasix gtt titrated to 100-200ml\n UOP/hr, goal 1-2L negative. Weaned NIMV to cool mist neb 70%.\n Attempted further wean to 50% with SPO2 down to mid 80s. Placed back of\n 70%. Later, placed on 6LNC to eat w/ SPO2 90-94%. Per team, goal SPO2\n 93%. Given IS and educated on proper technique. Encouraged C&DB.\n Response:\n SPO2 93-97% on cool mist neb 70%. Pt w/ negative I/Os 3500ml at 15:00-\n Lasix stopped per team. Edema and DOE without change. Using IS\n appropriately with reminders.\n Plan:\n Continue to monitor volume status. Assess lungs, oxygenation, DOE,\n edema. Encourage C&DB/ IS 10x/hr.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Large semi-formed stool this AM, very dark brown, +foul smelling.\n Guaiac positive. HCT repeat 29 (31). S/p 2 units PRBC over night.\n Action:\n Team notified. GI following. Continued IV protonix gtt.\n Response:\n HCT stable. Stool x 1.\n Plan:\n Continue to closely follow HCT. Further work up of bleed to be done\n after completely stable from CV standpoint. GI aware and following.\n Consent already obtained for EGD when able.\n Renal failure, acute (Acute on chronic renal failure)\n Assessment:\n Unclear of pt\ns current baseline though some records indicate Cr\n baseline 1.6. Currently 3.0 this AM. Hourly UOP>100ml/hr r/t Lasix gtt.\n Action:\n Following serial Cr/BUN, urine output. Team attempting to obtain better\n history from PCP. - (ACE-I).\n Response:\n Repeat Cr slightly down to 2.8.\n Plan:\n Repeat Cr/BUN later this evening. Continue to monitor daily BUN/CR.\n Hourly UOP.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 5.8 this AM despite being diuresed w/ IV lasix drip.\n Action:\n Given 30gm Kaexeylate overnight.\n Response:\n Large BM in AM. Recheck K after stool= 4.1.\n Plan:\n Continue to closely follow electrolytes in setting of ARF.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642069,
"text": "Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642316,
"text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642430,
"text": "Pulmonary edema\n Assessment:\n Pt cont with crackles at bases, cont to req high O2, slept comfortably\n at 15-30 degrees\n Action:\n Cont lasix gtt at 5mg/hr, titrate Os as needed, currently 4l NC, 50%\n CN.\n Response:\n UO 60-80cc/hr, sats high 90\ns, drop to 88 with CN off and only NC 4L\n on.\n Plan:\n Cont gentle diuresis and follow sats\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable last eve, passed OB(+) stool overnight x1(incontinent). BP\n stable as cardiac meds resumed.\n Action:\n Monitoring, repeat hct sent this am\n Response:\n Check hct\n Plan:\n Transfuse as needed, plan for EDG when stable from cardiac standpoint.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 642138,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 10:32 PM\n BLOOD CULTURED - At 01:40 AM\n EKG - At 02:35 AM\n Attempted BiPAP wean at 3AM with desat to 82%\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Furosemide (Lasix) - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 81 (73 - 85) bpm\n BP: 133/53(74) {114/50(66) - 139/64(80)} mmHg\n RR: 22 (20 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 14 mL\n 182 mL\n PO:\n 60 mL\n TF:\n IVF:\n 14 mL\n 122 mL\n Blood products:\n Total out:\n 1,100 mL\n 1,400 mL\n Urine:\n 300 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,087 mL\n -1,219 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 848 (710 - 848) mL\n PS : 12 cmH2O\n RR (Spontaneous): 21\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 20 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: ///21/\n Ve: 13.6 L/min\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 12cm but obscured by mask\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: Dullness at L base, rales way up bilaterally symmetrical\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 274 K/uL\n 10.6 g/dL\n 174 mg/dL\n 3.0 mg/dL\n 21 mEq/L\n 5.6 mEq/L\n 66 mg/dL\n 103 mEq/L\n 138 mEq/L\n 31.9 %\n 13.3 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n WBC\n 13.3\n Hct\n 31.9\n Plt\n 274\n Cr\n 3.0\n TropT\n 1.41\n Glucose\n 174\n Other labs: CK / CKMB / Troponin-T:528/39/1.41, Lactic Acid:1.6 mmol/L,\n Albumin:3.9 g/dL, Mg++:2.3 mg/dL\n Assessment and Plan\n 87 yoM w/ a h/o CKD presents with ACS in setting of severe anemia\n likely secondary to UGI bleed.\n .\n # CORONARIES: NSTEMI given lack of ST elevations on EKG, did have pain\n and positive troponins. He is high risk and ideally would undergo\n maximal medical therapy and undergo cardiac catheterization however he\n has a high risk given large GI bleed. In addition his symptoms began 48\n hours ago and are likely secondary to his bleed rather than plaque\n rupture. Given bleed will need to medically manage.\n -high dose statin\n -low dose beta blocker, up titrate as tolerated\n -transfuse for hct < 30\n -start ACEi eventually when Cr stabilized and out of acute setting\n -aspirin 325mg daily\n -EKG in a.m.\n .\n # PUMP: obtain echo to evaluate EF as well as for valvular disease or\n possible complications of missed infarction. The patient is in acute\n heart failure with signs of both L and R heart failure. Lasix drip with\n goal diuresis 1 liter negative today.\n -continue BiPAP, with blood transfusions may need intubation if\n oxygenation worsens\n -BP currently normal, hold antihypertensives for now and start as\n needed\n .\n # RHYTHM: sinus rhythm, monitor on tele\n .\n # GI bleed: Melena with a hct drop, however Hct stable overnight.\n Likely bleeding source, given ACS will have to transfuse to goal HCT of\n 30.\n -maintain active type and screen\n -GI consult- f/u recs\n -protonix drip at 8mg / hr\n -2 large bore IVs (has 4 PIV now)\n -other causes for anemia would be chronic or possibly hemolysis\n -having hard stool now, seen by GI in ED, consented by GI for EGD in\n case, likely in future\n -? cirrhosis 30 years ago but hadn't had any further characterization,\n since then has cut down his drinking. will send albumin. No other\n stigmata of liver disease. Varicies are another possible source but\n cirrhosis / portal hypertension seems unlikely\n .\n # Acute on Chronic Renal failure: Given GI bleed and MI / CHF likely a\n result of pre-renal causes. (bleed vs. poor forward flow from CHF)\n -send u/a and urine lytes\n -if not improving obtain renal ultrasound\n -baseline cr from 1 year ago was 1.6\n .\n # ANION GAP ACIDOSIS: anion gap improved to 14 from 18. Lactate mostly\n normal, but may have been more elevated at time of gap. Elevated BUN\n may suggest a small component of uremia. Glucose was 242, but given\n this degree of hyperglycemia his gap is unlikely related to DKA. No\n ketones on UA\n - Continue to trend lytes\n .\n # HYPERKALEMIA: possibly related to acute renal failure.\n -send p.m. hct, likely will come down with lasix drip\n -recheck p.m. potassium\n .\n # LEUKOCYTOSIS: Afebrile with downtrending WBC. Elevated WBC likely as\n a result of acute MI however will need to rule out other causes.\n -f/u final read on CXR\n -send urine culture, u/a. Blood cultures, f/u final read of CXR\n -re-culture if , hold off on antibiotics for now but did\n recieve broad spectrum abx upon initial presentation.\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n -qid finger stick glucose\n -hold oral hypoglycemics\n .\n FEN: Will advance diet. Resume NPO if planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n DISPO: CCU\n .\n .\n Active Medications ,\n 1. Aspirin 81 mg PO DAILY Order date: @ 1009\n 6. Metoprolol Tartrate 12.5 mg PO TID\n hold for sbp < 100 or HR < 55 Order date: @ 0029\n 2. Atorvastatin 80 mg PO DAILY Order date: @ 0029\n 7. Pantoprazole 8 mg/hr IV INFUSION Order date: @ 2305\n 3. Furosemide 0-10 mg/hr IV DRIP INFUSION\n titrate to UOP 100 cc/hr Order date: @ 0639\n 8. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: @\n 2300\n 4. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 2300\n 9. Sodium Polystyrene Sulfonate 30 gm PO ONCE Duration: 1 Doses Order\n date: @ 0225\n 5. Insulin SC (per Insulin Flowsheet)\n Sliding Scale & Fixed Dose Order date: @ 0034\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:35 PM\n 18 Gauge - 10:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642140,
"text": "87 y/o male presented to with chest pain/SOB since\n PM. Took nitro SL x 2 with no relief. Family took pt to HFH ED,\n given 40 mg furosemide x 2, TN I = 3.94, CK 500s, CK MB 34, Hct 22.\n Transferred to ED with NSTEMI, no EKG changes. K 5.8 even after\n IV lasix-> Given kaexeylate. +GIB, GI team following. Given 2 units\n PRBC last evening. Req\ning NIMV , weaned am .\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Cardiac enzymes trending downward. BP 120s-140s/80s. HR 90-100s ST on\n lopressor 12.5 TID. EKG with no acute changes. CP and abdominal pain\n free.\n Action:\n Continued to trend enzymes. Daily EKGs. Assessed for CP. Med mgt of\n CAD. ECHO today.\n Response:\n Enzymes trending downward.\n Plan:\n Pulmonary edema\n Assessment:\n LS rales\n up bilaterally, esp wheezing. SPO2 100% NIMV. +Dry non\n productive cough (pt stated cough usually productive at home).\n Action:\n CXR today w/ pulmonary edema. IV lasix gtt titrated to 100-200ml\n UOP/hr, goal 1-2L negative. Weaned NIMV to cool mist neb 70%.\n Encouraged C&DB.\n Response:\n SPO2 92-97% on cool mist neb.\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Large semi-formed stool this AM, very dark brown, +foul smelling.\n Guaiac positive. HCT repeat 29 (31). s/p 2 units PRBC over night.\n Action:\n Team notified. GI following. Continued IV protonix gtt.\n Response:\n HCT stable. Stool x _______.\n Plan:\n Continue to closely follow HCT. Further work up of bleed to be done\n after completely stable from CV standpoint. GI aware and following.\n Consent already obtained for EGD when able.\n Renal failure, acute (Acute on chronic renal failure)\n Assessment:\n Unclear of pt\ns current baseline though some records indicate Cr\n baseline 1.6. Currently 3.0 this AM. Hourly UOP>100ml/hr r/t Lasix gtt.\n Action:\n Following serial Cr/BUN, urine output. Team attempting to obtain better\n history from PCP. - (ACE-I).\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 5.8 this AM despite being diuresed w/ IV lasix drip.\n Action:\n Given 30gm Kaexeylate overnight.\n Response:\n Large BM in AM. Recheck K after stool= 4.1.\n Plan:\n Continue to closely follow electrolytes in setting of ARF.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644156,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644157,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644160,
"text": "87 yo male adm with NSTEMI w/ new diastolic CHF in setting of\n GIB. MI medically managed. IV lasix gtt for CHF, now resolved per CXR.\n Sent to 3 for a few days until when temp spiked to 104 PR. Pt\n found to have C-diff colitis. Abd CT with severe pancolitis versus\n walled-off bowel perforation. Surgery following- no need for urgent\n bowel surgery. NPO until further notice for bowel rest. PICC\n repositioned in IR .\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n WBC trending down, abdomen distended but less firm. Afebrile. small\n lt brn mucousy stool,\n Action:\n Continues on po vancomycin and iv flagyl, pt OOB to chair w/ith 2\n assists, Started TPN this eve.\n Response:\n Plan:\n Monitor wbc, keep npo except for po asa and vancomycin. , continue\n TPN. ^ activity as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642567,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix (? 80-120 mg IV?) for (+)CHF-- TN I =\n 3.94, CK 500s, CK MB 34, Hct 22. He was also given ASA /NTP and was\n transferred to ED with NSTEMI, no EKG changes-(thought to be\n stress ischemia d/t drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. Hct stable at 31 since\n transfusion,. Lasix gtt at 5 mg /hr w/ good response, neg 8 liters\n since admission. Initial o2 requirements high, now down to 4lnp w/ sats\n 95%. Cr down to baseline of 2.2.\n Hyperglycemia\n Assessment:\n Continued high bs\n Action:\n Covered per HISS\n Response:\n Plan:\n Monitor bs, ? ^ glargine\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No s/s bleeding, hct stable\n Action:\n Response:\n Plan:\n Follow hct\n Pulmonary edema\n Assessment:\n , Improved oxygenation\n Action:\n Continue lasix gtt\n Response:\n Plan:\n Monitor resp status\n Cardiac dysrhythmia other\n Assessment:\n HR 80-100, sinus rhythm, on lopressor 75 mg tid and diltiazem 30 mg qid\n until ~ 1600 hr ^ 150\ns atrial tachycardia w/ varying block. Bp stable,\n pt asymptomatic, ekg done\n Action:\n Given lopressor 5 mg iv x2\n Response:\n Hr 110-120\n Plan:\n Monitor rhythm, response to cv meds\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642568,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix (? 80-120 mg IV?) for (+)CHF-- TN I =\n 3.94, CK 500s, CK MB 34, Hct 22. He was also given ASA /NTP and was\n transferred to ED with NSTEMI, no EKG changes-(thought to be\n stress ischemia d/t drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. Hct stable at 31 since\n transfusion,. Lasix gtt at 5 mg /hr w/ good response, neg 8 liters\n since admission. Initial o2 requirements high, now down to 4lnp w/ sats\n 95%. Cr down to baseline of 2.2.\n Hyperglycemia\n Assessment:\n Continued high bs\n Action:\n Covered per HISS\n Response:\n Plan:\n Monitor bs, ? ^ glargine\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No s/s bleeding, hct stable\n Action:\n Response:\n Plan:\n Follow hct\n Pulmonary edema\n Assessment:\n , Improved oxygenation\n Action:\n Continue lasix gtt\n Response:\n Plan:\n Monitor resp status\n Cardiac dysrhythmia other\n Assessment:\n HR 80-100, sinus rhythm, on lopressor 75 mg tid and diltiazem 30 mg qid\n until ~ 1600 hr ^ 150\ns atrial tachycardia w/ varying block. Bp stable,\n pt asymptomatic, ekg done\n Action:\n Given lopressor 5 mg iv x2\n Response:\n Hr 110-120\n Plan:\n Monitor rhythm, response to cv meds\n Deep Venous Thrombosis (DVT), Lower extremity\n Assessment:\n Pt has had pneumo boots on since admission, when he got up to the chair\n today he c/o pain behind L knee, area not swollen or red.\n Action:\n by MD, lower extremety US ordered\n Response:\n Plan:\n Monitor\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 642710,
"text": "Pulmonary edema\n Assessment:\n Pt CHF improving, decreased O2 requirements\n Action:\n Gentle diuresis with lasix gtt, decreased to 2.5mg/hr this AM d/t\n rising creatinine. Repleated with 40mEq KCL this AM for K+ 3.6. Weaned\n to 3L NC with sats >92\n Response:\n UO 50-80cc/hr, neg 1L at MN, 8L LOS\n Plan:\n Cont gentle diuresis, follow lytes, lung exam, sats.\n Hyperglycemia\n Assessment:\n BS in 200\ns today\n Action:\n Covered with SS humolog, diet changed to diabetic was heart healthy\n Response:\n BS elevated\n Plan:\n Will need cont monitoring and regulation of insulin\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP, VS stable. CHF improving\n Action:\n Increasing doses of lopressor and dilt, on ASA, Lipitor\n Response:\n HR decreased to 60\ns today with increased meds.\n Plan:\n Cont to monitor.\n Cardiac dysrhythmia other\n Assessment:\n Pt in NSR today, no afib since last night\n Action:\n Increased lopressor and dilt\n Response:\n NSR\n Plan:\n Cont telemetry.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 644290,
"text": "TITLE:\n Chief Complaint:\n 87 yoM w/ h/o CKD presented with acute on chronic diastolic CHF\n exacerbation and ACS in the setting of GI bleed, then developed C. diff\n colitis while awaiting EGD/colonoscopy.\n 24 Hour Events:\n PICC readjusted by IR. TPN started yesterday.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:22 PM\n Metronidazole - 04:11 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 04:10 AM\n Other medications:\n Clonidine patch\n ASA 81mg\n Lopressor 20mg IV q4hrs\n Pantopazole 40mg IV\n Vanco 250mg po\n Flagyl 500mg IV q8hrs\n Clindamycin TP\n Glargine/SSI\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.4\n HR: 76 (67 - 90) bpm\n BP: 154/57(82) {95/34(49) - 173/86(93)} mmHg\n RR: 19 (2 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,404 mL\n 427 mL\n PO:\n 90 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 1,050 mL\n 345 mL\n Urine:\n 1,050 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n 354 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n GEN: NAD\n HEENT: MMM, no JVD\n CV: RRR, no murmurs, quiet HS\n PULM: CTA bilaterally\n ABD: distended, tympanitic, nontender, soft, positive BS, no guarding,\n no rebound\n EXT: distal edema, WWP, 2+ distal pulses\n NEURO: A+O x 3\n Labs / Radiology\n 795 K/uL\n 11.5 g/dL\n 250 mg/dL\n 1.6 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 53 mg/dL\n 120 mEq/L\n 147 mEq/L\n 35.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n 05:43 AM\n 05:00 AM\n 06:00 AM\n 04:00 AM\n WBC\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n 16.4\n 15.3\n 16.1\n Hct\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n 37.7\n 38.4\n 35.3\n Plt\n 394\n 446\n 517\n 95\n Cr\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n 1.7\n 1.7\n 1.6\n Glucose\n 140\n 133\n 142\n 114\n 149\n 139\n 165\n 173\n 250\n Other labs: Mg++:2.4 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presented with acute on chronic diastolic CHF\n exacerbation and ACS in the setting of GI bleed, then developed C. diff\n colitis while awaiting EGD/colonoscopy.\n # HYPERNATREMIA: Na 147, trending upwards. Likely secondary to being\n NPO and lack of free water in TPN. Deficit is 2.5L.\n - Will start patient on D5 @ 100cc/hr, for 1.5L. Will hold if\n patient\ns SBP > 160.\n # CLOSTRIDIUM DIFFICILE INFECTION: No longer tender abdomen but still\n distended. Decreased stool frequency and volume. Improved.\n - Not currently surgical emergency. Surgery recommends starting po\n once patient has started to have proper BMs. Will start Ice chips\n today.\n - IV flagyl, PO Vanc.\n - NPO and NPR\n # DIASTOLIC CONGESTIVE HEART FAILURE: Appears euvolemic.\n - Will monitor closely as patient is receiving IVFs\n # GI BLEED: Presented with GIB, but since then has been stable, guaiac\n neg and Hct stable.\n - will defer EGD until stable\n - protonix IV BID\n # ACUTE ON CHRONIC RENAL FAILURE: Improved. Cr 1.6. Renal function\n better than baseline of 2.2\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol\n # TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for\n pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF and\n dependency on filling time\n # HYPERTENSION: SBPs have been has high as 170s. Concern for possible\n flash pulmonary edema.\n - Continue Lopressor to 20mg IV q4hrs\n - Hydral prn for SBP > 160\n FEN: NPO for bowel rest. Nutrition consult for TPN recs\n ACCESS: PIV's. PICC for TPN\n PROPHYLAXIS: pneumoboots, PO PPI, SQ heparin\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU. Possibly to floor if stable tomorrow.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 08:30 AM\n PICC Line - 12:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642327,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix (? 80-120 mg IV?) for (+)CHF-- TN I =\n 3.94, CK 500s, CK MB 34, Hct 22. He was also given ASA /NTP and was\n transferred to ED with NSTEMI, no EKG changes-(thought to be\n stress ischemia d/t drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF.\n His Bipap/ Mask ventilation was weaned am AM and he was switched\n to 6 l np for eating alterating with 70% cool neb otherwise.\n He remained on IV lasix gtt from admit to CCU until afternoon\n due to I/O greatly (-)\n over 4 liters!\n He remains on IV protonix gtt for GIB and has only had 1 episode of\n melena s/p k-kexilate dose. B Blocker was resumed and has been\n increased over the course of the past 2 shifts in hopes of controlling\n rate for (+) dialstolic dysfunction.\n Pt remains A and O x 3 since admit to CCU.\n Pulmonary edema\n Assessment:\n Pt remains w/ signifigant o2 requirement, 94-95%, down to 80\n90% on\n 6lnp,\n Action:\n Lasix gtt resumed at 3 mg/hr, pt using incentive spirometry\n Response:\n u/o 120-160cc/hr, ~ 1400cc neg since mn, cr 2.7 this am ( baseline)\n Plan:\n Titrate Lasix gtt to mainbtain u/o > 120cc/hr, encourage use of\n incentive espirometry\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable at 31, no stool\n Action:\n Ultrasound of abdomen\n Response:\n Awaiting results of ultrasound\n Plan:\n Monitor hct, guiac any stools, endoscopy when clinically more stable\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Ck trending down, painfree, HR 86-99 sr no vea., bp stable\n Action:\n Started on diltiazem 30 mg qid, clonidine patch .3 mg q24 hr.\n Response:\n Hr 80-90\ns down from 100 this am\n Plan:\n Monitor response to change in cv meds.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642566,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix (? 80-120 mg IV?) for (+)CHF-- TN I =\n 3.94, CK 500s, CK MB 34, Hct 22. He was also given ASA /NTP and was\n transferred to ED with NSTEMI, no EKG changes-(thought to be\n stress ischemia d/t drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. Hct stable at 31 since\n transfusion,. Lasix gtt at 5 mg /hr w/ good response, neg 8 liters\n since admission. Initial o2 requirements high, now down to 4lnp w/ sats\n 95%. Cr down to baseline of 2.2.\n Hyperglycemia\n Assessment:\n Continued high bs\n Action:\n Covered per HISS\n Response:\n Plan:\n Monitor bs, ? ^ glargine\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No s/s bleeding, hct stable\n Action:\n Response:\n Plan:\n Follow hct\n Pulmonary edema\n Assessment:\n , Improved oxygenation\n Action:\n Continue lasix gtt\n Response:\n Plan:\n Monitor resp status\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642173,
"text": "87 y/o male presented to with chest pain/SOB since\n PM (took nitro SL x 2 with no relief). IN OSH ED, given 40 mg\n furosemide x 2, TN I = 3.94, CK 500s, CK MB 34, Hct 22. Transferred to\n ED with NSTEMI, no EKG changes. K 5.8 even after IV lasix-> Given\n kaexeylate. +GIB, GI team following. Given 2 units PRBC last evening.\n Req\ning NIMV , weaned am . IV lasix gtt/ IV protonix\n gtt.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Cardiac enzymes trending downward. BP 120s-140s/80s. HR 90-100s ST on\n lopressor 12.5 TID. EKG with no acute changes. CP and abdominal pain\n free.\n Action:\n Continued to trend enzymes. Daily EKG. Assessed for CP. Med mgt of\n CAD. Lopressor increased to 25mg TID. ECHO today revealing diastolic\n CHF.\n Response:\n Enzymes trending downward. EKG without change. Pain free.\n Plan:\n Medical mgt of ACS/CAD. Baby ASA in setting GIB. Continue to cycle\n CE\ns. Daily EKGs. Assess for CP. Monitor response to increased\n lopressor.\n Pulmonary edema/ Diastolic Heart Failure\n Assessment:\n LS rales\n up bilaterally, exp. wheezing. SPO2 100% NIMV. +Dry non\n productive cough (pt stated cough usually productive at home). Bilat\n pitting LE edema to mid-calf, worse at ankles, +. Dyspnea and desat\n 88-90% with minimal exertion.\n Action:\n CXR today w/ pulmonary edema. IV lasix gtt titrated to 100-200ml\n UOP/hr, goal 1-2L negative. Weaned NIMV to cool mist neb 70%.\n Attempted further wean to 50% with SPO2 down to mid 80s. Placed back of\n 70%. Encouraged C&DB.\n Response:\n SPO2 92-97% on cool mist neb 70%. Pt w/ negative I/Os 3500ml at 15:00-\n Lasix stopped per team. Edema and DOE without change.\n Plan:\n Continue to monitor volume status. Assess lungs, oxygenation, DOE,\n edema.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Large semi-formed stool this AM, very dark brown, +foul smelling.\n Guaiac positive. HCT repeat 29 (31). S/p 2 units PRBC over night.\n Action:\n Team notified. GI following. Continued IV protonix gtt.\n Response:\n HCT stable. Stool x 1.\n Plan:\n Continue to closely follow HCT. Further work up of bleed to be done\n after completely stable from CV standpoint. GI aware and following.\n Consent already obtained for EGD when able.\n Renal failure, acute (Acute on chronic renal failure)\n Assessment:\n Unclear of pt\ns current baseline though some records indicate Cr\n baseline 1.6. Currently 3.0 this AM. Hourly UOP>100ml/hr r/t Lasix gtt.\n Action:\n Following serial Cr/BUN, urine output. Team attempting to obtain better\n history from PCP. - (ACE-I).\n Response:\n Repeat Cr slightly down to 2.8.\n Plan:\n Repeat Cr/BUN later this evening. Continue to monitor daily BUN/CR.\n Hourly UOP.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K 5.8 this AM despite being diuresed w/ IV lasix drip.\n Action:\n Given 30gm Kaexeylate overnight.\n Response:\n Large BM in AM. Recheck K after stool= 4.1.\n Plan:\n Continue to closely follow electrolytes in setting of ARF.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643364,
"text": "87 yo male w/ PMH DM, HTN, hyperlipidemia, CKD who p/w acute NSTEMI,\n acute on chronic diastolic CHF in setting of GIB. Diuresed w/ IV Lasix\n gtt. Med mgt of NSTEMI r/t GIB. Called out to 3 and\n triggered AM for change in MS to 104PR. GI following.\n Scope on hold until more stable. Sent to CCU for further mgt.\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Approx 10 loose/ semi formed foul-smelling bowel movements in 12 hour\n shift. Incotinent, sometimes requesting bedpan. Stool brown w/\n non-digested food. Guiac positive. HCT stable at 34. Abd soft, ND.\n Hyperactive BS x 4 quad. Pt currently NPO for somnolence. WBC today up\n to 22 from 12.\n Action:\n Offered toileting frequently. No sting barrier to buttocks/perineal\n area for protection. Barrier cream after loose stools. C-diff spec\n sent, #1 . Initiated IV flagyl at 16:00. IVF for hydration.\n Response:\n Stooling less frequently over course of shift. GI following. Skin\n remained intact.\n Plan:\n Await results of C-diff. Continue to trend #BMs, fevers, WBCs. Skin\n care PRN. IV flagyl while pt can not take Pos.\n Atrial Fibrillation\n Assessment:\n Pt converted back to afib around noon in setting of holding PO rate\n control meds- lopressor and diltiazem. Did receive one IV lopressor\n dose prior to conversion into AF. HR 100s-130s, rare PVCs.\n Action:\n IV lopressor increased from 7.5mg QID to q 4 hours. EKG obtained in\n Afib. Also started on IV hydration at 100ml/hr.\n Response:\n HR 100-110s after IV lopressor doses.\n Plan:\n Continue to monitor HR/rhythm. IV lopressor as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. VSS.\n Action:\n IV lopressor Q4 hours as unable to swallow PO meds r/t somnolence.\n Response:\n Stable this shift.\n Plan:\n Continue to monitor. Daily EKGs. Assess for chest pain.\n (Hyperthermia, Pyrexia, not of Unknown Origin)\n Assessment:\n WBC almost double this AM at 22. Tmax 102.6 via rectal probe. HR high\n normal, BP stable. UOP stable at 20-100/hour. Intermittent shivering-\n cooling blanket not applied b/c of this.\n Action:\n Tylenol 650 PR q 4hrs. Cont temp monitoring. IV zosyn and vanco given\n as ordered. Flagyl IV added as above. Blood cx\ns sent x 2. C-diff sent\n x one. ECHO complete to assess for vegetation.\n Response:\n No change in MS- somnolent. Temperature remains 101.5-102.6 PR.\n Plan:\n Continue to trend WBC, curve. IV anbx. Cooling blanket if \n climbs. Tylenol q 4 hours.\n Altered mental status (not Delirium)\n Assessment:\n Fluctuating MS-improves w/ temperature decreases and worsens w/ .\n Alert x . Somnolent most of day, rousing to voice only. Able to\n follow commands w/ prompting.\n Action:\n Head CT done, results PND. IV anbx.\n Response:\n Plan:\n Safety precautions. Continue to assess MS.\n \n Assessment:\n Entire back covered w/ red raised follicular papules.\n Action:\n Dermatology consulted. Antibiotic cream applied daily.\n Response:\n stable, pt denied itching/pain.\n Plan:\n Per dermatology- likely folliculitis and NOT drug-induced.\n Recommended topical anbx cream. Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643365,
"text": "87 yo male w/ PMH DM, HTN, hyperlipidemia, CKD who p/w acute NSTEMI,\n acute on chronic diastolic CHF in setting of GIB. Diuresed w/ IV Lasix\n gtt. Med mgt of NSTEMI r/t GIB. Called out to 3 and\n triggered AM for change in MS to 104PR. GI following.\n Scope on hold until more stable. Sent to CCU for further mgt.\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Approx 10 loose/ semi formed foul-smelling bowel movements in 12 hour\n shift. Incotinent, sometimes requesting bedpan. Stool brown w/\n non-digested food. Guiac positive. HCT stable at 34. Abd soft, ND.\n Hyperactive BS x 4 quad. Pt currently NPO for somnolence. WBC today up\n to 22 from 12.\n Action:\n Offered toileting frequently. No sting barrier to buttocks/perineal\n area for protection. Barrier cream after loose stools. C-diff spec\n sent, #1 . Initiated IV flagyl at 16:00. IVF for hydration.\n Response:\n Stooling less frequently over course of shift. GI following. Skin\n remained intact.\n Plan:\n Await results of C-diff. Continue to trend #BMs, fevers, WBCs. Skin\n care PRN. IV flagyl while pt can not take Pos.\n Atrial Fibrillation\n Assessment:\n Pt converted back to afib around noon in setting of holding PO rate\n control meds- lopressor and diltiazem. Did receive one IV lopressor\n dose prior to conversion into AF. HR 100s-130s, rare PVCs.\n Action:\n IV lopressor increased from 7.5mg QID to q 4 hours. EKG obtained in\n Afib. Also started on IV hydration at 100ml/hr.\n Response:\n HR 100-110s after IV lopressor doses.\n Plan:\n Continue to monitor HR/rhythm. IV lopressor as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. VSS.\n Action:\n IV lopressor Q4 hours as unable to swallow PO meds r/t somnolence.\n Response:\n Stable this shift.\n Plan:\n Continue to monitor. Daily EKGs. Assess for chest pain.\n (Hyperthermia, Pyrexia, not of Unknown Origin)\n Assessment:\n WBC almost double this AM at 22. Tmax 102.6 via rectal probe. HR high\n normal, BP stable. UOP stable at 20-100/hour. Intermittent shivering-\n cooling blanket not applied b/c of this.\n Action:\n Tylenol 650 PR q 4hrs. Cont temp monitoring. IV zosyn and vanco given\n as ordered. Flagyl IV added as above. Blood cx\ns sent x 2. C-diff sent\n x one. ECHO complete to assess for vegetation.\n Response:\n No change in MS- somnolent. Temperature remains 101.5-102.6 PR.\n Plan:\n Continue to trend WBC, curve. IV anbx. Cooling blanket if \n climbs. Tylenol q 4 hours.\n Altered mental status (not Delirium)\n Assessment:\n Fluctuating MS-improves w/ temperature decreases and worsens w/ .\n Alert x . Somnolent most of day, rousing to voice only. Able to\n follow commands w/ prompting.\n Action:\n Head CT done, results PND. IV anbx.\n Response:\n No change in MS. noted this shift.\n Plan:\n Safety precautions. Continue to assess MS.\n \n Assessment:\n Entire back covered w/ red raised follicular papules.\n Action:\n Dermatology consulted. Antibiotic cream applied daily.\n Response:\n stable, pt denied itching/pain.\n Plan:\n Per dermatology- likely folliculitis and NOT drug-induced.\n Recommended topical anbx cream. Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643430,
"text": "87 yo male who presentedon w/ NSTEMI, acute on chronic diastolic\n CHF exacerbation & anemia d/t GIB. NSTEMI was medically managed.\n Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to floor\n . Triggered back prior to scheduled endoscopy for changes in\n MS, fevers (104 pr) ^ wbc 22, (13.4) ^ loose stools (ob+). Prob\n C-diff, 1^st sample () is positive, started on iv flagyl\n (vanco/zosyn) Pt also in/out of rapid AF, being successfully tx w/ iv\n lopressor q4. MS has improved, now alert & follows commands. Conts w/\n low grade fevers (99.4-7ax), Cre 2.6 (baseline). ECHO done showed no\n vegetations.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643431,
"text": "87 yo male who presentedon w/ NSTEMI, acute on chronic diastolic\n CHF exacerbation & anemia d/t GIB. NSTEMI was medically managed.\n Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to floor\n . Triggered back prior to scheduled endoscopy for changes in\n MS, fevers (104 pr) ^ wbc 22, (13.4) ^ loose stools (ob+). Prob\n C-diff, 1^st sample () is positive, started on iv flagyl\n (vanco/zosyn) Pt also in/out of rapid AF, being successfully tx w/ iv\n lopressor q4. MS has improved, now alert & follows commands. Conts w/\n low grade fevers (99.4-7ax), Cre 2.6 (baseline). ECHO done showed no\n vegetations.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 642690,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Called out but then called back in. Overnight developed irregular SVT,\n likely atrial tachycardia with intermittent conduction. Received\n lopressor and dilt IV and then increased PO doses of both meds.\n Returned to NSR around midnight. Had some leg pain, LENIs ordered.\n CXR showed no new consolidation. PM labs repleated. Daughter raised\n possibility of transferring back to be closer to family but agreed that\n it might be safer to keep him here.\n This morning he complains of leg pain but no chest pain, dyspnea, or\n pain anywhere else\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Metoprolol - 05:01 PM\n Diltiazem - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.8\nC (100\n HR: 88 (70 - 128) bpm\n BP: 125/47(66) {103/31(52) - 140/79(83)} mmHg\n RR: 18 (15 - 26) insp/min\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,209 mL\n 234 mL\n PO:\n 1,040 mL\n 200 mL\n TF:\n IVF:\n 169 mL\n 34 mL\n Blood products:\n Total out:\n 2,260 mL\n 380 mL\n Urine:\n 2,260 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,051 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98% on 3L desat to 88 with coughing\n ABG: ////\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 12cm but obscured by mask\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: Dullness at L base, rales way up bilaterally symmetrical\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 140\n [image002.gif]\n 100\n [image002.gif]\n 48\n [image004.gif]\n 189\n AGap=16\n [image005.gif]\n 3.6\n [image002.gif]\n 28\n [image002.gif]\n 2.6\n [image007.gif]\n Mg: 2.2\n ALT:\n AP:\n Tbili: 2.2\n Alb:\n AST:\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n 89\n 13.4\n [image007.gif]\n 9.2\n [image004.gif]\n 216\n [image008.gif]\n [image004.gif]\n 27.8\n [image007.gif]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n Plt\n 274\n 264\n 255\n 249\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n Other labs: CK / CKMB / Troponin-T:334/6/1.41, ALT / AST:20/29, Alk\n Phos / T Bili:61/1.8, Lactic Acid:1.6 mmol/L, Albumin:3.9 g/dL, LDH:256\n IU/L, Ca++:10.1 mg/dL, Mg++:1.8 mg/dL, PO4:3.7 mg/dL\n BCX NGTD; Chest PA/Lat: stable pulm edema, no consolidation.\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation.\n .\n # DIASTOLIC CONGESTIVE HEART FAILURE: His presentation is consistent\n with acute on chronic CHF. He was significantly diuresed, now 9L\n negative for LOS. Cr is mildly elevated today but still seems to have\n fluid overload, as he stil has an O2 requirement. ECHO showed no WMA\n or valvular disease, rather impaired relaxation. Tachycardia has\n generally resolved.\n - Will continue diuresis with decreased lasix drip rate (2.5 mg/hr)\n with a goal of -500 cc.\n - Continue to wean O2 as tolerates\n .\n # LEUKOCYTOSIS: Low-grade temperature and persestantly elevated white\n count. Elevated WBC could be a result of acute MI, DVT, but might also\n represent slowly brewing infection. Urine culture negative. Blood\n cultures pending. CXR with no evidence of new infiltrate.\n - No antibiotics for now\n - Follow cultures.\n - re-culture if spikes\n .\n # LEG PAIN: be secondary to compression from pneuomboots. No\n swelling, but must r/o DVT. Also possibly related to gout in setting\n of diuresis, but no evidence of joint symptoms on exam.\n - vascular ultrasound today\n .\n # NON-ST ELEVATION MYOCARDIAL INFARCTION - He presented with chest pain\n for 48 hours prior to admission and positive troponins but no ST or T\n wave changes on EKG. His troponins came down over his first day and he\n remains pain free. He was started on medical management with ASA, BB,\n statin, with a goal of adding an ACEi when renal function stabilizes.\n - ASA, Metoprolol, Statin\n - transfuse for hct < 25 if symptomatic\n - Will consider further diagnostic workup with stress, cath, MR, or CT\n once stable.\n .\n # SINUS TACHYCARDIA: Had A-fib/A-flutter last night that broke with\n iincreased nodal blocking. Will continue on increased doses of\n metoprolol 100 TID and dilt 60 mg QID, as diastolic HF not tolerant of\n A-fib.\n .\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable, although Hct is somewhat down this\n morning. Stools remain guiac positive. Given chest pain free, ok to\n allow Hct to drift to 25. He had cirrhosis 30 years ago but hadn't had\n any further characterization, since then has cut down his drinking. No\n physical exam findings of liver disease, but ultrasound showed fatty\n change. US findings could be consistent with cirrhosis but is more\n likely related to congestion.\n - Will recheck Hct in PM\n - GI following, scope planned for monday but may need to be earlier if\n bleeding picks up.\n - protonix PO BID\n .\n # ACUTE ON CHRONIC RENAL FAILURE: Baseline Cr 1.6, Peak here 3.\n - History consistent with prerenal causes but FeUrea not consistent\n (45%). be ATN secondary to prolonged hypoperfusion, vs med related,\n vs postrenal.\n - If not improving obtain renal ultrasound\n .\n # ANION GAP ACIDOSIS: anion gap was elevated on admission without\n significant lactare or ketones and modestly elevated BUN. This has\n since resolved, with a gap today of 12.\n .\n # HYPERKALEMIA: resolved with diuresis\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n - Poor control, so lantus increased to 10U\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: Call out today to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:38 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": "2181-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642368,
"text": "Pulmonary edema\n Assessment:\n Continues on cn at 50% and 5l nc. With mask off sats drop to mid to low\n 80s. no c/o sob. Basilar crackles. Lasix gtt ^\nd to 5mg/hr w goal\n 100ccuop hourly.\n Action:\n Diuresing to lasix gtt\n Response:\n Cont w hi fio2 req\n Plan:\n Diureses as tol\n Hyperglycemia\n Assessment:\n Bs 244 this eve. Tol po w good intake.\n Action:\n Glargine given. Humolog per ss.\n Response:\n Plan:\n Cont to follow qid bs.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643426,
"text": "87 yo male who presented with NSTEMI, acute on chronic diastolic CHF\n exacerbation & anemia d/t GIB. NSTEMI was medically managed. Diuresed\n on Lasix gtt & tnsf w/ prbc. Pt now febrile, source unclear.\n .\n # Fever: Tmax yesterday, still febrile. Pt on Vanc/Zosyn. BC and\n UCx show NGTD, WBC count increased to 22 today. Unclear source. Pt\n had several BM overnight. Pt still lethargic and AO x 1. Prostate\n exam shows enlarged prostate, but no evidence of boggy prostate. CXR\n shows hazy opacity in , unclear if this is evolving PNA.\n - Pending CDiff. Start IV Flagyl 500mg TID.\n - Continue Abx\n - F/u cultures\n - Will CT head today.\n # Acute on chronic diastolic CHF: Resolving. Lungs CTAB, JVD 6cm. .\n - Will give gentle fluids as patient is not taking pos.\n - Switch po BB to IV.\n - Echo to r/o vegetations.\n # Atrial Fibrillation: Patient\ns HR has been in low 100s.\n - As patient unable to take pos, will hold ASA 81mg for now.\n Will consider restarting once patient recovers.\n - Continue IV BB q8hrs and prn for HR > 100.\n .\n # GI bleed: Presented with Hct drop and melena but since admission and\n transfusion hct has been stable.\n - Will scope once patient is stable.\n .\n # Chronic Renal failure: Baseline Cr 2.6, Cr 2.6 today.\n - Monitor\n .\n .\n # DM: lantus 9uqhs. insulin sliding scale, goal BG < 150.\n - Monitor\n .\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643505,
"text": "TITLE:\n Chief Complaint:\n ACS\n 24 Hour Events:\n Initiated on IV yesterday. AO x 3.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Metronidazole - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Metoprolol - 04:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 37.6\nC (99.7\n HR: 85 (85 - 127) bpm\n BP: 112/45(62) {101/32(52) - 145/70(81)} mmHg\n RR: 22 (19 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,665 mL\n 335 mL\n PO:\n TF:\n IVF:\n 1,665 mL\n 335 mL\n Blood products:\n Total out:\n 955 mL\n 160 mL\n Urine:\n 955 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 710 mL\n 175 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: No JVD\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: Bibasilar rales\n ABDOMEN: S, Mild LLQ TTP, no rebound\n EXTREMITIES: No C/C/E\n Labs / Radiology\n 446 K/uL\n 10.8 g/dL\n 133 mg/dL\n 3.0 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 84 mg/dL\n 103 mEq/L\n 140 mEq/L\n 31.6 %\n 19.7 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n Plt\n 274\n 264\n 255\n 249\n 216\n 394\n 446\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n 133\n Other labs:, ALT / AST:45/45, Alk Phos / T Bili:83/1.9, Amylase /\n Lipase:56/23, Lactic Acid:1.6 mmol/L, Albumin:2.8 g/dL, LDH:240 IU/L,\n Mg++:2.5 mg/dL,\n Assessment and Plan\n 87 yoM w/ h/o CKD who presented with acute on chronic diastolic CHF\n exacerbation and ACS, not resolving. Pt with resolving fevers and AMS,\n likely sec to C Diff colitis.\n .\n # C Diff: Afebrile since 7pm last night, Tmax 102.6. Patient started\n empirically yesterday with IV, CDiff confirmed yesterday\n evening. BC and UCx show NGTD, WBC count decreased to 19.7 today.\n Patient AO x3.\n - d/c Vanc/Zosyn\n - transition to po Flagyl\n - F/u cultures\n # Acute on chronic diastolic CHF: Resolving. Lungs CTAB, JVD 6cm. .\n - Will give gentle fluids as patient is not taking pos.\n - Switch IV BB to po. Restart Statin, ASA\n - Echo to r/o vegetations.\n # Atrial Fibrillation: Patient\ns HR has been in low 100s.\n - Restart ASA.\n - Continue BB.\n .\n # GI bleed: Presented with Hct drop and melena but since admission and\n transfusion hct has been stable.\n - Will contact GI and see if willing to scope tomorrow\n .\n # Acute on Chronic Renal failure: Baseline Cr 2.6, Cr 3.0 today.\n Likely secondary to pre-renal etiology.\n - Will give IVFs @ 125cc/hr, recheck lytes this PM.\n .\n .\n # DM: lantus 9uqhs. insulin sliding scale, goal BG < 150.\n - Monitor\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: Pending.\n 1. IV access: Peripheral line Order date: @ 1246\n 11. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1120\n 2. IV access: Peripheral line Order date: @ 1246\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale & Fixed Dose Order date: @ 1557\n 3. 1000 mL NS\n Continuous at 125 ml/hr for 1000 ml Order date: @ 0901\n 13. Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 1246\n 4. Acetaminophen 325-650 mg PO/PR Q4H:PRN Order date: @ 0538\n 14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Order date: @ 0902\n 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Order date: @ 1246\n 15. Metoprolol Tartrate 100 mg PO BID\n Hold for SBP <100 HR <60 Order date: @ 0905\n 6. Aspirin 81 mg PO DAILY Order date: @ 0906\n 16. Olanzapine (Disintegrating Tablet) 5 mg PO QHS:PRN Order date:\n @ 2339\n 7. Atorvastatin 80 mg PO DAILY Order date: @ 0906\n 17. Pantoprazole 40 mg PO Q24H Order date: @ 0909\n 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR Order date: @\n 1246\n 18. Sarna Lotion 1 Appl TP :PRN Order date: @ 1246\n 9. Clindamycin 1 Appl TP DAILY\n to back Order date: @ 2245\n 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1246\n 10. Heparin 5000 UNIT SC TID Order date: @ 1246\n 20. 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: @ 1246\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643624,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. All AM labs pending, last Cre 3.0, has conts maintenance fluids\n infusing.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n C-diff colitis confirmed, conts sm loose ob+ stools.\n Action:\n consulted. Conts on iv flagyl & po Vanco, & now po flagyl added\n per surgery request. Had Abd CT.\n Response:\n declined intervention stating poor candidate. CT images limited.\n Plan:\n HO spoke w/ daughter regarding , no changes. Cont current abx\n therapy, gentle fluid hydration, monitor Cre.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 642520,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:21 AM\n No Events overnight\n Feels better, no chest pain, other pain. Breathing is much improved.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:25 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.9\nC (98.4\n HR: 93 (70 - 93) bpm\n BP: 124/53(70) {109/31(52) - 148/60(79)} mmHg\n RR: 16 (11 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,094 mL\n 677 mL\n PO:\n 840 mL\n 600 mL\n TF:\n IVF:\n 254 mL\n 77 mL\n Blood products:\n Total out:\n 2,910 mL\n 1,720 mL\n Urine:\n 2,910 mL\n 1,720 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,816 mL\n -1,043 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///29/\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 6cm\n CARDIAC: PMI non displaced. RRR, 1/6 systolic murmur @ USB\n LUNGS: Scattered rales. No wheezes.\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 249 K/uL\n 10.7 g/dL\n 140 mg/dL\n 2.2 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.3 %\n 15.2 K/uL\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n Plt\n 274\n 264\n 255\n 249\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n Other labs: CK / CKMB / Troponin-T:334/6/1.41, ALT / AST:20/29, Alk\n Phos / T Bili:61/1.8, Lactic Acid:1.6 mmol/L, Albumin:3.9 g/dL, LDH:256\n IU/L, Ca++:10.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation.\n .\n # DIASTOLIC CONGESTIVE HEART FAILURE: His presentation is consistent\n with acute on chronic CHF. He was significantly diuresed, now 8L\n negative for LOS. He has not had elevations in Cr or hypotension.\n ECHO showed no WMA or valvular disease, rather impaired relaxation.\n Tachycardia has generally resolved.\n - Will continue diuresis with lasix drip with a goal of 1-2L\n - Continue to wean O2 as tolerates\n .\n # LEUKOCYTOSIS: Low-grade temperature and persestantly elevated white\n count. Elevated WBC could be a result of acute MI, but might also\n represent slowly brewing infection. Urine culture negative. Blood\n cultures pending.\n - Will check PA and lateral today to eval for brewing PNA that may have\n been masked by volume\n - Consider CT if worsening.\n - No antibiotics for now\n - Follow cultures.\n - re-culture if spikes, consider antibiotics based on CXR findings from\n today.\n .\n # NON-ST ELEVATION MYOCARDIAL INFARCTION - He presented with chest pain\n for 48 hours prior to admission and positive troponins but no ST or T\n wave changes on EKG. His troponins came down over his first day and he\n remains pain free. He was started on medical management with ASA, BB,\n statin, with a goal of adding an ACEi when renal function stabilizes.\n - ASA, Metoprolol, Statin\n - transfuse for hct < 30 if symptomatic\n - Will consider further diagnostic workup with stress, cath, MR, or CT\n once stable.\n .\n # SINUS TACHYCARDIA: Has was tachycardic since coming off BiPAP.\n Originally this was refractory to increasing doses of metoprolol from\n 12.5mg TID to 75mg TID, that was done to allow for diastolic filling\n time. His tachycardia has since improved with improving respiratory\n status, suggesting tachycardia was secondary to resp discomfort.\n .\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable. Given ACS transfuse to goal HCT\n of 30 with symptoms. He had cirrhosis 30 years ago but hadn't had any\n further characterization, since then has cut down his drinking. No\n physical exam findings of liver disease, but ultrasound showed fatty\n change. US findings could be consistent with cirrhosis but is more\n likely related to congestion.\n - Type and screen, IVs, guaiac stool\n - GI following\n - protonix PO BID\n - having hard stool now, seen by GI in ED, consented by GI for EGD in\n case, likely in future\n .\n # ACUTE ON CHRONIC RENAL FAILURE: Baseline Cr 1.6, Peak here 3.\n - History consistent with prerenal causes but FeUrea not consistent\n (45%). be ATN secondary to prolonged hypoperfusion, vs med related,\n vs postrenal.\n - If not improving obtain renal ultrasound\n .\n # ANION GAP ACIDOSIS: anion gap continues to be elevated at 16 with\n normal albumin.\n - Lactate normal, no sign of ketoacidosis\n - Possibly uremia\n - ? check tox screen or osmolar gap to eval for ingestions. IE:\n Ethylene glycol -> cardiopulm failure, renal failure, AG acidosis.\n .\n # HYPERKALEMIA: resolved with diuresis\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n - Poor control, will increase to 10U\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643822,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CT Scan:\n 1. Focus of eccentric dilatation of descending colon, in the left lower\n quadrant, with asymmetrical distribution of contrast and air and\n significant fat tissue stranding, which either represents acute\n diverticulitis or perforation realted to colitis. There is currently no\n evidence of free intraperitoneal spillage or air.\n 2. Second eccentric dilatation, which might be site of giant sigmoid\n diverticulum.No inflammation is seen around this and while contrast is\n seen within it it does not appear to represent an acute finding.\n 3. There is no small-bowel obstruction, the dilated loops of the small\n bowel are likely due to ileus.\n 4. Severe pancolitis-relative sparing proximally.\n 5. Bilateral pleural effusion with some adjacent small basilar\n atelectasis, and evidence of prior asbestos exposure.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Metronidazole - 04:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history: None\n Review of systems: Persistent LLQ abdominal pain, otherwise feels\nwell\n, no SOB, no CP\n Flowsheet Data as of 06:15 AM\n Vital signs\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 79 (68 - 79) bpm\n BP: 160/123(131) {105/38(60) - 164/123(131)} mmHg\n RR: 20 (9 - 22) insp/min\n SpO2: 94% RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 2,018 mL\n 437 mL\n PO:\n 125 mL\n 175 mL\n TF:\n IVF:\n 1,888 mL\n 262 mL\n Blood products:\n Total out:\n 1,193 mL\n 590 mL\n Urine:\n 1,193 mL\n 590 mL\n Balance:\n 825 mL\n -153 mL\n Physical Examination\n GENERAL: Alert and oriented, NAD\n HEENT: MMM, no JVD\n CARDIAC: RRR, SEM at USB\n LUNGS: CTAB, trace basilar crackles\n ABDOMEN: distended, tympanic. BS+ Tenderness most pronounced at LLQ.\n No clear rebound or guarding\n EXTREMITIES: WWP\n Labs / Radiology\n 684 K/uL\n 11.9 g/dL\n 149 mg/dL\n 2.0 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 73 mg/dL\n 110 mEq/L\n 143 mEq/L\n 37.5 %\n 23.3 K/uL\n [image002.jpg]\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n WBC\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n Hct\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n Plt\n 255\n 249\n 216\n 394\n 446\n 517\n 500\n 684\n Cr\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n Glucose\n 113\n 133\n 140\n 189\n 140\n 133\n 142\n 114\n 149\n Other labs: PT / PTT / INR:15.1/31.5/1.3, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:8.2 mg/dL, Mg++:2.8 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation. Course\n complicated by severe CDiff colitis\n # CLOSTRIDIUM DIFFICILE INFECTION:\n - On exam appears stable (abdomen distended, tympanitic and tender in\n LLQ)\n - CT scans showed pancolitis and area of ? contained bowel perforation\n vs diverticulitis. Reevaluated by surgery but considered to not require\n urgent surgery as continues to be hemodynamically stable, abd pain not\n worsening and poor surgical candidate.\n - IV flagyl, PO Vanc; PR Vanco if no improvement.\n # DIASTOLIC CONGESTIVE HEART FAILURE: Originally presented in CHF, but\n has since been improving. Has been getting IVF in setting of infection\n and hypotension, responding well with UOP. Satting well.\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable.\n - Will consider EGD once acute medical issues resolved.\n - protonix PO BID\n # ACUTE ON CHRONIC RENAL FAILURE: Returned to baseline of 2.2. Continue\n IVF as per adequate UOP.\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol, Statin\n # SINUS TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be\n new for pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF and\n dependency on filling time\n FEN: NPO for bowel rest\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PO PPI\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n 1. Metoprolol Tartrate 100 mg PO BID Hold for SBP <100 HR <60\n 9. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n 2. Valsartan 160 mg PO DAILY Hold for SBP <100, HR <60\n 10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN\n 3. Aspirin 81 mg PO DAILY\n 11. Olanzapine (Disintegrating) 5mg PO QHS:PRN\n 4. Atorvastatin 80 mg PO DAILY\n 12. Pantoprazole 40 mg PO Q24H\n 5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n 13. Acetaminophen 325-650 mg PO/PR Q4H:\n 6. Vancomycin Oral Liquid 250 mg PO Q6H Day #1 \n 14. Insulin SC Sliding Scale & Fixed Dose\n 7. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Start \n 15. Sarna Lotion 1 Appl TP :PRN\n 8. Heparin 5000 UNIT SC TID\n 16. Clindamycin 1 Appl TP DAILY to back\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 642514,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:21 AM\n CALLED OUT\n No Events overnight\n Feels better, no chest pain, other pain. Breathing is much improved.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:25 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.9\nC (98.4\n HR: 93 (70 - 93) bpm\n BP: 124/53(70) {109/31(52) - 148/60(79)} mmHg\n RR: 16 (11 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,094 mL\n 677 mL\n PO:\n 840 mL\n 600 mL\n TF:\n IVF:\n 254 mL\n 77 mL\n Blood products:\n Total out:\n 2,910 mL\n 1,720 mL\n Urine:\n 2,910 mL\n 1,720 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,816 mL\n -1,043 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///29/\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 6cm\n CARDIAC: PMI non displaced. RRR, 1/6 systolic murmur @ USB\n LUNGS: Scattered rales. No wheezes.\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 249 K/uL\n 10.7 g/dL\n 140 mg/dL\n 2.2 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 40 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.3 %\n 15.2 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n Plt\n 274\n 264\n 255\n 249\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n Other labs: CK / CKMB / Troponin-T:334/6/1.41, ALT / AST:20/29, Alk\n Phos / T Bili:61/1.8, Lactic Acid:1.6 mmol/L, Albumin:3.9 g/dL, LDH:256\n IU/L, Ca++:10.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 642657,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Called out but then called back in. Overnight developed irregular SVT,\n likely atrial tachycardia with intermittent conduction. Received\n lopressor and dilt IV and then increased PO doses of both meds.\n Returned to NSR around midnight. Had some leg pain, LENIs ordered.\n CXR showed no new consolidation. PM labs repleated. Daughter raised\n possibility of transferring back to be closer to family but agreed that\n it might be safer to keep him here.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 5 mg/hour\n Other ICU medications:\n Metoprolol - 05:01 PM\n Diltiazem - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.8\nC (100\n HR: 88 (70 - 128) bpm\n BP: 125/47(66) {103/31(52) - 140/79(83)} mmHg\n RR: 18 (15 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n Total In:\n 1,209 mL\n 234 mL\n PO:\n 1,040 mL\n 200 mL\n TF:\n IVF:\n 169 mL\n 34 mL\n Blood products:\n Total out:\n 2,260 mL\n 380 mL\n Urine:\n 2,260 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,051 mL\n -146 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 12cm but obscured by mask\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: Dullness at L base, rales way up bilaterally symmetrical\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 249 K/uL\n 10.7 g/dL\n 140 mg/dL\n 2.2 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 40 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.3 %\n 15.2 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n Plt\n 274\n 264\n 255\n 249\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n Other labs: CK / CKMB / Troponin-T:334/6/1.41, ALT / AST:20/29, Alk\n Phos / T Bili:61/1.8, Lactic Acid:1.6 mmol/L, Albumin:3.9 g/dL, LDH:256\n IU/L, Ca++:10.1 mg/dL, Mg++:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation.\n .\n # DIASTOLIC CONGESTIVE HEART FAILURE: His presentation is consistent\n with acute on chronic CHF. He was significantly diuresed, now 8L\n negative for LOS. He has not had elevations in Cr or hypotension.\n ECHO showed no WMA or valvular disease, rather impaired relaxation.\n Tachycardia has generally resolved.\n - Will continue diuresis with lasix drip with a goal of 1-2L\n - Continue to wean O2 as tolerates\n .\n # LEUKOCYTOSIS: Low-grade temperature and persestantly elevated white\n count. Elevated WBC could be a result of acute MI, but might also\n represent slowly brewing infection. Urine culture negative. Blood\n cultures pending.\n - Will check PA and lateral today to eval for brewing PNA that may have\n been masked by volume\n - Consider CT if worsening.\n - No antibiotics for now\n - Follow cultures.\n - re-culture if spikes, consider antibiotics based on CXR findings from\n today.\n .\n # NON-ST ELEVATION MYOCARDIAL INFARCTION - He presented with chest pain\n for 48 hours prior to admission and positive troponins but no ST or T\n wave changes on EKG. His troponins came down over his first day and he\n remains pain free. He was started on medical management with ASA, BB,\n statin, with a goal of adding an ACEi when renal function stabilizes.\n - ASA, Metoprolol, Statin\n - transfuse for hct < 30 if symptomatic\n - Will consider further diagnostic workup with stress, cath, MR, or CT\n once stable.\n .\n # SINUS TACHYCARDIA: Has was tachycardic since coming off BiPAP.\n Originally this was refractory to increasing doses of metoprolol from\n 12.5mg TID to 75mg TID, that was done to allow for diastolic filling\n time. His tachycardia has since improved with improving respiratory\n status, suggesting tachycardia was secondary to resp discomfort.\n .\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable. Given ACS transfuse to goal HCT\n of 30 with symptoms. He had cirrhosis 30 years ago but hadn't had any\n further characterization, since then has cut down his drinking. No\n physical exam findings of liver disease, but ultrasound showed fatty\n change. US findings could be consistent with cirrhosis but is more\n likely related to congestion.\n - Type and screen, IVs, guaiac stool\n - GI following\n - protonix PO BID\n - having hard stool now, seen by GI in ED, consented by GI for EGD in\n case, likely in future\n .\n # ACUTE ON CHRONIC RENAL FAILURE: Baseline Cr 1.6, Peak here 3.\n - History consistent with prerenal causes but FeUrea not consistent\n (45%). be ATN secondary to prolonged hypoperfusion, vs med related,\n vs postrenal.\n - If not improving obtain renal ultrasound\n .\n # ANION GAP ACIDOSIS: anion gap continues to be elevated at 16 with\n normal albumin.\n - Lactate normal, no sign of ketoacidosis\n - Possibly uremia\n - ? check tox screen or osmolar gap to eval for ingestions. IE:\n Ethylene glycol -> cardiopulm failure, renal failure, AG acidosis.\n .\n # HYPERKALEMIA: resolved with diuresis\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n - Poor control, will increase to 10U\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:38 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": "2181-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643961,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Remains NPO for GI depcompression. Asking for water and ice chips.\n Abd firm, distented but no pain. Active BS. Very small stools,\n golden mucus. Guiac neg.\n Action:\n Contin. On po vano and IV flagyl per surgical recs. Gave freq. mouth\n care and few ice chips. No water.\n Explanations given to pt.\n plan of care.\n Response:\n Pt. denies pain/cramping. No change in exam.\n Plan:\n Contin. Antibiotics, NPO, freq. exams. Follow plan with\n team/surgery. Await PICC placement today\n Altered mental status (not Delirium)\n Assessment:\n Pt. A/O x3. occas. would wake in middle of night thinking it was\n morning but reoriented easily. Pt. anxious about family visiting\n today. Talking about getting OOB and walking.\n Action:\n Freq. orientation as needed. Safety measures in place. will reassess\n in AM ie getting OOB with MD o.k.\n Response:\n Pt. verbalized understanding. Slept well when left alone. No\n delirium or restlessness.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642510,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix (? 80-120 mg IV?) for (+)CHF-- TN I =\n 3.94, CK 500s, CK MB 34, Hct 22. He was also given ASA /NTP and was\n transferred to ED with NSTEMI, no EKG changes-(thought to be\n stress ischemia d/t drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF.\n His Bipap/ Mask ventilation was weaned am AM and he was switched\n to 6 l np for eating alterating with 70% cool neb otherwise.\n He remained on IV lasix gtt from admit to CCU until afternoon\n due to I/O greatly (-)\n over 4 liters!\n He remains on IV protonix gtt for GIB and has only had 1 episode of\n melena s/p k-kexilate dose. B Blocker was resumed and has been\n increased over the course of the past 2 shifts in hopes of controlling\n rate for (+) dialstolic dysfunction.\n Pt remains A and O x 3 since admit to CCU.\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642641,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix (? 80-120 mg IV?) for (+)CHF-- TN I =\n 3.94, CK 500s, CK MB 34, Hct 22. He was also given ASA /NTP and was\n transferred to ED with NSTEMI, no EKG changes-(thought to be\n stress ischemia d/t drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF.\n His Bipap/ Mask ventilation was weaned am AM and he was switched\n to 6 l np for eating alterating with 70% cool neb otherwise.\n He remained on IV lasix gtt from admit to CCU until afternoon\n due to I/O greatly (-)\n over 4 liters!\n He remains on IV protonix gtt for GIB and has only had 1 episode of\n melena s/p k-kexilate dose and was switched to PO protonix without\n further need for transfusion.\n B Blocker was resumed and has been increased over the course of\n the past 2 shifts in hopes of controlling rate for (+) dialstolic\n dysfunction.\n Pt remains A and O x 3 since admit to CCU.\n Pt resumed lasix gtt, increased lopressor for rate control and\n diltiazem was added. Pt was ready for c/o with much better HR control\n and less 02 requirement by . He developed atrial tachycardia by\n the late afternoon and required increasing both lopressor and diltiazem\n meds with success.\n Pulmonary edema\n Assessment:\n Pt admitted to CCU for acute CHF in setting of NSTEMI/transfusion\n currently remains with I/O (-) and out of CHF on minimal 02.\n Action:\n PT remains on 5 mg lasix gtt.\n Response:\n U.o this shift- 50-100cc/hour- i/o as of MN (-)1 liter. O2 sats 94-96%\n on 4 liter NP.\n Plan:\n ? d/c lasix gtt today and/or switch to standing PO/IV doses. Continue\n to closely monitor I/O, O2 sats, lung sounds, AM CXR. Continue\n Incentive spirometer/ encourage deep breathe/cough. Increase activity\n as pt tolerates to improve oxygenation/activity tolerance. Keep HR\n under control in setting of (+) diastolic dysfunction.\n Cardiac dysrhythmia other\n Assessment:\n Pt with SR/ST since admission developing Atrial tachy to 130\ns late\n afternoon/early evening with stable BP.\n Action:\n PT given 5 mg lopressor IV x 2 as well as 10 mg diltiazem x 1 IVP.\n Increased po doses of lopressor to 100 tid and diltiazem to 60 mg qid.\n Response:\n Pt achieving rate control by 11p-12a HR remains 80-90\ns while resting,\n remains with some PAC\ns , short runs SVT to 120- esp with any activity.\n Plan:\n Continue to ramp up doses of Ca and B blockers. Consider A aBlation if\n pt continues to have atrial tachy issues.Watch for any further CHF in\n setting of rapid rhythm epsisodes. Keep pt aware of plan of care. c/o\n to floor once once CV status stabilized.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643951,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events: Meds changed to IV. Scheduled for PICC today for TPN\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:01 PM\n Metronidazole - 08:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:30 PM\n Metoprolol - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.5\n HR: 80 (64 - 84) bpm\n BP: 140/43(69) {103/32(65) - 168/69(94)} mmHg\n RR: 20 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,375 mL\n 126 mL\n PO:\n 325 mL\n 60 mL\n TF:\n IVF:\n 1,050 mL\n 66 mL\n Blood products:\n Total out:\n 1,415 mL\n 345 mL\n Urine:\n 1,415 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n -40 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GENERAL: Alert and oriented, NAD\n HEENT: MMM, no JVD\n CARDIAC: RRR, SEM at USB\n LUNGS: CTAB, trace basilar crackles\n ABDOMEN: distended, tympanic. BS+ Tenderness most pronounced at LLQ.\n No clear rebound or guarding\n EXTREMITIES: WWP\n Labs / Radiology\n 684 K/uL\n 11.9 g/dL\n 149 mg/dL\n 2.0 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 73 mg/dL\n 110 mEq/L\n 143 mEq/L\n 37.5 %\n 23.3 K/uL\n [image002.jpg]\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n WBC\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n Hct\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n Plt\n 255\n 249\n 216\n 394\n 446\n 517\n 500\n 684\n Cr\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n Glucose\n 113\n 133\n 140\n 189\n 140\n 133\n 142\n 114\n 149\n Other labs: PT / PTT / INR:15.1/31.5/1.3, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:8.2 mg/dL, Mg++:2.8 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation. Course\n complicated by severe CDiff colitis\n # CLOSTRIDIUM DIFFICILE INFECTION:\n - On exam appears stable (abdomen distended, tympanitic and tender in\n LLQ)\n - CT scans showed pancolitis and area of ? contained bowel perforation\n vs diverticulitis. Reevaluated by surgery but considered to not require\n urgent surgery as continues to be hemodynamically stable, abd pain not\n worsening and poor surgical candidate.\n - IV flagyl, PO Vanc; PR Vanco if no improvement.\n # DIASTOLIC CONGESTIVE HEART FAILURE: Originally presented in CHF, but\n has since been improving. Has been getting IVF in setting of infection\n and hypotension, responding well with UOP. Satting well.\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable.\n - Will consider EGD once acute medical issues resolved.\n - protonix PO BID\n # ACUTE ON CHRONIC RENAL FAILURE: Returned to baseline of 2.2. Continue\n IVF as per adequate UOP.\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol, Statin\n # SINUS TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be\n new for pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF and\n dependency on filling time\n FEN: NPO for bowel rest\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PO PPI\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:17 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": "2181-12-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642509,
"text": "Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 642247,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix (? 80-120 mg IV?) for (+)CHF-- TN I =\n 3.94, CK 500s, CK MB 34, Hct 22. He was also given ASA /NTP and was\n transferred to ED with NSTEMI, no EKG changes-(thought to be\n stress ischemia d/t drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF.\n His Bipap/ Mask ventilation was weaned am AM and he was switched\n to 6 l np for eating alterating with 70% cool neb otherwise.\n He remained on IV lasix gtt from admit to CCU until afternoon\n due to I/O greatly (-)\n over 4 liters!\n He remains on IV protonix gtt for GIB and has only had 1 episode of\n melena s/p k-kexilate dose. B Blocker was resumed and has been\n increased over the course of the past 2 shifts in hopes of controlling\n rate for (+) dialstolic dysfunction.\n Pt remains A and O x 3 since admit to CCU.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt admitted to CCU s/p NSTEMI d/t GIB/anemia stress inducing ischemia\n Action:\n Started lopressor- increased to 50 mg tid at MN and given 25 mg extra\n PO x 2 as well as 5 mg IVP x 2 for HR persistently >90-100 ST.\n Response:\n Pt\ns heart rate 89-98 ST, no VEA. BP stable- 130/50\ns. Denies CP.\n Plan:\n Continue to maximize rate/pressure- add ACE once renal fx comes back\n down towards baseline. Continue to ramp up lopressor does to better\n control rate. Continue to closely assess pt for any further CP/signs\n of ischemia.\n Pulmonary edema\n Assessment:\n Pt admitted to CCU s/p MI and GIB with (+) pulmonary edema\n Action:\n Pt started on lasix gtt after ER boluses of lasix. I/O greatly (-) so\n lasix gtt d/c. I/O (-)4200cc as of MN in spite of no further lasix.\n Response:\n Pt remains on 70% neb /alternating with 6l np for eating and still is\n desaturating to mid 80\ns with O2 off and appears SOB with any activity.\n Lung sounds remain with (+) crackles and wheeze in spite of large\n diuresis. Pt remains with ST 90\ns-100 this shift\n so attempting to\n control rate with lopressor doses( see above).\n Plan:\n Continue to ramp up lopressor to get better rate control in pt with\n diastolic dysfunction. Continue to closely watch renal rx and assess AM\n CXR for progress of CHF/ More lasix as needed. Continue to titrate O2\n to keep sats >93%. Incentive spirometry while immobile on bedrest.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n PT admitted to CCU s/p (+)melena and GIB , inducing ischemia/NSTEMI.\n Action:\n Pt transfused with 2 u PRBC for Hct 22- Hct has returned up to the 30\n range. Pt started and remains on Protonix gtt since admission- 8mg.\n Response:\n Pt remains free of melena this shift. Last 2 Hct checks have been even\n and stable.\n Plan:\n Check AM Hct with other AM labs. Transfuse to Hct >30. Continue to\n assess for any further sign of GIB> plan to have pt scoped before d/c\n to home, once otherwise medically stable.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 642205,
"text": "Pt received on NIV but taken off at 8a and placed on 100% aerosol mask.\n Pt tolerated well and was able to wean FiO2 to 70%. Pt does dip his\n sats with activity. Has diuresed. NIV pulled.:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 642714,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix for (+)CHF-- TN I = 3.94, CK 500s, CK\n MB 34, Hct 22. He was also given ASA /NTP and was transferred to\n ED with NSTEMI, no EKG changes-(thought to be stress ischemia d/t\n drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF.\n His Bipap/ Mask ventilation was weaned am . He has been further\n diuresed with lasix gtt.\n B Blocker was resumed and has been increased over the course of\n the past 2 shifts in hopes of controlling rate for (+) dialstolic\n dysfunction. Dilt added.\n Pt remains A and O x 3 since admit to CCU.\n Pt was ready for c/o with much better HR control and less 02\n requirement by . He developed afib by the late afternoon yesterday\n and required increasing both lopressor and diltiazem meds with success.\n Lower ext US done today for L leg pain, neg for clots. Family has\n expressed that pt lives alone, has and they are concerned about\n dc directly to home, wondering if one week in rehab would be best.\n Pulmonary edema\n Assessment:\n Pt CHF improving, decreased O2 requirements\n Action:\n Gentle diuresis with lasix gtt, decreased to 2.5mg/hr this AM d/t\n rising creatinine. Repleated with 40mEq KCL this AM for K+ 3.6. Weaned\n to 3L NC with sats >92\n Response:\n UO 50-80cc/hr, neg 1L at MN, 8L LOS\n Plan:\n Cont gentle diuresis, follow lytes, lung exam, sats.\n Hyperglycemia\n Assessment:\n BS in 200\ns today\n Action:\n Covered with SS humolog, diet changed to diabetic was heart healthy\n Response:\n BS elevated\n Plan:\n Will need cont monitoring and regulation of insulin\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP, VS stable. CHF improving\n Action:\n Increasing doses of lopressor and dilt, on ASA, Lipitor\n Response:\n HR decreased to 60\ns today with increased meds.\n Plan:\n Cont to monitor.\n Cardiac dysrhythmia other\n Assessment:\n Pt in NSR today, no afib since last night\n Action:\n Increased lopressor and dilt\n Response:\n NSR\n Plan:\n Cont telemetry.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 642722,
"text": "This is an 87 y/o male who presented to OSH with chest pain/SOB since\n PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix for (+)CHF-- TN I = 3.94, CK 500s, CK\n MB 34, Hct 22. He was also given ASA /NTP and was transferred to\n ED with NSTEMI, no EKG changes-(thought to be stress ischemia d/t\n drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, atibx for (+) WC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF. Pt inc of sm amt dark brown stool this am, OB(+).\n His Bipap/ Mask ventilation was weaned am . He has been further\n diuresed with lasix gtt.\n B Blocker was resumed and has been increased over the course of\n the past 2 shifts in hopes of controlling rate for (+) dialstolic\n dysfunction. Dilt added.\n Pt remains A and O x 3 since admit to CCU.\n Pt was ready for c/o with much better HR control and less 02\n requirement by . He developed afib by the late afternoon yesterday\n and required increasing both lopressor and diltiazem meds with success.\n Lower ext US done today for L leg pain, neg for clots. Family has\n expressed that pt lives alone, has and they are concerned about\n dc directly to home, wondering if one week in rehab would be best.\n Pulmonary edema\n Assessment:\n Pt CHF improving, decreased O2 requirements\n Action:\n Gentle diuresis with lasix gtt, decreased to 2.5mg/hr this AM d/t\n rising creatinine. Repleated with 40mEq KCL this AM for K+ 3.6. Weaned\n to 3L NC with sats >92\n Response:\n UO 50-80cc/hr, neg 1L at MN, 8L LOS\n Plan:\n Cont gentle diuresis, follow lytes, lung exam, sats.\n Hyperglycemia\n Assessment:\n BS in 200\ns today\n Action:\n Covered with SS humolog, diet changed to diabetic was heart healthy\n Response:\n BS elevated\n Plan:\n Will need cont monitoring and regulation of insulin\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP, VS stable. CHF improving\n Action:\n Increasing doses of lopressor and dilt, on ASA, Lipitor\n Response:\n HR decreased to 60\ns today with increased meds.\n Plan:\n Cont to monitor.\n Cardiac dysrhythmia other\n Assessment:\n Pt in NSR today, no afib since last night\n Action:\n Increased lopressor and dilt\n Response:\n NSR\n Plan:\n Cont telemetry.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 82.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin, Diabetes - Oral \n CV-PMH: CAD, CHF, Hypertension, MI\n Additional history: hyperlipidemia, chronic renal failure,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:117\n D:47\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 0 %\n 24h total in:\n 980 mL\n 24h total out:\n 1,015 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 06:43 AM\n Potassium:\n 3.6 mEq/L\n 06:43 AM\n Chloride:\n 100 mEq/L\n 06:43 AM\n CO2:\n 28 mEq/L\n 06:43 AM\n BUN:\n 48 mg/dL\n 06:43 AM\n Creatinine:\n 2.6 mg/dL\n 06:43 AM\n Glucose:\n 189 mg/dL\n 06:43 AM\n Hematocrit:\n 27.8 %\n 06:43 AM\n Finger Stick Glucose:\n 232\n 01:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 peripheral IV's\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 15:00 PM\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645546,
"text": "87Male admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel. \n exlap, colectomy, ileostomy, and \ns Pouch.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Pt groaning and acknowledging pain. Follows\n commands. Moves all extremities. Picks at invasive tubing. Pt became\n increasingly agitated\n Action:\n Pt given roxicet for pain and then haldol for agitation. Pt placed on\n restraints to prevent any tubes from being removed by pt.\n Response:\n Pt relaxed after each dose of roxicet and one time dose of haldol\n administration. Restraints were removed when pt was sleeping.\n Plan:\n Continue to monitor neurological status. Give pain meds as needed. Use\n restraints if pt becomes more agitated.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. Pt\ns ileostomy stoma pink with soft\n greenish stool. +BS +Flatus. Abdominal incision reddish and not\n approximated (team aware). WBC wnl, afebrile. VRE in wound bed.\n Action:\n Pt given flagyl, zosyn, vanco and linezolid. DSD changed. 3^rd C-diff\n specimen collected.\n Response:\n Pt remains afebrile, wound incision looks the same. Stoma still looks\n healthy and pink. Abdomen still distended and soft.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt extremely edematous, skin tears on right and left arm. Pt 9 liters\n positive. Lytes wnl.\n Action:\n Pt given lasix po BID. Weights taken daily. Goal per team is to keep pt\n negative daily.\n Response:\n Pt was negative a liter . Pt wt decreased by 8.8 kg. Lytes wnl.\n Plan:\n Continue to keep pt negative daily with lasix administration. Weigh pt\n daily. Monitor electrolytes\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645629,
"text": "87Male admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel.\n exlap, colectomy, ileostomy, and \ns Pouch. Tx to TSICU\n where pt was aggressively fluid resuscitated. Pt was placed on Lasix\n gtt, weaned and extubated .\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Responds at times to questioning, other times\n does not. Inconsistently will follow commands. Moves all extremities.\n Pulls at tubing, dislodged dophoff tube this am.\n Action:\n Pt placed on restraints to prevent any tubes from being removed by pt.\n Haldol given X 1 for agitation.\n Response:\n After haldol dosing, pt less agitated.\n Plan:\n Continue to monitor neurological status and agitation.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. +BS. Ostomy draining large amts brown soft\n formed stool. Pt dislodged dophoff tube this am.\n Action:\n New dophoff tube placed, TF infusing at goal rate of 45cc/hr.\n Response:\n Pt remains afebrile, wound incision looks the same. Stoma still looks\n healthy and pink. Abdomen still distended and soft.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning with any type of stimulation\n Action:\n Roxicett given.\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Pt weak due to complicated hospital course, laying in bed for long\n periods of time.\n Action:\n PT consulted\n Response:\n Pt OOB to chair with max assist. Pt OOB for a few hours, hoyered back\n to bed this afternoon.\n Plan:\n Continue with PT, continue to get pt OOB, ROM, ambulate when stronger.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 645690,
"text": "87yo M admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel.\n exlap, colectomy, ileostomy, and \ns Pouch. Tx to TSICU\n where pt was aggressively fluid resuscitated. Pt was placed on Lasix\n gtt, weaned and extubated .\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Responds at times to questioning, other times\n does not. Inconsistently will follow commands. Moves all extremities.\n Pulls at tubing, dislodged dobhoff tube this am.\n Action:\n Pt placed on restraints to prevent any tubes from beingdelf\n d/c\nd, for pts safety.\n Haldol given X 1 for agitation during day shift.\n Response:\n After haldol dosing, pt less agitated.\n Plan:\n Continue to monitor neurological status and agitation.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. +BS. Ostomy draining large amts brown soft\n formed stool. Pt dislodged dophoff tube this am.\n Action:\n New dophoff tube placed, TF infusing at goal rate of 45cc/hr.\n Response:\n Tolerating TF\ns, stoma intact with large amts brown soft stool.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning with any type of stimulation. Unable to rate or identify\n location of pain.\n Action:\n Roxicett given PO.\n Response:\n Pain well controlled.\n Plan:\n Continue to monitor pain, treat with pain med as needed.\n Muscle Performace, Impaired\n Assessment:\n Pt weak due to complicated hospital course, laying in bed for long\n periods of time.\n Action:\n PT consulted\n Response:\n Pt OOB to chair with max assist. Pt OOB for a few hours, hoyered back\n to bed this afternoon.\n Plan:\n Continue with PT, continue to get pt OOB, ROM, ambulate when stronger.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 82.9 kg\n Daily weight:\n 86.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Diabetes - Insulin, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: hyperlipidemia, chronic renal failure,\n Surgery / Procedure and date: , s/p ex lap, L colectomy w/\n Hartmann's pouch, end colostomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:170\n D:72\n Temperature:\n 98.8\n Arterial BP:\n S:155\n D:42\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,050 mL\n 24h total out:\n 2,910 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:21 AM\n Potassium:\n 3.9 mEq/L\n 02:21 AM\n Chloride:\n 108 mEq/L\n 02:21 AM\n CO2:\n 23 mEq/L\n 02:21 AM\n BUN:\n 40 mg/dL\n 02:21 AM\n Creatinine:\n 1.7 mg/dL\n 02:21 AM\n Glucose:\n 164 mg/dL\n 02:21 AM\n Hematocrit:\n 29.2 %\n 02:21 AM\n Finger Stick Glucose:\n 180\n 06:00 PM\n Valuables / Signature\n Patient valuables: sent w/ pt\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: \n Transferred to: \n Date & time of Transfer: 2100\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 645691,
"text": "87yo M admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel.\n exlap, colectomy, ileostomy, and \ns Pouch. Tx to TSICU\n where pt was aggressively fluid resuscitated. Pt was placed on Lasix\n gtt, weaned and extubated .\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Responds at times to questioning, other times\n does not. Inconsistently will follow commands. Moves all extremities.\n Pulls at tubing, dislodged dobhoff tube this am.\n Action:\n Pt placed on restraints to prevent any tubes from beingdelf\n d/c\nd, for pts safety.\n Haldol given X 1 for agitation during day shift.\n Response:\n After haldol dosing, pt less agitated.\n Plan:\n Continue to monitor neurological status and agitation.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. +BS. Ostomy draining large amts brown soft\n formed stool. Pt dislodged dophoff tube this am.\n Action:\n New dophoff tube placed, TF infusing at goal rate of 45cc/hr.\n Response:\n Tolerating TF\ns, stoma intact with large amts brown soft stool.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning with any type of stimulation. Unable to rate or identify\n location of pain.\n Action:\n Roxicett given PO.\n Response:\n Pain well controlled.\n Plan:\n Continue to monitor pain, treat with pain med as needed.\n Muscle Performace, Impaired\n Assessment:\n Pt weak due to complicated hospital course, laying in bed for long\n periods of time.\n Action:\n PT consulted\n Response:\n Pt OOB to chair with max assist. Pt OOB for a few hours, hoyered back\n to bed this afternoon.\n Plan:\n Continue with PT, continue to get pt OOB, ROM, ambulate when stronger.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 82.9 kg\n Daily weight:\n 86.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Diabetes - Insulin, Diabetes - Oral \n CV-PMH: CAD, Hypertension\n Additional history: hyperlipidemia, chronic renal failure,\n Surgery / Procedure and date: , s/p ex lap, L colectomy w/\n Hartmann's pouch, end colostomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:170\n D:72\n Temperature:\n 98.8\n Arterial BP:\n S:155\n D:42\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,050 mL\n 24h total out:\n 2,910 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:21 AM\n Potassium:\n 3.9 mEq/L\n 02:21 AM\n Chloride:\n 108 mEq/L\n 02:21 AM\n CO2:\n 23 mEq/L\n 02:21 AM\n BUN:\n 40 mg/dL\n 02:21 AM\n Creatinine:\n 1.7 mg/dL\n 02:21 AM\n Glucose:\n 164 mg/dL\n 02:21 AM\n Hematocrit:\n 29.2 %\n 02:21 AM\n Finger Stick Glucose:\n 180\n 06:00 PM\n Valuables / Signature\n Patient valuables: sent w/ pt\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: \n Transferred to: \n Date & time of Transfer: 2100\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645543,
"text": "87Male admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel. \n exlap, colectomy, ileostomy, and \ns Pouch.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Pt groaning and acknowledging pain. Follows\n commands. Moves all extremities. Picks at invasive tubing. Pt became\n increasingly agitated\n Action:\n Pt given roxicet for pain and then haldol for agitation. Pt placed on\n restraints to prevent any tubes from being removed by pt.\n Response:\n Pt relaxed after each dose of roxicet and one time dose of haldol\n administration. Restraints were removed when pt was sleeping.\n Plan:\n Continue to monitor neurological status. Give pain meds as needed. Use\n restraints if pt becomes more agitated.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. Pt\ns ileostomy stoma pink with soft\n greenish stool. +BS +Flatus. Abdominal incision reddish and not\n approximated (team aware). WBC wnl, afebrile. VRE in wound bed.\n Action:\n Pt given flagyl, zosyn, vanco and linezolid. DSD changed. 3^rd C-diff\n specimen collected.\n Response:\n Pt remains afebrile, wound incision looks the same. Stoma still looks\n healthy and pink. Abdomen still distended and soft.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt extremely edematous, skin tears on right and left arm. Pt 9 liters\n positive. Lytes wnl.\n Action:\n Pt given lasix po BID. Weights taken daily. Goal per team is to keep pt\n negative daily.\n Response:\n Pt was negative a liter . Pt wt decreased by 8.8 kg. Lytes wnl.\n Plan:\n Continue to keep pt negative daily with lasix administration. Weigh pt\n daily. Monitor electrolytes\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645532,
"text": "87Male admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel. \n exlap, colectomy, ileostomy, and \ns Pouch.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Pt groaning and acknowledging pain. Follows\n commands. Moves all extremities. Picks at invasive tubing. Pt became\n increasingly agitated\n Action:\n Pt given roxicet for pain and then haldol for agitation. Pt placed on\n restraints to prevent any tubes from being removed by pt.\n Response:\n Pt relaxed after each dose of roxicet and haldol administration.\n Restraints were removed when pt was sleeping.\n Plan:\n Continue to monitor neurological status. Give pain meds as needed. Use\n restraints if pt becomes more agitated.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt\ns ileostomy stoma pink with soft greenish stool. +BS +Flatus.\n Abdominal incision reddish and not approximated (team aware). WBC wnl,\n afebrile. VRE in wound bed.\n Action:\n Pt given flagyl, zosyn, vanco and linezolid. DSD changed. 3^rd C-diff\n specimen collected.\n Response:\n Pt afebrile, wound incision looks the same. Stoma still looks healthy\n and pink.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645535,
"text": "87Male admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel. \n exlap, colectomy, ileostomy, and \ns Pouch.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Pt groaning and acknowledging pain. Follows\n commands. Moves all extremities. Picks at invasive tubing. Pt became\n increasingly agitated\n Action:\n Pt given roxicet for pain and then haldol for agitation. Pt placed on\n restraints to prevent any tubes from being removed by pt.\n Response:\n Pt relaxed after each dose of roxicet and haldol administration.\n Restraints were removed when pt was sleeping.\n Plan:\n Continue to monitor neurological status. Give pain meds as needed. Use\n restraints if pt becomes more agitated.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. Pt\ns ileostomy stoma pink with soft\n greenish stool. +BS +Flatus. Abdominal incision reddish and not\n approximated (team aware). WBC wnl, afebrile. VRE in wound bed.\n Action:\n Pt given flagyl, zosyn, vanco and linezolid. DSD changed. 3^rd C-diff\n specimen collected.\n Response:\n Pt remains afebrile, wound incision looks the same. Stoma still looks\n healthy and pink. Abdomen still distended and soft.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt extremely edematous, skin tears on right and left arm. Pt 9 liters\n positive. Lytes wnl.\n Action:\n Pt given lasix po BID. Weights taken daily. Goal per team is to keep pt\n negative daily.\n Response:\n Pt was negative a liter . Pt wt decreased by Lytes wnl.\n Plan:\n Continue to keep pt negative daily with lasix administration. Weigh pt\n daily. Monitor electrolytes\n"
},
{
"category": "Nutrition",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 645620,
"text": "Subjective\n Pt confused\n Objective\n Pertinent medications: Abx, SS lytes, gloargine, RISS, pepcid, Heparin,\n others noted\n Labs:\n Value\n Date\n Glucose\n 164 mg/dL\n 02:21 AM\n Glucose Finger Stick\n 199\n 01:00 PM\n BUN\n 40 mg/dL\n 02:21 AM\n Creatinine\n 1.7 mg/dL\n 02:21 AM\n Sodium\n 137 mEq/L\n 02:21 AM\n Potassium\n 3.9 mEq/L\n 02:21 AM\n Chloride\n 108 mEq/L\n 02:21 AM\n TCO2\n 23 mEq/L\n 02:21 AM\n PO2 (arterial)\n 95. mm Hg\n 02:33 AM\n PCO2 (arterial)\n 38 mm Hg\n 02:33 AM\n pH (arterial)\n 7.41 units\n 02:33 AM\n pH (urine)\n 5.0 units\n 11:35 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 02:33 AM\n Albumin\n 2.4 g/dL\n 09:10 PM\n Calcium non-ionized\n 8.8 mg/dL\n 02:21 AM\n Phosphorus\n 3.7 mg/dL\n 02:21 AM\n Ionized Calcium\n 1.29 mmol/L\n 02:33 AM\n Magnesium\n 1.9 mg/dL\n 02:21 AM\n Current diet order / nutrition support: Nutren Pulmonary @ 45mL/hr\n (1620 kcals/73 gr aa)\n GI: Abd:soft/dist/+bs\n Assessment of Nutritional Status\n Specifics:\n Pt extubated yesterday. NGT placed for TF\ns decreased MS. TF\n changed per recs to decrease fluids in and decrease \ns volume\n overload and elevatd BG\ns respectively. Pt was tolerating @ goal s/\n problems until pt pulled NGT. Team replaced NGT, awaiting confirmation\n of placement.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Resume feeds @ goal, once NGT placement\n confirmed\n BG and lyte management as you are\n Repeat swallow eval when MS improved\n Please page c/ ?'s #\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645107,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q18, zosyn, flagyl, fentanyl prn, simvastatin, lasix gtt\n 24 Hour Events:\n Post operative day:\n POD#4 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:05 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 PM\n Metronidazole - 08:16 PM\n Infusions:\n Furosemide (Lasix) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Metoprolol - 05:53 PM\n Fentanyl - 06:00 PM\n Dextrose 50% - 10:40 PM\n Other medications:\n Flowsheet Data as of 01:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 38\nC (100.4\n HR: 103 (82 - 103) bpm\n BP: 93/64(78) {54/32(43) - 149/101(113)} mmHg\n RR: 18 (12 - 27) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (3 - 9) mmHg\n Total In:\n 3,150 mL\n 133 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,470 mL\n 30 mL\n Blood products:\n Total out:\n 5,675 mL\n 280 mL\n Urine:\n 5,600 mL\n 280 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -2,525 mL\n -147 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 552 (512 - 770) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 42\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.38/34/113/22/-3\n Ve: 12.8 L/min\n PaO2 / FiO2: 283\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 556 K/uL\n 8.6 g/dL\n 69 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 110 mEq/L\n 138 mEq/L\n 26.6 %\n 21.8 K/uL\n [image002.jpg]\n 02:25 PM\n 04:39 PM\n 02:04 AM\n 02:14 AM\n 03:39 PM\n 02:18 AM\n 02:38 AM\n 11:49 AM\n 11:56 AM\n 09:21 PM\n WBC\n 25.7\n 23.2\n 21.8\n Hct\n 27.9\n 27.3\n 26.6\n Plt\n \n Creatinine\n 1.2\n 1.3\n 1.4\n 1.4\n 1.5\n 1.6\n TCO2\n 19\n 20\n 22\n 21\n Glucose\n 89\n 110\n 160\n 92\n 84\n 111\n 69\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:303 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.6 mg/dL, Mg:2.2 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, EDEMA, PERIPHERAL, INTESTINE,\n PERFORATION OF (PERFORATION OF HOLLOW VISCUS), MALNUTRITION, ATRIAL\n FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS,\n CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), GASTROINTESTINAL\n BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87M presenting w/ NSTEMI, CHF exac, C. Diff s/p\n perforated diverticulitis, left colectomy w/ Hartmann's pouch, end\n colostomy ()\n Neurologic: Pain controlled, wean sedation towards goal of extubation\n Cardiovascular: Aspirin, Beta-blocker, Statins, lasix gtt\n Pulmonary: Extubate today, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: NPO\n Nutrition: TPN\n Renal: Foley, Adequate UO, cont lasix gtt, replete e'lytes as needed\n Hematology: HCT OK\n Endocrine: Insulin drip decreased\n Infectious Disease: cont vanco, zosyn, flagyl\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: colostomy\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, Arrhythmia, Post-op hypotension\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 59 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, UF Heparin in TPN\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 645688,
"text": "87yo M admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel.\n exlap, colectomy, ileostomy, and \ns Pouch. Tx to TSICU\n where pt was aggressively fluid resuscitated. Pt was placed on Lasix\n gtt, weaned and extubated .\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Responds at times to questioning, other times\n does not. Inconsistently will follow commands. Moves all extremities.\n Pulls at tubing, dislodged dobhoff tube this am.\n Action:\n Pt placed on restraints to prevent any tubes from beingdelf\n d/c\nd, for pts safety.\n Haldol given X 1 for agitation during day shift.\n Response:\n After haldol dosing, pt less agitated.\n Plan:\n Continue to monitor neurological status and agitation.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. +BS. Ostomy draining large amts brown soft\n formed stool. Pt dislodged dophoff tube this am.\n Action:\n New dophoff tube placed, TF infusing at goal rate of 45cc/hr.\n Response:\n Tolerating TF\ns, stoma intact with large amts brown soft stool.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning with any type of stimulation. Unable to rate or identify\n location of pain.\n Action:\n Roxicett given PO.\n Response:\n Pain well controlled.\n Plan:\n Continue to monitor pain, treat with pain med as needed.\n Muscle Performace, Impaired\n Assessment:\n Pt weak due to complicated hospital course, laying in bed for long\n periods of time.\n Action:\n PT consulted\n Response:\n Pt OOB to chair with max assist. Pt OOB for a few hours, hoyered back\n to bed this afternoon.\n Plan:\n Continue with PT, continue to get pt OOB, ROM, ambulate when stronger.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644561,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n s/p sigmoid colectomy, end illeostomy and hartmans pouch on \n Action:\n Fluid bolus given for low CVP and low UO. ABD distended, yet soft to\n touch. Hypoactive BS present. Abx continue. NGT to LWS with bilious\n output. Lytes repleted.\n Response:\n Hemodynamically stable, UO improved this shift. HCT stable.\n Plan:\n Continue to monitor UO/BP. Fluid to be given for low UO/BP.\n Rash\n Assessment:\n Healing rash to back\n Action:\n Cont topical cipro and lotion\n Response:\n Rash red but healing\n Plan:\n Cont with lotions and frequest repositioning. Watch for drug reactions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure\n Action:\n Fluid bolus given to maintain adequate UO\n Response:\n Pt responded well, UO improved overnight\n Plan:\n Continue to monitor UO\n Hyperglycemia\n Assessment:\n Pt with hx DM, elevated BS last shift, insulin gtt started\n Action:\n Insulin gtt titrated to maintain adequate BS control\n Response:\n BS well controlled\n Plan:\n Continue with Q1/hr BS, continue with insulin gtt. ? start NPH today or\n add more insulin to TPN\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Hx NSTEMI, tropi elevated post op\n Action:\n Cycling CE and following ekg, lopressor given IV, statin started today\n Response:\n Cont in NSR, tropi trending down\n Plan:\n 3d set CE due at 8pm\n"
},
{
"category": "Nutrition",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 644829,
"text": "Subjective\n intubated/sedated\n Objective\n Pertinent medications: heparin, Abx, Ca SS, K SS, lasix gtt, propofol\n gtt, insulin gtt, others noted\n Labs:\n Value\n Date\n Glucose\n 110 mg/dL\n 02:04 AM\n Glucose Finger Stick\n 137\n 12:00 PM\n BUN\n 31 mg/dL\n 02:04 AM\n Creatinine\n 1.3 mg/dL\n 02:04 AM\n Sodium\n 140 mEq/L\n 02:04 AM\n Potassium\n 3.9 mEq/L\n 02:04 AM\n Chloride\n 117 mEq/L\n 02:04 AM\n TCO2\n 17 mEq/L\n 02:04 AM\n PO2 (arterial)\n 115 mm Hg\n 02:14 AM\n PCO2 (arterial)\n 32 mm Hg\n 02:14 AM\n pH (arterial)\n 7.38 units\n 02:14 AM\n pH (urine)\n 5.0 units\n 11:35 PM\n CO2 (Calc) arterial\n 20 mEq/L\n 02:14 AM\n Albumin\n 2.4 g/dL\n 09:10 PM\n Calcium non-ionized\n 9.3 mg/dL\n 02:04 AM\n Phosphorus\n 3.7 mg/dL\n 02:04 AM\n Ionized Calcium\n 1.44 mmol/L\n 02:14 AM\n Magnesium\n 1.9 mg/dL\n 02:04 AM\n ALT\n 24 IU/L\n 03:38 AM\n Alkaline Phosphate\n 58 IU/L\n 03:38 AM\n AST\n 34 IU/L\n 03:38 AM\n Amylase\n 86 IU/L\n 09:10 PM\n Total Bilirubin\n 0.4 mg/dL\n 03:38 AM\n Triglyceride\n 190 mg/dL\n 05:00 AM\n Current diet order / nutrition support: TPN Rx Today : 1600cc(210\n dex/80 gr aa/50 fat) c/ 60 units insulin 1534 kcals\n GI: Abd: firm/dist/hypo bs\n Assessment of Nutritional Status\n Specifics:\n 87 y/o male s/p ex-lap c/ \ns perf\nd diverticulum ,\n remains on TPN for nutrition support. Current TPN +propofol meeting\n 100% estimated needs. Once propfol gtt off, will need to increase dex\n in TPN meet est. needs c/ TPN alone. BG\ns well controlled c/ Insulin\n gtt @ 3units/hr, and 35 units insulin in current TPN. Insulin\n increased to 60 units in tonight\ns bag to hopefully decrease gtt\n requirements. Lasix gtt started for diuresis. Can decrease TPN volume\n slightly to help. High ionized Ca today. Will hold Ca in TPN for now\n and trend.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n Tube feeding / TPN recommendations: Once propfol off, increase dex in\n TPN to 250 grams new goal =1500cc(250dex/80 aa/50 fat) 1690 kcals\n Increase insulin in TPN daily prn\n Titrate insulin gtt per protocol\n lyte management as you are-please check PTH\n Please page c/ ?'s #\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-19 00:00:00.000",
"description": "TSICU progress note",
"row_id": 644408,
"text": "Chief Complaint: Fever, abdominal pain\n 24 Hour Events:\n BLOOD CULTURED - At 10:00 PM\n URINE CULTURE - At 11:50 PM\n ARTERIAL LINE - START 03:00 AM\n MULTI LUMEN - START 03:00 AM\n FEVER - 102.2\nF - 12:00 AM\n admitted TSICU, weening off neo and esmolol to metop, fluid resusc for\n post op, decreasing uop\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:11 AM\n Vancomycin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:52 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 36.2\nC (97.2\n HR: 90 (72 - 128) bpm\n BP: 166/48(80) {85/37(49) - 173/51(89)} mmHg\n RR: 12 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 9 (8 - 11)mmHg\n Total In:\n 3,819 mL\n 6,032 mL\n PO:\n TF:\n IVF:\n 2,648 mL\n 5,533 mL\n Blood products:\n Total out:\n 1,275 mL\n 168 mL\n Urine:\n 1,275 mL\n 93 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,544 mL\n 5,864 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 16 cmH2O\n Plateau: 12 cmH2O\n Compliance: 71.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.34/28/143/17/-8\n Ve: 11 L/min\n PaO2 / FiO2: 286\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\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, wound c/d/i\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 723 K/uL\n 10.5 g/dL\n 235 mg/dL\n 1.4 mg/dL\n 17 mEq/L\n 4.1 mEq/L\n 42 mg/dL\n 118 mEq/L\n 144 mEq/L\n 32.7 %\n 19.3 K/uL\n [image002.jpg]\n 05:00 AM\n 06:00 AM\n 04:00 AM\n 05:20 PM\n 09:10 PM\n 10:46 PM\n 01:35 AM\n 03:38 AM\n 04:40 AM\n 07:11 AM\n WBC\n 15.3\n 16.1\n 13.1\n 19.3\n Hct\n 38.4\n 35.3\n 38.6\n 34\n 32.7\n Plt\n 23\n Cr\n 1.7\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.06\n TCO2\n 16\n 15\n 16\n Glucose\n 165\n 173\n 250\n 35\n Other labs: PT / PTT / INR:16.7/35.5/1.5, CK / CKMB /\n Troponin-T:51/6/0.06, ALT / AST:24/34, Alk Phos / T Bili:58/0.4,\n Amylase / Lipase:86/87, Fibrinogen:303 mg/dL, Lactic Acid:2.0 mmol/L,\n Albumin:2.4 g/dL, LDH:194 IU/L, Ca++:8.6 mg/dL, Mg++:1.7 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n MALNUTRITION\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n RASH\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPERGLYCEMIA\n ASSESSMENT AND PLAN: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n NEUROLOGIC: intubated/sedated\n Pain: fentanyl prn\n CARDIOVASCULAR: CXR, EKG, cycle cardiac, will discuss w/ cards re: tx\n NSTEMI. Con't ASA, statin, BB. transfuse for Hct < 25. further dx w/u\n per cards. CHF had improved, will follow fluid status, CXR and exam.\n was on esmolol gtt, ween off to metop iv. was also on neo gtt, no off.\n PULMONARY: intubated, no issues, minimize vent setting.\n GI / ABD: s/p above . rectal drain. NPO. ? GI bleed w/ melena\n early in hospital course, no issues since and Hct stable.\n NUTRITION: NPO\n RENAL: Cr baseline and pt w/ non anion gap met acidosis, hyperK has\n normalized, post operatively oliguric with uop, fluid resusc\n HEMATOLOGY: Hct stable. no current issues\n ENDOCRINE: SSI\n ID: vanc (PO and IV),zosyn,flagyl\n LINES/TUBES/DRAINS: PICC, RIJ, NGT, ETT,\n WOUNDS: ostomy, abdominal wound c/d/i\n IMAGING: cxr - lines in place, no obvious chf/acute process\n FLUIDS: LR @ 100, bolus prn\n CONSULTS: GI, derm, DM, need touch base w/ cards?\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: ssi, high sugars, consider tightening ssi\n PROPHYLAXIS:\n DVT - sch, boots\n STRESS ULCER - PPI\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: need\n CODE STATUS: full\n DISPOSITION: TSICU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:05 PM 66. mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: high post\n op sugars\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645356,
"text": "87yo male initially admitted on to CCU with pulmonary edema,\n +STEMI and LGIB. To OR emergently for xlap, colectomy, colostomy\n and \ns pouch for perforated divertic.\n Prior to admit, pt lived at home independently with family nearby. PMH\n includes DM,CHF.HTN, CRF.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear with diminished bases and fine crackles. PS 5/5 with sats\n 100%. Strong productive cough with occ suctioning required.\n Action:\n Maintained current settings.\n Response:\n RSBI to be done this am.\n Plan:\n Extubate if meets criteria.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Abdomen softly distended. + BS. Ilieostomy red and protruding. Output\n soft green stool in good amt. HCT stable.\n Action:\n Stool without obvious signs blood. Am labs pending.\n Response:\n Stable. TF advancing to goal of 80cc/g.\n Plan:\n Titrate food to goal as tolerated. Revisit dietary orders if pt able to\n extubate and swallow.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 644792,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q24, zosyn, flagyl, fentanyl prn, simvastatin\n 24 Hour Events:\n Recieved 1L LR bolus, UOP improved throughout the day.\n Post operative day:\n POD#2 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:40 PM\n Piperacillin/Tazobactam (Zosyn) - 11:48 PM\n Metronidazole - 04:19 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 01:30 AM\n Metoprolol - 04:19 AM\n Other medications:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.6\nC (99.6\n HR: 85 (76 - 94) bpm\n BP: 136/37(67) {97/37(63) - 170/61(96)} mmHg\n RR: 15 (9 - 25) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 9 (5 - 12) mmHg\n Total In:\n 6,279 mL\n 1,063 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,548 mL\n 705 mL\n Blood products:\n Total out:\n 1,555 mL\n 400 mL\n Urine:\n 1,475 mL\n 400 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 4,724 mL\n 663 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 537 (479 - 1,090) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 39\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.38/32/115/17/-4\n Ve: 9 L/min\n PaO2 / FiO2: 287\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n mild crackles at the bases), (Sternum: Stable )\n Abdominal: mildly distended, incision c/d/i, ostomy pink\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 588 K/uL\n 9.0 g/dL\n 110 mg/dL\n 1.3 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 31 mg/dL\n 117 mEq/L\n 140 mEq/L\n 27.3 %\n 23.2 K/uL\n [image002.jpg]\n 05:39 PM\n 07:40 PM\n 08:58 PM\n 09:31 PM\n 04:03 AM\n 04:14 AM\n 02:25 PM\n 04:39 PM\n 02:04 AM\n 02:14 AM\n WBC\n 16.0\n 22.9\n 25.7\n 23.2\n Hct\n 27.7\n 29.5\n 27.9\n 27.3\n Plt\n 583\n 643\n 619\n 588\n Creatinine\n 1.2\n 1.3\n 1.2\n 1.3\n Troponin T\n 0.05\n TCO2\n 16\n 18\n 16\n 19\n 20\n Glucose\n 174\n 124\n 68\n 89\n 110\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:303 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.3 mg/dL, Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS), MALNUTRITION,\n ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF\n COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT\n DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n Neurologic: Pain controlled, Sedated on propofol, will minimize\n sedation as we approach extubation\n Pain: well controlled, fentanyl prn\n Cardiovascular: Aspirin, Beta-blocker, Statins, NSTEMI CE's cycled and\n negative, cont statin, lopressor, ASA, HR and BP stable\n Pulmonary: Cont ETT\n Gastrointestinal / Abdomen: intubated, no issues, minimimal vent\n settings, will work towards extubation, will probably need diuresis\n first\n Nutrition: TPN, NPO\n Renal: Foley, Adequate UO, Cr baseline, Adequate UOP, is 16L positive,\n will need to be diuresed\n Hematology: Hct 27.3, stable\n Endocrine: Insulin drip, Insulin gtt, sugars have been controlled well\n Infectious Disease: Check cultures, vanc,zosyn,flagyl, Vanc was redosed\n to q18 will need to check vanc trough, f/u cultures\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: LR, LR @ 100\n Consults: General surgery, GI, Cardiology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN without Lipids - 04:51 AM 66. mL/hour\n Glycemic Control: Insulin infusion, Insulin in TPN\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644929,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 64.4\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 9 mL /\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n :\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n :\n Plan: Patient remains intubated on mechanical support. Current vent\n settings PSV 5, Peep 5, Fio2 40%. Tolerating well with spont vols 600\n and RR high teens. BS clear bilaterally. Sx\nd for secretions as above.\n Increased secretions over course of shift. ETT rotated to L side and\n taped at 22cm/lip. No further changes made. Fluid positive. Lasix\n drip. No further weaning at this time.\n Plan: Continue with mechanical support and reassess for extubation once\n fluid status is stable.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645293,
"text": "87yo male admitted with pulmonary edema, lower GI bleed, +STEMI. To OR\n emergently for xlap, colectomy, colostomy, \ns pouch for\n perforated divertic.\n Prior to admit, pt lived at home independently with family nearby.\n PMH includes DM,CHF.HTN, CRF.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n -Pt s/p ex-lap, colectomy . Present BS this shift, +flatus. Stoma\n pink, draining moderate amts brown liquid stool. Abd soft, distended\n -Hct trending down this am to 22.3\n -Midline abd incision with small amts serous sanginous drainage.\n Action:\n -TPN to finish this evening. TF started this am at 20cc/hr, increase\n Q8/hr. Rectal tube draining small amts clear liquid mucus\n -Transfused with 2 units PRBC\n -Abd dressing changed, staples intact.\n Response:\n -Minimal residuals from TF\n -Rectal tube DC\n -Post transfusion HCT 31.1\n Plan:\n -Advance TF as tolerated\n -Monitor HCT QD\n Pulmonary edema\n Assessment:\n Hx CHF,CRF, +NSTEMI on admit, now s/p xlap with fluid overload postop\n Action:\n Lasix drip decreased to 1mg/hr d/t ^^ BUN/creatinine, minimize IVF,\n replete lytes as indicated.Pulmonary hygiene, wean mechanical\n ventilation until pt is adequately diuresed\n Response:\n u/o remains brisk 100-200/hr, -3000 for 24 hrs, pt still 11,000\n positive. Lytes WNL, BP stable, tolerating CPAP well with adequate ABG\n Plan:\n Continue diuresis as tolerated, monitor renal fxn, wean vent\n Edema, peripheral\n Assessment:\n Pt with \\ edema\n Action:\n Lasix gtt DC\nd. Lasix IV and PO given X 1.\n Response:\n Pt with brisk UO this shift\n Plan:\n Continue to monitor diuresis. Monitor lytes, renal function.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645295,
"text": "87yo male admitted with pulmonary edema, lower GI bleed, +STEMI. To OR\n emergently for xlap, colectomy, colostomy, \ns pouch for\n perforated divertic.\n Prior to admit, pt lived at home independently with family nearby. PMH\n includes DM,CHF.HTN, CRF.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n -Pt s/p ex-lap, colectomy . Present BS this shift, +flatus. Stoma\n pink, draining moderate amts brown liquid stool. Abd soft, distended\n -Hct trending down this am to 22.3\n -Midline abd incision with small amts serous sanginous drainage.\n Action:\n -TPN to finish this evening. TF started this am at 20cc/hr, increase\n Q8/hr. Rectal tube draining small amts clear liquid mucus\n -Transfused with 2 units PRBC\n -Abd dressing changed, staples intact.\n Response:\n -Minimal residuals from TF\n -Rectal tube DC\n -Post transfusion HCT 31.1\n Plan:\n -Advance TF as tolerated\n -Monitor HCT QD\n Edema, peripheral\n Assessment:\n Pt with generalized anasarca\n Action:\n Lasix gtt DC\nd. Lasix IV and PO given X 1.\n Response:\n Pt with brisk UO this shift\n Plan:\n Continue to monitor diuresis. Monitor lytes, renal function.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 644598,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q24, zosyn, flagyl, fentanyl prn, simvastatin\n 24 Hour Events:\n EKG - At 01:30 PM\n Post operative day:\n POD#1 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:21 AM\n Metronidazole - 04:21 AM\n Piperacillin/Tazobactam (Zosyn) - 06:19 AM\n Infusions:\n Insulin - Regular - 4.1 units/hour\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:19 PM\n Fentanyl - 02:21 AM\n Metoprolol - 04:20 AM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.2\nC (98.9\n HR: 91 (59 - 94) bpm\n BP: 129/52(78) {66/23(33) - 173/64(89)} mmHg\n RR: 15 (0 - 29) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 7 (5 - 15) mmHg\n Total In:\n 14,871 mL\n 2,328 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,953 mL\n 1,836 mL\n Blood products:\n 250 mL\n Total out:\n 1,293 mL\n 475 mL\n Urine:\n 1,113 mL\n 425 mL\n NG:\n 75 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 13,578 mL\n 1,853 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 526 (448 - 668) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 35\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.36/28/125/20/-7\n Ve: 12 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender: palpation\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 643 K/uL\n 9.6 g/dL\n 68 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 114 mEq/L\n 139 mEq/L\n 29.5 %\n 22.9 K/uL\n [image002.jpg]\n 02:23 PM\n 03:00 PM\n 04:00 PM\n 05:00 PM\n 05:39 PM\n 07:40 PM\n 08:58 PM\n 09:31 PM\n 04:03 AM\n 04:14 AM\n WBC\n 16.0\n 22.9\n Hct\n 27.7\n 29.5\n Plt\n 583\n 643\n Creatinine\n 1.2\n 1.3\n Troponin T\n 0.05\n TCO2\n 16\n 16\n 18\n 16\n Glucose\n 199\n 220\n 214\n 174\n 124\n 68\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:88.4 %, Lymph:8.4 %, Mono:2.6 %,\n Eos:0.5 %, Fibrinogen:303 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.2 mg/dL, Mg:2.2 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS), MALNUTRITION,\n ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF\n COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT\n DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87M w/ NSTEMI, cdiff; perf sigmoid diverticulitis\n s/p ex lap, L colectomy w/ Hartmann's pouch, end colostomy ()\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, would increase\n lopressor as BP tolerates\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: NGT clamp well tolerated, cont TPN\n Nutrition: TPN, NPO\n Renal: Foley, Adequate UO, bolus IVF as needed. consider lasix once\n acidosis improved\n Hematology:\n Endocrine: Insulin drip\n Infectious Disease: cont vanco, zosyn, flagyl; wbc's trending up,\n remains afebrile\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: colostomy\n Imaging:\n Fluids: LR\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, Arrhythmia, Post-op\n hypotension, Acute renal failure\n ICU Care\n Nutrition:\n TPN without Lipids - 10:57 PM 66. mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645012,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645207,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt continues on PSV 5/5+ 40%, tolerating very well. RSBI =\n 53.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645346,
"text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 8 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI completed on PS 5=17. Plan for extubation today.\n Reason for continuing current ventilatory support: Hemodynimic\n instability; Comments: Plan to diurese more before extubation.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645352,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear with diminished bases and fine crackles. PS 5/5 with sats\n 100%. Strong productive cough with occ suctioning required.\n Action:\n Maintained current settings.\n Response:\n RSBI to be done this am.\n Plan:\n Extubate if meets criteria.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Abdomen softly distended. + BS. Ilieostomy red and protruding. Output\n soft green stool in good amt. HCT stable.\n Action:\n Stool without obvious signs blood. Am labs pending.\n Response:\n Stable. TF advancing to goal of 80cc/g.\n Plan:\n Titrate food to goal as tolerated. Revisit dietary orders if pt able to\n extubate and swallow.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644920,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Taken to OR emergently due to perforation of bowel. s/p sigmoid\n colectomy, end illeostomy and hartmans pouch on . Abd remains firm\n and distended, hypoactive BS. NGT to LWS. IV abx as ordered. Midline\n incision with large amts serous sang drainage. Rectal tube intact.\n Generalized anasarca, wt up.\n Action:\n Scant amts bilious output via OGT. Dressing changed this shift, less\n drainage noted. Lasix gtt titrated to maintain goal of 200cc UO/hr.\n Response:\n Hemodynamically stable, pt meeting goal of UO 200cc/hr. No drainage\n via rectal tube.\n Plan:\n Continue to monitor pain, hemodynamics, continue to diuresis, monitor\n lytes.\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Insulin gtt titrated to maintain adequate BS control.\n Response:\n Bs better controlled. Goal bs <150\n Plan:\n Cont insulin gtt, continue to monitor BS.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644335,
"text": "87 yo male adm with NSTEMI w/ new diastolic CHF in setting of\n GIB. MI medically managed. Sent to 3 for a few days until \n when temp spiked to 104 PR. Pt found to have C-diff colitis. Abd CT\n with severe pancolitis versus walled-off bowel perforation-abx. Surgery\n following- no need for urgent bowel surgery. NPO until further notice\n for bowel rest. PICC repositioned in IR -tpn started. Na+\n 147, receiving D5W for 1.5L. Blood sugars elevated on tpn now even\n higher w/ D5W. HISS & Glargine adjusted.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2181-12-19 00:00:00.000",
"description": "ICU Event Note",
"row_id": 644338,
"text": "Clinician: Nurse\n Pt 87 yo male w/ PMH CAD, HTN, hyperlipidema, CRF, insulin dependent DM\n who presented to with NSTEMI, diastolic HF, and non-urgent\n UGIB. Medically managed, stabilized and sent to 3. Triggered and\n sent back to CCU with altered MS and T104 PR. Found to be +C-diff-\n treated w/ PO vanco and IV flagyl. Pt w/ significant abd distension- CT\n abdomen w/ ?walled off bowel perforation versus pancolitis. Made NPO\n for bowel rest, started on TPN via PICC. Rec\ning 20mg IV\n lopressor q 4 hours for HR control as pt cannot take any Pos. Abdomen\n very firm and distended x several days.\n This evening approx 21:30- pt noted to be riggoring in bed. Skin warm\n to the touch. HR 120s, BP 140s-150s/70s, RR 20s, T 96.6 PO, blood sugar\n 424. Pt given additional blanket w/ no improvement, FS treated w\n insulin. CCU team notified- called Sugery team. Blood and urine\n cultures sent. Temp checked rectally 100.6 PR. Portable KUB w/ free\n air. Surgical team in to evaluate. VS remained stable w/ HR 120s-130s.\n 1L NS bolus over 60min for probable sepsis. IV vanco and zosyn given.\n Pt's dtr (HCP) and son called by CCU physicians. Surgical\n and Anesthesia consent obtained via telephone. Anesthesia in to bring\n pt to OR 12:35am .\n Total time spent: 180 minutes\n Patient is critically ill.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644494,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV 5/5 tolerating well vt 600-700 rr 12-20\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to remain intubated overnight as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645070,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on full vent support. No changes made overnight.\n RSBI deferred D/t high peep. Will continue to closely monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 644751,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q24, zosyn, flagyl, fentanyl prn, simvastatin\n 24 Hour Events:\n Recieved 1L LR bolus, UOP improved throughout the day.\n Post operative day:\n POD#2 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:40 PM\n Piperacillin/Tazobactam (Zosyn) - 11:48 PM\n Metronidazole - 04:19 AM\n Infusions:\n Insulin - Regular - 3 units/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 01:30 AM\n Metoprolol - 04:19 AM\n Other medications:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.6\nC (99.6\n HR: 85 (76 - 94) bpm\n BP: 136/37(67) {97/37(63) - 170/61(96)} mmHg\n RR: 15 (9 - 25) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 9 (5 - 12) mmHg\n Total In:\n 6,279 mL\n 1,063 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,548 mL\n 705 mL\n Blood products:\n Total out:\n 1,555 mL\n 400 mL\n Urine:\n 1,475 mL\n 400 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 4,724 mL\n 663 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 537 (479 - 1,090) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 39\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.38/32/115/17/-4\n Ve: 9 L/min\n PaO2 / FiO2: 287\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n mild crackles at the bases), (Sternum: Stable )\n Abdominal: mildly distended, incision c/d/i, ostomy pink\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 588 K/uL\n 9.0 g/dL\n 110 mg/dL\n 1.3 mg/dL\n 17 mEq/L\n 3.9 mEq/L\n 31 mg/dL\n 117 mEq/L\n 140 mEq/L\n 27.3 %\n 23.2 K/uL\n [image002.jpg]\n 05:39 PM\n 07:40 PM\n 08:58 PM\n 09:31 PM\n 04:03 AM\n 04:14 AM\n 02:25 PM\n 04:39 PM\n 02:04 AM\n 02:14 AM\n WBC\n 16.0\n 22.9\n 25.7\n 23.2\n Hct\n 27.7\n 29.5\n 27.9\n 27.3\n Plt\n 583\n 643\n 619\n 588\n Creatinine\n 1.2\n 1.3\n 1.2\n 1.3\n Troponin T\n 0.05\n TCO2\n 16\n 18\n 16\n 19\n 20\n Glucose\n 174\n 124\n 68\n 89\n 110\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:303 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.3 mg/dL, Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS), MALNUTRITION,\n ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF\n COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT\n DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n Neurologic: Pain controlled, Sedated on propofol, will minimize\n sedation as we approach extubation\n Pain: well controlled, fentanyl prn\n Cardiovascular: Aspirin, Beta-blocker, Statins, NSTEMI CE's cycled and\n negative, cont statin, lopressor, ASA, HR and BP stable\n Pulmonary: Cont ETT\n Gastrointestinal / Abdomen: intubated, no issues, minimimal vent\n settings, will work towards extubation, will probably need diuresis\n first\n Nutrition: TPN, NPO\n Renal: Foley, Adequate UO, Cr baseline, Adequate UOP, is 16L positive,\n will need to be diuresed\n Hematology: Hct 27.3, stable\n Endocrine: Insulin drip, Insulin gtt, sugars have been controlled well\n Infectious Disease: Check cultures, vanc,zosyn,flagyl, Vanc was redosed\n to q18 will need to check vanc trough, f/u cultures\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: LR, LR @ 100\n Consults: General surgery, GI, Cardiology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN without Lipids - 04:51 AM 66. mL/hour\n Glycemic Control: Insulin infusion, Insulin in TPN\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645067,
"text": "87yo male admitted with pulmonary edema, lower GI bleed, +STEMI. To OR\n emergently for xlap, colectomy, colostomy, \ns pouch for\n perforated divertic.\n Prior to admit, pt lived at home independently with family nearby.\n PMH includes DM,CHF.HTN, CRF.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt S/P xlap, colectomy, colostomy . Hypoactive BS, abd firm and\n distended. Oral gastric tube clamped most of shift. Stoma pink, dg\n small bilious fluid. Rectal drain in place\n Action:\n TPN infusing to optimize nutrition, midline incision dsg changed- small\n amt bloody drainage from lower aspect of wound.\n Response:\n Hypoactive BS, no aspirate from oral gastric tube\n Plan:\n Monitor for return of bowel fxn, supportive care, start TF when able to\n tolerate\n Pulmonary edema\n Assessment:\n Pt with hx of CHF,CRF, + STEMI on admit, now s/p xlap with fluid\n overload postop.\n Action:\n Lasix gtt, titrate to 200-250 per hour u/o, minimize fluid intake,\n replete electrolytes as needed.Pulmonary hygiene, maintain mechanical\n ventilation until adequate diuresis is achieved\n Response:\n -2600 for last 24 hours, lytes WNL x2, BP stable off pressors\n Plan:\n Continue current Rx\n Hyperglycemia\n Assessment:\n Pt with hx DM, on TPN,\n Action:\n Insulin gtt titrate for glycemic control\n Response:\n Insulin off for several hours, lowest BS= 56,\n amp D50 given.\n Currently on 2u/hr, glucose 110\n Plan:\n Continue to monitor BS, titrate insulin\n Events- R radial Aline removed, new Aline L radial artery.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645069,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: pt remains on vent , 40%. RSBI 45 this morning.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645071,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on full vent support. No changes made overnight.\n RSBI deferred D/t high peep. Will continue to closely monitor.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RRT\n on: 05:19 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645291,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644854,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Taken to OR emergently due to perforation of bowel. s/p sigmoid\n colectomy, end illeostomy and hartmans pouch on \n Action:\n abd firm and distended, hypoactive+ bs Abd inc draining moderate amt\n serosang output, dressing changed often. NGT to low cont sx. Cont abx\n Vanco, Zosyn, and flagyl. Fentanyl given for pain control.propofol for\n sedation\n Response:\n NGT patent scant output. Illeostomy stoma red, serosang drainage. No\n out put from rectal tube\n Plan:\n support hemodynamics as needed, control pain, cont bowel decompression\n via rectal tube and OGT.\n Rash\n Assessment:\n Healing rash to back\n Action:\n Cont topical cipro and lotion\n Response:\n Rash red but healing\n Plan:\n Cont with lotions and frequest repositioning.\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Insulin gtt cont, insulin increased in TPN, pt followed by \n Response:\n Bs better controlled. Goal bs <150\n Plan:\n Cont insulin gtt and Q1hr bs. With increase in insulin in TPN goal to\n d/c insulin gtt\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Hx NSTEMI, tropi elevated post op\n Action:\n Cycling CE and following ekg, lopressor given IV, simvastatin given\n Response:\n Cont in NSR,\n Plan:\n Cont to monitor\n Edema, peripheral\n Assessment:\n Anasarca from intense fluid rescuition and poor renal status\n Action:\n Lasix gtt started with goal hourly out put 200cc/hr\n Response:\n 200cc or greater / hr since the start of lasix gtt.\n Plan:\n Cont diuresis as tol. monitor electrolytes.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645445,
"text": "87yo male admitted with pulmonary edema, lower GI bleed, +STEMI. To OR\n emergently for xlap, colectomy, colostomy, \ns pouch for\n perforated divertic.\n Prior to admit, pt lived at home independently with family nearby. PMH\n includes DM,CHF.HTN, CRF.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n -Pt s/p ex-lap, colectomy . Present BS this shift, +flatus. Stoma\n pink, draining moderate amts brown liquid stool. Abd soft, distended\n -OGT dc\nd with extubation\n -Midline abd incision with small amts serous sanginous drainage, not\n approximated, incision reddened.\n Action:\n - Dophoff tube placed and TF restarted at goal of 45ccc/hr\n -Abd dressing changed, staples intact, TSICU HO into evaluate incision\n site.\n Response:\n -Pt tolerating TF\n -Primary team will evaluate incision site.\n Plan:\n Monitor abd incision for s/s infection, continue with TF\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt noted with grimicing, elevated vital signs\n Action:\n Pt given Roxicett via dophoff tube\n Response:\n Pain resolved, pt able to sleep on and off throughout shift\n Plan:\n Continue to monitor pain, Roxicett PRN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 87 YO M s/p colectomy, intubated since surgery on . Pt on minimal\n vent settings this am with RSBI of 17 and adequate blood gas.\n Action:\n Pt extubated this am, placed on face tent 40% FIO2\n Response:\n Pt tolerating well with SATS >96%.\n Plan:\n Continue to monitor respiratory status.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645062,
"text": "Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt S/P xlap, colectomy, colostomy . Hypoactive BS, abd firm and\n distended. Oral gastric tube clamped most of shift. Stoma pink, dg\n small bilious fluid. Rectal drain in place\n Action:\n TPN infusing to optimize nutrition, midline incision dsg changed- small\n amt bloody drainage from lower aspect of wound.\n Response:\n Hypoactive BS, no aspirate from oral gastric tube\n Plan:\n Monitor for return of bowel fxn, supportive care\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645154,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n s/p sigmoid colectomy, end illeostomy and hartmans pouch on . Abd\n remains distended soft to firm, hypoactive BS. NGT to LWS. IV abx as\n ordered. Midline incision with large amts serous sang drainage. Rectal\n tube intact sutured. Generalized anasarca, wt up. Abd wound not\n approximated, so abd wound able to drain\n Action:\n Lasix gtt, monitoring stoma. stool output just 100 cc brown liquid\n stool this shift from ileostomy. Rectal tube remains in place per\n surgery.Lytes drawn 1600\n Response:\n Hemodynamically stable, pt meeting goal of UO 200-250cc/hr. Rectal tube\n with 100cc or blood tinged mucoid drainage. Lytes WNL 1600.\n .\n Plan:\n Continue to monitor pain, hemodynamics, continue to diuresis, monitor\n lytes\n Hyperglycemia\n Assessment:\n BS better today Ranging 90-140\ns. Not responding to SQ heparin due to\n anasarca\n Action:\n Remains on insulin gtt, q1 hr blood sugars. Drip units per hr.\n Insulin 90 units in TPN. Drawing BS from A line with 5cc waste first.\n Response:\n Blood sugars 90-140\n Plan:\n ? Increase insulin in TPN.Adjust gtt as needed, currently adeq blood\n sugar control.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt fluid overloaded, elevated BUN/CRT, electrolyte imbalance.\n Action:\n Pt cont with lasix drip. Goal 200-250 cc u/o per hr.\n Response:\n Pt with adeq u/o 200-250 per hr. Lytes repleted prn.\n Plan:\n Cont lasix gtt, recheck lytes. ? Plan to extubate tomorrow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 645156,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644747,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n 87 YO s/p sigmoid colectomy, end illeostomy and hartmans pouch on \n Action:\n Abd continues to be firm and distended, + bs + flatus. Pain controlled\n with fentanyl PRN. IV ABX as ordered. Abd incision draining large amts\n serous sang drainage.\n Response:\n Illeostomy red, scant amts serous sang output. Rectal tube intact for\n decompression.\n Pt hemodynamically stable this shift.\n Plan:\n Continue to monitor hemodynamics,? dc rectal tube today, monitor pain.\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Continues on insulin gtt at 3 units/hr\n Response:\n BS well controlled, no changes made to insulin gtt this shift\n Plan:\n Continue with insulin gtt at 3 units/hr, titrate if needed. Add more\n insulin to TPN today.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644898,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 64.4\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 9 mL /\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n :\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n :\n Plan: Patient remains intubated on mechanical support. Current vent\n settings PSV 5, Peep 5, Fio2 40%. Tolerating well with spont vols 600\n and RR high teens. BS clear bilaterally. Sx\nd for secretions as above.\n Increased secretions over course of shift. ETT rotated to L side and\n taped at 22cm/lip. No further changes made. Fluid positive. Lasix drip.\n No further weaning at this time.\n Plan: Continue with mechanical support and reassess for extubation once\n fluid status is WNL.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645065,
"text": "Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt S/P xlap, colectomy, colostomy . Hypoactive BS, abd firm and\n distended. Oral gastric tube clamped most of shift. Stoma pink, dg\n small bilious fluid. Rectal drain in place\n Action:\n TPN infusing to optimize nutrition, midline incision dsg changed- small\n amt bloody drainage from lower aspect of wound.\n Response:\n Hypoactive BS, no aspirate from oral gastric tube\n Plan:\n Monitor for return of bowel fxn, supportive care, start TF when able to\n tolerate\n Pulmonary edema\n Assessment:\n Pt with hx of CHF,CRF, + STEMI on admit, now s/p xlap with fluid\n overload postop.\n Action:\n Lasix gtt, titrate to 200-250 per hour u/o, minimize fluid intake,\n replete electrolytes as needed.Pulmonary hygiene, maintain mechanical\n ventilation until adequate diuresis is achieved\n Response:\n -2600 for last 24 hours, lytes WNL x2, BP stable off pressors\n Plan:\n Continue current Rx\n Hyperglycemia\n Assessment:\n Pt with hx DM, on TPN,\n Action:\n Insulin gtt titrate for glycemic control\n Response:\n Insulin off for several hours, lowest BS= 56,\n amp D50 given.\n Currently on 2u/hr, glucose 110\n Plan:\n Continue to monitor BS, titrate insulin\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644851,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Taken to OR emergently due to perforation of bowel. s/p sigmoid\n colectomy, end illeostomy and hartmans pouch on \n Action:\n abd firm and distended, hypoactive+ bs Abd inc draining moderate amt\n serosang output, dressing changed often. NGT to low cont sx. Cont abx\n Vanco, Zosyn, and flagyl. Fentanyl given for pain control.propofol for\n sedation\n Response:\n NGT patent scant output. Illeostomy stoma red, serosang drainage. No\n out put from rectal tube\n Plan:\n support hemodynamics as needed, control pain, cont bowel decompression\n via rectal tube and OGT.\n Rash\n Assessment:\n Healing rash to back\n Action:\n Cont topical cipro and lotion\n Response:\n Rash red but healing\n Plan:\n Cont with lotions and frequest repositioning.\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Insulin gtt cont, insulin increased in TPN, pt followed by \n Response:\n Bs better controlled. Goal bs <150\n Plan:\n Cont insulin gtt and Q1hr bs. With increase in insulin in TPN goal to\n d/c insulin gtt\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Hx NSTEMI, tropi elevated post op\n Action:\n Cycling CE and following ekg, lopressor given IV, simvastatin given\n Response:\n Cont in NSR,\n Plan:\n Cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645031,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Resident progress note - TSICU",
"row_id": 644966,
"text": "Chief Complaint: Fever, abdominal pain\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:20 AM\n 24 HOUR EVENTS: started lasix gtt w/ goal of diuresing 150 to see if\n stable, then 200 cc/h, adjusted tpn w/ insulin and added h2. Cr\n trending up plateau at 1.4.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:52 PM\n Metronidazole - 04:08 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Furosemide (Lasix) - 2 mg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 01:27 AM\n Metoprolol - 04:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: Parenteral nutrition\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 98 (79 - 101) bpm\n BP: 155/45(75) {124/41(61) - 155/59(78)} mmHg\n RR: 18 (9 - 28) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (5 - 10)mmHg\n Total In:\n 4,017 mL\n 483 mL\n PO:\n TF:\n IVF:\n 2,333 mL\n 198 mL\n Blood products:\n Total out:\n 3,268 mL\n 1,170 mL\n Urine:\n 3,233 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 749 mL\n -687 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 647 (537 - 719) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 39\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.38/35/103/18/-3\n Ve: 10.3 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, No(t)\n Sedated, Tone: Not assessed\n Labs / Radiology\n 556 K/uL\n 8.6 g/dL\n 84 mg/dL\n 1.4 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 32 mg/dL\n 113 mEq/L\n 139 mEq/L\n 26.6 %\n 21.8 K/uL\n [image002.jpg]\n 09:31 PM\n 04:03 AM\n 04:14 AM\n 02:25 PM\n 04:39 PM\n 02:04 AM\n 02:14 AM\n 03:39 PM\n 02:18 AM\n 02:38 AM\n WBC\n 22.9\n 25.7\n 23.2\n 21.8\n Hct\n 29.5\n 27.9\n 27.3\n 26.6\n Plt\n 643\n 619\n 588\n 556\n Cr\n 1.3\n 1.2\n 1.3\n 1.4\n 1.4\n TCO2\n 18\n 16\n 19\n 20\n 22\n Glucose\n 124\n 68\n 89\n 110\n 160\n 92\n 84\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CKMB /\n Troponin-T:96/6/0.05, ALT / AST:24/34, Alk Phos / T Bili:58/0.4,\n Amylase / Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %,\n Mono:2.2 %, Eos:1.4 %, Fibrinogen:303 mg/dL, Lactic Acid:0.9 mmol/L,\n Albumin:2.4 g/dL, LDH:194 IU/L, Ca++:9.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n EDEMA, PERIPHERAL\n INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS)\n MALNUTRITION\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n RASH\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPERGLYCEMIA\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n NEUROLOGIC: Sedated on propofol, will minimize sedation as we approach\n extubation\n Pain: well controlled, fentanyl prn\n CARDIOVASCULAR: NSTEMI CE's cycled and negative, cont statin,\n lopressor, ASA, HR and BP stable in setting of active diuresis\n PULMONARY: intubated, no issues, minimimal vent settings, will work\n towards extubation after we are able to diurese.\n GI / ABD: s/p left colectomy, colostomy, rectal drain. NPO.\n NUTRITION: TPN/NPO\n RENAL: lasix gtt, follow electrolytes and replace prn. Cr trending up,\n active diuresis w/ goal -200/h and -2L/d\n HEMATOLOGY: Hct 27.3, stable\n ENDOCRINE: Insulin gtt, sugars have been controlled well. Increase in\n TPN\n ID: vanc,zosyn,flagyl, Vanc was redosed to q18 will need to check vanc\n trough, f/u cultures\n LINES/TUBES/DRAINS: PICC, RIJ, NGT, ETT, arterial line\n WOUNDS: ostomy, abdominal wound c/d/i\n IMAGING:\n FLUIDS: kvo\n CONSULTS: GI, derm, DM, cards\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: insulin in TPN . and drip. Increase amount in TPN\n PROPHYLAXIS:\n DVT - sch, boots\n STRESS ULCER - PPI\n VAP BUNDLE - Yes\n COMMUNICATIONS:\n ICU Consent: will obtain\n CODE STATUS: full\n DISPOSITION: TSICU\n ICU Care\n Nutrition:\n TPN without Lipids - 07:48 PM 66. mL/hour\n Glycemic Control: Insulin infusion, Blood sugar well controlled,\n Insulin in TPN\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments: need to have family sign ICU consent\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645670,
"text": "87Male admitted to MICU service for pulmonary edema, GI bleed\n (d/t diverticulitis). Ruled in for MI and perforated bowel.\n exlap, colectomy, ileostomy, and \ns Pouch. Tx to TSICU\n where pt was aggressively fluid resuscitated. Pt was placed on Lasix\n gtt, weaned and extubated .\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x1. Responds at times to questioning, other times\n does not. Inconsistently will follow commands. Moves all extremities.\n Pulls at tubing, dislodged dophoff tube this am.\n Action:\n Pt placed on restraints to prevent any tubes from being removed by\n pt. Haldol given X 1 for agitation.\n Response:\n After haldol dosing, pt less agitated.\n Plan:\n Continue to monitor neurological status and agitation.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Abdomen soft and distended. +BS. Ostomy draining large amts brown soft\n formed stool. Pt dislodged dophoff tube this am.\n Action:\n New dophoff tube placed, TF infusing at goal rate of 45cc/hr.\n Response:\n Tolerating TF\ns, stoma intact with large amts brown soft stool.\n Plan:\n Continue to monitor abdominal incision, BS and stoma.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt moaning with any type of stimulation\n Action:\n Roxicett given PO. Fentanyl given IV when there was no GI access\n Response:\n Pain well controlled.\n Plan:\n Continue to monitor pain, treat with pain med as needed.\n Muscle Performace, Impaired\n Assessment:\n Pt weak due to complicated hospital course, laying in bed for long\n periods of time.\n Action:\n PT consulted\n Response:\n Pt OOB to chair with max assist. Pt OOB for a few hours, hoyered back\n to bed this afternoon.\n Plan:\n Continue with PT, continue to get pt OOB, ROM, ambulate when stronger.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645188,
"text": "Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt s/p xlap, colectomy . Hypoactive BS, abd softly distended.Oral\n gastric tube clamped except for meds. Stoma pink, draining liquid brown\n stool.Rectal tube in place\n Action:\n TPN infusing, midline incision dressing changed, small clot removed\n from incision.\n Response:\n < 10cc aspirate from Oral gastric tube, now with liquid stool form\n ostomy, continues to have mucous from rectal drain. Abdomen softer than\n yesterday\n Plan:\n ? start tube feeding, monitor for return of bowel fxn, supportive care\n Pulmonary edema\n Assessment:\n Hx CHF,CRF, +NSTEMI on admit, now s/p xlap with fluid overload postop\n Action:\n Lasix drip decreased to 1mg/hr d/t ^^ BUN/creatinine, minimize IVF,\n replete lytes as indicated.Pulmonary hygiene, wean mechanical\n ventilation until pt is adequately diuresed\n Response:\n u/o remains brisk 100-200/hr, -3000 for 24 hrs, pt still 11,000\n positive. Lytes WNL, BP stable, tolerating CPAP well with adequate ABG\n Plan:\n Continue diuresis as tolerated, monitor renal fxn, wean vent\n Hyperglycemia\n Assessment:\n Pt with hx DM on TPN.\n Action:\n Insulin in TPN, also on drip for glucose control, hourly blood glucose\n readings\n Response:\n Hypoglycemic overnight, requiring\n amp D50, insulin off most of shift\n until BS>100\n Plan:\n Monitor BS, titrate insulin\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645278,
"text": "87yo male admitted with pulmonary edema, lower GI bleed, +STEMI. To OR\n emergently for xlap, colectomy, colostomy, \ns pouch for\n perforated divertic.\n Prior to admit, pt lived at home independently with family nearby.\n PMH includes DM,CHF.HTN, CRF.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt s/p xlap, colectomy . Present BS this shift, +flatus. Stoma\n pink, draining moderate amts brown liquid stool. Abd soft, distended\n Hct trending down this am to 22_____\n Hypoactive BS, abd softly distended.Oral gastric tube clamped except\n for meds. Stoma pink, draining liquid brown stool.Rectal tube in place\n Action:\n TPN to finish this evening. TF started this am at 20cc/hr, increase\n Q8/hr. Rectal tube draining small amts clear liquid mucus\n Transfused with 2 units PRBC\n TPN infusing, midline incision dressing changed, small clot removed\n from incision.\n Response:\n Minimal residuals\n Rectal tube DC\n Post transfusion HCT ____\n < 10cc aspirate from Oral gastric tube, now with liquid stool form\n ostomy, continues to have mucous from rectal drain. Abdomen softer than\n yesterday\n Plan:\n Advance TF as tolerated\n Monitor HCT QD.\n ? start tube feeding, monitor for return of bowel fxn, supportive care\n Pulmonary edema\n Assessment:\n Hx CHF,CRF, +NSTEMI on admit, now s/p xlap with fluid overload postop\n Action:\n Lasix drip decreased to 1mg/hr d/t ^^ BUN/creatinine, minimize IVF,\n replete lytes as indicated.Pulmonary hygiene, wean mechanical\n ventilation until pt is adequately diuresed\n Response:\n u/o remains brisk 100-200/hr, -3000 for 24 hrs, pt still 11,000\n positive. Lytes WNL, BP stable, tolerating CPAP well with adequate ABG\n Plan:\n Continue diuresis as tolerated, monitor renal fxn, wean vent\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644312,
"text": "87 yo male adm with NSTEMI w/ new diastolic CHF in setting of\n GIB. MI medically managed. Sent to 3 for a few days until \n when temp spiked to 104 PR. Pt found to have C-diff colitis. Abd CT\n with severe pancolitis versus walled-off bowel perforation-abx. Surgery\n following- no need for urgent bowel surgery. NPO until further notice\n for bowel rest. PICC repositioned in IR -tpn started. Na+\n 147, receiving D5W for 1.5L. Blood sugars elevated on tpn now even\n higher w/ D5W. HISS & Glargine adjusted.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644483,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Taken to OR emergently due to perforation of bowel. s/p sigmoid\n colectomy, end illeostomy and hartmans pouch.\n Action:\n Cont to actively fluid resuscitate with LR and albumin for hypotension\n and low u/o. abd firm and distended, + bs + flatus. Abd wound draining\n serosang output, dressing reinforced. NGT to low cont sx. Cont abx\n Vanco, Zosyn, and flagyl. Fentanyl given for pain control.\n Response:\n b/p wax and wanes u/o follows, b/p supported with fluid and responds\n well. Lactate down to 1.7. NGT coiled in mouth, tube replaced and\n confirmed by CXR. Illeostomy stoma red, serosang drainage.\n Plan:\n Cont fluid resuscitation as needed, support hemodynamics, control pain.\n Rash\n Assessment:\n Healing rash to back\n Action:\n Cont topical cipro and lotion\n Response:\n Rash red but healing\n Plan:\n Cont with lotions and frequest repositioning. Watch for drug reactions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure\n Action:\n Fluid bolus to support b/p and u/o\n Response:\n Pt responds well to fluid, creat down,\n Plan:\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Insulin gtt started\n Response:\n Bs better controlled. Goal bs <150\n Plan:\n Cont insulin gtt and Q1hr bs.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644581,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n s/p sigmoid colectomy, end illeostomy and hartmans pouch on \n Action:\n Fluid bolus given for low CVP and low UO. ABD distended, yet soft to\n touch. Hypoactive BS present. Abx continue. NGT to LWS with bilious\n output. Lytes repleted.\n Response:\n Hemodynamically stable, UO improved this shift. HCT stable.\n Plan:\n Continue to monitor UO/BP. Fluid to be given for low UO/BP.\n Rash\n Assessment:\n Continues with red rash to back.\n Action:\n Sarna lotion PRN, Cipro topical lotion\n Response:\n Rash healing\n Plan:\n Continue to monitor, continue with current treatment\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure\n Action:\n Fluid bolus given to maintain adequate UO\n Response:\n Pt responded well, UO improved overnight\n Plan:\n Continue to monitor UO\n Hyperglycemia\n Assessment:\n Pt with hx DM, elevated BS last shift, insulin gtt started\n Action:\n Insulin gtt titrated to maintain adequate BS control\n Response:\n BS well controlled\n Plan:\n Continue with Q1/hr BS, continue with insulin gtt. ? start NPH today or\n add more insulin to TPN\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Hx NSTEMI\n Action:\n Last set of enzymes cycled this shift, monitoring HR, Lopressor given\n Response:\n Cont in NSR, trop continues to trend down\n Plan:\n Continue to monitor HR, hemodynamics\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645032,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Pt continues with elevated blood sugars.\n Action:\n Remains on insulin gtt, q1 hr blood sugars. Drip 3-4 units per hr.\n Response:\n Blood sugars lowered to 90\ns from 130\ns. Slightly labile today\n Plan:\n Increasing insulin dose in TPN for a.m. Adjust cont gtt as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt fluid overloaded, elevated BUN/CRT, electrolyte imbalance.\n Action:\n Pt cont with lasix drip. Goal 200-250 cc u/o per hr. Potassium and\n magnesium repletion today.\n Response:\n Pt with adeq u/o 200-250 per hr. Lytes repleted.\n Plan:\n Cont lasix gtt, recheck lytes. Plan to extubate tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645034,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n s/p sigmoid colectomy, end illeostomy and hartmans pouch on . Abd\n remains distended soft to firm, hypoactive BS. NGT to LWS. IV abx as\n ordered. Midline incision with large amts serous sang drainage. Rectal\n tube intact sutured. Generalized anasarca, wt up\n Action:\n Lasix gtt, monitoring stoma. No stool output just 25 cc serous sang\n drainage this shift from ileostomy. Rectal tube remains in place per\n surgery.\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Pt continues with elevated blood sugars.\n Action:\n Remains on insulin gtt, q1 hr blood sugars. Drip 3-4 units per hr.\n Response:\n Blood sugars lowered to 90\ns from 130\ns. Slightly labile today\n Plan:\n Increasing insulin dose in TPN for a.m. Adjust cont gtt as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt fluid overloaded, elevated BUN/CRT, electrolyte imbalance.\n Action:\n Pt cont with lasix drip. Goal 200-250 cc u/o per hr. Potassium and\n magnesium repletion today.\n Response:\n Pt with adeq u/o 200-250 per hr. Lytes repleted.\n Plan:\n Cont lasix gtt, recheck lytes. Plan to extubate tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645035,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n s/p sigmoid colectomy, end illeostomy and hartmans pouch on . Abd\n remains distended soft to firm, hypoactive BS. NGT to LWS. IV abx as\n ordered. Midline incision with large amts serous sang drainage. Rectal\n tube intact sutured. Generalized anasarca, wt up. Abd wound not\n approximated, so abd wound able to drain\n Action:\n Lasix gtt, monitoring stoma. No stool output just 25 cc serous sang\n drainage this shift from ileostomy. Rectal tube remains in place per\n surgery.\n Response:\n Hemodynamically stable, pt meeting goal of UO 200-250cc/hr. No drainage\n via rectal tube.\n .\n Plan:\n Continue to monitor pain, hemodynamics, continue to diuresis, monitor\n lytes\n Hyperglycemia\n Assessment:\n Pt continues with elevated blood sugars. Not responding to SQ heparin\n due to anasarca\n Action:\n Remains on insulin gtt, q1 hr blood sugars. Drip 3-4 units per hr.\n Response:\n Blood sugars lowered to 90\ns from 130\ns. Slightly labile today\n Plan:\n Increasing insulin dose in TPN for a.m. Adjust gtt as needed,\n currently adeq blood sugar control.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt fluid overloaded, elevated BUN/CRT, electrolyte imbalance.\n Action:\n Pt cont with lasix drip. Goal 200-250 cc u/o per hr. Potassium and\n magnesium repletion today.\n Response:\n Pt with adeq u/o 200-250 per hr. Lytes repleted.\n Plan:\n Cont lasix gtt, recheck lytes. Plan to extubate tomorrow.\n Suggested to team to add heparin to TPN in a.m. Cont to monitor.\n"
},
{
"category": "Rehab Services",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 645566,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: /\n Reason of referral: Re-Evaluation\n History of Present Illness / Subjective Complaint: 87M admit w/\n NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid diverticulitis\n w/ free air , s/p ex lap, L colectomy w/ Hartmann's pouch, end\n colostomy requiring prolonged ICu stay and intubation, extubated\n .\n Past Medical / Surgical History: HTN, Hyperlipidemia, DMII, CAD, Acute\n on chronic diastolic\n CHF, h/o EtOH abuse, ? CRI\n Medications: Simvastatin, OxycoDONE, Metoprolol, Haloperidol\n Radiology: Cxr: no evidence of pleural effusion\n Labs:\n 29.2\n 9.8\n 487\n 12.5\n [image002.jpg]\n Other labs:\n Activity Orders:\n Social / Occupational History:\n Living Environment:\n Prior Functional Status / Activity Level:\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt eyes open t/o less\n than 20% of evaluation. Pt was not following 1 step commands, minimal\n eye contact. verbal communication, no attempts at communication. Pt\n was groaning during PROM\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 85\n 111/38\n 96% 3L\n Rest\n /\n Sit\n 94\n 122/51\n 96% RA\n Activity\n /\n Stand\n /\n Recovery\n 89\n 125/47\n 95% RA\n Total distance walked:\n Minutes:\n Pulmonary Status: Diminished LS t/o\n Integumentary / Vascular: Ostomy pouch, R IJ, foley, minimal B LE edema\n Sensory Integrity: Pt grimacing with pain with PROM of all extremities\n Pain / Limiting Symptoms: Pt appeared uncomfortable during bed mobility\n and with PROM\n Posture:\n Range of Motion\n Muscle Performance\n B LE grossly WFL\n B shldr flexion limited by muscle guarding\n Pt spontaneously moving all extremities\n Motor Function: Pt not following commands, ? increased tone in B UE and\n LE verse muscle guarding/shortening from bedrest.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n T\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt required Max A x 2 to achieve sitting at EOB and Mod A to\n maintain. Pt was able to perform sit to stand x 3, only clearing approx\n 5 inches from bed c Max A x 2\n Max A x 2 for squat pivot transfer\n Education / Communication: Pt status discussed with RN. Pt educated on\n role of PT. Pt was left in recliner chair with pad. Rec RN use\n lift for back to bed transfer.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Muscle Performance, Impaired\n 3.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 87 yo m admitted c NSTEMI s/p\n colectomy for perforated sigmoid. Pt presents with above impairments\n c/w decondidtioning. Pt is functioning well below baseline. Pt was\n extremely lethargic and was not able to participate with PT evaluation.\n Hopefully with improvement in MS pt will be able to make gains with\n mobility. He will require rehab upon d/c\n Goals\n Time frame: 1wk\n 1.\n Follow > 50% of commands\n 2.\n Maintain eyes open t/o eval\n 3.\n Mod A for bed mobility\n 4.\n Mod A for transfer\n 5.\n Tolerate full standing c Mod A > 1min\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n F/u balance, ROm, strength, mobility, and transfer training\n Nsging should use lift or stretcher chair for all transfers.\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645570,
"text": "SICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, RISS, Metoprolol 50\n PO TID, famotidine, Vanco PO, Linezolid, zosyn, flagyl, fentanyl prn,\n simvastatin, lasix 40 PO BID, lantus\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:27 AM\n EXTUBATION - At 10:31 AM\n STOOL CULTURE - At 05:08 AM\n extubated, cont diuresis, tolerating TF's, HD stable, lopressor\n increased to 50mg TID, C. Diff negative. TF's changed to nutren pulm to\n decrease fluids.\n Post operative day:\n POD#7 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:27 PM\n Linezolid - 02:00 AM\n Metronidazole - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:22 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:30 AM\n Fentanyl - 12:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Famotidine (Pepcid) - 08:05 AM\n Other medications:\n Flowsheet Data as of 10:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.3\n HR: 89 (69 - 96) bpm\n BP: 125/47(67) {110/37(55) - 151/56(78)} mmHg\n RR: 21 (10 - 21) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (1 - 13) mmHg\n Total In:\n 2,303 mL\n 1,226 mL\n PO:\n Tube feeding:\n 673 mL\n 450 mL\n IV Fluid:\n 1,320 mL\n 646 mL\n Blood products:\n Total out:\n 3,340 mL\n 1,150 mL\n Urine:\n 3,040 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,037 mL\n 76 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: 7.41/38/95./23/0\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace)\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 487 K/uL\n 9.8 g/dL\n 164 mg/dL\n 1.7 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 108 mEq/L\n 137 mEq/L\n 29.2 %\n 12.5 K/uL\n [image002.jpg]\n 04:15 AM\n 07:58 AM\n 12:00 PM\n 02:10 PM\n 06:00 PM\n 12:00 AM\n 04:17 AM\n 04:34 AM\n 02:21 AM\n 02:33 AM\n WBC\n 15.7\n 12.5\n Hct\n 22.3\n 31.1\n 29.8\n 29.2\n Plt\n 520\n 487\n Creatinine\n 1.7\n 1.7\n TCO2\n 20\n 24\n 25\n Glucose\n 102\n 113\n 119\n 191\n 234\n 164\n Other labs: PT / PTT / INR:16.8/46.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:659 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:8.8 mg/dL, Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, RESPIRATION / GAS\n EXCHANGE, IMPAIRED, RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ELECTROLYTE & FLUID\n DISORDER, OTHER, EDEMA, PERIPHERAL, INTESTINE, PERFORATION OF\n (PERFORATION OF HOLLOW VISCUS), MALNUTRITION, ATRIAL FIBRILLATION\n (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM\n DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), GASTROINTESTINAL BLEED, UPPER\n (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n Neurologic: Pain controlled\n Cardiovascular:\n Pulmonary: no issues\n Gastrointestinal / Abdomen: good stool, tf at goal,\n Nutrition: Tube feeding, Speech and Swallow eval\n Renal: Adequate UO, goal -1L\n Hematology: stable\n Endocrine: RISS, Lantus (R), good control\n Infectious Disease: zosyn/linezolid/flagyl/po vanc\n Lines / Tubes / Drains: Foley, a line d/c\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Post-op shock, Other: diverticulitis\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:44 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:00 PM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645571,
"text": "SICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, RISS, Metoprolol 50\n PO TID, famotidine, Vanco PO, Linezolid, zosyn, flagyl, fentanyl prn,\n simvastatin, lasix 40 PO BID, lantus\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:27 AM\n EXTUBATION - At 10:31 AM\n STOOL CULTURE - At 05:08 AM\n extubated, cont diuresis, tolerating TF's, HD stable, lopressor\n increased to 50mg TID, C. Diff negative. TF's changed to nutren pulm to\n decrease fluids.\n Post operative day:\n POD#7 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:27 PM\n Linezolid - 02:00 AM\n Metronidazole - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:22 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:30 AM\n Fentanyl - 12:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Famotidine (Pepcid) - 08:05 AM\n Other medications:\n Flowsheet Data as of 10:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.3\n HR: 89 (69 - 96) bpm\n BP: 125/47(67) {110/37(55) - 151/56(78)} mmHg\n RR: 21 (10 - 21) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (1 - 13) mmHg\n Total In:\n 2,303 mL\n 1,226 mL\n PO:\n Tube feeding:\n 673 mL\n 450 mL\n IV Fluid:\n 1,320 mL\n 646 mL\n Blood products:\n Total out:\n 3,340 mL\n 1,150 mL\n Urine:\n 3,040 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,037 mL\n 76 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: 7.41/38/95./23/0\n PaO2 / FiO2: 240\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace)\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 487 K/uL\n 9.8 g/dL\n 164 mg/dL\n 1.7 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 108 mEq/L\n 137 mEq/L\n 29.2 %\n 12.5 K/uL\n [image002.jpg]\n 04:15 AM\n 07:58 AM\n 12:00 PM\n 02:10 PM\n 06:00 PM\n 12:00 AM\n 04:17 AM\n 04:34 AM\n 02:21 AM\n 02:33 AM\n WBC\n 15.7\n 12.5\n Hct\n 22.3\n 31.1\n 29.8\n 29.2\n Plt\n 520\n 487\n Creatinine\n 1.7\n 1.7\n TCO2\n 20\n 24\n 25\n Glucose\n 102\n 113\n 119\n 191\n 234\n 164\n Other labs: PT / PTT / INR:16.8/46.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:659 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:8.8 mg/dL, Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, RESPIRATION / GAS\n EXCHANGE, IMPAIRED, RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ELECTROLYTE & FLUID\n DISORDER, OTHER, EDEMA, PERIPHERAL, INTESTINE, PERFORATION OF\n (PERFORATION OF HOLLOW VISCUS), MALNUTRITION, ATRIAL FIBRILLATION\n (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM\n DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), GASTROINTESTINAL BLEED, UPPER\n (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n Neurologic: Pain controlled\n Cardiovascular:\n Pulmonary: no issues\n Gastrointestinal / Abdomen: good stool, tf at goal,\n Nutrition: Tube feeding, Speech and Swallow eval\n Renal: Adequate UO, goal -1L\n Hematology: stable\n Endocrine: RISS, Lantus (R), good control\n Infectious Disease: zosyn/linezolid/flagyl/po vanc. Will d/c flagyl and\n PO vanco after last c-diff is negative.\n Lines / Tubes / Drains: Foley, a line d/c\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: Post-op shock, Other: diverticulitis\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:44 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:00 PM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645189,
"text": "87yo male admitted with pulmonary edema, lower GI bleed, +STEMI. To OR\n emergently for xlap, colectomy, colostomy, \ns pouch for\n perforated divertic.\n Prior to admit, pt lived at home independently with family nearby.\n PMH includes DM,CHF.HTN, CRF.\n Intestine, perforation of (perforation of hollow viscus)\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt s/p xlap, colectomy . Hypoactive BS, abd softly distended.Oral\n gastric tube clamped except for meds. Stoma pink, draining liquid brown\n stool.Rectal tube in place\n Action:\n TPN infusing, midline incision dressing changed, small clot removed\n from incision.\n Response:\n < 10cc aspirate from Oral gastric tube, now with liquid stool form\n ostomy, continues to have mucous from rectal drain. Abdomen softer than\n yesterday\n Plan:\n ? start tube feeding, monitor for return of bowel fxn, supportive care\n Pulmonary edema\n Assessment:\n Hx CHF,CRF, +NSTEMI on admit, now s/p xlap with fluid overload postop\n Action:\n Lasix drip decreased to 1mg/hr d/t ^^ BUN/creatinine, minimize IVF,\n replete lytes as indicated.Pulmonary hygiene, wean mechanical\n ventilation until pt is adequately diuresed\n Response:\n u/o remains brisk 100-200/hr, -3000 for 24 hrs, pt still 11,000\n positive. Lytes WNL, BP stable, tolerating CPAP well with adequate ABG\n Plan:\n Continue diuresis as tolerated, monitor renal fxn, wean vent\n Hyperglycemia\n Assessment:\n Pt with hx DM on TPN.\n Action:\n Insulin in TPN, also on drip for glucose control, hourly blood glucose\n readings\n Response:\n Hypoglycemic overnight, requiring\n amp D50, insulin off most of shift\n until BS>100\n Plan:\n Monitor BS, titrate insulin\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644314,
"text": "87 yo male adm with NSTEMI w/ new diastolic CHF in setting of\n GIB. MI medically managed. Sent to 3 for a few days until \n when temp spiked to 104 PR. Pt found to have C-diff colitis. Abd CT\n with severe pancolitis versus walled-off bowel perforation-abx. Surgery\n following- no need for urgent bowel surgery. NPO until further notice\n for bowel rest. PICC repositioned in IR -tpn started. Na+\n 147, receiving D5W for 1.5L. Blood sugars elevated on tpn now even\n higher w/ D5W. HISS & Glargine adjusted.\n Hyperglycemia\n Assessment:\n Known diabetic. Elevated fsbs now mid-upper 300s\n Action:\n Pm glargine & q6hr humolog ss coverage increased\n Response:\n PM fsbx 390 covered w 12u sq humolog.\n Plan:\n ?increase pm glargine dose. Contin q6hr coverage.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644476,
"text": "Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644741,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n 87 YO s/p sigmoid colectomy, end illeostomy and hartmans pouch on \n Action:\n Abd continues to be firm and distended, + bs + flatus. Pain controlled\n with fentanyl PRN. IV ABX as ordered. Abd incision draining large amts\n serous sang drainage.\n Response:\n Illeostomy red, scant amts serous sang output. Rectal tube intact for\n decompression.\n Pt hemodynamically stable this shift.\n Plan:\n Continue to monitor hemodynamics,? dc rectal tube today, monitor pain.\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Continues on insulin gtt at 3 units/hr\n Response:\n BS well controlled, no changes made to insulin gtt this shift\n Plan:\n Continue with insulin gtt at 3 units/hr, titrate if needed. Add more\n insulin to TPN today.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644849,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White /\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Diurese\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645174,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n s/p sigmoid colectomy, end illeostomy and hartmans pouch on . Abd\n remains distended but soft, hypoactive BS. Now putting out brown liquid\n stool. NGT to LWS with minimal outputs. IV abx as ordered. Midline\n incision with mod amts serous sang drainage. Rectal tube intact\n sutured. Generalized anasarca, wt up. Abd wound not approximated for\n drainage.\n Action:\n Iv Vanco d/c\nd this afternoon, Iv linezolid started for a resistant\n bacteria in peritoneum.Lasix gtt continues to help reduce fluid\n balance, monitoring stoma color/output. Stool output 100 cc brown\n liquid stool this shift from ileostomy. Rectal tube remains in place\n per surgery. Lytes drawn 1600.\n Response:\n Hemodynamically stable, pt meeting goal of UO 200-250cc/hr. Rectal tube\n with 100cc or blood tinged mucoid drainage. Lytes WNL 1600.\n .\n Plan:\n Continue to monitor pain, hemodynamics, continue to diuresis, monitor\n lytes\n Hyperglycemia\n Assessment:\n BS better today Ranging 90-140\ns. Not responding to SQ heparin due to\n anasarca\n Action:\n Remains on insulin gtt, q1 hr blood sugars. Drip remained 1-1.5\n units per hr. Insulin 90 units in TPN. Drawing BS from A line with 5cc\n waste first.\n Response:\n Blood sugars 90-140\n Plan:\n ? Increase insulin in TPN.Adjust gtt as needed, currently adeq blood\n sugar control.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt fluid overloaded, elevated BUN/CRT, electrolyte imbalance.\n Action:\n Pt cont with lasix drip. Goal 200-250 cc u/o per hr.\n Response:\n Pt with adeq u/o 200-250 per hr. Lytes repleted prn.\n Plan:\n Cont lasix gtt, recheck lytes. ? Plan to extubate tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 645175,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n s/p sigmoid colectomy, end illeostomy and hartmans pouch on . Abd\n remains distended but soft, hypoactive BS. Now putting out brown liquid\n stool. NGT to LWS with minimal outputs. IV abx as ordered. Midline\n incision with mod amts serous sang drainage. Rectal tube intact\n sutured. Generalized anasarca, wt up. Abd wound not approximated for\n drainage.\n Action:\n Iv Vanco d/c\nd this afternoon, Iv linezolid started for a resistant\n bacteria in peritoneum.Lasix gtt continues to help reduce fluid\n balance, monitoring stoma color/output. Stool output 100 cc brown\n liquid stool this shift from ileostomy. Rectal tube remains in place\n per surgery. Lytes drawn 1600.\n Response:\n Hemodynamically stable, pt meeting goal of UO 200-250cc/hr. Rectal tube\n with 100cc or blood tinged mucoid drainage. Lytes WNL 1600.\n .\n Plan:\n Continue to monitor pain, hemodynamics, continue to diuresis, monitor\n lytes\n Hyperglycemia\n Assessment:\n BS better today Ranging 90-140\ns. Not responding to SQ heparin due to\n anasarca\n Action:\n Remains on insulin gtt, q1 hr blood sugars. Drip remained 1-1.5\n units per hr. Insulin 90 units in TPN. Drawing BS from A line with 5cc\n waste first.\n Response:\n Blood sugars 90-140\n Plan:\n ? Increase insulin in TPN.Adjust gtt as needed, currently adeq blood\n sugar control.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt fluid overloaded, elevated BUN/CRT, electrolyte imbalance.\n Action:\n Pt cont with lasix drip. Goal 200-250 cc u/o per hr.\n Response:\n Pt with adeq u/o 200-250 per hr. Lytes repleted prn.\n Plan:\n Cont lasix gtt, recheck lytes. ? Plan to extubate tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated, still fluid overloaded.\n Action:\n Cont diuresis, monitor gas\ns, placed on 0/0 psupp rr 40\n hyperdynamic.\n Response:\n Remains intubated, cont lasix gtt, ? extubate tomorrow if possible.\n Plan:\n Cont to closely monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645235,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, linezolid,\n zosyn, flagyl, vanco PO, fentanyl prn, simvastatin, lasix gtt\n 24 Hour Events:\n Post operative day:\n POD#5 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:05 AM\n Linezolid - 02:11 PM\n Metronidazole - 08:29 PM\n Piperacillin/Tazobactam (Zosyn) - 05:59 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:34 AM\n Fentanyl - 11:06 AM\n Dextrose 50% - 11:07 PM\n Metoprolol - 07:58 AM\n Other medications:\n Flowsheet Data as of 08:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.7\nC (99.9\n HR: 88 (76 - 106) bpm\n BP: 100/41(54) {100/41(54) - 100/41(54)} mmHg\n RR: 17 (5 - 26) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 6 (1 - 35) mmHg\n Total In:\n 2,911 mL\n 877 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,370 mL\n 338 mL\n Blood products:\n Total out:\n 6,355 mL\n 1,175 mL\n Urine:\n 5,985 mL\n 1,125 mL\n NG:\n Stool:\n Drains:\n 170 mL\n Balance:\n -3,444 mL\n -298 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 508 (453 - 563) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 53\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: 7.41/31/126/22/-3\n Ve: 7.1 L/min\n PaO2 / FiO2: 315\n Physical Examination\n Labs / Radiology\n 564 K/uL\n 8.0 g/dL\n 102 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 109 mEq/L\n 135 mEq/L\n 22.3 %\n 17.4 K/uL\n [image002.jpg]\n 11:56 AM\n 09:21 PM\n 01:59 AM\n 06:29 AM\n 09:28 AM\n 04:04 PM\n 01:30 AM\n 01:36 AM\n 04:15 AM\n 07:58 AM\n WBC\n 22.1\n 17.4\n Hct\n 27.1\n 24.1\n 22.3\n Plt\n 624\n 564\n Creatinine\n 1.6\n 1.6\n 1.7\n 1.8\n TCO2\n 21\n 20\n 24\n 24\n 20\n Glucose\n 69\n 126\n 142\n 88\n 102\n Other labs: PT / PTT / INR:16.8/46.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:659 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.0 mg/dL, Mg:2.3 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ELECTROLYTE & FLUID DISORDER, OTHER, EDEMA,\n PERIPHERAL, INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS),\n MALNUTRITION, ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C\n DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87M NSTEMI, ARF, CHF, C. Diff, s/p ex lap, L\n colectomy w/ Hartmann's pouch, end colostomy ()\n Neurologic: Pain controlled, wean sedation\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: d/c rectal tube\n Nutrition: TPN, NPO, consider transition to TF today\n Renal: Foley, Adequate UO, cont lasix home dose\n Hematology: Serial Hct, f/u hct s/p transfusion\n Endocrine: RISS, insulin in TPN\n Infectious Disease: linezolid, zosyn, vanco po, flagyl; repeat C. Diff\n sample today\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: partially open midline incision, no discharge\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, Arrhythmia, (Respiratory\n distress: Failure), Acute renal failure\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 59 mL/hour\n Glycemic Control: Regular insulin sliding scale, Insulin in TPN\n Lines:\n PICC Line - 12:00 PM\n Multi Lumen - 03:00 AM\n Arterial Line - 03:38 AM\n Prophylaxis:\n DVT: Boots (heparin in TPN)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645236,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, linezolid,\n zosyn, flagyl, vanco PO, fentanyl prn, simvastatin, lasix gtt\n 24 Hour Events:\n Post operative day:\n POD#5 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:05 AM\n Linezolid - 02:11 PM\n Metronidazole - 08:29 PM\n Piperacillin/Tazobactam (Zosyn) - 05:59 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:34 AM\n Fentanyl - 11:06 AM\n Dextrose 50% - 11:07 PM\n Metoprolol - 07:58 AM\n Other medications:\n Flowsheet Data as of 08:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.7\nC (99.9\n HR: 88 (76 - 106) bpm\n BP: 100/41(54) {100/41(54) - 100/41(54)} mmHg\n RR: 17 (5 - 26) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 6 (1 - 35) mmHg\n Total In:\n 2,911 mL\n 877 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,370 mL\n 338 mL\n Blood products:\n Total out:\n 6,355 mL\n 1,175 mL\n Urine:\n 5,985 mL\n 1,125 mL\n NG:\n Stool:\n Drains:\n 170 mL\n Balance:\n -3,444 mL\n -298 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 508 (453 - 563) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 53\n PIP: 11 cmH2O\n SPO2: 99%\n ABG: 7.41/31/126/22/-3\n Ve: 7.1 L/min\n PaO2 / FiO2: 315\n Physical Examination\n Labs / Radiology\n 564 K/uL\n 8.0 g/dL\n 102 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 109 mEq/L\n 135 mEq/L\n 22.3 %\n 17.4 K/uL\n [image002.jpg]\n 11:56 AM\n 09:21 PM\n 01:59 AM\n 06:29 AM\n 09:28 AM\n 04:04 PM\n 01:30 AM\n 01:36 AM\n 04:15 AM\n 07:58 AM\n WBC\n 22.1\n 17.4\n Hct\n 27.1\n 24.1\n 22.3\n Plt\n 624\n 564\n Creatinine\n 1.6\n 1.6\n 1.7\n 1.8\n TCO2\n 21\n 20\n 24\n 24\n 20\n Glucose\n 69\n 126\n 142\n 88\n 102\n Other labs: PT / PTT / INR:16.8/46.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:659 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.0 mg/dL, Mg:2.3 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ELECTROLYTE & FLUID DISORDER, OTHER, EDEMA,\n PERIPHERAL, INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS),\n MALNUTRITION, ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C\n DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87M NSTEMI, ARF, CHF, C. Diff, s/p ex lap, L\n colectomy w/ Hartmann's pouch, end colostomy ()\n Neurologic: Pain controlled, wean sedation\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: d/c rectal tube\n Nutrition: TPN, NPO, consider transition to TF today\n Renal: Foley, Adequate UO, cont lasix home dose\n Hematology: Serial Hct, f/u hct s/p transfusion\n Endocrine: RISS, insulin in TPN\n Infectious Disease: linezolid, zosyn, vanco po, flagyl; repeat C. Diff\n sample today\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: partially open midline incision, no discharge\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, Arrhythmia, (Respiratory\n distress: Failure), Acute renal failure\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 59 mL/hour\n Glycemic Control: Regular insulin sliding scale, Insulin in TPN\n Lines:\n PICC Line - 12:00 PM\n Multi Lumen - 03:00 AM\n Arterial Line - 03:38 AM\n Prophylaxis:\n DVT: Boots (heparin in TPN)\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644569,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Expectorated / None\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details.RSBI done on 0 peep/ 5 ips 35.Very fluid positive this am.\n Sedated with propofol. Will cont to monitor resp and fluid status. Plan\n to wean to extubate as tol.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644571,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Expectorated / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644576,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Expectorated / None\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details.RSBI done on 0 peep/ 5 ips 35. Sedated with propofol. Fluid\n overloaded this AM. Will cont to monitor resp and fluid status.Plan to\n wean to extubate.\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644678,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645394,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q18, zosyn, flagyl, fentanyl prn, simvastatin, lasix gtt\n 24 Hour Events:\n Post operative day:\n POD#6 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:57 AM\n Linezolid - 01:34 AM\n Metronidazole - 04:00 AM\n Vancomycin - 06:01 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 AM\n Metoprolol - 07:28 AM\n Other medications:\n Flowsheet Data as of 09:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 36.4\nC (97.5\n HR: 84 (73 - 106) bpm\n BP: 145/43(73) {103/40(61) - 183/66(111)} mmHg\n RR: 14 (9 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (2 - 15) mmHg\n Total In:\n 3,418 mL\n 1,004 mL\n PO:\n Tube feeding:\n 288 mL\n 310 mL\n IV Fluid:\n 1,176 mL\n 545 mL\n Blood products:\n 750 mL\n Total out:\n 4,515 mL\n 970 mL\n Urine:\n 4,025 mL\n 770 mL\n NG:\n Stool:\n Drains:\n 90 mL\n Balance:\n -1,097 mL\n 34 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 595 (402 - 747) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 17\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.33/43/137/22/-3\n Ve: 7.6 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 520 K/uL\n 9.9 g/dL\n 234 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 107 mEq/L\n 137 mEq/L\n 29.8 %\n 15.7 K/uL\n [image002.jpg]\n 01:30 AM\n 01:36 AM\n 04:15 AM\n 07:58 AM\n 12:00 PM\n 02:10 PM\n 06:00 PM\n 12:00 AM\n 04:17 AM\n 04:34 AM\n WBC\n 17.4\n 15.7\n Hct\n 24.1\n 22.3\n 31.1\n 29.8\n Plt\n 564\n 520\n Creatinine\n 1.8\n 1.7\n TCO2\n 24\n 20\n 24\n Glucose\n 88\n 102\n 113\n 119\n 191\n 234\n Other labs: PT / PTT / INR:16.8/46.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:659 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:8.8 mg/dL, Mg:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ELECTROLYTE & FLUID DISORDER, OTHER, EDEMA,\n PERIPHERAL, INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS),\n MALNUTRITION, ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C\n DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n Neurologic: Pain controlled, DC sedation for extubation\n Pain: Roxicet prn\n Cardiovascular: NSTEMI CE's cycled and negative, cont statin,\n lopressor, ASA, HR and BP stable in setting of active diuresis\n Pulmonary: Extubate today, minimimal vent settings, cont diuresis\n towards extubation possibly today.\n Gastrointestinal / Abdomen: s/p left colectomy, colostomy, rectal drain\n D/C'd. Ostomy producing stool with no gas, rectal tube d/c'd. started\n TF.\n Nutrition: Tube feeding, TF slowly advancing to goal\n Renal: Foley, Adequate UO, lasix 40 , con't good uop, cr trend up,\n follow electrolytes and replace prn. active diuresis w/ goal -200/h and\n -2L/d\n Hematology: post transfusion Hct 31, appropriate, no obvious sources of\n bleeding\n Endocrine: RISS, SSI, added baseline lantus. sugars controlled\n Infectious Disease: Check cultures, Zosyn, linezolid, po vanc, flagyl\n Lines / Tubes / Drains: Foley, NGT, ETT, PICC, RIJ, NGT, ETT, arterial\n line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, (Respiratory distress),\n Peritonitis, Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:00 PM\n Multi Lumen - 03:00 AM\n Arterial Line - 03:38 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments: Restart SQH and Pepcid\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645395,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q18, zosyn, flagyl, fentanyl prn, simvastatin, lasix gtt\n 24 Hour Events:\n Post operative day:\n POD#6 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:57 AM\n Linezolid - 01:34 AM\n Metronidazole - 04:00 AM\n Vancomycin - 06:01 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:00 AM\n Metoprolol - 07:28 AM\n Other medications:\n Flowsheet Data as of 09:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 36.4\nC (97.5\n HR: 84 (73 - 106) bpm\n BP: 145/43(73) {103/40(61) - 183/66(111)} mmHg\n RR: 14 (9 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (2 - 15) mmHg\n Total In:\n 3,418 mL\n 1,004 mL\n PO:\n Tube feeding:\n 288 mL\n 310 mL\n IV Fluid:\n 1,176 mL\n 545 mL\n Blood products:\n 750 mL\n Total out:\n 4,515 mL\n 970 mL\n Urine:\n 4,025 mL\n 770 mL\n NG:\n Stool:\n Drains:\n 90 mL\n Balance:\n -1,097 mL\n 34 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 595 (402 - 747) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 17\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.33/43/137/22/-3\n Ve: 7.6 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 520 K/uL\n 9.9 g/dL\n 234 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 40 mg/dL\n 107 mEq/L\n 137 mEq/L\n 29.8 %\n 15.7 K/uL\n [image002.jpg]\n 01:30 AM\n 01:36 AM\n 04:15 AM\n 07:58 AM\n 12:00 PM\n 02:10 PM\n 06:00 PM\n 12:00 AM\n 04:17 AM\n 04:34 AM\n WBC\n 17.4\n 15.7\n Hct\n 24.1\n 22.3\n 31.1\n 29.8\n Plt\n 564\n 520\n Creatinine\n 1.8\n 1.7\n TCO2\n 24\n 20\n 24\n Glucose\n 88\n 102\n 113\n 119\n 191\n 234\n Other labs: PT / PTT / INR:16.8/46.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:659 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:8.8 mg/dL, Mg:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), .H/O RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ELECTROLYTE & FLUID DISORDER, OTHER, EDEMA,\n PERIPHERAL, INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS),\n MALNUTRITION, ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C\n DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n Neurologic: Pain controlled, DC sedation for extubation\n Pain: Roxicet prn\n Cardiovascular: NSTEMI CE's cycled and negative, cont statin,\n lopressor, ASA, HR and BP stable in setting of active diuresis\n Pulmonary: Extubate today, minimimal vent settings, cont diuresis\n towards extubation possibly today.\n Gastrointestinal / Abdomen: s/p left colectomy, colostomy, rectal drain\n D/C'd. Ostomy producing stool with no gas, rectal tube d/c'd. started\n TF.\n Nutrition: Tube feeding, TF slowly advancing to goal\n Renal: Foley, Adequate UO, lasix 40 , con't good uop, cr trend up,\n follow electrolytes and replace prn. active diuresis w/ goal -200/h and\n -2L/d\n Hematology: post transfusion Hct 31, appropriate, no obvious sources of\n bleeding\n Endocrine: RISS, SSI, added baseline lantus. sugars controlled\n Infectious Disease: Check cultures, Zosyn, linezolid, po vanc, flagyl\n Lines / Tubes / Drains: Foley, NGT, ETT, PICC, RIJ, NGT, ETT, arterial\n line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, (Respiratory distress),\n Peritonitis, Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:00 PM\n Multi Lumen - 03:00 AM\n Arterial Line - 03:38 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments: Restart SQH and Pepcid\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-19 00:00:00.000",
"description": "TSICU progress note",
"row_id": 644434,
"text": "Chief Complaint: Fever, abdominal pain\n 24 Hour Events:\n BLOOD CULTURED - At 10:00 PM\n URINE CULTURE - At 11:50 PM\n ARTERIAL LINE - START 03:00 AM\n MULTI LUMEN - START 03:00 AM\n FEVER - 102.2\nF - 12:00 AM\n admitted TSICU, weening off neo and esmolol to metop, fluid resusc for\n post op, decreasing uop\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:11 AM\n Vancomycin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:52 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: NPO\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 36.2\nC (97.2\n HR: 90 (72 - 128) bpm\n BP: 166/48(80) {85/37(49) - 173/51(89)} mmHg\n RR: 12 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 9 (8 - 11)mmHg\n Total In:\n 3,819 mL\n 6,032 mL\n PO:\n TF:\n IVF:\n 2,648 mL\n 5,533 mL\n Blood products:\n Total out:\n 1,275 mL\n 168 mL\n Urine:\n 1,275 mL\n 93 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,544 mL\n 5,864 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 33\n PIP: 16 cmH2O\n Plateau: 12 cmH2O\n Compliance: 71.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.34/28/143/17/-8\n Ve: 11 L/min\n PaO2 / FiO2: 286\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\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, wound c/d/i\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 723 K/uL\n 10.5 g/dL\n 235 mg/dL\n 1.4 mg/dL\n 17 mEq/L\n 4.1 mEq/L\n 42 mg/dL\n 118 mEq/L\n 144 mEq/L\n 32.7 %\n 19.3 K/uL\n [image002.jpg]\n 05:00 AM\n 06:00 AM\n 04:00 AM\n 05:20 PM\n 09:10 PM\n 10:46 PM\n 01:35 AM\n 03:38 AM\n 04:40 AM\n 07:11 AM\n WBC\n 15.3\n 16.1\n 13.1\n 19.3\n Hct\n 38.4\n 35.3\n 38.6\n 34\n 32.7\n Plt\n 23\n Cr\n 1.7\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.06\n TCO2\n 16\n 15\n 16\n Glucose\n 165\n 173\n 250\n 35\n Other labs: PT / PTT / INR:16.7/35.5/1.5, CK / CKMB /\n Troponin-T:51/6/0.06, ALT / AST:24/34, Alk Phos / T Bili:58/0.4,\n Amylase / Lipase:86/87, Fibrinogen:303 mg/dL, Lactic Acid:2.0 mmol/L,\n Albumin:2.4 g/dL, LDH:194 IU/L, Ca++:8.6 mg/dL, Mg++:1.7 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n MALNUTRITION\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n RASH\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPERGLYCEMIA\n ASSESSMENT AND PLAN: 87 yo M, admitted for NSTEMI, developed sigmoid\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n NEUROLOGIC: intubated/sedated\n Pain: fentanyl prn\n CARDIOVASCULAR: CXR, EKG, cycle cardiac, will discuss w/ cards re: tx\n NSTEMI. Con't ASA, statin, BB. transfuse for Hct < 25. further dx w/u\n per cards. CHF had improved, will follow fluid status, CXR and exam.\n was on esmolol gtt, ween off to metop iv. was also on neo gtt, no off.\n Begin statin.\n PULMONARY: intubated, no issues, minimize vent setting. Change to PSV\n GI / ABD: s/p above . rectal drain. NPO. ? GI bleed w/ melena\n early in hospital course, no issues since and Hct stable.\n NUTRITION: NPO\n RENAL: Cr baseline and pt w/ non anion gap met acidosis, hyperK has\n normalized, post operatively oliguric with uop, fluid resusc\n HEMATOLOGY: Hct stable. no current issues\n ENDOCRINE: SSI\n ID: vanc (PO and IV),zosyn,flagyl\n LINES/TUBES/DRAINS: PICC, RIJ, NGT, ETT,\n WOUNDS: ostomy, abdominal wound c/d/i\n IMAGING: cxr - lines in place, no obvious chf/acute process\n FLUIDS: LR @ 100, bolus prn\n CONSULTS: GI, derm, DM, need touch base w/ cards?\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: ssi, high sugars, consider tightening ssi\n PROPHYLAXIS:\n DVT - sch, boots\n STRESS ULCER - PPI\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: need\n CODE STATUS: full\n DISPOSITION: TSICU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:05 PM 66. mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: high post\n op sugars\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643280,
"text": "This is an 87 y/o male adm who presented to OSH with chest\n pain/SOB since PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix for (+)CHF-- TN I = 3.94, CK 500s, CK\n MB 34, Hct 22. He was also given ASA /NTP and was transferred to\n ED with NSTEMI, no EKG changes-(thought to be stress ischemia d/t\n drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, anbx for (+) WBC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF. Pt inc of sm amt dark brown stool this am,\n OB(+). His Bipap/ Mask ventilation was weaned am . He has been\n further diuresed with lasix gtt.\n B Blocker was resumed and has been increased over the course of\n the past 2 shifts in hopes of controlling rate for (+) dialstolic\n dysfunction. Dilt added. Pt was ready for call out with much better HR\n control and less 02 requirement by . He developed afib by the late\n afternoon yesterday and required increasing both lopressor and\n diltiazem meds with success. Lower ext US done for L leg pain, neg for\n clots. Called out to 3 still on IV lasix gtt.\n Yesterday, - pt triggered for altered mental status, (had been\n A&Ox3 throughout admission), A&O x 1 only. Very lethargic. Blood cx\n UA drawn and sent. Foley cath placed. Temp at that time 99.1PR. Pt\n improved and sent to GI for planned endoscopy, however procedure\n cancelled when pt noted to have Temp 102 PR. Back to 3, pt's temp\n rechecked 104 PR. Triggered again for pyrexia/altered MS and sent back\n to CCU for further mgt.\n Rash\n Assessment:\n Rash on back. Folliculitis per Derm.\n Action:\n Topical clindamycin ordered and applied\n Response:\n Rash has not progressed or seems to hurt/itch\n Plan:\n Continue with clindamycin and monitor rash.\n Altered mental status (not Delirium)\n Assessment:\n Alert/ lethargic at times agitated at times. Follows commands\n inconsistently. Oriented to person.\n Action:\n Zyprexa x 1 for restlessness/agitation\n Response:\n 5mg zyprexa with good effect.\n Plan:\n Zyprexa prn hs for confusion agitation.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Rigors, spiking to 102.6\n Action:\n Rectal probe reinserted for closer monitoring. Tylenol po given.\n Response:\n Temp still elevated. Pt. unable to swallow pills without aspiration.\n Meds changed to IV and Tylenol changed to PR.\n Plan:\n Swallow study today. Reapply cooling blanket if temp does not lower.\n F/U on cultures continue antibiotics.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Loose stools x 4. Brown with undigested food visable. Guiac +\n Action:\n Toileted frequently. Using bedpan.\n Response:\n Continues to have guiac + stools.\n Plan:\n Monitor stools. Follow hct. Endoscopy when stable/afebrile.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644508,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Taken to OR emergently due to perforation of bowel. s/p sigmoid\n colectomy, end illeostomy and hartmans pouch on \n Action:\n Cont to actively fluid resuscitate with LR and albumin for hypotension\n and low u/o. abd firm and distended, + bs + flatus. Abd inc draining\n serosang output, dressing reinforced. NGT to low cont sx. Cont abx\n Vanco, Zosyn, and flagyl. Fentanyl given for pain control.\n Response:\n b/p wax and wanes u/o follows, b/p supported with fluid and responds\n well. Lactate down to 1.7. NGT coiled in mouth, tube replaced and\n confirmed by CXR. Illeostomy stoma red, serosang drainage.\n Plan:\n Cont fluid resuscitation as needed, support hemodynamics, control pain.\n Rash\n Assessment:\n Healing rash to back\n Action:\n Cont topical cipro and lotion\n Response:\n Rash red but healing\n Plan:\n Cont with lotions and frequest repositioning. Watch for drug reactions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure\n Action:\n Fluid bolus to support b/p and u/o\n Response:\n Pt responds well to fluid, creat down 1.2 bun 39\n Plan:\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Insulin gtt started\n Response:\n Bs better controlled. Goal bs <150\n Plan:\n Cont insulin gtt and Q1hr bs.\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Hx NSTEMI, tropi elevated post op\n Action:\n Cycling CE and following ekg, lopressor given IV, statin started today\n Response:\n Cont in NSR, tropi trending down\n Plan:\n 3d set CE due at 8pm\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643289,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n FEVER - 103.8\nF - 12:20 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:14 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 39.2\nC (102.6\n HR: 97 (73 - 104) bpm\n BP: 145/44(70) {90/32(51) - 145/104(115)} mmHg\n RR: 26 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 580 mL\n 600 mL\n PO:\n 180 mL\n TF:\n IVF:\n 400 mL\n 600 mL\n Blood products:\n Total out:\n 665 mL\n 280 mL\n Urine:\n 665 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -85 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 12cm but obscured by mask\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: Dullness at L base, rales way up bilaterally symmetrical\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 394 K/uL\n 11.7 g/dL\n 140 mg/dL\n 2.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 73 mg/dL\n 99 mEq/L\n 137 mEq/L\n 34.3 %\n 22.2 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n Plt\n 274\n 264\n 255\n 249\n 216\n 394\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n Other labs: Lactic Acid:1.6 mmol/L, Mg++:2.2 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation.\n .\n # NSTEMI - Troponins trending down, painfree.\n - For now, optimal medical management with ASA, BB, statin and\n eventually ACEi when renal function stabilizes.\n - transfuse for hct < 30 if symptomatic\n - ? furthur workup later (stress, cath, MR, CT) vs attributing events\n to GIB.\n .\n # acute on chronic diastolic CHF: Pt improving with 4L net diuresis\n yest, but still appears fluid overloaded.\n - Will continue diuresis with lasix drip\n - ECHO showed no WMA or valvular disease, rather impaired relaxation\n - Continue to wean O2 as tolerates\n - Continue to attempt rate control to allow for diastolic filling and\n forward flow. Unclear why continues to be so tachycardic (see below).\n .\n # Sinus Tachycardia: Has been tachycardic since taken off BiPAP, thus\n likely secondary to resp discomfort.\n - Have been increasing doses of BB to allow for diastolic filling time\n but have only decreased HR to 90s with increase of metoprolol from\n 12.5mg TID to 75mg TID and a few 5mg IV additional doses.\n .\n # GI bleed: Presented with Hct drop and melena but since admission and\n transfusion hct has been stable.\n - Given ACS will have to transfuse to goal HCT of 30 with symptoms.\n - Type and screen, IVs, guaiac stool\n - GI following\n - protonix drip at 8mg/hr switch to PO BID today\n -having hard stool now, seen by GI in ED, consented by GI for EGD in\n case, likely in future\n -? cirrhosis 30 years ago but hadn't had any further characterization,\n since then has cut down his drinking. will send albumin. No other\n stigmata of liver disease. Varicies are another possible source but\n cirrhosis / portal hypertension seems unlikely\n .\n # Anemia: Acute from GIB but likely also chronic aspect.\n - ? workup, MCV normal with very slightly elevated RDW. (? Hemolysis,\n CKI, MDS, mild iron def with macrocytic)\n .\n # Acute on Chronic Renal failure: Baseline Cr 1.6, Peak here 3.\n - History consistent with prerenal causes but FeUrea not consistent\n (45%). be ATN secondary to prolonged hypoperfusion, vs med related,\n vs postrenal.\n - If not improving obtain renal ultrasound\n .\n # ANION GAP ACIDOSIS: anion gap continues to be elevated at 16 with\n normal albumin.\n - Lactate normal, no sign of ketoacidosis\n - Possibly uremia\n - ? check tox screen or osmolar gap to eval for ingestions. IE:\n Ethylene glycol -> cardiopulm failure, renal failure, AG acidosis.\n .\n # HYPERKALEMIA: resolved with diuresis\n .\n # LEUKOCYTOSIS: Afebrile with downtrending WBC. Elevated WBC likely as\n a result of acute MI.\n - CXR with improved CHF but RLL opacity ? edema vs PNA. Will recheck\n today.\n - UCx, BCx pending\n - re-culture if spikes, consider antibiotics based on CXR findings from\n today. ?Got broad spectrum abx upon initial presentation.\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n - Poor control, will increase to 10U\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU to\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:25 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": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643438,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers (104 pr) ^ wbc 22 (13.4) ^ loose stools (ob+).\n Prob C-diff, 1^st sample () is positive, started on iv flagyl\n (vanco/zosyn) Pt also in/out of rapid AF, being successfully tx w/ iv\n lopressor q4. MS has improved, now alert, responds to vocal & follows\n commands. Conts w/ low grade fevers (99.4-7ax), Cre 2.6 (baseline).\n ECHO done showed no vegetations/ dry, has iv fluids infusing.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n 1^st Sample tested positive for C-diff\n Action:\n Placed on contact precautions, already started on iv flagyl.\n Response:\n 2 more episodes of loose ob+ stools overnoc\n Plan:\n Cont precautions, flagyl. Needs 2 more samples to r/i. Monitor Temps,\n Hct. Scope pending.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in rapid AF, Hr 120-150s. BPs 90s.\n Action:\n Tx w/ iv lopressor q4, cont holding po\ns d/t ? asp risk.\n Response:\n Converted to SR 80s p MN\n Plan:\n Cont rate control w/ iv BB. Tylenol for fever spikes & cont abx\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644019,
"text": "87 yo male adm with NSTEMI w/ new diastolic CHF in setting of\n GIB. MI medically managed. IV lasix gtt for CHF, now resolved per CXR.\n Sent to 3 for a few days until when temp spiked to 104 PR. Pt\n found to have C-diff colitis. Abd CT with severe pancolitis versus\n walled-off bowel perforation. Surgery following- no need for urgent\n bowel surgery. NPO until further notice for bowel rest. Pt still\n awaiting PICC placement for TPN. IV nurse today and placed\n PICC, however CXR shows line in coiled. LINE LEFT IN PLACE- DO NOT\n USE! To be advanced in IR tomorrow . Has not eaten in at least 5\n days. Spoke with team who ordered PPN until PICC placed for TPN.\n Tachycardia/ Hypertension\n Assessment:\n S/P NSTEMI this admission. HR 70s-80s at rest, increased to 100 w/\n activity. BP 130s-180s/70s. These measurements in setting of\n withholding PO cardiac meds for STRICT NPO status and IV lopressor 10mg\n Q 4hours.\n Action:\n Team increased dose to 20mg IV lopressor Q4 hours.\n Response:\n Resting HR down to low 70s. BP still labile 130-160s/70s.\n Plan:\n Continue to monitor VS. Has only had one dose of lopressor 20mg IV. If\n HTN persists, check with about possibly adding another .\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n 4 liquid, yellow mucous-like stools today with streaking on sheets in\n between. Perineal skin intact. Afebrile. WBC improved to 16 from 23.\n Abdomen firm, distended. Hyperactive BSx4 quad.\n Action:\n Continue IV flagyl Q8 hours, PO vanco q 6 hours.\n Response:\n Decreasing # of stools. Afebrile.\n Plan:\n Continue to monitor.\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented to person/ place/ time. Occasional forgetfulness.\n Much improved MS now compared to when febrile a few days ago.\n Action:\n Bed alarms at all times, chair alarmed when OOB. Safety precautions.\n Reoriented as needed.\n Response:\n Remained safe throughout shift. Improved confusion.\n Plan:\n Continue safety precautions.\n Malnutrition\n Assessment:\n Pt without food x 5 days. First limited by new dysphasia in setting of\n altered MS, now with new questionable bowel perforation so Strict NPO\n and nothing per rectum per surgery team until further notice.\n Action:\n Team alerted of concern re: malnourishment. PICC line ordered for TPN-\n IV nurse and placed PICC, however coiled per Xray. Line\n left in L AC until IR can repair tomorrow. Team alerted- ordered PPN.\n Response:\n PPN initiated at 1700.\n Plan:\n PPN for now. To IR tomorrow for PICC, then start TPN.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 644077,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Metoprolol - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.1\nC (95.1\n HR: 74 (66 - 90) bpm\n BP: 136/49(71) {109/42(61) - 179/110(116)} mmHg\n RR: 18 (10 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 847 mL\n 450 mL\n PO:\n 120 mL\n 90 mL\n TF:\n IVF:\n 440 mL\n 110 mL\n Blood products:\n Total out:\n 1,120 mL\n 280 mL\n Urine:\n 1,120 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -273 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Labs / Radiology\n 708 K/uL\n 12.3 g/dL\n 165 mg/dL\n 1.7 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 56 mg/dL\n 119 mEq/L\n 147 mEq/L\n 38.4 %\n 15.3 K/uL\n [image002.jpg]\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n 05:43 AM\n 05:00 AM\n WBC\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n 16.4\n 15.3\n Hct\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n 37.7\n 38.4\n Plt\n 249\n 216\n 394\n 446\n \n Cr\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n 1.7\n 1.7\n Glucose\n 140\n 189\n 140\n 133\n 142\n 114\n 149\n 139\n 165\n Other labs: PT / PTT / INR:15.6/40.7/1.4, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:9.5 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presented with acute on chronic diastolic CHF\n exacerbation and ACS in the setting of GI bleed, then developed C. diff\n colitis while awaiting EGD/colonoscopy.\n # CLOSTRIDIUM DIFFICILE INFECTION: Continues to be stable to\n improving. Abdomen distended, tympanitic and slighltly less tender in\n LLQ, WBC down and afebrile. CT scans showed pancolitis and area of\n possible contained bowel perforation vs diverticulitis. He was\n reevaluated by surgery but considered not to require surgery as\n continues to be hemodynamically stable, abd pain not worsening and poor\n surgical candidate.\n - IV flagyl, PO Vanc.\n - NPO and NPR\n - IV nutrition as will be NPO for several days\n Abd distended/firm. No pain. active BS. Passing mucoid stool \n times/night.\n # MALNUTRITION: PICC misplaced, will be readjusted today by IR,\n meanwhile started PPN.\n # DIASTOLIC CONGESTIVE HEART FAILURE: Originally presented in CHF, but\n has since been improving. Has been getting IVF in setting of infection\n and hypotension, responding well with UOP. Satting well without\n crackles on exam. Will continue to monitor with conservative fluid\n repleation as needed.\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable. Currently Guiac negative.\n - Will consider EGD once acute medical issues resolved.\n - protonix IV BID\n # ACUTE ON CHRONIC RENAL FAILURE: Returned to baseline of 2.2. Continue\n IVF as per adequate UOP.\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol, Statin\n # TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for\n pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF\n and dependency on filling time\n # HYPERTENSION: Increased dose of Lopressor to 20mg IV q4hrs\n FEN: NPO for bowel rest. Nutrition consult for TPN recs\n ACCESS: PIV's. Will attempt to place PICC today for TPN.\n PROPHYLAXIS: pneumoboots, PO PPI, SQ heparin\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n Active Medications ,\n 1. Vancomycin Oral Liquid 250 mg PO Q6H Day #1 \n 2. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Start \n 3. Metoprolol Tartrate 20 mg IV Q4H\n 4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n 5. Aspirin 300 mg PR DAILY\n 6. Heparin 5000 UNIT SC TID\n 7. Pantoprazole 40 mg IV Q24H\n 8. Sarna Lotion 1 Appl TP :PRN\n 11. Acetaminophen325-650mg PO/PR Q4H:PRN\n 9. Clindamycin 1 Appl TP DAILY to back\n 12. Insulin SC fixed and sliding sclae\n 10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643727,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Abdomen tender esp LLQ, distended. 4 small lt brn mucousy stools today,\n afebrile. Hemodynamically stable, wbc 24.9 (26.2), on po vanc and iv\n flagyl. Pt lethargic but easily arousable, oriented, cooperative.\n Action:\n Repeat CT, follow abd exam, surgical consult. PO flagyl d/c\n Response:\n CT results pnd, abd firm, distended, tender. At this time surgery\n will only consider if pt is hemodynamically unstable\n Plan:\n Follow abd exam, hemodynamics, wbc, continue abx, f/u CT scan\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr down to 2.2, u/o trending down throughout day, on NS at 100cc/hr\n Action:\n NS inc to 125cc/hr\n Response:\n Plan:\n Monitor cr, u/o\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643796,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing at\n 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Patient had numerous small mucous loose stool during the night. Patient\n is on PO vanco and IV flagyl. Pt abdomen is firm and distended. Pt\n complained of pain on palpation over the LUQ. Patient was afebrile.\n Action:\n Pt received IV flagyl and PO vanco. Patient was frequently turned and\n barrier cream applied. Pt seen earlier in the shift by surgery.\n Response:\n Patient continued to have loose mucous stool. Surgery is on hold but\n will continue to follow patients case.\n Plan:\n Cont with abx regimen, cont to assess level of pain over LUQ, and cont\n to monitor hemodynamic status. Monitor WBC.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt K was 3.0 on morning labs. Pt given IV and PO postassium during the\n day shift.\n Action:\n Labs were drawn this evening.\n Response:\n K is now 4.4\n Plan:\n Cont to monitor K level. Draw in am?\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patients Cre level was 2.2, BUN was 78 this evening. Pt has increased\n edema in his lower extremities.\n Action:\n Patients continuous IV fluid was reduced to 50ml/hr\n Response:\n Patient continued to diurese adequately during the 12hr shift.\n Plan:\n Cont to monitor Cre level, urine output, and edema.\n Altered mental status (not Delirium)\n Assessment:\n Patient frequently states he is in his bed at home. Patient also states\n that he needs to leave and get to the hospital.\n Action:\n Oriented the patient to person, place, and time frequently. Provided\n emotional support.\n Response:\n Patient cont to be disoriented at times. Quickly became oriented once\n reminded where he was.\n Plan:\n Continue to orient patient as needed. Provide emotional support.\n Note: Patients BP steadily increased over the shift. Pt ordered back on\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643799,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing at\n 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Patient had numerous small mucous loose stool during the night. Patient\n is on PO vanco and IV flagyl. Pt abdomen is firm and distended. Pt\n complained of pain on palpation over the LUQ. Patient was afebrile.\n Action:\n Pt received IV flagyl and PO vanco. Patient was frequently turned and\n barrier cream applied. Pt seen earlier in the shift by surgery.\n Response:\n Patient continued to have loose mucous stool. Surgery is on hold but\n will continue to follow patients case.\n Plan:\n Cont with abx regimen, cont to assess level of pain over LUQ, and cont\n to monitor hemodynamic status. Monitor WBC.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt K was 3.0 on morning () labs. Pt given IV and PO postassium\n during the day shift.\n Action:\n Labs were drawn this evening.\n Response:\n K is now 4.4\n Plan:\n Cont to monitor K level. Draw in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patients Cre level was 2.2, BUN was 78 this evening. Pt has increased\n edema in his lower extremities.\n Action:\n Patients continuous NS IV fluid was reduced to 50ml/hr\n Response:\n Patient continued to diurese adequately during the 12hr shift.\n Plan:\n Cont to monitor Cre level, urine output, and edema.\n Altered mental status (not Delirium)\n Assessment:\n Patient frequently states he is in his bed at home. Patient also states\n that he needs to leave and get to the hospital.\n Action:\n Oriented the patient to person, place, and time frequently. Provided\n emotional support.\n Response:\n Patient cont to be disoriented at times. Quickly became oriented once\n reminded where he was.\n Plan:\n Continue to orient patient as needed. Provide emotional support.\n Note: Patients BP steadily increased over the shift. Pt ordered back on\n Diovan. Received his first dose at\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644015,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers to 104PR. Pan cx\nd, found to have C-diff colitis,\n 2 samples tested positive, started on iv flagyl also added po flagyl\n w/ po Vanco. Abdominal CT w/ ?walled off bowel perforation (r/t\n diverticulitis) vs severe pancolitis. Surgery consulted and found pt to\n be poor surgical candidate. Made pt NPO until further notice. Awaiting\n PICC placement for initiation of TPN. Conts w/ freq small loose ob+\n stools. Pt also with paroxysmal rapid AF that responds to IV lopressor.\n Remains A+Ox3, is now afebrile. Last Cr 2.2 (3.0), has continous\n maintenance fluids infusing at 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n 4 liquid, yellow mucous-like stools today with streaking on sheets in\n between. Perineal skin intact. Afebrile. WBC improved to 16 from 23.\n Abdomen firm, distended. Hyperactive BSx4 quad.\n Action:\n Continue IV flagyl Q8 hours, PO vanco q 6 hours.\n Response:\n Decreasing # of stools. Afebrile.\n Plan:\n Continue to monitor.\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented to person/ place/ time. Occasional forgetfulness.\n Much improved MS now compared to when febrile a few days ago.\n Action:\n Bed alarms at all times, safety precautions. Reoriented as needed.\n Response:\n Remained safe throughout shift. Improved confusion.\n Plan:\n Continue safety precautions.\n Malnutrition\n Assessment:\n Pt without food x several days. First limited by new dysphasia in\n setting of altered MS, now with new questionable bowel perforation so\n NPO per surgery team until further notice.\n Action:\n Team alerted of concern re: malnourishment. PICC line ordered for TPN-\n IV nurse and placed PICC, however coiled per Xray. Line\n left in L AC until IR can repair tomorrow. Team alerted- ordered PPN.\n Response:\n PPN initiated at 1700.\n Plan:\n PPN for now. To IR tomorrow for PICC, then start TPN.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644413,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644414,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644415,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644416,
"text": "Clinician: Nurse\n Pt 87 yo male w/ PMH CAD, HTN, hyperlipidema, CRF, insulin dependent DM\n who presented to with NSTEMI, diastolic HF, and non-urgent\n UGIB. Medically managed, stabilized and sent to 3. Triggered and\n sent back to CCU with altered MS and T104 PR. Found to be +C-diff-\n treated w/ PO vanco and IV flagyl. Pt w/ significant abd distension- CT\n abdomen w/ ?walled off bowel perforation versus pancolitis. Made NPO\n for bowel rest, started on TPN via PICC. Rec\ning 20mg IV\n lopressor q 4 hours for HR control as pt cannot take any Pos. Abdomen\n very firm and distended x several days.\n This evening approx 21:30- pt noted to be riggoring in bed. Skin warm\n to the touch. HR 120s, BP 140s-150s/70s, RR 20s, T 96.6 PO, blood sugar\n 424. . CCU team notified- called Sugery team. Portable KUB w/ free air.\n Surgical team in to evaluate.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644417,
"text": "Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644420,
"text": "Clinician: Nurse\n Pt 87 yo male w/ PMH CAD, HTN, hyperlipidema, CRF, insulin dependent DM\n who presented to with NSTEMI, diastolic HF, and non-urgent\n UGIB. Medically managed, stabilized and sent to 3. Triggered and\n sent back to CCU with altered MS and T104 PR. Found to be +C-diff-\n treated w/ PO vanco and IV flagyl. Pt w/ significant abd distension- CT\n abdomen w/ ?walled off bowel perforation versus pancolitis. Made NPO\n for bowel rest, started on TPN via PICC. Rec\ning 20mg IV\n lopressor q 4 hours for HR control as pt cannot take any Pos. Abdomen\n very firm and distended x several days.\n Last evening approx 21:30- pt noted to be riggoring in bed. Skin warm\n to the touch. HR 120s, BP 140s-150s/70s, RR 20s, T 96.6 PO, blood sugar\n 424. CCU team notified- called Sugery team. Portable KUB w/ free air.\n Pt taken to OR emergently for ex lap.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Pt arrived to TSICU from OR s/p ex lap w/ sigmoid colectomy and\n ileostomy for perfed diverticuli at 3am. Off pressors on arrival w/\n VVS, Abd soft distended w/ midline incision covered w/ DSD, small amt\n bright red drainage at inferior aspect of dsg, marked. Ileostomy\n appliance intact, ostomy pink and edematous, small amt of flatus vis\n ostomy noted and small amt serosang fluid in bag. Bowel sounds\n active. Pt hemodynamically stable over remainder of shift however pt\n w/ decreasing urine output as shift progressed and no urine from 6a-7a\n .\n Action:\n Post-op labs sent, pt bloused w/ total of 1.5 liters of crystalloid for\n low u/o\n Response:\n Creat back at 1.4, hct stable, no urine output thus far s/p fluid\n bolus.\n Plan:\n Con\nt maintenance fluid as ordered and bolus per team for con\nt low\n u/o, follow CVP, hr, BP closely\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt oliguric post-op as above\n Action:\n Fluid bolus\n Response:\n Con\nt w/ minimal u/o\n Plan:\n Bolus as ordered, con\nt to follow creat and CVP, BP and HCTs\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Pt in SR post-op w/ HR 70-90, rare PVC/APC, ectopy usually when pt\n being turned or stressed.\n Action:\n Post-op EKG obtained and given to HO, troponin and CK\ns sent post-op\n Response:\n EKG wnl\ns per HO, troponin elevated ,\n Plan:\n Con\nt to monitor for changes, rate control as ordered w/ IVP metropolol\n as tolerated, follow repeat CK\ns/troponin\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644505,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Taken to OR emergently due to perforation of bowel. s/p sigmoid\n colectomy, end illeostomy and hartmans pouch on \n Action:\n Cont to actively fluid resuscitate with LR and albumin for hypotension\n and low u/o. abd firm and distended, + bs + flatus. Abd inc draining\n serosang output, dressing reinforced. NGT to low cont sx. Cont abx\n Vanco, Zosyn, and flagyl. Fentanyl given for pain control.\n Response:\n b/p wax and wanes u/o follows, b/p supported with fluid and responds\n well. Lactate down to 1.7. NGT coiled in mouth, tube replaced and\n confirmed by CXR. Illeostomy stoma red, serosang drainage.\n Plan:\n Cont fluid resuscitation as needed, support hemodynamics, control pain.\n Rash\n Assessment:\n Healing rash to back\n Action:\n Cont topical cipro and lotion\n Response:\n Rash red but healing\n Plan:\n Cont with lotions and frequest repositioning. Watch for drug reactions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure\n Action:\n Fluid bolus to support b/p and u/o\n Response:\n Pt responds well to fluid, creat down 1.2 bun 39\n Plan:\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Insulin gtt started\n Response:\n Bs better controlled. Goal bs <150\n Plan:\n Cont insulin gtt and Q1hr bs.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644712,
"text": "Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644713,
"text": "87 yo M, admitted for NSTEMI, developed sigmoid diverticulitis and\n perforated, taken to OR emergently now s/p sig colectomy, end\n colostomy, hartmann's pouch.\n Intestine, perforation of (perforation of hollow viscus)\n Assessment:\n Taken to OR emergently due to perforation of bowel. s/p sigmoid\n colectomy, end illeostomy and hartmans pouch on \n Action:\n abd firm and distended, + bs + flatus. Abd inc draining serosang\n output, dressing changed often. NGT to low cont sx. Cont abx Vanco,\n Zosyn, and flagyl. Fentanyl given for pain control.\n Response:\n Lactate down to .9 NGT patent scant output. Illeostomy stoma red,\n serosang drainage. No out put from rectal tube\n Plan:\n support hemodynamics as needed, control pain, cont bowel decompression\n via rectal tube and OGT.\n Rash\n Assessment:\n Healing rash to back\n Action:\n Cont topical cipro and lotion\n Response:\n Rash red but healing\n Plan:\n Cont with lotions and frequest repositioning.\n Hyperglycemia\n Assessment:\n Hx DM, elevated bs not responding to sq insulin s/s\n Action:\n Insulin gtt cont, insulin in TPN, pt followed by \n Response:\n Bs better controlled. Goal bs <150\n Plan:\n Cont insulin gtt and Q1hr bs.\n Acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Hx NSTEMI, tropi elevated post op\n Action:\n Cycling CE and following ekg, lopressor given IV, simvastatin given\n Response:\n Cont in NSR,\n Plan:\n Cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643435,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers (104 pr) ^ wbc 22 (13.4) ^ loose stools (ob+).\n Prob C-diff, 1^st sample () is positive, started on iv flagyl\n (vanco/zosyn) Pt also in/out of rapid AF, being successfully tx w/ iv\n lopressor q4. MS has improved, now alert & follows commands. Conts w/\n low grade fevers (99.4-7ax), Cre 2.6 (baseline) receiving iv fluids.\n ECHO done showed no vegetations, dry.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n 1^st Sample tested positive for C-diff\n Action:\n Placed on contact precautions, already started on iv flagyl.\n Response:\n 2 episodes of loose ob+ stools overnoc\n Plan:\n Cont precautions, flagyl. Needs 2 more samples. Monitor Temps, Hct\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in rapid AF, Hr 120-150s. BPs 90s.\n Action:\n Tx w/ iv lopressor q4, holding dilt d/t\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643723,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643725,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643784,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing at\n 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Patient had numerous small mucous loose stool during the night. Patient\n is on PO vanco and IV flagyl. Pt abdomen is firm and distended. Pt\n complained of pain on palpation over the LUQ. Patient was afebrile.\n Action:\n Pt received IV flagyl and PO vanco. Patient was frequently turned and\n barrier cream applied. Pt seen earlier in the shift by surgery.\n Response:\n Patient continued to have loose mucous stool. Surgery is on hold but\n will continue to follow patients case.\n Plan:\n Cont with abx regimen, cont to assess level of pain over LUQ, and cont\n to monitor hemodynamic status.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt K was 3.0 on morning labs. Pt given IV and PO postassium during the\n day shift.\n Action:\n Labs were drawn this evening.\n Response:\n K is now 4.4\n Plan:\n Cont to monitor K level. Draw in am?\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patients Cre level was 2.2, BUN was 78 this evening. Pt has increased\n edema in his lower extremities.\n Action:\n Patients continuous IV fluid was reduced to 50ml/hr\n Response:\n Plan:\n Cont to monitor Cre level, urine output, and edema.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643785,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing at\n 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Patient had numerous small mucous loose stool during the night. Patient\n is on PO vanco and IV flagyl. Pt abdomen is firm and distended. Pt\n complained of pain on palpation over the LUQ. Patient was afebrile.\n Action:\n Pt received IV flagyl and PO vanco. Patient was frequently turned and\n barrier cream applied. Pt seen earlier in the shift by surgery.\n Response:\n Patient continued to have loose mucous stool. Surgery is on hold but\n will continue to follow patients case.\n Plan:\n Cont with abx regimen, cont to assess level of pain over LUQ, and cont\n to monitor hemodynamic status. Monitor WBC.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt K was 3.0 on morning labs. Pt given IV and PO postassium during the\n day shift.\n Action:\n Labs were drawn this evening.\n Response:\n K is now 4.4\n Plan:\n Cont to monitor K level. Draw in am?\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patients Cre level was 2.2, BUN was 78 this evening. Pt has increased\n edema in his lower extremities.\n Action:\n Patients continuous IV fluid was reduced to 50ml/hr\n Response:\n Patient continued to diurese adequately during the 12hr shift.\n Plan:\n Cont to monitor Cre level, urine output, and edema.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 644001,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events: Meds changed to IV. Scheduled for PICC today for TPN\n S: Feeling\nvery well,\n much improved. No pain overnight and mild LLQ\n pain this morning. BM. No CP, SOB, other pain or new sx.\n Tele: no sig events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:01 PM\n Metronidazole - 08:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:30 PM\n Metoprolol - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.8\nC (96.5\n HR: 80 (64 - 84) bpm\n BP: 140/43(69) {103/32(65) - 168/69(94)} mmHg\n RR: 20 (12 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,375 mL\n 126 mL\n PO:\n 325 mL\n 60 mL\n TF:\n IVF:\n 1,050 mL\n 66 mL\n Blood products:\n Total out:\n 1,415 mL\n 345 mL\n Urine:\n 1,415 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n -40 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n GENERAL: Alert and oriented, NAD\n HEENT: MMM, no JVD\n CARDIAC: RRR, SEM at USB\n LUNGS: CTAB\n ABDOMEN: distended, tympanic. BS+ Tenderness most pronounced at LLQ.\n No clear rebound or guarding\n EXTREMITIES: WWP\n Labs / Radiology\n 146\n [image002.gif]\n 114\n [image002.gif]\n 63\n [image004.gif]\n 139\n AGap=15\n [image005.gif]\n 4.5\n [image002.gif]\n 22\n [image002.gif]\n 1.7\n [image007.gif]\n Mg: 2.7\n 91\n 16.4\n [image007.gif]\n 12.1\n [image004.gif]\n 692\n [image008.gif]\n [image004.gif]\n 37.7\n [image007.gif]\n PT: 16.0\n PTT: 34.2\n INR: 1.4\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n WBC\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n Hct\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n Plt\n 255\n 249\n 216\n 394\n 446\n 517\n 500\n 684\n Cr\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n Glucose\n 113\n 133\n 140\n 189\n 140\n 133\n 142\n 114\n 149\n Other labs: PT / PTT / INR:15.1/31.5/1.3, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:8.2 mg/dL, Mg++:2.8 mg/dL, PO4:3.6 mg/dL\n No new imaging or micro data.\n Assessment and Plan\n 87 yoM w/ h/o CKD presented with acute on chronic diastolic CHF\n exacerbation and ACS in the setting of GI bleed, then developed C. diff\n colitis while awaiting EGD/colonoscopy.\n # CLOSTRIDIUM DIFFICILE INFECTION: Continues to be stable to\n improving. Abdomen distended, tympanitic and slighltly less tender in\n LLQ, WBC down and afebrile. CT scans showed pancolitis and area of\n possible contained bowel perforation vs diverticulitis. He was\n reevaluated by surgery but considered not to require surgery as\n continues to be hemodynamically stable, abd pain not worsening and poor\n surgical candidate.\n - IV flagyl, PO Vanc.\n - NPO\n - IV nutrition as will be NPO for several days\n # DIASTOLIC CONGESTIVE HEART FAILURE: Originally presented in CHF, but\n has since been improving. Has been getting IVF in setting of infection\n and hypotension, responding well with UOP. Satting well without\n crackles on exam. Will continue to monitor with conservative fluid\n repleation as needed.\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable. Currently Guiac negative.\n - Will consider EGD once acute medical issues resolved.\n - protonix IV BID\n # ACUTE ON CHRONIC RENAL FAILURE: Returned to baseline of 2.2. Continue\n IVF as per adequate UOP.\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol, Statin\n # SINUS TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be\n new for pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF and\n dependency on filling time\n FEN: NPO for bowel rest. Nutrition consult for TPN recs\n ACCESS: PIV's. Will attempt to place PICC today for TPN.\n PROPHYLAXIS: pneumoboots, PO PPI, SQ heparin\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n 1. IV access: Peripheral line Order date: @ 1246\n 12. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1120\n 2. IV access: Peripheral line Order date: @ 1246\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale & Fixed Dose Order date: @ 1557\n 3. IV access: PICC, heparin dependent Location: Left, Date inserted:\n Order date: @ 1151\n 14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Start Order date: @ \n 4. Acetaminophen 325-650 mg PO/PR Q4H:PRN Order date: @ 0538\n 15. Metoprolol Tartrate 20 mg IV Q4H\n Hold for HR < 60, SBP < 100 Order date: @ 1416\n 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Order date: @ 1246\n 16. Olanzapine (Disintegrating Tablet) 5 mg PO QHS:PRN Order date:\n @ 2339\n 6. Aspirin 300 mg PR DAILY Order date: @ 1619\n 17. Pantoprazole 40 mg IV Q24H Order date: @ 1619\n 7. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR Order date: @\n 1246\n 18. Sarna Lotion 1 Appl TP :PRN Order date: @ 1246\n 8. Clindamycin 1 Appl TP DAILY\n to back Order date: @ 2245\n 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1246\n 9. Heparin 5000 UNIT SC TID Order date: @ 1246\n 20. 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: @ 1246\n 10. 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: @ 1151\n 21. Vancomycin Oral Liquid 250 mg PO Q6H\n Day #1 Order date: @ \n 11. IV access request: PICC Evaluate, Place Indication: TPN Urgency:\n Routine Order date: @ 0931\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643780,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643781,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Patient had numerous small mucous loose stool during the night.\n Action:\n Response:\n Patient continued to have loose mucous stool.\n Plan:\n Cont\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643782,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Patient had numerous small mucous loose stool during the night. Patient\n is on PO vanco and IV flagyl. Pt abdomen is firm and distended. Pt\n complained of pain on palpation over the LUQ. Patient was afebrile.\n Action:\n Pt received IV flagyl and PO vanco. Patient was frequently turned and\n barrier cream applied. Pt seen earlier in the shift by surgery.\n Response:\n Patient continued to have loose mucous stool. Surgery is on hold but\n will continue to follow patients case.\n Plan:\n Cont with abx regimen, cont to assess level of pain over LUQ, and cont\n to monitor hemodynamic status.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt K was\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644071,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Abd distended/firm. No pain. active BS. Passing mucoid stool \n times/night.\n Action:\n Contin. On IV flagyl and po vanco per surgical recs. Strict NPO and\n nothing by rectum.\n Response:\n Per surgery, appears stable and slighty improved. Pt. denies\n pain/cramping\n Plan:\n Follow plan as outlined.\n Cardiac dysrhythmia other\n Assessment:\n HR 70-80\ns SR. no VEA. Hx of Afib/flutter has been stable. u/o\n stable.\n Action:\n Lopressor 20mg IV q4hr.\n Response:\n BP coming down to 120\ns-150\ns/ following lopressor doses.\n Plan:\n Follow HR/rthym. Monitor lytes.\n Malnutrition\n Assessment:\n Started PPN \n overnight infusion while waiting for PICC line to be\n reassessed under fluro today.\n Action:\n NPO. PPN infusing via periph. IV.\n Response:\n Pt. asking for water and ice. Given sip with vanco dose. Freq. oral\n care.\n Plan:\n Start TPN when PICC line in place.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 644615,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI.\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q24, zosyn, flagyl, fentanyl prn, simvastatin\n 24 Hour Events:\n EKG - At 01:30 PM\n Post operative day:\n POD#1 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:21 AM\n Metronidazole - 04:21 AM\n Piperacillin/Tazobactam (Zosyn) - 06:19 AM\n Infusions:\n Insulin - Regular - 4.1 units/hour\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 10:19 PM\n Fentanyl - 02:21 AM\n Metoprolol - 04:20 AM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.2\nC (98.9\n HR: 91 (59 - 94) bpm\n BP: 129/52(78) {66/23(33) - 173/64(89)} mmHg\n RR: 15 (0 - 29) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 66 Inch\n CVP: 7 (5 - 15) mmHg\n Total In:\n 14,871 mL\n 2,328 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,953 mL\n 1,836 mL\n Blood products:\n 250 mL\n Total out:\n 1,293 mL\n 475 mL\n Urine:\n 1,113 mL\n 425 mL\n NG:\n 75 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 13,578 mL\n 1,853 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 526 (448 - 668) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 35\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.36/28/125/20/-7\n Ve: 12 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender: palpation\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 643 K/uL\n 9.6 g/dL\n 68 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 114 mEq/L\n 139 mEq/L\n 29.5 %\n 22.9 K/uL\n [image002.jpg]\n 02:23 PM\n 03:00 PM\n 04:00 PM\n 05:00 PM\n 05:39 PM\n 07:40 PM\n 08:58 PM\n 09:31 PM\n 04:03 AM\n 04:14 AM\n WBC\n 16.0\n 22.9\n Hct\n 27.7\n 29.5\n Plt\n 583\n 643\n Creatinine\n 1.2\n 1.3\n Troponin T\n 0.05\n TCO2\n 16\n 16\n 18\n 16\n Glucose\n 199\n 220\n 214\n 174\n 124\n 68\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:88.4 %, Lymph:8.4 %, Mono:2.6 %,\n Eos:0.5 %, Fibrinogen:303 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.2 mg/dL, Mg:2.2 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS), MALNUTRITION,\n ATRIAL FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF\n COLITIS, CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT\n DELIRIUM), RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87M w/ NSTEMI, cdiff; perf sigmoid diverticulitis\n s/p ex lap, L colectomy w/ Hartmann's pouch, end colostomy ()\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins, would increase\n lopressor as BP tolerates\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: NGT clamp well tolerated, cont TPN\n Nutrition: TPN, NPO\n Renal: Foley, Adequate UO, bolus IVF as needed. consider lasix once\n acidosis improved\n Hematology:\n Endocrine: Insulin drip\n Infectious Disease: cont vanco, zosyn, flagyl; wbc's trending up,\n remains afebrile\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: colostomy\n Imaging:\n Fluids: LR\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, Arrhythmia, Post-op\n hypotension, Acute renal failure\n ICU Care\n Nutrition:\n TPN without Lipids - 10:57 PM 66. mL/hour\n Glycemic Control: Insulin infusion\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2181-12-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 644764,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643930,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Remains NPO for GI depcompression. Asking for water and ice chips.\n Abd firm, distented but no pain. Active BS. Very small stools,\n golden mucus. Guiac neg.\n Action:\n Contin. On po vano and IV flagyl per surgical recs. Gave freq. mouth\n care and few ice chips. No water.\n Explanations given to pt.\n plan of care.\n Response:\n Pt. denies pain/cramping. No change in exam.\n Plan:\n Contin. Antibiotics, NPO, freq. exams. Follow plan with\n team/surgery. Await PICC placement today\n Altered mental status (not Delirium)\n Assessment:\n Pt. A/O x3. occas. would wake in middle of night thinking it was\n morning but reoriented easily. Pt. anxious about family visiting\n today. Talking about getting OOB and walking.\n Action:\n Freq. orientation as needed. Safety measures in place. will reassess\n in AM ie getting OOB with MD o.k.\n Response:\n Pt. verbalized understanding. Slept well when left alone. No\n delirium or restlessness.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643425,
"text": "87 yo male who presented with NSTEMI, acute on chronic diastolic CHF\n exacerbation & anemia. Pt now febrile, source unclear.\n .\n # Fever: Tmax yesterday, still febrile. Pt on Vanc/Zosyn. BC and\n UCx show NGTD, WBC count increased to 22 today. Unclear source. Pt\n had several BM overnight. Pt still lethargic and AO x 1. Prostate\n exam shows enlarged prostate, but no evidence of boggy prostate. CXR\n shows hazy opacity in , unclear if this is evolving PNA.\n - Pending CDiff. Start IV Flagyl 500mg TID.\n - Continue Abx\n - F/u cultures\n - Will CT head today.\n # Acute on chronic diastolic CHF: Resolving. Lungs CTAB, JVD 6cm. .\n - Will give gentle fluids as patient is not taking pos.\n - Switch po BB to IV.\n - Echo to r/o vegetations.\n # Atrial Fibrillation: Patient\ns HR has been in low 100s.\n - As patient unable to take pos, will hold ASA 81mg for now.\n Will consider restarting once patient recovers.\n - Continue IV BB q8hrs and prn for HR > 100.\n .\n # GI bleed: Presented with Hct drop and melena but since admission and\n transfusion hct has been stable.\n - Will scope once patient is stable.\n .\n # Chronic Renal failure: Baseline Cr 2.6, Cr 2.6 today.\n - Monitor\n .\n .\n # DM: lantus 9uqhs. insulin sliding scale, goal BG < 150.\n - Monitor\n .\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-22 00:00:00.000",
"description": "Resident progress note - TSICU",
"row_id": 644910,
"text": "Chief Complaint: Fever, abdominal pain\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:20 AM\n 24 HOUR EVENTS: started lasix gtt w/ goal of diuresing 150 to see if\n stable, then 200 cc/h, adjusted tpn w/ insulin and added h2. Cr\n trending up plateau at 1.4.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:52 PM\n Metronidazole - 04:08 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Furosemide (Lasix) - 2 mg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:29 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 01:27 AM\n Metoprolol - 04:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: Parenteral nutrition\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 98 (79 - 101) bpm\n BP: 155/45(75) {124/41(61) - 155/59(78)} mmHg\n RR: 18 (9 - 28) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (5 - 10)mmHg\n Total In:\n 4,017 mL\n 483 mL\n PO:\n TF:\n IVF:\n 2,333 mL\n 198 mL\n Blood products:\n Total out:\n 3,268 mL\n 1,170 mL\n Urine:\n 3,233 mL\n 1,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 749 mL\n -687 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 647 (537 - 719) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 39\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.38/35/103/18/-3\n Ve: 10.3 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, No(t)\n Sedated, Tone: Not assessed\n Labs / Radiology\n 556 K/uL\n 8.6 g/dL\n 84 mg/dL\n 1.4 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 32 mg/dL\n 113 mEq/L\n 139 mEq/L\n 26.6 %\n 21.8 K/uL\n [image002.jpg]\n 09:31 PM\n 04:03 AM\n 04:14 AM\n 02:25 PM\n 04:39 PM\n 02:04 AM\n 02:14 AM\n 03:39 PM\n 02:18 AM\n 02:38 AM\n WBC\n 22.9\n 25.7\n 23.2\n 21.8\n Hct\n 29.5\n 27.9\n 27.3\n 26.6\n Plt\n 643\n 619\n 588\n 556\n Cr\n 1.3\n 1.2\n 1.3\n 1.4\n 1.4\n TCO2\n 18\n 16\n 19\n 20\n 22\n Glucose\n 124\n 68\n 89\n 110\n 160\n 92\n 84\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CKMB /\n Troponin-T:96/6/0.05, ALT / AST:24/34, Alk Phos / T Bili:58/0.4,\n Amylase / Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %,\n Mono:2.2 %, Eos:1.4 %, Fibrinogen:303 mg/dL, Lactic Acid:0.9 mmol/L,\n Albumin:2.4 g/dL, LDH:194 IU/L, Ca++:9.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.2\n mg/dL\n Assessment and Plan\n EDEMA, PERIPHERAL\n INTESTINE, PERFORATION OF (PERFORATION OF HOLLOW VISCUS)\n MALNUTRITION\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n RASH\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPERGLYCEMIA\n diverticulitis and perforated, taken to OR emergently now s/p sig\n colectomy, end colostomy, hartmann's pouch.\n NEUROLOGIC: Sedated on propofol, will minimize sedation as we approach\n extubation\n Pain: well controlled, fentanyl prn\n CARDIOVASCULAR: NSTEMI CE's cycled and negative, cont statin,\n lopressor, ASA, HR and BP stable in setting of active diuresis\n PULMONARY: intubated, no issues, minimimal vent settings, will work\n towards extubation\n GI / ABD: s/p left colectomy, colostomy, rectal drain. NPO.\n NUTRITION: TPN/NPO\n RENAL: lasix gtt, follow electrolytes and replace prn. Cr trending up,\n active diuresis w/ goal -200/h and -2L/d\n HEMATOLOGY: Hct 27.3, stable\n ENDOCRINE: Insulin gtt, sugars have been controlled well\n ID: vanc,zosyn,flagyl, Vanc was redosed to q18 will need to check vanc\n trough, f/u cultures\n LINES/TUBES/DRAINS: PICC, RIJ, NGT, ETT, arterial line\n WOUNDS: ostomy, abdominal wound c/d/i\n IMAGING:\n FLUIDS: kvo\n CONSULTS: GI, derm, DM, cards\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: ssi\n PROPHYLAXIS:\n DVT - sch, boots\n STRESS ULCER - PPI\n VAP BUNDLE - Yes\n COMMUNICATIONS:\n ICU Consent: will obtain\n CODE STATUS: full\n DISPOSITION: TSICU\n ICU Care\n Nutrition:\n TPN without Lipids - 07:48 PM 66. mL/hour\n Glycemic Control: Insulin infusion, Blood sugar well controlled,\n Insulin in TPN\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments: need to have family sign ICU consent\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643627,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n C-diff colitis confirmed, WBC 24.9 (26.3) conts sm loose ob+ stools.\n Action:\n consulted. Conts on iv flagyl & po Vanco, & now po flagyl added\n per surgery request. Had Abd CT.\n Response:\n declined intervention stating poor candidate. CT images limited.\n Plan:\n HO spoke w/ daughter regarding , no changes. Cont current abx\n therapy, gentle fluid hydration, cont monitoring UOP, Cre.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644057,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Abd distended/firm. No pain. active BS. Passing mucoid stool \n times/night.\n Action:\n Contin. On IV flagyl and po vanco per surgical recs. Strict NPO and\n nothing by rectum.\n Response:\n Per surgery, appears stable and slighty improved. Pt. denies\n pain/cramping\n Plan:\n Follow plan as outlined.\n Cardiac dysrhythmia other\n Assessment:\n HR 70-80\ns SR. no VEA. Hx of Afib/flutter has been stable. u/o\n stable.\n Action:\n Lopressor 20mg IV q4hr.\n Response:\n BP coming down to 120\ns-150\ns/ following lopressor doses.\n Plan:\n Follow HR/rthym. Monitor lytes.\n Malnutrition\n Assessment:\n Started PPN \n overnight infusion while waiting for PICC line to be\n reassessed under fluro today.\n Action:\n NPO. PPN infusing via periph. IV.\n Response:\n Pt. asking for water and ice. Given sip with vanco dose. Freq. oral\n care.\n Plan:\n Start TPN when PICC line in place.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643478,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 11:00 AM\n TRANSTHORACIC ECHO - At 03:00 PM\n BLOOD CULTURED - At 03:25 PM\n BLOOD CULTURED - At 06:00 PM\n FEVER - 102.6\nC - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Metronidazole - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Metoprolol - 04:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 37.6\nC (99.7\n HR: 85 (85 - 127) bpm\n BP: 112/45(62) {101/32(52) - 145/70(81)} mmHg\n RR: 22 (19 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,665 mL\n 335 mL\n PO:\n TF:\n IVF:\n 1,665 mL\n 335 mL\n Blood products:\n Total out:\n 955 mL\n 160 mL\n Urine:\n 955 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 710 mL\n 175 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 446 K/uL\n 10.8 g/dL\n 133 mg/dL\n 3.0 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 84 mg/dL\n 103 mEq/L\n 140 mEq/L\n 31.6 %\n 19.7 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n Plt\n 274\n 264\n 255\n 249\n 216\n 394\n 446\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n 133\n Other labs:, ALT / AST:45/45, Alk Phos / T Bili:83/1.9, Amylase /\n Lipase:56/23, Lactic Acid:1.6 mmol/L, Albumin:2.8 g/dL, LDH:240 IU/L,\n Mg++:2.5 mg/dL,\n Assessment and Plan\n 87 yoM w/ h/o CKD who presented with acute on chronic diastolic CHF\n exacerbation and ACS, not resolving. Pt now febrile, source unclear.\n .\n # Fever: Tmax yesterday, still febrile. Pt on Vanc/Zosyn. BC and\n UCx show NGTD, WBC count increased to 22 today. Unclear source. Pt\n had several BM overnight. Pt still lethargic and AO x 1. Prostate\n exam shows enlarged prostate, but no evidence of boggy prostate. CXR\n shows hazy opacity in , unclear if this is evolving PNA.\n - Pending CDiff. Start IV Flagyl 500mg TID.\n - Continue Abx\n - F/u cultures\n - Will CT head today.\n # Acute on chronic diastolic CHF: Resolving. Lungs CTAB, JVD 6cm. .\n - Will give gentle fluids as patient is not taking pos.\n - Switch po BB to IV.\n - Echo to r/o vegetations.\n # Atrial Fibrillation: Patient\ns HR has been in low 100s.\n - As patient unable to take pos, will hold ASA 81mg for now.\n Will consider restarting once patient recovers.\n - Continue IV BB q8hrs and prn for HR > 100.\n .\n # GI bleed: Presented with Hct drop and melena but since admission and\n transfusion hct has been stable.\n - Will scope once patient is stable.\n .\n # Chronic Renal failure: Baseline Cr 2.6, Cr 2.6 today.\n - Monitor\n .\n .\n # DM: lantus 9uqhs. insulin sliding scale, goal BG < 150.\n - Monitor\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: Pending.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:26 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": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643776,
"text": "C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643835,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CT Scan:\n 1. Focus of eccentric dilatation of descending colon, in the left lower\n quadrant, with asymmetrical distribution of contrast and air and\n significant fat tissue stranding, which either represents acute\n diverticulitis or perforation realted to colitis. There is currently no\n evidence of free intraperitoneal spillage or air.\n 2. Second eccentric dilatation, which might be site of giant sigmoid\n diverticulum.No inflammation is seen around this and while contrast is\n seen within it it does not appear to represent an acute finding.\n 3. There is no small-bowel obstruction, the dilated loops of the small\n bowel are likely due to ileus.\n 4. Severe pancolitis-relative sparing proximally.\n 5. Bilateral pleural effusion with some adjacent small basilar\n atelectasis, and evidence of prior asbestos exposure.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Metronidazole - 04:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history: None\n Review of systems: Persistent LLQ abdominal pain, otherwise feels\nwell\n, no SOB, no CP\n Flowsheet Data as of 06:15 AM\n Vital signs\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 79 (68 - 79) bpm\n BP: 160/123(131) {105/38(60) - 164/123(131)} mmHg\n RR: 20 (9 - 22) insp/min\n SpO2: 94% RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 2,018 mL\n 437 mL\n PO:\n 125 mL\n 175 mL\n TF:\n IVF:\n 1,888 mL\n 262 mL\n Blood products:\n Total out:\n 1,193 mL\n 590 mL\n Urine:\n 1,193 mL\n 590 mL\n Balance:\n 825 mL\n -153 mL\n Physical Examination\n GENERAL: Alert and oriented, NAD\n HEENT: MMM, no JVD\n CARDIAC: RRR, SEM at USB\n LUNGS: CTAB, trace basilar crackles\n ABDOMEN: distended, tympanic. BS+ Tenderness most pronounced at LLQ.\n No clear rebound or guarding\n EXTREMITIES: WWP\n Labs / Radiology\n 684 K/uL\n 11.9 g/dL\n 149 mg/dL\n 2.0 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 73 mg/dL\n 110 mEq/L\n 143 mEq/L\n 37.5 %\n 23.3 K/uL\n [image002.jpg]\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n WBC\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n Hct\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n Plt\n 255\n 249\n 216\n 394\n 446\n 517\n 500\n 684\n Cr\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n Glucose\n 113\n 133\n 140\n 189\n 140\n 133\n 142\n 114\n 149\n Other labs: PT / PTT / INR:15.1/31.5/1.3, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:8.2 mg/dL, Mg++:2.8 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation. Course\n complicated by severe CDiff colitis\n # CLOSTRIDIUM DIFFICILE INFECTION:\n - On exam appears stable (abdomen distended, tympanitic and tender in\n LLQ)\n - CT scans showed pancolitis and area of ? contained bowel perforation\n vs diverticulitis. Reevaluated by surgery but considered to not require\n urgent surgery as continues to be hemodynamically stable, abd pain not\n worsening and poor surgical candidate.\n - IV flagyl, PO Vanc; PR Vanco if no improvement.\n # DIASTOLIC CONGESTIVE HEART FAILURE: Originally presented in CHF, but\n has since been improving. Has been getting IVF in setting of infection\n and hypotension, responding well with UOP. Satting well.\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable.\n - Will consider EGD once acute medical issues resolved.\n - protonix PO BID\n # ACUTE ON CHRONIC RENAL FAILURE: Returned to baseline of 2.2. Continue\n IVF as per adequate UOP.\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol, Statin\n # SINUS TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be\n new for pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF and\n dependency on filling time\n FEN: NPO for bowel rest\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PO PPI\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n 1. Metoprolol Tartrate 100 mg PO BID Hold for SBP <100 HR <60\n 9. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n 2. Valsartan 160 mg PO DAILY Hold for SBP <100, HR <60\n 10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN\n 3. Aspirin 81 mg PO DAILY\n 11. Olanzapine (Disintegrating) 5mg PO QHS:PRN\n 4. Atorvastatin 80 mg PO DAILY\n 12. Pantoprazole 40 mg PO Q24H\n 5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n 13. Acetaminophen 325-650 mg PO/PR Q4H:\n 6. Vancomycin Oral Liquid 250 mg PO Q6H Day #1 \n 14. Insulin SC Sliding Scale & Fixed Dose\n 7. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Start \n 15. Sarna Lotion 1 Appl TP :PRN\n 8. Heparin 5000 UNIT SC TID\n 16. Clindamycin 1 Appl TP DAILY to back\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643840,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing at\n 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 643844,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 82.9 kg\n 29.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 128%\n 69 kg\n Diagnosis: CP\n PMH : DM, HTN, hyperlipidemia, CKD\n Food allergies and intolerances: NKFA\n Pertinent medications: SS Humalog, glargine, Heparin, Abx, protonix,\n others noted\n Labs:\n Value\n Date\n Glucose\n 149 mg/dL\n 04:17 AM\n Glucose Finger Stick\n 138\n 12:00 PM\n BUN\n 73 mg/dL\n 04:17 AM\n Creatinine\n 2.0 mg/dL\n 04:17 AM\n Sodium\n 143 mEq/L\n 04:17 AM\n Potassium\n 4.0 mEq/L\n 04:17 AM\n Chloride\n 110 mEq/L\n 04:17 AM\n TCO2\n 21 mEq/L\n 04:17 AM\n pH (urine)\n 5.5 units\n 08:16 AM\n Albumin\n 2.8 g/dL\n 05:25 AM\n Calcium non-ionized\n 8.2 mg/dL\n 04:11 AM\n Phosphorus\n 3.6 mg/dL\n 04:11 AM\n Magnesium\n 2.8 mg/dL\n 04:17 AM\n ALT\n 45 IU/L\n 05:25 AM\n Alkaline Phosphate\n 83 IU/L\n 05:25 AM\n AST\n 45 IU/L\n 05:25 AM\n Amylase\n 56 IU/L\n 05:25 AM\n Total Bilirubin\n 1.9 mg/dL\n 05:25 AM\n WBC\n 23.3 K/uL\n 04:17 AM\n Hgb\n 11.9 g/dL\n 04:17 AM\n Hematocrit\n 37.5 %\n 04:17 AM\n Current diet order / nutrition support: NPO\n GI: Abd: firm/dist\n Access: pending PICC\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, advanced age\n Estimated Nutritional Needs based on adjusted BW\n Calories: 1650- (25-28 cal/kg)\n Protein: 69-83 (1-1.2 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate NPO\n Specifics:\n 87 y/o male s/p ACT yesterday to evaluate worsening abd pain and\n distention. CT showed severe pancolitis and likely ileus. Nutrition\n consulted for TPN recs. Agree c/ TPN for nutrition need for bowel\n rest. High Magnesium noted, will hold in TPN for today.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n Check chemistry 10 panel daily\n Once PICC placed and checked, rec Day 1 Starter TPN c/ non-std lytes:\n 20 NaAc, 35NaPO4, 20 KCl, 20 KAc, 10 Ca c/10 units insulin\n Advance to TPN goal pending glycemic control- 1600cc (300dex/80 aa/50\n fat) 1840 kcals\n Please check trig, no lipids if >400mg/dL\n BG management as you are, will increase insulin in TPN daily prn\n Please page c/?'s #\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643910,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers to 104PR. Pan cx\nd, found to have C-diff colitis,\n 2 samples tested positive, started on iv flagyl also added po flagyl\n w/ po Vanco. Abdominal CT w/ ?walled off bowel perforation (r/t\n diverticulitis) vs severe pancolitis. Surgery consulted and found pt to\n be poor surgical candidate. Made pt NPO until further notice. Awaiting\n PICC placement for initiation of TPN. Conts w/ freq small loose ob+\n stools. Pt also with paroxysmal rapid AF that responds to IV lopressor.\n Remains A+Ox3, is now afebrile. Last Cr 2.2 (3.0), has continous\n maintenance fluids infusing at 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n 4 liquid, yellow mucous-like stools today with streaking on sheets in\n between. Perineal skin intact. Afebrile. WBC still remain elevated 23.\n Abdomen firm, distended. Hyperactive BSx4 quad.\n Action:\n Continue IV flagyl Q8 hours, PO vanco q 6 hours.\n Response:\n Decreasing # of stools. Afebrile.\n Plan:\n Continue to monitor.\n Altered mental status (not Delirium)\n Assessment:\n MS greatly improved from this RNs last assessment 2 days ago. Pt still\n with some confusion/forgetfulness when first roused, but when fully\n awake and engaged A&Ox3.\n Action:\n Bed alarms at all times, safety precautions. Reoriented as needed.\n Response:\n Remained safe throughout shift. Improved confusion.\n Plan:\n Continue safety precautions.\n Malnutrition\n Assessment:\n Pt without food x several days. First limited by new dysphasia in\n setting of altered MS, now with new questionable bowel perforation so\n NPO per surgery team until further notice.\n Action:\n Team alerted of concern re: malnourishment. PICC line ordered for TPN-\n IV unable to place PICC today, pt on schedule for 1^st in AM. TPN bag\n in CCU fridge. All Meds changed to IV/ SC/ pt able to swallow\n liquid vanco per surgery w/ small sip of water after.\n Response:\n Awaiting PICC.\n Plan:\n PICC 1^st thing in AM, then start TPN. Nutrition team to follow.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645050,
"text": "TSICU\n HPI:\n 87M admit w/ NSTEMI, GIB, CHF exacerbation, ARF, cdiff; perf sigmoid\n diverticulitis w/ free air , s/p ex lap, L colectomy w/ Hartmann's\n pouch, end colostomy ()\n Chief complaint:\n Fever, abdominal pain\n PMHx:\n HTN, HLD, DMII, CAD, Acute on chronic diastolic CHF, h/o EtOH abuse, ?\n CRI\n Current medications:\n Aspirin, Clindamycin topical, Heparin 5000 sc tid, Insulin gtt,\n Metoprolol Tartrate 5mg IV Q4, Pantoprazole, Propofol gtt, Vancomycin\n 1gm Q18, zosyn, flagyl, fentanyl prn, simvastatin, lasix gtt\n 24 Hour Events:\n Post operative day:\n POD#4 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:05 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 PM\n Metronidazole - 08:16 PM\n Infusions:\n Furosemide (Lasix) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Metoprolol - 05:53 PM\n Fentanyl - 06:00 PM\n Dextrose 50% - 10:40 PM\n Other medications:\n Flowsheet Data as of 01:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 38\nC (100.4\n HR: 103 (82 - 103) bpm\n BP: 93/64(78) {54/32(43) - 149/101(113)} mmHg\n RR: 18 (12 - 27) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (3 - 9) mmHg\n Total In:\n 3,150 mL\n 133 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,470 mL\n 30 mL\n Blood products:\n Total out:\n 5,675 mL\n 280 mL\n Urine:\n 5,600 mL\n 280 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -2,525 mL\n -147 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 552 (512 - 770) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 42\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.38/34/113/22/-3\n Ve: 12.8 L/min\n PaO2 / FiO2: 283\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 556 K/uL\n 8.6 g/dL\n 69 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 110 mEq/L\n 138 mEq/L\n 26.6 %\n 21.8 K/uL\n [image002.jpg]\n 02:25 PM\n 04:39 PM\n 02:04 AM\n 02:14 AM\n 03:39 PM\n 02:18 AM\n 02:38 AM\n 11:49 AM\n 11:56 AM\n 09:21 PM\n WBC\n 25.7\n 23.2\n 21.8\n Hct\n 27.9\n 27.3\n 26.6\n Plt\n \n Creatinine\n 1.2\n 1.3\n 1.4\n 1.4\n 1.5\n 1.6\n TCO2\n 19\n 20\n 22\n 21\n Glucose\n 89\n 110\n 160\n 92\n 84\n 111\n 69\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:303 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.6 mg/dL, Mg:2.2 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, EDEMA, PERIPHERAL, INTESTINE,\n PERFORATION OF (PERFORATION OF HOLLOW VISCUS), MALNUTRITION, ATRIAL\n FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS,\n CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), GASTROINTESTINAL\n BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 87M presenting w/ NSTEMI, CHF exac, C. Diff s/p\n perforated diverticulitis, left colectomy w/ Hartmann's pouch, end\n colostomy ()\n Neurologic: Pain controlled, wean sedation towards goal of extubation\n Cardiovascular: Aspirin, Beta-blocker, Statins, lasix gtt\n Pulmonary: Extubate today, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:\n Nutrition: TPN\n Renal: Foley, Adequate UO, cont lasix gtt, replete e'lytes as needed\n Hematology:\n Endocrine: Insulin drip\n Infectious Disease: cont vanco, zosyn, flagyl\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds: colostomy\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: Acute MI / Ischemia, Arrhythmia, Post-op hypotension\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 59 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 645052,
"text": "TSICU\n HPI:\n 45M pedestrian struck by car, unknown speed, found in prone position, +\n LOC, + EtOH, transferred by ambulance to . CT scans revealed 2\n left frontal extra-axial collections, along with the following:\n - blood left temporal bone - SAH, approximately 3mm left frontal\n subdural hematoma without significant midline shift\n - fractures of right sphenoid bone (greater , lesser , body)\n - fracture of right occipital bone\n - right maxillary sinus fracture\n - blood in sphenoid sinuses\n - probable fracture of orbital surface of rt zygomatic bone\n Pt transferred to TICU for further management.\n Chief complaint:\n pedestrian hit by car\n PMHx:\n denies\n Current medications:\n lopressor, ativan prn, fentanyl prn, dilantin, RISS, zofran prn,\n morphine prn\n 24 Hour Events:\n Post operative day:\n POD#4 - exploratory laparoscopy for perfed diverticulum, sigmoid\n colectomy and ileostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:05 AM\n Piperacillin/Tazobactam (Zosyn) - 05:54 PM\n Metronidazole - 08:16 PM\n Infusions:\n Furosemide (Lasix) - 4 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:00 PM\n Metoprolol - 05:53 PM\n Fentanyl - 06:00 PM\n Dextrose 50% - 10:40 PM\n Other medications:\n Flowsheet Data as of 02:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 38\nC (100.4\n HR: 103 (82 - 103) bpm\n BP: 93/64(78) {54/32(43) - 149/101(113)} mmHg\n RR: 18 (12 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.6 kg (admission): 82.9 kg\n Height: 66 Inch\n CVP: 5 (3 - 9) mmHg\n Total In:\n 3,150 mL\n 156 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,470 mL\n 34 mL\n Blood products:\n Total out:\n 5,675 mL\n 280 mL\n Urine:\n 5,600 mL\n 280 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n -2,525 mL\n -124 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 552 (512 - 770) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 42\n PIP: 11 cmH2O\n SPO2: 98%\n ABG: 7.38/34/113/22/-3\n Ve: 12.8 L/min\n PaO2 / FiO2: 283\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, facial swelling throughout\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 556 K/uL\n 8.6 g/dL\n 69 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 110 mEq/L\n 138 mEq/L\n 26.6 %\n 21.8 K/uL\n [image002.jpg]\n 02:25 PM\n 04:39 PM\n 02:04 AM\n 02:14 AM\n 03:39 PM\n 02:18 AM\n 02:38 AM\n 11:49 AM\n 11:56 AM\n 09:21 PM\n WBC\n 25.7\n 23.2\n 21.8\n Hct\n 27.9\n 27.3\n 26.6\n Plt\n \n Creatinine\n 1.2\n 1.3\n 1.4\n 1.4\n 1.5\n 1.6\n TCO2\n 19\n 20\n 22\n 21\n Glucose\n 89\n 110\n 160\n 92\n 84\n 111\n 69\n Other labs: PT / PTT / INR:16.9/35.3/1.5, CK / CK-MB / Troponin\n T:96/6/0.05, ALT / AST:24/34, Alk-Phos / T bili:58/0.4, Amylase /\n Lipase:86/87, Differential-Neuts:90.4 %, Lymph:5.7 %, Mono:2.2 %,\n Eos:1.4 %, Fibrinogen:303 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.4\n g/dL, LDH:194 IU/L, Ca:9.6 mg/dL, Mg:2.2 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, EDEMA, PERIPHERAL, INTESTINE,\n PERFORATION OF (PERFORATION OF HOLLOW VISCUS), MALNUTRITION, ATRIAL\n FIBRILLATION (AFIB), C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS,\n CLOSTRIDIUM DIFFICILE), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM),\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), GASTROINTESTINAL\n BLEED, UPPER (MELENA, GI BLEED, GIB), HYPERGLYCEMIA\n Assessment and Plan: 45M pedestrian struck by car, +ETOH, SAH/SDH,\n multiple cranial fractures\n Neurologic: Neuro checks Q: 1 hr, Pain controlled, Clear C-spine, f/u\n dilantin level, cont dilantin 100mg TID, f/u final read CT\n Cardiovascular: Beta-blocker, cycle CE's\n Pulmonary: Stable on RA\n Gastrointestinal / Abdomen:\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, Q12hrs\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery, Trauma surgery, Cardiology, plastic surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural), Multiple\n injuries (Trauma), Closed head injury\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 59 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:00 PM\n Arterial Line - 03:00 AM\n Multi Lumen - 03:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643905,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers to 104PR. Pan cx\nd, found to have C-diff colitis,\n 2 samples tested positive, started on iv flagyl also added po flagyl\n w/ po Vanco. Abdominal CT w/ ?walled off bowel perforation (r/t\n diverticulitis) vs severe pancolitis. Surgery consulted and found pt to\n be poor surgical candidate. Made pt NPO until further notice. Awaiting\n PICC placement for initiation of TPN. Conts w/ freq small loose ob+\n stools. Pt also with paroxysmal rapid AF that responds to IV lopressor.\n Remains A+Ox3, is now afebrile. Last Cr 2.2 (3.0), has continous\n maintenance fluids infusing at 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n 4 liquid, yellow mucous-like stools today with streaking on sheets in\n between.\n Action:\n Continue\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 644231,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ANGIOGRAPHY - At 11:00 AM\n for PICC\n PICC LINE - START 12:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:22 PM\n Metronidazole - 04:11 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 04:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.4\n HR: 76 (67 - 90) bpm\n BP: 154/57(82) {95/34(49) - 173/86(93)} mmHg\n RR: 19 (2 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,404 mL\n 427 mL\n PO:\n 90 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 1,050 mL\n 345 mL\n Urine:\n 1,050 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n 354 mL\n 82 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\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 795 K/uL\n 11.5 g/dL\n 250 mg/dL\n 1.6 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 53 mg/dL\n 120 mEq/L\n 147 mEq/L\n 35.3 %\n 16.1 K/uL\n [image002.jpg]\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n 05:43 AM\n 05:00 AM\n 06:00 AM\n 04:00 AM\n WBC\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n 16.4\n 15.3\n 16.1\n Hct\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n 37.7\n 38.4\n 35.3\n Plt\n 394\n 446\n 517\n 95\n Cr\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n 1.7\n 1.7\n 1.6\n Glucose\n 140\n 133\n 142\n 114\n 149\n 139\n 165\n 173\n 250\n Other labs: PT / PTT / INR:15.6/40.7/1.4, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:9.5 mg/dL, Mg++:2.4 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presented with acute on chronic diastolic CHF\n exacerbation and ACS in the setting of GI bleed, then developed C. diff\n colitis while awaiting EGD/colonoscopy.\n # CLOSTRIDIUM DIFFICILE INFECTION: No longer tender abdomen but still\n distended. Decreased stool frequency and volume.\n - Not currently surgical emergency\n - IV flagyl, PO Vanc.\n - NPO and NPR\n # MALNUTRITION: PICC for TPN misplaced, will be readjusted today by IR,\n meanwhile started PPN.\n # DIASTOLIC CONGESTIVE HEART FAILURE: Appears euvolemic\n # GI BLEED: Presented with GIB, but since then has been stable, guaiac\n neg and Hct trending up.\n - will defer EGD\n - protonix IV BID\n # ACUTE ON CHRONIC RENAL FAILURE: Renal function better than baseline\n of 2.2\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol, Statin\n # TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for\n pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF and\n dependency on filling time\n # HYPERTENSION: Increased dose of Lopressor to 20mg IV q4hrs\n FEN: NPO for bowel rest. Nutrition consult for TPN recs\n ACCESS: PIV's. PICC for TPN\n PROPHYLAXIS: pneumoboots, PO PPI, SQ heparin\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:00 PM 41. mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 08:30 AM\n PICC Line - 12:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2181-12-18 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 644243,
"text": "Objective\n Pertinent medications: glargine, ss hum, abx, D5W @150ml/hr x 1.5L,\n others noted\n Labs:\n Value\n Date\n Glucose\n 250 mg/dL\n 04:00 AM\n Glucose Finger Stick\n 227\n 05:00 PM\n BUN\n 53 mg/dL\n 04:00 AM\n Creatinine\n 1.6 mg/dL\n 04:00 AM\n Sodium\n 147 mEq/L\n 04:00 AM\n Potassium\n 3.8 mEq/L\n 04:00 AM\n Chloride\n 120 mEq/L\n 04:00 AM\n TCO2\n 20 mEq/L\n 04:00 AM\n pH (urine)\n 5.5 units\n 08:16 AM\n Albumin\n 2.8 g/dL\n 05:25 AM\n Calcium non-ionized\n 9.5 mg/dL\n 05:00 AM\n Phosphorus\n 3.5 mg/dL\n 05:00 AM\n Magnesium\n 2.4 mg/dL\n 04:00 AM\n ALT\n 45 IU/L\n 05:25 AM\n Alkaline Phosphate\n 83 IU/L\n 05:25 AM\n AST\n 45 IU/L\n 05:25 AM\n Amylase\n 56 IU/L\n 05:25 AM\n Total Bilirubin\n 1.9 mg/dL\n 05:25 AM\n Triglyceride\n 190 mg/dL\n 05:00 AM\n WBC\n 16.1 K/uL\n 04:00 AM\n Hgb\n 11.5 g/dL\n 04:00 AM\n Hematocrit\n 35.3 %\n 04:00 AM\n Current diet order / nutrition support: tpn + RI\n Assessment of Nutritional Status\n 87 yoM w/ h/o CKD presented with CHF exacerbation and ACS in the\n setting of GI bleed, then developed C. diff colitis while awaiting\n EGD/colonoscopy, pt s/p PICC placement and TPN initiated last night,\n noted FSBG elevated, will increase RI in TPN and cont to adv TPN to\n goal as tol. Noted pt with ^Na, started on D 5W this am- this will\n likely elevate pt\ns FSBG, cont SShum prn.\n Medical Nutrition Therapy Plan - Recommend the Following\n TPN recommendations for , 1600ml ( 210dex/80aa/50lip), 35NaPhos,\n 40KAc, 5 Mg, 10Ca, 22units RI\n Check chemistry 10 panel daily, adj TPN prn\n Cont BG management, SS hum prn\n Goal TPN provided BG <150 will be 1600ml( 300dex/80aa/50lip) to provide\n 1840kcal/day\n f/u, please page if has ?\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643234,
"text": "This is an 87 y/o male adm who presented to OSH with chest\n pain/SOB since PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix for (+)CHF-- TN I = 3.94, CK 500s, CK\n MB 34, Hct 22. He was also given ASA /NTP and was transferred to\n ED with NSTEMI, no EKG changes-(thought to be stress ischemia d/t\n drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, anbx for (+) WBC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF. Pt inc of sm amt dark brown stool this am,\n OB(+). His Bipap/ Mask ventilation was weaned am . He has been\n further diuresed with lasix gtt.\n B Blocker was resumed and has been increased over the course of\n the past 2 shifts in hopes of controlling rate for (+) dialstolic\n dysfunction. Dilt added. Pt was ready for call out with much better HR\n control and less 02 requirement by . He developed afib by the late\n afternoon yesterday and required increasing both lopressor and\n diltiazem meds with success. Lower ext US done for L leg pain, neg for\n clots. Called out to 3 still on IV lasix gtt.\n Today - pt triggered for altered mental status, (had been A&Ox3\n throughout admission), A&O x 1 only. Very lethargic. Blood cx\ns/ UA\n drawn and sent. Foley cath placed. Temp at that time 99.1PR. Pt\n improved and sent to GI for planned endoscopy, however procedure\n cancelled when pt noted to have Temp 102 PR. Back to 3, pt's temp\n rechecked 104 PR. Triggered again for pyrexia/altered MS and sent back\n to CCU for further mgt.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. VSS. NSR HR 70s-90s (tachy w/ fever).\n Action:\n Cont ASA/STATIN/ BB/Dilt.\n Response:\n Stable this shift.\n Plan:\n Continue to monitor. Daily EKGs. Assess for chest pain.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Arrived to CCU w/ T 104 PR. Pt somnolent, unable to open eyes but\n following other commands. WBC 12.4. Lactate 1.8. Skin very hot to\n touch. IV Vanco still infusing from 3. Unclear of source of\n infection- 3 sent bld cxs/ UA. Also of note- left lower arm\n phlebitis s/p PIV removal, R knee tapped for ?gout, and new rash\n on back\n all possible sources?\n Action:\n Tepid water bath to torso, 1000mg Tylenol given with little decrease in\n temp- Cooling blanket applied. IV Zosyn also ordered and given.\n Response:\n Temp down to 99.1 PO at 18:00. Cooling blanket removed.\n Plan:\n Continue to trend WBC, fever curve. IV anbx. Cooling blanket if fever\n climbs.\n Altered mental status (not Delirium)\n Assessment:\n Pt arrived to CCU somnolent, rousing to voice. Able to follow some\n commands but would not open his eyes. As fever decreased, pt more\n awake/alert attempting to get OOB, pull at foley cath/ PIVs. Hollering\n out\nLET ME OUT OF THIS BED!\n and\nI have to go to the bathroom\n. Given\n bed pan several times without BM. Foley cath in place. Repeated\n attempts at getting OOB req\ning 1:1 staff supervision. Also shaking\n bilat upper extremities- appearing purposeful and not like riggors.\n Action:\n CCU team alert of above behavior. Ordered and given 5mg SL zyprexa x\n one.\n Response:\n Temporary decrease in agitation after PO zyprexa. 1:1 supervision\n maintained. Bed alarms on at all times. Frequent toileting. MS\n improved significantly after temperature down <100.\n Plan:\n Safety precautions. Continue to assess MS. Family coming to visit\n tonight to help pt orient.\n Rash\n Assessment:\n Entire back covered w/ red raised follicular papules.\n Action:\n Dermatology consulted. Barrier cream applied in meantime.\n Response:\n Stable rash.\n Plan:\n Per dermatology- rash likely folliculitis and NOT drug-induced.\n Recommended topical anbx cream- not yet ordered by team. Continue to\n monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643466,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 11:00 AM\n TRANSTHORACIC ECHO - At 03:00 PM\n BLOOD CULTURED - At 03:25 PM\n BLOOD CULTURED - At 06:00 PM\n FEVER - 102.6\nC - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Metronidazole - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 PM\n Metoprolol - 04:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 37.6\nC (99.7\n HR: 85 (85 - 127) bpm\n BP: 112/45(62) {101/32(52) - 145/70(81)} mmHg\n RR: 22 (19 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 1,665 mL\n 335 mL\n PO:\n TF:\n IVF:\n 1,665 mL\n 335 mL\n Blood products:\n Total out:\n 955 mL\n 160 mL\n Urine:\n 955 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 710 mL\n 175 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 446 K/uL\n 10.8 g/dL\n 133 mg/dL\n 3.0 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 84 mg/dL\n 103 mEq/L\n 140 mEq/L\n 31.6 %\n 19.7 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n Plt\n 274\n 264\n 255\n 249\n 216\n 394\n 446\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n 133\n Other labs: CK / CKMB / Troponin-T:334/6/1.41, ALT / AST:45/45, Alk\n Phos / T Bili:83/1.9, Amylase / Lipase:56/23, Lactic Acid:1.6 mmol/L,\n Albumin:2.8 g/dL, LDH:240 IU/L, Ca++:10.1 mg/dL, Mg++:2.5 mg/dL,\n PO4:3.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE)\n ALTERATION IN ELIMINATION RELATED TO DIARRHEA\n RASH\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n DEEP VENOUS THROMBOSIS (DVT), LOWER EXTREMITY\n CARDIAC DYSRHYTHMIA OTHER\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n ACIDOSIS, METABOLIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n PULMONARY EDEMA\n ACUTE CORONARY SYNDROME (ACS, UNSTABLE ANGINA, CORONARY ISCHEMIA)\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPERGLYCEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:26 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": "2181-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643610,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT 3 hrs p drinking barricat, contrast still\n mostly in stomach. Conts w/ freq small loose ob+ stools. Pt also went\n back in rapid AF approx 2am, lopressor was recently changed to 100mg po\n q12. Remains A+Ox3, now afeb. All AM labs pending, last Cre 3.0, has\n maintenance fluids infusing.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n 1^st Sample tested positive for C-diff\n Action:\n Placed on contact precautions, already started on iv flagyl.\n Response:\n 2 more episodes of loose ob+ stools overnoc\n Plan:\n Cont precautions, flagyl. Needs 2 more samples to r/i. Monitor Temps,\n Hct. Scope pending.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in rapid AF, Hr 120-150s. BPs 90s.\n Action:\n Tx w/ iv lopressor q4, cont holding po\ns d/t ? asp risk.\n Response:\n Converted to SR 80s p MN\n Plan:\n Cont rate control w/ iv BB. Tylenol for fever spikes & cont abx\n"
},
{
"category": "Nutrition",
"chartdate": "2181-12-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 645272,
"text": "Subjective\n pt intubated\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 113\n 12:00 PM\n Glucose Finger Stick\n 111\n 06:00 AM\n BUN\n 38 mg/dL\n 01:30 AM\n Creatinine\n 1.8 mg/dL\n 01:30 AM\n Sodium\n 135 mEq/L\n 01:30 AM\n Potassium\n 4.0 mEq/L\n 01:30 AM\n Chloride\n 109 mEq/L\n 01:30 AM\n TCO2\n 22 mEq/L\n 01:30 AM\n Calcium non-ionized\n 9.0 mg/dL\n 01:30 AM\n Phosphorus\n 4.3 mg/dL\n 01:30 AM\n Ionized Calcium\n 1.39 mmol/L\n 09:28 AM\n Magnesium\n 2.3 mg/dL\n 01:30 AM\n ALT\n 24 IU/L\n 03:38 AM\n Alkaline Phosphate\n 58 IU/L\n 03:38 AM\n AST\n 34 IU/L\n 03:38 AM\n Amylase\n 86 IU/L\n 09:10 PM\n Total Bilirubin\n 0.4 mg/dL\n 03:38 AM\n Triglyceride\n 190 mg/dL\n 05:00 AM\n Current diet order / nutrition support: TPN : 1425cc(210 dex/80\n aa/50 fat) 1534 kcals\n TF Rx: Replete c/ Fiber @80mL/hr (2040 kcals/127 gr aa)\n GI: Abd soft/dist/+bs\n Assessment of Nutritional Status\n Specifics:\n 87 y/o male s/p ex-lap, L colectomy c/ \ns procedure , has\n been receiving TPN as primary nutrition since . Now transitioning\n to TF\ns, tolerating @ 20mL/hr., c/ plan to d/c TPN p/ current bag.\n Would change to volume restricted, low , TF in setting of diuresis\n and h/o high BG\ns requiring insulin gtt. Elevated ionized Ca despite\n omission of Ca from TPN, no recent PTH level.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via NS\n Tube feeding recommendations: Would change TF to Nutren Pulmonary c/\n goal 45mL/hr (1620 kcals/73 gr aa)\n Residual check q 4, hold if >200mL\n BG and lyte management as you are\n Please check PTH\n Please call c/ ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643223,
"text": "This is an 87 y/o male adm who presented to OSH with chest\n pain/SOB since PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix for (+)CHF-- TN I = 3.94, CK 500s, CK\n MB 34, Hct 22. He was also given ASA /NTP and was transferred to\n ED with NSTEMI, no EKG changes-(thought to be stress ischemia d/t\n drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, anbx for (+) WBC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF. Pt inc of sm amt dark brown stool this am, OB(+).\n His Bipap/ Mask ventilation was weaned am . He has been further\n diuresed with lasix gtt.\n B Blocker was resumed and has been increased over the course of\n the past 2 shifts in hopes of controlling rate for (+) dialstolic\n dysfunction. Dilt added. Pt was ready for c/o with much better HR\n control and less 02 requirement by . He developed afib by the late\n afternoon yesterday and required increasing both lopressor and\n diltiazem meds with success. Lower ext US done for L leg pain, neg for\n clots. Called out to 3 .\n Today - pt triggered for altered mental status, Temp 104 PR.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643226,
"text": "This is an 87 y/o male adm who presented to OSH with chest\n pain/SOB since PM (took nitro SL x 2 with no relief).\n In OSH ED he was given lasix for (+)CHF-- TN I = 3.94, CK 500s, CK\n MB 34, Hct 22. He was also given ASA /NTP and was transferred to\n ED with NSTEMI, no EKG changes-(thought to be stress ischemia d/t\n drop in Hct/ (+)GIB.)\n In the ER at , pt was treated with more lasix( 40 mg x 2), TNG\n gtt, anbx for (+) WBC. He was transfused with 2 units PRBC for Hct 22\n and was in moderate amount of respiratory distress, so also started on\n Bipap/Mask ventilation .\n He was transferred to CCU for further tx/ eval. His K was 5.8 even\n after IV lasix-> Given kaexeylate. Due to his +GIB/ melena-, GI team\n was consulted and will perform scope once his CV status is more stable\n and he is out of CHF. Pt inc of sm amt dark brown stool this am,\n OB(+). His Bipap/ Mask ventilation was weaned am . He has been\n further diuresed with lasix gtt.\n B Blocker was resumed and has been increased over the course of\n the past 2 shifts in hopes of controlling rate for (+) dialstolic\n dysfunction. Dilt added. Pt was ready for c/o with much better HR\n control and less 02 requirement by . He developed afib by the late\n afternoon yesterday and required increasing both lopressor and\n diltiazem meds with success. Lower ext US done for L leg pain, neg for\n clots. Called out to 3 .\n Today - pt triggered for altered mental status, (had been A&Ox3\n throughout admission),Temp 104 PR, shaking.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643341,
"text": "TITLE:\n Chief Complaint:\n ACS, sec to GI bleed.\n Fevers\n 24 Hour Events:\n Pt transferred to CCU, started on Vanc/Zosyn. BC NGTD, UCx NGTD, UA\n clean. Unclear source of infection.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:14 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.9\nC (103.8\n Tcurrent: 39.2\nC (102.6\n HR: 97 (73 - 104) bpm\n BP: 145/44(70) {90/32(51) - 145/104(115)} mmHg\n RR: 26 (17 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 580 mL\n 600 mL\n PO:\n 180 mL\n TF:\n IVF:\n 400 mL\n 600 mL\n Blood products:\n Total out:\n 665 mL\n 280 mL\n Urine:\n 665 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -85 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: NAD, AOX1\n HEENT: JVP 6cm\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: CTAB\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: No c/c/e\n SKIN: Folliculitis on back\n Labs / Radiology\n 394 K/uL\n 11.7 g/dL\n 140 mg/dL\n 2.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 73 mg/dL\n 99 mEq/L\n 137 mEq/L\n 34.3 %\n 22.2 K/uL\n [image002.jpg]\n 09:12 PM\n 01:08 AM\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n WBC\n 13.3\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n Hct\n 31.9\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n Plt\n 274\n 264\n 255\n 249\n 216\n 394\n Cr\n 3.0\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n TropT\n 1.41\n Glucose\n 174\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n Other labs: Lactic Acid:1.6 mmol/L, Mg++:2.2 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD who presented with acute on chronic diastolic CHF\n exacerbation and ACS, not resolving. Pt now febrile, source unclear.\n .\n # Fever: Tmax yesterday, still febrile. Pt on Vanc/Zosyn. BC and\n UCx show NGTD, WBC count increased to 22 today. Unclear source. Pt\n had several BM overnight. Pt still lethargic and AO x 1. Prostate\n exam shows enlarged prostate, but no evidence of boggy prostate. CXR\n shows hazy opacity in , unclear if this is evolving PNA.\n - Pending CDiff. Start IV Flagyl 500mg TID.\n - Continue Abx\n - F/u cultures\n - Will CT head today.\n # Acute on chronic diastolic CHF: Resolving. Lungs CTAB, JVD 6cm. .\n - Will give gentle fluids as patient is not taking pos.\n - Switch po BB to IV.\n - Echo to r/o vegetations.\n # Atrial Fibrillation: Patient\ns HR has been in low 100s.\n - As patient unable to take pos, will hold ASA 81mg for now.\n Will consider restarting once patient recovers.\n - Continue IV BB q8hrs and prn for HR > 100.\n .\n # GI bleed: Presented with Hct drop and melena but since admission and\n transfusion hct has been stable.\n - Will scope once patient is stable.\n .\n # Chronic Renal failure: Baseline Cr 2.6, Cr 2.6 today.\n - Monitor\n .\n .\n # DM: lantus 9uqhs. insulin sliding scale, goal BG < 150.\n - Monitor\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: Pending.\n Acetaminophen 325-650 mg PO/PR Q4H:PRN Order date: @ 0538\n Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 1246\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Order date: @ 1246\n Metoprolol Tartrate 7.5 mg IV Q6H Order date: @\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR Order date: @ 1246\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1406\n Clindamycin 1 Appl TP DAILY\n to back Order date: @ 2245\n Olanzapine (Disintegrating Tablet) 5 mg PO QHS:PRN Order date: \n @ 2339\n Heparin 5000 UNIT SC TID Order date: @ 1246\n Piperacillin-Tazobactam Na 2.25 g IV Q8H Order date: @ 1249\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale & Fixed Dose Order date: @ 1246\n . Sarna Lotion 1 Appl TP :PRN Order date: @ 1246\n Vancomycin 1000 mg IV Q48H Order date: @ 1246\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643683,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Increasing abdominal pain and distension, as well as WBC, throughout\n the day. Surgury consulted, poor surgical candidate. Started on PO\n and IV flagyl and PO Vanc per insistance of surgical attending (ID\n recommended only IV flagyl and PO Vanc). CT scan with pancolitis, no\n evidence of toxic megacolin. Lactate nl.\n Speach and swallow rec thin liq.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Vancomycin - 08:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Pantoprazole (Protonix) - 11:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.7\nC (98.1\n HR: 86 (74 - 115) bpm\n BP: 134/59(78) {110/34(53) - 153/67(89)} mmHg\n RR: 17 (11 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,121 mL\n 854 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,641 mL\n 849 mL\n Blood products:\n Total out:\n 640 mL\n 400 mL\n Urine:\n 640 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,481 mL\n 454 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GENERAL: Alert and oriented, less drowsy than last night.\n Uncomfortable\n HEENT: JVP D\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: CTAB\n ABDOMEN: distended, tympanic. BS+ Tenderness most pronounced at LLQ.\n No clear rebound or guarding\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 500 K/uL\n 10.5 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.0 mEq/L\n 73 mg/dL\n 109 mEq/L\n 141 mEq/L\n 32.6 %\n 24.9 K/uL\n [image002.jpg]\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n WBC\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n Hct\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n Plt\n \n 517\n 500\n Cr\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n Glucose\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n 133\n 142\n 114\n Other labs: PT / PTT / INR:14.6/29.6/1.3, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n CT Abd/pelvis: Diffuse stranding about the colon consistent with pan\n colitis. Given + cultures for C.Diff this is the most likely cause.\n Evaluation of the vessels for ischemic cause impossible given lack of\n contrast but not in the correct distribution. No evidence of\n perforation. Small bilateral effusions. Non- specific dilation4 of the\n small bowel to 3.6 cm. Healed left lateral rib fractures. Sigmoid\n colon with eccentric dilation, self-contained, consistent with self\n contained rupture or diverticulum. Gradual transition of contrast c/w\n incomplete SBO or ilius.\n Blood culture NG. C. diff (+)\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation.\n .\n # CLOSTRIDIUM DIFFICILE INFECTION: Appears stable with persistent\n abdominal distension but slightly decreased WBC and increasing urine\n output. Nonetheless, severe abdominal pain and inflammation is\n concerning.\n - IV flagyl, PO Vanc; might consider Vanc enema if worsening.\n - Surgery following but patient is at high risk for surgery given\n intolerance of anemia in the setting of GI bleed.\n - IVF to keep UOP > 25 cc/hr\n - Serial abdominal exams\n # DIASTOLIC CONGESTIVE HEART FAILURE: Originally presented in CHF, but\n has since been improving. He required IV resuscitation that will need\n to be removed once cleared from acute infection.\n - O2 as needed\n - gental rehydration\n .\n # SINUS TACHYCARDIA: Had A-fib/A-flutter on this admission, although no\n record of this previously. Had an episode that broke last week with\n metoprolol and dilt. He again had an episode last night that broke\n spontaneously. Would consider restarting dilt if needed for HR control\n as he may not be intolerant of decreased filling time.\n .\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable, although Hct is somewhat down this\n morning.\n - Will consider EGD once acute medical issues resolved.\n - protonix PO BID\n .\n # ACUTE ON CHRONIC RENAL FAILURE: Baseline Cr 1.6, Peak here 3.\n Continues to improve.\n - renally dose medications, follow HCT.\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n - Poor control, so lantus increased to 10U\n .\n FEN: NPO for GI decompression.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n 1. IV access: Peripheral line Order date: @ 1246\n 13. Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 1246\n 2. IV access: Peripheral line Order date: @ 1246\n 14. Metoprolol Tartrate 100 mg PO BID\n Hold for SBP <100 HR <60 Order date: @ 0905\n 3. 1000 mL NS\n Continuous at 100 ml/hr Order date: @ 2320\n 15. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Start Order date: @ \n 4. Acetaminophen 325-650 mg PO/PR Q4H:PRN Order date: @ 0538\n 16. Olanzapine (Disintegrating Tablet) 5 mg PO QHS:PRN Order date:\n @ 2339\n 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Order date: @ 1246\n 17. Pantoprazole 40 mg PO Q24H Order date: @ 0909\n 6. Aspirin 81 mg PO DAILY Order date: @ 0906\n 18. Potassium Chloride 40 mEq PO ONCE Duration: 1 Doses Order date:\n @ 0700\n 7. Atorvastatin 80 mg PO DAILY Order date: @ 0906\n 19. Potassium Chloride 40 mEq / 500 ml NS IV ONCE Duration: 1 Doses\n Order date: @ 0700\n 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR Order date: @\n 1246\n 20. Potassium Chloride 40 mEq PO ONCE Duration: 1 Doses\n packets please Order date: @ 0730\n 9. Clindamycin 1 Appl TP DAILY\n to back Order date: @ 2245\n 21. Sarna Lotion 1 Appl TP :PRN Order date: @ 1246\n 10. Heparin 5000 UNIT SC TID Order date: @ 1246\n 22. 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: @ 1246\n 11. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1120\n 23. 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: @ 1246\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale & Fixed Dose Order date: @ 1557\n 24. Vancomycin Oral Liquid 250 mg PO Q6H\n Day #1 Order date: @ \n"
},
{
"category": "Nutrition",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 643684,
"text": "Potential for nutrition risk. Pt admitted with chest pain, had MI and\n GIB. Pt is currently NPO since evening of d/t increasing abd pain\n and distention. Pt is c-diff positive. RN pt was eating well before\n becoming NPO and plan is to advance diet when GI symptoms improve. SLP\n saw pt and recommended soft, thin liquids. Will continue to follow. Pls\n page with questions \n"
},
{
"category": "Physician ",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643685,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Increasing abdominal pain and distension, as well as WBC, throughout\n the day. Surgury consulted, poor surgical candidate. Started on PO\n and IV flagyl and PO Vanc per insistance of surgical attending (ID\n recommended only IV flagyl and PO Vanc). CT scan with pancolitis, no\n evidence of toxic megacolin. Lactate nl.\n Speach and swallow rec thin liq.\n 2 stools overnight\n Feels a bit better. No cp, sob. Belly is unchanged.\n Tele: Afib from 2AM to 4:30 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Vancomycin - 08:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Pantoprazole (Protonix) - 11:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.7\nC (98.1\n HR: 86 (74 - 115) bpm\n BP: 134/59(78) {110/34(53) - 153/67(89)} mmHg\n RR: 17 (11 - 25) insp/min\n SpO2: 98% / 2L, 97%/RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,121 mL\n 854 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,641 mL\n 849 mL\n Blood products:\n Total out:\n 640 mL\n 400 mL\n Urine:\n 640 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,481 mL\n 454 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GENERAL: Alert and oriented, less drowsy than last night.\n Uncomfortable\n HEENT: JVP D\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: CTAB, trace basilar crackles\n ABDOMEN: distended, tympanic. BS+ Tenderness most pronounced at LLQ.\n No clear rebound or guarding\n EXTREMITIES: WWP\n Labs / Radiology\n 500 K/uL\n 10.5 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.0 mEq/L\n 73 mg/dL\n 109 mEq/L\n 141 mEq/L\n 32.6 %\n 24.9 K/uL\n [image002.jpg]\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n WBC\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n Hct\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n Plt\n \n 517\n 500\n Cr\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n Glucose\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n 133\n 142\n 114\n Other labs: PT / PTT / INR:14.6/29.6/1.3, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n CT Abd/pelvis: Diffuse stranding about the colon consistent with pan\n colitis. Given + cultures for C.Diff this is the most likely cause.\n Evaluation of the vessels for ischemic cause impossible given lack of\n contrast but not in the correct distribution. No evidence of\n perforation. Small bilateral effusions. Non- specific dilation4 of the\n small bowel to 3.6 cm. Healed left lateral rib fractures. Sigmoid\n colon with eccentric dilation, self-contained, consistent with self\n contained rupture or diverticulum. Gradual transition of contrast c/w\n incomplete SBO or ilius.\n Blood culture NG. C. diff (+)\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation.\n .\n # CLOSTRIDIUM DIFFICILE INFECTION: Appears stable with persistent\n abdominal distension but slightly decreased WBC and increasing urine\n output. Nonetheless, severe abdominal pain and inflammation is\n concerning.\n - IV flagyl, PO Vanc; might consider Vanc enema if worsening.\n - Surgery following but patient is at high risk for surgery given\n intolerance of anemia in the setting of GI bleed.\n - IVF to keep UOP > 25 cc/hr\n - Serial abdominal exams\n # DIASTOLIC CONGESTIVE HEART FAILURE: Originally presented in CHF, but\n has since been improving. He required IV resuscitation that will need\n to be removed once cleared from acute infection.\n - O2 as needed\n - gental rehydration\n .\n # SINUS TACHYCARDIA: Had A-fib/A-flutter on this admission, although no\n record of this previously. Had an episode that broke last week with\n metoprolol and dilt. He again had an episode last night that broke\n spontaneously. Would consider restarting dilt if needed for HR control\n as he may not be intolerant of decreased filling time.\n .\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable, although Hct is somewhat down this\n morning.\n - Will consider EGD once acute medical issues resolved.\n - protonix PO BID\n .\n # ACUTE ON CHRONIC RENAL FAILURE: Baseline Cr 1.6, Peak here 3.\n Continues to improve.\n - renally dose medications, follow HCT.\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n - Poor control, so lantus increased to 10U\n .\n FEN: NPO for GI decompression.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n 1. IV access: Peripheral line Order date: @ 1246\n 13. Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 1246\n 2. IV access: Peripheral line Order date: @ 1246\n 14. Metoprolol Tartrate 100 mg PO BID\n Hold for SBP <100 HR <60 Order date: @ 0905\n 3. 1000 mL NS\n Continuous at 100 ml/hr Order date: @ 2320\n 15. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Start Order date: @ \n 4. Acetaminophen 325-650 mg PO/PR Q4H:PRN Order date: @ 0538\n 16. Olanzapine (Disintegrating Tablet) 5 mg PO QHS:PRN Order date:\n @ 2339\n 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Order date: @ 1246\n 17. Pantoprazole 40 mg PO Q24H Order date: @ 0909\n 6. Aspirin 81 mg PO DAILY Order date: @ 0906\n 18. Potassium Chloride 40 mEq PO ONCE Duration: 1 Doses Order date:\n @ 0700\n 7. Atorvastatin 80 mg PO DAILY Order date: @ 0906\n 19. Potassium Chloride 40 mEq / 500 ml NS IV ONCE Duration: 1 Doses\n Order date: @ 0700\n 8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR Order date: @\n 1246\n 20. Potassium Chloride 40 mEq PO ONCE Duration: 1 Doses\n packets please Order date: @ 0730\n 9. Clindamycin 1 Appl TP DAILY\n to back Order date: @ 2245\n 21. Sarna Lotion 1 Appl TP :PRN Order date: @ 1246\n 10. Heparin 5000 UNIT SC TID Order date: @ 1246\n 22. 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: @ 1246\n 11. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1120\n 23. 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: @ 1246\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale & Fixed Dose Order date: @ 1557\n 24. Vancomycin Oral Liquid 250 mg PO Q6H\n Day #1 Order date: @ \n"
},
{
"category": "Physician ",
"chartdate": "2181-12-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 644166,
"text": "TITLE:\n Chief Complaint:\n 87 yo M with GIB c/b NSTEMI medically managed. Hospital course c/b\n severe C Diff colitis.\n 24 Hour Events:\n PICC line misplaced, to be adjusted by IR today, meanwhile received\n PPN.\n Subjective: Feels well, no abdominal pain, no SOB, no CP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Metoprolol - 04:00 AM\n Other medications: See below\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.1\nC (95.1\n HR: 74 (66 - 90) bpm\n BP: 136/49(71) {109/42(61) - 179/110(116)} mmHg\n RR: 18 (10 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 847 mL\n 450 mL\n PO:\n 120 mL\n 90 mL\n TF:\n IVF:\n 440 mL\n 110 mL\n Blood products:\n Total out:\n 1,120 mL\n 280 mL\n Urine:\n 1,120 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n -273 mL\n 170 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n GEN: NAD\n HEENT: MMM, no JVD\n CV: RRR, no murmurs, quiet HS\n PULM: CTA bilaterally\n ABD: distended, tympanitic, nontender, soft, positive BS, no guarding,\n no rebound\n EXT: distal edema, WWP, 2+ distal pulses\n NEURO: A+O x 3\n Labs / Radiology\n 708 K/uL\n 12.3 g/dL\n 165 mg/dL\n 1.7 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 56 mg/dL\n 119 mEq/L\n 147 mEq/L\n 38.4 %\n 15.3 K/uL\n [image002.jpg]\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n 08:17 PM\n 04:17 AM\n 05:43 AM\n 05:00 AM\n WBC\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n 23.3\n 16.4\n 15.3\n Hct\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n 37.5\n 37.7\n 38.4\n Plt\n 249\n 216\n 394\n 446\n \n Cr\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n 2.2\n 2.0\n 1.7\n 1.7\n Glucose\n 140\n 189\n 140\n 133\n 142\n 114\n 149\n 139\n 165\n Other labs: PT / PTT / INR:15.6/40.7/1.4, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:9.5 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 87 yoM w/ h/o CKD presented with acute on chronic diastolic CHF\n exacerbation and ACS in the setting of GI bleed, then developed C. diff\n colitis while awaiting EGD/colonoscopy.\n # CLOSTRIDIUM DIFFICILE INFECTION: No longer tender abdomen but still\n distended. Decreased stool frequency and volume.\n - Not currently surgical emergency\n - IV flagyl, PO Vanc.\n - NPO and NPR\n # MALNUTRITION: PICC for TPN misplaced, will be readjusted today by IR,\n meanwhile started PPN.\n # DIASTOLIC CONGESTIVE HEART FAILURE: Appears euvolemic\n # GI BLEED: Presented with GIB, but since then has been stable, guaiac\n neg and Hct trending up.\n - will defer EGD\n - protonix IV BID\n # ACUTE ON CHRONIC RENAL FAILURE: Renal function better than baseline\n of 2.2\n # DM: On lantus and ISS (amaryl held while NPO)\n # CAD\n s/p NSTEMI in setting of GI bleed, not cathed.\n - Medically managed with ASA, Metoprolol, Statin\n # TACHYCARDIA: Had episodes of A-fib/A-flutter (confirmed to be new for\n pt) now resolved.\n - Can restart dilt if HR control required, given diastolic CHF and\n dependency on filling time\n # HYPERTENSION: Increased dose of Lopressor to 20mg IV q4hrs\n FEN: NPO for bowel rest. Nutrition consult for TPN recs\n ACCESS: PIV's. PICC for TPN\n PROPHYLAXIS: pneumoboots, PO PPI, SQ heparin\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU\n Active Medications ,\n 1. Vancomycin Oral Liquid 250 mg PO Q6H Day #1 \n 7. Pantoprazole 40 mg IV Q24H\n 2. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Start \n 8. Sarna Lotion 1 Appl TP :PRN\n 3. Metoprolol Tartrate 20 mg IV Q4H\n 9. Clindamycin 1 Appl TP DAILY to back\n 4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR\n 10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n 5. Aspirin 300 mg PR DAILY\n 11. Acetaminophen325-650mg PO/PR Q4H:PRN\n 6. Heparin 5000 UNIT SC TID\n 12. Insulin SC fixed and sliding sclae\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 644214,
"text": "87 yo male adm with NSTEMI w/ new diastolic CHF in setting of\n GIB. MI medically managed. Sent to 3 for a few days until \n when temp spiked to 104 PR. Pt found to have C-diff colitis. Abd CT\n with severe pancolitis versus walled-off bowel perforation-. Surgery\n following- no need for urgent bowel surgery. NPO until further notice\n for bowel rest. PICC repositioned in IR -tpn started.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Continued loose watery greenish stools-very sm amt. Afebrile.\n Action:\n Freq offering of bedpan. Excellent skin care-wo breakdown @ present.\n as ordered.\n Response:\n Afebrile w norm wbc.\n Plan:\n Contact precautions. as ordered.\n Rash\n Assessment:\n Sm raised rash over back. Wo co puritis.\n Action:\n Sarna lotion.\n Response:\n Without c/o.\n Plan:\n Contin present management.\n Hyperglycemia\n Assessment:\n Known diabetic. Elevated fsbs-mid 200\n Action:\n Pm glargine & q6hr humolog ss coverage.\n Response:\n Am fsbx 250 covered w 4u sq humolog.\n Plan:\n ?increase pm glargine dose. Contin q6hr coverage.\n Cardiac dysrhythmia other\n Assessment:\n NSR wo ectopy. HR 70-80.\n Action:\n Lopressor 20mg iv q4hrs.\n Response:\n Controlled HR.\n Plan:\n Contin present management.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643325,
"text": "Alteration in Elimination Related to Diarrhea\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643326,
"text": "Alteration in Elimination Related to Diarrhea\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643328,
"text": "87 yo male w/ PMH DM, HTN, hyperlipidemia, CKD who p/w acute NSTEMI,\n acute on chronic diastolic CHF in setting of GIB. Diuresed w/ IV Lasix\n gtt. Med mgt of NSTEMI r/t GIB. Called out to 3 and\n triggered AM for change in MS to 104PR. Sent to CCU for\n further mgt.\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Approx 10 loose/ semi formed foul-smelling bowel movements in 12 hour\n shift. Incotinent, sometimes requesting bedpan. Not thin enough for\n fecal bag. Guiac positive. HCT stable at 34. Abd soft, ND. Hyperactive\n BS x 4 quad. Pt currently NPO for somnolence. WBC today up to 22 from\n 12.\n Action:\n Offered toileting frequently. No sting barrier to buttocks/perineal\n area for protection. Barrier cream after loose stools. C-diff spec\n sent, #1 .\n Response:\n Plan:\n Await results of C-diff. Continue to trend #BMs, fevers, WBCs. Skin\n care PRN.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. VSS. NSR HR 70s-90s (tachy w/ ).\n Action:\n IV lopressor QID as unable to swallow PO meds r/t somnolence.\n Response:\n Stable this shift.\n Plan:\n Continue to monitor. Daily EKGs. Assess for chest pain.\n (Hyperthermia, Pyrexia, not of Unknown Origin)\n Assessment:\n WBC almost double this AM at 22. Tmax 102.6 via rectal probe. HR high\n normal, BP stable. UOP stable at 20-50. Intermittent shivering- cooling\n blanket not applied b/c of this.\n Action:\n Tylenol 650 PR q 4hrs. Cont temp monitoring. IV zosyn and vanco given\n as ordered.\n Response:\n Plan:\n Continue to trend WBC, curve. IV anbx. Cooling blanket if \n climbs.\n Altered mental status (not Delirium)\n Assessment:\n Fluctuating MS-improves w/ temperature decreases and worsens w/ .\n Alert x . Sleeping most of day, rousing to voice only. Able to\n follow commands w/ prompting.\n Action:\n Head CT. IV anbx.\n Response:\n Plan:\n Safety precautions. Continue to assess MS.\n \n Assessment:\n Entire back covered w/ red raised follicular papules.\n Action:\n Dermatology consulted. Antibiotic cream applied daily.\n Response:\n stable, pt denied itching/pain.\n Plan:\n Per dermatology- likely folliculitis and NOT drug-induced.\n Recommended topical anbx cream. Continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643388,
"text": "87 yo male w/ PMH DM, HTN, hyperlipidemia, CKD who p/w acute NSTEMI,\n acute on chronic diastolic CHF in setting of GIB. Diuresed w/ IV Lasix\n gtt. Med mgt of NSTEMI r/t GIB. Called out to 3 and\n triggered AM for change in MS to 104PR. GI following.\n Scope on hold until more stable. Sent to CCU for further mgt.\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Approx 10 loose/ semi formed foul-smelling bowel movements in 12 hour\n shift. Incotinent, sometimes requesting bedpan. Stool brown w/\n non-digested food. Guiac positive. HCT stable at 34. Abd soft, ND.\n Hyperactive BS x 4 quad. Pt currently NPO for somnolence. WBC today up\n to 22 from 12.\n Action:\n Offered toileting frequently. No sting barrier to buttocks/perineal\n area for protection. Barrier cream after loose stools. C-diff spec\n sent, #1 . Initiated IV flagyl at 16:00. IVF for hydration.\n Response:\n Stooling less frequently over course of shift. GI following. Skin\n remained intact.\n Plan:\n Await results of C-diff. Continue to trend #BMs, fevers, WBCs. Skin\n care PRN. IV flagyl while pt can not take Po\n Atrial Fibrillation\n Assessment:\n Pt converted back to afib around noon in setting of holding PO rate\n control meds- lopressor and diltiazem. Did receive one IV lopressor\n dose prior to conversion into AF. HR 100s-130s, rare PVCs.\n Action:\n IV lopressor increased from 7.5mg QID to q 4 hours. EKG obtained in\n Afib. Also started on IV hydration at 100ml/hr.\n Response:\n HR 100-110s after IV lopressor doses. ***Converted back to NSR 90s at\n 17:07***\n Plan:\n Continue to monitor HR/rhythm. IV lopressor as ordered.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP. VSS.\n Action:\n IV lopressor Q4 hours as unable to swallow PO meds r/t somnolence.\n Response:\n Stable this shift.\n Plan:\n Continue to monitor. Daily EKGs. Assess for chest pain.\n (Hyperthermia, Pyrexia, not of Unknown Origin)\n Assessment:\n WBC almost double this AM at 22. Tmax 102.6 via rectal probe. HR high\n normal, BP stable. UOP stable at 20-100/hour. Intermittent shivering-\n cooling blanket not applied b/c of this.\n Action:\n Tylenol 650 PR q 4hrs. Cont temp monitoring. IV zosyn and vanco given\n as ordered. Flagyl IV added as above. Blood cx\ns sent x 2. C-diff sent\n x one. ECHO complete to assess for vegetation.\n Response:\n No change in MS- somnolent. Temperature remains 101.5-102.6 PR. ECHO\n with no obvious vegetation but endocarditis can not be ruled out, EF\n 50%.\n Plan:\n Continue to trend WBC, curve. IV anbx. Cooling blanket if \n climbs. Tylenol q 4 hours.\n Altered mental status (not Delirium)\n Assessment:\n Fluctuating MS-improves w/ temperature decreases and worsens w/ .\n Alert x . Somnolent most of day, rousing to voice only. Able to\n follow commands w/ prompting.\n Action:\n Head CT done. IV anbx.\n Response:\n No change in MS. noted this shift. Head CT WNL.\n Plan:\n Safety precautions. Continue to assess MS.\n \n Assessment:\n Entire back covered w/ red raised follicular papules.\n Action:\n Dermatology consulted. Antibiotic cream applied daily.\n Response:\n stable, pt denied itching/pain.\n Plan:\n Per dermatology- likely folliculitis and NOT drug-induced.\n Recommended topical anbx cream. Continue to monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2181-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 643649,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Increasing abdominal pain and distension, as well as WBC, throughout\n the day. Surgury consulted, poor surgical candidate. Started on PO\n and IV flagyl and PO Vanc per insistance of surgical attending (ID\n recommended only IV flagyl and PO Vanc). CT scan with pancolitis, no\n evidence of toxic megacolin. Lactate nl.\n Speach and swallow rec thin liq.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Vancomycin - 08:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Pantoprazole (Protonix) - 11:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.7\nC (98.1\n HR: 86 (74 - 115) bpm\n BP: 134/59(78) {110/34(53) - 153/67(89)} mmHg\n RR: 17 (11 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,121 mL\n 854 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,641 mL\n 849 mL\n Blood products:\n Total out:\n 640 mL\n 400 mL\n Urine:\n 640 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,481 mL\n 454 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOX3\n HEENT: JVP of 12cm but obscured by mask\n CARDIAC: PMI non displaced. RRR, crescendo / decrescendo murmur @\n USB, HSM at apex\n LUNGS: Dullness at L base, rales way up bilaterally symmetrical\n ABDOMEN: moderate distension, liver edge palpable 3cm below costal\n margin, no fluid wave, BS+, non tender\n EXTREMITIES: WWP, trace bilat pedal edema R > L\n Labs / Radiology\n 500 K/uL\n 10.5 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 21 mEq/L\n 3.0 mEq/L\n 73 mg/dL\n 109 mEq/L\n 141 mEq/L\n 32.6 %\n 24.9 K/uL\n [image002.jpg]\n 09:16 AM\n 05:45 PM\n 05:56 AM\n 05:08 PM\n 05:37 AM\n 06:43 AM\n 05:25 AM\n 05:24 AM\n 06:17 PM\n 04:11 AM\n WBC\n 14.9\n 13.9\n 15.2\n 13.4\n 22.2\n 19.7\n 26.3\n 24.9\n Hct\n 29.2\n 31.3\n 31.5\n 31.1\n 31.3\n 27.8\n 34.3\n 31.6\n 34.7\n 32.6\n Plt\n \n 517\n 500\n Cr\n 2.8\n 2.7\n 2.6\n 2.2\n 2.2\n 2.6\n 2.6\n 3.0\n 2.9\n 2.2\n Glucose\n 186\n 230\n 113\n 133\n 140\n 189\n 140\n 133\n 142\n 114\n Other labs: PT / PTT / INR:14.6/29.6/1.3, CK / CKMB /\n Troponin-T:334/6/1.41, ALT / AST:45/45, Alk Phos / T Bili:83/1.9,\n Amylase / Lipase:56/23, Lactic Acid:1.4 mmol/L, Albumin:2.8 g/dL,\n LDH:240 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n CT Abd/pelvis: Diffuse stranding about the colon consistent with pan\n colitis. Given + cultures for C.Diff this is the most likely cause.\n Evaluation of the vessels for ischemic cause impossible given lack of\n contrast but not in the correct distribution. No evidence of\n perforation. Small bilateral effusions. Non- specific dilation4 of the\n small bowel to 3.6 cm. Healed left lateral rib fractures.\n Blood culture NG. C. diff (+)\n Assessment and Plan\n 87 yoM w/ h/o CKD presents with acute on chronic diastolic CHF\n exacerbation and ACS. Likely progression of events: GIB -> Anemia ->\n Cardiac ischemia -> Tachycardia with poor diastolic filling time + 2U\n pRBC for Hct 22 in setting of chest pain -> CHF exacerbation.\n .\n # CLOSTRIDIUM DIFFICILE INFECTION\n On PO and IV flagyl and PO Vanc.\n Surgery is following. Currently stable.\n - IV flagyl, PO Vanc\n - IVF to keep UOP > 25 cc/hr\n - Serial abdominal exams\n # DIASTOLIC CONGESTIVE HEART FAILURE: His presentation is consistent\n with acute on chronic CHF. He was significantly diuresed, now 9L\n negative for O2 as needed\n - gental rehydration\n .\n # LEUKOCYTOSIS: Low-grade temperature and persestantly elevated white\n count. Elevated WBC could be a result of acute MI, DVT, but might also\n represent slowly brewing infection. Urine culture negative. Blood\n cultures pending. CXR with no evidence of new infiltrate.\n - No antibiotics for now\n - Follow cultures.\n - re-culture if spikes\n .\n # LEG PAIN: be secondary to compression from pneuomboots. No\n swelling, but must r/o DVT. Also possibly related to gout in setting\n of diuresis, but no evidence of joint symptoms on exam.\n - vascular ultrasound today\n .\n # NON-ST ELEVATION MYOCARDIAL INFARCTION - He presented with chest pain\n for 48 hours prior to admission and positive troponins but no ST or T\n wave changes on EKG. His troponins came down over his first day and he\n remains pain free. He was started on medical management with ASA, BB,\n statin, with a goal of adding an ACEi when renal function stabilizes.\n - ASA, Metoprolol, Statin\n - transfuse for hct < 25 if symptomatic\n - Will consider further diagnostic workup with stress, cath, MR, or CT\n once stable.\n .\n # SINUS TACHYCARDIA: Had A-fib/A-flutter last night that broke with\n iincreased nodal blocking. Will continue on increased doses of\n metoprolol 100 TID and dilt 60 mg QID, as diastolic HF not tolerant of\n A-fib.\n .\n # GI BLEED: He presented with Hct drop and melena but since admission\n and transfusion Hct has been stable, although Hct is somewhat down this\n morning. Stools remain guiac positive. Given chest pain free, ok to\n allow Hct to drift to 25. He had cirrhosis 30 years ago but hadn't had\n any further characterization, since then has cut down his drinking. No\n physical exam findings of liver disease, but ultrasound showed fatty\n change. US findings could be consistent with cirrhosis but is more\n likely related to congestion.\n - Will recheck Hct in PM\n - GI following, scope planned for monday but may need to be earlier if\n bleeding picks up.\n - protonix PO BID\n .\n # ACUTE ON CHRONIC RENAL FAILURE: Baseline Cr 1.6, Peak here 3.\n - History consistent with prerenal causes but FeUrea not consistent\n (45%). be ATN secondary to prolonged hypoperfusion, vs med related,\n vs postrenal.\n - If not improving obtain renal ultrasound\n .\n # ANION GAP ACIDOSIS: anion gap was elevated on admission without\n significant lactare or ketones and modestly elevated BUN. This has\n since resolved, with a gap today of 12.\n .\n # HYPERKALEMIA: resolved with diuresis\n .\n # DM: lantus 7uqhs. insulin sliding scale, goal BG < 150.\n - Poor control, so lantus increased to 10U\n .\n FEN: Will advance diet. NPO when planned for EGD.\n ACCESS: PIV's\n PROPHYLAXIS: pneumoboots, PPI given GI bleed\n CODE: FULL code\n CONTACT: in law ; Daughter \n O: CCU to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:26 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": "2181-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643810,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers. Pan cx\nd, found to have C-diff colitis, 2\n samples tested positive, started on iv flagyl also added po flagyl w/\n po Vanco. Went for abd CT approx 3 hrs p drinking barricat, results\n limited d/t contrast still mostly in stomach. Conts w/ freq small loose\n ob+ stools. Pt also went back in/out rapid AF approx 2am, HO aware,\n lopressor was recently changed to 100mg po q12. Remains A+Ox3, is now\n afeb. Last Cre 2.2 (3.0), has conts maintenance fluids infusing at\n 50ml/hr.\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Patient had numerous small mucous loose stool during the night. Patient\n is on PO vanco and IV flagyl. Pt abdomen is firm and distended. Pt\n complained of pain on palpation over the LUQ. Patient was afebrile.\n Action:\n Pt received IV flagyl and PO vanco. Patient was frequently turned and\n barrier cream applied. Pt seen earlier in the shift by surgery.\n Response:\n Patient continued to have loose mucous stool. Surgery is on hold but\n will continue to follow patients case.\n Plan:\n Cont with abx regimen, cont to assess level of pain over LUQ, and cont\n to monitor hemodynamic status. Monitor WBC.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt K was 3.0 on morning () labs. Pt given IV and PO potassium\n during the day shift.\n Action:\n Labs were drawn this evening.\n Response:\n K is now 4.4\n Plan:\n Cont to monitor K level. Draw in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patients Cre level was 2.2, BUN was 78 this evening. Pt has increased\n edema in his lower extremities.\n Action:\n Patients continuous NS IV fluid was reduced to 50ml/hr\n Response:\n Patient continued to diurese adequately during the 12hr shift.\n Plan:\n Cont to monitor Cre level, urine output, and edema.\n Altered mental status (not Delirium)\n Assessment:\n Patient frequently states he is in his bed at home. Patient also states\n that he needs to leave and get to the hospital.\n Action:\n Oriented the patient to person, place, and time frequently. Provided\n emotional support.\n Response:\n Patient cont to be disoriented at times. Quickly became oriented once\n reminded where he was.\n Plan:\n Continue to orient patient as needed. Provide emotional support.\n Note: Patients BP steadily increased over the shift. Pt ordered back on\n Diovan (Valsartan).\n 06:11 AM\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643544,
"text": "Rash\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2181-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 643550,
"text": "87 yo male who presented on w/ NSTEMI, acute on chronic\n diastolic CHF exacerbation & anemia d/t GIB. NSTEMI was medically\n managed. Diuresed on Lasix gtt & tnsf w/ prbc. Stable & called out to\n floor . Triggered back prior to scheduled endoscopy for\n changes in MS, fevers (104 pr) ^ wbc 22 (13.4) ^ loose stools (ob+).\n Prob C-diff, 1^st sample () is positive, started on iv flagyl\n (vanco/zosyn) Pt also in/out of rapid AF, being successfully tx w/ iv\n lopressor q4. MS has improved, now alert, responds to vocal & follows\n commands. Conts w/ low grade fevers (99.4-7ax), Cre 2.6 (baseline).\n ECHO done showed no vegetations/ dry, has iv fluids infusing\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct 31.6 this am down from 34.3 , multiple stools, brown, loose,\n Action:\n Guiac stool, follow hct\n Response:\n Ob+\n Plan:\n Mon;itor hct, s/s bleeding, guiac stool\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr ^ 3.0 from 2.6 , u/o began trending down mid day\n Action:\n started on ns 125cc/hr\n Response:\n u/o improving\n Plan:\n Follow renal fx\n C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)\n Assessment:\n Multiple sm-med loose brn stool, tm 100.2., abd increasingly distended\n and tender\n Action:\n Flagyl d/c, zosyn d/c, vancomycin changed from iv to po, KUB done, plan\n for ct, pt taking baracat, starting at\n 1700\n Response:\n Cont stooling, low grade temp\n Plan:\n Monitor temp, stool, abdominal assessment, CT scan this eve\n"
}
] |
80,696 | 153,743 | The patient with history of painless jaundice x 3 weeks was admitted to the General Surgical Service for evaluation and treatment. On , the patient underwent ERCP, which was unsuccessful for CBD stent placement and only pancreatic stent was placed ( please refer to the Operative Note for details). On same day, patient underwent placement of PTBD. After procedure, the patient arrived on the floor and was started on regular diet, on IV fluids and antibiotics, with a foley catheter (placed by Urology), and IV Dilaudid for pain control. On patient underwent CTA, which demonstrated 24 mm mass in the pancreatic head/ampullary region with possible extent ion into duodenal wall. Patient was evaluated for possible Whipple/bypass resection. Neuro/Delirium: Patient was completely independent with ADL prior admission. Pain was controlled with IV Dilaudid with good result. Patient was on baseline mental status until , where overnight patient became extremely agitated, required Haldol and four point restraints. Patient's mental status improved during day time, but overnight patient's mental status changed again. Patient received IV Haldol and 4 points restraints were applied again. Next day geriatric consult was called and recommendations were followed. Patient was ordered to have 1:1 sitter and started on olanzapine. Pain medication was reduced, patient was encouraged to take more PO nutrition. Mental status was slightly improving day by day. On , sitter was discontinued, patient did fairly well with 15 min safety checks. Patient was AO x 2, more interactive, he followed all commands. Patient was screened to be discharge in long term facility and was accepted for transfer on . On patient was triggered for tachycardia, became unresponsive and was transferred in ICU. On , patient was made DNR/DNI and started on protocol. Patient expired on . CV: During admission patient had several episodes of sinus tachycardia. His cardiac status was monitored via telemetry unit. The patient remained stable from a cardiovascular standpoint until his death. Pulmonary: The patient remained stable from a pulmonary standpoint until his death. GI/GU/FEN: Patient was on regular diet after ERCP and PTBD placement. When mental status declined, nutritional consult was obtained and patient was started on TPN. Patient continue to have good PO, and he was only on starter TPN. TPN was discontinued on . PICC line was removed. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: Patient was started on empiric ABX treatment on admission. On , PTBD was capped and patient was tolerated well. Patient's cultures were sent and came back positive for Pseudomonas Aeruginosa in bile and blood. Patient was continued on ABX until protocol initiated. WBC and fever curve were closely monitored during hospitalization, patient had WBC of 29 on transfer in the ICU. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: Patient was found to have bloody diarrhea on x 2 and small hematemesis. HCT dropped to 20.2 from 31.5. Patient was given 5 units of RBC total, HCT improved to 29.6. EGD was performed and found no active bleeding. GI was consulted for colonoscopy, no colonoscopy was performed due to patient's status improved and HCT was stable. Patient's HCT was monitored throughout hospitalization and was stable until . Patient was in ICU for acute mental status change, his HCT dropped from 31.4 to 18. 3 units of RBC was transferred, HCT up to 29. EGD was performed and found brisk bleed in ampullary region, suspecting hemobilia. Angio was recommended, HCP decided to make patient . No further interventions were made, patient was started on protocol and expired on . Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay. | Pancreatic duct stent was placed and left in place. Pancreatic stent is noted in situ. IMPRESSION: Left PIC catheter tip projects over mid SVC. FINDINGS: Left PIC catheter tip projects over mid SVC. Percutaneous transhepatic biliary ductal stent is noted in situ. Check cholangiogram demonstrating decompression of the biliary ductal system as compared to the prior study dated . CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Dependent linear atelectasis at the lung bases, which are otherwise clear. Cholangiogram through the needle demonstrated dilated right intrahepatic biliary system and a dilated common bile duct. There is a right-sided central venous catheter with the distal lead tip in the mid SVC, appropriately sited. Request for cholangiogram and internalization of the PTC drain if possible. Replaced right hepatic artery otherwise conventional hepatic arterial and venous anatomy with widely patent SMA, SMV, and portal veins. Replaced right hepatic artery otherwise conventional hepatic arterial and venous anatomy with widely patent SMA, SMV, and portal veins. Contrast was injected to confirm the location of the Kumpe catheter in the bowel loop. A small ammount of contrast was seen to flow across the terminal CBD stricture into the bowel loop. Contrast was injected through the sidearm of the sheath which demonstrated decompressed biliary ductal system as compared to the prior study dated . 24 mm mass in the pancreatic head/ampullary region which appears to be confined to the pancreas except possible extension in to the duodenal wall and slightly into the pancreaticoduodenal groove. The skin around the right upper abdomen near the catheter entry site was prepped and draped in the usual sterile fashion. Following this decision the Kumpe catheter was removed and a 0.035 wire was advanced into the common bile duct. Under fluoroscopic guidance the lower border of the right lung was noted on deep inspiration. Evaluate for pancreaticobiliary mass or obstruction. The distal most portion of the pancreatic duct is visualized and appears normal. ANESTHESIA: A general anesthesia was provided. There is a replaced right hepatic artery. This demonstrated dilated right and left intrahepatic biliary ducts and a dilated common bile duct with a complete distal obstruction near the ampulla. IMPRESSION: There is a stricture of the distal common bile duct with proximal narrowing minimally visualized due to inability to cannulate the CBD. The right upper abdomen was prepped and draped in the usual sterile fashion. There is otherwise conventional hepatic arterial anatomy. There is a 24 x 24 mm hypodense pancreatic head or ampullary mass (3A:47). Surgical clips are seen at the GE junction and upper abdomen. Replaced right hepatic artery otherwise conventional hepatic arterial and venous anatomy with widely patent SMA, SMV, and portal veins, without evidence of vascular involvement. Sterile dressings were applied. We then passed a short Kumpe catheter through the sheath which was manipulated over a Glidewire to negotiate the stricture and passed into the bowel loop. There is a small blush of contrast adjacent to the the PTBD likely a perfusion anomaly. Surgical clips are noted. TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen before and after administration of 200 cc IV Optiray contrast. The kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or (Over) 8:46 AM CTA ABD W&W/O C & RECONS Clip # Reason: Eval for pancreatic/biliary mass/obstruction Admitting Diagnosis: JAUNDICE Contrast: OPTIRAY Amt: 200 FINAL REPORT (Cont) hydroureter. Sinus tachycardia, rate 114. There may be some extension into the duodenal wall, but the mass is otherwise confined to the pancreatic head/ampullary region. A 0.018 guidewire was placed through the needle and the needle exchanged for an Accustick sheath. 1% lidocaine was used for local anesthesia. However, there is high grade stenosis noted in the terminal CBD with trickle of contrast flowing into the distal bowel. The Tip sheath was advanced into the common bile duct and a cholangiogram was performed. Pancreatic stent in expected position without pancreatic duct dilation snd percutaneous transhepatic biliary catheter with tip in the CHD with no bile duct dilation. Admitting Diagnosis: JAUNDICE Contrast: OPTIRAY Amt: 45 ********************************* CPT Codes ******************************** * CHANGE PERC BILIARY DRAINAGE C -78 RELATED PROCEDURE DURING POSTOPE * * CHANGE PERC TUBE OR CATH W/CON * **************************************************************************** MEDICAL CONDITION: 78 year old man with PTC drain. CTA ABDOMEN: Atherosclerotic disease of the abdominal aorta is noted with soft and hard plaque. Admitting Diagnosis: JAUNDICE Contrast: OPTIRAY Amt: 45 FINAL REPORT (Cont) IMPRESSION: 1. After infiltrating with 1% lidocaine, a right intercostal midaxillary approach was used to the right lobe of the liver. There is a 3.1 x 2.5 x 4.4 cm hypodense lesion in the upper pole of the left kidney with a thin septation. | 10 | [
{
"category": "Radiology",
"chartdate": "2107-08-01 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 1151192,
"text": "GI BLEEDING STUDY Clip # \n Reason: 78 Y/O WITH BRBPR\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 16.4 mCi Tc-m RBC ();\n HISTORY: 78 YO male with BRBPR.\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and dynamic images of the abdomen for 60 minutes\n were obtained. Futher images and a lateral view of the pelvis were not obtained\n due to deterioration in patient''s clinical status.\n\n Blood flow images show flow through the normal abdominal vasculature without\n evidence of acute GI bleed.\n\n Dynamic blood pool images show no evidence of acute GI bleed.\n\n IMPRESSION:\n\n 1. No evidence of acute GI bleed.\n\n The examination was stopped after 60 minutes due to deterioration in patient''s\n clinical status.\n\n\n\n\n , M.D.\n , M.D. Approved: TUE 4:10 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": "2107-07-29 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1151195,
"text": " 2:31 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images from \n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with 3 wks of painless jaundice, MRCP shows dilation of biliary\n tree down to ampulla, normal PD\n REASON FOR THIS EXAMINATION:\n Please review ERCP images from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Painless jaundice with dilatation of biliary tree on MRCP.\n\n TECHNIQUE: 13 fluoroscopic spot views obtained during ERCP without\n radiologist present.\n\n IMPRESSION:\n There is a stricture of the distal common bile duct with proximal narrowing\n minimally visualized due to inability to cannulate the CBD. The distal most\n portion of the pancreatic duct is visualized and appears normal. Pancreatic\n duct stent was placed and left in place. Surgical clips are noted. For\n further details, please see the ERCP report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-07-29 00:00:00.000",
"description": "INTRO PERC TRNASHEPATIC STENT",
"row_id": 1150863,
"text": " 6:07 PM\n PTC Clip # \n Reason: please perform PTC and placement of PTBD\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * INTRO PERC TRNASHEPATIC STENT PERC TRANSHEPATIC CHOLANGIOGRA *\n * -59 DISTINCT PROCEDURAL SERVICE PERC TRANSHEPATIC CHOLANGIOGRA *\n * -59 DISTINCT PROCEDURAL SERVICE CATH/STENT FOR INT/EXT BILIARY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with likely distal cholangioCA and biliary obstruction\n REASON FOR THIS EXAMINATION:\n please perform PTC and placement of PTBD\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 78-year-old man with obstructive jaundice, suspected to be\n from a distal cholangiocarcinoma. An ERCP attempt at cannulating the bile\n duct was unsuccessful earlier today; however, the pancreatic duct was\n successfully cannulated and a drain was placed. A PTC and PTBD placement was\n requested.\n\n COMPARISON: ERCP images from 27/8/.\n\n CLINICIANS: Dr. and Dr. . Dr. , the\n attending radiologist was present and supervising throughout.\n\n ANESTHESIA: A general anesthesia was provided. Local anesthesia with 1%\n lidocaine.\n\n PROCEDURE AND FINDINGS: An informed consent was obtained after explaining the\n procedure, benefits, alternatives and risks involved. Patient was brought to\n angiography suite and placed supine on the imaging table. The right upper\n abdomen was prepped and draped in the usual sterile fashion. A pre-procedure\n huddle and timeout was performed as per protocol.\n\n Under fluoroscopic guidance the lower border of the right lung was noted on\n deep inspiration. After infiltrating with 1% lidocaine, a right intercostal\n midaxillary approach was used to the right lobe of the liver. A 15 cm x\n 21-gauge Cook needle was inserted into the right lobe of liver under\n fluoroscopic control and gradually pulled out while injecting diluted\n contrast. After three needle passes a peripheral right intrahepatic bile duct\n was opacified with contrast. Cholangiogram through the needle demonstrated\n dilated right intrahepatic biliary system and a dilated common bile duct. A\n 0.018 guidewire was placed through the needle and the needle exchanged for an\n Accustick sheath. The guidewire was then upsized to a 0.035 stiff Glidewire,\n and the Accustick sheath was exchanged for a 5 French x 23 cm Tip\n sheath. The Tip sheath was advanced into the common bile duct and a\n cholangiogram was performed. This demonstrated dilated right and left\n intrahepatic biliary ducts and a dilated common bile duct with a complete\n distal obstruction near the ampulla. The cystic duct was dilated and contrast\n was noted to be filling the gall-bladder. Through the Tip sheath, using\n a combination of 5 French Kumpe catheter and an 0.035 Glidewire attempts were\n (Over)\n\n 6:07 PM\n PTC Clip # \n Reason: please perform PTC and placement of PTBD\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n made to cross the obstruction at the ampulla, but were unsuccessful. No\n contrast was noted to be flowing into the small bowel. After a few failed\n attempts, a decision was made to decompress the biliary system and then\n reattempt to cross the obstruction in the future after decompression of the\n system. Following this decision the Kumpe catheter was removed and a 0.035\n wire was advanced into the common bile duct. The Tip sheath was\n then removed and a 6 French pigtail catheter, which was modified by cutting\n extra side holes, was placed over the guidewire and the guidewire removed.\n The pigtail was formed and locked in the distal common bile duct to act as an\n external drain. The catheter was connected to a drainage bag. Further\n attempts to cross the obstruction will be made after decompression of the\n biliary system. The catheter was secured to the skin with 0-silk suture and a\n Statlock device. Sterile dressings were applied. Patient tolerated the\n procedure well and there were no immediate complications. The patient was\n transferred to PACU in a stable condition at the end of the procedure.\n\n IMPRESSION:\n 1. Percutaneous transhepatic cholangiogram demonstrating dilated right and\n left intrahepatic biliary ducts and dilated common bile duct. A complete\n obstruction of the distal CBD was noted and attempts to cross into the bowel\n were unsuccessful at this stage.\n 2. A modified 6 French external biliary catheter was placed with the pigtail\n formed and locked in the distal CBD and connected to an external drainage bag.\n\n Attempts to cross the obstruction into the bowel would be made in a few days\n time after decompressing the biliary system.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-07-30 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1150913,
"text": " 8:46 AM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: Eval for pancreatic/biliary mass/obstruction\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with painless jaundice s/p ERCP\n REASON FOR THIS EXAMINATION:\n Eval for pancreatic/biliary mass/obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SAT 10:42 AM\n 24 mm mass in the pancreatic head/ampullary region which appears to be\n confined except possible extension in to the duodenal wall. Replaced right\n hepatic artery otherwise conventional hepatic arterial and venous anatomy with\n widely patent SMA, SMV, and portal veins. 4.8-cm slightly complex cyst in the\n left kidney. Attention on follow up recommended.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male with painless jaundice, status post ERCP.\n Evaluate for pancreaticobiliary mass or obstruction.\n\n COMPARISON: No prior study available for comparison.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen\n before and after administration of 200 cc IV Optiray contrast. Coronal and\n sagittal reformats were displayed.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Dependent linear atelectasis at the\n lung bases, which are otherwise clear.\n\n The liver demonstrates normal homogeneous enhancement. There is mild\n intrahepatic biliary ductal dilatation, predominantly in the left lobe. CBD is\n not dilated, but there is hyperemia of the wall likely related to recent\n dilataion/inflammation. Percutaneous transhepatic biliary ductal stent is\n noted in situ. There is a small blush of contrast adjacent to the the PTBD\n likely a perfusion anomaly. The gallbladder is collapsed demonstrates mild\n wall edema with layering hyperdense material compatible with vicarious\n excretion of contrast. Surgical staples are noted in the pancreaticoduodenal\n groove likely related to prior duodenal ulcer and causing streak artifact.\n Surgical staples are also noted at the\n GE junction.\n\n There is a 24 x 24 mm hypodense pancreatic head or ampullary mass (3A:47).\n There may be some extension into the duodenal wall, but the mass is otherwise\n confined to the pancreatic head/ampullary region. Evaluation for enlarged GDA\n or common hepatic artery lymph nodes is limited by streak artifact, but there\n is no apparent lymphadenopathy. Pancreatic stent is noted in situ. The main\n pancreatic duct is not dilated.\n\n Spleen and bilateral adrenal glands are normal. The kidneys enhance and\n excrete contrast symmetrically without evidence of hydronephrosis or\n (Over)\n\n 8:46 AM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: Eval for pancreatic/biliary mass/obstruction\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hydroureter. There is a 3.1 x 2.5 x 4.4 cm hypodense lesion in the upper pole\n of the left kidney with a thin septation. Multiple other small hypodensities\n are noted in the bilateral kidneys, which are too small to further\n characterize but likely represent simple cysts. No free air or fluid in the\n abdomen. No mesenteric or retroperitoneal lymphadenopathy is noted.\n Non-opacified loops of small and large bowel and stomach are normal. Surgical\n staples are noted in the subcutaneous tissue of the anterior abdomen.\n\n CTA ABDOMEN: Atherosclerotic disease of the abdominal aorta is noted with soft\n and hard plaque. There is a replaced right hepatic artery. There is otherwise\n conventional hepatic arterial anatomy. The SMA, SMV and portal vein are\n widely patent without evidence of filling defect or stenosis.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\n There is multilevel degenerative change of the thoracic spine.\n\n IMPRESSION:\n 1. 24 mm mass in the pancreatic head/ampullary region which appears to be\n confined to the pancreas except possible extension in to the duodenal wall and\n slightly into the pancreaticoduodenal groove. This most likely represents a\n pancreatic adenocarcinoma, but amopullary carcinoma and cholangiocarcinoma are\n possible.\n\n 2. Replaced right hepatic artery otherwise conventional hepatic arterial and\n venous anatomy with widely patent SMA, SMV, and portal veins, without evidence\n of vascular involvement. No definite lymphadenopathy. Pancreatic stent in\n expected position without pancreatic duct dilation snd percutaneous\n transhepatic biliary catheter with tip in the CHD with no bile duct dilation.\n\n 3. 4.8-cm slightly complex cyst in the left kidney. Attention on follow up\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-07-30 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1150914,
"text": ", P. FA9A 8:46 AM\n CTA ABD W&W/O C & RECONS Clip # \n Reason: Eval for pancreatic/biliary mass/obstruction\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with painless jaundice s/p ERCP\n REASON FOR THIS EXAMINATION:\n Eval for pancreatic/biliary mass/obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 24 mm mass in the pancreatic head/ampullary region which appears to be\n confined except possible extension in to the duodenal wall. Replaced right\n hepatic artery otherwise conventional hepatic arterial and venous anatomy with\n widely patent SMA, SMV, and portal veins. 4.8-cm slightly complex cyst in the\n left kidney. Attention on follow up recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-08-02 00:00:00.000",
"description": "CHANGE PERC BILIARY DRAINAGE CATHETER",
"row_id": 1151401,
"text": " 3:27 PM\n BILIARY CATH REPLACE Clip # \n Reason: internalize PTC drain if possible.\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 45\n ********************************* CPT Codes ********************************\n * CHANGE PERC BILIARY DRAINAGE C -78 RELATED PROCEDURE DURING POSTOPE *\n * CHANGE PERC TUBE OR CATH W/CON *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with PTC drain. Drain pulled per nursing staff to AM.\n REASON FOR THIS EXAMINATION:\n internalize PTC drain if possible.\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL INDICATION: 78-year-old man with PTC drain. There is a likelihood of\n drain being displaced. Request for cholangiogram and internalization of the\n PTC drain if possible.\n\n CLINICIANS: Dr. and Dr. . The attending was\n present and supervising during the entire procedure.\n\n Moderate conscious sedation was provided by administering divided doses of 100\n mcg of fentanyl throughout the intra-service time of 40 minutes during which\n the patient's hemodynamic parameters were continuously monitored. 1% lidocaine\n was used for local anesthesia.\n\n PROCEDURE AND FINDINGS: A written informed consent was obtained after\n explaining the risks, benefits and alternatives to the procedure. The patient\n was brought to the angiography suite and placed supine on the table. A\n timeout and huddle were performed as per protocol. The skin around the\n right upper abdomen near the catheter entry site was prepped and draped in the\n usual sterile fashion.\n\n A scout image demonstrated the catheter in the right abdomen. There was a\n small kink noted peripherally. The catheter was then cut beyond the hub and a\n wire was passed, over which the catheter was removed. We then placed\n a 6 French sheath over the wire. Contrast was injected through the sidearm of\n the sheath which demonstrated decompressed biliary ductal system as compared\n to the prior study dated . A small ammount of contrast was\n seen to flow across the terminal CBD stricture into the bowel loop. We then\n passed a short Kumpe catheter through the sheath which was manipulated over a\n Glidewire to negotiate the stricture and passed into the bowel loop. Contrast\n was injected to confirm the location of the Kumpe catheter in the bowel loop.\n 8 French pigtail catheter was then passed over an Amplatz wire with pigtail\n looped in the small bowel. Contrast was injected to confirm the position of\n the pigtail and the smooth passage of contrast via the side holes. This\n catheter was secured to the skin using 0 silk suture and StatLock placed. The\n catheter was connected to a bag for external drainage. Sterile sponge\n dressings were applied. The patient had no immediate complication and was\n shifted to the floor.\n\n (Over)\n\n 3:27 PM\n BILIARY CATH REPLACE Clip # \n Reason: internalize PTC drain if possible.\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Removal of the external 6.3 French biliary drain over the wire.\n\n 2. Check cholangiogram demonstrating decompression of the biliary ductal\n system as compared to the prior study dated . However, there\n is high grade stenosis noted in the terminal CBD with trickle of contrast\n flowing into the distal bowel.\n\n 3. Successful negotiation of the stricture and placement of internal-external\n drain, 8 French in size with pigtail formed in the jejunal loop.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-08-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1152974,
"text": " 8:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess placement\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man new intubation, new CVL, left subclavian\n REASON FOR THIS EXAMINATION:\n assess placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 78-year-old man with new intubation and new central venous catheter.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The tip of the endotracheal tube is 4 cm above the carina, appropriately\n sited. There is a right-sided central venous catheter with the distal lead\n tip in the mid SVC, appropriately sited. There are no pneumothoraces. Lungs\n are grossly clear. A CP angle has been excluded from the field of view. The\n nasogastric tube and the side port are below the gastroesophageal junction.\n There is a drain seen within the right upper quadrant. Surgical clips are\n seen at the GE junction and upper abdomen. Cardiac silhouette is within\n normal limits.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-08-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1151500,
"text": " 9:37 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a left sided picc line placed 46cm and needs tip conf\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with PICC who needs it for TPN.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed 46cm and needs tip confirmation please\n page at \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left PICC line placement.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n Left PIC catheter tip projects over mid SVC. No pneumothorax.\n\n Lung volumes are normal. Lungs are clear without focal consolidations. No\n pulmonary edema or pleural effusions. Heart size is normal. Mediastinal and\n hilar silhouettes are normal.\n\n Multiple surgical clips project over upper abdomen.\n\n\n IMPRESSION:\n\n Left PIC catheter tip projects over mid SVC.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-08-12 00:00:00.000",
"description": "Report",
"row_id": 239202,
"text": "Sinus tachycardia, rate 114. Low voltage in the limb leads. Otherwise, tracing\nis within normal limits. Compared to the previous tracing of the low\nvoltage is new. T waves are also more prominent throughout the tracing. These\nchanges are non-specific but myocardial ischemia is not excluded as an\netiology. Consider electrolyte changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-07-31 00:00:00.000",
"description": "Report",
"row_id": 239203,
"text": "Sinus rhythm. Tracing is within normal limits. No previous tracing available\nfor comparison.\n\n"
}
] |
25,605 | 122,822 | The patient was admitted status post occiput to C3 fusion without intraoperative complication. Postoperatively, her vital signs were stable. She was monitored in the recovery room. Her strength was in all muscle groups. Her sensation was intact to light touch. She was in a hard collar. She was extubated in the recovery room. She was kept on q 1 h. neuro checks. Her SBP was kept at less than 150. On postoperative day 1, her incision was clean and dry, and her strength continued to be in all muscle groups. She was in a hard collar. She was out-of-bed ambulating. She was in for a PT and OT evaluation, and continued to be ruled out for an MI. On her postoperative EKG, she had ST depression with also elevated CPKs into the 500 range. ST depression was laterally without chest pain. She was treated with IV Lopressor and Lasix. She was transferred to the CCU for MI management, and treated with Lopressor and lisinopril for rate control. She was in the CCU for 2 days and then transferred back to the regular floor. The patient was started on aspirin and continued on Lopressor for rate control. She was transferred to the regular floor on . She also had an x-ray on . She had a bedside swallow evaluation which she failed with thin liquids. She was not even able to tolerate 2 tsp of liquid without coughing. She was kept n.p.o., and they felt that she should just be reevaluated in a couple of days when some of her swelling from surgery subsided. She was seen by physical therapy and occupational therapy, and felt to require a short rehab stay. She did have a couple of bouts of short runs of V-tach. Her electrolytes were stable. She will require continued cardiology follow-up, and will require a catheterization as an outpatient. About 2 weeks after discharge is when she can be safely catheterized and anticoagulated per Dr. , the neurosurgeon. Her hard collar was removed, and a video swallow was repeated on , and she again failed with thin liquids, and she continues to have a Dobbhoff feeding tube in for nutrition. She will need to have a video swallow or bedside swallow repeated in 1 week. If she passes at bedside, she may need a video swallow to assure there is no aspiration. Neurologically, she remained stable. Cardiovascular stable. Vital signs are stable. | Moderate pulmonary artery systolic pressure, mildright ventricular hypokinesis, and a dilated descending thoracic aorta arealso now identified.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). Fixation screws are in place within the posterior vertebral body of C3 with an unchanged appearance when compared to the previous day. The tube and the tip appear to be within the gastric fundus, and does not definitely pass into the hiatus. Myocardial infarction.Height: (in) 63Weight (lb): 135BSA (m2): 1.64 m2BP (mm Hg): 143/64HR (bpm): 66Status: InpatientDate/Time: at 11:48Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (tape not available)of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. IMPRESSION: Unchanged examination when compared to the previous day with apparent fracture at the base of the dens and a posterior cervical fusion device extending from C3 to the occiput. Hemovac in place with small amt of drng, hct stable. It is malpositioned, with its distal radio-opaque portion in the distal esophagus. Normal ascending aorta diameter. ModeratePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a moderate risk (prophylaxis recommended). Mildlydilated descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). There is moderate [2+} tricuspid regurgitation. Interval improvement in mild volume overload/CHF. Mild global RV free wall hypokinesis.AORTA: Normal aortic root diameter. A fracture with adjacent sclerosis traverses the base of the dens that appears unchanged when compared to the previous day. The left ventricular cavity is moderately dilated with severe globalhypokinesis. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is no pericardialeffusion.Compared with the report of the prior study (tape unavailable for review) of, the left ventricle is slightly larger and the severity of mitralregurgitation has increased. Rightventricular chamber size is normal with mild global free wall hypokinesis. IMPRESSION: Mild congestive heart failure with cardiomegaly with small left pleural effusion. Hr 70-80's Sr with rare pvc's noted. Moderate to severe (3+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. CXR PA/LAT post op completed at 1400.ID low grade temp 100po, remains on cefozolin TID.GU-voiding well on commode. Drsg of head intact with small amt of bloody drng. CCU NPNS: "I am here...you know here"O: See vs/objective data per care vue. Thereis moderate pulmonary artery systolic hypertension. The alignment of the cervical spine is unchanged with severe degenerative change throughout the cervical spine that is most prominent at the levels of L4-5 and C5-6. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic regurgitation.The mitral valve leaflets are mildly thickened. Left ventricular wall thicknesses arenormal. AP SUPINE CHEST: Comparison to . A minor degree of low density is noted in the periventricular white matter of both cerebral hemispheres, likely representing chronic microvascular infarction. Incision/staple line intact with small amount of serosang drainage noted at top of incision. IMPRESSION: 1) Slight thickening of the posterior nasopharyngeal mucosa and thickening of the prevertebral soft tissues anterior to C3 and C4 without evidence of discrete fluid collection. Presumably, the right-sided C1 cerclage wire has become displaced through the posterior ring fracture site. The C1-2 malalignment has equivocally occurred since exam (difficult assessment due to change in positioning) and there is interval removal of the posterior skin staples. Sinus rhythm with one ventricular premature beat. A large portion of the infrarenal aortic aneurysm is thrombosed. Since the previous tracing of there are newST segment depressions in the inferolateral leads and the Q-T interval hasshortened. 3) Dilated descending thoracic aorta above diaphragmatic hiatus, maximal axial dimensions of 4.3 x 4.5 cm. Sinus rhythmLead(s) unsuitable for analysis: V2Leftward axisIV conduction defectLeft ventricular hypertrophyInferior/lateral ST-T changes may be due to hypertrophy and/or ischemiaLeft atrial abnormalitySince previous tracing of , no significant change In addition, there appears to be a fracture of the posterior right aspect of the ring of C1, also with sclerotic margins indicating a somewhat chronic process. 2) Displaced cerclage wire adjacent to the arch of C1 on the right and left C4 screw not located in the osseous lamina but at the edge of the C3-4 facet. Sinus rhythm with a single atrial premature beat. Visualized portions of the mastoid air cells and middle ear cavities are normally aerated. Also noted is stenosis of the origins of the SMA and . Prevertebral soft tissues appear unremarkable. Left ventricular hypertrophy. There was some regurgitation of contrast material into the nasopharynx. The visualized portions of the lung apices appear unremarkable. The diaphragms are flattened. Previously described abnormalities persist.TRACING #1 5) Stenotic origins of the celiac artery and SMA. Degenerative changes (Over) 2:19 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: eval for bleed, hematoma, perforation, e/o infection Admitting Diagnosis: C1-2 INSTABILITY/SDA Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) are also present within the spine, where there is a predominantly convex right rotatory scoliosis. Sinus rhythm.Borderline IV conduction defectLeft ventricular hypertrophySeptal ST elevation - cannot rule out myocardial injuryExtensive ST-T changes are probably due to ventricular hypertrophySince previous tracing of , no significant change | 33 | [
{
"category": "Nursing/other",
"chartdate": "2180-04-23 00:00:00.000",
"description": "Report",
"row_id": 1596210,
"text": "CCU Nursing Progress Note\nS-\"I can not hear very good without my hearing aides.\"\nO-Neuro alert and oriented x3. Episode of finding pt sitting in the chair by the side of the bed. Was slightly disoriented, could not say why she got OOB. Quickly reoriented but alittle restless. Received zyprexa 5mg SL. Neuro checks intact without weakness. Had received one percocett for neck pain prior to confusion. All four side rails up and bed alarm set.\nCV-VSS with increase in lopressor 100mg po TID. HR 65-75 NSR with SBP 110-130/. HR increases with minimal activity or OOB to 88-92 NSR. CPK coming down 285/29.\nResp- LS diminished at bases on 1 liter NP with sats 94-96%. CXR PA/LAT post op completed at 1400.\nID low grade temp 100po, remains on cefozolin TID.\nGU-voiding well on commode. IVF D5/12NS at 50cc/hr until able to take po's.\nGI-NGT with TF started ProBalance at 10cc/hr-GOAL 500cc/hr. Abd soft, No BM +flatus. HCT stable 32.\nActivity-OOB chair with assist for 90 minutes. c/o back ache and uncomfortable returned to bed.\nSkin-Neck operative site-dressing changed by surgery. Incision/staple line intact with small amount of serosang drainage noted at top \nof incision. Hemovac draining 60cc over 12 hours. J collar on, pt having difficult time keeping chin\nSocial-son called for pt uodate. All pt belonging retrieved from \"basement locker\" for all pre op pts;2 hearing aides, glasses/case, lower denture, pill box, clothing.\nDispo-discharge to home with services. POC prob heart cath within 1 week.\nA/P-Stable peri op MI\nContinue to monitor HR GOAL < 70 titrate lopressor.\nClosely assessmental starus\nIncrease activity as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-04-24 00:00:00.000",
"description": "Report",
"row_id": 1596211,
"text": "CCU NPN\nnpn addendum.\n Attempted to give pt toprol xl, unable to crush this med, pt unable to swallow pill, with ^^ coughing, team aware. To place a ngt and change to regular lopressor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-04-24 00:00:00.000",
"description": "Report",
"row_id": 1596212,
"text": "CCU NPN\nS:\"This is so uncomfortable (neck brace).\"\nO: See vs/objective data per care vue. Conts to have low grade temp on cefazolin, no tylenol given.\n Hr 70-80's Sr with rare pvc's noted. Rec'd additional 25mg lopressor po and XL dose increased. No significant change in hr after dose. Bp 120-140's.\n Lungs with diminished aeration at bases otherwise clear. O2 at 1lnp. Has a very weak cough non-productive.\n Voiding via bedpan, yellow clear urine. Stating that she hasn't had a bm since admit. Basically NPO due to difficulty with swallowing. Did take pill with custard, but currently only giving pills that are absolutely necessary. She is scheduled to have a swallow study today. Abd soft with good bowel sounds.\n She is alert and oriented x 3. No episodes of confusion. She is moving all extrems equally strong. Pupils remain small (approx 2mm). Her incision is dry with a dry drsg the site. The hemovac is intact drng serosang fluid (see flow for total amts). She does c/o pain in legs when she stands up, but no numbness or tingling. She has gotten oob to chair x 2 tonight. She is uncomfortable in the bed. The neck collar has remained intact though at one time she was loosening it up. Reminded her that it was important to leave it on.\nA: s/p fusion of C1-C2 to occipit c/b mi\n hemodynamically stable on large dose of lopressor\nP: cont to follow neuro assess....\n PT consult today to increase activity (her cane is in the room)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-04-23 00:00:00.000",
"description": "Report",
"row_id": 1596209,
"text": "CCU NPN\nS: \"I am here...you know here\"\nO: See vs/objective data per care vue. ^ temp to 99.9 rec'd tylenol and conts on cefazolin.\n Hr initially high 70's to low 80's started esmolol gtt and increased to total of 150mcg/kg/min with very little effect on hr (down to the mid 70's) but decrease in bp to the 90-100's. Gave total of 10mg IV lopressor and decreased esmolol gtt with no change in hr/bp, therefore dc'd esmolol gtt and she rec'd diltiazem total of 10mg with decrease in hr to the mid 60's sr and bp 100-120's. Rec'd 2 additional dilt boluses of 10mg when hr increased up to the 70's with good effect (hr back to the 60's). Increased po lopressor to 75mg tid. Cpk's at 8pm basically unchanged from previous draw, but in am they have decreased down to the mid 400's. Awaiting MB and troponin.\n Lungs with diminished aeration at bases otherwise clear. Taking inhalers on own. O2 at 2lnp with sats in the upper 90's.\n Voiding via bedpan. No bm. Rec'ing D51/2NS at 50cc/hr until taking po's better. Is taking ice chips without problem. water to drink and noted that she had a very difficult time swallowing it (seemed to choke on it). Dobhoff intact via left nare, flushes easily. Abd soft.\n Initially alert and oriented x 3. As night progressed became agitated, attempting to get oob (in order to go to bathroom). Thought she was at home. Rec'd zyprexa 5mg with fair effect, did not sleep much but she was much more appropriate. She was very restless the whole night and slept very little. Cont to attempt to get oob to use bathroom, side rails ^ x 4 and bed alarms on.\n Cervical collar in place, she states that the collar is very uncomfortable. Neuro in to see pt, stating that her neck is stable but it is important to leave the collar on. Hemovac in place with small amt of drng, hct stable. Drsg of head intact with small amt of bloody drng. No neuro deficits noted, pupils are small, difficult to assess for reaction (but do appear to be + for reaction.\nA: R'ing in for MI\n ^ hr unresponsive to esmolol and lopressor therefore used iv dilt\n agitation improved with zyprexa\n neck stable\nP: cont with dilt prn to maintain hr 50-60's while increasing the dose of lopressor\n follow ms\n cont to provide emotional support\n ? refit of cervical collar\n"
},
{
"category": "Echo",
"chartdate": "2180-04-24 00:00:00.000",
"description": "Report",
"row_id": 68866,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 63\nWeight (lb): 135\nBSA (m2): 1.64 m2\nBP (mm Hg): 143/64\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 11:48\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data. Echocardiographic results were reviewed by telephone\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is moderately dilated with severe global\nhypokinesis. No masses or thrombi are seen in the left ventricle. Right\nventricular chamber size is normal with mild global free wall hypokinesis. The\ndescending thoracic aorta is dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral\nregurgitation is seen. There is moderate [2+} tricuspid regurgitation. There\nis moderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, the left ventricle is slightly larger and the severity of mitral\nregurgitation has increased. Moderate pulmonary artery systolic pressure, mild\nright ventricular hypokinesis, and a dilated descending thoracic aorta are\nalso now identified.\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": "2180-04-22 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 867124,
"text": " 2:00 PM\n PORTABLE ABDOMEN Clip # \n Reason: check dobboff placement.\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with difficulty eating needs Dobboff placement.\n REASON FOR THIS EXAMINATION:\n check dobboff placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check Dobbhoff catheter placement.\n\n KUB: There are no prior films for comparison. The tip of the enteric tube is\n in the proximal most stomach. The abdomen is filled with prominent but not\n frankly dilated air and stool filled loops of colon, with a large amount of\n stool present in the right and proximal transverse colon. There is no\n evidence of obstruction. Degenerative changes are incidentally noted in both\n hips, right greater than left.\n\n IMPRESSION: 1) Enteric catheter tube tip in proximal most stomach.\n 2) Prominent stool proximal colon.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-21 00:00:00.000",
"description": "O C-SPINE (PORTABLE) IN O.R.",
"row_id": 866982,
"text": " 8:08 AM\n C-SPINE (PORTABLE) IN O.R. Clip # \n Reason: FUSION OCCIPITO CERVICAL\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n FINAL REPORT\n Occipital fusion.\n\n Films in the OR demonstrate interval appearance of hardware placement. Pedicle\n screws at C3 and the more superior portion of the prosthesis placed in the\n occiput of the calvarium related to the occipital cervical fusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 867089,
"text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltration\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with S/P C3 occipit fusion, H/O CHF\n REASON FOR THIS EXAMINATION:\n infiltration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for infiltrate.\n\n PORTABLE CHEST: Comparison is made to prior study dated . The bony\n thorax is intact. Midline structures are stable. There is somewhat limited\n evaluation of the left retrocardiac area due to technique, but no definite\n acute process is seen on this single view. The left lateral costophrenic\n angle is not as sharply defined previously, possibly related to technique.\n PA/lateral would be helpful, when possible.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-22 00:00:00.000",
"description": "C-SPINE NON-TRAUMA 2-3 VIEWS",
"row_id": 867112,
"text": " 11:01 AM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: screw position, C1 versus C2 position\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p C3-occiput fusion\n REASON FOR THIS EXAMINATION:\n screw position, C1 versus C2 position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year old female status post C3/occiput fusion. Evaluate\n position of screws and the position of C1 relative to .\n\n FINDINGS: Comparison is made to an operative film of the previous day and a\n preoperative radiograph from .\n\n A fusion device is in place extending from the occiput through the posterior\n elements of C1, C2, and C3. Fixation screws are in place within the posterior\n vertebral body of C3 with an unchanged appearance when compared to the\n previous day. The alignment of the cervical spine is unchanged with severe\n degenerative change throughout the cervical spine that is most prominent at\n the levels of L4-5 and C5-6. A fracture with adjacent sclerosis traverses the\n base of the dens that appears unchanged when compared to the previous day. A\n surgical drain is in place as well as posterior staples and prevertebral soft\n tissue swelling, which are consistent with the patient's recent surgical\n history.\n\n IMPRESSION: Unchanged examination when compared to the previous day with\n apparent fracture at the base of the dens and a posterior cervical fusion\n device extending from C3 to the occiput. Unchanged alignment of the cervical\n spine.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 867211,
"text": " 2:00 PM\n CHEST (PA & LAT) Clip # \n Reason: ? CHF\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with with cardiac history who recieved lasix today\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for CHF.\n\n CHEST X-RAY: Comparison is made to prior film from one day earlier. There is\n a new feeding tube. It is malpositioned, with its distal radio-opaque portion\n in the distal esophagus. Cardiac and mediastinal contours are stable, with\n enlargement of the cardiac silhouette again noted. There is no frank CHF\n versus infiltrate. The lateral view demonstrates small bilateral pleural\n effusions.\n\n IMPRESSION: 1) Malpositioned feeding tube. This was called to the nurse\n caring for this patient.\n 2) No overt CHF.\n 3) Small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 867282,
"text": " 8:47 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval NG placement\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with S/P C3 occipit fusion, H/O CHF. s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n eval NG placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of NG tube position.\n\n COMPARISON: Study from 2 hours prior, on .\n\n PORTABLE AP CHEST RADIOGRAPH: An enteric feeding catheter tube is seen, and\n has been repositioned. The tip appears to be within the proximal stomach. The\n remainder of the exam is unchanged from the most recent study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 867271,
"text": " 7:14 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval NGT placement\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with S/P C3 occipit fusion, H/O CHF. s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n Eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate enteric feeding catheter position.\n\n COMPARISON: Study from the same day, , one hour prior.\n\n PORTABLE AP CHEST RADIOGRAPH: Again seen is an enteric feeding catheter with\n the tip positioned within the gastric fundus. It does not appear to\n definitively pass superior to the gastroesophageal junction. This appears\n unchanged from the prior study. The remainder of the exam, including the lung\n fields, hilar, mediastinal contours, and surgical drain within the soft\n tissues of the neck are stable in appearance.\n\n IMPRESSION: No apparent interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 867587,
"text": " 11:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 80 yr old woman s/p cervical fusion now with new onset heada\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with\n REASON FOR THIS EXAMINATION:\n 80 yr old woman s/p cervical fusion now with new onset headache please assess\n for stroke/hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Status post cervical fusion with new onset of headache. Assess for\n stroke or hemorrhage.\n\n TECHNIQUE: Noncontrast head CT scan.\n\n FINDINGS: The large posterior cervical metallic internal fixation device\n extending from the occipital bone to the C3-C4 level creates extensive streak\n artifacts, which render the posterior fossa images, particularly near the\n medulla, essentially uninterpretable. Allowing for this significant technical\n limitation, there is no definite sign for the presence of an intracranial\n hemorrhage or obvious major vascular territorial infarction. There is mild-\n to-moderate generalized brain atrophy, which is relatively age-appropriate. A\n minor degree of low density is noted in the periventricular white matter of\n both cerebral hemispheres, likely representing chronic microvascular\n infarction. There are no other overt extracranial abnormality seen, but again\n the study is of limited quality due to the extensive metallic internal\n fixation devices.\n\n CONCLUSION: Poor quality study, with no overt signs for intracranial\n hemorrhage or obvious infarction at this time.\n\n COMMENT: There are no preceding head imaging studies from this hospital\n available for comparison or correlation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 867266,
"text": " 6:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval NGT site\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with S/P C3 occipit fusion, H/O CHF. s/p NGT placement\n REASON FOR THIS EXAMINATION:\n eval NGT site\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of NG tube placement. Status post cervical fusion.\n\n COMPARISON: Study from .\n\n PORTABLE AP CHEST RADIOGRAPH: Enteric feeding catheter is seen and has been\n advanced in comparison to the prior study. The tube and the tip appear to be\n within the gastric fundus, and does not definitely pass into the hiatus. The\n lung fields are clear. No pleural effusions or pneumothorax is identified. A\n drain is seen extending into the soft tissues of the neck, with several\n surgical clips, likely from recent surgery. The heart size and mediastinal\n contours are stable in appearance. Degenerative changes are seen within the\n mid thoracic spine.\n\n IMPRESSION: Entire feeding catheter coils within the tube with the tip\n positioned at the gastric fundus. If there is concern that the tip passes\n beyond the GE junction, further evaluation with fluoroscopic imaging can be\n obtained.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 868141,
"text": " 12:24 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for PNA\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80F s/p C3 occiput fusion, s/p demand myocardial ischemia, COPD, with NGT and\n increasing WBC\n REASON FOR THIS EXAMINATION:\n Please evaluate for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female patient with myocardial ischemia, COPD and\n nasogastric tube.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared\n with the previous study of .\n\n The patient has underlying pulmonary emphysema. There is prominence of the\n pulmonary vasculature and cardiomegaly indicating superimposed mild congestive\n heart failure. There is probably a small left pleural effusion, which appears\n decreased in size.\n\n A feeding tube terminates in the gastric fundus. No pneumothorax is seen.\n\n IMPRESSION: Mild congestive heart failure with cardiomegaly with small left\n pleural effusion. Emphysema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-06 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 868739,
"text": " 9:08 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: PLease image diaphragm to evaluate for free air\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with severe abdominal pain p PEG placement\n REASON FOR THIS EXAMINATION:\n PLease image diaphragm to evaluate for free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain following PEG placement.\n\n An upright view is obtained. There is no free air. A PEG is noted\n terminating in the left upper quadrant in the region of the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 868621,
"text": " 11:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with S/P C3 occipit fusion, H/O CHF. s/p NGT placement\n now with WBC 20\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent cervical fracture. Hx CHF, now increasing leukocytosis.\n\n AP SUPINE CHEST: Comparison to . NG tube has been removed. Heart\n size upper limits of normal but stable. Mediastinal and hilar contours are\n unremarkable. There is underlying emphysema. No evidence of consolidation to\n suggest aspiration or pneumonic infiltrate. Improvement in underlying\n congestive heart failure.\n\n IMPRESSION: No evidence of pneumonia. Interval improvement in mild volume\n overload/CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-10 00:00:00.000",
"description": "C-SPINE NON-TRAUMA 2-3 VIEWS",
"row_id": 869289,
"text": " 3:05 PM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: evaluate for alignment\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with h/o C3-occipital fusion now with hardware out of place.\n REASON FOR THIS EXAMINATION:\n evaluate for alignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess fusion.\n\n AP and lateral views of the cervical spine (three radiographs) show posterior\n fusion of the occiput to the C1, C2, and C3 elements. There are screws in the\n posterior elements of C3 and in the occiput with corresponding wires in the\n posterior portions of C1 and C2. There is disk narrowing at most levels with\n grade I posterior listhesis of several mid cervical vertebral bodies. There\n is 8 mm of posterior displacement of C2 body relative to C1 indicating\n disruption of the transverse ligament and/or disruption of the poorly\n visualized dens. The C1-2 malalignment has equivocally occurred since exam (difficult assessment due to change in positioning) and there is\n interval removal of the posterior skin staples. Posterior fixation rods\n remain unchanged.\n\n IMPRESSION: Suboptimal assessment posterior cervical/occipital fusion.\n Possible interval C1-2 subluxation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-10 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 869287,
"text": " 2:50 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: evaluate alignment/hardware (please do images with saggital\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with h/o C3-occipital fusion with recent CT neck showing\n misplaced wire and a screw.\n REASON FOR THIS EXAMINATION:\n evaluate alignment/hardware (please do images with saggital and coronal\n reconstruction)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old with occipital to C3 fusion with recent CT\n demonstrating misplaced wire and screw.\n\n TECHNIQUE: CT of the cervical spine without IV contrast. Coronal and\n sagittal reformatted images were obtained.\n\n Comparison is made to neck CT from one day earlier.\n\n FINDINGS:\n There is a transverse fracture through the odontoid process with anterior\n displacement of the proximal portion of the dens. Margins around the fracture\n site are somewhat sclerotic indicating a chronic process. In addition, there\n appears to be a fracture of the posterior right aspect of the ring of C1, also\n with sclerotic margins indicating a somewhat chronic process. As noted on the\n CT from one day earlier, the right-sided C1 cerclage wire does not encircle\n arch of C1. Presumably, this has become displaced through the fracture in the\n posterior portion of the ring of C1. The left-sided cerclage wire is again\n noted to encircle the posterior elements of C2 and the posterior portion of\n the arch of C1. A fusion plate with two screws is seen along the base of the\n skull. Pedicle screws are seen in the body of C4. As noted on yesterday's\n CT, the left-sided screw is not within the pedicle and is located at the edge\n of the C3-4 facet, outside of the osseous structures. The right-sided screw\n is well seated within the lamina.\n\n There is moderate-to-severe multilevel spinal stenosis in the upper and mid\n cervical spine with multilevel degenerative changes. Prevertebral soft\n tissues appear unremarkable. The visualized portions of the upper lung fields\n are clear.\n\n IMPRESSION:\n Fractures of the posterior right aspect of the ring of C1 and the mid portion\n of the odontoid process as described above. There is no change in appearance\n of fusion hardware compared to the study of one day earlier. Presumably, the\n right-sided C1 cerclage wire has become displaced through the posterior ring\n fracture site.\n (Over)\n\n 2:50 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: evaluate alignment/hardware (please do images with saggital\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 869006,
"text": " 8:31 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for infiltrate\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80F s/p C3 occiput fusion, s/p demand myocardial ischemia, COPD with\n persistent leukocytosis.\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman status post C3 fusion, COPD with persistent\n leukocytosis.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: Cardiac, mediastinal and hilar contours are stable.\n Pulmonary vasculature is unremarkable. The lungs are clear. The diaphragms\n are flattened. There are no definite pleural effusions. Osseous and soft\n structures are stable.\n\n IMPRESSION: COPD. No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-09 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 869138,
"text": " 2:58 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: evaluate for sinusitis\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with fever and leukocytosis\n REASON FOR THIS EXAMINATION:\n evaluate for sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with fever and leukocytosis. Evaluate for\n sinusitis.\n\n TECHNIQUE: Axial non-contrast CT scans through the paranasal sinuses were\n performed. No previous studies of the sinuses are available for comparison.\n\n FINDINGS:\n\n There is a small amount of mucosal thickening in the left maxillary sinus. No\n fluid level is identified. The right maxillary sinus is clear. There is a\n single opacified left posterior ethmoid air cell. The frontal sinus and\n sphenoid sinus cavities are clear. Visualized portions of the mastoid air\n cells and middle ear cavities are normally aerated.\n\n IMPRESSION: There is no sinus fluid to indicate acute sinusitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-09 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 869139,
"text": " 2:59 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: FEVER, LEUKOCYTOSIS, PHARYNGEAL EDEMA, ULCERATION\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with fever, leukocytosis, pharyngeal edema and ulceration.\n REASON FOR THIS EXAMINATION:\n Evaluate to mass/abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, leukocytosis, pharyngeal edema and ulceration, evaluate\n for mass or abscess.\n\n COMPARISON: Plain films of the cervical spine dated .\n\n TECHNIQUE: Axial MDCT images were obtained through the neck following the\n administration of 100 cc of intravenous Optiray.\n\n CONTRAST: Intravenous nonionic contrast was administered due to the patient's\n debility.\n\n CT OF THE NECK WITH INTRAVENOUS CONTRAST: The patient is status post fusion\n procedure, with fixation plate extending from the posterior aspect of the\n occiput to the C4 vertebra. The right C1 cerclage wire does not appear to\n encircle the arch of C1. No postoperative CT of the neck is available to\n determine if this represents a change in position. The left C1 cerclage wire\n encircles the left posterior arch of C1 and cerclage wires about the posterior\n elements of C2 are noted in symmetric position bilaterally. A left- sided C4\n screw is located at the edge of the C3-4 facet and is not lodged in bone. The\n right C4 screw is seated within the lamina. There is persistent spinal\n stenosis from approximately C3 through C6, due to posterior spondylosis.\n\n There is thickening of the posterior nasopharyngeal mucosa and soft tissue\n thickening within the prevertebral tissues anterior to C3 and C4. No discrete\n fluid collection is identified within the retropharyngeal space. There are\n several small anterior and posterior cervical triangle lymph nodes, which are\n subcentimeter in size.\n\n The visualized portions of the lung apices appear unremarkable.\n\n IMPRESSION:\n 1) Slight thickening of the posterior nasopharyngeal mucosa and thickening of\n the prevertebral soft tissues anterior to C3 and C4 without evidence of\n discrete fluid collection. Clinical correlation is recommended.\n\n 2) Displaced cerclage wire adjacent to the arch of C1 on the right and left\n C4 screw not located in the osseous lamina but at the edge of the C3-4 facet.\n\n 3) Multilevel cervical spinal stenosis.\n\n (Over)\n\n 2:59 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: FEVER, LEUKOCYTOSIS, PHARYNGEAL EDEMA, ULCERATION\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-08 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 868984,
"text": " 3:37 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval swelling for source; inflammatory, infectious, etc.\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p cervical fusion 17 days ago with persistent swelling\n where pt unable to swallow\n REASON FOR THIS EXAMINATION:\n eval swelling for source; inflammatory, infectious, etc.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fusion of occiput-C3. Patient unable to swallow post\n surgery. Evaluate for aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOW: The study was performed in conjunction with a\n speech therapist. Barium of various consistencies, including nectar thick,\n thin and pudding were administered. There is evidence of prevertebral soft\n tissue swelling, posteriorly and left laterally. During swallowing, the\n epiglottis was unable to deflect appropriately. In addition, the boluses\n consistently moved down the right side of the posterior pharynx. There was\n some regurgitation of contrast material into the nasopharynx. No aspiration\n events were demonstrated.\n\n IMPRESSION: Prevertebral soft tissue swelling predominantly posteriorly and\n to the left, interfering with the mechanics of swallowing. Please refer to\n the report of speech pathologist for further details.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-06 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 868770,
"text": " 2:19 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: eval for bleed, hematoma, perforation, e/o infection\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p PEG s/p cath now with 6 point Hct drop and abdominal pain\n in LLQ, LUQ\n REASON FOR THIS EXAMINATION:\n eval for bleed, hematoma, perforation, e/o infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post percutaneous gastrostomy tube and catheterization,\n now with a six-point hematocrit drop and left lower quadrant abdominal pain.\n\n TECHNIQUE: MDCT images of the abdomen and pelvis were acquired following\n administration of oral 150 cc of Optiray IV contrast. Coronal and sagittal\n reconstructions were made.\n\n COMPARISON: Abdominal radiographs from earlier the same day.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is bibasilar atelectasis, but no\n discrete pulmonary nodules, pleural, or pericardial effusions. There is no\n free intraabdominal fluid or air. The liver, spleen, gallbladder, and\n pancreas are unremarkable. There is mild dilatation of the extrahepatic and\n central intrahepatic biliary tree, which is at the upper limits of normal\n given the patient's age. Several low attenuation foci are seen within both\n kidneys, which are not fully characterized but could be cysts. No\n pathologically enlarged mesenteric or retroperitoneal nodes are seen. The\n stomach contains a G-tube in appropriate position in the antrum. No contrast\n leak is visualized. Small bowel is all normal in caliber.\n\n There is a large fusiform infrarenal aortic aneurysm with maximal axial\n dimensions of 4.5 x 4.8 cm. Dilatation extends into the aortic bifurcation.\n The supradiaphragmatic descending aorta is also very dilated, with maximal\n axial dimensions of 4.3 x 4.5 cm. Also noted is stenosis of the origins of\n the SMA and . These vessels also demonstrate heavy vascular calcification.\n A large portion of the infrarenal aortic aneurysm is thrombosed. The distance\n from the renal arteries to the start of dilatation is approximately 13 mm.\n There is no evidence of retroperitoneal hemorrhage, or stranding, with a clear\n fat plane visible around the aneurysm. A deeply penetrating anterior\n ulceration is seen in the superior aspect of the aneurysm sac.\n\n CT OF THE PELVIS WITH IV CONTRAST: There are scattered colonic diverticuli,\n but no evidence of acute diverticulitis. There is no free fluid in the\n pelvis. The bladder contains a Foley catheter and air. No enlarged inguinal\n or pelvic nodes are seen.\n\n BONE WINDOWS: Degenerative changes are seen within both hips, right greater\n than left. Several bone islands are also visualized. Degenerative changes\n (Over)\n\n 2:19 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: eval for bleed, hematoma, perforation, e/o infection\n Admitting Diagnosis: C1-2 INSTABILITY/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are also present within the spine, where there is a predominantly convex right\n rotatory scoliosis.\n\n IMPRESSION:\n 1) 4.5 x 4.8 cm infrarenal aortic aneurysm with 13 mm neck between renal\n arteries and proximal aneurysm sac.\n 2) Deep area of ulceration anteriorly within the superior aspect of the\n aneurysm sac. No evidence of active extravasation or dissection.\n 3) Dilated descending thoracic aorta above diaphragmatic hiatus, maximal\n axial dimensions of 4.3 x 4.5 cm.\n 4) G-tube located appropriately in stomach. No evidence of free air or free\n fluid within the abdomen.\n 5) Stenotic origins of the celiac artery and SMA. These vessels are also\n heavily calcified.\n 6) No evidence of acute diverticulitis. No evidence of retroperitoneal\n hemorrhage.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-07 00:00:00.000",
"description": "Report",
"row_id": 156254,
"text": "Sinus rhythm. No change since the previous tracing of .\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-05 00:00:00.000",
"description": "Report",
"row_id": 156255,
"text": "Sinus rhythm with one ventricular premature beat. No change since the previous\ntracing of . Previously described abnormalities persist.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2180-04-27 00:00:00.000",
"description": "Report",
"row_id": 156256,
"text": "Sinus rhythm\nLead(s) unsuitable for analysis: V2\nLeftward axis\nIV conduction defect\nLeft ventricular hypertrophy\nInferior/lateral ST-T changes may be due to hypertrophy and/or ischemia\nLeft atrial abnormality\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2180-04-24 00:00:00.000",
"description": "Report",
"row_id": 156483,
"text": "Sinus rhythm.\nBorderline IV conduction defect\nLeft ventricular hypertrophy\nSeptal ST elevation - cannot rule out myocardial injury\nExtensive ST-T changes are probably due to ventricular hypertrophy\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2180-04-23 00:00:00.000",
"description": "Report",
"row_id": 156484,
"text": "Sinus rhythm. Since the previous tracing of probably no significant\nchange.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2180-04-22 00:00:00.000",
"description": "Report",
"row_id": 156485,
"text": "Sinus rhythm. Since the previous tracing of T waves are again inverted\nin leads III and aVF. Otherwise, findings are as previously described.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2180-04-22 00:00:00.000",
"description": "Report",
"row_id": 156486,
"text": "Sinus rhythm. Since the previous tracing of the rate has decreased and\nST-T wave abnormalities are less marked.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2180-04-22 00:00:00.000",
"description": "Report",
"row_id": 156487,
"text": "Sinus tachycardia. Since the previous tracing of there are new\nST segment depressions in the inferolateral leads and the Q-T interval has\nshortened. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2180-04-17 00:00:00.000",
"description": "Report",
"row_id": 156488,
"text": "Sinus rhythm with a single atrial premature beat. Borderline intraventricular\nconduction delay. Left ventricular hypertrophy. Clinical correlation is\nsuggested. No previous tracing available for comparison.\n\n"
}
] |
27,660 | 193,625 | A/P: 77 y/o Female with HTN, DM2, CAD S/P CABG, Afib, ESRD S/P Renal Transplant, and RAS S/P Angioplasty with rising creatinine and elevated blood pressure, but asymptomatic. . 1. Acute on Chronic Renal Failure: Likely etiology of rising creatinine is worsening of her chronic kidney disease due to hypertensive nephrosclerosis and diabetic nephropathy. Urine studies were consistent with an intrinsic cause of renal failure and patient had nephrotic range proteinuria. Renal transplant ultrasound with Dopplers was negative for RAS and showed normal venous flow. Serum protein and urine protein had been negative in . The patient's diuretics were held for concern of renal hypoperfusion. Prograf levels were followed and were within therapeutic range, making renal failure secondary to prograf unlikely. - 2. Hypertension: Blood pressure was elevated while in hospital and patient's medications were changed to correct this. We increased her labetalol to 200mg, amlodipine was increased to 10mg and clonidine was increased to 0.2mg tid. - 3. Leg Edema: Has normal EF, so possibly diastolic failure vs. worsening renal disease. Etiology is most likely anasarca secondary to protein losing nephropathy. However, patient's diuretics were held. - 4. Right Basilar Decreased breath sounds: Likely pleural effusion. Doubt PNA given lack of cough, sputum, fevers. CXR unread but appears to have stable chronic R sided effusion. As appears stable otherwise, patient was not treated at this time. - 5. Irregular rate: Hx of Afib, not on coumadin. On ECG, NSR with PAC's, LVH and RBBB. - continue beta blocker as well rate controlled - coumadin has been held because of diverticular bleed requiring hemicolectomy - 6. DM Type II: - diabetic diet - regular insulin sliding scale - 7. CAD s/p CABG and stenting: No chest pain. - cont beta blocker and statin - not on aspirin or plavix, unclear when last stent was put in, but possibly stopped because of bleed. - 8. Diastolic Dysfunction: Pt was continued on antihypertensives with good effect. - 9. Secondary Hyperparathyroidism: Pt was continued on calcitriol. PTH level was checked and remained elevated. Calcium levels were within normal. - 10. Hypothyroidism: Continued on home regimen of levothyroxine; TSH elevated but free T4 normal - 11. Anemia: Likely ACD from renal disease. HCT was stable with no evidence of bleeding. - 12. h/o Gout: Allopurinol was held in house - Medications on Admission: nsulin 12 untis NPH and regular insulin sliding scale Prednisone 5 mg QAM Amiodarone 100 mg QOD Calcitriol 0.25 mcg DAILY Levothyroxine 100 mcg DAILY Pantoprazole 40 gm DAILY Labetolol 150 mg Tacrolimus (Prograf) 2 mg Furosemide 80 mg Amlodipine 5 mg DAILY Lipitor 10 mg DAILY Allipurinol 100 mg QHS Metolazone 2.5 mg QSAT and QTHURS Ferrous Sulfate 325 mg DAILY Sodium Bicarbonate 650 mg DAILY Potassium 20 mEQ Clonidine 0.1 mg Vitamin D Aranesp . Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Outpatient Lab Work Please draw CBC, chem-10, FK 506 level. Please fax results to transplant center at 12. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) UNITS Subcutaneous q AM. 15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Community VNA, Attelboro Discharge Diagnosis: Primary: Acute on chronic renal insufficiency Hypertension Diabetes Type II Atrial fibrillation Secondary: CAD s/p CABG Diastolic Dysfunction End Stage Renal Failure S/P Renal Transplant Secondary Hyperparathyroidism Hypothyroidism Anemia Discharge Condition: Good Discharge Instructions: You were admitted to the hospital with worsening renal function. This is most likely due to chronic kidney disease. You underwent a kidney biopsy while you were in the hospital. You should follow up with Dr. on . . You should also have your blood drawn on THIS FRIDAY. We have given you a prescription for this. You can have them drawn at the transplant center. . If you develop any worrisome symptoms such as abdominal pain, pain at the site of biopsy, bleeding, blood in your urine, pain with urination, , chest pain , shortness of breath, please contact your doctor or return to the emergency room. . Followup Instructions: You have the following appointment scheduled for you: Provider: , MD Phone: Date/Time: 8:00 Provider: , MD Phone: Date/Time: 10:30 | Premature atrial contractions arealso present. Premature atrial contractions. Right bundle-branch block.Left ventricular hypertrophy by voltage in lead V4. Sinus rhythm. Two core biopsies were obtained of the lower pole of the transplant kidney. 9:56 AM BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # Reason: eval for etiology of rising creatinine Admitting Diagnosis: S/P KIDNEY TRANSPLANT;INCREASED CREATINE MEDICAL CONDITION: 78 year old woman h/o transplant with rising creatinine REASON FOR THIS EXAMINATION: eval for etiology of rising creatinine FINAL REPORT CLINICAL INDICATION: Rising creatinine in a transplant patient. Compared to tracing of there is an increase in QRS voltageand ST-T wave changes are more pronounced. PROCEDURE: Ultrasound guidance was provided for the Radiology Department for core biopsy of the patient's transplant kidney by the Nephrology Department. | 2 | [
{
"category": "Radiology",
"chartdate": "2111-12-16 00:00:00.000",
"description": "GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)",
"row_id": 987610,
"text": " 9:56 AM\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: eval for etiology of rising creatinine\n Admitting Diagnosis: S/P KIDNEY TRANSPLANT;INCREASED CREATINE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman h/o transplant with rising creatinine\n REASON FOR THIS EXAMINATION:\n eval for etiology of rising creatinine\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Rising creatinine in a transplant patient.\n\n PROCEDURE: Ultrasound guidance was provided for the Radiology Department for\n core biopsy of the patient's transplant kidney by the Nephrology Department.\n Two core biopsies were obtained of the lower pole of the transplant kidney.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-12-15 00:00:00.000",
"description": "Report",
"row_id": 291765,
"text": "Sinus rhythm. Premature atrial contractions. Right bundle-branch block.\nLeft ventricular hypertrophy by voltage in lead V4. Non-specific ST-T wave\nchanges. Compared to tracing of there is an increase in QRS voltage\nand ST-T wave changes are more pronounced. Premature atrial contractions are\nalso present.\n\n"
}
] |
2,365 | 169,783 | 47 yo F with h/o HIV, HCV c/b cirrhosis and varices and 3 recent admissions for GIB and 2 PE's respectively, now s/p TIPS procedure with banding of varices. 1. HCV cirrhosis-Pt had a sucessful TIPS procedure. Post procedure she had elevated LFTs, which was thought to be related to post-TIPS and resolved over the course of the admission. Unasyn started post procedure for fever spike, but later d/c. Pt was called out of the unit after a 24 hour stay. U/S showed patent TIPS. LFTS continued to decline while on the floor until discharge. Pt D/c'd on lactulose 2. Fever- Post op fever covered with unasyn 3 gm IV q6 for possible atelectasis. Pt became afevrile with negative urine and blood culture. 3. PE/DVTs-s/p filter: Pts anticoagulation was held periprocedure and restarted later in course due to a low Hct (lowest was 26, recieved 2 units during stay) which responded and remained stable. It was resarted on with 10 mg coumadin qd over two days, which brought her INR to 2.7, goal. She will be D/c on coumadin 5 mg with INR check on Fri, and then every few days, with results to be faxed to Dr . 4. HIV/AIDS: HAART therapy stopped as LFTs increased but restarted on . Bactrim continued for HSV and PCP . CD4 and viral load draw before D/c. 5. Anemia: Hct was low on , prompting two overall transfusion over 48 hours which she tolerated well. 6. Depression: Effexor and Trazodone continued. 7. Pain: Oxycodone and IV morphine prn for pain mgmt. D/c with oxycodone, two weeks supply. Pt has fentanyl patched at home. 8. IVDU: Continued Methadone in , recieve it with gentiva as outpt. 9. Wheezing/Asthma: albuterol inhaler prn. Pt was D/c in good condition after successful removal of central line with good hemostasis and dressing. Pt will follow up with Dr later this month and Dr in the future. | A 0.035 wire was advanced through the micropuncture sheath into the right hepatic vein under fluoroscopic guidance. Again seen is a left-sided central venous catheter, with the tip now positioned in the distal SVC. This demonstrated hepatopetal flow into the inferior vena cava. 12:06 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOP ABD/PEL LIMITED Reason: please assess patency of shunt. PORTABLE AP CHEST: A newly inserted left internal jugular central venous line tip is in the right atrium, and should be withdrawn several cm. IMPRESSION: Repositioning of the left-sided central venous catheter is seen with the tip now positioned in the distal SVC. The tapered catheter and stiffening cannula were removed. IMPRESSION: S/P left internal jugular central venous line placement. The tapered catheter was advanced over the wire until it was appropriately positioned in the right hepatic vein. The 4.5 Fr micropuncture sheath with inner dilator was exchanged for the access needle. A 0.018 guidewire was advanced through the access needle until the tip was present in the superior vena cava. DOPPLER FINDINGS: The patient's TIPS is patent with flow velocities within the proximal TIPS measured at 98 cm/sec, within the mid TIPS at 162 cm/sec, and within the distal tips at 123 cm/sec. The tip is in the right atrium and should be withdrawn several cm. Portal venography performed with the catheter tip positioned in the superior mesenteric vein demonstrated significant variceal branches from the left gastric vein. In the Recovery Room, the 9-French sheath was removed from the right internal jugular vein and manual pressure was held until hemostasis was achieved. The 10-French bright tip sheath was advanced into the proximal right hepatic vein. The C2 catheter was then positioned in the superior mesenteric vein. ANESTHESIA: General endotracheal. A balloon-occlusion catheter was advanced to a distal branch of the right hepatic vein. Comparison to earlier studies of demonstrated a pattern of interstitial pulmonary edema. A TIPS catheter is identified. With the use of a super stiff 0.035 glidewire, the main portal vein was entered. Slightly limited doppler examination shows a patent main portal vein with flow in a hepatopetal direction measured at 78 cm/sec. The main, right, and left hepatic arteries appear patent. FINDINGS: The pre-TIPS wedged hepatic venous pressure measured 39 mm Hg. Again, with the use of the 0.035 Glidewire, the C2 Cobra glide catheter was advanced into a separate variceal branch of the left gastric vein. Pressures were measured in the superior mesenteric vein, the free right hepatic vein, and the right atrium. FINAL REPORT INDICATION: Central venous line placement. The hepatic venous system as measured within the left and middle hepatic veins is patent. Left jugular CV line is in distal SVC. Over the Amplatz wire, a 5- French multipurpose catheter was advanced into the superior mesenteric vein. intrahepatic hematoma? intrahepatic hematoma? intraperitoneal blood? At this time, the glidewire was exchanged for a 0.035 super stiff amplatz wire. The 5-French catheter was advanced over the Glidewire until the tip was appropriately positioned in the main portal vein. The anterior right portal vein demonstrates expected hepatofugal flow. With the assistance of the 0.035 Glidewire, the C2 Cobra glide catheter was advanced into the left gastric vein. A 10- French bright-tip sheath with inner dilator from the - TIPS kit was advanced over the wire through the right atrium until the tip of the sheath was present in the IVC. 2) Portal venography demonstrated significant variceal branches from the left gastric vein. The liver has a coarsened nodular echotexture, consistent with cirrhosis. The balloon-occlusion catheter was removed an d a 5- French catheter with inner puncture needle was then advanced through the sheath. The shunt extended from the main portal vein to the distal right hepatic vein. The post-TIPS mean right atrial pressure measured 19 mm Hg. IMPRESSION: 1) Successful transjugular intrahepatic portosystemic shunt performed via the right internal jugular vein. FINAL REPORT CHEST 2 VIEWS PA & LATERAL: HISTORY: TIPS procedure with fever and crackles. Venography performed by hand injection via the C2 Cobra catheter demonstrated obliteration of the variceal branches. The inner dilator was removed. Under ultrasound guidance, the right internal jugular vein was accessed using a 21- gauge micropuncture needle. The pre-TIPS hepatic venous pressure gradient measured 23 mm Hg. The pre- TIPS hepatic venous pressure gradient measured 23 mm Hg. The hepatic venous pressure gradient was then measured. The post-TIPS portal venous pressure measured 23 mm Hg. Note is made of a very subtle underlying interstitial pattern within the lung parenchyma. The post-TIPS hepatic venous pressure gradient measured 4 mm Hg. The post-TIPS hepatic venous pressure gradient measured 4 mm Hg. IMPRESSION: Minimal residual interstitial pattern which is likely due to resolving interstitial pulmonary edema. FINDINGS: scale, color flow and Doppler exam of the right upper quadrant was performed. The gallbladder is incompletely distended. IMPRESSION: 1) Patent TIPS with wall-to-wall flow. After the administration of 2 g of Kefzol, followed by the induction of general anesthesia, the patient's right neck was prepped and draped in the standard sterile fashion. Needs to be anticoag'd but has h/o bleeding from esoph varices. The hepatic portion of the IVC appears patent. The TIPS is patent with wall- to-wall flow. Sludge and gallbladder wall edema. 5:46 PM CHEST (PORTABLE AP) Clip # Reason: pulled CVL back 3cm Admitting Diagnosis: CHRONIC HEPATITIS C; CHIRRHOSIS OF LIVER, ESOPHAGEAL VARICES\ TIPS/SDA MEDICAL CONDITION: s/p CVL placement REASON FOR THIS EXAMINATION: pulled CVL back 3cm FINAL REPORT INDICATION: Reevaluate central venous line position. | 8 | [
{
"category": "Radiology",
"chartdate": "2178-09-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 836751,
"text": " 2:08 PM\n CHEST (PA & LAT) Clip # \n Reason: pneumonia? effusion?\n Admitting Diagnosis: CHRONIC HEPATITIS C; CHIRRHOSIS OF LIVER, ESOPHAGEAL VARICES\\ TIPS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman recently in ICU s/p TIPS with fevers, crackles.\n\n REASON FOR THIS EXAMINATION:\n pneumonia? effusion?\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST : Compared to .\n\n CLINICAL INDICATION: Fever and crackles. Question pneumonia.\n\n A left internal jugular vascular catheter remains in satisfactory position.\n The heart size is normal. The lungs demonstrate no focal areas of\n consolidation. The previously noted small pleural effusions have nearly\n resolved in the interval with only minimal residual right pleural effusion\n remaining. Note is made of a very subtle underlying interstitial pattern\n within the lung parenchyma. Comparison to earlier studies of \n demonstrated a pattern of interstitial pulmonary edema.\n\n IMPRESSION: Minimal residual interstitial pattern which is likely due to\n resolving interstitial pulmonary edema. No new or worsening areas of\n opacification to suggest pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-09-03 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 836364,
"text": " 12:06 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: please assess patency of shunt.\n Admitting Diagnosis: CHRONIC HEPATITIS C; CHIRRHOSIS OF LIVER, ESOPHAGEAL VARICES\\ TIPS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman s/p TIPS now w/elevated bili, fevers, and elevated WBC\n REASON FOR THIS EXAMINATION:\n please assess patency of shunt and assess for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post TIPS on . Elevated bilirubin and fever.\n\n COMPARISON: Abdominal ultrasound of .\n\n FINDINGS: scale, color flow and Doppler exam of the right upper quadrant\n was performed. A TIPS catheter is identified. The TIPS is patent with wall-\n to-wall flow. The proximal, mid and distal velocities in the TIPS are 114,\n 191, 161 cm/sec respectively.\n\n The gallbladder is incompletely distended. There are stones an sludge in the\n gallbladder. The gallbladder wall is diffusely thickened but not edematous,\n consistent with chronic cholecystitis. This may be related to chronic liver\n disease. There is no intrahepatic or extrahepatic biliary ductal dilatation.\n The common duct measures 5 mm.\n\n IMPRESSION:\n\n 1) Patent TIPS with wall-to-wall flow.\n 2) Chronic cholecystitis.\n 3) Normal bile ducts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-09-06 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 836746,
"text": " 1:14 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: post tips complication? intrahepatic hematoma? intraperito\n Admitting Diagnosis: CHRONIC HEPATITIS C; CHIRRHOSIS OF LIVER, ESOPHAGEAL VARICES\\ TIPS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman s/p TIPS now falling Hct, RUQ pain, mild increase\n abdominal distension. hemodynamically stable.\n REASON FOR THIS EXAMINATION:\n post tips complication? intrahepatic hematoma? intraperitoneal blood?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old female status-post tips with right upper quadrant\n pain and increased abdominal distension.\n\n FINDINGS: There is no evidence of intraabdominal ascites. The liver has a\n coarsened nodular echotexture, consistent with cirrhosis. No intrahepatic\n biliary ductal dilatation is seen. The common duct is not dilated, measuring\n less than 6 mm in greatest dimension. There is evidence of gallbladder wall\n edema with sludge present within the gallbladder.\n\n DOPPLER FINDINGS: The patient's TIPS is patent with flow velocities within\n the proximal TIPS measured at 98 cm/sec, within the mid TIPS at 162 cm/sec,\n and within the distal tips at 123 cm/sec. The main portal vein is patent with\n a measured flow velocity appearing elevated at 79 cm/sec. The hepatic portion\n of the IVC appears patent. The hepatic venous system as measured within the\n left and middle hepatic veins is patent. The anterior right portal vein\n demonstrates expected hepatofugal flow. The left portal vein could not be\n visualized on this study. The main, right, and left hepatic arteries appear\n patent.\n\n IMPRESSION\n\n 1. Patent TIPS with wall-to-wall flow and no evidence of ascites. Slightly\n limited doppler examination shows a patent main portal vein with flow in a\n hepatopetal direction measured at 78 cm/sec. Flow velocities within the\n TIPS were measured from 98 to 162 to 123 cm/sec (proximal to distal).\n\n 2. Sludge and gallbladder wall edema. The finding could reflect the\n patient's chronic liver disease, however, a HIDA scan could be performed\n to better evaluate this finding.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836340,
"text": " 5:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulled CVL back 3cm\n Admitting Diagnosis: CHRONIC HEPATITIS C; CHIRRHOSIS OF LIVER, ESOPHAGEAL VARICES\\ TIPS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p CVL placement\n\n REASON FOR THIS EXAMINATION:\n pulled CVL back 3cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Reevaluate central venous line position.\n\n PORTABLE AP CHEST X-RAY: Comparison is made to a study from the same day,\n approximately 3 hours prior.\n\n Again seen is a left-sided central venous catheter, with the tip now\n positioned in the distal SVC. No pneumothorax is seen. The prominence of the\n pulmonary vasculature, consistent with CHF, is again seen and slightly\n improved compared to previous exam. Cardiac size is unchanged. No focal\n opacities or consolidations are seen.\n\n IMPRESSION: Repositioning of the left-sided central venous catheter is seen\n with the tip now positioned in the distal SVC. Slight improvement in CHF..\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-09-02 00:00:00.000",
"description": "EMBO NON NEURO",
"row_id": 836263,
"text": " 7:41 AM\n TIPS Clip # \n Reason: TIPS - spoke with . Please schedule for\n Contrast: OPTIRAY Amt: 340\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * INSERT HEPATIC HUNT TIPS 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * -51 MULTI-PROCEDURE SAME DAY 2ND ORDER OR> VENOUS SYSTEM *\n * -59 DISTINCT PROCEDURAL SERVICE 2ND ORDER OR> VENOUS SYSTEM *\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\n * F/U STATUS INFUSION/EMBO CATH, TRANSLUM ANGIO NONLASER *\n * CATH, TRANSLUM ANGIO NONLASER C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * STENT NOCOAT.NOCOVER W/ SYSTEM C1887 CATHETER GUIDING INF/PERF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER C2628 C=VAS-CATH OCCLUSION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with chronic HepC, cirrhosis with esoph varices who was\n admitted for pulm embolus s/p IVC filter placement. Needs to be anticoag'd but\n has h/o bleeding from esoph varices.\n REASON FOR THIS EXAMINATION:\n TIPS - spoke with . Please schedule for (tues). Attn:\n Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n HISTORY: 47 year old female with hepatitis C, cirrhosis, and grade III\n esophageal varices. Please perform TIPS.\n\n PROCEDURE: The procedure was performed by Dr. , Dr. \n , and Dr. . Dr. , the Staff Radiologist, was present\n and supervising throughout. After the risks and benefits of the procedure\n were discussed with the patient and informed consent was obtained, the patient\n was placed supine on the angiography table. After the administration of 2 g\n of Kefzol, followed by the induction of general anesthesia, the patient's\n right neck was prepped and draped in the standard sterile fashion. Under\n ultrasound guidance, the right internal jugular vein was accessed using a 21-\n gauge micropuncture needle. A 0.018 guidewire was advanced through the access\n needle until the tip was present in the superior vena cava. Using a #11 blade\n scalpel, the skin entry site was incised. The 4.5 Fr micropuncture sheath\n with inner dilator was exchanged for the access needle. The guidewire and\n inner dilator were then removed. A 0.035 wire was advanced through\n the micropuncture sheath into the right hepatic vein under fluoroscopic\n guidance. The venous access site was then sequentially dilated with number 6-\n , 8- , and 10-French dilators. A 10- French bright-tip sheath with inner\n dilator from the - TIPS kit was advanced over the wire\n through the right atrium until the tip of the sheath was present in the IVC.\n The inner dilator was removed. The sheath was assembled to a continuous side-\n arm flush. With the wire in the right hepatic vein, a 10- Fr -\n (Over)\n\n 7:41 AM\n TIPS Clip # \n Reason: TIPS - spoke with . Please schedule for\n Contrast: OPTIRAY Amt: 340\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n tapered catheter covering a 14- gauge metal stiffening cannula was\n introduced through the 10- French sheath. The tapered catheter was advanced\n over the wire until it was appropriately positioned in the right\n hepatic vein.\n\n A balloon-occlusion catheter was advanced to a distal branch of the right\n hepatic vein. With the balloon inflated, a wedged CO2 portal venogram was\n obtained. The balloon-occlusion catheter was removed an d a 5- French catheter\n with inner puncture needle was then advanced through the sheath. With the\n stiffening cannula angled 90 degrees anteriorly, multiple passes were made\n with the needle until a branch of the right portal vein was successfully\n entered. With the use of a super stiff 0.035 glidewire, the main portal vein\n was entered. The 5-French catheter was advanced over the Glidewire until the\n tip was appropriately positioned in the main portal vein. At this time, the\n glidewire was exchanged for a 0.035 super stiff amplatz wire. The tapered\n catheter and stiffening cannula were removed. The 10-French bright tip sheath\n was advanced into the proximal right hepatic vein. Over the Amplatz wire, a 5-\n French multipurpose catheter was advanced into the superior mesenteric vein.\n The hepatic venous pressure gradient was then measured. Following this, the 5-\n French multipurpose catheter was exchanged for a balloon angioplasty catheter.\n The liver parenchyma was sequentially dilated along the course of the\n parenchymal tract extending from the main portal vein to the distal right\n hepatic vein with an 8-mm x 4-cm balloon. A self-expanding bare metal 10-mm x\n 94-mm Wallstent was deployed along the previously dilated tract. The shunt\n extended from the main portal vein to the distal right hepatic vein. Following\n deployment, the stent was sequentially dilated with a 10-mm x 4-cm balloon. A\n 5-French C2 Cobra Glide catheter was advanced over a 0.035 Glidewire into the\n superior mesenteric vein. Portal venography was performed. This demonstrated\n hepatopetal flow into the inferior vena cava. There were multiple variceal\n branches present extending from the left gastric vein.\n\n With the assistance of the 0.035 Glidewire, the C2 Cobra glide catheter was\n advanced into the left gastric vein. With the catheter in a peripheral\n location, the Glidewire was removed. 7 cc of absolute alcohol was injected,\n followed by embolization of the variceal branch with two 3-mm x 4-cm\n microcoils and two 4-mm x 4-cm microcoils. Again, with the use of the 0.035\n Glidewire, the C2 Cobra glide catheter was advanced into a separate variceal\n branch of the left gastric vein. 6 cc of absolute alcohol was injected,\n followed by embolization with four separate 4-mm x 4-cm microcoils. Venography\n performed by hand injection via the C2 Cobra catheter demonstrated\n obliteration of the variceal branches. The C2 catheter was then positioned in\n the superior mesenteric vein. Pressures were measured in the superior\n mesenteric vein, the free right hepatic vein, and the right atrium. The C2\n Cobra glide catheter was removed.\n\n The 10-French angiographic sheath with side- arm flush was exchanged over a\n (Over)\n\n 7:41 AM\n TIPS Clip # \n Reason: TIPS - spoke with . Please schedule for\n Contrast: OPTIRAY Amt: 340\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n wire for a 9-French sheath. The sheath was sutured to the skin using a\n number 2-0 silk suture. The patient was extubated and transferred to the\n Recovery Room following the procedure. In the Recovery Room, the 9-French\n sheath was removed from the right internal jugular vein and manual pressure\n was held until hemostasis was achieved. The patient tolerated the procedure\n well with no immediate post-procedure complications.\n\n FINDINGS: The pre-TIPS wedged hepatic venous pressure measured 39 mm Hg. The\n free hepatic venous pressure measured 16 mm Hg. The pre-TIPS hepatic venous\n pressure gradient measured 23 mm Hg. The post-TIPS portal venous pressure\n measured 23 mm Hg. The post-TIPS mean right atrial pressure measured 19 mm Hg.\n The post-TIPS hepatic venous pressure gradient measured 4 mm Hg. Portal\n venography performed with the catheter tip positioned in the superior\n mesenteric vein demonstrated significant variceal branches from the left\n gastric vein. Two variceal branches were successfully treated with absolute\n alcohol, followed by embolization with microcoils.\n\n ANESTHESIA: General endotracheal.\n\n COMPLICATIONS: There were no immediate post-procedural complications.\n\n IMPRESSION:\n\n 1) Successful transjugular intrahepatic portosystemic shunt performed via the\n right internal jugular vein. The 10-mm x 94-mm bare metal Wallstent extends\n from the main portal vein to the distal right hepatic vein. Following\n deployment, the shunt was sequentially dilated with a 10-mm balloon. The pre-\n TIPS hepatic venous pressure gradient measured 23 mm Hg. The post-TIPS\n hepatic venous pressure gradient measured 4 mm Hg.\n\n 2) Portal venography demonstrated significant variceal branches from the left\n gastric vein. Two large variceal branches were treated with absolute alcohol\n injection followed by microcoil embolization. Post-embolization venography\n demonstrated obliteration of the variceal branches.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836331,
"text": " 3:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tip position, PTX?\n Admitting Diagnosis: CHRONIC HEPATITIS C; CHIRRHOSIS OF LIVER, ESOPHAGEAL VARICES\\ TIPS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p CVL placement\n REASON FOR THIS EXAMINATION:\n tip position, PTX?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Central venous line placement.\n\n PORTABLE AP CHEST: A newly inserted left internal jugular central venous line\n tip is in the right atrium, and should be withdrawn several cm. No\n pneumothorax is seen. Cardiac size is unchanged. There is increased\n prominence of the pulmonary vasculature consistent with CHF. No focal\n consolidations are seen.\n\n IMPRESSION: S/P left internal jugular central venous line placement. The tip\n is in the right atrium and should be withdrawn several cm. No pneumothorax.\n\n Results conveyed to the PACU anesthesia housestaff at the time the study was\n performed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-09-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 836464,
"text": " 5:53 PM\n CHEST (PA & LAT) Clip # \n Reason: PNA? effusions?\n Admitting Diagnosis: CHRONIC HEPATITIS C; CHIRRHOSIS OF LIVER, ESOPHAGEAL VARICES\\ TIPS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman recently in ICU s/p TIPS with fevers, crackles.\n\n REASON FOR THIS EXAMINATION:\n PNA? effusions?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS PA & LATERAL:\n\n HISTORY: TIPS procedure with fever and crackles.\n\n Left jugular CV line is in distal SVC. No pneumothorax. Allowing for low lung\n volumes, heart size is normal. There is mild upper zone redistribution and\n small bilateral pleural effusions. Minimal atelectasis is present in the left\n costophrenic region and at the right lung base but no definite evidence for\n pneumonia.\n\n IMPRESSION: Mild CHF with small bilateral pleural effusions and bibasilar\n atelectases. No definite pneumonia.\n\n"
},
{
"category": "ECG",
"chartdate": "2178-09-03 00:00:00.000",
"description": "Report",
"row_id": 276280,
"text": "Ectopic atrial rhythm. Since the previous tracing of the configuration\nof the P waves has changed. Non-specific T wave abnormalities persist.\n\n\n"
}
] |
30,588 | 165,603 | A/P: 78M IDDM, tachy brady syndrome, s/p PPM placement and s/p recent lacunar infarct, s/p cardioversion for a fib became bradycardic / hypotensive- tx to CCU, now hemodynamically stable and called out to floor w/ active issues as R trunk superficial hematoma and anemia related to this as well as acute on chronic renal failure. . #Rhythm: He was in atrial fibrillation upon admission. Given his reduced functional capacity, it was though he might benefit from cardioversion and short term anticoagulation, especially if he is in a controlled setting like rehab or skilled nursing facility to decrease risk of fall. Heparin was started, as was amiodarone. He underwent cardioversion, which was complicated by bradycardia and hypotension, with pacemaker firing at 40bpm. He spent three days in the PACU, the duration extended because of medication-related mental status changes. He stabilized and returned to the floor. He also did not remain in NSR, but reverted to afib, at which time anticoagulation and amiodarone was stopped. The decision to stop anticoagulation was made with discussions with his family. His pacemaker was adjusted to fire at 50 bpm given his hypotension during the episode. His aspirin was increased to 325mg qday. His rate control continued with carvedilol. . #CAD: He was transferred from the OSH for cardiac catheterization given his elevated enzymes and decrease in EF on ECHO. He did not undergo cath at because it was felt that medical management would be more appropriate in a patient with this many comorbidities. He was given aspirin as above as well as lipitor. . #Pump: (LVEF>55%) w/ LV diastolic dysfunction. He had a chest xray consistent with pulmonary edema in the PACU and he diuresed impressively with IV lasix. He was continued on carvedilol, though his ace-inhibitor was held because of his worsening renal failure. . # Anemia- likely secondary to superficial hematoma and in the setting of cardioversion in the PACU. HCT improved with transfusion of one unit of pRBCs back to his baseline during the stay of 30 or greater. . #neuro: He had focal weakness upon admission, old facial droop, and poor mental status. Per neurology, his symptoms/signs are likely due at least in part to lacunar infarct, pure motor of internal capsule. CT negative for bleed x 4 here. No MRI given pacer. His mental status continued to wax and wane, and he was though possibly to be encephalopathic from meds plus acute illness. He likely has a degree of dementia, and his symptoms can partly be attributed to delirium in the setting of changing environments, acute illness, and medications. Patient's course complicated by acute on chronic renal failure to poor PO intake, and urinary tract infection. . #Acute on chronic renal insufficiency: His creatinine initially improved upon admission, but worsened after his PACU stay, possibly related to his episode of hypotension or related to the IV lasix he received. His lasix was then held, as was his ace-inhibitor. . #DM: NPH and ISS . #FEN: diabetic/heart healthy diet, . #PPx: INR supertherapeutic - sc heparin when it drops below 2, bowel regimen . #Access: PIV . While in the ICU patient had multiorgan failure. Family meetings were held and the patient was made CMO and died comfortably on . | There is left ventricularhypertrophy. Borderline PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor parasternal views.Suboptimal image quality - poor subcostal views. Mild to moderate (+) MR. LVinflow pattern c/w restrictive filling abnormality, with elevated LA pressure.TRICUSPID VALVE: Normal tricuspid valve leaflets. Compared to theprevious tracing of atrial fibrillation with controlled ventricularresponse has appeared. Traceaortic regurgitation is seen. Wandering atrial pacemaker and occasional ventricular ectopy. The rhythm appears to be atrial fibrillation.Conclusions:The left atrium is moderately dilated. Tachypneic/hypoxic/hypotensive. The aortic root is mildly dilated at thesinus level. Sinus rhythm and frequent atrial ectopy and occasional ventricular ectopy.Diffuse non-specific ST-T wave changes. Pt currently appears comfortable, although remains with Cheynne resp and longer periods of apnea. There is borderline pulmonary artery systolichypertension. Pt resists yankauer; catheter passed through Right nare very gently x2 for large amt old blood and thin tan secr. Syncope.Height: (in) 68Weight (lb): 170BSA (m2): 1.91 m2BP (mm Hg): 123/80HR (bpm): 69Status: InpatientDate/Time: at 08:31Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild to moderate (+) mitral regurgitation is seen. Downsloping ST segments in thelateral leads suggest myocardial ischemia. Regular rhythm with a premature atrial contraction. Mildspontaneous echo contrast in the LAA. The right atrium is moderately dilated.There is mild symmetric left ventricular hypertrophy with normal cavity size.Due to suboptimal technical quality, a focal wall motion abnormality cannot befully excluded. Ventricular ectopy. Mild to moderate mitral andmild tricuspid regurgitation. Marked sinus bradycardia with occasional A-V conduction and idioventricularrhythm is new as compared with prior tracing of . The leftventricular inflow pattern suggests a restrictive filling abnormality, withelevated left atrial pressure. There is an anterior space which most likely represents a fatpad.Compared with the prior study (images reviewed) of , left ventriculardiastolic function has worsened. Normal interatrialseptum. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Dilated left atrium and leftatrial appendage with significant spontaneous echo contrast and reducedejection velocity of the left atrial appendage. NoTEE related complications.Conclusions:The left atrium is dilated. Right ventricular function. Mild [1+] TR. Cerebrovascular event/TIA.Height: (in) 66Weight (lb): 167BSA (m2): 1.85 m2BP (mm Hg): 118/53HR (bpm): 77Status: InpatientDate/Time: at 11:56Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA. Transferred to MICU for possible intubation.EVENTS: Adm to MICU; Bolus x2 for low UOP and Low BP;NEURO: Son stated to floor RN that pt's baseline is confused. IMPRESSION: Unchanged mild pulmonary edema. Atrial fibrillation with controlled ventricular response. Atrial fibrillation with controlled ventricular response. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Abd softly distended. Atrial fibrillation. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. FINDINGS: In comparison with study of , respiratory motion somewhat degrades the image. BP remained low and pt was given several fluid boluses. Diffuse non-specific ST-T wave changes.Compared to the previous tracing atrial fibrillation is new. Mild to moderate (+) mitralregurgitation is seen. The left atrial appendage emptying velocity is depressed (<0.2m/s).No thrombus is seen in the left atrial appendage. Aspirated. Atrial fibrillation with a controlled ventricularresponse. Compared to tracing #1 ST segmentdepression may be slightly less pronounced.TRACING #2 Mild to moderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild spontaneous echo contrast is present in the left atrialappendage. No AR.MITRAL VALVE: Normal mitral valve leaflets. Transvenous right ventricular pacer lead follows the expected course. Transmitral Doppler and TVI c/w GradeIII/IV (severe) LV diastolic dysfunction. Compared to theprevious tracing of wandering atrial pacemaker has appeared.TRACING #3 The ascending aorta is moderately dilated. CHEST AP: There is stable moderate cardiomegaly and pulmonary vascular congestion. Lateral ST segmentdepression. Enlargement of the cardiac silhouette persists. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Attempting to verbalize; incomprehensible.CV: Hr 70s-50s SR; BP difficult to evaluate by NBP and manually. Moderate cardiomegaly and mediastinal vascular engorgement are longstanding. Cannot exclude ischemia. Focal calcifications in aortic root.Moderately dilated ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Significant tetany all extremeties; decreased overnight. Depressed LAA emptying velocity(<0.2m/s) No thrombus in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body ofthe RA or RAA. No PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Compared to theprevious tracing of the ST segment depression previously recordedis more prominent with T wave inversions in leads I, aVL and V3-V6 andST segment depression in lead II. Respiratory distress. Subtle opacity in the right middle lobe with silohuette of the heart border may represent early infiltrate. Stools foul smelling, pastey brown x2 since adm to MICU.GU: Foley intact; low UOP. The aortic valve leaflets (3) are mildly thickened.There is no aortic valve stenosis. Transmitral Doppler and tissue velocity imaging are consistentwith Grade III/IV (severe) LV diastolic dysfunction. MS/Resp status did not improve. PATIENT/TEST INFORMATION:Indication: Left ventricular function. NPN 7a-7pAfter change of shift this am, pt unresponsive to sternal rub, with bilateral crackles all the way up. The lateral ST segment changes persist.Clinical correlation is suggested.TRACING #4 No ASD by 2D or color Doppler.AORTA: Complex (>4mm) atheroma in the aortic arch. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation. Guaiac +. Suboptimal image quality -poor suprasternal views. Complex (>4mm) atheroma inthe descending thoracic aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The degree of interstitial edema is not significantly changed. The hemidiaphragms are not sharply seen, though this could merely reflect the respiration of the patient rather than a true finding. LS coarse throughout. Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded. Doboff placed in IR. ST segment changes may be slightly morepronounced.TRACING #1 | 17 | [
{
"category": "Radiology",
"chartdate": "2119-04-04 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1006146,
"text": " 8:17 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please evaluate for acute pathology such as aspiration\n Admitting Diagnosis: S/P MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with vascular dementia, atrial fibrillation, DM, tachy-brady\n syndrome, now with cough.\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute pathology such as aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetes with cough.\n\n FINDINGS: In comparison with study of , respiratory motion somewhat\n degrades the image. Enlargement of the cardiac silhouette persists. The\n hemidiaphragms are not sharply seen, though this could merely reflect the\n respiration of the patient rather than a true finding. Prominence of central\n vessels persists and a pacemaker device remains in place.\n\n No gross evidence of pneumonia on this limited study. A lateral view would be\n most helpful if clinically possible.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-03-30 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1005524,
"text": " 2:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate lung fields, fluid status\n Admitting Diagnosis: S/P MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hypoxia, altered mental status\n REASON FOR THIS EXAMINATION:\n please evaluate lung fields, fluid status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man with hypoxia, altered mental status.\n\n COMPARISON: at 3:33 a.m.\n\n CHEST AP: There is stable moderate cardiomegaly and pulmonary vascular\n congestion. The degree of interstitial edema is not significantly changed.\n No pleural effusion is definitely identified. Single lead pacemaker or ICD\n device is in unchanged position.\n\n IMPRESSION: Unchanged mild pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-04-04 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1006246,
"text": " 6:43 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for interval change in imaging\n Admitting Diagnosis: S/P MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with probable aspiration during Dobhoff placement now with\n respiratory distress\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change in imaging\n ______________________________________________________________________________\n WET READ: JXKc TUE 8:00 PM\n Feeding tube continues to be coiled in stomach, tip not visualized.\n Cardiomegaly. Subtle opacity in the right middle lobe with silohuette of the\n heart border may represent early infiltrate. jkang (p).\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:07 P.M., \n\n HISTORY: Dobbhoff tube placed. Respiratory distress.\n\n IMPRESSION: AP chest compared to through at 3:57 p.m.:\n\n Over the course of the day, a new region of consolidation may have developed\n in the right mid lung partially obscuring a small portion of the right heart\n border, concerning for new pneumonia. Moderate cardiomegaly and mediastinal\n vascular engorgement are longstanding. There is no pulmonary edema or\n appreciable pleural effusion. Nasogastric tube is looped several times in the\n stomach before passing out of view. Transvenous right ventricular pacer lead\n follows the expected course. No pneumothorax.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2119-03-29 00:00:00.000",
"description": "Report",
"row_id": 83423,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA.\nHeight: (in) 66\nWeight (lb): 167\nBSA (m2): 1.85 m2\nBP (mm Hg): 118/53\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 11:56\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 thrombus/mass in the body of the LA. Mild\nspontaneous echo contrast in the LAA. Depressed LAA emptying velocity\n(<0.2m/s) No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of\nthe RA or RAA. No mass or thrombus in the RA or RAA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\nthe descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No\nTEE related complications.\n\nConclusions:\nThe left atrium is dilated. No thrombus/mass is seen in the body of the left\natrium. Mild spontaneous echo contrast is present in the left atrial\nappendage. The left atrial appendage emptying velocity is depressed (<0.2m/s).\nNo thrombus is seen in the left atrial appendage. No spontaneous echo contrast\nis seen in the body of the right atrium or right atrial appendage. No mass or\nthrombus is seen in the right atrium or right atrial appendage. No atrial\nseptal defect is seen by 2D or color Doppler. There are complex (>4mm)\natheroma in the aortic arch. There are complex (>4mm) atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) are mildly thickened.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are structurally normal. Mild to moderate (+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: No left atrial appendage thrombus. Dilated left atrium and left\natrial appendage with significant spontaneous echo contrast and reduced\nejection velocity of the left atrial appendage. Mild to moderate mitral and\nmild tricuspid regurgitation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2119-03-27 00:00:00.000",
"description": "Report",
"row_id": 83424,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Shortness of breath. Syncope.\nHeight: (in) 68\nWeight (lb): 170\nBSA (m2): 1.91 m2\nBP (mm Hg): 123/80\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 08:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). Transmitral Doppler and TVI c/w Grade\nIII/IV (severe) LV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\nModerately dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR. LV\ninflow pattern c/w restrictive filling abnormality, with elevated LA pressure.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality - poor subcostal views. Suboptimal image quality -\npoor suprasternal views. The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent\nwith Grade III/IV (severe) LV diastolic dysfunction. Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The ascending aorta is moderately dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. Mild to moderate (+) mitral regurgitation is seen. The left\nventricular inflow pattern suggests a restrictive filling abnormality, with\nelevated left atrial pressure. There is borderline pulmonary artery systolic\nhypertension. There is an anterior space which most likely represents a fat\npad.\n\nCompared with the prior study (images reviewed) of , left ventricular\ndiastolic function has worsened.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-04-05 00:00:00.000",
"description": "Report",
"row_id": 1655483,
"text": "MICU 7 RN Note 1900-0700\n\nSee FHP for details of admission to and transfers within.\n\nChange of MS today; stopped eating. Doboff placed in IR. Aspirated. Tachypneic/hypoxic/hypotensive. Transferred to MICU for possible intubation.\n\nEVENTS: Adm to MICU; Bolus x2 for low UOP and Low BP;\n\nNEURO: Son stated to floor RN that pt's baseline is confused. Baseline changed yesterday on floor; pt stopped eating. Significant tetany all extremeties; decreased overnight. Pt opens mouth to command but not coop with oral care. Squeezed both hands; reflex? Left weaker than right. Moved toes on command. Attempting to verbalize; incomprehensible.\n\nCV: Hr 70s-50s SR; BP difficult to evaluate by NBP and manually. Became easier as tetany lessened. AM BPs 80-90s/50-60s (MAP >60). Bolus LR 500 at midnight and LR 300cc at 0200 without increase in UOP. BP responded. LFA PIV; RAC PIV both patent. RAC good blood return. Venodynes on. Major ecchymotic areas back/flanks/left inner thigh. Pt fell at home earlier this month. Hct pending. Vit K 10mg x1 adm for INR 3.2. Chemistries pending (K and P high last eve). EKG done on admission.\n\nINTEG: Ecchymosis back/flank/L thigh. Psoriasis R mid axil, lower back and 2 on right thigh. Cream ordered; not on unit yet. Abr below elbow and right knee from fall at home.\n\nRESP: Kussmaul type respirations at times but primarily this am. RR 30-40s; did not decrease signif but did become quieter after oral sx. noted; depth more than rate. Neuro thinks he might have had new stroke. Secretions; old blood. Pt resists yankauer; catheter passed through Right nare very gently x2 for large amt old blood and thin tan secr. LS coarse throughout. Sats high 90s on 4L NC. (arrived MICU on NRB).\n\nGI: Doboff in place; XRay shows it looping in stomach. MD had said not to use it; please consult with team. Abd softly distended. +BS. Guaiac +. Stools foul smelling, pastey brown x2 since adm to MICU.\n\nGU: Foley intact; low UOP. 30/hour after 1st bolus; 5-10/hour since 2nd bolus. Creat increased after Lasix 20mg in previous days: diuresed 4L.\n\nMetabolic acidosis with Resp Compensation.\n\nID: Clindamycin DCd after one dose; awaiting to evaluate renal function. Temp trending up: Oral temp 101.1\n\nENDO: BS covered with 6 Humalog at midnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-04-05 00:00:00.000",
"description": "Report",
"row_id": 1655484,
"text": "RN Addendum 1900-0700\n\nHct 26.9/down from 30.3 last eve\nK+ 4.7 down from 5.1\nP 5.1 down from 7\nCr 4.7 UP from 4.6\n\nINR 4.0 (@0450) up from 3.2 (@9pm) (Vit K adm Subcu at 2300)\n\nIVF: 1L D5W w/3amps Bicarb completed at 0600.\n\nLR used for boluses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-04-05 00:00:00.000",
"description": "Report",
"row_id": 1655485,
"text": "NPN 7a-7p\nAfter change of shift this am, pt unresponsive to sternal rub, with bilateral crackles all the way up. Pt with no gag or cough reflex and unable to protect airway, and with progressively worse Cheynne resp. Decision was made to intubate the pt. Family was notified and ultimately intubtaion was put on hold. Pt was more bradycardic and hypotensive, EP interrogated pacer and set to demand at 70BPM. BP remained low and pt was given several fluid boluses. MS/Resp status did not improve. Pt's family arrived and family meeting was held. Family decided after discussion not to cont agressive measures and make pt comfortable. Pt currently appears comfortable, although remains with Cheynne resp and longer periods of apnea. Pt cont to have crackles in bilat lobes. Scopalomine patch applied and pt will be medicated with prn morphine as needed for comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-04-06 00:00:00.000",
"description": "Report",
"row_id": 1655486,
"text": "NPN 1900-0700:\nNeuro: After being unresponsive yesterday, pt received alert, opening eyes to verbal stimuli, verbalized his name and place (hospital), oriented x2, though confused otherwise, responded to verbal stimuli by squeezing hands, and denied pain/discomfort.\n\nResp: Breathing with difficulty at times, tachypneac, LS coarse all through, coughing nonproductively, airway applied in his mouth and copious thick yellowish to blood tinged secretions suctioned, pt got agitated at suctioning and hygiene times and other procedures, otherwise, calm and cooperative, didn't need any Morphine sulfate.\n\nCV: BP improved, received 72/32, later improved to 147/105, started on cefepime IV, difficult to palpate peripheral pulses, with 2 PIV lines.\n\nGI/GU: NPO, abdomen softly distended, BS present, passed 2 loose brownish BM, with Foley cath U/O 10-50 cc/hr.\n\nInteg: with abrasions and hematomas as per carevieu, T max 99.5.\n\nSocial: family called and updated on pt's improvement in responsiveness level, still CMO.\n\nPlan: continue monitoring mental status changes, pulmonary toileting, continue antibiotics, F/U on culture results, update family on plan of care, administer Morphine sulfate PRN, pt is till on comfort measures.\n"
},
{
"category": "ECG",
"chartdate": "2119-04-01 00:00:00.000",
"description": "Report",
"row_id": 224844,
"text": "Regular rhythm with a premature atrial contraction. Possible sinus rhythm\nalthough P wave morphology is difficult to discern. Lateral ST segment\ndepression. Cannot exclude ischemia. Compared to tracing #1 ST segment\ndepression may be slightly less pronounced.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-31 00:00:00.000",
"description": "Report",
"row_id": 224845,
"text": "Atrial fibrillation. Long QTc interval. Downsloping ST segments in the\nlateral leads suggest myocardial ischemia. Compared to the previous tracing\nof QTc interval is longer. ST segment changes may be slightly more\npronounced.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-30 00:00:00.000",
"description": "Report",
"row_id": 224846,
"text": "Atrial fibrillation with controlled ventricular response. Compared to the\nprevious tracing of atrial fibrillation with controlled ventricular\nresponse has appeared. The lateral ST-T wave changes consistent with ischemia\nhave increased. Clinical correlation is suggested.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-29 00:00:00.000",
"description": "Report",
"row_id": 224847,
"text": "Sinus rhythm and frequent atrial ectopy and occasional ventricular ectopy.\nDiffuse non-specific ST-T wave changes. Compared to the previous tracing\nof the rate has increased. The lateral ST segment changes persist.\nClinical correlation is suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-29 00:00:00.000",
"description": "Report",
"row_id": 224848,
"text": "Wandering atrial pacemaker and occasional ventricular ectopy. Compared to the\nprevious tracing of wandering atrial pacemaker has appeared.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-29 00:00:00.000",
"description": "Report",
"row_id": 224849,
"text": "Marked sinus bradycardia with occasional A-V conduction and idioventricular\nrhythm is new as compared with prior tracing of . Followup and clinical\ncorrelation are suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-29 00:00:00.000",
"description": "Report",
"row_id": 224850,
"text": "Atrial fibrillation with controlled ventricular response. Compared to the\nprevious tracing of the ST segment depression previously recorded\nis more prominent with T wave inversions in leads I, aVL and V3-V6 and\nST segment depression in lead II. These findings are consistent with\nacute anterolateral and apical ischemic process. There is left ventricular\nhypertrophy. Followup and clinical correlation are suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2119-03-26 00:00:00.000",
"description": "Report",
"row_id": 224851,
"text": "Artifact is present. Atrial fibrillation with a controlled ventricular\nresponse. Ventricular ectopy. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing atrial fibrillation is new.\n\n"
}
] |
32,439 | 184,523 | Admitted the day of surgery, taken to the OR for AVR (tissue) and raplacement of ascending aorta & total arch (please see operative note for details of procedure). Post-op, she was taken to the ICU on neosynephrine drip for BP support. Initially, she required some blood products & IV fluids for labile BP, she was placed on inotropes for cardiac index. She was duiresed over the next few days, and ultimately extubated on POD # 5. Her pressors & inotropes were also weaned off during those days. On POD # 6, a speech/swallow evalutaion was obtained due to some apparent difficulty swallowing. She was diagnosed w/mild to moderate dysphagia, and a diet of ground solids and thin liquids was ordered. She was transferred from the ICU to the telemetry floor later on POD # 6. Her beta blockers were started and increased, continues with diuresis, and has remained hemodynamically stable. She remains slow to progress from a physical therapy standpoint. She is now ready to be transferred to a rehab facility to continue with physical therapy & speech/swallowing therapy. | Mild (1+) mitral regurgitation is seen.POSTBYPASSLV systolic function is preserved. S/P AVR WITH REPLACEMENT OF AORTIC ARCHO: ARRIVED SEDATED ON PROPOFOL, TRANSIENT NEO, SR WITH MIN CT DRAINAGE. Nodefinite aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen. Neuro: Pt lethargic but . Indeterminate PAsystolic pressure.PERICARDIUM: Trivial/physiologic pericardial effusion. The mediastinal drain and left chest tubes are in expected position. og->lws w/billious drainage. +hypo bs. MIN CT DRAINAGE SINCE. There is mild aortic valve stenosis (area1.2-1.9cm2). Left basal consolidation and pleural effusion. There is left pleural effusion. Small amount of pneumomediastinum. repeat hct. 120'S WITH SHORT BURSTS OF AF. foley to bedside drainage with good HUO on Lasix gtt 2 mg/hr.Endo: SSRI per CVICU protocol.Skin: intact; sternal/mediastinal dsgs CDI. Suboptimalimage quality - ventilator. The mitral valve leaflets are mildlythickened. The aortic root is mildly dilated atthe sinus level. Lung sounds ess clear bilat. Evaluate pleural effusions. extubation once pt. MIN CT DRAINAGE. Preoperative assessment.Status: InpatientDate/Time: at 12:45Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Moderately dilated LV cavity. DSGS D+I. wean neo as tol. LS clear, dim at bases after suctioning. Mild AS (AoVA1.2-1.9cm2). Moderate (2+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is small apical pneumothorax with questionable basal small amount of intrapleural air. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. PACS AND RARE PVC NOTED. PATIENT/TEST INFORMATION:Indication: Tamponade/pericardial effusion.Height: (in) 63Weight (lb): 130BSA (m2): 1.61 m2BP (mm Hg): 160/90HR (bpm): 90Status: InpatientDate/Time: at 08:57Test: Portable TTE (Focused views)Doppler: Limited Doppler and no color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.Conclusions:PREBYPASSThe left ventricular cavity is moderately dilated. +pp bilat. The contoursof the descending thoracic aorta are unchanged compared to prebypass. Edematous. TamponadeBP (mm Hg): 80/50HR (bpm): 80Status: InpatientDate/Time: at 00:30Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). HCT 24.8-27.9-31.6. There is a 1.5-2.0cm echogenic filled space anterior to the rightventricle and left ventricle which appears similar to the pre-operative imagesof and likely represents epicardial fat. neuro) Pt. BS DIMINISHED LEFT BASE, CLEAR OTHERWISE. Up to 160's-170's with agitation, non sustained. CI VIA FICK>2 . PADS 23-29.CVP 20 HCT 24.8 ^1UPC. Endotracheal tube, right introducer sheath, nasogastric tube are unchanged. COnt lasix gtt per above parameters. Verified by venous sample to recal CCO. NEO OFF NTG. PERRLA. PERRLA. DL DR. RESP: VENT SETTINGS AND ABG AS PER FLOW. RESP: VENT SETTINGS AND ABG AS PER FLOW. Bilateral small pleural effusions and lower lobe atelectasis. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Responds well to Ativan IV. Post ABG WNL. Hypertensive with minimal activity or stimulation up to 170's. diuresis. tol cpapplan: cont milrinone, cpap as tol. prn dilaudid and ativan w/ effect.refer to flowsheet for specifics.assess: labile bp this am. Cont PSV wean. Loose BM x1. tol wean off neosynephrine. ID: AFEBRILE. cont afib. flush w/ NS. DSGS D+I. po k+ repletion.resp: lungs clear. + BOWEL SOUNDS. PERRLA. Lung sounds coars esuct sm th tan sput. extubation. afebrile. sinus tachy to low 110's. + PLACEMENT OGT. monitor vs/temp. cvicupt w/ labile bp this am neosynephrine to off and ntg on briefly then return to neo. Lung sounds coarse suct mod th tan sput. Upper extremities cool, palpable pulses/ good csm.Resp: ls crackles/ dim, exp wheezes when anxious, mdi's, enc cdb/is. Lung sounds sl coarse suct sm th tan sput(spec obt). Neuro: Lethargic, , follows commands. to wean when hemodynamically stable. resp careremains intub/vented in simv mode. repostion w/ efect.cv: vss as per flowsheet. k repleted. Follow cx. +BSGU: FOley patent. HCT 31. oriented.pain: c/o pain w/ turn to rt side only. PLEASE SEE FLOW AND ABG. ekg nsr, no ectopy, rate 70s, at , woke up and became htn to 180s, hr up to 120s. glucose rx per protocol, gtt is off now. Swan dc'd. to cont milrinone per team but began low dose lopressor via ogt. OGT clamped. BS course bilat. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. SVO2 70'S,CI >3. remained marginally hyotensive, still with borderline uo, until, when milrinone decreased to .125, sbp stabilized, and hr drifted back to 70s, weaning neo now. cx sent.assess: stable dayplan: pulm hygiene. bs clear to occ.rhonchorous,equal bilaterally. abd large, bsp. 7p-7aNeuro: Pt a/ox3, calls out at times, calms with reasurance/ reorientation, ? picc vs abx to po. ogt to lws, mod bile drainage. diuresis later. perrla wnl.CV: sr with pac's, lytes repleted. lft up. Plan extubation when more alertGI: NPO for ? Cont assess cardio/resp status. 20 MEQ KCL X2. vent mode change to cpap +5/ 15 ips w/ good abg. Anteroseptal myocardialinfarction of indeterminate age. sternal, mediastinal and right upper chest sites all inatct, scant amts of drainage, dressings changed. . ABD SOFT. MEDICATED ALSO FOR HTN.A: DIURSESING, SVO2 70'S, CI>3.P: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO TO KEEP SBP 100-130'S,SVO2,CI, PP, CT DRAINAGE, DSGS, RESP STATUS- SPUTUM C+S PENDING, NEURO STATUS- OFFER REASSURANCE-ATIVAN PRN, I+O- ? amiodarone change to po. svo2 in 70s. LASIX GTT TO BE STARTED IF UO DROPS BELOW 100ML/HR. Tachypneic with agitation. Cont PSV and wean to extub today. MILRINONE CONTINUES AT .125MCQ. ? ? ? good cough. AS PER ORDERS. to start heparin infusion. mae's, follows commands. Plan to extubate when pt more alert. Resp CarePt remains on vent. CI>3. SBP REQUIRING NEO PRESENTLY AT .25MCQ TO KEEP SBP 100-130. breath sounds coarse, ett suctioned for mod to large amts thick tan secretions. | 33 | [
{
"category": "Radiology",
"chartdate": "2158-03-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000382,
"text": " 7:44 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for widening mediastinum\n Admitting Diagnosis: AORTIC ANEURYSM\\AORTIC VALVE / ASCENDING AORTA REPLACEMENT;AORTIC ARCH REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78F s/p AVR(21Pericardial tissue)Replacement Asc Ao & Total Arch\n w/Reimplantation of Greater vessels(Medussa Graft) with hypotension\n REASON FOR THIS EXAMINATION:\n eval for widening mediastinum\n ______________________________________________________________________________\n WET READ: ARHb FRI 8:08 PM\n Compared to recent prior the upper mediastinum remains prominent though it is\n unclear how much of this stems from recent surgery. It does not appear\n significantly changed in the short term interim. If there is clinical concern,\n further evaluation with CT would be helpful.\n Increased interstitial markings may represent worsening volume overload.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after extensive cardiovascular\n surgery.\n\n Portable AP chest radiograph compared to , obtained at 6:11\n p.m.\n\n Compared to the previous radiographs, there is increase in interstitial and\n parenchymal perihilar opacities suggesting worsening of pulmonary edema. The\n post-surgical mediastinal contours are stable. The position of tubes and\n lines is unchanged.\n\n IMPRESSION:\n\n Worsening pulmonary edema. Findings were reported by the radiology resident,\n Dr. , on , shortly after the radiograph.\n\n dl\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-03-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1000425,
"text": " 9:03 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? PAC position after advancing it.\n Admitting Diagnosis: AORTIC ANEURYSM\\AORTIC VALVE / ASCENDING AORTA REPLACEMENT;AORTIC ARCH REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman POD # 1 from cardiac surgery\n REASON FOR THIS EXAMINATION:\n ? PAC position after advancing it.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: Cardiac surgery. Evaluate pulmonary arterial catheter position.\n\n COMPARISON: .\n\n FINDINGS: The pulmonary arterial catheter is more distal location than on\n previous radiographs. There is evidence of previous sternotomy. There is\n evidence of widening of the thoracic aorta as on previous radiographs. There\n is left basal consolidation. There is left pleural effusion. The\n endotracheal tube is in satisfactory position.\n\n IMPRESSION:\n 1. Interval advancement of pulmonary arterial catheter.\n 2. Thoracic aortic aneurysm.\n 3. Left basal consolidation and pleural effusion.\n\n\n DL\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-03-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000415,
"text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess bleesing\n Admitting Diagnosis: AORTIC ANEURYSM\\AORTIC VALVE / ASCENDING AORTA REPLACEMENT;AORTIC ARCH REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p AVR, arch replacement\n REASON FOR THIS EXAMINATION:\n Assess bleesing\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient after aortic valve and aortic\n surgery.\n\n Compared to the previous radiograph there is improvement in the interstitial\n opacities suggesting resolution of pulmonary edema. The tubes and lines are\n in unchanged standard position. There is no evidence of pneumothorax or\n increased pleural effusion. There is no mediastinal widening. The bibasal\n left more than right atelectasis is unchanged.\n\n\n\n\n DL\n\n DR. \n"
},
{
"category": "Echo",
"chartdate": "2158-03-18 00:00:00.000",
"description": "Report",
"row_id": 86091,
"text": "PATIENT/TEST INFORMATION:\nIndication: Tamponade/pericardial effusion.\nHeight: (in) 63\nWeight (lb): 130\nBSA (m2): 1.61 m2\nBP (mm Hg): 160/90\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 08:57\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe MD caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size is normal with moderately depressed\nfree wall contractility. A well-seated bioprosthetic aortic valve prosthesis\nis present. There is a 1.5-2.0cm echogenic filled space anterior to the right\nventricle and left ventricle which appears similar to the pre-operative images\nof and likely represents epicardial fat.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2158-03-18 00:00:00.000",
"description": "Report",
"row_id": 85745,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension, s/p aortic root and valve replacement, ? Tamponade\nBP (mm Hg): 80/50\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 00:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator. Emergency study performed by the cardiology fellow\non call.\n\nConclusions:\nSuboptimal study.\nThe left atrium is dilated. A partially echogenic \"mass\" is seen around the\nupper pole of the left atrium (clip #) suggestive of a hematoma. Overall\nnormal left ventricular cavity size and global systolic function (LVEF>55%).\nRight ventricular chamber size is normal. The aortic root is mildly dilated at\nthe sinus level. A bioprosthetic aortic valve prosthesis is present. No\ndefinite aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. The pulmonary artery systolic pressure could not be determined. No\ndefinite pericardial effusion is seen.\n\nIf clinically indicated, a follow-up study by a lab son is suggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2158-03-17 00:00:00.000",
"description": "Report",
"row_id": 85746,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic dissection. Aortic valve disease. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 12:45\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Moderately dilated LV cavity. Overall normal LVEF (>55%).\n\nLV WALL MOTION: remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Markedly dilated ascending aorta. Markedly dilated descending aorta\nComplex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (AoVA\n1.2-1.9cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nConclusions:\nPREBYPASS\nThe left ventricular cavity is moderately dilated. Overall left ventricular\nsystolic function is normal (LVEF>55%). The remaining left ventricular\nsegments contract normally. Right ventricular chamber size and free wall\nmotion are normal. The ascending aorta is markedly dilated to 6.0 cm. The\nsinotubular junction dimension is normal. The descending thoracic aorta is\nmarkedly dilated up to 6cm. There are complex (>4mm) atheroma in the\ndescending thoracic aorta. There is a large mural thrombus/old dissection\nafter the left subclavian artery travelling distally. The aortic valve\nleaflets (3) are mildly thickened. There is mild aortic valve stenosis (area\n1.2-1.9cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\n\nPOSTBYPASS\nLV systolic function is preserved. There is a well seated, well functioning\nbioprosthesis in the aortic position. There is trace AI of indeterminite\norigin. A graft prosthesis is visualized in the ascending aorta. The contours\nof the descending thoracic aorta are unchanged compared to prebypass.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-03-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1001394,
"text": " 7:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: AORTIC ANEURYSM\\AORTIC VALVE / ASCENDING AORTA REPLACEMENT;AORTIC ARCH REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n HISTORY: AVR. Evaluate pleural effusions.\n\n IMPRESSION: AP chest compared to through 19.\n\n Bilateral pleural effusion, moderate on the left, increased, small on the\n right, stable since . Heart size is mildly enlarged, but\n unchanged. Thoracic aorta is generally very large and tortuous, this too is\n probably stable. The upper lungs are grossly clear aside from vascular\n congestion. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1000820,
"text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c\n Admitting Diagnosis: AORTIC ANEURYSM\\AORTIC VALVE / ASCENDING AORTA REPLACEMENT;AORTIC ARCH REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ascending aortic arch replacement.\n\n CHEST, ONE VIEW: Comparison with (9:17 and 8:05 a.m.), (19:53 and 18:11), . Endotracheal tube, right introducer sheath,\n nasogastric tube are unchanged. Swan-Ganz catheter has been removed. The\n density outlining the aortic knob is less dense today, but slightly larger.\n There is also a tiny amount of air outlining the aortic knob, representing\n mediastinal air. Bilateral small pleural effusions and lower lobe\n atelectasis. Osseous structures are unchanged.\n\n IMPRESSION:\n 1. Slight widening but decreased density of aortic arch; this is of uncertain\n significance, and can represent changes in the periaortic hematoma, however,\n attention should be paid to this region in followup examinations.\n 2. Small amount of pneumomediastinum.\n 3. Bilateral pleural effusions and associated atelectasis.\n 4. Improved fluid status compared with .\n\n DL\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-03-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1000354,
"text": " 5:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: AORTIC ANEURYSM\\AORTIC VALVE / ASCENDING AORTA REPLACEMENT;AORTIC ARCH REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p AVR, Replacement of Asc Ao and Total Arch\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n WET READ: ARHb FRI 7:35 PM\n Multiple lines and tubes appear well positioned without PTX post aortic\n repair. Retrocardiac atelectasis and component of volume overload likely.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient after AVR, ascending aorta and\n arch replacement, with reimplantation of great vessels.\n\n Portable AP chest radiograph compared to previous chest CT obtained on , .\n\n The ET tube tip is 5 cm above the carina. The NG tube tip is in the stomach.\n The Swan-Ganz tip is at the level of right ventricular outflow tract. The\n mediastinal drain and left chest tubes are in expected position. The haziness\n and indistinctness of the aortic knob most likely related to recent surgery\n with some thickening of the left upper mediastinum related to the same cause.\n\n Mild pulmonary edema is present. Bibasal atelectasis left more than right is\n related to recent surgery. There is small apical pneumothorax with\n questionable basal small amount of intrapleural air.\n\n\n\n DL\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-17 00:00:00.000",
"description": "Report",
"row_id": 1672875,
"text": "S/P AVR WITH REPLACEMENT OF AORTIC ARCH\nO: ARRIVED SEDATED ON PROPOFOL, TRANSIENT NEO, SR WITH MIN CT DRAINAGE. PADS 23-29.CVP 20 HCT 24.8 ^1UPC.\n 1840 SVO2 40'S FROM 50'S, SBP 70'S WITH PADS AS HIGH AS 39. PT ROLLED SIDE TO SIDE- CT JUNKY STRIPPED,1L LR RECEIVED .5 MG CALCIUM CHLORIDE X2 ,APACED@90, #2UPC INFUSED. NEO TO 2 MCQ, TTE REVEALED SMALL PERICARDIAL EFFUSION, NO OTHER ISSUES, UNDERFILLED. NEO OFF NTG. PROPOFOL OFF WITH RIGHT ARM AND LEFT LEG MOVEMENT NOT TO COMMAND. TO REMAIN SEDATED OVERNIGHT.\n CARDIAC: SR TO A PACED WITHOUT ATRIAL/VENTRICULAR ARRTYHYMIAS. SBP 106 OFF NEO/NTG. PADS LOW TEWNTIES, CVP 15. SVO2 RECALLIBRATED AT 2140 61. FOLLOWING FICK CI>2. DSGS D+I. CT DRAINAGE WITH INCIDENT 200 ML IN 1 HOUR. MIN CT DRAINAGE SINCE. PALP PP FEET WARMER. HCT 24.8-27.9-31.6.\n RESP: VENT SETTINGS AND ABG AS PER FLOW. SUCTIONED FOR A SMALL AMOUNT OF THICK BLOODY SPUTUM/. BS CLEAR UPPER, DIMINISHED BIBASILAR, NO CHEST TUBE LEAK. O2 SATS >99%.\n NEURO: NOT REVERSED REMAINS ON PROPOFOL AT 40 MCQ. PROPOFOL OFF WITH HYPOTENSION MOVED RIGHT ARM AND LEFT LEG NOT TO COMMAND. PERL .\n GI: CARAFATE X1. OGT + PLACEMENT 75 ML GREEN BILIOUS DRAINAGE. ABD SOFT. ABSENT BOWEL SOUNDS.\n GU: MARGINAL UO'\n ENDO: HAS NOT RECEIVED ANY SSI. RECEIVED 20 UNITS IN OR.\n ID : VANCO AT 2100\n PAIN: RECIEVED 12.5MG IV X2. 2 MG MORPHINE X 2 DUE TO ^ SBP.\n SOCIAL: DAUGHTER AND FAMILY INTO VISIT AND UPDATED.\nA: DECREASED SVO2 TO 40'S WITH ^PAD AND HYPOTENSION.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, SVO2,FICK CI, CT DRAINAGE, PP, DSGS, RESP STATUS-? WAKE AND WEAN IN AM, NEURO STATUS-PROPOFOL TO REMAIN ON OVERNIGHT, I+O, LABS PENDING, AS PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-18 00:00:00.000",
"description": "Report",
"row_id": 1672876,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear bilat. ANGs improved and stable at present. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-18 00:00:00.000",
"description": "Report",
"row_id": 1672877,
"text": "shift update:\n\nneuro: remains sedated on propofol. no spontaneous movements except for with mouth care. pearl. medicated w/morphine 2mg ivp x2 for assumed pain.\n\ncv/skin: apaced at 90, underlying nsr 60's. x2 brief self limited runs of afib bp did not tolerate, magnesium given w/good effect. vwires not assessed d/t hemodynamic instablility. svo2 initially 63 w/co 3.6 by cco, pt turned to back svo2 dropped to low 50's sbp<80. 1.5l ns given & neo started, svo2 to 60, ci<2 & sbp 90's. hct 27->2u prbc given post hct 35. continues to look dry ci 1.96 svo2 high 50's, svr 1700 & remains on neo ho aware 500ns infusing w/imediate effect svo2 ^63%, currently trending down again. ct w/minimal drainage. ct's stripped by ho w/no change in output. +pp bilat. lytes wnl in am labs.\n\nresp: lungs clear but dim in bases. abg's good. no vent changes made overnight.\n\ngi/gu: abd soft. +hypo bs. og->lws w/billious drainage. foley patent w/clear yellow urine. hourly uop adequate.\n\nendo: bs>130 insulin gtt started but stopped d/t bs 70's. see flowsheet.\n\nid: tmax 99.5. vanco due at 0800.\n\nsocial: daughter called update given.\n\nplan: pain management. ?wake & wean. repeat hct. cont to monitor hemodynmics, resp status, i&o, labs. wean neo as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-18 00:00:00.000",
"description": "Report",
"row_id": 1672878,
"text": "S/P AORTIC REPLACEMENT\nO: CARDIAC: 0700 ON EPI . 120'S WITH SHORT BURSTS OF AF. PACS AND RARE PVC NOTED. EPI DC'D- RECEIVED 2 MG MAGNESIUM, 1 L NS, PACED 80-90 WITHOUT FURTHER ECTOPY, RECIEVED 1 MG IV DILAUDID WITH GOOD EFFECT. CONTINUES A PACED 80-90- UNDERLYING RYTHYM 57 SB. SBP REQUIRING NEO PRESENTLY AT 1 MCQ TO KEEP SBP >90.RECEIVED AN ADDITIONAL 2L LR AND PRESENTLY RECEIVING ALBUMIN. PADS 20'S WITH CVP TEENS AFTER SWAN ADVANCED 4 CM BY FELLOW. CI VIA FICK>2 . MILRINONE STARTED AT .25 MCQ DUE TO ECHO PERFORMED AND RV SLUGGISH. SVO2 HIGH 50'S THIS AM TO 60'S WITH MILRINONE. HCT 35.2 AT 1330. EXTREMITIES WARM AND DRY. PALP PP. MIN CT DRAINAGE.\n RESP: VENT SETTINGS AND ABG AS PER FLOW. LAVAGED AND SUCTIONED FOR A SMALL AMOUNT OF THICK BLOODY SPUTUM. BS DIMINISHED LEFT BASE, CLEAR OTHERWISE. O2 SAT >95%. NO CHEST TUBE LEAK.\n NEURO: PROPOFOL BEING SLOWLY WEANED TO EVALUATE NEURO STATUS, HAS MAE-NOT TO COMMAND. PERL.\n GI: + PLACEMENT OF OGT, ABD SOFT, ABSENT BOWEL SOUNDS. NO STOOL. CARAFATE AND ZANTAC AS PER ORDERS. OGT DRAINED 75 ML GREEN BILIOUS DRAINAGE.\n GU: MARGINAL UOP UNTIL 1000 AFTER RECEIVING FLUID 300 ML/130/110. CREAT .8.\n ENDO: HAS NOT RECEIVED ANY SSI.\n ID: VANCO 1 GM X 1 @ 0800.\n PAIN: TAKES DILAUDID AT HOME FOR BACK PAIN , RECEIVED 1 MG IV DIALUDID X 2 WITH GOOD EFFECT. 2 MG MORPHINE IV X 2.\n SOCIAL: DAUGHTER AND GRANDSON INTO VISIT AND UPDATED. DR. INTO TO UPDATE FAMILY.\nA: MILRINONE WITH GOOD EFFECT. DILAUDID WITH GOOD EFFECT. MAE.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO AS TOLERATED - KEEP MAP>60 WITH SBP>90, PADS, CVP , LIKES HIGHER FILLING PRESSURES IN LIGHT OF RV, SVO2,CI- HAVE BEEN FOLLOWING FICKS, PP-CSM/TEMP, CT DRAINAGE, DSGS, RESP STATUS- ? WAKE AND WEAN- WILL REMAIN INTUBATED TODAY DUE TO FLUID STATUS, FOLLOW ABGS/O2 SATS, NEURO STATUS- WAKE ASSESS NEURO ? RESEDATE, I+O- LR AND ALBUMIN AS NEEDED PER ORDERS. LABS PENDING, AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-22 00:00:00.000",
"description": "Report",
"row_id": 1672893,
"text": "Nursing Progress Note\nNeuro: awakens to name, follows commands appropriately. moves all extremtities, though weak. PERRLA. becomes agitated/hypertensive with stimulation/activity and pulls at soft limb immobilizers. calms to verbal cues. given dilaudid via NGT for c/o back pain.\n\nCV: SR/1st Degree AV Block. No ectopy noted. HR 60s-80 at rest and up to 110 with agitation. SBP 110-130. Up to 160's-170's with agitation, non sustained. goal SBP <140. repleted K+ x 2 and Mag x 1. palpable pedal pulses. afebrile.\n\nResp: LS coarse, suctioned for moderate amounts thick tan sputum. LS clear, dim at bases after suctioning. O2 sats 96-99 on CPAP with PS (50% 5/5). can follow commands but not hold head up off of pillow. ABGs WNL.\n\nGI/GU: abd soft, non tender. (+) BS. (-) BM this shift. OGT remains clamped. no n/v. tolerated meds without difficulty. foley to bedside drainage with good HUO on Lasix gtt 2 mg/hr.\n\nEndo: SSRI per CVICU protocol.\n\nSkin: intact; sternal/mediastinal dsgs CDI. R upper chest wall with steristrips covered with DSD.\n\nSocial: no calls from family overnoc.\n\nPlan: pain management, wean to extubate, ? precedex to facilitate weaning? pulmonary hygiene, continue IV abx, including zosyn started last night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-22 00:00:00.000",
"description": "Report",
"row_id": 1672894,
"text": "Neuro: Pt lethargic but . PERRLA. Follows commands. Voice hoarse. Anxious at times. Dilaudid for back pain, pt takes at home.\nCV: HR 80-110, PR 0.22. sr, with occ pac noted, resolved with lyte replacement and beta blockers. Hypertensive with minimal activity or stimulation up to 170's. Transient. Po lopressor increased, prn hydralazine and IV lopressor given as well. Palp pedal pulses. Edematous. HIT screen sent due to PLT 72.\nResp: Pt extubated at 1000. Pt initially on face tent 70%, weaned to NC 5l with sats >93%. Lungs with increasing crackles 1/2 up bilateral lungs post extubation. Coughing and raising small amt thick yellow. Post ABG WNL. Pt tacypneic when awake but at rest RR 15-20, non labored. Have not started IS due to lethargy. To begin MDI's tonight.\nGI: Pt not taking po's yet, just ice chips. Med given with spoonful ice cream. +bs. Abd soft. pt has +gag, but pt to get swallow study per Dr. . Pt to start PPI, zantac dc'd due to following plts.\nGU: COntinues on lasix gtt at 2mg/hr, goal uop negative 100cc/hr. Foley patent.\nPlan: Cont assess cardio/resp status. Pulm toilet. COnt lasix gtt per above parameters. Wean O2 and increase activity and diet as tol\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-17 00:00:00.000",
"description": "Report",
"row_id": 1672874,
"text": "resp care - Pt received from OR intubated with #7.5ETT, 22@lip, and placed on full vent support. BLBS slightly coarse. Plan to wean to extubate. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-21 00:00:00.000",
"description": "Report",
"row_id": 1672889,
"text": "neuro) Pt. awakens and becomes agitated and hypertensive. mostly occuring when she coughs and needs suctioning. Responds well to Ativan IV. MAE and nods head to questions.\n\nCV) SVO2 68-72%. Verified by venous sample to recal CCO. CI >2.2.Neo turned off due to Hypertension. Peripheries warm and pink with palp. pedal pulses. HR up to 100 when awake and 70's when sedate.\n\nPulm) abg's wnl. IPS 15cm on cpap 5cm. Secretions thick tan; sample sent to lab for C&S. Strong cough; breath sounds coarse before sx;clear after sx.\n\nGI) NPO/tube feedings at 10cc/hr. No increase for now. Residuals bilious in color mixed with TF/ + bowel sounds. No stool. Ranitidine for GI prophylaxis.\n\nGu) good huo with lasix drip at 2mg/hr.Goal for huo = 100cc/hr.\n\nID) afebrile. WBC 13.9.\n\nEndo ) SSRI protocol.\n\nPlan) continue to diurese; replete electrolytes. wean Milrinone CI>2.\nwean pressure support for ? extubation once pt. is more negative with I/O.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-21 00:00:00.000",
"description": "Report",
"row_id": 1672890,
"text": "Respiratory care\npt weaned to cpap/psv 5/5 with abg's with in normal limits. Plan to extubate when pt more alert.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-21 00:00:00.000",
"description": "Report",
"row_id": 1672891,
"text": "Neuro: Lethargic, , follows commands. PERRLA. Pt anxious at times. Ativan dc'd.\nCv: HR 70-100, sr, lopressor increased. Hypertensive with anxiety. Swan dc'd. CI>3. Chest tubes and epicardial wires discontinued. Continues to be edematous.\nResp: Remains orally intubated, ventilator weaned to PS 5/5 50%, ABG WNL. Lungs coarse at bases, sx thick tan. Tachypneic with agitation. Plan extubation when more alert\nGI: NPO for ? extubation. OGT clamped. Loose BM x1. +BS\nGU: FOley patent. Lasix gtt at 2mg/hr, UOP 100-200cc/hr.\nID: Sputum cx pending but +gram cocci, sensitivites pending. Started on Vanco, awaiting ID approval for Zosyn, pan cx. Afebrile.\nSocial: daughter in and updated on plan of care\nPlan: Extubate when more awake. Cont assess cardio/resp status. Follow cx. Pulmonary hygiene.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-22 00:00:00.000",
"description": "Report",
"row_id": 1672892,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coars esuct sm th tan sput. ABGs stable on current vent settings; no vent changes required overnoc. Cont PSV and wean to extub today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-18 00:00:00.000",
"description": "Report",
"row_id": 1672879,
"text": "resp care\nremains intub/vented in simv mode. bs clear to occ.rhonchorous,equal bilaterally. sxned for thick old brownish/bloody sputum. to wean when hemodynamically stable. pao2 only 80's at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-19 00:00:00.000",
"description": "Report",
"row_id": 1672880,
"text": "ekg apaced at 90 with underlying nsr in 7os, fewq pacs seen, no vent ectopy. sbp maintained with neo, titrated to maintain > 100, < 140. filling pressures stable, co/ci acceptable, remains on milrinone at .25 mcg. svo2 in 70s. afebrile. uo marginal, 30-40cc/hr, occ sediment noted. glucose rx per protocol, gtt is off now. breath sounds clear to coarse with exp wheezes, decreased at left base. ett suctioned for thick brown secretions. no vent changes overnight, see carevue for settings and abgs. small amts serosang via chest tubes, no air leaks. sternal, mediastinal and right upper chest sites all inatct, scant amts of drainage, dressings changed. abd soft, very few bowel sounds heard, no stool. ogt to lws, thick green gastric drainage. skin warm and slightly diaphoretic, generalized edema, intact on back and buttocks, weight is up 20 kg. feet warm, dp and pt pulses palp bilat. sedated with propofol at 20 mcg, opens eyes to voice, mae to command, perrl. medicated for pain associated with turning x 2. plan to wean pressors as tol, wean to extubate when ready, monitor electrolytes, manage pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-19 00:00:00.000",
"description": "Report",
"row_id": 1672881,
"text": "NEURO: Pt lethargic, follows commands approp, denies any pain, PERRLA, MAE to commands, IV ativan/dilaudid for anxiety/pain\n\nRESP: Remains on SIMV, no vent changes, Sats 95%, lung sounds coarse at times, needs ETT suction (mod tan-blood tinged secretions), CTs to suction, serosanguinous drainage, no air leak/crepitus noted\n\nCV: NSR, 80-90s without ectopy, keep SBP >100 but <140, Neo off since 1530, increased Milrinone to 0.25,mcg (due to SVO2/CO decrease, urine outputs), SVO2 >70 after recal, CI >2.0, pacing wires attached but pacerbox off (A wires do not fully capture), afebrile\n\nGI/GU: OGT to LCS, abd soft, nontender, hypo BS; Foley to gravity with marginal urine output, plan is to keep even, plan to recheck lytes\n\nENDO: Insulin drip off\n\nSOCIAL: Family visited and updated on Pt's plan care/status\n\nPLAN: Continue to monitor hemodynamics, resp status, urine outputs, LABS, manage pain as needed\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-19 00:00:00.000",
"description": "Report",
"row_id": 1672882,
"text": "Resp Care\nPt remains on vent. Intubated with 7.5 ett @ 19 lip, patent and secure. Suctioned mod amt of brown secretions. BS course bilat. No changes made. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-20 00:00:00.000",
"description": "Report",
"row_id": 1672883,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct mod th tan sput. ABGs stable; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-23 00:00:00.000",
"description": "Report",
"row_id": 1672895,
"text": "7p-7a\nNeuro: Pt a/ox3, calls out at times, calms with reasurance/ reorientation, ? dilaudid causing periods of confusion. Has allergy to percocet unsure of tylenol, md aware. mae's, follows commands. Dilaudid given for incisional pain with good relief. perrla wnl.\n\nCV: sr with pac's, lytes repleted. palpable pulses, goal sbp<140, hydralazine held due to sbp<140. Upper extremities cool, palpable pulses/ good csm.\n\nResp: ls crackles/ dim, exp wheezes when anxious, mdi's, enc cdb/is. 96% on 4lnc.\n\nGI/GU: abd soft, + bs, flatus, no bm this shift, lasix drip continues, goal of uop to be >100cc/hr, per team.\n\nEndo: regular insulin sliding scale per cvicu protocol\n\nSkin: see flowsheet\n\nSocial: Daughter called updated on poc\n\nPlan: enc is, lasix drip continues for uop>100cc/hr, pulmonary toilet, ? change pain medicine to held decrease confusion, pain mgmt, amb.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-20 00:00:00.000",
"description": "Report",
"row_id": 1672884,
"text": "ekg nsr, no ectopy, rate 70s, at , woke up and became htn to 180s, hr up to 120s. ativan and dilaudid given, with sbp down to 80s, neo restarted and 1000cc volume given. remained marginally hyotensive, still with borderline uo, until, when milrinone decreased to .125, sbp stabilized, and hr drifted back to 70s, weaning neo now. glucose rx per protocol, shut off at 72, dropped to 52 the next hour, was 77 when rechecked. k repleted. breath sounds coarse, ett suctioned for mod to large amts thick tan secretions. abgs wnl, resp rx unable to do rsbi, pt did not breathe. sternal wound dry, small amt sang drainage sround ct sites, had two dumps of 200 and 170cc from cts after turning, reported to ho. abd soft, bowel sounds present, no stool. ogt to lws, mod bile drainage. feet warm, dp and pt pulses palp bilat. skin on back and buttocks is intact, generalized edema. opens eyes to voice, denied pain when asked, but medicated x 2 with dilaudid for increased sbp with movement and turning, follows all commands. plan to continue to wean pressors, begin diuresis if possible, wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-20 00:00:00.000",
"description": "Report",
"row_id": 1672885,
"text": "cvicu\npt w/ labile bp this am neosynephrine to off and ntg on briefly then return to neo. vent mode change to cpap +5/ 15 ips w/ good abg. MV ~8L. to cont milrinone per team but began low dose lopressor via ogt. sinus tachy to low 110's. ? diuresis later. prn dilaudid and ativan w/ effect.\nrefer to flowsheet for specifics.\nassess: labile bp this am. tol cpap\nplan: cont milrinone, cpap as tol. low dose beta block. ? diuresis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-20 00:00:00.000",
"description": "Report",
"row_id": 1672886,
"text": "cvicu update\nneuro: more alert as day went on. oriented.\n\npain: c/o pain w/ turn to rt side only. repostion w/ efect.\n\ncv: vss as per flowsheet. tol wean off neosynephrine. cont afib. no vea. amiodarone change to po. poor iv access r/t + body edema. iv team unable to place picc. to start heparin infusion. po k+ repletion.\n\nresp: lungs clear. good cough. IS to 500cc. wean to room air. o2 sats ~95%.\n\ngi/gu: uop marginal via foley this am but by this afternoon autodiuresing. tol clear lix diet w/ enc. lft up. abd large, bsp. inc loose brown stool x1. rt chole tube draining bile. flush w/ NS. cx sent.\n\nassess: stable day\n\nplan: pulm hygiene. monitor vs/temp. ? picc vs abx to po.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-20 00:00:00.000",
"description": "Report",
"row_id": 1672887,
"text": "S/P AORTIC REPLACEMENT WITH AVR\nO: CARDIAC: SR 90'S-100'S WITH RARE PAC NOTED . WITHOUT VEA. A WIRES SENSE AND CAPTURE, V WIRES SENSE - CAPTURE NOT CHECKED DUE TO HR>100. SBP REQUIRING NEO PRESENTLY AT .25MCQ TO KEEP SBP 100-130. SVO2 70'S,CI >3. MILRINONE CONTINUES AT .125MCQ. DSGS D+I. CT DRAINAGE ML/HR EXTREMITIES WARM AND DRY. HCT 31. 20 MEQ KCL X2.\n RESP: SUCTIONED FOR SMALL AMOUNTS OF THICK TAN BLOODY SPUTUM, SPUTUM C+S SENT. BS DIMINISHED INTERMITTENTLY LEFT BASE. CLEAR OTHERWISE. NO TUBE LEAK. CPAP TO WITH GOOD ABG HOWEVER PT FELT DYSPNEA THEREFORE PUT BACK TO CPAP . PLEASE SEE FLOW AND ABG. O2 SATS >95%.\n NEURO: EASILY , , FOLLOWS COMMANDS, ANSWERS QUESTIONS WITH NODDING YES/NO.PERL.\n GI: FS RPLETE WITH FIBER.TF AT 10 ML/HR AT GOAL NOT TO BE ADVANCED. + PLACEMENT OGT. 50 ML RESIDUAL AT . ABD SOFT. + BOWEL SOUNDS. NO STOOL.\n GU: UO AS LOW AS 8 ML PRIOR TO 11AM. LASIX 20 MG AT 1310 WITH 1.3 L DIURESIS. LASIX GTT TO BE STARTED IF UO DROPS BELOW 100ML/HR.\n ID: AFEBRILE.\n SKIN: PERINEUM REDDENED , GENERAL EDEMA,\n SOCIAL: DAUGHTER AND FAMILY INTO VISIT AND UPDATED.\n PAIN/ANXIETY: RECEIVED 2 MG PO DILAUDID, .5MG IV DILAUDID X3 WITH GOOD EFFECT OF BACK PAIN AND INSIONAL DISCOMFORT WITH COUGHING. MEDICATED ALSO FOR HTN.\nA: DIURSESING, SVO2 70'S, CI>3.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO TO KEEP SBP 100-130'S,SVO2,CI, PP, CT DRAINAGE, DSGS, RESP STATUS- SPUTUM C+S PENDING, NEURO STATUS- OFFER REASSURANCE-ATIVAN PRN, I+O- ? START LASIX GTT IF UO <100ML/HR - HOWEVER 3L NEGATIVE AS OF 2100, LABS PENDING. AS PER ORDERS. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-03-21 00:00:00.000",
"description": "Report",
"row_id": 1672888,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse suct sm th tan sput(spec obt). ABGs stable on current vent settings; no vent changes required. Cont PSV wean.\n"
},
{
"category": "ECG",
"chartdate": "2158-03-17 00:00:00.000",
"description": "Report",
"row_id": 214740,
"text": "Atrial pacing, at rate 90. Borderline low voltage. Anteroseptal myocardial\ninfarction of indeterminate age. Compared to the previous tracing of \natrial pacing has changed from 80-90 beats per minute.\n\n"
},
{
"category": "ECG",
"chartdate": "2158-03-18 00:00:00.000",
"description": "Report",
"row_id": 214741,
"text": "Atrial paced rhythm. Low voltage. T wave abnormalities with inversions in\nearly precordial leads. Compared to the previous tracing of atrial\npacing is new and voltage has decreased. ST-T wave abnormalities are new.\nClinical correlation is suggested.\n\n"
}
] |
89,575 | 198,482 | Pt was admitted to the neurosurgery service and monitored closely in ICU. Her exam remained stable neurologically. Repeat head CT was stable. She was transferred to the floor. She was seen in consultation by geriatric service who recommended 1) UA that was negative, 2) dilantin dc'd (she is to recieve one week course to prevent seizure) 3) swallowing evaluation - she underwent video swallow and had no difficulties or aspiration. She was seen by PT and cleared for home. She was discharged to daughter who was going to transport pt by train to - moving into . Advised needs f/u Head CT in one month. | FINDINGS: There is a thin, 4-mm maximal thickness, extra-axial hemorrhage layering over the right frontal convexity, anteriorly (2:14-19); there is no significant mass effect or shift of midline structures. Laryngeal elevation felt timely and wfl topalpation.SUMMARY / IMPRESSION:Ms. did not have any overt signs of aspiration, but herhistory is concerning for possible silent aspiration givenchronic cough, weight loss and colored phlegm combined with CXRappearance. Subdural hemorrhage (SDH) Assessment: Neuro intact, perrla, 3-4mm. Past Medical / Surgical History: hypothyroidism, Anemia, DM, Hypercholesterolemia Medications: Acetaminophen, Levothyroxine, Metoprolol, Phenytoin,Allupurinol, Propanolol Radiology: Head Ct: R frontal SDH Labs: 36.0 11.2 97 7.7 [image002.jpg] Other labs: Activity Orders: as tolerated RN Social / Occupational History: Lives alone, but has 2 supportive dtrs. The right Port-A-Cath catheter tip terminates at the level of low SVC. Objective Test Arousal / Attention / Cognition / Communication: A&Ox3, pleasant and cooperative Hemodynamic Response Aerobic Capacity HR BP RR O[2 ]sat HR BP RR O[2] sat RPE Supine / Rest / Sit 62 129/43 10 99 Activity / Stand 66 136/59 17 98 Recovery 52 144/60 18 100 Total distance walked: Minutes: Pulmonary Status: BS diminished at bases Integumentary / Vascular: R facial abrasian Sensory Integrity: Sensation diminished in bilat. F s/p fall with resulting R SDH that p/w above impairments associated with nonprogressive d/o of the CNS. Cardiovascular: Stable, will restart home meds tomorrow, keep SBP<140 with PRN lopressor Pulmonary: IS, Stable Gastrointestinal / Abdomen: Stable Nutrition: NPO, Nursing swallow eval, then regular diet once stable Renal: Adequate UO Hematology: Stable anemia myelodysplasia, not anticoagulated, adequate platelet counts Endocrine: RISS Infectious Disease: no I.D. Cardiovascular: Stable, will restart home meds tomorrow, keep SBP<140 with PRN lopressor Pulmonary: IS, Stable Gastrointestinal / Abdomen: Stable Nutrition: NPO, Nursing swallow eval, then regular diet once stable Renal: Adequate UO Hematology: Stable anemia myelodysplasia, not anticoagulated, adequate platelet counts Endocrine: RISS Infectious Disease: no I.D. CT HEAD WITHOUT INTRAVENOUS CONTRAST. Subdural hemorrhage (SDH) Assessment: A&Ox2-3, mildly confused to exact date but appropriately aware to situation. The remainder of the examination, including mild-moderate global atrophy and relatively mild chronic microvascular infarction in bihemispheric periventricular white matter, is unchanged. Response: Exam unchanged. Response: Exam unchanged. (Did become very sleepy and mildly confused directly after dilantin loading dose given, sx have since resolved). Action: Serial neuro checks, sbp mgmt <140, maintenance ivf, dilantin q8h. Mastication was veryslightly prolonged but without significant oral cavity residue.She required sips of liquid to clear residue from cracker. issues Lines / Tubes / Drains: Foley, peripheral IV Wounds: Imaging: CT scan head today Fluids: D5 1/2 NS Consults: Neuro surgery Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: Indwelling Port (PortaCath) - 09:31 AM Prophylaxis: DVT: Boots Stress ulcer: Not indicated VAP bundle: Comments: Communication: Comments: Code status: Disposition: ICU Total time spent: issues Lines / Tubes / Drains: Foley, peripheral IV Wounds: Imaging: CT scan head today Fluids: D5 1/2 NS Consults: Neuro surgery Billing Diagnosis: ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: Indwelling Port (PortaCath) - 09:31 AM Prophylaxis: DVT: Boots Stress ulcer: Not indicated VAP bundle: Comments: Communication: Comments: Code status: Disposition: ICU Total time spent: Pain / Limiting Symptoms: no c/o pain Posture: kyphotic Range of Motion Muscle Performance bilat. TSICU HPI: 84F on no anticoagulants s/p fall from standing with 4 mm SDH Chief complaint: fall PMHx: PMH: Hypothyroid, Anemia, DM, hypercholesterolemia PSH: none known : Lipitor, Metformin, Levoxyl, Inderal, Iron, Procrit, Isosorbide monoitrate Soc: does not smoke, no alcohol Current medications: 24 Hour Events: Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Flowsheet Data as of 11:34 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since a.m. Tmax: 36.5C (97.7 T current: 36.5C (97.7 HR: 90 (90 - 92) bpm BP: 129/64(80) {129/64(80) - 142/69(88)} mmHg RR: 22 (18 - 22) insp/min SPO2: 97% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 47.5 kg (admission): 47.5 kg Total In: PO: Tube feeding: IV Fluid: Blood products: Total out: 0 mL 550 mL Urine: 550 mL NG: Stool: Drains: Balance: 0 mL -550 mL Respiratory support O2 Delivery Device: None SPO2: 97% ABG: //// Physical Examination General Appearance: No acute distress, No(t) Anxious, No(t) Well nourished, No(t) Overweight / Obese, Cachectic HEENT: PERRL, No(t) Pupils fixed and dilated, No(t) Left pupil dilated, No(t) Right pupil dilated, EOMI Cardiovascular: (Rhythm: Regular, No(t) Irregular), (Murmur: No(t) Systolic, No(t) Diastolic), (Distant heart sounds: No(t) Absent, No(t) Present), Split S2 Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath Sounds: CTA bilateral : , No(t) Wheezes : , No(t) Crackles : , No(t) Rhonchorous : , No(t) Diminished: , No(t) Absent : ), (Sternum: No(t) Stable , No(t) Click , No(t) Open, No(t) Drainage) Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , No(t) Peritoneal sign, No(t) Obese Left Extremities: (Edema: Absent, No(t) Trace, No(t) 1+, No(t) 2+, No(t) 3+, No(t) 4+), (Temperature: Warm, No(t) Cool) Right Extremities: (Edema: Absent, No(t) Trace, No(t) 1+, No(t) 2+, No(t) 3+, No(t) 4+), (Temperature: Warm, No(t) Cool) Neurologic: (Awake / Alert / Oriented: x 3, No(t) x 2, No(t) x 1), Follows simple commands, (Responds to: Verbal stimuli), No(t) Moves all extremities, (RUE: Weakness, No(t) No movement), (LUE: Weakness, No(t) No movement), (RLE: No(t) Weakness, No(t) No movement), (LLE: No(t) Weakness, No(t) No movement), R shoulder pain with resistance, no passive ROM pain Labs / Radiology [image002.jpg] Assessment and Plan Assessment and Plan: 84 yo F s/p fall without LOC, onto R side of face, now with 4mm R frontal SDH, without neurological deficits Neurologic: Neuro checks Q: 1 hr, Will load with Dilantin and watch for seizures. | 17 | [
{
"category": "Physician ",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 471244,
"text": "TSICU\n HPI:\n 84 yo female fall from standing, denies LOC, believes she slipped.\n Several previous falls in past. R facial abrasion\n Chief complaint:\n trauma\n PMHx:\n PMH: Hypothyroid, Anemia, DM, hypercholesterolemia, myelodysplatic\n syndrome, angiodysplasia, vertigo\n PSH: hysterectomy, CABG (11 yrs ago), CCY, cardiac stents (4-5 years\n ago)\n : Levoxyl 0.075', Inderal 120'', ISDN 30', Metformin 500''',\n protonix 40'', Lipitor 20', Allopurinol 300', ASA 81', procrit PRN,\n Folate.\n Soc: does not smoke, no alcohol\n Current medications:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 09:31 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 01:35 PM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.7\nC (98\n HR: 89 (75 - 93) bpm\n BP: 143/58(81) {117/46(65) - 153/74(92)} mmHg\n RR: 11 (11 - 27) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.8 kg (admission): 47.5 kg\n Total In:\n 1,137 mL\n 541 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,137 mL\n 541 mL\n Blood products:\n Total out:\n 1,510 mL\n 830 mL\n Urine:\n 1,510 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -373 mL\n -289 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 97 K/uL\n 11.2 g/dL\n 211 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 102 mEq/L\n 134 mEq/L\n 36.0 %\n 7.7 K/uL\n [image002.jpg]\n 11:05 AM\n 09:53 PM\n WBC\n 10.8\n 7.7\n Hct\n 39.0\n 36.0\n Plt\n 100\n 97\n Creatinine\n 0.8\n 0.9\n Troponin T\n <0.01\n Glucose\n 83\n 211\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CK-MB / Troponin\n T:12//<0.01, Ca:9.0 mg/dL, Mg:2.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 84 y/o F with R SDH s/p fall\n Neurologic: Neuro checks Q: 2 hr, altered mental status after dilantin\n dose 7/14, no further imaging, stable SDH\n Cardiovascular: keep SBP < 140\n Pulmonary: stable, no active issues\n Gastrointestinal / Abdomen: regular diet\n Nutrition: Regular diet\n Renal: no issues, autoregulate volume status\n Hematology: not anticoagulated, has MDS with regular growth factor\n infusions, currently stable\n Endocrine: ISS, not diabetic\n Infectious Disease: no signs of infection\n Lines / Tubes / Drains: pIV\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: sub dural hematoma\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 09:31 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32\n"
},
{
"category": "Nursing",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 471168,
"text": "84 yo female s/p witnessed fall from standing in kitchen at home. Per\n family, pt struck head on counter as she fell. Taken initially to OSH\n () via EMS, CT showed ?epidural hematoma, transferred to \n for w/u. repeat scans show stable, small 4mm R frontal SDH. Neuro\n exam intact, to TSICU for observation.\n See medical and surgical hx in H&P.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro intact, A&Ox3, appropriate, normal baseline strength in all\n extrems, follows commands consistently, PERRLA. +cough/gag. No seizures\n or other neuro s/s noted. Pt denies pain. Sleeping throughout shift,\n one episode of confusion upon awakening, although pt easily reoriented.\n Tol regular diet, VSS. RA\n Action:\n Neuro exams q4hrs\n SBP mgmt <140\n Dilantin administered Q8h.\n Response:\n Exam unchanged.\n Plan:\n Cont neuro checks q4h, tx to floor when bed available\n"
},
{
"category": "Physician ",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 471233,
"text": "TSICU\n HPI:\n 84 yo female fall from standing, denies LOC, believes she slipped.\n Several previous falls in past. R facial abrasion\n Chief complaint:\n trauma\n PMHx:\n PMH: Hypothyroid, Anemia, DM, hypercholesterolemia, myelodysplatic\n syndrome, angiodysplasia, vertigo\n PSH: hysterectomy, CABG (11 yrs ago), CCY, cardiac stents (4-5 years\n ago)\n : Levoxyl 0.075', Inderal 120'', ISDN 30', Metformin 500''',\n protonix 40'', Lipitor 20', Allopurinol 300', ASA 81', procrit PRN,\n Folate.\n Soc: does not smoke, no alcohol\n Current medications:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 09:31 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 01:35 PM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.3\n T current: 36.7\nC (98\n HR: 89 (75 - 93) bpm\n BP: 143/58(81) {117/46(65) - 153/74(92)} mmHg\n RR: 11 (11 - 27) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 46.8 kg (admission): 47.5 kg\n Total In:\n 1,137 mL\n 541 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,137 mL\n 541 mL\n Blood products:\n Total out:\n 1,510 mL\n 830 mL\n Urine:\n 1,510 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -373 mL\n -289 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 97 K/uL\n 11.2 g/dL\n 211 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 102 mEq/L\n 134 mEq/L\n 36.0 %\n 7.7 K/uL\n [image002.jpg]\n 11:05 AM\n 09:53 PM\n WBC\n 10.8\n 7.7\n Hct\n 39.0\n 36.0\n Plt\n 100\n 97\n Creatinine\n 0.8\n 0.9\n Troponin T\n <0.01\n Glucose\n 83\n 211\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CK-MB / Troponin\n T:12//<0.01, Ca:9.0 mg/dL, Mg:2.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 84 y/o F with R SDH s/p fall\n Neurologic: Neuro checks Q: 2 hr, altered mental status after dilantin\n dose 7/14, no further imaging, stable SDH\n Cardiovascular: keep SBP < 140\n Pulmonary: stable, no active issues\n Gastrointestinal / Abdomen: regular diet\n Nutrition: Regular diet\n Renal: no issues, autoregulate volume status\n Hematology: not anticoagulated, has MDS with regular growth factor\n infusions, currently stable\n Endocrine: ISS, not diabetic\n Infectious Disease: no signs of infection\n Lines / Tubes / Drains: pIV\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 09:31 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 471218,
"text": "84 yo female s/p witnessed fall from standing in kitchen at home. Per\n family, pt struck head on counter as she fell. Taken initially to OSH\n () via EMS, CT showed ?epidural hematoma, transferred to \n for w/u. repeat scans show stable, small 4mm R frontal SDH. Neuro\n exam intact, to TSICU for observation.\n See medical and surgical hx in H&P.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro intact, A&Ox3, appropriate, normal baseline strength in all\n extrems, follows commands consistently, PERRLA. +cough/gag. No seizures\n or other neuro s/s noted. Pt denies pain. Sleeping throughout shift,\n one episode of confusion upon awakening, although pt easily reoriented.\n Tol regular diet, VSS. RA\n Action:\n Neuro exams q4hrs\n SBP mgmt <140\n Dilantin administered Q8h.\n Response:\n Exam unchanged.\n Plan:\n Cont neuro checks q4h, tx to floor when bed available\n"
},
{
"category": "Physician ",
"chartdate": "2140-08-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 471081,
"text": "TSICU\n HPI:\n 84F on no anticoagulants s/p fall from standing with 4 mm SDH\n Chief complaint:\n fall\n PMHx:\n PMH: Hypothyroid, Anemia, DM, hypercholesterolemia\n PSH: none known\n : Lipitor, Metformin, Levoxyl, Inderal, Iron, Procrit, Isosorbide\n monoitrate\n Soc: does not smoke, no alcohol\n Current medications:\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.5\nC (97.7\n T current: 36.5\nC (97.7\n HR: 90 (90 - 92) bpm\n BP: 129/64(80) {129/64(80) - 142/69(88)} mmHg\n RR: 22 (18 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 47.5 kg (admission): 47.5 kg\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious, No(t) Well\n nourished, No(t) Overweight / Obese, Cachectic\n HEENT: PERRL, No(t) Pupils fixed and dilated, No(t) Left pupil dilated,\n No(t) Right pupil dilated, EOMI\n Cardiovascular: (Rhythm: Regular, No(t) Irregular), (Murmur: No(t)\n Systolic, No(t) Diastolic), (Distant heart sounds: No(t) Absent, No(t)\n Present), Split S2\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: CTA bilateral : , No(t) Wheezes : , No(t) Crackles : , No(t)\n Rhonchorous : , No(t) Diminished: , No(t) Absent : ), (Sternum: No(t)\n Stable , No(t) Click , No(t) Open, No(t) Drainage)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, No(t)\n Distended, No(t) Tender: , No(t) Peritoneal sign, No(t) Obese\n Left Extremities: (Edema: Absent, No(t) Trace, No(t) 1+, No(t) 2+,\n No(t) 3+, No(t) 4+), (Temperature: Warm, No(t) Cool)\n Right Extremities: (Edema: Absent, No(t) Trace, No(t) 1+, No(t) 2+,\n No(t) 3+, No(t) 4+), (Temperature: Warm, No(t) Cool)\n Neurologic: (Awake / Alert / Oriented: x 3, No(t) x 2, No(t) x 1),\n Follows simple commands, (Responds to: Verbal stimuli), No(t) Moves all\n extremities, (RUE: Weakness, No(t) No movement), (LUE: Weakness, No(t)\n No movement), (RLE: No(t) Weakness, No(t) No movement), (LLE: No(t)\n Weakness, No(t) No movement), R shoulder pain with resistance, no\n passive ROM pain\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 84 yo F s/p fall without LOC, onto R side of face,\n now with 4mm R frontal SDH, without neurological deficits\n Neurologic: Neuro checks Q: 1 hr, Will load with Dilantin and watch for\n seizures.\n Cardiovascular: Stable, will restart home meds tomorrow, keep SBP<140\n with PRN lopressor\n Pulmonary: IS, Stable\n Gastrointestinal / Abdomen: Stable\n Nutrition: NPO, Nursing swallow eval, then regular diet once stable\n Renal: Adequate UO\n Hematology: Stable anemia myelodysplasia, not anticoagulated,\n adequate platelet counts\n Endocrine: RISS\n Infectious Disease: no I.D. issues\n Lines / Tubes / Drains: Foley, peripheral IV\n Wounds:\n Imaging: CT scan head today\n Fluids: D5 1/2 NS\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 09:31 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-08-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 471084,
"text": "TSICU\n HPI:\n 84F on no anticoagulants s/p fall from standing with 4 mm SDH\n Chief complaint:\n fall\n PMHx:\n PMH: Hypothyroid, Anemia, DM, hypercholesterolemia\n PSH: hysterectomy, cardiac stenting, cholecystectomy, has sternotomy\n scar but does not recall surgery\n : Lipitor, Metformin, Levoxyl, Inderal, Iron, Procrit, Isosorbide\n monoitrate\n Soc: does not smoke, no alcohol\n Current medications:\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.5\nC (97.7\n T current: 36.5\nC (97.7\n HR: 90 (90 - 92) bpm\n BP: 129/64(80) {129/64(80) - 142/69(88)} mmHg\n RR: 22 (18 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 47.5 kg (admission): 47.5 kg\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -550 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI, swelling over R temple\n Cardiovascular: RRR, III/VI systolic murmur\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: CTA bilateral : , No(t) Wheezes : , No(t) Crackles : , No(t)\n Rhonchorous : , No(t) Diminished: , No(t) Absent : ), (Sternum: No(t)\n Stable , No(t) Click , No(t) Open, No(t) Drainage)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, No(t)\n Distended, No(t) Tender: , No(t) Peritoneal sign, No(t) Obese\n Left Extremities: (Edema: Absent, No(t) Trace, No(t) 1+, No(t) 2+,\n No(t) 3+, No(t) 4+), (Temperature: Warm, No(t) Cool)\n Right Extremities: (Edema: Absent, No(t) Trace, No(t) 1+, No(t) 2+,\n No(t) 3+, No(t) 4+), (Temperature: Warm, No(t) Cool)\n Neurologic: (Awake / Alert / Oriented: x 3, No(t) x 2, No(t) x 1),\n Follows simple commands, (Responds to: Verbal stimuli), No(t) Moves all\n extremities, (RUE: Weakness, No(t) No movement), (LUE: Weakness, No(t)\n No movement), (RLE: No(t) Weakness, No(t) No movement), (LLE: No(t)\n Weakness, No(t) No movement), R shoulder pain with resistance, no\n passive ROM pain\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Assessment and Plan: 84 yo F s/p fall without LOC, onto R side of face,\n now with 4mm R frontal SDH, without neurological deficits\n Neurologic: Neuro checks Q: 1 hr, Will load with Dilantin and watch for\n seizures.\n Cardiovascular: Stable, will restart home meds tomorrow, keep SBP<140\n with PRN lopressor\n Pulmonary: IS, Stable\n Gastrointestinal / Abdomen: Stable\n Nutrition: NPO, Nursing swallow eval, then regular diet once stable\n Renal: Adequate UO\n Hematology: Stable anemia myelodysplasia, not anticoagulated,\n adequate platelet counts\n Endocrine: RISS\n Infectious Disease: no I.D. issues\n Lines / Tubes / Drains: Foley, peripheral IV\n Wounds:\n Imaging: CT scan head today\n Fluids: D5 1/2 NS\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 09:31 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 471309,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n A&Ox2-3, mildly confused to exact date but appropriately aware to\n situation.\n PERRL 3mm.\n Moves all extremities with normal strength but has unsteady gait.\n Action:\n Q4 neuro exams\n Dilantin seizure prophylaxis\n PT consult\n Speech & swallow consult for history of cough and observed cough with\n po intake\n Response:\n No acute neuro exams\n Ambulated in with PT, walker obtained for patient to take home\n Per speech & swallow no overt signs of aspiration\n Plan:\n Reorient frequently\n Obtain UA when voids\n Video swallow tomorrow\n Ineffective Coping\n Assessment:\n Pt states she is independent and has lived alone\nall these years\n States she will\nthink about\n having help at home\n Was to move to on Tuesday to be with daughter\n Action:\n Unable to fly for 2-3 weeks\n Unable to go home without 24 hour supervision due to fall risk\n Response:\n Social work consult\n Daughter involved in plan of care\n Plan:\n To remain hospitalized overnight pending AM video swallow\n Family obtaining PCT for home care until patient can safely travel to\n \n"
},
{
"category": "Nursing",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 471310,
"text": "HPI:\n 84 yo female fall from standing, denies LOC, believes she slipped.\n Several previous falls in past. R facial abrasion\n Chief complaint:\n trauma\n PMHx:\n PMH: Hypothyroid, Anemia, DM, hypercholesterolemia, myelodysplatic\n syndrome, angiodysplasia, vertigo\n PSH: hysterectomy, CABG (11 yrs ago), CCY, cardiac stents (4-5 years\n ago)\n : Levoxyl 0.075', Inderal 120'', ISDN 30', Metformin 500''',\n protonix 40'', Lipitor 20', Allopurinol 300', ASA 81', procrit PRN,\n Folate.\n Soc: does not smoke, no alcohol\n Subdural hemorrhage (SDH)\n Assessment:\n A&Ox2-3, mildly confused to exact date but appropriately aware to\n situation.\n PERRL 3mm.\n Moves all extremities with normal strength but has unsteady gait.\n Action:\n Q4 neuro exams\n Dilantin seizure prophylaxis\n PT consult\n Speech & swallow consult for history of cough and observed cough with\n po intake\n Response:\n No acute neuro exams\n Ambulated in with PT, walker obtained for patient to take home\n Per speech & swallow no overt signs of aspiration\n Plan:\n Reorient frequently\n Obtain UA when voids\n Video swallow tomorrow\n Ineffective Coping\n Assessment:\n Pt states she is independent and has lived alone\nall these years\n States she will\nthink about\n having help at home\n Was to move to on Tuesday to be with daughter\n Action:\n Unable to fly for 2-3 weeks\n Unable to go home without 24 hour supervision due to fall risk\n Response:\n Social work consult\n Daughter involved in plan of care\n Plan:\n To remain hospitalized overnight pending AM video swallow\n Family obtaining PCT for home care until patient can safely travel to\n \n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 47.5 kg\n Daily weight:\n 46.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, CHF\n Additional history: hypothyroid, hypercholesterolemia, myelodysplasia\n syndrome (chronic anemic, gets blood draws weekly w/ Procrit dosing),\n angiodysplasia to gut (s/p laser and tamoxifen tx), >40# weight loss in\n last year\n surgical hx: appy, 4 vessel CABG > 10 yrs ago, TAH,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:45\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 63 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 821 mL\n 24h total out:\n 1,070 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 09:53 PM\n Potassium:\n 4.1 mEq/L\n 09:53 PM\n Chloride:\n 102 mEq/L\n 09:53 PM\n CO2:\n 24 mEq/L\n 09:53 PM\n BUN:\n 19 mg/dL\n 09:53 PM\n Creatinine:\n 0.9 mg/dL\n 09:53 PM\n Glucose:\n 211 mg/dL\n 09:53 PM\n Hematocrit:\n 36.0 %\n 09:53 PM\n Finger Stick Glucose:\n 177\n 02:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: walker\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: yellow ring with clear stones left ring finger\n Transferred from: T/\n Transferred to: 1124\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 471313,
"text": "HPI:\n 84 yo female fall from standing, denies LOC, believes she slipped.\n Several previous falls in past. R facial abrasion\n Chief complaint:\n trauma\n PMHx:\n PMH: Hypothyroid, Anemia, DM, hypercholesterolemia, myelodysplatic\n syndrome, angiodysplasia, vertigo\n PSH: hysterectomy, CABG (11 yrs ago), CCY, cardiac stents (4-5 years\n ago)\n : Levoxyl 0.075', Inderal 120'', ISDN 30', Metformin 500''',\n protonix 40'', Lipitor 20', Allopurinol 300', ASA 81', procrit PRN,\n Folate.\n Soc: does not smoke, no alcohol\n Subdural hemorrhage (SDH)\n Assessment:\n A&Ox2-3, mildly confused to exact date but appropriately aware to\n situation.\n PERRL 3mm.\n Moves all extremities with normal strength but has unsteady gait.\n Action:\n Q4 neuro exams\n Dilantin seizure prophylaxis\n PT consult\n Speech & swallow consult for history of cough and observed cough with\n po intake\n Response:\n No acute neuro exams\n Ambulated in with PT, walker obtained for patient to take home\n Per speech & swallow no overt signs of aspiration\n Plan:\n Reorient frequently\n Obtain UA when voids\n Video swallow tomorrow\n Ineffective Coping\n Assessment:\n Pt states she is independent and has lived alone\nall these years\n States she will\nthink about\n having help at home\n Was to move to on Tuesday to be with daughter\n Action:\n Unable to fly for 2-3 weeks\n Unable to go home without 24 hour supervision due to fall risk\n Response:\n Social work consult\n Daughter involved in plan of care\n Plan:\n To remain hospitalized overnight pending AM video swallow\n Family obtaining PCT for home care until patient can safely travel to\n \n Demographics\n Attending MD:\n \n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n Admission weight:\n 47.5 kg\n Daily weight:\n 46.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Oral \n CV-PMH: CAD, CHF\n Additional history: hypothyroid, hypercholesterolemia, myelodysplasia\n syndrome (chronic anemic, gets blood draws weekly w/ Procrit dosing),\n angiodysplasia to gut (s/p laser and tamoxifen tx), >40# weight loss in\n last year\n surgical hx: appy, 4 vessel CABG > 10 yrs ago, TAH,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:45\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 63 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 821 mL\n 24h total out:\n 1,070 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 09:53 PM\n Potassium:\n 4.1 mEq/L\n 09:53 PM\n Chloride:\n 102 mEq/L\n 09:53 PM\n CO2:\n 24 mEq/L\n 09:53 PM\n BUN:\n 19 mg/dL\n 09:53 PM\n Creatinine:\n 0.9 mg/dL\n 09:53 PM\n Glucose:\n 211 mg/dL\n 09:53 PM\n Hematocrit:\n 36.0 %\n 09:53 PM\n Finger Stick Glucose:\n 177\n 02:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: walker\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: yellow ring with clear stones left ring finger\n Transferred from: T/\n Transferred to: 924\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Bedside Swallow Evaluation",
"row_id": 471303,
"text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 84 y/o female admitted on\n s/p fall from standing with obvious facial abrasion. Pt\nreported having a chronic cough over the last year she has\ntreated with cough syrup combined with weight loss. CXR showed\nright upper and right lower lobe opacities concerning for\naspiration. Pt is being followed by Geriatrics who informed me pt\nwill likely return home to live with her daughter and given the\nconcern for aspiration on CXR it would be beneficial to have her\nevaluated prior to d/c. Staff have reported observing some\ncoughing with drinking and taking meds. She admitted to coughing\nup yellow phlegm in the morning when she wakes up.\nPMH includes hypothyroid, anemia, DM and hypercholesterolemia\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the T/SICU.\nCognition, language, speech, voice:\nPt was awake and alert, oriented to self only for me. Language\nwas fluent and appropriate in response to direct questions, but\nher spontaneous speech was confused and often off topic /\nrepetitive. Speech and voice were grossly wfl .\nTeeth: average condition\nSecretions: wfl in the oral cavity - baseline vocal quality was\nclear\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Tongue was at midline with functional strength and ROM.\nPalatal elevation was symmetrical.\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tsp, cup, straw),\npurees, apple cobbler, and crackers. Mastication was very\nslightly prolonged but without significant oral cavity residue.\nShe required sips of liquid to clear residue from cracker. She\ndid not have any overt coughing, throat clearing or changes in\nvocal quality but O2 SATs did drop very slightly x 2 (98-96%)\nafter water. Laryngeal elevation felt timely and wfl to\npalpation.\nSUMMARY / IMPRESSION:\nMs. did not have any overt signs of aspiration, but her\nhistory is concerning for possible silent aspiration given\nchronic cough, weight loss and colored phlegm combined with CXR\nappearance. I feel she can remain on her current diet for tonight\nand we can complete a video swallow tomorrow at 9am to r/o silent\naspiration before d/c.\nA Dysphagia Outcome Severity Scale (DOSS) rating will be deferred\npending video swallow tomorrow.\nRECOMMENDATIONS:\n1. Pt can continue on regular diet with thin liquids for tonight.\n2. Pills whole with water.\n3. Video swallow tomorrow at 9am to r/o silent aspiration before\nd/c.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 14:10-14:30\nTotal time: 50 minutes\n [BUTTON Input] (not implemented)_____\n 14:45\n"
},
{
"category": "Rehab Services",
"chartdate": "2140-08-25 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 471304,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: / 432.1\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: Pt. is 84 yo female\n s/p fall from standing R SDH.\n Past Medical / Surgical History: hypothyroidism, Anemia, DM,\n Hypercholesterolemia\n Medications: Acetaminophen, Levothyroxine, Metoprolol,\n Phenytoin,Allupurinol, Propanolol\n Radiology: Head Ct: R frontal SDH\n Labs:\n 36.0\n 11.2\n 97\n 7.7\n [image002.jpg]\n Other labs:\n Activity Orders: as tolerated RN\n Social / Occupational History: Lives alone, but has 2 supportive dtrs.\n Planned to move in with dtr, next week. Dtr will be staying with her\n after hospitaliation\n Living Environment: 1 level home. Shower chair, grab bars in bathroom\n Prior Functional Status / Activity Level: PTA. Amb with SC.\n Showers in sitting.\n Objective Test\n Arousal / Attention / Cognition / Communication: A&Ox3, 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 62\n 129/43\n 10\n 99\n Activity\n /\n Stand\n 66\n 136/59\n 17\n 98\n Recovery\n 52\n 144/60\n 18\n 100\n Total distance walked:\n Minutes:\n Pulmonary Status: BS diminished at bases\n Integumentary / Vascular: R facial abrasian\n Sensory Integrity: Sensation diminished in bilat. lower legs.\n Pain / Limiting Symptoms: no c/o pain\n Posture: kyphotic\n Range of Motion\n Muscle Performance\n bilat. UEs/LEs: WFL throughout\n bilat. UEs: > except shldr flexors: 4-/5, bilat. LEs: >.\n Motor Function: no abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt. amb 200 ft with RW with S, min VCs for technique.\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 T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: no LOB during amb. with RW. + Rhomberg, Tinetti Balance: ,\n , Total 18/27, high risk for falls\n Education / Communication: Pt./family edu re: Role of PT, , d/c plan\n to home with PT, RN comm re: d/c plan home with PT\n Intervention:\n Other:\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Gait, Impaired\n 3.\n Knowledge, Impaired\n Clinical impression / Prognosis: Pt. is 84 y.o. F s/p fall with\n resulting R SDH that p/w above impairments associated with\n nonprogressive d/o of the CNS. Pt. . with ambulation with RW\n and has met all STGs. Anticipate d/c home with family assistance once\n medically ready. Also, recommend home safety evaluation upon d/c.\n Goals\n Time frame: met on eval\n 1.\n supine to sit .\n 2.\n sit to stand .\n 3.\n Amb 200 ft with RW with S\n 4.\n Verbalize understanding of Role of PT\n 5.\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration:\n d/c acute PT\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face time: 12:15-13:00\n"
},
{
"category": "Nursing",
"chartdate": "2140-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 471133,
"text": "84 yo female s/p witnessed fall from standing in kitchen at home. Per\n family, pt struck head on counter as she fell. Taken initially to OSH\n () via EMS, CT showed ?epidural hematoma, transferred to \n for w/u. repeat scans show stable, small 4mm R frontal SDH. Neuro\n exam intact, to TSICU for observation.\n See medical and surgical hx in H&P.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro intact, perrla, 3-4mm. denies pain, vision disturbances. (Did\n become very sleepy and mildly confused directly after dilantin loading\n dose given, sx have since resolved).\n Action:\n Serial neuro checks, sbp mgmt <140, maintenance ivf, dilantin q8h.\n Response:\n Exam remains intact, sleepy most of shift, easily awakened for exam.\n Strength weak overall (pt\ns baseline). As above, became mildly\n confused and lethargic after dilantin.\n Plan:\n Advance diet to regular, neuro checks q4h now, per attending may\n transfer to floor tonight, likely to be d/c\nd home next 24-48 hrs.\n note: pt has fallen 3x in last month per family, will need PT/OT safety\n eval prior to discharge. Per daughter , pt will be moving down to\n TX next week to live with her from this point on.\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-26 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1088954,
"text": " 9:09 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspiration\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with r sdh\n REASON FOR THIS EXAMINATION:\n eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chronic cough and right lower lobe pneumonia.\n\n COMPARISON: None available.\n\n SWALLOWING VIDEO FLUOROSCOPY: Oropharyngeal swallowing video fluoroscopy was\n performed in conjunction with the speech and swallow division. Multiple\n consistencies of barium were administered.\n\n Barium passed freely through the oropharynx and esophagus without evidence of\n obstruction with some residue in the piriform sinus.\n\n There was no gross aspiration or penetration.\n\n For details, please refer to the speech and swallow division note in the OMR.\n\n IMPRESSION: There was no gross aspiration or penetration; however, there was\n some residue in the piriform sinus. For details, please refer to speech and\n swallow division note in the OMR.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088608,
"text": " 11:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate portacath placement\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with trauma, OSH portacath\n REASON FOR THIS EXAMINATION:\n evaluate portacath placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of Port-A-Cath placement that was placed\n in outside hospital.\n\n Portable AP chest radiograph was reviewed with no prior studies available for\n comparison.\n\n The right Port-A-Cath catheter tip terminates at the level of low SVC. The\n patient is after median sternotomy. The heart size is normal. Mediastinal\n position, contour and width are unremarkable. There is right upper lung\n opacity as well as right basal opacity, chronicity undetermined that might be\n related to prior infection or represent other process such as aspiration or\n infection, correlation with clinical history is recommended.\n\n If comparison with prior studies become available, addendum will be gladly\n added.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088549,
"text": " 4:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: H/O SDH FROM OSH. EVAL.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with 5mm SDH from OSH\n REASON FOR THIS EXAMINATION:\n please eval for progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp WED 5:17 AM\n 4mm R frontal SDH (no comp available)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Report of subdural hematoma on right.\n\n COMPARISON: None available at the time of dictation.\n\n CT HEAD WITHOUT INTRAVENOUS CONTRAST.\n\n FINDINGS: There is a thin, 4-mm maximal thickness, extra-axial hemorrhage\n layering over the right frontal convexity, anteriorly (2:14-19); there is no\n significant mass effect or shift of midline structures. No intraparenchymal\n hemorrhage is seen. Periventricular white matter hypodensities are compatible\n with chronic microvascular disease. Ventricles, sulci, and cisterns are of\n normal configuration and size for age, with some prominence of the lateral\n ventricular temporal horns, bilaterally. There is no depressed skull fracture.\n Mastoid air cells are clear. Visualized paranasal sinuses are unremarkable.\n\n IMPRESSION: Approximately 4-mm thick right frontal subdural hematoma, with no\n significant mass effect; no other hemorrhage and no skull fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088609,
"text": " 11:29 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: evaluate SDH\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with SDH s/p fall\n REASON FOR THIS EXAMINATION:\n evaluate SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT WED 2:36 PM\n 1. No significant short-interval change in the thin subdural hematoma\n overlying the right frontal convexity, with no significant mass effect or\n associated shift of midline structures.\n 2. No new hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST, :\n\n HISTORY: 84-year-old woman with SDH, status post fall; evaluate.\n\n TECHNIQUE: Contiguous 5 mm axial MDCT sections were obtained from the skull\n base to the vertex and viewed in brain and bone window on the workstation.\n\n FINDINGS: The study is compared with the NECT obtained some seven hours\n earlier. There has been no significant short-interval change in the thin\n extra-axial, likely subdural, hematoma overlying the right frontal convexity,\n anteriorly. This measures 4 mm in maximal thickness with no significant mass\n effect on the subjacent gyri or shift of normally midline structures. No\n other focus of hemorrhage is seen. The remainder of the examination,\n including mild-moderate global atrophy and relatively mild chronic\n microvascular infarction in bihemispheric periventricular white matter, is\n unchanged. As before, no skull fracture is seen.\n\n IMPRESSION:\n 1. No significant short-interval change in the thin subdural hematoma\n overlying the right frontal convexity, with no significant mass effect or\n associated shift of midline structures.\n 2. No new hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-08-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1088610,
"text": ", NSURG TSICU 11:29 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: evaluate SDH\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with SDH s/p fall\n REASON FOR THIS EXAMINATION:\n evaluate SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No significant short-interval change in the thin subdural hematoma\n overlying the right frontal convexity, with no significant mass effect or\n associated shift of midline structures.\n 2. No new hemorrhage.\n\n"
}
] |
74,857 | 107,543 | Primary Reason for Hospitalization: Patient is a 27-year-old male with a history of CLL status post allogeneic transplant in early complicated by chronic extensive moderate graft-versus-host disease involving the GI tract and capillary leak syndrome, and recent PE who presents in septic shock. 1. Septic Shock: The patient initially presented hypotensive to the 70s, febrile to 103.2 and hypoxic to 91% on NRB. He was transferred to the ICU on intubated and sedated. He was initially covered broadly with linezolid, cefepime, cipro, and micafungin. He was noted on admission to have numerous areas of skin breakdown with erythema on the left thigh concerning for infection. On the morning of HD1, this area of erythema became bullous and the blistering extended up to his mid-abdomen/torso and down to his left knee and became the most concerning and obvious source of infection. Blood, stool, and urine cultures were all sent and negative. He was given hydrocortisione 100mg IV q8 for adrenal insufficiency given his history of chronic prednisone use. He was given IVF and pressors, and a left IJ line and an arterial line were placed. As his infectious sources were controlled with antibiotics, he was weaned off of pressors by HD3. On the floors, patient hemodynamically stable and weaned off hydrocortisone and restarted home dose prednisone 12.5mg daily Hospital course was prolonged by repeated episodes of hypoxia requiring ICU transfers. He was noted to have VRE bacteremia, resistant to daptomycin, during his final ICU stay. He was treated with linezolid, but due to extremely poor vascular access, HD and left PICC lines were not removed, but were treated with daptomycin locks. Blood cultures cleared VRE by . Unfortunately, during this time, a bullous right wrist lesion was noted to be expanding, and biopsy and MRI were consistent with invasive mucormycosis. He was deemed a poor surgical candidate for debridement or amputation due to extensive comorbidities and attempts to treat medically with ambisome were continued. The size and extent of the right wrist Mucor infection expanded, and the right hand demonstrated progressive cysnosis, pallor by . Additionally, further skin biopsies showed VRE growing within left groin lesion. By patient was pressor dependent, persistent sepsis, persistent bone marrow failure, with progressive renal impairment, evolving progressive lactic acidosis, and progressive systemic acidemia. Following multiple discussions with health care proxy and extensive number of family members, all clearly indicated that patient would not want to be maintained on life support in the context of severe medical illness and continued decline in condition. On the unannomous decision to proceed with assuring comfort as the priority. Following discontinuation of dialysis and vasopressor support, the patient peacefully expired in the presence of family members. 2. Hypoxemic respiratory failure: The patient had large A-a gradient on presentation, and was therefore intubated and sedated with fentanyl and midazolam. Patient was soon extubated, and by the morning of HD3, he was breathing comfortably on 2L NC. After being transferred to the floor, he remained on minimal O2 support. However, on , the patient was found to be hypoxic to the 80s on RA with increased work of breathing. He was placed on a NRB without significant improvement and was intubated for respiratory distress. This was attributed to PNA seen on chest CT as well as metabolic acidosis secondary to renal failure. He remained on ventilatory support until HD 21 (), at which time he was again extubated. Within four days following extubation, he was able to maintain oxygenation and ventilation on room air. Following callout to the floor, however, he developed an episode of large volume epistaxis and hemoptysis, of unclear etiology, and developed respiratory distress, likely secondary to aspiration. He was transferred back to the ICU and was initally placed on 100% oxygen, and following cessation of hemoptysis was eventually weaned down to 3L oxygen via nasal cannula prior to transfer back to the floor. His respiratory status waxed and waned and again required ICU transfer on . He was again noted to have significant oropharyngeal bleeding, and due to repeated aspiration and hypoxia was intubated on . CXR's showed persitently low long volumes with bilateral infilatrates. Additionally, as he developed anuric renal failure and hypotension, fluid balance was difficult to achieve and he became grossly fluid overloaded. By , the decision to cease supplemental O2 with ventilation was made along with his family and HCP due to insurmountable disease and medical futility. 3. CMV Viremia: Patient had a history of known CMV and while in the hospital he was continued on gancyclovir. Surveillance CMV viral loads demonstrated a marked jump in his CMV viral load to , and patient was changed to foscarnet due to likely resistance to ganciclovir. CMV viral load on was . 4. MSSA scalded skin reaction: The patient first complained of pain in L upper thigh and inguinal area on via telephone to oncology nurse. On admission, he was noted to have purpura, bullae, erythema and warmness on the left anterior thigh that progressed to the abdomen. CT torso to knees did not show evidence of necrotizing fascitis. Two 4mm punch biopsies showed occlusive thrombotic vasculopathy, consistent with a scalded skin reaction, and his infection was initially treated with Vancomycin, but switched to daptomycin because of vamcomycin-associated . His pain was managed with long and short acting opioid agents, as well as lidocaine gtt and PCA. Following intubation on , patient remained on fentanyl gtt. 5. Mucormycosis: On the patient was discovered to have a small erythematous lesion on his right medial forearm. This had a small black scab/eschar in the middle and was surrounded by peeling skin. There was concern for cellulitis, investigated with ultrasound on and again on the 28th. Lesion remained stable until noted to be more painful and expanding on . Biopsy showed invasive mucormycosis. Patient was not a surgical candidate for debridement and hand became cyanotic and cool. MRI was suggestive of marrow infarction along with significant invasive diesease. He was treated with ambisome and CT of sinus showed no evidence of maxillofacial disease, and BAL showed no sign of pulmonary disease. Biopsy of left groin lesion showed VRE but no evidence of mucor. Unfortunately, wound continued to expand aggressively prior to the cessastion of pressors. 6. PNA: Shortly after the patient's admission, he was noted to have signs of PNA on CXR and CT. He was already on empiric antibiotic coverage, so pneumonia was monitored on subsequent AM CXRs. On HD13 as his respiratory status deteriorated, he was found to have increased pulmonary edema, pleural effusion, and PNA. CXR showed RUL infiltrate and LLL collapse. He was treated with linezolid and meropenem for presumed HCAP, later switched to vancomycin and meropenem as he became neutropenic. This course was continued for 8 days. Subsequent BAL on and showed no evidence of infection despite persistent consolidations and hypoxemia. 7. Bleeding: The patient developed large volume hemoptysis and epistaxis on . ENT was consulted and perrformed a scan and biopsy/ culture of sinuses. Neisseria was grown, but in small volume, and thought to be insignificant. The patient was considered to be too unstable to withstand bronchoscopy. He was intitially continued on heparin gtt due to his significant history of known DVT's. HW, as his oropharyngeal bleeding continued to compromise his tenuous respiratory status, heparin gtt was discontinued on . He received numerous platelet transfusions to maintain platelet count >30. 8. Nutritional: Due to recurrent mucosal bleeding and clots formation in his OP, patient developed significant dysphagia and odynophagis during his final ICU transfer. NG and OG tubes were not able to be placed, and patient was started on TPN sans lipids. Of note, due to extremely poor venous access, a dedicated line was not able to be used for TPN. 9. Acute Renal Failure: During the hospital stay, he developed a metabolic acidosis and acute renal failure. Etiology of renal failure thought to be Vancomycin (supratherapeutic to trough 35) as well as hypoperfusion from insensible volume loss. Additionally, some element of foscarnet toxicity was thought to play a role as well. Albumin 50-100g/day was given per renal recommendations, without improvement in renal fucntion. By HD13 he had a Cr of 3.4 and was found to have a pH of 7.30. He was started on CRRT on HD15, which was used both to normalize his acid-base status and to reduce the significant anasarca developed secondary to his skin infection and fluid resuscitation for sepsis. He was switched to HD with good results, moving to a 3x weekly schedule on . As his blood pressures became lower, he was again transitioned to CRRT. 8. DVT's: Patient was found to have extensive clots of his central veins involving the IVC, the subclavian veins, and an internal jugular vein on this stay. He was treated with heparin gtt and lovenox. Heparin-dependent antibodies were negative. Anticoagulation was discontinued on due to signficant bleeding. 9. Hypertension: Once the patient's sepsis resolved on HD3, the patient began to experience hypertension to the SBP 170s, particularly associated with pain. He is hypertensive at baseline, controlled with Lasix and metoprolol. As an inpatient he was given metoprolol with occasional doses of hydralazine for SBP>170. His volume status was addressed with CRRT/HD. 10. Portacath infection: Port site swab grew MRSA on HD3, one possible source of infection. Patient was already on vancomycin for left leg infection, which was continued for an 8 day course sufficient to cover this skin infection. 11. Anemia: The patient has a baseline anemia, worsened on presentation. He received 2 units PRBC at OSH and his hct remained stable on admission. Initial hemolysis labs were negative and there was no evidence of DIC. His Hct improved initially, but declined as hospital stay continued, likely due to severe disease and recurrent bleeding. He received 26 units pRBC during this admission. 12. Tachycardia: Patient had sinus tach throughout ICU stay, thought to initially be secondary to sepsis and inflammatory response and later due to a component of pain from skin infection that the team was actively trying to control. He was given fluid boluses as needed for fluid repletion and monitored on telemetry. During his final ICU admission, he was repeatedly found to convert to atrial flutter. Blood pressures remained stable during these episodes, and were treated with IV nodal agents as needed. 13. Hyperglycemia. Patient was hyperglycemic throughout admission, likely secondary to IV hydrocortisone and stress response of illness. No known hx of diabetes. He was maintained on an ISS. 14. GVHD: Appears stable at this time. Patient was given stress dose steroids as above and was then tapered back down according to BMT recommendations. 15. CLL: Patient appears to have been in remission since transplant, although his transplant course was complicated by capillary leak. During his stay he was maintained on GVHD treatment with steroids, and was given antibiotic prophylaxis with valgancyclovir (CMV), micafungin (fungal), and atovaquone (PCP). He was treated with Neupogen for neutropenia for a total 5 day course. Given a positive beta-glucan result he was switched to voriconazole on . 16. Hyponatremia: As patient became increasingly hypervolumic due to anuric renal failure, patient developed hypervolemic hyponatremia. Fluid balance was attempted to be controlled by HD/UF and CRRT with poor results. Na on was 127. | Minimal decrease extent of a pre-existing right pleural effusion. FINDINGS: A right internal jugular approach central venous catheter tip terminates within the low SVC. 2.Discrete focal opacity in the right mid lung concerning for a pneumonic consolidation. Right internal jugular is probably terminating into the low SVC/atrium. Stable small pericardial effusion and T9 superior endplate compression fx. 3.Unchanged left lower lung atelectasis. There is a new discrete opacity in the right mid lung, which is concerning for a pneumonic consolidation. Even with the patient in a flexed , endotracheal tube is low with the tip projecting right above the carina. Mediastinal vascular engorgement indicates elevated central venous pressure or volume, and moderate cardiomegaly is unchanged. CT OF PROXIMAL LOWER EXTREMITIES: The gluteus medius shows low density suggesting edema or inflammation. Unchanged retrocardiac atelectasis. Skin of the right anterior neck around existing triple lumen central line was prepped and draped in a sterile fashion. The course of the internal jugular vein catheter is unchanged, the previously seen nodular right upper lobe opacity is less obvious on today's film. IMPRESSION: 1.Stable mild-to-moderately sever pulmonary edema. Stable deep vein thrombosis. Right upper lobe rounded ground glass opacity (4 x 3 cm) without central necrosis or cavity formation corresponds to the finding on a previous CXR and likely represents pneumonia, less likely GVHD or leukemic infiltrate. There are noechocardiographic signs of tamponade.IMPRESSION: Normal left ventricular cavity size and wall thickness with mildlydepressed left ventricular systolic function. Mild global RV free wall hypokinesis.Abnormal septal motion/position.AORTA: Moderately dilated aorta at sinus level. IMPRESSION: No acute intracranial pathological process, with sinuses better assessed on accompanying sinus CT. Opacification of bilateral mastoid air cells. -Central line in low SVC -Bibasilar patchy lung opacities unchanged from prior - likely scarring/atelectasis. No echocardiographic signs oftamponade.GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads orelectrodes. RV functiondepressed.AORTA: Mildy dilated aortic root. Suboptimal image quality -patient unable to cooperate.Conclusions:The left atrium is normal in size. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Very small pericardial effusion. No PS.Physiologic PR.PERICARDIUM: Very small pericardial effusion. Dilated main PA.PERICARDIUM: Very small pericardial effusion. -Non-contrast images of abdominopelvic viscera within normal limits. Normal ascending aorta diameter.AORTIC VALVE: ?# aortic valve leaflets.MITRAL VALVE: Mildly thickened mitral valve leaflets.TRICUSPID VALVE: Normal PA systolic pressure.PERICARDIUM: Small pericardial effusion. MUSCULOSKELETAL: T9 compression fracture is unchanged from the prior examination. -Loss of vertebral body height of T9 - though unchanged from prior. Again, there are low lung volumes with stable cardiomediastinal silhouette. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Skin of the right anterior neck around the insertion site of the temporary right-sided internal jugular dialysis line was prepped and draped in a sterile fashion. Severity of bilateral lung bronchiectasis, right side more than left side, is unchanged. Blood return was obtained, and 0.018 inch guidewire was advanced into the superior vena cava. A right central venous catheter is unchanged with tip reaching the right atrium. Evaluate for discrete abscess or hematoma. The right side of the neck was prepped and draped in a sterile fashion. Attention was then turned to the left anterior neck, where the skin was prepped and draped in sterile fashion. At the conclusion of the procedure, the tip of the hemodialysis in the superior third of the right atrium. A scout image was taken of the existing hemodialysis line which looked to be in place. The needle was then exchanged for a micropuncture sheath, through which was passed into the right atrium and appropriate measurements were taken. Endotracheal tube, left central line and esophageal catheter has been removed. The gallbladder is within normal limits without cholelithiasis or pericholecystic fluid. Mild cardiomegaly and top normal size pulmonary artery. At the conclusion of the procedure, the tip of the Power double-lumen central line was in the superior third of the right atrium. Bibasal linear opacities are unchanged, most likely representing atelectasis although in the right lung the opacity is relatively and might reflect infectious process. IMPRESSION: Multifocal ground-glass opacities and pulmonary consolidation in the upper lobes are unchanged. There persist unchanged low lung volumes with bibasilar atelectasis. Bilateral lower lung atelectasis, left side more than right side, are unchanged. FINDINGS: Multifocal areas of ground-glass opacity and patchy consolidation in both upper lobes and right middle lobe, are unchanged since the prior study. Previously identified right-sided internal jugular approach double-lumen catheter remains in unchanged position terminating in the upper portion of the right atrium. Cardiomediastinal contours are unchanged with cardiomegaly accentuated by the low lung volumes. CONTRAINDICATIONS for IV CONTRAST: renal failure WET READ: KKgc SUN 3:21 PM Multifocal ground-glass opacities and pulmonary consolidation in the upper lobes are unchanged. Wedge compression deformities are seen from T7-12, L1, L2, and L4 over the background of severe osteopenia, all unchanged. Slight in bilat streaky opacities = interstitial PNA + atelectasis based on CT. Bilat lines in RA as before. COMPARISON: CT torso without contrast and CT chest without contrast . Diffuse non-specific T wave abnormalities likely secondaryto rate. Diffuse non-specific T wave abnormalities likely secondaryto rate. Non-specific ST-T wave abnormalities inthe inferior and lateral leads. Diffuse non-specific ST-T wave abnormalities. T wave abnormalities.Since the previous tracing of the rate is slower. Poor R wave progression.Possible left ventricular hypertrophy. Compared to theprevious tracing of the T wave inversions in the right precordial leadsare less prominent and the ventricular ectopic activity has diminished. Ventricular premature beats are seen on thecurrent tracing. The non-specific ST-T wave changes persist but aresomewhat less prominent in leads I and aVL. Poor R wave progression of uncertainsignificance. Diffuse non-specific T wave abnormalities likely secondaryto rate.TRACING #3 Compared to the previous tracing of thepatient is no longer in sinus tachycardia with occasional ventricularpremature beats. Non-specific ST-T wave changes. Non-specific T wave changes. ST-T waveabnormalities may be less prominent. Non-specificanteroseptal ST-T wave changes persist.TRACING #2 Sinus tachycardia with ventricular premature beats and significant baselineartifact. These changes are non-specific andnon-diagnostic. Left ventricular hypertrophy with lateralST-T wave abnormalities. Sinus tachycardia with ventricular premature beats. Sinus tachycardia with ventricular premature beats. Sinus tachycardia with ventricular premature beats and baseline artifact.Possible biatrial enlargement. Compared to the previous tracing of ventricular premature beats are now noted and lateral T wave abnormalities areslightly more prominent. | 90 | [
{
"category": "Radiology",
"chartdate": "2112-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201308,
"text": " 5:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess lungs\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M with CLL, mult rounds of chemo with allo transplant in , now\n hypotensive.\n REASON FOR THIS EXAMINATION:\n please assess lungs\n ______________________________________________________________________________\n WET READ: SPfc WED 10:56 PM\n Low lung volumes. Increased left lower lobe opacity may be infectious or\n atelectatic\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: AP supine portable radiograph of the chest.\n\n Comparison was made with prior radiographs through .\n\n INDICATION: 23-year-old man with CLL, lung changes.\n\n FINDINGS: Bilateral lung volumes are low. Bibasal atelectasis, left more\n than right, are persisting and unchanged since -3 . A concomitant left\n lung base consolidation cannot be ruled out. Aerated parts of bilateral\n lungs are free of consolidation. Cardiomediastinal contours are unchanged.\n Distal end of the orogastric tube is below the level of diaphragm and is\n within the stomach, though the tip is beyond the view of radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-17 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1201318,
"text": " 6:44 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Placement of new RIJ CVL\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with resp failure, sepsis h/o BMT for CLL\n REASON FOR THIS EXAMINATION:\n Placement of new RIJ CVL\n ______________________________________________________________________________\n WET READ: SPfc WED 11:13 PM\n Right IJ ends at the upper cavoatrial junction. Otherwise minimal interval\n change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH:\n\n INDICATION: Respiratory failure, sepsis, evaluation for internal jugular vein\n line.\n\n COMPARISON: , 5:30 p.m.\n\n FINDINGS: The patient has received a new internal jugular vein on the right.\n The tip of the line projects over the cavoatrial junction. There is no\n evidence of complication, notably no pneumothorax. Otherwise, the\n radiographic appearance is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-06 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1204124,
"text": " 5:21 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line on L, needs a double lumen PICC\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 12\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -79 UNRELATED PROCEDURE/SERVICE DURI *\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * FLUORO GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\n * US GUID FOR VAS. ACCESS US GUID FOR VAS. ACCESS *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, chronic GVHD, now septic w/ MRSA scalded skin\n syndrome, poor access\n REASON FOR THIS EXAMINATION:\n please place PICC line on L, needs a double lumen PICC\n ______________________________________________________________________________\n FINAL REPORT\n PLACEMENT OF A PICC LINE. PLACEMENT OF A TEMPORARY DIALYSIS LINE. VENOGRAM\n OF THE RIGHT UPPER EXTREMITY.\n\n CLINICAL INDICATION: A 27-year-old man with chronic lymphocytic leukemia,\n chronic GVHD with MRSA sepsis and poor venous access. Renal failure in need\n of dialysis. Fluid overload.\n\n Witnessed informed consent for placement of a temporary dialysis line was\n obtained over the telephone from the healthcare proxy. The patient\n was placed on the angiographic table in supine position. Placement of a PICC\n line was approached first. A timeout and huddle protocols for both procedures\n were carried out prior to the procedure according to the Hospital\n policy.\n\n Skin of the right upper extremity was prepped and draped in a sterile manner.\n Local anesthesia was affected by 1% lidocaine. A fully compressible and\n patent right cephalic vein was identified. Dr. accessed the right\n cephalic vein using a 21-gauge micropuncture needle under realtime ultrasound\n guidance utilizing high-frequency linear array transducer with images stored.\n A 0.018 nitinol guidewire was then advanced through the needle into the right\n cephalic vein. However, the guidewire could not be advanced into the right\n subclavian vein. A 4 French sheath was then advanced over the guidewire and\n exchanged for a 21- gauge needle. A venogram of the right upper extremity was\n performed, demonstrated occluded right subclavian vein with elaborate network\n of collateral veins, tributaries of the cephalic vein draining the right upper\n extremity venous outflow. A double-lumen PICC line was truncated to 14 cm in\n length and inserted functionally as a midline catheter through a peel-away\n sheath which was subsequently removed.\n\n The attention was then diverted to the right anterior neck. Skin of the right\n anterior neck around existing triple lumen central line was prepped and draped\n in a sterile fashion. Through an existing triple-lumen catheter port, a\n Bentson guidewire was advanced into the inferior vena cava. The triple-lumen\n (Over)\n\n 5:21 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line on L, needs a double lumen PICC\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n catheter was removed and 12 French dialysis catheter with VIP port was\n inserted. The tip of the catheter was demonstrated in the right atrium at the\n conclusion of the procedure. The patient tolerated the procedure well. The\n catheter was sutured to the skin and covered with sterile dressings.\n\n IMPRESSION:\n 1. Uncomplicated insertion of a triple-lumen dialysis catheter with a VIP\n port into the right atrium via the right internal jugular vein with ultrasound\n and fluoro guidance.\n 2. Placement of a truncated right upper extremity PICC line via the right\n cephalic vein with the tip in the distal cephalic vein functioning as a\n midline catheter.\n 3. Chronic occlusion of the right subclavian vein with elaborate collateral\n venous tributaries of the chest wall draining the right upper extremity.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203428,
"text": " 2:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval positiom of left central line\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with respiratory failure now on HD.\n REASON FOR THIS EXAMINATION:\n eval positiom of left central line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Evaluate position of central line.\n\n COMPARISON: .\n\n FINDINGS: Single portable frontal view of the chest shows a left IJ catheter\n coursing into the upper subclavian. The tip is directed towards the wall of\n the vessel, if adequate blood withdrawal is achieved, position is likely\n satisfactory. ET tube and right IJ catheter are unchanged in position.\n Bilateral opacities and retrocardiac opacity are unchanged. No pneumothorax\n or pleural effusion.\n\n IMPRESSION: Satisfactory position of left central line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202993,
"text": " 6:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm edema, infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, recovering from septic shock, tachypenic with\n desaturations into low 90s\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema, infiltrate\n ______________________________________________________________________________\n WET READ: ENYa TUE 1:00 AM\n Low lung volumes. No pulmonary edema. Marked cardiomegaly, unchanged. R IJ\n CVL terminates in the lower SVC. No PTX.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: CLL, recovering from septic shock, evaluation for pulmonary\n edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Low lung volumes, without pulmonary edema or pneumonia. Unchanged\n retrocardiac atelectasis. The presence of a minimal left pleural effusion\n cannot be excluded. Unchanged course and position of the right central venous\n access line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203858,
"text": " 4:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with respiratory failure from ? PNA, volume overload and\n acidosis\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old man with respiratory failure, query pneumonia, to\n look for interval changes.\n\n TECHNIQUE: Supine portable radiograph of chest.\n\n Comparisons were made with prior chest radiographs through ,\n with the most recent from .\n\n FINDINGS: Bilateral lung volumes are low. Mild to moderately sever pulmonary\n edema is relatively unchanged. There is a new discrete opacity in the right\n mid lung, which is concerning for a pneumonic consolidation. Pleural\n effusion, if any, is minimal on the left side. Appearance of Left lower lobe\n atelectasis is no different since prior radiograph. Right and left central\n lines are terminating into the low SVC. Tip of the endotracheal tube is\n approximately 2.2 cm above the carina with neck in a flexed position and is\n appropriate.\n\n IMPRESSION:\n\n 1.Stable mild-to-moderately sever pulmonary edema.\n\n 2.Discrete focal opacity in the right mid lung concerning for a pneumonic\n consolidation.\n\n 3.Unchanged left lower lung atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201350,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27-year-old male with a history of CLL status post allogeneic transplant in\n early complicated by graft-versus-host disease, capillary leak syndrome,\n PE who presents in septic shock.\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Portable supine radiograph of the chest.\n\n Comparison is made with prior radiograph through with the most\n recent from .\n\n IMPRESSION: Endotracheal tube is approximately 3 cm above the carina. Right\n internal jugular is probably terminating into the low SVC/atrium. Orogastric\n tube is coursing below the level of diaphragm and the distal end appears to be\n in the stomach, though the tip is beyond the view of the radiograph.\n Bilateral lung volumes are persistently low. Bibasal atelectasis, left more\n than right are relatively unchanged. There are no relevant changes in the\n aerated portions of the bilateral lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203198,
"text": " 6:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?status of pneumonia, et tube location\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL p/w respiratory distress, ventilated, has new\n pneumonia\n REASON FOR THIS EXAMINATION:\n ?status of pneumonia, et tube location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with CLL, presenting with respiratory distress.\n Evaluate for status of new pneumonia.\n\n EXAMINATION: Single frontal portable chest radiograph.\n\n COMPARISONS: , , and .\n\n FINDINGS:\n\n The right internal jugular approach venous catheter tip projects in the region\n of the cavoatrial junction. Even with the patient in a flexed , \n endotracheal tube is low with the tip projecting right above the carina.\n\n There are low lung volumes which accentuates diffuse perihilar pulmonary\n parenchymal opacification. There is unchanged dense consolidation\n demonstrated within the left lower lobe, likely atelectasis and a small\n pleural effusion. There is no evidence of pneumothorax. The\n cardiomediastinal and hilar contours are stable.\n\n IMPRESSION:\n 1. Low-lying endotracheal tube with tip just above the carina with the neck\n in a flexed position.\n 2. Low lung volumes limit assessment, but there is apparent bilaeral perhilar\n parenchymal opacification, with distribution favoring edema. Repeat radiograph\n with improved inspiratory effort may be helpful for more complete\n characterization, particularly considering clinical concern for pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-06 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1204033,
"text": " 8:55 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please assess for interval change, sources of infection.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with 27 y/o M CLL/SLL s/p allogeneic stem cell transplant\n complicated by GVHD of the gut and chronic capillary leak syndrome with\n respiratory distress.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change, sources of infection.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n COMPUTED TOMOGRAPHY OF THE THORAX:\n\n INDICATION: 27-year-old man with CLL, status post allogenic stem cell\n transplantation, marked graft-versus-host disease. Capillary leak and\n respiratory distress, evaluation for interval changes.\n\n COMPARISON: .\n\n TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,\n no administration of intravenous contrast material, multiplanar\n reconstructions.\n\n FINDINGS: The examination is compared with . As compared to this\n examination, there is unchanged presence of substantial motion artifacts\n caused by respiration, limiting the interpretation of the findings. The\n pre-existing ground-glass opacity in the right upper lobe is now denser and\n smaller, apparently reflecting thickening organization. Atelectatic changes\n at the dorsal aspect of the right upper lobe have almost completely resolved.\n Minimal decrease extent of a pre-existing right pleural effusion. The\n opacities at the bases of the right lower lobe have decreased in extent.\n\n On the left, the extent of the pre-existing opacities is unchanged. Also\n unchanged is a small amount of left pleural effusion. Larger parenchymal\n opacities have not newly occurred. The monitoring and support devices appear\n in correct position. Unchanged moderate cardiomegaly. Unchanged appearance\n of the mediastinum and the upper abdominal organs.\n\n IMPRESSION: As compared to , the pre-existing right upper lobe\n opacity is in the course of organization. More subtle opacities in the right\n upper lobe have almost completely resolved. Improved are areas of atelectasis\n at the bases of the right lower lobe. The appearance of the left hemithorax,\n including a small left pleural effusion, is unchanged. Overall, the\n examination is limited by respiratory motion artifacts.\n\n No mediastinal lesions. No substantial pericardial effusion.\n\n (Over)\n\n 8:55 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please assess for interval change, sources of infection.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202771,
"text": " 10:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Rule out pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Very low lung volumes with moderate cardiomegaly and extensive left\n basal atelectasis. Small left pleural effusion. No evidence of pulmonary\n edema. Unchanged appearance of the right lung with minimal basal atelectasis,\n but without evidence of pneumonia. The course of the internal jugular vein\n catheter is unchanged, the previously seen nodular right upper lobe opacity is\n less obvious on today's film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203639,
"text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pulm status\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, volume overloaded, \n REASON FOR THIS EXAMINATION:\n assess pulm status\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 27-year-old man with CLL and volume overload.\n\n FINDINGS: Comparison is made to previous study from .\n\n There are bilateral central venous catheters. The left-sided catheter is\n perpendicular to the SVC wall. These positions are unchanged. Endotracheal\n tube and feeding tube is also seen. There are markedly low lung volumes with\n crowding of the pulmonary vascular markings. There is again seen some\n increased opacity at the right base, which may represent developing\n infiltrate. There is a left retrocardiac opacity which is stable. Overall,\n there has not been any significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203048,
"text": " 8:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm edema, infiltrate, pna\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with acute resp distress\n REASON FOR THIS EXAMINATION:\n evaluate for pulm edema, infiltrate, pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute respiratory distress.\n\n COMPARISON: .\n\n FINDINGS: Single upright portable view of the chest shows worsening left\n pleural effusion and complete atelectasis of the left lower lobe. There are\n new focal opacities within the right mid lung consistent with pneumonia. The\n right IJ line is in standard position. No pneumothorax. Cardiac size is\n difficult to assess.\n\n IMPRESSION: Worsening left pleural effusion and complete left lower lobe\n atelectasis. New right focal opacities consistent with pneumonia.\n\n These findings were discussed with Dr. at 10:28 on by\n telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203156,
"text": " 4:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess for interval change and endotracheal tube plac\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, newly intubated.\n REASON FOR THIS EXAMINATION:\n please assess for interval change and endotracheal tube placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: 27-year-old male patient with chronic lymphatic leukemia, newly\n intubated, assess for interval change and endotracheal tube placement.\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 eight hours earlier during the same day. During the\n interval, the patient has been intubated. The ETT terminates in the lower\n trachea, just 2 cm above the level of the carina. It is recommended to\n withdraw the tube by a few centimeters not to jeopardize unilateral bronchial\n obstruction by the tube. No pneumothorax has developed. Previously\n identified right subclavian approach central venous line remains in unchanged\n position. No new pulmonary abnormalities are seen. The left-sided basal\n density obliterating the diaphragmatic contour and suggestive of\n atelectasis-infiltrate persists.\n\n IMPRESSION: Successful intubation, recommendation to withdraw ETT by a few\n centimeters was transmitted to referring physician, , by\n telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-18 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1201425,
"text": " 12:45 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please do CT torso down to knee to assess ?nec fasc. bad ce\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n -year-old male with a history of CLL status post allogeneic transplant in early\n complicated by graft-versus-host disease, capillary leak syndrome, PE who\n presents in septic shock with bad cellulitis on L thigh.\n REASON FOR THIS EXAMINATION:\n please do CT torso down to knee to assess ?nec fasc. bad cellulitis\n CONTRAINDICATIONS for IV CONTRAST:\n ?allergy\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE TORSO\n\n INDICATION FOR STUDY: History of CLL status post allogenic transplant with\n complications of graft-versus-host disease, capillary leak syndrome and\n pulmonary embolism now presents with septic shock and cellulitis on left\n thigh. Present study is to further evaluate infectious versus obstructive\n process in the left thigh.\n\n COMPARISON EXAM: CT of torso with contrast .\n\n TECHNIQUE: Multidetector CT-acquired axial images from the thoracic inlet to\n the knees after administration of IV contrast (Optiray). Coronally and\n sagittally reformatted images were displayed with 5-mm slice thickness. The\n only documented allergy turned out to involve shellfish so contrast was\n administered intravenously to maximize the diagnostic utility of the study and\n was uneventful.\n\n CT OF CHEST WITH IV CONTRAST: The patient remains intubated. An orogastric\n tube terminates in the stomach. A central catheter terminates in the\n superior vena cava. A soft tissue defect is similar along the right upper\n anterior chest wall associated with port removal (3:6). The heart is mildly\n enlarged. There is trace pericardial fluid and tiny pleural effusions. There\n are no definite pulmonary arterial filling defects, noting the limitations of\n technique including motion artifact, but small pulmonary emboli are hard to\n exclude. There are increased patchy opacities in the lower lungs. These are\n not entirely specific but suggest multifocal atelectasis which is most\n prominent in the medial basilar left lower lobe.\n\n CT ABDOMEN WITH IV AND ORAL CONTRAST: The liver enhances homogeneously with\n no evidence of lesions, cysts, or biliary dilatation. Its attenuation is\n relatively compared to the spleen, however, suggesting there may be fatty\n infiltration. The gallbladder is normal with normal wall thickness and no\n pericholecystic fluid evident. The spleen enhances homogeneously with no\n evidence of lesions; the pancreas, kidneys, and adrenals bilaterally are\n unremarkable.\n\n The stomach and small bowel are unremarkable. The mid to lower sigmoid colon\n (Over)\n\n 12:45 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please do CT torso down to knee to assess ?nec fasc. bad ce\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n exhibits slight wall thickening and mucosal hyperdensity, probably\n enhancement, suggesting an inflammatory or possibly infectious process.\n\n CT PELVIS WITH IV AND ORAL: The prostate and bladder are unremarkable. A\n Foley is seen in place in the bladder, which is mostly collapsed. There is no\n retroperitoneal or mesenteric lymphadenopathy. There is no free fluid or air\n in the abdomen, but here is increased focal anasarca, particularly along the\n right flank but widespread and increased over comparison exam. A deep vein\n thrombosis involving the left external iliac and femoral veins, and probably\n extending through to the popliteal vein shows a similar degree of pelvic\n extension. There is scrotal fluid found bilaterally likely hydrocele and\n substantial in size.\n\n CT OF PROXIMAL LOWER EXTREMITIES: The gluteus medius shows low density\n suggesting edema or inflammation. The left proximal lower extremity is\n diffusely swollen including the prominent fat stranding along the lateral deep\n subcutaneous fat. No gas is seen. The overlying skin appears thickened,\n particularly a focal area along the anterior thigh which is probably\n conspicuous clinically (3:122).\n\n BONE WINDOW: Several mild thoracolumbar compression deformities are\n unchanged. The bone are probably demineralized. There are no focal\n destructive lesions.\n\n IMPRESSION:\n\n 1. Asymmetric fat stranding along the soft tissues of the lateral left hip\n and thigh suggesting edema or inflammation. Deep fascial infection is not\n excluded by this study. The extent of deep compartment involvement of\n infection or inflammation is not well characterized and MR could be of\n potential value in further assessment if needed clinically. No gas or\n drainable collection is visualized.\n\n 2. Wall thickening and mucosal enhancement seen along the sigmoid colon\n suspicious for colitis.\n\n 3. Large quantity of scrotal fluid; clinical correlation is recommended and\n consideration of ultrasound if needed clinically.\n\n 4. Stable deep vein thrombosis.\n\n 5. Increased lung opacities; although not specific, these are suggestive of\n atelectasis.\n\n 6. Similar soft tissue defect at site of removed port.\n (Over)\n\n 12:45 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please do CT torso down to knee to assess ?nec fasc. bad ce\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 7. Suggestion of fatty liver.\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-31 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1203312,
"text": " 6:25 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: placement of LIJ dialysis catheter\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with h/o CLL s/p allogenic stem cell transplant complicated by\n chronic GVHD of his gut, with a recent admission to the ICU for sepsis from a\n bullous cellulitis, who now has increased respiratory\n REASON FOR THIS EXAMINATION:\n placement of LIJ dialysis catheter\n ______________________________________________________________________________\n WET READ: ENYa WED 9:23 PM\n ETT tip now 3.6 cm above the carina. Bilateral IJ CVL terminates at lower SVC.\n NGT terminates below the diaphragm. Very low lung volumes. Severe and\n persistent bilateral opacities, L > R. No PTX.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Catheter placement.\n\n FINDINGS: In comparison with the study of earlier in this date, there has\n been placement of a left IJ catheter that extends to the mid to lower portion\n of the SVC. ET tube tip is approximately 3.6 cm above the carina. Diffuse\n bilateral pulmonary opacifications persist.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201913,
"text": " 10:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Are there any infiltrates or enlarging pleural effusions?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with recent ICU stay secondary to severe sepsis, likely\n secondary to MRSA infection. Would like to obtain chest x-ray as patient still\n on 4L NC.\n REASON FOR THIS EXAMINATION:\n Are there any infiltrates or enlarging pleural effusions?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:46 A.M., \n\n HISTORY: Severe sepsis. Question enlarging pleural effusion or new\n pneumonia.\n\n IMPRESSION: AP chest compared to through :\n\n New 2.5 cm wide nodular lesion in the right mid lung has developed from a less\n well-defined region of vague radiopacity on and may contain a cavity.\n As such, septic embolus should be considered, alternatively a small\n aspiration-related lung abscess, but because of the rapid development, not\n tuberculosis, and probably not fungal infection. Moderate right basal\n atelectasis is longstanding. A much larger region of consolidation in the\n left lower lobe, has progressed since . Much of this is probably\n atelectasis, but concurrent pneumonia could be present and either could\n explain a moderate left pleural effusion, which has also increased in size\n since . Mediastinal vascular engorgement indicates elevated central\n venous pressure or volume, and moderate cardiomegaly is unchanged. No\n pneumothorax.\n\n The physician at pager and I discussed these findings.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-22 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1201987,
"text": " 5:17 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: lung abscess/ embolus/ pneumonia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL s/p SCT, complicated by GVHD, now with MRSA bullous\n skin lesions/abscess, recovering from septic shock, now with new nodular lesion\n on CXR concerning for abscess/emboli\n REASON FOR THIS EXAMINATION:\n lung abscess/ embolus/ pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 6:36 PM\n 1. Right upper lobe rounded ground glass opacity (4 x 3 cm) without central\n necrosis or cavity formation corresponds to the finding on a previous CXR and\n likely represents pneumonia, less likely GVHD or leukemic infiltrate.\n 2. Interval increase of a small to moderate left pleural effusion. Stable\n small right effusion.\n 3. Slight increase of left lower lobe and stable right lower peribronchial\n opacities, likely atelectasis.\n 4. Slight increase of the anasarca.\n 5. Stable small pericardial effusion and T9 superior endplate compression fx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with CLL, status post stem cell transplant\n complicated by graft-versus-host disease, now with multiple MRSA skin lesions.\n For evaluation of recent nodular opacification on radiograph.\n\n EXAMINATION: CT of the chest without intravenous contrast.\n\n COMPARISONS: Portable radiograph from , CT examinations from \n and .\n\n TECHNIQUE: Helically acquired axial images from the thoracic inlet to the\n upper abdomen were obtained at 1.25 and 5-mm collimation. In addition coronal\n and sagittal reformations are provided for review.\n\n FINDINGS:\n\n A right internal jugular approach central venous catheter tip terminates\n within the low SVC. A subcutaneous tissue defect in the right anterior chest\n wall, site of the removed infusion, has no associated fluid collection.\n\n A round, 3.5 x 3.1cm, ground glass opacity in the anterior segment of the\n right upper lobe corresponds to a lesion that was new on yesterday's\n conventional chest radiograph, but less radiodense than expected. There is no\n cavitation. Mild bibasilar peribronchiolar opacification is greater on the\n left than the right. Bilateral pleural effusions are small.\n\n Moderate cardiomegaly is stable and a small pericardial effusion has\n increased. The great vessels are unremarkable on this non-contrast\n examination. The tracheobronchial tree is patent to the subsegmental level.\n (Over)\n\n 5:17 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: lung abscess/ embolus/ pneumonia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is no axillary, mediastinal or hilar lymphadenopathy.\n\n This examination is not tailored for subdiaphragmatic evaluation. The\n visualized colon is relatively decompressed. The visualized upper abdomen is\n otherwise unremarkable.\n\n Diffuse anasarca is unchanged since the recent examination.\n\n BONE WINDOWS: There are no bone lesions are suspicious for malignancy or\n infection; several thoracic vertebral compression fractures are chronic,\n including the most severe at T9.\n\n IMPRESSION:\n 1. 3.5-cm area of ground-glass lesion in the right upper lobe may be\n resolving since it first appeared on . Given the decrease in density,\n differential diagnosis includes atypical infection, hemorrhage or infarction.\n\n 2. Interval increase since in lower lobe opacification, particularly\n on the left, probable atelectasis, less likely pneumonia.\n\n 3. Small bilateral pleural effusions.\n\n 4. Increased small pericardial effusion.\n\n The right upper lobe opacification can be monitored with radiographs, though\n if the clinical picture suggests infarction, CTA is recommended to look for\n pulmonary embolism.\n\n Findings were discussed with Dr. at 12:15PM via telephone by Dr.\n .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1211018,
"text": " 11:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with worsening resp status, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n WET READ: EHAd TUE 4:24 PM\n Bibasilar heterogeneous opacities, increased on right, compatible with\n atelectasis, but in the appropriate clinical setting, superimposed pneumonia\n may be considered.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old man with worsening respiratory status. Evaluate for\n interval change.\n\n COMPARISON: . . .\n\n FINDINGS: Single frontal view of the chest was obtained. The heart size and\n cardiomediastinal silhouette are stable. Bibasilar hazy opacities, slightly\n increased at the right base, compatible with atelectasis, but in the\n appropriate clinical setting, multifocal pneumonia should be considered.\n Endotracheal tube is in satisfactory position. No change in the position of\n left and right central catheters. No pneumothorax.\n\n IMPRESSION: Bibasilar heterogeneous opacities, increased on right, compatible\n with atelectasis, but in the appropriate clinical setting, superimposed\n pneumonia may be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-24 00:00:00.000",
"description": "R MR WRIST W/O CONTRAST RIGHT",
"row_id": 1210949,
"text": " 8:30 PM\n MR WRIST W/O CONTRAST RIGHT Clip # \n Reason: to evaluate right wrist. Is there evidence of deep tissue or\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with neutropenia, respiratory failure, and invasive fungal\n disease on biopsy of R wrist. Concern for deeper invasion that would make\n surgery or amputation necessary. pt with fluctuating renal\n function and currently on intermittent dialysis\n REASON FOR THIS EXAMINATION:\n to evaluate right wrist. Is there evidence of deep tissue or bone invations?\n CONTRAINDICATIONS for IV CONTRAST:\n intemittently on dialysis with fluctuating renal function\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: CMDk MON 11:08 PM\n the study is limited due to lack of IV contrast. There is no evidence of\n marrow replacement to suggest bone marrow involvement. There is extensive soft\n tissue edema as well as extensive edema involving the muscles. pt has known\n mucor involving the wrist. D/W Dr at 11pm \n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Invasive fungal disease seen on right wrist biopsy in a patient\n with neutropenia.\n\n COMPARISON: Ultrasound from \n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet. Contrast was not administered related to history of\n intermittent dialysis. Note that the patient's wrist was edematous,\n precluding scanning an atypical wrist coil. Acquired sequences include proton\n density axial, STIR axial and coronal, T1-weighted axial and coronal, and\n T2-weighted axial and sagittal sequences through the right wrist.\n\n FINDINGS: Bony structures reveal no cortical disruption or periostitis. Bone\n marrow signal is notable for serpiginous areas of edema involving the base of\n the first metacarpal, the distal radius (series 8, image 9) and the radial\n aspect of the distal ulna adjacent to the distal radioulnar joint. Areas of\n mild edema are also visualized at the base of the fourth and fifth metacarpals\n (series 8, image 12), though this is mild in contrast to the extensive\n surrounding soft tissue edema. Assessment of the intrinsic ligaments of the\n wrist is limited, given the technique though the scapholunate and\n lunotriquetral ligaments appear intact, as does the TFCC. There is no fluid\n in the distal radioulnar joint.\n\n The flexor tendons and contents of the carpal tunnel are normal as is the\n median nerve. Of the extensor tendons, note is made of tenosynovitis of the\n extensor carpi radialis brevis and longus tendons (series 14, image 15).\n Additionally, there is minimal tenosynovitis of the fourth digit extensor\n (Over)\n\n 8:30 PM\n MR WRIST W/O CONTRAST RIGHT Clip # \n Reason: to evaluate right wrist. Is there evidence of deep tissue or\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n tendons.\n\n There is striking edema involving all visualized muscles of the proximal hand.\n In addition, note is made of extensive subcutaneous edema surrounding the\n wrist and proximal hand. There is no fluid collection.\n\n IMPRESSION:\n 1. Marked muscular edema involving all visualized muscles as well as\n extensive subcutaneous edema without focal fluid collection. Given the\n history of positive biopsy, these findings are consistent with extensive\n cellulitis and myositis.\n 2. Serpiginous bone marrow signal abnormalities involving the base of the\n first metacarpal, distal radius and portions of the distal ulna, concerning\n for bone infarctions given the history of infectious vascular invasion.\n\n These results were discussed via telephone by Dr. with Dr. \n at 10:54 on \n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210213,
"text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post intubation CXR\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with resp distress. intubated\n REASON FOR THIS EXAMINATION:\n post intubation CXR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-intubation.\n\n FINDINGS: In comparison with the study of , the tip of the endotracheal\n tube measures approximately 5 cm above the carina. Little change in the\n appearance of the central catheter and hemodialysis catheter. Again, there\n are low lung volumes with stable cardiomediastinal silhouette. Increasing\n pulmonary vascular congestion with progression of opacification in the\n retrocardiac region. This is consistent with volume loss in the left lower\n lobe, though the air bronchogram pattern raises the possibility of\n superimposed pneumonia in this region. There is also a more focal area of\n opacification in the right upper and left mid zone, worrisome for possible\n supervening infection.\n\n If clinically possible, a repeat study with better inspiration would be most\n helpful.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210875,
"text": " 5:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrathoracic process, interval change, ETT placement.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL/SLL s/p SCT currently with VRE bacteremia, CMV\n viremia, mucor and respiratory distress requiring intubation.\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process, interval change, ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 0600\n\n HISTORY: 27-year-old man with CLL/SLL with bacteremia and respiratory\n distress.\n\n COMPARISON: at 0543.\n\n Endotracheal tube and catheters remain in satisfactory position. The lung\n volumes are low. The bilateral patchy pulmonary infiltrates do not appear\n significantly changed. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210367,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrathoracic process, interval change and evaluation of\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL s/p SCT currently in ICU for respiratory distress,\n currently intubated.\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process, interval change and evaluation of ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: CLL, currently intubated, evaluation for endotracheal tube.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are unchanged. The tip of the endotracheal tube projects 4.3 cm above\n the carina. The lung volumes have minimally increased, potentially result of\n increased ventilatory pressures. The overall extent and distribution of the\n pre-existing bilateral parenchymal consolidations and opacities are unchanged.\n No new parenchymal opacities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1211463,
"text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o interval change, intrathoracic process, ETT placement.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL s/p SCT currently with multiple infections and\n intubated for respiratory distress.\n REASON FOR THIS EXAMINATION:\n r/o interval change, intrathoracic process, ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess ET tube. Patient with respiratory distress with\n multiple infections.\n\n Comparison is made with prior study performed a day earlier.\n\n The ET tube tip is 3.7 cm above the carina. Bilateral central catheters are\n in the cavoatrial junction and upper right atrium, unchanged. There is no\n pneumothorax. Cardiomegaly and widened mediastinum arew stable.\n\n There are low lung volumes. Moderate pulmonary edema with bibasilar\n atelectasis larger on the left side and unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1211292,
"text": " 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old man with respiratory distress.\n\n COMPARISON: , , . CT chest .\n\n FINDINGS: Frontal view of the chest was obtained. Mild cardiomegaly is\n stable. Low lung volumes persist with unchanged pulmonary vascular\n congestion, pulmonary edema, and bibasilar atelectasis. Left lower lobe\n consolidation, particularly of the retrocardiac area, is stable. Endotracheal\n tube, right hemodialysis catheter, and left PICC are all unchanged in\n appropriate position.\n\n IMPRESSION:\n 1. Unchanged pulmonary vascular congestion and pulmonary edema.\n 2. Unchanged left lower lobe consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1210733,
"text": " 5:51 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for disseminated mucor\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL c/b VRE bacteremia, renal failure, and respiratory\n failure now with mucormycosis on wrist.\n REASON FOR THIS EXAMINATION:\n Eval for disseminated mucor\n CONTRAINDICATIONS for IV CONTRAST:\n Dialysis dependent renal failure\n ______________________________________________________________________________\n WET READ: SHSf SAT 8:24 PM\n No acute intracranial process with sinuses better assessed on accompanying\n sinus CT. Opacification of bilateral mastoid air cells.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL with VRE bacteremia and renal failure with mucormycosis on\n the wrist. Assess for disseminated Mucor.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Coronal and sagittal reformations were prepared.\n\n COMPARISONS: CT of the head from .\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\n major vascular territorial infarction. -white matter differentiation\n appears preserved. There is no shift of normally midline structures.\n Ventricles and sulci are normal in size and configuration. There is no\n fracture. There is opacification of the bilateral mastoid air cells, which is\n new since the prior study. The paranasal sinuses are better assessed on the\n sinus CT. There is no bony destruction seen to suggest mucormycosis.\n\n IMPRESSION: No acute intracranial pathological process, with sinuses better\n assessed on accompanying sinus CT. Opacification of bilateral mastoid air\n cells.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-22 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1210734,
"text": " 5:51 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Eval for disseminiated mucor\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL c/b VRE bacteremia, renal failure, and respiratory\n failure now with mucormycosis on wrist.\n REASON FOR THIS EXAMINATION:\n Eval for disseminiated mucor\n CONTRAINDICATIONS for IV CONTRAST:\n Dialysis dependend renal failure\n ______________________________________________________________________________\n WET READ: SHSf SAT 8:23 PM\n Interval increase in degree of sinus disease with mucosal thickening and\n secretions present in the ethmoid air cells and nasal cavity along with\n mucosal thickening increased in the bilateral maxillary sinuses. Moderate\n sphenoid sinus thickening as before. Much of this increased secretion could be\n related to intubation. No bony destruction to suggest invasive mucormycosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CLL complicated by VRE bacteremia, renal failure and respiratory\n failure with mucormycosis on wrist. Assess for disseminated mucor.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the paranasal\n sinuses without intravenous contrast. Coronal reformations were prepared.\n\n COMPARISONS: CT sinus from .\n\n FINDINGS: The frontal sinuses display only minimal mucosal thickening.\n There is mild mucosal thickening in the anterior and middle ethmoid air cells,\n with more pronounced mucosal thickening and aerosolized secretions in the\n posterior ethmoid air cells bilaterally. There is mucosal thickening and\n mucus retention cysts versus polyps in the maxillary sinuses, without\n air-fluid levels seen. There is moderate-to-severe mucosal thickening\n demonstrated again, as before, in the sphenoid sinus. There is also extensive\n secretion in the nasal cavity. These abnormalities, at least in part, could be\n due to the patient's intubated status. No bony destruction is seen. The\n lamina papyracea appear intact. The cribriform plats are also intact. The\n anterior clinoid processes are not pneumatized. There is no fracture. The\n brain is better assessed on the accompanying head CT scan.\n\n IMPRESSION: Interval increase in degree of sinus disease, with mucosal\n thickening and secretions present in the ethmoid air cells and nasal cavity,\n along with mucosal thickening increased in the bilateral maxillary sinuses.\n Moderate sphenoid sinus thickening as before. Much of this increased secretion\n could be related to intubation. No bony destruction to suggest invasive\n mucormycosis.\n (Over)\n\n 5:51 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Eval for disseminiated mucor\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1211129,
"text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with intubation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:08 A.M., \n\n HISTORY: 27-year-old man intubated.\n\n IMPRESSION: AP chest compared to through 11:\n\n Moderate-to-severe pulmonary edema has recurred worsening the appearance of\n pre-existing left lower lobe consolidation. Heart is moderately enlarged,\n unchanged. Pleural effusions are presumed, but small. ET tube is in standard\n placement. Dual-channel hemodialysis line ends just above and just below the\n level of the superior cavoatrial junction alongside the left subclavian line\n in the right atrium. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209880,
"text": " 5:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change, fluid vs infection vs blood\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with worsening hypoxia, known bacteremia\n REASON FOR THIS EXAMINATION:\n Eval for interval change, fluid vs infection vs blood\n ______________________________________________________________________________\n WET READ: SHSf SUN 6:55 PM\n Markedly low lung volumes.\n Dense bibasilar opacities increased since the prior likely atelectasis.\n\n Right upper lung opacity is new and could reflect atelectasis as well given\n the low lung volumes though supervening pneumonia cannot be fully excluded.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:32 P.M \n\n HISTORY: Worsening hypoxia and known bacteremia.\n\n IMPRESSION: AP chest compared to chest radiographs since , most\n recently :\n\n Pulmonary vascular congestion has been present since , unchanged\n today since , accompanied by a moderate to severe cardiomegaly and\n mediastinal vascular engorgement also unchanged. Low lung volumes have been\n present throughout, accompanied by bibasilar consolidation, most likely\n atelectasis. A dual-channel right supraclavicular central venous line ends in\n the right atrium, alongside a left PIC catheter. No pneumothorax. Pleural\n effusions are presumed but not large.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-22 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1206377,
"text": " 9:46 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Is there compression fracture? Kidney Stone?\n Admitting Diagnosis: SEPSIS\n Field of view: 45\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, chronic steroid therapy, and acute renal failure\n recovering from toxic shock syndrome with new right flank pain and unable to\n stand for x-ray.\n REASON FOR THIS EXAMINATION:\n Is there compression fracture? Kidney Stone?\n CONTRAINDICATIONS for IV CONTRAST:\n dialysis-dependent acute kidney injury\n ______________________________________________________________________________\n WET READ: 11:20 PM\n -Non-contrast examination done per ordering clinician\n\n -No calculi within the kidneys, ureters or bladder. No hydronephrosis.\n -Non-contrast images of abdominopelvic viscera within normal limits.\n -Loss of vertebral body height of T9 - though unchanged from prior. No acute\n compression fracture.\n -Multiple healed rib fractures bilaterally.\n -Central line in low SVC\n -Bibasilar patchy lung opacities unchanged from prior - likely\n scarring/atelectasis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST\n\n DATE: .\n\n COMPARISON: and multiple prior examinations.\n\n CLINICAL INDICATION: 27-year-old man with CLL, chronic steroid therapy, and\n acute renal failure recovering from toxic shock syndrome, now with new right\n flank pain and unable to stand for x-ray. Is there compression fracture?\n Kidney stone?\n\n TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained without\n the use of intravenous contrast. Coronal and sagittal reformatted images were\n constructed.\n\n FINDINGS:\n\n ABDOMEN: There are no renal calculi or ureteral calculi.\n\n There is no hydronephrosis. Central venous catheter tip terminates at the\n superior cavoatrial junction. The heart is borderline enlarged. There is no\n pericardial or pleural effusion. Mild bronchiectasis and linear stranding at\n bilateral bases is similar to the prior examination, if not slightly improved.\n\n (Over)\n\n 9:46 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Is there compression fracture? Kidney Stone?\n Admitting Diagnosis: SEPSIS\n Field of view: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Non-contrast technique limits evaluation of the solid abdominal viscera. The\n collapsed gallbladder, liver, spleen, adrenal glands and pancreas are grossly\n unremarkable. There is no upper abdominal, mesenteric or retroperitoneal\n lymphadenopathy. Aortocaval lymph node measuring 6 mm is noted along with\n smaller retroperitoneal lymph nodes. Just inferior to the aortic bifurcation,\n there is a new area of fat stranding with a 5-mm lymph node. Ill-defined\n margins makes this area difficult to measure, however, area measures\n approximately 4.5 x 2.6 cm in transverse and craniocaudal dimensions\n respectively.\n\n Loops of small and large bowel are grossly unremarkable. The appendix is\n within normal limits. Multiple pills are present within the cecum and\n descending colon. There is a small 1.9 x 2.5 cm paraumbilical hernia with\n mesenteric fat. There is asymmetric subcutaneous fat stranding along the left\n flank (2:53). This may relate to positional anasarca. There is significant\n muscle atrophy given the patient's age.\n\n PELVIS: The bladder, seminal vesicles, rectum and prostate are grossly\n unremarkable. There is no pelvic lymphadenopathy or free fluid.\n\n MUSCULOSKELETAL: T9 compression fracture is unchanged from the prior\n examination. Multiple additional thoracic and lumbar vertebral bodies\n demonstrate superior endplate deformities, most prominent at T11, T12, L2 and\n L4 are also unchanged from the prior examination. There is no new compression\n deformity.\n\n IMPRESSION:\n 1. No renal or ureteral calculi or hydronephrosis.\n 2. No acute vertebral compression deformity. Stable multilevel compression\n deformities.\n 3. New ill-defined fat stranding in the retroperitoneum, just inferior to the\n aortic bifurcation with a probable 5 mm associated lymph node. Lymphatic\n involvement of known CLL is considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-13 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1205003,
"text": " 9:54 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval for lesions, tumor\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with GVHD and epistaxis - PLEASE NO CONTRAST !\n REASON FOR THIS EXAMINATION:\n eval for lesions, tumor\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: PRib TUE 1:25 PM\n 1. No evidence of masses or bony dehiscence.\n\n 2. Mild mucosal thickening of left anterior and right posterior ethmoid air\n cells. Mucosal retention cyst in right and left maxillary sinuses. Moderate\n to severe mucosal thickening in right sphenoid sinus.\n\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Graft-versus-host disease, CLL status post stem cell transplant,\n epistaxis, evaluate for lesions or tumor.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.\n Coronal reformatted images were prepared.\n\n FINDINGS: The frontal sinuses are well aerated. There is mild mucosal\n thickening in a left anterior ethmoid air cell and in a right posterior\n ethmoid air cell. There is moderate to severe mucosal thickening of the right\n sphenoid sinus. The left sphenoid sinus is hypoplastic and well aerated.\n There is a mucus retention cyst in the left and right maxillary sinuses. The\n ostiomeatal units are patent. The nasal septum is deviated to the left with a\n bone spur. The nasal cavities are well aerated, without evidence of polyps\n or masses. The lamina papyracea are intact. The cribriform plate is intact.\n There is no other bone erosion or sclerosis. There is no evidence of\n periapical lucency in the maxillary alveolar ridge. The orbits are\n unremarkable on this non-contrast study. This study is not technically\n optimal for assessment of intracranial structures, but mild diffuse atrophy is\n seen in the imaged portion of the brain.\n\n IMPRESSION:\n\n 1. Moderate to severe mucosal thickening in the right sphenoid sinus. Milder\n mucosal changes in maxillary and ethmoid sinuses. No osseous erosion or\n remodeling.\n\n 2. No evidence of a mass on noncontrast evaluation.\n (Over)\n\n 9:54 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval for lesions, tumor\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-13 00:00:00.000",
"description": "CT NECK W/O CONTRAST (EG: PAROTIDS)",
"row_id": 1205004,
"text": " 9:54 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: neck lesions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with GVHD and epistaxis, coughing up blood - PLEASE NO\n CONTRAST !\n REASON FOR THIS EXAMINATION:\n neck lesions\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PRib TUE 1:36 PM\n 1. No exophytic mucosal masses or areas of focal mass effect.\n\n 2. 2.3cm x 1.8cm x 2.1cm enlarged level 2 lymph node on the left, new compared\n to neck CT from . No necrosis or surrounding inflammatory changes. No\n other areas of pathological lymphadenopathy by imaging criteria.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Graft versus host disease, coughing up blood, evaluate for neck\n lesions.\n\n COMPARISON: CT neck on .\n\n TECHNIQUE: Routine non-enhanced multidetector CT study of the neck was\n performed with images obtained from the skull base to the thoracic inlet using\n 2.5-mm thick sections. Coronal and axial reformations were performed. No iv\n contrast was administered due to renal failure.\n\n FINDINGS: There is no evidence of an exophytic mucosal mass. Compared to the\n study on , there is a new 2.3 cm x 1.8 cm x 2.1 cm enlarged left\n level 2, without evidence of necrosis or surrounding inflammatory change. The\n thyroid gland is unremarkable. The sublingual and submandibular salivary\n glands are unremarkable.\n\n There is opacification of the right and left mastoid tip air cells. The\n paranasal sinuses are better assessed on the concurrent dedicated sinus CT.\n\n There are no lytic or sclerotic bone lesions.\n\n There is bilateral pulmonary opacities, described in the concurrent chest CT\n report.\n\n IMPRESSION:\n\n New enlarged left level 2 lymph node. No evidence of an exophytic mucosal\n mass.\n\n (Over)\n\n 9:54 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: neck lesions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Echo",
"chartdate": "2112-10-13 00:00:00.000",
"description": "Report",
"row_id": 79354,
"text": "PATIENT/TEST INFORMATION:\nIndication: Tachycardia/abnormal ekg (h/o CLL s/p allogenic stem cell transplant/MRSA sepsis/increased hypoxia.\nHeight: (in) 66\nWeight (lb): 190\nBSA (m2): 1.96 m2\nBP (mm Hg): 108/62\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 11:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mildly dilated LV cavity. Mild global LV hypokinesis. LV\ndysnchrony is present.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion. There is an anterior space which\nmost likely represents a fat pad, though a loculated anterior pericardial\neffusion cannot be excluded.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity is mildly\ndilated. There is mild global left ventricular hypokinesis (LVEF = 40%). Left\nventricular dysnchrony is present. Right ventricular chamber size is normal.\nwith mild global free wall hypokinesis. The aortic root is mildly dilated at\nthe sinus level. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic stenosis or aortic regurgitation. The\nmitral valve appears structurally normal with trivial mitral regurgitation.\nThere is no mitral valve prolapse. The estimated pulmonary artery systolic\npressure is normal. There is a very small pericardial effusion. There is an\nanterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Mild global biventricular systolic dysfunction. Very small\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2112-09-15 00:00:00.000",
"description": "Report",
"row_id": 79355,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 182\nBSA (m2): 1.92 m2\nBP (mm Hg): 131/78\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 14:19\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: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC was not visualized.\nThe RA pressure could not be estimated.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Mildly\ndepressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis.\nAbnormal septal motion/position.\n\nAORTA: Moderately dilated aorta at sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. No masses or vegetations on aortic\nvalve, but cannot be fully excluded due to suboptimal image quality. No AS. No\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No masses or vegetations\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\nTrivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No masses or\nvegetations are seen on the tricuspid valve, but cannot be fully excluded due\nto suboptimal image quality. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Very small pericardial effusion. There is an anterior space which\nmost likely represents a fat pad, though a loculated anterior pericardial\neffusion cannot be excluded. No echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality - poor\nsuprasternal views. Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\npatient unable to cooperate.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is mildly depressed (LVEF= 45 %). The right ventricular cavity is\ndilated with mild global free wall hypokinesis. There is abnormal septal\nmotion/position. The aortic root is moderately dilated at the sinus level. The\nnumber of aortic valve leaflets cannot be determined. No masses or vegetations\nare seen on the aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. There is no aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. No masses or vegetations\nare seen on the mitral valve, but cannot be fully excluded due to suboptimal\nimage quality. Trivial mitral regurgitation is seen. No masses or vegetations\nare seen on the tricuspid valve, but cannot be fully excluded due to\nsuboptimal image quality. There is borderline pulmonary artery systolic\nhypertension. There is a very small pericardial effusion. There is an anterior\nspace which most likely represents a prominent fat pad. There are no\nechocardiographic signs of tamponade.\n\nIMPRESSION: Normal left ventricular cavity size and wall thickness with mildly\ndepressed left ventricular systolic function. Moderately dilated aortic root.\nNo clinically significant valvular regurgitation or stenosis. Borderline\npulmonary artery systolic hypertension. Very small percicardial effusion.\n\nCompared with the prior study (images reviewed) of , the overall left\nventricular systolic function appears to have minimally improved, although the\npreviously reported ejection fraction may have been an underestimate.\n\nThe absence of valvular vegetations/abscesses on transthoracic echocardiogram\ndoes not preclude its presence. If clinical suspicion for endocarditis is\nhigh, consider transesophageal echocardiogram.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 79356,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 66\nWeight (lb): 217\nBSA (m2): 2.07 m2\nBP (mm Hg): 128/98\nHR (bpm): 124\nStatus: Inpatient\nDate/Time: at 14:10\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 wall thickness and cavity size. Moderately depressed\nLVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: ?# aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nTRICUSPID VALVE: Normal PA systolic pressure.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality as the patient was difficult to position.\nSuboptimal image quality - body habitus. Suboptimal image quality - patient\nunable to cooperate. Resting tachycardia (HR>100bpm). Left pleural effusion.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is moderately depressed (LVEF= 35-40%). The\nright ventricular cavity is dilated with mild global free wall hypokinesis.\nThe aortic root is mildly dilated at the sinus level. The number of aortic\nvalve leaflets cannot be determined. The mitral valve leaflets are mildly\nthickened. The estimated pulmonary artery systolic pressure is normal. There\nis a small pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the prior study (images reviewed) of , image quality on\nboth studies is sub-optimal making direct comparisons difficult. The function\nof the more distal left ventricular segments is probably marginally better.\nThe other findings are similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2112-08-23 00:00:00.000",
"description": "Report",
"row_id": 79357,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 217\nBSA (m2): 2.07 m2\nBP (mm Hg): 142/92\nHR (bpm): 106\nStatus: Inpatient\nDate/Time: at 10:27\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Moderate global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\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.\nSuboptimal image quality. Suboptimal image quality - patient unable to\ncooperate. Bilateral pleural effusions.\n\nConclusions:\nThere is moderate global left ventricular hypokinesis (LVEF = 30-35%). Right\nventricular chamber size is normal with borderline normal free wall function.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. No masses or\nvegetations are seen on the aortic valve. The mitral valve leaflets are\nstructurally normal. No mass or vegetation is seen on the mitral valve.\nTrivial mitral regurgitation is seen. No vegetation/mass is seen on the\npulmonic valve. There is no pericardial effusion.\n\nIMPRESSION: No vegetations or clinically-significant valvular disease seen.\nModerate global left ventricular systolic dysfunction.\n\nCompared with the prior study (images reviewed) of , LV function has\nslightly improved. The other findings are similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2112-08-18 00:00:00.000",
"description": "Report",
"row_id": 79358,
"text": "PATIENT/TEST INFORMATION:\nIndication: R/O Tamponade\nHeight: (in) 66\nWeight (lb): 217\nBSA (m2): 2.07 m2\nBP (mm Hg): 94/42\nHR (bpm): 124\nStatus: Inpatient\nDate/Time: at 07:56\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\ndepressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. RV function\ndepressed.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Dilated main PA.\n\nPERICARDIUM: Very small pericardial effusion. Effusion circumferential.\nEffusion echo dense, c/w blood, inflammation or other cellular elements. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is severely depressed (LVEF= 25 %), with regional variation.\nThe right ventricular free wall is hypertrophied. Right ventricular chamber\nsize is normal. with depressed free wall contractility. The aortic root is\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis or\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The main\npulmonary artery is dilated. There is a very small pericardial effusion. The\neffusion appears circumferential. The effusion is echo dense, consistent with\nblood, inflammation or other cellular elements. There are no echocardiographic\nsigns of tamponade.\n\nCompared to the prior study of , contractile function of both\nventricles is markedly reduced. Consider therapy for acute cardiac\ngraft-versus host disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205471,
"text": " 12:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infection and line imaging\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man w cll, gvhd, with new HD line, on abx for bacteremia (VRE)\n REASON FOR THIS EXAMINATION:\n infection and line imaging\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: 27-year-old man with history of graft-versus-host disease with\n new HD line.\n\n TECHNIQUE: Semi-upright portable radiograph of chest.\n\n Comparisons were made with prior chest radiographs through ,\n with the most recent from .\n\n IMPRESSION: The HD line through left internal jugular approach is new with tip\n terminating approximately at cavoatrial junction. Bilateral lung volumes are\n very low. Bibasilar atelectases, left side more than right side are unchanged\n since . Pleural effusion, if any, appears minimal on the\n left side. Wide cardiomediastinal silhouette is likely from low lung volumes.\n There are lung opacities concerning for pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-13 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1204999,
"text": " 9:32 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: lung lesions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with GVHD and epistaxis, coughing up blood - PLEASE NO\n CONTRAST !\n REASON FOR THIS EXAMINATION:\n lung lesions\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n COMPUTED TOMOGRAPHY OF THE THORAX\n\n INDICATION: Hemoptysis, graft-versus-host disease.\n\n COMPARISON: .\n\n TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,\n no administration of intravenous contrast material, multiplanar\n reconstructions.\n\n FINDINGS: The examination is compared to . In the interval,\n the patient has been extubated. There is mild lipomatosis of the mediastinum.\n No incidental thyroid findings. In the mediastinal fat, no enlarged or\n pathological lymph nodes are detected.\n\n The large mediastinal vessels appear unremarkable.\n\n As on the previous examination, severe motion artifacts due to aspiration\n substantially limit the assessment of the lung parenchyma. The pre-existing\n bilateral upper lobe parenchymal opacities are overall unchanged in extent and\n severity.\n\n A pre-existing left lower lobe parenchymal opacity with air bronchograms is\n slightly more extensive than on the previous examination. Newly appeared is a\n right lower lobe basal opacity of similar morphology. The location and\n appearance of the opacities would be consistent with atelectasis, aspiration,\n or pneumonia, or a combination of these.\n\n There are no substantial pleural effusions.\n\n Within the limits of the examination, there is no evidence for intrabronchial\n or intratracheal lesions.\n\n No changes in the upper abdominal organs.\n\n IMPRESSION: As compared to the previous examination, there are newly appeared\n right lower lobe opacities and a slightly more extensive left lower lobe\n opacity. Both opacities have air bronchograms. The pre-existing bilateral\n upper lobe opacities are stable. The changes could correspond to atelectasis,\n (Over)\n\n 9:32 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: lung lesions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aspiration, or pneumonia. No pleural effusions. No mediastinal lymph node\n enlargement.\n\n The entire examination is limited by severe respiratory motion artifacts.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-17 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1205602,
"text": " 2:13 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Needs hemodialysis\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED -79 UNRELATED PROCEDURE/SERVICE DURI *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with anuric\n REASON FOR THIS EXAMINATION:\n Needs hemodialysis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient needs hemodialysis and current line accidentally pulled\n out.\n\n OPERATORS: Dr. and Dr. performed the\n procedure.\n\n ANALGESIA: Analgesia was provided by 25 mcg of fentanyl and 1% local\n lidocaine was used.\n\n PROCEDURE: Written informed consent was obtained from the patient after the\n procedure was explained in detail along with the risks, benefits and\n alternatives. The patient was brought to the angiographic suite and laid\n supine on the table. The right side of the neck was prepped and draped in a\n sterile fashion. A preprocedural huddle and a timeout was performed per \n protocol.\n\n The right internal jugular vein was imaged by ultrasound. There appeared to\n be a small amount of clot in the right IJ and it was partially compressible.\n This was accessed with a needle and a wire was passed through the needle which\n was confirmed fluoroscopically to be in the SVC. The needle was taken out and\n a sheath was threaded in. The guidewire was then exchanged with ,\n which was threaded into the IVC. Multiple dilations were performed with 12\n and 14 French dilators, after which the temporary dialysis line was threaded\n over the wire and the tip was confirmed to be in the right atrium\n fluoroscopically. Then, the wire was pulled out and the line was stitched in\n place with 0 silk and sterile dressings were applied. The patient tolerated\n the procedure well and had no immediate complications.\n\n IMPRESSION: Uncomplicated placement of a 14.4 French temporary dialysis line\n in the right IJ. The line length is 15 cm. The tip is in the right atrium.\n The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-23 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1210814,
"text": " 3:21 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Is there evidence of invasive fungal disease on chest imagin\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with neutropenia, respiratory failure, and invasive fungal\n disease on biopsy of R wrist. Concern that may be systemic manifestation of\n process in lungs as well since pt had worsened respiratory status since last\n chest CT which was before he was diagnosed with cutaneous fungal disease.\n REASON FOR THIS EXAMINATION:\n Is there evidence of invasive fungal disease on chest imaging in patient with\n cutaneous disease?\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT\n\n INDICATION: Patient with neutropenia, respiratory failure, to assess for\n invasive fungal disease\n\n TECHNIQUE: Unenhanced MDCT of thorax was performed using a standard\n department protocol. Contiguous axial images at 5-mm and 1.25-mm slice\n thickness were reviewed concurrently with coronal and sagittal reformats.\n Comparisons were made with prior chest CTs through , with the most\n recent one from .\n\n FINDINGS:\n\n AIRWAYS AND LUNGS: Airways are patent to subsegmental level. Minimal\n secretions are seen in trachea and left main bronchus. Since the prior study\n dated , diffuse ground-glass opacities in the bilateral\n lungs, predominantly in the upper lobes, have worsened. However, bilateral\n lower lung consolidations have improved. Severity of bilateral lung\n bronchiectasis, right side more than left side, is unchanged. There are no\n findings to suggest an invasive fungal infection.\n\n MEDIASTINUM: Right internal jugular line and left Port-A-Cath ends at\n cavoatrial junction. Tip of the endotracheal tube terminates approximately\n 1.2 cm above the carina. Caliber of main pulmonary artery proximal to\n bifurcation measures 33 mm and is top normal. Heart size is mildly prominent\n without any pericardial effusion. There is no pathological enlargement of\n mediastinal, supraclavicular, or axillary lymph nodes.\n\n ABDOMEN: The study is not tailored for evaluation of abdomen; however,\n limited views were unremarkable. Both adrenal glands are normal in\n morphology.\n\n BONES: There is no bone lesion suspicious for malignancy/infection. Wedge\n compression of multiple lower thoracic vertebral bodies is stable.\n\n\n (Over)\n\n 3:21 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Is there evidence of invasive fungal disease on chest imagin\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Since , bilateral upper lobe predominant ground-glass\n opacities, right side more than left side, have progressed, bilateral lower\n lung consolidations have improved and severity of bronchiectasis is unchanged.\n The interval progression of the ground-glass opacities suggests a worsening\n infection and is nonspecific for particular etiology but not consistent with\n invasive fungal infection. Improved bilateral lower lobe consolidation\n represented combination of infection, atelectasis and aspiration.\n\n 2. Mild cardiomegaly and top normal size pulmonary artery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205340,
"text": " 2:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA vs. effusion vs. atalectasis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with increased O2 req (GVHD s/p SLL/CLL)\n REASON FOR THIS EXAMINATION:\n ?PNA vs. effusion vs. atalectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with history of CLL with recent respiratory\n distress, now extubated with increased O2 requirement.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent radiograph dated , . Correlation with CT of the chest dated .\n\n FINDINGS: Lung volumes remain low. Bibasilar atelectasis/consolidation are\n not significantly changed. As compared to the prior examination, a perihilar\n opacities appear improved consistent with a component of edema. No\n pneumothorax is seen. The cardiomediastinal silhouette is unchanged. A\n right-sided central line is unchanged with tip reaching the right atrium.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-11 00:00:00.000",
"description": "R US EXTREMITY NONVASCULAR RIGHT",
"row_id": 1204760,
"text": " 2:21 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: PT WITH NEW RIGHT WRIST LESION, EVAL FOR ABSCESS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with MRSA scalded skin syndrome now with new R wrist lesion\n REASON FOR THIS EXAMINATION:\n eval for abscess\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh SUN 4:55 PM\n 10 x 20 x 2 mm subcutaneous fluid collection adjacent to but not involving the\n nearby tendon sheath.\n PFI VERSION #1 JEKh SUN 4:52 PM\n 10 x 20 x 2 mm fluid collection adjacent to the tendon sheath.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old male with MRSA scalded skin syndrome, now with right\n wrist lesion.\n\n STUDY: Ultrasound of the right wrist.\n\n COMPARISON: .\n\n FINDINGS: Transverse and sagittal views over the medial aspect of the right\n wrist were obtained. Subcutaneous edema is demonstrated. A hypoechoic region\n measuring 1 x 2 cm that is 2 mm in thickness is demonstrated just over but not\n involving the adjacent tendon sheath. There is not appreciable surrounding\n hyperemia.\n\n IMPRESSION: 10 x 20 x 2 mm subcutaneous fluid collection adjacent/superficial\n to but not involving the nearby tendon sheath.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204972,
"text": " 3:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: stat\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n stat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with respiratory distress, now status post\n extubation.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Prior examinations, ranging from to .\n\n FINDINGS: Lung volumes remain low. The patient is in anti-lordtic\n positioning. Focal opacities at the bases are felt to likely represent\n atelectasis, increased on the right. No large pneumothorax is seen, though\n the lung apices are excluded from the field of view of the radiograph. The\n cardiomediastinal silhouette is unchanged. A right central venous catheter is\n unchanged with tip reaching the right atrium.\n\n IMPRESSION: Low lung volumes with increased right lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210674,
"text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrathoracic process, interval change, ETT placement.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL/SLL s/p SCT currenting in ICU and intubated for\n respiratory distress.\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process, interval change, ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST\n\n HISTORY: 27-year-old man with CLL, respiratory distress.\n\n COMPARISON: at 05:35.\n\n Endotracheal tube is 2.4 cm above the carina. Left and right central\n catheters remain in satisfactory position. Cardiomegaly is unchanged. The\n heterogeneous infiltrates in both lower lung zones are not significantly\n changed. The infiltrate in the axillary portion of the right lung may be\n slightly improved. There is no evidence of pneumothorax.\n\n IMPRESSION: Minimal if any change, favor pneumonia over asymmetric pulmonary\n edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210537,
"text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrathoracic process, interval change, ETT placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL s/p SCT c/b viremia and bacteremia transfered to ICU\n for resipratory distress, currently intubated.\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process, interval change, ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:35 A.M., \n\n HISTORY: CLL. Viremia and bacteremia. Respiratory distress.\n\n IMPRESSION: AP chest compared to through :\n\n Given chronic moderate-to-severe cardiomegaly and mediastinal vascular\n engorgement it is possible that multifocal heterogeneous pulmonary\n opacification is asymmetric edema but I am more concerned about pneumonia,\n particularly at the lung bases and in the axillary region of the right lung.\n Pleural effusion is small if any. No pneumothorax. ET tube ends above the\n upper margin of the clavicles no less than 5.5 cm above the carina, and should\n be advanced 2-3 cm for more secured seating.\n\n A left internal jugular line ends alongside the dual-channel right\n supraclavicular central venous dialysis catheter in the upper right atrium.\n No mediastinal widening to suggest active bleeding.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-16 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1205458,
"text": " 10:37 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ?gallstones, liver inflammation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with elevated alk phos /VRE in blood\n REASON FOR THIS EXAMINATION:\n ?gallstones, liver inflammation\n ______________________________________________________________________________\n FINAL REPORT\n LIMITED ABDOMINAL ULTRASOUND\n\n DATE: .\n\n COMPARISON: CT torso, .\n\n CLINICAL HISTORY: 27-year-old man with elevated alk phos/VRE in blood.\n Question gallstones, liver inflammation.\n\n TECHNIQUE: Multiple son grayscale images of the abdomen were\n obtained. Select images were supplemented with color Doppler and spectral\n waveform analysis.\n\n Examination is limited by mobile technique and patient's body habitus. The\n left lobe of the liver is poorly visualized, as is the pancreas. In the\n visualized portions of the liver, there is mildly coarsened echotexture\n without focal lesion identified. There is no evidence of fatty deposition.\n The gallbladder is within normal limits without cholelithiasis or\n pericholecystic fluid. There is no intrahepatic or extrahepatic biliary\n dilatation. The common hepatic duct measures 3-4 mm.\n\n The spleen is partially visualized, measuring 9.1 cm. Limited sagittal views\n of the kidneys reveal no hydronephrosis.\n\n There is no ascites.\n\n IMPRESSION:\n 1. Limited mobile examination without cholelithiasis.\n 2. Coarsened echotexture of the liver without fatty deposition. Underlying\n hepatocellular disease cannot be excluded on this exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-09 00:00:00.000",
"description": "US EXTREMITY NONVASCULAR",
"row_id": 1204567,
"text": " 4:24 PM\n US EXTREMITY NONVASCULAR Clip # \n Reason: please assess for abscess/hematoma\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, chronic GVHD, now with MRSA scalded skin syndrome\n with new erythematous/warm area on right wrist at area of previous IV. Of note,\n on Vanco for 2 weeks.\n REASON FOR THIS EXAMINATION:\n please assess for abscess/hematoma\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc FRI 5:16 PM\n PFI: Complex fluid tracking along fascial planes without discrete drainable\n fluid collection or hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with CLL, chronic graft versus host disease with\n new erythematous warm area involving the right wrist at the site of previous\n IV. Evaluate for discrete abscess or hematoma.\n\n EXAMINATION: Focused ultrasound examination of the right wrist.\n\n COMPARISONS: None available.\n\n FINDINGS: A focused ultrasound examination was performed at the site of\n clinical concern in the right wrist. In this region, there is fluid with\n internal echoes tracking tracking along the subcutaneous soft tissue planes,\n extending approximately 2.6 cm in length, without a discrete drainable fluid\n collection or hematoma identified. There is generalized subcutaneous edema\n and skin thickening. The underlying vein in the region of interest\n demonstrates normal venous flow.\n\n IMPRESSION: Subcutaneous edema and fluid tracking along the soft tissue\n planes, but no discrete abscess identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204401,
"text": " 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: baseline CXR\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, MRSA scalded skin syndrome, extubated today\n REASON FOR THIS EXAMINATION:\n baseline CXR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with chronic lymphocytic leukemia and MRSA, now\n status post extubation.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent radiographs dated , and correlation with CT of the chest dated .\n\n FINDINGS: As compared to the prior radiographs, there is improved aeration of\n both lungs with improved edema. Atelectasis at the left base remains.\n Cardiomegaly is unchanged. No pneumothorax is seen. Right internal jugular\n venous catheter reaches the right atrium. Endotracheal tube, left central\n line and esophageal catheter has been removed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-09 00:00:00.000",
"description": "US EXTREMITY NONVASCULAR",
"row_id": 1204568,
"text": ", S. OMED 4:24 PM\n US EXTREMITY NONVASCULAR Clip # \n Reason: please assess for abscess/hematoma\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, chronic GVHD, now with MRSA scalded skin syndrome\n with new erythematous/warm area on right wrist at area of previous IV. Of note,\n on Vanco for 2 weeks.\n REASON FOR THIS EXAMINATION:\n please assess for abscess/hematoma\n ______________________________________________________________________________\n PFI REPORT\n PFI: Complex fluid tracking along fascial planes without discrete drainable\n fluid collection or hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-16 00:00:00.000",
"description": "EXCH CENTRAL NON-TUNNELED",
"row_id": 1205514,
"text": " 5:09 PM\n TUNNELED CENTRAL LINE PLACEMEN Clip # \n Reason: please place new HD line on right side\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * EXCH CENTRAL NON-TUNNELED -79 UNRELATED PROCEDURE/SERVICE DURI *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL s/p BMT complicated by GVHD, in need of HD tomorrow;\n line placed yesterday didn't work\n REASON FOR THIS EXAMINATION:\n please place new HD line on right side\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old man with CLL status post BMT complicated by GVHD in\n need of HD tomorrow. The line placed yesterday did not work.\n\n OPERATORS: Dr. performed the procedure. Dr. \n (attending physician), was present and supervised the procedure\n throughout.\n\n ANESTHESIA: Moderate sedation was administered via divided doses of 75 mg of\n fentanyl throughout the total intraservice time of 30 minutes, during which\n the patient's cardiovascular status was continuously monitored.\n\n PROCEDURE: Written informed consent was taken from the patient after\n explaining the procedure, its benefits, risks and alternatives. The patient\n was brought into the angio suite and laid supine on the table. The exisitng HD\n line and area around it were preped and draped in a sterile fasion. A pre\n procedural huddle and timeout was performed per protocol.\n\n A scout image was taken of the existing hemodialysis line which looked to be\n in place. All the lumens were withdrawing blood but with a little bit of\n resistance. There were flushing without any resistance. wire was\n advanced down the VIP port into the IVC. Once the was confirmed to be\n in the IVC fluoroscopically, the existing hemodialysis line was pulled over\n the wire and a new 20-cm temporary hemodialysis line with a VIP port was\n inserted. The tip was confirmed to be in the right atrium. The wire was\n taken out and all the lumens withdrew and flushed without any resistance. The\n catheter was sutured in place. Sterile dressing was applied on the catheter.\n The patient tolerated the procedure well. He did not have any complications.\n\n IMPRESSION: Uncomplicated exchange of a temporary hemodialysis line with a\n VIP port over the wire. The renal fellow Dr. was notified by a page at\n 6:15 PM.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204978,
"text": " 6:33 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with ASPIRATION, HYPOXEMIA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with history of aspiration and hypoxemia.\n Interval evaluation.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Prior examinations, ranging from to .\n\n FINDINGS: Lung volumes are extremely low, causing vascular crowding. Right\n perihilar and infrahilar opacity is unchanged. New left perihilar opacity is\n seen. No focal parenchymal opacity to suggest pneumonia is seen. No pleural\n effusion or pneumothorax is present.\n\n IMPRESSION: Increased left perihilar and stable right perihilar\n consolidations versus edema.\n\n Findings discussed with Dr. at 11:30 am .\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-15 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1205347,
"text": " 3:08 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: temporary dialysis line placement\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with renal failure on HD\n REASON FOR THIS EXAMINATION:\n temporary dialysis line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old man with renal failure, on HD, temporary dialysis\n line placement requested.\n\n OPERATORS: Dr. and Dr. performed the\n procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n 50 mcg of fentanyl and 0.5 mg of Versed throughout the intraservice time of 20\n minutes, during which the patient's hemodynamic parameters were continuously\n monitored.\n\n PROCEDURE: Written informed consent was obtained from the patient after\n explaining the indications, risks, benefits and alternatives to the procedure.\n The patient was laid supine in the angio suite. The left neck and anterior\n chest wall were prepped in the sterile fashion. A preprocedural timeout and\n huddle were performed per protocol.\n\n Under son guidance, a patent left IJ was accessed using a\n micropuncture needle and a guidewire was passed through the needle. The\n needle was then exchanged for a micropuncture sheath, through which \n was passed into the right atrium and appropriate measurements were taken. The\n was then passed into the IVC for stability. The micropuncture sheath\n was taken out and the tract was serially dilated. Then, the 20-cm temporary\n dialysis line with a VIP port was threaded over the with the tip in the\n right atrium.\n\n All ports were withdrawing blood and flushed easily. The catheter was sutured\n to the skin and sterile dressing was applied. The patient tolerated the\n procedure well. There were no immediate complications.\n\n IMPRESSION: Uncomplicated placement of a 20-cm, three-lumen temporary\n hemodialysis line with a VIP port.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-23 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 1206493,
"text": " 4:13 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please exchange temp HD line for tunnelled HD line and also\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 60\n Type of Port: None\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n \"This procedure was done under fluoroscopic and ultrasound guidance with hard\n copy images on file.\"\n\n\n DR. \n\n 4:13 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please exchange temp HD line for tunnelled HD line and also\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 60\n Type of Port: None\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with ESRD and need for access\n REASON FOR THIS EXAMINATION:\n please exchange temp HD line for tunnelled HD line and also please place\n tunnelled double lumen power access line, with questions. Thanks\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURES:\n 1. Conversion of a temporary double-lumen hemodialysis line inserted by the\n right internal jugular vein approach into a tunneled double-lumen hemodialysis\n line,\n 2. De insertion of a tunneled Power double-lumen central line by the\n left internal jugular vein approach,\n 3. Superior vena cava venogram via the left brachiocephalic vein: .\n\n INDICATION: 27 year-old man with ESRD requiring access for hemodialysis and\n medications.\n\n PHYSICIANS: , MD; , MD.\n\n MEDICATIONS: The procedure was performed under monitored conscious sedation.\n The patient received a total quantity of 2 mg of midazolam and 200 mcg of\n fentanyl intravenously during the total procedural time of 2 hours and 50\n minutes while his hemodynamic parameters and pulse oximetry were continuously\n monitored by a trained radiology nurse.\n\n TECHNIQUE/FINDINGS:\n\n Informed consent for both procedures was obtained after risks and potential\n complications had been discussed with the patient. The patient was positioned\n on the angiography table in usual supine position. The huddle and timeout\n protocol were carried out prior to all procedures according to the \n Hospital policy.\n\n Skin of the right anterior neck around the insertion site of the temporary\n right-sided internal jugular dialysis line was prepped and draped in a sterile\n fashion. Local anesthesia was effected with 1% lidocaine. Heparin was\n removed from both ports of the dialysis line prior to advancement of a\n guidewire. Silk suture securing the line to the skin was cut, and a 0.035\n inch guidewire was successfully advanced into the suprarenal inferior\n vena cava through one of the ports of the central line. Attention was then\n turned to the anterior chest wall. Subcutaneous soft tissues were\n anesthetized with 1% lidocaine with epinephrine. A small skin incision was\n made with a scalpel, and subcutaneous soft tissue tunnel connecting to the\n venipuncture site was created by blunt preparation. The tunnel was placed\n more laterally secondary to a previous port pocket that was being packed. A\n (Over)\n\n 4:13 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please exchange temp HD line for tunnelled HD line and also\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 60\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 19-cm long tip-to-cuff hemodialysis catheter was pulled through the soft\n tissue tunnel and advanced through an appropriate peel-away sheath into the\n right atrium. The skin over the venipuncture was sutured using 4-0 Vicryl\n suture. The line was secured to the skin outside the tunnel using 0 silk\n sutures. Sterile dressings were applied.\n\n Attention was then turned to the left anterior neck, where the skin was\n prepped and draped in sterile fashion. Son interrogation of the left\n anterior neck demonstrated a predominantly thrombosed left internal jugular\n vein, which was only partially compressible. Local anesthesia was effected\n with 1% lidocaine. Due to partial compressibility and demonstration of a\n patent left internal jugular vein on recent cross-sectional imaging studies of\n the neck in , the procedure of insertion of the central line was\n deemed feasible, and the left internal jugular vein was punctured under\n ultrasound visualization using a 21-gauge micropuncture needle. Blood return\n was obtained, and 0.018 inch guidewire was advanced into the superior vena\n cava. The micropuncture needle was then exchanged for an appropriate\n peel-away sheath. A digital subtraction venogram was then performed through\n the peel-away sheath by injection of 10 mL of undiluted Omnipaque 220, which\n demonstrated high-grade stenosis of the central left brachiocephalic vein with\n partial thrombosis of the left brachiocephalic and left internal jugular veins\n more peripherally. The superior vena cava is widely patent. To facilitate\n advancement of a PICC, a 0.018 Glidewire was advanced into the right atrium\n through the peel-away sheath. However, attempts to advance the PICC over the\n Glidewire were met with resistance at the level of mid left brachiocephalic\n vein. A 4 French MPA-1 catheter was then successfully advanced over the\n Glidewire into the superior vena cava paving the way for advancement of a\n double-lumen PowerPICC into the right atrium. The PICC was tunneled through a\n subcutaneous soft tissue tunnel inferior and lateral to the venipuncture site.\n At the conclusion of the procedure, the tip of the Power double-lumen central\n line was in the superior third of the right atrium. At the conclusion of the\n procedure, the tip of the hemodialysis in the superior third of the right\n atrium. The line flushed and aspirated well and was instilled with heparined\n saline. Sterile dressings were applied.\n\n IMPRESSION:\n\n 1. Successful conversion of a temporary right internal jugular hemodialysis\n line into a tunneled right internal jugular hemodialysis line with tip in the\n right atrium under fluoroscopic guidance. The hemodialysis line is ready to\n use.\n 2. High-grade stenosis of the central left brachiocephalic vein near the\n junction with the superior vena cava with partial thrombosis of the left\n brachiocephalic vein and left internal jugular vein more peripherally. Due to\n (Over)\n\n 4:13 PM\n TUNNELED DIALYSIS LINE PLACEME Clip # \n Reason: please exchange temp HD line for tunnelled HD line and also\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 60\n Type of Port: None\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n soft consistency and recent age of the thrombus, placement of the left\n internal jugular central line through the clot was deemed feasible and was\n successful. The left internal jugular central venous line is ready to use.\n 3. The clinical team was advised not remove the left internal jugular central\n venous line without consulting interventional radiology.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-11 00:00:00.000",
"description": "R US EXTREMITY NONVASCULAR RIGHT",
"row_id": 1204761,
"text": ", M 27 () \n , S. OMED 2:21 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: PT WITH NEW RIGHT WRIST LESION, EVAL FOR ABSCESS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with MRSA scalded skin syndrome now with new R wrist lesion\n REASON FOR THIS EXAMINATION:\n eval for abscess\n ______________________________________________________________________________\n PFI REPORT\n 10 x 20 x 2 mm subcutaneous fluid collection adjacent to but not involving the\n nearby tendon sheath.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-17 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1205618,
"text": " 4:07 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC for HD\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 8\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -79 UNRELATED PROCEDURE/SERVICE DURI *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with HD dependent renal failure\n REASON FOR THIS EXAMINATION:\n PICC for HD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old man with hemodialysis-dependent renal failure, needs\n a PICC for IV access, for medication and fluids.\n\n OPERATORS: Dr. performed the procedure and Dr. \n reviewed the images.\n\n ANALGESIA: It was provided by 1% lidocaine.\n\n PROCEDURE AND FINDINGS: Verbal informed consent was obtained from the patient\n after explaining the procedure, risks, benefits and alternatives. Patient was\n brought to the angiographic suite and laid supine on the table. The right arm\n was prepped and draped in a sterile fashion. Preprocedural timeout and huddle\n were performed per protocol.\n\n Under ultrasound guidance, the patent right brachial vein was accessed and a\n wire was tried to be threaded in, but there was a stenosis at the subclavian\n vein and the wire was not feeding in. This was confirmed angiographically and\n by contrast injection. So it was decided to leave a midline venous access. A\n 16 cm long single-lumen 4 French PICC was threaded over the wire into the\n brachial vein. The guidewire was removed and sterile dressing was applied at\n the PICC line.\n\n The patient tolerated the procedure well. She did not have any immediate\n complications.\n\n IMPRESSION: Uncomplicated successful placement of a midline venous line in\n the mid axillary vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209088,
"text": " 6:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrathoracic process and compare with prior.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with 27 yo male with h/o CLL s/p allogenic stem cell transplant\n complicated by chronic GVHD of his gut with icreased hypoxia.\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process and compare with prior.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Portable supine radiograph of chest.\n\n Comparisons were made with prior chest radiographs from \n with the most recent from .\n\n FINDINGS:\n Previously seen supporting and monitoring devices are in standard position.\n Bilateral lung volumes remain low and there are no new relevant findings.\n Assessment of the left lung was limited as most of it was obscured by the\n widened mediastinum presumably from the low lung volumes and due to flexed\n position of the neck obscuring most of the lung apices. Increased\n retrocardiac density on the left side suggesting left lower lung volumes is no\n different to the prior radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207833,
"text": " 4:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with new cough and chest pain\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrates\n ______________________________________________________________________________\n WET READ: MDAg SUN 9:51 PM\n Low lung volumes. Increased opacity at left base may be crowding of vessels vs\n increased atelectasis. Unchanged right basilar atelectasis. Support devices in\n unchanged positions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: New cough and chest pain.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n Right central venous line and left subclavian line are in unchanged position\n terminating at the low SVC/cavoatrial junction. Cardiomediastinal silhouette\n is unchanged. Bibasal linear opacities are unchanged, most likely\n representing atelectasis although in the right lung the opacity is relatively\n and might reflect infectious process. There is no apparent pleural\n effusion noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-03 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1207922,
"text": " 9:02 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL s/p allo SCT complicatedby chronic GVHD, with fevers\n and new onset hypoxia\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with CLL, status post allo stem cell transplant,\n compatibility complicated by chronic graft-versus-host disease. Fever and new\n onset hypoxia, evaluate for pneumonia.\n\n TECHNIQUE: Unenhanced MDCT of thorax was performed using a standard\n department protocol.\n\n Comparisons were made with prior chest CTs through , with most\n recent from .\n\n FINDINGS:\n\n LUNGS AND AIRWAYS: Central airways are patent till subsegmental level. Since\n , revious multifocal pneumonic consolidation and ground glass\n opacities in both upper lobes, lingula and middle lobe have significantly\n decreased. Opacities in the dependent portions of the bilateral lower lungs\n representing either aspiration, atelectasis, or pneumonic consolidation have\n also minimally improved. Bilateral pleural effusion is trace.\n\n MEDIASTINUM: Bilateral central line terminates at the cavoatrial junction.\n There is no pathological enlargement of mediastinal, supraclavicular, or\n axillary lymph nodes. Thyroid gland is normal. Heart is normal size without\n pericardial effusion.\n\n ABDOMEN: The study is not tailored for evaluation of the abdomen; however,\n limited views were unremarkable.\n\n BONES: Mild wedge compression deformities of sixth and ninth vertebral body\n are unchanged. Degenerative changes at multiple vertebral body levels are\n seen. There is no bone lesion suspicious for malignancy/infection.\n\n\n IMPRESSION:\n\n Since , bilateral multifocal pneumonia and ground glass\n opacification as well as bilateral lower lobes opacities representing either\n atelectasis, aspiration, or pneumonia have decreased.\n (Over)\n\n 9:02 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207569,
"text": " 2:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema? pleural effusions? pneumonia?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL and recovering HD-dependent and 4 pound weight\n gain from yesterday. Now with 2L oxygen requirement new from yesterday.\n REASON FOR THIS EXAMINATION:\n pulmonary edema? pleural effusions? pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Patient with 4-pound weight gain in one day with new oxygen\n requirement.\n\n Comparison is made with prior study .\n\n There persist unchanged low lung volumes with bibasilar atelectasis. There is\n no evident pneumothorax or large pleural effusion. The chin of the patient\n obscures the apices of the lungs. Bilateral central catheters are unchanged\n in standard position. Cardiomediastinal contours are unchanged with\n cardiomegaly accentuated by the low lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-06 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1208459,
"text": " 10:16 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please eval for PNA or intraabdominal or RP bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with GVHD of gut and neutropenic fevers and dropping HCT on\n heparin GTT\n REASON FOR THIS EXAMINATION:\n please eval for PNA or intraabdominal or RP bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 4:18 PM\n 1. No acute intra-abdominal or intrapelvic process. Specifically, there is\n no evidence of RP bleed.\n 2. Interval increase in patchy ground-glass opacities throughout the upper\n lung zones since the CT examination concerning for\n worsening multifocal pneumonia.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with graft-versus-host disease of GI tract with\n neutropenic fevers and decreasing hematocrit values.\n\n COMPARISON: Chest CT available from and abdominal CT from\n .\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the chest, abdomen, and pelvis\n were obtained without the use of IV or oral contrast. Coronal and sagittal\n reformations were performed at 5-mm slice thickness.\n\n CHEST: A left IJ catheter terminates at the cavoatrial junction. A larger\n right IJ catheter terminates within the right atrium. The heart size is top\n normal. The left ventricle is enlarged. There is no pericardial effusion.\n The main pulmonary artery is enlarged. Scattered axillary and mediastinal\n lymph nodes do not meet CT criteria for lymphadenopathy.\n\n Moderate atelectasis is present at the posterior aspect of both lungs. In\n comparison to examination, there has been an interval\n increase in patchy ground-glass opacities and focal consolidations within the\n upper zones, which may reflect worsening multifocal pneumonia. There is no\n effusion. No discrete mass is detected.\n\n ABDOMEN: Non-contrast enhanced views of the liver, gallbladder, pancreas,\n adrenal glands, kidneys, spleen, and stomach are normal. There is no\n mesenteric or retroperitoneal lymphadenopathy, and no free air or free fluid.\n A moderate amount of fluid is seen throughout the distal colon extending to\n the rectal vault.\n\n PELVIS: The urinary bladder and prostate are within normal limits. No\n intrapelvic free fluid or lymphadenopathy.\n\n (Over)\n\n 10:16 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please eval for PNA or intraabdominal or RP bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or\n lytic lesions are identified. Wedge compression deformities are seen from\n T7-12, L1, L2, and L4 over the background of severe osteopenia, all unchanged.\n\n\n IMPRESSION:\n 1. No acute intra-abdominal or intrapelvic process. Specifically, there is\n no evidence of RP bleed.\n 2. Interval increase in patchy ground-glass opacities throughout the upper\n lung zones since the CT examination concerning for\n worsening multifocal pneumonia.\n\n The initial findings were discussed by Dr. with Dr. at 2:20 p.m. on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-09 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1208835,
"text": " 10:20 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Is there interval worsening of infiltrates compared to \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with significant hypoxia and worsning chest CT imaging on \n and . There is concern for viral pneumonia, pulmonary hemorrhage, and PCP\n pneumonia as well as typical HAP.\n REASON FOR THIS EXAMINATION:\n Is there interval worsening of infiltrates compared to and and is\n there evidence of hemorrhage?\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: KKgc SUN 3:21 PM\n Multifocal ground-glass opacities and pulmonary consolidation in the upper\n lobes are unchanged. Mild interval progression of the dense consolidation in\n the right lower lobe, likely reflecting a combination of atelectasis,\n infection, and or aspiration. New small right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old man with significant hypoxia and worsening pulmonary\n abnormalities on CT imaging of and . Clinical concern for viral\n pneumonia, pulmonary hemorrhage, and PCP .\n\n COMPARISON: CT torso without contrast and CT chest without contrast\n .\n\n TECHNIQUE: MDCT helical images were acquired through the chest without\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: Multifocal areas of ground-glass opacity and patchy consolidation\n in both upper lobes and right middle lobe, are unchanged since the prior\n study. Also seen are dense consolidations involving the dependent portion of\n both lower lobes, right greater than left. There is mild interval progression\n of the consolidation in the right lower lobe. These consolidations likely\n reflect a combination of atelectasis, infection, and superimposed aspiration.\n Small right pleural effusion is new since the prior study. No pneumothorax is\n identified. No significant mediastinal, hilar, or axillary adenopathy is\n seen. Within the limitations of a non-contrast study, the thoracic aorta is\n unremarkable. The heart is mildly enlarged. There is no pericardial\n effusion.\n\n Bilateral internal jugular approach central venous catheters are seen, with\n the left terminating in the cavoatrial junction and the right terminating in\n the right atrium. Main pulmonary artery is mildly enlarged measuring 3.4 cm,\n suggestive of pulmonary arterial hypertension.\n\n This study is not tailored for evaluation of the subdiaphragmatic organs.\n Within this limitation, the imaged portion of the upper abdomen including the\n liver, spleen, adrenal glands are unremarkable.\n (Over)\n\n 10:20 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Is there interval worsening of infiltrates compared to \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONES AND SOFT TISSUES: No bone lesion concerning for infection or malignancy\n are detected. Mild compression of T6, T7, T9 and T12 vertebral bodies, are\n unchanged since the prior study.\n\n IMPRESSION:\n Multifocal ground-glass opacities and pulmonary consolidation in the upper\n lobes are unchanged. Mild interval progression of the dense consolidation in\n the right lower lobe, likely reflecting a combination of atelectasis,\n infection, and or aspiration. New small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208429,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with ?PNA\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 27-year-old with pneumonia. Please evaluate for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: Left and right central venous lines are in unchanged correct\n position. Cardiomediastinal silhouette is unchanged. The lung volumes are\n very low. In comparison to the prior study there appears to be little\n interval change with the left retrocardiac densities and the right perihilar\n density still visible and unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207431,
"text": " 7:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema? effusions? pneumonia?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27yo male with 3 pound weight gain and increasing oxygen requirement. Just\n d/c'd HD this week and UOP improving but still in positive fluid balance.\n REASON FOR THIS EXAMINATION:\n pulmonary edema? effusions? pneumonia?\n ______________________________________________________________________________\n WET READ: 9:26 PM\n\n Right IJ HD line extends to cavoatrail jxn. Left IJ catheter extends to\n distal SVC. persistently low lung volumes but slightly improved aeration at\n the lung bases. stable heat size. no pulmonary edema or pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Incresed oxygen requirement.\n\n Portable AP radiograph of the chest was reviewed in comparison with , .\n\n The left central venous line tip is at the cavoatrial junction. The right\n central venous line has been inserted terminating in the right\n atrium/cavoatrial junction. Cardiomediastinal silhouette is unchanged. There\n is interval improvement of bibasilar atelectasis. Small amount of pleural\n effusion is most likely present. Within the limitations of this examination,\n no evidence of pneumothorax is seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208207,
"text": " 4:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 yo male with h/o CLL s/p allogenic stem cell transplant complicated by\n chronic GVHD of his gut, recent MRSA sepsis, in MICU twice this admission,\n first , and second admission , who now has increased hypoxia\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n DATE: .\n\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 27-year-old male patient with history of chronic lymphatic\n leukemia status post allogenic stem cell transplant complicated by chronic\n GVHD of his gut, recent MRSA sepsis, in MICU twice during this admission. Now\n with increased hypoxia.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. Comparison is made with the next preceding similar study\n dated . Previously identified right-sided internal jugular\n approach double-lumen catheter remains in unchanged position terminating in\n the upper portion of the right atrium. A left-sided subclavian approach\n central venous line is also in unchanged position terminating to the right of\n the midline in the area of the mid portion of the SVC. No pneumothorax has\n developed. The on previous examination identified pulmonary density on the\n left base in retrocardiac position persists and may have increased slightly.\n There is no new evidence of pneumothorax or pleural effusion. On the right\n base, a plate atelectasis has developed but no other new abnormalities are\n seen and the right lateral pleural sinus remains free. During the latest\n examination interval, the patient underwent a chest CT on .\n The bilateral patchy densities on the bases and plate atelectases were shown\n in greater detail. It is concluded that no major interval change has occurred\n as can be identified on this portable single view chest examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209280,
"text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrathoracic process\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL/SLL s/p allo SCT with increased hypoxia.\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Increased hypoxia. Patient is status post allo transplant.\n\n Comparison is made with prior study .\n\n Bilateral central lines remain in standard unchanged position. There are\n persistent low lung volumes. Cardiomegaly and widened mediastinum are stable.\n Bibasilar opacities larger on the left side are unchanged consistent with\n atelectasis but pneumonia cannot be excluded. Right upper lobe opacity has\n improved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208777,
"text": " 5:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for O2 desaturation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with new onset O2 desaturation\n REASON FOR THIS EXAMINATION:\n eval for O2 desaturation\n ______________________________________________________________________________\n WET READ: MLHh SAT 8:05 PM\n Low lung vols. Slight in bilat streaky opacities = interstitial PNA +\n atelectasis based on CT. Bilat lines in RA as before.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: New onset of O2 desaturation, evaluate for cause.\n\n CHEST\n\n The position of the various lines remains unchanged. The heart is enlarged.\n Perihilar opacities are still present, perhaps a little less marked. No\n effusions are identified.\n\n IMPRESSION: Mild improvement since prior chest x-ray.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208919,
"text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with increased O2 req and GVHD\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increased oxygen requirement.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Monitoring and support devices remain in place. Continued low lung\n volumes with bibasilar atelectasis, especially in the retrocardiac region\n consistent with volume loss in the left lower lobe.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209573,
"text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess lung fields for acute process\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL, aspirating blood intermittently\n REASON FOR THIS EXAMINATION:\n Assess lung fields for acute process\n ______________________________________________________________________________\n FINAL REPORT\n Semi-erect portable radiograph of chest.\n\n Comparisons were made with prior chest radiographs through ,\n with the most recent from .\n\n FINDINGS: Left porta catheter and dual-lumen right central line catheter end\n in the upper right atrium. Bilateral lung volumes are low. Bilateral lower\n lung atelectasis, left side more than right side, are unchanged.\n Cardiomediastinal silhouette and hilar contours are stable. There are no new\n lung opacities of concern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208813,
"text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with GVHD of gut and shortness of breath w/ ? CMV pneumotitis\n vs. pulm hemoorhage\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Graft-versus-host disease.\n\n Shortness of breath.\n\n CHEST:\n\n Lung volumes are very low and fluid is likely present in the minor fissure in\n addition to costophrenic angles. There is loss of the left hemidiaphragm and\n this could be due to atelectasis and/or pneumonia in this region.\n\n IMPRESSION: Increasing pleural effusions and opacification of left lower\n lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208258,
"text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval progression\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with CLL/SLL, new hypoxia\n REASON FOR THIS EXAMINATION:\n interval progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: New hypoxia.\n\n Portable AP radiograph of the chest was reviewed in comparison to , .\n\n Left and right central venous lines are in unchanged position. Bibasilar\n atelectasis is unchanged. Comparison with the prior study is difficult since\n the patient was imaged in significant lordotic projection and his head is\n obscuring upper lungs. Within those limitations, no substantial change since\n the prior study demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208585,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with possible pna\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: AP semi-upright portable radiograph of chest.\n\n Comparisons were made with prior chest radiographs through \n with the most recent from .\n\n FINDINGS: Bilateral central venous lines terminate in the right atrium. Both\n lung volumes remain low. Since , there is no difference in\n bilateral predominantly mid and lower lung opacities. In an appropriate\n clinical setting, these may either reflect atelectasis or pneumonic\n consolidation. On concurrent comparison with the recent CT torso study, it\n appears that most of the lower lung opacity is attributed to the lung\n atelectasis, whereas patchy mid and upper lobe opacities are suggestive of\n multifocal pneumonic consolidation. cardiomediastinal and hilar contours are\n unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1207954,
"text": ", OMED 7F 11:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute head bleed?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with extensive clots of central nenous system and falling\n platelets on heparin gtt\n REASON FOR THIS EXAMINATION:\n acute head bleed?\n CONTRAINDICATIONS for IV CONTRAST:\n renal\n ______________________________________________________________________________\n PFI REPORT\n No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-10-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1207953,
"text": " 11:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: acute head bleed?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with extensive clots of central nenous system and falling\n platelets on heparin gtt\n REASON FOR THIS EXAMINATION:\n acute head bleed?\n CONTRAINDICATIONS for IV CONTRAST:\n renal\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRAf MON 12:01 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Extensive clot of the central nervous system and falling platelet on\n heparin drip, evaluate for acute bleed.\n\n TECHNIQUE: Contiguous axial sections of the brain without IV contrast.\n\n COMPARISON: CT of the neck without contrast from .\n\n FINDINGS: No hemorrhage, edema or shift of normally midline structures.\n Study is limited by motion, but overall appears normal. The ventricles and\n sulci are normal in size and caliber. No suspicious osseous lesions. The\n mastoid air cells are well aerated. Again seen is moderate mucosal thickening\n within the sphenoid sinus, unchanged from prior exams. Scattered white matter\n abnormalities from the MRI are not appreciated on this study.\n\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 203953,
"text": "Sinus tachycardia. Diffuse T wave abnormalities likely secondary to rate.\nCompared to the previous tracing there is no change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-28 00:00:00.000",
"description": "Report",
"row_id": 203954,
"text": "Sinus tachycardia. Diffuse non-specific T wave abnormalities likely secondary\nto rate.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-27 00:00:00.000",
"description": "Report",
"row_id": 203955,
"text": "Sinus tachycardia. Diffuse non-specific T wave abnormalities likely secondary\nto rate. Compared to the previous tracing there is no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 203956,
"text": "Sinus tachycardia. Diffuse non-specific T wave abnormalities likely secondary\nto rate. Compared to the previous tracing no diagnostic changes.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-25 00:00:00.000",
"description": "Report",
"row_id": 203957,
"text": "Normal sinus rhythm with ventricular premature beats. Left atrial abnormality.\nPoor R wave progression in leads V1-V6 raises the possibility of old\nanterolateral myocardial infarction. Non-specific ST-T wave abnormalities in\nthe inferior and lateral leads. Compared to the previous tracing of \nventricular premature beats are now noted and lateral T wave abnormalities are\nslightly more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-24 00:00:00.000",
"description": "Report",
"row_id": 203958,
"text": "Sinus rhythm. Leftward axis. Late R wave proression. T wave abnormalities.\nSince the previous tracing of the rate is slower. ST-T wave\nabnormalities may be less prominent. Otherwise, unchanged.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-21 00:00:00.000",
"description": "Report",
"row_id": 203959,
"text": "Sinus tachycardia. Compared to tracing #1 the rate is faster. Non-specific\nanteroseptal ST-T wave changes persist.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-19 00:00:00.000",
"description": "Report",
"row_id": 203960,
"text": "Sinus tachycardia. Delayed R wave transition in the anterior precordial leads.\nCompared to the previous tracing of the rate is faster. Ventricular\npremature beats are no longer seen. Non-specific anteroseptal ST-T wave changes\npersist.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2112-10-20 00:00:00.000",
"description": "Report",
"row_id": 203717,
"text": "Compared to tracing #1 the patient has gone from atrial flutter with a rapid\nventricular response to normal sinus rhythm with frequent ventricular premature\nbeats. There is marked baseline artifact on the current tracing. J point\nelevation. Non-specific ST-T wave changes in the right precordial leads may\nhave been present to some degree in tracing #1 as well, although obscured by\nthe baseline artifact due in part to atrial flutter.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2112-10-20 00:00:00.000",
"description": "Report",
"row_id": 203718,
"text": "Atrial flutter with a rapid ventricular rate of 160 beats per minute.\nModerate baseline artifact. Non-specific ST-T wave changes. Compared to the\nprevious tracing of no diagnostic interval change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2112-10-19 00:00:00.000",
"description": "Report",
"row_id": 203719,
"text": "Atrial flutter with 2:1 A-V block. There are non-specific ST segment changes.\nCompared to the previous tracing there is considerable baseline\nartifact but there are no longer frequent ventricular premature beats and the\nrhythm has gone from sinus tachycardia to atrial flutter with an increase in\nrate from 121 to 158. The non-specific ST-T wave changes persist but are\nsomewhat less prominent in leads I and aVL. No other diagnostic interval\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-10-13 00:00:00.000",
"description": "Report",
"row_id": 203720,
"text": "Sinus tachycardia with ventricular premature beats and baseline artifact.\nPossible biatrial enlargement. Left axis deviation. Poor R wave progression.\nPossible left ventricular hypertrophy. Non-specific ST-T wave changes could\nbe due to left ventricular hypertrophy but cannot exclude ischemia. Compared\nto the previous tracing of artifact is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-10-12 00:00:00.000",
"description": "Report",
"row_id": 203721,
"text": "Sinus tachycardia with ventricular premature beats. Possible biatrial\nenlargement. Leftward axis. Left ventricular hypertrophy with lateral\nST-T wave abnormalities. Compared to the previous tracing of lateral\nST-T wave abnormalities are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-10-08 00:00:00.000",
"description": "Report",
"row_id": 203722,
"text": "Normal sinus rhythm with occasional ventricular premature beats. T wave\ninversions in leads V1-V3 suggest the possibility of anteroseptal myocardial\nischemia. Voltage criteria for left ventricular hypertrophy. Compared to the\nprevious tracing of the T wave inversions in the right precordial leads\nare less prominent and the ventricular ectopic activity has diminished.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-10-03 00:00:00.000",
"description": "Report",
"row_id": 203723,
"text": "Normal sinus rhythm with frequent ventricular premature beats in a bigeminal\npattern. There is T wave inversion in the conducted beats in leads V1-V4 with\npoor R wave progression. Compared to the previous tracing of the\npatient is no longer in sinus tachycardia with occasional ventricular\npremature beats. Non-specific ST-T wave changes noted at that time in\nleads I and aVL are not present on the current tracing. Poor R wave progression\nin leads V1-V6 is no longer seen on the current tracing. Marked T wave\ninversion in leads V1-V4 is new, however. These changes are non-specific and\nnon-diagnostic.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-09-10 00:00:00.000",
"description": "Report",
"row_id": 203724,
"text": "Sinus tachycardia with ventricular premature beats. Possible biatrial\nenlargement. Leftward axis. Poor R wave progression of uncertain\nsignificance. Diffuse non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of heart rate and non-specific ST-T wave abnormalities\nhave increased. Axis is more leftward and loss of R wave in the lateral\nprecordial leads may reflect lead placement but suggest clinical correlation\nand repeat tracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-09-05 00:00:00.000",
"description": "Report",
"row_id": 203725,
"text": "Sinus tachycardia with ventricular premature beats and significant baseline\nartifact. Non-specific T wave changes. Compared to the previous tracing\nof artifact persists. Ventricular premature beats are seen on the\ncurrent tracing.\n\n"
}
] |
30,593 | 187,958 | Pt was admitted to the hospital following the above mentioned procedure - please see op report for details. Postoperatively, pt had low urine output and bleeding, and pt was admitted to the ICU for serial Hcts and monitoring. On POD1, pt was transfused 2U PRBCs, and on POD2 he received another 2U PRBCs for persistent bleeding; he was hemodynamically stable during this period. While he was in the ICU, he worked some with PT, but was limited secondary to pain. Pt's Hct was stable throughout the remainder of POD2 (following the transfusion) and on POD3, after 4 stable serial Hcts, he was transferred to the floor, and lovenox was started on in the AM. TLD: Pt's CVL was d/c'd on POD3, foley was d/c'd on POD4, and his hemovac was d/c'd on POD1. Pain: Pt's pain was initially trteated with a PCA, but this was changed to po oxycodone post-operatively, and his pain was treated with this an tylenol while in-house ID: pt received perio-op ancef for 24 hrs Activity: Pt was 50% WB with posterior precautions (for 6 weeks post-op) | Chief Complaint: s 24 Hour Events: - Remained hemodynamically stable - Hct trended: 34.5 -> 26.4 -> 21.4 - Patient currently being transfused 2 units Allergies: Lisinopril Cough; Aspirin Anemia; Last dose of Antibiotics: Cefazolin - 02:00 AM Infusions: Other ICU medications: Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 06:30 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.9C (100.2 Tcurrent: 37.1C (98.7 HR: 73 (73 - 106) bpm BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg RR: 14 (10 - 17) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Total In: 525 mL 1,518 mL PO: TF: IVF: 525 mL 1,288 mL Blood products: 230 mL Total out: 105 mL 85 mL Urine: 55 mL 85 mL NG: Stool: Drains: 50 mL Balance: 420 mL 1,433 mL Respiratory support O2 Delivery Device: Face tent SpO2: 100% ABG: ///24/ Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 21.4 % [image002.jpg] 03:30 AM Hct 21.4 Microbiology: No new Assessment and Plan 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated post-op bleeding. Anticipated Discharge: Rehab Plan: Ther-Ex, transfers, ambulation w/ RW, balance, inc. endurance, wean O2. peripheral pulse assessment done q4hr as needed. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. - Will continue to monitor pm CBC, if platelets lower, will consider platelet tx at that time # Osteoarthritis s/p THA: now POD#1 from surgery. Response: Some general non pitting edema noted. Bladder pressure is WNL.. Hct stable. - Will continue to monitor pm CBC, if decreasing, can consider plt tx, no need at this time # Osteoarthritis s/p THA: now POD#1 from surgery. - Will continue to monitor pm CBC, if decreasing, can consider plt tx, no need at this time # Osteoarthritis s/p THA: now POD#1 from surgery. Central line care per protocol being maintained.VSS being done Q1hr. received 2uPRBC, w/ appropriate bump in Hct to 28.2. - Hold oral meds for now (metformin, actos, glipizide) - RISS # Hypertension: hold anti-hypertensives until Hct stable # FEN: Replete lytes prn, IVF as above, PO as tolerated ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 09:30 PM Multi Lumen - 11:35 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Continue ICU monitoring for now, can consider c/o later today He was transfered to the MICU for further monitoring Problem - Description In Comments Assessment: Pt with noted swelling of right hip, area is warm and skin taught to the touch, right foot cool though equally so to left, pedal pulses palpable, pt able to wiggle toes, hemovac in place in right hip, surgical dsg d&I, repeat hct this am with 4 point drop, u/o ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP: 94-122/42-57 Action: Overnight pt received 2 500cc fluid boluses, ordered to receive 2 UPRBC, first of two started at 0445, pt is a difficult venipuncture, this RN unable to obtain morning labs, HO attempted arterial stick, only able to obtain enough blood for 0330 hct, pt also receiving maintenance LR at 125/hr Response: Pt with some response in u/o with second FB, HR decreased with fluid adm, VSS Plan: Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip and dsg, PT consult tomorrow to obtain wedge pillow if appropriate, continue to provide fluid for goal u/o of 30cc/hr Pain control (acute pain, chronic pain) Assessment: Obtained pt very lethargic, as noted above while in PACU there was difficulty maintaining good pain control w/o over sedation, pts mental status improving throughout the shift, able to report pain scored at , pain located in right hip Action: Minimizing pt turns and movements in bed, keeping right hip straight with pillow between legs, pt received 2 5mg doses of oxycodone with good effect Response: Pt sleeping comfortably throughout the shift, PRN pain medications with good effect Plan: Continue to monitor pain control, pt will likely require larger doses of pain medication with increased activity during the day Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Problem R total hip replacement Assessment: R hip drsg : scant sanguinous drainage noted. Intervention: Supine ther-ex x 10 reps: AP, hip rolls, hip AB/AD, SAQ, HS Other: Diagnosis: 1. peripheral pulse assessment done q4hr as needed. Hypertension - hold meds for now as was hypotensive and bleeding 4. Plan: Transfuse for Hct <24. Plan: Transfuse for Hct <24. - Will continue to monitor pm CBC, if platelets lower, will consider platelet tx at that time # Osteoarthritis s/p THA: now POD#1 from surgery. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p XRT. | 43 | [
{
"category": "Physician ",
"chartdate": "2178-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322918,
"text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units,\n but said it's expected after such a bloody case. will need to\n re-address in AM\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\n unchanged. Mild interstitial edema which was present on has\n resolved and there is no appreciable pleural effusion. Thoracic aorta\n is generally large and tortuous but not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - CVL today for more definitive access as patient with only one working\n PIV at this time (also very hard peripheral stick). Will also aid with\n overall volume monitoring\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Touch base with orthopedics later this morning to confirm they do not\n want further imaging/? If they would like to assess pressure in right\n thigh with probe\n - Awaiting am labs until CVL placed as unable to draw blood\n peripherally\n - IVF/blood prn volume; patient appears dry on exam\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, additional morphine being careful to avoid\n sedation/somnolence\n - Ortho recs\n - PA/lat hip films final read\n - Continue peri-op prophylactic antibiotics.\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 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": "2178-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322920,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units,\n but said it's expected after such a bloody case. will need to\n re-address in AM\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\n unchanged. Mild interstitial edema which was present on has\n resolved and there is no appreciable pleural effusion. Thoracic aorta\n is generally large and tortuous but not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - CVL today for more definitive access as patient with only one working\n PIV at this time (also very hard peripheral stick). Will also aid with\n overall volume monitoring\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Touch base with orthopedics later this morning to confirm they do not\n want further imaging/? If they would like to assess pressure in right\n thigh with probe\n - Awaiting am labs until CVL placed as unable to draw blood\n peripherally\n - IVF/blood prn volume; patient appears dry on exam\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, additional morphine being careful to avoid\n sedation/somnolence\n - Ortho recs\n - PA/lat hip films final read\n - Continue peri-op prophylactic antibiotics.\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: PO\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322933,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr period with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n INR 1.0\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of the trachea to suggest a hematoma. Heart\n size is mildly enlarged and unchanged. Mild interstitial edema which\n was present on has resolved and there is no appreciable\n pleural effusion. Thoracic aorta is generally large and tortuous but\n not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct trend over 24 hours is\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\nd a total of 6\n units prbcs over 24 hours and is currently receiving 2 more units\n PRBCs. Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\n be done to rule out other areas of bleed (such as RP)\n - IVF/blood prn volume; patient appears dry on exam\n - As it is still not entirely clear if patient is bleeding anywhere\n other than his thigh, will check bladder pressure to monitor abdominal\n pressures as a measure to follow along with thigh diameter\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets.\n - Will continue to monitor pm CBC, if platelets lower, will consider\n platelet tx at that time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "ECG",
"chartdate": "2178-05-26 00:00:00.000",
"description": "Report",
"row_id": 124465,
"text": "Sinus rhythm. P-R interval prolongation. Since the previous tracing\nof there is no significant change.\n\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322800,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n - Remained hemodynamically stable\n - Hct trended: 34.5 -> 26.4 -> 21.4\n - Patient currently being transfused 2 units\n - Ortho attending this am: requesting CVL for CVP monitoring\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 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 06:30 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: 37.1\nC (98.7\n HR: 73 (73 - 106) bpm\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,518 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 230 mL\n Total out:\n 105 mL\n 85 mL\n Urine:\n 55 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 1,433 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Gen: NAD\n CV: RRR, no m/r/g\n Pulm: CTAB anteriorly\n Abd: Soft, NTND, obese\n Ext: L thigh with tense skin, much larger than right, wound dressed and\n intact, peripheral pulses full and symmetric bilat\n Labs / Radiology\n 222\n 1.0\n 24\n 4.6\n 19\n 105\n 138\n 21.4 %\n [image002.jpg] Ca 7.7 Mag 1.4 Phos 3.7\n AM Labs pending\n 03:30 AM\n Hct\n 21.4\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. No\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - CVL today for more definitive access as patient with only one working\n PIV at this time (also very hard peripheral stick). Will also aid with\n overall volume monitoring\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Touch base with orthopedics later this morning to confirm they do not\n want further imaging/? If they would like to assess pressure in right\n thigh with probe\n - Awaiting am labs until CVL placed as unable to draw blood\n peripherally\n - IVF/blood prn volume; patient appears dry on exam\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, additional morphine being careful to avoid\n sedation/somnolence\n - Ortho recs\n - PA/lat hip films final read\n - Continue peri-op prophylactic antibiotics.\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO as tolerated\n Glycemic Control: ISS, holding oral meds\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker (famotidine)\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Case Management ",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 322809,
"text": "Insurance information\n Primary insurance: EverCare\n Secondary insurance:\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None known prior to admission\n DME / Home O[2]: none prior to admission\n Functional Status / Home / Family Assessment:\n Pt. lives with his family in . He is independent with all\n personal care ADL's. His primary language is Portugese\n Primary Contact(s): (son) \n Health Care Proxy: .\n Dialysis: Yes\n Referrals Recommended: Physical Therapy, Occupational Therapy\n Current plan: Undetermined\n Unclear what level of services will be required at discharge. Case\n Management will follow for DC needs, The patient did have a stay at\n in .\n Patient (s) to Discharge:\n Patient discussed with multidisciplinary team: No\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Physician Resident and Attending Progress Note",
"row_id": 323055,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n -Post Hct check up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -Ortho recs: Hold lovenox, WBAT\n -bladder pressure 14->7->6\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Gen: NAD, AAOx3\n CV: RRR, no m/r/g\n Pulm: CTAB anteriorly\n Abd: Soft, NTND, obese\n Ext: L thigh with tense skin, larger than right, wound dressed and\n intact, peripheral pulses full and symmetric bilat, pain on deep\n palpation of R thigh, though improved from prior\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6 today\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable\n - IVF/blood prn volume; patient is tolerating PO\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor, if decreasing, can consider plt tx, no need\n at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated, aggressive\n bowel regimen\n ICU Care\n Nutrition:\n PO, diabetic diet\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: c/o to ortho today\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n Key points:\n - hct stable now, rose with transfusions. Plt count higher on repeat\n check.\n - pain much better controlled\n - safe for transfer to floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:58 ------\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 323064,
"text": "77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\n limb girth 23in\n Action:\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\n Response:\n No s/s of bleeding, repeated Hct-28.2\n Plan:\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\n w/pain meds\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain- distention and rt hip pain, unable to score due to\n language barrier.\n Action:\n prn oxycodone, Tylenol q6hr, reposition and support the limb\n Response:\n Intermittent pain as low as 0/10.\n Plan:\n Continue w/ pain assessment, pain meds prn, and reposition and ambulate\n when possible.\n Neuro: a/oX , speaking, understands some English, Right\n lower extremity: Partial weight bearing.\n Resp: NC 2L sats at 96-98%, bil LS clear, diminished at the bases, IS\n use and DB/coughing encouraged.\n Cardio: denies CP or SOB, pneumoboots on, LE edema, peripheral pulses\n present w/Doppler.\n GU: foley w/clear yellow urine w/adequate amnt of urine.\n GI. Abd soft distended, positive for BS and flatus, started on bowel\n regimen., regular diabetic diet- tolerates well no N?V.\n Pain: c/o abd discomfort\nbloated\n and intermittent RT hip pain- on\n Tylenol q6hr and oxycodone prn.\n Skin: rat hip incision w/staples, mild-moderate serosang drainage. 2\n skin tears over rt thigh and RLQ abd w/dsd and tegaderm.\n Patient due to have Xray of his hip prior to discharge. Will be done on\n the floor.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n RIGHT HIP OSTEOARTHRITIS/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 109 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Precautions:\n PMH: Anemia, Diabetes - Oral , GI Bleed\n CV-PMH: Hypertension\n Additional history: prostate ca s/p xrt from 99-00, BPH, gastritis,\n esophagitis, doudentitis, gastric ulcers in stomach body and antrum,\n hemmorrhoids, h pylori, GIB, vertigo, osteoarthritis\n Surgery / Procedure and date: EGD 06\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:59\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 580 mL\n 24h total out:\n 2,685 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 99 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 8 mg/dL\n 02:57 AM\n Creatinine:\n 0.7 mg/dL\n 02:57 AM\n Glucose:\n 114 mg/dL\n 02:57 AM\n Hematocrit:\n 28.2 %\n 08:50 AM\n Finger Stick Glucose:\n 152\n 12:00 PM\n Valuables / Signature\n Patient valuables: sent w/patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/\n Transferred to: R12\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2178-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322967,
"text": "Electrolyte & fluid disorder, other\n Assessment:\n Trend lab values, monitor for change in hemodynamics and v/s.\n Action:\n Patient given calcium carbonate x3 dose for low Ca. MgSO4 x1 today.\n Response:\n Patient remains free of arrhythmia or any other symptoms at this time\n urinary output has been adequate and v/s remain stable. Patient denies\n any discomfort at this time.\n Plan:\n Monitor lab values and treated as order by other health care provider.\n , acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n V/S being doing q1hr and prn. Urinary output checked hourly and trends\n evaluated. Lab values also being monitored.\n Action:\n Received 2units of blood today with pending checks for improvement.\n Response:\n Patient\ns v/s remains stable for client. Continues on O2 via NC and\n saturating welll. No obvious signs of bleeding noted. No BM this shift.\n Plan:\n Continue with blood transfusions as ordered by physician and monitor\n /s and fluid status.\n Problem - Hip surgery\n Assessment:\n Observe wound dressing for drainage, measure limb for increase in\n diameter. Monitor pulses\n Action:\n Dressing to right hip changed, area cleansed and dressed with ABD and\n mepore tape\n Response:\n Patient tolerated procedure well. Has had moderate amount of drainage\n from incision site. Dressing dry and intact at this time.\n Plan:\n Continue to monitor for fluid loss and observe limb for increase in\n size. Monitor pulses distal to wound. Monitory v/s\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322775,
"text": "Chief Complaint: s\n 24 Hour Events:\n - Remained hemodynamically stable\n - Hct trended: 34.5 -> 26.4 -> 21.4\n - Patient currently being transfused 2 units\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 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 06:30 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: 37.1\nC (98.7\n HR: 73 (73 - 106) bpm\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,518 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 230 mL\n Total out:\n 105 mL\n 85 mL\n Urine:\n 55 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 1,433 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 21.4 %\n [image002.jpg]\n 03:30 AM\n Hct\n 21.4\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n # Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - monitor peripheral pulses\n - PT consult requested for POD 2 or 3\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker (famotidine)\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 323042,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n -Post Hct check up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -Ortho recs: Hold lovenox, WBAT\n -bladder pressure 14->7->6\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Gen: NAD, AAOx3\n CV: RRR, no m/r/g\n Pulm: CTAB anteriorly\n Abd: Soft, NTND, obese\n Ext: L thigh with tense skin, larger than right, wound dressed and\n intact, peripheral pulses full and symmetric bilat, pain on deep\n palpation of R thigh, though improved from prior\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6 today\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable\n - IVF/blood prn volume; patient is tolerating PO\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor, if decreasing, can consider plt tx, no need\n at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated, aggressive\n bowel regimen\n ICU Care\n Nutrition:\n PO, diabetic diet\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: c/o to ortho today\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 323044,
"text": "77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\n limb girth 23in\n Action:\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\n Response:\n No s/s of bleeding, repeated Hct-28.2\n Plan:\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\n w/pain meds\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain- destantion and rt hip pain , unable to score due to\n language barrier.\n Action:\n prn oxycodone, Tylenol q6hr, reposition and support the limb\n Response:\n Intermittent pain as low as 0/10.\n Plan:\n Continue w/ pain assessment, pain meds prn, reposition and ambulate\n when possible.\n Neuro: a/\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 323046,
"text": "77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct- 28.5 no s/s of bleeding, vitals signs stable, no BM to guaiac,\n limb girth 23in\n Action:\n Monitor HCT q6hr, monitor for s/s of bleeding/compartment syndrome\n Response:\n No s/s of bleeding, repeated Hct-28.2\n Plan:\n Monitor for s/s of bleeding, HCT q6hr, increasing pain w/no relief\n w/pain meds\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain- distention and rt hip pain, unable to score due to\n language barrier.\n Action:\n prn oxycodone, Tylenol q6hr, reposition and support the limb\n Response:\n Intermittent pain as low as 0/10.\n Plan:\n Continue w/ pain assessment, pain meds prn, and reposition and ambulate\n when possible.\n Neuro: a/oX , speaking, understands some English, Right\n lower extremity: Partial weight bearing.\n Resp: NC 2L sats at 96-98%, bil LS clear, diminished at the bases, IS\n use and DB/coughing encouraged.\n Cardio: denies CP or SOB, pneumoboots on, LE edema, peripheral pulses\n present w/Doppler.\n GU: foley w/clear yellow urine w/adequate amnt of urine.\n GI. Abd soft distended, positive for BS and flatus, started on bowel\n regimen., regular diabetic diet- tolerates well no N?V.\n Pain: c/o abd discomfort\nbloated\n and intermittent RT hip pain- on\n Tylenol q6hr and oxycodone prn.\n Skin: rat hip incision w/staples, mild-moderate serosang drainage. 2\n skin tears over rt thigh and RLQ abd w/dsd and tegaderm.\n Patient due to have Xray of his hip prior to discharge. Will be done on\n the floor.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n RIGHT HIP OSTEOARTHRITIS/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 109 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Precautions:\n PMH: Anemia, Diabetes - Oral , GI Bleed\n CV-PMH: Hypertension\n Additional history: prostate ca s/p xrt from 99-00, BPH, gastritis,\n esophagitis, doudentitis, gastric ulcers in stomach body and antrum,\n hemmorrhoids, h pylori, GIB, vertigo, osteoarthritis\n Surgery / Procedure and date: EGD 06\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:151\n D:59\n Temperature:\n 99.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 580 mL\n 24h total out:\n 2,685 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 99 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 8 mg/dL\n 02:57 AM\n Creatinine:\n 0.7 mg/dL\n 02:57 AM\n Glucose:\n 114 mg/dL\n 02:57 AM\n Hematocrit:\n 28.2 %\n 08:50 AM\n Finger Stick Glucose:\n 152\n 12:00 PM\n Valuables / Signature\n Patient valuables: sent w/patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322776,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n - Remained hemodynamically stable\n - Hct trended: 34.5 -> 26.4 -> 21.4\n - Patient currently being transfused 2 units\n - Ortho attending this am: requesting CVL for CVP monitoring\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 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 06:30 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: 37.1\nC (98.7\n HR: 73 (73 - 106) bpm\n BP: 110/42(60) {94/41(56) - 134/57(74)} mmHg\n RR: 14 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,518 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 230 mL\n Total out:\n 105 mL\n 85 mL\n Urine:\n 55 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 1,433 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 222\n 1.0\n 24\n 4.6\n 19\n 105\n 138\n 21.4 %\n [image002.jpg] Ca 7.7 Mag 1.4 Phos 3.7\n AM Labs pending\n 03:30 AM\n Hct\n 21.4\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. Hct with acute drop overnight\n from 34.5 to 26.4 to 21.4. Pt currently receiving 2 units PRBCs.\n Orthopedics aware.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n # Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - monitor peripheral pulses\n - PT consult requested for POD 2 or 3\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker (famotidine)\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322780,
"text": "77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the MICU\n for further monitoring\n Problem - Description In Comments\n Assessment:\n Pt with noted swelling of right hip, area is warm and skin taught to\n the touch, right foot cool though equally so to left, pedal pulses\n palpable, pt able to wiggle toes, hemovac in place in right hip,\n surgical dsg d&I, repeat hct this am with 4 point drop, u/o\n ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP:\n 94-122/42-57\n Action:\n Overnight pt received 2 500cc fluid boluses, ordered to receive 2\n UPRBC, first of two started at 0445, pt is a difficult venipuncture,\n this RN unable to obtain morning labs, HO attempted arterial stick,\n only able to obtain enough blood for 0330 hct, pt also receiving\n maintenance LR at 125/hr\n Response:\n Pt with some response in u/o with second FB, HR decreased with fluid\n adm, VSS\n Plan:\n Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip\n and dsg, PT consult tomorrow to obtain wedge pillow if appropriate,\n continue to provide fluid for goal u/o of 30cc/hr\n Pain control (acute pain, chronic pain)\n Assessment:\n Obtained pt very lethargic, as noted above while in PACU there was\n difficulty maintaining good pain control w/o over sedation, pt\ns mental\n status improving throughout the shift, able to report pain scored at\n , pain located in right hip\n Action:\n Minimizing pt turns and movements in bed, keeping right hip straight\n with pillow between legs, pt received 2 5mg doses of oxycodone with\n good effect\n Response:\n Pt sleeping comfortably throughout the shift, PRN pain medications with\n good effect\n Plan:\n Continue to monitor pain control, pt will likely require larger doses\n of pain medication with increased activity during the day\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322782,
"text": "------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 07:14 ------\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322794,
"text": "Chief Complaint: Postop bleeding\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 77 yo man s/p total hip arthroplasty. H/O GIB. EBL intraop 1.5L in OR\n got 3L LR, 2U PRBC. No known CAD. Normotensive in OR. Hct 34.5--> 24 in\n PACU (though different techniques).\n 24 Hour Events:\n Hemodynamically stable- no episodes of hypotension.\n Hct 34.5--> 26.4--> 21.4.\n Hemovac removed, site oozing.\n RN noted apneic episodes while sleeping.\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Neurologic: No(t) Numbness / tingling\n Pain: Moderate\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.8\nC (98.2\n HR: 70 (70 - 106) bpm\n BP: 113/53(67) {94/41(56) - 134/57(74)} mmHg\n RR: 13 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 1,663 mL\n PO:\n TF:\n IVF:\n 525 mL\n 1,288 mL\n Blood products:\n 375 mL\n Total out:\n 105 mL\n 180 mL\n Urine:\n 55 mL\n 150 mL\n NG:\n Stool:\n Drains:\n 50 mL\n 30 mL\n Balance:\n 420 mL\n 1,483 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, dry mucosa\n Cardiovascular: (S1: Normal), (S2: Distant), distant HS\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Tight and enlarged right thigh\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): all, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 21.4 %\n [image002.jpg]\n 03:30 AM\n Hct\n 21.4\n Assessment and Plan\n BLOOD LOSS\n 20% Hct drop postop. Hemodynamically stable but poor urine output.\n H/O GI bleed.\n No known significant cardiac history.\n Has received total of 4U PRBC and 4.6L crystalloid.\n Pending repeat hct to check response to transfusion. Needs more fluid\n resuscitation.\n Will place CVC.\n Obviously holding antihypertensive meds.\n Guaiac all stools.\n RISK OF COMPARTMENT SYNDROME\n Discuss with ortho. Exam difficult to guage.\n POSTOP PAIN MANAGEMENT\n PO diet.\n H2 blocker.\n Pneumoboots.\n FULL CODE.\n ICU Care\n Nutrition:\n Comments: PO diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 40\n"
},
{
"category": "Rehab Services",
"chartdate": "2178-05-28 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 322952,
"text": "Subjective:\n \", I'm better today.\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: Hct 24.2 after 6 units of pRBC. Getting 2\n additional units of pRBC today.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n T\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n PWB R LE, RW\n\n\n\n T\n\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 112\n 129/p\n 18\n 94% RA\n Activity\n Sit\n 115\n 142/78\n Recovery\n Sit\n 106\n 114/50\n 21\n 96%RA\n Total distance walked: N/A\n Minutes:\n Gait: Took few small steps with RW with min A x 1 and CG x 1, decreased\n cadence, decreased step length\n Balance: Seated: initially required max A at EOB 2' lateral and\n posterior LOB; with proper positioning and verbal cues, pt able to\n maintain with B UE support and CG.\n Standing: required B UE support and CG x 2.\n Education / Communication: Educated patient as to role of PT, transfer\n technique.\n Communicated with RN.\n Other: Clarification of Functional Status: Rolled with mod A x 1, sup\n to sit with mod A x 2, sit to stand with mod A x 2, trasferred via\n stand pivot with min A x 2 with RW.\n Assessment: Patient was more alert and able to participate with therapy\n today. Anticipate continued improvement as patients hematocrit rises\n and energy level improves. Patient continues to need aggressive rehab\n with PT/OT on d/c.\n Anticipated Discharge: Rehab\n Plan: Transfer train with RW, gait train with RW, ther-ex with PT co-op\n student, hip ROM, patient education.\n OOB to chair daily with RN with gait belt (can order through\n distribution #7711) and 2 person assist.\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-28 00:00:00.000",
"description": "Physician Resident and Attending Progress Note",
"row_id": 322956,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr period with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n INR 1.0\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of the trachea to suggest a hematoma. Heart\n size is mildly enlarged and unchanged. Mild interstitial edema which\n was present on has resolved and there is no appreciable\n pleural effusion. Thoracic aorta is generally large and tortuous but\n not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct trend over 24 hours is\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\nd a total of 6\n units prbcs over 24 hours and is currently receiving 2 more units\n PRBCs. Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\n be done to rule out other areas of bleed (such as RP)\n - IVF/blood prn volume; patient appears dry on exam\n - As it is still not entirely clear if patient is bleeding anywhere\n other than his thigh, will check bladder pressure to monitor abdominal\n pressures as a measure to follow along with thigh diameter\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets.\n - Will continue to monitor pm CBC, if platelets lower, will consider\n platelet tx at that time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n Key issue is hct remains 24% despite 6U PRBC transfusion. Undergoing 2U\n more now. No change in thigh circumference and exam thigh seems less\n tight than yesterday. Pt c/o extreme pain, but on exam localizes to hip\n area. Will check bladder pressure just to have a baseline and continue\n to check thigh measurement if hct does not rise appropriately. Also\n check plt count with next hct. No indication for platelet transfusion\n now.\n Critically ill with persistent blood loss requiring close observation\n in MICU.\n Time: 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:16 ------\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 323020,
"text": "Chief Complaint:\n 24 Hour Events:\n -delay in getting second unit of PRBCs, awaiting repeat HCT/PLT,\n transfusion goal for PLTs <50K.\n -post Hct check is up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -ortho recs: if Hct not bumping, ok with imaging, hold lovenox, WBAT\n -bladder pressure 14\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable.\n - IVF/blood prn volume; patient appears dry on exam\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor pm CBC, if decreasing, can consider plt tx,\n no need at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Continue ICU monitoring for now, can consider c/o later\n today\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 323021,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n -delay in getting second unit of PRBCs, awaiting repeat HCT/PLT,\n transfusion goal for PLTs <50K.\n -post Hct check is up to 27.6 from 24, a bump but not appropriate for 2\n units, plts up too to 121, stable on next check at MN 27.8, on am labs\n 28.4\n -ortho recs: if Hct not bumping, ok with imaging, hold lovenox, WBAT\n -bladder pressure 14\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 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: 37.2\nC (99\n HR: 83 (83 - 114) bpm\n BP: 153/57(81) {117/43(63) - 158/114(118)} mmHg\n RR: 16 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (5 - 15)mmHg\n Bladder pressure: 7 (6 - 14) mmHg\n Total In:\n 2,194 mL\n 40 mL\n PO:\n 1,060 mL\n TF:\n IVF:\n 384 mL\n 40 mL\n Blood products:\n 750 mL\n Total out:\n 5,580 mL\n 1,020 mL\n Urine:\n 5,580 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,386 mL\n -980 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 125 K/uL\n 9.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 99 mEq/L\n 137 mEq/L\n 28.5 %\n 9.5 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n 06:45 PM\n 11:54 PM\n 02:57 AM\n WBC\n 9.7\n 9.5\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n 27.6\n 27.8\n 28.5\n Plt\n 97\n 121\n 125\n Cr\n 0.8\n 0.7\n Glucose\n 123\n 114\n Other labs: PT / PTT / INR:11.9/27.9/1.0, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:1.6 mg/dL\n Imaging: No new\n Microbiology: No new\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct increased to 28.4 this morning\n from 24 after 2 units. Has been stable over two measurements. Patient\n has rec\nd a total of 8 units prbcs since admission. Orthopedics saw\n patient this morning, recommended continue monitoring, WBAT.\n - Continue to cycle Hct q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter, has been stable at 24in.\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - No need for further imaging at this point as Hct stable.\n - IVF/blood prn volume; patient appears dry on exam\n - Bladder pressure 14->6->7. Can continue to monitor, has been stable.\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets. Improved without transfusion.\n - Will continue to monitor pm CBC, if decreasing, can consider plt tx,\n no need at this time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT recommending rehab\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Continue ICU monitoring for now, can consider c/o later\n today\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322866,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Drainage from right lateral hip and thigh incision being monitored.\n Continuous hemodynamic monitoring in progress. Right IJ triple lumen\n central line insitu with CVP monitoring. Assess right thigh for extreme\n distention, thigh circumference measured for comparison, and distal\n pulses being assessed. Trending lab valve monitoring with necessary\n interventions.\n Action:\n Right IJ central line placed this am to facilitate monitoring of\n hemodynamic values. Central line care per protocol being maintained.VSS\n being done Q1hr. peripheral pulse assessment done q4hr as needed.\n Consented Blood transfusions given in relevance to lab values. Pad\n beneath right leg assessed frequently and changed as needed. Continue\n IV therapy as ordered.\n Response:\n No adverse reaction noted to blood transfusion, VSS remain within\n acceptable limits for patient. Dressing to right thigh soiled but\n intact. Two pads moderately saturated with bloody drainage changed over\n the last 12hours. Peripheral pulses remain weak but palpable with\n regular rate and rhythm. Urinary output has picked up and is within\n acceptable limits.\n Plan:\n Continue CVP monitoring and other hemodynamic assessments. IVF as\n ordered. Monitor urinary output and follow lab trends with appropriate\n interventions as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Monitor skin integrity, VSS and CVP values. Trend lab values\n comparatively. Monitor Mg, Na, k, and Ca levels. Observe for abnormal\n EKG rhythms.\n Action:\n Given Magnesium sulfate for Mg of 1.4 Also received Calcium gluconate\n for Ca of 7.7.\n Response:\n Some general non pitting edema noted. Urinary output remains adequate.\n Lab value have not deteriorated.\n Plan:\n Continue se\n Diabetes Mellitus (DM), Type II\n Assessment:\n Random blood sugar being monitored q4hr. Observe for signs of hyper or\n hypoglycemia.\n Action:\n Blood sugar being managed per sliding scale oral hypoglycemic on hold\n Response:\n Blood sugars have been within normal limits and pt has shown no signs\n of hyper or hypoglycemia\n Plan:\n Continue q4hr. blood glucose level and manage per sliding scale orders.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323008,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure .\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is\n WNL.. Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): 24in. B DP\ns & PT\ns are weakly palpable (no\n change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Thigh girth may be increased as different person is measuring it.\n Thigh girth up by 0.25in.\n Plan:\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\n etc.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n ------ Protected Section ------\n 0300 Hct 28.5, still stable.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:36 ------\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322833,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Patient able to verbalize discomfort. Noted increase pain with movement\n and to touch of the right thigh and hip. Obvious swelling to area\n surrounding incision evident same is warn too touch.\n Action:\n Physicians aware of patients pain issue. Currently receives Oxycodone\n 5-10mg po as needed. Can also have morphine IV, however patient\n reluctant to have same. States it makes him\nfunny in the head\n Response:\n Tolerating oral analgesic well, VSS remain WNL for client, and he is\n able to sleep intermittently. Can consider medicating prior to activity\n with clients consent.\n Plan:\n Continue to assess for discomfort through verbal inquiry and monitor\n for changes in V/S.\n"
},
{
"category": "Rehab Services",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 323061,
"text": "Subjective:\n \"Today was better.\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: Pt. received 2uPRBC, w/ appropriate bump in Hct\n to 28.2. Pt called out and awaiting bed.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n PWB R LE\n\n\n\n\n T\n\n Ambulation:\n PWB R LE\n\n\n\n\n T\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 94\n 134/62\n 98% 2L\n Activity\n Stand\n 112\n 116/61\n 98% 2L\n Recovery\n Sit\n 96\n 125/56\n 96% 2L\n Total distance walked: 4 steps forwards and backwards, x2\n Minutes:\n Gait: Pt. ambulated w/ Mod A x1 and Min A x1- 4 steps forward and\n backward, x2. Pt. independently advanced BLE. Absent heel strike B,\n minimal circumduction of RLE to clear from floor, decreased step length\n and wide BOS.\n Pt. maintained WBing status w/o cues self limitations of pain.\n Pt. performed sit to stand transfer 3x, w/ Min A x2.\n Balance: -LOB during ambulation, increased postural sway during static\n standing, likely in pt. attempt to shift weight from RLE.\n Education / Communication: Pt: Role of PT, goals of treatment session,\n technique and sequencing w/ RW.\n Other:\n Assessment: 77 yo M s/p RTHR c/b diffuse blood loss post operatively is\n now progressing slowly, but well w/ PT. Pt. tolerated multiple sit to\n stand transfers today w/ decreased support since yesterday. Pt. also\n now advancing RLE w/o assist. Anticipate as medical stability\n improves, pt. will continue to progress daily with PT. Pt. remains a\n strong rehab canddate.\n Anticipated Discharge: Rehab\n Plan: Ther-Ex, transfers, ambulation w/ RW, balance, inc. endurance,\n wean O2.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322756,
"text": "77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the MICU\n for further monitoring\n Problem - Description In Comments\n Assessment:\n Pt with noted swelling of right hip, area is warm and skin taught to\n the touch, right foot cool though equally so to left, pedal pulses\n palpable, pt able to wiggle toes, hemovac in place in right hip,\n surgical dsg d&I, repeat hct this am with 4 point drop, u/o\n ~10-15cc/hr, HR: 75-106 NSR with first degree AV block, BP:\n 94-122/42-57\n Action:\n Overnight pt received 2 500cc fluid boluses, ordered to receive 2\n UPRBC, first of two started at 0445, pt is a difficult venipuncture,\n this RN unable to obtain morning labs, HO attempted arterial stick,\n only able to obtain enough blood for 0330 hct, pt also receiving\n maintenance LR at 125/hr\n Response:\n Pt with some response in u/o with second FB, HR decreased with fluid\n adm, VSS\n Plan:\n Obtain repeat hct post transfusion, ?plebotomy, continue to monitor hip\n and dsg, PT consult tomorrow to obtain wedge pillow if appropriate,\n continue to provide fluid for goal u/o of 30cc/hr\n Pain control (acute pain, chronic pain)\n Assessment:\n Obtained pt very lethargic, as noted above while in PACU there was\n difficulty maintaining good pain control w/o over sedation, pt\ns mental\n status improving throughout the shift, able to report pain scored at\n , pain located in right hip\n Action:\n Minimizing pt turns and movements in bed, keeping right hip straight\n with pillow between legs, pt received 2 5mg doses of oxycodone with\n good effect\n Response:\n Pt sleeping comfortably throughout the shift, PRN pain medications with\n good effect\n Plan:\n Continue to monitor pain control, pt will likely require larger doses\n of pain medication with increased activity during the day\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322750,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322865,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Patient able to verbalize discomfort. Noted increase pain with movement\n and to touch of the right thigh and hip. Obvious swelling to area\n surrounding incision evident same is warn too touch.\n Action:\n Physicians aware of patients pain issue. Currently receives Oxycodone\n 5-10mg po as needed. Can also have morphine IV, however patient\n reluctant to have same. States it makes him\nfunny in the head\n Response:\n Tolerating oral analgesic well, VSS remain WNL for client, and he is\n able to sleep intermittently. Can consider medicating prior to activity\n with clients consent.\n Plan:\n Continue to assess for discomfort through verbal inquiry and monitor\n for changes in V/S.\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 322739,
"text": "TITLE:\n Chief Complaint: post-op bleeding\n HPI:\n 77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the \n for further monitoring after discussing with the ortho attending. The\n drainage in the hip drain was considered normal.\n Denies pain except for hip pain. no difficulty with breathing. other\n ROS not obtainable due to sedation.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Infusions:\n Cefazolin in PACU\n Other ICU medications:\n Other medications:\n amlodopine 10 mg daily\n diovan 160 mg daily\n glipizide 10 mg daily\n metformin 1000 mg \n actos 30 mg daily\n simvastatin 20 mg daily\n Past medical history:\n Family history:\n Social History:\n hypertension\n diabetes mellitus type 2\n hypercholesterolemia\n prostate cancer s/p XRT\n osteoarthritis\n GI bleed - Dieulafoy lesion \n diabetes\n Occupation:\n Drugs: none\n Tobacco: quit in after 20yrs of smoking\n Alcohol: 1 glass of wine per night\n Other: He is from , retired. He is married.\n Review of systems:\n Constitutional: No(t) Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Edema\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: Foley\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Jaundice\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: Headache\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: right hip\n Flowsheet Data as of 11:20 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 88 (88 - 106) bpm\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\n RR: 17 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 516 mL\n PO:\n TF:\n IVF:\n 516 mL\n Blood products:\n Total out:\n 0 mL\n 95 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 421 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, right hip wound pressure\n dressing, drain in place\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 8:17pm\n Na 138 Cl 105 BUN 19 Gluc 222 AGap=9\n K 4.6 CO2 24 Cr 1.0\n Ca: 7.7 Mg: 1.4 P: 3.7\n WBC 14.1 Hb 8.3 Hct 26.4 Plt179 MCV 85\n 11:41a\n Na 141 Cl 107 BUN 13 Gluc 113 AGap=8\n K 4.6 CO2 27 Cr 0.9\n estGFR: >75 (click for details)\n Ca: 8.3 Mg: 1.7 P: 4.0\n WBC 9.9 Hb 11.5 Hct 34.5 Plt 155 MCV 82\n Imaging: AP port CXR - low lung volumes. large heart. stable RLL\n opacity. mild increased pulmonary markings\n Microbiology: none\n ECG: sinus\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. currently appears to be\n stabilizing Hct over past 4 hours.\n - cycle Hct q6 for now\n - transfuse for <24% as this would likely suggest significant\n re-bleeding\n - guaiac all stools\n .\n Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - PT consult requested for POD 2 or 3\n DM2: adequate control for now.\n - hold metformin for now\n - hold actos for now\n - continue glipizide\n - RISS\n Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 322740,
"text": "TITLE: PGY2 Admit Note\n Chief Complaint: post-op bleeding\n HPI:\n 77 year old man with hx of hypertension, DM2, prostate cancer s/p XRT,\n and GI bleed presents following right total hip arthroplasty\n complicated by post-operative bleeding.\n .\n He underwent elective right THA earlier today. Estimated intra-op blood\n loss was 1500cc. He received 3L of LR and 2 units of pRBCs.\n Intra-op he had stable HR, BP, O2sat, EtCO2. In the PACU he received\n pain medication with (dilaudid x1, morphine x1, tylenol, toradol x1,\n dilaudid PCA, oxycodone). Upon arriving to the PACU his Hct was 34.5.\n At 7:45pm his spun hematocrit was 24. He was transfered to the \n for further monitoring after discussing with the ortho attending. The\n drainage in the hip drain was considered normal.\n Denies pain except for hip pain. no difficulty with breathing. other\n ROS not obtainable due to sedation.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Infusions:\n Cefazolin in PACU\n Other ICU medications:\n Other medications:\n amlodopine 10 mg daily\n diovan 160 mg daily\n glipizide 10 mg daily\n metformin 1000 mg \n actos 30 mg daily\n simvastatin 20 mg daily\n Past medical history:\n Family history:\n Social History:\n hypertension\n diabetes mellitus type 2\n hypercholesterolemia\n prostate cancer s/p XRT\n osteoarthritis\n GI bleed - Dieulafoy lesion \n diabetes\n Occupation:\n Drugs: none\n Tobacco: quit in after 20yrs of smoking\n Alcohol: 1 glass of wine per night\n Other: He is from , retired. He is married.\n Review of systems:\n Constitutional: No(t) Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Edema\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Diarrhea, No(t)\n Constipation\n Genitourinary: Foley\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Jaundice\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Neurologic: Headache\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: right hip\n Flowsheet Data as of 11:20 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 88 (88 - 106) bpm\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\n RR: 17 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 516 mL\n PO:\n TF:\n IVF:\n 516 mL\n Blood products:\n Total out:\n 0 mL\n 95 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 421 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present. Heme negative brown\n stool in vault\n Extremities: Right: Absent, Left: Absent, right hip wound pressure\n dressing, drain in place\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 8:17pm\n Na 138 Cl 105 BUN 19 Gluc 222 AGap=9\n K 4.6 CO2 24 Cr 1.0\n Ca: 7.7 Mg: 1.4 P: 3.7\n WBC 14.1 Hb 8.3 Hct 26.4 Plt179 MCV 85\n 11:41a\n Na 141 Cl 107 BUN 13 Gluc 113 AGap=8\n K 4.6 CO2 27 Cr 0.9\n estGFR: >75 (click for details)\n Ca: 8.3 Mg: 1.7 P: 4.0\n WBC 9.9 Hb 11.5 Hct 34.5 Plt 155 MCV 82\n Imaging: AP port CXR - low lung volumes. large heart. stable RLL\n opacity. mild increased pulmonary markings\n Microbiology: none\n ECG: sinus\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n Acute blood loss anemia: likely secondary to surgical bleeding. no\n stool output yet to suggest GI source. currently appears to be\n stabilizing Hct over past 4 hours.\n - cycle Hct q6 for now\n - transfuse for <24% as this would likely suggest significant\n re-bleeding\n - guaiac all stools\n .\n Osteoarthritis s/p THA: now POD#O from surgery.\n pain control with tylenol, additional morphine\n - ortho recs\n - PA/lat hip films\n - peri-op prophylactic antibiotics.\n - hold LMWH for now\n - monitor peripheral pulses\n - PT consult requested for POD 2 or 3\n DM2: adequate control for now.\n - hold metformin for now\n - hold actos for now\n - continue glipizide\n - RISS\n Hypertension: hold anti-hypertensives until Hct stable\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 322743,
"text": "Chief Complaint: post-operative hct drop\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 77 year old man who came in today for an elective R THR and was found\n to have a drop in his hct from 44.3 (in ) to 34.5 (initial in the\n PACU) to 24. EBL 1500cc, 2 units PRBC given and 3 liters of LR.\n Operative course was uncomplicated but in the PACU received multiple\n pain meds. Drain output is not excessive. No BRBPR. No melena.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n amlopipine, glipizide, metformin, actose, simvastatin\n Past medical history:\n Family history:\n Social History:\n Prostate CA - s/p XRT\n h/o GIB - iulefoy's\n HTN\n DM\n OA\n DM\n Occupation: retired\n Drugs:\n Tobacco: stopped in , 20+ pack years\n Alcohol: 1 drink/night\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\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, Foley\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Rash\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 01:07 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: 37.3\nC (99.2\n HR: 88 (88 - 106) bpm\n BP: 94/51(61) {94/51(61) - 134/57(74)} mmHg\n RR: 17 (10 - 17) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 525 mL\n 8 mL\n PO:\n TF:\n IVF:\n 525 mL\n 8 mL\n Blood products:\n Total out:\n 105 mL\n 0 mL\n Urine:\n 55 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 420 mL\n 8 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, sleepy but\n arousable\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, guaiac negative\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: R hip with dressing and drain\n minimal amount of\n blood in drain\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): person, place, location, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 179\n 26.4\n 222\n 1.0\n 24\n 25\n 95\n 4.6\n 138\n 14.1\n [image002.jpg]\n Imaging: CXR - Low lung volumes, opacity in RRR, deviated trachea\n CT (pre-op) - + mediastinal nodes, patchy ground glass\n ECG: NSR, PR slightly prolonged, small volts in precordial leads, no\n acute ST/T wave changes\n Assessment and Plan\n Assessment - 77 year old man with low hct after R THR. Suspect much of\n this was actually intraoperative loss and then re-equilibration from\n IVF.\n 1. Anemia - Will need to be careful to watch for true post-operative\n bleeding - follow drain output, exam. Will follow hct q6 hours.\n Guaiac stools. Will call ortho if hct falls again and give more blood.\n 2. Post-op pain - will use dilaudid PCA when awake. For now, seems\n quite sedate and comfortable.\n 3. Hypertension - hold meds for now as was hypotensive and bleeding\n 4. DM - hold metformin & glyburide until eating, ISS but may need NPH\n 5. R THR - will talk to them about when to restart anticoagulation -\n will hold for now.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 09:30 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322900,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt cont to have moderate amounts of oozing from right hip dressing.\n Site appears to be the same in size and color.\n Action:\n Dressing reinforced, Pt received 1 unit PRBCs\n Response:\n No appropriate bump in Hct, but it remains stable at 24.\n Plan:\n Monitor Q6H Hcts, ? transfusing one more unit of blood. Surgery to\n change dressing.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o less pain overnight, only with movement and turning.\n Action:\n Pt medicated with 1mg IV Dilaudid x2\n Response:\n Pt slept comfortably between doses, easily arousable to voice. Pt able\n to turn better after medicating.\n Plan:\n Cont to monitor pain, prn Dilaudid or Oxycodone.\n"
},
{
"category": "Physician ",
"chartdate": "2178-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322932,
"text": "Chief Complaint: 77 year old man with hx of hypertension, DM2, prostate\n cancer s/p XRT, and GI bleed presents following right total hip\n arthroplasty complicated by post-operative bleeding\n 24 Hour Events:\n MULTI LUMEN - START 11:35 AM\n tripple lumen central line placed successfully with normal f/u Xray\n - Pain worsened after PT; got one dose of dilaudid 1 mg with good\n effect, then did not require any more pain meds till midnight. pulses\n good. thigh diameter mainatined at 23.75 inches\n - Received 4 units of pRBC in 24 hr perior with only 1.5 pt increase in\n HCT. Ortho aware that there was no significant increase after 2 units,\n but said it's expected after such a bloody case. will need to\n re-address in AM\n - Had CVL placed\n Allergies:\n Lisinopril\n Cough;\n Aspirin\n Anemia;\n Last dose of Antibiotics:\n Cefazolin - 08:04 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37\nC (98.6\n HR: 82 (66 - 118) bpm\n BP: 141/55(71) {109/43(41) - 156/69(83)} mmHg\n RR: 12 (8 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (0 - 11)mmHg\n Total In:\n 4,421 mL\n 268 mL\n PO:\n 480 mL\n 100 mL\n TF:\n IVF:\n 2,463 mL\n 168 mL\n Blood products:\n 1,478 mL\n Total out:\n 1,460 mL\n 1,630 mL\n Urine:\n 1,430 mL\n 1,630 mL\n NG:\n Stool:\n Drains:\n 30 mL\n Balance:\n 2,961 mL\n -1,362 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Gen:\n CV:\n PULM:\n ABD:\n EXT:\n Labs / Radiology\n 97 K/uL\n 8.7 g/dL\n 123 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 24.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:30 AM\n 11:33 AM\n 07:22 PM\n 01:38 AM\n 03:57 AM\n WBC\n 9.7\n Hct\n 21.4\n 22.8\n 24.6\n 24.2\n 24.0\n Plt\n 97\n Cr\n 0.8\n Glucose\n 123\n Other labs: PT / PTT / INR:12.3/29.8/1.0, Ca++:7.9 mg/dL, Mg++:1.9\n mg/dL, PO4:2.3 mg/dL\n Imaging: IMPRESSION: AP chest compared to :\n New right internal jugular central venous line ends at the superior\n cavoatrial junction. Mild widening of the mediastinum to the right of\n the midline is probably venous engorgement since there is no\n contralateral displacement of\n the trachea to suggest a hematoma. Heart size is mildly enlarged and\n unchanged. Mild interstitial edema which was present on has\n resolved and there is no appreciable pleural effusion. Thoracic aorta\n is generally large and tortuous but not focally dilated.\n Assessment and Plan\n 77 year old man with DM2, HTN, osteoartitis s/p right THA complicated\n post-op bleeding.\n # Acute blood loss anemia: Secondary to surgical bleeding. No stool\n output yet to suggest GI source. Hct trend over 24 hours is\n 21.4->22.8->24.6->24.2->24 this morning. Patient has rec\nd a total of 6\n units prbcs over 24 hours and is currently receiving 2 more units\n PRBCs. Orthopedics aware this morning.\n - Post-tx Hct and cycle q6\n - Transfuse for <24% as this would likely suggest significant\n re-bleeding\n - Guaiac all stools\n - Continue to monitor thigh diameter\n - Will continue to monitor for signs of compartment syndrome (ie pain\n out of proportion to exam)\n - Awaiting post-tx Hct to determine if futher imaging such as CT should\n be done to rule out other areas of bleed (such as RP)\n - IVF/blood prn volume; patient appears dry on exam\n - As it is still not entirely clear if patient is bleeding anywhere\n other than his thigh, will check bladder pressure to monitor abdominal\n pressures as a measure to follow along with thigh diameter (which has\n been stable).\n # Thrombocytopenia: Likely in the setting of 6 units prbcs without\n platelets.\n - Will continue to monitor pm CBC, if platelets lower, will consider\n platelet tx at that time\n # Osteoarthritis s/p THA: now POD#1 from surgery.\n - Pain control with tylenol, oxycodone and dilaudid being careful to\n avoid sedation/somnolence\n - Ortho recs\n - Hold LMWH for now in the setting of bleed, will discuss\n anticoagulation with ortho once Hct stabilized\n - Monitor peripheral pulses\n - PT consult requested for POD 2 or 3 once acute issues resolved\n # DM2: Adequate control for now.\n - Hold oral meds for now (metformin, actos, glipizide)\n - RISS\n # Hypertension: hold anti-hypertensives until Hct stable\n # FEN: Replete lytes prn, IVF as above, PO as tolerated\n ICU Care\n Nutrition: PO\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 09:30 PM\n Multi Lumen - 11:35 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Famotidine\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322988,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure .\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is WNL..\n Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): 24in. B DP\ns & PT\ns are weakly palpable (no\n change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Thigh girth may be increased as different person is measuring it.\n Thigh girth up by 0.25in.\n Plan:\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\n etc.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"
},
{
"category": "Rehab Services",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 322845,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 715.95 / hip OA\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 77 y/o male adm \n for R THR 2' OA. Course was c/b post-operative bleeding. Received 6\n units of pRBC in the .\n Past Medical / Surgical History: DM2, increased chol, HTN, prostate CA,\n BPH, GIB, CHF\n Medications: insulin, oxycodone, morphine\n Radiology: CXR : borderine cardiac decompensation\n Labs:\n 22.8\n 8.3\n 179\n 14.1\n [image002.jpg]\n Other labs:\n Activity Orders: bedrest, R LE PWB\n Social / Occupational History: Married, supportive dtr\n Environment: Lives with wife and dtr, 1 level home, 1 FOS to\n enter\n Prior Functional Status / Activity Level: I PTA, amb without AD but\n with physical assist of another person, assist for ADLs, 1 fall 2 weeks\n ago\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, pleasant,\n cooperative, primary language is portuguese\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 89\n 119/65\n 17\n 100%\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n 90\n 134/56\n 17\n 97%\n Total distance walked: N/A\n Minutes:\n Pulmonary Status: NARD\n Integumentary / Vascular: R lateral hip incision covered with\n elastoplast, saturated with sanguinous drainage, foley, central line\n Sensory Integrity: grossly intact to LT\n Pain / Limiting Symptoms: c/o severe pain R hip with ROM\n Posture: supine in bed\n Range of Motion\n Muscle Performance\n WFL B UE except R shoulder flexion 100 degrees (limited by pain which\n started after surgery); WFL L LE; R LE ankle and knee WFL; R hip\n flexion 0-60 degrees flexion, IR to neutral\n B UE > except R shoulder flexors 3-/5\n L LE > , R LE: DF , quads \n Motor Function: moves all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Clarification: All mobility deferred 2' bedrest order, hematocrit of\n 22.8 with significant continued post-op bleeding and pain.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: N/A\n Education / Communication: Educated patient as to role of PT, PT plan\n of care.\n Communicated with RN.\n Intervention: Supine ther-ex x 10 reps: AP, hip rolls, hip AB/AD, SAQ,\n HS\n Other:\n Diagnosis:\n 1.\n Gait, Impaired\n 2.\n Muscle Performace, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Range of Motion, Impaired\n 5.\n Transfers, Impaired\n Clinical impression / Prognosis: Patient is a 77 y/o male adm for R THR\n c/b postoperative bleeding. Patient presents with above defecits\n consistent with joint arthroplasty. Anticipate that patient will need\n rehab on d/c despite limited evaluation today. Will follow up for\n further mobility assessment and to further assist with d/c planning\n Goals\n Time frame: 1 week\n 1.\n Roll with mod A\n 2.\n Sup to sit with mod A\n 3.\n Assess OOB\n 4.\n R hip ROM 0-90 degrees flexion, 25% IR, 10 degrees ER, 10 degrees AB\n 5.\n Independent with HEP\n 6.\n Indepently state hip precautions\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 5-7x/week x 1 week\n Assess mobility\n Transfer train\n R hip ROM\n ther-ex\n Patient education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322989,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure .\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is\n WNL.. Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): 24in. B DP\ns & PT\ns are weakly palpable (no\n change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Thigh girth may be increased as different person is measuring it.\n Thigh girth up by 0.25in.\n Plan:\n Transfuse for Hct <24. Continue to measure thigh girth, check pulses\n etc.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322841,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Drainage from right lateral hip and thigh incision being monitored.\n Continuous hemodynamic monitoring in progress. Right IJ triple lumen\n central line insitu with CVP monitoring. Assess right thigh for extreme\n distention, thigh circumference measured for comparison, and distal\n pulses being assessed. Trending lab valve monitoring with necessary\n interventions.\n Action:\n Right IJ central line placed this am to facilitate monitoring of\n hemodynamic values. Central line care per protocol being maintained.VSS\n being done Q1hr. peripheral pulse assessment done q4hr as needed.\n Consented Blood transfusions given in relevance to lab values. Pad\n beneath right leg assessed frequently and changed as needed. Continue\n IV therapy as ordered.\n Response:\n No adverse reaction noted to blood transfusion, VSS remain within\n acceptable limits for patient. Dressing to right thigh soiled but\n intact. Two pads moderately saturated with bloody drainage changed over\n the last 12hours. Peripheral pulses remain weak but palpable with\n regular rate and rhythm. Urinary output has picked up and is within\n acceptable limits.\n Plan:\n Continue CVP monitoring and other hemodynamic assessments. IVF as\n ordered. Monitor urinary output and follow lab trends with appropriate\n interventions as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n Monitor skin integrity, VSS and CVP values. Trend lab values\n comparatively. Monitor Mg, Na, k, and Ca levels. Observe for abnormal\n EKG rhythms.\n Action:\n Given Magnesium sulfate for Mg of 1.4 Also received Calcium gluconate\n for Ca of 7.7.\n Response:\n Some general non pitting edema noted. Urinary output remains adequate.\n Lab value have not deteriorated.\n Plan:\n Continue se\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322982,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Plan:\n Transfuse for Hct <24.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322983,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is mildly\n elevated (in range).\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Plan:\n Transfuse for Hct <24.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322984,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct 27.8 @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM. Bladder pressure is mildly\n elevated (in range). Hct stable.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Thigh girths checked for potential compartment syndrome.\n Response:\n Plan:\n Transfuse for Hct <24.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.5 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322979,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.5 (up from 24. ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Response:\n Plan:\n Continue to check thigh girths & monitor for compartment syndrome.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 6 units PC\n since that time. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p\n XRT.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322980,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Response:\n Plan:\n Continue to check thigh girths & monitor for compartment syndrome.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 6 units PC\n since that time. PMH: DM2, HTN, GI bleeding, BPH, prostate CA s/p\n XRT.\n"
},
{
"category": "Nursing",
"chartdate": "2178-05-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322981,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct 27.6 (up from 24.0 ) @ 1800. Hct @ 00. No BM since .\n Bladder pressure 14-15.\n Action:\n Given senna, bisacodyl, colace & MOM to induce BM.\n Response:\n Unable to guiac stool until patient has BM.\n Plan:\n Continue to check Hct q 6 hrs. Give more bowel meds & get up OOB if\n possible.\n Problem\n R total hip replacement \n Assessment:\n R hip drsg : scant sanguinous drainage noted. Thigh girth\n (from 23.75 in): B DP\ns & PT\ns are weakly palpable (no change).\n Action:\n Response:\n Plan:\n Continue to check thigh girths & monitor for compartment syndrome.\n This is a 77 yr old man from who had R total hip surgery\n . He lost 1500cc blood intra-op. He has received 8 units PC\n since that time. Dropped Hct from 34.2 to 24 in PACU, & Hct has only\n increased by points since then. PMH: DM2, HTN, GI bleeding, BPH,\n prostate CA s/p XRT.\n"
}
] |
24,357 | 111,518 | EKG exhibited st^ in anterolateral leads which lead to recatheterization. However, T waves now appeawr to bebiphasic in leads V4-V6 suggesting lateral ischemia compared to the previoustracing of . Prior inferiormyocardial infarction. Mild (1+) mitral regurgitation is seen.Conclusions:1. Pt went to cath on found to of proximal LAD & proximal LCX. WENT FOR ROUTINE ETT C/O CP. Prior inferior myocardial infarction. Compared to the previous tracing of there ismore prominent downsloping ST segment depression in leads I and aVL and theappearance of frequent ventricular ectopy. CP resolved after inferior pole was reopened. There is severeglobal left ventricular hypokinesis. O2 SATS 95+ ON 3.0 L VIA NC.ID: AFEBRILE. Sinus bradycardiaPrior inferior myocardial infarctionDiffuse ST-T abnormalitiesSince previous tracing of : Lateral ST-T changes decreased Mild (1+) mitral regurgitation is seen. HR 69-77 W/ PVC'S RARE-OCCASSIONAL. Compared to the previous tracing of nodiagnostic change.TRACING #1 2nd PCI revealed stent patency but occlusion of inferior pole. SVG-D1 known occl. LV dilation @ stress, suggestive of ischemia. Overall left ventricular systolicfunction is severely depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. MAX PO TEMP 97.4. Severe partial reversible defect in the inferior LV wall. Left atrial abnormality. The SVG & OM1 was stented but infer pole outflow vessel of the OM had mod slow flow after intervention & was recrossed & dilated restoring flow. TRANS DSG APPLIED C&D. CABG ' WITH LIMA TO LAD, SVG TP D2, SVG TO OM. DP +2, PT +1. C/O BACK PAIN D/T CATH PROCEDURE. Sinus bradycardia. - OOZE OR HEMATOMA PRESENT. There is more prominent ST segmentdepression in leads I and aVL, while the biphasic T waves, previously recordedin leads V4-V6, have resolved. AM GLUC 144HCT 35.2. There is mildmitral annular calcification. K+ 3.6, CA 8.5, phos 5.0, MG 1.7, CK 825. C/O NAUSEA UPON ADMISSION. Left ventricular function.S/p VF arrestHeight: (in) 64Weight (lb): 182BSA (m2): 1.88 m2BP (mm Hg): 118/59HR (bpm): 85Status: InpatientDate/Time: at 16:40Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity is mildly dilated. USING URINAL @ 0600 W/OUT DIFFICULTY. Pt entered V-fib arrest on floor secondary to thrombosis fo OM inferior pole vessel., defib X1, IVB amiod. ST DEPRESSIONS SEEN IN V5, V6,I & aFL with max st depressions in V5. NBP 87-118/40-59. Clinical correlation issuggested.TRACING #3 Overall left ventricular systolic function isseverely depressed.2. There is severe global leftventricular hypokinesis. Arrived w/ no C/O CP but nausea. CATH WITH STENT PLACEMENT TO NATIVE MID RCA 3VD PATENT SVG TO OM2- OCCLUSIVE SVG TO DIAG, PATENT LIMA TO LAD, PATENT STENT TO THE MID RCA, PROX RCA HAD A FOCAL 80% STENOSIS & DISTAL RCA HAD A SEVERE FOCAL 90% STENOSIS PRIOR TO ORIGIN OF THE rPDA s/p stent placement to prox & distal RCA.ADMITTING HX: PT RECENTLY C/O ^SOB WITH EXERTION. The left ventricular cavity is mildly dilated. WBC 14.4.GI/GU: NPO EXCEPT WITH MEDS. Sinus tachycardia with frequent ventricular ectopy and couplets. Diffuse non-specificST-T wave abnormalities. Rule out active lateral ischemia.Clinical correlation is suggested. PT ON 2 MCG/KG/MIN. GIVEN 5TH MG & SERAX @ 0100. GIVEN 2MG MORE WITH MOD EFFECT. ABP 124-140/55-66. Given 320cc of contrast. +BS ALL 4 QUADRANTS, -BM. Clinical correlation is suggested.TRACING #2 SVG to OM1 midsegment w/ 80% focal lesion LIMALAD was patent w/LAD after touchdown TO. - COMPLICATIONS.P: FOLLOW CURRENT MEDICAL MANAGEMENT & C/O PT TO FLOOR. The aortic valve leaflets are mildly thickened. 60% midsegment stenosis in prev stented RCA. RR 12-19. GIVEN MORPHINE 1MG X2 WITH MINIMAL EFFECT. RECEIVING 2 LITER OF 2 OF IVF. The mitral valve leafletsare mildly thickened. SUPPORT PT WHERE INDICATED. SHEATH PULLED @ 2300. Sinus rhythm with increase in raste compared to the previous tracingof . Nuclear medicine revealed severe reversible defect in distal anterior & apical walls. Superior pole was dilated and restored as well. CK/MB 128RESP: NO C/O SOB. RECEIVED 320 CC OF CONTRAST DURING STUDY- BUN/CR 11/0.7.SKIN: WNLACCESS: LEFT WRIST #20G.DISP: FULL CODESOCIAL: FAMILY VISITED.A: POST CATH TOLERATED WELL. INITIAL LITER D5 1/2NS GLUCOSE 238, 2ND BAG CHANGED TO 1/2 NS 125CC/HR. COOPERATIVE & APPROPRIATE. CCU ADMITTING NOTE(Continued)S ALONE PROVIDE AT HOME RESOURCES. LUNG SOUNDS CLEAR. PATIENT/TEST INFORMATION:Indication: H/O cardiac surgery with CABG . Sinus rhythm withi increase in rate compared to the previous tracingof . No vomiting occurred.NEURO: A&OX3. Technically limited study. PRESSURE APPLIED FOR 20 MIN. PT SLEPT SOUNDLY UNTIL 0500.CV: NO C/O CP. SHEATH PULLED TOLERATED WELL. Global HK with sn EF of 40% noted. CCU ADMITTING NOTE58 YEAR OLD MALE ADMITTED TO CCU POST CATHETERIZATION & SHEATH PLACEMENT.ALLERGIES: NKDAPMH: Interior wall MI, CAD-(MULTIPLE SIBLINGS DIED OF PREMATURE CAD), HTN, +CHOL, HYPERLIPIDEMIA, TOB USE 2-3PPDX30YRS> QUIT 10 YRS AGO. Otherwise, no change. SOCIAL WORKER PT | 8 | [
{
"category": "Nursing/other",
"chartdate": "2111-07-17 00:00:00.000",
"description": "Report",
"row_id": 1579027,
"text": "CCU ADMITTING NOTE\n58 YEAR OLD MALE ADMITTED TO CCU POST CATHETERIZATION & SHEATH PLACEMENT.\n\nALLERGIES: NKDA\n\nPMH: Interior wall MI, CAD-(MULTIPLE SIBLINGS DIED OF PREMATURE CAD), HTN, +CHOL, HYPERLIPIDEMIA, TOB USE 2-3PPDX30YRS> QUIT 10 YRS AGO.\n CABG ' WITH LIMA TO LAD, SVG TP D2, SVG TO OM.\n CATH WITH STENT PLACEMENT TO NATIVE MID RCA\n 3VD PATENT SVG TO OM2- OCCLUSIVE SVG TO DIAG, PATENT LIMA TO LAD, PATENT STENT TO THE MID RCA, PROX RCA HAD A FOCAL 80% STENOSIS & DISTAL RCA HAD A SEVERE FOCAL 90% STENOSIS PRIOR TO ORIGIN OF THE rPDA s/p stent placement to prox & distal RCA.\n\nADMITTING HX: PT RECENTLY C/O ^SOB WITH EXERTION. WENT FOR ROUTINE ETT C/O CP. ST DEPRESSIONS SEEN IN V5, V6,I & aFL with max st depressions in V5. Nuclear medicine revealed severe reversible defect in distal anterior & apical walls. Severe partial reversible defect in the inferior LV wall. LV dilation @ stress, suggestive of ischemia. Global HK with sn EF of 40% noted. Pt went to cath on found to of proximal LAD & proximal LCX. 60% midsegment stenosis in prev stented RCA. SVG-D1 known occl. SVG to OM1 midsegment w/ 80% focal lesion LIMA_LAD was patent w/LAD after touchdown TO. The SVG & OM1 was stented but infer pole outflow vessel of the OM had mod slow flow after intervention & was recrossed & dilated restoring flow. Superior pole was dilated and restored as well. Pt entered V-fib arrest on floor secondary to thrombosis fo OM inferior pole vessel., defib X1, IVB amiod. EKG exhibited st^ in anterolateral leads which lead to recatheterization. 2nd PCI revealed stent patency but occlusion of inferior pole. CP resolved after inferior pole was reopened. Given 320cc of contrast. Arrived w/ no C/O CP but nausea. No vomiting occurred.\n\nNEURO: A&OX3. COOPERATIVE & APPROPRIATE. C/O BACK PAIN D/T CATH PROCEDURE. GIVEN MORPHINE 1MG X2 WITH MINIMAL EFFECT. GIVEN 2MG MORE WITH MOD EFFECT. GIVEN 5TH MG & SERAX @ 0100. PT SLEPT SOUNDLY UNTIL 0500.\n\nCV: NO C/O CP. HR 69-77 W/ PVC'S RARE-OCCASSIONAL. NBP 87-118/40-59. ABP 124-140/55-66. SHEATH PULLED @ 2300. PRESSURE APPLIED FOR 20 MIN. - OOZE OR HEMATOMA PRESENT. TRANS DSG APPLIED C&D. DP +2, PT +1. PT ON 2 MCG/KG/MIN. RECEIVING 2 LITER OF 2 OF IVF. INITIAL LITER D5 1/2NS GLUCOSE 238, 2ND BAG CHANGED TO 1/2 NS 125CC/HR. AM GLUC 144\nHCT 35.2. K+ 3.6, CA 8.5, phos 5.0, MG 1.7, CK 825. CK/MB 128\n\nRESP: NO C/O SOB. LUNG SOUNDS CLEAR. RR 12-19. O2 SATS 95+ ON 3.0 L VIA NC.\n\nID: AFEBRILE. MAX PO TEMP 97.4. WBC 14.4.\n\nGI/GU: NPO EXCEPT WITH MEDS. C/O NAUSEA UPON ADMISSION. +BS ALL 4 QUADRANTS, -BM. CONDOM CATH DRAINING CLEAR YELLOW URINE. USING URINAL @ 0600 W/OUT DIFFICULTY. RECEIVED 320 CC OF CONTRAST DURING STUDY- BUN/CR 11/0.7.\n\nSKIN: WNL\n\nACCESS: LEFT WRIST #20G.\n\nDISP: FULL CODE\nSOCIAL: FAMILY VISITED.\n\nA: POST CATH TOLERATED WELL. SHEATH PULLED TOLERATED WELL. - COMPLICATIONS.\n\nP: FOLLOW CURRENT MEDICAL MANAGEMENT & C/O PT TO FLOOR. SUPPORT PT WHERE INDICATED. SOCIAL WORKER PT \n"
},
{
"category": "Nursing/other",
"chartdate": "2111-07-17 00:00:00.000",
"description": "Report",
"row_id": 1579028,
"text": "CCU ADMITTING NOTE\n(Continued)\nS ALONE PROVIDE AT HOME RESOURCES.\n\n"
},
{
"category": "Echo",
"chartdate": "2111-07-17 00:00:00.000",
"description": "Report",
"row_id": 94901,
"text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery with CABG . Left ventricular function.\nS/p VF arrest\nHeight: (in) 64\nWeight (lb): 182\nBSA (m2): 1.88 m2\nBP (mm Hg): 118/59\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 16:40\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity is mildly dilated. There is severe\nglobal left ventricular hypokinesis. Overall left ventricular systolic\nfunction is severely depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nConclusions:\n1. The left ventricular cavity is mildly dilated. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n2. The aortic valve leaflets are mildly thickened. The mitral valve leaflets\nare mildly thickened. Mild (1+) mitral regurgitation is seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-07-18 00:00:00.000",
"description": "Report",
"row_id": 272646,
"text": "Sinus tachycardia with frequent ventricular ectopy and couplets. Prior inferior\nmyocardial infarction. Compared to the previous tracing of there is\nmore prominent downsloping ST segment depression in leads I and aVL and the\nappearance of frequent ventricular ectopy. Rule out active lateral ischemia.\nClinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2111-07-17 00:00:00.000",
"description": "Report",
"row_id": 272647,
"text": "Sinus rhythm with increase in raste compared to the previous tracing\nof . Left atrial abnormality. There is more prominent ST segment\ndepression in leads I and aVL, while the biphasic T waves, previously recorded\nin leads V4-V6, have resolved. Otherwise, no change. Clinical correlation is\nsuggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2111-07-16 00:00:00.000",
"description": "Report",
"row_id": 272648,
"text": "Sinus rhythm withi increase in rate compared to the previous tracing\nof . Technically limited study. However, T waves now appeawr to be\nbiphasic in leads V4-V6 suggesting lateral ischemia compared to the previous\ntracing of . Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2111-07-16 00:00:00.000",
"description": "Report",
"row_id": 272649,
"text": "Sinus bradycardia. Prior inferior myocardial infarction. Diffuse non-specific\nST-T wave abnormalities. Compared to the previous tracing of no\ndiagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2111-07-15 00:00:00.000",
"description": "Report",
"row_id": 272650,
"text": "Sinus bradycardia\nPrior inferior myocardial infarction\nDiffuse ST-T abnormalities\nSince previous tracing of : Lateral ST-T changes decreased\n\n"
}
] |
|
2,040 | 124,831 | In short, this is a 63-year-old mostly Spanish-speaking male with a history of end-stage renal disease on hemodialysis who presents with a question of seizures, intubated, now transferred to the floor with probable SVC syndrome and access issues. 1. NEUROLOGY: It is unlikely that the patient ever had a seizure. During this episode, trembling, the patient was noted to have a fingerstick of 36. In addition, he was continually talking through the rhythmic motions. It is much more likely that the patient was simply having symptomatic hypoglycemia. The patient was intubated after receiving loading doses of Ativan and Dilantin. His head CT was negative, and his MRI was negative for bleed but showed only old bilateral lacunar disease. No lumbar puncture was performed because of a low index of suspicion for infectious sources of mental status changes. The patient continued to be delirious, especially at night. However, as the Ativan came out of his system, he became less delirious and more oriented. He was continued on olanzapine 5 mg p.o. q.d. At this time, there still is an EEG pending from from which he was transferred. However, given the low likelihood for seizure activity, this may not need to be further followed. 2. HEMATOLOGY: The patient has known right and left-sided upper extremity clots, and as of , had 40% occlusion of the SVC. The patient was admitted on Coumadin. This was held and the patient was started on heparin. Given the new upper torso pitting edema and concern for SVC, it is probable that some of these clots have migrated into the path of the SVC. The patient was also sent for hypercoagulability workup. Many of these results are still pending. The patient was noted to have a protein S deficiency, but this may not be significant in the presence of active clotting. On , the patient received an ultrasound vein mapping. This showed the presence of only left-sided internal jugular clots. However, the SVC could not be assessed. The plan at this point is to visualize the upper torso venous system through angiography while performing a fistulogram. This is scheduled for . For now, the patient is maintained on a heparin drip. 3. ACCESS: On admission, the patient had an old left EJ versus subclavian that was inserted on this past admission about two weeks ago. This line is used for temporary dialysis. The patient also has a right midline catheter that was used for infusion of IV Oxacillin. However, this was found to be nonfunctioning. The patient received a left femoral central line for both Oxacillin and heparin infusion. The patient also has a left AV fistula with positive thrill, however, poor blood flow was noted during hemodialysis on . The patient is status post fistulogram and angioplasty of that same AV fistula about a week and a half ago. As already noted, the patient is scheduled for an AV fistulogram on . If this is found to be operational, the left EJ versus the subclavian line should be taken out, especially as the patient has been spiking fevers. If AV fistula is not viable, Transplant Surgery will need to reassess the fistula, and a temporary Perma-Cath will need to be placed. From past admissions, the patient is a big access problem, and placement of even a will be very difficult in this patient. The right midline catheter was removed on . 4. INFECTIOUS DISEASE: The patient is currently being treated for presumed osteomyelitis in the setting of MSSA bacteremia that was noted on past admissions. He is receiving Oxacillin IV, 1 gram q. four hours. This is to be continued through . Of note, the patient started spiking again on this admission, up to 102 degrees Fahrenheit. All of the patient's blood cultures have been negative. The patient is essentially anuric. His chest x-ray initially indicated the presence of opacity, but the final read was read as atelectasis. The patient was initially placed on levo and Flagyl for aspiration pneumonia. However, once the chest x-ray was confirmed, this combination was stopped. The most likely source of the fever is the left-sided EJ versus subclavian that was placed on the last admission. However, because the patient is such an access issue, there was a decision to treat through this infection as long as the blood cultures remained negative. 5. CARDIOVASCULAR: The patient has a history of atrial fibrillation. On , the patient was noted to be in atrial flutter, hemodynamically stable. The patient received IV Lopressor and IV Diltiazem and converted to normal sinus rhythm. The patient had an echocardiogram on , which showed an EF of 60-70%, bidirectional stent, ASD, normal free wall motion, and mild pulmonary artery hypertension. The patient was continued on his Lopressor, Captopril, aspirin. 6. RENAL: The patient continues hemodialysis on Mondays, Wednesdays, and Fridays. Continue on PhosLo, Nephrocaps, Epogen, sodium bicarbonate. 7. HEMATOLOGY: The patient has anemia secondary to renal failure. His baseline hematocrit runs around 28. Hematocrit has been stable. 8. PROPHYLAXIS: The patient is to continue Protonix. 9. CODE STATUS: The patient is a full code. DR., 12-927 Dictated By: MEDQUIST36 D: 14:34 T: 11:18 JOB#: | Grossly normal flow can be seen within the internal carotid and right vertebral arteries Images of the circle of are degraded by motion artifact. IMPRESSION: 1) Vascath terminates in the mid-SVC, and right-sided PICC line terminates within the axilla. FINDINGS: There has been interval removal of the ET tube. PATIENT/TEST INFORMATION:Indication: Reassess for LV function and shunt.Height: (in) 66BP (mm Hg): 142/74Status: InpatientDate/Time: at 11:51Test: TTE(Complete)Doppler: Focused pulse and color flowContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. 8:01 AM AV FISTULOGRAM SCH Clip # Reason: functioning AVF, clots in upper torso? FINDINGS: A left sided central venous line is present with tip in the SVC. AnterolateralST-T wave changes suggestive of myocardial ischemia persist. There is near-complete thrombus of the left internal jugular vein with a tiny amount of flow through this vessel. A right-sided PICC line again terminates in the axilla. A small secundum atrial septal defect (ASD)is present. FINDINGS: Again seen is a left subclavian hemodialysis catheter, terminating in the mid-SVC. A small secundumatrial septal defect (ASD) is present.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. REASON FOR THIS EXAMINATION: functioning AVF, clots in upper torso? There is nomitral valve prolapse. There is nomitral valve prolapse. UNABLE TO GET GOOD IMAGES DESPITE MEDICATED WITH VERSED. Left external jugular dialysis cath intact. Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) Thereafter, an 0.035 wire was placed through the sheath and advanced under fluoroscopy until its tip was in the inferior vena cava. There are anterolateral ST-T wave abnormalities suggestive ofanterolateral myocardial ischemia. REASON FOR THIS EXAMINATION: does pt have intracranial bleed No contraindications for IV contrast FINAL REPORT INDICATION: Seizures, intubated. Major, symptomatic stenosis of the superior vena cava. There isa bidirectional shunt across the interatrial septum at rest. Atrial fibrillation with a moderate ventricular response. Additionally, the right cephalic vein was evaluated. Sinus rhythmAnterolateral ST-T changes may be due to myocardial ischemiaCompared to previous tracing of , sinus rhythm has appeared. There ismild thickening of the mitral valve chordae.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Bilateral hemidiaphragms are less distinct on today's exam suggesting increased bibasilar atelectasis. (Over) 8:01 AM AV FISTULOGRAM SCH Clip # Reason: functioning AVF, clots in upper torso? There are focalcalcifications in the ascending aorta.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is a bidirectional shunt across theinteratrial septum at rest (left-to-right on color-flow imaging; right-to-leftby air bubble contrast imaging). The aortic valve leaflets (3) are mildly thickened butnot stenotic. Mediastinal contours are unchanged allowing for differences in patient positioning. IMPRESSION: Worsening bibasilar atelectasis with probable left pleural effusion. PERIPHERAL PULSES PRESENT WITH DOPPLER. Probable small left pleural effusion. Mild tricuspid [1+] regurgitation is seen.There is mild pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Contrast study was performed with one iv injection of 8 ccsof agitated normal saline at rest.Conclusions:The left atrium is normal in size. There is mild mitral annular calcification. IMPRESSION: Chronic near-complete thrombus of the left internal jugular vein. Evaluate for upper-extremity DVT. MRI HEAD DONE, CHEST UNABLE TO OBTAIN. REASON FOR THIS EXAMINATION: pleave eval ett placement FINAL REPORT INDICATION: Intubated after seizure. Multiple T1 low attenuation lesions within the thalami, internal capsule and basal ganglia suggest multiple prior chronic lacunes. Left AV fistula with faint thrill and bruit. ST-T wave abnormalities are more marked.TRACING #1 Resolution of the narrowing was shown on a follow-up venogram. pt does not open eyes, and pt pupils are equal but not reactive, Dr. aware.Resp: pt remains intubated on vent AC/12/650/.50/5. It revealed patency of the arteriovenous anastomosis and the brachial artery proximally and distally to the anastomosis with no significant stenosis. There is normal respiratory variation throughout the veins of both the right and left upper extremities excluding the left internal jugular vein. Pt has H/O DVT, pt sup vena cava in belived to be clottted, pt head and swollen due to this clot. There are focal calcificationsin the aortic root. Pt has hematuria due to pt pulling on foley HO aware. There is mild thickening of the walls of the left internal jugular vein. Baseline artifactSinus rhythmModest lateral T wave changes are nonspecificLow limb leads voltageSince previous tracing of : probably no significant change CT BRAIN WITHOUT IV CONTRAST: The ventricles, cisterns and sulci are normal. Again seen are lacunar infarcts in the caudate nucleus bilaterally and the right cerebellar hemisphere. | 19 | [
{
"category": "Radiology",
"chartdate": "2145-11-24 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 776236,
"text": " 11:36 AM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: please eval for acute stroke\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with AMS, ?seizure (new) with upgoing babinskis bilaterally\n REASON FOR THIS EXAMINATION:\n please eval for acute stroke\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Confusion. Question of new seizure.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain were obtained\n with and without IV contrast. 2D and 3D multiplanar reformatted images were\n created.\n\n MRI OF THE BRAIN W/O CONTRAST: The study is extremely limited by patient\n motion. In particular, the susceptibility and FLAIR images are somewhat\n degraded. Multiple T1 low attenuation lesions within the thalami, internal\n capsule and basal ganglia suggest multiple prior chronic lacunes. There are\n no abnormal signal intensities on diffusion weighted imaging to suggest acute\n ischemia. No shift of normally midline structures or mass effect is seen. The\n ventricles, cisterns, and sulci are symmetric without significant enlargement\n or effacement. No acute hemorrhage is identified.\n\n MRA OF THE BRAIN AND CAROTID ARTERIES: These images are degraded by motion\n artifact. Grossly normal flow can be seen within the internal carotid and\n right vertebral arteries\n\n Images of the circle of are degraded by motion artifact. Fine vascular\n detail is not obtained. There is normal flow within the basilar and\n intracranial carotid arteries. Branch vessels are not well evaluated.\n\n IMPRESSION:\n\n No evidence of acute brain infarction. Limited study due to motion artifact\n with significant degradation of MRA sequences.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-25 00:00:00.000",
"description": "B UNILAT UP EXT VEINS US BILAT",
"row_id": 776386,
"text": " 4:12 PM\n UNILAT UP EXT VEINS US BILAT Clip # \n Reason: please perform vein mapping of entire upper extremity includ\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with h/o ESRD on HD p/w MS changes, b/l UE swelling concerning\n for SVC syndrome. Pt. has h/o numerous b/l UE clots.\n REASON FOR THIS EXAMINATION:\n please perform vein mapping of entire upper extremity including SVC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of end-stage renal disease, on hemodialysis, with mental\n status changes and bilateral upper extremity swelling concerning for SVC\n syndrome. Evaluate for upper-extremity DVT.\n\n BILATERAL UPPER EXTREMITY ULTRASOUND: -scale, color, and Doppler\n son of both internal jugular, subclavian, axillary and brachial veins\n were performed. Additionally, the right cephalic vein was evaluated. There\n is near-complete thrombus of the left internal jugular vein with a tiny amount\n of flow through this vessel. There is mild thickening of the walls of the\n left internal jugular vein. No thrombus is identified within the right\n internal jugular vein, both subclavians, axillary and brachial veins. No\n thrombus is identified within the right cephalic vein. There is neointimal\n thickening within the right subclavian vein where the PICC line enters with\n normal color flow through this area. There is normal respiratory variation\n throughout the veins of both the right and left upper extremities excluding\n the left internal jugular vein. The left upper extremity fistula was not\n evaluated.\n\n IMPRESSION: Chronic near-complete thrombus of the left internal jugular vein.\n No occlusive thrombus in the other veins evaluated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 776289,
"text": " 7:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p extubation airway protection s/p seizure now w/\n tachycardia and fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Extubated. Now with tachycardia and fever.\n\n COMPARISON: .\n\n FINDINGS: There has been interval removal of the ET tube. Left-sided central\n venous line remains in unchanged position. The cardiac and mediastinal\n contours are unchanged allowing for patient rotation. Bilateral\n hemidiaphragms are less distinct on today's exam suggesting increased\n bibasilar atelectasis. Probable small left pleural effusion. Left-sided PICC\n line tip is in the axillary vein.\n\n IMPRESSION: Worsening bibasilar atelectasis with probable left pleural\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 776473,
"text": " 3:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with ESRD on HD presents with fever.\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemodialysis with fever.\n\n TECHNIQUE: A single portable AP view of the chest is compared with 2 days\n prior.\n\n FINDINGS: Again seen is a left subclavian hemodialysis catheter, terminating\n in the mid-SVC. A right-sided PICC line again terminates in the axilla. The\n cardiomediastinal silhouette is unremarkable. No focal pulmonary opacities,\n pleural effusions, or pneumothorax. Pulmonary vasculature is unremarkable.\n\n IMPRESSION:\n 1) Vascath terminates in the mid-SVC, and right-sided PICC line terminates\n within the axilla.\n\n 2) No evidence of focal pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 776070,
"text": " 10:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleave eval ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with intubation for airway protection s/p seizure.\n REASON FOR THIS EXAMINATION:\n pleave eval ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated after seizure.\n\n COMPARISON: .\n\n FINDINGS: A left sided central venous line is present with tip in the SVC.\n Endotracheal tube is in good position several cm above the carina. The heart\n is top normal in size with slight left ventricular enlargement. Mediastinal\n contours are unchanged allowing for differences in patient positioning. There\n is interval worsening of left lower lobe consolidation and collapse. No\n definite pleural effusion. No pneumothorax. The soft tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: Good placement of ET tube. Increased left lower lobe\n consolidation and collapse.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 776074,
"text": " 12:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: does pt have intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with report of seizure, now intubated.\n REASON FOR THIS EXAMINATION:\n does pt have intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizures, intubated.\n\n TECHNIQUE: Axial images of the brain were obtained without IV contrast.\n\n COMPARISON: .\n\n CT BRAIN WITHOUT IV CONTRAST: The ventricles, cisterns and sulci are normal.\n There is no shift of normal midline structures or mass affect. The /white\n matter differentiation is normal. There are no pathologic extra-axial fluid\n collections. Again seen are lacunar infarcts in the caudate nucleus\n bilaterally and the right cerebellar hemisphere. There are vascular\n calcifications. There is soft tissue and fluid in the left maxillary sinus,\n bilateral ethmoidal air cells and bilateral sphenoid sinuses. The patient is\n intubated. There is also a small fluid level in the posterior right mastoid.\n Dense carotid calcifications are present.\n\n IMPRESSION:\n\n 1.No evidence of intracranial hemorrhage. If clinically indicated, contrast-\n enhanced MR imaging may be useful for further evaluation of seizures.\n 2.Sinus disease.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-30 00:00:00.000",
"description": "PTA VENOUS",
"row_id": 776845,
"text": " 8:01 AM\n AV FISTULOGRAM SCH Clip # \n Reason: functioning AVF, clots in upper torso?\n Contrast: OPTIRAY Amt: 150\n ********************************* CPT Codes ********************************\n * PTA VENOUS PTA VENOUS *\n * -59 DISTINCT PROCEDURAL SERVICE INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PTA VENOUS *\n * PTA VENOUS -59 DISTINCT PROCEDURAL SERVICE *\n * ART VENEOUS SHUNT -22 EXTRA CHARGE *\n * CATH, TRANSLUM ANGIO NONLASER CATH, TRANSLUM ANGIO NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 150 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with h/o ESRD on HD with new SVC syndrome, poorly functioning\n L AVF.\n REASON FOR THIS EXAMINATION:\n functioning AVF, clots in upper torso?\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 63 year old male with end stage renal disease on dialysis through\n left arm brachiocephalic arteriovenous (AV) fistula, now presents with\n significant swelling of left face and both arms with left side being worse.\n\n RADIOLOGISTS: Drs. and , with the attending\n radiologist Dr. being present for the entire procedure. Dr.\n reviewed the exam.\n\n PROCEDURE AND FINDINGS: The risks and benefits were explained to the patient\n and consent was obtained. The patient was placed supine on the angiographic\n table and the right arm was prepped and draped in sterile fashion. Local\n anesthesia using 1% Lidocaine was applied to the puncture site. Under\n son guidance, the left cephalic vein near the arteriovenous fistula\n was accessed using a 21 gauge needle and an 0.018 wire was placed into the\n vein toward the venous side. The needle was exchanged for a micropuncture\n sheath which was connected to the power injector.\n AV fistulogram was performed along the course of the cephalic vein to the\n level of the right atrium. The venograms demonstrated a focal stenosis in the\n dilated cephalic vein at the level of the mid arm and also confirmed the\n known, severe stenosis of the superior vena cava (SVC). There is a left\n internal jugular dialysis catheter with its tip in the SVC. This might be\n related to the development of the stenosis. No intrathoracic collateral is\n seen; there is, however, collateral filling from the left mid-arm towards the\n axilla and then left lateral thoracic wall caudally.\n Pressure measurements were performed through a 5-French straight catheter.\n They demonstrated mean pressures of 13 mmHg in the right atrium and 31 mmHg in\n the left brachiocephalic vein (i.e., gradient of 18 mmHg).\n A pressure cuff was insufflated over the upper arm and a venogram was\n repeated. It revealed patency of the arteriovenous anastomosis and the\n brachial artery proximally and distally to the anastomosis with no significant\n stenosis.\n (Over)\n\n 8:01 AM\n AV FISTULOGRAM SCH Clip # \n Reason: functioning AVF, clots in upper torso?\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Thereafter, an 0.035 wire was placed through the sheath and advanced\n under fluoroscopy until its tip was in the inferior vena cava. The\n micropuncture sheath was exchanged for a 6 French sheath. The focal stenosis\n in the cephalic vein was dilated using a 6 mm X 4 cm balloon. Resolution of\n the narrowing was shown on a follow-up venogram.\n The sheath was removed and a 18 mm X 4 cm balloon was placed over the wire\n into the stenotic SVC and dilated repeatedly under fluoroscopy up to 5\n atmospheres. Follow up venograms through the sidearm of the sheath showed\n significant improvement of the diameter of the SVC. Repeat pressure\n measurements through a 4 French multiside hole straight catheter showed\n complete resolution of pressure gradient across the superior vena cava.\n The catheter and sheath were then removed and local hemostasis was achieved by\n manual compression. The patient tolerated the procedure well with no\n complications.\n\n MEDICATIONS: For conscious sedation, a total of 75 micrograms of Fentanyl was\n given in small divided intravenous doses under continuous hemodynamic\n monitoring. Total of 165 ml IV Optiray 320 dilated by half.\n\n IMPRESSION:\n\n 1. Major, symptomatic stenosis of the superior vena cava. Low-pressure\n balloon venoplasty (18 mm) resulted in highly satisfactory immediate\n angiographic and manometric results.\n\n 2. Focal stenosis in the left cephalic vein at the mid-arm level. This was\n dilated to 6 mm in diameter with no immediate complication.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 777219,
"text": " 4:34 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with fever and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n History of cough and fever.\n\n Heart size is borderline for technique. No evidence for CHF. There is a small\n ill-defined area of air space consolidation in the right upper lobe, new since\n the prior study of . No definite pleural effusions.\n\n IMPRESSION: Small area of right upper lobe pneumonia, new since the prior\n study of .\n\n"
},
{
"category": "Echo",
"chartdate": "2145-11-25 00:00:00.000",
"description": "Report",
"row_id": 69269,
"text": "PATIENT/TEST INFORMATION:\nIndication: Reassess for LV function and shunt.\nHeight: (in) 66\nBP (mm Hg): 142/74\nStatus: Inpatient\nDate/Time: at 11:51\nTest: TTE(Complete)\nDoppler: Focused pulse and color flow\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. There is\na bidirectional shunt across the interatrial septum at rest. A small secundum\natrial septal defect (ASD) is present.\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: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is normal in diameter. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. The tricuspid valve\nsupporting structures are normal. Mild tricuspid [1+] regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension.\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: Contrast study was performed with one iv injection of 8 ccs\nof agitated normal saline at rest.\n\nConclusions:\nThe left atrium is normal in size. There is a bidirectional shunt across the\ninteratrial septum at rest (left-to-right on color-flow imaging; right-to-left\nby air bubble contrast imaging). A small secundum atrial septal defect (ASD)\nis present. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF 60-70%). Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\nnot stenotic. The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared to the previous study of , the left ventricular\nejection fraction is significantly increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-10 00:00:00.000",
"description": "Report",
"row_id": 154724,
"text": "Sinus rhythm. There are anterolateral ST-T wave abnormalities suggestive of\nanterolateral myocardial ischemia. Compared to the previous tracing of \nanterolateral ST-T wave changes are new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-28 00:00:00.000",
"description": "Report",
"row_id": 154725,
"text": "Baseline artifact\nSinus rhythm\nModest lateral T wave changes are nonspecific\nLow limb leads voltage\nSince previous tracing of : probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-24 00:00:00.000",
"description": "Report",
"row_id": 154726,
"text": "Sinus rhythm. Since the previous tracing of the rhythm is again sinus\nand the rate is slower. There is no other diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-24 00:00:00.000",
"description": "Report",
"row_id": 154727,
"text": "There is a rapid supraventricular rhythm most probably atrial flutter.\nSince the previous tracing of the rhythm is new and the rate is more\nrapid. ST-T wave abnormalities are more marked.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-12 00:00:00.000",
"description": "Report",
"row_id": 154722,
"text": "Sinus rhythm\nAnterolateral ST-T changes may be due to myocardial ischemia\nCompared to previous tracing of , sinus rhythm has appeared. Otherwise\nno change.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-10 00:00:00.000",
"description": "Report",
"row_id": 154723,
"text": "Atrial fibrillation with a moderate ventricular response. Anterolateral\nST-T wave changes suggestive of myocardial ischemia persist. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-23 00:00:00.000",
"description": "Report",
"row_id": 1288080,
"text": "S-\"I have something in my mouth!\"\n\nO-Extubated at 1600 after successfully weaned to PS. Hoarse voice but moving adequate air with strong cough. Sats 97-99% on face shovel.\nVSS. BP non-labile. NSR. No ectopy. Extremely agitated-trying to get OOB and yelling. Verbal reassurance not helpful. Haldol 0.5 mg IV given at 1810 with minimal effect. Hemodialysis this afternoon and 3.3 KG were taken off. Pt received one unit PRBC's during dialysis for a HCT of 25.Tolerated well. FSBS remained stable-no episiodes of hypoglycemia. Heparin started IV and present rate is 1150U/Hr. Current PTT pending. Left groin TLC oozing moderate amts of blood.\nTeam aware. Left AV fistula with faint thrill and bruit. Left external jugular dialysis cath intact. Hematuria noted from foley catheter. ? pt agitated and pulling at it.\n\nA-Extubated-tolerated shovel mask well\n\nP-MRI/MRA later this evening when pt has settled down, monitor respiratort status, FSBS to assess for hypoglycemia, m seizure activity and reassure pt and provide a safe environment.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-24 00:00:00.000",
"description": "Report",
"row_id": 1288081,
"text": "review of systems:\n\nNeuro: UTA pts neuro status fully, pt speaks only spanish and is aggitated. pt trying to get out of bed and trashing around in bed. Pt MAE well. pt pupils equal and reactive but sluggish. Pt has recived a couple of doses of haldol which has not seemed to work. pt has + babinski bilaterally.\n\nResp: pt remains on 50% face tent and sao2 > 92%. pt has had no secreations, but pts lungs sound very coarse.\n\nCV: pt BP has remained stable WNL, currently 147/45 in a normal ST with no ectopy noted. pt remains on hep gtt, PTT was hight @ 2300, so gtt turned off and then decreased per hep protocol. pt recived 1 unit of blood due to a HCT of 28. ptt and post tranfusion HCT pending. Pt is oozing ALOT of blood around left fem TLC, pressure dressing changed many times, HO made aware.\n\nGI/GU: Pt has a few loose brown stools tonight. Pt has hematuria due to pt pulling on foley HO aware.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-24 00:00:00.000",
"description": "Report",
"row_id": 1288082,
"text": "NURSING NOTE: 7A-1300\n PT SPANISH SPEAKING ONLY. WITH HELP OF TRANSLATOR, FOLOWS SOME SIMPLE COMMANDS. PER TRANSLATOR PT'S SPANISH IS NOT CLEAR. MAE. NORMAL EQUAL STRENGTHS. BECOMES AGGITATED AT TIMES CALLING OUT AND FIDGETY. SOFT WRIST RESTRANITS AND FREQUENT CHECKS. FAMILY AT BEDSIDE IS HELPFUL FOR PT'S AGITATION. PUPILS FIXED AT 3MM WITH DOWNWARD PALSY NOTED. LARGE AMOUNT OF NECK AND HEAD SWELLING, PERI-ORBITAL EDEMA ALSO PRESENT.\n\nRESP- O2 TITRATED TO 4L N/C WITH SATS 97-100%. RR 16-24. NPC. LUNG SOUNDS COARSE.\n\nCV- HR ST 100-110'S NO ECTOPY OBSERVED. SBP 130-150'S. PERIPHERAL PULSES PRESENT WITH DOPPLER. HEPARIN INFUSION WAS OFF AT 7AM FOR PTT 140. PTT RECHECKED AT 1130 WAS 41.8 AND GTT WAS RESTARTED AT 600U/H. NEXT PTT DUE AT 1730.\n\nGI- ABD SOFT NT ND +BS 2 SMALL BM'S TODAY. SPEC SENT FOR CDIFF TODAY PENDING. NO PO MEDS GIVEN YET AS PT WOULD NOT COOPERATE WITH ASSESSING SWALLOWING. TEAM AWARE.\n\nGU- FOLEY PATENT FOR SMALL AMOUNTS OF BLOODY URINE. PT WENT TO HD TODAY AT APPROX 1300.\n\nACCESS- L FEMORAL TLCL BLEEDING AT SITE MODERATE AMOUNTS, TEAM MADE AWARE AND PTT THIS AM WAS SUPERTHERAPEUTIC. PRESSURE DSG APPLIED. L PICC CLOOTED PER REPORT FROM NOC SHIFT. L EJ DIALYSIS CATHETER, AND HAS L UPPER ARM AV FISTULA.\n\nSOCIAL-WIFE AT BEDSIDE THIS AM, DR ASSISTED IN TRANSLATING.\n\n PT WENT TO MRI TODAY. UNABLE TO GET GOOD IMAGES DESPITE MEDICATED WITH VERSED. MRI HEAD DONE, CHEST UNABLE TO OBTAIN. TEAM AWARE. FROM MRI PT WAS TRANSFERRED TO HD UNIT. PT IS TO TRANSFER TO 723 AFTER HD COMPLETE. TRANSFER NOT FAXED TO FLOOR, FOLLOW-UP REPORT TO BE CALLED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-23 00:00:00.000",
"description": "Report",
"row_id": 1288079,
"text": "Review of systems:\n\nNeuro: pt came to MICU and was sedated from OSH, after about 1 hour pt woke up and became very aggitated, pt recived adivan and fentanyl for sedation. After head CT pt was started on propofol gtt to sedate pt. pt is currently sedated on 10 mcg/kg/min of propofol. pt will grimase and flex to painful stim. pt does not open eyes, and pt pupils are equal but not reactive, Dr. aware.\n\nResp: pt remains intubated on vent AC/12/650/.50/5. pt sao2 is > 965. pt requires q 4 hour suctioning for scant amount of thick tan secreations. plan is to attempt to extubate pt this morning.\n\nCV: pt BP is stable WNL, currently 133/47, pt is in NSR with no ectopy noted. pt takes PO BP meds at home, PO meds currently on hold for extubation in AM. Pt has H/O DVT, pt sup vena cava in belived to be clottted, pt head and swollen due to this clot. Pt PICC line has since clotted.\n\nGI/GU: Pt has ESRD, with HD MWF, he missed HD and will recive HD this morning. pt has a L SC HD cath as well as a fistula in left arm with a + bruit and thrill.\n\nLines: pt had a left fem TLC placed.\n\n\n"
}
] |
26,027 | 127,906 | 38 M with h/o epilepsy, alcoholism, alcohol withdrawal seizures, and delirium tremens (per pt report) who presents in alcohol withdrawal requesting treatment. . 1. EtOH Withdrawal: Patient presented to the emergency department requesting detox. His last drink was approx 6 hours prior to arrival. He typically drinks gallon on Vodka daily. His EtOH level on arrival was 317. Tox screen was otherwise negative. Patient became increasingly hypertensive, tachycardic, and tremulous. He was given Ativan 2mg IV and Valium for a total of 40mg IV over 3 hours though he continued to show signs of withdrawal. He was admitted to the ICU Continues and required approx 200mg of Valium over 6 hour period to control his symptoms of withdrawal. He was given a banana bag and started on Thiamine, Folate, and MVT. The morning after discharge the patient left AMA. . 2. Anion Gap Acidosis: Likely starvation versus alcoholic ketoacidosis. Resolved after two liters of IVF. . 3. H/0 Epilepsy: No longer on meds. Reports seizure prior to presentation. Not clear if this was a alcohol withdrawal seizure. Patient was monitored on seizure precautions. AED were not restarted prior to presentation. . 4. Scabies: Patient with evidence of scabies on exam. Contact precautions applied. Treated with both Permethrin and Ivermectin x one. Bendaryl and Sarna as needed for itching. | FINDINGS: In comparison with the study of , there is little change and no evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. The outermost portion of the left hemithorax has been excluded from the image. | 1 | [
{
"category": "Radiology",
"chartdate": "2204-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1165770,
"text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new infiltrate\n Admitting Diagnosis: ETOH WITHDRAWL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with alcoholism and new mental status\n REASON FOR THIS EXAMINATION:\n new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Alcoholism with new mental status changes.\n\n FINDINGS: In comparison with the study of , there is little change and no\n evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,\n or pleural effusion. The outermost portion of the left hemithorax has been\n excluded from the image.\n\n\n"
}
] |
31,495 | 188,823 | Patient is a 73 yo woman with PMH of brain tumor s/p VP shunt , near deafness, hypothyroid and colon CA last year who presented to ED yesterday at 2300 with mental status changes. According to the daughter, the patient has in town from for the alst 2 weeks visiting for a graduation. Last night she had had 3 glasses of wine the of her MS changes. Last night during the graduation party said that she was feeling tired and that she was going to go upstairs to go to bed. About an hour later, she came down the stares and had notable face/eye trauma as if she had fallen. Her speech was dysarthric and she was mumbling. She said "I don't know what happened" and could not give explanation. Taken to ED. She was found to have bilateral SDH L >R and was transferred here. Here in the ICU, would open eyes and intermittently seemed to follow commands. She is very hard of hearing per daughter and nearly deaf. She was noted by ICU team to be moving x 4 but not speaking, and sleepy. She was obeserved in the ICU for 24 hours, and started on Folate, Thiamine, and Dilantin prophylactically. Subsequent CT scans revealved stability of SDH, and no worsening such to indicate surgical evacuation. Given her medical history a MRI/MRA was obtained(results included previously in this summary). Patient had inquired about receving her ongoing care in her come country of . Discharge planning has been moving toward that goal. She has a neurologist who follows her in , Dr. . This is acceptable per Dr. , and case managment has been working with the daughter to make arrangements to this effect. Physical therapy has continued to work with the patient in-house pending the finalization of these plans. The PT and OT felt that she did not require rehab but that she did need continued therapy after discharge. The patient will be discharged with the plan to go back home to with home PT and OT services. | Unchanged position of shunt catheter, with collapsed ventricles which may reflect intracranial hypotension or overshunting. LUNG SOUNDS DIMINISHED ON RT THROUGH NOC, THOUGH CLEAR BILATERALLY THIS AM.NEURO: LOC RANGES ALERT->LETHARGIC. TECHNIQUE: Non-contrast head CT. FINDINGS: Small bilateral convexity subdural hematomas are little changed, with subarachnoid blood again seen tracking along the tentorium, and upwards towards the vertex. Otherwise, little interval change in the bilateral convexity subdural hemorrhages, and bilateral subarachnoid blood. Normal flow void signal is identified in the vascular structures. Shunt catheter is unchanged in position, tip near the foramen of . The remainder of the visualized paranasal sinuses remain normally aerated. NURSING UPDATECV: HR NSR, NO ECTOPY. NURSING UPDATECV: HR NSR, NO ECTOPY. REASON FOR THIS EXAMINATION: eval No contraindications for IV contrast WET READ: KYg SAT 2:26 AM biconvexity subdural hematoma. IMPRESSION: No significant new interval change in the previously described subdural hematomas and subarachnoid hemorrhage. Slight interval increase in size of subdural hemorrhage in the inferior left frontal lobe, with minimal edema and mass effect on regional sulci. Paranasal sinuses remain normally aerated. The shunt catheter is unchanged in position with the tip near to the foramen of . The heart size and the mediastinal contours are within normal limits. REASON FOR THIS EXAMINATION: eval acute process No contraindications for IV contrast WET READ: KN SAT 4:02 AM Agree. Lungs are diminished at bases, clear upper lobes. FINDINGS: In comparison with the prior study, again there is evidence of bilateral subdural hematomas along the convexity with associated subarachnoid hemorrhage, no significant change is noted in the size and configuration of these collections. TECHNIQUE: Non-contrast MDCT-acquired axial images of the facial bones. Subdural hemorrhage in the left inferior frontal lobe has slightly increased, with minimal edema and mass effect seen on subjacent sulci. Pontine calcification is unchanged. NON-CONTRAST HEAD CT: There are bilateral cerebral convexity subdural hematoma with additional foci of subarachnoid blood noted within the left vertex and right temporal lobe. No intraparenchymal diffusion abnormalities are detected, the hematomas demonstrate mild restricted diffusion. Diffuse non-specific T wave flattening. Subarachnoid blood seen predominantly in the high left frontal sulci, left greater than right is little changed. There is a somewhat shallow level of inspiration and there is some blunting of the left CP angle suggesting some pleural fluid. A shunt catheter is seen via a right posterior occiput approach and terminates within the right frontal of the lateral ventricle adjacent to the septum pellucidum. FINDINGS: The cervical spine maintains a normal alignment without fracture or subluxation. REASON FOR THIS EXAMINATION: eval No contraindications for IV contrast WET READ: KYg SAT 2:29 AM no fractures. Note is made of biconvexity subdural hematoma, which is evaluated on head CT. SOFT, BOWEL SOUNDS +.GU: HUO MARGINAL, CLEAR YELLOW->AMBER VIA F/CATH.PT MONITORED .DR IN CLOSE ICU ATTENDANCE.SEE CAREVUE FLOWSHEETS FOR DETAILED DATA. Mild mucosal thickening is noted in the ethmoidal air cells. Note is made of collapsed ventricle suggesting the presence of intracranial hypotension or overshunting. IMPRESSION: No facial fracture. UE'S NORMAL STRENGTH, LIFT AND HOLDING BLE'S. TEMP RESOLVED WITHOUT INTERVENTION. small foci of sa blood at the left vertex and right temporal lobe. Right occipital burr hole. TECHNIQUE: Non-contrast MDCT-acquired axial images of the cervical spine from the skull base to the level of T2. A shunt catheter is seen via a right occipital approach terminating within the right frontal of the lateral ventricle adjacent to the septum pellucidum. Punctate low signal areas are identified in the pons related with previously described calcifications. Abd is soft, +BSX4. Bilateral cerebral convexity subdural hematomas with small foci of subarachnoid blood within the left vertex and right temporal lobe. TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained, axial T2, axial FLAIR, axial magnetic susceptibility, the T1-weighted sequences were repeated after the administration of gadolinium contrast in axial, sagittal, and coronal projections. Dr WET READ VERSION #1 KYg SAT 2:51 AM no fracture or subluxation. Please See Carevue for Specifics.Pt is arousable to name and stimuli, opens eyes, pt is aphasic, does not follow commands, PERL, withdraws all ext to nailbed pressure. No prevertebral soft tissue abnormality is detected. NSR, no ectopy, SBP 130-140's. After the administration of contrast, there is evidence of diffuse leptomeningeal enhancement possibly related with the recent fractures and hematomas. NEURO; MAE, DOES NOT FOLLOW COMMANDS, PERL AND BRISK, EOM'S INTACT, WITHDRAWS TO NOXIOIUS STIMULI, TAKEN FOR HEAD CAT AND MRI TODAY, MEDIC IN MRI SUITE FOR AGITATION, LETHARGIC THIS PM BUT EASILY AROUSEABLE,CARDIOVASCULAR; HR 60'S-70'S SR, GOA IS TO KEEP SYS 100-140 PER DR. , TEMP 100.6, LABS DRAWN THIS PM BUT PT DIFFICULT TO OBTAIN LAB DRAWS, ? COMPARISON: Prior CTs of the head dated . Ventricles remain collapsed. foley with c/y/u. IMPRESSION: No fracture or subluxation. FINDINGS: No fracture is detected. Basal cisterns are normal. The - white matter differentiation is preserved. Diffuse leptomeningeal enhancement, likely related with the recent fractures and subdural hematomas. FUTURE ATTEMPT AT A LINE INSERTIONRESPIR; LUNGS CLEAR, 02 SAT 98% ON R/A, FEW EXPIR WHEEZES THIS PM, EXPECTORATED SMALL AMT THICK YELLOW MUCOUS, REPOSITIONED FREQUENTLY AND CHEST PT DONEGI; DOBOFF FEEDING TUBE PLACED FOR MEDS AND CONFIRMED BY X RAY PER SICU HO, ? Hypodensity is seen within the left basal ganglia which likely represents old lacunar infarct. STOOL SOFTENERS IF NEEDEDPLAN; KEEP SYS < 160, FREQUENT NEURO CHECKS, PT FREQUENTLY TO SURROUNDINGS, SPEECH/SWALLOWING EVAL TOMORROW, ? Sinus rhythm. the ventricles are collapsed suggesting intracranial hypotension. The ventricles are collapsed which is suggestive of intracranial hypotension or overshunting. REMAINS NPO AT THIS TIME.GU: ADEQUATE HUO > 30CC/H.PLAN: SPEECH AND SWALLOW EXAM.TRANSFER TO HOSPITAL WHEN MD/MD AND TRANSPORT ARRANGEMENTS MADE.PT MONITORED .DR IN CLOSE ICU ATTENDANCE.SEE CAREVUE FLOWSHEETS FOR DETAILED DATA. | 12 | [
{
"category": "Radiology",
"chartdate": "2117-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015682,
"text": " 9:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pos Dobhoff\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with SDH s/p Dobhoff placement\n REASON FOR THIS EXAMINATION:\n ?pos Dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 9:58\n\n INDICATION: Dobbhoff positioning.\n\n FINDINGS:\n\n There are no relevant comparison films. An NG tube extends below the level of\n the diaphragm cannot be seen with tube extends beyond the confines of the\n image. There is a somewhat shallow level of inspiration and there is some\n blunting of the left CP angle suggesting some pleural fluid. There is no\n patchy consolidation visualized. The heart size and the mediastinal contours\n are within normal limits.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-06-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1015694,
"text": " 12:13 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: T1 w/ gadolinium 3 planes\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with brain tumor & b/l SDH\n REASON FOR THIS EXAMINATION:\n T1 w/ gadolinium 3 planes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MRI of the head with and without contrast and MRA of the head.\n\n CLINICAL INDICATION: 73-year-old woman with history of subdural hematoma and\n facial fractures.\n\n COMPARISON: Prior CTs of the head dated .\n\n TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,\n axial T2, axial FLAIR, axial magnetic susceptibility, the T1-weighted\n sequences were repeated after the administration of gadolinium contrast in\n axial, sagittal, and coronal projections.\n\n FINDINGS: In comparison with the prior study, again there is evidence of\n bilateral subdural hematomas along the convexity with associated subarachnoid\n hemorrhage, no significant change is noted in the size and configuration of\n these collections. There is no evidence of shift of normally midline\n structures. Multiple lacunar ischemic changes are noted in the basal ganglia,\n more evident on the left side, prominent perivascular space is identified on\n the right external capsule. After the administration of contrast, there is\n evidence of diffuse leptomeningeal enhancement possibly related with the\n recent fractures and hematomas. No intraparenchymal diffusion abnormalities\n are detected, the hematomas demonstrate mild restricted diffusion. Normal\n flow void signal is identified in the vascular structures. Mild mucosal\n thickening is noted in the ethmoidal air cells. Punctate low signal areas are\n identified in the pons related with previously described calcifications.\n\n IMPRESSION: No significant new interval change in the previously described\n subdural hematomas and subarachnoid hemorrhage. There is no evidence of\n diffusion abnormalities or acute ischemic changes. Diffuse leptomeningeal\n enhancement, likely related with the recent fractures and subdural hematomas.\n Hyperintensity areas noted on FLAIR located in the subcortical white matter\n and basal ganglia consistent with chronic lacunar ischemic changes and small-\n vessel disease. The shunt catheter is unchanged in position with the tip near\n to the foramen of . There is no evidence of hydrocephalus. Right\n occipital burr hole.\n\n (Over)\n\n 12:13 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: T1 w/ gadolinium 3 planes\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-06-26 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1015653,
"text": " 1:41 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with tx with subdurals and SA, ? facial fx.\n REASON FOR THIS EXAMINATION:\n eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN SAT 4:02 AM\n Agree. Dr \n WET READ VERSION #1 KYg SAT 2:51 AM\n no fracture or subluxation.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 72-year-old female with subdural and subarachnoid\n hemorrhage. 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 T2. Multiplanar reformatted images were\n obtained.\n\n FINDINGS: The cervical spine maintains a normal alignment without fracture or\n subluxation. Multilevel degenerative changes are seen involving the cervical\n spine, most notably disc space narrowing and endplate osteophytes at C5-C6. No\n prevertebral soft tissue abnormality is detected. A catheter is seen coursing\n through the right lateral neck. Mucosal thickening is seen within the\n sphenoid sinuses.\n\n IMPRESSION: No fracture or subluxation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-06-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1015651,
"text": " 1:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with tx with subdurals and SA, ? facial fx.\n REASON FOR THIS EXAMINATION:\n eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg SAT 2:26 AM\n biconvexity subdural hematoma. small foci of sa blood at the left vertex and\n right temporal lobe. shunt catheter is present. the ventricles are collapsed\n suggesting intracranial hypotension.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 73-year-old female with subdural and subarachnoid\n hemorrhage.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: There are bilateral cerebral convexity subdural\n hematoma with additional foci of subarachnoid blood noted within the left\n vertex and right temporal lobe. There is no shift of normally midline\n structures. The - white matter differentiation is preserved. Hypodensity\n is seen within the left basal ganglia which likely represents old lacunar\n infarct. A shunt catheter is seen via a right occipital approach terminating\n within the right frontal of the lateral ventricle adjacent to the septum\n pellucidum. The ventricles are collapsed which is suggestive of intracranial\n hypotension or overshunting. Calcification is noted within the pons. Mucosal\n thickening is seen within the ethmoid and sphenoid sinuses. The remainder of\n the visualized paranasal sinuses remain normally aerated. No fracture is\n identified.\n\n IMPRESSION:\n 1. Bilateral cerebral convexity subdural hematomas with small foci of\n subarachnoid blood within the left vertex and right temporal lobe.\n\n 2. A shunt catheter is seen via a right posterior occiput approach and\n terminates within the right frontal of the lateral ventricle adjacent to\n the septum pellucidum. Note is made of collapsed ventricle suggesting the\n presence of intracranial hypotension or overshunting.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-06-26 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1015652,
"text": " 1:40 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Q. FX.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with tx with subdurals and SA, ? facial fx.\n REASON FOR THIS EXAMINATION:\n eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg SAT 2:29 AM\n no fractures.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 73-year-old female with subdural and subarachnoid\n hemorrhage. Evaluate for facial fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the facial bones.\n Multiplanar reformatted images were obtained.\n\n FINDINGS: No fracture is detected. Mucosal thickening is seen within the\n sphenoid sinuses and ethmoid air cells. Note is made of biconvexity subdural\n hematoma, which is evaluated on head CT.\n\n IMPRESSION: No facial fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-06-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1015690,
"text": " 10:55 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval changeplease perform at noon \n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with B SDH, SAH, brain tumor s/p fall\n REASON FOR THIS EXAMINATION:\n interval changeplease perform at noon \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old female with bilateral subdural and subarachnoid\n hemorrhages, and known brain tumor, status post fall. Please evaluate for\n interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Small bilateral convexity subdural hematomas are little changed,\n with subarachnoid blood again seen tracking along the tentorium, and upwards\n towards the vertex. Subdural hemorrhage in the left inferior frontal lobe has\n slightly increased, with minimal edema and mass effect seen on subjacent\n sulci. Subarachnoid blood seen predominantly in the high left frontal sulci,\n left greater than right is little changed. There is no new hemorrhage.\n\n Shunt catheter is unchanged in position, tip near the foramen of .\n Ventricles remain collapsed. Basal cisterns are normal. Pontine\n calcification is unchanged. Paranasal sinuses remain normally aerated.\n\n IMPRESSION:\n\n 1. Slight interval increase in size of subdural hemorrhage in the inferior\n left frontal lobe, with minimal edema and mass effect on regional sulci.\n Otherwise, little interval change in the bilateral convexity subdural\n hemorrhages, and bilateral subarachnoid blood.\n\n 2. Unchanged position of shunt catheter, with collapsed ventricles which may\n reflect intracranial hypotension or overshunting.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-06-27 00:00:00.000",
"description": "Report",
"row_id": 1663642,
"text": "NEURO; MORE AWAKE AND INTERACTIVE THAN YESTERDAY, FOLLOWS SIMPLE COMMANDS, ABLE TO SHOW TWO FINGERS AND HOLD BOTH LEGS UP OFF MATTRESS, SPEECH IS GARBLED BUT FREQUENTLY ABLE TO INTERPRET WHAT PT IS SAYING, CONFUSED TO SURROUNDINGS AND REASON SHE IS HERE, UP IN CHAIR WITH ASSIST OF TWO, SLIGHTLY UNSTEADY GAIT BUT PT ASSISTED WITH TRANSFER OOB\nHYDRALAZINE X 1 THIS PM TO KEEP SYS < 160 (NEW GOAL PER DR.)\nEEG AT BEDSIDE TODAY\n\nCARDIOVASCULAR; HR 60'S-50'S SR-SB, TEMP 98.3,\nA LINE INTACT LEFT RADIAL,\nRESPIR; LUNGS CLEAR, CHEST\nPT Q FEW HRS, PT WELL BUT NOT RAISING SPUTUM AT PRESENT, 02 SAT 96% ON R/A, ENCOURAGED WITH COUGHING AND DEEP BREATHING BUT NEEDS REINFORCEMENT\n\nGI; TUBE FEEDS STARTED VIA DOBOFF FEEDING TUBE AM, PT PULLED TUBE OUT AND FEEDS ON HOLD FOR NOW, PER SICU HO, SPEECH/SWALLOWING EVAL TOMORROW\nNO BM THIS SHIFT, ? STOOL SOFTENERS IF NEEDED\n\nPLAN; KEEP SYS < 160, FREQUENT NEURO CHECKS, PT FREQUENTLY TO SURROUNDINGS, SPEECH/SWALLOWING EVAL TOMORROW, ? TRANSFER OUT OF SICU\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-06-28 00:00:00.000",
"description": "Report",
"row_id": 1663643,
"text": "NURSING UPDATE\nCV: HR NSR, NO ECTOPY. HYDRALAZINE 10MG IV X1 FOR SBP 164 EARLY NOC, SBP SINCE MAINTAINED @ GOAL<160.\n\nRESP: SATS IN LOW 90'S EARLY NOC, O2 2L APPLIED, HAS MAINTAINED 95-98 SINCE. LUNG SOUNDS DIMINISHED ON RT THROUGH NOC, THOUGH CLEAR BILATERALLY THIS AM.\n\nNEURO: LOC RANGES ALERT->LETHARGIC. ORIENTED TO PERSON AND SOMETIMES PLACE. BACK TO SLEEP QUICKLY AFTER EXAM. NORMAL STRENGTH ALL EXTREMITIES, TURNING IN BED INDEPENDANTLY. PUPILS EQUAL IN SIZE AND REACTIVITY. C/O HEADACHE X2, MORPHINE 1MG IV WITH MOD EFFECT, BUT NAUSEA FOLLOWED, ZOFRAN 4MG WITH GOOD EFFECT, TYLENOL 650MG PR FOR PERSISTANT HEADACHE, THIS TIME WITH GOOD EFFECT.\n\nGI: SOFT, BOWEL SOUNDS PRESENT, NO BM. REMAINS NPO AT THIS TIME.\n\nGU: ADEQUATE HUO > 30CC/H.\n\nPLAN: SPEECH AND SWALLOW EXAM.\nTRANSFER TO HOSPITAL WHEN MD/MD AND TRANSPORT ARRANGEMENTS MADE.\n\nPT MONITORED .\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-06-26 00:00:00.000",
"description": "Report",
"row_id": 1663639,
"text": "Please See Carevue for Specifics.\n\nPt is arousable to name and stimuli, opens eyes, pt is aphasic, does not follow commands, PERL, withdraws all ext to nailbed pressure. NSR, no ectopy, SBP 130-140's. Lungs are diminished at bases, clear upper lobes. Abd is soft, +BSX4. foley with c/y/u. Right side face and eye swollen and bruising.\n\nPOC: EEG to due out seizure activity, ?repeat head CT, continue to closely monitor neuro status. Family meeting to discuss pt plan of care. Continue to offer emotional support to pt and pt family throughout hospital stay.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-06-26 00:00:00.000",
"description": "Report",
"row_id": 1663640,
"text": "NEURO; MAE, DOES NOT FOLLOW COMMANDS, PERL AND BRISK, EOM'S INTACT, WITHDRAWS TO NOXIOIUS STIMULI, TAKEN FOR HEAD CAT AND MRI TODAY, MEDIC IN MRI SUITE FOR AGITATION, LETHARGIC THIS PM BUT EASILY AROUSEABLE,\n\nCARDIOVASCULAR; HR 60'S-70'S SR, GOA IS TO KEEP SYS 100-140 PER DR. , TEMP 100.6, LABS DRAWN THIS PM BUT PT DIFFICULT TO OBTAIN LAB DRAWS, ? FUTURE ATTEMPT AT A LINE INSERTION\n\nRESPIR; LUNGS CLEAR, 02 SAT 98% ON R/A, FEW EXPIR WHEEZES THIS PM, EXPECTORATED SMALL AMT THICK YELLOW MUCOUS, REPOSITIONED FREQUENTLY AND CHEST PT DONE\n\nGI; DOBOFF FEEDING TUBE PLACED FOR MEDS AND CONFIRMED BY X RAY PER SICU HO, ? TUBE FEEDS IN FUTURE\n\nPLAN; HRLY NEURO CHECKS, KEEP SYS 100-140, CHEST PT AND REPOSITION, EMOTIONAL SUPPORT TO FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-06-27 00:00:00.000",
"description": "Report",
"row_id": 1663641,
"text": "NURSING UPDATE\nCV: HR NSR, NO ECTOPY. BP @ GOAL<140. ARTERIAL LINE INSERTED BY DR AND MED STUDENT WITHOUT DIFFICULTY.\n\nRESP: BREATH SOUNDS CLEAR, NTS FOR SMALL THICK YELLOW. SATS 92% EARLY SHIFT, O2 APPLIED VIA NASAL PRONGS AND INCREASED TO 4L TO KEEP SPO2>95%.\n\nNEURO: VERY LETHARGIC AND DIFFICULT TO ROUSE EARLY NOC. LIGHTENED UP SLIGHTLY OVERNOC, ATTEMPTED TO SAY \"GOODMORNING\" @ 0400, STARTED FOLLOWING COMMANDS, SQUEEZED HANDS BILATERALLY ON COMMAND. UE'S NORMAL STRENGTH, LIFT AND HOLDING BLE'S. PUPILS EQUAL IN SIZE AND REACTIVITY. DILANTIN<THERAPEUTIC AT 8.4 THIS AM.\n\nID: TEMP SPIKE 102.1 @ , PAN CX. TEMP RESOLVED WITHOUT INTERVENTION. WBC 9.9 THIS AM.\n\nENDO: REG INSULIN GIVEN PJER SLIDING SCALE/FINGERSTICK.\n\nGI: DOBHOFF NGT IN PLACE. SOFT, BOWEL SOUNDS +.\n\nGU: HUO MARGINAL, CLEAR YELLOW->AMBER VIA F/CATH.\n\nPT MONITORED .\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "ECG",
"chartdate": "2117-06-26 00:00:00.000",
"description": "Report",
"row_id": 213973,
"text": "Sinus rhythm. Diffuse non-specific T wave flattening. No previous tracing\navailable for comparison.\n\n"
}
] |
46,034 | 170,420 | 42 year old man with ETOH cirrhosis admitted with altered mental status in the setting of cellulitis. Brief hospital course by problem: . # Altered mental status: CT head neg for acute process. No evidence of hypercarbia on VBG. No meningismus on exam to raise concern for encephalitis or meningitis. Paracentesis negative for SBP. Most likely secondary to hyponatremia and encephalopathy in the setting of infection. Mental status improved with antibiotics, lactulose, and rifaximin. . # LLE cellulitis: Pt was initially treated with vancomycin, however he had a bad reaction to the vancomycin (possibly red man's syndrome), and received solumedrol and benadryl, and was switched to IV clindamycin. Wound culture grew Staph aureus. Pt MRSA negative. The patient remained afebrile with stable vitals and improving , he was switched to PO clindamycin to complete a 7-day course. . # : Creatinine was 1.8 on admission. Urine sodium <10, fractional excretion of urea 25%, c/w pre-renal physiology. Patient was fluid overloaded, so he was diuresed with IV lasix and spironolactone, and creatinine normalized. Pt was discharged on 60mg PO lasix QD and 100mg spironolactone QD. . # Hyponatremia: Sodium was 125 on admission, likely secondary to cirrhosis. Sodium normalized. . # ETOH Cirrhosis: RUQ ultrasound without evidence of portal vein thrombosis. Treated with diuretics, lactulose and rifaximin. . # Painful left 2nd toe: Pt states that he had a recent fall and has since had pain in the second toe on the left foot. Foot x-ray was negative for fracture. . # Code status: Full code. . # Outstanding issues: - F/u RUQ ultrasound final read | At the porta hepatis, there is an apparently nonocclusive filling defect within the main portal vein. Mild (1+) mitralregurgitation is seen. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. Mild tomoderate [+] TR. QRS axis is not as leftwardand repolarization prolongation is again noted. The aortic valve leaflets (3) are mildly thickened but aortic stenosisis not present. IMPRESSION: No acute fracture identified. Mild talonavicular dorsal spurring. IMPRESSION: No evidence of left lower extremity DVT. Non-specific ST-T wave change with QTc intervalprolongation. Moderate ascites. Mild degenerative changes noted in dorsal mid-foot. Mild (1+)MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The diameters of aorta at the sinus, ascending and arch levels arenormal. There is noventricular septal defect. Moderate amount of ascites. Mild degenerative changes of the tibiotalar joint with joint space narrowing and tiny osteophytes. The visualized portal vein is patent, with no definite thrombus seen. Normal waveforms demonstrated. No definite fractures. No acute intracranial abnormality. IMPRESSION: No convincing evidence of a portal vein thrombus. Sinus rhythm with borderline sinus bradycardia. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Small mucus retention cyst is seen inferiorly in the right maxillary sinus and there is a small amount of aerosolized secretions seen in the frontal sinus on the right. Compared to the previous tracing of voltage criteria forleft ventricular hypertrophy are not as apparent. There is no appreciable pleural effusion. Trace aortic regurgitation is seen. Right ventricular chamber size and free wall motionare normal. Cardiomediastinal silhouette is stable. Focal, apparently nonocclusive filling defect in the main portal vein at the porta hepatis, with hepatopetal flow just proximal, with a velocity of 40 cm/sec. There is a moderate amount of ascites. WET READ VERSION #1 CXWc FRI 3:22 PM Targeted evaluation of the main portal vein shows nonocclusive filling defect at the porta hepatis, with a normal waveform and velocity 40 cm/s just before the thrombus. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). No ankle effusion identified. PATIENT/TEST INFORMATION:Indication: Volume overloadHeight: (in) 75Weight (lb): 240BSA (m2): 2.37 m2BP (mm Hg): 120/58HR (bpm): 98Status: InpatientDate/Time: at 13:51Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. There is normal compressibility, flow and augmentation. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. This could represent nonocclusive thrombus, or could be artifact. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , no major change. Clinical correlation issuggested. The tricuspid valve leaflets are mildly thickened.There is mild pulmonary artery systolic hypertension. No resting LVOT gradient. No AS. No MVP. There is no mitral valve prolapse. COMPARISON: None. COMPARISON: None. No dislocations. Lung volumes remain low, but the lungs are otherwise clear. Possibleleft ventricular hypertrophy. Evaluate for portal venous thrombus. Baseline artifact. IMPRESSION: 1. TECHNIQUE: Axial CT images were acquired through the head without intravenous contrast. Ventricles and sulci are normal in size and in configuration. There is interval development of left retrocardiac opacity that is worrisome for interval development of infectious process. IMPRESSIONS: 1. Limited visualization of the liver. No TS. FINDINGS: There is no intracranial hemorrhage, edema, mass effect or vascular territorial infarction. There is no pneumothorax. Overall the study is not adequate for evaluation of the hepatic vasculature and dedicated liver Doppler ultrasound recommended. No MS. No atrial septal defect is seen by 2D orcolor Doppler. Small amounts of gas are seen in the cavernous sinus bilaterally, presumably related to intravenous catheter. Paranasal sinus disease. INDICATION: Concern for fracture of second digit. The mitral valve leafletsare mildly thickened. Portable AP chest radiograph was compared to . Small locules of gas in the cavernous sinus bilaterally. There is no fracture. FINDINGS: Dorsal soft tissue swelling. This is most likely related to peripheral intravenous catheter. A well-corticated ossific fragment is seen lateral to the second toe PIP joint, likely representing sequelae from prior trauma. COMPARISON: . 1:59 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: Eval for portal venous thrombosis MEDICAL CONDITION: 41 y/o M end stage liver disease REASON FOR THIS EXAMINATION: Eval for portal venous thrombosis WET READ: CXWc FRI 4:02 PM Targeted, limited evaluation of the main portal vein shows the suggestion of nonocclusive filling defect at the porta hepatis, although with a normal waveform and velocity 40 cm/s just before the filling defect. Left ventricular wall thickness, cavity size andregional/global systolic function are normal (LVEF >55%). There is lateral subluxation of the distal phalanx of the 2nd toe relative to the middle phalanx. 2. 2. There is a lateral subluxation of the distal phalanx in the 2nd toe relative to the middle phalanx. 7:34 PM FOOT AP,LAT & OBL LEFT Clip # Reason: Concern for fracture of 2nd digit. 3. REASON FOR THIS EXAMINATION: Concern for fracture of 2nd digit. TARGETED RIGHT UPPER QUADRANT ULTRASOUND TO EVALUATE THE MAIN PORTAL VEIN: Grayscale, color, and Doppler ultrasound was used to assess the main portal vein as requested. WET READ: SPfc SUN 8:10 PM No fracture. | 8 | [
{
"category": "Radiology",
"chartdate": "2169-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1148856,
"text": " 9:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with alcoholic cirrhosis, admitted with altered mental status,\n possible evolving sepsis\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with alcoholic cirrhosis.\n\n Portable AP chest radiograph was compared to .\n\n There is interval development of left retrocardiac opacity that is worrisome\n for interval development of infectious process. Lung volumes remain low, but\n the lungs are otherwise clear. There is no appreciable pleural effusion.\n There is no pneumothorax. Cardiomediastinal silhouette is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1148800,
"text": " 2:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver disease, mental status changes, fall\n REASON FOR THIS EXAMINATION:\n Acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc FRI 4:03 PM\n no acute abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change in a patient with liver disease.\n\n TECHNIQUE: Axial CT images were acquired through the head without intravenous\n contrast. Coronal and sagittal reformatted images were also reviewed.\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect or vascular\n territorial infarction. Ventricles and sulci are normal in size and in\n configuration. There is no fracture. Small amounts of gas are seen in the\n cavernous sinus bilaterally, presumably related to intravenous catheter.\n Small mucus retention cyst is seen inferiorly in the right maxillary sinus and\n there is a small amount of aerosolized secretions seen in the frontal sinus on\n the right.\n\n IMPRESSION:\n 1. No acute intracranial abnormality.\n 2. Small locules of gas in the cavernous sinus bilaterally. This is most\n likely related to peripheral intravenous catheter.\n 3. Paranasal sinus disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-07 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 1148791,
"text": " 1:58 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LLE SWELLING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver dx, swollen left leg\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n WET READ: CXWc FRI 3:19 PM\n No LLE DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man with end-stage liver disease and swollen left\n leg.\n\n COMPARISON: None.\n\n LEFT LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler ultrasound was\n used to evaluate the left common femoral, superficial femoral, popliteal and\n calf veins. There is normal compressibility, flow and augmentation.\n\n IMPRESSION: No evidence of left lower extremity DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-07 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1148792,
"text": " 1:59 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Eval for portal venous thrombosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 y/o M end stage liver disease\n REASON FOR THIS EXAMINATION:\n Eval for portal venous thrombosis\n ______________________________________________________________________________\n WET READ: CXWc FRI 4:02 PM\n Targeted, limited evaluation of the main portal vein shows the suggestion of\n nonocclusive filling defect at the porta hepatis, although with a normal\n waveform and velocity 40 cm/s just before the filling defect. Overall the\n study is not adequate for evaluation of the hepatic vasculature and dedicated\n liver Doppler ultrasound recommended.\n WET READ VERSION #1 CXWc FRI 3:22 PM\n Targeted evaluation of the main portal vein shows nonocclusive filling defect\n at the porta hepatis, with a normal waveform and velocity 40 cm/s just before\n the thrombus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with end-stage liver disease. Evaluate for\n portal venous thrombus.\n\n COMPARISON: .\n\n TARGETED RIGHT UPPER QUADRANT ULTRASOUND TO EVALUATE THE MAIN PORTAL VEIN:\n Grayscale, color, and Doppler ultrasound was used to assess the main portal\n vein as requested. At the porta hepatis, there is an apparently nonocclusive\n filling defect within the main portal vein. There is wall-to-wall color flow\n just proximal to the focus of thrombus, with a velocity of 40 cm/sec,\n demonstrating hepatopetal flow.\n\n There is a moderate amount of ascites.\n\n IMPRESSIONS:\n 1. Focal, apparently nonocclusive filling defect in the main portal vein at\n the porta hepatis, with hepatopetal flow just proximal, with a velocity of 40\n cm/sec. This could represent nonocclusive thrombus, or could be artifact.\n Recommend dedicated liver Doppler evaluation.\n\n 2. Moderate ascites.\n\n Change in wet read discussed with at 3:45pm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-09 00:00:00.000",
"description": "L FOOT AP,LAT & OBL LEFT",
"row_id": 1149057,
"text": " 7:34 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: Concern for fracture of 2nd digit.\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with LLE cellulitis.\n REASON FOR THIS EXAMINATION:\n Concern for fracture of 2nd digit.\n ______________________________________________________________________________\n WET READ: SPfc SUN 8:10 PM\n No fracture. There is a lateral subluxation of the distal phalanx in the 2nd\n toe relative to the middle phalanx. Mild degenerative changes noted in dorsal\n mid-foot.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Three views of the left foot .\n\n COMPARISON: None.\n\n INDICATION: Concern for fracture of second digit.\n\n FINDINGS: Dorsal soft tissue swelling. No ankle effusion identified. No\n definite fractures. No dislocations. There is lateral subluxation of the\n distal phalanx of the 2nd toe relative to the middle phalanx. A\n well-corticated ossific fragment is seen lateral to the second toe PIP joint,\n likely representing sequelae from prior trauma. Mild talonavicular dorsal\n spurring. Mild degenerative changes of the tibiotalar joint with joint space\n narrowing and tiny osteophytes.\n\n IMPRESSION: No acute fracture identified.\n\n"
},
{
"category": "Echo",
"chartdate": "2169-07-08 00:00:00.000",
"description": "Report",
"row_id": 88172,
"text": "PATIENT/TEST INFORMATION:\nIndication: Volume overload\nHeight: (in) 75\nWeight (lb): 240\nBSA (m2): 2.37 m2\nBP (mm Hg): 120/58\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 13:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: 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. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The diameters of aorta at the sinus, ascending and arch levels are\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. Trace aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , no major change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2169-07-07 00:00:00.000",
"description": "Report",
"row_id": 232880,
"text": "Baseline artifact. Sinus rhythm with borderline sinus bradycardia. Possible\nleft ventricular hypertrophy. Non-specific ST-T wave change with QTc interval\nprolongation. Compared to the previous tracing of voltage criteria for\nleft ventricular hypertrophy are not as apparent. QRS axis is not as leftward\nand repolarization prolongation is again noted. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-07-08 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1148893,
"text": " 7:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: ALCOHOLIC CIRRHOSIS,ABD PAIN,EVAL FOR PV THROMBOSIS\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n WET READ: ENYa SAT 8:39 AM\n Unchanged exam from yesterday.\n ______________________________________________________________________________\n FINAL REPORT\n DUPLEX DOPPLER ABDOMEN\n\n INDICATION: Alcoholic cirrhosis, abdominal pain, evaluate for PV thrombosis.\n\n FINDINGS: This study was performed on . Surveillance showed\n there was no dictation attached to this study, therefore it was dictated on\n .\n\n Moderate amount of ascites. Limited visualization of the liver. The\n visualized portal vein is patent, with no definite thrombus seen. Normal\n waveforms demonstrated.\n\n IMPRESSION:\n No convincing evidence of a portal vein thrombus.\n\n"
}
] |
7,939 | 125,516 | The patient was admitted to the TSICU s/p his motorcycle crash. He was emergently taken to the operating room on for incision and drainage of his right tibial plateau and spanning ex-fix. See operative note for details. He returned to the TSICU post-operatively. He remained intubated secondary to his poor respiratory status. On he was taken to the operating room for ORIF of his right acetabulum and R gamma nail. See operative note for details. He returned to the TSICU post-op and remained intubated. On he was brought to the operating room for ORIF of his right tibial plateau. He returned to the TSICU post-op. The patient developed fevers in the TSICU. This was attributed to pneumonia. He was placed on vancomycin and ceftazidime as recommended by infectious disease. On he was extubated without incident and transferred later in the day to the floor without incident. On he was transferred to the orthopedic service from the trauma service. On he was taken to the operating room with spine service for fixation of his sacral fractures and L4 fracture. See operative note for details. He was extubated and brought to the recovery room in stable condition. Once stable in the PACU he was transferred to the floor. On an IVC filter was placed by vascular surgery. On the floor he did well. He worked with physical therapy and progressed well. He received tranfusions for post-operative anemia and his electrolytes were repleted. On he was brought to the operating room for revision of his right gamma nail and VAC placement of his . He tolerated this well. His labs and vitals remained stable. His hospital course was otherwise without incident. He is being discharged today to rehab in stable condition. | clear with minimal secreations.abgs:hyperoxygenated with otherwise normal parameters.PlaN: to OR for right leg/pelvis fx. Vented/sedated/stabilized. +cap refill, csm. Resp CarePt. Abd soft non tender.GU- u/o adeqSkin- RLE in splint with DSD, externally rotated.Drsg by . Mod general edema. Palp pedal and PT pulses with good CSM to BLEs. Right DP pulse dopplerable and Right PT, DP and PT palpable. Has left sublcavian cordis w/CCO swan. See carevue for exacts. ABP stable, drsg . Hypo BS. NIL SUCTIONED VIA OG IN OR. Mild (1+) mitralregurgitation is seen.3. Tube moved and reCV: Temp up to 102.3 orally. Promote w/ fiber via OGT started and advanced slowly R/T hypo BS. #8.0 ETT 24 @lip. Using IS with RN. Foley patent with adeq UO. ON PROPOFOL AND FENTANYL.RESP: VENTILATED. BS sl decreased, rel clear bilat. Right radial arterial line dampened, highly positional; d/c'd. Chest CT from reveals "bilat opacities".plan: cont vent support. F/U with TEE report. Tylenol administered via OGT. Gaze is deviated up and left: PERRLA.CV: NSR, ST freq MFVEA, 80's-100's. Using PCA with effective relief.Resp: Lung sounds clear, equal bilaterally, diminished bibasilar. LS CTA. PAS/D 36/18 -> 44/28, Wedge pressure this a.m. 3. Repositioned and re-taped. Anterior, septal, apical and inferior hypokinesis ispresent with some preservation of lateral wall motion.2. Right triple lumen CVL in place, CVP transducing sharply, generally . and Crt wnl.Endo: Bld sugars 120-160's corrected with RISS. PT STABLE. follow hct, cont sedation, awaiting or. Adeq amts of output. EPi off immediatly. ABG -resp alkalosis with normal oxygenation.Lungs dim LLL, coarse on R consistent with new opacity on R per CXR.Sxd mod amts thick tan sputum. ABGs consistent with resp alkolosis. LOWER ABD INCISION WITH STAPLES INTACT. 07-1400See carevue for objective data.Remains sedated on proprofol/fentanyl gtt. Left fields CTA.GI: abd softly distended; BS hypoactive. Repeat Pan cultured.OR with Dr cancelled.RESP:Remains orally intubated tolerating minimal settings. abg acceptable, slightly hypercarbic, compensated.cv: bp labile w/ stimulus, settles quickly at rest. Right a-line, RSC T/L clean. ANTERIOR LOWER LEG SUTURED SITE CLEAN- APPLIED XEROFORM/DSD. lytes repleted prn.gi: belly large, soft, bs present. Right leg remains in immobilizer; sang ooze lateral lower leg. TSICU NSG PROGRESS NOTE 11P-7A/ S/P MVAS- INTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE- HR- 100-114 ST, MINIMAL VEA. SX FOR THICK WHITISH SPUTUM- SMALL AMT.LUNG SOUNDS CL- DIM AT BASES.ID- AFEBRILE THIS SHIFT- 100.6-99.9 PO- REMAINS ON KEFZOL/GENT FOR (+) SPUTUM CULTURE AND S/P OR. Agressive bronchial hygeine...? ABG's cont resp alkalosis, adequate oxygenation. HCT 23.8 , UNCHANGED FROM THIS AM.RESP--SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. Right leg dsg D/I; splint maintained in place. Will squeeze and release and repeat, and is spontaneously localizing to ETT when not restrained.HEMODYNAMICS:ST most of day. TO GO TO OR TODAY FOR INTERNAL FIXATION OF TIB/FIB AND REMOVAL OF EXTERNAL DEVICE.PT HCT DOWN TO 23.3 FROM 24-25- HO AWARE- NO TRANSFUSION CURRENTLY.LOWER EXTREMITY PULSES (+) PALP OR DOPPLERABLE BILATERALLY.MS/ PT SLIGHTLY LIGHTER ON LESS SEDATION AS COMPARED WITH PREVIOUS NEURO ASSESSMENT BY REPORT, PREVIOUS SHIFT.- REQUIRING SOME BOLUS WITH TURNING/PIN CARE/PAINFUL INTERVENTIONS. suprapubic dsg d+i, rle immobilizer in place, dg serous dge from dsg, hemovac in placeID- temp to 102, pan cx. Right hip with small to mod amt of serous drainage. minimal residualsGU- foley indwelling/patent. Sinus rhythm with ventricular premature complexesLeft atrial abnormalityEarly precordial QRS transition - is nonspecificModest nonspecific low amplitude lateral T wave changesSince previous tracing of , lateral T wave amplitude lower filling pressures stable, co/ci . reinforced scheduled visiting hours.a: hemodynamics stable, comfortable w/ fentanyl, sedation. Sinus tachycardiaVentricular premature complexLeft atrial abnormalityModest low amplitude lateral T waves - are nonspecific and may be within normallimitsSince previous tracing of , ST-T wave changes decreased good strength in upper extremities, resists movement .CV- SR-ST w/pain, BP up to 170's w/pain, 120-140's @rest. Resp Care Note, Pt remains on current vent settings. Aline dampened, better after dsg change- gd waveform. cardiac meds restarted yest. Wean sedation as tolerated. ^ ectopy towards end of shift, mgso4 2 gm for mg=1.9pulses positive, palpable despite edema.boots in place.TLC in place, site unremarkable. Resp CarePt. to monitor filling pressures, vs, hct. lytes repleted prn. Again seen are right sacral fractures, comminuted right femoral, iliac, and superior pubic ramus fractures, and fixation hardware, which somewhat obscures evaluation of the lower pelvis structures. cont to w/u temps, follow cx Tiny foci of air are identified in the region of the hardware, related to expected postoperative change, if recent. CT PELVIS WITH IV CONTRAST: Sigmoid diverticulosis is seen, without diverticulitis. Continues on kefzol, clinda and gentamycinSkin: RLE dressing changed by ortho, hemovac d/c'd. abnormality FINAL REPORT INDICATION: Trauma, extubated, not diaphoretic and tachycardic. (Over) 11:58 CT LOW EXT W/O C RIGHT Clip # Reason: r/o fx tib plateau FINAL REPORT (Cont) There is a comminuted fracture of the proximal diaphysis of the fibula. Right sacral fracture and rt L5 transverse process fracture. Fracture of the right side of the sacrum and transverse process of L5 is noted. Proximal fibular diaphyseal fracture. The location of hematoma is extraperitoneal. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # Reason: ORIF RT.TIBIAL PLATEU FX FINAL REPORT HISTORY: Fracture fixation. These demonstrate portions of an right femoral intramedullary rod and extensive hardware in the proximal right tibia, which is incompletely visualized. | 72 | [
{
"category": "Echo",
"chartdate": "2152-06-13 00:00:00.000",
"description": "Report",
"row_id": 78180,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 69\nWeight (lb): 230\nBSA (m2): 2.19 m2\nBP (mm Hg): 103/51\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Moderately\ndepressed LVEF.\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. Mild (1+) MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition.\n\nConclusions:\n1. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is\nmoderately depressed. Anterior, septal, apical and inferior hypokinesis is\npresent with some preservation of lateral wall motion.\n2. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen.\n3. There is no pericardial effusion.\n4. Compared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-12 00:00:00.000",
"description": "Report",
"row_id": 1368044,
"text": "Admission note:\n\nInvolved in Motor cycle crash earlier this evening. Alert and oriented in ED. Right open tib/fib, right acetabular and femoral neck fxs.\n\nReceived from OR post Xfix application to right open tib/fib fx. Became hemodynamicly unstable in OR, case ended and brought to room. Still needs to have right acetabular fx and femoral neck repair done.\nOn epi w/SBP >200 and HR 130's. EPi off immediatly. Anasthesia admin 100 mcg of fentanyl and SBP lowers to 150-160.\n\nROS:\n\nNeuro: Sedated on propofol. Fentanyl gtt at 100 mcg. Prior to starting fentanyl was beginning to awaken, eyes opened to voice, lifted head off bed, and some movement of both arms noted before fentanyl begins to work. PEARRLA. C collar inplace. Log roll and spine recautions maintained.\n\nCV: Sinus tach w/PVCs, pairs, multifocal. S1S2. Has left sublcavian cordis w/CCO swan. PAs 35-40s/20's. CVP 3. SVO2 75 or >. Has left radial abp line. Peripheral pulses palpable w/great ease in all 4 extremities. P boots and heparin sub q for DVT prophylaxis.\n\nResp: Orally intubated and on vent. Fio2 weaned to 40%. ABGs w/metabolic acidosis. Tx w/1 liter of NS, with improving acidosis.\nLung sounds clear. No resp distress noted, = rise and fall of chest. Sats 100%.\n\nGI: Oral sump placed, positioned verified to be correct via instillation and auscultation of air bolus. H2 blocer orderd for GI prophylaxis.\n\nGu: Foley patent draining clear yellow urine in QS.\\\n\nENDO: FSG covered w/RSSI.\n\nLabs: Mag and IC need repletion, awaiting orders.\n\nSocial: Mother waiting to visit.\n\nPlan: Correct metobolic acidosis. Monitor CMS checks to RLE. Pulmonary toileting. Clear TLS and C spine. Mobilization. Pain control. Monitor, tx, support, and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-12 00:00:00.000",
"description": "Report",
"row_id": 1368045,
"text": "Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS sl decreased, rel clear bilat. Sx'd for small amts thick yellow sputum. Most recent ABG reveals metabolic acidosis w/ hyperoxia. No vent changes made this shift. Chest CT from reveals \"bilat opacities\".\nplan: cont vent support. Pt to return to OR possibly tomorrow. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-12 00:00:00.000",
"description": "Report",
"row_id": 1368046,
"text": "NPN 7a-7p \n\n41 y.o. male s/p MCC -> Pt struck by car on right side, thrown over handle bars, noted to have landed on his back. No LOC, but known confusion after accident. Admitted to OSH (), then transfer to . DX: Tib/Fib fracture, and acetabular/femoral neck fracture, with L 5 transverse process fx.\n\nROS:\n\nNeuro: Pt sedated throughout day on Propofol 40mcg/kg/min and fentanyl gtt at 50mcg/hr. Lightened for daily wakeup/neuro checks. Pt opening his eyes to verbal stim, pupils equal and briskly reactive @ 2-3mm. Pt following commands consistently, appropriately nodding yes and no to questions asked by this RN. Pt is able to lift and hold UE's and LLE. Moves RLE on the bed d/t injury. At times agitated with wakeups, pt settles with verbal reassurance. Pt on Fentanyl for pain. Increased as able to tolerate for adequate pain control. Currently at 75 mcg/hr of Fentanyl with adeq pain relief. Cerv collar on, logroll dc'd by ortho team.\n\nCV: ST 105-113 with frequent ectopy, multiple PVC's. Was seen here back in for possible ICD plcment. s/p cardiomyopathy with low EF 10%, 35% at last follow up appt. with cardiology. Arterial Line to left hand, zero'd and re-leveled. SBP 99-121/60-70's correlating well with NBP. PAS/D 36/18 -> 44/28, Wedge pressure this a.m. 3. Dr. aware of difficulty wedging. SVO2 70's. PA line measured at 56. EDVI 90-140. Positive pulses bilaterally, easily palpable. +cap refill, csm. sc heparin and PB's for DVT prophylaxis.\n\nResp: O2 sats 97-99% on 40% FIO2. #8.0 ETT 24 @lip. Repositioned and re-taped. Current vent settings-> AC 40% FIO2/ 5 Peep/700x12, pt is breathing up to 3 breaths over the settings. Sux'd today for min amts of thick white/yellow secretions. Oral mucosa intact, frequent mouth care. LS CTA. Pt initially with metabolic acidosis, improved throughout shift. Last ABG's 7.34/40/160/23\n\nHem: HCT 31.9 PLT 173 WNL PT 12.6/PTT 23/INR1.1\n\nAccess: Left 16 gauge PIV / L-art line/ LSC PA line with Cordis/ Right 16 gauge PIV. Field Iv's d/c'd\n\nGI: Pt is on Pepcid q12 hrs. OGT to LCWS with very minimal output. Plcmt checked via air injection/auscultation. Abd softly distended. No bowel sounds present this a.m. now very hypoactive. No feeds started as of yet. No stool.\n\nGU: U/o via catheter, yellow with no sediment. Adeq amts of output. Last Potassium 4.5, Mag 2.4 after 4gm repletion. Lactic acid trending down since admission currently 2.3 from 2.8. Calcium Gluc 2 gms repleted. and Crt wnl.\n\nEndo: Bld sugars 120-160's corrected with RISS. No hx of diabetes\n\nID: Tmax 100.3 via swan. No anbx ordered at this time. WBC 14.4\n\nSKIN: Skin intact. No breakdown to buttocks. X-FIX to RLE with 10 lb wt added to traction. Ex-fix draining mod-lg amts of sanguinous drainage, wrapped with ace wrap. Aspen collar on at all times. Collar care completed.\n\nSocial: Pt lives with his girlfriend. Family in to visit today. Mom is the next of , in to visit today, calls for updates. Affect/quest\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-12 00:00:00.000",
"description": "Report",
"row_id": 1368047,
"text": "(Continued)\nions appropriate. Emotional support provided.\n\nAct: Pt was clr'd from logroll per Icu/ortho team. Pt is able to have hob no > than 45 degrees (for comfort reasons with acetabular fx). Turn and position through day.\n\nA: 41 y.r. old male s/p MCC. Vented/sedated/stabilized. Hemodynamically stable. Ex fix for tib/fib fx this am, awaiting OR for acetabular/femoral head fx\n\nP: Pt to have surgery for unstable femoral neck fx, possibly tues/wed. Monitor neuro, hemodynamics, pain. Initiate vent wean post surgery. Monitor hemodynamics/resp status. Monitor ex-fix/surgical site. CSM. Maintain safety. Provide emotional support to patient and family. Social work to consult in a.m.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-13 00:00:00.000",
"description": "Report",
"row_id": 1368048,
"text": "Resp Care\nPt. remains intubated overnight w/o change.\nBs: ess. clear with minimal secreations.\nabgs:hyperoxygenated with otherwise normal parameters.\nPlaN: to OR for right leg/pelvis fx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-13 00:00:00.000",
"description": "Report",
"row_id": 1368049,
"text": "t-sicu nsg note:\nneuro- pt remains sedated on fentanyl gtt @ 75mcg/hr and propofol gtt @ 40mcg/kg/min, he responds to voice, follows commands occ becomes restless to voice and care but quickly settles w/ reassurance. perrla 3mm brisk, strong cough, lifts ue's and lle off bed, moves rle on bed.\n\nresp- sxn infreq for sm amts of thick yellow secretions, vent settings unchanged a/c 40% 700x12 peep of 5, spont resp . bs cta, met acidosis resolved.\n\ncvs- fp's wnl, ci>3.5, svo2=71-73% pcwp 9, cvp 5-11, sbp 106-130's, hr 102-110 nt w/ up to 28 pvc's per min multifocal and in triplets.lytes wnl K+ 4.1, mg 2.0, Lr infusing @ 125cc/hr. hct 22\n\n\ngi- ogt drained scant amt clear fluid, abd soft,obese, no flatus, no stool, bs hypoactive.\n\ngu- foley patent for ~60cc cyu/hr\n\nskin- intact behind collar and back side, sm abrasion to r shin covered w/ bacitracin and 2x2, rle in 10 lbs skeletal traction via xfix, ace wrap soaked and draining mod amt sanguinous drainage.\n\nendo- no riss required.\n\nsocial- mother called twice, looking for info regarding or plans for today.\n\na: stable on present settings\n\np: monitor cvs/nms per routine, cont to assess volume and electrolyte status. follow hct, cont sedation, awaiting or.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-13 00:00:00.000",
"description": "Report",
"row_id": 1368050,
"text": "Respiratory care\npt on the vent tol well no changes made. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-13 00:00:00.000",
"description": "Report",
"row_id": 1368051,
"text": "NPN 0700-1900\n Pt is a 41 yo s/p MCC hit on R side by car and thrown over handlebars per report.\n Injuries included: R extensive communicated and displaced R fem neck fracture, multiple fractures of acetabulum and pubi rami, transverse process L5 fx, fracture line through sacrum. Hematoma and soft tissue swelling around fractures, hematoma anterior bladder, right open tib/fib. compression fx of T4.\n Hospital course complicated by preexsisting cardiomyopathy.\n\n Pt is sedated on fentanyl and propofol with good effect. When lightened on propofol he FCs and MAEs consistently. Lifts arms and head off bed. Nods no to pain and follows voice with gaze. PERLA.\n\nResp- No vent changes made and ABGs WNL. Small thick yellow ETT secretions. Lungs clear to auscultation. No signs/symptoms pulm edema.\n\nCV- SR-ST with freq ventricular ectopy. Swan in place, see carevue for #s. TEE done, final report pending. Afebrile. HCT dropped from 22.4 to 20.9. BG 105x2. Received 2u PRBCs over several hours. Palp pedal and PT pulses with good CSM to BLEs. Cap refill<3s. Mod general edema. Skin w/d. dressing changed on R calf. Suture intact. Had been oozing mod amt sang drainage throughout day. After dressing change at 1600 no further drainage.\n\nGI/GU- Abd soft, distended. Hypo BS. OGT to LWS with scant drainage, auscultate air in abd. Foley patent with adeq UO.\n\n Mother at bedside most of day. Updated by RN, Dr and ortho team. Asking appropriate questions and support provided.\n\nPlan- Cont serial HCts. Monitor resp status for s/s pulm edema. F/U with TEE report. Cont to provide support to family. Plan for OR in am tomorrow with Dr .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-16 00:00:00.000",
"description": "Report",
"row_id": 1368064,
"text": "1445-1900\nSEE CAREVUE FOR VITAL SIGNS.\n\nPT WENT TO OR @ 1455 RETURNING @ 1820. PT STABLE. NO SIGNIFICANT EVENTS IN OR.\n\nNEURO: SEDATED ON PROPOFOL.\n\nCV: HYPERTENSIVE. ON PROPOFOL AND FENTANYL.\n\nRESP: VENTILATED. +++ GREEN/BROWN SECRETIONS SUCTIONED. SATS 99-100% SINCE RETURN.\n\nGI: TUBE FEED TO BE RECOMMENCED. NIL SUCTIONED VIA OG IN OR. NOW TO LWS.\n\nGU: ADEQUATE U/O.\n\nSOCIAL: PTS MOTHER UPDATED BY RN RE: SURGERY AND IS VISITING PT AT PRESENT. SHE HAS NOT SPOKEN WITH MD .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-17 00:00:00.000",
"description": "Report",
"row_id": 1368065,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes made overnight. BS's coarse at times, diminished on LLL. Sxing thick tan/bloody secretions. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-17 00:00:00.000",
"description": "Report",
"row_id": 1368066,
"text": "Respiratory Care (Addendum):\nChanged to CPAP/PSV support mode per team. ABG's to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-17 00:00:00.000",
"description": "Report",
"row_id": 1368067,
"text": "NPN, 1900-0700\nneuro: lightly sedated on propofol and fentanyl gtts. Arouses to voice w/ open eyes. Follows commands slowly. MAE. Gaze is deviated up and left: PERRLA.\n\nCV: NSR, ST freq MFVEA, 80's-100's. K+ repleted aggressively. Pulses + by Doppler signal.\n\nPulm: orally intubated on AC overnoc; weaned to CPAP/PS 5/5 x 50% w/ excellent ABG's. Copious thick tan secretions. Weak cough and gag.\nBS course through, distant bases.\n\nGI: abd softly distended, hypo BS. No flatus or stool. Promote w/ fiber via OGT started and advanced slowly R/T hypo BS. Min residuals.\n\nGU: F/C urine clear amber, adequate OP. RF labs WNL\n\nskeletal: No pressure areas; skin grossly intact. Right hip stapled incisions C/D, Clear serous drainage from most distal. Right leg encased in aces and immobilizer, draining large amount serous from hemovac site, which is draining bloody fluid. CSM right leg intact.\n\nEndo: RISS, no coverage needed.\n\nID: WBC WNL; Tmax 100.7, po. Cont on gentamycin and cefazolin.\n\nP: wean and extubate. Restart pre-adm cardiac meds. Maintain right leg immobilizer at all times..DO NOT REMOVE or manipulate at all, per Ortho. Advance TF to goal. aggressive pulm toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-17 00:00:00.000",
"description": "Report",
"row_id": 1368068,
"text": "Respiratory Care Note\nPt received on PSV 5/5 as noted with VT 700-1000 and RR 15-25. BS essentially clear with good aeration. SBT 5/0 done VT 722 and RR 18 with a RSBI of 25. Pt taken to CT scan for head secondary to Pt weaned off sedation, but not waking. Plan to remain intubated on PSV at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-22 00:00:00.000",
"description": "Report",
"row_id": 1368089,
"text": "NPN 7a-7pm \n\nROS:\n\nN- A & Ox3, generalized weakness from decreased activity to ext's but moves all except RLE. RLE-> Injured leg. Pupils = reactive at 4mm\nDenies HA. Pt weaned off Propofol and Fentanyl. Pt started on Morphine PCA 1.5/6/15. Cerv collar clr'd this evening\n\nCV- SR-ST, Hr occasionally up to 110-120 with agitation/increasing temps. See carevue for exacts. Ocassional PVC's. ABP stable, drsg . Pos pulses, good CSM, warm/nml in color. Venodynne to LLE only.\n\n Pt extubated, on a humidified shovel mask with adeq saturation. Lungs clr in upper airways, decreased in bases. Using IS with RN.\n\n PT on a house diet. Tolerating Liquids no aspiration noted. Positive BS, denies n/v. Abd soft non tender.\n\nGU- u/o adeq\n\nSkin- RLE in splint with DSD, externally rotated.Drsg by . Site to right hip and abd with staples.\n\nSoc: family in to visit patient.\n\nEndo- RISS, no insulin needed.\n\n Pt spiked over noc, low grade temps today. Plan for OR when temps decreased. Pt on vanco and Ceftaz.\n\nLytes: WNL no repletion needed\n\nA: Pt extubated today, tolerating extubation. Stable. Collar clr'd\n\nP: Monitor overnight, monitor resp status, possible transfer to floor if stable tomorrow. Provide emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-23 00:00:00.000",
"description": "Report",
"row_id": 1368090,
"text": "T/SICU Nursing 19-07\nNeuro: Alert, oriented to hospital, accident, self; disoriented to exact date, city. At times makes bizarre statements. Pupils 4mm, equal, round, briskly reactive. MAE purposefully and to command; can only wiggle toes on injured RLE.\n\nPain: Complaining of pain in RLE with movement only. Using PCA with effective relief.\n\nResp: Lung sounds clear, equal bilaterally, diminished bibasilar. Coughs but swallows sputum. Using IS with encouragement. SPO2 high 90's on 4L NC. Denies dyspnea.\n\nCV: Sinus tachycardia with rate 98-119, frequent VEA including bigeminy. SBP generally low 100's-one teens. 5mg lopressor given x1 as ordered with no effect on HR, however did lower SBP temporarily to high 80's. Palpable pulses in all extremities. Right radial arterial line dampened, highly positional; d/c'd. Right triple lumen CVL in place, CVP transducing sharply, generally . Pboot on left leg, on lovenox sc. Stable anemia hct 24.7.\n\nGI: Abdomen softly distended vs obese; complaining of constipation, given dulcolax PR and colace; had one large soft brown BM at 4am. Diminished appetite.\n\nGU: Foley to gravity draining clear yellow urine in adequate amounts.\n\nEndo: RISS with no coverage required.\n\nLytes: No repletions indicated.\n\nSkin: Intact, surgical incisions clean and dry with staples OTA.\n\nID: Tmax 101.5->100.0 **WBC 26.1 from 18.4**\n\nSocial: Numerous family visitors in early evening.\n\nPlan:\nMaintain safety\nPain management\nPulmonary toileting\nAdvance diet as tolerated\nNotify team of acute changes\nAwaiting surgery with orthopedics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-15 00:00:00.000",
"description": "Report",
"row_id": 1368058,
"text": "NPN: Review of Systems\nNeuro: Sedated w/ propofol and pain managed w/ fentanyl. Doses increased over the coarse of the day. Pt had nodded \"yes\" when asked if he was in pain. Propofol turned off to assess neuro status-> Pt followed commands; wiggled toes, stuck out tongue and squeezed hands. Strong productive cough.\n\nResp: Secretions increased throughout the day. Copious amts of thick yellow secretions. Sao2 dropped to low 90s, HR up to 140s-> relieved after suctioning and PS increased to 10. Gentamicin started for gram (-) rods in sputum. Oral sore present on left corner of mouth. Tube moved and re\n\nCV: Temp up to 102.3 orally. Blood and urine cultures sent. Sputum pending. Tylenol administered via OGT. Sinus tach w/ PVCs. Blood pressure has been stable this shift. Please see flowsheet for further data and assessment. Right DP pulse dopplerable and Right PT, DP and PT palpable. to touch. PA line rewired to triple lumen. Tip cultured. X-ray confirmed placement. A-line changed d/t clotting of previous one.\n\nGI: D51/2 NS w/ 20meq KCl infusing at 80cc/hr. Promote w/ fiber to be started at 20cchr. Green fluid via OGT.\n\nEndo: Blood sugar=132-> no insulin coverage per sliding scale.\n\nHeme: HCT=24.7 from 25.\n\nID: Febrile as noted above and cultures pending. Continue w/ antibiotics.\n\nSkin: No presssure wounds present. Abdominal and hip dressing dry and intact. RLE dressings changed d/t serous drainage.\n\nSocial: Mother in by bedside. Provided consent for Dr. surgery which is anticipated to occur on monday.\n\nA: Febrile.? lungs source. Hemodynamics stable.\n\nP: Or tomorrow for leg to be fixed and monday for lower back. Start TF at 20cc/hr and make NPO after MN. Suction as needed. Sedate/maintain comfort. F/U w/ culture results. gentamicin trough level prior to 2nd dose. HCT to be drawn at 6pm.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-15 00:00:00.000",
"description": "Report",
"row_id": 1368059,
"text": "Respiratory Care: Pt remains on current vent settings, see carevue for details. Sxing tan/rusty secretions. No vent changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-15 00:00:00.000",
"description": "Report",
"row_id": 1368060,
"text": "T/SICU NPN: 1500-2300\nS/O: System Review:\n\nNeuro: sedated on propofol and fentanyl drips overall more sedated\nno eye opening to stimuli pupils pinpoint no gag no cough\nwithdrawing all extremities to nailbed pressure fentanyl decreased to 100mcg/hr(from 140mcg/hr) and propofol weaned to 35mcg/kg/min(from 50mcg/kg/min) now, opening eyes to voice/stimuli eyes deviated upwards pupils 2mm with brisk reaction continues to withdrawl to nailbed pressure not following commands tends to stiffen extremities/body with stimulation gag/cough minimal c-collar remains on\n\nCVS: HR 120's>>>100's NST with multi-focal PVC's SBP 100's\nSBP up with stimulation as high as 170's a-line wired over by\nDr. CVP 8-11 LE: + palpable pedal pulses skin warm to touch with brisk capillary refill\n\nRespiratory: remains orally intubated and ventilated on PSV PS=10\nPeep=10 Fio2 50% RR 8-12 TV's 900-1200's Sao2 > 96%\nABG: 140-46-7.40-30+3 lungs clear, decreased at bases suctioned\nfor scant to small amounts of thick yellow-tan secretions\n\nRenal: foley patent and draining clear yellow urine 80-250cc/hr\nK+ 3.7 repleted with 20meq kcl D51/2NS w/20meq KCL at 80cc/hr\nMg++ 2.0\n\nGI: abdomen obese no bowel sounds no bm started on fs promote/fiber at 20cc/hr via ogt last residual 40cc(2hrs after starting tf's) on pepcid\n\nEndrocrine: fs q6hrs fingersticks 112>>104 no insulin required\n\nHeme: HCT q8hr last HCT 25.7 started on lovenox heparin d/c\non pnuemoboots\n\nID: tmax 102.4 sent second set of blood cultures for re-wired a-line\ncontinues on kefzol and gentamycin gnr's in sputum\n\nSkin: right leg>>ex-fix on pin sites draining serous fluid pin care\ndone right shin laceration>>>sutured red with small amt of bloody drainage right hip and low pelvic dsg's dry/intact back and buttocks intact with no redness\n\nPyschosocial: mother called and updated on clinical situation and questions answered\n\nOR tomorrow: anesthesia/surgical consents obtained NPO after mid-night\n\nA: febrile awaiting culture results more sedated weaning sedatives\n\nP: continue to monitor above parameters check culture results\nto OR tomorrow for further orthopedic surgeries\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-16 00:00:00.000",
"description": "Report",
"row_id": 1368061,
"text": "TSICU NSG PROGRESS NOTE 11P-7A/ S/P MVA\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE- HR- 100-114 ST, MINIMAL VEA. AM K- 3.9- TO RECEIVED 20 KCL PER PROTOCOL. BP- 95/50-107/60.\nNO ISSUES CURRENTLY.\n\n PT REMAINS ON PRESSURE SUPPORT- 10/10 PEEP 50%- TIDAL VOLUMES 1 L - 1.3 LITERS, RESP RATE- . ADEQUATE VENTILATION/OXYGENATION-\nAM ABG- 7.39-49-148. SX FOR THICK WHITISH SPUTUM- SMALL AMT.\nLUNG SOUNDS CL- DIM AT BASES.\n\nID- AFEBRILE THIS SHIFT- 100.6-99.9 PO- REMAINS ON KEFZOL/GENT FOR (+) SPUTUM CULTURE AND S/P OR. TYLENOL X 1. WC- 11.2.\n\nGU- GOOD UO- 60-200CC/HOUR- (+) 1575 OVERALL I/O.\nCLEAR YELLOW URINE. REMAINS ON IVF AT 80CC/HOUR.\n\nGI- NPO AFTER MN- FOR OR TO FOLLOW CASE TODAY.\nHYPO TO ABSENT ABD SOUNDS-- BLOOD SUGARS Q 6 HOUR- NO INSULIN THIS SHIFT.\n\nLINES- NEW ALINE OVER WIRE FROM 6/1 L RADIAL, TLC LEFT IJ AS WELL.\n\nORTHO- S/P EXTERNAL FIXATION OF TIB FIB FX- PIN SITES CLEAN, MINIMAL REDNESS. ANTERIOR LOWER LEG SUTURED SITE CLEAN- APPLIED XEROFORM/DSD\n. TO GO TO OR TODAY FOR INTERNAL FIXATION OF TIB/FIB AND REMOVAL OF EXTERNAL DEVICE.\nPT HCT DOWN TO 23.3 FROM 24-25- HO AWARE- NO TRANSFUSION CURRENTLY.\nLOWER EXTREMITY PULSES (+) PALP OR DOPPLERABLE BILATERALLY.\n\n\nMS/ PT SLIGHTLY LIGHTER ON LESS SEDATION AS COMPARED WITH PREVIOUS NEURO ASSESSMENT BY REPORT, PREVIOUS SHIFT.- REQUIRING SOME BOLUS WITH TURNING/PIN CARE/PAINFUL INTERVENTIONS. , .\nREMAINS ON PROPOFOL GTT AND FENT GTT- NO CHANGE IN DOSES- SEE FLOWSHEET.\n\nA/ PT S/P FX OF MVA C/B FX TIB/FIB CURRENTLY REMAINS HEMODYNAMICALLY STABLE , ON VENTILATORY SUPPORT.\nNPO FOR AM OR PLANNED FOR INTERNAL FIXATION OF FX.\n\nCONTINUE TO CLOSELY MONITOR HEMODYNAMICS ESP IN SETTING OF UNDERLYING CARDIOMYOPATHY. HOLDING OFF TRANSFUSION CURRENTLY. CONSIDER GENTLE DIURESIS AS HEMODYNAMICS ALLOW IF I/O TRENDS TOO (+) OVERALL.\nPULM TOILET, SX/MAINTAIN AIRWAY AS NECESSARY.\nCONTINUE ANTIBX AS ORDERED.\nRESUME NUTRITION POST OP ONCE MEDICALLY APPROPRIATE.\nSKIN CARE/PIN CARE/COLLAR CARE PER T SICU STANDARD OF CARE.\nKEEP PT COMFORTABLE, FREE OF PAIN. FENT/PROPOFOL GTT CONTINUE.\nKEEP FAMILY AWARE OF CURRENT PROGRESS AND PLAN OF CARE.\nOR THIS MORNING/AFTERNOON AS PLANNED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-16 00:00:00.000",
"description": "Report",
"row_id": 1368062,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Latest abg results determined a compensated respiraotry acidemia with excellent oxygenation on the current settings.\n\nNo RSBI measured due to the level of PEEP currently required and the fact that the patient is scheduled for the OR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-16 00:00:00.000",
"description": "Report",
"row_id": 1368063,
"text": "07-1400\n\nSee carevue for objective data.\n\nRemains sedated on proprofol/fentanyl gtt. Opens eyes intermittingly\nto name being called.\nNo vent changes. Maintaining O2 sats. Minimal suctioning required.\nNSR/ST with frequent PVC's.\nNPO for OR this afternoon. SSRI per FSBS. Maintenance fluid continues.\nPin care done to lower extremities-large amount of serous fluid from pin sites. Both extremities swollen but with palpable pulses.\nGrimacing when turned with hypertension/tachycardia-fentanyl gtt increased to 150 mcg/kg/min with good effect.\nO/C to OR.\n\nContinue current POC.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-21 00:00:00.000",
"description": "Report",
"row_id": 1368083,
"text": "NPN, 1900-0700\nneuro: lightly sedated on propofol following eve of resp distres secretions w/ tachypnea, freq MFVEA. Responds to verbal when lightened. , . Follows commands inconsisitently. Med w/ ativan and morphine q4-5 hrs.\n\nCV: ST, freq MFVEA, mult brief salvos vtach, freq bigeminy. 12 lead EKG unchanged. HR 90's-140; CVP 9-14. SBP 90's-140's. Pulses palpable throughout.\n\nPulm: orally intubated on CMV 650 x 50% x 14 x 5. RSBI > 200. Copious thick tan secretions w/ sang clots. BS rhonchorous anteriorly, bronchial posteriorly w/ I/E wheezes. No vent changes. ABG's cont resp alkalosis, adequate oxygenation. Pt was labored, tachypneic, fatiguing until sedation restarted.\n\nGI: abd softly distended; BS hypo. +flatus, no stool despite dulcolax pr, MOM, colace. w/ fiber at goal, 85 cc/hr w/ min residuals.\n\nGU: F/C urine amber-->>clear yellow, adequate OP. RF labs cont WNL.\n\nskeletal: no pressure areas. Groins moist, pink, intact-->>miconazole powder. Hip wounds C/D. Right leg dsg D/I; splint maintained in place. Right a-line, RSC T/L clean. C-collar remains in place.\n\nEndo: RISS, no coverage required.\n\nID: Tmax 103.6, rectal, down to 100.2 after ice compresses, tylenol, ect. Started on vanco and ceftaz. WBC 15\n\nSocial: mult family members have vs and called.\n\nA: worsening resp failure..?ARDS bil pneumonia. ? septic picture evolving. Sluggish GI function.\n\nP: ?bronch. ? maintain sedation until weanable. ?start reglan.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-21 00:00:00.000",
"description": "Report",
"row_id": 1368084,
"text": "T/SICU NURSING PROGRESS NOTE 0700-1900\nNeuro--remains sedated on propofol 30 mcg/kg/min. Medicated with 6-10 mg iv MSO4 q2hr for leg pain. Facial grimace with increase in HR,RR with any movement of BLE. Pt nods head inconsistently to simple questions. Squeezes hands and wiggles toes to command. Pupils 4-5mm and reactive. Also received Ativan 2mg x1.\n\nCardiac--HR SR/ST with frequent multifocal PVC's. SBP 120-150/80's. CVP-.\n\nResp--No vent changes done. Bilateral breath sounds range from clear to bronchial->rhoncherous. Sx q2 hrs for moderate amts of tan thick sputum. No ABG's drawn as pt's VS have not changed and SaO2 is >98% on 50% FiO2. CPT given x2. No bronch done today.\n\nGI--Tolerating tube feeds at goal. HO disimpacted pt today and pt has stooled x2 in small amts. Hypoactive BS. Min. tube feed residuals.\n\nGU--foley cath patent draining >80 cc hr of yellow urine.\n\nENDO--SSRI coverage given and needed x2. Last BS 120. No lytes drawn at this time.\n\nSKIN--R leg brace removed and dressing changed by ortho. Sutures are intact. There is a couple of areas of maceration around bone puncture site. DSD applied and brace placed back on. Buttocks and back without breakdown. Turned q2 hrs. Oral membranes are dry. R leg noted this am to be more externally rotated than yesterday. HO and ortho notified and leg films done downstairs. COllar care given. Neck intact. Lower abd incision with staples intact and dry.\n\nID--T max 100.5. Pt received tylenol at 0800, 1200 and has not received since. Temp at 1700 100.1. Remains on Vanco and Ceftazadine.\n\nPAIN--Medicated with 6-10 mg IV q2hrs. Pt grimaces with any touch to RLE. He nods head yes when asked if he is in pain. At 1700, pt was given 10mg SC mso4 for good relief. Also given 2mg iv Ativan.\n\n, girlfriend (who was in accident with pt) and sister-in-law in to visit. They have been updated regarding pt's condition. They are happy about fever coming down. Asking questions regarding how long tube will be in and will they put a trach in.\n father and brother have not been in to visit.\n\nA--No temp spike today. Increase need for pain med. DOwn for leg films for increased external rotation.\n\nP--Con't to monitor, con't pulm toilet. Check am labs. COn't to medicate and assess relief. Offer support to pt and family. Attempt to wean vent tomorrow if tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-21 00:00:00.000",
"description": "Report",
"row_id": 1368085,
"text": "Resp CAre\n\nPt remains intubated and on full vent support. MV is being maintained in the 17-20L range. Spo2 100%. BS with occasional rhonchi and wheezing and suctioning thick tan sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-22 00:00:00.000",
"description": "Report",
"row_id": 1368086,
"text": "RESP CARE: Pt remains intubated/on vent per carevue. No changes this shift. Lungs dim bibasilar. Sxd thick tan sputum. RSBI-81. Pt remains febrile.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-22 00:00:00.000",
"description": "Report",
"row_id": 1368087,
"text": "ASSESSMENT AS NOTED\n\nRES: NO CHANGES IN SETTINGS, ON 5PEEP, MAINTAINS PO2>120, SATS 100, LS CLEAR/DIM, SUCTIONED SM AMNT THICK ,\n\nCV: IN S/TACH WITH MULTIPLE PVCS AT TIMES, SEDATED WITH SBP >100, WHEN AWAKE UP TO 140S, + WEAK PULSES, +PERIPHERAL EDEMA\n\nNEURO: ON PROPOFOL AND FENTANYL GTT, FOLLOW COMMANDS, MOVES BOTH ARMS, FENTANYL UP TO 150 TO CONTROL PAIN, R/LEG EXTERNALY ROTATED 90 DEG ANGLE, CER COLLAR IS ON\n\nID: LOW GRADE TEMP 99-101.5, NO TYLENOL WAS GIVEN , FAN IS ON, CONT ON VANCO, CEFTAZIDIME\n\nGI: TOL TF AT 85/H W/O RESIDUALS, NO BM YET, +BS,\n\nGU: BRISK U/O,\n\nSKIN: R/LEG SPLINT AND DSD INTACT, BACK IS INTACT, SWEATING A LOT\n\nSOCIAL: FAMILY CALLED TWICE DURING THE NIGHT\n\nPLAN: CLEARFY IVF ORDER, MONITOR RES, PAIN CONTROL,ID, WEAN OFF WENT IF POSSIBLE, ?DATE OF SURGERY FOR R/HIP REDUCTION IN FUTURE\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-22 00:00:00.000",
"description": "Report",
"row_id": 1368088,
"text": "RESPIRATORY CARE: PT. EXTUBATED TO A 50 AEROSOL MASK\nAFTER HAVING AN RSBI OF BETWEEN 40-50 AND A GOOD ABG\nON A PS 5/5. C + R THICK BLOOD-TINGED SPUTUM. SPO2\n97-100 %. DOING WELL. WILL ENCOURAGE C+DBING AND\nWILL MONITOR RESPIRATORY STATUS CLOSELY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-19 00:00:00.000",
"description": "Report",
"row_id": 1368076,
"text": "Resp Care: Pt remains intubated via #8 ETT rotated and secured 24cm at lip. BS coarse bilat. Sx'd for mod amts thick yellow sputum. MDI's given as ordered. ABG WNL. No vent changes made this shift. Plan: awaiting OR when afebrile. Cont vent support. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-19 00:00:00.000",
"description": "Report",
"row_id": 1368077,
"text": "Nursing Progress Note:\nPlease refer to CareVue for specifics.\n\nEVENTS TODAY:\nFebrile to 102.7. Repeat Pan cultured.\nOR with Dr cancelled.\n\nRESP:\nRemains orally intubated tolerating minimal settings. Has spontaneous cough and copious thick tan secretions. Requires aggressive pulmonary tolieting. Also has clear oral secretions and has required frequent oral care. Chest clear to coarse. CXR attended.\n\nNEURO:\nAlert, looking around room, regarding and tracking examiner. Obeys commands intermittantly but uncooperative with some interventions such as turning. Denying pain but given morphine prn for grimacing and turning. Does not move legs until he is resisting our attempt to reposition him. Will squeeze and release and repeat, and is spontaneously localizing to ETT when not restrained.\n\nHEMODYNAMICS:\nST most of day. Has multifocal PVCs. Maintaining BP within range of normal most of day but has hypertension with interventions, promptly returning to baseline when left alone. Grossly diaphoretic most of day, and hot on palpation, now feet are cold and moist. A-line is intermittantly positional.\n\nENDOCRINE:\nBlood sugars in 120s. No coverage per sliding scale.\n\nFLUIDS/LYTES:\nMaintenance fluids at 50mls /hr. Magnesium for repletion.\n\nGI:\nAbd obese. Bowel sounds present. Tube feeds recommenced as not for OR today. No BM today.\n\nID:\nPt has spiked to 103.7 at report time. Pt pan cultured earlier this afternoon. Antibiotics as charted. At this time pt is spiking and also agitated and tachypneic, so was given morphine and ativan to help settle.\n\nRENAL:\nSatisfactory urine output. Urine is amber at times. Cr within range of normal.\n\nSKIN:\nDiaphoretic and skin marks easily but it is intact. Dr took Rt leg dressing down this am. There are several wounds, some surgical and one mid anterior lower leg which was the site of the open fracture per Dr . The wounds are clean with minimal ooze. There are puncture sites to legs which are oozing a small amount of hemoserous ooze. Dr want these free to drain.\n\nSOCIAL:\nMother visiting, reminded of ICU visitation policy. Questions addressed.\n\nPLAN:\nWatch fever.\nFOllow cultures.\nPulmonary toilet.\nAdd bowel regime.\nPossible OR at later date.\nTitrate tube feeds to goal.\nPossible change to assist control if continues to labor while febrile.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-20 00:00:00.000",
"description": "Report",
"row_id": 1368078,
"text": "RESP CARE: Pt remains intubateed/on vent with settings per carevue flowsheet. No changes made this shift.Pt had been placed back on rate during the day due to tachypnea,T max 103.9. ABG -resp alkalosis with normal oxygenation.Lungs dim LLL, coarse on R consistent with new opacity on R per CXR.Sxd mod amts thick tan sputum. RSBI-98.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-20 00:00:00.000",
"description": "Report",
"row_id": 1368079,
"text": "NPN, 1900-0700\nneuro: arouses to voice w/ open eyes; follows commands inconsisitently. Moves UE's w/ near normal strength, moves LLE on bed. Min spontaneous movement noted RLE, withdraws from pain. Med w/ ativan + morphine q 4-5 hrs w/ adeqaute sedation/analgesia.\n\nCV: ST, MFVEA, 100-140's. MAP 80-100's. CVP 10-14. Pulses palpable throughout. Pboots in place.\n\nPulm: orally intubated on CMV 650 x 50% x 14 x 5 w/ resp. alkalosis, adequate oxygenation. RR 20's at rest, 30-40's w/ agitation. Strong cough, weak gag. Copious creamy tan secretions. BS rhonchorous right anterior and mid posterior fields, diminished bibasilar. Left fields CTA.\n\nGI: abd softly distended; BS hypoactive. Promote w/ fiber via oral sump advanced to goal, 85cc; min residuals. +flatus, no BM.\n\nGU: F/C urine clear amber; OP 80+/hr. Renal function labs cont WNL.\n\nskeletal: No pressure areas; skin grossly intact except for surgical sites. Right hip stapled wounds C/D. Right leg remains in immobilizer; sang ooze lateral lower leg. CSM intact RLE. A-line pink, positional; LSC T/L pink, nl wave. C-collar in place.\n\nEndo: RISS, no coverage required.\n\nID: WBC up to 12; Tmax 103.9, rectally. Cooling blanket, tylenol, sponge baths-->>T this am 101 po. Cont on clindamycin, cefazolin, gentamycin; started on levofloxacin.\n\nSocial: mother called x 3 during noc, very anxious.\n\nA: worsening respiratory failure pneumonia (gm+/- rods & gr+ cocci from ) Stable HD, GI, renal, neuro functions.\n\nP: ? adequste coverage for pulm cxs. New pulm cx pending. ? re-line a-line and central lines in setting of fever and line sites. Agressive bronchial hygeine...? rotating bed. Emotional support for mother.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-20 00:00:00.000",
"description": "Report",
"row_id": 1368080,
"text": "T/SICU NURSING PROGRESS NOTE 0700-1900\nCARDIAC--MULTIFOCAL PVC'S BUT NO RUNS. HR ST >100'S. SBP 120-140'S. HCT 23.8 , UNCHANGED FROM THIS AM.\n\nRESP--SX Q2 HRS FOR MODERATE AMTS OF THICK TAN SPUTUM. ETT ROTATED. BREATH SOUNDS CLEAR IN UPPER LOBES BILATERALLY. CRACKLES IN R LOWER BASE THIS AM NOW JUST DIMINISHED. LLL IS COARSE. SAO2>97%. PT RESISTS WITH ANY TYPE OF CPT AND SUCTIONING.\n\nGI--TUBE FEEDS AT GOAL. RESIDUALS 70-80 CC. NO STOOL. ABD OBESE AND FIRM BUT PT DOES NOT GRIMACE WITH BELLY IS PALPATED. NO STOOL.\n\nGU--FOLEY CATH PATENT DRAINING >100 CC HR OF YELLOW URINE.\n\nENDO--UNREMARKABLE. NO SSRI COVERAGE.\n\nSKIN--L CORNER OF MOUTH WITH BREAKDOWN. ETT ROTATED. BUTTOCKS WITHOUT BREAKDOWN. LOWER ABD INCISION WITH STAPLES INTACT. RLE HAS SUTURES AND OLD PIN HOLE SITES WHICH HAVE DRAINED SEROUS DRAINAGE. AREA ON ANTERIOR TIB SITE THAT APPEARS MACERATED. DSD APPLIED WITH KLING LEG PLACED BACK IN KNEE IMMOBILIZER. R HIP WITH DSD. SCROTUM IS EDEMATOUS. ORAL MEMBRANES ARE DRY.COLLAR CARE GIVEN. NECK INTACT.\n\nID--FEBRILE TO 102.2 ABX CHANGED TO CEFTAZADINE AND VANCO WHICH HE HAS RECEIVED 1ST DOSE OF EACH TODAY. DOWN FOR CT OF PELVIS, CHEST AND ABD TO SEE IF THERE IS ANYTHING UNUSUAL. PT HAS CONSOLIDATIONS IN BLL.\n\nPAIN--NODS HEAD WHEN ASKED IF HE IS IN PAIN. MEDICATED WITH MSO4 AND ATIVAN SEVERAL TIMES THROUGHOUT THE DAY.\n\nCOPING--MOTHER IN TO VISIT ALL DAY. SHE HAS BEEN UPDATED ABOUT PLAN OF CARE. FATHER BE IN LATER TODAY. PER PT'S MOM, GIRLFRIEND , WAS RELEASED FROM THE HOSPITAL OVER THE WEEKEND.\n\nNEURO--OCCASIONALLY OPENS EYES TO NAME. INCONSISTENTLY FOLLOWS SIMPLE COMMANDS. MOVES ALL EXTR. ON BED AND BUE WILL LIFT AND HOLD AS WILL LLE. PEARL AT 2-3 MM.\n\nA--REMAINS WITH INCREASE IN TEMP AND ECTOPY.\n\nP--CON'T PULM TOILET. CHECK LYTES . CON'T ABX. OFFER SUPPORT TO PT AND FAMILY. NEXT DATE FOR OR IF ALL IS OK IS FRIDAY. IF PT HAS EMERGENCY, IT BE PERFORMED SOONER BUT PLAN IS FOR FRIDAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-20 00:00:00.000",
"description": "Report",
"row_id": 1368081,
"text": "Resp Care\n\nPt remains intubated on A/C. Pt transported to CT w/o incident. PT suctioned for thick tan secretions and plugs. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-21 00:00:00.000",
"description": "Report",
"row_id": 1368082,
"text": "RESP CARE: Pt remains intubated/on vent settings per carevue. Pt tachypneic early in shift with RR 30s/vent asynchrony/increased cardiac ectopy.Pt started on propofol with good effect noted. More reg resp pattern, RR 20s. Lungs coarse bilat Sxd copious amts tenacious tan sputum. ABGs consistent with resp alkolosis. RSBI>200. Pt remains febrile.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-15 00:00:00.000",
"description": "Report",
"row_id": 1368056,
"text": "nursing progress note\n\nneuro: pt remains intubated, sedated. propofol weaned slightly w/ change to cpap, pt at times resistent to any stimulus, opening eyes spont. perrla, 2mm. inconsist. follows commands. fentanyl boluses given prn for turns w/ good effect.\n\nresp: cpap+ps tol well, o2 sats 96-100%. ls coarse throughout. sx mod amts thick yellow secretions. cough, gag intact. abg acceptable, slightly hypercarbic, compensated.\n\ncv: bp labile w/ stimulus, settles quickly at rest. sinus tachy, much ventric. ectope noted (baseline). filling pressures stable, cvp remains mid teens. unable to wedge pa cath, icu team aware. co elevated, svo2 mid 80s-low 90s. note persistent low grade fever. lytes repleted prn.\n\ngi: belly large, soft, bs present. og to lws, mod amts bilious output.\n\ngu: foley patent clear yellow urine, qs.\n\nendo: bg's stable.\n\nid: tmax 101.5, less than 24h post op, icu team aware. tylenol given for comfort. wbc stable at 10.\n\nskin: ex fix pin sites clean, serosang drainage. open tibia lac sutured, mod amt serosang drainage as well. pelvic repair incisions all w/ post op dsgs, dry.\n\nsocial: family in last evening, supportive. called overnight for updates.\n\na: s/p pelvic repair, I+D right tibia, stable intra/post op course. hemodynamics stable, filling pressures unchanged. low grade febrile. hct holding at 25.\n\np: cont aggressive pulm toilet, d/c pa catheter, change to triple lumen access. cont current pain management, sedation while intub. await OR trip for ORIF of right tib/fib, sacral pinning. will need MRI in near future to f/u w/ T4 injury.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-15 00:00:00.000",
"description": "Report",
"row_id": 1368057,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results revealed a compensated respiratory acidemia with excellent oxygenation on the current settings.\n\nRSBI = 16.7 on 0-PEEP and ATC off.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-18 00:00:00.000",
"description": "Report",
"row_id": 1368072,
"text": "T-SICU NURSING PROGRESS NOTE\nNeuro: Opens eyes to name, continues with eyes rolled back slightly but turns toward person calling his name. Intermittently following commands, MAEs weakly. Pupils equal and reactive. Med with MS04 Q4H for pain.\n\nCV: HR 110s, ST up to 130s with pain and fevers, occas to freq PVCs. BP running 120s-140s systolic. Between 4-5pm pt more tachycardic and hypertensive, lighter, med with Ms04 for pain with effect. BP now running 130s systolic. Skin warm to touch, diaphoretic after receiving tylenol and defervescing. (+)palpable distal pulses bilat.\n\nResp: Remains on PSV 5/5, 40% Fi02. Breath sounds coarse on right, clear to diminished on the left. Strong cough, productive of moderate amt of thick tan secretions. Also with moderate amt of tan oral secretions.\n\nGI: Abdomen soft, (+)bowel sounds, no stool, no flatus. Tolerating tube feeds, advanced to 70cc/hr at 1600, residuals < 20cc.\n\nGU: Adequate urine output, see I & O for details\n\nEndo: Blood sugar 140-150 this shift, covered with regular insulin per sliding scale\n\nID: Remains febrile throughout the day, t. max 102.2. Cultures sent this am pending. Continues on kefzol, clinda and gentamycin\n\n\nSkin: RLE dressing changed by ortho, hemovac d/c'd. Right knee and RLL incis with sutures, small to mod amt of serosang drainage, no redness. Right hip with small to mod amt of serous drainage. Suprapubic incis OTA with staples, no redness or drainage. Back/buttocks and heels intact.\n\nSocial: Pt's family in to visit today, updated on patient's condition, all questions answered.\n\nA: 41 yo male s/p MCA with multiple ortho injuries, persistent fevers\n\nP: Continue to monitor neuro status, medicate for pain prn, advance tube feeds to goal of 85cc/hr. Follow culture results. ? Hold TF at MN for OR tomorrow. Provide support to patient and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-18 00:00:00.000",
"description": "Report",
"row_id": 1368073,
"text": "Resp Care: Pt remains intubated via #8 ETT retaped and secured at 24cm at lip. BS coarse bilat. Sx'd for small amt thick tan sputum. ABG WNL. No vent changes made this shift. Plan: cont vent support. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-19 00:00:00.000",
"description": "Report",
"row_id": 1368074,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions.Started on atrovent mdi's.Temp 101.5. Agitated when awake.Given some morphine.HR-ST with PVC'S.RSBI done ON 0 PEEP/5 IPS 43.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-14 00:00:00.000",
"description": "Report",
"row_id": 1368052,
"text": "nursing progress note\n\nneuro: pt remains intubated, sedated. lightened last eve for exam. mae, strong to bue. following commands, perrla, 2-3mm bilat. nods to pain when awake, given bolus fentanyl prn for turns, sx, etc w/ good effect.\n\nresp: ac mode continued, no changes made overnight. pt overbreathing vent when stimulated, volumes becoming very high during these times. o2 sats stable, abg wnl. ls clear, slightly dimin to bases. cough, gag intact. sx sm amts thick tan secretions.\n\ncv: cont w/ much ventric. ectope, rate 80s-100. bp stable, map consist. >65. filling pressures stable, co/ci . cvp 10-14. extrem warm, edematous. ppp bilat. lytes repleted prn. given 2u prbc overnight for hct 23.4, little improvement noted post transfusion, 25. repeat hct pending.\n\ngi: ogt repositioned last eve, draining mod amt bilious output. belly large, soft. bs present. remains npo.\n\ngu: u/o dropped last night, mod sized clot removed w/ irrigation. urimeter changed, draining clear yellow urine qs since.\n\nendo: bg's stable.\n\nid: low grade temps persist, tmax 100.8. ancef dosing continued.\n\nskin: open fx site to right tibia clean, large amt serosang drainage noted. pin sites clean, sm amts sanguinous drainage. ecchymotic areas to inner thigh, right hip.\n\nsocial: family in last eve, updates provided, all ques answered. reinforced scheduled visiting hours.\n\na: hemodynamics stable, comfortable w/ fentanyl, sedation. neuro exam intact, pulses remain intact to ble, extrem remain warm.\n\np: cont. to monitor filling pressures, vs, hct. replete lytes as needed, await OR today for pelvic, L5 repairs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-14 00:00:00.000",
"description": "Report",
"row_id": 1368053,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning abg results determined a compensated respiratory acidemia with very good oxygenation on the current settings.\n\nNo RSBI measured due to scheduled OR procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-14 00:00:00.000",
"description": "Report",
"row_id": 1368054,
"text": "nursing progress note\nevents- to or today from 9-3pm. screws placed in r femur and r femoral head, fib not fixed, ? friday.will need eventual hip replacement,\ntibia cleaned/ debrided\n\nneuro- pt remains sedated on propofol and fentanyl, arouses to voice, family at bedside. pre-op nodding ,obeying commands, postop very sleepy, mae.\n cv- sr-st, freq pvc's. bp stable by aline, pa pressures up w/stimuli\nswan now at 50 cm (was at 56cm preop), waveform adequate.svo2 re-cal, running in 70's.co had 1u pc's in or, hct now 27. boots on pulses +, good cap refill\n\nresp- placed on cpap 5/5 at 1830, tol well, mv . ls sl. coarse postop,pt to stay tubed- anticipating or on friday\n\ngi- sump to lws, bilious secretions. no bs heard\n\ngu- foley qs, clear yellow, no further clots\n\nid- remp 99, no issues\n\nskin- external fixation remains in place, pin sites clean, multiple surgical incisions with dressings intact. Sang draiange from tib/fib wound.\n\nsocial- mother, daughter-in-law at bedside, updated by Dr and RN\n\nplan-To OR on friday for ORIF fibia, most likily remain intubated til then, cont on ps as tolerated. Wean sedation as tolerated. Provide ongoing support to family. D/c swan in am and rewire to TLC. Start TF in am.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-14 00:00:00.000",
"description": "Report",
"row_id": 1368055,
"text": "Respiratory Care: Pt continues on ventilatory support. Initially on AC when back from OR today. Changed to PS 5/5 60% this eve, and tolerating well at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-19 00:00:00.000",
"description": "Report",
"row_id": 1368075,
"text": "nursing progress note\nNeuro- more awake, looks to speaker, obeys commands inconsistently.\nHas 4+ strength to resist turning! mso4 4mg w/effect for discomfort.\n\nCV- ST,occ-freq pvc's, aline bp 130's, up to 170's w/pain.hct 20's, color good, all pulses +, boots in place. tlc,aline in place, sites wnl.\n\nResp- remains on cpap, , 50%, oxygenation good, sao2 99-100.sxn copious thick yellow/tan secretions from mouth and ett.? extubation after or today.\n\nGI- tf off @ 0500- on call to or. bs+, no flatus or stool. minimal residuals\n\nGU- foley indwelling/patent. u/o clr yellow, qs\n\nID- cont w/ temp 101-102, pt has not been afebrile in>24hrs. pan cx , results pending, + sinusitis by head ct. on ancef, genta,clinda\n\nPlan- on call to or today for fusion of back by Dr. . ? extubation post op, pain cosult for chronic pain meds.? ortho to change dressing to rle. cont to w/u temps, follow cx\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-17 00:00:00.000",
"description": "Report",
"row_id": 1368069,
"text": "7a-7p\nneuro: pt sedated on propofol & fentanyl gtts, pt with eyes rolled back this am, ho aware, propofol off, pt still with eyes rolled back & not following commands, withdrawing to pain, PERL, moving all xtremites except R leg, fentanyl gtt decreased throughout day & down to only 25 mcg/hr by this afternoon, pt still not responding to commands & eyes continued to roll back so pt for head ct scan @ 1730, result negative\n\ncv: hr st(106-118), occasional pvc's, sbp stable, po lopressor, zestril & carvedilol started today\n\nresp: on 50% cpap 5/5 ps, tol well, lg amt tan thick secretions, bs+ all lobes & course, clears with sux, RSBI(25) & abg good but pt not extubated due to mental status & lg amt secretions, sat 99-100, rr 12-18\n\ngi: tf on hold today due to ? of extubation, tf resumed this pm after ct scan(fs promote @ 20 cc/hr, do not advance) no stool, iv pepcid\n\ngu: foley patent, clear yellow urine, good uo\n\nother: family in & updated on pt's condition, R leg with knee immobilizer @ all times, sm amt serou drainaged from R leg, bilat distal pulses by doppler, sm amt serous drainage from R hip suture line, ivf continue @ 80cc/hr, temp spike to 101.7 @ 1600, tylenol given, pt needs to be pan cultured, K+ & MG+ repleated\n\nplan: continue to monitor mental status, plan to extubate tomorrow when pt more awake, pan culture\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-18 00:00:00.000",
"description": "Report",
"row_id": 1368070,
"text": "Resp Care\nPt. remains intubated on minimal vent. support . Vt's 600-700cc/ MV 8-12lpm.\nBs: CEB, with minimal secreations.\nabgs:hyperoxygenated with slight metabolic alkalosis.\nPlan: rsbi 35.4 however MS may continue to prevent pt. from being extubated/protecting airway.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-06-18 00:00:00.000",
"description": "Report",
"row_id": 1368071,
"text": "nursing progress note\nNeuro- off propofol and fentanyl, sl. more responsive now, nods yes to pain, obey commands slowly. mso4 w/effect. good strength in upper extremities, resists movement .\n\nCV- SR-ST w/pain, BP up to 170's w/pain, 120-140's @rest. cardiac meds restarted yest. ^ ectopy towards end of shift, mgso4 2 gm for mg=1.9\npulses positive, palpable despite edema.boots in place.TLC in place, site unremarkable. Aline dampened, better after dsg change- gd waveform. ivf . to 50cc/hr\n\n\nResp- remains on cpap 50%, 5+5. sao2>95%. rr20's, ls diminished, esp @ bases. sxn thick tan/ sputum, also from mouth- ct head shows severe sinusitis.ett not moved d/t ulcer @l side of mouth.\n\nGI- tf to increase to goal of 85- currently at 50cc/hr, tol well, min residuals.no stool.\nGU- foley indwelling/patent, u/o qs\nSkin- intact, r hip sutures intact, dg sm amt serous fluid. suprapubic dsg d+i, rle immobilizer in place, dg serous dge from dsg, hemovac in place\n\nID- temp to 102, pan cx. currently on genta and ancef\nplan- prn pain meds to optimize wakefulness, investigate source of temps ? sinuses.optimize nutritional status, ivf as able\n? extubate..\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2152-07-03 00:00:00.000",
"description": "Report",
"row_id": 192063,
"text": "Sinus tachycardia with frequent ventricular premature beats. Left atrial\nabnormality. Intraventricular conduction defect. Compared to the previous\ntracing of the ventricular ectopic activity has increased. Otherwise, no\ndiagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2152-06-23 00:00:00.000",
"description": "Report",
"row_id": 192064,
"text": "Sinus rhythm with ventricular premature complexes\nLeft atrial abnormality\nEarly precordial QRS transition - is nonspecific\nModest nonspecific low amplitude lateral T wave changes\nSince previous tracing of , lateral T wave amplitude lower\n\n"
},
{
"category": "ECG",
"chartdate": "2152-06-21 00:00:00.000",
"description": "Report",
"row_id": 192065,
"text": "Sinus tachycardia\nVentricular premature complex\nLeft atrial abnormality\nModest low amplitude lateral T waves - are nonspecific and may be within normal\nlimits\nSince previous tracing of , ST-T wave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2152-06-12 00:00:00.000",
"description": "Report",
"row_id": 192066,
"text": "Sinus tachycardia with frequent ventricular premature beats. Modest\nnon-specific inferolateral ST-T wave changes. Compared to the previous tracing\nof rate is faster but there are no other significant diagnostic\nchanges.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-20 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 914847,
"text": " 10:15 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: evaluate R sided opacity on prior CXR as recommended by atte\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate R sided opacity on prior CXR as recommended by attending radiologist\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right-sided opacity on prior chest x-rays, further evaluation\n recommended.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the thoracic\n inlet to the pubic symphysis after administration of IV contrast only. This\n study was compared with chest x-ray of and CT torso .\n\n CT CHEST WITH IV CONTRAST: These images are somewhat limited by motion. The\n low-density nodule on the left thyroid lobe is again identified. The patient\n is intubated. There is a left subclavian central venous line terminating in\n the distal SVC. A nasogastric tube is seen coursing below the diaphragm and\n into the stomach. Bilateral fluffy airspace opacities are identified in both\n upper lobes, consistent with contusion. Additionally, there are bilateral\n lower lobe dense consolidations corresponding to the unusual contour seen on\n chest x-ray of . There is no pericardial or pleural effusion. No\n hilar, axillary, or mediastinal lymphadenopathy is identified. Heart and\n great vessels are normal.\n\n CT ABDOMEN: Liver, spleen, pancreas, adrenals, kidneys, stomach and small\n bowel loops are normal given lack of oral contrast. The gallbladder is\n surgically absent. There is no free fluid or free air. There is no evidence\n of traumatic organ injury.\n\n CT PELVIS WITH IV CONTRAST: Sigmoid diverticulosis is seen, without\n diverticulitis. A Foley is present in the bladder. There is stranding\n surrounding the anterior aspect of the bladder wall and the posterior to the\n rectum. Stranding in the subcutaneous tissues is seen, consistent with some\n edema. Soft tissue density material representing hemorrhage is seen layering\n anterior and lateral to the left psoas muscle and along the right ureter.\n\n Again seen are right sacral fractures, comminuted right femoral, iliac, and\n superior pubic ramus fractures, and fixation hardware, which somewhat obscures\n evaluation of the lower pelvis structures. No new fractures are identified.\n Transverse process fracture of L5 is also noted.\n\n IMPRESSION:\n 1. Multifocal airspace opacities concentrated in both upper lobes, consistent\n with pulmonary contusions. Right hemithorax density seen on chest x-ray is\n accounted for consolidations in both lower lobes, probably related to\n (Over)\n\n 10:15 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: evaluate R sided opacity on prior CXR as recommended by atte\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aspiration.\n\n 2. Status post fixation of comminuted right femoral fracture and pelvic\n fractures. Small amount of hematoma along left paracolic gutter. Improved\n bladder wall hematoma in association with right pelvic fractures.\n\n 3. Sigmoid diverticulosis without diverticulitis.\n\n 4. Thyroid nodule which can be further evaluated by thyroid ultrasound on a\n non-emergent basis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-07-02 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 916429,
"text": " 2:33 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: **Please extend views to knee*** evaluate hip fracture anato\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41M s/p Left hip fx\n REASON FOR THIS EXAMINATION:\n **Please extend views to knee*** evaluate hip fracture anatomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE PELVIS AND RIGHT LOWER EXTREMITY WITHOUT CONTRAST DATED .\n\n CLINICAL HISTORY: Please evaluate hip fracture in a 41-year-old male status\n post MVC.\n\n TECHNIQUE: Non-contrast CT scan of the pelvis and right femur was performed\n using 2.5 mm collimation. Images were reformatted in the coronal and sagittal\n planes.\n\n COMPARISON: Prior CT scan dated and plain films dated .\n\n FINDINGS: Posterior spinal fixation hardware is seen spanning the L5-S1\n level. This is a new finding when compared to prior CT examination. Tiny\n foci of air are identified in the region of the hardware, related to expected\n postoperative change, if recent. Hardware are also seen within both iliac\n bones. The hardware appears to be in good position. Previously identified\n sacral fractures are not significantly changed.\n\n There is a rod transfixing a comminuted superior right pubic ramus fracture.\n There is significant comminution of the anterior right acetabulum resulting in\n at least an 18 mm gap. An intramedullary rod with gamma nail fixes the right\n proximal femur fracture. The proximal right femur fracture is severely\n comminuted. Fracture is also identified within the right inferior pubic\n ramus.\n\n There is a severely comminuted fracture of the right kne tibial plateau. A\n side plate and multiple screws are unchanged in position when compared to\n prior examination.\n\n IMPRESSION: Status post ORIF for multiple fractures, as described above.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 914564,
"text": " 5:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: cause for decreased mental status?\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with s/p motorcycle accident w/ decreased responsiveness.\n REASON FOR THIS EXAMINATION:\n cause for decreased mental status?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm SAT 6:56 PM\n no mass effect or hemorrhage. Severe sinusitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident, unresponsiveness.\n\n TECHNIQUE: Head CT without contrast.\n\n FINDINGS: There is no mass effect, hydrocephalus, shift of normally midline\n structures or infarction. The density values of the brain parenchyma are\n within normal limits.\n\n A severe opacification of the sphenoid and frontal sinuses as well as the\n ethmoid air cells with moderate to severe opacification of the maxillary\n sinuses. No fractures are present.\n\n IMPRESSION: No mass effect or hemorrhage. Severe sinusitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-07-01 00:00:00.000",
"description": "R FEMUR (AP & LAT) RIGHT",
"row_id": 916324,
"text": " 11:46 AM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: pre-op eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle accident, multiple RLE fractures\n\n REASON FOR THIS EXAMINATION:\n pre-op eval\n ______________________________________________________________________________\n FINAL REPORT\n 41-year-old male with motorcycle accident and multiple right lower extremity\n fractures.\n\n COMPARISON: .\n\n RIGHT FEMUR, FIVE VIEWS: Again demonstrated is a comminuted intertrochanteric\n fracture of the right proximal femur. There is a fixation screw fixating the\n anterior column and medial wall of the acetabulum. An intramedullary rod with\n a gamma nail fixes the right proximal femoral fracture. Ghost tracks from\n prior fixation hardware are noted in the distal femur. A lateral plate and\n multiple screws fixate the comminuted tibial plateau fracture. There is no\n evidence of hardware complication.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915378,
"text": " 7:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for cardiopulm. abnormality\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, just extubated, now diaphoretic and tachycardic.\n\n REASON FOR THIS EXAMINATION:\n Eval. for cardiopulm. abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, extubated, not diaphoretic and tachycardic. Evaluate for\n cardiopulmonary abnormality.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH\n\n There has been interval removal of the endotracheal tube, right subclavian\n line, and left subclavian line. Cardiomediastinal hilar contours appear\n unchanged. No focal consolidation is seen within the lungs. There are low\n lung volumes limiting complete assessment of the pulmonary vasculature.\n\n IMPRESSION: No focal consolidations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 914862,
"text": " 11:54 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check CVL\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, intubated, fevers\n\n REASON FOR THIS EXAMINATION:\n check CVL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, intubated, fevers.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: The endotracheal tube, left subclavian central\n venous catheter, and feeding tube are in standard positions. A new right\n subclavian central venous catheter tip is positioned within the lower SVC.\n There is no pneumothorax. Heart is mildly enlarged, unchanged. There is\n worsening consolidation within the left lower lobe with loss of the\n diaphragmatic contour, consistent with worsening atelectasis and/or\n infiltrate. Small left pleural effusion persists. There is improved aeration\n within the right base with residual atelectasis identified. There is no\n pneumothorax. No lower lung volumes are present on the current study, and\n there is crowding of the pulmonary vasculature at the bases with a\n perivascular haze present bilaterally suggestive of possible volume overload.\n\n IMPRESSION:\n\n 1. Satisfactory placement of right subclavian central venous catheter. No\n pneumothorax.\n\n 2. Worsening left lower lobe consolidation with persistent small left pleural\n effusion.\n\n 3. Possible mild volume overload.\n\n 4. Improved aeration within the right lung base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 915445,
"text": " 4:19 PM\n CHEST (PA & LAT) Clip # \n Reason: pna\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with questionable pna / fevers persistant\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest performed on .\n\n HISTORY: 41-year-old man with questionable pneumonia and fevers.\n\n FINDINGS: Comparison is made to prior study from .\n\n There are low lung volumes that limit evaluation. The lateral radiograph is\n suboptimal due to patient's large body habitus and overlying arm as well as\n the poor inspiratory effort. Allowing for this, however, there is no focal\n consolidation, signs for pulmonary edema or pleural effusions. The cardiac\n silhouette and mediastinum are prominent but may be secondary to the AP\n technique and low lung volumes. Bony structures are intact.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 914765,
"text": " 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, intubated, fevers\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old male with trauma, intubated, fever.\n\n Portable AP chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: Endotracheal tube and left subclavian venous catheter are unchanged\n compared to the prior study. The distal nasogastric tube is terminating in\n left upper quadrant. Cardiac and mediastinal contours are unchanged, with\n somewhat prominent cardiac shadows. Note is made of new rounded opacity\n overlying the right hilum, which may represent consolidation, however, the\n etiology is uncertain. Note is made of atelectasis in left lower lobe.\n\n IMPRESSION: Tubes and lines as described above. New rounded opacity\n overlying the right hilum, of unknown etiology. This can represent early\n pneumonia, however, given the history of trauma, other process should be\n considered, and clinical correlation and close followup is recommended. If\n necessary, please perform CT scan.\n\n The finding was discussed with the referring physician, . , by\n telephone at the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-11 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 913820,
"text": " 11:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: cuts through upper right femur to eval for Fx\n Field of view: 47 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle accident\n REASON FOR THIS EXAMINATION:\n cuts through upper right femur to eval for Fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa MON 2:02 AM\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded by\n hematoma.\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\n extravasion on delayed scan.)\n 3. No aortic injury.\n 4. Lt thyroid nodule.\n 5. Right sacral fracture and rt L5 transverse process fracture.\n WET READ VERSION #1 MNIa MON 12:35 AM\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded\n by hematoma.\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\n extravasion on delayed scan.)\n 3. No aortic injury.\n WET READ VERSION #2 MNIa MON 12:59 AM\n 1. Extensively comminuted fracture of the rt femoral neck fracture with\n impaction, with fractures of acetabulum, ischium and pubic rami, surrounded by\n hematoma.\n 2. Hematoma and hemorrhagic fluid tracking down anterior to the bladde (no\n extravasion on delayed scan.)\n 3. No aortic injury.\n 4. Lt thyroid nodule.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old woman with motor cycle accident.\n\n TECHNIQUE: Contiguous axial CT images of the abdomen, chest, abdomen, and\n pelvis were obtained with the administration of IV contrast . Multiplanar\n reformation images are reconstructed.\n\n No comparison.\n\n FINDINGS:\n\n CHEST: There is no evidence of acute aortic injury. No mediastinal hematoma.\n No pericardial or pleural effusion. No evidence of pneumothorax. There are\n bilateral dependent opacities, however, no suspicious mass or consolidation is\n noted.\n\n (Over)\n\n 11:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: cuts through upper right femur to eval for Fx\n Field of view: 47 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ABDOMEN: The patient is status post cholecystectomy. No free air. No\n ascites. The liver, spleen, pancreas, adrenal glands and kidneys, the\n visualized portions of large and small intestines are within normal limits.\n\n PELVIS: The visualized portions of large and small intestines are within\n normal limits. No free air. No lymphadenopathy.\n\n Note is made of hyperdense hematoma with fat stranding anterior to the urinary\n bladder, tracking down along the anterior abdominal wall. On the delayed\n scan, the urinary bladder is distended with contrast, however, there is no\n evidence of extravasation. The hematoma appears to be located in the\n extraperitoneal space on sagittal reformation. Hematoma along the right psoas\n muscle is noted.\n\n Note is made of extensively comminuted displaced fracture of the right femoral\n neck with bone fragment and medial angulation of the femoral head, associated\n with multiple fracture lines in the acetabulum with bone fragment anteriorly,\n as well as fracture lines through the right pubic rami and right side of the\n sacrum. There is associated soft tissue fat stranding and hematoma\n surrounding the right hip joint. There is a hematoma medial to the right\n acetabulum, with some mass effect to the urinary bladder. Iliac arteries are\n patent and no evidence of active extravasation is noted. No rib fracture is\n seen. Fracture of the right side of the sacrum and transverse process of L5 is\n noted.\n\n IMPRESSION:\n\n 1. Extensive comminuted and displaced fracture of the right femoral neck with\n medial angulation of the head, as well as multiple fractures involving\n acetabulum, pubic rami. The fracture line through the right side of the\n sacrum as well as fracture of the right transverse process of L5.\n\n 2. Hematoma and soft tissue swelling surrounding the above-mentioned\n fracture. Hematoma anterior to the bladder, tracking just beneath the\n abdominal wall. No evidence for bladder injury. Hematoma along the psoas\n muscle.\n The location of hematoma is extraperitoneal.\n\n The information was communicated with the trauma team in person at the time of\n examination, and was also discussed with the referring physician, . \n by telephone, and was also flagged to ED dashboard.\n\n\n (Over)\n\n 11:47 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: cuts through upper right femur to eval for Fx\n Field of view: 47 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-11 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 913821,
"text": " 11:52 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o Fx\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: The findings regarding T4 fracture was communicated to the covering\n physician, . , by telephone at 9:30 p.m. on . We tried to\n reach the ordering physician, . , however, was not successful, and\n therefore, the information was also sent to Dr. by e-mail.\n\n\n 11:52 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o Fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle\n REASON FOR THIS EXAMINATION:\n r/o Fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DBH MON 5:04 PM\n Scoliosis, no gross fracture.\n\n NOTE ADDED AT ATTENDING REVIEW: There is a compression fracture of T4\n with a retropulsed fragment into the spinal canal. The bone does not appear to\n produce severe canal narrowing, but cannot rule out disk protrusion or\n hematoma.\n WET READ VERSION #1 MNIa MON 12:08 AM\n Scoliosis, no gross fracture.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 41-year-old male with motorcycle.\n\n C-SPINE CT WITHOUT CONTRAST.\n\n No comparison.\n\n FINDINGS: Note is made of severe scoliosis, however, there is no gross\n fracture or dislocation. No prevertebral soft tissue swelling.\n\n IMPRESSION: Marked scoliosis. No gross fracture or dislocation.\n\n\n NOTE ADDED AT ATTENDING REVIEW: There is a compression fracture of T4, with\n retropulsion of an inferior endplate fragment. CT is extremely limited for\n analyzing canal narrowing. There appears to be only mild osseous encroachment\n on the canal, but the possibility of soft tissue abnormality, such as disk\n protusion or hematoma, cannot be evaluated. If clinically indicated, recommend\n CT of the thoracic and lumbar spine and perhaps an MR of the spine.\n\n Findings discussed with Dr. at 5:30 pm on .\n\n\n\n\n\n\n\n\n (Over)\n\n 11:52 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o Fx\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-11 00:00:00.000",
"description": "R CT LOW EXT W/O C RIGHT",
"row_id": 913822,
"text": " 11:58\n CT LOW EXT W/O C RIGHT Clip # \n Reason: r/o fx tib plateau\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with motorcycle\n REASON FOR THIS EXAMINATION:\n r/o fx tib plateau\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa MON 12:30 AM\n Extensively comminuted tibial plateau fracture with hematoma and deep tissue\n air. Comminuted fracture of prox. fibula.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle accident, rule out tibial plateau fracture.\n\n TECHNIQUE:\n\n Thin section axial images were obtained from the distal femur through the mid\n calf and reconstructed using both bone and soft tissue algorithm. Coronal and\n sagittal reconstructions were also generated. The patient's leg is imaged in\n slight flexion, resulting in some distortion of the axial images\n presently available.\n\n RIGHT LOWER EXTREMITY, WITHOUT CONTRAST:\n\n PRELIMINARY WET :\n\n Please note that a wet was provided by the radiology resident on the\n PACS requisition as follows: \"extensively comminuted tibial plateau fracture\n involving joint surface with hematoma and deep tissue air. Comminuted\n proximal fibular fracture (spiral). Discussed with trauma team (by resident\n , M,\"\n\n FINAL REPORT:\n\n There is a markedly comminuted fracture of the proximal tibia, extending into\n the tibial plateau, with considerable axial dispersion of the fracture\n fragments. The articular surface components extend into the lateral plateau,\n into the tibial eminence, and into the medial tibial plateau. The distal\n major fracture lines exit in the medial and lateral metaphyses, with\n comminution. There is dispersion of fragments posteriorly, with small\n fragments lying adjacent to the popliteal vessels, though they do not appear\n to directly impinge on the vessels (series 2, images 139-117). The main\n longitudinal axis of the tibial shaft is displaced posteriorly with respect to\n the markedly comminuted proximal tibia, best appreciated on sagittal views.\n The tibial tubercle (insertion site of patellar tendon) is avulsed. There is\n also considerable comminution at the expected insertion site of the posterior\n cruciate ligament. The ACL is not effectively evaluated here.\n\n There is a joint effusion, with air within the joint. There is extensive\n surrounding soft tissue edema as well as some subcutaneous emphysema.\n (Over)\n\n 11:58\n CT LOW EXT W/O C RIGHT Clip # \n Reason: r/o fx tib plateau\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is a comminuted fracture of the proximal diaphysis of the fibula. The\n proximal tibiofibular joint remains congruent.\n\n IMPRESSION:\n\n 1. Markedly comminuted and impacted fracture of the proximal tibia, with\n extensive involvement of the tibial plateau and posterior displacement of the\n main shaft of the tibia. Avulsion of patellar tendon from tibial tubercle.\n Comminution at expected site of PCL insertion. Bony fragments abutting the\n popliteal vessels.\n\n 2. Proximal fibular diaphyseal fracture.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-12 00:00:00.000",
"description": "R TIB/FIB (AP & LAT) RIGHT",
"row_id": 913825,
"text": " 4:06 AM\n TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: RT TIB FIB FX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with right tib/fib fracture.\n\n Three fluoroscopic images obtained during fixation of comminuted tibial\n plateau fracture and proximal fibular fracture, without the radiologist\n present. Rod is noted only on AP view, and neither end is seen. Please also\n refer to the official surgical report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-16 00:00:00.000",
"description": "RO KNEE (AP, LAT & OBLIQUE) RIGHT IN O.R.",
"row_id": 914446,
"text": " 3:21 PM\n KNEE (AP, LAT & OBLIQUE) RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: ORIF RT.TIBIAL PLATEU FX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture fixation.\n\n 2 minutes 8 seconds of fluoroscopy time. Exam consists of five AP and lateral\n intraoperative radiographs of the right knee and proximal leg. Since last\n exam the markedly comminuted and displaced fracture of the proximal\n tibia and lateral tibial plateau has been fixated by a curved lateral plate\n and multiple screws. A second small anterior plate and screws is also\n present. Again noted is the fracture of the adjacent proximal fibula. Bone\n detail obscured for technical reasons.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 914287,
"text": " 12:59 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check CVL\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, s/p Line placement\n\n REASON FOR THIS EXAMINATION:\n check CVL\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the new central venous line placement.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 3.3 cm above the carina. The Swan-Ganz catheter was\n exchanged by a subclavian central venous line with its tip at the junction of\n the brachiocephalic vein with the superior vena cava. The NG tube now is\n properly inserted with its tip in the stomach.\n\n The heart size is normal. There is no evidence of congestive heart failure.\n There are bibasilar lower lobe atelectases, left more than right, which are\n worsening seen the previous film.\n\n IMPRESSION:\n\n 1. Normal position of the left central venous line with no evidence of\n pneumothorax.\n\n 2. Worsening bibasilar atelectases.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-27 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 915785,
"text": " 2:30 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: possible IVC filter placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with\n REASON FOR THIS EXAMINATION:\n possible IVC filter placement\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VEINS.\n\n INDICATION: 41-year-old man with possible IVC filter placement.\n\n BILATERAL LOWER EXTREMITY VEINS: Grayscale and color Doppler ultrasound were\n performed. There is normal compressibility, color flow, and Doppler signal\n within the common femoral, superficial femoral, and popliteal veins.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-21 00:00:00.000",
"description": "R HIP UNILAT MIN 2 VIEWS RIGHT",
"row_id": 915041,
"text": " 1:52 PM\n HIP UNILAT MIN 2 VIEWS RIGHT; FEMUR (AP & LAT) RIGHT Clip # \n KNEE (2 VIEWS) RIGHT; TIB/FIB (AP & LAT) RIGHT\n PELVIS (AP ONLY)\n Reason: assess alignment of fractures\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, multiple RLE fx's\n REASON FOR THIS EXAMINATION:\n assess alignment of fractures\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right hip, two views. .\n\n HISTORY: 41-year-old man with trauma and multiple lower extremity fractures.\n\n FINDINGS: There is a single screw seen fixating the anterior column and\n medial wall of the acetabulum. There is an intramedullary rod with a gamma\n nail seen, fixating a comminuted intertrochanteric fracture of the right\n proximal femur. There are no signs of hardware complications. Ghost pin\n tracks are seen in the distal femur. The patient has a comminuted tibial\n plateau fracture, which is fixated by lateral plate and multiple screws, seen\n through the tibial plateau. The patient has a brace, which limits soft tissue\n detail. Visualization of the distal ankle is within normal limits.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-26 00:00:00.000",
"description": "O L-SPINE (AP & LAT) IN O.R.",
"row_id": 915656,
"text": " 5:13 PM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: L5 TO ILIUM FUSION IN OR FOR L5-S1 FACET JOINT FX AND SACRAL FX\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fusion.\n\n Two intraoperative lateral radiographs of the lumbar spine were obtained\n without a radiologist present. These demonstrate fusion hardware overlying\n L5-S2. For additional details, please consult the operative report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-07-03 00:00:00.000",
"description": "R HIP UNILAT MIN 2 VIEWS RIGHT",
"row_id": 916537,
"text": " 9:50 AM\n HIP UNILAT MIN 2 VIEWS RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: REVISION RT HIP HARDWARE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right hip hardware revision.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Fluoro time recorded as 1.48 minutes on the electronic\n requisition. Nine spot views were obtained. These demonstrate portions of an\n right femoral intramedullary rod and extensive hardware in the proximal right\n tibia, which is incompletely visualized. A proximal fibular fracture is also\n demonstrated. A proximal femur fracture is also seen. Assessment of fine\n bony detail is limited due to RF technique.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-14 00:00:00.000",
"description": "PELVIS WITH JUDET VIEWS",
"row_id": 914150,
"text": " 2:16 PM\n PELVIS WITH JUDET VIEWS; HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT\n Reason: TRAUMA, DHS HIP, ORIF OF RIGHT ACETABULUM, FRACTURE\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Pelvis with Judet view.\n\n HISTORY: Trauma.\n\n Eight intraoperative fluoroscopic views of the femur and hemipelvis without\n right and left label were obtained during the open reduction and internal\n fixation of intertrochanteric fracture with an intramedullary nail and\n proximal and distal screws as well as internal fixation of anterior acetabular\n fracture with a cancellous screw. An inferior pubic ramus fracture is also\n noted. The final films are not available.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 913916,
"text": " 4:04 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Position of line, pneumothorax\n Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with trauma, s/p Line placement\n REASON FOR THIS EXAMINATION:\n Position of line, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:38 A.M. .\n\n HISTORY: Trauma. Line placement. Possible pneumothorax.\n\n IMPRESSION: AP chest _____ with the only prior chest imaging, CT scan from\n :\n\n ET tube is in standard placement, nasogastric tube is looped in the\n hypopharynx and ends in the lower esophagus. The course of the Swan-Ganz\n catheter is distorted by cardiac motion, but the tip projects over the right\n pulmonary artery. Repeat examination should be performed to document\n continuity of the line.\n\n Lungs are very low in volume, but aside from mild left infrahilar atelectasis,\n probably clear. Supine positioning is probably responsible for distention of\n mediastinal veins. The heart is normal in size. No pneumothorax. Dr. \n was paged to discuss these findings, at the time of dictation.\n\n\n"
}
] |
11,772 | 165,749 | Blood gas in the Emergency Department revealed a pH of 7.44, PCO2 of 32, PO2 of 211, bicarbonate of 22, and lactate of 1.9. The patient had a small left temporal laceration which was cleaned and repaired with three 3-0 nylon sutures. The patient underwent numerous studies (see below). The patient was admitted to the Trauma Cardiothoracic Intensive Care Unit in stable condition. The patient was admitted and admitted to the Cardiothoracic Intensive Care Unit for observation. She self-extubated on arrival to the floor. She did well, breathing spontaneously with a clear airway with an alert and oriented mental status. No issues through the following morning. In the Emergency Department, the patient underwent radiologic evaluation including a head CT, chest x-ray, abdominal and pelvic CT; all of which were negative. A CT of the cervical spine was negative as well. The patient's collar was removed, and her cervical spine clinically cleared. On examination in the morning of hospital day one (and the day of discharge), the patient's vital signs revealed a temperature current of 37.8, a temperature maximum of 37.8, blood pressure of 108/45, a heart rate of 83, breathing 17 times per minute with an oxygen saturation of 97% on room air, and in no distress. Physical examination revealed the patient to be alert and oriented times three with a clear sensorium. Her heart was regular in rate and rhythm. No murmurs, rubs or gallops. Her lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, and nondistended, with positive bowel sounds. Her extremities were warm with palpable dorsalis pedis pulses and posterior tibialis pulses. She moved all extremities spontaneously. Neurologic examination revealed strength was throughout. Cranial nerves II through XII were intact. No sensory deficits. | IMPRESSION: Central venous line placement without pneumothorax. IMPRESSION: No intracerebral hemorrhage. TECHNIQUE: Noncontrast head CT. IMPRESSION: 1) No evidence of intra-abdominal injury. Otherwise normal trauma chest and pelvis. Only the medial aspects of the clavicles are visualized and no fracture is seen in this region. SICU NPN 11p-7aS/o- Pt neurologically intact throughout the shift, PERL, denies dizziness/blurry vision, states that she has a HA yet that it is only a . FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally midline structures, or enlargement of the ventricles. GU- voiding w/o diff via foley, IVF con't at 100cc's hr overnoc. No cervical spine fracture. TSICU Nursing Progress NOte-Discharge Note-Neuro-Alert and oriented x3, no c/o dizziness, h/a, double/blurred vision. There is no duodenal hematoma. The SI joints and pubic symphysis are not widened. There is no loss of vertebral body or disc height. There is no abnormal adenopathy within the mesentery or retroperitoneum. No cervical spine fractures are visualized. MAE's w/ full strengths, no pronator drift, facial movements symetrical. on a scale of for pain, took no pain med over . There is no prevertebral soft tissue swelling. The mediastinum is not widened. No fractures are seen within the visualized osseous structures. VSS - DENIES CARDIAC C/O'S OR PAIN ISSUES - ALERT/ORIENTED X3 - AFFECT/QUESTIONS/CONCERNS APPROPRIATE. EXTUBATED UPON ARRIVAL, MAINTAINING ADEQUATE OXYGENATION - DENIES SOB. A trace amount of free fluid is seen within the pelvis adjacent to a normal appearing uterus and adnexa. No fractures are identified. No apical capping or shift of the trachea is seen. The small bowel is nonopacified but adequately visualized and there are no areas of wall thickening or luminal dilatation. The vasculature is within normal limits. There are no major or minor vascular territorial infarcts. No rib fractures are identified. There is normal alignment of the cervical vertebral bodies. The patient is intubated but the tip of the endotracheal tube is no visualized and is therefore likley above the thoracic inlet. There is no effusion. There are no pelvic masses or enlarged inguinal lymph nodes. There is no pneuomothorax. Nonionic contrast was administered in accordance with the trauma protocol. No fractures or malalignments are seen. TRAUMA CHEST: The apices are not included. Right upper lobe tiny pulmonary nodule. The heart size is normal given technique. No pneumothorax is seen and no focal consolidations to suggest pulmonary contusions are seen. GI- abd soft nondistended, took small sips H2O this AM. The heart size is normal. T/SICU 15:00:PT ARRIVED TO UNIT FROM EW/CTS ->STABLE. The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys have a normal appearance. Hemodynamically stable in SR w/ BP 100-110/40-50, resp- lungs clear, RR 12-16, sat 98-100% on RA. No subcapsular hematomas are seen along the liver or spleen. ET tube tip at the level of the thoracic inlet. C/O SEVERE HA WITH N/V,TX WITH ZOFRAN/MS IV WITH GOOG EFFECT,REPEATED WHEN SYMPTOMS REOCCURED.CARDIAC- VSS,IN NSR.SHE HAS A RT SUBCLAVIAN TRAUMA LINE INFUSING LR AT 100CC/HR.IN ADDITION SHE HAS THREE PERIPHERAL #18G IV'S WHICH FLUSH WELL.RESP-LS CLEAR,NO RESP DISTRESS NOTED.WEANED TO RA. PERLA @ 4mm/, , oob to chair independently w/o dizziness.CV -HR 70 SR, BP 120/70.Skin- Head Lac, no new d/c, old blood cleaned off as able. r/o ptx, confirm position. TLS AND C-SPINE CLEARED BY TEAM - CERVICAL COLLAR D/C'D. No comparison studies. AP PELVIS ON TRAUMA BOARD: The right greater trochanter is not completely included on this study. Soft tissue swelling over the right parieto-frontal calvarium. The endotracheal tube (seen on CT examination) has been removed and the NG tube has also been removed. Nausea improved, no need for antiemetics over as well. Coronal and sagittal reformatted images were obtained. The remainder of the large intestine is collapsed but there is no evidence of wall thickening or luminal dilatation. CHEST, PORTABLE: A right sided subclavian central venous line terminates in the central most aspect of the right subclavian vein. cvl placement. cvl placement. cvl placement. On lung windows incidental note is made of a small pleural-based pulmonary nodule in the right upper lobe posteriorly. There is no free air or free fluid within the abdomen. r/o ptx. The orbits, sinuses and osseous structures are normal; however, there is an area of soft tissue swelling over the right parieto-frontal skull, within the scalp. The ET tube tip is at the thoracic inlet. TECHNIQUE: Helically acquired contiguous axial images were obtained through the cervical spine. IMPRESSION: 1. IMPRESSION: 1. The lung fields are clear. The lung fields are clear. There is no prior study for comparison. confirm position. There is no free air within the pelvis. The soft tissues of the neck are symmetric. Central line placement. FINDINGS: C1 through T2 are visualized. CT ABDOMEN AFTER IV CONTRAST: There is some dependent atelectasis at the left lung base. The line tip is located at the central most aspect of the subclavian vein. Pager . Reformatted images support the above findings. If patient is intubated endotracheal tube should be advanced. TECHNIQUE: Helically acquired CT images were obtained from the lung bases through the pubic symphysis after the administration of 150 cc Optiray contrast. CT PELVIS AFTER IV CONTRAST: The rectum and sigmoid colon are full of stool. Trace erythema @ site, 1+ tenderness.Stable --probable concussion.Plan--Discharged to home w/ parents.Concussion, Laceration, Suture Care discharge instructions reviewed w/ patient and mother, stating good understanding of documents. The bladder contains a Foley and is collapsed. Results were discussed with the Trauma Team. 2. 2. 3. COMPARISON: Trauma chest radiograph from 90 minutes previously. FINAL REPORT INDICATION: Fall from bike. PT REMAINS NPO.N/V RELIVED WITH MEDICATION AS ABOVE PT CLEAR,YELLOW URINE VIA FOLEY CATHETER.PARENTS HAVE BEEN IN WITH PT MUCH OF THE EVENING. SOCIAL WORK NOTE:Pt and family known to this SW from pt's ED arrival. Please see my printed OMR note for further information. | 10 | [
{
"category": "Radiology",
"chartdate": "2108-06-19 00:00:00.000",
"description": "CT EMERGENCY HEAD W/O CONTRAST",
"row_id": 764181,
"text": " 12:58 PM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: bike accident\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old with bike accident with loc\n REASON FOR THIS EXAMINATION:\n bike accident\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Fall from bike with loss of consciousness.\n\n No comparison studies.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally\n midline structures, or enlargement of the ventricles. There are no major or\n minor vascular territorial infarcts. The orbits, sinuses and osseous\n structures are normal; however, there is an area of soft tissue swelling over\n the right parieto-frontal skull, within the scalp.\n\n IMPRESSION: No intracerebral hemorrhage. Soft tissue swelling over the right\n parieto-frontal calvarium.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-19 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 764182,
"text": " 12:59 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: bike accident\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old with bike accident with loc\n REASON FOR THIS EXAMINATION:\n bike accident\n ______________________________________________________________________________\n WET READ: DCsc TUE 2:21 PM\n NO ABD INJURY\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST, AT 13:50:\n\n INDICATION: Bike accident with loss of consciousness.\n\n TECHNIQUE: Helically acquired CT images were obtained from the lung bases\n through the pubic symphysis after the administration of 150 cc Optiray\n contrast. Nonionic contrast was administered in accordance with the trauma\n protocol.\n\n There is no prior study for comparison.\n\n CT ABDOMEN AFTER IV CONTRAST: There is some dependent atelectasis at the left\n lung base. The liver, gallbladder, pancreas, spleen, adrenal glands, and\n kidneys have a normal appearance. There is no abnormal adenopathy within the\n mesentery or retroperitoneum. There is no free air or free fluid within the\n abdomen. The small bowel is nonopacified but adequately visualized and there\n are no areas of wall thickening or luminal dilatation. No subcapsular\n hematomas are seen along the liver or spleen. There is no duodenal hematoma.\n\n CT PELVIS AFTER IV CONTRAST: The rectum and sigmoid colon are full of stool.\n The remainder of the large intestine is collapsed but there is no evidence of\n wall thickening or luminal dilatation. There is no free air within the\n pelvis. The bladder contains a Foley and is collapsed. A trace amount of\n free fluid is seen within the pelvis adjacent to a normal appearing uterus and\n adnexa. There are no pelvic masses or enlarged inguinal lymph nodes.\n\n No fractures are seen within the visualized osseous structures.\n\n IMPRESSION:\n 1) No evidence of intra-abdominal injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-19 00:00:00.000",
"description": "TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)",
"row_id": 764184,
"text": " 12:59 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: bike accident\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old with bike accident with loc\n REASON FOR THIS EXAMINATION:\n bike accident\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fell off bike then hit by car.\n\n TRAUMA CHEST: The apices are not included. The patient is intubated but the\n tip of the endotracheal tube is no visualized and is therefore likley above\n the thoracic inlet. An NG tube is seen looping in the stomach with tip in the\n fundus. The heart size is normal given technique. The mediastinum is not\n widened. No apical capping or shift of the trachea is seen. The lung fields\n are clear. No pneumothorax is seen and no focal consolidations to suggest\n pulmonary contusions are seen. No rib fractures are identified. Only the\n medial aspects of the clavicles are visualized and no fracture is seen in this\n region.\n\n AP PELVIS ON TRAUMA BOARD: The right greater trochanter is not completely\n included on this study. No fractures or malalignments are seen. The SI joints\n and pubic symphysis are not widened.\n\n IMPRESSION:\n 1. If patient is intubated endotracheal tube should be advanced.\n 2. Otherwise normal trauma chest and pelvis.\n\n Results were discussed with the Trauma Team.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 764187,
"text": " 1:24 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: bike accident with loc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old woman with bike accident and loc\n REASON FOR THIS EXAMINATION:\n bike accident with loc\n ______________________________________________________________________________\n WET READ: NTo TUE 2:39 PM\n no c-spine fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bicyclist hit by car with loss of consciousness.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained through\n the cervical spine. Coronal and sagittal reformatted images were obtained.\n\n FINDINGS: C1 through T2 are visualized. There is no prevertebral soft tissue\n swelling. There is normal alignment of the cervical vertebral bodies. There\n is no loss of vertebral body or disc height. No cervical spine fractures are\n visualized. The soft tissues of the neck are symmetric. The ET tube tip is\n at the thoracic inlet. On lung windows incidental note is made of a small\n pleural-based pulmonary nodule in the right upper lobe posteriorly.\n\n Reformatted images support the above findings.\n\n IMPRESSION:\n\n 1. No cervical spine fracture.\n\n 2. ET tube tip at the level of the thoracic inlet.\n\n 3. Right upper lobe tiny pulmonary nodule.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 764188,
"text": " 1:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p fall from bike. cvl placement. r/o ptx, confirm position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old woman s/p fall. cvl placement. r/o ptx. confirm position.\n REASON FOR THIS EXAMINATION:\n s/p fall from bike. cvl placement. r/o ptx, confirm position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall from bike. Central line placement.\n\n COMPARISON: Trauma chest radiograph from 90 minutes previously.\n\n CHEST, PORTABLE: A right sided subclavian central venous line terminates in\n the central most aspect of the right subclavian vein. The heart size is\n normal. The vasculature is within normal limits. The lung fields are clear.\n There is no effusion. There is no pneuomothorax. No fractures are identified.\n The endotracheal tube (seen on CT examination) has been removed and the NG\n tube has also been removed.\n\n IMPRESSION: Central venous line placement without pneumothorax. The line tip\n is located at the central most aspect of the subclavian vein.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-20 00:00:00.000",
"description": "Report",
"row_id": 1416147,
"text": "SICU NPN 11p-7a\nS/o- Pt neurologically intact throughout the shift, PERL, denies dizziness/blurry vision, states that she has a HA yet that it is only a . on a scale of for pain, took no pain med over . Nausea improved, no need for antiemetics over as well. MAE's w/ full strengths, no pronator drift, facial movements symetrical. Hemodynamically stable in SR w/ BP 100-110/40-50, resp- lungs clear, RR 12-16, sat 98-100% on RA. GI- abd soft nondistended, took small sips H2O this AM. GU- voiding w/o diff via foley, IVF con't at 100cc's hr overnoc. Hct 34.6 yest afternoon , stable at 33.8 this AM.\nA/P- stable , advance DAT, activity, D/C foley and probable discharge to floor or home this PM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-20 00:00:00.000",
"description": "Report",
"row_id": 1416148,
"text": "TSICU Nursing Progress NOte-Discharge Note-\nNeuro-\nAlert and oriented x3, no c/o dizziness, h/a, double/blurred vision. PERLA @ 4mm/, , oob to chair independently w/o dizziness.\nCV -HR 70 SR, BP 120/70.\nSkin- Head Lac, no new d/c, old blood cleaned off as able. Trace erythema @ site, 1+ tenderness.\nStable --probable concussion.\nPlan--\nDischarged to home w/ parents.\n\nConcussion, Laceration, Suture Care discharge instructions reviewed w/ patient and mother, stating good understanding of documents. Trauma Clinic number provided, and instructed to call in next 24 hours and make F/U appt for 1 week.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-19 00:00:00.000",
"description": "Report",
"row_id": 1416144,
"text": "SOCIAL WORK NOTE:\nPt and family known to this SW from pt's ED arrival. Please see my printed OMR note for further information. Met with pt and her parents this afternoon to offer continued support. Pt has been extubated and is alert, fully oriented, and able to answer questions and engage pleasantly in conversation. This SW will f/u tomorrow with pt and family if pt remains on T-SICU. Family has contact information for this SW and I encouraged parents and pt to be contact if further support needed. Pager .\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-19 00:00:00.000",
"description": "Report",
"row_id": 1416145,
"text": "T/SICU 15:00:\n\nPT ARRIVED TO UNIT FROM EW/CTS ->STABLE. EXTUBATED UPON ARRIVAL, MAINTAINING ADEQUATE OXYGENATION - DENIES SOB. TLS AND C-SPINE CLEARED BY TEAM - CERVICAL COLLAR D/C'D. VSS - DENIES CARDIAC C/O'S OR PAIN ISSUES - ALERT/ORIENTED X3 - AFFECT/QUESTIONS/CONCERNS APPROPRIATE. PARENTS IN ROOM W/PT - RESTING COMFORTABLY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-19 00:00:00.000",
"description": "Report",
"row_id": 1416146,
"text": "T/SICU\nPT IS A 19 YO WOMEN WHO FELL VS WAS STRUCK WHILE RIDING HER BICYCLE.SHE WAS WEARING A HELMET.SHE HAD LOC AT THE SCENE,VOMITING,WAS INTUBATED AND SEDATED,MEDFLIGHTED TO .SHE HAS NO PMH,NO ALLERGIES AND TAKES NO MEDS AT HOME.PEARL AT THE SCENE\n\nAT ,SHE WAS CLEARED BOTH BY XRAY AND PHYSICAL EXAM FOR HER TLS.C-SPINE CLEARED.INJURIES INCLUDE A LAC TO HER SCALP.UPON ARRIVAL TO T/SICU, SHE WAS EXTUBATED TO NC.\n\nROS:\n\n PT IS ON Q 2HR NEURO CHECKS.SHE HAS BEEN ALERT AND ORIENTED X 3,PEARL,GRASPS EQUAL. C/O SEVERE HA WITH N/V,TX WITH ZOFRAN/MS IV WITH GOOG EFFECT,REPEATED WHEN SYMPTOMS REOCCURED.\n\nCARDIAC- VSS,IN NSR.SHE HAS A RT SUBCLAVIAN TRAUMA LINE INFUSING LR AT 100CC/HR.IN ADDITION SHE HAS THREE PERIPHERAL #18G IV'S WHICH FLUSH WELL.\n\nRESP-LS CLEAR,NO RESP DISTRESS NOTED.WEANED TO RA.\n\n PT REMAINS NPO.N/V RELIVED WITH MEDICATION AS ABOVE\n\n PT CLEAR,YELLOW URINE VIA FOLEY CATHETER.\n\nPARENTS HAVE BEEN IN WITH PT MUCH OF THE EVENING.\n"
}
] |
23,061 | 194,030 | 1) Gram negative bacteremia: patient presented with symptoms suspicious for rigor but she was afebrile. Blood cultures were drawn and the anaerobic bottle grew gram negative rods, which are consistent with possible anaerobic gut organisms. She was treated with levofloxacin and flagyl while in the hospital and asymptomatic since presentation. CT of the abdomen/pelvis and MRCP were negative for identifying a source of infection. The ERCP service was contact and felt that without symptoms and with a normal MRCP, that ERCP was not necessary. Her LFT's were stable at discharge. She was discharged on 14 day total course of antibiotics. 2) Atrial fibrillation: She was noted to go into A fib two days into hospitalization, with rapid response to 150-180's and associated hypotension. She was transferred to the CCU and spontaneously converted a few hours after entering A fib following fluid boluses, metoprolol, and 150 mg of amiodarone. TSH/free T4 were normal. She was in NSR since that time, and will be set up with an event monitor at her cardiologist's office the day following discharge. Her propranolol daily dose was changed to atenolol for longer duration of action and to avoid multiple doses during the day. She was also maintained on heparin while hospitalized and started on coumadin for CHADS2 score of at least 2 at discharge, which will be managed by her PCP's office. She was not felt to need a bridge to coumadin and the heparin was discontinued at discharge. 3) Chest pain/CAD: CTA of the chest, EKG, and cardiac enzymes are negative. Her chest pain was felt to possibly be secondary to stable angina, or was possibly secondary to paroxysmal A fib. She was maintained on statin, Imdur (changed to once daily), atenolol, and started on a low dose of lisinopril. 4) Hypothyroidism: she was continued on synthroid. TSH/free T4 were normal. 5) Code - She was DNR/DNI | Focal calcifications in aortic root.Normal ascending aorta diameter. There is no pericardial effusion.IMPRESSION: Preserved global and regional biventricular systolic function.Mild-moderate mitral regurgitation. Normal regional LV systolic function. Hypertension.Height: (in) 56Weight (lb): 154BSA (m2): 1.59 m2BP (mm Hg): 142/63HR (bpm): 74Status: InpatientDate/Time: at 11:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. moves all extrem, OOB to commode with steady gate.CV- remains in SR, rare PVc, rate 60-70 BP 110/43--143/60. ModeratePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. Moderate [2+]tricuspid regurgitation is seen. abx: levoflox + flagyl.RESP: LS clear. The common bile duct and pancreatic duct taper normally up to the ampulla, which appears unremarkable. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. No LA mass/thrombus (best excluded by TEE).RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Trace aortic regurgitation is seen. There is mild central biliary ductal dilatation. The spleen appears within normal limits. Mild to moderate (+) mitral regurgitation is seen. Dynamic volumetric images were acquired before, during, and after intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. Slight dry cough, not expectorating any sputum.CV:- Monitored in NSR, rare ectopics seen, rate 70-85bpm. ERCP '-> biliary dilitation. Pulmonary vascularity appears within normal limits. Portal venous flow is hepatopetal. Sinus rhythmAtrial premature complexesNonspecific precordial/anterior T wave abnormalitiesSince previous tracing of the same date, no significant change To observe RT AC site.ID:- Afebrile, given antibitics as needed, No obvious signs of infection known to be bacrteremic.SKIN:- Pressure areas intact, however whilcst using cammode rt buttock did get pinched slightly,r esulting in a small blood blister, duoderm applied. There is moderate pulmonary artery systolichypertension. ekg obtained - HO notified - assessed pt. Mild to moderate (+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mildly prominent mediastinal lymph nodes, and right hilar lymph nodes. Tollerated atenolol and lisinorpil well, without major drop in prssure. CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: The bladder, distal ureters, uterus are normal. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. pt with positive BC, source unknown , continues on antibiotics, afebrile, normotensive.P: NPO for MRI, follow rhythm, bp, resp status, assess for pain, support pt, OOB to chair with assist. Pneumobilia without evidence of a dependent biliary filling defect. A usual screening mammography is recommended. The common bile duct is within normal limits status post cholecystectomy measuring 9 mm. Bowels open x1, good amount.ACCESS:- Peripheral lines patent, sites satisfactory.ID:- Afebrile, antibiotics given as ordered. Moderate tricuspid regurgitation.Pulmonary artery systolic hypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). NPN 7 Pm - 7 AMs: " I really feel fine, can you take this IV out? Slightly prominent infundibulum along the medial aortic arch, apparently the origin of a small vessel, of doubtful clinical significance. Started empirically on abx. TECHNIQUE: Axial non-contrast and contrast images through the abdomen and pelvis. Regionalleft ventricular wall motion is normal. She came to reg floor but later was found to be hypotensive and in rapid A- Fib, to unit yesterday where she received loading dose of amiodarone and converted to SR. Pt stable overnight, remains in SR, BP stable and no chest discommfort. am PTT 150- infusion on hold at 630 to 730am - restart gtt @ 800u/hr at 730amGI/GU: voiding well. Clinical decisions regarding the needfor prophylaxis should be based on clinical and echocardiographic data.Conclusions:The left atrium is normal in size. Atrial fibrillation with rapid ventricular responseDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in partischemia - clinical correlation is suggestedSince previous tracing of , rapid atrial fibrillation and further ST-Twave changes now present Usual mammographic screening is recommended. Abdomen soft and non tender, bowel sounds heard.ACCESS:- All 3 PIVs', removed as infilrated within hours of each other, IV placed new PIV. cont cardiac meds. Has continued to be in sr, pain free.resp: Initially pt on 100% NRB w/ sats high90's, after conversion to sr, sats 100% on 2lnp. Bedside AP chest radiograph dated compared to the prior chest radiograph dated . (Over) 4:22 PM CTA CHEST W&W/O C &RECONS Clip # Reason: eval PE, dissection Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) 3. Abdomen soft and non tender, continues on stool softener. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There are small bilateral pleural effusions and bibasilar atelectasis. Small bilateral breast calcifications are noted. Normal aortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). No left atrial mass/thrombus seen (bestexcluded by transesophageal echocardiography). Given lopressor 2.5 mg iv x3 w/ no appreciable change in hr, then given a150 mg amiodarone load, after which pt converted to sr rate 70's, no vea. Right ventricular chamber size andfree wall motion are normal. No c/o abd discomfort since CCU admit.gu: vdg qsid: afebrile, cont on abxskin: intactsocial: has been living in senior housing, scheduled to move to , daughter in with pt most of afternoon.Pt has macular degeneration and has very poor eyesight.A: RAF w/ hypotension, converted to sr after lopressor and amiodaroneP: NPO for MRCP this eve, monitor rhythm, bp Transferred to floor, c/o abd tenderness and fever w/ unknown source. There is bibasilar atelectasis, but otherwise the lungs are clear. Sinus rhythmAtrial premature complexesNonspecific precordial/anterior T wave abnormalitiesNo previous tracing available for comparison | 19 | [
{
"category": "Nursing/other",
"chartdate": "2130-09-28 00:00:00.000",
"description": "Report",
"row_id": 1563757,
"text": "CCU Progress note 0700-1900\nRESP:- On room air for most of the day, Sa02 96-100%, RR 12-16, bilateral air entry haerd to all lungfields. Slight dry cough, not expectorating any sputum.\n\nCV:- Monitored in NSR, rare ectopics seen, rate 70-85bpm. SBP 100-120s'. Tollerated atenolol and lisinorpil well, without major drop in prssure. Peripherally warm to touch. Heparin re-stated at 850 units/hr, PTT collected late as had to wait for phebotomy to collect as very difficult stick.\n\nNEURO:- A&O x3, able to change own position from bed to chair as needed. and chatty. Walking to bathroom with assitance. PT seen and assessed.\n\nGU:- walking to bathrom and voiding in the bathroom, good amounts of clear yellow urine.\n\nGI:- Eaten very little today, had 1 x slice of toast only despite freequent encourgment from family. Refused neutraphos. Abdomen soft and non tender, continues on stool softener. Bowels open x1, good amount.\n\nACCESS:- Peripheral lines patent, sites satisfactory.\n\nID:- Afebrile, antibiotics given as ordered. Not coughing/expectorating sputum. NO other signs of infection. Awaiting rest of culture data.\n\nSKIN:- Pressure areas inatact, blister on RT buttock much better, just appaers as a bruise now. Able to change own position as needed. Full bedbath and sheet change given, feet soaked.\n\nFAMILY:- Daughter telephoned and today, updated on plan of care. No other enquires from family as yet today.\n\nPLAN:- For possible discahrge today/tomorrow, called out to the floor when bed avalible. To continue with heaprin as ordered and titrate as needed-> to convert to oral when discharge date organised. For possible home saftey evalutaion on discharged as movinmg into new home at . To continue to give full explination of care to patient and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-28 00:00:00.000",
"description": "Report",
"row_id": 1563758,
"text": "CCU Progress note 0700-1900\nADDENDUM:- Pt able to go home today, heparin stopped started oral warfarin and antibiotics, tollerated well. All vitals within normal limits. Discahrged home with services at . All information given and explinated to both patient and daughter.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-27 00:00:00.000",
"description": "Report",
"row_id": 1563755,
"text": "CCU Progress Note 0700-\nRESP:- Has remained on room air during the day, Sa02 94-96%, RR 14-16 and regular. Bilateral air entry heard to all lungfields. Not coughing/expectorating sputum.\n\nCV:- Monitored in NSR 70-80bpm, no ectopics seen. SBP 119-130s', MAP 60-70s'. Tollerated cardiac meds well, propanaolol given before order picked up for atenolol, so to start that in the am. Peripherally warm to touch. MG replaeted with IV mag, will take PO K+ once had MRI. Commenced heparin at 1200 units/hr at 1300.\n\nNEURO:- A&O x3, lady, a little angry this morning as she could not eat and she wanted to go home. For MRI this afternoon. Able to teransfer self with minimal assistance from bed to chair. Has short nap this afternoon. PERL 2-3mm.\n\nGU:- Using cammode as needed, voiding good amounts of clear yellow urine.\n\nGI:- Ate a small amount for breakfast, NPO for procdure since. Bowels not moved, taking colase, not had bowel movement since monday. Abdomen soft and non tender, bowel sounds heard.\n\nACCESS:- All 3 PIVs', removed as infilrated within hours of each other, IV placed new PIV. Possibly need second line placed later today. To observe RT AC site.\n\nID:- Afebrile, given antibitics as needed, No obvious signs of infection known to be bacrteremic.\n\nSKIN:- Pressure areas intact, however whilcst using cammode rt buttock did get pinched slightly,r esulting in a small blood blister, duoderm applied. Able to change own position in the bed as needed.\n\nFAMILY:- Daughter into visited this morning, eagerly awaiting MRI! also. Updated on plan of care, has spoken to her also on the phone.\n\nPLAN:- for MRI at somepoint this aftertoon, to continue with the antibiotics as ordered. To continue to give fulle xplination of care to aptient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-28 00:00:00.000",
"description": "Report",
"row_id": 1563756,
"text": "ccu progress note 7p-7a\n\nEVENTS: episode of CP at 5am this morning - maalox + crackers given with some relief to . ekg obtained - HO notified - assessed pt. O2 in place 2L. Ntg 0.3mg SL given total of 3 times with cessation of CP at 6am.\n\nNEURO: A+Ox3. OOB to chair + BSC. family in in the evening - updated by CCU team re plan of care + treatment/meds/tests. walking well under supervision. parkinson-like intentional tremors.\n\nID: afebrile. abx: levoflox + flagyl.\n\nRESP: LS clear. ra sats 93-95%. placed on O2 2L during CP episode this morning.\n\nCARDIAC: SR 60-70s. SBP 120-130s. To start increased dose atenolol 50mg in am. started dose captopril 6.25mg last nite - to start on lisinopril 2.5mg po today. Isordil 60mg qd. rec'd ntg s/l x3 this morning. Heparin 1050u/hr. am PTT 150- infusion on hold at 630 to 730am - restart gtt @ 800u/hr at 730am\n\nGI/GU: voiding well. BM x1 this morning. poor appetite. had toast and tea after MRI - took oral KCL replacements at that time (ordered in am). encourage po intake - poor appetite - \"everything is tasteless, I am not hungry\"\n\nPLAN: please restart HEPERIN gtt @ 730am @ 800u/hr. cont cardiac meds. monitor for CP, encourage pt to notify nurse for any discomfort or CP as she waited to say anything to nurse overnight. \"It was only a little pain, I get it in the past\" \" last 30 years, little pains are nothing.\" transfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-26 00:00:00.000",
"description": "Report",
"row_id": 1563751,
"text": "CCU NSG ADMIT\n76 yo woman presented to ew w/ chest pressure and nausea while walking at the mall. In EW EKG-> frequent pvd's no st changes, pain lasted several hrs not relieved w/ ntg. negative ck and troponin. Transferred to floor, c/o abd tenderness and fever w/ unknown source. Started empirically on abx. + BC . ERCP '-> biliary dilitation. CT central buliary ductal dilatation, hepatic cyst.\n\nThis am pt c/o feeling dizzy, palpatations. Found to be in rapid af w/ rate ~ 160, hypotensive w/ sbp 50. Transferred to CCU for further evaluation and tx.\n\nPt arrived to CCU ~ 1100, awake, alert, oriented x3, mentating well, cooperative.\nHR 140-160 RAF.bp 80-96/40-50 IVF 200cc/hr, given ~ 2 liters ivf on floor. Given lopressor 2.5 mg iv x3 w/ no appreciable change in hr, then given a150 mg amiodarone load, after which pt converted to sr rate 70's, no vea. sbp up to mid teens. Has continued to be in sr, pain free.\nresp: Initially pt on 100% NRB w/ sats high90's, after conversion to sr, sats 100% on 2lnp. lungs cta\ngi: poor appitite. NPO at this time for MRCP this evening. MRI checklist done. No c/o abd discomfort since CCU admit.\ngu: vdg qs\nid: afebrile, cont on abx\nskin: intact\nsocial: has been living in senior housing, scheduled to move to , daughter in with pt most of afternoon.\nPt has macular degeneration and has very poor eyesight.\nA: RAF w/ hypotension, converted to sr after lopressor and amiodarone\nP: NPO for MRCP this eve, monitor rhythm, bp\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-27 00:00:00.000",
"description": "Report",
"row_id": 1563752,
"text": "NPN 7 Pm - 7 AM\n\ns: \" I really feel fine, can you take this IV out? I can't stand all these wires.\"\n\no: please see careview for vitals and other objective data\n\nPt with PMH of CAD, GERD, macular degeneration, recent neg stress test\nadmitted to CCU with RAF. She originally experienced CP & dizzyness in the mall and CP here in ER, which did not respond to ntg. she had negative troponin and EKG. Pt also spiked a fever to 101 and BC was drawn ( GNR, origin unknown), she received fluid bolus and IV antibiotics. Pt was transferred here yesterday from floor with rapid A fib, txed with 500 ns bolus, Iv lopressor and Loading dose of amiodarone. Pt converted to SR after amiodarone and has remained in SR overnight and she is pain free.\n\nNeuro: Alert ox3, communicates well in english. moves all extrem, OOB to commode with steady gate.\n\nCV- remains in SR, rare PVc, rate 60-70 BP 110/43--143/60. No complaints of chest pain.\n\nRespiratory: lungs clear, sats 98-100 on 2L, down to 93-94 on room air. denies SOB.\n\nGI: pt has hx of billiary stent, and had elevated liver enzymes. She is due for MRI tomorrow nad is NPO. abd soft. denies discomfort.\n\nGU: voids clear yellow urine, good amounts 1600 cc overnight.\n\nsocial; dtr is supportive, visiting all day until 9 PM. Pt is moving to tomorrow. Pt is anxious to go back home, but has her dtr and professional movers to help her.\n\nA: pt sp event of rapid atrail fib, treated with IV amio load with good effect as well as fluids, remains in SR since yesterday afternoon. pt with positive BC, source unknown , continues on antibiotics, afebrile, normotensive.\n\nP: NPO for MRI, follow rhythm, bp, resp status, assess for pain, support pt, OOB to chair with assist. keep pt and family updated on POC as discussed in ccu rounds.\nshe has positive BC on\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n pt stared on levo and metrondiazole. She came to reg floor but later was found to be hypotensive and in rapid A- Fib, to unit yesterday where she received loading dose of amiodarone and converted to SR. Pt stable overnight, remains in SR, BP stable and no chest discommfort. afebrile.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-27 00:00:00.000",
"description": "Report",
"row_id": 1563753,
"text": "(Continued)\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-27 00:00:00.000",
"description": "Report",
"row_id": 1563754,
"text": "CCU Progress Note 0700-\nADDENDUM:- Pt taken to MRI for scan at 1830, nurse escort not needed, oreder written. heparin infusion continues at 12units/hr for PTT on return from MRI. Small blister/briuse on rt buttock, sustained when sitting on cammode, duoderm dressing inplace, to observe for bleeding as on heparin. Very upset prior to scan, reassurance given by medical and nursing staff.\n"
},
{
"category": "Echo",
"chartdate": "2130-09-27 00:00:00.000",
"description": "Report",
"row_id": 69336,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Hypertension.\nHeight: (in) 56\nWeight (lb): 154\nBSA (m2): 1.59 m2\nBP (mm Hg): 142/63\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No LA mass/thrombus (best excluded by TEE).\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. No resting LVOT gradient.\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. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Based on AHA\nendocarditis 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 normal in size. No left atrial mass/thrombus seen (best\nexcluded by transesophageal echocardiography). Left ventricular wall\nthickness, cavity size, and systolic function are normal (LVEF>55%). Regional\nleft ventricular wall motion is normal. Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion. Trace aortic regurgitation is seen. The\nmitral valve leaflets are structurally normal. There is no mitral valve\nprolapse. Mild to moderate (+) mitral regurgitation is seen. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Preserved global and regional biventricular systolic function.\nMild-moderate mitral regurgitation. Moderate tricuspid regurgitation.\nPulmonary artery systolic hypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2130-09-28 00:00:00.000",
"description": "Report",
"row_id": 164627,
"text": "Technically difficult study\nSinus rhythm\nQT interval prolonged for rate\nSince previous tracing, atrial fibrillation resolved\n\n"
},
{
"category": "ECG",
"chartdate": "2130-09-26 00:00:00.000",
"description": "Report",
"row_id": 164628,
"text": "Atrial fibrillation with rapid ventricular response\nDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , rapid atrial fibrillation and further ST-T\nwave changes now present\n\n"
},
{
"category": "ECG",
"chartdate": "2130-09-24 00:00:00.000",
"description": "Report",
"row_id": 164629,
"text": "Sinus rhythm\nAtrial premature complexes\nNonspecific precordial/anterior T wave abnormalities\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2130-09-24 00:00:00.000",
"description": "Report",
"row_id": 164630,
"text": "Sinus rhythm\nAtrial premature complexes\nNonspecific precordial/anterior T wave abnormalities\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933962,
"text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with hypoxia following A fib\n\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia following atrial fibrillation.\n\n Bedside AP chest radiograph dated compared to the prior chest\n radiograph dated . In the interval, there has been no change\n in the radiographic appearance of the chest, including probable mild\n cardiomegaly, normal pulmonary vascularity, clear lungs, absence of sizable\n pleural effusions.\n\n IMPRESSION: No CHF, no change since previous examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933606,
"text": " 3:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with near syncope, intermittent CP, hypoxia\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Near syncope, intermittent chest pain and hypoxia.\n\n COMPARISON: None.\n\n PORTABLE CHEST: Cardiac and mediastinal contours appear unremarkable.\n Pulmonary vascularity appears within normal limits. Linear opacities at the\n left base likely represent atelectasis. No evidence of pleural effusion.\n\n IMPRESSION: Linear opacity at the left base likely represents atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-24 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 933609,
"text": " 4:22 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: eval PE, dissection\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with chest pain radiating to back, hypoxic\n REASON FOR THIS EXAMINATION:\n eval PE, dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SUN 6:02 PM\n no pe or dissection; small infundibulum at origin or arch vessel of doubtful\n significance; pneumobilia with slight prominent central bile ducts, suggest\n clinical correlation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 76-year-old woman with chest pain and near syncope.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial non-contrast CT images of the chest were first obtained,\n followed by a CT angiogram of the chest with intravenous contrast. Sagittal,\n coronal, and bilateral posterior oblique projection reconstructions were also\n performed.\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There are multiple subcentimeter\n slightly prominent mediastinal lymph nodes, the largest an upper medistinal\n nodes, of borderline size measuring 11 mm in diameter. There are also mildly\n prominent subcentimeter right hilar nodes. The heart, great vessels, and\n pericardium are unremarkable. There is a small medial infundibulum along the\n medial aortic arch associated with a small branch vessel. This is of doubtful\n clinical significance and measures up to 4 mm in diameter. There are a few\n calcifications in the aortic arch. There is no evidence of pulmonary\n embolism. There is bibasilar atelectasis, but otherwise the lungs are clear.\n\n Small bilateral breast calcifications are noted. A usual screening\n mammography is recommended.\n\n There are several subcentimeter hypoattenuating foci in the liver which are\n too small to characterize. The visualized left lobe shows pneumobilia with a\n slightly prominent duct. This may relate to prior cholecystectomy, but\n correlation with clinical history is recommended. Otherwise limited views of\n the upper abdomen are unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism or aortic dissection.\n\n 2. Slightly prominent infundibulum along the medial aortic arch, apparently\n the origin of a small vessel, of doubtful clinical significance.\n (Over)\n\n 4:22 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: eval PE, dissection\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Mildly prominent mediastinal lymph nodes, and right hilar lymph nodes.\n\n 4. Bibasilar atelectasis.\n\n 5. Pneumobilia, with slight prominence of the visualized central hepatic bile\n ducts. Correlation with clinical history and laboratory data is recommended.\n\n 6. Breast calcifications. Usual mammographic screening is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-25 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 933738,
"text": " 2:33 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: eval source of fever\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with hx of biliary stones p/w fever, abdominal tenderness\n REASON FOR THIS EXAMINATION:\n eval source of fever\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of biliary stones, abdominal pain, and fever.\n\n TECHNIQUE: Axial non-contrast and contrast images through the abdomen and\n pelvis. Multiplanar reformats were performed.\n\n CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There are small bilateral\n pleural effusions and bibasilar atelectasis. There are multiple low\n attenuations within the dome of the liver, too small to characterize. There\n is a 6-mm right hepatic cyst. There is pneumobilia in this patient status\n post cholecystectomy. There is mild central biliary ductal dilatation. The\n common bile duct is within normal limits status post cholecystectomy measuring\n 9 mm. The pancreas, spleen, splenule, adrenal glands, kidneys, ureters, and\n large and small bowel are normal. There is no free air, free fluid, or\n lymphadenopathy. There is atherosclerotic calcification of the descending\n aorta.\n\n CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: The bladder, distal ureters,\n uterus are normal. There is no free fluid or lymphadenopathy.\n\n BONE WINDOWS: No suspicious lesions.\n\n REFORMATTED IMAGES: These show no fluid collections.\n\n IMPRESSION:\n 1. No explanation of the patient's symptoms.\n 2. Central biliary ductal dilatation and pneumobilia.\n 3. Hepatic cyst. Small low attenuations in the liver, too small to\n characterize.\n 4. Small bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-27 00:00:00.000",
"description": "MRCP (MR ABD W&W/OC)",
"row_id": 934059,
"text": " 6:59 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: eval for filling defects\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with h/o CAD, s/p cholecystectomy and biliary\n stenting/removal presents with epigastric pain, GNR bacteremia of unclear\n source\n REASON FOR THIS EXAMINATION:\n eval for filling defects\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old lady with history of coronary artery disease,\n cholecystectomy, and biliary stenting (removed in ) with Gram-negative rod\n bacteremia of unknown origin.\n\n TECHNIQUE:\n\n Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet.\n Dynamic volumetric images were acquired before, during, and after intravenous\n administration of 0.1 mmol/kg of gadolinium-DTPA. Subtraction images and\n multidimensional reformatted images were created and reviewed on an\n independent workstation.\n\n The liver shows no evidence of intrahepatic biliary duct dilatation or focal\n hepatic mass. There are a few scattered tiny simple cysts. Portal venous\n flow is hepatopetal.\n\n Air is identified within the biliary system (pneumobilia), which impacts the\n quality of the biliary imaging. Nevertheless, no dependent filling defect is\n identified. The gallbladder is surgically absent. The common bile duct and\n pancreatic duct taper normally up to the ampulla, which appears unremarkable.\n The extrahepatic biliary system, notably the common bile duct, is mildly\n dilated with a maximum diameter of approximately 11.5 mm.\n\n The pancreas appears unremarkable. There is no evidence of pancreas divisum.\n The adrenal glands and kidneys appear unremarkable. Incidental note is made\n of bibasilar atelectasis. The spleen appears within normal limits.\n\n IMPRESSION:\n 1. Pneumobilia without evidence of a dependent biliary filling defect.\n 2. Cholecystectomy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933853,
"text": " 10:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out PNA or pulm edema\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with sudden onset CP/SOB this am\n\n REASON FOR THIS EXAMINATION:\n rule out PNA or pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath and chest pain.\n\n Portable AP chest radiograph compared to .\n\n The heart size is mildly enlarged, but stable. The mediastinum is in normal\n position, contour, and width. The lungs are clear. The pleural surfaces are\n smooth with no pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n"
}
] |
32,059 | 105,207 | Patient is an 82 year old male with past medical history significant for prior CVA with resultant left-sided hemi-paresis, coronary artery disease, and renal insufficiency who presented with hypotension and fever, found to have urosepsis secondary to e. coli infection. . # Septic shock: At time of admission, patient met SIRS criteria. He was initially continued on levophed and intravenous fluids with a goal mean arterial pressure of over 60. Levophed was quickly weaned off and the patient remained hemodynamically stable. Urine and blood cultures returned positive for e. coli. Antibiotic treatment was initiated with vancomycin and zosyn, but was changed to ceftriaxone when sensitivites returned. At time of admission, there was evidence of end-organ injury with an elevated lactate of 4.7 on admission, which normalized following resuscitation. He remained hemodynamically stable during after admission to the intensive care unit, and was transferred to the regular medical floor. Surveillance cultures demonstrated no growth at time of discharge. His foley was discontinued. He will need to complete 14 days total of antibiotic therapy (ceftriaxone)-- will be his last day of treatment. * Cultures will need to be followed up from Rehab. . # Renal failure: Patient's creatinine was elevated to 3.8 at time of admission, with a BUN of 118. This was felt to likely pre-renal in setting of sepsis and hypotension, likely leading to acute tubular necrosis. His creatinine continued to trend downward during his admission, and was 2.4 at time of discharge. He continue to have good urine output. A renal ultrasound demonstrated no evidence of obstruction or hydronephrosis. His foley was discontinued and he was able to void without difficulty. * He will need a basic chemistry panel checked on the day after discharge to ensure that his creatinine is stable or improving. He will also need a basic chemistry panel checked 4-5 days after discharge as well. * He may benefit from gentle intravenous fluids if his creatinine does not continue to improve or rises. . # Elevated troponin: Patient's cardiac enzymes bumped during his stay. An EKG showed no acute changes. The bump in cardiac enzymes was felt to be demand ischemia in setting of sepsis and hypotension. His cardiac enzymes were trended and his troponin peaked at 0.22. The elevated troponin may also have been due to his acute renal failure. He reported no chest pain or other symptoms. - He was continued on an aspirin and statin. - His beta-blocker was re-introduced at a low dose and titrated up to his home dose once his blood pressure normalized. - He was kept on telemetry but this was stopped after there were no significant abnormalities. . # Anemia: By report to the intensive care team, patient was anemic prior to his admission, though his baseline hematocrit was unknown. There was no clear source of evidence of bleeding, although there was a question of possible blood tinged vomitus at rehab. He had no emesis during his stay. He was transfused two units of packed red blood cells for a hematocrit of 22, with appropriate bump in his hematocrit, which remained stable during his stay. His stools were guaiac negative. * Appropriate work up, if desired and not previously completed, should be done on an outpatient basis. * He should have a complete blood count checked with his labs at one and 4-5 days after admission. . # History of clostridium difficile infection: Patient had history of c. difficile infection, but had completed treatment prior to admission. He was started on flagyl during his stay given concerns about c. difficile infection, however his stool was found to be c. difficile negative. His significant leukocytosis was concerning for possible recurrent infection, but he had no diarrhea, and his abdominal exam remained benign. * Given that he is on ceftriaxone for his urinary and blood stream infection, he should be monitored carefully for any evidence of c. difficile recurrence and re-started on flagyl in that event. . # Diabetes Mellitus: Patient was hypoglycemic at time of admission, and initially did not require very much insulin. After his tube feeds were re-started, his blood sugars then rose to the 200's to 300's. His lantus was re-started at about half of his home dose, 20 units, on the day prior to discharge. A sliding scale of humalog was also used. * His finger sticks should be monitored closely, and his lantus dose will likely need to be increased as his infection improves. . # Leukocytosis: Patient developed significant leukocytosis during his stay, with a WBC elevated to 40. At time of discharge, it had trended downward to 28. This was felt to be multifactorial due to his e. coli infection, and cortisol stimulation testing that was completed while in the intensive care unit. C. difficile infection was also considered, and he should be monitored carefully for evidence of his. A differential also revealed a few bands, however much improved from time of admission. * A complete blood count should be drawn the day and 4-5 days after discharge to monitor his leukocytosis to ensure that it is trending downward. . # Anxiety, depression: Patient's home doses of zoloft and xanax were restarted prior to discharge. . # Gout: Patient's home medications of allopurinol and colchinine were helding during his admission and may be re-started when indicated. . # Hypernatremia, fluid status: Patient became markedly hypernatremic during his stay, likely due to insensible losses and aggressive normal saline resuscitation during his intensive care unit stay. He was given D5 fluids to treat his hypernatremia, and free water flushes were increased to 300 mL q4 hours. His sodium improved slowly to 146 at time of admission. * He will need a basic chemistry panel checked the day after admission, and again in days to ensure that his sodium is stable and within a normal range. . # Prophylaxis: A proton pump inhibitor was continued, and heparin subcutaneous was used for DVT prophylaxis. Mouth care was maintained with mouth swabs and moisturing agents. . # Nutrition: Nutrition was consulted and tube feeds were re-started at their recommendation. Speech and swallow was consulted, and it was felt that he should continue his NPO status. A video swallow may be of assistance to further evaluate this if desired, on an outpatient basis. His tubefeeding was as follows: Nutren Renal Full strength, 45 ml/hr, with free water flush 300 mL water every 4 hours. . # Access: A right internal jugular line was pulled prior to discharge, and peripheral IV was kept in place. . # Code: Patient's code status was DNR/DNI based on discussions with family. | CK 159 (268)MB 18, Troponin 0.14. REMAINS A DNR/DNI.PT. FINDINGS: The right IJ line is in the mid SVC. LS clear Bilat.CVS: Sinus tach w/ occasional PVC's HR/ B/P and pressors as above. CVP 10-12.Access: R arm PIV x2, R IJ TL CVL.GI: abd soft , tube in abd Clamped, sm amt bilious residual noted, pt had sm amt soft brown stool x1. Left anteriorfascicular block. remains NPO at this time.GU: foley cath placed in ED w/ 1200ml immediate output. Hct was noted to be 22.2 w/ no obvious s/s of bleeding. Peripheral pulses 3+ DP/2+DT neg edema. Consider left atrial abnormality. Left anterior fascicular block. IMPRESSION: Right IJ line in standard position. Marked left axisdeviation. HAS NKDA.PT. BAD soft, BS +. K+ 5.1 IV access R IJ CVP 13-17. pressors/abx/ etc.pt arrived in the MICU on levophed 0.03mcg/kg/min w/ sbp's in the 80's and map in the 50's HR 110's. IS NSR 60-80'S WITH NO NOTED ECTOPY. pt transferred to ED where his temp was 102, sbp 70's-80's. New right IJ. Otherwise, no change.TRACING #1 Moves R side well, mod str. PT. PT. PT. PT. PT. PT. PT. REMAINS ON FLAGYL, VANCOMYCIN, AND ZOSYN.PLAN IS FOR POSSIBLE C/O TO THE FLOOR. There is a square radioopaque density over the left clavicle, of uncertain clinical significance. source, and hypotensive w/ sbp's in the 60's at NH. Baseline artifact. RESIDUALS ARE LOW AND WNL'S. Cards consult EKG NSTEMI, Demand ischemia. L side no movement r/t CVA. ; prostate Ca; CRI; DMII; CAD; and anemia who became febrile to 103 ? Right IJ catheter again is seen in place. HCT after PC 28.neuro: pt speaking, confused( per family confused at baseline), opens eyes spont, does not follow commands.moves R side, no movment on left side (s/p CVA).at time pt becomes agitation.resp: 5L NC, sat 98-100%, SL clear.cv: recived with HR 120's, overnight down to 93-98,with agitation up to 110's.cont NEO, recived NEO 0.5 mcg/kg/min, dropped BP to 82/50, increased NEO titrate to MAP>60 SBP >90. Moves LE on bed Left sided hemiparesis.CV: HR 100-110 ST no ectopy, @1600 started lopressor 12.5mg HR 90's NSR. Lungs clear fine crackles @ basesID: Contact precautions + c-diff, afebrile WBC 35.8 (42), Blood cx GNR, +U/A, Vanco, Zosyn, flagylGU: foley u/o 50-140cc/hr autodiuresis. Right bundle-branch block. pt is DNR/DNI per family, but may rec. Left axis deviation. ATN BUN/creat 122/3.5GI: abd soft + BS inplace clamped awaiting nutrition eval to resume TF. @ times will respond appropriately 1-2word. PERRLS.Pulm: pt recieved on 100% NRB 02 sat 98-100%, ABG 7.39/29/129/18, will wean 02 as tol. The QRS complexis narrower. HAS PEGTUBE WHICH TUBE FEEDS WERE STARTED LAST HS. NBP 110-128/56-70 MAPS>65. B/P REMAINS STABLE RANGING 103-140'S/60-80'S. HAS REMAINS AFEBRILE THROUGHOUT THIS SHIFT.PT. IMPRESSION: Little change. pt NPO. Passing soft stool x5.Derm: skin impaired coccyx abrasion duoderm applied.Social: DNR/DNI. pt received total 6L fluids, start on Levo , became tachy 120's, changed to NEo. IMPRESSION: Limited study. No obvious hydronephrosis. The right costophrenic angle is not visualized; however, the remaining lungs are clear. trending down. 500ml n/s bolus x 2, IV Zosyn, Vanco, and is now recieving 1st of 2 units PRBC's. pressor switched to Neo at 0.5mcg/kg/min, titrated to 1mcg/kg/min w/ maps in the 70's and HR in the 100's. REMAINS ON CONTACT PRECAUTIONS FOR CDIFF IN STOOL. O2 SATS REMAIN >96% WHILE ON 3L/MIN VIA NASAL CANNULA.PT. seriel Cardiac Enzymes. ABD IS OTHERWISE BENIGN AND PT. This discordance suggests the possibility of cardiomyopathy or pericardial effusion. WITH NO COVERAGE REQUIRED. Sinus tachycardia. Sinus tachycardia. Since the previous tracingno significant change.TRACING #2 no evidence of bleeding via G-tube.id:contact precaution for pos C.diff. BLOOD SUGARS ARE WNL'S RANGING 120'S. 3:19 PM RENAL U.S. levophed titrated to 0.09mcg/kg/min w/ maps increasing to 65-70's however pt became agitated and tachycardic w/ HR in the 120's. afebriel, cont Zocyn/flagylaccess: RIJ, 2piv.skin: abrasion on coccyx area, duoderm aplleid.social: DNR/DNI,pressors ok. pt'd daughter visited/updated.plan: cont monitoirng resp/cardio status wean NEO to keep MAP>60 follow HCT ,signs of bleedign cont ABX, follow temp. DOES NOT MOVE LEFT UPPER EXTREMITY. PULSES ARE VERY WEAK BUT PALPABLE. CVP MONITORED AND RANGES .RESP STATUS REMAINS CLEAR THROUGHOUT WITH RESP RATE CONTROLLED. NO EDEMA NOTED. HAS BEEN OFF NEO FOR ALMOST 24HRS. ABD IS SOFT WITH BOWELS SOUNDS EASILY AUDIBLE AND PT. IS SPEAKING ONLY, SPEAKS FEW ENGLISH WORDS AND HAS BASELINE DEMENTIA. FINDINGS: In comparison with the study of , there is little overall change. dropped HCT to 22, recieved 2 unit PC. RENAL ULTRASOUND: There is no comparison. 9:30 AM CHEST PORT. MICU7 RN Note 0700-1900Events: FB 500cc Tacychardic, later in day resumed Lopressor.Neuro: Responsive to verbal stimulation. Moves RUE random, LUE no movement. Please evaluate. lactate has trended down to 3.5.ROS:Neuro: pt awake, Russian speaking only and per family confused, non communicative at baseline. MICU Nurse admission/progress note 1300-1900Pt is an 82yo M, PMH: Alzhiemers; s/p R CVA w/ L hemi. Enlargement of the cardiac silhouette persists with relatively mild elevation of pulmonary venous pressure. Language barrier speaking, repetatively, Confusion. COMPARISON: None available. Maintenance IV D5NS 80cc/hr.resp: RR 16-20 O2 wean to 3L/Min, Sats 95-98%. CVP 10-14, start on D%NS 80cc/hr.cardiac ensymes sent, morning labs pending. Lactate 4.5 pt started on levophed and given IV abx in ED, then transferred to MICU for further management. Left kidney measures 10.6 cm, and the right kidney measures 11.6 cm. 1900-0700 rn notes micu82 y.o m with h/o of CVA in , L isded hemiparesis,dementia, DM CAD, s/p G-tube presented to ED from rehab with fever, hypotension to 70's, vomiting ?coffee ground, eleveted lactate. ALSO HAS GNR IN BLOOD AND IN URINE. eyes open not following commands. In addition to pressors, pt rec. | 9 | [
{
"category": "Radiology",
"chartdate": "2107-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1006108,
"text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for vol overload\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with sepsis\n REASON FOR THIS EXAMINATION:\n eval for vol overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis, to evaluate for volume overload.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Enlargement of the cardiac silhouette persists with relatively mild\n elevation of pulmonary venous pressure. This discordance suggests the\n possibility of cardiomyopathy or pericardial effusion. Tortuosity of the\n aorta is seen, but no evidence of pleural effusion or acute pneumonia.\n\n Right IJ catheter again is seen in place.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-03-14 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1006014,
"text": " 9:30 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placement, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with fever, hypoTN, new R IJ\n REASON FOR THIS EXAMINATION:\n eval for line placement, pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE FOR LINE PLACEMENT\n\n INDICATION: 82-year-old man with fever, hypotension. New right IJ. Please\n evaluate.\n\n COMPARISON: None available.\n\n FINDINGS: The right IJ line is in the mid SVC. There is no pneumothorax. The\n right costophrenic angle is not visualized; however, the remaining lungs are\n clear. The cardiomediastinal silhouette is enlarged, but this appears due to\n technical factors as the patient is markedly rotated. The hila are also\n enlarged; however, this is also likely due to technical factors. There are no\n pleural effusions. There is a square radioopaque density over the left\n clavicle, of uncertain clinical significance.\n\n IMPRESSION: Right IJ line in standard position. No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-03-14 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 1006069,
"text": " 3:19 PM\n RENAL U.S. PORT Clip # \n Reason: please check for obstruction\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with renal failure and sepsis\n REASON FOR THIS EXAMINATION:\n please check for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with renal failure and sepsis.\n\n RENAL ULTRASOUND: There is no comparison. The study is limited due to\n limited cooperation from the patient. Left kidney measures 10.6 cm, and the\n right kidney measures 11.6 cm. There is no hydronephrosis or obvious mass or\n stone identified on this ultrasound.\n\n IMPRESSION: Limited study. No obvious hydronephrosis.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-16 00:00:00.000",
"description": "Report",
"row_id": 1668854,
"text": "PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. IS SPEAKING ONLY, SPEAKS FEW ENGLISH WORDS AND HAS BASELINE DEMENTIA. PT. DOES NOT MOVE LEFT UPPER EXTREMITY. PT. HAS REMAINS AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. IS NSR 60-80'S WITH NO NOTED ECTOPY. B/P REMAINS STABLE RANGING 103-140'S/60-80'S. PULSES ARE VERY WEAK BUT PALPABLE. NO EDEMA NOTED. PT. HAS BEEN OFF NEO FOR ALMOST 24HRS. CVP MONITORED AND RANGES .\n\nRESP STATUS REMAINS CLEAR THROUGHOUT WITH RESP RATE CONTROLLED. O2 SATS REMAIN >96% WHILE ON 3L/MIN VIA NASAL CANNULA.\n\nPT. HAS PEGTUBE WHICH TUBE FEEDS WERE STARTED LAST HS. NUTREN PULMONARY STARTED AT 10CC/HR, ADVANCE 10CC Q4HRS FOR A GOAL RATE OF 40CC/HR. RESIDUALS ARE LOW AND WNL'S. BLOOD SUGARS ARE WNL'S RANGING 120'S. WITH NO COVERAGE REQUIRED. ABD IS OTHERWISE BENIGN AND PT. ABD IS SOFT WITH BOWELS SOUNDS EASILY AUDIBLE AND PT. HAS HAD FOUR SOFT COLORED STOOLS. FOLEY CATHETER REMAINS INTACT WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.\n\nSKIN EXHIBTIS DUODERM TO COCCYX AREA WITH TWO SMALL AREAS JUST ABOVE DUODERM WHICH ARE ALL OLD AND HEALING PER DAUGHTER. TLC REMAINS INTACT WITH ALL PORTS FUNCTIONING WELL.\n\nPT. REMAINS ON CONTACT PRECAUTIONS FOR CDIFF IN STOOL. PT. ALSO HAS GNR IN BLOOD AND IN URINE. PT. REMAINS ON FLAGYL, VANCOMYCIN, AND ZOSYN.\n\nPLAN IS FOR POSSIBLE C/O TO THE FLOOR. PT. DAUGHTER STRESSED CONCERN OVER HIS INFECTION AND THE POSSIBLITY THAT THEY WON'T GO AWAY. PT'S DAUGHTER STRESSED THAT SHE JUST WANTED WHAT WAS BEST FOR HER FATHER WITHOUT CAUSING HIM DISTRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-14 00:00:00.000",
"description": "Report",
"row_id": 1668851,
"text": "MICU Nurse admission/progress note 1300-1900\nPt is an 82yo M, PMH: Alzhiemers; s/p R CVA w/ L hemi.; prostate Ca; CRI; DMII; CAD; and anemia who became febrile to 103 ? source, and hypotensive w/ sbp's in the 60's at NH. pt transferred to ED where his temp was 102, sbp 70's-80's. Hct was noted to be 22.2 w/ no obvious s/s of bleeding. Lactate 4.5 pt started on levophed and given IV abx in ED, then transferred to MICU for further management. pt is DNR/DNI per family, but may rec. pressors/abx/ etc.\n\npt arrived in the MICU on levophed 0.03mcg/kg/min w/ sbp's in the 80's and map in the 50's HR 110's. levophed titrated to 0.09mcg/kg/min w/ maps increasing to 65-70's however pt became agitated and tachycardic w/ HR in the 120's. pressor switched to Neo at 0.5mcg/kg/min, titrated to 1mcg/kg/min w/ maps in the 70's and HR in the 100's. In addition to pressors, pt rec. 500ml n/s bolus x 2, IV Zosyn, Vanco, and is now recieving 1st of 2 units PRBC's. lactate has trended down to 3.5.\n\nROS:\nNeuro: pt awake, Russian speaking only and per family confused, non communicative at baseline. Moves R side well, mod str. L side no movement r/t CVA. PERRLS.\n\nPulm: pt recieved on 100% NRB 02 sat 98-100%, ABG 7.39/29/129/18, will wean 02 as tol. LS clear Bilat.\n\nCVS: Sinus tach w/ occasional PVC's HR/ B/P and pressors as above. CVP 10-12.\n\nAccess: R arm PIV x2, R IJ TL CVL.\n\nGI: abd soft , tube in abd Clamped, sm amt bilious residual noted, pt had sm amt soft brown stool x1. remains NPO at this time.\n\nGU: foley cath placed in ED w/ 1200ml immediate output. now draining clody yellow urine w/ sediment. UOP 80-100ml/hr.\n\nSkin: Sm Stg II decub on coccyx, cleaned, moisture vbarrier applied.\n\nsocial: family spoke to MD, updated r/t pt cond/ POC, geriatric fellow also involved and will speak w/ family in am to reassess situation and plan going forward.\n\nPlan:wean 02 as tol\nwean pressors as tol\ncont IV abx, blood products as ordered\nmonitor lytes, hct, replete/tx as needed.\nreaddress POC w/ family in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-15 00:00:00.000",
"description": "Report",
"row_id": 1668852,
"text": "1900-0700 rn notes micu\n\n82 y.o m with h/o of CVA in , L isded hemiparesis,dementia, DM CAD, s/p G-tube presented to ED from rehab with fever, hypotension to 70's, vomiting ?coffee ground, eleveted lactate. pt received total 6L fluids, start on Levo , became tachy 120's, changed to NEo. dropped HCT to 22, recieved 2 unit PC. HCT after PC 28.\n\nneuro: pt speaking, confused( per family confused at baseline), opens eyes spont, does not follow commands.moves R side, no movment on left side (s/p CVA).at time pt becomes agitation.\n\nresp: 5L NC, sat 98-100%, SL clear.\n\ncv: recived with HR 120's, overnight down to 93-98,with agitation up to 110's.cont NEO, recived NEO 0.5 mcg/kg/min, dropped BP to 82/50, increased NEO titrate to MAP>60 SBP >90. CVP 10-14, start on D%NS 80cc/hr.cardiac ensymes sent, morning labs pending. start on hydrocortison IV.\n\ngi/gu: foley drainged yellow clear urine 35-80cc/hr. BAD soft, BS +. pt NPO. no evidence of bleeding via G-tube.\n\nid:contact precaution for pos C.diff. afebriel, cont Zocyn/flagyl\n\naccess: RIJ, 2piv.\n\nskin: abrasion on coccyx area, duoderm aplleid.\n\nsocial: DNR/DNI,pressors ok. pt'd daughter visited/updated.\n\nplan: cont monitoirng resp/cardio status\n wean NEO to keep MAP>60\n follow HCT ,signs of bleedign\n cont ABX, follow temp.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-15 00:00:00.000",
"description": "Report",
"row_id": 1668853,
"text": "MICU7 RN Note 0700-1900\n\nEvents: FB 500cc Tacychardic, later in day resumed Lopressor.\n\nNeuro: Responsive to verbal stimulation. eyes open not following commands. @ times will respond appropriately 1-2word. Language barrier speaking, repetatively, Confusion. Moves RUE random, LUE no movement. Moves LE on bed Left sided hemiparesis.\n\nCV: HR 100-110 ST no ectopy, @1600 started lopressor 12.5mg HR 90's NSR. NBP 110-128/56-70 MAPS>65. Cards consult EKG NSTEMI, Demand ischemia. seriel Cardiac Enzymes. trending down. CK 159 (268)MB 18, Troponin 0.14. Peripheral pulses 3+ DP/2+DT neg edema. K+ 5.1 IV access R IJ CVP 13-17. Maintenance IV D5NS 80cc/hr.\n\nresp: RR 16-20 O2 wean to 3L/Min, Sats 95-98%. Lungs clear fine crackles @ bases\n\nID: Contact precautions + c-diff, afebrile WBC 35.8 (42), Blood cx GNR, +U/A, Vanco, Zosyn, flagyl\n\nGU: foley u/o 50-140cc/hr autodiuresis. ATN BUN/creat 122/3.5\n\nGI: abd soft + BS inplace clamped awaiting nutrition eval to resume TF. Passing soft stool x5.\n\nDerm: skin impaired coccyx abrasion duoderm applied.\n\nSocial: DNR/DNI. Daughter called updated on status.\n\nplan: resume Betablockers\n Cardiac echo \n call out to floor\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-15 00:00:00.000",
"description": "Report",
"row_id": 135676,
"text": "Baseline artifact. Sinus tachycardia. Left axis deviation. Left anterior\nfascicular block. Right bundle-branch block. Since the previous tracing\nno significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-14 00:00:00.000",
"description": "Report",
"row_id": 135677,
"text": "Sinus tachycardia. Consider left atrial abnormality. Marked left axis\ndeviation. Left anterior fascicular block. Right bundle-branch block.\nSince the previous tracing of the rate has increased. The QRS complex\nis narrower. Otherwise, no change.\nTRACING #1\n\n"
}
] |